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BACKGROUND: Little is known regarding obstructive sleep apnea’s (OSA’s) prevalence or the factors related to OSA remission post–metabolic bariatric surgery (MBS) in adolescents. OBJECTIVES: To identify the baseline OSA prevalence in adolescents with severe obesity and examine factors associated with post-MBS OSA remission. SETTING: Tertiary-care children’s hospital. METHODS: We conducted a retrospective chart review of 81 patients pre-MBS with OSA assessments done between June 2017 to September 2020 to collect demographic characteristics; co-morbidities; polysomnography (PSG) results, if indicated; and weight data. Chi-square or Mann-Whitney tests compared baseline characteristics and surgical outcomes by pre-MBS OSA status. McNemar’s test or t tests assessed differences in baseline characteristics, stratified by remission versus no remission of OSA. RESULTS: The patients were 71% female, had an average age of 16.9 ± 2.0 years, and had a mean body mass index (BMI) of 47.9 ± 7.3 kg/m(2). Half (50%) of the patients were Hispanic and 20% had type 2 diabetes. The OSA prevalence, defined as an Obstructive Apnea Hypopnea Index (OAHI) score ≥5, was 54% pre-MBS (n = 44), with 43% having severe OSA (OAHI > 30). Those with OSA were older (17.3 versus 16.4 yr, respectively; P = .05), more likely to be male (79% versus 42%, respectively; P = .022), and had higher baseline weights (142.0 versus 126.4 kg, respectively; P = .001) than those without OSA. Of the 23 patients with a post-MBS PSG result (average 5 mo post MBS), 15 (66%) had remission of OSA. Patients with OSA remission had a lower average pre-MBS BMI (46.0 versus 57.7 kg/m(2), respectively; P < .001) and weight (132.9 versus 172.6 kg, respectively; P = .002) but no significant differences in percentage weight loss through 12 months post MBS versus those with continued OSA. CONCLUSION: The OSA prevalence in an adolescent MBS population was higher than that in the general adolescent population with severe obesity. Remission of OSA was correlated with lower pre-MBS BMI and weight, but not weight loss within the first year post-MBS. (Surg Obes Relat Dis 2021;17:711–717.)

Background: Home oxygen therapy is often required in children with chronic respiratory conditions. This document provides an evidence-based clinical practice guideline on the implementation, monitoring, and discontinuation of home oxygen therapy for the pediatric population. Methods: A multidisciplinary panel identified pertinent questions regarding home oxygen therapy in children, conducted systematic reviews of the relevant literature, and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the quality of evidence and strength of clinical recommendations. Results: After considering the panel’s confidence in the estimated effects, the balance of desirable (benefits) and undesirable (harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were developed for or against home oxygen therapy specific to pediatric lung and pulmonary vascular diseases. Conclusions: Although home oxygen therapy is commonly required in the care of children, there is a striking lack of empirical evidence regarding implementation, monitoring, and discontinuation of supplemental oxygen therapy. The panel formulated and provided the rationale for clinical recommendations for home oxygen therapy based on scant empirical evidence, expert opinion, and clinical experience to aid clinicians in the management of these complex pediatric patients and identified important areas for future research.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3- to 4-year recurring cycle of topics. These topics will be presented at the 2020 International Conference. Below is the pediatric pulmonary medicine core, including pediatric hypoxemic respiratory failure; modalities in noninvasive management of chronic respiratory failure in childhood; surgical and nonsurgical management of congenital lung malformations; an update on smoke inhalation lung injury; an update on vaporizers, e-cigarettes, and other electronic delivery systems; pulmonary complications of sarcoidosis; pulmonary complications of congenital heart disease; and updates on the management of congenital diaphragmatic hernia.

