Behavior problems associated with sleep disordered breathing in school-aged children--the Tucson children's assessment of sleep apnea study

Eczema and sleep and its relationship to daytime functioning in children

Chronic childhood eczema has significant morbidity characterised by physical discomfort, emotional distress, reduced child and family quality-of-life and, of particular note, disturbed sleep characterised by frequent and prolonged arousals. Sleep disturbance affects up to 60% of children with eczema, increasing to 83% during exacerbation. Even when in clinical remission, children with eczema demonstrate more sleep disturbance than healthy children. Notably, disturbed sleep in otherwise healthy children is associated with behavioural and neurocognitive deficits. Preliminary evidence suggests that disturbed sleep in children with eczema is also associated with behavioural deficits while the impact on neuropsychological functioning remains unexplored. In conclusion, a disease which affects up to 20% of children in some countries and may produce long-term behavioural and neurocognitive deficits merits further evaluation using standardised tests of sleep, behaviour and neurocognition.

Sleep-disordered breathing, behavior, and academic performance in Taiwan schoolchildren

OBJECTIVE

The behaviors of children may be affected by sleep-disordered breathing (SDB). This study adopts a cross-sectional approach to investigate the relationship between the sleep apneas-hypopneas index during sleep and the behavioral and academic performance of schoolchildren in Taiwan.

METHODS

A total of 138 children (85 boys and 53 girls), ages 6-11, were recruited from two elementary schools to participate in this study. Overnight polysomnographic examinations in hospital were performed to assess sleep quality, including total sleep time, arousal index, apneas-hypopneas index, desaturation index, and lowest oxygen saturation, as well as the percentage of total sleep time spent in rapid eye movement, stage 1, stage 2, stage 3, and stage 4. The children's parents and teachers were required to complete a Chinese version of the Child Behavior Checklist and Teacher's Report Form to assess child behavior and academic achievement.

RESULTS

Compared with children without SDB (apneas-hypopneas index ≤1), those with severe SDB (apneas-hypopneas index >15) exhibited more irregular behavioral performance in somatic complaints (odds ratio (OR) = 9.43; 95% confidence interval (CI) = 1.04-85.71) and attention (OR = 9.95; 95% CI = 1.02-97.00). However, different severities of SDB groups did not show significant associations in academic performance.

CONCLUSION

Our study suggests that children with severe SDB may predispose to somatic complaints and attention problems so that sleep examination or medical intervention might be provided at an early age in these children.

Neurocognitive performance and behavior before and after treatment for sleep-disordered breathing in children

Neurocognitive and behavioral problems are increasingly reported in children with sleep-disordered breathing (SDB). The impact of treatment for SDB on neurocognition and behavior is, therefore, an issue of increasing importance. To date, there has been little consideration given to the quality of studies when reviewing associated neurocognitive and behavioral problems in children with SDB, and furthermore, there has been little systematic review of treatment outcomes. The aim of this review was to provide an up-to-date and critical review of the current literature. Findings indicate a specific pattern of neurocognitive problems in children with SDB; however, the pattern of behavioral problems is less clear. Very few studies were found to provide a rigorous investigation of posttreatment neurocognitive and behavior outcomes. Despite this, relatively consistent improvements in global intelligence, attention, and visual spatial ability are shown; however, persistent deficits in other domains are also evident. For behavior, problems of hyperactivity, aggression or conduct problems, and somatic complaints improve following treatment. In contrast, symptoms of anxiety and social problems less consistently improve. These findings should aid in the development of more targeted investigations and well-designed studies exploring both the causative mechanisms and the treatment response for neurocognitive and behavior problems in children with SDB.

