Sleep problems and daytime somnolence in a German population-based sample of snoring school-aged children

Risk of sleep problems in a clinical sample of children who stutter

PURPOSE

Previous studies have shown increased prevalence of sleep problems among people who stutter. However, there is a lack of knowledge about what these sleep problems may specifically be.

METHOD

Fifty children who stutter (CWS) from 6;0 to 12;9 years of age and 50 age- and gender-matched controls participated in this study. Parents did not report coexisting conditions, excepting stuttering and/or sleep problems. Sleep problems were investigated using a standardized questionnaire answered by parents. The questionnaire shows cut-off scores to identify the risk of sleep problems as a whole and on each one of the six subscales (i.e., disorders of initiating and maintaining sleep; sleep breathing disorders; disorders of arousal; sleep-wake transition disorders; disorders of excessive somnolence; and sleep hyperhidrosis). Scores above the cut-off are suggestive of sleep problems.

RESULTS

Twenty-one CWS scored higher than the cut-off on the sleep questionnaire compared to only two controls (p < 0.00001). Specifically, CWS scored higher than controls in disorders of initiating and maintaining sleep, sleep-wake transition disorders (especially jerking, sleep talking, and bruxism), and disorders of excessive somnolence (p < 0.0083, corrected for multiple comparisons).

DISCUSSION

Compared to controls, CWS are at greater risk for sleep problems, which are not consequences of coexisting disorders. Present findings confirm and expand current knowledge about sleep problems in CWS. Directionality possibilities and clinical implications are discussed.

Effects of rapid maxillary expansion on sleep disturbance scale for children: A longitudinal CASE-series study

OBJECTIVE

To evaluate the effects of rapid maxillary expansion (RME) on Sleep Disturbance Scale for Children (SDSC) with maxillary atresia.

MATERIALS AND METHODS

The sample consisted of 27 paediatric patients evaluated through a Brazilian version of the SDSC, answered by their guardians at the following experimental time points: T0 (before installing the Hyrax expander), T1 (on the day of expander stabilization), T2 (3 months after expander stabilization), T3 (immediately after expander removal, following 6 months of retention), and T4 (3 months post-retention). Multilevel Poisson analysis adjusted for repeated measures was performed to compare outcomes across the assessment time points.

RESULTS

The mean age of patients was 9.1 years (SD = 1.46). The total SDSC scores decreased and were statistically significant from T2 onwards (P < .01), with a decrease of 24% at T4 compared with T1 (IRR 0.76; 95% CI 0.69-0.84). The mean scores at T4 were already lower than the cutoff point for risk of sleep disorders. Regarding the specific domains, there was a significant reduction in sleep breathing disorders, sleep-wake transition disorders, and disorders of excessive somnolence as of T2 (P < .01), T3 (P < .05) and T4 (P < .05), respectively.

CONCLUSION

RME in children with maxillary atresia had a positive effect on the reduction of total SDSC scores after 3 months of expander stabilization, sustained over 6 and 9 months and significant reduction in sleep breathing disorders domain, sleep-wake transition disorders domain, and disorders of excessive somnolence domain over time points.

A systematic review of Nightmare prevalence in children

The purpose of this narrative review was to describe prevalence rates of nightmares and nightmare disorder in school-aged youth according to sample characteristics and methods used to assess nightmares. We searched PsychINFO, PubMed, and CINAHL databases to identify empirical peer-reviewed articles and grey literature published between 2001 and 2021. Sixty-nine studies from 23 countries were included. The prevalence of nightmares was between 1% and 11% in the past week and 25% to 35% in the past month in pediatric developmental samples and between 27% and 57% in the past week and 18%-22% in the past month in psychiatric samples. The prevalence of nightmare disorder was approximately between 3% and 6% in pediatric developmental samples and 10%-12% in psychiatric samples. Nightmare prevalence peaks between ages 10 and 14 then decreases with older age. Generally, prevalence was higher in girls than boys, and one study suggested gender divergence started around age 14. Children's self-reports were higher than parent reports, except in samples with comorbid psychiatric problems where there was more parent-child agreement. Inconsistencies in nightmare definitions and measurement were observed across the literature and indicate a need for standardized measurement of nightmares.

Behavioral and cognitive outcomes of habitual snoring in children aged 2-14 years in Chengdu, Sichuan

PURPOSE

Habitual snoring is associated with cognitive, behavioral, and other physiological problems of children. Few studies have reported specifically on the relationships between snoring and those problems in children as noticed by their parents. We aimed to identify the cognitive, behavioral, and sleep-related nocturnal problems in children with HS as noted by their parents.

MATERIALS AND METHODS

A cross-sectional survey was performed in Chengdu, Sichuan, China. Children aged 2-14 years from four districts were randomly chosen to participate. Questionnaires were completed voluntarily by the children's parents/guardians.

RESULTS

A total of 1548 questionnaires were analyzed and classified those children as 463 habitual snorers (HS group, 30.4 %), 683 occasional snorers (OS group, 44.8 %), and 402 non-snorers (NS group, 26.4 %). The percentages of children with sleep-related nocturnal symptoms were 94.6 %, 87.3 %, and 66.9 % in the HS, OS, and NS groups. Percentages of children with cognitive problems were 76.2 %, 74.6 %, and 64.9 % in the HS, OS, and NS groups, respectively (P < 0.001). The frequencies of daytime behavioral problems were 68.3 %, 61.5 %, and 46.8%in the HS, OS, and NS groups, respectively (P < 0.001).The average number of sleep-related nocturnal symptoms, cognitive symptoms and daytime behavioral problems was higher in the HS group than in the OS and NS groups.