Objective: To examine sleep behaviors and their associations with health characteristics in a cohort of adolescents with severe obesity undergoing bariatric surgery at Children’s Hospital Colorado. Methods: A retrospective chart review of electronic medical records was performed. All patients receiving care at the Children’s Hospital Colorado (CHCO) Bariatric Surgery Center between 06/17-08/19 were included. Demographic, medical and family history, self-reported sleep behaviors, and laboratory measures were abstracted, including medical problem list (e.g., type 2 diabetes (T2D), hypertension) and body mass index (BMI). A sleep behavior risk score (SBRS) was developed using five criteria (short sleep defined as Results: Data from 78 patients, aged 16.82.1, were reviewed. The majority of patients were female (71%), Hispanic (52%) and in 10-12 th grade in school (64%). Prior to surgery, 24% of the patients were diagnosed with hypertension and 20% with type 2 diabetes. The majority of patients (60%) had a high SBRS at baseline. High SBRS was significantly associated with higher baseline BMI (49.2 vs 45.0; p=0.03). SBRS score was not significantly associated with diagnosis of hypertension, type 2 diabetes, hyperlipidemia, or obstructive sleep apnea. Conclusions: In a population of adolescents seen in the Bariatric Surgery Center at CHCO, a majority of patients met criteria for high risk sleep behaviors, and worse sleep behaviors preoperatively were related to higher baseline BMI. A high SBRS may adversely impact adolescents’ overall health prior to surgery, which may have implications for weight loss success post-surgery. The evaluation for sleep health should be more rigorously evaluated and standardized as part of efforts to improve health outcomes in patients undergoing bariatric surgery.

Objectives Neuroendocrine cell hyperplasia of infancy (NEHI) is a children's interstitial and diffuse lung disease of unknown etiology that presents in infancy with characteristic findings of tachypnea, retractions, crackles, and hypoxemia. At the present, the mainstay of treatment is oxygen supplementation to normalize oxygen saturations and decrease work of breathing. There are characteristic pulmonary function, radiographic, and histologic findings, but polysomnography (PSG) data has not been reported. We sought to report PSG data and implications for management and treatment of NEHI patients. Methods A retrospective chart review was performed under a Colorado Institutional Review Board approved protocol for which consent was waived. Informatics for Integrating Biology and the Bedside was used to query the electronic medical record at Children's Hospital Colorado for patients with both a diagnosis of NEHI and a PSG. PSG was performed for clinical reasons. Routine sleep quality and respiratory parameters were recorded and analyzed. Results Of our 77 patients with NEHI, 14 (19%) children underwent PSG during the study period. Eight children met criteria for OSA and three met criteria for CSA. Ten patients had low oxygen saturations during a study, six had low sleep efficiency, and three had periodic limb movement disorder. Conclusions Patients with NEHI may have sleep related breathing disorders that contribute to disrupted sleep, including obstructive and central sleep apnea, hypoxemia, decreased sleep efficiency, and increased periodic limb movement disorder. PSG should be considered as part of NEHI management, as it may lead to recognition of clinically significant sleep-disordered breathing.

Study objectives Continuous positive airway pressure (CPAP) is effective but challenging for children with obstructive sleep apnea (OSA). High-flow air via open nasal cannula (HFNC) as treatment in children remains controversial. We report the efficacy of HFNC in children with OSA and CPAP intolerance, a titration protocol, and a discussion of potential mechanisms. Methods Patients aged 1 to 18 years with OSA (defined by obstructive apnea-hypopnea index [OAHI] greater than 1 event/h) and CPAP intolerance were enrolled. Routine polysomnography data obtained during 1 night wearing HFNC was compared with diagnostic data by Wilcoxon rank-sum test. Results Ten school-age subjects (representing all patients attempting HFNC at our institution to date) with varied medical conditions, moderate to severe OSA, and CPAP intolerance wore HFNC from 10 to 50 L/min of room air with oxygen supplementation if needed (room air alone for 6 of the 10). HFNC reduced median OAHI from 11.1 events/h (interquartile range 8.7-18.8 events/h) to 2.1 events/h (1.7-2.2 events/h; P = .002); increased oxyhemoglobin saturation (SpO2) mean from 91.3% (89.6% to 93.5%) to 94.9% (92.4% to 96.0%; P Conclusions High-flow nasal cannula reduces respiratory events, improves oxygenation, reduces heart rate, and may be effective for CPAP intolerant children with moderate to severe OSA. Our data suggest HFNC warrants further study and consideration by payers as OSA therapy.