Urinary proteins for the diagnosis of obstructive sleep apnea syndrome

Approximately 2-3% of all children in the United States suffer from obstructive sleep apnea (OSA). This condition is characterized by repeated events of partial or complete obstruction of the upper airways during sleep leading to recurring episodes of hypercapnia, hypoxemia, and arousal throughout the night as well as snoring, which afflicts 7-10% of all children. Since clinical history and physical examination are unreliable in the differentiation between children with OSA and children with primary snoring (PS) who have no apparent alteration in sleep architecture, current diagnostic approaches for OSA require an overnight sleep study (ONP). ONP is onerous, relatively unavailable, labor intensive, and inconvenient, leading to long waiting periods and unnecessary delays in diagnosis and treatment. Development of noninvasive biomarker(s) capable of reliably distinguishing children with PS from those with OSA would greatly facilitate timely screening and diagnosis of OSA in children. Therefore, we hypothesized that proteomic strategies in the urine may permit the identification of biomarker(s) that reliably screen for OSA. In this study, time-of-flight mass spectrometry was used to profile proteins in the first morning void urines from children. We discovered that urocortins are increased in OSA and provide a noninvasive approach for quick and convenient diagnosis otf OSA in snoring children.

Kindergarten children's failure to qualify for first grade could result from sleep disturbances

Every year, 7% to 15% of preschool children are found to be underqualified for first grade. We examined whether sleep disturbances are factors in school readiness and their association with neurocognitive skills and behavior. The population included 148 kindergarten students. The study group consisted of 50 students who were assessed by the educational authority as unready for first grade. Children who were scheduled to attend first grade (n = 98) were in the control group. All children/parents filled in a sleep questionnaire and underwent a week of actigraphic sleep/wake study as well as cognitive and behavioral assessments. Children in the study group had significantly shorter total sleep time, reduced sleep efficiency, and increased number of nighttime awakenings. There were significant correlations between sleep variables, and cognitive and behavioral scores. In conclusion, children who fail to qualify for first grade have significantly inferior sleep patterns. Sleep disturbances were associated with cognitive and emotional immaturity.

Inefficient or insufficient encoding as potential primary deficit in neurodevelopmental performance among children with OSA

Memory (M) impairments have been suggested in pediatric Obstructive Sleep Apnea along with attention and executive (AE), language (L), and visuospatial (V) dysfunctions. NEPSY assessment of children aged 5-9 years who were either healthy (N = 43), or who had OSA without L, V, AE (OSA(-), N = 22) or with L (N = 6), V (N = 1), AE (N = 3) (OSA(+), N = 10) dysfunctions revealed no gross memory problems in OSA; however, over the three learning trials of cross-modal association learning of name with face, the OSA(-) progressively improved performance, whereas the OSA(+) failed to progress. No within-group differences between immediate and delayed memory tasks were apparent. The data suggest the presence of slower information processing, and/or secondary memory problems, in the absence of retrieval or recall impairments among a subset of children with OSA. We hypothesize that inefficient/insufficient encoding may account for the primary deficit.

Association Between Sleep Disordered Breathing and Behavior in School-Aged Children: The Tucson Children's Assessment of Sleep Apnea Study

STUDY OBJECTIVES: This study analyzed the association between the Respiratory Disturbance Index (RDI) and two behavior measures, the Conners' Parent Rating Scale (CPRS-R) and the Child Behavior Checklist (CBCL) in school-aged children to determine whether there is an optimal threshold of Sleep-disordered Breathing (SDB) associated with increased risk of behavior problems. METHODS: The Tucson Children's Assessment of Sleep Apnea Study (TuCASA) is an observational cohort study of 6-11 year old Caucasian and Hispanic children designed to assess the anatomic, physiologic and neurocognitive correlates of SDB. 403 children with both polysomnography (PSG) and behavioral data were included in this analysis. Three definitions of SDB were used: RDI independent of oxygen desaturation (RDI0), RDI with 2% oxygen desaturation (RDI2) and RDI with 3% oxygen desaturation (RDI3). T-scored behavioral data were dichotomized at a cutoff point of 65, a score indicative of moderate to severe clinical impairment. Logistic regression was used to access the risk associated with SDB. RESULTS: The analyses conducted using three different definitions of RDI suggest that the likelihood of having a clinically significant CPRS-R or CBCL subscale score was not necessarily progressive or linear across RDI categories. Cutoff points and prevalences for each definition of RDI proposed to be indicators of clinically significant SDB were RDI0 ≥ 7 (19.38%), RDI2 ≥ 2 (29.38%) and RDI3 ≥ 0.5 (23.96%) events per hour of sleep. Behaviors such as CPRS oppositional, social problems, psychosomatic and CBCL somatic complaints, social problems and aggressive behaviors were found to be significantly associated with SDB. CONCLUSIONS: This analysis found an increased risk of behavior problems such as somatic complaints, oppositional or aggressive behaviors and social problems associated with sleep-disordered breathing in school-aged children. RDI cut points for three definitions of SDB are proposed: 7 for RDI0, 2 for RDI2, and 0.5 for RDI3 respectively.