CONCLUSIONS

HS is a significant contributor to sleep-related nocturnal symptoms and daytime cognitive and behavioral problems in children, as reported by their parents/guardians. HS and OS are important contributors to poor sleep quality and daytime cognitive and behavioral problems in children.

Arabic translation and validation of a pediatric sleep questionnaire to assess the prevalence of sleep-disordered breathing among Saudi pre-school children

OBJECTIVES

(1) To translate to Arabic a validated pediatric sleep questionnaire, (2) To assess the validity and reliability of the translated questionnaire, and (3) To assess the prevalence of sleep-disordered breathing (SDB) among a group of pre-school children in Jeddah, Saudi Arabia.

METHODS

Using forward and back-translation, a set of 6 hierarchically arranged questions that comprise the Gozal sleep questionnaire was translated into Arabic. Validity was assessed using face validity and content validity for consistency and clarity, using both item-level and scale-level content validity indices (I-CVI, S-CVI). Consent forms were sent to 1783 mothers recruited from 8 different pre-schools in Jeddah between October 2017 and April 2018, and 209 signed and returned the consent forms. Out of this sample, 34 mothers were contacted to assess internal consistency using Cronbach's alpha, and test-retest reliability using Interclass correlation coefficient (ICC). Finally, all 209 mothers were contacted to answer the questionnaire to obtain the prevalence of SDB.

RESULTS

Using face validity and content validity, the translated questionnaire proved to be valid with perfect I-CVI and S-CVI. Internal consistency (Cronbach's Alpha 0.64-0.89) and test-retest reliability (ICC=0.87, p<0.001) showed the translated questionnaire to have good to favorable reliability. Depending on the severity of SDB, the prevalence of SDB was 7.7%, 5.7%, and 3.8% for mild, moderate and severe cut-off values respectively.

CONCLUSION

A validated pediatric sleep questionnaire to assess SDB was translated into Arabic and the translation proved to be valid and reliable. The prevalence of SDB was found to be very comparable to other areas in the world.

Fragmentary Hypnic Myoclonus and Other Isolated Motor Phenomena of Sleep

Excessive fragmentary hypnic myoclonus, hypnic jerks, hypnagogic foot tremor, alternating leg muscle activation, and sleep-related cramps are less known sleep-related motor disorders (SRMDs). These manifestations are frequently missed or misinterpreted polygraphic findings that can be frequently confused with the more frequent SRMDs. These symptoms can present as isolated motor symptoms but can be also the cause of otherwise cryptogenic insomnias and somnolence. Expanding the knowledge on these isolated symptoms and defining their polygraphic and clinical features are essential for their identification. However, clear cut-offs to discern between the isolated phenomenon and the disorder are still to be found.

Influence of age and gender on reference values for common pediatric sleep questionnaires: Results from a community-based study

OBJECTIVES

Sleep problems are often assessed using questionnaires, but it is unclear whether the responses given are influenced by age and gender. We addressed this question in several widely used pediatric sleep questionnaires and provide age-dependent percentile curves.

METHODS

Data of a community-based study in schoolchildren were reanalyzed (N = 163, 50% males, age 6-17 years). Children and their parents completed the Sleep-Related Breathing Disorder Scale (SRBDS) of the Pediatric Sleep Questionnaire, the Sleep Disturbance Scale for Children (SDSC), the Sleep Self Report (SSR) of the Children's Sleep Habits Questionnaire in a long and short version, the Epworth Sleepiness Scale in a parent- (ESSp) and self-report version for children (ESSc), and the Pediatric Daytime Sleepiness Scale (PDSS). Linear and quantile regression analysis was used to i) assess the influence of age and gender on scores of questionnaire scales/subscales, ii) to calculate age- and gender-appropriate reference values and iii) to provide age-depending percentile curves.

RESULTS

Only the PDSS showed relevant gender differences (β [95th confidence interval] = 0.155 [0.000; 0.270], p-value = 0.04, reference category: male), while the following subscales were all age dependent: SRBDS-somnolence and behavioral subscales, SDSC-somnolence subscale, SSR-long and short version; ESSp and ESSc, as well as the PDSS.

CONCLUSIONS

Age and gender should be taken into account for research purposes and individual patient assessments regarding sleep problems. Preliminary age- and gender-appropriate reference values and percentile curves are now available and may be used by researchers and clinicians.

Obstructive sleep apnea and dermatologic disorders

Obstructive sleep apnea (OSA) is present in at least 2% of women and 4% of men, and its prevalence is increasing, because a major predisposing factor for OSA is a high body mass index. Psoriasis has the most strongly substantiated link with OSA, where the relationship may be bidirectional. Dermatologic disorders may be comorbid with OSA due to several factors: (i) the heightened proinflammatory state in OSA, which can occur independent of body mass index, and may exacerbate inflammatory dermatoses; (ii) intermittent hypoxemia may promote neovascularization and tumor growth in certain cancers, such as melanoma; (iii) obesity, present in majority of OSA patients, can be associated with a heightened proinflammatory state; (iv) upper airway obstruction due to local tumors or soft tissue swelling due to physical urticaria or angioedema; (v) acute nasal congestion in the atopic patient with allergic rhinitis; (vi) dermatologic disorders associated with other OSA risk factors (eg, acanthosis nigricans and metabolic syndrome); and (vii) a high sympathetic tone (eg, in atopic dermatitis) and resultant sleep fragmentation contributing to upper airway instability during sleep. In many instances, the dermatology patient with OSA may have other medical and psychiatric comorbidities that are also associated with increased OSA risk.

