First night effect for polysomnographic data in children and adolescents with suspected sleep disordered breathing

Longitudinal association between short sleep, body weight, and emotional and learning problems in Hispanic and Caucasian children

STUDY OBJECTIVE

To determine the impact of lower amounts of childhood sleep assessed by polysomnogram on development of obesity, being anxious or depressed, or having learning problems 5 years later.

DESIGN

Prospective cohort.

PARTICIPANTS

Subjects were 304 community participants from the Tucson Children's Assessment of Sleep Apnea study, aged 6-12 years old at baseline.

MEASUREMENTS AND RESULTS

Children were classified according to baseline sleep as those who slept ≥ 9 h/night, those who slept > 7.5 to < 9 h/night, and those who slept ≤ 7.5 h/night. Odds of overweight/obese (≥ 85(th) BMI percentile), obese (≥ 95(th) BMI percentile), anxious or depressed, and learning problems at follow-up were assessed according to baseline sleep categories. Children who slept ≤ 7.5 h/night had higher odds of being obese (OR = 3.3, P < 0.05) at follow-up than children who slept ≥ 9 h/night. Borderline significance for overweight/obese (OR = 2.2, P < 0.1), anxious or depressed (OR = 3.3, P < 0.1), and having learning problems (OR = 11.1, P < 0.1) were seen for children who slept ≤ 7.5 h/night as compared to those who slept ≥ 9 h/night. A mean increase in BMI of 1.7 kg/m(2) (P = 0.01) over the 5 years of follow-up was seen for children who slept ≤ 7.5 h/night compared to those who slept ≥ 9 h/night. These relationships did not differ between Hispanic and Caucasian children.

CONCLUSIONS

Children with reduced amounts of sleep (≤ 7.5 h/night) had an increased risk for higher body weight in early adolescence. Similarly, children who slept ≤ 7.5 h/night had higher risk of being anxious or depressed or having learning problems in early adolescence.

Sleep architecture and behavioral abnormalities in children and adolescents

OBJECTIVE

To investigate the association between sleep disordered breathing (SDB) and parent report of attention and behavioral problems in children, as well as the association between sleep stage duration and measures of child functioning in a clinically referred sample.

METHODS

A chart review was conducted of 95 children with clinical history of SDB who completed an overnight polysomnography study in a pediatric sleep laboratory. Child functioning was assessed at the time of the sleep study by parent report on the Child Behavior Checklist (CBCL). The apnea hypopnea index was used as a measure of SDB severity.

RESULTS

The apnea hypopnea index was associated with externalizing behavior, but not attention problems on the CBCL. In children 2-3 years old, stage 4 sleep duration was associated with externalizing behavior. In children 4-16 years old, REM sleep duration was associated with externalizing behavior.

CONCLUSIONS

Children with increased SDB severity may be at greater risk for behavioral problems. Differences between the association of sleep stages and externalizing behavior in toddlers compared with older children suggests possible developmental differences in the association between sleep and behavior.

Sleep assessments in healthy school-aged children using actigraphy: concordance with polysomnography

Actigraphic (ACT) recordings are used widely in schoolchildren as a less intrusive and more extended approach to evaluation of sleep problems. However, critical assessment of the validity and reliability of ACT against overnight polysomnography (NPSG) are unavailable. Thus, we explored the degree of concordance between NPSG and ACT in school-aged children to delineate potential ACT boundaries when interpreting pediatric sleep. Non-dominant wrist ACT was recorded simultaneously with NPSG in 149 healthy school-aged children (aged 4.1-8.8 years, 41.7% boys, 80.4% Caucasian) recruited from the community. Analyses were limited to the Actiware (MiniMitter-64) calculated parameters originating from 1-min epoch sampling and medium sensitivity threshold value of 40; i.e. sleep period time (SPT), total sleep time (TST) and wake after sleep onset (WASO). SPT was not significantly different between ACT and NPSG. However, ACT underestimated TST significantly by 32.2±33.4 min and overestimated WASO by 26.3±34.4 min. The decreased precision of ACT was also evident from moderate to small concordance correlation coefficients (0.47 for TST and 0.09 for WASO). ACT in school-aged children provides reliable assessment of sleep quantity, but is relatively inaccurate during determination of sleep quality. Thus, caution is advocated in drawing definitive conclusions from ACT during evaluation of the sleep-disturbed child.

