SLEEP ABNORMALITIES AND POLYSOMNOGRAPHIC PROFILE IN CHILDREN WITH DRUG-RESISTANT EPILEPSY

Factors associated with poor sleep in children with drug-resistant epilepsy

OBJECTIVE

We aimed to investigate sleep in children with drug-resistant epilepsy (DRE), including developmental and epileptic encephalopathies (DEEs). Next, we examined differences in sleep macrostructure and microstructure and questionnaire outcomes between children with well-controlled epilepsy (WCE) and children with DRE. Furthermore, we wanted to identify factors associated with poor sleep outcome in these children, as some factors might be targets to improve epilepsy and neurodevelopmental outcomes.

METHODS

A cross-sectional study was conducted in children 4 to 18-years-old. Children without epilepsy, with WCE, and with DRE were included. Overnight electroencephalography (EEG), including chin electromyography and electrooculography, to allow sleep staging, was performed. Parents were asked to fill out a sleep questionnaire. Classical five-stage sleep scoring was performed manually, spindles were automatically counted, and slow wave activity (SWA) in the first and last hour of slow wave sleep was calculated.

RESULTS

One hundred eighty-two patients were included: 48 without epilepsy, 75 with WCE, and 59 with DRE. We found that children with DRE have significantly lower sleep efficiency (SE%), less time spent in rapid eye movement (REM) sleep, fewer sleep spindles, and a lower SWA decline over the night compared to children with WCE. Subjectively more severe sleep problems were reported by the caregivers and more daytime sleepiness was present in children with DRE. Least absolute shrinkage and selection operator (LASSO) regression showed that multifocal interictal epileptiform discharges (IEDs), benzodiazepine treatment, and longer duration of epilepsy were associated with lower SE% and lower REM sleep time. The presence of multifocal discharges and cerebral palsy was associated with fewer spindles. Benzodiazepine treatment, drug resistance, seizures during sleep, intellectual disability, and older age were associated with lower SWA decline.

SIGNIFICANCE

Both sleep macrostructure and microstructure are severely impacted in children with DRE, including those with DEEs. Epilepsy parameters play a distinct role in the disruption REM sleep, spindle count, and SWA decline.

Sleep and Its Disturbance in Parents of Children and Adolescents with Epilepsy: A Systematic Review and Meta-Analysis

Sleep disturbances are commonly reported by parents of children and adolescents with epilepsy. However, evidence synthesis including quality and quantity of sleep in parents of children and adolescents with epilepsy is lacking. This systematic review and meta-analysis was conducted to quantify pooled mean estimates of parental sleep variables and to determine the prevalence of sleep disturbances in parents of children and adolescents with epilepsy. Five electronic databases, PubMed, Medline, Embase, PsychINFO, and CINAHL, were systematically searched from inception to September 2021. Eleven observational studies examining parents of pediatric patients aged <18 years with epilepsy using a quantitative measure of sleep duration, sleep quality, or sleep disturbance were reviewed. Our results showed that the pooled nocturnal sleep duration was 5.93 hours (95% CI: 4.64 to 7.21 hours). Overall sleep quality as estimated by the bias-adjusted pooled Pittsburgh Sleep Quality Index total score was 6.65 (95% CI: 5.98 to 7.33). Parents of children with epilepsy had significantly higher Pittsburgh Sleep Quality Index total scores compared to parents of healthy children (differences in means 1.84, 95% CI: 1.29 to 2.39). The pooled estimated prevalence of parental sleep disturbances was 58.1% (95% CI: 45.7% to 69.6%). Our findings demonstrate a high prevalence of sleep disturbances with poor sleep quality and substantial reductions in sleep time in parents of children and adolescents with epilepsy. Healthcare professionals in pediatric neurology clinics should proactively initiate screening for sleep disturbances in parents of children and adolescents with epilepsy and refer parents to a sleep specialist when necessary.

The Relationship Between Sleep, Epilepsy, and Development: a Review

PURPOSE OF REVIEW

To review the relationship between sleep, neurodevelopment, and epilepsy and potential underlying physiological mechanisms.

RECENT FINDINGS

Recent studies have advanced our understanding of the role of sleep in early brain development and epilepsy. Epileptogenesis has been proposed to occur when there is a failure of normal adaptive processes of synaptic and homeostatic plasticity. This sleep-dependent transformation may explain the cognitive impairment seen in epilepsy, especially when occurring early in life. The glymphatic system, a recently discovered waste clearance system of the central nervous system, has been described as a potential mechanism underlying the relationship between sleep and seizures and may account for the common association between sleep deprivation and increased seizure risk. Epilepsy and associated sleep disturbances can critically affect brain development and neurocognition. Here we highlight recent findings on this topic and emphasize the importance of screening for sleep concerns in people with epilepsy.