Sleep-disordered breathing, sleep duration, and childhood overweight: a longitudinal cohort study

OBJECTIVES

To examine independent associations between sleep-disordered breathing (SDB), sleep duration from birth through 6.75 years, and body mass index (BMI) through 15 years of age in a population-based cohort.

STUDY DESIGN

The Avon Longitudinal Study of Parents and Children collected parent questionnaire data on child sleep duration and SDB symptoms from birth through 6.75 years and child BMI from the Avon Longitudinal Study of Parents and Children research clinics (n = 1899). For SDB, logistic regression models-minimal, confounder, and confounder + sleep duration adjusted-examined associations with BMI at 7, 10, and 15 years of age. For short sleep duration (≤10th percentile), comparable SDB-adjusted models examined associations with BMI at 15 years of age.

RESULTS

Children with the worst SDB symptoms vs asymptomatic children, had increased odds of overweight at 7 (OR = 2.08, 95% CI = 1.04-4.17), 10 (OR = 1.79, 95% CI = 1.02-3.16), and 15 years of age (OR = 2.25, 95% CI = 1.27-3.97) in models adjusted for sleep duration. Similarly, short sleep duration at ≈5-6 years was associated with overweight at 15 years, independent of SDB. Children with short sleep duration at 4.75 years were more likely to be overweight at 15 years in minimally (OR = 2.21, 95% CI = 1.52-3.20), confounder (OR = 1.99, 95% CI = 1.34-2.96), and SDB-adjusted (OR = 2.04, 95% CI = 1.36-3.04) models.

CONCLUSIONS

Both SDB and short sleep duration significantly and independently increase children's odds of becoming overweight. Findings underscore the potential importance of early identification and remediation of SDB, along with insufficient sleep, as strategies for reducing childhood obesity.

Sleep disordered breathing and airway disease in primary ciliary dyskinesia

BACKGROUND AND OBJECTIVE

Sleep-disordered breathing (SDB) may develop in primary ciliary dyskinesia (PCD), leading to these diseases worsening one another.

METHODS

Sixteen stable PCD patients (4.9-17.2 years) and 42 controls underwent overnight respiratory polysomnography (rPSG) and Sleep Disturbances Scale for Children (SDSC). In PCD we assessed nasal endoscopy, pulmonary function tests and chest high-resolution computed tomography (HRCT).

RESULTS

Compared with controls, PCD had higher obstructive apnoea (4.7 vs 0.2, P < 0.001), central apnoea (0.8 vs 0.2, P < 0.001), hypopnoea (1.8 vs 0.2, P < 0.001), apnoea-hypopnoea (7.8 vs 0.6, P < 0.001), oxygen desaturation indexes (ODI; 0.7 vs 0.2, P = 0.002), and mean oxygen desaturation (4% vs 1%, P < 0.001), while mean and nadir oxygen saturation (97.1% vs 98.1, P < 0.001) (93% vs 97.2%, P < 0.001) were lower, respectively. In PCD, SDSC was unrelated to rPSG (P > 0.05), with total score and subscores of disorders in initiating and maintaining sleep, and sleep-wake transition lower than controls. PCD patients had chronic rhinosinusitis (100%) and adenoidal hypertrophy (50%). Total HRCT score was 7 (range 0-14). ODI correlated with functional residual capacity (r = 0.8, P = 0.02), total HRCT (r = 0.6, P = 0.03) and peribronchial thickening scores (r = 0.7, P = 0.02). Oxygen saturation was associated with bronchiectasis severity score (r = -0.6, P = 0.02).

CONCLUSIONS

PCD's parents may underestimate SDB. As nocturnal desaturation is associated with lung function and structure abnormalities, SDB may significantly contribute to pulmonary morbidity.

A survey of parentally reported sleep health disorders in Estonian 8-9 year old children

Background

Pediatric sleep research is rather new in Estonia. There has not been a comprehensive study of age specific sleep disorders in Estonian children. The aim of this study was to investigate sleep disorders in a sample of Estonian second grade children.

We hypothesized that:

• Children with low BMI are as susceptible to SDB as are children with high BMI.

• Under weight children are susceptible to residual SDB after adenotonsillectomy.

• Parasomnias present with SDB in children.

• Excessive day time sleepiness is a significant symptom which leads parents to suspect sleep disorders in their child.

Methods

A retrospective questionnaire based survey was used to analyze factors influencing sleep, parasomnias, daytime sleepiness, and sleep disordered breathing (SDB). 1065 Pediatric Sleep Questionnaire (PSQ) packets were distributed by post to randomly selected parents of second grade students; 703 (66%) subjects were included in the study group; each parent/guardian participant had one second grade child. Descriptive statistics were used to compare characteristics of SDB symptomatic and healthy children. We used logistic regression to analyze factors influencing sleep and parasomnias in relation to SDB severity. Odds ratios (OR) and 95% CI were used to estimate relative risk.