Many parents report their child's breathing and sleep patterns during overnight sleep study as atypical

Many parents report their child's breathing and sleep patterns during overnight sleep study as atypical.

OBJECTIVE

To determine how closely parents/guardians of children undergoing polysomnography (PSG) felt the breathing and sleep patterns observed during PSG resembled those typically seen at home.

METHODS AND SUBJECTS

Retrospective chart and post-PSG questionnaire review of 200 consecutive PSGs.

RESULTS

In all, 19 questionnaires were not completed, and 5 were only partially completed. A total of 115 respondents (64.2%) described the child's breathing patterns as "typical," 6 (3.4%) as "louder," and 58 (32.4%) as "quieter" than usual. Overall 69 respondents (38.7%) described the child's sleep as "typical," 45 (25.2%) as "more restless," and 21 (11.8%) as "better" than usual; 45 respondents (25.2%) described a longer and 16 (9%) a shorter sleep latency than usual.

CONCLUSION

Many respondents felt their child's breathing (35.8%) and sleeping (61.3%) patterns the night of the PSG did not reflect those usually seen at home, raising questions about how representative of normal breathing and sleep patterns those seen in the sleep lab truly are.

Sleep disorders in succinic semialdehyde dehydrogenase deficiency: a family report

BACKGROUND

Succinic semialdehyde dehydrogenase deficiency (SSADH) is a rare neurometabolic disorder involving the degradation of gamma-aminobutyric acid. Clinically, SSADH deficiency causes progressive or static encephalopathy with late infantile to early childhood onset. It is known that sleep disorders are a common clinical finding in these patients. However, very few studies have investigated sleep disorders with polysomnographies.

AIM OF THE STUDY

To analyze sleep disorders breathing, sleep architecture and paroxysmal EEG activity through polysomnographic recordings of two siblings suffering from SSADH deficiency

METHOD

Each patient underwent laboratory diurnal and overnight video-polysomnographic recordings in a room specially dedicated to mothers and their children.

RESULTS

The background EEG activity during quiet wakefulness consisted in abnormal, diffuse, low-voltage, disorganized slow theta waves. In both patients there was a general disorganisation of the sleep architecture with an increase of light sleep and a decrease of REM sleep. In patient 1, during sleep, there were 36 hypopneas, 13 central apneas and one obstructive apnea with a variable duration of 7-30s. The apnea/hypopnea index (AHI) was 7/h and oxygen saturation dropped to 80% during the respiratory events. In patient 2, the respiratory events consisted in 8 central apneas and 23 hypopneas of 6-20s; no obstructive apneas or hypopneas were observed. The oxygen saturation dropped to 90% during the apneas and the AHI was 5/h.

CONCLUSION

Sleep-disordered breathing (SDB) is a common finding in patients with SSADH deficiency and polysomnography recording is a useful tool for its diagnosis.

Utility of subjective sleep assessment tools for healthy preschool children: a comparative study between sleep logs, questionnaires, and actigraphy

Background

Sleep pattern is an important factor in a child’s mental, behavioural and physical status. To evaluate the sleep patterns of children, subjective tools such as sleep logs and questionnaires are still widely used in addition to objective methods of sleep assessment. Despite the established correlation between subjective and objective sleep variables, the characteristic features of subjective assessment have not been elucidated.

Methods

To investigate the characteristics of parental sleep assessment (daily sleep log and brief questionnaire) in preschool children, a 7-day actigraphic sleep study was conducted in 48 healthy 5-year-old children.

Results

Sleep schedule variables in the parental reports generally correlated well with actigraphic assessment of sleep patterns; however, sleep periods were longer in parental reports than in actigraphic recordings. Although the daily sleep log was better correlated with actigraphy, the brief questionnaire showed a good correlation with sleep pattern on weekday actigraphic assessments. Parental reports recorded fewer than 10% of the night wakings recorded by actigraphy.

Conclusions

Subjective sleep assessments remain useful, although their utility depends on the purpose and size of the study in question. However, knowledge of the potential biases and characteristics of such assessments is essential for correct interpretation of the data.

Evaluation of sham-CPAP as a placebo in CPAP intervention studies

STUDY OBJECTIVES

To evaluate the use of sham-continuous positive airway pressure (CPAP) treatment as a placebo intervention.

DESIGN AND SETTING

Analysis of polysomnograms performed in fixed order without sham-CPAP and on the first night of the sham-CPAP intervention in participants in the CPAP Apnea Trial North American Program (CATNAP), a randomized, placebo controlled trial evaluating the effects of CPAP treatment on daytime function in adults with newly diagnosed mild to moderate obstructive sleep apnea (apnea hypopnea index (AHI) 5-30).

