Recurrence of Pediatric OSA: The Role of Oral-Intestinal Dysbiosis

Table 1: Sex ratio.

Table 2: Age of children.

Table 3:AHI recurrence

Table 4: Type of procedures.

Table 5: Associated digestive disorders

Table 6: Numbers of infections per year.

Table 7: Number of viral infections

Table 8: Number of bacterial infections.

Table 9: Measure of calprotectin.

Table 10: Time of recurrence.

Role of the immune system reading and interpretation of children’s health records

The information from the health records of children with recurrent OSA is extremely rich in insights, provided one knows how to search for, find, and interpret them (Figure 2). These teachings primarily focus on immunodeficiency in light of the number of recurrent infections and their frequencies (Tables 7 & 8). Indeed, most children with recurrent OSA, regardless of gender and age (Tables 1&2), present relatively early between 3-6 years old] with various viral infections that coexist in the same young patient. Indeed, the majority of children experience recurrent infections, particularly middle ear infections (otitis), which take the gold medal for recurrent infections, followed by the common cold (rhinopharyngitis) (Table 6). Caused by numerous different viruses, this upper respiratory tract infection is highly contagious and manifests as a runny nose, sneezing, a mild cough, and sometimes a low-grade fever. These situations may suggest an immune deficiency allowing the maintenance of inflammation with high levels of calprotectin (Table 9 & 10). In short, the body is less resistant to infectious agents (bacteria, viruses, parasites, etc.). The lack of capacity of the infant immune system to defend itself against environmental pathogens explains the frequency of repeated viral and/or bacterial infections in these children. Similarly, another piece of information provided by the health record of children with recurrent OSA shows that the respiratory and intestinal tracts are generally the most involved because the antigen most often enters thru the nose or mouth [7-9] to reach the intestine, and it is in the mucous membranes of these physiological systems that the encounter with immune cells occurs. Moreover, the sometimesuntimely prescription of antibiotics is another piece of information also found in the health record, even it does not always contribute to the protection of the oro-naso-facial microbiota of proximity and intestinal continuity (Table 5).

Role of proximal oro-naso-facial microbiota and continuous intestinal microbiota

The oral microbiota, the second most abundant microbiota after the digestive tract, is an important component of the human microbiota [7,8]. It communicates with the nasopharynx and the oropharynx, serves as an entry point to the digestive system, and is a source of microbial transmission [8,9]. Moreover, it is known that children with oral breath have a drier mouth, a lower oral pH, a higher level of free sialic acid, and poorer oral health. The oral microbiota hosts more than 700 bacterial species, which contribute to the good health of the mouth (teeth, gums, tongue...), and, more broadly, to the health of the organism. A disruption of this balance (dysbiosis), due to poor oral hygiene [9], a decrease in immunity paving the way for pathogens for local infections (carious lesions, proximal, deep distal). Ten bacterial genera, including the most important ones (Lactobacillus, Escherichia, Bifidobacterium, Capnocytophaga, Bacteroidetes, Parvimonas, Bacteroides, Klebsiella, Lautropia, and Prevotella), are present in the salivary samples [7] of children with OSA. If oral hygiene and dental care remain a means of prevention, the most relevant and efficient method is surely the long-term maintenance of lip closure, which guaranties the absence of bacterial ingestion and inhalation. Oral pathogens are likely to migrate from the proximity sphere (ENT) to a sphere of continuity (Intestine) (Table 3-5). This could explain some Recurrent Abdominal Pain (RAP) that children complain about. The ENT microbiota, three microbiomes in one (ear, nose, throat), is composed of three distinct bacterial floras: the oral microbiota, the auricular microbiota, and the nasopharyngeal microbiota. Various diseases can result from their imbalance. The concept of a dysbiotic oral cavity as a source of distant infection is now accepted [7-9]. The inability of the infant immune system to defend itself against environmental pathogens explains the frequency of repeated viral or bacterial infections in children. The respiratory and intestinal tracts are generally the most involved (Tables 1-10).

At the level of the external auditory canal, the composition of the auricular microbiota is similar to that of the skin. Recent studies have highlighted the harmless presence of Alloiococcus otitis and Corynebacterium otitidis, two bacterial species previously exclusively associated with middle ear infections. This discovery suggests that the external auditory canal may serve as an infectious reservoir for the middle ear. Although similar to the oral microbiota, the nasopharyngeal microbiota, which lines the nasal passages and pharynx, is composed of very different germs.

Role of the state of the vagus nerve and inflammation

The vagus nerve or pneumogastric nerve connects the brain to various organs, including the respiratory and gastric systems. Diet plays a crucial role in the development of the immune system. The intestinal bacteria found near this nerve impact its activity; the vagus nerve is also involved in the regulation of breathing. It plays a role in regulating the diameter of the airways and the respiratory rate. This nerve is involved in the secretion of digestive enzymes and gastric acid. An essential function of the vagus nerve is the regulation of the body’s inflammatory state. By acting on the immune system, it helps prevent an inflammatory runaway. That’s why a varied diet, rich in green vegetables and sources of vitamins, is essential for the development of immune defense. Indeed, more than 70% of immune cells are located in the intestinal area. As a result, we can clearly understand the influence of digestive inflammatory pathologies on the recurrence of pediatric OSA. Vitamin D deficiencies, particularly in the recurrence of pediatric tye 1 OSA, the lack of vitamin D seems to influence both the innate immune system and the acquired immune system. Indeed, 1α-hydroxylation produces calcitriol within various immune system cells, where it exerts autocrine and paracrine effects. However, vitamin D remains one of the most common vitamin deficiencies in children. It can also be difficult to obtain enough vitamin D through diet alone, given that it is naturally present in very few foods. This vitamin plays a very important role in the immune system: it helps regulate certain genes involved in immunity against viruses and bacteria.

Duality content/container interest of integrative medicine

Researchers from Marshall University (West Virginia) have shown the possible role of the gut microbiome in sleep apnea. Their review of the literature, published in the journal Sleep Medicine, indeed highlights the links between gut health and sleep apnea, thus paving the way for new therapeutic approaches to managing this common but often overlooked disorder: Thus, improving digestive health, i.e., considering the oral microbiota and knowing how to establish the links between the oro-facial sphere and the intestine, would be a truism if integrative medicine, rejecting the dualities of “container/content,” found its rightful place in the concert of therapeutic arsenals.