Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA).

Obstructive sleep apnea is a chronic illness with increasing prevalence. In addition to associated cardiovascular comorbidities, obstructive sleep apnea syndrome has been linked to poor quality of life, occupational accidents, and motor vehicle crashes secondary to excessive daytime sleepiness. Although continuous positive airway pressure is the gold standard for sleep apnea treatment, its effects on quality of life are not well defined. In the current study we investigated the effects of treatment on quality of life using the data from the Apnea Positive Pressure Long-term Efficacy Study (APPLES), a randomized controlled trial of continuous positive airway pressure (CPAP) versus sham CPAP. The Calgary Sleep Apnea Quality of Life Index (SAQLI) was used to assess quality of life. Overall we found no significant improvement in quality of life among sleep apnea patients after CPAP treatment. However, after stratifying by OSA severity, it was found that long-term improvement in quality of life might occur with the use of CPAP in people with severe and possibly moderate sleep apnea, and no demonstrable improvement in quality of life was noted among participants with mild obstructive sleep apnea.

Effects of sleep patterns and obesity on increases in blood pressure in a 5-year period: report from the Tucson Children's Assessment of Sleep Apnea Study.

OBJECTIVES: To determine associations between body mass index and sleep on blood pressure in a 5-year period from childhood to adolescence. STUDY DESIGN: Study consisted of a longitudinal, community-based sample of 334 children recruited at ages 6 through 11 years. Each participant underwent in-home polysomnography initially and then 5 years later. Individual systolic blood pressure (SBP) and diastolic blood pressure (DBP) were calculated at both points during wake periods and classified as hypertensive when SBP or DBP was ≥ 95th standardized percentiles for height and weight. RESULTS: Hypertension was present in 3.6% of the sample at time one and increased to 4.2% 5 years later. Obesity prevalence increased from 15.0% to 19.5%. Normal changes in sleep architecture were observed in the sample. With random effects modeling, which controlled for age, sex, and ethnicity, change in obesity status and decrease in total sleep time were indicated to be associated with increases in SBP. Change in obesity status was also associated with increases in DBP in the 5-year period. A trend for sleep-disordered breathing to increase SBP was noted. CONCLUSIONS: Increases in SBP and DBP were associated with increasing body mass index and decreased total sleep time in a 5-year period from childhood to adolescence.

Incidence and remission of sleep-disordered breathing and related symptoms in 6- to 17-year old children--the Tucson Children's Assessment of Sleep Apnea Study.

OBJECTIVE: To determine the incidence and remission of sleep-disordered breathing in adolescent children. STUDY DESIGN: A total of 319 children completed 2 home polysomnograms approximately 5 years apart. Sleep-disordered breathing (SDB) was determined to be present if a child had a respiratory disturbance index>or=1 event per hour associated with >or=3% oxygen desaturation. Subjective symptoms such as witnessed apnea, excessive daytime sleepiness, difficulty initiating and maintaining sleep, and habitual loud snoring were considered present if they occurred frequently or almost always. Body mass index percentiles were calculated with childhood growth charts from the Centers for Disease Control and Prevention adjusted for sex and age. RESULTS: The mean age at assessment was 8.5 years at baseline and 13.7 years at follow-up, respectively. Incident SDB was more common in boys (odds ratio [OR]=3.93, P=.008, confidence interval [CI]=1.41-10.90). Children with prevalent SDB were more likely to be boys (OR=2.48, P=.006) and had a greater increase in body mass index percentile change (OR 1.01, P=.034). Children with prevalent SDB also had 3.41 greater odds for development of obesity from baseline to follow-up in comparison with children with prevalent NoSDB. CONCLUSIONS: Adolescent boys are more likely to have persistent and incident SDB than girls. Children with prevalent SDB are more likely to have development of obesity. These risks are similar to those observed in adults.

Sleep-disordered breathing and mortality: a prospective cohort study.

