Approach to a sleepy child: Diagnosis and treatment of excessive daytime sleepiness in children and adolescents

A Closer Look at Paediatric Sleep: Sleep Health and Sleep Behavioural Disorders in Children and Adolescents

Adequate sleep is crucial for healthy development, contributing significantly to physical and mental well-being. While research on paediatric sleep is expanding, there remain several open questions. This narrative review provides an overview of our current knowledge on paediatric sleep health and identifies literature gaps, considering factors such as age, gender, cultural differences, and the interplay between sleep, physical activity, nutrition, and mental health. It also considers sleep health in the more specific group of children with neurodevelopmental disorders. By viewing paediatric sleep health as a multidimensional construct, this review discusses age-specific issues, including the different factors affecting satisfaction, daytime alertness, sleep timing, efficiency and duration, and sleep-related behaviours. While gender differences in sleep health become apparent after puberty, few studies have addressed sex differences in children or different parental attitudes toward sleep in boys and girls. Cultural differences in sleep duration, timing, and setting are reported from infancy through adolescence; however, the cultural influence on sleep health, particularly during adolescence, remains unclear. This is crucial when considering the effects of screen time, smartphone use, and social media exposure on sleep. Further research is required to understand how sleep, nutrition, and physical health interact throughout the developmental span. Additionally, this review underscores the protective nature of sleep for adolescent mental health and for the management of emotional and behavioural problems in children with neurodevelopmental disorders. The review identifies critical areas for future research to enhance our understanding of paediatric sleep health and develop more effective and tailored interventions and preventive programmes.

Cultural Approaches to Addressing Sleep Deprivation and Improving Sleep Health in Japan: Sleep Issues Among Children and Adolescents Rooted in Self-Sacrifice and Asceticism

This narrative review examines the issue of sleep deprivation among children and adolescents in Japan, exploring its cultural origins and evaluating the current state of sleep education and interventions. It emphasizes the profound influence of the Bushidō spirit, with its focus on self-sacrifice and asceticism, as a core factor in the undervaluation of sleep in Japanese society. While educational initiatives and interventions highlighting the importance of sleep exist, significant limitations remain in improving sleep habits. Sleep deprivation continues to affect children and adolescents, despite its considerable impact on mental health and academic performance. This review presents a method for personalized sleep duration estimation and assesses its potential impact on improving sleep health by using optimal sleep duration calculations. The review also proposes practical steps to improve sleep duration through individualized strategies, integrating cultural context to mitigate the serious health risks associated with insufficient sleep. Ultimately, it underscores the need for targeted strategies to improve sleep among children and adolescents-particularly through personalized optimal sleep duration estimation-while advocating for a shift in cultural perspective beyond self-sacrifice and asceticism. The review highlights the importance of cultural transformation and suggests future research directions and practical applications.

The effects of experimental sleep disruption on daytime performance among children with asthma living in urban environments

OBJECTIVES

Children with asthma living in urban environments are at risk for disrupted sleep due to the presence of nocturnal asthma symptoms and urban stressors. Suboptimal sleep can affect children's daily functioning. The current study examined the effects of experimental sleep disruption on daytime performance in children with persistent asthma from urban backgrounds.

METHOD

Twenty-four children (8-10 years old) with asthma living in urban environments participated in an experimental, laboratory-based sleep disruption protocol. Children completed a baseline night consisting of uninterrupted sleep, followed by a disruption night, with 2-minute arousals every 20 minutes of sleep. Sleep and sleep disruptions were monitored via polysomnography. Daytime performance measurements (Psychomotor Vigilance Task; Daytime Sleepiness, child- and caregiver-report) were evaluated at baseline and after sleep disruption using t-tests and percent change calculations.

RESULTS

No significant differences in attention or daytime sleepiness were observed between the uninterrupted night of sleep and the disrupted night of sleep (p-values >.05). Percent change calculations showed that children demonstrated poorer attention (decreased response speed; increased reaction time, lapses, total errors, false starts) and more daytime sleepiness (caregiver- and child-report) following a night of sleep disruption compared to an uninterrupted night of sleep. Gender and racial/ethnic group differences in outcomes were also examined.

