Restless sleep in children: A systematic review

Restless sleep disorder in a sample of children and adolescents with autism spectrum disorder: preliminary results from a case series

STUDY OBJECTIVES

Sleep disorders are a frequent comorbidity among children with autism spectrum disorder (ASD). Among sleep-related issues of ASD, restless sleep is a common complaint. In recent years, restless sleep disorder (RSD) has been proposed as a new clinical entity, characterized by agitated sleep as its predominant manifestation. Despite the high prevalence of sleep disorders and data reporting restless sleep among ASD patients, to date no study has yet characterized RSD within patients with ASD. Therefore, the aim of our study was to assess the occurrence of RSD in a sample of children and adolescents with ASD through clinical and polysomnographic assessment.

METHODS

Children and adolescents with ASD ages 6-18 years were recruited for the study. Through parental interviews, patients with a suspected RSD were selected and offered diagnostic investigation by video-polysomnography and blood tests to assess martial balance.

RESULTS

Among the 129 participants included, 16 patients (12.4%) were found to have a suspected RSD. Only 6 (4.7%) underwent video-polysomnography due to lack of compliance or family refusal. In 6/6 participants examined, the disorder was confirmed by video-polysomnography movement analysis (total movement index ≥ 5 events/h) and ferritin values were found in the normal range.

CONCLUSIONS

RSD does not appear to be particularly frequent among patients with ASD and that of iron metabolism may not be the main factor implicated in the pathogenesis of RSD within this population. Additional evaluation is needed to confirm the result and further investigate the etiological mechanisms underlying the disorder.

CITATION

Voci A, Mazzone L, De Stefano D, Valeriani M, Bruni O, Moavero R. Restless sleep disorder in a sample of children and adolescents with autism spectrum disorder: preliminary results from a case series. J Clin Sleep Med. 2024;20(3):427-432.

The association of obstructive sleep apnea and behavioral insomnia in children ages 10 and under

STUDY OBJECTIVES

Behavioral insomnia of childhood (BIC) and obstructive sleep apnea (OSA) are highly prevalent conditions affecting 10%-20% and 1%-5% of children, respectively. Studies in adults and adolescents have suggested that comorbid insomnia and OSA may have distinct clinical characteristics. The association between the two conditions in the pediatric population has not been thoroughly investigated. This study aimed to examine the association between BIC and OSA in young children.

METHODS

Children, 6 months to 10 years old, referred to a sleep specialist and polysomnography at the Hadassah Medical Center between 2018 and 2021 were included in this retrospective analysis. We excluded children with chromosomal and craniofacial abnormalities, posttonsillectomy, or neurological impairment. BIC diagnosis was extracted from the electronic health records in accordance with the International Classification of Sleep Disorders, third edition criteria. OSA was diagnosed by polysomnography (apnea-hypopnea index > 2 events/h).

RESULTS

Of 312 children (age 4.42 ± 2.42 years), 126 (40.4%) were non-OSA non-BIC, 125 (40.1%) OSA non-BIC, 34 (10.9%) BIC non-OSA, and 27 (8.7%) comorbid insomnia and OSA. OSA and non-OSA children had a similar prevalence of BIC. Children in the comorbid insomnia and OSA group were significantly younger (2.22 ± 1.21 years). Younger age at polysomnography, premature birth, and increased periodic leg movements on polysomnography were independently associated with OSA in a multivariable analysis. Lower body mass index, regardless of OSA, was associated with BIC.

CONCLUSIONS

Current findings do not support an association between behavioral insomnia of childhood and obstructive sleep apnea in children. Healthcare providers should consider each of these sleep disorders in children presenting with sleep difficulties since each has distinct diagnostic and therapeutic options.

CITATION

Yelov L, Reiter J, Meira E Cruz M, Gileles-Hillel A. The association of obstructive sleep apnea and behavioral insomnia in children ages 10 and under. J Clin Sleep Med. 2024;20(2):245-251.

