Assessment and Management of Sleep Disturbances in Atopic Dermatitis: A Review.

Atopic dermatitis (AD) is a chronic burdensome inflammatory skin disease with well-established cutaneous and systemic comorbidities and disease burden. AD particularly has profound impacts on sleep in individuals of all ages. Sleep disturbances (SDs) affect 6.2% of school-age children and 33-87.1% of adults with AD. This narrative review addresses the burden of SD in AD patients, as well as biological mechanisms of SD in AD, including biological clocks influencing sleep, inflammation, and behavior. Approaches for early detection, diagnosis, objective quantification, patient education, and management are reviewed. It is imperative to break the itch-scratch cycle to reduce SDs and improve quality of life in individuals with AD.

Association of obstructive sleep apnea and total sleep time with health-related quality of life in children undergoing a routine polysomnography: a PROMIS approach.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) negatively impacts health-related quality of life (HR-QoL) in adults, but few pediatric studies have explored this relationship or the relationships between HR-QoL domains. METHODS: Patients aged 8-17 years visiting the sleep laboratory from July 2019 to January 2020 for overnight polysomnography participated in the study. Controls seen for problems other than sleep disturbance were recruited from Department of Pediatrics outpatient clinics. HR-QoL was assessed by Patient-Reported Outcome Measure Information System (PROMIS) profile questionnaires, version 2.0. Statistical analysis was conducted using R 3.6.0 (R Foundation for Statistical Computing, Vienna, Austria). RESULTS: One hundred twenty-two patients were included in the final analysis. Sixty-four patients were males (52.4%). Twenty-nine (23.8%) had mild OSA, 8 (6.6%) had moderate OSA, 17 (13.9%) had severe OSA, 46 (37.7%) were without OSA, and 22 (18.0%) were controls. Patients referred for polysomnography had lower physical function mobility compared with controls (P = .03). Increased OSA severity was linearly associated with a decrease in physical function mobility (P = .008). Correlation analysis revealed that physical function mobility was positively associated with total sleep time (P = .02) and negatively associated with apnea-hypopnea index (P = .01). Age was positively associated with fatigue (P = .02) and negatively associated with deep sleep (P < .001). Regression analysis revealed that physical function mobility was positively associated with total sleep time (P = .02) and negatively associated with apnea-hypopnea index (P = .04) after controlling for age, sex, and number of arousals. CONCLUSIONS: OSA and total sleep time were associated with problems with physical function mobility after adjusting for age, sex, and number of arousals. CITATION: Xu S, Turakhia S, Miller M, et al. Association of obstructive sleep apnea and total sleep time with health-related quality of life in children undergoing a routine polysomnography: a PROMIS approach. J Clin Sleep Med. 2022;18(3):801-808.

Cervical spinal cord compression in infants with achondroplasia: should neuroimaging be routine?

PURPOSE: To examine results of magnetic resonance imaging (MRI), polysomnograms (PSG), and patient outcomes in patients with achondroplasia in light of recent screening recommendations for infants with achondroplasia. METHODS: We reviewed medical records of 49 patients with achondroplasia followed at our institution between September 1997 and January 2017, including physical exams, MRIs, PSGs (when available), and surgical histories. Appropriate PSG data were available for 39 of these patients. RESULTS: Twenty-seven of 49 patients had cervical cord compression on MRI, and 20 of those patients required surgery. Central apnea was detected in 2/23 patients with cervical cord compression in whom PSG data was available. Physical exam revealed depressed deep-tendon reflexes in two patients with cord compression and one patient without cord compression. Besides hypotonia in some, the neurological exams of these patients were unremarkable. CONCLUSIONS: Cervical cord compression is a common occurrence in infants with achondroplasia and necessitates surgical intervention in some patients. Physical exam and PSG are poor predictors of the presence of cord compression or the need for surgery. All infants with achondroplasia should have MRIs of the craniocervical junction in the first 6 months of life.

Validation of Polyvinylidene Fluoride Impedance Sensor for Respiratory Event Classification during Polysomnography in Children.

STUDY OBJECTIVES: Polysomnography is the gold standard for diagnosis and characterization of severity of sleep-disordered breathing. Accuracy and reliability of the technology used are critical to the integrity of the study's interpretation. Strict criteria for obstructive sleep apnea in children are lacking and diagnosis often requires consideration of frequency of respiratory events in addition to other measures. Current American Academy of Sleep Medicine recommendations for pediatric patients includes use of respiratory inductance plethysmography (RIP) belts, whereas polyvinylidene fluoride (PVDF) belts are currently only acceptable for use in adults. We hypothesized that PVDF belts would be equally effective as RIP belts for detection of respiratory effort and events in children. METHODS: Children ages 2-17 y were recruited from a large pediatric tertiary referral center after obtaining consent for participation. Fifty subjects were recruited (average age, 7.8 y). Clinically relevant limits of agreement were predetermined to be a difference in total count of obstructive or central apneas or hypopneas of ± 5 events. RESULTS: Scoring of respiratory events was not significantly different by belt type based on Bland-Altman plots of total apnea-hypopnea index and obstructive apneas. Obstructive hypopneas scoring ranged beyond our clinical limit of agreement. Findings in obese subjects were consistent with the larger sample with the exception of an increase in outliers. Artifact amount was comparable (RIP 10.9% ± 22.5% and PVDF 10.5% ± 19.5%). CONCLUSIONS: Based on these findings, PVDF belts appear to be as effective as RIP belts in detection of respiratory effort and events in children. COMMENTARY: A commentary on this article appears in this issue on page 159.

