Cyclic alternating pattern in children with obstructive sleep apnea and its relationship with adenotonsillectomy, behavior, cognition, and quality of life

Abstract

Study objectives: To determine in children with obstructive sleep apnea (OSA) the effect of adenotonsillectomy (AT) on the cyclic alternating pattern (CAP) and the relationship between CAP and behavioral, cognitive, and quality-of-life measures.

Methods: CAP parameters were analyzed in 365 overnight polysomnographic recordings of children with mild-to-moderate OSA enrolled in the Childhood Adenotonsillectomy Trial (CHAT), randomized to either early AT (eAT) or watchful waiting with supportive care (WWSC). We also analyzed CAP in a subgroup of 72 children with moderate OSA (apnea-hypopnea index > 10) that were part of the CHAT sample. Causal mediation analysis was performed to determine the independent effect of changes in CAP on selected outcome measures.

Results: At baseline, a higher number of A1 phases per hour of sleep was significantly associated with worse behavioral functioning (caregiver Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC): ρ = 0.24, p = 0.042; caregiver Conners' Rating Scale Global Index: ρ = 0.25, p = 0.036) and lower quality of life (OSA-18: ρ = 0.27, p = 0.022; PedsQL: ρ = -0.29, p = 0.015) in the subgroup of children with moderate OSA, but not across the entire sample. At 7-months follow-up, changes in CAP parameters were comparable between the eAT and WWSC arms. CAP changes did not account for significant proportions of variations in behavioral, cognitive, and quality-of-life performance measures at follow-up.

Conclusions: We show a significant association between the frequency of slow, high-amplitude waves with behavioral functioning, as well as the quality of life in children with moderate OSA. Early AT in children with mild-to-moderate OSA does not alter the microstructure of nonrapid eye movement sleep compared with watchful waiting after an approximately 7-month period of follow-up.

Clinical trial: The study "A Randomized Controlled Study of Adenotonsillectomy for Children With Obstructive Sleep Apnea Syndrome" was registered at Clinicaltrials.gov (#NCT00560859).

Keywords: adenotonsillectomy; child behavior; children; cognitive performance; cyclic alternating pattern; deep learning; quality of life; sleep; sleep-disordered breathing.

Figure 1.

Causal mediation model to identify the independent effect of CAP changes on CHAT outcome measures. Causal mediation diagram illustrating the direct effect of treatment on the CHAT outcome (c′), the effect of treatment on ∆CAP as mediator (a), and the effect of the ∆CAP as mediator on the CHAT outcome (b). The product of the paths (a) and (b) equals the indirect effect on the CHAT outcome.