Comorbid insomnia and sleep apnea in children: a preliminary explorative study.

Insomnia and sleep-disordered breathing (SDB) are prevalent sleep disorders. These disorders can therefore be concurrently present - comorbid insomnia and sleep apnea (COMISA). The prevalence of COMISA in the paediatric age range is unclear. As such, phenotypic constructs should help better define this comorbid condition if it exists in children and improve both diagnostic sensitivity and ultimately clinical care outcomes. We aimed to evaluate the frequency of insomnia in children and adolescents referred for evaluation of sleep symptoms suggestive of SDB in one initial (Cohort#1) and verify such findings in an independent cohort (Cohort#2) using a retrospective cross-sectional approach in patients aged 9-19 years presenting at a sleep centre to be evaluated for symptoms of SDB. Cohort #1 comprised 50 consecutive children (58% males; mean [SD] age 13.6 [3.3] years; median [interquartile range, IQR] Epworth Sleepiness Scale score 10 [6-12]) who were evaluated using validated SDB and insomnia questionnaires. Cohort#2 was extracted from electronic medical records and included 384 polysomnographically evaluated children (mean [SD] age 12.9 [3.6] years; mean [SD] body mass index z score 1.27 [0.28]; median Epworth Sleepiness Scale score 9.7 [4-17]). In Cohort #1, 56% were at high risk of SDB, 36% had insomnia alone, and 18% were at high risk of COMISA. The prevalence of COMISA in Cohort #2 was 16%, 72% had SDB alone, and 12% had insomnia alone. In both cohorts, COMISA manifested as increased propensity for sleepiness and fatigue during both waking and daytime. Thus, the presence of COMISA is frequent in the paediatric age range and accompanied by a more prominent symptomatic phenotype.

Temporomandibular disorders in patients with polysomnographic diagnosis of sleep bruxism: a case-control study.

BACKGROUND: Temporomandibular disorders (TMD) is a collective term that refers to complaints of temporomandibular joint (TMJ) pain, fatigue and/or pain of the craniocervical muscles, limitation of movement of the mandible, and TMJ noises. Sleep bruxism (SB) is a disorder involving rhythmic (phasic) or non-rhythmic (tonic) masticatory muscle activity during sleep and is not a movement disorder or a sleep disorder in otherwise healthy individuals. The present study aimed to support or reject the null hypothesis that there is no association between SB and TMD. METHODS: The study population was recruited from patients who visited the Artmedica Clinic, Mossoro city, Rio Grande do Norte, Brazil. Patients who underwent polysomnography received information about the research and were invited to participate following the inclusion and exclusion criteria. The study sample consisted of 40 individuals with age ranging from 19 to 76 years. The subjects were administered the questionnaire of the European Academy of Craniomandibular Disorders (AEDC). Those who answered affirmatively to at least one question of the questionnaire were recommended to visit the primary researcher's dental clinic for examination; those who met the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) were evaluated, and their condition was classified into one or more subtypes of TMD. The subjects were divided into 4 groups according to the polysomnographic findings and the responses to the AEDC questionnaire. Of the 40 individuals who answered the AEDC questionnaire and underwent polysomnography, 28 presented with TMD symptoms. The data were expressed as simple frequency and percentage values using statistical software. Values of p < 0.05 were considered to be significant. RESULTS: The results showed that the frequency of TMD in individuals diagnosed to have SB was 46.4%. According to the DC/TMD of the 28 individuals, the most prevalent TMD subtype was local myalgia (85.7%). Of the total subjects, 32.5% had TMD and SB, 36.4% were males, and in the age range of 31 to 40 years (40%). CONCLUSION: In this study sample, there was no association between SB as currently defined and TMD, thus confirming previous findings on this topic.

Comorbid Insomnia and Sleep Apnea: COMISA.

The term "comorbid insomnia and sleep apnea" (COMISA) has been used to categorize the co-occurrence of the most prevalent and impacting sleep disorders. Meanwhile, both insomnia and sleep apnea have been shown to be associated with increased stress levels and cardiometabolic risk, a major cause of mortality. The better knowledge about such convergence would be critical for better understanding pathophysiological pathways and mechanisms. This article provides an overview of epidemiologic aspects, clinical findings, and mechanisms subsiding COMISA. Odontostomatological approach with mandibular advancement devices are discussed as an effective therapeutic approach in these patients.

