"I can't sleep!": gathering the evidence for an innovative intervention for insomnia in cancer patients.

Sleep-wake disturbances, in particular insomnia, are experienced by 30%-75% of oncology patients, yet no effective interventions have been designed to address this distressing symptom in the ambulatory setting. In response to an identified gap in care, I share the development and evaluation of an innovative sleep intervention designed specifically for the ambulatory setting. Preliminary findings, as well as an informative blueprint for conducting point-of-care research, are described. As a "bedside" nurse it is possible and within our moral imperative and social justice mandate to take action to find evidence-informed solutions to improve care for populations of patients experiencing gaps in care. The "I" used throughout the article refers to the lead author Surya.

Sleep problems and associated factors in children with juvenile idiopathic arthritis: a systematic review.

BACKGROUND: Sleep problems are common among children with chronic illnesses such as Juvenile Idiopathic Arthritis (or JIA). However, little is known about the frequency and severity of sleep disturbance(s) and the factors that are associated with sleep problems in children with JIA. The mechanism(s) of the relationships characterizing the development or exacerbation of sleep problems in children with JIA are still unknown, however studies have reported an association. The purpose of this study was to synthesize existing research related to sleep problems in children with JIA. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement guided the conduct and reporting of this review. An experienced librarian conducted searches in MEDLINE, EMBASE, PsychINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to January 2012, to identify potentially relevant citations. Two members independently selected, rated methodological quality using the QUIPS tool, and extracted data from included studies. RESULTS: Ten studies were included and findings varied across studies; studies were mostly cross-sectional, or case-controlled designs, with only one cohort study available. Four studies found that children and adolescents diagnosed with JIA had significantly more sleep disturbances when compared to healthy controls. Pain was most often associated with sleep disturbances. The heterogeneous findings highlight the complex relationships between JIA and sleep, and low methodological quality of studies in the field. CONCLUSIONS: This review supports an association between poor sleep and increased symptoms related to JIA, specifically the experience of pain. However, results need to be interpreted cautiously given the inconsistent findings regarding factors associated with sleep problems in JIA, the limited evidence available, and its low quality. Furthermore it is not yet determined if the poor sleep patterns predate the symptoms reported with JIA. More research is vital to understanding the factors that predict or perpetuate poor sleep in children and adolescents diagnosed with JIA.

Prader-Willi syndrome, excessive daytime sleepiness, and narcoleptic symptoms: a case report.

INTRODUCTION: Sleep abnormalities, including narcolepsy and cataplexy, are a common feature of Prader-Willi syndrome. Long-term treatment with the central nervous system stimulant modafinil has not been reported. In this case report we present a longitudinal perspective of sleep abnormalities in a nine-year-old Caucasian girl with Prader-Willi syndrome from age two to age nine, and detail the response to treatment with the central nervous system stimulant modafinil. CASE PRESENTATION: Our patient presented at two years of age with hypersomnia and narcoleptic episodes with cataplectic features. Initial polysomnograph testing revealed adequate sleep efficiency, but increased sleep fragmentation especially during rapid eye movement sleep. The narcoleptic episodes continued and a repeat polysomnograph at age five years confirmed features consistent with narcolepsy. Further sleep studies at six years, including a multiple sleep latency test, demonstrated signs of excessive daytime sleepiness. Treatment with modafinil was initiated at age seven years six months due to persistent hypersomnia and narcoleptic symptoms. Two polysomnograph studies were performed following treatment with modafinil, at age eight years six months and nine years three months. These studies showed excellent sleep efficiency and improvement of rapid eye movement sleep parameters, supporting the beneficial effects of long-term modafinil therapy. CONCLUSIONS: Long-term modafinil therapy may ameliorate the sleep disturbances of Prader-Willi syndrome and should be the focus of future clinical trials.

Obesity negatively impacts lung function in children and adolescents.

