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Dye TJ. Clinical Evaluation and Management of Narcolepsy in Children and Adolescents. Semin Pediatr Neurol 2023; 48:101089. [PMID: 38065636 DOI: 10.1016/j.spen.2023.101089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023]
Abstract
While sleepiness is common among children, and particularly adolescents, profound sleepiness in the setting of apparently adequate sleep should prompt consideration of a central disorder of hypersomnolence. These disorders, which include narcolepsy, idiopathic hypersomnia, Kleine-Levin syndrome, and others, are likely underrecognized in the pediatric population. Narcolepsy in particular should be of interest to child neurologists as the unique signs and symptoms of this disease often prompt evaluation in pediatric neurology clinics. While sleepiness may appear to be a straightforward complaint, its evaluation requires a nuanced approach. Cataplexy, a hallmark of narcolepsy, can be confused for other neurologic conditions, though understanding its various manifestations makes it readily identifiable. Clinicians should be aware of these symptoms, as delay in diagnosis and misdiagnosis are common in childhood narcolepsy. While treatment options have been limited in the past, many new therapeutic options have become available and can result in significant improvement in symptoms. Given the age at presentation, paroxysmal and chronic features, diagnostic modalities, and available treatment options, the field of child neurology is well equipped to see patients with narcolepsy. In this review, I will focus on the presentation, evaluation, and management of pediatric patients with narcolepsy.
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Affiliation(s)
- Thomas J Dye
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary - Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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2
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Abstract
SUMMARY Sleep disorders are common after traumatic brain injury (TBI). This study will review the spectrum and proposed mechanisms of TBI-associated sleep disorders and discuss the clinical approach to diagnosis and management of them. Disordered and fragmented sleep with insomnia and daytime sleepiness is very common after TBI. Sleep disruption contributes to morbidity and neurocognitive and neurobehavioral deficits and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of TBI and improve patient outcomes. Evaluating sleep disorders in TBI should be an important component of TBI assessment and management. Finally, newer research techniques for early diagnosis, prognosis, and improved outcomes after TBI will also be addressed.
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Affiliation(s)
- Joseph Kaleyias
- Department of Paediatrics, East Sussex Health Care NHS Trust, London, United Kingdom
| | - Sanjeev V Kothare
- Division of Pediatric Neurology, Department of Pediatrics, Cohen Children's Medical Center, New York, New York, U.S.A.; and
- Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, U.S.A
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3
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Lividini A, Pizza F, Filardi M, Vandi S, Ingravallo F, Antelmi E, Bruni O, Cosentino FII, Ferri R, Guarnieri B, Marelli S, Ferini-Strambi L, Romigi A, Bonanni E, Maestri M, Terzaghi M, Manni R, Plazzi G. Narcolepsy type 1 features across the life span: age impact on clinical and polysomnographic phenotype. J Clin Sleep Med 2021; 17:1363-1370. [PMID: 33666167 DOI: 10.5664/jcsm.9198] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVES Narcolepsy type 1 (NT1) is a chronic neurological disorder typically arising during adolescence and young adulthood. Recent studies demonstrated that NT1 presents with age-specific features, especially in children. With this study we aimed to describe and to compare the clinical pictures of NT1 in different age groups. METHODS In this cross-sectional, multicenter study, 106 untreated patients with NT1 enrolled at the time of diagnosis underwent clinical evaluation, a semistructured interview (including the Epworth Sleepiness Scale), nocturnal video-polysomnography, and the Multiple Sleep Latency Test. Patients were enrolled in order to establish 5 age-balanced groups (childhood, adolescence, adulthood, middle age, and senior). RESULTS The Epworth Sleepiness Scale score showed a significant increase with age, while self-reported diurnal total sleep time was lower in older and young adults, with the latter also complaining of automatic behaviors in more than 90% of patients. Children reported the cataplexy attacks to be more frequent (> 1/d in 95% of patients). "Recalling an emotional event," "meeting someone unexpectedly," "stress," and "anger" were more frequently reported in adult and older adult patients as possible triggers of cataplexy. Neurophysiological data showed a higher number of sleep-onset rapid eye movement periods on the Multiple Sleep Latency Test in adolescent compared to senior patients and an age-progressive decline in sleep efficiency. CONCLUSIONS Daytime sleepiness, cataplexy features and triggers, and nocturnal sleep structure showed age-related difference in patients with NT1; this variability may contribute to diagnostic delay and misdiagnosis.
