Sleep-disordered breathing associated with poor academics and surgical improvement [Pediatrics Classics Series]
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1. Sleep-associated gas exchange abnormalities were highly prevalent among a first-grade study cohort with poor academic performance. About 18% of participants had oxygenation abnormalities assessed during overnight observation.
2. School performance, as gauged by grades, improved significantly among children who received surgical intervention for abnormal breathing patterns during sleep.
3. Symptoms of disordered sleep, as assessed by follow-up questionnaire, were significantly worse among children who did not undergo surgical tonsillectomy and adenoidectomy.
Original Date of Publication: September 1998
Study Rundown: Previous studies indicated that a substantial portion of children suffer from obstructive sleep apnea (OSA) and primary snoring (PS) which can result in health consequences such as pulmonary hypertension, failure to thrive, and systematic hypertension. In addition, disordered breathing patterns during sleep have been linked to behavioral disturbances. To prevent these negative outcomes, children with sleep disorders commonly undergo tonsillectomy and adenoidectomy. Despite this prior work, no prospective, controlled trial had investigated the potential cognitive outcomes of individuals with OSA. Researchers in this study aimed to determine whether or not sleep-associated gas exchange abnormalities (SAGEA) among children performing poorly in school was related to academic difficulties and whether or not surgical intervention aided in resolution of cognitive and disordered sleep symptoms. Results indicated that a large number of cohort participants had PS (22.2%) and SAGEA (18.1%) and that both school performance and symptoms could improve through surgical intervention. This study is limited in the use of SpO2 as a measure of oxygenation, which does not indicate whether obstruction or a lower respiratory process is responsible for desaturation and in the use of academic performance as the sole measure of cognition. Despite these limitations, this study added evidence obtained in a prospective, controlled manner to mostly case study-based findings. Current recommendations encourage adenotonsillectomy to prevent the physical, behavioral, and cognitive complications discussed here, with particular attention paid to assessing for potential residual disease requiring further intervention.
Click to read the study in Pediatrics
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In-Depth [prospective, controlled cohort study]: Two hundred ninety-seven first-grade students in the lowest 10th performance percentile of their class were recruited for study participation in an overnight study. To assess sleep-disordered breathing symptoms, students’ parents first filled out an OSA Syndrome (OSAS) questionnaire regarding childhood sleep behavior and respiratory compromise. Then, the children underwent overnight respiratory analysis including pulse oximetry (SpO2) and transcutaneous carbon dioxide tension (TCCO2). SAGEA was diagnosed based upon a high score on the questionnaire along with 2 desaturations (periods of > 5% reductions in baseline SpO2 or SpO2 < 90%) per hour and/or an elevated TCCO2 > 8 mmHg compared with normal, waking values during an overnight study. Children without changes in SpO2 or TCCO2, but an elevated questionnaire score were diagnosed with PS. Children testing positive for SAGEA were followed 3 months and then 1 year after diagnosis date to assess if patients underwent surgical intervention. Cognitive outcomes were assessed through school records both 1 year before and 1 year after completion of the overnight study. For analysis, children were grouped into those who had no abnormalities on overnight study (CO), those with PS, those with SAGEA who went untreated (NT), and those who were treated surgically (TR). Two-way analyses of variance, Newman-Keuls tests, and paired t tests were completed.
Of the 297 children tested, 66 met criteria for PS (22.2%) and 54 for SAGEA (18.1%). Twenty-four had surgical treatment for their disorder (TR), while 30 went untreated (NT). In comparing academic scores between groups, mean grades among the TR group increased significantly from first to second grade (2.43 + 0.17 in first grade v. 2.87 + 0.19, p < 0.001). Only 2 of the 24 children in the TR group remained in the lowest 10th percentile following intervention. Those in the NT group had no significant improvement in grades (2.44 + 0.13 in first grade v. 2.46 + 0.15 in second grade). Upon follow-up questionnaire administration to parents of NT and TR children, untreated children scored significantly higher, indicating worse symptoms, compared to surgically treated children (10.4 + 2.6 in NT v. 1.7 + 2.4 in TR, p < 0.001).
© 2014 2 Minute Medicine, Inc. All rights reserved. No part of this article may be reproduced, distributed or transmitted in any form or by any means without the prior written permission of 2 Minute Medicine, Inc. To license this content, contact 2 Minute Medicine, Inc. This article is for informational and educational purposes only; it is not medical advice and does not replace the judgment of a qualified healthcare professional.
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