Efficacy of Melatonin for Inducing Sleep in Pediatric Electroencephalogram Recordings: A Single-Blind Randomized Controlled Pilot Study.

Objective To compare the efficacy of melatonin, melatonin with sleep deprivation, and chloral hydrate with sleep deprivation on sleep induction in Asian children. Methods: For this randomized single-blind controlled trial, we recruited 45 children aged 1-5 years and older who were not cooperative on electroencephalogram (EEG) recordings, randomly allocated to three groups: melatonin (group A), melatonin and sleep deprivation (group B), or chloral hydrate and sleep deprivation (group C). Between-group comparisons were performed using the Kruskal-Wallis and Mann-Whitney U tests. Results: Stage II sleep was achieved in 92.8%, 100%, and 100% of participants in groups A, B, and C, respectively. Sleep latency was significantly shorter in Group C than in Groups A (p = .022) and B (p = .027), while Group C had better sleep efficacy than Groups A (p = .02) and B (p = .04). Conclusion: Melatonin with sleep deprivation is less effective at inducing sleep than combined chloralhydrate and sleep deprivation.

Sleep-related rhythmic movement disorder in children: a mini-review.

Sleep-related rhythmic movement disorder (SRRMD) occurs in both infants and children. This disorder rarely occurs or persists in adolescence or adulthood. Rhythmic movement during sleep in children is often asymptomatic and considered a benign condition. It is classified as SRRMD when movement significantly disrupts sleep, results in daytime functional impairment, or causes self-inflicted body injury. Several studies have demonstrated that SRRMD occurs in all sleep stages. Few studies have investigated rhythmic movement disorder (RMD) in children. SRRMD is a clinical diagnosis supported by home video recordings. When the clinical history is insufficient to provide a definitive diagnosis of SRRMD, and other sleep-related conditions or seizure disorders are suspected, video-polysomnography is indicated. There are currently no clinical guidelines for treating SRRMD.

Sleep impairments and quality of life in Thai adolescents with systemic lupus erythematosus.

PURPOSE: Adolescents with systemic lupus erythematosus (SLE) are susceptible to sleep impairments. We aimed to determine the prevalence and factors related to sleep impairments, and the associations of sleep impairments with health-related quality of life (HRQOL) in Thai adolescents with SLE. METHODS: Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire for Adolescents (PHQA), and Pediatric Quality of Life Inventory™ 4.0 Core Scales were administered to 57 participants with SLE aged 13-18 years to evaluate sleep, depression, and HRQOL, respectively. Participants were divided into "good sleep" (PSQI scores <5) and "poor sleep" groups (PSQI scores ≥5). Participants with body mass index (BMI) >23 kg/m2 were classified into the high BMI group. FINDINGS: Eighteen participants (31.6%) were in the poor sleep group. High BMI and PHQA scores were associated with sleep impairments with the odds ratio of 8.00 (95% CI 1.50-42.64; p = 0.02), and 1.25 (95% CI 1.01-1.54; p = 0.04), respectively. In terms of HRQOL, adolescents with SLE had the highest scores in social functioning and the lowest scores in school functioning. Good sleepers had better scores than poor sleepers across all sub-categories except for social functioning, and the difference was significant in emotional functioning (90% (IQR 75-100) vs. 70% (IQR 55-85); p = 0.03). CONCLUSIONS: A substantial number of adolescents with SLE had sleep impairments, which decreased HRQOL, particularly in emotional functioning. Sleep impairments were associated with obesity and depression. IMPLICATIONS: Proactive management in addressing weight, mood, and sleep problems should be included in the multidisciplinary care of adolescents with SLE to improve their health and well-being.

Dengue infection triggered immune mediated necrotizing myopathy in children: a case report and literature review.

