Pediatric Sleep‐Disordered Breathing Year in Review 2024

ABSTRACT

Background

Numerous articles on pediatric sleep‐disordered breathing were published in the medical literature in 2024. While not intended to be exhaustive, this review aims to spark interest within the scientific community focused on pediatric sleep‐disordered breathing.

Methods

It briefly summarizes recent advances in the diagnosis and screening of obstructive sleep‐disordered breathing (SDB), the pathophysiology of obstructive SDB, and its treatment, including home mechanical respiratory support.

Conclusion

The goal is to provide some of the latest and most relevant information from 2024 to support the clinical care of children affected by sleep‐disordered breathing.

1. Introduction

Sleep‐disordered breathing (SDB) in children continues to receive considerable attention in the medical literature. In 2024, several publications addressed SDB and obstructive sleep apnea syndrome (OSA) in children from different angles, including screening, diagnostic approach, pathophysiology, treatment and novel technology. While not exhaustive, this review provides a selective overview of studies particularly noteworthy, which may ultimately lead to changes in the clinical practice. The aim of the article is to provide an overview of publications and to encourage readers to take an interest in the community's work over the past year. This narrative review is based on articles retrieved from PubMed using the keywords “sleep‐disordered breathing” AND “children,” as well as “long‐term home ventilation” AND “children.”

1.1. Diagnosis and Screening of Obstructive Sleep‐Disordered Breathing

Full overnight in‐lab polysomnography (PSG) is traditionally considered necessary to diagnose children suspected of SDB. The limited availability of sleep laboratories worldwide continues to prevent many children suspected of having SDB from accessing PSG. While efficient screening and diagnosis of the obstructive sleep‐disordered breathing (SDB) spectrum in children remain a clinical priority, the optimal diagnostic approach continues to be a subject of debate. In practice, oximetry and home sleep apnea testing (HSAT) are increasingly being utilized to diagnose obstructive sleep apnea (OSA) or, at minimum, to help triage children for referral to in‐laboratory PSG. Regardless of the chosen diagnostic strategy, a thorough clinical history and physical examination for risk factors and complications of obstructive SDB remain essential to appropriately contextualize and accurately interpret oximetry and HSAT findings. The following summaries of publications in 2024 illustrate the ongoing discussions on the diagnosis and screening of obstructive SDB in children.

Selby et al. assessed the accuracy of several oximetry metrics in evaluating the severity of OSA in 322 typically developing children aged 1 to 16 years. The AHI was calculated from overnight cardiorespiratory polygraphy, the standard diagnostic test for pediatric OSA in the UK. The following metrics were evaluated: 3% and 4% oxygen desaturation indices (ODI3 and ODI4), the delta 12 s index, and minimum oxygen saturation. ODI3 and ODI4 demonstrated the highest diagnostic accuracy: an ODI3 ≥ 7/h and an ODI4 ≥ 4/h predicted OSA with sensitivities/specificities of 58%/85% and 46%/92%, respectively. An ODI3 ≥ 8/h was the best predictor of an obstructive AHI ≥ 5/h (sensitivity 82%, specificity 84%) [1].

Wilson et al. conducted a retrospective case‐control study involving 163 patients referred to a tertiary sleep center to assess the effectiveness of a home oximetry service in reducing the time between referral and treatment. These patients were compared to a historical cohort of 311 patients who had previously undergone PSG. The time from the request for a sleep‐related study to ear, nose, and throat surgery was reduced from 359 days in the PSG group to 187 days in the oximetry group (p < 0.05). Although derived from a retrospective study, this substantial difference in treatment delay between the two groups suggests that a home oximetry service may help expedite OSA treatment in children suspected of having obstructive SDB [2].

Landry et al. conducted a systematic review of the literature evaluating the diagnostic accuracy of Level III and Level IV home sleep apnea tests (HSAT) for pediatric obstructive sleep apnea (OSA). Level III HSAT was defined as recording at least four channels, including a minimum of two channels for respiratory movement or a combination of respiratory movement and airflow, one for oxygen saturation, and one for heart rate. Level IV HSAT was defined as a continuous single‐ or dual‐parameter recording, most commonly nocturnal pulse oximetry. The authors concluded that Level III HSAT consistently demonstrated higher diagnostic accuracy for moderate‐to‐severe pediatric OSA and therefore holds promise as a reliable diagnostic tool in this context. In contrast, current evidence remains insufficient to support the stand‐alone use of Level IV HSAT—primarily oximetry‐based—for diagnosing OSA in most children [3].