Results

Parents of children with SDB complaints seem to pay attention to sleep disorders especially when a child is suffering from excessive day time sleepiness. Parasomnias are present simultaneously with SDB and tend to worsen in relation to more severe SDB complaints. Many underweight children have SDB symptoms after adenotonsillectomy.

Conclusion

SDB symptoms are found in both overweight and underweight children. Both groups should be observed, especially in terms of the current focus on overweight children. Careful follow up after SDB treatment is necessary in case of under and overweight children. Parental suspicions regarding SDB are noticeably higher in cases of excessive daytime sleepiness in their children.

Migraine and periodic limb movement disorders in sleep in children: a preliminary case-control study

BACKGROUND

The relationships between sleep and headaches are complex and manifold. About the variety of phenomena that can disrupt the sleep macrostructure and can impact its restorative function, the periodic limb movements disorder (PLMd) can be considered as the most powerful.No studies are known about the role of PLMd in the pathophysiology of migraine in children.Aim of study is to assess the prevalence of PLMd and migraine and their relationship with disability and pain intensity in a pediatric sample, referred for migraine without aura by pediatricians.

METHODS

After a preliminary sleep habits screening with the Sleep Disturbances Scale for Children, 34 migraine subjects affected by migraine without aura (20 M, 14 F) (mean age 9.08; SD ± 2.28) and 51 volunteers healthy children (28 M, 23 F) (mean age 9.37; SD ± 1.81) accepted to underwent overnight PSG recordings in the Sleep Laboratory of the Clinic of Child and Adolescent Neuropsychiatry, in order to define the macrostructural sleep characteristics and the prevalence of PLMd. Subsequently, the migraineurs sample was studied in order to define the relationship between disability, pain intensity, therapeutical responsiveness and the presence of PLMd.

RESULTS

In the migraineurs children group, the individuals with PLM pathological index (PLMI ≥ 5) represent the 26.47% of sample and present higher frequency (p < 0.001), intensity (p < 0.001), duration (p = 0.006) and life impairment as scored in the PedMIDAS (p < 0.001) of headache and lower efficacy of prophylactic (p = 0.001) and acute (p = 0.006) pharmacological treatment than MoA children without PLM pathological index.

CONCLUSIONS

This preliminary study indicates the potential value of the determination of the PLMd signs, and the importance of the PSG evaluation in children affected by migraine, particularly when the clinical and pharmacological management tend to fail in the attacks control.

Primary nocturnal enuresis as a risk factor for sleep disorders: an observational questionnaire-based multicenter study

INTRODUCTION

Primary nocturnal enuresis (PNE) is a common problem in developmental age with an estimated overall prevalence ranging from 1.6% to 15%, and possible persistence during adolescence. There is a growing interest in the sleep habits of children affected by PNE, which is derived from the contradictory data present in clinical literature. The aim of the present study was to evaluate the presence of sleep disturbances in a population of children affected by PNE, and to identify whether PNE could be considered as a risk factor for sleep disturbances among children.

MATERIALS AND METHODS

A total of 190 PNE children (97 males, 93 females) aged 7-15 years, (mean 9.64 ± 1.35 years), and 766 typically developing children matched for age (P = 0.131) and gender (P = 0.963) were enrolled. To evaluate the presence of sleep habits and disturbances, all of the subjects' mothers filled out the Sleep Disturbances Scale for Children (SDSC), a questionnaire consisting of six subscales: Disorders in Initiating and Maintaining Sleep (DIMS), Sleep Breathing Disorders (SBD), Disorders of Arousal (DA), Sleep-Wake Transition Disorders (SWTD), Disorders of Excessive Somnolence (DOES), and Nocturnal Hyperhidrosis (SHY). The results were divided into "pathological" and "normal" scores using a cut-off value (pathological score = at least three episodes per week), according to the validation criteria of the test. Then, the Chi-square test was used to calculate the statistical difference and a univariate logistic regression analysis was applied to determine the role of PNE as a risk factor for the development of each category of sleep disorders and to calculate the odds ratio (OR).

RESULTS

PNE children show a higher prevalence of all sleep disturbances (41.03% DIMS; 85.12% SBD; 63.29% DA; 67.53% SWTD; 31.28% DOES; 37.92% SHY; 25.33% SDSC total score), and according to OR results (SDSC total score OR = 8.293, 95% confidence interval [CI] = 5.079-13.540; DIMS OR = 7.639, 95% CI = 5.192-11.238; SBD OR = 35.633, 95% CI = 22.717-55.893; DA OR = 13.734, 95% CI = 9.476-19.906; SWTD OR = 14.238, 95% CI = 9.829-20.625; DOES OR = 5.602, 95% CI = 3.721-8.432; SHY OR = 6.808, 95% CI = 4.608-10.059), PNE could be considered as a risk factor for the development of sleep disorders.

CONCLUSION

Among PNE children, sleep could be strongly altered, thus helping to affirm the hypothesis that PNE tends to alter sleep architecture, or it could itself be the consequence of an abnormal sleep structure. The findings also point to the existence of a potential increase in the risk of developing sleep disorders in the presence of PNE.

