Sleep characteristics in children with Down syndrome

Sleep spindles are reduced in children with Down syndrome and sleep-disordered breathing

BACKGROUND

Children with Down syndrome (DS) are at increased risk of sleep-disordered breathing (SDB). We investigated sleep spindle activity, as a marker of sleep quality, and its relationship with daytime functioning in children with DS compared to typically developing (TD) children.

METHODS

Children with DS and SDB (n = 44) and TD children matched for age, sex and SDB severity underwent overnight polysomnography. Fast or Slow sleep spindles were identified manually during N2/N3 sleep. Spindle activity was characterized as spindle number, density (number of spindles/h) and intensity (density × average duration) on central (C) and frontal (F) electrodes. Parents completed the Child Behavior Check List and OSA-18 questionnaires.

RESULTS

In children with DS, spindle activity was lower compared to TD children for F Slow and F Slow&Fast spindles combined (p < 0.001 for all). Furthermore, there were no correlations between spindle activity and CBCL subscales; however, spindle activity for C Fast and C Slow&Fast was negatively correlated with OSA-18 emotional symptoms and caregiver concerns and C Fast activity was also negatively correlated with daytime function and total problems.

CONCLUSIONS

Reduced spindle activity in children with DS may underpin the increased sleep disruption and negative effects of SDB on quality of life and behavior.

IMPACT

Children with Down syndrome (DS) are at increased risk of sleep-disordered breathing (SDB), which is associated with sleep disruption affecting daytime functioning. Sleep spindles are a sensitive marker of sleep quality. We identified for the first time that children with DS had reduced sleep spindle activity compared to typically developing children matched for SDB severity. The reduced spindle activity likely underpins the more disrupted sleep and may be associated with reduced daytime functioning and quality of life and may also be an early biomarker for an increased risk of developing dementia later in life in children with DS.

Intracapsular Versus Total Tonsillectomy in Patients with Trisomy 21

OBJECTIVES

Intracapsular tonsillectomy and adenoidectomy (iTA) has become a popular alternative to extracapsular tonsillectomy and adenoidectomy (TT) for the treatment of pediatric obstructive sleep apnea (OSA) due to improved recovery and fewer complications. The objective of this study was to compare surgical recovery and impact on OSA of iTA versus TT in patients with Trisomy 21 (T21).

METHODS

This is a case series with chart review of all T21 patients who underwent iTA or TT at our institution between July 1, 2015 and August 15, 2022. Data collected included demographics, comorbidities, preoperative sleep studies, intraoperative data, complications and recovery, postoperative sleep studies, and follow-up data.

RESULTS

There were 62 (21.7%) patients who underwent iTA and 224 (78.3%) patients who underwent TT. The iTA group had significantly lower pain scores (p < 0.001), decreased use of narcotics (p < 0.001), shorter length of stay (p = 0.003), and faster return to oral intake (p = 0.01) during their postoperative hospital admission, and fewer 30-day complications (p = 0.009) compared to the TA group. Both groups showed significant improvements in their sleep studies. For 41 (66.1%) of iTA patients who had follow-up, median follow-up was 1.8 years and for 169 (75.4%) TT patients, median follow-up was 2.6 years. At follow-up, 21 of 41 (51.2%) iTA patients and 83 of 169 (49.1%) TT patients exhibited OSA symptoms (p = 0.084) and tonsillar regrowth was not significantly different between the two groups (p = 0.12).

CONCLUSION

Patients with T21 experience less pain and fewer postoperative respiratory complications from iTA than from TT. The short-term impact of iTA versus TT on OSA, as measured by poysomnography, does not differ between the two techniques.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2430-2437, 2024.

Sleep in people with and without intellectual disabilities: a systematic review and meta-analysis

BACKGROUND

Sleep problems are regularly reported in people with intellectual disabilities. Recent years have seen a substantial increase in studies comparing sleep in people with intellectual disabilities to control participants, with an increase in the use of validated, objective measures. Emerging patterns of differences in sleep time and sleep quality warrant pooled investigation.

METHODS

A systematic search was conducted across three databases (Ovid Embase, PsycInfo and Medline) and returned all papers comparing sleep in people with intellectual disabilities to a control group, published since the last meta-analysis on the topic. A quality framework was employed to rate the risk of bias across studies. Separate meta-analyses of sleep duration and sleep quality were conducted. Subgrouping compared findings for those studies with participants with genetic syndromes or neurodevelopmental conditions and those with heterogeneous intellectual disability.

RESULTS

Thirteen new papers were identified and combined with those from the previous meta-analysis to provide 34 papers in total. Quality of studies was generally rated highly, though sampling provided risk of bias and adaptive functioning was rarely measured. People with intellectual disability associated with genetic syndromes or neurodevelopmental conditions sleep for shorter time periods (standardised mean difference = .26) and experience worse sleep quality (standardised mean difference = .68) than their peers. People with intellectual disability of heterogeneous origin show no difference in sleep time but have poorer sleep quality. There was some evidence that age moderated these effects.

CONCLUSIONS

People with intellectual disability have poorer sleep than those without. Subtle patterns suggest that aetiology of intellectual disability moderates the topography of these difficulties, with further work needed to differentiate common and distinct mechanisms across groups.

Developmental changes in obstructive sleep apnea and sleep architecture in Down syndrome

BACKGROUND

Down syndrome (DS, also known as Trisomy 21) is a condition associated with abnormal neurodevelopment and a higher risk for sleep apnea. Our study sought to better understand and characterize the age-related developmental differences in sleep architecture and obstructive sleep apnea (OSA) severity in children with DS compared to euploid individuals.

METHODS

Retrospective review of polysomnograms in over 4151 infants, children, and adolescents in the pediatric sleep center at Children's National Hospital in Washington D.C. (0-18 years) including 218 individuals with DS.

RESULTS

The primary findings of our study are that: (1) severe OSA (obstructive apnea-hypopnea index ≥ 10/h) was more prevalent in the DS group (euploid 18% vs. DS 34%, p < 0.001) with the highest OSA severity being present in young children (<3 years old) and adolescents (>10 years old), (2) abnormalities in sleep architecture in children with DS were characterized by a prolonged rapid-eye movement (REM) sleep onset latency (SOL) (euploid 119 min vs. DS 144 min, p < 0.001) and greater arousal indexes (euploid 10.7/h vs. DS 12.2/h, p < 0.001), (3) developmental changes in the amount of REM sleep or slow wave sleep were not different in DS individuals relative to euploid children, (4) multivariate analyses showed that OSA and REM sleep latency differences between DS and euploid individuals were still present after adjusting by age, biological sex, and body mass index.

CONCLUSION

Severe OSA is highly prevalent in children with DS and follows an age-dependent "U" distribution with peaks in newborns/infants and children >10 years of age. Children with DS also have disturbances in sleep architecture characterized by a longer REM SOL and elevated arousal indexes. As sleep cycle generation and continuity play crucial roles in neuroplasticity and cognitive development, these findings offer clinically relevant insights to guide anticipatory guidance for infants, children, and adolescents with DS.

Sleep and behavioral problems in Down syndrome: differences between school age and adolescence

Background

Individuals with Down syndrome (DS) are at risk of developing sleep problems. In spite of the well-established knowledge on the presence of sleep difficulties in DS individuals and the associated emotional and behavioral problems, less is known about the possible differences in the kind of associations between sleep and emotional/behavioral problems across different age ranges.

Methods

In this retrospective study, we included 289 participants with DS aged 6-18 years with the aims to explore differences in the distribution of sleep problems between specific age groups (school age vs. adolescence) and to identify specific age-based associations between sleep problems and emotional/behavioral problems.

Results

Some differences in the distribution of sleep problems have emerged between age groups. Moreover, differences in the patterns of association between emotional/behavioral difficulties and sleep problems-in particular, sleep-related breathing difficulties and parasomnias-have been observed. However, sleep-wake transition disorders and excessive daily somnolence appear to be related to emotional and behavioral problems (both internalizing and externalizing), in general, across school age and adolescence.

Discussion

These results remark the importance of appropriate neuropsychiatric and psychological evaluation taking into account the age-specific needs and features of individuals with DS.

