Sleep in Children with Congenital Malformations of the Central Nervous System

Biological pathways leading to septo-optic dysplasia: a review

BACKGROUND

The precise etiology of septo-optic dysplasia (SOD) remains elusive, to date a complex interaction between genetic predisposition and prenatal exposure to environmental factors is believed to come into play. Being SOD such a heterogeneous condition, disruption of many developmental steps in the early forebrain development might occur. The knowledge of genes possibly determining SOD phenotype should be improved, therefore in this review the authors attempt to highlight the genetic pathways and genes related to this clinical condition.

MAIN BODY

Literature search was conducted and updated in November 2023, using PubMed and Google Scholar to identify primary research articles or case reports with available full text using the following search string "case reports," "humans," "septo-optic dysplasia," "optic nerve hypoplasia," with a recognized genetic diagnosis. Moreover, a review of genetic pathways with an involvement in SOD etiology was conducted. This review thus represents the authors' perspective based on selected literature. The several pathways presented might be already associated to other disease phenotypes and interplay with genes and pathways known to have a role in SOD determination. Those pathways may converge and thus, the implicated genes may function as cascading regulators at multiple levels.

CONCLUSION

The present data suggest that genes other than HESX1, SOX2, SOX3, and OTX2 might be investigated in candidate individuals with a clinical diagnosis of SOD corresponding to the presence of at least two diagnostic criteria, particularly in the presence of additional syndromic anomalies.

Resting Energy Expenditure and Metabolic Features in Children With Septo-Optic Dysplasia

Context

Septo-optic dysplasia (SOD) is a major cause of congenital hypopituitarism and is known to be associated with overweight and obesity in up to 44% of children. Given the role of the hypothalamus in hormonal regulation, we sought to assess the association of resting energy expenditure (REE), appetite and physical activity with SOD.

Objective

To characterize REE and other metabolic features in patients with SOD and evaluate relationships with elevated body mass index (BMI).

Methods

Children with SOD above 5 years of age attending Perth Children's Hospital participated. A CosMED Q-NRG indirect calorimeter was used to calculate mean measure REE (mREE). This was compared with predictive REE (pREE) based on the Schofield equation to determine mREE/pREE quotient. A BMI z-score >1 was considered elevated. Parents/carers completed a questionnaire about pituitary function, the Hyperphagia Questionnaire and the Sleep Disturbances Scale for Children (SDSC).

Results

Twenty-six participants underwent testing (9 female, mean age 12.1 years) with 11 having elevated BMI and 15 with pituitary hormone deficiencies. Mean mREE was 1309 kcal/day (838-1732), mREE/pREE quotient was 88.8% ± 10.1. mREE/pREE quotient was similar in those with elevated BMI compared with normal BMI (83.3% ± 12.5 vs 92.1% ± 7.2, P = .068). Those with midline defects had a higher mREE/pREE quotient (91.8% ± 8.1 vs 80.4% ± 11.3, P = .026). Hyperphagia and SDSC scores were similar between BMI groups. Hyperphagia domain scores were higher in children with multiple hypopituitarism, pituitary structural defects, and normal septum pellucidum (P = .044, .042, and .033, respectively).

Conclusion

Children with SOD had lower mREE than predicted and hyperphagia scores were higher in those with biochemical or structural pituitary changes, suggesting that hypothalamic dysfunction could drive BMI elevation in SOD. Indirect calorimetry may be used to guide the management of overweight and obesity in SOD.

Characteristics of sleep disordered breathing in children with achondroplasia

PURPOSE

We aimed to evaluate the characteristics of sleep disordered breathing (SDB) in a cohort of pediatric patients with achondroplasia and to describe magnetic resonance imaging (MRI) findings and management strategies.

METHODS

A single center retrospective study that included a cohort of pediatric achondroplasia patients and age, gender, and AHI-matched normally developed controls. Medical records and PSGs were reviewed for both cohorts and additionally MRI findings and SDB management strategies were evaluated in the achondroplasia cohort.

