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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Adenotonsillar hypertrophy is the leading cause of obstructive sleep apnea syndrome &#40;OSAS&#41; in childhood&#46; The treatment of choice is currently adenotonsillectomy &#40;ATT&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;3</span></a> but defining ATT and its effectiveness&#44; and determining whether or not this is really the best approach calls for a review of all available evidence&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In one of the first meta-analyses published&#44; ATT efficacy was reported to be 82&#46;9&#37;&#59; however&#44; in subsequent systematic reviews this figure ranges between 59&#46;8&#37; and 66&#46;3&#37; and is even lower in obese children &#40;12&#37; for the apnea&#47;hypopnea index &#91;AHI&#93; &#60; 1&#47;h and 49&#37; for AHI &#60; 5&#47;h&#41;&#46; The prospective NANOS study&#44; performed in obese children in the general population&#44; showed that 43&#46;5&#37; had residual OSAS&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> The Childhood Adenotonsillectomy Trial &#40;CHAT&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> the only randomized controlled trial designed to assess the effectiveness of ATT compared to a strategy of watchful waiting&#44; confirmed that surgical treatment improves sleep respiratory parameters &#40;79&#37; vs 46&#37;&#41;&#44; and obesity was&#44; once again&#44; identified as a factor for worse response to treatment&#46; More favorable quality-of-life outcomes were obtained after ATT&#44; but on the other hand&#44; sleep-disordered breathing normalized without treatment in some children in the watchful waiting group&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> In addition to obesity&#44; a history of asthma&#44; OSAS severity&#44; and age &#8805;7 years were identified as predictive factors for a worse response to treatment in a study that included 578 children&#44; of whom only 27&#46;2&#37; achieved complete resolution of their OSAS &#40;AHI &#60;1&#47;h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> This shows the need for a more critical analysis of the true effectiveness of ATT&#44; given that published success rates vary widely and different AHI cut-off points have been used&#44; clearly suggesting that AHI alone is not a good measure of efficacy&#46; Other polysomnographic or clinical procedures may have to be implemented to provide a better assessment of therapeutic efficacy in OSAS&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">One suggested approach to assessing treatment efficacy in children with OSAS involves a &#8220;target organ&#8221; strategy&#59; in other words&#44; determining efficacy in terms of control of morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> ATT improves symptoms&#44; quality of life&#44; behavior&#44; growth patterns&#44; and cardiovascular parameters&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;3</span></a> The available evidence regarding neurocognitive effects is still contradictory&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> but a post hoc analysis of CHAT study data shows an improvement in certain cognitive and behavioral functions when only affected children are analyzed before and after ATT&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The major question&#44; then&#44; is who to treat&#44; since not all children with AHI &#62;1&#47;h develop morbidity&#46; Strategies using biomarkers of organ damage<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;11</span></a> are being developed to help us individualize treatment&#59; this&#44; in turn&#44; will help monitor treatment efficacy&#46; Similarly&#44; serum levels of biomarkers such as C-reactive protein fall after ATT in children with OSAS&#44; earmarking this parameter as a potential biomarker of residual OSAS&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> The use of metabolic markers has also raised some interest&#46; While some studies&#44; such as CHAT&#44; found no changes&#44; others showed significant improvements in insulin resistance and high-density lipoproteins after ATT&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Another important factor is endothelial dysfunction&#46; This clinically silent precursor of vascular atherosclerosis occurs in a significant proportion of children with OSAS&#44; particularly when associated with obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> As mentioned above&#44; specific biomarkers may be useful indicators of endothelial dysfunction and response to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">An additional aspect of treatment concerns ATT-related complications&#58; respiratory problems&#44; the most common complication &#40;9&#46;4&#37;&#41;&#44; are 5 times more frequent in children with OSAS than without&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Other surgical techniques&#44; such as tonsillotomy&#44; have been explored with the main aim of reducing complications&#46; Tonsillectomy was compared with tonsillotomy in a recent meta-analysis&#59; no significant differences were found in the resolution of OSAS&#44; but the risk