Restless sleep disorder in children with epileptic and non-epileptic nocturnal attacks

Restless sleep disorder (RSD) is an important sleep disorder characterised by the presence of frequent large muscle movements (LMM) during sleep, which may be comorbid to other conditions/diseases. In this study, we investigated the frequency and the characteristics of RSD among children who were evaluated by polysomnography (PSG) due to epileptic and non-epileptic nocturnal attacks. We analysed consecutively children younger than 18 years who were referred for PSG recording due to abnormal motor activities during sleep. The diagnosis of nocturnal events as sleep-related epilepsy was made based on the current consensus. Patients who were referred with suspicion of sleep-related epilepsy, but who were diagnosed to have non-epileptic nocturnal events and children with a definitive diagnosis of NREM sleep parasomnias were also enrolled. Sixty-two children were analysed in this study (17 children with sleep-related epilepsy, 20 children with NREM parasomnia, and 25 children with nocturnal events not otherwise classified [neNOS]). The mean number of LMM, LMM index, LMM-associated with arousal and its index were all significantly higher in children with sleep-related epilepsy. Restless sleep disorder was present in 47.1% of patients with epilepsy, 25% of patients with parasomnia, and in 20% of patients with neNOS. The mean A3 duration and the A3 index were higher in children with sleep-related epilepsy and RSD compared with those with parasomnia and restless sleep disorder. Patients with RSD had lower ferritin levels than those without RSD in all subgroups. Our study demonstrates a high prevalence of restless sleep disorder in children with sleep-related epilepsy, associated with an increased cyclic alternating pattern.

Management of obstructive sleep apnea syndrome type 1 in children and adolescents - A French consensus

This document is the outcome of a group of experts brought together at the request of the French Society of Sleep Research and Medicine to provide recommendations for the management of obstructive sleep apnea syndrome type 1 (OSA1) in children. The recommendations are based on shared experience and published literature. OSA1 is suspected when several nighttime respiratory symptoms related to upper airway obstruction are identified on clinical history taking. A specialist otolaryngologist examination, including nasofibroscopy, is essential during diagnosis. A sleep study for OSA1 is not mandatory when at least two nighttime symptoms (including snoring) are noted. Therapeutic management must be individualized according to the location of the obstruction. Ear, nose, and throat (ENT) surgery is often required, as hypertrophy of the lymphoid tissues is the main cause of OSA1 in children. According to clinical findings, orthodontic treatment generally associated with specialized orofacial-myofunctional therapy might also be indicated. Whatever treatment is chosen, follow-up must be continuous and multidisciplinary, in a network of trained specialists.

Large muscle group movements during sleep in healthy people: normative values and correlation to sleep features

STUDY OBJECTIVES

To investigate the frequency and characteristics of large muscle group movements (LMMs) during sleep in healthy adults.

METHODS

LMMs were scored following the International Restless Legs Syndrome Study Group criteria in 100 healthy participants aged 19-77 years. A LMM was defined as a temporally overlapping increase in EMG activity and/or the occurrence of movement artifacts in at least two channels. LMM indices and durations in total sleep time (TST), NREM and REM sleep, and association with arousals, awakenings, and/or respiratory events were calculated. Correlations of LMMs indices and durations with sleep architecture, respiratory and motor events, and subjective sleep quality were investigated.

RESULTS

Median LMMs index in TST was 6.8/h (interquartile range (IQR), 4.5-10.8/h), median mean duration 12.4 s (IQR 10.7-14.4 s). Mean LMMs duration was longer in NREM (median 12.7 s, IQR 11.1-15.2 s) versus REM sleep (median 10.3 s, IQR 8.0-13.5s), p < 0.001. LMMs associated with awakening increased with age (p = 0.029). LMMs indices in TST were higher in men than women (p = 0.018). LMMs indices correlated positively with N1 sleep percentage (ρ = 0.49, p < 0.001), arousal index (ρ = 0.40, p = 0.002), sleep stages shift index (ρ = 0.43, p < 0.001, apnea index (ρ = 0.36, p = 0.017), and video-visible movements indices (ρ = 0.45, p < 0.001), and negatively with N3 sleep (ρ = -0.38, p= 0.004) percentage.

