Overview

The goal of the study was to see if children’s treatment response to early adenotonsillectomy (eAT) could be predicted using the sleep quality index (SQI), which is based on cardiopulmonary coupling (CPC). We were specifically interested in changes in metabolic health.

What was the approach to solving the problem?

We did post-hoc analysis of photoplethysmography-data (PLETH) collected during polysomnography (PSG) sleep studies, utilizing the SleepImage System cardiopulmonary-coupling (CPC) algorithm for sleep analysis. The SleepImage System is FDA cleared and MDR-CE marked software as a medical device which aids healthcare professionals to evaluate, diagnose, and manage sleep disorders in children from 2-years of age, adolescents, and adults. We used the system’s CPC-based sleep quality index (SQI) to assess sleep quality.

What NSRR data were used?

For this project we utilized the Childhood Adenotonsillectomy Trial (CHAT). Included in the data-set are both children that underwent early adenotonsillectomy and a control group. We only utilized data from the children that had eAT which resulted in 196 children (46.4% male) with quality PLETH-recordings extracted from the PSG-studies at baseline and at follow-up, 7-months after surgery.

What were the results?

We observed that 7-months after eAT surgery, children with moderate-severe OSA and lower-SQI at baseline (Group2) on average had significantly less increase in their BMI z-score when compared to children with high-SQI and mild-OSA (Group1). Children in Group2 also significantly improved their SQI (+ 2.06) and AHI (-5.0) compared to decline in SQI (-3.75) and minor change in AHI (-0.34) in Group1, respectively. Children that improved their sleep quality and OSA with surgery (GroupRemission; AHI< 1.0, SQI75) were significantly younger (6.59 vs. 7.41 years), with lower BMI z-score (0.90 vs. 1.34), fasting insulin (7.54 vs. 12.58 IU/ml) and glucose (4.45 vs. 4.60 mmol/L) compared to children still presenting OSA or compromised sleep quality (GroupResidual; AHI1 and/or SQI<75) at follow-up. GroupRemission also had significantly better quality of life according to parents (88.70 vs. 81.05) and behavior measured by the Child Behavior Checklist (45.89 vs. 50.37) and with Conners DSM-IV (47.21 vs. 52.35).

What were the conclusions and implications of this work?

The results indicate that children with mild-OSA and high-SQI may be less likely to benefit from eAT and at increased risk of weight gain. In this group Watchful Waiting with Supportive Care (WWSC) and disease tracking might be appropriate as initial recommendation in this group.

Are there any tools available?

No online tools other than the SleepImage System, www.SleepImage.com

Social Media

LinkedIn: @SleepImage

Paper Summary

Obstructive Sleep Apnea and Sleep Quality

Good sleep quality is important during childhood for healthy physical and cognitive development. Untreated sleep disorders may negatively affect this process and the child’s prospects. Obstructive sleep apnea (OSA) is the most prevalent sleep disorder in young children. The most common risk factor for OSA in children is adenotonsillar-hypertrophy and adenotonsillectomy often the first line of therapy to treat OSA in children.

OSA is a known risk factor for developing cardiovascular- (CVD) and cardiometabolic- (CMD) disease mediated through sleep fragmentation, intermittent hypoxia and oxidative stress causing chronic systemic inflammation, endothelial dysfunction, and metabolic dysregulation with increased risk of atherosclerosis, hypertension, insulin resistance, obesity, and metabolic syndrome.

The apnea hypopnea index (AHI) is the most common measure used to diagnose and to evaluate efficacy of OSA therapy. The AHI does not include sleep-fragmenting measures and in isolation may not sufficiently reflect the complex pathophysiological mechanisms of intermittent hypoxia and sleep fragmentation caused by apnea events. In children with OSA, electroencephalogram (EEG) based sleep architecture is relatively preserved and measuring autonomic arousals may possibly better identify sleep-fragmenting effects of apnea events in children. Measuring autonomic arousals and sleep quality may therefore possibly offer additional information when evaluating sleep in children and response to therapy in children treated for OSA.

Experimental Data

We used overnight polysomnogram (PSG) from a large prospective study evaluating the effect of early adenotonsillectomy (eAT) compared to watchful waiting with supportive care (WWSC) in children aged 5-9.9-years, the Childhood Adenotonsillectomy Trial (CHAT). In our analysis we included children randomized to eAT with quality PLETHT-signal (n=196; 46.4% male). Stratifying the cohort at baseline into children having high sleep quality and mild-OSA (SQI75, AHI<5.0; Group1) and children with compromised sleep quality and moderate-severe-OSA (SQI <75, AHI5.0; Group2) we observed that 7-months after eAT children in Group2, on average had less increase in their BMI z-score when compared to children in Group1 (0.13 vs. 0.27, p=0.025). Children in Group2 also significantly improved their SQI +2.06 and AHI -5.0 compared to decline in SQI (-3.75, p=0.015) and minor change in AHI (-0.36, p=0.002) in Group1, respectively. Stratifying the cohort at follow-up based on improvements in SQI and AHI to evaluate effect on metabolic health (GroupRemission; AHI< 1.0, SQI75 and GroupResidual; AHI1 and/or SQI<75) we observed GroupRemission to be younger (6.59 vs. 7.41, p<0.001), with lower BMI z-score (0.90 vs. 1.34 ,p=0.021), fasting insulin (7.54 vs. 12.58 IU/ml, p=0.017) and glucose (4.45 vs. 4.60 mmol/L, p=0.049) compared to GroupResidual. GroupRemission had better lipid metabolism, low-density-lipoprotein (90.26 vs. 97.94 mg/dL; p=0.081) and cholesterol (154.66 vs. 164.36 mg/dL; p=0.076), though not significantly. Finally, GroupRemission had significantly better quality of life according to parents (88.70 vs. 81.05; p=0.001) and behavior measured by the Child Behavior Checklist (45.89 vs. 50.37; p=0.022) and with Conners DSM-IV (47.21 vs. 52.35; p=0.002).

Conclusion

The results indicate that children with high-SQI and mild-OSA have less benefit from eAT-surgery and may benefit from WWSC and/or other interventions with disease monitoring to evaluate if and then when surgery may be needed. Treatment tracking should improve outcomes as treating both the intermittent hypoxia and sleep fragmentation to increase sleep quality is needed to improve cardiovascular- and cardiometabolichealth, behavior and QL in children suffering from OSA.

“Sleep quality, sleep apnea, and metabolic health in children treated with adenotonsillectomy” by Magnusdottir et al., Sleep Breath 27, 1527-1540 (2023) https://link.springer.com/article/10.1007/s11325-022-02747-3