Cassibba et al. studied 130 children with a median age of 5.4 years [interquartile range: 3.5–8.4]. They found that obstructive alveolar hypoventilation—defined as elevated PCO₂ without an accompanying increase in the apnea–hypopnea index (i.e., not meeting the criteria for OSA)—is exceedingly rare in children without comorbidities. Alveolar hypoventilation was significantly more common in children with severe OSA. These findings support the feasibility of conducting an initial sleep study without CO₂ monitoring in this population, thereby reinforcing the potential role of HSAT [4].

Gowai et al addressed the validity of oximetry as a screening and diagnostic test for OSA in 60 obese children aged between 1 and 16 years, compared with results of PSG or cardiorespiratory polygraphy. Overall, they found a sensitivity of 71% in diagnosing OSA, with a specificity of 66% and a positive predictive value of 69%. The sensitivity increased to 88% in subjects with severe OSA. The authors conclude that, in obese children, a positive oximetry result is helpful and can help in treatment decisions without the need of PSG [5].

Ng et al. conducted a scoping review of 40 international and national guidelines on pediatric OSA or pediatric obesity to assess recommendations for OSA screening in obese children. Recommendations were found in 53% of the guidelines and were inconsistent. The authors ultimately recommend clinically based screening for OSA in all children with a body mass index (BMI) at or above the 85th percentile or with a rapid upward crossing of two BMI percentiles, followed by PSG to confirm the diagnosis in those with high clinical suspicion [6].

Jarrell et al. retrospectively reviewed the charts of 997 children evaluated for Chiari type I malformation at a single institution. SDB was diagnosed in 147 patients, corresponding to an overall prevalence of 15% and a prevalence of 47% among the 310 children who underwent PSG. Among children with SDB, 33% had central sleep apnea, 27% had OSA, 9% had mixed apnea, and 31% were unspecified. Lower cranial nerve dysfunction, tonsillar position, Chiari type 1.5 malformation, and BMI were significantly associated with the presence of SDB. Notably, SDB was found in 57% of asymptomatic patients referred for PSG. The authors conclude that SDB is highly prevalent in children with Chiari type I malformation and may be present even in the absence of symptoms. Identifying risk factors for SDB may help clinicians recognize children at increased risk [7].

Kalyoncu et al. prospectively assessed pulmonary function in 44 patients with Duchenne muscular dystrophy (mean age 10.8 ± 3.1 years) to evaluate SDB, including nocturnal hypoventilation and OSA. They measured sniff nasal inspiratory pressure (SNIP), spirometry, and maximal inspiratory and expiratory pressures to determine the optimal timing for PSG. OSA was present in 70.5% of patients (mild in 50%, moderate‐to‐severe in 20.5%), while nocturnal hypoventilation occurred in 4.5%. SNIP values were significantly lower in patients with moderate‐to‐severe OSA compared with those without. A SNIP < 40 cmH₂O was associated with OSA in 93% of patients. The authors conclude that SNIP is a valuable, noninvasive marker for early detection of upper airway muscle involvement in DMD [8].

1.2. Physiopathology of Obstructive Sleep‐Disordered Breathing

Romero‐Peralta et al. systematically reviewed 15 studies on sex‐based differences in OSA between girls and boys. Based on the limited available data, they concluded that these differences are influenced by hormonal status and are minimal during the premenarcheal period. Furthermore, adolescent girls demonstrated a lower prevalence of obesity and craniofacial abnormalities, and milder OSA severity, likely due to a larger upper airway area and earlier tonsil regression. Hyperactivity is more commonly observed in boys [9].

Ruiz Jiménez et al. conducted a retrospective chart review of 788 pediatric patients under 18 years of age who underwent PSG to analyze the relationship between nutritional parameters and OSA throughout childhood and adolescence. The group of 393 children diagnosed with OSA was age‐matched to 395 “control” children with normal PSG results. The authors observed a trend toward lower BMI in OSA patients under 2 years of age, while older children—especially adolescents—with OSA had higher BMI compared to controls. They hypothesize that in children under 2 years, low BMI may be a consequence of OSA, whereas in older patients, elevated BMI may contribute to the development of OSA, similar to the adult population [10].