Phenotyping OSA: Conceptualization and Implications for Treatment with Mandibular Advancement Devices.

Obstructive Sleep Apnea (OSA) is a common medical disorder and the most impacting sleep disturbance. OSA derive from the narrowing of the upper airway during sleep, which result in recurrent episodes of ventilatory disturbances expressed by an increased airflow resistance (flow limitation and hypopneas) and often an absence of ventilation (apneas). The high heterogeneity in the clinical picture of OSA turns diagnostic and treatment challenging. In the last decade different phenotypes, referring to specific categories of patients that can be distinguished from others by features and related clinical meaningful attributes, were identified. Those phenotypes may predict clinically important outcomes as those deriving from MAD therapy.

The association of obstructive sleep apnea and behavioral insomnia in children ages 10 and under.

STUDY OBJECTIVES: Behavioral insomnia of childhood (BIC) and obstructive sleep apnea (OSA) are highly prevalent conditions affecting 10%-20% and 1%-5% of children, respectively. Studies in adults and adolescents have suggested that comorbid insomnia and OSA may have distinct clinical characteristics. The association between the two conditions in the pediatric population has not been thoroughly investigated. This study aimed to examine the association between BIC and OSA in young children. METHODS: Children, 6 months to 10 years old, referred to a sleep specialist and polysomnography at the Hadassah Medical Center between 2018 and 2021 were included in this retrospective analysis. We excluded children with chromosomal and craniofacial abnormalities, posttonsillectomy, or neurological impairment. BIC diagnosis was extracted from the electronic health records in accordance with the International Classification of Sleep Disorders, third edition criteria. OSA was diagnosed by polysomnography (apnea-hypopnea index > 2 events/h). RESULTS: Of 312 children (age 4.42 ± 2.42 years), 126 (40.4%) were non-OSA non-BIC, 125 (40.1%) OSA non-BIC, 34 (10.9%) BIC non-OSA, and 27 (8.7%) comorbid insomnia and OSA. OSA and non-OSA children had a similar prevalence of BIC. Children in the comorbid insomnia and OSA group were significantly younger (2.22 ± 1.21 years). Younger age at polysomnography, premature birth, and increased periodic leg movements on polysomnography were independently associated with OSA in a multivariable analysis. Lower body mass index, regardless of OSA, was associated with BIC. CONCLUSIONS: Current findings do not support an association between behavioral insomnia of childhood and obstructive sleep apnea in children. Healthcare providers should consider each of these sleep disorders in children presenting with sleep difficulties since each has distinct diagnostic and therapeutic options. CITATION: Yelov L, Reiter J, Meira E Cruz M, Gileles-Hillel A. The association of obstructive sleep apnea and behavioral insomnia in children ages 10 and under. J Clin Sleep Med. 2024;20(2):245-251.

Enhancing Sleep Quality in Pediatric Intensive Care: A Chronobiological Perspective.

Biologic synchronized rhythmicity is a critical physiologic process. The lack of synchronized rhythms, mainly those showing a circadian basis, like sleep, heart rate, and arterial pressure, often leads to several organic challenges usually associated with adverse outcomes. Sleep itself, as an independent regulator of many crucial body functions, should preferentially occur with minimum interferences to optimize its plastic role toward structural and functional recovery and regeneration. Hence, patients will mostly benefit from both circadian and sleep-related optimized functions in order to improve prognosis and reduce patients' discharge times.

Morphometric measures and desaturations: Proposal for an index with improved accuracy for obstructive sleep apnea screening.

