Natural history of sleep disordered breathing in prepubertal children transitioning to adolescence

Abstract

Because there is a lack of agreed upon diagnostic criteria, it is critical to understand the natural history of obstructive sleep apnoea (OSA) in children in order to establish treatment strategies based on objective data.The Penn State Child Cohort is a representative, general-population sample of 700 elementary school children at baseline, of whom 421 were reassessed 8 years later, during adolescence.The remission of childhood apnoea-hypopnoea index (AHI) ≥2 events per h in adolescence was 52.9%. Using the higher threshold of AHI ≥5 events per h, remission was 100.0%, with 50.0% partially remitting to AHI 2- <5 events per h and the other half remitting to AHI <2 events per h. The incidence of adolescent AHI ≥2 events per h in those with childhood AHI <2 events per h was 36.5%, while the incidence of AHI ≥5 events per h in those with childhood AHI <5 events per h was 10.6%. This longitudinal study confirms that prepubertal OSA tends to resolve naturally during the transition to adolescence, and that primary snoring and mild sleep disordered breathing (SDB) do not appear to be strongly associated with progression to more severe SDB.The key risk factors for SDB in adolescence are similar to those found in middle-aged adults (i.e. male sex, older age and obesity). Moreover, consistent with recent studies in adults, this study includes the novel cross-sectional finding that visceral fat is associated with SDB as early as adolescence.

Searching for the happy medium in the therapeutic approach to childhood sleep disordered breathing

“…In this study, only 12% of the children had both polysomnographic and symptomatic resolution under watchful waiting. Unfortunately, in the present study by BIXLER et al [1], data regarding changes in blood pressure, physical examination and psychometric assessment were not provided. This information would have been very useful to confirm whether the observed AHI decrease was associated with an improvement in symptoms and, more importantly, an absence of long-term adverse outcomes, or whether, on the contrary, some children had experienced non-reversible consequences in spite of the reduction in AHI metrics.…”

“…The time span of 8 years in the paper of BIXLER et al [1] seems too long, considering the potential adverse health outcomes and the risk of progression of SDB. It is necessary to define clear-cut follow-up appointments to reassess whether SDB remits or not, not only from a polysomnographic, but also from a clinical, point of view.…”

“…These recommendations are based on strong evidence demonstrating that SDB may impair quality of life and increase blood pressure, hyperactivity symptoms, cognitive deficits, academic difficulties and behavioural disorders [3][4][5][6]. The preferred treatment in children is adenotonsillectomy [2], which in the study by BIXLER et al [1] showed a trend, albeit nonsignificant, towards an increased incidence of SDB in adolescence, a finding also reported in other studies [7]. Therefore, the key question would be to choose between an early treatment, assuming the risks of surgery or even the possibility that surgery itself may pose an additional risk for the development of SDB at an older age, and waiting in the hope that, in most cases, the disease will remit with growth.…”

“…Moreover, the impairment of health status and cardiovascular risks associated with this disorder means that there are ethical implications in withholding treatment to observe its evolution over time. In this respect, children may offer a unique possibility for better tracing the onset and course of the disease, given the fewer coexisting comorbidities and chronic diseases in this population.The paper by BIXLER et al [1] in the current issue of European Respiratory Journal sheds some light on the natural history of SDB in the transition from childhood to adolescence, by reassessing a large cohort of children 8 years after baseline evaluation. This study provides two main findings: 1) all children with severe SDB (apnoea−hypopnoea index (AHI) >5 episodes per hour) and most with moderate SDB (defined in this study as an AHI of 2−5 episodes per hour) experienced either partial or complete remission in the AHI; and 2) risk factors for SDB in adolescence were similar to those found in adulthood but were very different from those observed in childhood.…”

“…The paper by BIXLER et al [1] in the current issue of European Respiratory Journal sheds some light on the natural history of SDB in the transition from childhood to adolescence, by reassessing a large cohort of children 8 years after baseline evaluation. This study provides two main findings: 1) all children with severe SDB (apnoea−hypopnoea index (AHI) >5 episodes per hour) and most with moderate SDB (defined in this study as an AHI of 2−5 episodes per hour) experienced either partial or complete remission in the AHI; and 2) risk factors for SDB in adolescence were similar to those found in adulthood but were very different from those observed in childhood.…”