Schiza et al. reviewed the potential role of reduced vitamin D levels in OSA. They reported that data from the literature strongly support a connection between sleep quality, OSA, and reduced vitamin D levels in both adults and children. Multiple mechanisms may be involved, including noninflammatory myopathy of the upper airway muscles leading to reduced pharyngeal patency, as well as tonsillar hypertrophy and rhinitis secondary to dysfunctional immunomodulation. However, many aspects of the relationship between insufficient vitamin D levels and OSA remain unclear. It is still uncertain whether vitamin D deficiency predisposes individuals to OSA or if OSA contributes to vitamin D deficiency. Notably, although vitamin D deficiency could be a contributing factor to OSA, it is likely just one component of a more complex picture. Further studies are needed to investigate not only the potential long‐term benefits of OSA treatment in raising vitamin D levels, but also the efficacy of vitamin D supplementation in patients with OSA [11].

Previous studies have shown that lower respiratory tract infections (LRTIs) occurring in the first 2 years of life—but not afterward—significantly increase the risk of developing OSA by age five. In this new study conducted within a prospective birth cohort comprising 2962 participants, Gayoso‐Liviac et al. confirm their hypothesis that the risk of OSA is higher in children who experienced severe LRTIs requiring hospitalization (n = 235), compared to those treated as outpatients (n = 394). Overall, the risk in infants with severe LRTI was twofold higher than in children without early‐life LRTIs. In addition, they report that the time elapsed between LRTI and OSA diagnosis was similar in mild and severe LRTI cases (medians of 23 and 25.5 months, respectively). While the precise mechanisms underlying the increased risk of OSA in children with early‐life LRTIs remain unclear, the following hypotheses have been proposed: persistent or recurrent viral respiratory infections may promote nasopharyngeal lymphoid proliferation; respiratory viruses may also affect upper airway neuromotor control, contributing to nasopharyngeal obstruction. Alternatively, infants who develop OSA after a severe LRTI might be intrinsically predisposed to both conditions. Further investigation into how early‐life respiratory infections influence the onset of pediatric OSA is clearly warranted [12].

In a population‐based, retrospective study analyzing 2100 children aged 1–19 years hospitalized for influenza infection, Wang and Chiu assessed the impact of OSA—previously diagnosed in 420 of them—on clinical outcomes. After propensity score matching, their logistic regression analysis revealed that children with OSA had a significantly longer length of stay, higher total hospital costs, and an increased risk of pneumonia compared to those without OSA. The authors conclude that their findings underscore the importance of recognizing and managing OSA in the context of influenza‐related infections among children [13]. An accompanying editorial by Gozal highlights the significance of these unique and important results, which suggest that early intervention with antiviral therapy may help mitigate complications in children with OSA hospitalized for influenza. However, caution should be maintained until results from prospective clinical trials on the subject become available [14].

1.3. Treatment of Sleep‐Disordered Breathing

Sleep‐disordered breathing (SDB) and obstructive sleep apnea (OSA) remain subjects of considerable debate, and clinical practices vary widely across the world. This section highlights 2024 publications that explore various aspects of SDB management, including surgical interventions, pharmacologic treatments, alternative procedures, and respiratory support strategies.

1.4. Adenotonsillectomy

For most pediatric patients, adenotonsillectomy (AT) remains the cornerstone of OSA management. However, several clinical challenges remain unresolved, including the indications for surgery in the absence of frank OSA, optimal surgical techniques, and the risk of persistent OSA following the procedure.

Mitchell et al. investigated whether a combination of clinical characteristics could differentiate children with primary snoring (apnea‐hypopnea index [AHI] < 1) from those with mild OSA (AHI 1–3) and thus identify patients who might benefit from AT. The Pediatric Adenotonsillectomy for Snoring (PATS) trial was a multicenter, single‐blind, randomized study that included 459 children. The median age was 6.0 years (4.0, 7.5), and 88 participants (19.2%) had obesity. Black race, obesity, and elevated urinary cotinine levels—a marker of second‐hand smoke exposure—were associated with higher odds of mild OSA compared to primary snoring. However, no individual factor, or combination of factors, was able to reliably discriminate between the two groups. The authors conclude that distinguishing primary snoring from mild OSA continues to rely on PSG, and no specific clinical profile reliably identifies children likely to benefit from AT [15].