OBJECTIVES: To investigate the relationship between weight status (body mass index [BMI] percentile and BMI z-score) and lung volumes in healthy children and adolescents. HYPOTHESES: We hypothesized that: (a) there would be a significant inverse relationship between age- and sex-specific BMI distribution and functional residual capacity (FRC), and expiratory reserve volume (ERV), respectively; and (b) obese children would have significantly reduced FRC and ERV compared to their non-obese peers. METHODS: The medical records of all individuals who successfully performed pulmonary function testing between 2000 and 2007 at two university children's hospitals were reviewed. Participants were excluded if they had cardiopulmonary, neuromuscular, or chest wall disease. RESULTS: Of 1,469 record reviewed, 327 subjects met study criteria. Percent predicted ERV was lowest in the obese group (P < 0.001) while residual volume (RV) was lowest in the overweight and obese groups (P < 0.001). Underweight participants had a lower percent predicted forced vital capacity (FVC) (P = 0.027) and vital capacity (VC; P = 0.039). Obese participants had the lowest FEV1 /FVC (P < 0.001). A positive linear relationship existed between BMI z-score and percent predicted FVC, VC, and diffusing capacity of carbon monoxide (DLCO ). A negative linear relationship was found between BMI z-score and percent predicted FRC, ERV, RV, and absolute FEV1 /FVC. CONCLUSIONS: Our results show that increasing weight status in children and adolescents is associated with a general reduction in lung volume measurements, which may reflect impaired lung function, increased respiratory symptoms, and decreased functional status.

Full-night versus 4h evening polysomnography in children less than 2years of age.

OBJECTIVE: Pediatric polysomnogaphy (PSG) is associated with significant burden in terms of personnel time, resource use, and patient/family discomfort. We hypothesized that 4-h abbreviated PSG may be a suitable alternative to full-night PSG in children 24months of age and younger. METHODS: PSG results from the first 4-h were compared to the full-length studies from 105 children. Outcomes included total, obstructive, and central apnea indices. Sleep disordered breathing (SDB) was defined as an apnea-hypopnea index (AHI) >1.5events/h and obstructive sleep apnea (OSA) was defined as an obstructive AHI>1.5 events/h. Cutoffs for central apneas were 3events/h for subjects >6months of age and 10events/h for subjects ⩽6months of age. RESULTS: All but one subject had abnormal SDB by the full-night PSG and all individuals had at least one REM period in the first 4h of sleep. Mean oxygen saturations and end-tidal CO(2), did not significantly differ between full-night and 4-h PSG. 4-h PSG showed high sensitivity for total AHI (100% for ⩽6months and 92.9% for >6months respectively), obstructive AHI (97.9%; 91.1% respectively), and central apnea index (100%; 72.2% respectively). Agreement was lower for those with lower AHI. CONCLUSIONS: The high prevalence of SDB observed suggests that the goals of PSG in this age group at our center may be to determine the type and severity of SDB rather than presence or absence. The high sensitivity between full-night and 4-h PSG supports the use of 4-h PSG in children 24months and under, especially those ⩽6months of age.

Non-respiratory indications for polysomnography and related procedures in children: an evidence-based review.

OBJECTIVE: This evidence-based review provides a systematic and comprehensive review of the literature regarding the utility of polysomnography for the evaluation of non-respiratory sleep disorders in children including hypersomnias, parasomnias, sleep-related movement disorders, and sleep in other special populations. METHODS: A task force of pediatric sleep medicine experts performed a systematic review of the literature regarding the use of polysomnography for non-respiratory sleep disorders in children. They identified and graded 76 papers as evidence. RESULTS: The main results include (1) polysomnography combined with the multiple sleep latency test is useful for evaluating disorders of excessive somnolence to objectively quantify sleepiness. The results have to be interpreted with consideration of the pubertal stage and regularity of the sleep patterns of the child; (2) polysomnography is indicated in children with parasomnias or sleep related movement disorders who have a high likelihood of having obstructive sleep apnea (OSA); (3) polysomnography is not routinely indicated in children with enuresis unless there is a high likelihood of OSA; (4) polysomnography can be helpful in evaluating children with restless legs syndrome (RLS) and when periodic limb movement disorder (PLMD) is suspected. CONCLUSIONS: These findings suggest that, in children with non-respiratory sleep disorders, polysomnography should be a part of a comprehensive sleep evaluation in selected circumstances to determine the nature of the events in more detail or when the suspicion of OSA is relatively high.