RESULTS

A total of 15 subjects were included in the achondroplasia cohort and they were matched to 15 normally developed subjects included in the control group. 60% were found to have an AHI in the moderate-to-severe range, and 86.7% subjects were found to have apnea that was predominately obstructive in nature. There were no significant differences found in sleep efficiency, wake after sleep onset, arousal index, time spent in each sleep stage, or oxygen desaturation nadir between the two groups. In the achondroplasia group, MRI findings demonstrated foramen magnum stenosis in 33.3% (5 patients), 2 of whom had subsequent decompression surgery. Within this cohort, 3 patients underwent adenotonsillectomy and 4 patients received positive airway pressure therapy.

CONCLUSION

There were no significant differences found between sleep architecture and arousal index between children with achondroplasia and normally developed control subjects. This supports the belief that general management strategies for pediatric SDB, including adenotonsillectomy and continuous positive airway pressure, may be beneficial in this population. However, due to the increased risk of foramen magnum stenosis in this population, evaluation of SDB should also include neuroimaging when clinically warranted.

Sleep profile in patients with septo-optic-pituitary dysplasia: protocol for a prospective cohort study

INTRODUCTION

Children with septo-optic-pituitary dysplasia (SOD) may experience a range of visual impairments and hormonal dysfunctions beyond developmental delay/intellectual disability. The literature describes sleep fragmentation, circadian rhythm disruptions and reduced sleep efficiency. These manifestations are believed to be closely linked to both structural and functional abnormalities associated with SOD, potentially disrupting the natural circadian rhythm. Both anomalies in midline brain structures and decreased visual input could potentially impact melatonin secretion, although a distinct melatonin profile for SOD patients has yet to be identified. Furthermore, the specific contribution of these factors to sleep disturbances in SOD remains unexplored. The aim of this study is to evaluate the quality of sleep and its characteristics, along with the melatonin profile, among paediatric patients diagnosed with SOD. A comparison will be made between these findings and those of children with isolated bilateral visual impairment, as well as patients with agenesis of the corpus callosum.

METHODS AND ANALYSIS

Participants aged between 3 and 18 years previously diagnosed with SOD will be recruited prospectively. Each participant will be assessed at baseline and at each follow-up visit scheduled to evaluate the clinical course. Sleep quality and daytime sleepiness changes will be tracked using actigraphic assessment, standardised sleep questionnaires and a sleep EEG. Additionally, plasma and salivary melatonin profiles will be assessed for each participant.

ETHICS AND DISSEMINATION

This study has been approved by local Ethics Committee (N°0049187/23). The study findings will be shared through publication in an international peer-reviewed journal and presented at both national and international conferences.

TRIAL REGISTRATION NUMBER

NCT06262152.

Anxiety and Depression and Sleep Problems Among Patients with Fetal Alcohol Spectrum Disorders

Background/Objectives: Sleep disturbances are common among children with fetal alcohol spectrum disorders (FASD) and are often accompanied by emotional and behavioral challenges. This study aimed to evaluate the relationship between sleep problems, anxiety, and depressive symptoms in children with FASD. Methods: The study included 90 children aged 7 to 16 years diagnosed with FASD, who were primarily in foster or adoptive care. Participants completed validated psychometric tools, including the Children's Sleep Habits Questionnaire (CSHQ), State Trait Anxiety Inventory for Children (STAIC) and Children's Depression Inventory 2 (CDI 2). Results: Sleep disturbances were significant, with 71.1% of participants scoring above the clinical threshold in CSHQ. State anxiety, measured by STAIC C-1, was positively correlated with specific sleep difficulties, such as bedtime resistance (r = 0.30, p = 0.008) and sleep anxiety (r = 0.31, p = 0.005). However, no correlation was found between trait anxiety (STAIC C-2) and sleep problems. Parent-reported depressive symptoms, measured using CDI 2:P, were strongly associated with general sleep disturbances (r = 0.27, p < 0.011), parasomnias (r = 0.33, p = 0.002) and daytime sleepiness (r = 0.34, p < 0.001). Conclusions: These findings suggest that sleep disturbances in children with FASD are closely related to state anxiety and depressive symptoms. The results emphasize the need for targeted interventions addressing sleep and emotional health in this population. Further research is needed to examine these relationships and their implications for clinical practice.