In a related commentary in JAMA Otolaryngology–Head & Neck Surgery, Friedman NR remarked that for children with primary snoring or mild OSA (low AHI), AT may be a reasonable option if they exhibit daytime symptoms and caregivers perceive a potential benefit despite the surgical risks. For families uncertain about proceeding with surgery, PSG remains an important tool to inform shared decision‐making [16].

One critical component of AT decision‐making is the risk of postoperative respiratory complications. Kou et al. addressed this issue by identifying clinical and PSG parameters associated with postoperative complications in children with high‐risk OSA. Their study included 307 patients and found that intensive care unit admissions and major interventions (such as noninvasive ventilation or intubation) were significantly associated with neuromuscular disease, higher obstructive AHI, elevated peak CO₂, and lower oxygen nadir on preoperative PSG. Children with neuromuscular disorders and those aged 0–2 years were at increased risk for intensive care unit admission and prolonged hospitalization [17].

In recent years, intracapsular tonsillectomy via coblation has gained popularity among otolaryngologists due to its association with fewer postoperative complications, reduced pain, and more rapid recovery compared to traditional tonsillectomy. A study by Ahmarani et al. evaluated the long‐term outcomes of this coblation surgery, with particular focus on tonsillar regrowth. Among 85 patients followed for a mean duration of 6.1 years, regrowth was observed in only 2 children. The study also demonstrated a significant decrease in OSA‐18 scores postprocedure, suggesting sustained clinical benefit [18].

An increasing number of children are diagnosed with both central sleep apnea (CSA) and OSA. Several studies have explored the impact of AT on CSA in this population. Eitan et al. conducted a scoping review of 15 studies assessing the effect of AT on CSA in children with OSA. Notably, across these studies, AT was associated with a reduction in CSA ranging from 40.9% to 80%, confirming that AT may improve both obstructive and central components of SDB [19].

1.5. Treatment Options Beyond Adenotonsillectomy

It is well recognized in clinical practice that a proportion of children will have residual SDB following AT. Several recent publications have explored alternative therapeutic strategies.

The American Thoracic Society issued an Official Clinical Practice Guideline for the management of persistent OSA in children, which includes six recommendations [20]:

• Continuous positive airway pressure (CPAP) may be considered for children with persistent OSA who are not candidates for site‐specific upper airway surgery.

• Orthodontic and dentofacial orthopedic treatment may be appropriate for children with persistent OSA who exhibit specific craniofacial abnormalities.

• Weight loss interventions should be recommended for children who are overweight or obese.

• Lingual tonsillectomy may be considered in children with lingual tonsillar hypertrophy.

• Supraglottoplasty should be considered for those with sleep‐dependent laryngomalacia.

• Montelukast may be considered as an adjunct therapy for children already receiving intranasal corticosteroids.

The Otolaryngologic Clinics of North America has published two comprehensive reviews addressing potential surgical options to target residual obstruction following AT. These publications emphasize the importance of drug‐induced sleep endoscopy (DISE) and/or dynamic cross‐sectional imaging to identify sites of persistent airway obstruction. Available surgeries are grouped according to the sites of obstruction:

• Surgical approaches targeting the nasal cavity, nasopharynx, and soft palate include subcutaneous inferior turbinate resection, septoplasty, adenoidectomy, and expansion sphincter pharyngoplasty [21].

• In the tongue base and laryngeal regions, options may include lingual tonsillectomy, posterior midline glossectomy and tongue or hyoid suspension. Additionally, supraglottoplasty and epiglottopexy have demonstrated benefit in cases of laryngeal collapse or obstruction [22].

Prior studies have shown the effectiveness of lingual tonsillectomy in managing persistent OSA in children. A review by Williamson et al. analyzed postoperative outcomes in 174 children who underwent lingual tonsillectomy. Among the subgroup with pre‐ and postoperative PSG, there was a significant improvement in AHI (p < 0.001), with a mean preoperative AHI of 7.9 ± 13.4 (range: 1–123) and a postoperative mean of 4.0 ± 7.8 (range: 0.0–54). Surgical failure was identified in 25 patients and was associated with a BMI z‐score > 2 (p = 0.025) or trisomy 21 (p = 0.05) [23].