Executive summary of respiratory indications for polysomnography in children: an evidence-based review.

OBJECTIVE: This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children. METHODS: A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep. RESULTS: The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support. CONCLUSIONS: Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.

Delivery of pediatric sleep services via telehealth: the Alberta experience and lessons learned.

Concerns regarding a child's sleep, identified by a caregiver or by the health care practitioner, are commonly raised but often left unexplored. Families in geographically isolated areas, with limited access to specialty services such as pediatric sleep medicine, are at increased risk for unmet treatment needs. Telehealth is a potential vehicle for delivery of these specialty services and overcoming barriers in diagnosing and treating sleep disorders in children by improving access and enhancing support for the families in their communities. This article describes the initiation of a pilot program in the delivery of multidisciplinary pediatric sleep medicine services via telehealth in Alberta, Canada.

Prevalence of overweight and obesity in children and adolescents with type 1 diabetes mellitus.

BACKGROUND: Information about the prevalence of obesity in children with type 1 diabetes mellitus (DM1) is inconsistent and limited. The burden of the concurrent problems of obesity and DM1 can have notable medical, psychological, and social implications for both patients and their families. AIMS: To determine prevalences of overweight and obesity in children with DM1 compared to a control population. METHODS: In a cross-sectional study, we compared the prevalence of overweight/obesity in 390 children with DM1 (males 54%) and 565 controls (CONT; males 60%) aged 6 to 16 years. Overweight and obesity were defined as body mass indices between the 85th and 95th percentiles, and greater than the 95th percentile for age, respectively. RESULTS: Overall, 29.5% DM1 and 18.1% CONT (p < 0.001) were either obese or overweight. The prevalence of obesity alone did not differ (DM1 5.4% vs CONT 8.2%), but a greater rate of overweight was seen in the DM1 group (DM 24.1% vs CONT 10.0%, p < 0.001). Rate's of overweight were higher in the DM1 than CONT across all age groups and in both genders (males: DM1 20.1% vs CONT 8.9%, p < 0.001; females: DM1 28.7% vs CONT 11.5%, p < 0.001). Only females showed an increase in overall overweight/obesity rate (DM1 34.8% vs CONT 16.4%, p < 0.001) and this was most evident in older girls. CONCLUSIONS: Children with DM1 are more overweight, but not more obese, than their nondiabetic counterparts. Additional research is warranted to evaluate the characteristics of DM1 and its management that may influence weight gain.

Disordered respiratory control in children with partial cerebellar resections.

While the cerebellum is not traditionally thought of as having an important role in respiratory control, breathing involves cyclic motor acts that require cerebellar coordination. We postulate that children with partial cerebellar resections have disordered respiratory control due to altered synchronization of ventilatory muscles. We reviewed the records of 36 children following partial cerebellar resections due to neoplasms confined to the cerebellum. P aCO2 values were elevated in 19% of patients. Six patients had apneic or bradypneic events documented within the first month after resection. Two patients required intubation with assisted ventilation, and one needed assisted ventilation for 7.3 weeks. Those with apnea had lower oxygen saturations, and a longer need for supplemental oxygen. Patients with apnea were older than those without apnea. Swallowing, which uses many of the same muscles as those needed to maintain upper airway patency, was dysfunctional in 50% of those with apneas. We conclude that children with cerebellar resections have an increased incidence of apnea, hypoventilation, and hypoxemia not otherwise explained by pulmonary disease, and some require prolonged assisted ventilation. We speculate that these abnormalities are manifestations of altered respiratory control caused by dysfunctional cerebellar coordination of ventilatory muscles.