of recurrence after the less invasive procedure was significantly greater&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Borgstr&#246;m et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> conducted a randomized controlled trial which showed that 13&#37; of children who had undergone tonsillotomy required a second intervention&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although most of the research and knowledge focuses on ATT procedures&#44; we should not forget that other therapeutic options have become available&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Obesity is a clear risk factor and predicts worse response to ATT in children with OSAS&#46; Dietary intervention is indicated in all obese children and particularly in those with mild OSAS without adenotonsillar hypertrophy&#44; and improvements have been observed in respiratory parameters after a 50&#37; weight loss&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Both cohort studies and randomized trials focusing on medical treatment with topical nasal corticosteroids and leukotriene-modifying anti-inflammatories have demonstrated efficacy in children with mild OSAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17&#44;18</span></a> With regard to residual OSAS&#44; Kheirandish et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> found a reduction in AHI of 3&#46;9 &#177; 1&#46;2 to 0&#46;3 &#177; 0&#46;3 in 22 children with mild residual OSAS post-ATT who received treatment for 12 weeks&#44; whereas no changes were observed in the control group of children who did not receive treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Craniofacial abnormalities are another predisposing factor for OSAS&#44; and in these cases&#44; orthodontic treatment can play an important role&#46; Maxillary expansion devices increase the transversal diameter of the hard palate&#44; thus improving AHI&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> No differences were observed between the two groups in a sequential randomized study of ATT followed by maxillary expansion compared to maxillary expansion followed by ATT&#44; suggesting that combined treatment is needed&#46; The evidence available on intraoral devices is still scant&#46; Such studies would be of great interest&#44; particularly if these devices reduce the frequency of residual OSAS&#44; and if they are effective in the long-term prevention of adult OSAS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">There has been a growing interest in recent years in myofunctional therapy&#44; particularly in the prevention of recurrence and&#47;or treatment of persistent OSAS&#44; and in relation to language and nasal breathing rehabilitation&#46; However&#44; it has not been adopted in routine clinical practice&#44; and evidence of improvement is derived from non-randomized studies involving a small number of children&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Treatment with positive airway pressure is not curative&#44; and its use in children is problematic&#44; mainly because of lack of adherence&#44; poor tolerance&#44; and side effects&#46; The few published series limited its use primarily to children with craniofacial abnormalities&#44; severe residual OSAS&#44; particularly in children with obesity&#44; neuromuscular diseases&#44; and surgical contraindications&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;3</span></a> Treatment with high-flow nasal prongs is a possible alternative to positive airway pressure&#44; but the studies published to date are case series&#44; and more research is required&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">To conclude&#44; we believe that now&#44; more than ever&#44; the treatment of OSAS in children needs to be updated to reflect the state of the knowledge&#46; An approach involving different therapeutic levels and treatment combinations is needed&#44; breaking the spell of the &#8220;snoring-apnea-ATT&#8221; mantra&#44; and paving the way toward individualized treatment&#46; In addition to the implementation of stratified therapeutic algorithms&#44; research in the next few years will focus on defining clinical phenotypes that are not exclusively based on polysomnography&#46; Morbidity must also be taken into consideration&#44; and biomarkers must be developed in order to select the right patients for each treatment&#46; Aside from the need for studies into the latest therapeutic strategies that can minimize risk while maximizing effectiveness&#44; our challenge is to develop efficacy measures that are not based exclusively on AHI&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">DG receives financial support in his position as the Herbert T&#46; Abelson Professor of Pediatrics and research funding from the National Institutes of Health contract no&#46; HL130984&#46;</p></span></span>"
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Editorial
Treatment of Obstructive Sleep Apnea Syndrome in Children: More Options, More Confusion
Tratamiento del síndrome de apnea obstructiva del sueño en niños: más opciones, más confusión
María Luz Alonso-Álvareza, Pablo E. Brockmannb, David Gozalc,
Corresponding author
dgozal@uchicago.edu

Corresponding author.