BACKGROUND: Immune-mediated necrotizing myopathy (IMNM) is a subgroup of idiopathic inflammatory myopathies manifesting with progressive weakness, elevated serum creatine kinase (CK) levels, and necrotizing myopathic features on muscle biopsy. There is a paucity of data on the clinical presentation of IMNM in children. We report a paediatric patient who developed anti-3-hydroxy-3-methylglutaryl-CoA reductase (anti-HMGCR)-positive necrotizing myopathy after recent dengue infection. CASE PRESENTATION: A previously healthy 9-year-old boy presented with acute proximal muscle weakness after recovery from dengue infection. Five days after the fever subsided, he could not stand from a squatting position. He denied having skin rash, arthritis, or other systemic features. He had marked elevation of CK level of 30,833 mg/dL and was put on steroid therapy. The patient initially responded to oral prednisolone, however the weakness persisted and muscle enzymes increased as steroids were decreased. He was then referred to our hospital for further assessment. Subsequent investigation revealed anti-HMGCR positivity along with specific histopathological findings consistent with IMNM. The patient was treated with six cycles of intravenous immunoglobulin (IVIG) monthly, then followed by a gradual taper of prednisolone and oral methotrexate weekly with complete recovery in motor power. CONCLUSIONS: Our report presents a child with clinical manifestations of IMNM which can be categorized as acute onset of muscle weakness following dengue infection. Two key points supporting a diagnosis in this case are clinical response after immunosuppressive therapy and absence of rashes found in juvenile dermatomyositis.

Caregiver perceptions of sleep problems and desired areas of change in young children.

OBJECTIVE: To explore the prevalence of and relationship between caregiver-reported sleep problems and sleep-related desired areas of change in young children (0-36 months) in a multinational sample. METHODS: Caregivers (96.5% mothers) of 2219 young children (birth to 3 years; M = 13.7 mos; 49.8% male) completed an online survey including an abbreviated Brief Infant Sleep Questionnaire-Revised (BISQ-R) and questions about desired areas of change regarding their child's sleep. Data were collected in six countries (Indonesia, Japan, New Zealand, Singapore, Thailand, and United States). RESULTS: Overall, 35% of caregivers reported a sleep problem and nearly all (96%) indicated a desired area of change, with 76% endorsing changes in 3 or more categories (bedtime/falling asleep, overnight, morning, and naps). Desiring a change in their child's sleep was universal across age group and country, with those perceiving a sleep problem more likely to endorse an area of change than those without a sleep problem. Overall, the top change categories were bedtime (80%), naps (74%), and overnight (67%). Top specific areas of change related to sleeping for longer stretches, waking up later in the morning, and having an earlier bedtime. CONCLUSIONS: Although one-third of caregivers perceived that their child had a sleep problem, nearly all caregivers identified desired areas of change related to their child's sleep, across the first three years of life and all countries. Sleep education, such as normalizing sleep challenges that are developmentally appropriate, is warranted for all families of young children, regardless of whether sleep problems are endorsed.

Insomnia: Focus on Children.

Pediatric insomnia is relatively common in general pediatric practice and has an even higher prevalence in those with neurodevelopmental disorders. Detailed sleep history, sleep diary, associated daytime symptoms, and factors contributing to insomnia should be thoroughly evaluated to determine the diagnosis and further plan for management. Behavioral management should be the first step for the management of insomnia in children and adolescents. Although there is no FDA-approved medication for the treatment of insomnia in children, some medications may be prescribed with caution, particularly if behavioral management is not effective, in selected conditions, and if the benefits outweigh the risks.

Neurocysticercosis in Children.

Neurocysticercosis is one of the most common parasitic infections in the central nervous system in children. The usual clinical manifestation is new-onset focal seizure. However, there are other multiple clinical manifestations, such as increased intracranial pressure, meningoencephalitis, spinal cord syndrome, and blindness. The diagnosis needs high index of suspicion with clinical history, physical examination, neuroimaging, and immunologic studies. Recent advances in neuroimaging and serology facilitate the accurate diagnosis. Management of neurocysticercosis should focus on critical symptoms first, such as the use of antiepileptic drugs and medical or surgical therapy for increased intracranial pressure.