STUDY OBJECTIVE: To evaluate the sensitivity and specificity of the combined Kushida morphometric model (KMM) and the oxygen desaturation index (ODI) for screening individuals with obstructive sleep apnea. METHODS: Diagnostic test study with adults >18 years, both sexes, polysomnography, body mass index, neck circumference and intraoral measurements. RESULTS: 144 patients were invited; of these, 75 met the exclusion criteria. 55 individuals presented AHI ≥5 ev/h and 14, an AHI <5 ev/h. Three AHI cut-off points were evaluated: AHI ≥5, ≥15, ≥30 ev/h. When adopting the cut-off point of AHI ≥5 ev/h, the KMM showed sensitivity (SE) = 60.0 %, specificity (SP) = 71.4 % and 95 % confidence interval of the area under the curve (95 % CI of AUC) = 0.655; the combination of KMM and ODI (KMM + ODI) revealed SE = 73.0 %, SP = 71.4 % (95 % CI of AUC = 0.779) and the ODI showed SE = 76.4 % and SP = 92.9 % (95 % CI of AUC = 0.815). At the cut-off point of AHI ≥15 ev/h, the KMM presented SE = 64.1 %, SP = 76.7 % (95 % CI of AUC = 0.735); the KMM + ODI showed SE = 82.1 %, SP = 83.3 % (95 % CI of AUC = 0.895); and the ODI presented SE = 76.9 %, SP = 100.0 % (95 % CI of AUC = 0.903). For the cut-off point of AHI ≥30 ev/h, the KMM showed SE = 56.0 %, SP = 77.2 % (95 % CI of AUC = 0.722); the KMM + ODI revealed SE = 92.0 %, SP = 79.5 % (95 % CI of AUC = 0.926); and the ODI showed SE = 92.0 %, SP = 90.9 % (95 % CI of AUC = 0.941). CONCLUSION: The combination of oxygen desaturation index and Kushida morphometric model improved the sensitivity and specificity of this model regardless of obstructive sleep apnea severity suggesting greater effectiveness in risk prediction.

The enigma of sleep: Implications of sleep neuroscience for the dental clinician and patient.

BACKGROUND: Sleep disturbances have been shown to result in considerable morbidity and mortality. It is important for dental clinicians to understand the neuroscience behind sleep disorders. TYPES OF STUDIES REVIEWED: The authors conducted a search of the literature published from January 1990 through March 2024 of sleep medicine-related articles, with a focus on neuroscience. The authors prioritized articles about the science of sleep as related to dental medicine. RESULTS: The authors found a proliferation of articles related to sleep neuroscience along with its implications in dental medicine. The authors also found that the intricate neuroscientific principles of sleep medicine are being investigated robustly. The salient features of, and the differences between, central and obstructive sleep apneas have been elucidated. Sleep genes, such as CRY, PER1, PER2, and CLOCK, and their relationship to cancer and neurodegeneration are also additions to this rapidly developing science. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The dental clinician has the potential to be the first to screen patients for possible sleep disorders and make prompt referrals to the appropriate medical professionals. This can be lifesaving as well as minimize potential future morbidity for the patient.

Sleep Bruxism and Sleep Structure in Comorbid Insomnia and Obstructive Sleep Apnea (COMISA) Syndrome: A Polysomnographic Study.

Introduction: Comorbid insomnia and obstructive sleep apnea (COMISA) is not a well-identified sleep disorder, despite having a significant impact on health. This study investigates the relationship between sleep bruxism (SB) and sleep architecture in patients with COMISA, obstructive sleep apnea (OSA), and in those without any sleep disorders. Methods: 119 patients were included in the study and divided into three groups: OSA, COMISA, and a control group. Polysomnographic (PSG) examination provided parameters related to sleep architecture, OSA, and characteristics of SB. Results: The bruxism episode index (BEI) and other SB parameters were not found to be statistically different between the three groups (p > 0.05). There was no statistical difference in measured sleep architecture between the COMISA and OSA groups (p > 0.05). In comparison to the control group, participants in the COMISA group were found to have an increased apnea-hypopnea index (AHI), oxygen desaturation index (ODI), respiratory disturbance index (RDI), all arousals (AA), and respiratory arousals (RA) (p < 0.05). Among COMISA patients, AA and RA were shown to have a positive linear correlation with the number of bradycardia events per hour (r = 0.49, r = 0.48, p < 0.05). Conclusions: SB does not occur in patients with COMISA more frequently than in patients with OSA or those without any sleep disorders. PSG parameters are not specific for COMISA; therefore, in order to differentiate this disorder from OSA alone, a comprehensive patient assessment has to be performed.