a Sleep Unit, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Carlos III, Hospital Universitario de Burgos (HUBU), Burgos, Spain
b Sleep Medicine Center, Department of Pediatric Cardiology and Pulmonology, Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
c Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL, USA
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Adenotonsillar hypertrophy is the leading cause of obstructive sleep apnea syndrome &#40;OSAS&#41; in childhood&#46; The treatment of choice is currently adenotonsillectomy &#40;ATT&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;3</span></a> but defining ATT and its effectiveness&#44; and determining whether or not this is really the best approach calls for a review of all available evidence&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In one of the first meta-analyses published&#44; ATT efficacy was reported to be 82&#46;9&#37;&#59; however&#44; in subsequent systematic reviews this figure ranges between 59&#46;8&#37; and 66&#46;3&#37; and is even lower in obese children &#40;12&#37; for the apnea&#47;hypopnea index &#91;AHI&#93; &#60; 1&#47;h and 49&#37; for AHI &#60; 5&#47;h&#41;&#46; The prospective NANOS study&#44; performed in obese children in the general population&#44; showed that 43&#46;5&#37; had residual OSAS&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> The Childhood Adenotonsillectomy Trial &#40;CHAT&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> the only randomized controlled trial designed to assess the effectiveness of ATT compared to a strategy of watchful waiting&#44; confirmed that surgical treatment improves sleep respiratory parameters &#40;79&#37; vs 46&#37;&#41;&#44; and obesity was&#44; once again&#44; identified as a factor for worse response to treatment&#46; More favorable quality-of-life outcomes were obtained after ATT&#44; but on the other hand&#44; sleep-disordered breathing normalized without treatment in some children in the watchful waiting group&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> In addition to obesity&#44; a history of asthma&#44; OSAS severity&#44; and age &#8805;7 years were identified as predictive factors for a worse response to treatment in a study that included 578 children&#44; of whom only 27&#46;2&#37; achieved complete resolution of their OSAS &#40;AHI &#60;1&#47;h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> This shows the need for a more critical analysis of the true effectiveness of ATT&#44; given that published success rates vary widely and different AHI cut-off points have been used&#44; clearly suggesting that AHI alone is not a good measure of efficacy&#46; Other polysomnographic or clinical procedures may have to be implemented to provide a better assessment of therapeutic efficacy in OSAS&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">One suggested approach to assessing treatment efficacy in children with OSAS involves a &#8220;target organ&#8221; strategy&#59; in other words&#44; determining efficacy in terms of control of morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> ATT improves symptoms&#44; quality of life&#44; behavior&#44; growth patterns&#44; and cardiovascular parameters&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;3</span></a> The available evidence regarding neurocognitive effects is still contradictory&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> but a post hoc analysis of CHAT study data shows an improvement in certain cognitive and behavioral functions when only affected children are analyzed before and after ATT&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The major question&#44; then&#44; is who to treat&#44; since not all children with AHI &#62;1&#47;h develop morbidity&#46; Strategies using biomarkers of organ damage<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;11</span></a> are being developed to help us individualize treatment&#59; this&#44; in turn&#44; will help monitor treatment efficacy&#46; Similarly&#44; serum levels of biomarkers such as C-reactive protein fall after ATT in children with OSAS&#44; earmarking this parameter as a potential biomarker of residual OSAS&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> The use of metabolic markers has also raised some interest&#46; While some studies&#44; such as CHAT&#44; found no changes&#44; others showed significant improvements in insulin resistance and high-density lipoproteins after ATT&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Another important factor is endothelial dysfunction&#46; This clinically silent precursor of vascular atherosclerosis occurs in a significant proportion of children with OSAS&#44; particularly when associated with obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> As mentioned above&#44; specific biomarkers may be useful indicators of endothelial dysfunction and response to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">An additional aspect of treatment concerns ATT-related complications&#58; respiratory problems&#44; the most common complication &#40;9&#46;4&#37;&#41;&#44; are 5 times more frequent in children with OSAS than without&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Other surgical techniques&#44; such as tonsillotomy&#44; have been explored with the main aim of reducing complications&#46; Tonsillectomy was compared with tonsillotomy in a recent