Prevalence of EEG paroxysmal activity in a population of children with obstructive sleep apnea syndrome

Transvenous phrenic nerve stimulation for treating central sleep apnea may regulate sleep microstructure

STUDY OBJECTIVES

To assess the impact of transvenous phrenic nerve stimulation (TPNS) on non-rapid eye movement sleep microstructure quantified by cyclic alternating pattern (CAP) in individuals with central sleep apnea (CSA).

METHODS

We analyzed baseline and 6-month follow-up overnight polysomnograms (PSG) in 134 CSA patients enrolled in the remedē System Pivotal Trial implanted with TPNS randomized (1:1) to neurostimulation (treatment group) or no stimulation (control group). Differences in CAP rate, A1 index, and A2+A3 index between study arms at follow-up were assessed using Analysis of Covariance adjusted for baseline values.

RESULTS

On follow-up PSG, the treatment group showed a decrease in the frequency of A2+A3 phases compared to controls (-5.86 ± 11.82 vs. 0.67 ± 15.25, p = 0.006), while the frequency of A1 phases increased more in the treatment group (2.57 ± 11.67 vs. -2.47 ± 10.60, p = 0.011). The change in CAP rate at follow-up was comparable between study arms.

CONCLUSIONS

TPNS treatment for central sleep apnea may affect sleep microstructure. Brief phases of rapid cortical activity appear to be replaced by short phases of slower cortical activity, which may promote sleep continuity. Further investigations are warranted to elucidate the mechanisms underlying the effect of TPNS on CAP.

The interaction between circadian rhythm and epilepsy

Evidence about the interaction between circadian rhythms (CR) and epilepsy has been expanded with the application of advanced detection technology. An adequate understanding of how circadian system and epilepsy interact with each other could contribute to more accurate seizure prediction as well as rapid development of potential treatment timed to specific phases of CR. In this review, we present the reciprocal relationship between CR and epileptic activities from aspects of sleep effect, genetic modulation and brain biochemistry. It has been found that sleep-wake patterns, circadian timing systems and multidien rhythms have essential roles in seizure activities and interictal epileptiform discharge (IED). For instance, specific distribution patterns of seizures and IED have been reported, i.e., lighter non-rapid eye movement (NREM) sleep stage (stage 2) induces seizures while deeper NREM sleep stage (stage 3) activates IEDs. Furthermore, the epilepsy type, seizure type and seizure onset zone can significantly affect the rhythms of seizure occurrence. Apart from the common seizure types, several specific epilepsy syndromes also have a close correlation with sleep-wakefulness patterns. Sleep influences the epilepsy rhythm, and conversely, epilepsy alters the sleep rhythm through multiple pathways. Clock genes accompanied by two feedback loops of regulation have an important role in cortical excitability and seizure occurrence, which may be involved in the mTORopathy. The suprachiasmatic nuclei (SCN) has a rhythm of melatonin and cortisol secretion under the circadian pattern, and then these hormones can feed back into a central oscillator to affect the SCN-dependent rhythms, leading to variable but prominent influence on epilepsy. Furthermore, we discuss the precise predictive algorithms and chronotherapy strategies based on different temporal patterns of seizure occurrence for patients with epilepsy, which may offer a valuable indication for non-invasive closed-loop treatment system. Optimization of the time and dose of antiseizure medications, and resynchronization of disturbed CR (by hormone therapy, light exposure, ketogenic diet, novel small molecules) would be beneficial for epileptic patients in the future. Before formal clinical practice, future large-scale studies are urgently needed to assist prediction and treatment of circadian seizure activities and address unsolved restrictions.

Sleep microstructure in attention deficit hyperactivity disorder according to the underlying sleep phenotypes