Nocturnal eczema: Review of sleep and circadian rhythms in children with atopic dermatitis and future research directions.

Children with atopic dermatitis (AD) experience significant sleep disruption, and clinically, the disease is noted to worsen in a circadian manner at night. Epidemiologic findings highlight many negative consequences of AD, such as impaired linear growth, which is uniquely related to disturbed sleep. Clinical guidelines currently recommend assessing sleep in patients with AD as a crucial parameter of disease control with appropriate treatment. In this review we describe our current understanding of the roles of sleep cycles and circadian rhythms in the nighttime exacerbation of AD (nocturnal eczema). We present a schematic to explain the mechanism of nocturnal eczema. Treatment options for sleep disturbance and future directions for research are discussed in the context of AD.

Mallampati score and pediatric obstructive sleep apnea.

RATIONALE: Pediatric obstructive sleep apnea (OSA) is common, and a delay in diagnosis can lead to significant morbidity. Polysomnography (PSG) is the gold standard for the diagnosis of OSA. However, difficulty accessing PSG due to the relative shortage of sleep centers with pediatric expertise can lead to a delay in the diagnosis and management of OSA. OBJECTIVES: To assess the utility of Mallampati score (sitting and supine) in predicting the presence and severity of OSA in children. METHODS: A retrospective study of 158 children from a single pediatric sleep center. All patients had a PSG and a physical examination documenting Mallampati score. The Mallampati score, tonsillar size, age, sex, and apnea hypopnea index (AHI) were analyzed. Odds ratio of having pediatric OSA (AHI > 1) with increase in Mallampati score and tonsillar size were calculated. MEASUREMENTS AND MAIN RESULTS: A significant correlation was found between Mallampati score, tonsillar size, and AHI. For every point increase in the Mallampati score, the odds ratio of having OSA increased by more than 6-fold. For every point increase in tonsillar size, the odds ratio of having OSA increased by more than 2-fold. CONCLUSIONS: Mallampati score and tonsillar size are independent predictors of OSA. Oral examination including Mallampati score and tonsillar size should be considered when evaluating a patient for OSA. They can be used to prioritize children who may need PSG.

Metabolic alterations in children with obstructive sleep apnea.

IMPORTANCE: The incidence of obesity is rising in the United States and has been linked to Obstructive Sleep Apnea (OSA) even in young children. Understanding the role that obesity and OSA play in alterations in metabolic variables that can lead to serious health issues is essential to the care and counseling of affected children. OBJECTIVES: To evaluate the association of alterations in metabolic variables, including insulin resistance, to OSA in young, obese children. DESIGN: Retrospective, case-control series. SETTING: Tertiary care children's hospital. PARTICIPANTS: Obese children aged 2-12 years who had undergone overnight polysomography and routine laboratory testing for lipid levels, fasting glucose, and insulin from January 1, 2006 to December 31, 2012 were identified from a TransMed Bio-Integration Suite and Epic's clarity database search. RESULTS: A total of 76 patients were included for analysis. Forty-three (56.6%) were male, and the mean age was 8.3±2.5 years (range, 2.4-11.9 years). The mean body mass index (BMI) z score was 2.8±0.75 (range, 1.7-6.3), and all patients were obese (BMI z score>95th percentile). Twenty two patients (28.9%) had an apnea-hypopnea index (AHI) <1/h (no OSA), 27 (35.5%) an AHI≥1<5/h, 12 (15.8%) had an AHI ≥5<9.99/h, and 15 (19.7%) had an AHI≥10/h. There was no significant difference in total cholesterol, triglycerides, high and low density lipoprotein levels, systolic and diastolic blood pressure in those patients with or without OSA. Fasting insulin, blood glucose, and homeostasis model assessment (HOMA) were significantly higher in patients with OSA compared to those with no OSA (p<0.01). AHI correlated to alterations in insulin as well as glucose homeostasis on multivariate analysis. Results from logistic regression analysis showed that fasting insulin (p<0.01), and HOMA (p<0.01) predicted severe OSA independent of age, gender, and BMI z score in these patients. CONCLUSION: Metabolic alterations in glucose and insulin levels, known to be associated with obesity and increased risk for cardiovascular disease, appear to relate to the severity of OSA in young children.

Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder.