Down syndrome patients with normal hearts: are they really normal?

Even though congenital heart disease is a common finding in down syndrome (DS) patients, some of them have anatomically normal hearts. However, the term "normal" might not be suitable, as these patients usually suffer from functional cardiac dysfunction. Several research highlighted that despite the absence of anatomical heart defects, subtle cardiac function derangements are present in DS patients. We aim to assess cardiac functions by Two-dimensional echocardiography and tissue Doppler imaging (TDI) in pediatric DS patients who have anatomically normal hearts. One hundred seventy-two patients with karyotyping confirmed DS with anatomically normal hearts and 165 healthy normal control children were enrolled in the current study. Their cardiac functions were assessed using both 2-dimensional echocardiography and TDI. Both patients and controls had structurally and anatomically normal hearts. In DS patients, the right side of the heart showed a significant reduction in both systolic and diastolic functions. Systolic dysfunction was evident by significantly decreased levels of Tricuspid annular plane systolic excursion and systolic wave by TDI. Diastolic dysfunction of the right ventricle was evident by prolonged deceleration time by conventional echocardiography and a significant decrease in annular tissue doppler velocity during early diastole/late diastole ratio by TDI. The E/De ratio was significantly increased. Even with anatomically normal hearts, DS patients should undergo cardiac function assessment by echocardiography & TDI. TDI is superior to conventional echocardiography in detecting subtle cardiac dysfunction especially left ventricular diastolic dysfunction in DS patients. TDI showed a significant decrease in the early/atrial ratio of mitral valve annulus and prolongation of left ventricle isometric relaxation time in DS children. Also, the left ventricle E/De ratio was prolonged denoting elevated filling pressures and diastolic dysfunction. This indicates that the TDI has higher sensitivity to detect diastolic dysfunction than conventional Echocardiography. Biventricular TDI-derived myocardial performance index was found to be significantly increased in DS children.

Sleep and behavioral problems in preschool-age children with Down syndrome

Sleep is a major concern, especially in people with Down Syndrome (DS). Beyond Obstructive Sleep Apnea, a number of other sleep difficulties have been reported in children with DS, such as delayed sleep onset, night-time awakenings, and early morning awakenings. The detrimental effect of sleep difficulties seems to contribute to and exacerbate the cognitive and behavioral outcomes of DS. Although the screening for sleep disorders is recommended early in age in DS, only a few studies have evaluated the sleep profile in preschool-age children with DS. The aim of the current study was to assess the association between sleep disturbances and behavioral problems in a group of preschool-age children with DS, by means of a feasible and easy-to-administer parent-report questionnaires. Seventy-one preschool-age children with DS, ranging in age from 3 to 5.11 years, were included in this retrospective study. Sleep disturbances were evaluated by means of the Sleep Disturbance Scale for Children, while emotional and behavioral problems by means of the Child Behavior Checklist. Sleep breathing disorders were the most frequent sleep difficulties reported by parents. Moreover, children with clinical scores in total sleep problems exhibited elevation of psychopathological symptoms, namely Total problems, Affective problems, Anxiety problems, Pervasive Developmental Problems, and Attention Deficit/Hyperactivity Problems. The identification of the broader connection between sleep difficulties and emotional and behavioral problems in preschool-age children with DS leads to important considerations for intervention.

Sleep-disordered breathing and sleep macro- and micro-architecture in children with Down syndrome

BACKGROUND

Children with Down syndrome (DS) are at increased risk of sleep-disordered breathing (SDB), which is associated with intermittent hypoxia and sleep disruption affecting daytime functioning. We aimed to compare the impact of SDB on sleep quality in children with DS compared to typically developing (TD) children with and without SDB.

METHODS

Children with DS and SDB (n = 44) were age- and sex-matched with TD children without SDB (TD-) and also for SDB severity with TD children with SDB (TD+). Children underwent overnight polysomnography with sleep macro- and micro-architecture assessed using electroencephalogram (EEG) spectral analysis, including slow-wave activity (SWA, an indicator of sleep propensity).

RESULTS

Children with DS had greater hypoxic exposure, more respiratory events during REM sleep, higher total, delta, sigma, and beta EEG power in REM than TD+ children, despite the same overall frequency of obstructive events. Compared to TD- children, they also had more wake after sleep-onset and lower sigma power in N2 and N3. The DS group had reduced SWA, indicating reduced sleep drive, compared to both TD groups.

CONCLUSIONS

Our findings suggest that SDB has a greater impact on sleep quality in children with DS compared to TD children.

IMPACT

SDB in children with DS exacerbates disruption of sleep quality, compared to TD children. The prevalence of SDB is very high in children with DS; however, studies on the effects of SDB on sleep quality are limited in this population. Our findings suggest that SDB has a greater impact on sleep quality in children with DS compared to TD children, and should be screened for and treated as soon as possible.

Human ARHGEF9 intellectual disability syndrome is phenocopied by a mutation that disrupts collybistin binding to the GABAA receptor α2 subunit

Intellectual disability (ID) is a common neurodevelopmental disorder that can arise from genetic mutations ranging from trisomy to single nucleotide polymorphism. Mutations in a growing number of single genes have been identified as causative in ID, including ARHGEF9. Evaluation of 41 ARHGEF9 patient reports shows ubiquitous inclusion of ID, along with other frequently reported symptoms of epilepsy, abnormal baseline EEG activity, behavioral symptoms, and sleep disturbances. ARHGEF9 codes for the Cdc42 Guanine Nucleotide Exchange Factor 9 collybistin (Cb), a known regulator of inhibitory synapse function via direct interaction with the adhesion molecule neuroligin-2 and the α2 subunit of GABAA receptors. We mutate the Cb binding motif within the large intracellular loop of α2 replacing it with the binding motif for gephyrin from the α1 subunit (Gabra2-1). The Gabra2-1 mutation causes a strong downregulation of Cb expression, particularly at cholecystokinin basket cell inhibitory synapses. Gabra2-1 mice have deficits in working and recognition memory, as well as hyperactivity, anxiety, and reduced social preference, recapitulating the frequently reported features of ARHGEF9 patients. Gabra2-1 mice also have spontaneous seizures during postnatal development which can lead to mortality, and baseline abnormalities in low-frequency wavelengths of the EEG. EEG abnormalities are vigilance state-specific and manifest as sleep disturbance including increased time in wake and a loss of free-running rhythmicity in the absence of light as zeitgeber. Gabra2-1 mice phenocopy multiple features of human ARHGEF9 mutation, and reveal α2 subunit-containing GABAA receptors as a druggable target for treatment of this complex ID syndrome.

Sleep-Related Rhythmic Movement Disorder in Young Children with Down Syndrome: Prevalence and Clinical Features

Sleep-related Rhythmic Movement Disorder (RMD) affects around 1% of UK pre-school children. Little is known about RMD in Down syndrome (DS). We aimed to determine: (a) the prevalence of RMD in children with DS aged 1.5–8 years; (b) phenotypic and sleep quality differences between children with DS and RMD and sex- and age-matched DS controls; and (c) night-to-night variability in rhythmic movements (RMs). Parents who previously reported RMs from a DS research registry of 202 children were contacted. If clinical history suggested RMD, home videosomnography (3 nights) was used to confirm RMs and actigraphy (5 nights) was used to assess sleep quality. Phenotype was explored by demographic, strengths and difficulties, Q-CHAT-10/social communication and life events questionnaires. Eight children had confirmed RMD. Minimal and estimated maximal prevalence were 4.10% and 15.38%, respectively. Sleep efficiency was significantly lower in RMD-cases (69.1%) versus controls (85.2%), but there were no other phenotypic differences. There was considerable intra-individual night-to-night variability in RMs. In conclusion, RMD has a high prevalence in children with DS, varies from night to night and is associated with poor sleep quality but, in this small sample, no daytime phenotypic differences were found compared to controls. Children with DS should be screened for RMD, which is amenable to treatment.

Sleep-related learning in Williams Syndrome and Down's Syndrome

This chapter addresses sleep research challenges for the study of neurodevelopmental disorders drawing upon two disorders such as Down Syndrome and Williams syndrome. General sleep problems are outlined here, however particular consideration is given to the syndrome-specific issues or challenges that may be crucial to advancing our understanding of sleep-related cognitive and behavioral issues.