1.6. Pharmacological Treatment

Pharmacologic therapy is often considered a first‐line treatment for pediatric OSA, particularly in cases where surgery may be delayed or avoided. A large observational cohort study by Rowe et al. evaluated the impact of intranasal steroids (INS) in 568 children. Among them, 51% underwent a trial of INS. Treatment with INS improved SDB symptoms as measured by the OSA‐5 score in 56% of those treated and significantly reduced the need for surgery (38% vs. 56%) compared to the non‐INS group—even though the non‐INS group had fewer baseline symptoms and signs of SDB. These findings highlight the value of considering pharmacologic therapy as a first‐line strategy in appropriate cases [24].

A comprehensive systematic review and network meta‐analysis conducted by Zhang et al. included 17 randomized controlled trials involving a total of 1367 children with OSA aged 2 to 14 years. Mometasone combined with montelukast, budesonide alone, and montelukast alone each demonstrated significantly greater efficacy than placebo in reducing AHI. The combination of mometasone furoate nasal spray and oral montelukast sodium showed the highest probability of being the most effective intervention [25].

1.7. High‐Flow Nasal Cannula

High‐flow nasal cannula (HFNC) is a strategy currently being explored to evaluate its effectiveness in treating pediatric patients with OSA. Home HFNC offers several potential advantages, including improved tolerability compared to positive airway pressure therapy (PAP) via mask interfaces.

D'Arienzo et al. conducted a retrospective review of children using HFNC to describe the indications and clinical outcomes in this population. Among the 35 patients included, 66% (n = 21) initiated HFNC therapy specifically for OSA. The majority demonstrated clinical improvement based on repeat PSG. However, four children eventually required escalation of home respiratory support to either CPAP or BPAP (bilevel PAP) at a mean duration of 347 days after starting HFNC. In two cases, escalation was due to progression of the underlying condition, while in the other two cases, the decision was influenced by family preferences, such as concerns about HFNC portability and cost [26].

A previous 2023 study by Fishman et al. showed that, among 18 participants, HFNC and CPAP therapies produced similar reductions in PSG‐based metrics in children aged 2–18 years with moderate‐to‐severe OSA, obesity, and medical complexity [27]. In a similar but more recent comparative study, Au et al. compared HFNC and CPAP with a focus on apnea‐specific hypoxic burden and pulse rate response, two metrics associated with elevated cardiovascular risk in adults. In a similar population of 17 children, results demonstrated that HFNC was as effective as CPAP in mitigating hypoxia but may be less effective than CPAP in reducing the heart rate response triggered by obstructive events [28]. Further studies involving a larger number of children are needed to confirm these results.

1.8. Treatment of Obstructive Sleep‐Disordered Breathing in Children Less Than 2 Years

• The diagnosis and management of SDB and OSA in infants can be particularly challenging. To support clinical decision‐making, the European Respiratory Society recently published an updated statement building on their previous 2017 recommendations [29]. Key highlights from this update include:

• The definition of OSA in infants likely differs from the one used in older children. In addition to AHI, clinicians should also consider additional parameters such as the desaturation index, the mean oxygen saturation, and the percentage of time spent in hypoxia. The statement also notes that an obstructive AHI greater than 5 events/hour may be normal in neonates as obstructive and central sleep apneas decline during infancy.

• Drug‐induced sleep endoscopy (DISE) may be helpful in determining the appropriate surgical approach, as both dynamic and fixed obstructions may contribute to obstructive SDB in this population.

• Surgical procedures such as AT, adenoidectomy, and supraglottoplasty may provide significant improvement when used in the appropriate clinical context.

• For infants who are not candidates for surgery or have persistent OSA following surgical intervention, PAP therapy remains a key treatment option. High‐flow nasal cannula may be used as a temporary measure or alternative in children who are PAP‐intolerant or awaiting definitive treatment.

Gurbani et al. compared the use of HFNC and low‐flow oxygen as treatments for OSA in infants. Nine infants were enrolled in the study (mean age 1.3 ± 1.7 months). OSA improved in 44% of infants treated with HFNC, compared to universal improvement among those receiving low‐flow oxygen. These findings suggest that low‐flow oxygen may be more effective than HFNC in infants. Interestingly, the authors hypothesize that the characteristic respiratory instability at this age—due to a high loop gain—may explain their response to low‐flow oxygen [30].

