Sleep apneas in children

There are many causes leading to breathing disorders in children. In the newborn period the immature central regulation of breathing can result in a pattern with apneas and bradycardias most commonly seen in the very premature infant. Therefore, during hospital stay many of these very tiny preterms and some of the very ill term infants do have severe apneas and do need medication and or mechanical support (nasal CPAP, positive pressure ventilation). In the first two to three months of life central dysmaturity can persist in some infants and apneas of infancy can occur further on. Infants with prolonged apneas and symptoms like paleness, cyanosis, stiffness or limpness are often investigated, treated or monitored. At the age of two to six, every tenth child is a loud snorer. Every fifth snorer at this age suffers from a severe upper airway obstruction. Factors that decrease pharyngeal size or increase pharyngeal compliance may lead to obstruction. Adenotonsillar hypertrophy is the most common associated condition, craniofacial disorders, central nervous system and neuromuscular problems and less obesity are disposing factors. Children may present nocturnal symptoms like snoring, difficult breathing or disturbed sleep, but most of them have daytime problems as initial complaint such as hyperactivity, behavioral problems, growth failure, poor school performance. Excessive daytime sleepiness is not so common in young children. The childhood obstructive sleep apnea syndrome is a common and serious problem. Children with symptoms suggesting severe obstruction should be evaluated and treated. Most children are cured by adenotonsillectomy whilst some require further therapy.     

Evaluation of the patient who has sleep complaints: a case-based method using the sleep process matrix

There are four sleep symptoms that patients can have: difficulty with sleep onset, problems occurring during sleep, difficulty awakening from sleep, and daytime sleepiness. These symptoms develop when there is a problem in one or more of the nine fundamental process domains that control sleep. These fundamentalsleep process domains are: circadian, homeostatic, ultradian, developmental, cardiorespiratory, neurological, psychiatric/behavioral,drugs/alcohol, and other medical problems. Successful treatment of the sleep problems depends on the correct identification of the underlying sleep processes that are causing the sleep symptom.The sleep process matrix is a way of organizing one's thinking to accomplish this task.     

儿童及青少年失眠的临床特征及治疗研究概况

儿童及青少年是生命历程的关键阶段,许多有助于确定当前和未来健康结果的行为模式在此间得以确立,儿童及青少年精神卫生保健至关重要。儿童及青少年失眠受青春期生理发育、学校及家庭等社会环境、心理行为等多种因素影响,囊括了入睡困难、睡眠时间不足、睡眠质量差和日间困倦等一系列症状,明显影响其精神状态和生活学习质量。儿童及青少年失眠的治疗方法以睡眠卫生教育、认知行为治疗和正念冥想等综合治疗为主。笔者从失眠的相关成因、症状和治疗方法3个方面对儿童及青少年失眠作一综述,为其临床诊疗提供参考。     

Myasthenia gravis and sleep

In myasthenia gravis respiratory function is often disturbed in the night, especially during REM sleep, despite of normal daytime respiratory function. Nevertheless, nocturnal respiratory problems are rarely diagnosed. Sleepiness, concentration and memory problems can be symptoms of a sleep related breathing disorder. Reports of reduction of REM sleep, memory dysfunction, and detection of acetylcholine receptor (AchR)-antibodies in the cerebrospinal fluid have lead to the hypothesis of a central nervous system involvement in myasthenia gravis. Possible mechanisms are centrally acting AchR-antibodies, unspecifically acting cytokines and hypoxia, possibly the most important influence upon REM sleep reduction and impaired cognitive function. In a patient presenting possible CNS-involvement (cephalea, fatigue, concentration and memory problems), a polysomnographic investigation should therefore be performed to detect a sleep related breathing disorder.     

The relationship between psychiatric diseases and insomnia

Sleep difficulties affect about one-third of American adults, yet these symptoms are not often addressed by patients and their physicians. Unresolved insomnia that impairs daytime function may be associated with significant psychiatric morbidity, predominantly major depression. Clinicians who are aware that these disorders frequently co-exist will be able to facilitate prompt diagnosis and initiate appropriate pharmacotherapeutic intervention. Antidepressant therapies may interfere with sleep quality; therefore, the management of insomnia in depressed patients should be addressed separately. Traditionally, benzodiazepines have been prescribed to treat sleep disturbances, but certain drugs in this class have limited benefits due to residual sedative effects that impair cognitive function, memory and general daytime performance. Zaleplon, a new, quick-acting, non-benzodiazepine sleep medication, may be clinically advantageous in promoting sleep without residual impairment.     

