Sleep Disorders: Assessment and Treatment in Preschool-Aged Children

Neurodevelopmental impairment in children with Robin sequence: A systematic review and meta-analysis

OBJECTIVE

To estimate the global prevalence of neurodevelopmental impairment in children with Robin sequence (RS) at one year or more of age.

STUDY DESIGN

Electronic databases such as PubMed, Embase, CINAHL, APA PsycInfo, Emcare, MedNAR and Cochrane library were searched systematically from inception to 31st May 2024. Studies reporting on the neurodevelopmental (global, cognitive, or motor) outcomes in children with RS were included. Data was extracted using a standardized form by two independent reviewers. Overall and subgroup-specific prevalence (95% CI) of neurodevelopmental impairment was estimated with random-effects meta-analysis. Subgroup analyses were performed for three categories of RS: isolated (no other associated abnormalities), syndromic RS (associated with a genetic syndrome), and RS plus (associated with non-syndromic congenital abnormalities).

RESULTS

A total of 2919 records were screened. Seventeen studies were included in the systematic review, of which data from 16 studies (n = 1008) were pooled for meta-analysis. The overall prevalence of neurodevelopmental impairment was 19 % (12-26 %). Neurodevelopmental impairment prevalence in isolated RS was 10 % (5 to16%), syndromic RS 19 % (02 to44%), and RS plus 63 % (39 to84%). The overall prevalence in non-isolated RS (syndromic and plus) was 35 % (22 to49%).

CONCLUSION

This is first systematic review and meta-analysis to report on the global prevalence of neurodevelopmental impairment in children with RS. Children with RS are at high risk of neurodevelopmental impairment and should be considered for long-term neurodevelopmental follow up. These findings will guide clinician counselling of parents, resource allocation, facilitate benchmarking, and enable the assessment of treatment impact in future studies.

Evaluation of sleep disorders in children and adolescents affected by Klinefelter syndrome

Klinefelter syndrome (KS) is the most common sex chromosomal aneuploidy in males (47,XXY karyotype in 80-90% of cases), primarily characterized by hypergonadotropic hypogonadism and infertility. It encompasses a broad phenotypic spectrum, leading to variability in neurocognitive and psychosocial outcomes among affected individuals. Despite the recognized correlation between KS and various neuropsychiatric conditions, studies investigating potential sleep disorders, particularly in pediatric subjects, are lacking. This study aimed to investigate the presence of sleep-related behaviors potentially suggestive of a sleep disorder in a cohort of pediatric patients with KS, in comparison with a group of healthy male age-matched controls. During the period from January to December 2023, a validated sleep questionnaire (Sleep Disturbance Scale for Children: SDSC) was administered to the primary caregivers of 80 children with KS: 40 of preschool age (3-5 years) and 40 of school age (6-16 years). Data were compared with a control group of 180 healthy age-matched male children: 90 of preschool age (3-5 years) and 90 of school age (6-16 years). Among preschoolers, the proportion of subjects with pathological non-restorative sleep T-scores was significantly higher in the KS group compared to controls (p = 0.03). In both KS and control groups, school-aged subjects had higher questionnaire scores compared to preschoolers. The school age KS group had significantly higher mean total T-scores and mean T-scores for disorders of initiating and maintaining sleep (DIMS), disorders of arousal (DA), and disorders of excessive somnolence (DOES) compared to controls (p < 0.01 for all). The KS group also showed significantly higher percentages of children with clinically relevant T-scores for DIMS, DA, DOES, sleep hyperhidrosis, and total T-scores.

CONCLUSION

Our study indicates that sleep disorders are more prevalent in children with KS than in the general population, especially in the school age group. Screening for sleep issues in the clinical setting using tools like the SDSC is warranted, and should start from age 6 for children with KS. Further research is needed to better understand the origins of these disturbances, the role of comorbidities, and their long-term effects to improve diagnosis and treatment strategies for these patients.

WHAT IS KNOWN

• Neurocognitive and psychosocial disorders can be observed in individuals with KS. • Sleep disorders may be associated with various neuropsychiatric conditions; however, they have not been sufficiently explored in individuals with KS, particularly in pediatric populations.

WHAT IS NEW

• Sleep-related problems are more common in children with KS compared to the general population, especially in the school age group with regard to DIMS, DA, and DOES factors. • Starting from 6 years of age, the SDSC might be a promising early diagnostic tool for sleep disorders in children with KS.

Daytime Sleepiness from Preschool Children's and Parents' Perspectives: Is There a Difference?