BACKGROUND: Sleep-disordered breathing is a common condition associated with adverse health outcomes including hypertension and cardiovascular disease. The overall objective of this study was to determine whether sleep-disordered breathing and its sequelae of intermittent hypoxemia and recurrent arousals are associated with mortality in a community sample of adults aged 40 years or older. METHODS AND FINDINGS: We prospectively examined whether sleep-disordered breathing was associated with an increased risk of death from any cause in 6,441 men and women participating in the Sleep Heart Health Study. Sleep-disordered breathing was assessed with the apnea-hypopnea index (AHI) based on an in-home polysomnogram. Survival analysis and proportional hazards regression models were used to calculate hazard ratios for mortality after adjusting for age, sex, race, smoking status, body mass index, and prevalent medical conditions. The average follow-up period for the cohort was 8.2 y during which 1,047 participants (587 men and 460 women) died. Compared to those without sleep-disordered breathing (AHI: <5 events/h), the fully adjusted hazard ratios for all-cause mortality in those with mild (AHI: 5.0-14.9 events/h), moderate (AHI: 15.0-29.9 events/h), and severe (AHI: >or=30.0 events/h) sleep-disordered breathing were 0.93 (95% CI: 0.80-1.08), 1.17 (95% CI: 0.97-1.42), and 1.46 (95% CI: 1.14-1.86), respectively. Stratified analyses by sex and age showed that the increased risk of death associated with severe sleep-disordered breathing was statistically significant in men aged 40-70 y (hazard ratio: 2.09; 95% CI: 1.31-3.33). Measures of sleep-related intermittent hypoxemia, but not sleep fragmentation, were independently associated with all-cause mortality. Coronary artery disease-related mortality associated with sleep-disordered breathing showed a pattern of association similar to all-cause mortality. CONCLUSIONS: Sleep-disordered breathing is associated with all-cause mortality and specifically that due to coronary artery disease, particularly in men aged 40-70 y with severe sleep-disordered breathing. Please see later in the article for the Editors' Summary.

Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS).

STUDY OBJECTIVES: Findings from population studies evaluating the progression and incidence of sleep disordered breathing have shown evidence of a longitudinal increase in the severity of sleep disordered breathing. The present study evaluates the association among changes in sleep disordered breathing, sleep symptoms, and quality of life over time. DESIGN: Prospective cohort study. Data were from the Sleep Heart Health Study. SETTING: Multicenter study. PARTICIPANTS: Three thousand seventy-eight subjects aged 40 years and older from the baseline and follow-up examination cycles were included. MEASUREMENTS: The primary outcomes were changes in the Physical Component Summary and Mental Component Summary scales obtained from the Medical Outcomes Study Short-Form Health Survey. The primary exposure was change in the respiratory disturbance index obtained from unattended overnight polysomnograms performed approximately 5 years apart. Other covariates included measures of excessive daytime sleepiness and difficulty initiating and maintaining sleep. RESULTS: Mean respiratory disturbance index increased from 8.1 +/- 11 SD at baseline to 10.9 +/- 14 (P < 0.0001) at follow-up. The mean Physical Component Summary and Mental Component Summary scores were 48.5 and 54.1 at baseline and 46.3 and 54.8 at follow-up. No associations between change in respiratory disturbance index and changes in Physical Component Summary or Mental Component Summary scores were seen. However, worsening of difficulty initiating and maintaining sleep and excessive daytime sleepiness were significantly associated with lower quality of life. CONCLUSIONS: A slight increase in severity of sleep disordered breathing was seen over 5 years; this was not associated with worsening of quality of life. However, subjective symptoms of quality of sleep and daytime sleepiness were associated with declining quality of life.

Mother Knows Best? Comparing Child Report and Parent Report of Sleep Parameters With Polysomnography.

STUDY OBJECTIVES: Parent report or child report is commonly used to obtain information on sleep in children. Data are lacking comparing the validity of parent-reported versus child-reported sleep parameters. METHODS: A total of 285 children (age 9 to 17 years) from the Tucson Children's Assessment of Sleep Apnea community cohort study were assessed. Parent report and child report of total sleep time (TST), sleep latency (SL), and sleep efficiency (SE) for a single night were compared to polysomnography (PSG). Intraclass correlations (ICCs) were used to evaluate agreement between child report, parent report, and PSG findings. RESULTS: When compared to PSG, children overestimated TST by a median of 32 minutes (interquartile range [IQR] 6 to 68), whereas parents overestimated TST by 36 minutes (IQR 13-70) (P = .006). Children overestimated SL by 4 minutes (IQR -8 to 20), whereas parents overestimated SL by 2 minutes (IQR -10 to 13) (P = .001). Children overestimated SE by 5% (IQR 0% to 11%), whereas parents overestimated SE by 6% (IQR 2% to 11%, P = .04). Both child-reported TST (ICC 0.722, P < .001) and parent-reported TST (ICC 0.776, P < .001) agreed substantially with PSG. Child-reported SL (ICC 0.467, P < .001) and parent-reported SL (r = .419, P < .001) moderately agreed with PSG. Least agreement with PSG was seen between child-reported SE (ICC 0.404, P < .001) and parent-reported SE (ICC 0.473, P < .001), but significant agreement was still present. CONCLUSIONS: When compared to PSG, children overestimate TST to a smaller degree than their parents and overestimate SL to a larger degree than their parents, but these differences appear small. Child and parent reports appear to be equally valid for TST, SL, and SE.