Critical components of a sleep assessment for clinical practice settings

Disturbed sleep affects multiple aspects of an individual's life, including daytime activity, social interactions, mood, and quality of life. Individuals with mental health issues often experience disturbed sleep, and particular attention must be given to underlying lifestyle, family issues, and health problems that may perpetuate a sleep complaint. In addition to patients' medical conditions, clinicians should ask patients about their sleep-wake patterns and medication use, since these factors contribute to disturbed sleep and adverse mental health outcomes. This article provides advanced practice nurses with a brief sleep assessment guide for use in psychiatric practice with adults or children.     

CRITICAL COMPONENTS OF A SLEEP ASSESSMENT FOR CLINICAL PRACTICE SETTINGS

Disturbed sleep affects multiple aspects of an individual's life, including daytime activity, social interactions, mood, and quality of life. Individuals with mental health issues often experience disturbed sleep, and particular attention must be given to underlying lifestyle, family issues, and health problems that may perpetuate a sleep complaint. In addition to patients' medical conditions, clinicians should ask patients about their sleep-wake patterns and medication use, since these factors contribute to disturbed sleep and adverse mental health outcomes. This article provides advanced practice nurses with a brief sleep assessment guide for use in psychiatric practice with adults or children.     

Sleep disorders in Parkinson's disease

Sleep quality is one of the major sources of dissatisfaction among patients with Parkinson's disease (PD). Insomnia, parasomnia and daytime sleep disorders are all common. The motor problems accompanying PD are well studied and documented, yet little is known about sleep and the other non-motor problems. Dopaminergic medications, the neurochemical and neurodegenerative changes may all contribute to the pathogenesis of sleep disorders in PD. Subjective or objective sleepiness assessment should routinely be performed by physicians looking after PD patients. Patients should be informed of the risks associated with excessive daytime sleepiness. Management is difficult and should be targeted to the specific sleep disorder and its likely cause. Simple sleep measures such as sleep hygiene should be tried first before pharmacological treatment is initiated.     

Asymptomatic Brady arrhythmias as a Marker for Sleep Apnea: Appropriate Recognition and Treatment May Reduce the Need for Pacemaker Therapy

Sleep apnea is associated with many adverse cardiovascular sequelae, including hypertension, nocturnal angina, decreased cardiac output, and bradyarrhythmias. The purpose of this study was to determine if patients referred for pacemaker therapy with asymptomatic bradyarrhythmias have underlying sleep apnea as the etiology of their bradyarrhythmias. This study included eight patients (7 males, 1 female) referred to a cardiac electrophysiology practice for pacemaker therapy. Patients included had asymptomatic bradyarrhythmias that consisted of severe sinus bradycardia, second-degree atrioventricular block, and complete heart block. In 7 of 8 patients, the bradyarrhythmias occurred at night or during the day while asleep. No patients were conditioned athletes. Symptoms often associated with bradyarrhythmias, such as lightheadedness and syncope, were not present. However, seven patients had at least one symptom suggestive of sleep apnea, such as excessive daytime fatigue, snoring, cessation of breathing during sleep (apnea), or frequent nighttime awakenings. Overnight polysomnography studies were obtained on patients who had one or more symptoms suggestive of sleep apnea. In this study 7 of 8 patients (88%) referred for pacemaker therapy with asymptomatic bradyarrhythmias were documented bv polysomnography to have sleep apnea. When treated with either sleep position modification, nasal continuous positive airway pressure (nasal CPAP), or tracheostomy, all seven patients had improvement in sleep apnea symptoms and remained asymptomatic from their bradyarrhythmias without pacemaker therapy over an average follow-up period of 22 months. One patient without symptoms suggestive of sleep apnea declined pacemaker therapy and remained asymptomatic. From these results, we concluded that asymptomatic transient bradyarrhythmias may suggest a diagnosis of sleep apnea. The evaluation of a patient referred for pacemaker therapy with asymptomatic bradyarrhythmias should include questions related to sleep apnea symptoms. Establishing the diagnosis of sleep apnea may reduce the need for pacemaker therapy and permit appropriate treatment of the underlying cause of these bradyarrhythmias.     

