Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis.

STUDY OBJECTIVES: To examine the risk of increased health care utilization (HU) linked to individual sleep disorders in children with chronic medical conditions. METHODS: Medicaid claims data from a cohort of 16,325 children enrolled in the Coordinated Healthcare for Complex Kids (CHECK) project were used. Sleep disorders and chronic medical conditions were identified using International Classification of Diseases, Ninth, and 10th Revision, codes. Three HU groups were identified based on participants' prior hospitalizations and emergency department (ED) visits in the 12 months prior to enrollment: low (no hospitalization or ED visit), medium (1-2 hospitalizations or 1-3 ED visits), and high (≥ 3 hospitalizations or ≥ 4 ED visits). The odds of being in an increased HU group associated with specific sleep disorders after controlling for confounding factors were examined. RESULTS: Children with chronic medical conditions and any sleep disorder had nearly twice the odds (odds ratio = 1.83; 95% confidence interval: 1.67-2.01) of being in an increased HU group compared with those without a sleep disorder. The odds of being in the increased HU group varied among sleep disorders. Only sleep-disordered breathing (odds ratio = 1.51; 95% confidence interval : 1.17-1.95), insomnia (odds ratio = 1.46; 95% confidence interval : 1.06-2.02), and circadian rhythm sleep disorder (odds ratio = 2.45; 95% confidence interval : 1.07-5.64) increased those odds. Younger age and being White were also linked to increased HU. CONCLUSIONS: Sleep disorders are associated with increased risk of heightened HU (ED visits and/or hospitalizations) in children with chronic medical conditions. This risk varies by specific sleep disorders. These findings indicate the need for careful evaluation and management of sleep disorders in this high-risk cohort. CITATION: Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. J Clin Sleep Med. 2024;20(4):595-601.

Visceral adiposity is related to insulin sensitivity and inflammation in adolescents with obesity and mild sleep disordered breathing.

OBJECTIVES: To evaluate the relationships between adipose tissue distribution, insulin secretion and sensitivity, sleep-disordered breathing, and inflammation in obese adolescents. METHODS: Cross-sectional study of 56 obese adolescents who underwent anthropometric measures, dual-energy X-ray absorptiometry, overnight polysomnography, oral glucose tolerance test (OGTT) and frequently sampled intravenous glucose tolerance test. Correlation and regression analyses were used to assess relationships between adiposity, insulin secretion and sensitivity, measures of sleep-disordered breathing (oxyhemoglobin nadir, SpO2; apnea hypopnea index, AHI; arousal index, AI; maximum end-tidal CO2; non-REM sleep duration), and inflammation (high-sensitivity C-reactive protein, hsCRP). RESULTS: Subjects (55% female) were mean (SD) 14.4 (2.1) years, with BMI Z-score of 2.3 (0.4). AHI was >5 in 10 (18%) subjects and 1< AHI ≤5 in 22 (39%). Visceral adipose tissue area (VAT) was positively correlated with OGTT 1 and 2 h insulin and 1 h glucose, and hsCRP (r=0.3-0.5, p≤0.007 for each). VAT was negatively correlated with sensitivity to insulin (r=-0.4, p=0.005) and SpO2 nadir (r=-0.3, p=0.04) but not with other sleep measures. After adjustment for BMI-Z, sex, population ancestry, age, and sleep measures, VAT remained independently associated with insulin measures and 1 h glucose, but no other measures of glycemia. SAT was not associated with measures of glycemia or insulin resistance. CONCLUSIONS: Among adolescents with obesity, visceral adiposity was associated with insulin resistance, SpO2 nadir, and inflammation. The independent association of visceral adiposity with insulin resistance highlights the potential role of VAT in obesity-related chronic disease.

Increased incidence of pediatric narcolepsy following the 2009 H1N1 pandemic: a report from the pediatric working group of the sleep research network.