Maternal dietary and environmental factors associated with infant circadian rhythm, growth, and temperament: Research protocol for a prospective cohort study

Introduction: Emerging evidence has been explored to determine the factors affecting the development of infant circadian rhythm. While fetal programming happens during the pregnancy period, external environmental cues and infant nutritional programming can have substantial effects on the infant circadian rhythm. Understanding prenatal and postnatal factors determining infant circadian rhythm can improve future interventions in optimizing maternal and infant health. Methods: This is a prospective observational cohort study, targeting 216 pregnant women from government maternity clinics in Kuala Lumpur, Malaysia. Pregnant women will be recruited at third trimester (baseline), and follow up at 3 months, and 6 months. A subsample will be collected for salivary cortisol analysis to determine circadian rhythm of the mother and infant at third trimester and 3 months. Data of eating misalignment, light exposure, chronotype, infant temperament, sleep quality, and mood will be collected via validated questionnaires. Anthropometric data and birth outcomes will be collected from antenatal and postnatal health records. Summary: Studies on infant circadian rhythm development have yet to be explored and established, hence this study presents a novel approach to identify the factors from prenatal to postnatal periods on infant circadian rhythm and its influence on growth and temperament. Findings from this study will provide insights in the critical timing which has larger effects on infant circadian rhythm development for future interventions to be conducted.

Sleep disorders in pediatric patients with agenesis of the corpus callosum

STUDY OBJECTIVES

There is limited information about sleep in agenesis of the corpus callosum (ACC). We aim to describe the sleep architecture and respiratory parameters of children with ACC.

METHODS

We performed a retrospective study of 20 patients with ACC who had polysomnography between 2000 and 2023. Demographic data, body mass index or weight for length, associated conditions, and polysomnography findings were collected. National Sleep Foundation sleep quality indicators as well as increased polysomnography arousal index ≥ 10 events/h were used in the analysis. Fisher's exact test or unpaired t test was used to compare groups.

RESULTS

Average age was 5.9 ± 5.4 years old. A total of 12/20 patients were male; 6/20 were overweight/obese; 14/20 had complete ACC, and 6/20 had partial ACC; 8/20 had seizures; 15/20 had ≥ 1 National Sleep Foundation poor sleep quality indicator (decreased sleep efficiency [45%], decreased rapid eye movement sleep [53%]); and 9/20 had increased arousals. Between complete and partial ACC, there was no difference in presence of ≥ 1 poor sleep quality indicator (P = .61), sleep efficiency (P = .34), rapid eye movement sleep (P = .28), and arousals (P = 1.0). 11/18 had obstructive sleep apnea (OSA); 5/11 had associated central sleep apnea. There was no difference in OSA between those with complete and partial ACC (P = 1.0). OSA was associated with children < 3 years old (P = .01).

CONCLUSIONS

Children with ACC have poor sleep quality, and many have OSA. There was no difference in sleep quality or presence of OSA between those with complete and partial ACC. OSA was seen more in younger children. Our study supports the need for screening of sleep-related disorders in patients with ACC.

CITATION

Kwon A, Gu PK, Zhang C, Davidson Ward SL, Perez IA. Sleep disorders in pediatric patients with agenesis of the corpus callosum. J Clin Sleep Med. 2024;20(10):1663-1667.

