The significance of aspects of screening for obstructive sleep apnoea in children with Down syndrome.

BACKGROUND: The sleep problems of children with intellectual disabilities remains a relatively neglected topic in spite of the consistent reports that such problems are common, often severe and persistent with potentially serious consequences for the children and their families. Children with Down syndrome (DS) are a case in point. They often suffer from obstructive sleep apnoea (OSA), early detection of which is recommended because of its potentially adverse effects on development. This study is concerned with aspects of assessment that have been considered important in helping to recognise OSA in children with DS. The relationships between different objective measures, and between these measures and parental reports of their child's sleep and daytime behaviour, were explored. METHOD: Overnight recordings were carried out on a group of children with DS (n = 31) involving video and audio recording, oximetry and activity monitoring during sleep. Parents also completed questionnaires concerning their child's sleep and daytime behaviour. RESULTS: Parents' reports of restless sleep and noisy breathing were supported by objective measures of activity during sleep and audio recording respectively. No significant association was found between objective measures of restlessness during sleep and 'snoring' (see later for definition), nor were objective measures of restlessness related to reductions in overnight blood oxygen levels. However, the objective measure of snoring was significantly associated with reductions in overnight blood oxygen levels. All three of the objective measures were significantly associated with parental reports of various types of disturbed daytime behaviour. CONCLUSIONS: The findings have implications for aspects of screening for OSA in children with DS and for the interpretation of the relevance of the results to the children's daytime behaviour.

Clinical diagnosis and misdiagnosis of sleep disorders.

Sleep disorders are common in all sections of the population and are either the main clinical complaint or a frequent complication of many conditions for which patients are seen in primary care or specialist services. However, the subject is poorly covered in medical education. A major consequence is that the manifestations of the many sleep disorders now identified are likely to be misinterpreted as other clinical conditions of a physical or psychological nature, especially neurological or psychiatric disorders. To illustrate this problem, examples are provided of the various possible causes of sleep loss, poor quality sleep, excessive daytime sleepiness and episodes of disturbed behaviour at night (parasomnias). All of these sleep disorders can adversely affect mental state and behaviour, daytime performance or physical health, the true cause of which needs to be recognised by clinicians to ensure that appropriate treatment is provided. As conventional history taking in neurology and psychiatry pays little attention to sleep and its possible disorders, suggestions are made concerning the enquiries that could be included in history taking schedules to increase the likelihood that sleep disorders will be correctly identified.

Review: psychiatric and medical consequences of disordered sleep.

OBJECTIVES: The aim of this article is to draw attention to the clinical importance of disordered sleep in psychiatry and to demonstrate the growing awareness of medical illness as a complication of disordered sleep. As background to these main objectives, some general points are made to illustrate present-day approaches to the common and often serious problem of sleep disturbance. METHODS: The review is based on a literature search from which key publications were selected to illustrate, in turn, main connections between disordered sleep and psychiatric and medical conditions. RESULTS: Many such connections are described. Throughout psychiatry, regarding patients whatever their age, these connections have implications for clinical assessment and management. Emphasis is placed on the risk of misdiagnosis of sleep disorders as psychiatric or medical conditions. Examples of this are provided. The growing evidence that disordered sleep can predispose to medical illness is discussed. CONCLUSION: As the subject of sleep and its disorders is particular relevant in psychiatry, a working knowledge of modern sleep medicine is important in all branches of psychiatric and other medical practice as well as in clinical research.

Ambulatory diagnostic monitoring of seizures in children.

Considerable scope still exists for more accurate recognition of childhood seizures and the definition of their precise type. Careful clinical observation is generally the most appropriate way of achieving these objectives. However, in a proportion of patients even detailed clinical evaluation will leave this issue unclear. Intensive neurodiagnostic monitoring carries the advantage over conventional EEG recordings in generally increasing the likelihood of recording during the child's attacks. Special consideration has to be given to children in carrying out intensive monitoring, largely because of their limited understanding of investigatory procedures and lessened ability to cooperate compared with adults, including adjustment to hospital admission. Equipment design must acknowledge the smaller size of children and the fact that they are generally more active than adult patients. In order to help interpretation of the EEG findings, great reliance has to be placed on the observation by parents and other observers in achieving adequate behavioral accounts. The comparative acceptance by children of the different recording procedures and their relative diagnostic yield are difficult to evaluate objectively. No systematic comparison has been made on the same group of children undergoing the various procedures. Consequently, comparisons have to be made on different patient groups investigated in different centers where it is likely there will be differences in selection criteria for investigation as well as the details of the procedure followed. Video/EEG, telemetry, and cassette recording are best seen as complementary procedures from which a choice is made depending on the child's problem and circumstances and, in particular, whether admission to hospital for video or telemetry is possible or likely to provide the opportunity for studying the clinical phenomena in question. All are capable of high levels of technical merit and a high degree of diagnostic yield when used with appropriate indications. However, especially for EEG services outside special centers and without extra staff resources, it is likely that cassette recording in its 8-channel form has distinct advantages, both in terms of acceptability to children and of operating costs.