The analysis of sleep microstructure in attention deficit hyperactivity disorder (ADHD) revealed an under-representation of the EEG slow component during NREM sleep. Previous studies either excluded or did not characterize objectively sleep disorders, which notoriously affect sleep architecture. The present study aimed to investigate the cyclic alternating pattern in a real clinical sample of children with ADHD, in whom sleep disorders could be considered. Twenty-seven consecutively enrolled drug-naïve children (mean age, 10.53 years; nine females) and 23 controls (mean age, 10.22 years; 11 females) underwent a full sleep investigation, including attended video-polysomnography. Visual cyclic alternating pattern analysis was performed in a blinded way. Children with ADHD had one or more sleep disorders (a narcolepsy-like phenotype was found in two cases, sleep onset insomnia in three cases, arousal disorder in one case, movement disorder phenotype in six cases and obstructive sleep apnea in 11 cases, and six children had sleep-related epileptiform discharges). Children with ADHD and normal controls showed a similar microstructure with a cyclic alternating pattern rate of about 50%. Children with obstructive sleep apnea had a significantly higher cyclic alternating pattern rate during stage N3. Despite not reaching statistical differences, a lower cyclic alternating pattern rate and A1 index were found in children without epileptic abnormalities/obstructive sleep apnea. Our analysis might allow differentiation of the "primary form" of ADHD associated with a decrease of NREM instability from those forms associated with sleep apnea and epileptic activity.

The role of sleep-related cognitive functions in the spectrum of benign epilepsy with centro-temporal spikes

Heterogeneous cognitive deficits have been described in the spectrum of benign epilepsy with centro-temporal spikes, which strongly correlate with the intensity of interictal epileptiform discharges and its spreading, in particular during sleep, mostly within the perisylvian cognitive network. The aim of this review is to discuss current findings regarding the connection between sleep alterations and cognitive function in the spectrum of benign epilepsy with centro-temporal spikes. A longer sleep onset latency is the only evident sleep macrostructure alteration reported in the spectrum of benign epilepsy with centro-temporal spikes. On a microstructural level, a higher spike count of descending compared to ascending slopes of sleep cycles, an impairment of slow wave downscaling, and amplitude and slope of slow waves were found in the spectrum of benign epilepsy with centro-temporal spikes. Moreover, children with benign epilepsy with centro-temporal spikes had a reduced non-rapid eye movement sleep instability, in terms of cyclic alternating pattern, similar to that found in children with attention-deficit hyperactivity disorders and in children with obstructive sleep apnea and centro-temporal spike during sleep. Children with benign epilepsy with centro-temporal spikes have a known comorbidity with attention-deficit hyperactivity disorders and obstructive sleep apnea.Conclusion: Considering the common sleep microstructure alterations, the presence of attention deficit and hyperactivity and/or sleep apnea may be a considered warning sign in the case of benign epilepsy with centro-temporal spikes. What is Known: • Sleep related-cognitive deficits have been described in the spectrum of benign epilepsy with centro-temporal spikes. The degree of sleep alterations may predict the neurocognitive outcome, and help clinicians to choose the right treatment. What is New: • Considering the common sleep microstructure alterations, attention deficit and sleep apnea, may be a considered warning signs.

The Mutual Interaction Between Sleep and Epilepsy on the Neurobiological Basis and Therapy

BACKGROUND

Sleep and epilepsy are mutually related in a complex, bidirectional manner. However, our understanding of this relationship remains unclear.

RESULTS

The literatures of the neurobiological basis of the interactions between sleep and epilepsy indicate that non rapid eye movement sleep and idiopathic generalized epilepsy share the same thalamocortical networks. Most of neurotransmitters and neuromodulators such as adenosine, melatonin, prostaglandin D2, serotonin, and histamine are found to regulate the sleep-wake behavior and also considered to have antiepilepsy effects; antiepileptic drugs, in turn, also have effects on sleep. Furthermore, many drugs that regulate the sleep-wake cycle can also serve as potential antiseizure agents. The nonpharmacological management of epilepsy including ketogenic diet, epilepsy surgery, neurostimulation can also influence sleep.

CONCLUSION

In this paper, we address the issues involved in these phenomena and also discuss the various therapies used to modify them.

To sleep, or not to sleep - that is the question, for polysomnography

Have we reached the point where respiratory polygraphy can replace polysomnography in the assessment of OSAS? http://ow.ly/UxCU30bNopq.

Neuropsychological consequences of sleep disturbance in children with epilepsy

A growing body of research reveals strong relationships between sleep disturbance, sleep architecture, and neuropsychological functioning in children. Children with epilepsy experience numerous neuropsychological comorbidities, including cognitive deficiencies and emotional/behavioral difficulties; thus, it is reasonable to consider the moderating role of sleep in this population. This review summarizes findings involving the prevalence and characteristics of sleep problems often experienced by children with epilepsy. The complex and bidirectional relationship between sleep and seizure frequency is discussed. Research pertaining to the relationship between sleep disturbance and daytime cognition as well as behavior reveals a substantial association between these variables. Clinically relevant practices related to the assessment and treatment of sleep-related complications are reviewed, and directions for further research involving intervention and assessment are also reviewed.

