OBSTRUCTIVE SLEEP APNEA DURING CHILDHOOD IN TERTIARY CARE CENTER IN SAUDI ARABIA

Background: Obstructive sleep apnea (OSA) is a common disorder with the prevalence of 1-5%. OSA in there is a paucity of data regarding OSA in children in our region. This is particularly important as OSA is associated with neurocognitive deficits and cardiovascular complication. The aim of this study is to evaluate the prevalence of OSA among children referred to specialized centre in Saudi Arabia. Methods: A retrospective chart reviewstudy involving children ≤18 years, identified from pediatric tertiary care centrewho had an overnight polysomnography (PSG).OSA was diagnosed if the obstructive apnea-hypopnea index (OAHI) washigher than 1event per hour. Results: There were 12 participants included.The mean age was 8 years (standard deviation [SD] ± 1.7). Of these, 6/12 (50%) had OSA. Compared with the non-OSA group, the OSA group had a lower sleep SpO2 during REM sleep (p = 0.008). Conclusion: Children with clinical symptoms should be referred for OSA diagnosis. A history of snoring may be useful indicators to facilitate a PSG, especially in resource-limited settings. should not alone to diagnose OSA as neither single nor combined symptoms that have satisfactory results in predicting OSA in children 7-10 . In pediatric population polysomnography (PSG) is the current gold standard for diagnosis of SDB 11 . The aim of this study is to emphasize the importance of diagnosis of OSA in children and to discuss the complication of OSA if left intreated 12 5–10 and > 10 according to rules. Patients’ demographics and polysomnographic data were presented as mean (standard deviation, SD) for continuous variables and number (percentage) for categorical variables. Comparisons between OSA and non-OSA groups were conducted using Student’s t test where appropriate for continuous variables, and Fisher’s exact test for categorical variables.


ISSN: 2320-5407
Int. J. Adv. Res. 8 (12), 1008-1012 should not be used alone to diagnose OSA as neither single nor combined symptoms that have satisfactory results in predicting OSA in children [7][8][9][10] . In pediatric population polysomnography (PSG) is the current gold standard for diagnosis of SDB 11 . The aim of this study is to emphasize the importance of diagnosis of OSA in children and to discuss the complication of OSA if left intreated 12 .

Method:-
This study was a retrospective chart review for patients who attended the sleep laboratory for an overnight PSG for evaluation of suspected OSA. Only patients less than 18 years were identified and included in the study. The body mass index (BMI) was calculated as weight (kg) divided by the height squared (m 2 ) which was measured at the time of PSG. Twelve patients were identified using clinical history, physical examination, and sleep questionnaire likethe Pittsburgh Sleep Quality Index (PSQI).The main presentation was snoring. The PSQI is a validated measure of selfreported sleep quality. It comprises 19 items in 7 component scales that assess sleep quality over the past month. The component scores of these scales are summed to yield a global PSQI score with a range of 0-21, with higher scores indicating worse sleep quality 13 .
PSG was performed and scored manually based on the American Academy of Sleep Medicine (AASM) guidelines 2 . Patients underwent a standard overnight PSG using Alice 6 (Philips, USA) Diagnostic sleep system with electrooculogram, electroencephalogram -EEG, electromyogram, EMG, nasal air flow, chest belt for thoracic and abdominal movements, pulse oximetry, snoring microphone, leg movements, analysis data acquisition and analysis systems. Video and audio recordings were obtained as well as body position.
The severity of OSA was determined by the obstructive apnea-hypopnea index (OAHI), the number of obstructive, mixed apneas, and obstructive hypopneas per hour during sleep. OSA was diagnosed if the OAHI was greater than 1 event per hour with severity range. Severity range is defined as mild, moderate, and severe if < 5 events/h, ≥ 5-10 events/h, and > 10 events/h, respectively according to pediatric rules.
Patients' demographics and polysomnographic data were presented as mean (standard deviation, SD) for continuous variables and number (percentage) for categorical variables. Comparisons between OSA and non-OSA groups were conducted using Student's t test where appropriate for continuous variables, and Fisher's exact test for categorical variables.