Self-reported subjective sleep quality and fatigue in patients with peritoneal dialysis treatment at home

The aim of this study was to describe habitual sleep, daytime symptoms, sleep-disturbing factors, current sleep during 1 week and fatigue in patients with peritoneal dialysis treatment at home and also discover predictions for sleep quality outcome. The knowledge should increase possibilities for supportive nursing health care. Fifty-five patients answered two mailed questionnaires and filled in a sleep diary. Of these, 60% had moderate, persistent sleep problems combined with daytime symptoms. Nocturnal awakenings with difficulties falling asleep again and a sleep duration predicted as 57% of sleep quality. Nocturnal pruritus and 'difficulties finding a comfortable sleeping position' were significant sleep-disturbing factors. Sleep quality predictors means progress in knowledge about the complexity of the situation for peritoneal dialysis patients. Poor sleep, daytime symptoms, sleep-disturbing factors and chronic fatigue need to be enlightened, especially for the nephrology nurses who are in a unique position to give supportive nursing health care.     

Prevalence of sleep disorders in childhood and adolescence with headache: a case-control study

Although a relationship between headache and sleep disturbances has been reported in adults, only few data have been available in children. Accordingly, we performed a survey to determine the prevalence of sleep disturbances in children with migraine and tension-type headache. A questionnaire of history and clinical data and of sleep disturbances was given to parents of 283 headache subjects (164 with migraine and 119 with tension-type headache). Results were compared to a normative group comparable for age and sex of 893 normal healthy subjects. Migraine subjects showed a higher prevalence of sleep disturbances during infancy as well as 3-month colic. In both headache groups, more parents had sleep disturbances and there was a higher occurrence of co-sleeping and napping. A high frequency of sleep disturbances involving sleep quality, night awakening, nocturnal symptoms and daytime sleepiness was reported in headache children. No statistical differences were found in the prevalence of sleep disturbances between migraine and tension-type headache. However, the migraine group tended to have "disturbed sleep" more often with increased prevalence of nocturnal symptoms such as sleep breathing disorders and parasomnias. Our results give further support to an association between sleep and migraine that may have a common intrinsic origin.     

Sleep and medical disorders

Extensive evidence links cardiovascular disease and sleep disordered breathing. OSA has adverse effects on blood pressure, cardiovascular status,and mortality. Effective CPAP therapy can improve blood pressure and cardiac function in patients who have OSA. Patients who have congestive heart failure have a high prevalence of sleep-disordered breathing, with OSA occurring in 30% of such patients and Cheyne-Stokes respiration in 40%.CPAP is the preferred mode of therapy for both types of sleep-disordered breathing in patients who have coexistent congestive heart failure. Nocturnal worsening of asthma is a common manifestation of this disease that indicates increased disease severity. Therapy focuses on judicious use of long-acting bronchodilators, and the presence of OSA should also be considered. COPD is frequently associated with impaired sleep, likely because of chronic dyspnea and sleep-associated hypoxemia. Appropriate therapy again includes long-acting bronchodilators and possibly nocturnal supplemental oxygen.Gastroesophageal reflux during sleep may lead to prolonged episodes of esophageal acid exposure and may be a common sequela of OSA, perhaps triggering nocturnal worsening of asthma. Endstage renal disease and chronic dialysis are commonly associated with a host of troublesome sleep problems,including OSA, RLS, PLMD, and daytime sleepiness.     

A Factor Analysis of Sleep Problems and their Psychological Associations in Children with Down's Syndrome

The aims of the study were (a) to identify statistically derived sleep disturbance factors in children with Down's syndrome and (b) to explore the possibility that these factors have different psychological associations when compared to each other. Principal components analysis was performed on the results of a parental sleep questionnaire survey on 91 children with Down's syndrome. Three significant sleep disturbance factors were obtained: (a) those where the problem was primarily one of getting the child to go to bed and/or settling to sleep (sleep onset problems); (b) those where the problem was characterised by disturbances during the night, i.e. nocturnal wakings and restlessness (sleep maintenance problems); and (c) those where the problem was primarily one of disordered breathing during sleep. Children showing any one of these types of sleep problems had significantly higher daytime behaviour problem and maternal stress scores than children showing none. Children showing disturbances through the night had higher daytime behaviour scores than all the other groups on virtually all the daytime scales. The findings of the study are discussed along with further research possibilities.     