1.9. Positive Airway Pressure Treatment

Escobar et al. conducted a state‐of‐the‐art review on the treatment of OSA using PAP, including CPAP and BPAP. The review extensively covers therapy initiation, pediatric interface considerations, selection of positive airway pressure mode, administration and potential complications, factors influencing adherence, remote monitoring via ventilator downloads, patient follow‐up, and weaning strategies. One of the main conclusions highlights the need for further research to overcome barriers to adherence [31].

Fauroux et al. also reviewed the use of CPAP in the treatment of pediatric OSA. Noting the growing number of children on long‐term CPAP therapy worldwide, they particularly emphasize the lack of validated criteria for CPAP initiation and weaning, as well as the need for consensus on the optimal frequency, monitoring, and methods of follow‐up (including the potential role of telemedicine). They conclude that chronic CPAP therapy in children should be delivered by an experienced pediatric multidisciplinary team [32].

Khirani et al. published a series of articles on various practical issues in home noninvasive respiratory support in children, including CPAP and noninvasive ventilation (NIV). They first review the devices available for home CPAP/NIV in children, as well as their limitations and pitfalls [33]. They show that CPAP/NIV devices cannot always detect breathing in children with small tidal volumes, not only due to low weight but also due to disease. In such cases, even if any CPAP/NIV device may be used to deliver a prescribed constant CPAP, the reliability of alarms and data from the built‐in software is not guaranteed; this includes basic data such as adherence to CPAP/NIV [34]. They highlight the importance of setting the correct values for the expiratory trigger sensitivity and the inspiratory time (Ti, Ti max, and Ti min) with various devices to prevent patient‐ventilator asynchronies [35]. They underscore the value of analyzing breath‐by‐breath built‐in software data to recognize residual respiratory events and patient‐ventilator asynchronies [36]. They illustrate potential drawbacks of some “comfort” options, such as a long ramp time at the beginning of the night leaving residual events untreated, or the automatic stop of the CPAP device unable to recognize the patient's breathing in the presence of unintentional leaks [37]. They report a case of a ventilator unable to deliver the prescribed inspiratory/expiratory pressure to a child in the presence of unintentional leaks, a problem that was recognized by analyzing the built‐in software data [38]. Following a narrative review of the interfaces available for home CPAP/NIV in children, which especially highlights the lack of options for infants and toddlers [33], they give a few useful tips and tricks to adjust masks in children. These include using mask and headgear parts from different manufacturers, and homemade adaptations of headgears [39].

Cithiravel et al. extensively review the use of volume‐assured pressure support modes available with various NIV devices. These modes are increasingly considered in pediatrics. Methods of initiation, specific ventilator settings, titration, interpretation of built‐in software data, challenges, and troubleshooting of alarms are reviewed [40].

A special issue of Pediatric Pulmonology, co‐edited by Cobanoglu, Zampoli, and Yalcin, provides a unique and comprehensive update on the multidisciplinary management of pediatric patients receiving home invasive mechanical ventilation. Among other topics, multiple authors review the indications, the transition from hospital to home, physiological monitoring, ventilator‐associated respiratory infections, psychosocial challenges for children and parents, home invasive ventilation in low‐resource settings, and weaning strategies [41]. In addition, Mack et al. conducted a scoping review on tracheostomy and long‐term invasive ventilation decision‐making in children, which highlights the high degree of uncertainty and complexity involved in this process, as well as the need for standardization consistent with a child's best interests and shared decision‐making [42].

Toussaint et al. reviewed 32 international reports—representing 8815 children—to assess the evolution of invasive versus noninvasive home mechanical ventilation in children over the past 24 years. Neuromuscular disorders remain the most common indication for home ventilation (37%), followed by cardiorespiratory (16%) and central nervous system (16%) disorders, and upper airway obstruction (13%). While NIV is now used in 72% of cases, invasive ventilation remains common in younger children and in countries with limited experience in NIV [43].