Clinical and mutation analysis of 51 probands with anophthalmia and/or severe microphthalmia from a single center

Clinical evaluation and mutation analysis was performed in 51 consecutive probands with severe eye malformations - anophthalmia and/or severe microphthalmia - seen in a single specialist ophthalmology center. The mutation analysis consisted of bidirectional sequencing of the coding regions of SOX2, OTX2, PAX6 (paired domain), STRA6, BMP4, SMOC1, FOXE3, and RAX, and genome-wide array-based copy number assessment. Fifteen (29.4%) of the 51 probands had likely causative mutations affecting SOX2 (9/51), OTX2 (5/51), and STRA6 (1/51). Of the cases with bilateral anophthalmia, 9/12 (75%) were found to be mutation positive. Three of these mutations were large genomic deletions encompassing SOX2 (one case) or OTX2 (two cases). Familial inheritance of three intragenic, plausibly pathogenic, and heterozygous mutations was observed. An unaffected carrier parent of an affected child with an identified OTX2 mutation confirmed the previously reported nonpenetrance for this disorder. Two families with SOX2 mutations demonstrated a parent and child both with significant but highly variable eye malformations. Heterozygous loss-of-function mutations in SOX2 and OTX2 are the most common genetic pathology associated with severe eye malformations and bi-allelic loss-of-function in STRA6 is confirmed as an emerging cause of nonsyndromal eye malformations.

Hypersomnia in children affected by migraine without aura: a questionnaire-based case-control study

BACKGROUND

The relationship between sleep and headache is meaningful and complex. Children affected by migraines tend to show many sleep disorders, such as insufficient sleep duration and excessive daytime somnolence. Therefore, the aim of this study is to assess the rate of reported sleep habits and self-reported sleepiness in a large pediatric sample of individuals affected by migraine without aura (MoA).

METHODS

The study population consisted of 271 children aged between 6 and 13 years affected by MoA. The control group was composed of 305 typically developing children. To assess the sleep habits of all individuals (MoA and control), parents filled out the Sleep Disturbance Scale for Children, and to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale.

RESULTS

The two study groups were matched for age (P = 0.124), sex distribution (P = 0.775), and body mass index z-score (P = 0.107). Parents of children affected by MoA reported a higher total score of sleep disorder symptoms (P <0.001), disorders of initiating and maintaining (P < 0.001), and disorders of arousal (P < 0.001) than did parents of controls. No significant differences were found in disorders of excessive somnolence. Conversely, in the Pediatric Daytime Sleepiness Scale, migraine children had higher scores (24.67 ± 3.19 vs 11.94 ± 4.81; P < 0.001) and a reduction in referred total sleep time mean duration (469.83 ± 98.112 vs 527.94 ± 83.02; P < 0.001) than typically developing children.

CONCLUSION

Our study identified differences in sleep habits and found a high prevalence of daytime somnolence in children affected by MoA, suggesting the need for routine sleep screening in the pediatric management of children with migraines.

Sleep problems, fatigue, and cognitive performance in Chinese kindergarten children

OBJECTIVE

To examine sleep problems and fatigue and their associations with cognitive performance in Chinese kindergarten children.

STUDY DESIGN

A cross-sectional analysis of baseline data from Jintan Child Cohort Study was conducted, which includes a cohort of 1656 kindergarten children in Jintan City, Jiangsu Province, China. The sample used in the current study consisted of 1385 children (44.8% girls, mean age 5.72 [SD = 0.42] years) for whom data on sleep problems or cognitive performance were available. Child Behavior Checklist was used to measure child sleep problems and fatigue, and Wechsler Preschool and Primary Scale of Intelligence-Revised was used to assess child IQ.

RESULTS

Sleep problems were prevalent, ranging from 8.9% for difficulty maintaining sleep to 70.5% for unwilling to sleep alone. Other reported sleep problems were difficulty initiating sleep (39.4%), nightmares (31.6%), sleep talking (28%), sleeping less (24.7%), and sleep resistance (23.4%). Fatigue was also prevalent, with 29.6% of children reported to be overtired and 12.6% lack of energy. Children with difficulty maintaining sleep, sleep talking, sleep resistance, or nightmares scored 2-3 points lower in full IQ than children without sleep problems. Children reported to have fatigue scored 3-6 points lower in full IQ than those children without fatigue.

CONCLUSIONS

Sleep problems and fatigue are prevalent in Chinese kindergarten children. Furthermore, sleep problems and fatigue are associated with poor cognitive performance.

Wired at a young age: the effect of caffeine and technology on sleep duration and body mass index in school-aged children

INTRODUCTION

Two problems affecting school-aged children in the United States are inadequate sleep and an increased prevalence of obesity. The purpose of this study was to quantify media-related technology use and caffeine consumption in order to assess their potential effects on sleep duration and body mass index (BMI) in children.

METHODS

The study was a secondary analysis of children 6 to 10 years of age (N = 625) from the National Sleep Foundation's Sleep in America Poll. Regression analysis was used to assess the relationship between caffeine and technology use, sleep variables, and BMI, adjusting for age, race, gender, and general health.

RESULTS

Almost 30% (29.5%) of the children consumed a daily caffeinated beverage, and 42.4% had a television in the bedroom. Children who drank caffeinated beverages had 15 fewer minutes of sleep per night than did children who did not drink such beverages (b = -0.27, p = .002). Children with three technology items in their bedroom received 45 fewer minutes of sleep than did children without these items in their bedroom (b = -0.75, p = .010). Having adjusted for variables, only drinking caffeinated beverages was associated with a BMI z score.