PARTICIPANTS

The first 104 CATNAP participants randomized to the sham-CPAP intervention arm.

MEASUREMENTS AND RESULTS

Compared to the polysomnographic measures without sham-CPAP, the study on the first night with sham-CPAP had statistically significant differences that suggested a decrease in sleep quality: decreased sleep efficiency, increased arousal index, increased time in stage 1 NREM sleep, and prolonged latency to REM sleep. However, all of these differences had a relatively small effect size. Compared to the polysomnogram without sham-CPAP, the number of hypopneas on the sham-CPAP polysomnogram was significantly increased and the number of apneas significantly decreased. Relatively minor differences in AHI with and without sham-CPAP were present and were dependent on the criteria used to score hypopneas.

CONCLUSION

Comparison of polysomnograms with and without sham-CPAP revealed differences that, although statistically significant, were small in magnitude and had relatively low effect sizes suggesting minimal clinical significance. The results support the use of sham-CPAP as a placebo intervention in trials evaluating the effects of CPAP treatment in patients with obstructive sleep apnea.

CLINICAL TRIAL INFORMATION

This paper was a secondary analysis of clinical trial data. CATNAP: CPAP Apnea Trial North American Program, the trial from which the data were obtained, is registered with clinicaltrial.gov. Registration #NCT00089752.

Sleep staging and respiratory events in refractory epilepsy patients: Is there a first night effect?

PURPOSE

We performed this analysis of possible first night effects (FNEs) on sleep and respiratory parameters in order to evaluate the need for two serial night polysomnograms (PSGs) to diagnose obstructive sleep apnea (OSA) in epilepsy patients.

METHODS

As part of a pilot multicenter clinical trial investigating the effects of treating sleep apnea in epilepsy, two nights of PSG recording were performed for 40 patients with refractory epilepsy and OSA symptoms. Sleep architecture was examined in detail, along with respiratory parameters including apnea/hypopnea index (AHI) and minimum oxygen saturation. Analysis included two-tailed t-tests, Wilcox sign rank analysis, and Bland Altman measures of agreement.

RESULTS

Total sleep time differed between the two nights (night 1,363.8 min + 59.4 vs. 386.3 min + 68.6, p = 0.05). Rapid eye movement (REM) sleep and percentage of REM sleep were increased during night two (night 1: 12.3% + 5.9 vs. night 2: 15.5% + 6.2, p = 0.007), and the total minutes of slow-wave sleep (SWS) were increased (night 1: 35.6 + 60.7 vs. night 2: 46.4 + 68.1, p = 0.01). No other sleep or respiratory variables differed between the two nights. Given an AHI inclusion criterion of five apneas per hour, the first PSG identified all but one patient with OSA.

DISCUSSION

Respiratory parameters showed little variability between the first and second nights. Sleep architecture was mildly different between the first and second PSG night. Performing two consecutive baseline PSGs to diagnose OSA may not be routinely necessary in this population.

Sleep-EEG patterns of school children suffering from symptoms of depression compared to healthy controls

Depression in children is often an elusive disorder and its diagnostic tools are a matter of controversy. Several scales have been developed in an attempt to specifically detect some of the major aspects of depression, i.e. anhedonia, sadness, hopelessness. On the other hand, in adults depression frequently induces changes in sleep patterns, particularly a shortening in REM sleep latency. The alteration of sleep patterns in depressed children has been a matter of controversy. It is possible that a diagnostic deficiency might be the source of the contradictory reports. In the present study, The Child Depression Inventory, a rating scale specifically developed for child depression was applied to 396 school children (8-12 years of age). Nearly 15% of the children (N = 45) obtained scores higher than the established limit in this test for normal healthy subjects. A sample of children found within the highest (N = 25) and within the lowest (N = 25) scores in the scale were selected. After a clinical evaluation, only those who meet the inclusion criteria (N = 21 for depressed and N = 7 for healthy controls) were electroencephalographically recorded. Children with depressive symptoms showed a significant shortening in REM sleep latency (mean = 108 min) when compared to non-depressed (mean = 150 min). In addition, significant increases were observed in sleep latency, REM sleep duration and the number of awakenings. Furthermore, results showed an unexpected high frequency of EEG abnormalities in children with depressive symptoms (75%) characterized by sharp waves and polyspikes in the frontal region. The present results support the notion that depression, in children, is accompanied by changes in sleep patterns, mainly concerning REM sleep.