This cross-sectional study investigated the level of daytime sleepiness and sleep-related behaviors in preschool children and compared their self-evaluations with the evaluations of their parents. It was conducted in Split-Dalmatian County, Croatia, among 196 preschool children aged 6-7 years seen at regular medical examinations, accompanied by their parents, using the Epworth sleepiness scale for children and parents/caregivers. Compared to their child's reports, parents tended to underestimate their child's sleepiness while sitting in a classroom at school (p = 0.001) and overestimate their child's sleepiness when lying down to rest or nap in the afternoon (p < 0.001). Boys were sleepier while sitting in a classroom at school during the morning than girls (p = 0.032). As much as 48.2% of preschool children had their own cellphones/tablets. Boys used video games (p < 0.001) and cellphones/tablets more than girls did (p = 0.064). Parental estimation of children playing video games at bedtime was lower than the child's report (p < 0.001). Children who had a TV in their bedroom reported more daytime sleepiness (p = 0.049), and those who played video games at bedtime went to sleep later during the weekend (p = 0.024). Also, children owning cellphone/tablets had longer sleep latency during the weekend compared to children not owning a cellphone (p = 0.015). This study confirmed that parents tend to underestimate children's habits of playing video games at bedtime and children's sleepiness during morning classes. Preschool children who use electronic devices at bedtime more frequently have prolonged sleep latency. These findings provide further evidence of the effects of electronic media devices on preschoolers' sleep patterns and daytime sleepiness.

General approach to treatment of genetic leukoencephalopathies in children and adults

Despite the enormous advancements seen in recent years, curative therapies for patients with genetic leukoencephalopathies are available for only a relatively small number of disorders. Therefore, symptomatic treatment and preventive management of the multiple clinical manifestations of patients with genetic leukoencephalopathies are critical in their care. The goals of the symptomatic treatment are to improve patients' quality of life, increase their survival, and reduce the impact on medical resources and related expenses. The coordinated work of a multidisciplinary team, including all specialists involved in the care of these patients, is the gold standard approach to manage and treat their complex and evolving clinical picture. Along with a multidisciplinary team, the relationship and close collaboration with the patient and their caregivers are essential. Their insight into the disease manifestations and management of the different issues should be integrated with the assessments of the multidisciplinary team to prevent clinical complications and preserve the quality of life of patients and their caregivers. Genetic leukoencephalopathies are very heterogeneous in terms of age of onset, clinical features, and disease course. However, many clinical features and problems are shared by most forms. Consequently, common therapeutic strategies apply to the majority of these diseases. This chapter presents the symptomatic approach for shared core clinical features presented by patients with genetic leukoencephalopathies divided by systems and, for each system, the specificities of some genetic leukoencephalopathies.

Using pharmacotherapy to address sleep disturbances in autism spectrum disorders

INTRODUCTION

Sleep disorders are the second most common medical comorbidity in autism spectrum disorder (ASD), with effects on daytime behavior and functioning, mood and anxiety, and autism core features. In children with ASD, insomnia also has a negative impact on the whole family's quality of life. Therefore, treatment of sleep disturbances should be considered as a primary goal in the management of ASD patients, and it is important to clarify the scientific evidence to inappropriate treatments.

AREAS COVERED

The authors review the current literature concerning the pharmacological treatment options for the management of sleep-related disorders in patients with ASD (aged 0-18 years) using the PubMed and Cochrane Library databases with the search terms: autism, autistic, autism spectrum disorder, ASD, drug, drug therapy, drug intervention, drug treatment, pharmacotherapy, pharmacological treatment, pharmacological therapy, pharmacological intervention, sleep, sleep disturbance, and sleep disorder.

EXPERT OPINION

Currently, clinicians tend to select medications for the treatment of sleep disorders in ASD based on the first-hand experience of psychiatrists and pediatricians as well as expert opinion. Nevertheless, at the present time, the only compound for which there is sufficient evidence is melatonin, although antihistamines, trazodone, clonidine, ramelteon, gabapentin, or suvorexant can also be considered for selection.

Sleeping and Dietary Factors Associated with Chronic Fatigue Syndrome in Taiwanese Preschoolers

The purpose of this research was to investigate the sleeping and dietary factors associated with the prevalence of chronic fatigue syndrome among Taiwanese preschoolers. Five-year-old preschoolers were randomly selected using a stratified multistage random cluster sampling method. The parents of the preschoolers completed a questionnaire containing items related to symptoms of fatigue and sleeping and dietary habits among the preschoolers. A total of 1536 valid questionnaires were returned. After obtaining the data, the researchers analyzed them using descriptive statistics and a chi-square test. The following results were obtained: (1) chronic fatigue syndrome was typically indicated by yawning during the day, feeling tired, and appearing sleepy; (2) the preschoolers with high sleep quality, adequate sleeping time, and a regular sleep schedule exhibited a lower degree of fatigue; (3) half of the preschoolers who ate three nutritionally balanced meals a day at a regular time exhibited a lower degree of fatigue. Among the three dimensions studied, fatigue was most strongly associated with the "sleepy and inactive/blunted responses/lacking in energy" dimension, followed by the "difficulty concentrating" dimension, and, finally, the "localized pain" dimension. In this study, the association between sleeping habits and symptoms of fatigue in preschool children was verified. The associations of dietary factors with symptoms of fatigue were not confirmed. It is suggested that parents establish a good sleep schedule for preschool children based on the study findings.