Effect of sleep disordered breathing on the sleep of bed partners in the Sleep Heart Health Study.

OBJECTIVE: To study the sleep quality of bed partners of persons with sleep disordered breathing in a non-clinical population based sample in a home environment. DESIGN: Cross-sectional study in a community sample. METHODS: 110 pairs of subjects living in the same household from the Tucson, Minnesota, and Pittsburgh sites of the Sleep Heart Health Study (SHHS) were included if both partners had an in-home, unattended polysomnogram (PSG) performed as a part of SHHS exam cycle 2. Sleep disordered breathing (SDB) was considered present if the respiratory disturbance index (RDI) was > or =10 events/h and no SDB if RDI was <5 events/h. Pairs were classified according to their SDB status and assigned to one of 3 groups: 1) NoSDB-NoSDB (n = 46), 2) NoSDB-SDB (n = 42), and 3) SDB-SDB (n = 22). RESULTS: There were no differences between the NoSDB-NoSDB and the SDB-SDB partners in their demographic, PSG, or quality of life variables. However, within the NoSDB-SDB group, NoSDB in comparison to their SDB partners weighed less (mean BMI: 26 vs. 29 kg/m2, P < 0.0003), had decreased stage 2% (55 vs. 64, P < 0.0001), increased stage 3 and 4% (21 vs. 11, P <0.0005) and a lower arousal index (13.8 vs. 20 events/h, P < 0.0001). When comparing the NoSDB subjects from the NoSDB-SDB group to subjects in the NoSDB-NoSDB group and to subjects in the SDB-SDB group, significant differences were seen for RDI and BMI but not for any other parameter. CONCLUSION: In a non-clinical population based sample, the sleep quality of bed partners of SDB subjects without SDB is better than their SDB bed partner. However, their sleep quality was not different in comparison to the sleep of those without SDB who also had a bed partner without SDB.

Obstructive sleep apnea-hypopnea and neurocognitive functioning in the Sleep Heart Health Study.

BACKGROUND AND PURPOSE: Obstructive sleep apnea-hypopnea (OSAH) is associated with sleep fragmentation and nocturnal hypoxemia. In clinical samples, patients with OSAH frequently are found to have deficits in neuropsychological function. However, the nature and severity of these abnormalities in non-clinical populations is less well defined. PATIENTS AND METHODS: One hundred and forty-one participants from the Tucson, AZ and New York, NY field centers of the Sleep Heart Health Study completed a battery of neuropsychological tests for 9-40 months (mean=24 months, SD=7 months) after an unattended home polysomnogram. Sixty-seven participants had OSAH (AHI>10) and 74 did not have OSAH (control (CTL), apnea-hypopnea index (AHI)<5). In addition to the individual tests, composite variables representing attention, executive function, MotorSpeed and processing speed were constructed from the neuropsychological test battery. RESULTS: There were no significant differences in any individual neuropsychological test or composite variable between the OSAH and CTL groups. However, when time spent with O(2) saturations less than 85% was dichotomized into those participants in the top quartile of the distribution and those in the lower three quartiles, motor speed was significantly impaired in those who were more hypoxemic. In addition, poorer motor speed (model adjusted R(2)=0.242, P<0.001) and processing speed performance (model adjusted R(2)=0.122, P<0.001) were associated with more severe oxygen desaturation even after controlling for degree of daytime sleepiness, age, gender and educational level. CONCLUSIONS: Mild to moderate OSAH has little impact on the selected measures of attention, executive function, motor speed and processing speed. However, hypoxemia adversely affects both motor and processing speed. These results suggest that in middle-aged to elderly adults the neuropsychological effects of clinically unrecognized mild to moderate OSAH are neither global nor large.