Sleep alterations in children with refractory epileptic encephalopathies: a polysomnographic study

Data on the relationship between sleep disturbances and refractory epileptic encephalopathies (EEs) are scarce. Our aim was to assess, by means of nocturnal polysomnography, if children with EEs present with objective alterations in sleep organization. Twenty-three children with EEs (12 males; mean age: 8.7±1.4years) and 40 healthy controls (22 males; mean age: 8.8±1.1years) underwent an overnight full polysomnography (PSG). Relative to controls, children with EEs showed a significant reduction in all PSG parameters related to sleep duration time in bed (TIB-min p<0.001), total sleep time (TST-min p<0.001), and sleep percentage (SPT-min p<0.001), as well as significantly higher REM latency (FRL-min p<0.001), rate in stage shifting (p=0.005), and number of awakenings/hour (p=0.002). Relative to controls, children with EEs also showed significant differences in respiratory parameters (AHI/h p<0.001, ODI/h p<0.001, SpO2% p<0.001, SpO2 nadir% p<0.001) and a higher rate of periodic limb movements (PLMs% p<0.001). Our findings suggest that sleep evaluation could be considered mandatory in children with refractory epileptic encephalopathy in order to improve the clinical management and the therapeutic strategies.

Obstructive sleep apnea and other sleep-related syndromes

Obstructive sleep apnea syndrome (OSAS) is a common disorder characterized by repetitive episodes of breathing cessation due to complete or partial collapse of the upper airway therefore affecting ventilation. It is quite common, with a prevalence of about 2-4%, has a strong genetic component, and creates a proinflammatory state with elevated TNFα and other cytokines. If untreated, OSA can lead to significant neurological problems that include stroke, cognitive decline, depression, headaches, peripheral neuropathy, and nonarteritic ischemic optic neuropathy (NAION). Treatment reverses some of these neurological problems. Treatment includes continuous positive airway pressure and its variants, oral appliances, weight loss, upper airway surgery, and rarely maxillofacial procedures. Other sleep breathing disorders such as hypoventilation, central sleep apnea, complex sleep apnea, and Cheyne-Stokes respiration are less common and are sometimes associated with neuromuscular disorders causing diaphragmatic paralysis, but can also be seen in opiate exposure and severe obesity.

The cooccurrence of interictal discharges and seizures in pediatric sleep-disordered breathing

Studies in the literature data have shown that the prevalence of obstructive sleep apnea (OSA) in children with epilepsy is high and that treatment for OSA leads to a reduction in the number of seizures; by contrast, few studies have demonstrated an increased prevalence of interictal epileptiform discharges (IEDs) or epilepsy in children with sleep-disordered breathing (SDB). The aim of the present study was to confirm the high prevalence of IEDs or epilepsy in a large sample of children with SDB and to collect follow-up data. Children were recruited prospectively and underwent their first video-polysomnography (video-PSG) for SDB in a teaching hospital sleep center. Of the 298 children who fulfilled the diagnostic criteria for sleep-disordered breathing, 48 (16.1%) children were found to have IEDs, three of these 48 children were also found to have nocturnal seizures (two females diagnosed with rolandic epilepsy and a male diagnosed with frontal lobe epilepsy). Only 11 subjects underwent a second video-PSG after 6months; at the second video-PSG, the IEDs had disappeared in six subjects, who also displayed a reduced AHI and an increased mean overnight saturation. Thirty-eight of the 250 children without IEDs underwent a second video-PSG after 6months. Of these 250 children, four, who did not display any improvement in the respiratory parameters and were found to experience numerous stereotyped movements during sleep, were diagnosed with nocturnal frontal lobe epilepsy. Our study confirms the high prevalence of IEDs in children with SDB. Follow-up data indicate that they may recede over time, accompanied by an improvement of sleep respiratory parameters.