Obstructive sleep apnea, seizures, and childhood apraxia of speech

Associations between obstructive sleep apnea and motor speech disorders in adults have been suggested, though little has been written about possible effects of sleep apnea on speech acquisition in children with motor speech disorders. This report details the medical and speech history of a nonverbal child with seizures and severe apraxia of speech. For 6 years, he made no functional gains in speech production, despite intensive speech therapy. After tonsillectomy for obstructive sleep apnea at age 6 years, he experienced a reduction in seizures and rapid growth in speech production. The findings support a relationship between obstructive sleep apnea and childhood apraxia of speech. The rather late diagnosis and treatment of obstructive sleep apnea, especially in light of what was such a life-altering outcome (gaining functional speech), has significant implications. Most speech sounds develop during ages 2-5 years, which is also the peak time of occurrence of adenotonsillar hypertrophy and childhood obstructive sleep apnea. Hence it is important to establish definitive diagnoses, and to consider early and more aggressive treatments for obstructive sleep apnea, in children with motor speech disorders.

Iron deficiency anemia in infancy is associated with altered temporal organization of sleep states in childhood

The highest prevalence of iron deficiency anemia (IDA) in infancy coincides with a time of rapid changes in sleep organization. Since IDA in infancy is associated with long-lasting neurofunctional effects despite iron treatment, the normal development of sleep patterns might be affected. Night polysomnographic recordings were performed in 55 healthy 4-y-old children (former IDA = 27, nonanemic controls = 28). Both groups were followed from infancy and were similar in background characteristics. The duration of each waking episode was measured, as was the duration of each episode of nonrapid eye movement (NREM) sleep stages 1 (NREM1), 2 (NREM2), and 3-4 (SWS), and rapid eye movement (REM) sleep. The data were analyzed according to the successive thirds of the total sleep time (TST). Relative to controls, former IDA children showed: a) longer duration of REM sleep episodes in the first third and shorter in the last third; b) more REM sleep episodes in the first third and fewer in the second third; and c) shorter latency to the first REM sleep episode and shorter NREM stage 2 and SWS episodes within the first sleep cycle. The results show that early IDA is associated with long-lasting alterations in the temporal organization of sleep patterns.

Reference values for sleep-related respiratory variables in asymptomatic European children and adolescents

AIM

Only a limited number of studies, designed to establish normal values for sleep-related respiratory variables in children, have been reported, and all are non-European. The aim of this study was to expand the knowledge on normative data in children.

METHODS

Subjects ranging from 6 to 16 years were recruited and underwent full polysomnography. Only subjects without sleep disordered breathing or other sleep problems as assessed by clinical history were included.

RESULTS

Sixty subjects were studied (<age> = 11.7 +/- 2.6 years; 28 boys; <relBMI> = 118.8 +/- 30.6%). <Central apnea index> was 0.85 +/- 1.06 (range: 0.0-5.5). <Obstructive apnea index> was 0.06 +/- 0.16 (range: 0.0-0.9); 11 patients had a total of 31 obstructive apneas. Only five obstructive hypopneas were detected with <obstructive apnea hypopnea index> = 0.08 +/- 0.17 (range: 0.0-0.9). <Respiratory disturbance index> was 1.98 +/- 1.39 (range: 0.1-7.2). <SaO2> was 97.0 +/- 0.6% (range: 96.0-98.0); <SaO2nadir> was 91.8 +/- 2.7% (range: 82.0-96.0); <% of total sleep time with SaO2 >or= 95%> was 98.7 +/- 2.1% (range: 90.8-100.0); <oxygen desaturation index> was 0.8 +/- 0.9 (range: 0.0-4.9) and <arousal index> was 6.1 +/- 1.8 (range: 2.7-10.9). Snoring was detected in 15 patients (4 overweight subjects), with no difference in patient characteristics and sleep-related respiratory variables between snorers and non-snorers. Subjects in the overweight group (n = 22) had a lower SaO2nadir (90.8 +/- 2.7 vs. 92.4 +/- 2.6; P = 0.01) and a higher ODI (1.3 +/- 1.3 vs. 0.4 +/- 0.4; P = 0.0002) than their normal weight peers.

CONCLUSION

Our data are in agreement with other non-European studies, designed to establish normal values in children.