Parent-rated behavior problems associated with overweight before and after controlling for sleep disordered breathing.

BACKGROUND: Researchers and clinicians are seeking to develop efficacious behavioral interventions to treat overweight children; however, few studies have documented the behavioral correlates of overweight children in community samples. The goal of this study was to determine the nature and prevalence of behavior problems for overweight school-aged children versus normal weight peers before and after controlling for the effect of sleep disordered breathing. METHODS: Hispanic and Caucasian children were invited to participate in a study of sleep through public elementary school classrooms. Anthropometric evaluation and behavioral ratings were collected for 402 children aged 6-11 years. Overweight was calculated using the Centers for Disease Control age- and gender-specific guidelines. Children were classified as overweight if they were at or above the 95th percentile for their age and gender group. Behavior problems were measured using the Conners' Parent Rating Scales-Revised and the Child Behavior Checklist. Sleep disordered breathing was assessed using in-home overnight polysomnography. RESULTS: Approximately 15% (59/402) of the sample was classified as overweight. Simple odds ratios indicated that overweight children were more likely to have clinically relevant levels of internalizing symptoms (OR 2.23, CI 1.05-4.72), psychosomatic complaints (OR 2.15, CI 1.02-4.54), withdrawal (OR 4.69, CI 2.05-10.73), and social problems (3.18, 1.53-6.60). When odds ratios were adjusted for level of sleep disordered breathing, withdrawal (OR 3.83 CI 1.59-9.22) and social problems (OR 2.49 CI 1.14-5.44) remained significantly higher for overweight subjects. CONCLUSION: After controlling for the effect of sleep disordered breathing, behaviors such as withdrawal and social problems, are common in overweight children and need to be taken into account in the design of interventions and services as they may act to moderate the efficacy of behavioral treatments.

Obstructive Sleep Apnea and Quality of Life: Comparison of the SAQLI, FOSQ, and SF-36 Questionnaires.

INTRODUCTION: The impact of sleep on quality of life (QoL) has been well documented; however, there is a great need for reliable QoL measures for persons with obstructive sleep apnea (OSA). We compared the QoL scores between the 36-Item Short Form of the Medical Outcomes Survey (SF-36), Calgary Sleep Apnea Quality of Life Index (SAQLI), and Functional Outcomes Sleep Questionnaire (FOSQ) in persons with OSA. METHODS: A total of 884 participants from the Sleep Heart Health Study second examination, who completed the SF-36, FOSQ, and SAQLI, and in-home polysomnograms, were included. The apnea hypopnea index (AHI) at 4% desaturation was categorized as no OSA (<5 /hour), mild to moderate OSA (5-30 /hour) and severe OSA (>30 /hour). QoL scores for each questionnaire were determined and compared by OSA severity category and by gender. RESULTS: Participants were 47.6% male, 49.2% (n=435) had no OSA, 43.2% (n=382) had mild to moderate OSA, and 7.6% (n=67) had severe OSA. Participants with severe OSA were significantly older (mean age = 63.7 years, p <.0001), had higher BMI (mean = 34.3 kg/m2, p <.0001) and had lower SF-36 Physical Component scores (PCS) (45.1) than participants with no OSA (48.5) or those with mild to moderate OSA (46.5, p= .006). When analyzed according to gender, no significant differences were found in males for QoL by OSA severity categories. However, females with severe OSA had significantly lower mean scores for the SAQLI (5.4, p= .006), FOSQ (10.9, p= .02), and SF-36 PCS (37.7, p<.0001) compared to females with no OSA (6.0, 11.5, 44.6) and those with mild to moderate OSA (5.9, 11.4, 48, respectively). Females with severe OSA also had significantly higher mean BMI (41.8 kg/m2,) than females with no OSA (26.5 kg/m2) or females with mild to moderate OSA (30.6 kg/m2, p<.0001). The SF-36 PCS and Mental Component Scores (MCS) were correlated with the FOSQ and SAQLI (r=.37 PCS vs FOSQ; r=.31 MCS vs FOSQ; r=.42 PCS vs SAQLI; r=.52 MCS vs SAQLI; and r=.66 FOSQ vs SAQLI, p<.001 for all correlations). Linear regression analyses, adjusting for potential confounders, indicated that the impact of OSA severity on QoL is largely explained by the presence of daytime sleepiness. CONCLUSION: The impact of OSA on QoL differs between genders with a larger effect on females and is largely explained by the presence of daytime sleepiness. Correlations among QoL instruments are not high and various instruments may assess different aspects of QoL.