DISCUSSION

The complex relationships between caffeine intake and the use of technology with shortened periods of sleep and increased BMI need further study. Future research should explore how these risk factors for shortened periods of sleep can be modified in this young population.

Association between PM₁₀ exposure and sleep of Egyptian school children

PURPOSE

This study aims to investigate the potential association between exposure to particulate matter with an aerodynamic diameter <10 μm (PM10) and sleep disturbances among Egyptian school children.

METHODS

In this cross-sectional study, parents of school children from four elementary schools in areas with different PM10 exposures filled out the Sleep Disturbance Scale for Children questionnaire in Arabic. Air pollution data were obtained from the Egyptian Environmental Affairs Agency.

RESULTS

The sample consisted of 276 children, 121 (44 %) of them were boys with a mean age of 9.26 ± 1.96 years. Disorders of initiating and maintaining sleep (DIMS), disorders of excessive somnolence, and the total score were reported in the clinical range (T score > 70) in 19.9, 24.3, and 24.3 % of the sample, respectively. A generalized additive model with adjustment for potential confounding factors was used to examine the association between PM10 exposure and sleep disturbances. There were statistically significant associations between PM10 exposure and DIMS and sleep hyperhidrosis (P < 0.05).

CONCLUSIONS

Air pollution exposure has a negative impact on children's sleep with significant association between exposure to PM10 and sleep disturbances.

Sleep bruxism: a comprehensive overview for the dental clinician interested in sleep medicine

Sleep bruxism (SB) is a common sleep-related motor disorder characterized by tooth grinding and clenching. SB diagnosis is made on history of tooth grinding and confirmed by polysomnographic recording of electromyographic (EMG) episodes in the masseter and temporalis muscles. The typical EMG activity pattern in patients with SB is known as rhythmic masticatory muscle activity (RMMA). The authors observed that most RMMA episodes occur in association with sleep arousal and are preceded by physiologic activation of the central nervous and sympathetic cardiac systems. This article provides a comprehensive review of the cause, pathophysiology, assessment, and management of SB.

Sleep of children living in institutional care facilities

PURPOSE

To describe sleep patterns and problems among institutionalized children.

METHODS

In this cross-sectional study, the caregivers of 118 children, aged 4-12 years from six institutional care facilities completed the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

The mean (±SD) of night bedtime was 21:05 ± 2:52, mean morning wake-up time was 06:58 ± 0:31, mean total sleep duration was 10 ± 1.1 h, and mean night-sleep duration was 9.5 ± 0.9 h. The percentage of children who took a daytime nap was 34.7% (n = 41) and the mean duration of nap was 0.5 ± 0.7 h. The most frequently reported sleep problems were bedtime resistance, daytime sleepiness and night awakening. Children with bedtime at or after 9 PM, night-sleep duration less than 10 h and daytime napping had more disturbed sleep.

CONCLUSIONS

Sleep problems are common among this sample of institutionalized children.

Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study

STUDY OBJECTIVES

To describe the prevalence, persistence, and characteristics associated with sleep disordered breathing (SDB) symptoms in a population-based cohort followed from 6 months to 6.75 years.

DESIGN

Avon Longitudinal Study of Parents and Children (ALSPAC).

SETTING

England, 1991-1999.

PARTICIPANTS

12,447 children in ALSPAC with parental report of apnea, snoring, or mouth-breathing frequency on any one of 7 questionnaires.

MEASUREMENTS

Symptom prevalence rates-assessed as "Always" and "Habitually"-are reported at 0.5, 1.5, 2.5, 3.5, 4.75, 5.75, and 6.75 years of age. The proportion of children in whom symptoms develop, persist or abate between observation points is reported. Exploratory multivariate analyses identified SDB risk factors at 1.5, 4.75, and 6.75 years.

RESULTS

The prevalence of apnea ("Always") is 1%-2% at all ages assessed. In contrast, snoring "Always" ranges from 3.6% to 7.7%, and snoring "Habitually" ranges from 9.6% to 21.2%, with a notable increase from 1.5- 2.5 years. At 6 years old, 25% are habitual mouth-breathers. The "Always" and "Habitual" incidence of each symptom between time points is 1%-5% and 5%-10%, respectively. In multivariate analyses of combined symptoms, socioeconomic factors have stronger, more persistent effects upon increased SDB risk than gestational age, gender, or race (aside from 1.5 years); adenoidectomy decreases risk by 40%-50%.

CONCLUSIONS

This is the first natural history study of the primary symptoms of SDB across a key 6-year period in the development of SDB symptoms. Snoring rates are higher and spike earlier than previously reported. Symptoms are dynamic, suggesting the need for early and continued vigilance in early childhood.

Risk factors and consequences of excessive autonomic activation during sleep in children

PURPOSE

The aim of this study was to assess risk factors for excessive autonomic activation during sleep (EAAS) and its association with sleep problems, impaired behavior, and poor academic performance in primary school children.

METHODS

Data from a community-based study on 997 primary school children were used. Based on nocturnal home pulse oximetry, autonomic activation during sleep was defined as a pulse rate increase by more than 20%. Children with ≥35.9 autonomic activations per hour (i.e., ≥ the 95(th) centile) were classified as suffering from EAAS and compared with controls. Sleep problems, impaired behavior, and academic performance were assessed by parental questionnaires and analysis of school reports.