Cosleeping and Behavioral Sleep Problems in School-aged Children with Neurodevelopmental and Mental Health Disorders

The aim of this study was to explore the presence of sleep-related complaints and their relationship to cosleeping in a sample of 57 children with mental health disorders. Information about the practice of cosleeping was collected through an interview and behavioral sleep problems were evaluated with a subset of items from the Spanish version of the Pediatric Sleep Questionnaire (PSQ). Controlling for age, cosleepers scored higher on insomnia, daytime sleepiness and poor sleep scheduling, compared to solitary sleepers. Therefore, mental health professionals should explore the child's sleep environment and, when necessary, use appropriate interventions to address such problems.     

Nightmares and disorders of dreaming

Dreams occur during all stages of sleep. Nightmares are common. They can be associated with poor sleep and diminished daytime performance. Frequent nightmares are not related to underlying psychopathology in most children and in some "creative" adults. However, recurrent nightmares are the most defining symptom of post-traumatic stress disorder and may be associated with other psychiatric illnesses. Night terrors are arousal disorders that occur most often in children and usually occur early in the sleep period. Patients with rapid-eye-movement behavior disorder often present with nocturnal injury resulting from the acting out of dreams. Dream disorders may respond to medication, but behavioral treatment approaches have shown excellent results, particularly in patients with post-traumatic stress disorder and recurrent nightmares.     

Evaluating a family-centred intervention for infant sleep problems

AIM: This paper reports a study to describe changes in parents' distress after a family-centred intervention for sleep problems of infants. BACKGROUND: Infant sleep problems are common and are related to depressive symptoms in mothers, but their impact on fathers has rarely been studied. Because childhood sleep problems and parental distress are associated, their interdependence should be recognized in research and in paediatric sleep practice. METHODS: All children hospitalized for sleep problems in a hospital in Iceland in 1997-1998 and their parents were studied using a pre- and post-test quasi-experimental design. The sample consisted of 33 infants (6-23 months of age), 33 mothers and 30 fathers. Parents' distress was assessed before and after treatment with regard to: (1) fatigue and resulting symptom distress; (2) parenting stress; (3) state-anxiety; and (4) depressive symptoms. Infants were treated for a variety of sleep problems by a paediatric nurse. The parents were simultaneously treated for distress by either the paediatric nurse or a specialist, depending on the nature of their problems. RESULTS: Mothers and fathers experienced a high degree of distress before the intervention, with no significant difference between them. Two months after the intervention both parents' distress had significantly improved. Parents' degree of distress was at a psychopathological level before the intervention but was reduced to population norms 2 months after the intervention. The paediatric nurse intervention was sufficient to reduce distress for 83% of parents. CONCLUSIONS: Health care professionals who care for infants with sleep problems should pay attention to the distressed responses of parents and support their recovery. An intervention such as that described here could be used by nurses for this purpose.     

Are Sleep Difficulties Associated With Migraine Attributable to Anxiety and Depression?

Objective.— To examine whether sleep complaints reported by migraineurs can be attributed to comorbid anxiety and/or depression. Background.— A consistent association between migraine and sleep complaints has been reported in community and clinical studies. However, anxiety and depression are often comorbid with migraine. Thus, it may be possible that the increased prevalence of sleep problems in migraineurs is attributable to comorbid anxiety and depression. To our knowledge, no previous studies have demonstrated that the associations are not solely attributed to comorbid anxiety and depression. Design and Methods.— Controlled family study of anxiety disorders and substance use disorders in a community in New Haven County, CT. The sample included 221 probands (41 migraineurs) and their 261 directly interviewed first‐degree relatives (39 migrainuers), including parents, siblings, and offspring over age 18. A lifetime history of migraine was obtained using the Diagnostic Interview for Headache Syndromes. A lifetime history of psychiatric disorders was obtained using the semi‐structured Schedule for Affective Disorders and Schizophrenia which was modified to incorporate Diagnostic and Statistical Manual diagnostic criteria. Several sleep items on current and lifetime sleep complaints were included as a subset of the interview. Results.— There was a significant association between migraine and the number of sleep problems as well as several specific sleep symptoms among probands and their adult relatives. Adults with migraine reported having significantly more lifetime sleep problems (OR [CI] = 2.3 [1.1‐4.6]), and more current sleep difficulties, specifically, inadequate sleep (2.5 [1.2‐5.0]), difficulty falling asleep (3.0 [1.5‐6.3]), and persistent nightmares of childhood onset (4.3 [1.8‐9.9]) than those without migraine. The associations between sleep problems and migraine persisted after controlling for both lifetime and current anxiety and mood disorders. Conclusions.— The association between sleep problems and migraine that is not solely explained by comorbid anxiety disorders or depression suggests that sleep problems should be evaluated among people with migraine.     