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Affiliation(s)
- Althea Lividini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Marco Filardi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Stefano Vandi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elena Antelmi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University of Rome, Italy
| | | | - Raffaele Ferri
- Sleep Research Center, Department of Neurology IC, Oasi Research Institute-IRCCS, Troina, Italy
| | - Biancamaria Guarnieri
- Center of Sleep Medicine, Department of Neurology, Villa Serena Hospital and Villa Serena Foundation for Research, Città S. Angelo, Pescara, Italy
| | - Sara Marelli
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Neurology-Sleep Disorders Centre, Milan, Italy
| | - Luigi Ferini-Strambi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Neurology-Sleep Disorders Centre, Milan, Italy
| | - Andrea Romigi
- IRCCS Neuromed Istituto Neurologico Mediterraneo Sleep Medicine Centre, Pozzilli, Italy
| | - Enrica Bonanni
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - Michelangelo Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - Michele Terzaghi
- Unit of Sleep Medicine and Epilepsy, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Raffaele Manni
- Unit of Sleep Medicine and Epilepsy, IRCCS Mondino Foundation, Pavia, Italy
| | - Giuseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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4
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Vignatelli L, Antelmi E, Ceretelli I, Bellini M, Carta C, Cortelli P, Ferini-Strambi L, Ferri R, Guerrini R, Ingravallo F, Marchiani V, Mari F, Pieroni G, Pizza F, Verga MC, Verrillo E, Taruscio D, Plazzi G. Red Flags for early referral of people with symptoms suggestive of narcolepsy: a report from a national multidisciplinary panel. Neurol Sci 2018; 40:447-456. [PMID: 30539345 PMCID: PMC6433801 DOI: 10.1007/s10072-018-3666-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/28/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Narcolepsy is a lifelong disease, manifesting with excessive daytime sleepiness and cataplexy, arising between childhood and young adulthood. The diagnosis is typically made after a long delay that burdens the disease severity. The aim of the project, promoted by the "Associazione Italiana Narcolettici e Ipersonni" is to develop Red Flags to detect symptoms for early referral, targeting non-sleep medicine specialists, general practitioners, and pediatricians. MATERIALS AND METHODS A multidisciplinary panel, including patients, public institutions, and representatives of national scientific societies of specialties possibly involved in the diagnostic process of suspected narcolepsy, was convened. The project was accomplished in three phases. Phase 1: Sleep experts shaped clinical pictures of narcolepsy in pediatric and adult patients. On the basis of these pictures, Red Flags were drafted. Phase 2: Representatives of the scientific societies and patients filled in a form to identify barriers to the diagnosis of narcolepsy. Phase 3: The panel produced suggestions for the implementation of Red Flags. RESULTS Red Flags were produced representing three clinical pictures of narcolepsy in pediatric patients ((1) usual sleep symptoms, (2) unusual sleep symptoms, (3) endocrinological signs) and two in adult patients ((1) usual sleep symptoms, (2) unusual sleep symptoms). Inadequate knowledge of symptoms at onset by medical doctors turned out to be the main reported barrier to diagnosis. CONCLUSIONS This report will hopefully enhance knowledge and awareness of narcolepsy among non-specialists in sleep medicine in order to reduce the diagnostic delay that burdens patients in Italy. Similar initiatives could be promoted across Europe.
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Affiliation(s)
- L Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - E Antelmi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - I Ceretelli
- Associazione Italiana Narcolettici e Ipersonni (AIN), Florence, Italy
| | - M Bellini
- Azienda USL Toscana centro Sedi di Prato, Prato, Italy
| | - C Carta
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - P Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - L Ferini-Strambi
- Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R Ferri
- Sleep Research Centre, Department of Neurology I.C., Oasi Research Institute - IRCCS, Troina, Italy
| | - R Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - F Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - V Marchiani
- Child Neuropsychiatric Unit, Polyclinic S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - F Mari
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - G Pieroni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - F Pizza
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - M C Verga
- Primary Care Pediatrics, ASL Salerno, Vietri sul Mare, SA, Italy
| | - E Verrillo
- Sleep and Long Term Ventilation Unit, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Academic Department of Pediatrics (DPUO) Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - D Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy.