Restless sleep disorder, restless legs syndrome, and periodic limb movement disorder-Sleep in motion!

Sleep-related movement disorders (SRMDs) represent an important part of pediatric sleep disorders. The most common complaint in SRMD is restless sleep at night. Restless sleep is reported in up to 80% of children with restless legs syndrome (RLS) and children with periodic limb movements of sleep (PLMS) disorder (PLMD). However, restless sleep causing daytime behavioral consequences can be seen in children without another apparent condition and has recently been identified as a new independent primary pediatric sleep disorder, called restless sleep disorder (RSD). This study describes these three main SRMDs (RSD, RLS, and PLMD), explains the new consensus criteria for RSD, emphasizes the rapidly evolving areas of research in this field, and proposes recommendations for future research. In particular, the published data constitute convincing evidence that sleep-related movements are disruptors of sleep quality and continuity. However, while important advancements have recently been reported in adults, a detailed analysis of the phenomenology and consequences of sleep-related movements has just started in children. New approaches, standardized diagnostic methods, and specific guidelines are needed in the field of pediatric SRMD.

Management of sleep disorders among children and adolescents with neurodevelopmental disorders: A practical guide for clinicians

There is a complex relationship between sleep disorders and childhood neurodevelopmental, emotional, behavioral and intellectual disorders (NDEBID). NDEBID include several conditions such as attention deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, epilepsy and learning (intellectual) disorders. Up to 75% of children and young people (CYP) with NDEBID are known to experience different types of insomnia, compared to 3% to 36% in normally developing population. Sleep disorders affect 15% to 19% of adolescents with no disability, in comparison with 26% to 36% among CYP with moderate learning disability (LD) and 44% among those with severe LD. Chronic sleep deprivation is associated with significant risks of behavioural problems, impaired cognitive development and learning abilities, poor memory, mood disorders and school problems. It also increases the risk of other health outcomes, such as obesity and metabolic consequences, significantly impacting on the wellbeing of other family members. This narrative review of the extant literature provides a brief overview of sleep physiology, aetiology, classification and prevalence of sleep disorders among CYP with NDEBIDs. It outlines various strategies for the management, including parenting training/psychoeducation, use of cognitive-behavioral strategies and pharmacotherapy. Practical management including assessment, investigations, care plan formulation and follow-up are outlined in a flow chart.

Practical Approaches and Knowledge Gaps in the Care for Children With Leukodystrophies

Leukodystrophies are a group of neurodegenerative genetic disorders that affect approximately 1 in 7500 individuals. Despite therapeutic progress in individual leukodystrophies, guidelines in neurologic care are sparse and consensus among physicians and caregivers remains a challenge. At patient advocacy meetings hosted by Hunter's Hope from 2016-2018, multidisciplinary experts and caregivers met to conduct a literature review, identify knowledge gaps and summarize best practices regarding neurologic care. Stages of severity in leukodystrophies guided recommendations to address different levels of need based on a newly defined system of disease severity. Four core neurologic domains prioritized by families were identified and became the focus of this guideline: sleep, pain, seizures/epilepsy, and language/cognition. Based on clinical severity, the following categories were used: presymptomatic, early symptomatic, intermediate symptomatic, and advanced symptomatic. Across the leukodystrophies, neurologic care should be tailored to stages of severity while accounting for unique aspects of every disease and multiple knowledge gaps present. Standardized tools and surveys can help guide treatment but should not overburden families.

Devices for Ambulatory Monitoring of Sleep-Associated Disorders in Children with Neurological Diseases

Good sleep quality is essential for a child's wellbeing. Early sleep problems have been linked to the later development of emotional and behavioral disorders and can negatively impact the quality of life of the child and his or her family. Sleep-associated conditions are frequent in the pediatric population, and even more so in children with neurological problems. Monitoring devices can help to better characterize sleep efficiency and sleep quality. They can also be helpful to better characterize paroxysmal nocturnal events and differentiate between nocturnal seizures, parasomnias, and obstructive sleep apnea, each of which has a different management. Overnight ambulatory detection devices allow for a tolerable, low cost, objective assessment of sleep quality in the patient's natural environment. They can also be used as a notification system to allow for rapid recognition and prompt intervention of events like seizures. Optimal monitoring devices will be patient- and diagnosis-specific, but may include a combination of modalities such as ambulatory electroencephalograms, actigraphy, and pulse oximetry. We will summarize the current literature on ambulatory sleep devices for detecting sleep disorders in children with neurological diseases.