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Dye TJ. Clinical Evaluation and Management of Narcolepsy in Children and Adolescents. Semin Pediatr Neurol 2023; 48:101089. [PMID: 38065636 DOI: 10.1016/j.spen.2023.101089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023]
Abstract
While sleepiness is common among children, and particularly adolescents, profound sleepiness in the setting of apparently adequate sleep should prompt consideration of a central disorder of hypersomnolence. These disorders, which include narcolepsy, idiopathic hypersomnia, Kleine-Levin syndrome, and others, are likely underrecognized in the pediatric population. Narcolepsy in particular should be of interest to child neurologists as the unique signs and symptoms of this disease often prompt evaluation in pediatric neurology clinics. While sleepiness may appear to be a straightforward complaint, its evaluation requires a nuanced approach. Cataplexy, a hallmark of narcolepsy, can be confused for other neurologic conditions, though understanding its various manifestations makes it readily identifiable. Clinicians should be aware of these symptoms, as delay in diagnosis and misdiagnosis are common in childhood narcolepsy. While treatment options have been limited in the past, many new therapeutic options have become available and can result in significant improvement in symptoms. Given the age at presentation, paroxysmal and chronic features, diagnostic modalities, and available treatment options, the field of child neurology is well equipped to see patients with narcolepsy. In this review, I will focus on the presentation, evaluation, and management of pediatric patients with narcolepsy.
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Affiliation(s)
- Thomas J Dye
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary - Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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2
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Blattner M, Maski K. Narcolepsy and Idiopathic Hypersomnia. Sleep Med Clin 2023; 18:183-199. [PMID: 37120161 DOI: 10.1016/j.jsmc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Narcolepsy types 1 and 2 and idiopathic hypersomnia are primary Central Nervous System (CNS) disorders of hypersomnolence characterized by profound daytime sleepiness and/or excessive sleep need. Onset of symptoms begins typically in childhood or adolescence, and children can have unique presentations compared with adults. Narcolepsy type 1 is likely caused by immune-mediated loss of orexin (hypocretin) neurons in the hypothalamus; however, the causes of narcolepsy type 2 and idiopathic hypersomnia are unknown. Existing treatments improve daytime sleepiness and cataplexy but there is no cure for these disorders.
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Affiliation(s)
- Margaret Blattner
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Kiran Maski
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, BCH3443, Boston, MA 02115, USA.
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Yu YA. Pediatric Sleep Medicine Cases. CURRENT SLEEP MEDICINE REPORTS 2022; 8:21-32. [PMID: 35345531 PMCID: PMC8943358 DOI: 10.1007/s40675-022-00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 11/13/2022]
Abstract
Purpose of the Review In this review, we will discuss commonly encountered pediatric sleep disorders, their clinical presentations, evaluation, and management. Recent Findings Sleep problems are common complaints in the pediatric population with an estimated prevalence of at least 25%. This review examines frequently seen pediatric sleep disorders including insomnia, obstructive sleep apnea, hypersomnolence, circadian rhythm sleep–wake disorders, parasomnias, and movement disorders. Their clinical manifestations vary, but left untreated, these sleep disorders result in significant impairment. A detailed sleep history is key component in the evaluation process. Other useful tools include sleep diaries, questionnaires, and actigraphy. Polysomnography is often required for diagnosis. Treatment varies depending on the underlying sleep disorder. Pharmacologic treatment is often limited due to the lack of studies of safety and efficacy in the pediatric population. Summary Sleep disorders are commonly encountered in the pediatric population. Their clinical manifestations vary, though without treatment, many result in significant impairment. Detailed sleep history is an essential part of the evaluation process, though polysomnography is often required. Treatment depends on the underlying diagnosis.
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Affiliation(s)
- Yolanda A Yu
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
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Pensato U, Pizza F, Plazzi G. Myasthenic or cataplectic facies? Ice pack test response in paediatric type 1 narcolepsy. Sleep Med 2021; 87:20-21. [PMID: 34508983 DOI: 10.1016/j.sleep.2021.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Umberto Pensato
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy.
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Abstract
PURPOSE OF REVIEW Narcolepsy is a central disorder of hypersomnolence with symptoms of excessive daytime sleepiness, sleep paralysis, and cataplexy. Cataplexy is the sudden loss of muscle tone in either the face, neck, trunk, and/or limbs, leading to a loss of voluntary muscle control. This article reviews recent research on the clinical characteristics of cataplexy. RECENT FINDINGS Longitudinal research in adults suggests that there may be a remission of cataplectic severity after symptom stabilization. First-line treatment options for cataplexy include sodium oxybate and pitolisant, with many drugs such as AXS-12, FT218, and JZP258 under investigation. Patients with cataplexy reported greater limitations of daily activities such as driving and exercise compared to patients without cataplexy. Cataplexy remains a challenge for children and adults with narcolepsy and can interfere with daily activities. There is no cure for narcolepsy, but cataplexy can be well-managed with current and promising new treatment options on the horizon.