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Plazzi G, Clawges HM, Owens JA. Clinical Characteristics and Burden of Illness in Pediatric Patients with Narcolepsy. Pediatr Neurol 2018; 85:21-32. [PMID: 30190179 DOI: 10.1016/j.pediatrneurol.2018.06.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/19/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Narcolepsy is a chronic and lifelong neurologic disorder with onset commonly occurring in childhood or adolescence, and affecting approximately 0.025% to 0.05% of the general population. The primary symptom is excessive daytime sleepiness, which is accompanied by cataplexy in 70% of patients. Other common symptoms include sleep paralysis, hallucinations upon falling asleep or waking, and disrupted nocturnal sleep. Narcolepsy is associated with a considerable burden of illness (BOI), which has been well characterized in adults, and is exacerbated by delays in symptom recognition, diagnosis, and intervention. METHODS This review describes the specific characteristics and BOI of pediatric narcolepsy, using a wide range of published research data. RESULTS Pediatric narcolepsy presents distinct challenges in diagnosis and management. Narcolepsy symptoms often initially manifest differently in children and adolescents versus adults, which may pose diagnostic dilemmas. Children often respond to sleepiness with irritability, hyperactivity, and poor attention, which may be misinterpreted as misbehavior or neurocognitive sequelae of other conditions. Pediatric cataplexy symptoms may include subtle and unusual facial expressions or choreic-like movements, which are not observed in adults. Insufficient sleep and circadian rhythm disorders presenting with excessive daytime sleepiness are common in adolescents, potentially confounding narcolepsy diagnosis. Pediatric narcolepsy is also associated with comorbidities including rapid weight gain, precocious puberty, and attention deficit hyperactivity disorder, and increased risk for deficits in social functioning, depression, and anxiety. School performance is also typically impaired, requiring special education services. CONCLUSIONS Thus, the discrete BOI of pediatric narcolepsy underscores the need for prompt and accurate diagnosis, and appropriate treatment of this disorder.
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Affiliation(s)
- Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
| | - Heather M Clawges
- Department of Pediatrics, Sleep Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WestVirginia
| | - Judith A Owens
- Division of Neurology, Boston Children's Hospital, Harvard Medical School, Waltham, Massachusetts
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The clinical spectrum of childhood narcolepsy. Sleep Med Rev 2018; 38:70-85. [DOI: 10.1016/j.smrv.2017.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/19/2022]
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Pillen S, Pizza F, Dhondt K, Scammell TE, Overeem S. Cataplexy and Its Mimics: Clinical Recognition and Management. Curr Treat Options Neurol 2017; 19:23. [PMID: 28478511 DOI: 10.1007/s11940-017-0459-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OPINION STATEMENT This review describes the diagnosis and management of cataplexy: attacks of bilateral loss of muscle tone, triggered by emotions and with preserved consciousness. Although cataplexy is rare, its recognition is important as in most cases, it leads to a diagnosis of narcolepsy, a disorder that still takes a median of 9 years to be diagnosed. The expression of cataplexy varies widely, from partial episodes affecting only the neck muscles to generalized attacks leading to falls. Moreover, childhood cataplexy differs from the presentation in adults, with a prominent facial involvement, already evident without clear emotional triggers ('cataplectic facies') and 'active' motor phenomena especially of the tongue and perioral muscles. Next to narcolepsy, cataplexy can sometimes be caused by other diseases, such as Niemann-Pick type C, Prader Willi Syndrome, or lesions in the hypothalamic or pontomedullary region. Cataplexy mimics include syncope, epilepsy, hyperekplexia, drop attacks and pseudocataplexy. They can be differentiated from cataplexy using thorough history taking, supplemented with (home)video recordings whenever possible. Childhood narcolepsy, with its profound facial hypotonia, can be confused with neuromuscular disorders, and the active motor phenomenona resemble those found in childhood movement disorders such as Sydenham's chorea. Currently, the diagnosis of cataplexy is made almost solely on clinical grounds, based on history taking and (home) videos. Cataplexy shows remarkable differences in childhood compared to adults, with profound facial hypotonia and complex active motor phenomena. Over time, these severe symptoms evolve to the milder adult phenotype, and this pattern is crucial to recognize when assessing the outcome of uncontrolled case series with potential treatments such as immunomodulation. Symptomatic treatment is possible with antidepressants and sodium oxybate. Importantly, management also needs to involve sleep hygiene advice, safety measures whenever applicable and guidance with regard to the social sequelae of cataplexy.