CONCLUSIONS

This is the first study providing normative data on LMMs frequency in healthy adults. LMMs are a ubiquitous phenomenon often associated with other events. Correlation with arousals and respiratory events suggests a potential clinical significance of LMMs in adults that awaits further investigation.

Restless Legs Syndrome and Restless Sleep Disorder in Children

Restless legs syndrome (RLS) affects 2% of children presenting with symptoms of insomnia, restless sleep, decreased quality of life, and effects on cognition and behavior. The International RLS Study Group and the American Academy of Sleep Medicine have published guidelines for the diagnosis and treatment of RLS in children. Restless sleep disorder has been recently identified in children and presents with frequent movements during sleep and daytime symptoms with polysomnography findings of at least 5 large muscle movements at night. Treatment options for both disorders include iron supplementation, either oral or intravenous with improvement in nighttime and daytime symptoms.

Sleep habits and sleep disorders in Italian children and adolescents: a cross-sectional survey

STUDY OBJECTIVES

The aim was to describe sleep habits and epidemiology of the most common sleep disorders in Italian children and adolescents.

METHODS

This was a cross-sectional study in which parents of typically developing children and adolescents (1-18 years) completed an online survey available in Italy, gathering retrospective information focusing on sleep habits and disorders.

RESULTS

Respondents were 4,321 typically developing individuals (48.6% females). Most of our sample did not meet the age-specific National Sleep Foundation recommendations for total sleep duration (31.9% of toddlers, 71.5% of preschoolers, 61.6% of school-age children, and 41.3% of adolescents). Napping was described in 92.6% of toddlers and in 35.2% of preschoolers. Regarding geographical differences, children and adolescents of northern Italy showed more frequent earlier bedtimes and rise times than their peers of central and southern Italy. The most frequently reported sleep disorder in our sample was restless sleep (35.6%), followed by difficulties falling asleep (16.8%), > 2 night awakenings (9.9%), and bruxism (9.6%). Data also suggest that longer screen time is associated with later bedtimes on weekdays in all age groups.

CONCLUSIONS

The current study shows that Italian children are at risk of sleep disorders, particularly insufficient sleep, restless sleep, and difficulty falling asleep. The study also provides normative sleep data by age group in a large cohort of typically developing Italian children, emphasizing the importance of the developmentally, ecologically, and culturally based evaluation of sleep habits and disorders.

CITATION

Breda M, Belli A, Esposito D, et al. Sleep habits and sleep disorders in Italian children and adolescents: a cross-sectional survey. J Clin Sleep Med. 2023;19(4):659-672.

Polysomnographic versus video scoring of large muscle group movements during sleep in children with restless sleep

BACKGROUND

Restless sleep is a common complaint in children with sleep and other disorders, when it occurs as an isolated symptom it can depict a separate condition called restless sleep disorder (RSD). A key diagnostic feature of RSD is the polysomnographic (PSG) scoring of five or more large muscle movements (LMM) per hour of sleep. Initial publications on RSD used video-PSG (vPSG) analysis to count LMM. However, recently, scoring criteria for LMM on PSG signals alone have been published, but their correlation with vPSG scoring has not been done. In this study we compare vPSG to PSG scoring of LMM in a group of children with restless sleep.

METHODS

Video-PSG studies from 20 children (14 boys and six girls, mean age 11.3 years, SD 4.17) were reviewed by a blinded scorer. First, scorer used a video analysis (video-LMM), then on a different day the scorer used PSG criteria for LMM without video (PSG-LMM).

RESULTS

PSG-LMM were found to be significantly more numerous than video-LMM (mean LMM index 8.6 ± 2.95 SD vs. 6.9 ± 2.40 SD, respectively) while their duration was not statistically different (mean LMM duration 11.6 ± 2.33 s vs. 11.6 ± 2.99 s, respectively). 95.4% of video-LMM were also detected by PSG. Both LMM indexes and durations obtained by the two methods correlated significantly between them. A cut off of 6.24 LMM/hour by PSG-LMM was calculated to be equivalent to 5 LMM by video-LMM.

