Rapid maxillary expansion in pediatric patients with obstructive sleep apnea: an umbrella review

Barbosa, Denise Fernandes; Bana, Laura Fernandes; Michel, Maria Cristina Buta; Cruz, Miguel Meira e; Zancanella, Edilson; Machado Júnior, Almiro José

doi:10.1016/j.bjorl.2023.02.004

Acessibilidade / Reportar erro

Brasil

Brazilian Journal of Otorhinolaryngology

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Review article • Braz. j. otorhinolaryngol. 89 (3) • May-Jun 2023 • https://doi.org/10.1016/j.bjorl.2023.02.004 copy

Rapid maxillary expansion in pediatric patients with obstructive sleep apnea: an umbrella review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Highlights

The studies of rapid maxillary expansion in obstructive sleep apnea children's treatment are based on low-quality evidence.
Management decisions should be linked to the phenotype, considering outcomes beyond the apnea-hypopnea index.
A health policy is needed focusing on respiratory disorders prevention.

Abstract

Objective

To compare polysomnographic parameters with others from the literature in order to provide more accurate information about Rapid Maxillary Expansion (RME) for treating Obstructive Sleep Apnea (OSA) in children, through raising the question: Is RME a good option for treating OSA in children? Prevention of mouth breathing during children's growth remains a challenge with significant clinical consequences. In addition, OSA induces anatomofunctional changes during the critical period of craniofacial growth and development.

Methods

The Medline, PubMed, EMBASE, CINAHL, Web of Science, SciELO and Scopus electronic databases were searched up to February 2021 for systematic reviews with meta-analysis in the English language. Among 40 studies on RME for treating OSA in children, we selected seven in which polysomnographic measurements of the Apnea-Hypopnea Index (AHI) had been made. Data were extracted and examined in order to clarify whether any consistent evidence exists for indicating RME as a treatment for OSA in children.

Results

We found no consistent evidence favoring RME for long-term treatment of OSA in children. All the studies presented considerable heterogeneity due to variability of age and length of follow-up.

Conclusion

Through this umbrella review, the need for methodologically better studies on RME is supported. Moreover, it can be considered that RME is not recommended for treating OSA in children. Further studies and more evidence identifying early signs of OSA are necessary in order to achieve consistent healthcare practice.

Keywords
Rapid maxillary expansion; Obstructive sleep apnea; Children; Systematic review; Meta-analysis

Study; year	Study site	Outcomes Analysed	Quality assessment^a a Quality assessment of Joanna Brings Institute for Reviewers’ Manual 2014: 1) Is the review question clarity and explicit stated? 2) Were the inclusion criteria appropriate for the review question? 3) Was the search strategy appropriate? 4) Were the sources and resources used to search for studies adequate? 5) Were the criteria for appraising studies appropriate? 6) Was critical appraisal conducted by two or more reviewers independently? 7) Were there methods to minimize errors in data extraction? 8) Were the methods used to combine studies appropriate? 9) Was the likelihood of publication bias assessed? 10) Were recommendations for policy and/or practice supported by the reported data? 11) Were the specific directives for new research appropriate?
Study; year	Study site	Outcomes Analysed	1	2	3	4	5	6	7	8	9	10	11
Huynh NT et al.; 2015	Canada	AHI	M	M	M	M	M	M	M	M	M	NM	U
Machado-Júnior AJ et al.; 2016	Brazil	AHI; apnea index; SaO₂	U	M	M	M	M	NM	NM	M	NM	M	M
Camacho M et al.; 2017	USA	AHI; LSAT	M	M	M	M	M	M	M	M	M	M	M
Vale F et al.; 2017	Portugal	AHI; SaO₂; AI; REM; SE	M	M	M	M	M	M	M	M	M	NM	U
Sánchez-Súcar AM et al.; 2019	Switzerland	AHI; RDI; SaO₂, ODI	M	M	M	M	M	M	M	M	M	NM	U
Lin SY et al.; 2020	Taiwan	AHI; SaO₂; ODI	M	M	M	M	M	M	M	M	M	M	M
Quinzi Vi et al.; 2020	Spain/Canada	AHI; SaO₂ in the short ‒ and long-term follow-up	M	M	M	M	M	M	M	M	NM	NM	M