Sleep-Disordered Breathing in an Infant With Achondroplasia and Foramen Magnum Stenosis

Sleep-disordered breathing (SDB) is a frequently recognized comorbidity in infants and children with achondroplasia due to alterations in craniofacial and upper airway anatomy. Foramen magnum stenosis and cervicomedullary compression can be associated with SDB in this population, requiring prompt evaluation by multidisciplinary teams. Untreated SDB is associated with adverse cardiovascular, metabolic, and behavioral effects in children, necessitating early screening and treatment of underlying causes. Cervicomedullary compression is also associated with increased mortality and sudden infant death in infants with achondroplasia. Management of SDB in children with achondroplasia may involve a combination of neurosurgical intervention, adenotonsillectomy, and/or continuous positive airway pressure (CPAP). We recognize a need for increased physician awareness of the recommended screening guidelines to optimize health outcomes for children with achondroplasia. In this report, we describe a case of a five-month-old infant with achondroplasia and severe SDB diagnosed by polysomnography and was found to have moderate-to-severe foramen magnum stenosis identified by MRI. Subsequently, this infant underwent foramen magnum decompression, which improved the severe SDB and was followed up for five years. Our case illustrates the importance of early screening in infants with achondroplasia for SDB to prevent further sequelae.

The utility of poly(somno)graphy in evaluating children with Chiari malformation type II before and after surgical intervention: a case series

BACKGROUND

Children with Chiari Malformation type II (CM-II) have an increased risk of sleep apnoea. The aim of the study was to describe the management of patients with CM-II in relation to sleep apnoea syndrome, clinical symptoms and magnetic resonance imaging (MRI) findings.

CASE SERIES PRESENTATION

The paper reports 8 consecutive patients with CM-II followed between September 2013 and April 2017. The prevalence of sleep apnoea syndrome was high with 6 out of 8 patients having mild-to-severe sleep apnoea. Patients with severe sleep apnoea syndrome (3 patients) were treated with upper airway surgery and/or noninvasive ventilation.

CONCLUSION

Our findings highlight the importance of respiratory polygraphy in the management of patients with CM-ΙΙ. Poly(somno)graphy is recommended in the follow-up care of children with CM-II.

Sleep in children from northeastern Brazil with congenital Zika syndrome: assessment using polysomnography

STUDY OBJECTIVES

We performed this study to describe the characteristics of sleep in children with congenital Zika syndrome through polysomnographic assessment.

METHODS

Polysomnography with neurological setup and capnography was performed. Respiratory events were scored according to American Academy of Sleep Medicine criteria. Children were classified based on neuroclinical examination as having corticospinal plus neuromuscular abnormalities or exclusively corticospinal abnormalities. Neuroradiological classification was based on imaging exams, with children classed as having supratentorial plus infratentorial abnormalities or exclusively supratentorial abnormalities.

RESULTS

Of 65 children diagnosed with congenital Zika syndrome, sleep apnea was present in 23 children (35.4%), desaturation in 26 (40%), and snoring in 13 (20%). The most prevalent apnea type was central in 15 children (65.2%), followed by obstructive apnea in 5 (21.7%) and mixed type in 3 (13%). The average of the lowest saturation recorded was slightly below normal (89.1 ± 4.9%) and the mean partial pressure of end-tidal carbon dioxide value was normal. Periodic leg movements were present in 48 of 65 children. Lower ferritin levels were observed in 84.6% of children. Palatine and pharyngeal tonsils (adenoids) were small in most children and not associated with the presence of obstructive apnea. Ventriculomegaly and subcortical and nucleus calcification were the most frequent neuroimaging findings. Supratentorial and infratentorial anomalies were present in 26.7% (16 of 60) and exclusively supratentorial changes in 73.3% (44 of 60). In the neuroclinical classification, isolated corticospinal changes were more frequent and the mean peak in capnography was lower in this group. There was no difference regarding the presence of apnea for children in the neuroclinical and neuroradiological classification groups.

CONCLUSIONS

Sleep disorders were frequent in children with congenital Zika syndrome, with central sleep apnea being the main finding.

CITATION

Brandão Marquis V, de Oliveira Melo A, Pradella-Hallinan M, et al. Sleep in children from northeastern Brazil with congenital Zika syndrome: assessment using polysomnography. J Clin Sleep Med. 2023;19(10):1759-1767.