CONCLUSIONS

PSG-LMM scoring criteria detects >95% of LLM scored by video-PSG. PSG-LMM lead to the detection of a higher number of movements, indicating their higher sensitivity in picking up LMM in PSG recording. This further supports that these criteria need adequate consideration for their eventual inclusion into the current sleep scoring manual. A higher index may be needed to diagnose RSD.

Prospective association of short sleep duration in newborns with bruxism behavior in children: The Japan Environment and Children's Study (JECS)

BACKGROUND

Bruxism is defined as a repetitive masticatory muscle activity, characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. Although the bruxism etiology can be bidirectionally described with sleep disorders, there are few studies available to understand the association of sleep duration with bruxism behavior in early childhood.

METHODS

A dataset of children (n = 90,148) from the Japan Environment and Children's Study (JECS) - an ongoing nationwide, prospective birth cohort study - was used to investigate the prospective association of the infant's sleep duration with bruxism behavior, which were acquired using self-reported questionnaire. After multiple imputation of data, the association between sleep duration and bruxism behavior in early childhood was examined using a binomial logistic regression analysis. It was conducted with adjustments for several maternal (e.g., age at delivery and sleep duration) and child-related (e.g., sex and sleep position) variables.

RESULTS

The prevalence of bruxism behavior at the ages of two and four were 16.2% and 22.5%, respectively. Using the shortest sleep duration group's participants (≤13 h) as the reference, the odds ratio (95% confidence interval) for prevalence of bruxism behavior decreased with longer sleep duration at one month of age, but not at 36 months of age, after covariate adjustments. Furthermore, in comparison with the impacts between daytime and nighttime sleep, nighttime sleep with longer duration were dominantly associated with bruxism behavior.

CONCLUSION

The sleep duration in infant stage, especially during newborn stage was associated with the prevalence of bruxism behavior in children.

The Effect of Napping on the Function of Problem Behavior for One Child With an Acquired Brain Injury

Many children experience sleep disruption in the form of difficulties falling asleep, staying asleep, or getting back to sleep. Children with acquired brain injuries (ABI) sometimes experience an exacerbation of these symptoms. Thus, researchers and practitioners alike need to identify creative assessment and treatment approaches to meet this population’s needs. The purpose of the current case study was to highlight one method for (a) determining a nap schedule and (b) evaluating the effect of fatigue on behavioral function for one child diagnosed with an ABI. We conducted a scatterplot analysis to identify periods in which problem behaviors occurred more or less often. These data informed when the child took naps. Afterward, the child participated in a functional analysis of problem behavior before a nap and again after a nap. Results showed both negative and positive reinforcement maintained problem behaviors before naps, while only positive reinforcement maintained problem behaviors after naps. Functional communication training (FCT) programs implemented to address escape, tangible, and attention functions before naps reduced problem behavior and increased communication. These data suggested that (a) motivating operations for problem behavior can differ depending on fatigue and (b) FCT is an effective intervention for problem behavior affected by fatigue. The current study provides an example of an assessment and treatment approach when biologic factors, like sleep, may influence problem behavior.

Intravenous iron therapy in the pediatric sleep clinic: a single institution experience

STUDY OBJECTIVES

Initial reports of intravenous (IV) iron administration have been promising for children with restless legs syndrome, periodic limb movement disorder, and restless sleep disorder. The aim of the current study was to evaluate further the clinical response to IV iron supplementation in children seen in a pediatric sleep clinic.

METHODS

We performed a retrospective chart review of children cared for in a single pediatric sleep clinic who also underwent IV iron infusion. Pre and post IV data regarding their sleep symptoms and ferritin levels were abstracted.