The clinical spectrum of sleep disorders in children is broad, ranging from primary snoring and obstructive sleep apnea (OSA) syndrome to complex sleep-related behaviors and movement disorders. Although snoring and OSA typically receive significant attention and discussion, other biologically based sleep disorders are as common, if not more common, in children. A general pediatrician is frequently presented with the complaint of sleep talking, sleep walking, or abnormal movements during sleep. Even more alarming is the presentation of the child suddenly and explosively screaming during sleep. Such complaints fall under the category of parasomnias. Exclusive to sleep and wake-to-sleep transitions, these parasomnias include arousals with abnormal motor, behavioral, autonomic, or sensory symptoms. Parasomnias can be noticeably dissimilar in clinical manifestations, but most share biologic characteristics. Three parasomnias associated with loud vocalizations associated with sleep that can present to general practitioners include sleep terrors, nightmares, and rapid eye movement sleep behavior disorder (RBD). Although usually benign, these sleep disorders can be disruptive and even potentially dangerous to the patient and can often be threatening to quality of life. In this article, we describe the clinical features of some of these disorders and how to differentiate between their alarming presentations.

Sleep related expiratory obstructive apnea in children.

STUDY OBJECTIVES: We describe the respiratory, cardiac, and sleep-related characteristics of two types of sleep-related respiratory pauses in children that can fulfill current criteria of pathological apnea, but often seem to be benign: prolonged expiratory apnea (PEA) and post-sigh central apnea (PSCA). METHODS: All outpatient comprehensive overnight polysomnography completed on children without significant underlying medical conditions completed during an 18-month period were retrospectively reviewed for the presence of augmented breaths followed by a respiratory pause. Events were identified as a PEA or PSCA based on characteristic features. Physiologic parameters associated with the respiratory events were recorded and compared. RESULTS: Fifty-seven (29 PEA and 28 PEA) events were identified in 17 patients (8.5 ± 3.5 years old). Median durations of PEA and PSCA were not significantly different. For both PEA and PSCA, average heart rate (HR) during the augmented breath before the respiratory pause differed from lowest instantaneous HR during the first half of the pause. When compared to each other, the lowest instantaneous HR recorded in the first half of PEA was lower than that for PSCA (63.9 [59.41-68.3] vs 66.75 [61.7-80.75]) beats per min, p = 0.03. No PEA or PSCA event was associated with an oxygen desaturation more than 3% from baseline. CONCLUSION: PEA and PSCA have stereotypic HR changes and resemble pathologic apneas but appear to be benign. Clinical significance of PEA and PSCA is yet to be determined. Consistent recognition of the events is required, given their frequency of occurrence and potential for misclassification.

Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children.

OBJECTIVE: This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders. PURPOSE: There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology--Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. RESULTS: The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.

Sleep abnormalities in children and adolescents with endocrine and metabolic disorders.

There is a complex interplay between sleep, metabolism and the function of the endocrine system. A number of endocrine systems are modulated by either the homeostatic drive to sleep, or by the function of the circadian system. As a result, changes in sleep duration and quality have reciprocal effects on hormone secretion and metabolism. In return, sleep disturbance can result from secondary consequences of abnormal endocrine and metabolic function. Inborn errors of metabolism have been demonstrated to have varying effects. The manifestations of lysosomal storage disorders are primarily dependent on the location of substance deposition; resultant effects include disruption of central respiratory control and changes in airway configuration. Neurologic consequences of these disorders include cases of epileptiform discharges in sleep and case reports of non-narcolepsy associated cataplexy.

Development and results of the first ABMS subspecialty Certification Examination in Sleep Medicine.

In November 2007, the first Certification Examination in Sleep Medicine was administered to 1,882 candidates under the cosponsorship of five member boards of the American Board of Medical Specialties (ABMS)--the American Board of Internal Medicine, the American Board of Family Medicine, the American Board of Otolaryngology, the American Board of Pediatrics, and the American Board of Psychiatry and Neurology. The pass rate was 73%. This paper chronicles the history of a certification examination in Sleep Medicine and the development of this new ABMS examination.

The scoring of arousal in sleep: reliability, validity, and alternatives.

The reliability and validity of EEG arousals and other types of arousal are reviewed. Brief arousals during sleep had been observed for many years, but the evolution of sleep medicine in the 1980s directed new attention to these events. Early studies at that time in animals and humans linked brief EEG arousals and associated fragmentation of sleep to daytime sleepiness and degraded performance. Increasing interest in scoring of EEG arousals led the ASDA to publish a scoring manual in 1992. The current review summarizes numerous studies that have examined scoring reliability for these EEG arousals. Validity of EEG arousals was explored by review of studies that empirically varied arousals and found deficits similar to those found after total sleep deprivation depending upon the rate and extent of sleep fragmentation. Additional data from patients with clinical sleep disorders prior to and after effective treatment has also shown a continuing relationship between reduction in pathology-related arousals and improved sleep and daytime function. Finally, many suggestions have been made to refine arousal scoring to include additional elements (e.g., CAP), change the time frame, or focus on other physiological responses such as heart rate or blood pressure changes. Evidence to support the reliability and validity of these measures is presented. It was concluded that the scoring of EEG arousals has added much to our understanding of the sleep process but that significant work on the neurophysiology of arousal needs to be done. Additional refinement of arousal scoring will provide improved insight into sleep pathology and recovery.