European expert guidance on management of sleep onset insomnia and melatonin use in typically developing children.

Sleeping problems are prevalent among children and adolescents, often leading to frequent consultations with pediatricians. While cognitive-behavioral therapy has shown effectiveness, especially in the short term, there is a lack of globally endorsed guidelines for the use of pharmaceuticals or over-the-counter remedies in managing sleep onset insomnia. An expert panel of pediatric sleep specialists and chronobiologists met in October 2023 to develop practical recommendations for pediatricians on the management of sleep onset insomnia in typically developing children. When sleep onset insomnia is present in otherwise healthy children, the management should follow a stepwise approach. Practical sleep hygiene indications and adaptive bedtime routine, followed by behavioral therapies, must be the first step. When these measures are not effective, low-dose melatonin, administered 30-60 min before bedtime, might be helpful in children over 2 years old. Melatonin use should be monitored by pediatricians to evaluate the efficacy as well as the presence of adverse effects.    Conclusion: Low-dose melatonin is a useful strategy for managing sleep onset insomnia in healthy children who have not improved or have responded insufficiently to sleep hygiene and behavioral interventions.

An online survey among general pediatricians on melatonin use in children with chronic insomnia.

OBJECTIVES: Although melatonin (MLT) is the molecule most used by pediatricians for sleep problems, scarce evidence exists on its use in healthy pediatric population. The objective of this study was to describe MLT use by Italian pediatricians in healthy children with chronic insomnia. STUDY DESIGN: A cross-sectional open survey was administered to Italian pediatricians, between June and November 2022, collecting information about their use of MLT in healthy children: age range of patients, dosages used, time of administration, duration of treatment, association with other treatments, perceived efficacy, and side effects. Data were reported as frequencies with their respective 95% confidence intervals. Chi-square statistics assessed significant differences between pediatricians who had training in pediatric sleep and those who did not. RESULTS: Among 428 respondents, 97.4% of pediatricians used MLT; 87.3% of them prescribed MLT in children aged 1-2 years, 62.1% in 2-5 years and 42.5% in 10-18 years. 84.9% of them suggested to take MLT 30 min before bedtime. 37.9% indicated to continue treatment for one month, 30.2% for 2-3 months. 74.1% of pediatricians usually prescribed MLT 1 mg/day. The most frequent treatment associated with MLT was sleep hygiene (85.4%). Almost all pediatricians found MLT effective in reducing difficulties falling asleep. Only 3.2% of them reported mild side effects. CONCLUSIONS: MLT is widely prescribed by Italian pediatricians, but no consensus exists about its use in typically developing children. There is a need for clear guidelines to optimize the use of MLT in healthy children.

Sleep habits and sleep disorders in Italian children and adolescents: a cross-sectional survey.

STUDY OBJECTIVES: The aim was to describe sleep habits and epidemiology of the most common sleep disorders in Italian children and adolescents. METHODS: This was a cross-sectional study in which parents of typically developing children and adolescents (1-18 years) completed an online survey available in Italy, gathering retrospective information focusing on sleep habits and disorders. RESULTS: Respondents were 4,321 typically developing individuals (48.6% females). Most of our sample did not meet the age-specific National Sleep Foundation recommendations for total sleep duration (31.9% of toddlers, 71.5% of preschoolers, 61.6% of school-age children, and 41.3% of adolescents). Napping was described in 92.6% of toddlers and in 35.2% of preschoolers. Regarding geographical differences, children and adolescents of northern Italy showed more frequent earlier bedtimes and rise times than their peers of central and southern Italy. The most frequently reported sleep disorder in our sample was restless sleep (35.6%), followed by difficulties falling asleep (16.8%), > 2 night awakenings (9.9%), and bruxism (9.6%). Data also suggest that longer screen time is associated with later bedtimes on weekdays in all age groups. CONCLUSIONS: The current study shows that Italian children are at risk of sleep disorders, particularly insufficient sleep, restless sleep, and difficulty falling asleep. The study also provides normative sleep data by age group in a large cohort of typically developing Italian children, emphasizing the importance of the developmentally, ecologically, and culturally based evaluation of sleep habits and disorders. CITATION: Breda M, Belli A, Esposito D, et al. Sleep habits and sleep disorders in Italian children and adolescents: a cross-sectional survey. J Clin Sleep Med. 2023;19(4):659-672.