RESULTS

Overall, 63 pediatric sleep patients underwent IV iron infusion, mostly with ferric carboxymaltose (n = 60), for restless legs syndrome (n = 30), periodic limb movement disorder (n = 22), and restless sleep disorder (n = 17). Of the 59 patients with clinical follow-up, 39 (73%) noted improvement in at least 1 symptom, and 14 (26%) did not notice improvement or noticed worsening symptoms. Of the 59 patients with preinfusion and postinfusion labs, the average ferritin level increased from 21.7 (13.3) to 147.9 (120.9) μg/L, P < .001. Comparing patients who experienced clinical improvement vs those who did not, there were no statistically significant differences in change in ferritin levels (P = .278), sex (P = .452), or age (P = .391). Ferritin change with infusion according to diagnostic subgroups (restless legs syndrome/periodic limb movement disorder/restless sleep disorder) was examined, and no significant differences were noted (F(2,56) = 0.852, P = .432). In terms of immediate adverse reactions to the IV infusion, 7 (11%) experienced at least 1 side effect, with the most common being behavior change (n = 6) or gastrointestinal discomfort (n = 4); no episodes of anaphylaxis or extravasation were noted.

CONCLUSIONS

These data provide additional support for the efficacy and safety of IV iron for pediatric restless legs syndrome, periodic limb movement disorder, and restless sleep disorder recalcitrant to oral iron.

CITATION

Ingram DG, Al-Shawwa B, DelRosso LM, Sharma M. Intravenous iron therapy in the pediatric sleep clinic: a single institution experience. J Clin Sleep Med. 2022;18(11):2545-2551.

Role of Psychologists in Pediatric Sleep Medicine

Sleep disorders commonly afflict infants, children, and adolescents and have a significant adverse impact on them and their families, sometimes to a severe degree. They can cause immediate stress and suffering and long-term loss of opportunities and potential. Many of these disorders can be well managed by the psychologist and often one is required, either as the sole provider or as an integral part of a team. Sleep disorders have a bidirectional interplay with mental health disorders. The patient may therefore present initially to the psychologist, primary care provider, or the sleep medicine specialist.

Children with neurodevelopmental disorders: how do they sleep?

PURPOSE OF REVIEW

In this review we summarized the available evidence on sleep disorders in children with neurodevelopmental disorders (NDDs) in particular: intellectual disability (including some genetic conditions such as Prader-Willi Syndrome, Smith-Magenis Syndrome), Autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), Developmental Coordination Disorder, language disorders, and specific learning disorders.

RECENT FINDINGS

Children with NDDs frequently suffer from sleep disturbances, with a higher prevalence than that of the general pediatric population.

SUMMARY

These problems tend to be chronic and may cause additional cognitive and behavioral difficulties, often affecting the whole family's well-being. Sleep behaviors are also related to other important developmental skills, such as attention and listening. Investigating sleep disorders in children with NDDs is therefore crucial in clinical practice. For a systematic approach in clinical practice, we propose the use of a short and easy to remember sleep screening tool.

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

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

Restless Sleep Disorder (RSD): a New Sleep Disorder in Children. A Rapid Review

PURPOSE OF REVIEW

Restless sleep disorder (RSD) is a recently identified pediatric sleep disorder characterized by frequent movements during sleep associated with daytime symptoms. In this review we summarize the expanding evidence of the clinical presentation of RSD, potential pathophysiology, associated comorbidities, and current treatment options that will help the pediatrician identify children with RSD in a timely manner.

RECENT FINDINGS

RSD is diagnosed in 7.7% of children referred evaluated in a pediatric sleep center. Children with RSD present with frequent nightly movements during sleep for at least 3 months, and have daytime symptoms related to poor sleep quality including excessive sleepiness, hyperactivity, irritability among other symptoms. Current evidence shows an increased sympathetic predominance, increased NREM sleep instability, and iron deficiency, as well as increased prevalence in parasomnias and attention deficit hyperactivity disorder. Consensus diagnostic criteria were recently published to diagnose RSD and emergent evidence suggests that iron supplementation improves its nighttime and daytime symptoms.

Large body movements on video polysomnography are associated with daytime dysfunction in children with restless sleep disorder

Restless sleep disorder (RSD) is a newly defined sleep-related movement disorder characterized by large muscle movements (LMM) in sleep. We examined the sleep study, clinical characteristics, and daytime functioning in children with RSD and compared them to children with periodic limb movement disorder (PLMD) or restless legs syndrome (RLS). Video polysomnography from 47 children with restless sleep was retrospectively reviewed for LMM and age- and sex-matched to 34 children with PLMD and 12 children with RLS. Data examined included PSG characteristics, ferritin, Pediatric Quality of Life (PedsQL), and Epworth Sleepiness Scale (ESS). Fourteen children met the clinical criteria for RSD with an LMM index of 5 or more per hour of sleep. Mean ESS was elevated in patients with RSD compared to either the PLMD or RLS groups though the result did not reach statistical significance (RSD = 10.20 ± 6.81, PLMD = 6.19 ± 4.14, RLS = 6.25 ± 4.90). The PedsQL score was significantly decreased in the RLS group compared to RSD and was reduced overall in all three groups (PedsQL Total RSD = 70.76 ± 18.05, PLMD = 57.05 ± 20.33, RLS = 53.24 ± 16.97). Serum ferritin values were similar in all three groups (RSD = 26.89 ± 10.29, PLMD = 33.91 ± 20.31, RLS = 23.69 ± 12.94 ng/mL, p = ns). Children with RSD demonstrate increased daytime sleepiness compared to PLMD or RLS and all three disease groups showed decreased quality of life. Further studies are needed to examine long-term consequences of RSD.

Literature Cases Summarized Based on Their Polysomnographic Findings in Rett Syndrome

Rett syndrome (RTT) is a severe and rare neurodevelopmental disorder affecting mostly girls. In RTT, an impaired sleep pattern is a supportive criterion for the diagnosis, yet little is known regarding the sleep structure and sleep respiratory events. Aiming to delineate sleep by aggregating RTT case (series) data from published polysomnographic studies, seventy-four RTT cases were collected from eleven studies up until 6 February 2022 (PROSPERO: CRD 42020198099). We compared the polysomnographic data within RTT stratifications and to a typically developing population. MECP2 cases demonstrated shortened total sleep time (TST) with increased stage N3 and decreased REM sleep. In cases with CDKL5 mutations, TST was longer and they spent more time in stage N1 but less in stage N3 than those cases affected by MECP2 mutations and a typically developing population. Sleep-disordered breathing was confirmed by the abnormal apnea/hypopnea index of 11.92 ± 23.67/h TST in these aggregated cases. No association of sleep structure with chronological age was found. In RTT, the sleep macrostructure of MECP2 versus CDKL5 cases showed differences, particularly regarding sleep stage N3. A severe REM sleep propensity reduction was found. Aberrant sleep cycling, possibly characterized by a poor REM ‘on switch’ and preponderance in slow and high-voltage sleep, is proposed.

Sleep-Wake and Circadian Disorders after Tick-Borne Encephalitis

Tick-borne encephalitis (TBE) is an infectious disease affecting the central nervous system. Recently, the occurrence of TBEV infections has steadily increased, reaching all-time high incidence rates in European countries. Up to 50% of patients with TBE present neurological sequelae, among them sleep–wake and circadian disorders (SWCD), which are poorly characterized. The aim of this review is to investigate the prevalence, clinical characteristics, and prognosis of SWCD after TBE. The literature review was performed in accordance with PRISMA guidelines. The quality of the paper was assessed using a standardized quality assessment. The analysis of SWCD was categorized into four different time intervals and two age groups. The literature search identified 15 studies, five including children and 10 including adults. In children, fatigue was most frequently observed with a prevalence of 73.9%, followed by somnolence/sleepiness, restlessness, and sleep-wake inversion. In adults, tiredness/fatigue was the most reported sequela with a prevalence of 27.4%, followed by extensive daytime sleepiness/somnolence, and insomnia (3.3%). Two studies showed impaired social outcomes in patients after TBE infections. SWCD after TBE in children and adults is a newly recognized sequela. Additional clinical and experimental research is needed to gain more precise insight into the clinical burden of SWCD after TBE and the underlying mechanisms.

Effects of Touchscreen Media Use on Toddlers' Sleep: Insights from Longtime ECG Monitoring

Wearable biomedical sensor technology enables reliable monitoring of physiological data, even in very young children. The purpose of the present study was to develop algorithms for gaining valid physiological indicators of sleep quality in toddlers, using data from an undisturbing and easy-to-use wearable device. The study further reports the application of this technique to the investigation of potential impacts of early touchscreen media use. Toddlers' touchscreen media use is of strong interest for parents, educators, and researchers. Mostly, negative effects of media use are assumed, among them, disturbances of sleep and impairments of learning and development. In 55 toddlers (32 girls, 23 boys; 27.4 ± 4.9 months; range: 16-37 months), ECG monitoring was conducted for a period of 30 (±3) h. Parents were asked about their children's touchscreen media use and they rated their children's sleep quality. The use of touchscreen media predicted the physiologically determined quality of sleep but not parent-reported sleep quality (such as sleep onset latency). Greater heart rate differences between restless sleep phases and restful sleep indicated poorer nighttime recovery in children with more frequent use of touchscreen media. The study demonstrates that the expert analysis of the ECG during sleep is a potent tool for the estimation of sleep quality in toddlers.

Restless sleep disorder in children with NREM parasomnias

STUDY OBJECTIVES

Restless sleep disorder (RSD) is a newly defined sleep disorder in the pediatric age group. Here, we investigated the frequency of RSD and the sleep characteristics in children with NREM (non-rapid eye movements) parasomnias associated with RSD.

METHODS

We analyzed all patients with NREM parasomnias for the last 1 year, and investigated the clinical and polysomnographic characteristics.

RESULTS

Twenty-eight children with NREM parasomnias and age- and gender-matched 20 healthy children were analyzed. The diagnosis of RSD was made in eight children with NREM parasomnias (28.6%), and none of the children had RSD in controls (p = 0.008). The most common diagnosis among children with RSD was somnambulism (six children), but not significantly (p = 0.308). Sleep efficiency was lower in children with RSD than those without RSD (p = 0.033). In cyclic alternating pattern analysis (CAP), CAP rate, durations and the indices of phases A1, A2, and A3 were significantly higher in children with NREM parasomnias in compared to controls. CAP parameters between children with or without RSD; however, were similar, except for higher index of phase A3 in children with RSD, suggesting arousal reactions accompanying RSD.

CONCLUSIONS

We demonstrated that RSD was present in almost one third of the children with NREM parasomnias. Sleep quality was worse in children with NREM parasomnias and RSD. An increase in sleep instability compatible with NREM parasomnia was present, while an increased phase A3 in RSD was remarkable. RSD is associated with a worse sleep quality and increased arousals, and should be questioned in children with NREM parasomnias.

Sleep problems among children with Fetal Alcohol Spectrum Disorders (FASD)- an explorative study

BACKGROUND

Fetal alcohol spectrum disorders (FASD) is a group of conditions resulting from prenatal alcohol exposure (PAE). Patients with FASD experience a variety of neuropsychological symptoms resulting from central nervous system impairment. Little is known about sleep disorders associated with PAE. The objective of this study was to investigate sleep problems related to FASD.

METHODS

Forty patients (median age 8 years (6; 11)) diagnosed with FASD and forty typically developing children (median age 10 years (8; 13)) were recruited for the 1st phase of the study. In the 1st phase, the screening of sleep problems was performed with Child Sleep Habit Questionnaire (CSHQ) filled in by a caregiver. Those of the FASD group who scored above 41 points were qualified to the 2nd phase of the study and had an in-lab attended polysomnography (PSG) performed. The measurements consisted of electroencephalogram, electrooculograms, chin and tibial electromyogram, electrocardiogram, ventilatory monitoring, breathing effort, pulse oximetry, snoring and body position. Their results were compared to PSG laboratory reference data.