Author; year	Number of studies/children	Age range/mean	AHI findings of pre- and post-treatment RME	Follow-up	Heterogeneity		p-value
Author; year	Number of studies/children	Age range/mean	AHI findings of pre- and post-treatment RME	Follow-up	Variation across studies	Level	p-value
Huynh NT et al.; 2015	5 studies/183	18y or younger	MD IV, Fixed, 95% CI 6.19 (5.81, 6.57)	4 weeks, 4-6 to 18 months	98%	High	<0.00001
Machado-Júnior AJ et al.; 2016	10 studies/350	0‒12y/6.7y	MD IV, Fixed, 95% CI −6.86 (−7.18, −6.54)	3 months to 14 years	98%	High	<0.00001
Camacho M et al.; 2017	17 studies/314	7.6 ± 2.0y	MD IV, Random, 95% CI −4.84 (−8.47, −1.21)	Less than 3y	99%	High	<0.0001
Camacho M et al.; 2017	17 studies/314	7.6 ± 2.0y	St. Mean Difference IV, Random, 95% CI −1.54 (−2.29, −0.78)	More than 3y	94%	High	<0.00001
Vale F et al.; 2017	5 studies/137	18y or younger	Random, SMD Effect Size, 95% CI 3.24 (0.34, 6.15) (AHI improvement)	12 months	98.02%	High	<0.0001
Vale F et al.; 2017	5 studies/137	18y or younger	Random, SMD Effect Size, 95% CI −2.91 (−4.80, −1.02) (AHI normalization)	12 months to normal	95.53%	High	<0.0001
Sánchez-Súcar AM et al.; 2019	9 studies/283	around 8y	MD, Fixed/Random, 95% CI −6.617 (−6.910, −6.324)/−5.797 (−9.06, −2.5)	Not specified	98.9%	High	=0.000
Lin SY et al.; 2020	14 studies/1064	under 19y/6.5 ± 0.2y	MD, Effect Size, 95% CI −1.90 (−5.33, 1.53)	3-months	44.9%	High	<0.001
Quinzi, VI et al.; 2020	6/102	6.7 ± 1.3y	MD IV, Random, 95% CI 5.11 (4.58, 5.64)	≤3 year in 79 children	97%	High	<0.00001
Quinzi, VI et al.; 2020	6/102	6.7 ± 1.3y	MD IV, Random, 95% CI 5.11 (4.58, 5.64)	>3 years in 23 children	97%	High	<0.00001

Author; year	Findings of RME outcome of OSA treatment	The necessity of RME investigation
Huynh NT et al.; 2015	May be effective.	More studies with larger sample sizes and with speciﬁc inclusion and exclusion criteria.
Machado-Júnior AJ et al.; 2016	May be effective.	More studies with follow-up.
Camacho M et al.; 2017	May be effective in the short term (<3-year follow-up).	More studies with long-term data (3-years of follow-up) to determine the growth effect and spontaneous OSA resolution.
Vale F et al.; 2017	An appropriate alternative in craniofacial abnormalities.	More studies with CONSORT guidelines.
Sánchez-Súcar AM et al.; 2019	May be effective in mild to moderate AHI, and effective in severe AHI with A&T.	More studies with measurement protocols for review comparison.
Lin SY et al.; 2019	It may not be effective in reducing AHI.	Trials that evaluate the newer technologies or combination therapies to identify the best treatment for pediatric OSA
Quinzi, Vi et al.; 2020	RME has efficacy in OSA.	Studies with OSAS treatment long-term.

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] ⁎ Corresponding author. E-Mail:zancaedi@unicamp.br (E. Zancanella).

Population	Children (age from 0 to 18 years) with obstructive sleep apnea.
Intervention	Rapid maxillary expansion.
Comparative group	Apnea hypopnea index, oxygen desaturation index, arousal index.
Outcomes	Improvement of polysomnographic measurements.