Self-reported sleep quality,strain and health in relation to perceived working conditions in females

Self-reported sleep quality, strain and health in relation to perceived working conditions in females The aims of this study were to examine self-reported sleep quality, perceived strain and health in relation to working conditions; the prevalence and severity of sleep disturbances and daytime distress arising from poor sleep in women on different work shifts. Furthermore, to see whether females with gastrointestinal symptoms, joint-, back- or muscle-pain and who are dissatisfied with working hours differ with regard to the above aspects. Finally, degree of strain-related symptoms and sleep difficulties were tested as predictors of sleep quality and general health outcome. Important research questions are whether registered nurses and those on rotating work shifts have greater sleep problems than others. A total of 156 females, aged 20-59 years, working at three different casualty departments, answered structured questionnaires. The results showed a persistently high rate of psycho-physiological long-term effects of stress related to working conditions. Thirty-four per cent were dissatisfied with their working hours, and exhibited significantly more mental strain, fatigue/excessive tiredness and inability to relax after work because of involuntary thoughts, in relation to working conditions than others did. Sixty-two females (39.7%) complained of insufficient sleep. The sleep quality outcome was significantly predicted by difficulty falling asleep (odds ratio 8.4), difficulty in falling asleep after nocturnal awakening (odds ratio 3.4) and perceived exhaustion (odds ratio 2.6). Females suffering from gastrointestinal symptoms and joint-, back- and muscle symptoms for several days in a week or even everyday were especially sensitive to worse sleep quality. Independent of work shifts, registered nurses exhibited a higher degree of mental strain and prolonged recovery in comparison with others. In conclusions, sleep initiation difficulties, troubled sleep and exhaustion significantly predicted reduced sleep quality outcome with decreased resilience to stress and vulnerability to psycho-physiological disorders in females working within the health care system.     

Practical Considerations for the Diagnosis and Management of Asthma in Older Adults

Although often considered a disease of childhood, the prevalence of asthma in US adults aged 65 years or older is similar to that in children, with the number of older patients needing care for asthma likely to continue to increase. As with most chronic diseases, there are challenges associated with the diagnosis and management of asthma in an older population. This review discusses these challenges, suggesting practical management strategies for primary care physicians and their teams. Asthma comprises a spectrum of phenotypes, some associated with adult onset. The symptoms and characteristics of patients with late-onset asthma can differ from those of patients with early-onset disease. Furthermore, older patients may fail to recognize respiratory symptoms as abnormal and have other comorbidities, complicating the differential diagnosis of asthma. Once diagnosed, the long-term goals of asthma management are no different in older adults than in anyone with asthma, with inhaled corticosteroids being the cornerstone of therapy. Comorbid conditions become more common with age and have a direct impact on a patient's respiratory symptoms and potential adverse effects of therapy, thereby influencing the choice of therapies and delivery systems and potentially increasing the likelihood of complex polypharmacy. In conclusion, asthma, although traditionally considered a disease of the young, should be considered as a potential diagnosis in older adults with respiratory symptoms, even without a history of asthma or allergies. As with all patients, the primary goals of asthma management in older adults are symptom control and exacerbation reduction.     

Snoring, not just a social nuisance

Snoring is a very common source of complaints from partners and neighbours. Snorers themselves are less likely to be affected, unless they have associated daytime sleepiness caused by the sleep disruption from obstructive sleep apnoea. There is increasingly firm evidence that obstructive sleep apnoea is associated with hypertension, cardiovascular, cerebrovascular and metabolic problems such as insulin resistance, even at mild levels which may not cause much daytime somnolence. In addition, the central and obstructive apnoeas found in cardiac failure affect heart muscle function. Treatment of the apnoea improves blood pressure and cardiac function and is likely to have a beneficial effect on mortality. Since obstructive sleep apnoea is common it should be sought by appropriate questioning in these patient groups. The treatments for obstructive sleep apnoea are effective but cumbersome and this remains a challenge if patients do not achieve obvious early benefits such as reduction in sleepiness or breathlessness.