RESULTS

According to the above-mentioned definition, EAAS was diagnosed in 52 children (67% male). Risk factors for EAAS were male gender (odds ratio [95% confidence interval]: 2.06 [1.14-3.72]) and presence of symptoms of sleep-disordered breathing (3.48 [1.29-9.43]). Children with EAAS had a higher prevalence of hyperactive behavior (39.2% vs. 26.0%; p = 0.05) and enuresis (5.8% vs. 0.8%; p = 0.017) but not of poor academic performance. The association with hyperactive behavior was confirmed in a subsample (n = 119) using the Strengths and Difficulties Questionnaire. Mean (SD) score of the hyperactive-inattentive scale was 4.5 (2.8) for EAAS and 3.4 (2.7) for non-EAAS (p = 0.04).

CONCLUSION

EAAS may be a marker of sleep disruption in children and may predict the occurrence of enuresis and hyperactive behavior.

The insulin gene variable number of tandemrepeats (INS VNTR) genotype and sleep disordered breathing in childhood obesity

Aim of our study is to verify the association between the genetic predisposition to hyperinsulinism due to the presence of the insulin gene (INS) I/I genotype and the development of sleep-related breathing disorders (SRBD) in obese children and adolescents. Two hundred and fifty-six obese children and adolescents (125 girls) have been investigated. As initial screening all subjects' mothers filled out the Sleep Disturbances Scale for Children (SDSC). The Sleep-Disordered Breathing (SDB) scale has been taken into account. Successively, a subgroup of 34 patients belonging to the first (14 children) and the last (20 children) SDB score quintiles underwent an overnight polysomnography and the apnea-hypopnea index (AHI) was evaluated. All subjects were genotyped for the INS VNTR and fasting insulin levels were evaluated. The population was divided into two groups according to the genotype: the first group was comprehensive of patients homozygotes for class I allele and the second group was composed by class III allele heterozygotes and homozygotes patients. Subjects I/I showed statistically signifIcant higher insulin levels (p<0.001) and SDB scores (p<0.001). Moreover, in the subgroup of patients investigated with polysomnography, class I homozygous subjects showed higher AHI compared to those patients carrying class III allele (p<0.001). Our data support the hypothesis that INS VNTR is associated with the development of SDB among obese children and adolescents.

Mood is associated with snoring in preschool-aged children

OBJECTIVE

To study emotional and behavioral problems and sleep and cognitive performance in snoring and nonsnoring 3- to 6-year-old children.

METHODS

As part of an epidemiological study of sleep disordered breathing (SDB) in preschool-aged children, 43 snorers and 46 nonsnorers participated in a clinical study. Their parents completed the Child Behavior Checklist (CBCL). The children were assessed with Wechsler Preschool and Primary Scale of Intelligence, Revised and subtests of the Developmental Neuropsychological Assessment (NEPSY-A) representing aspects of attention, language skills, sensorimotor functions, memory, and learning.

RESULTS

On the CBCL snoring children had significantly more parent reported internalizing symptoms (p < .05) than the nonsnoring children, especially symptoms of anxious/depressed mood (p < .01) and emotional reactivity (p < .05). More children from the snoring group than from the nonsnoring group (22 vs 11%) scored in the subclinical or clinical range on the internalizing scale. Interestingly, no significant difference between the groups was found in the amount of externalizing symptoms. The amount of sleep problems other than snoring was higher in the snoring than in the nonsnoring group (p < .01). On tests measuring auditory attention (p < .01) and language skills (verbal IQ, p < .05), the snoring group performed worse than the nonsnoring group.

CONCLUSIONS

Our results support the view that SDB should be considered a possible risk factor for mood disorder symptoms and impaired cognitive performance in children.

Obesity and excessive daytime sleepiness in prepubertal children with obstructive sleep apnea

INTRODUCTION

The epidemic of childhood obesity has prompted remarkable changes in the relative proportions of symptomatic overweight or obese children being referred for evaluation of habitual snoring. However, it remains unclear whether obesity modifies the relative frequency of daytime symptoms such as excessive daytime sleepiness.

METHODS

Fifty consecutive, nonobese, habitually snoring, otherwise-healthy children (age range: 6-9 years) and 50 age-, gender-, and ethnicity-matched obese children (BMI z score: >1.67) underwent an overnight polysomnographic evaluation, followed by a multiple sleep latency test the following day.

RESULTS

The mean obstructive apnea/hypopnea index values for the 2 groups were similar (nonobese: 12.0 +/- 1.7 episodes per hour of total sleep time; obese: 10.9 +/- 1.5 episodes per hour of total sleep time). However, the mean sleep latency for obese children was significantly shorter (12.9 +/- 0.9 minutes) than that for nonobese children (17.9 +/- 0.7 minutes). Furthermore, 21 obese children had mean sleep latencies of < or =12.0 minutes, compared with only 5 nonobese children. Although significant associations emerged between mean sleep latency, obstructive apnea/hypopnea index, proportion of total sleep time with oxygen saturation of <95%, and respiratory arousal index for the whole cohort, the slopes and intersects of the linear correlation of mean sleep latency with any of these polygraphic measures were consistently greater in the obese cohort.

CONCLUSIONS

The likelihood of excessive daytime sleepiness for obese children is greater than that for nonobese children at any given level of obstructive sleep apnea severity and is strikingly reminiscent of excessive daytime sleepiness patterns in adults with obstructive sleep apnea.