Genetic heterogeneity in corpus callosum agenesis

The corpus callosum is the largest white matter structure connecting the two cerebral hemispheres. Agenesis of the corpus callosum (ACC), complete or partial, is one of the most common cerebral malformations in humans with a reported incidence ranging between 1.8 per 10,000 livebirths to 230–600 per 10,000 in children and its presence is associated with neurodevelopmental disability. ACC may occur as an isolated anomaly or as a component of a complex disorder, caused by genetic changes, teratogenic exposures or vascular factors. Genetic causes are complex and include complete or partial chromosomal anomalies, autosomal dominant, autosomal recessive or X-linked monogenic disorders, which can be either de novo or inherited. The extreme genetic heterogeneity, illustrated by the large number of syndromes associated with ACC, highlight the underlying complexity of corpus callosum development. ACC is associated with a wide spectrum of clinical manifestations ranging from asymptomatic to neonatal death. The most common features are epilepsy, motor impairment and intellectual disability. The understanding of the genetic heterogeneity of ACC may be essential for the diagnosis, developing early intervention strategies, and informed family planning. This review summarizes our current understanding of the genetic heterogeneity in ACC and discusses latest discoveries.

Accuracy of ultrasonography in diagnosis of fetal central nervous system malformation

BACKGROUND

Prenatal examination is an important measure for the screening and diagnosis of fetal malformations.

AIM

To investigate the accuracy of ultrasonography in the diagnosis of fetal central nervous system (CNS) malformations.

METHODS

One hundred and thirteen pregnant women suspected of having fetal CNS malformations were examined at our hospital from December 2018 to October 2020 using two-dimensional ultrasonography and three-dimensional ultrasonography, respectively.

RESULTS

According to the pathological results, there were 79 cases of CNS malformations and 34 cases of non-CNS malformations among the 113 pregnant women suspected of having fetal CNS malformation. Fifty-one cases of CNS malformation and 26 cases of non-CNS malformation were detected by two-dimensional ultrasonography, and 73 cases of CNS malformation and 30 cases of non-CNS malformation were detected by three-dimensional ultrasonography. The diagnostic sensitivity (92.41%) and accuracy (91.15%) of three-dimensional ultrasonography were higher than those of two-dimensional ultrasonography (64.56% and 68.14%, respectively) (P = 0.000). The specificity of three-dimensional ultrasonography (88.24%) was higher than that of two-dimensional ultrasonography (76.47%); however, the difference was not significant (P = 0.203).

CONCLUSION

Three-dimensional ultrasonography has high application value in the diagnosis of fetal CNS malformations. In addition, the image quality is clear, and the diagnostic sensitivity and accuracy are high.

Sleep in children with microcephaly due to Zika virus infection: a systematic review

OBJECTIVE

To review the literature on sleep changes and brain function in children with microcephaly due to Zika virus.

METHOD

Systematic review conducted in the databases MEDLINE (PubMed), Scopus, Web of Science, CINAHL, EMBASE, LILACS, and SciELO and the grey databases Google Scholar and OpenGrey.

RESULTS

Ten Brazilian primary studies with observational research design were included. These were published between 2017 and 2020 with 516 children with microcephaly due to Zika virus infection aged 4 months to 4 years. Out of these, 4 investigated qualitative aspects of sleep using the questionnaires Brief Infant Sleep Questionnaire or Infant Sleep Questionnaire and 6 investigated changes in brain activities during sleep using the Electroencephalogram or Video-Electroencephalogram exams. The children's quality of sleep was not compromised in most studies. Changes in brain activity during sleep were frequent, with epileptogenic activity being a common finding among the studies.

CONCLUSION

The quality of sleep of children with microcephaly due to Zika virus has shown to be similar to that of children with typical development and the presented behavioral changes may be related to changes in electric brain activity.