Sleep's role in memory consolidation: What can we learn from atypical development?

Research conducted over the last century has suggested a role for sleep in the processes guiding healthy cognition and development, including memory consolidation. Children with intellectual and developmental disabilities (IDDs) tend to have higher rates of sleep disturbances, which could relate to behavior issues, developmental delays, and learning difficulties. While several studies examine whether sleep exacerbates daytime difficulties and attention deficits in children with IDDs, this chapter focuses on the current state of knowledge regarding sleep and memory consolidation in typically developing (TD) groups and those at risk for learning difficulties. In particular, this chapter summarizes the current literature on sleep-dependent learning across developmental disabilities, including Down syndrome, Williams syndrome, Autism Spectrum Disorder, and Learning Disabilities (Attention-Deficit/Hyperactivity Disorder and Dyslexia). We also highlight the gaps in the current literature and identify challenges in studying sleep-dependent memory in children with different IDDs. This burgeoning new field highlights the importance of considering the role of sleep in memory retention across long delays when evaluating children's memory processes. Further, an understanding of typical and atypical development can mutually inform recent theories of sleep's role in memory.

Behavioural and emotional disturbances associated with sleep-disordered breathing symptomatology in children with Down's syndrome

BACKGROUND

Down's syndrome (DS) predisposes to sleep-disordered breathing (SDB). In children with DS, behavioural and emotional disturbances secondary to SDB are often assumed to result from cognitive impairment alone. Our aim was to explore the relationship of behavioural and emotional disturbances with SDB in a population of children with DS.

METHODS

A modified sleep questionnaire, Epworth Sleepiness Scale (ESS), Paediatric ESS and the short form of the developmental behaviour checklist (DBC-P24) were sent to 261 carers of children aged 4 to 15 years with DS in 2012.

RESULTS

Of 120 participants, 25% had probable SDB. In children with probable SDB compared to those without nocturnal symptoms, the total behaviour problem score (TBPS) was significantly higher (20.3 ± 8.6/48 vs. 12 ± 7.5/48; P = 0.002) as was the PaedESS (7.7 ± 5.6/24 vs. 2.8 ± 3.5/24; P = 0.002). For every increase in frequency of choking attacks, snoring and night awakenings, the TBPS increased by 1.37, 1.28 and 1.75 points, respectively, indicating worsening behaviour. The TBPS was found to decrease by 1.31 points for every hour more of self-reported sleep duration (r = -0.25, P = 0.017).

CONCLUSIONS

SDB symptoms and shorter self-reported sleep duration are highly prevalent among children with DS and are independently associated with worsening behaviour using the TBPS.

Morbidity and mortality from adenotonsillectomy in children with trisomy 21

OBJECTIVE

Adenotonsillectomy (AT) is common in children with trisomy 21 but outcomes are variable. Therefore, practitioners must have accurate information regarding the risks of the procedure specific to trisomy 21 to help patients weigh the risks and benefits of surgery. The objective of this study was to better characterize morbidity and mortality risk factors from AT in children with trisomy 21.

METHODS

A single-center retrospective chart review of children with trisomy 21 who underwent AT was conducted from 1992 to 2019. The primary outcome was 30-day post-operative complication rate. Secondary outcomes included intraoperative complications, admission duration, emergency department visits, readmissions, reoperation rate and treatment failures.

RESULTS

Two-hundred and fifty one children met study criteria (median age 4.5 years). Seventy-eight patients (31.5%) had a post-operative complication requiring medical intervention, with respiratory issues (42, 53.8%), poor oral intake (29, 37.2%), and bleeding (14, 17.9%) being most common. Postoperatively, 72 patients (28.7%) had a prolonged hospital stay. Sleep disordered breathing (p = 0.003), ASA score >2 (p < 0.001), severe OSA (p = 0.003), preoperative ICU admission (p < 0.001), and aerodigestive comorbidities (p = 0.004) were associated with increased post-operative respiratory complications. No mortalities were identified.

CONCLUSION

This large single institution study evaluating morbidity and mortality following AT in children with trisomy 21 identified a morbidity rate of 31.5%. These findings may improve our ability to anticipate and manage postoperative morbidity in this vulnerable population and facilitate informed discussions with patients and caregivers considering AT.

Findings of routine nocturnal polysomnography in children with Down syndrome: a retrospective cohort study

STUDY OBJECTIVE

Children with Down syndrome (DS) are at risk for sleep disorders including; obstructive sleep apnea (OSA). Although OSA is diagnosed by polysomnography (PSG), the practicality of PSG in DS is questionable. Further, OSA treatment efficacy in DS is largely unknown given the challenges of PSG. Our aims were to review (i) the feasibility of PSG, and (ii) the efficacy (improvement in obstructive apnea hypopnea index (OAHI)) of OSA treatment using follow-up PSG in DS.

METHODS

Retrospective review of patients aged <21 years with DS who underwent PSG from October 2016 to June 2019. Successful PSG was determined using total sleep time (TST). PSG following treatment with adenotonsillectomy (AT) or positive airway pressure (PAP) was evaluated and compared to pre-treatment.

RESULTS

Among 248 patients with DS, only 11(4.4%) had unsuccessful PSG (TST<1h). Of the 237 successful studies (age: 7.9 ± 0.3y), average TST and sleep efficiency was 5.6 ± 0.1h and 79.5 ± 1.3%. 41 had post-AT PSG and 11(27%) achieved OSA cure (OAHI<2) with all demonstrating improved SE (p = 0.01) and OAHI (p = 0.0003). Multivariate analysis revealed only age was predictive (p = 0.003) of residual OSA post-AT. Of 24 children who underwent PAP titration, 20(83%) tolerated titration with improved OAHI (p = 0.01), however, no significant improvements in SE were observed.

CONCLUSIONS

In a large cohort of DS children, PSG was well tolerated. Following AT or PAP therapy, post treatment PSG confirmed efficacy, although residual OSA was identified. PSG is thus both feasible and useful in identifying OSA, OSA treatment response and should guide in decision making in children with DS.

Sleep Architecture in Children With Down Syndrome With and Without Obstructive Sleep Apnea

OBJECTIVE

To characterize polysomnographic sleep architecture in children with Down syndrome and compare findings in those with and without obstructive sleep apnea.

STUDY DESIGN

Case series with retrospective review.

SETTING

Single tertiary pediatric hospital (2005-2018).

METHODS

We reviewed the electronic health records of patients undergoing polysomnography who were referred from a specialized center for children with Down syndrome (age, ≥12 months). Continuous positive airway pressure titration, oxygen titration, and split-night studies were excluded.

RESULTS

A total of 397 children were included (52.4% male, 81.6% Caucasian). Mean age at the time of polysomnography was 4.7 years (range, 1.4-14.7); 79.4% had obstructive sleep apnea. Sleep variables were reported as mean (SD) values: sleep efficiency, 85% (11%); sleep latency, 29.8 minutes (35.6); total sleep time, 426 minutes (74.6); rapid eye movement (REM) latency, 126.8 minutes (66.3); time spent in REM sleep, 22% (7%); arousal index, 13.3 (5); and time spent supine, 44% (28%). There were no significant differences between those with obstructive sleep apnea and those without. Sleep efficiency <80% was seen in 32.5%; 34.3% had a sleep latency >30 minutes; 15.9% had total sleep time <360 minutes; and 75.6% had an arousal index >10/h. Overall, 69.2% had ≥2 metrics of poor sleep architecture. REM sleep time <20% was seen in 35.3%. REM sleep time decreased with age.

CONCLUSION

In children with Down syndrome, 32.5% had sleep efficiency <80%; 75.6% had an elevated arousal index; and 15.9% had total sleep time <360 minutes. More than a third of the patients had ≥3 markers of poor sleep architecture. There was no difference in children with or without obstructive sleep apnea.

Polysomnographic Outcomes After Observation for Mild Obstructive Sleep Apnea in Children Younger Than 3 Years

OBJECTIVE

Mild obstructive sleep apnea (OSA), particularly in young children, is often treated with observation. However, there is little evidence regarding the outcomes with this approach. Our aim was to assess the impact of observation on sleep for children aged <3 years with mild OSA.