meta-analysis&#59; no significant differences were found in the resolution of OSAS&#44; but the risk of recurrence after the less invasive procedure was significantly greater&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Borgstr&#246;m et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> conducted a randomized controlled trial which showed that 13&#37; of children who had undergone tonsillotomy required a second intervention&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although most of the research and knowledge focuses on ATT procedures&#44; we should not forget that other therapeutic options have become available&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Obesity is a clear risk factor and predicts worse response to ATT in children with OSAS&#46; Dietary intervention is indicated in all obese children and particularly in those with mild OSAS without adenotonsillar hypertrophy&#44; and improvements have been observed in respiratory parameters after a 50&#37; weight loss&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Both cohort studies and randomized trials focusing on medical treatment with topical nasal corticosteroids and leukotriene-modifying anti-inflammatories have demonstrated efficacy in children with mild OSAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17&#44;18</span></a> With regard to residual OSAS&#44; Kheirandish et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> found a reduction in AHI of 3&#46;9 &#177; 1&#46;2 to 0&#46;3 &#177; 0&#46;3 in 22 children with mild residual OSAS post-ATT who received treatment for 12 weeks&#44; whereas no changes were observed in the control group of children who did not receive treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Craniofacial abnormalities are another predisposing factor for OSAS&#44; and in these cases&#44; orthodontic treatment can play an important role&#46; Maxillary expansion devices increase the transversal diameter of the hard palate&#44; thus improving AHI&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> No differences were observed between the two groups in a sequential randomized study of ATT followed by maxillary expansion compared to maxillary expansion followed by ATT&#44; suggesting that combined treatment is needed&#46; The evidence available on intraoral devices is still scant&#46; Such studies would be of great interest&#44; particularly if these devices reduce the frequency of residual OSAS&#44; and if they are effective in the long-term prevention of adult OSAS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">There has been a growing interest in recent years in myofunctional therapy&#44; particularly in the prevention of recurrence and&#47;or treatment of persistent OSAS&#44; and in relation to language and nasal breathing rehabilitation&#46; However&#44; it has not been adopted in routine clinical practice&#44; and evidence of improvement is derived from non-randomized studies involving a small number of children&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Treatment with positive airway pressure is not curative&#44; and its use in children is problematic&#44; mainly because of lack of adherence&#44; poor tolerance&#44; and side effects&#46; The few published series limited its use primarily to children with craniofacial abnormalities&#44; severe residual OSAS&#44; particularly in children with obesity&#44; neuromuscular diseases&#44; and surgical contraindications&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;3</span></a> Treatment with high-flow nasal prongs is a possible alternative to positive airway pressure&#44; but the studies published to date are case series&#44; and more research is required&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">To conclude&#44; we believe that now&#44; more than ever&#44; the treatment of OSAS in children needs to be updated to reflect the state of the knowledge&#46; An approach involving different therapeutic levels and treatment combinations is needed&#44; breaking the spell of the &#8220;snoring-apnea-ATT&#8221; mantra&#44; and paving the way toward individualized treatment&#46; In addition to the implementation of stratified therapeutic algorithms&#44; research in the next few years will focus on defining clinical phenotypes that are not exclusively based on polysomnography&#46; Morbidity must also be taken into consideration&#44; and biomarkers must be developed in order to select the right patients for each treatment&#46; Aside from the need for studies into the latest therapeutic strategies that can minimize risk while maximizing effectiveness&#44; our challenge is to develop efficacy measures that are not based exclusively on AHI&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">DG receives financial support in his position as the Herbert T&#46; Abelson Professor of Pediatrics and research funding from the National Institutes of Health contract no&#46; HL130984&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alonso-&#193;lvarez ML&#44; Brockmann PE&#44; Gozal D&#46; Tratamiento del s&#237;ndrome de apnea obstructiva del sue&#241;o en ni&#241;os&#58; m&#225;s opciones&#44; m&#225;s confusi&#243;n&#46; Arch Bronconeumol&#46; 2018&#59;54&#58;409&#8211;411&#46;</p>"
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ISSN: 15792129
Original language: English
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