Incidence / predictors of pediatric obstructive sleep apnea with normal oximetry.

BACKGROUND: The polysomnogram (PSG) is the "gold standard" for diagnosing obstructive sleep apnea (OSA). However, nocturnal oximetry is a practical screening tool for children with adenotonsillar hypertrophy (ATH). This study aimed to investigate the incidence of, and predictive factors for, OSA in children with ATH and normal / inconclusive overnight oximetry. METHODS: The prospective study enrolled children aged 3-15 years with ATH and normal / inconclusive overnight oximetry. All participants underwent full-night PSG. To evaluate the predictors of OSA, we used logistic regression analysis, including sex, history of allergic rhinitis, body mass index z-score, neck circumference-height ratio, and polysomnographic parameters (obstructive apnea-hypopnea index (OAHI), nadir oxygen saturation (SpO2), peak end-tidal CO2 , and arousal index). RESULTS: The participants were 189 children; 167 (88%) were diagnosed with OSA by PSG. A history of allergic rhinitis (P = 0.033), and the PSG findings for nadir SpO2 (P = 0.027) and arousal index (P = <0.001) predicted the diagnosis of OSA. We divided patients with OSA into two groups (mild versus moderate to severe OSA). Patients with OAHI ≥5/h were defined as having moderate-to-severe OSA. No clinical factors significantly predicted OAHI ≥5. Of the 189 participants, 58 children (31%) were diagnosed with severe OSA (OAHI ≥10). The only PSG factor that predicted severe OSA was the arousal index (P < 0.001). CONCLUSIONS: The observed incidence of OSA in children aged 3-15 years with ATH and normal/inconclusive overnight oximetry was very high. A history of allergic rhinitis may help to triage the patients. The arousal index was a predictor of pediatric OSA.

Effect of Mozart K.448 on interictal epileptiform discharges in children with epilepsy: A randomized controlled pilot study.

BACKGROUND: Epilepsy is a common pediatric neurologic disease in Thailand. However, the mainstay antiepileptic pharmacotherapies can induce severe side effects. While the benefit of playing Mozart K.448 music has been studied as an alternative, supplementary, nonpharmacologic treatment for epilepsy, the literature features limited few randomized controlled trial studies of children. OBJECTIVE: We aimed to study the effect of Mozart K.448 for two pianos on interictal epileptiform discharges (IEDs), quantitative electroencephalogram (qEEG), and heart rate variability (HRV) in patients with epilepsy. METHODS: We employed a single-blinded randomized trial design with a placebo control. The treatment group listened to the first 8 min of Mozart K.448 for two pianos during EEG recording. The control group underwent an EEG recording of the same duration in a quiet environment. Interictal epileptiform discharges were manually counted for 8 min before, during, and after the song was plated. Quantitative electroencephalogram and HRV were analyzed in each period. RESULT: A total of 32 patients aged 0-18 years were enrolled. There were 12 patients in the music group and 14 patients in the control group; 67% of the patients in the former exhibited significantly decreased IEDs while listening to the music compared with 42% of the patients in the quiet group (RR [Relative Risk Reduction]: 0.72, p-value: <0.001, 95% confidence interval [CI]: 0.69-0.74). During music exposure, qEEG demonstrated an increase in the delta/theta to alpha/beta ratio relative to that of controls (median in music: +3% and control: -6%, p-value: 0.520). Heart rate variability analyses showed a decrease in the ratio of low frequency to high frequency (LF/HF), which represents parasympathetic activity during music exposure (decrease of 34%, p-value: 0.382). CONCLUSION: The present study showed that Mozart K.448 reduced the number of IEDs in children with epilepsy and that Mozart K.448 could enhance parasympathetic activity. However, possibly because of the small study population, statistical significance was not reached. Our study revealed the considerable potential of music in the treatment of pediatric epilepsy.

Unremitting diarrhoea in a girl diagnosed anti-N-methyl-D-aspartate-receptor encephalitis: A case report.

BACKGROUND: Asymptomatic cytomegalovirus (CMV) infection is common in children; in contrast, in children with a weakened immune system, invasive CMV can occur. This is the first case report of a severe manifestation of CMV esophago-enterocolitis in a girl diagnosed with anti-N-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis who received only a moderate dose of corticosteroid therapy. CASE SUMMARY: A 12-year-old-Thai girl presented with acute behavioural change and headache for 6 d. Electroencephalogram and positivity for NMDAR autoantibodies were compatible with anti-NMDAR encephalitis. Hence, she received pulse methylprednisolone 10 mg/kg per day for 4 d and continued with prednisolone 1.2 mg/kg per day. On day 42 of corticosteroid therapy, she developed unremitting vomiting and diarrhoea. Endoscopy showed multiple ulcers and erythaematous mucosa along the gastrointestinal tract. Tissue CMV viral load and viral-infected cells confirmed CMV esophago-enterocolitis. Therefore, the patient received ganciclovir 5 mg/kg per dose every 12 h for 3 wk and then 5 mg/kg per dose once daily for 3 wk. Unremitting diarrhoea slowly improved from stool output 1-4 L per day to 1-2 L per day after 3 wk of treatment. Pulse methylprednisolone 20 mg/kg for 5 d was initiated and continued with prednisolone 1 mg/kg per day. After this repeated pulse methylprednisolone treatment, surprisingly, diarrhoea subsided. Immunologic work-up was performed to rule out underlying immune deficiency with unremarkable results. CONCLUSION: Unremitting diarrhoea from CMV esophago-enterocolitis subsided with antiviral and methylprednisolone therapy, implying the immune and NMDAR dysregulation in anti-NMDAR encephalitis.

Behavioral problems in perinatally HIV-infected young children with early antiretroviral therapy and HIV-exposed uninfected young children: prevalence and associated factors.

Although behavioral problems have been observed in children and adolescents with perinatally-acquired HIV infection (PHIV), behavioral information regarding younger PHIV children are scarce. This study aims to identify behavioral problems in PHIV and HIV-exposed uninfected (HEU) children and to evaluate factors associated with such problems. A prospective study of PHIV and HEU young children was conducted. Behavioral problems were assessed with the Child Behavior Checklist (CBCL) at baseline and 12 months later among children aged 18-60 months old. The Patient Health Questionnaire-9 and the Parenting Styles & Dimensions Questionnaire identified primary caregivers' symptoms of depression and parenting styles, respectively, at both visits. Chi-squared analyses were used to compare the prevalence of behavioral problems between groups. Factors associated with behavioral problems were analyzed by logistic regression. From 2016 to 2017, 121 children (41 PHIV and 80 HEU) were assessed with no significant differences in prevalence of Total, Internalizing, Externalizing, and Syndrome scales problems between PHIV and HEU at both visits (p > 0.5). Primary caregivers' depression and lower education in addition to authoritarian and permissive parenting styles were significantly related to child behavioral problems. Family-centered care for families affected by HIV, including positive parenting promotion, mental health care, and education are warranted.

Clinical manifestations, treatment outcomes, and prognostic factors of pediatric anti-NMDAR encephalitis in tertiary care hospitals: A multicenter retrospective/prospective cohort study.

OBJECTIVE: Anti-NMDAR encephalitis is an acute autoimmune neurological disorder that is increasingly recognized in pediatric populations. Several studies of the disorder have been conducted worldwide but there are few publications in Thailand. Here, we describe the clinical manifestations, treatment outcomes, and prognostic factors in children with anti-NMDAR encephalitis. METHODS: Between January 2007 and September 2017, we conducted a retrospective/prospective cohort study of children diagnosed with anti-NMDAR encephalitis from three tertiary care hospitals in Thailand: King Chulalongkorn Memorial Hospital, Chonburi Hospital, and Prapokklao Hospital. We assessed the Modified Rankin Score (mRS) score for each participant to measure severity of disease and treatment outcome at baseline, 12, and 24 months. RESULTS: We recruited 14 participants (1-13 years with median age 8.4 years). Participants were followed up for a median of 20.5 months. Clinical manifestations included behavioral dysfunction (100%), movement disorder (93%), speech disorder (79%), sleep disorder (79%), and seizures (79%). All patients received first-line immunotherapy (corticosteroids: 100%, intravenous immunoglobulin: 79%, plasma exchange: 21%). Second-line immunotherapy (cyclophosphamide) was administered to 57% of patients. During the first 12 months, 8 patients (62%) achieved a good outcome (mRS ≤ 2). At 24 months, 9 patients (81%) had achieved a good outcome. Altered consciousness and central hypoventilation were predictors of poor outcome. (p < 0.05). CONCLUSIONS: We observed similar clinical manifestation of anti-NMDAR encephalitis in Thai children to those reported in other countries. Furthermore, the percentage of patients with good outcomes in our study was comparable with previous studies. Further studies are required to investigate other populations in other regions of Thailand.

Prognostic value of continuous electroencephalography in children undergoing therapeutic hypothermia after cardiac arrest: A pilot study.

OBJECTIVE: To determine the prognostic value of continuous electroencephalography (EEG) in children undergoing therapeutic hypothermia after cardiac arrest. METHOD: We retrospectively reviewed medical records and continuous EEG of all patients undergoing therapeutic hypothermia after cardiac arrest from November 2013 to September 2016. Demographic, clinical data and immediate complications were collected. Characteristics of continuous EEG including EEG background, time to normal trace (TTNT) and electrographic seizures were reviewed by investigators. Cerebral performance category scales at 6 months' follow up were evaluated and divided into good (grade 1-2) and poor (grade 3-5) outcome groups. RESULT: Six patients were included (two boys and four girls) with median age of 19.5 months (range13-128 months). Five patients (83.3%) presented with cardiac arrest from near-drowning and one patient with underlying acute lymphocytic leukemia presented an in-hospital cardiac arrest. Initial EKG rhythm was asystole in 3 patients (50%), pulseless activity in 1 patient (16.7%) and initially unknown in 2 patients (33.3%). Two patients (33.3%) who had EEG reactivity and TTNT within 5minutes and 2.5hours had good neurological outcome (CPC1). Four patients (66.7%) with absent EEG reactivity had poor neurological outcome (CPC4, 5 in 3 and 1 children respectively). Three patients from the poor outcome group had electrographic seizures, of whom 2/3 progressed to status epilepticus. Three out of four patients in the poor outcome group had the following complications: pneumonia, bleeding and pancreatitis. CONCLUSION: Early TTNT and EEG reactivity help to predict good neurological outcome in children undergoing therapeutic hypothermia after cardiac arrest. Seizures and status epilepticus may predict poor neurological outcome.

Prevalence of Sleep Disorders in Thai Children.