Sleep abnormalities demonstrated by home polysomnography in teenagers with chronic fatigue syndrome.

To provide objective information about sleep physiology in young people with chronic fatigue syndrome (CFS), home polysomnography (PSG) was performed on 18 teenagers, aged 11-17 years, in whom CFS had been diagnosed according to internationally accepted criteria. The results were compared with those for healthy controls matched individually for gender and age. Compared with controls, CFS subjects showed significantly higher levels of sleep disruption by both brief and longer awakenings. Disruption of sleep in this way could at least contribute to the daytime symptoms of young people with CFS. The underlying cause of the disruption needs to be considered in each individual case. Further research is required to clarify the relative contribution of this neurobiological aspect of CFS in young people.

Sleep-wake function in children with neurodevelopmental and psychiatric disorders.

Sleep disturbance is commonly described in children with developmental problems of a primarily physical or psychiatric nature. Its persistence is likely to adversely affect cognition, mood, behavior, and family functioning. Therefore, accurate diagnosis of the underlying sleep disorder, with prompt and effective treatment, can be considered essential for overall care. Reports of sleep disturbance in various neurodevelopmental and psychiatric disorders of childhood are outlined. The origins of the disturbance in each condition may lie in the disorder itself, the child's circumstances, or reflect comorbidity. Each contributory factor has implications for treatment strategies and outcome. Much remains to be discovered about childhood sleep disorders. However, sufficient information is already known to significantly improve their recognition and management if professional education in such matters improves.

Five patients with Rasmussen's syndrome investigated by single-photon-emission computed tomography.

Five patients with Rasmussen's syndrome (sometimes known as smouldering encephalitis), are presented. This rare form of childhood epilepsy is characterized by intractable partial seizures with progressive neurological and mental impairment. Diagnostic brain biopsy shows the histological changes of active encephalitis, consistent with a viral infection. Although the raised cerebrospinal fluid (CSF) complement and interferon levels seen in some patients support this hypothesis, no infective agent has yet been isolated. All five patients were investigated by transmission computed tomography (CT) of the head, electroencephalography (EEG) and cerebral single-photon-emission computed tomography (SPECT) using 99Tcm-hexamethylpropylenamine oxime (HMPAO) and in addition 123I-amphetamine (IMP) in Patient 1. 99Tcm-HMPAO is now regarded as reflecting cerebral perfusion, whereas the uptake of 123I-amphetamine is more dependent on cell function. In all patients SPECT imaging demonstrated an area of hypoperfusion/hypometabolism which corresponded to the anatomical localization of the epiletogenic foci found by clinical assessment, EEG and CT. In all cases the SPECT study also demonstrated a more extensive area of abnormality than CT, and in the two patients who had sequential studies, alteration in the size of the defect was found which correlated with the patients' changing clinical condition. SPECT imaging in Rasmussen's syndrome may facilitate anatomical localization of the area of pathology, and may demonstrate a changing pattern in cerebral hypoperfusion/hypometabolism. It could also serve as a guide to accurate brain biopsy.

Behavioural treatment for sleep problems in children with severe intellectual disabilities and daytime challenging behaviour: effect on mothers and fathers.

OBJECTIVES: The study aimed to assess the mental state of mothers and fathers following successful behavioural intervention for sleep problems in such children. DESIGN: A randomized controlled trial of behavioural interventions for sleep problems. METHODS: Parents of 15 children with severe intellectual disabilities, severe sleep problems, and challenging daytime behaviour received treatment for the child's sleep problem and were compared with 15 controls who received no treatment. Parental stress, sleepiness, locus of control, perceived control, and satisfaction with aspects of sleep were assessed. RESULTS: Successful treatment benefited the mothers, reducing stress, increasing perceived control and making them more satisfied with their sleep, their child's sleep, and their ability to cope with their child's sleep. Positive effects in the fathers were limited to increased satisfaction with their own sleep and their child's sleep; fathers tended to feel less control following treatment. Maternal sleepiness and perceived control, and aspects of parental satisfaction showed improvements in both the treatment and control groups. CONCLUSION: The effects of childhood sleep problems, and their resolution using behavioural interventions, may be different in mothers and fathers. This highlights the need to assess all family members in order to gain a greater understanding of how best to help families as a whole. The improvements in both control and treatment groups indicate that there may be non-specific effects of taking part in the study that played a therapeutic role.