Prevalence of cholelithiasis in lion tamarins (Leontopithecus spp.) kept under human care by using abdominal ultrasound.

BACKGROUND: Cholelithiasis is a digestive system disorder of multifactorial origin that occurs due to stones formed in the gallbladder. This study aimed at investigating by abdominal ultrasound examination the prevalence of cholelithiasis in lion tamarins kept under human care. METHODS: Thirty lion tamarins from five Brazilian zoos, including 17 golden lion tamarins and 13 golden-headed lion tamarins, were evaluated. RESULTS: Considering all lion tamarins, the overall frequency of cholelithiasis was 53.3% (16/30). There were no significant differences between species and sex. Cholelithiasis was predominant (75.0%) in lion tamarins older than 5 years. Septate gallbladder was observed in 86.6% (26/30) of the lion tamarins. Of these, 53.8% (14/26) had gallstones. Biochemical analysis revealed a moderate positive correlation between gamma-glutamyl transferase and the number of gallstones. CONCLUSIONS: Asymptomatic cholelithiasis is frequent in lion tamarins kept under human care. Therefore, systematic monitoring through ultrasound should be part of the preventive care of these animals.

A Narrative Review about Prosocial and Antisocial Behavior in Childhood: The Relationship with Shame and Moral Development.

We conducted a literature review aimed at identifying the origins of shame as well as its effects on moral development, especially in terms of behavioral outcomes, and we reflected on the practical implications of our findings. We explored the role of shame in moral development through cultural differences and parental influences, collecting evidence of psychopathological consequences of primary moral emotion dysregulation. These studies showed a dichotomous feature of shame, as a prosocial behavior enhancer in morally relevant situations and, simultaneously, a risk factor for aggressive and antisocial behaviors on other occasions. Dysregulated shame leads to maladaptive interpersonal behaviors, which could evolve towards psychopathological paths. Therefore, an integrated intervention is recommended in children with emotional/behavioral problems.

Children with neurodevelopmental disorders: how do they sleep?

PURPOSE OF REVIEW: In this review we summarized the available evidence on sleep disorders in children with neurodevelopmental disorders (NDDs) in particular: intellectual disability (including some genetic conditions such as Prader-Willi Syndrome, Smith-Magenis Syndrome), Autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), Developmental Coordination Disorder, language disorders, and specific learning disorders. RECENT FINDINGS: Children with NDDs frequently suffer from sleep disturbances, with a higher prevalence than that of the general pediatric population. SUMMARY: These problems tend to be chronic and may cause additional cognitive and behavioral difficulties, often affecting the whole family's well-being. Sleep behaviors are also related to other important developmental skills, such as attention and listening. Investigating sleep disorders in children with NDDs is therefore crucial in clinical practice. For a systematic approach in clinical practice, we propose the use of a short and easy to remember sleep screening tool.

Impact of COVID-19 lockdown on sleep in children with autism spectrum disorders.

STUDY OBJECTIVES: The impact of the COVID-19 outbreak on sleep of participants with autism spectrum disorder (ASD) was assessed. METHODS: Parents of 111 children and adolescents with ASD filled out an anonymous online survey shared via social media, investigating the sleep patterns and disturbances before and during the lockdown. RESULTS: The lockdown changed significantly the bedtime on weekdays in 57.8% of participants with ASD (56.9% delayed; 0.9% advanced) and the rise time in 69.2% (61.7% delayed and 7.5% advanced). Sleep duration varied on weekdays in 49.1% (24.1% increased; 25% decreased). During the lockdown, participants with ASD showed a significant increase of sleep disturbances, compared to the preceding period, especially falling asleep (35.1% vs 22.5%), anxiety at bedtime (22.5% vs 10.8%), sleep terrors (5.4% vs 0%), and daytime sleepiness (14.4% vs 3.6%). CONCLUSIONS: Lockdown affected sleep of patients with ASD, showing an increase of difficulty in falling asleep, anxiety at bedtime, sleep terrors, and daytime sleepiness. The outbreak of COVID-19 significantly worsened sleep disturbances of children with ASD. CITATION: Bruni O, Melegari MG, Breda M, et al. Impact of COVID-19 lockdown on sleep in children with autism spectrum disorders. J Clin Sleep Med. 2022;18(1):137-143.

