Abstract-Questions remain as to whether pediatric sleep disordered breathing increases the risk for elevated blood pressure and blood pressure-dependent cardiac remodeling. We tested the hypothesis that activity-adjusted morning blood pressure surge, blood pressure load, and diurnal and nocturnal blood pressure are significantly higher in children with sleep disordered breathing than in healthy controls and that these blood pressure parameters relate to left ventricular remodeling. 24-hour ambulatory blood pressure parameters were compared between groups. The associations between blood pressure and left ventricular relative wall thickness and mass were measured. 140 children met the inclusion criteria. In children with apnea hypopnea index Ͻ5 per hour, a significant difference from controls was the morning blood surge. Significant increases in blood pressure surge, blood pressure load, and in 24-hour ambulatory blood pressure were evident in those whom the apnea hypopnea index exceeded 5 per hour. Sleep disordered breathing and body mass index had similar effect on blood pressure parameters except for nocturnal diastolic blood pressure, where sleep disordered breathing had a significantly greater effect than body mass index. Diurnal and nocturnal systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure predicted the changes in left ventricular relative wall thickness. Therefore, sleep disordered breathing in children who are otherwise healthy is independently associated with an increase in morning blood pressure surge, blood pressure load, and 24-hour ambulatory blood pressure. The association between left ventricular remodeling and 24-hour blood pressure highlights the role of sleep disordered breathing in increasing cardiovascular morbidity. Key Words: sleep apnea Ⅲ children Ⅲ ambulatory blood pressure Ⅲ blood pressure surge Ⅲ blood pressure load Ⅲ cardiac remodeling Ⅲ hypertrophy T he association between sleep disordered breathing (SDB) and cardiovascular morbidity in adults has become an important consideration in the management of patients with SDB. Results from numerous cross-sectional and prospective studies of blood pressure (BP) control in adults support the concept that hypertension is an intermediate end point between SDB and cardiovascular disease. 1,2 Further support of this concept is derived from studies linking SDB to atherosclerotic pathways. [3][4][5][6] These studies provide insight into the mechanisms of vascular injury secondary to SDB. Although the impact of duration of this disorder on the development of risk factors for cardiovascular disease is difficult to estimate, morbidity secondary to SDB seems to manifest gradually, often taking decades. As such, with the exception of isolated cases of heart failure, children with SDB rarely show evidence of cardiovascular disease. Thus far, studies addressing whether children with SDB acquire risk factors for the early development of cardiovascular disease are inconclusive.Findings from several pediatric studies suggest ...

During the first year of life, infants spend most of their time in the sleeping state. Assessment of sleep during infancy presents an opportunity to study the impact of sleep on the maturation of the central nervous system (CNS), overall functioning, and future cognitive, psychomotor, and temperament development. To assess what is currently known regarding sleep during infancy and its effects on cognitive, psychomotor, and temperament development, we assessed the relevant literature published over the last several decades. To provide a foundation for a more in-depth understanding of this literature, we preface this with an overview of brain maturation, sleep development, and various assessment tools of both sleep and development during this unique period. At present, we do not have sufficient data to conclude that a causal relationship exists between infant sleep and cognitive, psychomotor, and temperament development. Caution should be used in predicting outcomes, as the timing and subjectivity of evaluations may obviate accurate assessment. Collectively, studies assess a wide array of sleep measures, and findings from one developmental period cannot be generalized readily to other developmental periods. Future studies should follow patients longitudinally. Additionally, refinements of existing assessment tools would be useful. In view of the relatively high reported pediatric prevalence of cognitive and behavioral deficits that carry significant long-term costs to individuals and society, early screening of sleep-related issues may be a useful tool to guide targeted prevention and early intervention.

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Bronchiectasis is highly prevalent in children with CPA and its presence in young children demonstrates that it can develop rapidly. Early identification of bronchiectasis, along with interventions aimed at preventing further airway damage, may minimize morbidity and mortality in patients with CPA.

Corresponding author's email: Paul.Boesch@cchmc.orgPressure ulcers are commonly acquired in pediatric institutions and are a key indicator of standard and effectiveness of care. Rationale:Pressure ulcers are associated with pain, infection, and length of hospitalization. Tracheostomy tubes cause pressure ulcers by creating a constant pressure interface with further disruption of skin integrity due to wetness from sweat and respiratory secretions. We recognized a high rate of tracheostomy-related pressure ulcers (TRPU) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention. We condensed them into a clinical bundle, and then implemented it into standard clinical practice.The setting was an 18-bed multidisciplinary unit within an academic children's hospital, whose primary mission is transition of Methods: children requiring invasive mechanical ventilation to home. All tracheostomy-dependent patients from July 2008-August 2010 were included. TRPU stage, description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPU were staged by a wound-care expert within 24 hours. The intervention model utilized a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. The interventions identified for incorporation into the TRPU-prevention bundle included the following: Skin Braden Q risk assessment and full body skin assessments daily, and device assessments every 8 hour shift, assessment:Moisture-free Hydrophilic polyurethane foam under tracheostomy to wick moisture from the skin surface, device interface:Pressure-free device "extended" style tracheostomy tubes in children with anatomy in which the neck was not clearly exposed in the neutral position interface: (figure 1). Figure 1 Fit of standard vs. extended-style tracheostomy tube in ventilated infant. Note the crowding of the ventilator circuit in the neck with focal pressure of the adapter edge against the sternum. This is the site of 72% of the TRPU that developed during the study period.Over the study period there were 717 patients and 8770 trach days evaluated; 22 TRPU were identified. There was a significant Results: decrease in the rate of patients who developed a TRPU from 8.1% during the baseline period, to 2.6% during bundle development, and 0.5% after the bundle was implemented (figure 2). The percentage of trach days affected by a TRPU decreased from 12.5% to 0.4% between baseline and implementation periods. There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.7% vs 0%, P=0.035) and days affected by a TRPU (6% vs 0.2%, P<0.0001). Figure 2

Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheostomy-skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect.