Pediatric sleep medicine comes into its own.
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Child↗
Biomedical subjects
Carole L Marcus
Publications and source records attributed to Carole L Marcus.
Daytime sleepiness and hyperactivity in children with suspected sleep-disordered breathing.
OBJECTIVES: Excessive daytime sleepiness (EDS) is seen less frequently as a presenting complaint in children with sleep-disordered breathing than in adults. Instead, symptoms of hyperactivity are often described. We hypothesized that children with suspected sleep-disordered breathing (S-SDB) were both sleepier and more hyperactive than control subjects. Furthermore, we hypothesized that overnight polysomnographic parameters correlated with sleepiness and hyperactivity. METHODS: A cross-sectional study was conducted at a university-affiliated hospital and a community-based pediatric clinic. A total of 108 patients with S-SDB (mean [standard deviation] age: 7 +/- 4 years) and 72 control subjects (8 +/- 4 years) were recruited. A modified Epworth Sleepiness Scale (ESS) and the Conners Abbreviated Symptom Questionnaire were administered. Polysomnography was performed in patients with S-SDB. RESULTS: Patients with S-SDB had a higher ESS (8.1 +/- 4.9 vs 5.3 +/- 3.9) and a higher Conners score (12.8 +/- 7.6 vs 9.0 +/- 6.2) than control subjects. On the basis of adult criteria, 28% of patients had EDS. There was no difference in the ESS and Conners scores of patients with primary snoring and patients with obstructive sleep apnea. The ESS had weak correlations with polysomnographic parameters. CONCLUSIONS: Although the ESS score of children with S-SDB was within the normal range for adults, these children were sleepier and more hyperactive than control subjects. However, these data should be confirmed by a population-based study.
Analysis of Variance↗
Improving pediatric compliance with positive airway pressure therapy: the impact of behavioral intervention.
STUDY OBJECTIVE: The purposes of this study were (1) to describe behavior interventions provided to improve compliance with positive airway pressure (PAP) therapies in children with obstructive sleep apnea, (2) to survey physician and caregiver satisfaction with these interventions, and (3) to present preliminary outcome data on the effects of these interventions. DESIGN: Retrospective, descriptive analysis. SETTING: Pediatric psychology consultation service at a university-affiliated rehabilitation hospital. PARTICIPANTS: 20 children (aged 1-17 years) with obstructive sleep apnea, referred by physicians for noncompliance with PAP. INTERVENTIONS: Patients self-selected into 1 of 3 groups: (1) a group receiving a 1.5-hour consultation and recommendation session (CR+), (2) a group receiving consultation and recommendations plus a course of behavior therapy (BT), and (3) a group for whom behavior therapy was recommended after the consultation and recommendations, but the family did not follow-up (CR-). RESULTS: Prior to behavior intervention, none of the children were consistently wearing the PAP equipment. After intervention, 75% of children who received behavior intervention (CR+ and BT groups) successfully tolerated PAP with increased hours of documented usage. This was in contrast to children whose families declined recommended behavior therapy (CR- group), of whom 0% increased their usage of PAP. High satisfaction ratings were obtained from referring physicians and patient caregivers for children in the CR+ and BT groups. CONCLUSIONS: The results are encouraging and support the importance of behavior analysis and therapy for increasing compliance and making the benefits of PAP available to a greater number of children.
Adolescent↗
Tolerance of esophageal pressure monitoring during polysomnography in children.
OBJECTIVES: To assess tolerance of esophageal pressure monitoring (EPM) among 5- to 13-year-old children during research polysomnography at study entry and again 1 year later. DESIGN: Prospective, observational study. SETTING: University-based sleep laboratory. PARTICIPANTS: Children scheduled for adenotonsillectomy or hernia repair. INTERVENTIONS: None; all operations were performed for clinical indications only. RESULTS: Forty-two of 336 families approached about the study declined to participate mainly to avoid EPM. The EPM was usually the main concern for the 47 adenotonsillectomy and 7 hernia-repair patients and families who did participate. Among 54 enrolled subjects, 51 allowed attempts at insertion of the esophageal catheter, and insertion was successful in all cases; 38 tolerated EPM for at least 2 hours; 33 maintained EPM for the entire night; and 36 had repeat EPM 1 year later for at least 2 hours. Reasons for EPM failure included crying at insertion, vomiting, pain, and inadvertent catheter removal during sleep. The children who tolerated EPM for at least 2 hours did not differ from other subjects based on age, sex, presence of a disruptive behavior disorder, anxiety, tonsil size, history of tonsillitis, or body mass index (all P > .05). CONCLUSIONS: The EPM was well tolerated in most school-aged volunteers, but many families did not volunteer, and some children were not able to endure EPM for at least 2 hours. Although better success might be achieved in clinical settings if EPM is medically indicated and not part of voluntary research, EPM is still likely to create significant concern, for children and parents, that must be weighed against anticipated benefits.
Adenoidectomy↗
Obstructive hypopneas in children and adolescents: normal values.
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Adolescent↗
Letter to the editor regarding our previous publication: "Secondary narcolepsy in children with brain tumors," SLEEP 2002; 25:435-439.
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Carrier Proteins↗
Pulse transit time as a measure of arousal and respiratory effort in children with sleep-disordered breathing.
The upper airway resistance syndrome (UARS) is associated with neurobehavioral morbidity in children. The diagnostic gold standard for UARS is esophageal manometry. However, this is invasive. Furthermore, upper airway obstructive events in sleeping children frequently terminate without visible electrocortical (EEG) arousal. The pulse transit time (PTT) is a noninvasive marker of blood pressure and, therefore, subcortical arousal. Blood pressure elevation, associated with respiratory arousal from sleep, results in a drop in the PTT. We hypothesized that: 1) the PTT is a more sensitive measure of respiratory arousal than EEG; and 2) the PTT arousal index can distinguish children with UARS from those with primary snoring. Polysomnography, including esophageal manometry and PTT, was measured prospectively in 24 symptomatic children and 10 normal controls. Apnea, hypopnea, and respiratory effort-related arousal events terminated in a PTT arousal 91%, 83%, and 80% of the time, and in an EEG arousal in 55%, 51%, and 43% (all p < 0.05), respectively. The PTT arousal index was significantly greater in children with UARS (6.8 events/h) than primary snoring (2.2 events/h) (p < 0.05). We conclude that, in children, PTT arousals are a more sensitive measure of obstructive events than visible EEG arousals.
Adult↗
Sleep disorders in children.
PURPOSE OF REVIEW: Childhood sleep disorders are one of the most prevalent complaints in the pediatrician's office. Infant sleep rhythm complaints from new mothers reach 46%, while childhood obstructive sleep apnea has a prevalence of 2% and adolescent insomnia with daily consequences surpasses that percentage. RECENT FINDINGS: Each sleep disorder must be considered in context of age, as age influences the presentation and impact on the developing child or adolescent. For example, sleep-disordered breathing resulting in adult sleepiness can contribute to death in infants. The symptoms of narcolepsy are often masked until after adolescence, resulting in psychologically costly misdiagnoses. SUMMARY: There are no outcome studies that track the long-term consequences of pediatric sleep disorders or their contribution to adult sleep problems, but this is an area of increasing research interest. This review assesses the most recent literature on pediatric sleep disorders from May 1, 2002, until April 30, 2003.
Adolescent↗
Secondary narcolepsy in children with brain tumors.
We report two cases of children with disabling daytime sleepiness associated with suprasellar tumors and hypothalamic obesity. Multiple sleep latency testing demonstrated features consistent with severe narcolepsy, with sleep latencies of 0.25 and 0.75 minutes, and REM latencies of 2.1 and 1.5 minutes, respectively. An additional patient with hypothalamic damage secondary to a brain tumor, who was thought to be in a vegetative state, had features of narcolepsy on polysomnography. All children responded well to treatment with stimulants. We speculate that secondary narcolepsy associated with hypothalamic tumors is due to damage or loss of hypothalamic hypocretin-containing neurons. In view of the good response to treatment, we recommend that all children with excessive daytime sleepiness and hypothalamic damage be evaluated for narcolepsy.
Adolescent↗
Body position and obstructive sleep apnea in children.
STUDY OBJECTIVES: In adults, sleep apnea is worse when the patient is in the supine position. However, the relationship between sleep position and obstructive apnea in children is unknown. The objective of this study was to evaluate the relationship between obstructive apnea and body position during sleep in children. DESIGN: Retrospective analysis of the relationship between body position and obstructive apnea in obese and non-obese children. SETTING: Tertiary care pediatric sleep center. PATIENTS: Otherwise healthy children, aged 1-10 years, undergoing polysomnography for suspected obstructive sleep apnea syndrome. Obese and non-obese children were evaluated separately. INTERVENTIONS: Retrospective review of the relationship between sleep position and obstructive apnea during polysomnography. MEASUREMENTS AND RESULTS: Eighty polysomnograms from 56 non-obese and 24 obese children were analyzed. Body position was determined by a sensor during polysomnography, and confirmed by review of videotapes. Children had a lower obstructive apnea hypopnea index when supine vs. prone, and shorter apneas when supine then when on their side. There was no difference in apnea duration between the supine and prone positions. Obese and non-obese children showed similar positional changes. CONCLUSIONS: Children with obstructive sleep apnea, in contrast to adults, breathe best when in the supine position.
Child, Preschool↗
Recurrent pneumothoraces associated with nocturnal noninvasive ventilation in a patient with muscular dystrophy.
Although a common complication of mechanical ventilation in acute respiratory failure, spontaneous pneumothorax has been rarely reported among patients on chronic, intermittent, noninvasive positive pressure support. We report the first case of recurrent pneumothoraces associated with nocturnal bilevel positive airway pressure ventilation via a nasal mask.A 26-year old man with chronic respiratory failure secondary to an unclassified neuromuscular condition suffered four separate episodes of spontaneous pneumothorax over a 12-month period. Two episodes occurred while he was asleep on bilevel positive airway pressure support. He was found to have numerous subpleural blebs, and we propose a mechanism for their development. Following open pleurodesis and blebectomy, the patient has not had another pneumothorax. Given the increasing utilization of chronic nocturnal bilevel positive airway pressure ventilation, we suggest that healthcare providers and patients be made aware of this potentially life-threatening complication.
Adult↗
Night-to-night variability of polysomnography in children with suspected obstructive sleep apnea.
OBJECTIVES: To determine whether a single polysomnographic night was a valid measure of obstructive sleep apnea syndrome (OSAS) in children with symptoms of sleep-disordered breathing. STUDY DESIGN: The night-to-night variability of respiratory and sleep parameters was measured prospectively in 30 snoring children aged 1.6 to 11.3 years (mean +/- SD, 4.1 +/- 2) by using 2 nocturnal polysomnograms performed 7 to 27 days apart (14 +/- 5 days). RESULTS: The mean of the respiratory variables including apnea index, apnea/hypopnea index, arterial oxygen saturation, and end-tidal partial pressure of carbon dioxide were not significantly different from night to night. Among the sleep parameters, there was no significant night-to-night difference in sleep efficiency, arousal index, percent rapid eye movement, or percent of slow wave sleep. Only the percentage of stage 2 was significantly different between the nights. The polysomnographic clinical diagnosis remained the same on both nights for all children, although the disease severity differed slightly in 2 patients. CONCLUSIONS: There is little clinically significant night-to-night variability in pediatric polysomnography, and no first-night effect. These data suggest that a single polysomnographic night is an adequate measure of the OSAS in children with symptoms of sleep-disordered breathing.
Child↗
Upper airway collapsibility during sleep in upper airway resistance syndrome.
STUDY OBJECTIVES: To compare upper airway collapsibility during sleep between patients with upper airway resistance syndrome (UARS), normal subjects, and patients with obstructive sleep apnea/hypopnea syndrome (OSA/H). DESIGN: A descriptive study of a series of clinical patients and a cohort of normal control subjects. SETTING: Two academic sleep-disorders centers. PATIENTS OR PARTICIPANTS: One hundred six adult patients with sleep-disordered breathing evaluated at the SUNY Sleep Disorders Center-Medicine and 12 adult subjects without habitual snoring or daytime sleepiness and with an apnea/hypopnea index (AHI) < 5/h evaluated at the Johns Hopkins Pediatric Sleep Disorders Center. INTERVENTIONS: All subjects underwent full-night polysomnography and a determination of pharyngeal critical pressure (Pcrit). All patients had a determination of therapeutic level of nasal continuous positive airway pressure (Ptherapeutic). MEASUREMENTS AND RESULTS: The mean +/- SD Pcrit of the 12 normal subjects was - 15.4 +/- 6.1 cm H(2)O; the mean Pcrit of the 22 UARS patients was - 4.0 +/- 2.1 cm H(2)O; the mean Pcrit of the 37 patients with mild-to-moderate OSA/H (AHI > or = 10/h and < 40/h) was - 1.6 +/- 2.6 cm H(2)O; and the mean Pcrit of the 47 patients with moderate-to-severe OSA/H (AHI > or = 40/h) was 2.4 +/- 2.8 cm H(2)O. The Pcrit of each group differed from that of all other groups (p < 0.01). The mean Ptherapeutic of patients with UARS was 6.9 +/- 1.7 cm H(2)O; the mean Ptherapeutic of patients with mild-to moderate OSA/H was 7.9 +/- 1.9 cm H(2)O (p = 0.08 compared with the Ptherapeutic of UARS patients); and the mean Ptherapeutic of patients with moderate-to severe OSA/H was 10.5 +/- 2.4 cm H(2)O (p < 0.0001 compared to each of the other patient groups). CONCLUSION: UARS is a syndrome of increased upper airway collapsibility during sleep. The upper airway collapsibility during sleep of patients with UARS is intermediate between that of normal subjects and that of patients with mild-to moderate OSA/H.
Adult↗