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Khalsa S, Qureshi K, Bagshaw AP, Rather A. Late Diagnosis of Narcolepsy With Cataplexy: A Novel Case of Cataplectic Facies Presenting in an Elderly Woman. J Clin Sleep Med 2019; 15:1687-1690. [PMID: 31739861 PMCID: PMC6853393 DOI: 10.5664/jcsm.8042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 11/13/2022]
Abstract
None Cataplectic facies is an unusual feature described in children with narcolepsy and cataplexy. The typical manifestations of cataplectic facies consist of repetitive mouth opening, tongue protrusion, and ptosis. An interesting observation is that the usual emotional triggers associated with cataplexy such as laughter and joking are not always present, thus hampering diagnosis of the underlying syndrome. Cataplectic facies is thought to be a phenomenon observed in the early stages of narcolepsy type 1 and is thought to disappear by the time the patient reaches puberty. We present a unique case of an elderly woman with narcolepsy type 1 demonstrating cataplectic facies. The novel circumstances of this case highlight that facial cataplexy can present later in life, in contrast with previous descriptions that report resolution of cataplectic facies before puberty. Wider recognition of these features throughout the life course may aid in accurate diagnosis and thereby ensure swift access to appropriate treatment.
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Affiliation(s)
- Sakh Khalsa
- Department of Neuropsychiatry, The Barberry National Centre for Mental Health, Birmingham, United Kingdom
- Centre for Human Brain Health and School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Kasim Qureshi
- Department of Neuropsychiatry, The Barberry National Centre for Mental Health, Birmingham, United Kingdom
| | - Andrew P. Bagshaw
- Centre for Human Brain Health and School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Amir Rather
- Department of Neuropsychiatry, The Barberry National Centre for Mental Health, Birmingham, United Kingdom
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Vignatelli L, Antelmi E, Ceretelli I, Bellini M, Carta C, Cortelli P, Ferini-Strambi L, Ferri R, Guerrini R, Ingravallo F, Marchiani V, Mari F, Pieroni G, Pizza F, Verga MC, Verrillo E, Taruscio D, Plazzi G. Red Flags for early referral of people with symptoms suggestive of narcolepsy: a report from a national multidisciplinary panel. Neurol Sci 2018; 40:447-456. [PMID: 30539345 PMCID: PMC6433801 DOI: 10.1007/s10072-018-3666-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/28/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Narcolepsy is a lifelong disease, manifesting with excessive daytime sleepiness and cataplexy, arising between childhood and young adulthood. The diagnosis is typically made after a long delay that burdens the disease severity. The aim of the project, promoted by the "Associazione Italiana Narcolettici e Ipersonni" is to develop Red Flags to detect symptoms for early referral, targeting non-sleep medicine specialists, general practitioners, and pediatricians. MATERIALS AND METHODS A multidisciplinary panel, including patients, public institutions, and representatives of national scientific societies of specialties possibly involved in the diagnostic process of suspected narcolepsy, was convened. The project was accomplished in three phases. Phase 1: Sleep experts shaped clinical pictures of narcolepsy in pediatric and adult patients. On the basis of these pictures, Red Flags were drafted. Phase 2: Representatives of the scientific societies and patients filled in a form to identify barriers to the diagnosis of narcolepsy. Phase 3: The panel produced suggestions for the implementation of Red Flags. RESULTS Red Flags were produced representing three clinical pictures of narcolepsy in pediatric patients ((1) usual sleep symptoms, (2) unusual sleep symptoms, (3) endocrinological signs) and two in adult patients ((1) usual sleep symptoms, (2) unusual sleep symptoms). Inadequate knowledge of symptoms at onset by medical doctors turned out to be the main reported barrier to diagnosis. CONCLUSIONS This report will hopefully enhance knowledge and awareness of narcolepsy among non-specialists in sleep medicine in order to reduce the diagnostic delay that burdens patients in Italy. Similar initiatives could be promoted across Europe.
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Affiliation(s)
- L Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - E Antelmi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - I Ceretelli
- Associazione Italiana Narcolettici e Ipersonni (AIN), Florence, Italy
| | - M Bellini
- Azienda USL Toscana centro Sedi di Prato, Prato, Italy
| | - C Carta
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - P Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - L Ferini-Strambi
- Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R Ferri
- Sleep Research Centre, Department of Neurology I.C., Oasi Research Institute - IRCCS, Troina, Italy
| | - R Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - F Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - V Marchiani
- Child Neuropsychiatric Unit, Polyclinic S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - F Mari
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - G Pieroni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - F Pizza
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - M C Verga
- Primary Care Pediatrics, ASL Salerno, Vietri sul Mare, SA, Italy
| | - E Verrillo
- Sleep and Long Term Ventilation Unit, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Academic Department of Pediatrics (DPUO) Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - D Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy.