STUDY DESIGN

Case-control study.

SETTING

Pediatric tertiary care center.

METHODS

We reviewed cases of children (<3 years old) diagnosed with mild OSA (obstructive apnea-hypopnea index, 1-5 events/h) who were treated with observation between 2012 and 2017 and had at least 2 polysomnograms performed 3 to 12 months apart. Demographic data and comorbid diagnoses were collected.

RESULTS

Twenty-six children met inclusion criteria; their median age was 7.2 months (95% CI, 1.2-22.8). Nine (35%) were female and 24 (92%) were White. Their median body mass index percentile was 39 (95% CI, 1-76). Comorbidities included cardiac disease (42.3%), laryngomalacia (42.3%), allergies (34.6%), reactive airway disease (23.1%), and prematurity (7.7%). The obstructive apnea-hypopnea index significantly decreased from 2.7 events/h (95% CI, 1-4.5) to 1.3 (95% CI, 0-4.5; P = .013). There was no significant improvement in median saturation nadir (baseline, 86%; P = .76) or median time with end-tidal carbon dioxide >50 mm Hg (baseline, 0 minutes; P = .34). OSA resolved in 8 patients (31%) and worsened in 1 (3.8%). Only race was a significant predictor of resolution per regression analysis; however, only 2 non-White children were included.

CONCLUSION

In our cohort, resolution of mild OSA occurred in 31% of patients treated with 3 to 12 months of observation. The presence of laryngomalacia, asthma, and allergies did not affect resolution. Larger studies are needed to better identify factors (including race) associated with persistent OSA and optimal timing of intervention for these children.

LEVEL OF EVIDENCE

4.

Sleep Supports Memory and Learning: Implications for Clinical Practice in Speech-Language Pathology

Purpose This tutorial aims to draw attention to the interactions among memory, sleep, and therapy potential and to increase awareness and knowledge in the field of speech-language pathology of the potential impact of sleep as a mediating or moderating factor in promoting therapeutic outcome. Method We highlight key findings from the literature on the cognitive neuroscience of memory, the neurophysiology of sleep, how sleep supports memory, and how sleep disruption affects memory and learning abilities in populations commonly served in speech-language pathology. Results Research increasingly points to the critical importance of sleep quality and quantity to memory and learning, and sleep disruption is linked to deficits in functional cognition that may limit our clients' ability to benefit from speech pathology interventions. Conclusions As a field dedicated to promoting memory, learning, and relearning through our interventions, any systemic factors that affect these abilities demand our attention. Although speech-language pathologists do not treat sleep disturbance, we play a critical role in recognizing the signs and symptoms of sleep disturbance and making appropriate referrals, as undiagnosed and untreated sleep disturbance can have serious impacts on success in therapeutic contexts. By considering how related factors affect memory and learning, we have the opportunity to take a whole client approach to maximizing our clients' therapy potential and functional progress.

Sleep problems and recall memory in children with Down syndrome and typically developing controls

BACKGROUND

Research conducted with typically developing (TD) infants and children generally indicates that better habitual sleep and sleep after learning are related to enhanced memory. Less is known, however, about associations between sleep and recall memory in children with Down syndrome (DS).

AIMS

The present study was conducted to determine whether parent-reported sleep problems were differentially associated with encoding, 1-month delayed recall memory, and forgetting over time in children with DS and those who were TD.

METHODS AND PROCEDURES

Ten children with DS (mean age = 33 months, 5 days) and 10 TD children (mean age = 21 months, 6 days) participated in a two-session study. At each session, recall memory was assessed using an elicited imitation paradigm. Immediate imitation was permitted at the first session as an index of encoding, and delayed recall was assessed 1 month later. In addition, parents provided demographic information and reported on child sleep problems.

OUTCOMES AND RESULTS

Although parents did not report more frequent sleep problems for children with DS relative to TD children, regression-based moderation analyses revealed that more frequent sleep problems were associated with increased forgetting of individual target actions and their order by children with DS. Evidence of moderation was not found when examining encoding or delayed recall.

CONCLUSIONS AND IMPLICATIONS

Although group differences were not found when considering parent-reported sleep problems, more frequent sleep problems were positively associated with increased forgetting by children with DS relative to those who were TD. Although future experimental work is needed to determine causality, these results suggest that improved sleep in children with DS might reduce forgetting, ultimately improving long-term recall memory.

Long Term Continuous Positive Airway Pressure and Non-invasive Ventilation in Obstructive Sleep Apnea in Children With Obesity and Down Syndrome

This review will focus on non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) therapy in children with obstructive sleep apnea (OSA) due to obesity and underlying syndromes. These children have a high prevalence of OSA and residual OSA after adenotonsillectomy. Therefore, a high proportion of these children are treated with CPAP or NIV. This review will focus on treatment selection tools and will subsequently cover specific issues on CPAP treatment in obese and syndromic children with a major focus on Down syndrome.

An Ultra-miniaturized Near Infrared Spectroscopy System to Assess Sleep Apnea in Children with Down Syndrome

Down syndrome is one of the health disorders that interferes with regular and healthy sleep. Most children with Down syndrome are referred to a sleep clinic for the assessment of the severity of their apnea. Regular polysomnography based assessment of apnea has been challenging with this sensitive patient population. We present our efforts towards developing a flexible adhesive bandage sized near infrared spectroscopy system (pediBand) for home-assessment of apnea in children with Down syndrome. Combined with inertial measurement units, pediBand record heart rate, heart rate variability, respiratory rate, arterial oxygen saturation and cerebral oxygen saturation. These are the essential parameters to assess sleep apnea and could also potentially be used in the assessment of sleep performance in general. A modified version of pediBand system was evaluated on adult patients and successfully demonstrated the changes in hemodynamic system triggered by sleep apnea.

Adherence to Guidelines for Screening Polysomnography in Children with Down Syndrome

Objectives

To compare the percentage and mean age of children with Down syndrome (DS) who underwent polysomnography (PSG) to evaluate for obstructive sleep apnea (OSA) before and after the introduction of the American Academy of Pediatrics guidelines recommending universal screening by age 4 years.

Study Design

Retrospective cohort study.

Setting

Single tertiary pediatric hospital.

Methods

This study is a review of patients with DS seen in a subspecialty clinic. Children born preguidelines (2000-2006) were compared with children born postguidelines (2007-2012) regarding percentage receiving PSG, age at first PSG, and rate of OSA.

Results

We included 766 children with DS; 306 (40%) were born preguidelines. Overall, 61% (n = 467) underwent PSG, with a mean ± SD age of 4.2 ± 2.9 years at first PSG; 341 (44.5%) underwent first PSG by age 4 years. The rate of OSA (obstructive index ≥1 event/hour) among children undergoing first PSG was 78.2%. No difference was seen in the percentage receiving PSG preguidelines (63.4%) versus postguidelines (59.4%, P = .26). The mean age at the time of first PSG was 5.3 ± 3.5 years preguidelines versus 3.4 ± 2.0 years postguidelines ( P < .0001). Children in the postguidelines cohort were more likely to undergo first PSG during the ages of 1 through 4 years (67.4% vs 52.1%, P < .0001). There was no difference in rates of OSA between the pre- and postguidelines cohorts (79.8% vs 75.9%, P = .32).

Conclusions

Nearly two-thirds of children with DS (61%) underwent PSG overall, with a significant shift toward completion of PSG at an earlier age after the introduction of the American Academy of Pediatrics guidelines for universal screening for OSA.

Sleep and sleep disordered breathing in children with down syndrome: Effects on behaviour, neurocognition and the cardiovascular system

Down syndrome (DS), the most common human chromosomal malformation, has an estimated annual incidence of one in 1000 live births worldwide. Sleep problems are common in children with DS, reported by parents in up to 65% of school-aged children, significantly higher rates than in typically developing (TD) children. Problems include difficulty in sleep initiation and maintenance together with obstructive sleep apnoea (OSA) which affects up to over 90%, of DS children compared with 1-5% in the general paediatric population. Any sleep problem has the potential to exert significant negative effects on daytime behaviour, learning and quality of life in TD children and there is now a growing body of evidence that children with DS are similarly affected. In addition to adverse effects on daytime functioning, OSA has adverse effects on the cardiovascular system and this is a particularly significant issue given the high rates of hypertension and premature cardiac disease in people with DS. This review discusses the effects of sleep problems and OSA on daytime functioning and cardiovascular function in children with DS and evidence of the effectiveness of treatment in improving outcomes and quality of life for these children.