Longitudinal differences in sleep duration in Hispanic and Caucasian children.

BACKGROUND AND AIM: Short sleep duration is associated with significant negative consequences, including poor school performance, behavioral problems, obesity, and hypertension. There is prior evidence that there are disparities in sleep duration related to ethnicity; however, there are no specific data on Hispanic children. We aimed to test the hypothesis that there are ethnic differences in parent-reported sleep duration in a community-based cohort of Hispanic and Caucasian children. METHODS: We examined the parent-reported sleep patterns of a community-based prospective cohort (Tucson Children's Assessment of Sleep Apnea study [TuCASA]) involving 338 Hispanic and Caucasian children at two time points approximately five years apart. RESULTS: In the initial phase of the TuCASA study with a cohort median age of 8.8 years (interquartile range (IQR), 7.6-10.1 years), parent-reported sleep duration during weekdays was shorter in Hispanic (median, 9.5 h; IQR, 9.0, 10.0 years) than in Caucasian children (10 h; IQR, 9.5, 10.0 h; p < 0.0001); however, this difference was not seen 5 years later when the cohort was older (median age, 13.3 years; IQR, 11.9-14.6 years; p = 0.43). In addition, Hispanic children had a significantly later bedtime at both time points (p < 0.02). In the initial phase, parent-reported sleep duration during weekends tended to be shorter in Hispanic than in Caucasian children (p = 0.06). CONCLUSIONS: Short sleep duration in Hispanic children may contribute to health disparities. Our research suggests that in Hispanic children, behavioral interventions toward improving sleep duration accomplished by earlier bedtimes or delayed school start times and mechanistic studies to unravel any inherent tendency toward a delayed sleep phase are needed.

Insomnia, Health-Related Quality of Life and Health Outcomes in Children: A Seven Year Longitudinal Cohort.

Insomnia is common in children, and is associated with decreased school performance and increased psychopathology. Although adult insomnia is linked to worsened health-related quality of life (HRQOL), there is insufficient data evaluating insomnia and HRQOL in children. We examined the HRQOL and health associations of insomnia in a longitudinal cohort of 194 children (96 girls, age at study start 8.7 ± 1.6 years, age at data analysis 15.0 ± 1.8 years) over 7 years. International Classification of Sleep Disorders, second edition (ICSD2) derived insomnia was seen intermittently in 27% of children, and was persistent in 4%. Children reporting ICSD2-derived insomnia had lower HRQOL. Additionally, the presence of insomnia was associated with an increased risk of reporting a new medical condition (intermittent insomnia odds ratio 5.9 [95% CI 1.3-26.7, p = 0.04], persistent insomnia odds ratio 8 [95% CI 2.3-27.7, p = 0.001]). Persistent ICSD2-derived insomnia was associated with an increased risk of reporting a new medication (odds ratio 4.9 (95% CI 1.0-23.6), p = 0.049), and reporting a new psychiatric medication (odds ratio 13.7, 95% CI: 2.6-73.5, p = 0.002). These associations were present even after adjusting for socioeconomic factors and the presence of obstructive sleep apnea. Insomnia in children is associated with worsened HRQOL and health outcomes.

Comparison of nasal pressure transducer and thermistor for detection of respiratory events during polysomnography in children.

STUDY OBJECTIVES: The results of small studies have suggested that a nasal-cannula pressure transducer has a higher sensitivity than a thermistor in detecting hypopneas and diagnosing sleep-disordered breathing in both adults and children. We compared a thermistor alone, and in conjunction with a pressure transducer, for detection of sleep-disordered breathing in children during in-home polysomnography. DESIGN: Retrospective analysis of a subsample of a prospective cohort study. SETTING: Students attending elementary school in the Tucson Unified School District. PARTICIPANTS: A subsample of the Tucson Children's Assessment of Sleep Apnea study population. MEASUREMENTS AND RESULTS: Polysomnographic recordings of 40 children (24 girls and 16 boys, mean age 9.2 +/- 1.7 years; range 6-11 years) were analyzed to compare the detection of sleep-disordered breathing events by 2 different methods of measuring airflow: thermistor alone and thermistor with nasal-cannula pressure transducer (transducer) used simultaneously. The transducer detected all the respiratory events detected by the thermistor, but the thermistor detected only 84% of the transducer-defined events. Consequently, the transducer-derived mean respiratory disturbance index was higher than that detected by the thermistor (7.0 +/- 3.8 vs 5.9 +/- 3.4, P < .001). The bias error between transducer respiratory disturbance index and thermistor respiratory disturbance index on a Bland-Altman plot was 1.08 (95% confidence interval, 0.8 - 1.4). There was good agreement between the thermistor and the transducer for making the diagnosis of sleep apnea using a cutoff of a respiratory disturbance index greater than 5 (kappa = 0.69). The quality of the tracings with the transducer was comparable to that of the thermistor, but the transducer dislodged more frequently. CONCLUSION: The use of a nasal transducer in conjunction with a thermistor was more sensitive than the thermistor alone in detecting sleep-disordered breathing in children during unattended polysomnography.