Epidemiology of pediatric obstructive sleep apnea

Pediatric obstructive sleep apnea (OSA) has become widely recognized only in the last few decades as a likely cause of significant morbidity among children. Many of the clinical characteristics of pediatric OSA, and the determinants of its epidemiology, differ from those of adult OSA. We systematically reviewed studies on the epidemiology of conditions considered part of a pediatric sleep-disordered breathing (SDB) continuum, ranging from primary snoring to OSA. We highlight a number of methodologic challenges, including widely variable methodologies for collection of questionnaire data about symptomatology, definitions of habitual snoring, criteria for advancing to further diagnostic testing, and objective diagnostic criteria for SDB or OSA. In the face of these limitations, estimated population prevalences are as follows: parent-reported "always" snoring, 1.5 to 6%; parent-reported apneic events during sleep, 0.2 to 4%; SDB by varying constellations of parent-reported symptoms on questionnaire, 4 to 11%; OSA diagnosed by varying criteria on diagnostic studies, 1 to 4%. Overall prevalence of parent-reported snoring by any definition in meta-analysis was 7.45% (95% confidence interval, 5.75-9.61). A reasonable preponderance of evidence now suggests that SDB is more common among boys than girls, and among children who are heavier than others, with emerging data to suggest a higher prevalence among African Americans. Less convincing data exist to prove differences in prevalence based on age. We conclude by outlining specific future research needs in the epidemiology of pediatric SDB.

Normative psychomotor vigilance task performance in children ages 6 to 11--the Tucson Children's Assessment of Sleep Apnea (TuCASA)

Although the psychomotor vigilance task (PVT) is commonly used in sleep and other research settings, normative data for PVT performance in children have not been published. This report presents normal PVT performance measures among children without a sleep disorder participating in the Tucson Children's Assessment of Sleep Apnea (TuCASA) study. TuCASA is a community-based, prospective study of sleep-disordered breathing in Caucasian and Hispanic children ages 6 to 11 years. A standard 10-min PVT trial was completed by 360 participants-48% female and 36% Hispanic; mean age 8.9 years. Detailed analyses were performed for 162 children with respiratory disturbance indices <1 and no parent-reported sleep problems. Mean and median reaction times (RT) decreased with increasing age (p trend < 0.001). Children ages 6 and 11 had median RTs of 544.24 and 325.70 ms, respectively. Standard deviations in RTs also decreased with increasing age (p trend = 0.001), as did lapses (p trend < 0.001), but no trend was apparent in total errors. There were statistically significant (p = 0.006) differences in the performance of boys and girls. Gender differences were greatest at age 6, where boys had shorter RTs, and decreased with age until performance was approximately equal by age 11. No ethnic differences were detected. Children's PVT performance improves with age and differs by gender. These differences should be considered when the PVT is utilized in pediatric populations.

Physical and emotional disturbances in children with adenotonsillar hypertrophy

OBJECTIVE

Enlarged tonsils and adenoids (part of Waldeyer's ring) are responsible for obstructive sleep disordered breathing. Obstructive sleep disordered breathing episodes lead to hypoxaemia, hypercapnia and a state of arousal, all of which affect normal development of the nervous system. In this study, two hypotheses were tested: (1) obstructive sleep disordered breathing is caused by adenotonsillar hypertrophy and is associated with hypoxia and brain dysfunction; and (2) children with obstructive sleep disordered breathing more commonly display emotional lability, depressive behaviour and anxiety.