Pediatric sleep apnea: early onset of the 'syndrome'?

Obstructive sleep apnea is a common disorder in childhood, particularly in the last decade when an increased prevalence of obesity has been documented. The neurocognitive and behavioral problems associated with this disorder have been known for a long time. However, the increased knowledge of cardiovascular and metabolic complications in adults with sleep apnea has been followed by a better understanding of the systemic effects of upper airway obstruction in children. Obstructive sleep apnea (OSA) has been shown to induce autonomic imbalance in children and to affect blood pressure, cerebral blood flow and cardiac function in an early phase. OSA may also induce chronic systemic inflammation and may contribute to the development of metabolic syndrome in obese children. Very recent research indicates that in children primary snoring, the mildest form of the sleep-disordered breathing spectrum, may also be associated with morbidity. It is, therefore, likely that these respiratory sleep disorders do not simply influence children's' performance in private and social life, but may more seriously affect children's' health. The aim of this review is to outline early systemic complications of obstructive sleep apnea and primary snoring in infants and children.

All snoring is not adenoids in young children

OBJECTIVE

To determine the prevalence of snoring in young children and to assess age, growth, previous surgery therapy, respiratory problems and sleep-related symptoms in relation to child's snoring, and to evaluate the relationship between child's snoring and parents' snoring and smoking.

CHILDREN AND METHODS

A cross-sectional study evaluated 2100 children 1-6 years of age in Helsinki, Finland. Child's frequency of snoring on a five-point scale (never to every night) and age, height, weight and body mass index, previous adenotonsillectomies, tympanostomies, allergic rhinitis and respiratory infections were determined as was frequency of parental snoring and smoking. Sleep problems were determined based on Finnish or Swedish modified version of the sleep disturbance scale for Children.

RESULTS

Of the 2100 eligible children, 1471 (71%) returned questionnaires. Children always or often snoring numbered 92 (6.3%), sometimes snoring, 183 (12.4%), and never or occasionally snoring, 1196 (81.3%). No difference in age (p=0.06) or gender (p=0.39) existed between snorers and non-snorers. History of previous adenotonsillectomies (p<0.001), allergic rhinitis (p<0.001), recurrent respiratory infections (p<0.001), and otitis media (p<0.001) were more common among snorers than among occasional or never-snorers. Nocturnal symptoms such as breathing problems, sleep hyperhydrosis, sleep-wake transition disorders, and daytime somnolence were associated with children's snoring. Frequency of children's snoring was also associated with parental snoring (p<0.001) and smoking (p<0.001).

CONCLUSIONS

Snoring is common among young children and is associated with previous adenotonsillectomy, allergic rhinitis, respiratory infections, nocturnal symptoms, and parents' snoring and smoking. The high prevalence of snoring among children with adenotonsillectomy raises the question whether adenotonsillectomy alone is adequate treatment for snoring in young children.

Sleep-related problems in pediatric obsessive-compulsive disorder

Although attention has been given to presence of sleep related problems (SRPs) in children with psychiatric conditions, little has been reported on SRPs in youth with obsessive-compulsive disorder (OCD). Sixty-six children and adolescents with OCD were administered the Children's Yale Brown Obsessive-Compulsive Scale and completed the Children's Depression Inventory and Multidimensional Anxiety Scale. Their parents completed the Child Behavior Checklist and Children's Obsessive-Compulsive Impact Scale. A subset of youth (n=41) completed a trial of cognitive-behavioral therapy. Frequency of eight specific SRPs was examined in relation to age, gender, OCD symptom severity, child-rated symptoms of depression and anxiety, parent-proxy ratings of internalizing and externalizing problems, and functional impairment. Ninety-two percent of youth experienced at least one SRP, with 27.3% reporting five or more SRPs. Total SRPs were positively associated with OCD symptom severity, child-rated anxiety, and parent-proxy ratings of internalizing problems. Total and several specific SRPs were reduced following cognitive-behavioral treatment. These results suggest that SRPs are relatively common in youth with OCD, are associated with symptom severity, and warrant attention during assessment and treatment.

Snoring in cleft patients with velopharyngoplasty

Some patients with cleft lip/palate or isolated cleft palate seem to develop snoring as one possible symptom of an obstructive sleep apnoea syndrome after velopharyngoplasty (VPP). The aim of this paper was to determine whether there was a difference in the posterior airway space (PAS) between patients with a VPP who snored and those who did not. Four standard parameters were measured in lateral cephalograms of 20 patients with cleft lip/palate and isolated cleft palate, without diagnosis of further syndromes (e.g. Pierre Robin sequence), having undergone VPP, to examine the dimensions of the PAS. Data were set in correlation to the symptom of snoring, and compared with those of 40 patients without cleft undergoing orthodontic treatment and with 20 patients with cleft lip/palate or isolated cleft palate but not VPP. Metric parameters were significantly different after VPP in patients with clefting and snoring compared to the group of cleft patients without snoring. All patients with clefts exhibited at least in one dimension a constriction when compared to patients without clefting. In conclusion, cleft lip/palate and isolated cleft palate patients tend to have constrictions of the PAS. VPP may induce snoring and further narrowing. Recall and analysis for obstructive sleep apnoea syndrome should be mandatory.