RESULTS

The number of participants with sleep disturbances was markedly higher in the FASD group as compared to typically developing children (55% vs. 20%). The age-adjusted odds ratio for a positive result in CSHQ was 4.31 (95% CI: 1.54-12.11; p = 0.005) for FASD patients as compared to the control group. Significant differences between the FASD as compared to the typically developing children were observed in the following subscales: sleep onset delay, night wakings, parasomnias, sleep disordered breathing, and daytime sleepiness. Children from the FASD group who underwent PSG experienced more arousals during the sleep as compared with the PSG laboratory reference data. The respiratory indices in FASD group appear higher than previously published data from typically developing children.

CONCLUSION

The results support the clinical observation that sleep disorders appear to be an important health problem in individuals with FASD. In particular distorted sleep architecture and apneic/hypopneic events need further attention.

Restless sleep disorder in children with attention-deficit/hyperactivity disorder

STUDY OBJECTIVES

Restless sleep is a very common parental complaint in children with attention-deficit/hyperactivity disorder (ADHD), but restless sleep has been seen in association with other comorbidities such as restless legs syndrome and obstructive sleep apnea. Restless sleep disorder (RSD) needs to be identified from other disorders when evaluating children with ADHD. In this study we aim to identify the prevalence of RSD in children with ADHD referred to our sleep center.

METHODS

This is a retrospective study of children with ADHD who underwent polysomnography. The following diagnostic and descriptive data were obtained for each patient: age, sex, presence/absence of RSD, other sleep disorders, psychiatric comorbidities, and medications. RSD was diagnosed per diagnostic criteria.

RESULTS

There were 66 children with ADHD. All of them underwent polysomnography, 17 were females, and 49 were males. Mean age was 11.6 years (± 3.6 standard deviation). The complaint of restless sleep was reported by the parents of 54 (81.1%) of the children; however, only 6 of them (9.1%) were diagnosed with RSD. Seventy-one percent had obstructive sleep apnea and 19.7% had restless legs syndrome. A significant number of patients had psychiatric comorbidities and were on various medications.

CONCLUSIONS

Although restless sleep is a common complaint reported in 81.1% of children with ADHD, only 9.1% had RSD. Most causes of restless sleep are secondary and associated with other sleep disorders, psychiatric comorbidities, or medication use.

Artificial Neural Networks Analysis of polysomnographic and clinical features in Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): from sleep alteration to "Brain Fog"

STUDY OBJECTIVES

PANS (pediatric acute onset neuropsychiatric syndrome) is thought to be the result of several mechanisms and multiple etiologies, ranging from endocrine/metabolic causes to postinfectious autoimmune and neuroinflammatory disorders. Sleep disorders represent one of the most frequent manifestations of PANS, involving around 80% of patients. The present study describes the clinical and polysomnographic features in a group of PANS children identifying the relationships between sleep disorders and other PANS symptoms.

METHODS

All participants underwent a clinical evaluation including comprehensive sleep history, polysomnography, cognitive assessment and blood chemistry examination. A data mining approach with fourth-generation artificial neural networks has been used in order to discover subtle trends and associations among variables.

RESULTS

Polysomnography showed abnormality in 17 out of 23 recruited subjects (73.9%). In particular, 8/17 children (47%) had ineffective sleep, 10/17 (58.8%) fragmented sleep, 8/17 (47.1%) periodic limb movement disorder (PLMD) and 11/17 (64.7%) REM-sleep without atonia (RSWA). Most subjects presented more than one sleep disturbances. Notably, among the 19/23 patients diagnosed with Tic/Tourette disorder, 8/19 (42.1%) show PLMD and 10/19 (52.6%) RSWA. Artificial neural network methodology and the auto-contractive map exploited the links among the full spectrum of variables revealing the simultaneous connections among them, facing the complexity of PANS phenotype.

CONCLUSION

Disordered sleep represents, for prevalence and impact on quality of life, a cardinal symptom in patients with PANS. Thus, considering the weight of sleep disturbances on diagnosis and prognosis of PANS, we could consider the possibility of including them among the major diagnostic criteria.