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Plazzi G, Clawges HM, Owens JA. Clinical Characteristics and Burden of Illness in Pediatric Patients with Narcolepsy. Pediatr Neurol 2018; 85:21-32. [PMID: 30190179 DOI: 10.1016/j.pediatrneurol.2018.06.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/19/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Narcolepsy is a chronic and lifelong neurologic disorder with onset commonly occurring in childhood or adolescence, and affecting approximately 0.025% to 0.05% of the general population. The primary symptom is excessive daytime sleepiness, which is accompanied by cataplexy in 70% of patients. Other common symptoms include sleep paralysis, hallucinations upon falling asleep or waking, and disrupted nocturnal sleep. Narcolepsy is associated with a considerable burden of illness (BOI), which has been well characterized in adults, and is exacerbated by delays in symptom recognition, diagnosis, and intervention. METHODS This review describes the specific characteristics and BOI of pediatric narcolepsy, using a wide range of published research data. RESULTS Pediatric narcolepsy presents distinct challenges in diagnosis and management. Narcolepsy symptoms often initially manifest differently in children and adolescents versus adults, which may pose diagnostic dilemmas. Children often respond to sleepiness with irritability, hyperactivity, and poor attention, which may be misinterpreted as misbehavior or neurocognitive sequelae of other conditions. Pediatric cataplexy symptoms may include subtle and unusual facial expressions or choreic-like movements, which are not observed in adults. Insufficient sleep and circadian rhythm disorders presenting with excessive daytime sleepiness are common in adolescents, potentially confounding narcolepsy diagnosis. Pediatric narcolepsy is also associated with comorbidities including rapid weight gain, precocious puberty, and attention deficit hyperactivity disorder, and increased risk for deficits in social functioning, depression, and anxiety. School performance is also typically impaired, requiring special education services. CONCLUSIONS Thus, the discrete BOI of pediatric narcolepsy underscores the need for prompt and accurate diagnosis, and appropriate treatment of this disorder.
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Affiliation(s)
- Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
| | - Heather M Clawges
- Department of Pediatrics, Sleep Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WestVirginia
| | - Judith A Owens
- Division of Neurology, Boston Children's Hospital, Harvard Medical School, Waltham, Massachusetts
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Abstract
Sleepiness is not uncommon in the pediatric population. Although the etiology can be multifactorial, sleepiness due to increased sleep drive, also called central hypersomnia, is a common cause. The third edition of the International Classification of Sleep Disorders updated the diagnostic criteria for several of the central disorders of hypersomnolence, most notably narcolepsy. Although the International Classification Of Sleep Disorders-3 is not specific to pediatric patients, the peak incidence for many of the included disorders occurs during childhood or adolescence. As a result, recognition of these lifelong and potentially debilitating disorders is imperative for providers who evaluate pediatric patients. This review provides an update on recent advances in the field and highlights some of the diagnostic dilemmas, unique clinical features, and variable presentations associated with central disorders of hypersomnolence within the pediatric population.
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Affiliation(s)
- Thomas J Dye
- Division of Neurology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH.
| | - Sejal V Jain
- Division of Neurology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH
| | - Sanjeev V Kothare
- Department of Neurology, NYU Langone Medical Center, New York, NY; Pediatric Sleep Program, Comprehensive Epilepsy & Sleep Center, NYU Langone Medical Center, New York, NY
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Babiker MOE, Prasad M. Narcolepsy in children: a diagnostic and management approach. Pediatr Neurol 2015; 52:557-65. [PMID: 25838042 DOI: 10.1016/j.pediatrneurol.2015.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To provide a diagnostic and management approach for narcolepsy in children. METHODS Narcolepsy is a chronic disabling disorder characterized by excessive daytime sleepiness, cataplexy, hypnogogic and/or hypnopompic hallucinations, and sleep paralysis. All four features are present in only half of the cases. Excessive daytime sleepiness is the essential feature of narcolepsy at any age and is usually the first symptom to manifest. A combination of excessive daytime sleepiness and definite cataplexy is considered pathognomonic of narcolepsy syndrome. RESULTS New treatment options have become available over the past few years. Early diagnosis and management can significantly improve the quality of life of patients with narcolepsy with cataplexy. CONCLUSION This review summarizes the pathophysiology, clinical features, and management options for children with narcolepsy.
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Affiliation(s)
- Mohamed O E Babiker
- Fraser of Allander Neurosciences Unit, Royal Hospital of Sick Children, Glasgow, UK
| | - Manish Prasad
- Department of Paediatric Neurology, Leicester Royal Infirmary, Leicester, UK.
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