A systematic review of treatments for settling problems and night waking in young children.

OBJECTIVES: To assess the efficacy of treatments for settling problems and night waking in young children. DESIGN: A systematic review of randomised controlled trials of interventions for settling problems and night waking in young children. SETTING: Electronic bibliographic databases and references on identified papers, hand searches, and personal contact with specialists. SUBJECTS: Children aged 5 years or less who had established settling problems or night waking. INTERVENTIONS: Interventions had to be described and a placebo, waiting list, or another intervention needed to have been used as a comparison. Interventions comprised drug trials or non-drug trials. MAIN OUTCOME MEASURES: Number of wakes at night, time to settle, or number of nights in which these problems occurred. RESULTS: Drugs seemed to be effective in treating night waking in the short term, but long term efficacy was questionable. In contrast, specific behavioural interventions showed both short term efficacy and possible longer term effects for dealing with settling problems and night waking. CONCLUSIONS: Given the prevalence and persistence of childhood sleep problems and the effects they can have on children and families, treatments that offer long lasting benefits are appealing and these are likely to be behavioural interventions.

Arousal norms for children age 5-16 years based on home polysomnography.

Fragmentation of sleep by brief arousals has become an acknowledged aspect of poor quality sleep but there is a shortage of normative data on such arousals, especially for children. Norms for arousals (defined according to American Sleep Disorders Association criteria) were compiled for 61 children age 5-16 years using the Oxford Medilog system for a single night of home polysomnography. No significant differences were seen between the five age subgroups considered in average number of arousals per hour of sleep although individual differences were apparent at each age level and arousal duration was somewhat longer at younger ages. The low arousal rates in the children studied are in keeping with other evidence that arousal rates increase throughout life. Boys were no different from girls in either arousal frequency or duration. Arousal frequency was correlated with PSG awakenings but only to a modest extent. These new normative values should be useful in clinical practice and research for the assessment of the quality of children's sleep.

Home polysomnography norms for children.

Home polysomnography (PSG) by means of ambulatory monitoring systems has distinct advantages over sleep laboratory recordings, especially for children. However, normative data have been lacking. Norms for conventional PSG variables were compiled for 60 children age 5-16 years using the Oxford Medilog ambulatory monitoring system. Recordings were confined to a single night in view of previous demonstrations that the sleep on the first night is not significantly affected by the recording procedure. The results are presented in 5 age subgroups. Broad comparisons with published laboratory PSG norms for children of the same ages suggest that in home recordings sleep duration is longer, and slow wave sleep is much more pronounced with a commensurate reduction in stage 2 NREM sleep. That is, sleep quality and quantity appears better at home even when adaptation to the laboratory situation has been promoted. These new normative data are considered valuable for both clinical and research purposes where physiological sleep studies in children are required.

Aspects of parasomnias in childhood and adolescence.

The many parasomnias now officially described often occur in young patients. They are at risk of being confused with each other if their characteristic features are not well known and if they are not carefully assessed, mainly clinically. Accurate diagnosis is essential for choice of treatment, which varies considerably for different parasomnias. These points are illustrated mainly by reference to arousal disorders (including sleepwalking and sleep terrors) and the other parasomnias, such as nightmares and sleep-related epilepsies, from which they must be distinguished.

A clinical approach to poorly controlled seizures in children.

Uncontrolled seizures are a serious problem and a source of much anxiety to physicians, parents and others concerned with the care of children with epilepsy. A systematic approach to the causes of poor seizure control, considering basic diagnostic, pharmacological, neurological and psychological factors, can reveal treatment possibilities previously unrecognized.

Practitioner review: assessment and treatment of sleep disorders in children and adolescents.

Sleep disorders in children are diverse in type, common, often serious in their effects yet neglected in professional education. They complicate many psychiatric disorders and can cause various cognitive and behavioural problems as well as more widespread difficulties in the family as a whole. Accurate assessment allows an appropriate choice from the various types of treatments that are now available but often under used. Diagnostic points and treatment approaches are outlined for the three main categories of childhood sleep disorder: sleeplessness; excessive sleepiness; and episodic disturbances related to sleep (parasomnias). The need for more widespread awareness of and provision for sleep disorders is emphasized.