Carrara et al. conducted a cross‐sectional study to describe the prevalence of CPAP/NIV treatment in children with central nervous system disorders. Data were collected from 182 children (median age: 10.2 years [Q1: 5.4; Q3: 14.8], range: 0.3–25) through the French national pediatric NIV/CPAP network, which brings together 27 pediatric university centers. The most common indications were multiple disabilities (35%), non‐tumoral spinal cord injury (19%), and central alveolar hypoventilation (14%). Seventy‐five percent of the patients were treated with NIV, and 25% with CPAP. The authors conclude that although noninvasive ventilatory support may be a suitable option in children with central nervous system disorders, future studies are needed to assess treatment efficacy and patient‐reported outcome measures [44].

1.10. Hypoglossal Nerve Stimulation in Children With OSA

Well established in the adult literature and now recognized as a safe and effective treatment for OSA, hypoglossal nerve stimulation (HGNS) has gained growing interest in the pediatric field over the past several years. It is increasingly viewed as a promising therapeutic option for children with OSA—specifically those with trisomy 21 who have persistent OSA despite AT and failed trials of PAP. However, several unresolved questions remain regarding its feasibility, efficacy, and target population. Recent literature from 2024 provides clinicians with new avenues to explore.

Rodriguez Lara et al. published a systematic review of studies examining the benefits, efficacy, and caregiver experiences with HGNS in children with trisomy 21. Nine studies evaluated clinical outcomes following implantation, while one study focused on parental experience. Across the included studies, there was consistent evidence of marked improvement in PSG and quality of life scores. These findings are encouraging for the trisomy 21 population. Notably, the studies primarily included adolescents with trisomy 21, as HGNS is currently FDA‐approved for use in that specific population [45]. However, Wasserman et al. reported a case of a 4‐year‐old child with trisomy 21 and treatment‐refractory OSA who underwent successful HGNS implantation without complications. This case supports the potential feasibility of HGNS in younger patients, provided that a shared decision‐making process is undertaken between families and physicians [46].

One of the greatest challenges with HGNS therapy remains patient selection and postimplantation optimization. Chieffe et al. published a consensus‐driven clinical algorithm, developed by an expert panel, in which 29 statements met criteria for agreement. These statements aim to guide clinicians in the adoption and management of this novel therapy [47]. Later in the year, Marcus et al. published a case series of three pediatric patients with trisomy 21 and persistent OSA despite HGNS. Optimization based on a novel algorithm—including adjustments to the stimulation and sensing leads, and the use of DISE when appropriate—resulted in significant improvement. All three patients experienced at least a 50% reduction in AHI, with two achieving normal‐to‐mild OSA (AHI < 5) [48].

Safety and complications associated with HGNS in the pediatric population have also been studied. In a retrospective case series, Chieffe et al. reviewed outcomes in 53 children with trisomy 21 (ages 10 to 22 years) and severe persistent OSA following AT (defined as AHI > 10 with < 25% central or mixed events) who underwent HGNS implantation. The mean age at implantation was 15.1 years. A total of 30 adverse events were reported: 17 nonserious (e.g., transient tongue discomfort, surgical site rash, cellulitis) and 13 serious. The latter included hospital readmissions for cellulitis, pain, device extrusion, and reoperations—commonly due to battery depletion—as well as pressure ulcer formation. These findings highlight some of the unique considerations and challenges in adapting HGNS technology for pediatric use [49].

2. Conclusion

The year 2024 was notable in the field of sleep‐disordered breathing in children. This literature review offers a brief overview of key publications in this area, though it is not intended to be exhaustive. The pediatric sleep medicine community is increasingly aware of the challenges related to limited access and resources for the screening and diagnosis of sleep‐disordered breathing in children. This growing awareness may signal a shift toward new strategies and alternative approaches in the near future. The highlighted articles also provide insights into evolving perspectives on pharmacological therapies, surgical interventions, and respiratory support options. Technological innovations, such as hypoglossal nerve stimulation, are attracting increasing interest. It will be exciting to see what advancements 2025 brings to these rapidly developing areas.

Author Contributions

Vincent Lavoie: writing – review and editing. Jean‐Paul Praud: writing – review and editing.

Conflicts of Interest

The authors declare no conflicts of interest.

Lavoie V., and Praud J.‐P., “Pediatric Sleep‐Disordered Breathing Year in Review 2024,” Pediatric Pulmonology 60 (2025): 1‐8. 10.1002/ppul.71304.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.