Modified STOP-Bang Tool for Stratifying Obstructive Sleep Apnea Risk in Adolescent Children.

PURPOSE: Obstructive sleep apnea (OSA) is prevalent in children and diagnostic polysomnography is costly and not readily available in all areas. We developed a pediatric modification of a commonly used adult clinical prediction tool for stratifying the risk of OSA and the need for polysomnography. METHODS: A total of 312 children (age 9-17 years) from phase 2 of the Tucson Children's Assessment of Sleep Apnea cohort study, with complete anthropomorphic data, parent questionnaires, and home polysomnograms were included. An adolescent modification of STOP-Bang (teen STOP-Bang) was developed and included snoring, tired, observed apnea, blood pressure ≥ 95th percentile, BMI > 95th percentile, academic problems, neck circumference >95th percentile for age, and male gender. An apnea-hypopnea index ≥ 1.5 events/hour was considered diagnostic of OSA. RESULTS: Receiver Operator Characteristic (ROC) curves for parent-reported STOP-Bang scores were generated for teenage and pre-teen children. A STOP-Bang score of < 3 in teenagers was associated with a negative predictive value of 0.96. ROC curves were also generated based upon child-reported sexual maturity rating (SMR; n = 291). The ability of teen STOP-Bang to discriminate the presence or absence of OSA as measured by the AUC for children with SMR ≥ 4 (0.83; 95%CI 0.71-0.95) was better than children with SMR < 4 (0.63; 95%CI 0.46-0.81; p = 0.048). CONCLUSIONS: In community dwelling adolescents, teen STOP-Bang may be useful in stratifying the risk of OSA.

Temporal Characteristics of the Sleep EEG Power Spectrum in Critically Ill Children.

STUDY OBJECTIVES: Although empirical evidence is limited, critical illness in children is associated with disruption of the normal sleep-wake rhythm. The objective of the current study was to examine the temporal characteristics of the sleep electroencephalogram (EEG) in a sample of children with critical illness. METHODS: Limited montage EEG recordings were collected for at least 24 hours from 8 critically ill children on mechanical ventilation for respiratory failure in a pediatric intensive care unit (PICU) of a tertiary-care hospital. Each PICU patient was age- and gender-matched to a healthy subject from the community. Power spectral analysis with the fast Fourier transform (FFT) was used to characterize EEG spectral power and categorized into 4 frequency bands: δ (0.8 to 4.0 Hz), θ (4.1 to 8.0 Hz), α (8.1 to 13.0 Hz), and ß1/ß2 (13.1 to 20.0 Hz). RESULTS: PICU patients did not manifest the ultradian variability in EEG power spectra including the typical increase in δ-power during the first third of the night that was observed in healthy children. Differences noted included significantly lower mean nighttime δ and θ power in the PICU patients compared to healthy children (p < 0.001). Moreover, in the PICU patients, mean δ and θ power were higher during daytime hours than nighttime hours (p < 0.001). CONCLUSIONS: The results presented herein challenge the assumption that children experience restorative sleep during critical illness, highlighting the need for interventional studies to determine whether sleep promotion improves outcomes in critically ill children undergoing active neurocognitive development.

Parasomnias and sleep disordered breathing in Caucasian and Hispanic children - the Tucson children's assessment of sleep apnea study.