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Affiliation(s)
- Sigrid Pillen
- Sleep Medicine Center Kempenhaeghe, P.O. Box 61, , 5590 AB, Heeze, The Netherlands.
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Institute of the Neurological SciencesAUSL di Bologna, Bologna, Italy
| | - Karlien Dhondt
- Department Pediatrics, Division of Child Neurology & Metabolism, Pediatric Sleep Center, Ghent University Hospital, Ghent, Belgium
| | - Thomas E Scammell
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston Children's Hospital, Boston, MA, USA
| | - Sebastiaan Overeem
- Sleep Medicine Center Kempenhaeghe, P.O. Box 61, , 5590 AB, Heeze, The Netherlands.,Eindhoven University of Technology, Eindhoven, The Netherlands
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8
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Singh K, Morse AM, Tkachenko N, Kothare SV. Sleep Disorders Associated With Traumatic Brain Injury-A Review. Pediatr Neurol 2016; 60:30-6. [PMID: 27161048 DOI: 10.1016/j.pediatrneurol.2016.02.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/04/2016] [Accepted: 02/23/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Sleep disorders are common are common following traumatic brain injury. METHODS In this article we review the spectrum and proposed mechanisms of traumatic brain injury associated sleep disorders and discuss the clinical approach to diagnosis and management of these disorders. RESULT Disordered sleep and wakefulness after traumatic brain injury is common. Sleep disruption contributes to morbidity, such as the development of neurocognitive and neurobehavioral deficits, and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of traumatic brain injury and improve patient outcomes. CONCLUSION Evaluating sleep disorders in traumatic brain injury should be an important component of post-traumatic brain injury assessment and management.
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Affiliation(s)
- Kanwaljit Singh
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Anne Marie Morse
- Sleep Center, Department of Neurology, New York University Langone Medical Center, New York, New York
| | - Nataliya Tkachenko
- Department of Pediatrics, Dnipropetrovsk State Medical Academy, Dnepropetrovsk, Dnipropetrovsk Oblast, Ukraine
| | - Sanjeev V Kothare
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Neurology, New York University Langone Medical Center, New York, New York.
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Gagner C, Landry-Roy C, Lainé F, Beauchamp MH. Sleep-Wake Disturbances and Fatigue after Pediatric Traumatic Brain Injury: A Systematic Review of the Literature. J Neurotrauma 2015; 32:1539-52. [DOI: 10.1089/neu.2014.3753] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Charlotte Gagner
- Department of Psychology, University of Montreal, Quebec, Canada
- Ste-Justine Hospital Research Center, Montreal, Quebec, Canada
| | | | - France Lainé
- Institut Universitaire de Gériatrie de Montréal Research Center, Montreal, Quebec, Canada
| | - Miriam H. Beauchamp
- Department of Psychology, University of Montreal, Quebec, Canada
- Ste-Justine Hospital Research Center, Montreal, Quebec, Canada
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Abstract
Sleepiness is not uncommon in the pediatric population. Although the etiology can be multifactorial, sleepiness due to increased sleep drive, also called central hypersomnia, is a common cause. The third edition of the International Classification of Sleep Disorders updated the diagnostic criteria for several of the central disorders of hypersomnolence, most notably narcolepsy. Although the International Classification Of Sleep Disorders-3 is not specific to pediatric patients, the peak incidence for many of the included disorders occurs during childhood or adolescence. As a result, recognition of these lifelong and potentially debilitating disorders is imperative for providers who evaluate pediatric patients. This review provides an update on recent advances in the field and highlights some of the diagnostic dilemmas, unique clinical features, and variable presentations associated with central disorders of hypersomnolence within the pediatric population.