A challenging case of sexsomnia in an adolescent female presenting with depressive-like symptoms.

Sleep-related sexualized behaviors occur in the parasomnia known as sexsomnia, recognized as a variant of confusional arousals in the International Classification of Sleep Disorders, third edition. These instinctive behaviors of a sexual nature emerge from deep non-rapid eye movement sleep, and patients often present with distinguishing features within this sleep disorder category. There are often adverse psychosocial consequences and not uncommonly medicolegal implications. While associations to psychiatric consequences from the sexsomnia have been demonstrated and efforts to further typify this condition have been made, sexsomnia remains incompletely characterized in the more than 200 published cases to date, with male predominance. We now present the first reported case of an adolescent female with sexsomnia that was triggered by the onset of Crohn's disease and its treatment with azathioprine and with interpersonal consequences leading to an initial psychiatric consultation on account of depressive symptoms. These symptoms were deemed to be secondary to the sexsomnia. In addition to describing unusual and clinically relevant features in this case of sexsomnia, this original case provides insights into triggers, predisposing factors, perpetuating factors, and therapeutic considerations that are important for raising awareness in sleep clinicians, primary care providers, and mental health professionals. CITATION: Brás J, Schenck CH, Andrade R, et al. A challenging case of sexsomnia in an adolescent female presenting with depressive-like symptoms. J Clin Sleep Med. 2023;19(10):1845-1847.

Rapid maxillary expansion in pediatric patients with obstructive sleep apnea: an umbrella review.

OBJECTIVE: To compare polysomnographic parameters with others from the literature in order to provide more accurate information about Rapid Maxillary Expansion (RME) for treating Obstructive Sleep Apnea (OSA) in children, through raising the question: Is RME a good option for treating OSA in children? Prevention of mouth breathing during children's growth remains a challenge with significant clinical consequences. In addition, OSA induces anatomofunctional changes during the critical period of craniofacial growth and development. METHODS: The Medline, PubMed, EMBASE, CINAHL, Web of Science, SciELO and Scopus electronic databases were searched up to February 2021 for systematic reviews with meta-analysis in the English language. Among 40 studies on RME for treating OSA in children, we selected seven in which polysomnographic measurements of the Apnea-Hypopnea Index (AHI) had been made. Data were extracted and examined in order to clarify whether any consistent evidence exists for indicating RME as a treatment for OSA in children. RESULTS: We found no consistent evidence favoring RME for long-term treatment of OSA in children. All the studies presented considerable heterogeneity due to variability of age and length of follow-up. CONCLUSION: Through this umbrella review, the need for methodologically better studies on RME is supported. Moreover, it can be considered that RME is not recommended for treating OSA in children. Further studies and more evidence identifying early signs of OSA are necessary in order to achieve consistent healthcare practice.

Sleep Quality and Social Jetlag in Young Adults During the Social Distancing Caused by COVID-19.

Introduction: This study aimed to evaluate the sleep quality and the Social Jetlag frequency in young adults during social distancing because of COVID-19. Methods: This is a cross-sectional study with 308 students aged ≥18 years and with Internet access. Questionnaires used: Pittsburgh Sleep Quality Index - Brazil (PSQI-BR), Epworth Sleepiness Scale, and Munich Chronotype Questionnaire. Results: The mean age of the students was 21 ± 3 years (17 - 42y), with no statistically significant difference between genders. The PSQI-BR indicated that 257 (83.4%) had poor sleep quality. The mean of Social Jetlag for young adults was 02:00 ± 01:49h, and we observed that 16.6% (n = 51) had Social Jetlag. Compared to men in the good sleep quality group, women had higher means for sleep duration on study days and free days, mid-point of sleep on study days and free days and corrected mid-point of sleep on free days. However, when compared to men in the group of poor sleep quality, we observed higher means for women regarding sleep duration on study days, the mid-point of sleep on study days, and the corrected mid-point of sleep on free days. Conclusions: Thus, the high frequency of young adult students who had poor sleep quality associated with Social Jetlag (2 hours) in the present study may reflect a pattern of sleep irregularity, which may be associated with impairment of environmental synchronizers and stimulation of social synchronizers during the lockdown resulting from the COVID-19 pandemic.