The utility of routine EEG in the diagnosis of sleep disordered breathing

Sleep disordered breathing (SDB) is a common medical condition. Its manifestations of snoring, nocturnal choking, arousals, and sleep fragmentation can lead to excessive daytime sleepiness, neuropsychological slowing, lapses of consciousness, and accidents that can be misinterpreted as epileptic phenomena. Moreover, patients with documented epilepsy commonly exhibit similar symptomatology because of the undiagnosed coexistence of sleep apnea. Therefore, a large proportion of patients referred to the electroencephalogram (EEG) laboratory primarily to confirm or refute the diagnosis of epilepsy could suffer from latent sleep apnea and the routine EEG has the potential to divulge it. We retrospectively evaluated the reporting of sleep apnea symptomatology (snoring, choking, gasping/deep breath, apnea, desaturation, excessive drowsiness) in routine inpatient and outpatient adult EEG studies performed in our institution over the past 12 years (39,130 studies, approximately half of which recorded at least early stages of sleep). Comparisons were performed with the medical records to ascertain the coexistence of objectively diagnosed SDB with polysomnography before or after the EEG study and the importance of reporting variations in assisting with the diagnosis. Two illustrative examples are provided. Sixty-nine EEG studies were identified, performed primarily to confirm, or refute the diagnosis of epilepsy. The mean age of the subjects at EEG was 64 years (range 30-89), and 55 (80%) were male. 36% of them suffered from known epilepsy. Snoring was the most commonly reported sign in 48 (70%) of the studies, followed by arousals in 29 (42%), apnea in 16 (23%), excessive drowsiness in 13 (19%), gasping/deep breath in 9 (13%), and desaturation in 7 (10%). A sleep disorder was suggested in 25 (36%) of the interpretations and a direct recommendation for a sleep study was made in 22 of them (32%). This interpretation was included in the impression of the report in 21 (30%) of the cases, in the detail in 20 (30%) of the cases and in both in 28 (40%). Only 14 (20%) patients underwent polysomnography, and all of them were formally diagnosed with SDB. Seven (50%) of them were diagnosed with obstructive sleep apnea, 2 (14%) with central sleep apnea, 3 (22%) with both, 1 (7%) with upper airways resistance syndrome, and 1 (7%) with primary snoring. From these 14 patients, 9 (64%) were diagnosed with a sleep study performed after the EEG, 4 (29%) before the EEG interpretation, and 1 (7%) had a repeat study after the EEG. In the logistic regression model applied, with the exception of the presence of arousals (odds ratio = 4.63, P = 0.033), none of the aforementioned symptomatology or the reporting of suspicion for SDB or the location (impression vs. detail) of the reporting showed a statistically significant association with the completion of a sleep study. Routine EEG offers a unique opportunity of direct clinical observation along with electrophysiologic and cardiorespiratory monitoring. When sleep is recorded, it can help identify clinical and electrographic features of sleep apnea and prompt confirmation with a polysomnogram in the appropriate clinical context. It can therefore serve as a valuable, adjunctive tool for the diagnosis of SDB. Our data highlight that potential but unveil its decreased use in the neurology community. Increased awareness is required by the EEG technologists, interpreting neurologists, and referring physicians, regarding reporting and using sleep apnea features on the EEG.

The sleep phenotypes of attention deficit hyperactivity disorder: the role of arousal during sleep and implications for treatment

About 25-50% of children and adolescents with attention-deficit hyperactivity disorder (ADHD) experience sleep problems. An appropriate assessment and treatment of such problems might improve the quality of life in such patients and reduce both the severity of ADHD and the impairment it causes. According to data in the literature and to the overall complexity of the interaction between ADHD and sleep, five sleep phenotypes may be identified in ADHD: (i) a sleep phenotype characterized mainly by a hypo-arousal state, resembling narcolepsy, which may be considered a "primary" form of ADHD (i.e. without the interference of other sleep disorders); (ii) a phenotype associated with delayed sleep onset latency and with a higher risk of bipolar disorder; (iii) a phenotype associated with sleep disordered breathing (SDB); (iv) another phenotype related to restless legs syndrome (RLS) and/or periodic limb movements; (v) lastly, a phenotype related to epilepsy/or EEG interictal discharges. Each sleep phenotype is characterized by peculiar sleep alterations expressed by either an increased or decreased level of arousal during sleep that have important treatment implications. Treatment with stimulants is recommended above all in the primary form of ADHD, whereas treatment of the main sleep disorders or of co-morbidities (i.e. bipolar disorders and epilepsy) is preferred in the other sleep phenotypes. All the sleep phenotypes, except the primary form of ADHD and those related to focal benign epilepsy or focal EEG discharges, are associated with an increased level of arousal during sleep. Recent studies have demonstrated that both an increase and a decrease in arousal are ascribable to executive dysfunctions controlled by prefrontal cortical regions (the main cortical areas implicated in the pathogenesis of ADHD), and that the arousal system, which may be hyperactivated or hypoactivated depending on the form of ADHD/sleep phenotype.