CONCLUSIONS

Children with asthma living in urban environments may be at risk for sleep disruption and impaired daytime functioning. More experimental sleep research with larger samples is necessary to further explore these associations.

Autonomic cardiovascular control is unaffected in children referred for assessment of excessive daytime sleepiness

There is conflicting evidence for impaired autonomic control of heart rate (HR) in adults with narcolepsy and idiopathic hypersomnolence (IH). Despite these chronic hypersomnia conditions primarily being diagnosed around the age of puberty, there are limited studies in children. The present study investigated cardiovascular control using heart rate variability (HRV) and the extent of nocturnal HR dipping during sleep in children and adolescents with narcolepsy and IH. Children having an overnight polysomnographic study followed by a multiple sleep latency test (MSLT) for investigation of excessive daytime sleepiness (EDS) between May 2010 to December 2023 were included: 28 children diagnosed with narcolepsy, 11 with IH, and 26 subjectively sleepy children who did not meet the diagnostic criteria for either narcolepsy or IH. Each clinically referred child was matched for age and sex with a control. Time domain and frequency domain HRV were calculated from ECG recorded at 512 Hz. There were no differences in either time domain or spectral analysis of HRV between clinical groups or between clinical groups and their control group. The expected sleep state differences in HRV were observed in all groups. There was also no difference in HR nocturnal dipping between groups. Despite evidence for abnormal autonomic function in adults with narcolepsy and IH, our study did not identify any abnormalities in HR, HR control, or nocturnal dipping of HR in children referred for assessment of EDS. This suggests that autonomic dysfunction may be a feature of these conditions that develops in later life.

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.

Distinguishing between children referred for assessment of excessive daytime sleepiness using polysomnographic measures

BACKGROUND

Currently, diagnosing narcolepsy and idiopathic hypersomnia (IH) in subjectively sleepy children requires an overnight polysomnographic sleep study followed by a daytime multiple sleep latency test (MSLT). We aimed to compare sleep macro-architecture to identify differences between these groups.

METHODS

All children referred for a MSLT between May 2010 to December 2023 whose parent consented for their data be used in research were eligible. Each child was age- and sex-matched to a control. Sleep stability was defined as the maintenance of a particular sleep stage before waking or transitioning to another sleep state. As a measure of sleep disturbance, the number and duration of bouts of each sleep stage was recorded.

RESULTS

28 children with Narcolepsy, 11 with IH and 26 with subjective sleepiness were included. Children with narcolepsy exhibited higher numbers of transitions to wake after sleep onset compared to their controls and to the subjectively sleepy group (p < 0.001 for both). The number of REM bouts was greater in the narcolepsy group compared to their control group (p < 0.001), the IH group (p < 0.05) and the subjectively sleepy group (p < 0.05), while the average duration of REM bouts was shorter in the narcolepsy group compared to both the IH group (p < 0.05) and subjectively sleepy group (p < 0.05). Mean sleep latency on the MSLT was correlated with a number of polysomnographic variables.

CONCLUSIONS

Our study suggests that specific sleep architecture patterns could potentially serve as diagnostic biomarkers for distinguishing paediatric narcolepsy from those with IH and those with a non-diagnostic MSLT.

Connecting clinicians and patients: The language of narcolepsy

Narcolepsy is a rare lifelong sleep disorder characterized by excessive daytime sleepiness with variable expression of cataplexy, sleep paralysis, sleep-related hallucinations and disrupted nocturnal sleep. Affected individuals also experience additional impairing symptoms, including (but not limited to) difficulties with attention, memory and concentration, brain fog, mood instability and fatigue, with a substantial impact on everyday life. Diagnostic delays of up to 10 years are common, primarily due to the substantial heterogeneity in clinical presentation of narcolepsy symptoms and presence of significant comorbidities. The disconnect in language used by clinicians and patients could be a factor contributing to diagnostic delays, but it has not been much studied. We followed a two-part approach to investigate the impact of this possible mismatch in language use. Firstly, a comprehensive literature search was conducted to identify publications reporting discrepancies in language relating to narcolepsy symptoms used by clinicians and patients. As a gap in the literature was anticipated, we supplemented the search results with practical strategies based on our clinical experience to facilitate dialog between clinicians and people living with narcolepsy, as well as proposing future research ideas. The findings of the narrative review, complemented by expert clinical opinion, are intended to help clinicians recognize narcolepsy symptoms and to refer patients with suspected narcolepsy, when appropriate. Although it is unknown to what extent a disconnect in language may contribute to diagnostic delays, we hope that better recognition of the varied clinical presentations of narcolepsy will lead to timelier diagnosis and help improve patient outcomes.