OBJECTIVE: To evaluate the prevalence of sleep disorders in Thai children who underwent polysomnography at a single institution. METHODS: A retrospective analysis of pediatric polysomnographic studies was performed from January 2011 through December 2014. RESULTS: One hundred sixty-six studies were conducted; 142, 7, and 17 were diagnostic, split-night, and positive airway pressure (PAP) titration studies, respectively. In total, 136 diagnostic/split-night studies were performed to diagnose sleep disorders with presentation of snoring (92.6 %), heavy breathing (0.7 %), witnessed apnea (14.7 %), excessive daytime sleepiness (10.3 %), hyperactivity (2.2 %), restless sleep (11.0 %), enuresis/nocturia (5.9 %), abnormal behavior (4.4 %) and poor weight gain (0.7 %). Eleven diagnostic studies and one split-night study were performed to follow-up obstructive sleep apnea (OSA) after adenoidectomy and/or tonsillectomy. One diagnostic study was conducted to follow-up OSA after postmandibular distraction. OSA was the most common diagnosis with a prevalence of 92.7 %; 40.4 % of patients were diagnosed with severe OSA. The prevalence of sleep-related hypoventilation was 15.4 %. The second most common diagnosis was periodic limb movement disorder with a prevalence of 20.6 %. Seventeen PAP titration studies were performed. Four CPAP titration studies were conducted for OSA treatment. Twelve bi-level (BiPAP) titration studies were performed in eight children with hypoventilation. One BiPAP/average volume-assured pressure support titration was conducted in a patient with congenital central hypoventilation syndrome (CCHS). CONCLUSIONS: The prevalence of sleep disorders in Thai children who underwent polysomnography at a tertiary-care hospital is very high. The factors that contribute are the limited availability and high costs of polysomnography in Thailand. This information will encourage pediatricians to look for sleep disorders in children.

Phenytoin toxicity in two-month-old Thai infant with CYP2C9 gene polymorphism--A case report.

Phenytoin is one of the most well established and most effective antiepileptic medications for the treatment of focal seizures. In our clinical practice, it has proven difficult to maintain therapeutic phenytoin levels in infants less than three months of age. Incidence of phenytoin toxicity in infants is very rare. The cytochrome P450 super family plays an important role in phenytoin metabolism, especially CYP2C9 and CYP2C19. In this case report, we profiled a two-month-old Thai infant who developed phenytoin toxicity resulting from CYP2C9 gene polymorphism.

Adherence to quality measures in a pediatric epilepsy center: a pilot study.

A retrospective study was conducted to determine compliance with the American Academy of Neurology quality measures for epilepsy care in a single tertiary care pediatric epilepsy clinic. Paper and electronic charts of children 0 to 20 years of age, with an established diagnosis of epilepsy, who receive their medical care at the Children's Hospital of Michigan in Detroit, were reviewed. Of the eight quality measures suggested for surveillance, the least compliant measures were counseling for young adults of childbearing age and recommendations regarding epilepsy specific safety issues. The quality measures where greatest adherence was demonstrated were ordering and review of electroencephalogram results at clinic visits and documentation of frequency of seizures. Practitioner education, use of electronic checklists, and an automated tracking system may enhance compliance and ultimately lead to superior patient care.

Epidemiology and clinical manifestation of rotavirus and norwalk-like viruses in Thai children.

Acute gastroenteritis is one of the most common diseases affecting children and rotavirus is the major etiological agent worldwide. Although the role of rotavirus as a causal agent of gastroenteritis has been previously established in Thailand, little is known about the epidemiology of Norwalk-like viruses. The present study was designed to determine the epidemiology and clinical manifestation of Norwalk-like viruses in comparison with rotavirus in Thailand. One hundred and one children with watery diarrhea between November 2002 and October 2003 were recruited into the study. The clinical data and stool specimens were collected for clinical analysis and rotavirus and Norwalk-like virus detection. Rotavirus and Norwalk-like viruses were detected viral agent by RT-PCR method. Of 101 stool samples obtained, rotavirus was detected in 25/101 (24.7%). Norwalk-like viruses were detected in 23/101 (22.7%). Dual infections were detected in 6/101 (5.9%). Rotavirus and Norwalk-like viruses peaked in the winter time. Clinical manifestations of rotavirus and Norwalk-like viruses were watery stool, nausea, vomiting, abdominal pain and fever Norwalk-like viruses and rotavirus were the most common etiologic agents in children with acute gastroenteritis in Thailand Epidemiology and clinical manifestations of rotavirus and Norwalk-like viruses were not different.