Changes in Sleep Patterns and Disorders in Children and Adolescents with Attention Deficit Hyperactivity Disorders and Autism Spectrum Disorders during the COVID-19 Lockdown.

BACKGROUND: The COVID-19 lockdown determined important changes in the sleep of a large percentage of the world population. We assessed the modifications of reported sleep patterns and disturbances in Italian children and adolescents with autism spectrum disorders (ASD) or attention deficit hyperactivity disorders (ADHD), compared to control children, before and during the COVID-19 lockdown in Italy. METHODS: Parents of 100 ASD, 236 ADHD patients, and 340 healthy children filled out an anonymous online survey and a modified version of the Sleep Disturbance Scale for Children (SDSC), advertised via social media, to evaluate sleep patterns and disturbances of their children before and during the lockdown. RESULTS: Before the lockdown, bedtime and risetime were not different between the three groups. During the lockdown, ADHD children tended to have a later bedtime and risetime than ASD and controls, while ASD children tended to maintain similar bedtime and risetime. Overall, during the lockdown, a reduced sleep duration significantly differentiated clinical groups from controls. Anxiety at bedtime, difficulties in falling asleep, and daytime sleepiness increased in all groups during the lockdown. Hypnic jerks, rhythmic movement disorders, night awakenings, restless sleep, sleepwalking, and daytime sleepiness increased in ASD and ADHD patients, in particular. CONCLUSIONS: This is the first study comparing sleep habits and disorders in ASD and ADHD during the lockdown showing specific differences consistent with the core characteristics of two neurodevelopmental disorders.

Irritability in developmental age: A narrative review of a dimension crossing paediatric psychopathology.

OBJECTIVE: Irritability is an important theme in paediatric psychiatry considering its high frequency in developmental age, its association with negative outcomes and consequently significant public health impact. Present as main or associated feature of several psychiatric diagnoses, irritability represents a challenge for clinicians who try to understand its origin and role in developmental psychopathology. In this review we try to: (1) get an overview of this dimension and its relationship with each of the main neuropsychiatric disorders in paediatric population and (2) provide a summary of currently available instruments to assess irritability in children and adolescents. METHOD: In this narrative review, an overview of irritability in children and adolescents is proposed focusing on selected literature. RESULTS: Irritability as feature of many paediatric psychiatric conditions has been evaluated by many authors and included in classifications of paediatric psychiatric diseases. Framework of irritability evolved over time and dimension of irritability has been investigated using different tools and methodologies, both qualitative and quantitative. Metrics of irritability as clinical dimension are important in the diagnostic process of paediatric diseases. CONCLUSION: Investigating the presence of irritability in all children with related disorders is mandatory if we consider the risk for functional impairment and affective and behavioural disorders associated with high levels of irritability. Using rigid threshold in developmental age to differentiate physiological from pathological irritability could lead many children having subthreshold levels of irritability to receive no diagnosis and, consequently, no treatment where instead a dimensional approach to irritability could allow to identify prodromal phase and prevent the evolution towards clinical pathological expressions.

The Use of Platelet-Rich Plasma and Rosuvastatin in Wound Healing in Rabbits: A Longitudinal Study.