Obstructive sleep apnea in infants

Obstructive sleep apnea in infants has a distinctive pathophysiology, natural history, and treatment compared with that of older children and adults. Infants have both anatomical and physiological predispositions toward airway obstruction and gas exchange abnormalities; including a superiorly placed larynx, increased chest wall compliance, ventilation-perfusion mismatching, and ventilatory control instability. Congenital abnormalities of the airway, such as laryngomalacia, hemangiomas, pyriform aperture stenosis, choanal atresia, and laryngeal webs, may also have adverse effects on airway patency. Additional exacerbating factors predisposing infants toward airway collapse include neck flexion, airway secretions, gastroesophageal reflux, and sleep deprivation. Obstructive sleep apnea in infants has been associated with failure to thrive, behavioral deficits, and sudden infant death. The proper interpretation of infant polysomnography requires an understanding of normative data related to gestation and postconceptual age for apnea, arousal, and oxygenation. Direct visualization of the upper airway is an important diagnostic modality in infants with obstructive apnea. Treatment options for infant obstructive sleep apnea are predicated on the underlying etiology, including supraglottoplasty for severe laryngomalacia, mandibular distraction for micrognathia, tonsillectomy and/or adenoidectomy, choanal atresia repair, and/or treatment of gastroesophageal reflux.

The effects of the ketogenic diet on behavior and cognition

Multiple forms of the ketogenic diet (KD) have been successfully used to treat drug-resistant epilepsy, however its mainstream use as a first-line therapy is still limited. Further investigation into its clinical efficacy as well as the molecular basis of activity is likely to assist in the reversal of any resistance to its implementation. In this review we shall attempt to elucidate the current state of experimental and clinical data concerning the neuroprotective and cognitive effects of the KD in both humans and animals. Generally, it has been shown by many research groups that effective implementation of KD exerts strong neuroprotective effects with respect to social behavior and cognition. We will also elucidate the role of KD in the interesting relationship between sleep, epilepsy and memory. Currently available evidence also indicates that, under appropriate control, and with further studies investigating any potential long-term side effects, the KD is also a relatively safe intervention, especially when compared to traditional anti-epileptic pharmacotherapeutics. In addition, due to its neuroprotective capacity, the KD may also hold potential benefit for the treatment of other neurological or neurodegenerative disorders.

Cyclic alternating pattern (CAP): the marker of sleep instability

Cyclic alternating pattern CAP is the EEG marker of unstable sleep, a concept which is poorly appreciated among the metrics of sleep physiology. Besides, duration, depth and continuity, sleep restorative properties depend on the capacity of the brain to create periods of sustained stable sleep. This issue is not confined only to the EEG activities but reverberates upon the ongoing autonomic activity and behavioral functions, which are mutually entrained in a synchronized oscillation. CAP can be identified both in adult and children sleep and therefore represents a sensitive tool for the investigation of sleep disorders across the lifespan. The present review illustrates the story of CAP in the last 25 years, the standardized scoring criteria, the basic physiological properties and how the dimension of sleep instability has provided new insight into pathophysiolology and management of sleep disorders.

Sleep and epilepsy in children and adolescents

Epilepsy and sleep disorders are considered by many to be common bedfellows. Several sleep phenomena may occur during nighttime taking a wide variety of forms and which can mimic seizures. Although most seizure sub-types have the potential to occur during sleep or wakefulness, sleep has a well-documented and strong association with specific epilepsy syndromes. Seizures in sleep also tend to occur during lighter stages of non-REM (NREM) sleep. The neurophysiologic process involved in the deepening of NREM sleep may also facilitate both seizures and IEDs. Epilepsy per se and/or seizures themselves promote sleep disruption and significantly affect the quality, quantity, and architecture of sleep. There are many causes of sleep disruption in patients with epilepsy, including inadequate sleep hygiene, coexisting sleep disorders, and circadian rhythm disturbances. Seizures themselves can disrupt sleep, even when they occur during wakefulness. Anti-epileptic drugs (AEDs) can also alter sleep in positive and negative ways, and these effects are independent of anticonvulsant actions. The end result of sleep disruption is excessive daytime sleepiness, worsening seizures, and poor quality of life. Screening for sleep disorders in the epilepsy population and appropriate intervention strategies will lead to overall improved quality of life and seizure control.