Extracellular Vesicles in Premature Aging and Diseases in Adulthood Due to Developmental Exposures

The developmental origins of health and disease (DOHaD) is a paradigm that links prenatal and early life exposures that occur during crucial periods of development to health outcome and risk of disease later in life. Maternal exposures to stress, some psychoactive drugs and alcohol, and environmental chemicals, among others, may result in functional changes in developing fetal tissues, creating a predisposition for disease in the individual as they age. Extracellular vesicles (EVs) may be mediators of both the immediate effects of exposure during development and early childhood as well as the long-term consequences of exposure that lead to increased risk and disease severity later in life. Given the prevalence of diseases with developmental origins, such as cardiovascular disease, neurodegenerative disorders, osteoporosis, metabolic dysfunction, and cancer, it is important to identify persistent mediators of disease risk. In this review, we take this approach, viewing diseases typically associated with aging in light of early life exposures and discuss the potential role of EVs as mediators of lasting consequences.

Septo-optic dysplasia

Septo-optic dysplasia (SOD) or de Morsier's syndrome is a rare congenital disorder characterized by a classic triad of: (a) optic nerve hypoplasia, (b) agenesis of septum pellucidum and corpus callosum, and (c) hypoplasia of the hypothalamic-pituitary axis. This chapter will outline the key information regarding the etiology and epidemiology of this syndrome with a focus on its comprehensive management. Particular attention will be paid to the diagnostic stage and the most relevant differential diagnosis, before moving to the complexities of its treatment. In fact, although SOD is not curable, many aspects of this syndrome can be improved through a tailored multidisciplinary approach consisting in hormonal replacement, corrective ophthalmological surgery, management of epileptic seizures, and active neuropsychological support.

Long Term Non-invasive Ventilation in Children With Central Hypoventilation

Central hypoventilation (CH) is a quite rare disorder caused by some congenital or acquired conditions. It is featured by increased arterial concentration of serum carbon dioxide related to an impairment of respiratory drive. Patients affected by CH need to be treated by mechanical ventilation in order to achieve appropriate ventilation and oxygenation both in sleep and wakefulness. In fact, in severe form of Congenital Central Hypoventilation Syndrome (CCHS) hypercarbia can be present even during the day. Positive pressure ventilation via tracheostomy is the first therapeutic option in this clinical condition, especially in congenital forms. Non-Invasive ventilation is a an option that must be reserved for more stable clinical situations and that requires careful monitoring over time.

Neuro-Ophthalmological Manifestations Of Septo-Optic Dysplasia: Current Perspectives

Septo-optic dysplasia (SOD), also known as de Morsier syndrome, is a rare congenital disorder belonging to the group of mid-line brain malformations. Despite the highly variable phenotypic penetration, its classical triad include a) optic nerve hypoplasia (ONH), b) agenesis of septum pellucidum and corpus callosum, and c) hypoplasia of the hypothalamo-pituitary axis. SOD has stringent diagnostic criteria requiring 2 or more features of the classic triad, therefore it represents a separate entity from other conditions such as ONH and achiasmia syndromes which share only some of these aspects, or SOD plus syndrome which is characterized by additional cortical abnormalities. Starting from its etiology and epidemiology, this narrative review focuses on the management of SOD patients, including their diagnosis, treatment and follow-up. To date, SOD is not curable; nonetheless, many of its symptoms can be improved through a tailored approach, consisting of hormonal replacement, corrective ophthalmological surgery and neuropsychological support.

Paediatric neurodisability and sleep disorders: clinical pathways and management strategies

Sleep disorders are common in children with neurodisability. Their presentation is often complex. This complexity of presentation can make sleep disorders in children with neurodisability daunting to diagnose and manage. Both parents and healthcare professionals have identified sleep disorders as a healthcare outcome that they prioritise in children with neurodisability. We aim to explore the challenges of diagnosing sleep problems, discuss common difficulties with sleep in children with neurodisability and will touch on how to set up a service to support and manage sleep, working through case examples.