Sleep-disordered breathing in paediatric setting: existing and upcoming of the genetic disorders

Childhood obstructive sleep apnea syndrome (OSAS) is characterized by anatomical and functional upper airway abnormalities as pathophysiological determinants, and clinical symptoms are frequently clear. OSAS is widely described in rare genetic disorders, such as achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, and mucopolysaccharidosis. Craniofacial and upper airway involvement is frequently morbid conditions. In children with genetic diseases, the clinical symptoms of OSAS are often slight or absent, and related morbidities are usually more severe and can be observed at any age. The present review is aimed to updating the discoveries regarding OSAS on Achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, Sickle cell disease, or encountered in our clinical practice (Ehlers-Danlos syndrome, Ellis-van Creveld syndrome, Noonan syndrome). Two additional groups of genetic disorders will be focused (mucopolysaccharidoses and osteogenesis imperfecta). The flowing items are covered for each disease: (I) what is the pathophysiology of OSAS? (II) What is the incidence/prevalence of OSAS? (III) What result from the management and prognosis? (IV) What are the recommendations? Considering the worries of OSAS, such as inattention and behavioural problems, daytime sleepiness, failure to thrive, cardiological and metabolic complications, the benefit of a widespread screening and the treatment in children with genetic diseases is undoubtful. The goals of the further efforts can be the inclusion of various genetic diseases into guidelines for the screening of OSAS, updating the shreds of evidence based on the research progression.

Obstructive Sleep Apnea in Children with Down Syndrome: Demographic, Clinical, and Polysomnographic Features

Objectives

To evaluate demographic, clinical, and polysomnographic features of children with Down syndrome suspected of having obstructive sleep apnea. To identify factors that predict severe obstructive sleep apnea among children with Down syndrome.

Study Design

Case series with chart review.

Setting

Children’s Medical Center Dallas / University of Texas Southwestern Medical Center.

Subject and Methods

Demographic, clinical, and polysomnographic data were collected for children with Down syndrome aged 2 to 18 years. Simple and multivariable regression models were used to study predictors of severe obstructive sleep apnea (apnea-hypopnea index ≥10). P≤ .05 was considered significant.

Results

A total of 106 children with Down syndrome were included, with 89 (84%) <12 years old, 56 (53%) male, 72 (68%) Hispanic, 15 (14%) African American, and 14 (13%) Caucasian. Ninety percent of children had ≥1 medical comorbidities; 95 (90%) patients had obstructive sleep apnea; and 46 (44%) had severe obstructive sleep apnea. The mean SaO2 nadir was lower among obese than nonobese children (80% vs 85%, P = .02). Obese versus nonobese patients had a higher prevalence of severe obstructive sleep apnea (56% vs 35%, P = .03). Severe OSA was associated with heavier weight (odds ratio = 1.0, 95% CI: 1.0-1.1, P = .002) and age ≥12 years (odds ratio = 1.2, 95% CI: 0.2-2.5, P = .02). The multivariable model showed that severe obstructive sleep apnea was associated only with weight (odds ratio = 1.1, 95% CI: 1.0-1.1, P = .02).

Conclusion

Obese children with DS are at a high risk for severe OSA, with weight as the sole risk factor. The results of this study show the importance of monitoring the weight of children with DS and counseling parents of children with DS about weight loss.

Prevalence of Obstructive Sleep Apnea in Children With Down Syndrome: A Meta-Analysis

STUDY OBJECTIVES

To estimate the prevalence of obstructive sleep apnea (OSA) in children with Down syndrome.

METHODS

Two authors independently searched databases, namely PubMed, MEDLINE, EMBASE, and the Cochrane Review database. The keywords used were "Down syndrome," "Trisomy 21," "OSA," "sleep apnea syndromes," "polysomnography" and "polygraphy." The prevalence of OSA based on apnea-hypopnea index (AHI) greater than 1, 1.5, 2, 5, and 10 event/h was estimated using a random-effects model. Subgroup analyses were conducted for children in different countries, sample size, study year, and risk of bias. Finally, the prevalence of OSA was compared between two types of sleep studies (polysomnography versus polygraphy).

RESULTS

A total of 18 studies (1,200 children) were included (mean age: 7.7 years; 56% boys; mean sample size: 67 patients). Five studies had low risk of bias, and nine and four studies had moderate and high risk of bias, respectively. The OSA was evaluated through polygraphy in 2 studies, and polysomnography in 16 studies. For children who underwent polysomnography, the prevalences of OSA based on AHI > 1, 1.5, 2, 5, and 10 events/h were 69%, 76%, 75%, 50%, and 34%, respectively. Subgroup analyses revealed no significant difference among all subgroups. Meta-regression showed that AHI > 5 events/h was inversely correlated with age (P < .001). Moreover, the prevalence of OSA based on AHI > 1.5 events/h was lower in polygraphy compared with polysomnography (59% versus 76%, P = .037).

CONCLUSIONS

OSA is highly prevalent in children with Down syndrome. Prevalence of moderate to severe OSA is higher in younger age.

Pulmonary hemosiderosis in children with Down syndrome: a national experience

BACKGROUND

Pulmonary hemosiderosis is a rare and complex disease in children. A previous study from the French RespiRare® network led to two important findings: 20% of the children presented with both pulmonary hemosiderosis and Down syndrome (DS), and at least one tested autoantibody was found positive in 50%. This study investigates the relationships between pulmonary hemosiderosis and DS.

METHODS

Patients younger than 20 years old and followed for pulmonary hemosiderosis were retrieved from the RespiRare® database. Clinical, biological, functional, and radiological findings were collected, and DS and non-DS patients' data were compared.

RESULTS

A total of 34 patients (22 girls and 12 boys) were included, among whom nine (26%) presented with DS. The mean age at diagnosis was 4.1 ± 3.27 years old for non-DS and 2.9 ± 3.45 years old for DS patients. DS patients tended to present a more severe form of the disease with an earlier onset, more dyspnoea at diagnosis, more frequent secondary pulmonary hypertension, and an increased risk of fatal evolution.

CONCLUSIONS

DS patients have a higher risk of developing pulmonary hemosiderosis, and the disease seems to be more severe in this population. This could be due to the combination of an abnormal lung capillary bed with fragile vessels, a higher susceptibility to autoimmune lesions, and a higher risk of evolution toward pulmonary hypertension. A better screening for pulmonary hemosiderosis and a better prevention of hypoxia in DS paediatric patients may prevent a severe evolution of the disease.

Convergent validity of actigraphy with polysomnography and parent reports when measuring sleep in children with Down syndrome

BACKGROUND

There is a need for rigorous measures of sleep in children with Down syndrome as sleep is a substantial problem in this population and there are barriers to obtaining the gold standard polysomnography (PSG). PSG is cost-prohibitive when measuring treatment effects in some clinical trials, and children with Down syndrome may not cooperate with undergoing a PSG. Minimal information is available on the validity of alternative methods of assessing sleep in children with Down syndrome, such as actigraphy and parent ratings. Our study examined the concurrent and convergent validity of different measures of sleep, including PSG, actigraphy and parent reports of sleep among children with Down syndrome.

METHOD

A clinic (n = 27) and a community (n = 47) sample of children with Down syndrome were examined. In clinic, children with Down syndrome wore an actigraph watch during a routine PSG. In the community, children with Down syndrome wore an actigraph watch for a week at home at night as part of a larger study on sleep and behaviour. Their parent completed ratings of the child's sleep during that same week.

RESULTS

Actigraph watches demonstrated convergent validity with PSG when measuring a child with Down syndrome's total amount of sleep time, total wake time after sleep onset and sleep period efficiency. In contrast, actigraph watches demonstrated poor correlations with parent reports of sleep, and with PSG when measuring the total time in bed and total wake episodes. Actigraphy, PSG and parent ratings of sleep demonstrated poor concurrent validity with clinical diagnosis of obstructive sleep apnoea.