Introduction Significant weight loss is seen following bariatric surgery, leading to an ameliorative effect on obesity-related comorbidities such as OSA. Weight loss maintenance is a priority, and identifying factors that may be associated with weight loss outcomes following bariatric surgery is of high importance. The current study examined whether OSA symptoms and PAP therapy were associated with weight outcomes following bariatric surgery in adolescents. Methods Participants from the Teen-LABS Study, which follows adolescents undergoing bariatric surgery were examined. Demographic and anthropometric data, OSA diagnosis, and PAP prescription and self-reported usage information were assessed 6 months before surgery. Pediatric Sleep Questionnaire (PSQ) responses were utilized from baseline to 48 months post-surgery. All analyses were adjusted for time, age, sex, surgery type, and ethnicity. Results 242 adolescents (76% female, 72% White, age at surgery = 16.6 [1.6] years) were included. 57% had a diagnosis of OSA at pre-surgical baseline, and 56% of adolescents with OSA reported PAP use at pre-surgery. BMI increase over time from year 1-4 post-surgery was 11% more for those with high PSQ severity compared to those with low PSQ severity (p = 0.01). Those with pre-surgical OSA that reported using PAP “often” or “always” at baseline had an 8% lower increase in BMI from year 1-4 post-surgery compared to those that reported using PAP “rarely” or “sometimes” at baseline (p = 0.004). Finally, endorsing daytime sleepiness on the PSQ was associated with a 11% greater increase in BMI during years 1-4 post-surgery (p = 0.01). Conclusion OSA and daytime sleepiness may be associated with greater weight regain following bariatric surgery in adolescents. Adherence to PAP therapy pre-surgery may be a protective factor in preventing or reducing weight regain following surgery. Daytime sleepiness may be an effect of OSA, or due to the insufficient sleep that is prevalent among adolescents. Research is needed to examine the impact of additional aspects of sleep health such as duration, timing, and quality on health outcomes, as well as the impact of PAP adherence and sleep interventions on weight regain following bariatric surgery in adolescents with severe obesity. Support None.

Objectives To examine the relationship between insulin resistance (IR) and sleep/circadian health in overweight/obese adolescents. We hypothesized that insufficient and delayed sleep would be associated with IR in this population. Study design Thirty-one adolescents (mean age, 16.0 ± 1.4 years; 77% female) with body mass index ≥90th percentile for age/sex were recruited from outpatient clinics at a children's hospital. Participants underwent 1 week of objective home sleep monitoring with wrist actigraphy during the academic year. A 3-hour oral glucose tolerance test was conducted, followed by in-laboratory salivary dim-light melatonin sampling every 30-60 minutes from 5 p.m. to noon the next day. Regression analyses between sleep and circadian variables with IR were examined. Results Longer sleep time and time in bed on weekends and weekdays and earlier weekday bedtime were significantly associated with better insulin sensitivity. Participants who obtained less than the median duration of sleep per night (6.6 hours) had evidence of IR with compensatory insulin secretion compared with those obtaining ≥6.6 hours of sleep. A wider phase angle between bedtime and melatonin onset, indicating a later circadian timing of sleep onset, was significantly associated with IR. Conclusions Short sleep duration, later weekday bedtime, and later circadian timing of sleep were associated with IR in a cohort of adolescents with overweight/obesity during the school year. Further research is needed to better understand the physiology underlying these observations and to evaluate the impact of improved sleep and circadian health on metabolic health in this at-risk population.

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence.A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test.Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex.Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Sleep is a complex process that is essential to normal growth and development. The duration, timing, and architecture of sleep gradually change as a child matures. Disruption of sleep is associated with poor growth and development, neurocognitive impairment, increased cardiovascular risk, systemic inflammation, and diminished overall well-being. Primary care providers evaluate pediatric patients with a variety of symptoms that may not be obviously sleep-related but are consequences of inadequate or disrupted sleep. A thorough sleep history should be considered for all pediatric patients. In addition to sleep-disordered breathing, pediatric health care providers should be able to recognize, discuss, and initiate management for many common non-respiratory sleep disorders that are outlined in this chapter.

ObjectivesWe sought to describe the prevalence of restrictive lung function in structural congenital heart disease and to determine the effect of cardiothoracic surgical intervention.MethodsThe data from a retrospective review of the spirometry findings from pediatric patients with structural congenital heart disease were compared with the data from 220 matched controls. Restrictive lung function was defined as a forced vital capacity of 80%.ResultsOf the children with congenital heart disease, 20% met the criteria for restrictive lung function compared with 13.2% of the controls (P = .03). The prevalence in those with congenital heart disease without a surgical history was similar to that of the controls (odds ratio, 0.62; 95% confidence interval, 0.34-1.13). Restrictive lung function was more likely if surgical intervention had occurred within the first year of life (odds ratio, 1.96; 95% confidence interval, 1.08-3.55; P