Result:-
From May 2018 to March 2019, a total number of 12 children (5 females) were identified for baseline assessment. The mean age (±SD) was 8 (±2) year. The data for these patients are summarized in table 1.children known to have psychiatric disorders or other chronic comorbidities in addition to those on sedative drugs were excluded.
Overall, 6 out of 12 patients had evidence of OSA. Of those, 1was mild, 2 weremoderates, and 3 had severe OSA. There were no children who had an underlying significant CSA. By using univariate regression analysis, only the age was significant in OSA prediction (P = 0.02); however, there was no significant prediction in the multivariable regression model. The correlation between overnight oximetry and PSG showed that the desaturations index correlated with the OAHI (r = 0.64, P < 0.001). Other findings includes that the minimum sleep SpO2 during REM sleep was significantly lower in the OSA group (p = 0.008).PSGdata for these patients are summarized in table 2.

Discussion:-
The principal finding of this study was that OSA is highly prevalent,occurring in half of this population.This probably was due to very selected patients. Indeed,OSA is estimated at 1-5% in the school-aged children 14 and the prevalence of habitual snoring occurs in 5-12% of children;.Due to the complexity of studying young children, which is related to equipment, presence of sleep technicians, challenges in behaviour and appropriate medical care, younger children will need to have a PSG completed in a specialized pediatric facility.
While in adults, OSA frequently results from obesity, anatomical factors like adenoid and tonsillar hypertrophy, play a major role in pediatric OSA 15 . However, at present, the rate of childhood obesity is increasing significantly and is also a significant contributor to OSA. While non-obese children who have OSA, and who concurrently exhibit adeno-tonsillar hypertrophy (but without craniofacial abnormalities) can improve with surgical resection of their adenoids and/or tonsils, which is not the case with obese children [16][17][18] . One study has found that adenoid and tonsillar hypertrophy is associated with obesity, thus increasing the risk for OSA 19 . OSA is more common among boys and obese children 20 . First-degree relatives of children with OSA is considered a risk factor for development of OSA 21 .
Other risk factors such asretrognathia, macroglossia should be considered in pediatric OSA 22 . Children with other genetic diseases had higher prevalence of OSA [23][24][25] .
OSA is associated with poor quality sleep,thus these children remain in a state of partial sleep deprivation. Hence, they are at risk of developing the multiple complications of sleep deprivation including the production of the appetitive neurohormone ghrelin 26,27 . These children may also show ADHD-like symptoms of inattention and hyperactivity, as well as nocturnal enuresis 28 . A growing amount of evidence supports the conclusion that sleep deprivation has cumulative effects and interferes with normal cognitive functioning 29,30 . It also affects academic performance, mostly mathematics 6,31 .
As in adults, children with OSA also develop cardiovascular complications, particularly endothelial dysfunction [32][33][34] . While endothelial dysfunction initially leads to functional, andlater, anatomical complications of the vasculature, its early effects on the pulmonary vasculature and cardiac anatomy cannot be ignored 34 . A meta-analysis of cardiographic studies among children with OSA showed several important symptoms including significant increases in pulmonary arterial pressure, thickening of the interventricular septum, and dilation of the right ventricle [35][36][37] .
Other important adverse effects of OSA are metabolic abnormalities. OSA is associated with an increase in plasma levels of insulin and glucose in the fasting state 38 . OSA in obese children is associated with inflammation including elevation of inflammatory cytokines, increased leptin, and decreased adiponectin 39 . These cardiovascular and metabolic abnormalities may interfere with healthy development, thus posing a direct cost to public healthcare systems. A meta-analysis done by Galland et al included 16 studies which showed that OSA was significantly associated with poor academic performance for language of arts, mathematics, science, and with unsatisfactory learning problems 40 .
This study had several limitations.This was a retrospective study, and the children in questions was a referred cohort with reported snoring and was referred primarily to exclude OSA providing us with a highly selected, relatively small cohort.
In summary, OSA is not uncommon among children, and its broad consequences to personal health and wellbeing indicate that the condition deserves careful screening in children. Those identified in screening should be tested using polysomnography in a sleep clinic to determine the severity of OSA. After diagnosis, an individualized treatment should be carefully developed. In general, if anatomical factors are primary contributors to the condition, they should be corrected surgically, weight and dietary habits should be encouraged, and continuous positive airway pressure (CPAP) therapy should be advised.