CONCLUSION

Our current data suggest that actigraph watches demonstrate convergent validity and are sensitive to measuring certain sleep constructs (duration, efficiency) in children with Down syndrome. However, parent reports, such as the Children's Sleep Habits Questionnaire, may be measuring other sleep constructs. These findings highlight the importance of selecting measures of sleep related to target concerns.

Sleep Behavior and EEG Oscillations in Aged Dp(16)1Yey/+ Mice: A Down Syndrome Model

Down syndrome (DS) results from the triplication of genes located on human chromosome 21 (Hsa21). Though many cognitive and behavioral impairments are associated with DS, sleep disturbances remain poorly understood despite being a reported phenotype in approximately 60% of individuals diagnosed with DS. In this study, sleep and electroencephalography (EEG) oscillations were recorded from aged (12–14 mos.) Dp(16)1Yey/+ mice (Dp16), a mouse model of DS. We observed disrupted sleep demonstrated by increased activity during the dark phase and increased time awake at the expense of NREM sleep compared to wild-type mice. In addition, we found that Dp16 mice display significant differences in relative EEG power distribution among oscillation frequencies in both sleep and awake states. These results in Dp16 mice are consistent with sleep disturbances found in individuals with DS, and the abnormal EEG oscillations in aged Dp16 mice suggest a potential role for GABAergic activity in these sleep and EEG abnormalities. These sleep and EEG data reflect underlying differences in neuronal activity at the network level and thus are causative agents rather than merely symptoms of DS.

Links between sleep and daytime behaviour problems in children with Down syndrome

BACKGROUND

In the general population, sleep problems have an impact on daytime performance. Despite sleep problems being common among children with Down syndrome, the impact of sleep problems on daytime behaviours in school-age children with Down syndrome is an understudied topic. Our study examined the relationship between parent-reported and actigraphy-measured sleep duration and sleep quality with parent and teacher reports of daytime behaviour problems among school-age children with Down syndrome.

METHOD

Thirty school-age children with Down syndrome wore an actigraph watch for a week at home at night. Their parent completed ratings of the child's sleep during that same week. Their parent and teacher completed a battery of measures to assess daytime behaviour.

RESULTS

Parent reports of restless sleep behaviours on the Children's Sleep Habits Questionnaire, but not actigraph-measured sleep efficiency, was predictive of parent and teacher behavioural concerns on the Nisonger Child Behaviour Rating Form and the Vanderbilt ADHD Rating Scales. Actigraph-measured sleep period and parent-reported sleep duration on the Children's Sleep Habits Questionnaire was predictive of daytime parent-reported inattention. Actigraph-measured sleep period was predictive of parent-reported hyperactivity/impulsivity.

CONCLUSION

The study findings suggest that sleep problems have complex relationships to both parent-reported and teacher-reported daytime behaviour concerns in children with Down syndrome. These findings have implications for understanding the factors impacting behavioural concerns and their treatment in school-age children with Down syndrome.

Hypoglossal Nerve Stimulation in Adolescents With Down Syndrome and Obstructive Sleep Apnea

Importance

Obstructive sleep apnea (OSA) affects up to 60% of children with Down syndrome (DS) and may persist in half of patients after adenotonsillectomy. Children with DS who have persistent OSA often do not tolerate treatment with positive pressure airway support devices or tracheotomy for their residual moderate to severe OSA. The hypoglossal nerve stimulator is an implantable device that delivers an electrical impulse to anterior branches of the hypoglossal nerve in response to respiratory variation, resulting in tongue base protrusion that alleviates upper airway obstruction in adults.

Objective

To determine whether hypoglossal nerve stimulation is safe and effective in children with DS.

Design, Setting, and Participants

Case series of the first 6 adolescents with DS to undergo hypoglossal nerve stimulator implantation. Participants were 6 children and adolescents (12-18 years) with DS and severe OSA (apnea hypopnea index [AHI] > 10 events/h) despite prior adenotonsillectomy.

Intervention

Inspire hypoglossal nerve stimulator placement.

Main Outcomes and Measures

Patients were monitored for adverse events. Adherence to therapy was measured by hours of use recorded by the device. Efficacy was evaluated by comparing AHI and OSA-18, a validated quality-of-life instrument, scores at baseline and follow-up.

Results

In 6 patients (4 male, 2 female; aged 12-18 years), hypoglossal nerve stimulator therapy was well tolerated (mean use, 5.6-10.0 h/night) and effective, resulting in significant improvement in OSA. At 6- to 12-month follow-up, patients demonstrated a 56% to 85% reduction in AHI, with an overall AHI of less than 5 events/h in 4 children and less than 10 events/h in 2 children. Children also demonstrated a clinically significant improvement (mean [SD] overall change score, 1.5 [0.6]; range, 0.9-2.3) on the OSA-18, a validated quality-of-life instrument.

Conclusions and Relevance

Hypoglossal nerve stimulation was well tolerated and effective in the study population, representing a potential therapeutic option for patients with DS and refractory OSA after adenotonsillectomy who are unable to tolerate positive pressure airway devices.

Trial Registration

clinicaltrials.gov Identifier: NCT2344108.

Pediatric Obstructive Sleep Apnea in High-Risk Populations: Clinical Implications

Certain common medical conditions are associated with a higher risk of pediatric obstructive sleep apnea (OSA). A lower threshold for screening is therefore indicated for such patient cohorts. In this article, we briefly discuss the high prevalence of OSA in children born prematurely, and in those with Down syndrome, craniofacial disorders, and neuromuscular disorders. Primary care providers should have an increased index of suspicion for OSA in these children, considering the neurocognitive disability that occurs in these high-risk groups when OSA is left untreated. [Pediatr Ann. 2017;46(9):e336-e339.].

The facial morphology in Down syndrome: A 3D comparison of patients with and without obstructive sleep apnea

Obstructive sleep apnea (OSA) occurs at a high prevalence in patients with Down syndrome (DS). A polysomnogram, which is often cumbersome and challenging, remains the gold standard method of diagnosing OSA. OSA in patients with DS is often attributed to skeletal and soft-tissue structural alterations that are characteristic of the DS phenotype; as such, we hypothesized that assessing anthropometric facial measurements may be predictive of OSA in patients with DS. We used the 3dMDface sterophotography system to capture and create 3D facial images, and we subsequently identified facial landmarks using a single, experienced investigator and utilizing proprietary software to calculate inter-landmark distances and angles. We compared our findings with similar data for neurotypically developing participants. We further compared the findings in participants with DS with and without OSA. Participants with DS had maxillomandibular hypoplasia with smaller ear, nose, and eye measurements compared to neurotypically developing peers. We found no statistically significant differences in 3D photogrammetric measurements between participants with DS with or without OSA.

Tonsillectomy in Children with Down Syndrome: A National Cohort of Inpatients

Objective To describe the cost, length of stay, and incidence of postoperative hemorrhage associated with Down syndrome (DS) patients undergoing tonsillectomy in a national sample of inpatient children. Study Design This study uses a national cross-sectional cohort to analyze children with and without DS undergoing tonsillectomy with or without adenoidectomy. Setting 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. Subjects and Methods The database was analyzed for postoperative hemorrhage and respiratory compromise, length of stay, and total charges of hospital stay. These outcomes were compared between patients with DS vs patients without DS. Results In total, 7512 patients were identified who underwent tonsillectomy: 7159 patients without DS and 353 patients with DS. The non-DS group was younger with a median age of 3 years (range, 0-18) compared with a DS median age of 4 years (range, 0-20), P = .004. The DS group had a significant increase in postoperative hemorrhage compared with non-DS (10 [2.8%] vs 87 [1.2%], respectively), P = .024. However, the DS and non-DS groups were comparable for respiratory complications (5 [1.4%] vs 106 [1.5%], respectively), P = .922. Median length of stay was significantly increased in the DS group (1 [interquartile range (IQR), 1-3]) compared with the non-DS group (1 [IQR, 1-2]), P < .001. Median charges for hospital stay totaled $17,451 (IQR, $11,901-$24,949) for the DS group compared with $14,395 (IQR, $9739-$21,890) for the non-DS group, P < .001. Conclusion Across the United States, children with DS hospitalized for tonsillectomy have an increased length of stay and cost of care. These data also suggest an increased risk of postoperative hemorrhage during the initial admission without an increased risk of respiratory complications.