MATERIAL AND METHODS

A total of 225 children were examined. The study group consisted of 121 children with adenotonsillar hypertrophy (87 aged six to nine years and 34 aged 10 to 13 years) and with obstructive sleep apnoeas and hypopnoeas confirmed by polysomnography. Patients were compared with 104 children with no obstructive sleep disordered breathing and no adenotonsillar hypertrophy (74 aged six to nine years and 30 aged 10 to 13 years). The following tests were used to measure the children's emotional disorders: the children's depression inventory; the state-trait anxiety inventory for children; and the emotional instability scale. The average values and standard deviations were calculated for all results. Student's t-test was used to compare differences in all groups of children. The minimum level of p < 0.05 was set as statistically significant.

RESULTS

Children with adenotonsillar hypertrophy are more likely to experience poor brain development and sleep problems. They also have emotional disturbances. In the sick and healthy children aged six to nine years, mean results for the emotional instability scale were statistically significantly different in the two groups, being higher in children with adenotonsillar hypertrophy than in healthy children. Mean values for the children's depression inventory test were higher in children with adenotonsillar hypertrophy, but the differences were not statistically significant. In the state-trait anxiety inventory for children test, the mean T score was T = 1.760 and the level of significance was p = 0.08 for both groups. Since the standard level of significance was p < 0.05, the differences in mean values for the state-trait anxiety inventory for children test bordered on statistical significance. There were no differences between tests results in the older children (10 to 13 years).

CONCLUSIONS

Recent studies have confirmed the negative emotional effect of adenotonsillar hypertrophy induced obstructive sleep disordered breathing in children aged six to nine years. The main problems are emotional lability, and anxiety and depressive disturbances. Such emotional problems subside in older children (aged 10 to 13 years).

Comparison between reported and recorded total sleep time and sleep latency in 6- to 11-year-old children: the Tucson Children's Assessment of Sleep Apnea Study (TuCASA)

Research comparing parental report of sleep times to objectively obtained polysomnographic evidence of sleep times in schoolchildren is lacking. This report compares habitual sleep time and objectively recorded sleep time and sleep latency with parental reports of sleep time immediately after a night of polysomnography in elementary schoolchildren. Unattended home polysomnograms (PSG) were obtained from 480 children. On the night of the PSG, a parent was asked to complete a Sleep Habits Questionnaire, which inquired about the habitual total sleep time (HABTST) and habitual sleep onset latency (HABSOL) of his/her child on both school days and nonschool days. On the morning after the PSG, the parent was asked to estimate the total sleep time (ESTTST) and sleep onset latency (ESTSOL) of his/her child on the night of the recording. Comparisons were made to actual total sleep time (PSGTST) and sleep latency (PSGSOL) on the PSG. The sample was comprised of 50% girls, 42.3% Hispanic, and 53% aged 6-8 years. The mean HABTST, ESTTST, and PSGTST were 578, 547, and 480 min, respectively. HABTST was greater than both ESTST and PSGTST (p < 0.001). Moreover, ESTTST was greater than PSGTST (p < 0.001). The mean HABSOL, ESTSOL, and PSGSOL were 15, 17, and 11 min. ESTSOL was longer than PSGSOL (p < 0.001). There were no gender differences. However, Hispanic parents reported significantly less HABTST in their children than Caucasian parents (566 vs 587 min, p < 0.001). Parents of schoolchildren in this population-based sample substantially overestimated their children's actual total sleep time and sleep onset latency.

Reduced time in bed and obstructive sleep-disordered breathing in children are associated with cognitive impairment

OBJECTIVE

The purpose of this study was to determine if reduced time in bed as well as the degree of obstructive sleep-disordered breathing predicted the risk of impaired cognitive function in children with adenotonsillar hypertrophy suspected of having obstructive sleep-disordered breathing.

DESIGN

We studied 56 children, aged 6 to 12 years, with adenotonsillar hypertrophy referred for suspected obstructive sleep-disordered breathing. Children were given a sleep diary and underwent wrist actigraphy for 6 consecutive days and nights. On day 7, the children were given general cognitive tests, memory tests, and continuous performance tests followed by attended polysomnography that night. Parents completed snoring and behavior questionnaires.