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Affiliation(s)
- Thomas J Dye
- Division of Neurology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH.
| | - Sejal V Jain
- Division of Neurology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH
| | - Sanjeev V Kothare
- Department of Neurology, NYU Langone Medical Center, New York, NY; Pediatric Sleep Program, Comprehensive Epilepsy & Sleep Center, NYU Langone Medical Center, New York, NY
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11
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Prasad M, Setty G, Ponnusamy A, Hussain N, Desurkar A. Cataplectic facies: clinical marker in the diagnosis of childhood narcolepsy-report of two cases. Pediatr Neurol 2014; 50:515-7. [PMID: 24656461 DOI: 10.1016/j.pediatrneurol.2014.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 12/27/2013] [Accepted: 01/01/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Narcolepsy is a chronic disease and is commonly diagnosed in adulthood. However, more than half of the patients have onset of symptoms in childhood and/or adolescence. The full spectrum of clinical manifestations, namely excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis, is usually not present at disease onset, delaying diagnosis during childhood. Mean delay in diagnosis since symptom onset is known to be several years. Initial manifestations can sometimes be as subtle as only partial drooping of eyelids leading to confusion with a myasthenic condition. PATIENTS We present two children who presented with "cataplectic facies," an unusual facial feature only recently described in children with narcolepsy with cataplexy. RESULT The diagnosis of narcolepsy was confirmed by multiple sleep latency test along with human leukocyte antigen typing and cerebrospinal fluid hypocretin assay. CONCLUSION The diagnosis of narcolepsy with cataplexy at onset can be challenging in young children. With more awareness of subtle signs such as cataplectic facies, earlier diagnosis is possible. To date, only 11 children between 6 and 18 years of age presenting with typical cataplectic facies have been reported in the literature. We present two patients, one of whom is the youngest individual (4 years old) yet described with the typical cataplectic facies.
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Affiliation(s)
- Manish Prasad
- Department of Paediatrics, Pinderfield General Hospital, Wakefield, UK.
| | - Gururaj Setty
- Department of Paediatrics, Horton General Hospital, Banbury, UK
| | - Athi Ponnusamy
- Department of Clinical Neurophysiology, Sheffield Children's Hospital, Sheffield, UK
| | - Nahin Hussain
- Department of Paediatric Neurology, Leicester Royal Infirmary, Leicester, UK
| | - Archana Desurkar
- Department of Paediatric Neurology, Sheffield Children's Hospital, Sheffield, UK
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12
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Dhondt K, Verloo P, Verhelst H, Van Coster R, Overeem S. Hypocretin-1 deficiency in a girl with ROHHAD syndrome. Pediatrics 2013; 132:e788-92. [PMID: 23940246 DOI: 10.1542/peds.2012-3225] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare and complex pediatric syndrome, essentially caused by dysfunction of 3 vital systems regulating endocrine, respiratory, and autonomic nervous system functioning. The clinical spectrum of ROHHAD is broad, but sleep/wake disorders have received relatively little attention so far, although the central hypothalamic dysfunction would make the occurrence of sleep symptoms likely. In this case report, we expand the phenotype of ROHHAD with a number of striking sleep symptoms that together can be classified as a secondary form of narcolepsy. We present a 7-year-old girl with ROHHAD who displayed the classic features of narcolepsy with cataplexy: excessive daytime sleepiness with daytime naps, visual hallucinations, and partial cataplexy reflected in intermittent loss of facial muscle tone. Nocturnal polysomnography revealed sleep fragmentation and a sleep-onset REM period characteristic for narcolepsy. The diagnosis was confirmed by showing an absence of hypocretin-1 in the cerebrospinal fluid. We discuss potential pathophysiological implications as well as symptomatic treatment options.
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Affiliation(s)
- Karlien Dhondt
- Pediatric Sleep Centre, Centre for Neurophysiological Monitoring Unit, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.