Sleep Apnea and Hypoventilation in Patients with Down Syndrome: Analysis of 144 Polysomnogram Studies

Patients with Down syndrome (DS) are at risk for both obstructive sleep apnea (OSA) and central sleep apnea (CSA); however, it is unclear how these components evolve as patients age and whether patients are also at risk for hypoventilation. A retrospective review of 144 diagnostic polysomnograms (PSG) in a tertiary care facility over 10 years was conducted. Descriptive data and exploratory correlation analyses were performed. Sleep disordered breathing was common (seen in 78% of patients) with an average apnea-hypopnea index (AHI) = 10. The relative amount of obstructive apnea was positively correlated with age and body mass index (BMI). The relative amount of central sleep apnea was associated with younger age in the very youngest group (0–3 years). Hypoventilation was common occurring in more than 22% of patients and there was a positive correlation between the maximum CO₂ and BMI. Sleep disordered breathing, including hypoventilation, was common in patients with DS. The obstructive component increased significantly with age and BMI, while the central component occurred most in the very young age group. Due to the high risk of hypoventilation, which has not been previously highlighted, it may be helpful to consider therapies to target both apnea and hypoventilation in this population.

Outcome of adenotonsillectomy in children with Down syndrome and obstructive sleep apnoea

OBJECTIVE

To evaluate the outcome of adenotonsillectomy (AT) in a cohort of children with Down syndrome (DS) and obstructive sleep apnoea (OSA).

DESIGN

Retrospective, cross-sectional study.

SETTING

Tertiary care centre.

PATIENTS

Children with DS and OSA, without previous upper airway (UA) surgery.

INTERVENTIONS

AT and full overnight polysomnography.

MAIN OUTCOME RESULTS

A significant improvement of the obstructive apnoea-hypopnoea index (oAHI) after AT was obtained. No differences in sleep efficiency or sleep fragmentation were found postoperatively. Almost half of the children had persistent OSA (oAHI ≥5/hour).

RESULTS

Data are presented as median (lower-upper quartile). Thirty-four children were included, median age 4.0 years (2.7-5.8), body mass index (BMI) z-score 0.81 (-0.46-1.76), and oAHI 11.4/hour (6.5-22.7). The majority presented with severe OSA (58.9%). AT was performed in 22 children, tonsillectomy in 10 and adenoidectomy in two. Postoperatively, a significant improvement of the oAHI was measured from 11.4/hour (6.5-22.7) to 3.6/hour (2.1-9.5) (p=0.001), with a parallel increase of the minimum oxygen saturation (p=0.008). Children with initially more severe OSA had significantly more improvement after UA surgery (p=0.001). Persistent OSA was found in 47.1% of the children.

CONCLUSIONS

AT results in a significant improvement of OSA in children with DS without a change in sleep efficiency or sleep stage distribution. Severe OSA was associated with a larger reduction of OSA severity. Almost half of the children had persistent OSA, which was not correlated to age, gender or BMI z-score.

Young children with Down syndrome show normal development of circadian rhythms, but poor sleep efficiency: a cross-sectional study across the first 60 months of life

Objectives

To evaluate sleep consolidation and circadian activity rhythms in infants and toddlers with Down syndrome (DS) under light and socially entrained conditions within a familiar setting. Given previous human and animal data suggesting intact circadian regulation of melatonin across the day and night, it was hypothesized that behavioral indices of circadian rhythmicity would likewise be intact in the sample with DS.

Methods

A cross-sectional study of 66 infants and young children with DS, aged 5–67 months, and 43 typically developing age-matched controls. Sleep and measures of circadian robustness or timing were quantified using continuous in-home actigraphy recordings performed over seven days. Circadian robustness was quantified via time series analysis of rest-activity patterns. Phase markers of circadian timing were calculated alongside these values. Sleep efficiency was also estimated based on the actigraphy recordings.

Results

This study provided further evidence that general sleep quality is poor in infants and toddlers with DS, a population that has sleep apnea prevalence as high as 50% during the preschool years. Despite poor sleep quality, circadian rhythm and phase were preserved in children with DS and displayed similar developmental trajectories in cross-sectional comparisons with a typically developing (TD) cohort. In line with past work, lower sleep efficiency scores were quantified in the group with DS relative to TD children. Infants born with DS exhibited the worst sleep fragmentation; however, in both groups, sleep efficiency and consolidation increased across age. Three circadian phase markers showed that 35% of the recruitment sample with DS was phase-advanced to an earlier morning schedule, suggesting significant within-group variability in the timing of their daily activity rhythms.

Conclusions

Circadian rhythms of wake and sleep are robust in children born with DS. The present results suggest that sleep fragmentation and any resultant cognitive deficits are likely not confounded by corresponding deficits in circadian rhythms.

•

Circadian activity rhythms are robust in young children with Down syndrome.

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Early morning activity is phase-advanced in a subgroup.

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Infants with Down syndrome show significant sleep fragmentation.

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Sleep efficiency improves with age in children with Down syndrome, but still lags the trajectory seen in typical development.

Assessment of cardiac function in absence of congenital and acquired heart disease in patients with Down syndrome

BACKGROUND

Extra genetic material in patients with Down syndrome (DS) may affect the function of any organ system. We evaluated cardiac functions using conventional tissue Doppler and two-dimensional speckle tracking echocardiography in patients with DS in the absence of congenital and acquired heart disease in patients.

METHODS

A total of 115 patients with DS between 6 and 13 years of age with clinically and anatomically normal heart and 55 healthy children were included in this cross-sectional study. DS was diagnosed by a karyotype test. Patients with mosaic type were not included in this study. Systolic and diastolic functions were evaluated by echocardiography.

RESULTS

Pulsed waved Doppler transmitral early/late inflow velocity (E/A), tissue Doppler mitral annular early/late diastolic peak velocity (Ea/Aa), transtricuspid E/A and tricuspid valve annulus Ea/Aa, pulmonary venous Doppler systolic/diastolic (S/D) wave ratio were lower in patients with Down syndrome than in the control group (P=0.04, P=0.001, P<0.05, P<0.001, P<0.001, respectively). Mitral and tricuspid annular Ea were lower in patients with DS (P<0.001). The right and left ventricular myocardial performance indexes were higher in patients with DS than in the controls (P<0.01). They had significantly higher left ventricular mass, ejection fraction, the mitral annular plane systolic excursion values. However, the Down syndrome group compared with the controls had a lower strain values examined by two-dimensional longitudinal speckle-tracking strain echocardiography.

CONCLUSION

These findings suggest conventional tissue Doppler and two-dimensional longitudinal speckletracking strain echocardiography were useful methods of investigating ventricular function and identifying a higher incidence of biventricular dysfunction in patients with Down syndrome compared with the healthy controls.

Obstructive sleep apnea in children with cerebral palsy and epilepsy

AIM

To examine the risk of obstructive sleep apnea (OSA) in children with cerebral palsy (CP) and/or epilepsy.

METHOD

This cross-sectional study employs the Pediatric Sleep Questionnaire (PSQ), the Gross Motor Function Classification System (GMFCS), and chart review to identify symptoms of OSA in children presenting to a multi-specialty pediatric healthcare institution.

RESULTS

Two-hundred and fifteen patients were grouped into those with epilepsy (n=54), CP (n=18), both (n=55), and neither (comparison group, n=88). The comparison group comprised children with developmental disabilities but not children with typical development. Significantly increased PSQ scores (indicating increased risk of OSA) were found among children with CP (58%) and CP with epilepsy (67%) than among the comparison group (27%; p<0.001 and p<0.0001 respectively). Children with both CP and epilepsy had a greater number of increased PSQ scores compared with CP alone (p<0.05). Increased PSQ scores were observed with increasing CP severity as measured using the GMFCS. The PSQ identified more children at risk of OSA (46%) than did the medical record review for symptoms of OSA (8.2%, p<0.001).