RESULTS

Shorter mean time in bed for 6 nights and a history of nightly snoring were highly predictive of lower scores for the vocabulary and similarities cognitive function tests. Children who had a mean time in bed of 557 minutes and did not snore nightly were predicted to have vocabulary and similarities scores more than 1 standard deviation higher than children who had a mean time in bed of 521 minutes and snored nightly. Shorter mean time in bed and the log of the apnea hypopnea index also predicted lower vocabulary and similarities scores. Greater night to night variability in time in bed was significantly predictive of lower vocabulary and similarities scores, but variability was not as predictive as mean time in bed. Neither mean time in bed nor the coefficient of variation of time in bed predicted other cognitive or behavioral scores.

CONCLUSIONS

Short or variable time in bed and nightly snoring or higher apnea hypopnea index predicted impaired vocabulary and similarities scores in children with adenotonsillar hypertrophy suspected of having obstructive sleep-disordered breathing. The degree of cognitive impairment attributable to short time in bed and obstructive sleep-disordered breathing is clinically very significant.

Parent-rated behavior problems associated with overweight before and after controlling for sleep disordered breathing

Background

Researchers and clinicians are seeking to develop efficacious behavioral interventions to treat overweight children; however, few studies have documented the behavioral correlates of overweight children in community samples. The goal of this study was to determine the nature and prevalence of behavior problems for overweight school-aged children versus normal weight peers before and after controlling for the effect of sleep disordered breathing.

Methods

Hispanic and Caucasian children were invited to participate in a study of sleep through public elementary school classrooms. Anthropometric evaluation and behavioral ratings were collected for 402 children aged 6–11 years. Overweight was calculated using the Centers for Disease Control age- and gender-specific guidelines. Children were classified as overweight if they were at or above the 95th percentile for their age and gender group. Behavior problems were measured using the Conners' Parent Rating Scales-Revised and the Child Behavior Checklist. Sleep disordered breathing was assessed using in-home overnight polysomnography.

Results

Approximately 15% (59/402) of the sample was classified as overweight. Simple odds ratios indicated that overweight children were more likely to have clinically relevant levels of internalizing symptoms (OR 2.23, CI 1.05–4.72), psychosomatic complaints (OR 2.15, CI 1.02–4.54), withdrawal (OR 4.69, CI 2.05–10.73), and social problems (3.18, 1.53–6.60). When odds ratios were adjusted for level of sleep disordered breathing, withdrawal (OR 3.83 CI 1.59–9.22) and social problems (OR 2.49 CI 1.14–5.44) remained significantly higher for overweight subjects.

Conclusion

After controlling for the effect of sleep disordered breathing, behaviors such as withdrawal and social problems, are common in overweight children and need to be taken into account in the design of interventions and services as they may act to moderate the efficacy of behavioral treatments.

Pharyngeal critical pressure in children with mild sleep-disordered breathing

There is evidence that narrowing or collapse of the pharynx can contribute to obstructive sleep-disordered breathing (SDB) in adults and children. However, studies in children have focused on those with relatively severe SDB who generally were recruited from sleep clinics. It is unclear whether children with mild SDB who primarily have hypopneas, and not frank apnea, also have more collapsible airways. We estimated airway collapsibility in 10 control subjects (9.4 ± 0.5 yr old; 1.9 ± 0.2 hypopneas/h) and 7 children with mild SDB (10.6 ± 0.5 yr old; 11.5 ± 0.1 hypopneas/h) during stable, non-rapid eye movement sleep. None of the subjects had clinically significant enlargement of the tonsils or adenoids, nor had any undergone previous tonsillectomy or adenoidectomy. Airway collapsibility was measured by brief (2-breath duration) and sudden reductions in pharyngeal pressure by connecting the breathing mask to a negative pressure source. Negative pressure applications ranging from −1 to −20 cmH2O were randomly applied in each subject while respiratory airflow and mask pressure were measured. Flow-pressure curves were constructed for each subject, and the x-intercept gave the pressure at zero flow, the so-called critical pressure of the upper airway (Pcrit). Pcrit was significantly higher in children with SDB than in controls (−10.8 ± 2.8 vs. −15.7 ± 1.2 cmH2O; P < 0.05). There were no significant differences in the slopes of the pressure-flow relations or in baseline airflow resistance. These data support the concept that intrinsic pharyngeal collapsibility contributes to mild SDB in children.