Sleep in children with refractory epilepsy and epileptic encephalopathies: A systematic review of literature

Children with epilepsy have more sleep disorders compared to healthy children. The bidirectional interaction between epilepsy and sleep is not completely understood. However, disruption of sleep architecture during childhood may have consequences for cognitive development. As children with drug-refractory epilepsy often have intellectual disability, sleep disruption could be an important contributing factor in severity of their cognitive impairment. To better understand these interactions, sleep architecture in children with drug-refractory epilepsy and epileptic encephalopathies should be investigated. In this review, we conducted a systematic literature search on this topic. Articles that investigated sleep macro- and/or microstructure by means of electroencephalogram/polysomnography were included, as well as articles that used validated questionnaires. Sixteen articles were reviewed, eight of which used polysomnography. Only 2 articles examined sleep in children with epileptic encephalopathies. Consistent findings on measures of sleep architecture were a reduction in REM percentage and an increase in sleep fragmentation when comparing drug-refractory patients with non-refractory and healthy subjects. The findings on slow wave sleep were less clear. Studies with questionnaires unambiguously confirmed subjectively more sleep problems in children with drug-refractory epilepsy. This is the first review of literature in this patient population. More good quality sleep studies in children with drug-refractory epilepsy are warranted. The use of wearables in the home setting together with automatic sleep staging could provide more insights.

Parent-Reported Sleep Profile of Children With Early-Life Epilepsies

BACKGROUND

Sleep comorbidities are common, and sometimes severe, for children with early-life epilepsies (ELEs). Yet, there is a paucity of data regarding the profile of these sleep disturbances and their complications.

METHODS

Participants registered with the Rare Epilepsy Network (REN) were queried about sleep via online questionnaires. Descriptive statistics and logistic regression were performed.

RESULTS

Median age of the 356 children was 56 months (interquartile range 30 to 99), 56% were female, and 53% (188/356) endorsed a sleep concern. Frequent nighttime awakenings (157 of 350; 45%), difficulty falling asleep (133 of 350; 38%), and very restless sleep (118 of 345; 34%) were most endorsed. Nocturnal seizures were associated with sleep concerns and were reported in 75% (268 of 356) of children. Of the children with nocturnal seizures, 56% (118 of 268) had sleep concerns. Of the children without nocturnal seizures, 43% (38 of 88) had sleep concerns. Sleep concerns were most common in dup15q syndrome (16 of 19; 84%). Children aged 4 to ≤10 years (adjusted odds ratio [aOR] 16.1; 95% confidence interval [CI] 2.0, 131.0) and 10 to <13 years (aOR 22.2; 95% CI 2.6, 188.6) had a greater odds of having a sleep concern compared with children aged ≤6 months. Female sex appeared protective for sleep concerns (aOR 0.6; 95% CI 0.4, 0.9). The association between sleep concerns and nocturnal seizures was weaker when adjusted for sex and age category in a logistic regression model.

CONCLUSIONS

Reported sleep concerns are highly prevalent in children with ELEs and persist with age, in contrast to what is expected in healthy children. There may be unmet sleep-related clinical needs in children with ELEs.

Drug-Resistant Epilepsy and Obstructive Sleep Apnea: Exploring a Link Between the Two

Drug-resistant epilepsy accounts for approximately one third of all epilepsy cases; yet its exact etiopathogenesis still remains under intense exploration. Several factors have been advocated for predicting drug resistance in patients with epilepsy. Obstructive sleep apnea (OSA) is a commonly prevalent sleep disorder that exhibits a bidirectional and strong comorbidity with epilepsy. The exact pathophysiology of this comorbidity is not yet clearly explained. This study analyzes the relationship between drug-resistant epilepsy and OSA, and the findings indicate a strong role of rapid eye movement sleep (REMS) in the pathogenesis of this relationship. It also emerges from the study that REMS reduction is a prominent feature of OSA, and drug resistance in patients with epilepsy and treatment of OSA has been shown to restore REMS in several studies with concomitant improvement in seizure control.

Characterization of aEEG During Sleep and Wakefulness in Healthy Children

INTRODUCTION

Interpretation of amplitude-integrated EEG (aEEG) is hindered by lacking knowledge on physiological background patterns in children. The aim of this study was to find out whether aEEG differs between wakefulness and sleep in children.

METHODS

Forty continuous full-channel EEGs (cEEG) recorded during the afternoon and overnight in patients <18 years of age without pathologies or only solitary interictal epileptiform discharges were converted into aEEGs. Upper and lower amplitudes of the C3-C4, P3-P4, C3-P3, C4-P4, and Fp1-Fp2 channels were measured during wakefulness and sleep by two investigators and bandwidths (BW) calculated. Sleep states were assessed according to the American Academy of Sleep Medicine. Median and interquartile ranges (IQR) were calculated to compare the values of amplitudes and bandwidth between wakefulness and sleep.

RESULTS

Median age was 9.9 years (IQR 6.1-14.7). All patients displayed continuous background patterns. Amplitudes and BW differed between wakefulness and sleep with median amplitude values of the C3-C4 channel 35 μV (IQR: 27-49) for the upper and 13 μV (10-19) for the lower amplitude. The BW was 29 μV (21-34). During sleep, episodes with high amplitudes [upper: 99 μV (71-125), lower: 35 μV (25-44), BW 63 μV (44-81)] corresponded to sleep states N2-N3. High amplitude-sections were interrupted by low amplitude-sections, which became the longer toward the morning [upper amplitude: 39 μV (30-51), lower: 16 μV (11-20), BW 23 μV (19-31)]. Low amplitude-sections were associated with sleep states REM, N1, and N2. With increasing age, amplitudes and bandwidths declined.

CONCLUSION

aEEGs in non-critically ill children displayed a wide range of amplitudes and bandwidths. Amplitudes were low during wakefulness and light sleep and high during deep sleep. Interpretation of pediatric aEEG background patterns must take into account the state of wakefulness in in clinical practice and research.