OBJECTIVE: To test the hypothesis that platelet-rich plasma (PRP) improves wound healing in rabbits by analyzing morphologic alterations in lesions with the use of PRP alone or combined with rosuvastatin (RSV). METHODS: Eight adult male New Zealand rabbits were used in this study. Researchers created four wounds on the back of each rabbit with an 8-mm punch. The control wound was treated with a 0.9% sodium chloride solution. Experimental wounds were treated with PRP, RSV, or both PRP and RSV. Dressings were changed with a new application of PRP and RSV every 4 days for 16 days. Wounds were biopsied on days 0, 7, 10, 14, and 17 for histopathologic evaluation of the scar tissue. MAIN RESULTS: Histopathology revealed reepithelialization in 100% of wounds treated with PRP alone after 17 days of treatment, compared with 50% of wounds treated with RSV alone and 75% of the wounds treated with PRP and RSV. Further, combining RSV and PRP reduced blood loss. The use of PRP alone induced 100% neovascularization, compared with 50% and 62.5% in wounds treated with PRP and RSV and RSV alone, respectively. All experimental wounds had a higher percentage of collagen fibers on day 17 postlesion when compared with control wounds (78.27% ± 4.69%). There were no significant differences among treatments; however, wounds treated with RSV alone had the lowest amount of collagen fibers (85.98% ± 3.51%). Wounds treated with PRP alone or PRP and RSV had 90.07% ± 6.20% and 90.76% ± 3.51% collagen fibers, respectively. CONCLUSIONS: The results of this study indicate that PRP elicits higher healing activity in the first 7 days postlesion. Treatments with RSV alone or RSV and PRP did enhance other healing phases.

Fractal features of rabbit dermal wounds treated with platelet-rich plasma and topical rosuvastatin.

The healing process comprises a sequence of molecular and cellular events that interact to restore injured tissue. Biomaterials such as platelet-rich plasma (PRP) have been widely used to promote healing by better collagen distribution. Studies have also shown that statin-associated biomaterials may improve endothelial function and increase re-epithelialization. When assessing healing, the analysis of collagen architecture is critical. One form of evaluation used to identify structural changes in the skin is fractal dimension (FD) analysis, which facilitates the characterisation of irregular structures on histologic slides, and quantification of existing alterations by an accurate technique that is independent of the evaluator. The aim of the current study was to assess the feasibility of using rosuvastatin (RSV) alone and combined with autologous PRP to analyze collagen fibers by FD analysis. Skin lesions were experimentally induced in adult male rabbits, and were then treated with either sodium chloride solution (control), RSV gel, autologous PRP gel, or RSV gel and autologous PRP gel combined. Thirty-two biopsies of the lesions were obtained, on days 7, 14 and 17. All treatments were associated with reduced FDs at all three time-points. The FDs of the wounds that were treated with RSV and PRP combined were significantly lower on day 7 (P < 0.05), suggesting that the combination may favour the reorganisation of fibres during the initial healing process. The use of FD analysis for collagen evaluation was evidently reliable. More studies are needed, to evaluate collagen and healing associated with RSV and PRP in experimentally induced wounds.

Mirtazapine (Remeron) as treatment for non-mechanical vomiting after gastric bypass.

Two morbidly obese patients are reported who underwent gastric bypass and suffered nausea and vomiting 1 month after the operation. Endoscopy and upper GI series showed no evidence of stomal stenosis or other mechanical cause for a GI obstruction. Control of vomiting by current antiemetic drugs such as bromopride and ondansetrone was unsuccessful. The patients were then given Remeron Soltab (mirtazapine, Organon, Brazil) 30 mg once per day orally for 2 to 8 months. Nausea and vomiting disappeared within days after beginning the medication. Stomal stenosis is the main cause of vomiting after gastric bypass. After ruling out mechanical causes, other reasons for postoperative vomiting must be considered. Mirtazapine is a noradrenergic and specific serotonergic antidepressant, which blocks the 5HT3 receptor, leading to an antiemetic effect. It has successfully been used as an antiemetic drug in patients undergoing chemotherapy. We concluded that mirtazapine may be a successful option to treat non-mechanical postoperative vomiting in morbidly obese patients after gastric bypass.