BACKGROUND: Recent studies in children have demonstrated that frequent occurrence of parasomnias is related to increased sleep disruption, mental disorders, physical harm, sleep disordered breathing, and parental duress. Although there have been several cross-sectional and clinical studies of parasomnias in children, there have been no large, population-based studies using full polysomnography to examine the association between parasomnias and sleep disordered breathing. The Tucson Children's Assessment of Sleep Apnea study is a community-based cohort study designed to investigate the prevalence and correlates of objectively measured sleep disordered breathing (SDB) in pre-adolescent children six to 11 years of age. This paper characterizes the relationships between parasomnias and SDB with its associated symptoms in these children. METHODS: Parents completed questionnaires pertaining to their child's sleep habits. Children had various physiological measurements completed and then were connected to the Compumedics PS-2 sleep recording system for full, unattended polysomnography in the home. A total of 480 unattended home polysomnograms were completed on a sample that was 50% female, 42.3% Hispanic, and 52.9% between the ages of six and eight years. RESULTS: Children with a Respiratory Disturbance Index of one or greater were more likely to have sleep walking (7.0% versus 2.5%, p < 0.02), sleep talking (18.3% versus 9.0%, p < 0.006), and enuresis (11.3% versus 6.3%, p < 0.08) than children with an Respiratory Disturbance Index of less than one. A higher prevalence of other sleep disturbances as well as learning problems was observed in children with parasomnia. Those with parasomnias associated with arousal were observed to have increased number of stage shifts. Small alterations in sleep architecture were found in those with enuresis. CONCLUSIONS: In this population-based cohort study, pre-adolescent school-aged children with SDB experienced more parasomnias than those without SDB. Parasomnias were associated with a higher prevalence of other sleep disturbances and learning problems. Clinical evaluation of children with parasomnias should include consideration of SDB.

Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children--the Tucson Children's Assessment of Sleep Apnea study (TuCASA).

STUDY OBJECTIVES: This report describes clinical outcomes and threshold levels of respiratory disturbance index (RDI) associated with sleep-disordered breathing in children participating in the Tucson Children's Assessment of Sleep Apnea study. DESIGN: A community-based, prospective cohort study designed to assess the severity of sleep-related symptoms associated with sleep-disordered breathing in children aged 6 to 11 years. SETTING: Students attending elementary school in the Tucson Unified School District. PARTICIPANTS: Unattended home polysomnograms were completed on 239 children-55.2% boys, 51% Hispanic, and 55% between the ages of 6 and 8 years. MEASUREMENTS AND RESULTS: Based on full home polysomnography, levels of RDI that correspond to a higher prevalence of clinical symptoms of sleep-disordered breathing in children aged 6 to 11 were observed. An RDI of at least 5 was associated with frequent snoring (20.3% vs 9.1%, P<.01), excessive daytime sleepiness (22.9% vs 10.7%, P<.01), and learning problems (8.5% vs 2.5%, P<.04) when no oxygen desaturation accompanied the respiratory event. An RDI of at least 1 was associated with these symptoms when a 3% oxygen desaturation was required, snoring (24.0% vs 10.4%, P<.006), excessive daytime sleepiness (24.0% vs 13.4%, P<.04), and learning problems (10.7% vs 3.0%, P<.02). Hispanic or Caucasian ethnicity, sex, age category, obesity, insomnia, and witnessed apnea were not associated with RDI regardless of event definition. CONCLUSIONS: The Tucson Children's Assessment of Sleep Apnea study has shown that there are values of RDI based on polysomnography that correspond to an increased rate of clinical symptoms in children ages 6 to 11 years.

Symptoms related to sleep-disordered breathing in white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea Study.