Can EEG spectral analysis distinguish children with narcolepsy from those with idiopathic hypersomnia and subjective sleepiness?

EEG spectral analysis provides a more sensitive measure of sleep disruption than conventional sleep macro-architecture. We aimed to examine the use of this technique applied to overnight polysomnography in distinguishing children with narcolepsy and idiopathic hypersomnia (IH) from subjectively sleepy children with a non-diagnostic multiple sleep latency test. The relative power was calculated for delta (0.5-3.9 Hz), theta (4-7.9 Hz), alpha (8-11.9 Hz), sigma (12-13.9 Hz), and beta power (14-30 Hz). A mean value for each frequency was calculated for each 30 s epoch then averaged for each sleep stage within each child. Data are presented as median and interquartile range. Twenty-eight children with narcolepsy, 11 with IH, and 26 with subjective sleepiness were included and individually matched for age and sex with a control child. In N2, the F4 beta power was lower in the narcolepsy compared with the IH group (p < 0.05). The F4 theta power was higher in the narcolepsy compared with the subjectively sleepy group during wake (p < 0.001), N2 (p < 0.01), N3 (p < 0.05), and total sleep (p < 0.01). During total sleep the F4 delta power was lower in both the narcolepsy and IH groups compared with the subjectively sleepy group (p < 0.05 for both). Our study identified specific EEG frequencies which differed between groups of children referred for assessment of EDS. In particular, differences in theta and delta power in children with narcolepsy and IH compared with others with subjective sleepiness may provide insights into the pathophysiology associated these conditions.

Association between habitual snoring and vigilant attention in elementary school children

OBJECTIVES

Vigilant attention (VA) is a fundamental neurocognitive function. However, the association between habitual snoring (HS) and VA in community-based children remains unclear. Therefore, this study aimed to elucidate the association.

METHODS

The study included 2014 children from grades 1-6 across six elementary schools. Snoring frequency was evaluated using a questionnaire administered to parents. VA was assessed using a brief 3-min psychomotor vigilance test (PVT-B). Generalized linear models and multivariate logistic regression analysis were utilized to examine the association between snoring frequency and PVT-B performance. Impaired PVT-B performance was defined as the worst quartile of PVT-B metrics.

RESULTS

The PVT-B performance significantly improved with advancing school grade level (p trend < 0.0001). A significant negative correlation was observed between snoring frequency and PVT-B performance. Particularly, in grade 1, HS was associated with a higher risk of impaired PVT-B performance, including response speed (mean reciprocal reaction time) (adjusted odds ratio [aOR] 2.56, 95% confidence interval [CI]: 1.20-5.50), more slowest 10% RT (aOR 3.28, 95% CI: 1.51-6.88), and more lapse500 (number of lapse of reaction time ≥ 500 ms) (aOR 3.18, 95% CI: 1.45-6.80) compared to children without snoring.

CONCLUSIONS

Our findings show that VA rapidly improves throughout elementary school. Additionally, younger children with HS are at risk of VA deficits, emphasizing the importance of early intervention for HS.

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.

Pitolisant: Pediatric First Approval

Pitolisant (WAKIX^®), a histamine H₃ receptor antagonist/inverse agonist that has been developed by Bioprojet Pharma, is approved in the EU and USA and elsewhere for use in adults with narcolepsy with or without cataplexy. In February 2023, based on clinical data in patients aged 6 to < 18 years, pitolisant received its first approval in adolescents and children from the age of 6 years for the treatment of narcolepsy with or without cataplexy in the EU. This article summarizes the milestones in the development of pitolisant leading to this pediatric first approval for narcolepsy with or without cataplexy.