INTERPRETATION

Children with CP of greater severity or comorbid epilepsy are at increased risk of OSA. This study supports the routine questionnaire-based assessment for OSA as a regular part of the care of all children with CP, especially in those with more severe CP and those with epilepsy.

Hypoglossal Nerve Stimulator Implantation in an Adolescent With Down Syndrome and Sleep Apnea

Obstructive sleep apnea (OSA) is more common in children with Down syndrome, affecting up to 60% of patients, and may persist in up to 50% of patients after adenotonsillectomy. These children with persistent moderate to severe OSA require continuous positive airway pressure, which is often poorly tolerated, or even tracheotomy for severe cases. The hypoglossal nerve stimulator is an implantable device that produces an electrical impulse to the anterior branches of the hypoglossal nerve, resulting in tongue protrusion in response to respiratory variation. It is an effective treatment of sleep apnea in select adult patients because it allows for alleviation of tongue base collapse, improving airway obstruction. Herein we describe the first pediatric hypoglossal nerve stimulator implantation, which was performed in an adolescent with Down syndrome and refractory severe OSA (apnea hypopnea index [AHI]: 48.5 events/hour). The patient would not tolerate continuous positive airway pressure and required a long-standing tracheotomy. Hypoglossal nerve stimulator therapy was well tolerated and effective, resulting in significant improvement in the patient's OSA (overall AHI: 3.4 events/hour; AHI: 2.5-9.7 events/hour at optimal voltage settings depending on sleep stage and body position). Five months after implantation, the patient's tracheotomy was successfully removed and he continues to do well with nightly therapy.

Sleep Disturbance and Expressive Language Development in Preschool-Age Children With Down Syndrome

Recent evidence has suggested that sleep may facilitate language learning. This study examined variation in language ability in 29 toddlers with Down syndrome (DS) in relation to levels of sleep disruption. Toddlers with DS and poor sleep (66%, n = 19) showed greater deficits on parent-reported and objective measures of language, including vocabulary and syntax. Correlations between sleep and language were found in groups with equivalent medical and social backgrounds and after control for relevant behavioral comorbidities, including autism symptoms. These results emphasize the important role of quality sleep in all children's expressive language development, and may help increase our understanding of the etiology of language deficits in developmental disorders, potentially leading to new treatment approaches.

Comparative outcomes of severe obstructive sleep apnea in pediatric patients with Trisomy 21

OBJECTIVES

To analyze the outcomes of severe obstructive sleep apnea (OSA) in pediatric patients with Trisomy 21 compared with non-syndromic patients.

METHODS

A retrospective chart review was performed for patients with a diagnosis of severe obstructive sleep apnea, (defined as, Apnea-Hypopnea index (AHI) of ≥ 10) in a tertiary children's hospital. Data were analyzed for subjective and objective outcomes along with perioperative care and health care utilization. Patients with Trisomy 21 were compared with non-syndromic patients.

RESULTS

A total of 230 patients with severe OSA were included in the study. Eighteen of these patients had Trisomy 21. Adenotonsillectomy was the most common surgical intervention in both groups. There was no statistical difference in the preoperative AHI between groups. Post treatment AHI in the Trisomy 21 group changed from an average of 26.6 to an average of 11.6 as compared with 24.5 to 3.6 in the non-syndromic group. The average perioperative hospital stay was 3.8 days in Trisomy 21 group compared to 1.7 days for the non-syndromic group (p < 0.001, Mann-Whitney U test). Complete resolution was seen in 35% of the Trisomy 21 group versus 75% in the non-syndromic group.

CONCLUSIONS

A majority of Trisomy 21 patients with severe OSA had residual symptoms following surgical intervention. There is also an increased risk of post-operative airway intervention and increased length of hospital stay in these patients.

Prevalence of Congenital Heart Disease and Pulmonary Hypertension in Down's Syndrome: An Echocardiographic Study

Background

Down's syndrome (DS) is a genetic anomaly, which undergoes increased morbidity and mortality when associated with congenital heart disease (CHD). The aims of the study were to determine the prevalence of CHD and pulmonary hypertension (PH) in DS.

Methods

One hundred twenty-seven patients with DS living in Mexico City were evaluated by physical exam, electrocardiogram and echocardiogram.

Results

CHD was found in 40%. In 80% (n = 102) PH was present [systolic pulmonary artery pressure (SPAP) of 47 ± 19 mm Hg and mean pulmonary artery pressure (MPAP) of 32 ± 11 mm Hg]. Patients with CHD and PH were classified as having 1) no shunt (n = 18) with SPAP of 37 ± 9 mm Hg and MPAP of 25 ± 6 mm Hg and 2) with shunt (n = 26) with PASP of 57 ± 29 mm Hg and MPAP of 38 ± 19 mm Hg (p ≤ 0.001). In those without CHD or with CHD without shunt (n = 76), SPAP was 37 ± 19 mm Hg and the MPAP 25 ± 6 mm Hg. The prevalence of PH in DS was 5.9% at one year and 15% at 10 years. The odds ratio of PH in DS with CHD was 7.3 vs. 3 without CHD.

Conclusion

DS has a high prevalence of CHD and PH. PH prevalence increases when it is associated with CHD. The pathophysiology of PH in DS without CHD should be studied in the near future. Echocardiography is an indispensible tool for evaluation of DS.

Sleep-like behavior and 24-h rhythm disruption in the Tc1 mouse model of Down syndrome

Down syndrome is a common disorder associated with intellectual disability in humans. Among a variety of severe health problems, patients with Down syndrome exhibit disrupted sleep and abnormal 24-h rest/activity patterns. The transchromosomic mouse model of Down syndrome, Tc1, is a trans-species mouse model for Down syndrome, carrying most of human chromosome 21 in addition to the normal complement of mouse chromosomes and expresses many of the phenotypes characteristic of Down syndrome. To date, however, sleep and circadian rhythms have not been characterized in Tc1 mice. Using both circadian wheel-running analysis and video-based sleep scoring, we showed that these mice exhibited fragmented patterns of sleep-like behaviour during the light phase of a 12:12-h light/dark (LD) cycle with an extended period of continuous wakefulness at the beginning of the dark phase. Moreover, an acute light pulse during night-time was less effective in inducing sleep-like behaviour in Tc1 animals than in wild-type controls. In wheel-running analysis, free running in constant light (LL) or constant darkness (DD) showed no changes in the circadian period of Tc1 animals although they did express subtle behavioural differences including a reduction in total distance travelled on the wheel and differences in the acrophase of activity in LD and in DD. Our data confirm that Tc1 mice express sleep-related phenotypes that are comparable with those seen in Down syndrome patients with moderate disruptions in rest/activity patterns and hyperactive episodes, while circadian period under constant lighting conditions is essentially unaffected.

Obstructive sleep apnea in young infants with Down syndrome evaluated in a Down syndrome specialty clinic

Children with Down syndrome (DS) experience congenital and functional medical issues that predispose them to obstructive sleep apnea (OSA). Research utilizing stringent age criteria among samples of infants with DS and OSA is limited. This study examines clinical correlates of OSA among infants with DS. A retrospective chart review was conducted of infants ≤6 months of age referred to a DS clinic at a tertiary children's hospital over five-years (n = 177). Chi-square tests and binary logistic regression models were utilized to analyze the data. Fifty-nine infants underwent polysomnography, based on clinical concerns. Of these, 95% (56/59) had studies consistent with OSA. Among infants with OSA, 71% were identified as having severe OSA (40/56). The minimum overall prevalence of OSA among the larger group of infants was 31% (56/177). Significant relationships were found between OSA and dysphagia, congenital heart disease (CHD), prematurity, gastroesophageal reflux disease (GERD), and other functional and anatomic gastrointestinal (GI) conditions. Results indicate that odds of OSA in this group are higher among infants with GI conditions in comparison to those without. Co-occurring dysphagia and CHD predicted the occurrence of OSA in 36% of cases with an overall predictive accuracy rate of 71%. Obstructive sleep apnea is relatively common in young infants with DS and often severe. Medical factors including GI conditions, dysphagia and CHD may help to identify infants who are at greater risk and may warrant evaluation. Further studies are needed to assess the impact of OSA in infants with DS.