STUDY OBJECTIVES: The Tucson Children's Assessment of Sleep Apnea (TuCASA) study is designed to investigate the prevalence and correlates of objectively measured sleep-disordered breathing (SDB) in preadolescent children. This article describes the parental report of sleep symptoms associated with SDB in Hispanic and white children. DESIGN: A 13-question sleep habits screening questionnaire designed to assess the severity of sleep-related symptoms associated with SDB in children 4 to 11 years of age. SETTING: Questionnaires were completed by the parents of children attending elementary school in the Tucson Unified School District, Tucson, AZ. PARTICIPANTS: There were 1,494 questionnaires returned, which comprised a sample of whites (38%), Hispanics (45%), and other races (17%). Of these questionnaires, 1,214 were returned for the children of white (45.8%; 556 children) or Hispanic (54.2%; 658 children) ethnicity only. The primary analysis was completed on these 613 boys (50.5%) and 601 girls (49.5%). RESULTS: In the total sample of 1,494 children, parents were more likely to report excessive daytime sleepiness (EDS) in female children than in male children (p <.01), however, this association did not achieve significance in the sample of only white and Hispanic children (p <.07). Composite variables for EDS and witnessed apnea (WITAP) show that parents of Hispanic children were more likely to report EDS (p <.01) and WITAP (p <.007). Hispanic children were also more likely to have learning problems (LPs) [p <.03] and to snore frequently (SN) [p <.02] than were white children. There were no significant differences between boys and girls for SN or WITAP. Hispanic boys were more likely to have reports of EDS (p <.02) and LPs (p <.04) than white boys, however, there were no other significant differences in gender or ethnicity in reports of EDS or LPs for white or Hispanic boys and girls. Those children with frequent LPs were significantly more likely to have SN (p <.001), EDS (p <.001), and WITAP (p <.001). A logistic regression model predicting LP resulted in significant adjusted odds ratios (ORs) of 2.4 for SN, 2.5 for EDS, and 2.1 for children aged 8 to 11 years. A similar model for EDS resulted in significant adjusted ORs of 3.2 for SN, 5.7 for WITAP, and 1.6 for female gender. Ethnicity was not significant in either model. CONCLUSIONS: Hispanic children in the population-based TuCASA study experienced more frequent symptoms associated with SDB, such as SN, EDS, WITAP, and LPs, than did white children. Children with LPs are 2.4 times more likely to have SN, 2.5 times more likely to have EDS, and were 2.1 times more likely to be between the ages of 8 and 11 years. Children with EDS were 3.2 times more likely to have SN, 5.7 times more likely to have WITAP, and were 1.6 times more likely to be a girl.

Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea study.

BACKGROUND: The Tucson Children's Assessment of Sleep Apnea study (TuCASA) was designed to investigate the prevalence and correlates of objectively measured sleep-related breathing disorder (SBD) in preadolescent Hispanic and white children. OBJECTIVE: To describe the associations of SBD and elevation in resting blood pressure in the first 239 children enrolled in TuCASA. DESIGN: Children between the ages of 6 and 11 years (45% girls and 51% Hispanic) from elementary schools of the Tucson Unified School District were enrolled in this prospective cohort study. Resting systolic and diastolic blood pressure, sleep symptoms, and parental smoking status were obtained during evening home visits, followed by overnight unattended home polysomnography. RESULTS: The mean (SD) systolic and diastolic blood pressures were 98.4 (10.6) mm Hg and 62.0 (8.9) mm Hg, respectively. Fifteen children had hypertension. The mean (SD) respiratory disturbance index (2%), defined as the number of apneas and hypopneas per hour of sleep associated with a 2% oxygen desaturation, was 2.3 (3.8) events per hour. Factors independently associated with systolic and diastolic blood pressure elevation were obesity, sleep efficiency, and respiratory disturbance index (2%). CONCLUSIONS: In preadolescent children, elevated blood pressure is associated with SBD and obesity, as previously noted in adults. The control of obesity in childhood may be important to reduce the daytime consequences of SBD and to reduce the risks of life-long hypertension.

Sleep architecture in normal Caucasian and Hispanic children aged 6-11 years recorded during unattended home polysomnography: experience from the Tucson Children's Assessment of Sleep Apnea Study (TuCASA).

OBJECTIVE: To obtain normative sleep architecture data from unattended home polysomnography in Caucasian and Hispanic children aged 6-11 years. DESIGN AND SUBJECTS: Unattended home polysomnography was performed on a single night in Caucasian and Hispanic children aged 6-11 years as part of the Tucson Children's Assessment of Sleep Apnea Study (TuCASA), a cohort study designed to examine the prevalence and correlates of sleep disordered breathing. A subset of 42 children enrolled in TuCASA who had no symptoms of any sleep disorder and had polysomnograms without technical recording problems. RESULTS: Sleep architecture in preadolescent Caucasian and Hispanic children was not different between boys and girls. However, total sleep time (TST), sleep efficiency (SLE) and time spent in REM sleep declined with increasing age. In addition, the number of sleep to wake stage shifts was slightly higher in younger children. Hispanic children had less Stage 3/4 sleep (18+/-1 vs. 22+/-1%, P