Long-term sleep disturbances in children: a cause of neuronal loss

Short-term sleep loss is known to cause temporary difficulties in cognition, behaviour and health but the effects of persistent sleep deprivation on brain development have received little or no attention. Yet, severe sleep disorders that last for years are common in children especially when they have neurodevelopmental disabilities. There is increasing evidence that chronic sleep loss can lead to neuronal and cognitive loss in children although this is generally unrecognized by the medical profession and the public. Without the restorative functions of sleep due to total sleep deprivation, death is inevitable within a few weeks. Chronic sleep disturbances at any age deprive children of healthy environmental exposure which is a prerequisite for cognitive growth more so during critical developmental periods. Sleep loss adversely effects pineal melatonin production which causes disturbance of circadian physiology of cells, organs, neurochemicals, neuroprotective and other metabolic functions. Through various mechanisms sleep loss causes widespread deterioration of neuronal functions, memory and learning, gene expression, neurogenesis and numerous other changes which cause decline in cognition, behaviour and health. When these changes are long-standing, excessive cellular stress develops which may result in widespread neuronal loss. In this review, for the first time, recent research advances obtained from various fields of sleep medicine are integrated in order to show that untreated chronic sleep disorders may lead to impaired brain development, neuronal damage and permanent loss of developmental potentials. Further research is urgently needed because these findings have major implications for the treatment of sleep disorders.

The relationship between sleep and epilepsy: the effect on cognitive functioning in children

AIM

The purpose of this review was to examine the possible pathophysiological links between epilepsy, cognition, sleep macro- and microstructure, and sleep disorders to highlight the contributions and interactions of sleep and epilepsy on cognitive functioning in children with epilepsy.

METHOD

PubMed was used as the medical database source. No language restriction was placed on the literature searches, and citations of relevant studies in the paediatric age range (0-18 y) were checked. Studies including a mixed population but with a high percentage of children were also considered.

RESULTS

The searches identified 223 studies. One reviewer scanned these to eliminate obviously irrelevant studies. Three reviewers scanned the remaining 128 studies and their relevant citations. The review showed that several factors could account for the learning impairment in children with epilepsy: aetiology, electroencephalographic (EEG) discharges, and persistence and circadian distribution of seizures, etc. EEG discharges may affect cognition and sleep, even in the absence of clinical or subclinical seizures. The sleep deprivation and/or sleep disruption affect the neurophysiological and neurochemical mechanisms important for the memory-learning process, but also influence the expression of EEG discharges and seizures. Learning and memory consolidation can take place over extended periods, and sleep has been demonstrated to play a fundamental role in these processes through neuroplastic remodelling of neural networks. Epilepsy and EEG paroxysms may affect sleep structure, interfering with these physiological functions.

INTERPRETATION

Improvement in the long-term cognitive-behavioural prognosis of children with epilepsy requires both good sleep quality and good seizure control. The antiepileptic drug of choice should be the one that interferes least with sleep structure and has the best effect on sleep architecture--thus normalizing sleep instability, especially during non-rapid eye movement sleep.

Cyclic alternating pattern: A window into pediatric sleep

Cyclic alternating pattern (CAP) has now been studied in different age groups of normal infants and children, and it is clear that it shows dramatic changes with age. In this review we first focus on the important age-related changes of CAP from birth to peripubertal age and, subsequently, we describe the numerous studies on CAP in developmental clinical conditions such as pediatric sleep disordered breathing, disorders of arousal (sleep walking and sleep terror), pediatric narcolepsy, learning disabilities with mental retardation (fragile-X syndrome, Down syndrome, autistic spectrum disorder, Prader-Willi syndrome) or without (dyslexia, Asperger syndrome, attention-deficit/hyperactivity disorder). CAP rate is almost always decreased in these conditions with the exception of the disorders of arousal and some cases of sleep apnea. Another constant result is the reduction of A1 subtypes, probably in relationship with the degree of cognitive impairment. The analysis of CAP in pediatric sleep allows a better understanding of the underlying neurophysiological mechanisms of sleep disturbance. CAP can be considered as a window into pediatric sleep, allowing a new vision on how the sleeping brain is influenced by a specific pathology or how sleep protecting mechanisms try to counteract internal or external disturbing events.

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.