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13
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Poli F, Overeem S, Lammers GJ, Plazzi G, Lecendreux M, Bassetti CL, Dauvilliers Y, Keene D, Khatami R, Li Y, Mayer G, Nohynek H, Pahud B, Paiva T, Partinen M, Scammell TE, Shimabukuro T, Sturkenboom M, van Dinther K, Wiznitzer M, Bonhoeffer J. Narcolepsy as an adverse event following immunization: Case definition and guidelines for data collection, analysis and presentation. Vaccine 2013; 31:994-1007. [PMID: 23246545 DOI: 10.1016/j.vaccine.2012.12.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 12/05/2012] [Indexed: 01/11/2023]
Affiliation(s)
- Francesca Poli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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15
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White C, Hill EA, Morrison I, Riha RL. Diagnostic delay in REM sleep behavior disorder (RBD). J Clin Sleep Med 2012; 8:133-6. [PMID: 22505857 DOI: 10.5664/jcsm.1762] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES REM sleep behavior disorder (RBD) is a parasomnia in which normal muscle atonia of REM sleep is lost. The aim of this study was to confirm if diagnostic delay exists in RBD and identify any contributing factors. METHODS A database was compiled of 49 patients with RBD seen at a tertiary referral center from 2005 to 2011 by retrospective review of referral letters and polysomnographic (PSG) reports. Patients with comorbid narcolepsy were excluded. A questionnaire was sent to investigate diagnostic delay, management, and comorbidities. RESULTS Mean diagnostic delay was 8.7 ± 11 (median 4.5, IQR 1.75-11.75) years in 30 questionnaire responders. Common reasons for diagnostic delay included belief that symptoms were not serious enough to consult a doctor (59%), mild or infrequent occurrence of sleep behavior (56%), belief that symptoms may resolve (47%), and lack of knowledge of treatment options (47%). The bed partner was an important influence, with the decision to seek medical attention being made jointly by the patient and partner in 47%. CONCLUSIONS This study has demonstrated the existence of significant diagnostic delay in RBD, mainly due to lack of understanding of the disorder and its treatment by patients and members of the medical profession.
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Affiliation(s)
- Caroline White
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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Plazzi G, Pizza F, Palaia V, Franceschini C, Poli F, Moghadam KK, Cortelli P, Nobili L, Bruni O, Dauvilliers Y, Lin L, Edwards MJ, Mignot E, Bhatia KP. Complex movement disorders at disease onset in childhood narcolepsy with cataplexy. ACTA ACUST UNITED AC 2011; 134:3477-89. [PMID: 21930661 PMCID: PMC3235554 DOI: 10.1093/brain/awr244] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Narcolepsy with cataplexy is characterized by daytime sleepiness, cataplexy (sudden loss of bilateral muscle tone triggered by emotions), sleep paralysis, hypnagogic hallucinations and disturbed nocturnal sleep. Narcolepsy with cataplexy is most often associated with human leucocyte antigen-DQB1*0602 and is caused by the loss of hypocretin-producing neurons in the hypothalamus of likely autoimmune aetiology. Noting that children with narcolepsy often display complex abnormal motor behaviours close to disease onset that do not meet the classical definition of cataplexy, we systematically analysed motor features in 39 children with narcolepsy with cataplexy in comparison with 25 age- and sex-matched healthy controls. We found that patients with narcolepsy with cataplexy displayed a complex array of ‘negative’ (hypotonia) and ‘active’ (ranging from perioral movements to dyskinetic–dystonic movements or stereotypies) motor disturbances. ‘Active’ and ‘negative’ motor scores correlated positively with the presence of hypotonic features at neurological examination and negatively with disease duration, whereas ‘negative’ motor scores also correlated negatively with age at disease onset. These observations suggest that paediatric narcolepsy with cataplexy often co-occurs with a complex movement disorder at disease onset, a phenomenon that may vanish later in the course of the disease. Further studies are warranted to assess clinical course and whether the associated movement disorder is also caused by hypocretin deficiency or by additional neurochemical abnormalities.
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Affiliation(s)
- Giuseppe Plazzi
- Department of Neurological Sciences, University of Bologna, 40123 Bologna, Italy.
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