This study was aimed to evaluate the yearly incidence of pediatric narcolepsy prior to and following the 2009 H1N1 pandemic and to evaluate seasonal patterns of narcolepsy onset and associations with H1N1 influenza infection in the United States. This was a multicenter retrospective study with prospective follow-up. Participants were recruited from members of the Pediatric Working Group of the Sleep Research Network including 22 sites across the United States. The main outcomes were monthly and yearly incident cases of childhood narcolepsy in the United States, and its relationship to historical H1N1 influenza data. A total of 950 participants were included in the analysis; 487 participants were male (51.3%). The mean age at onset of excessive daytime sleepiness (EDS) was 9.6  ±â€… 3.9 years. Significant trend changes in pediatric narcolepsy incidence based on EDS onset (p  <  .0001) occurred over the 1998-2016 period, peaking in 2010, reflecting a 1.6-fold increase in narcolepsy incidence. In addition, there was significant seasonal variation in narcolepsy incident cases, with increased cases in spring (p  <  .05). Cross-correlation analysis demonstrated a significant correlation between monthly H1N1 infection and monthly narcolepsy incident cases (p  =  .397, p  <  .0001) with a lag time of 8 months. We conclude that there is a significant increase in pediatric narcolepsy incidence after the 2009 H1N1 pandemic in the United States. However, the magnitude of increase is lower than reported in European countries and in China. The temporal correlation between monthly H1N1 infection and monthly narcolepsy incidence, suggests that H1N1 infection may be a contributing factor to the increased pediatric narcolepsy incidence after the 2009 H1N1 pandemics.

Rates of diagnoses of sleep disorders in children with chronic medical conditions.

STUDY OBJECTIVES: This investigation examines sleep disorder (SD) diagnoses in a large population of children and adolescents with chronic medical conditions (CMCs). Little is known about SD diagnoses in this population. The large population used in this study allowed examination of SD rates by CMC type and demographics. METHODS: Data were from the Coordinated Health Care for Complex Kids (CHECK) project designed for Medicaid-funded children and adolescents with at least 1 CMC from a large metropolitan area. The study population (n = 16,609) was limited to children and adolescents, 0 to 18 years of age. SD and CMC diagnoses were obtained from Medicaid claims data. RESULTS: Fourteen percent of the population (mean age of 9.1 years [standard deviation = 5.2]; 35.8% African American; 56.4% male; 77 with more than 1 CMC) received a sleep disorder diagnosis. The most frequent diagnosis was sleep-disordered breathing (11.2%), followed by nocturnal enuresis (1.2%) and insomnia (1%). SDs were diagnosed more frequently in those with multiple CMCs than in those with 1 CMC (19.7% vs 5.8%; P < .001). Insomnia rates in Hispanic/Latinx (1.2%) and African American (0.8%) children and adolescents were significantly lower (both P < .001) than in Caucasians (3.5%). Odds of receiving a sleep diagnosis varied among CMCs. CONCLUSIONS: Our analysis of Medicaid claims data of a large urban cohort offers detailed information about the rates of sleep diagnoses and suggests underdiagnosis of SDs in this vulnerable, high-risk, primarily ethnic minority population. Underrecognition of sleep disorders has short- and long-term health and economic consequences. Study results may help clinicians implement appropriate SD screening and management for children and adolescents with CMCs. CITATION: Adavadkar PA, Pappalardo AA, Glassgow AE, et al. Rates of diagnoses of sleep disorders in children with chronic medical conditions. J Clin Sleep Med. 2022;18(8):2001-2007.

The relationship between sleep-disordered breathing, blood pressure, and urinary cortisol and catecholamines in children.

STUDY OBJECTIVES: Hypertension is a complication of obstructive sleep apnea (OSA) syndrome in adults. A correlation between OSA syndrome and elevated blood pressure (BP) is suggested in children, but its pathogenesis remains unclear. Our aim was to study the effects of sleep and sleep apnea on BP and sympathetic nervous system activation as measured by serum cortisol and urinary catecholamines. We hypothesized that children with OSA syndrome would have higher BP, urinary catecholamines, and cortisol compared with controls. METHODS: We measured BP during polysomnography in 78 children with suspected sleep-disordered breathing and 18 nonsnoring controls. BP was measured during wakefulness and every 30-60 minutes throughout the night. All participants had 24-hour urinary catecholamine and free cortisol collections 48 hours before polysomnography. RESULTS: BP varied with sleep stage; it was highest during wakefulness and N1 and lowest during non-rapid eye movement stage 3. Children classified as high apnea-hypopnea index (AHI) snorers (AHI >5 events/h) had a greater prevalence of systolic hypertension (57%) than low-AHI snorers (22%) and nonsnoring controls (22%; P = .04). The high-AHI snorers also had higher diastolic BP (P < .02) as well as blunted nocturnal diastolic BP changes during sleep (P = .02) compared with low-AHI snorers (AHI <5 events/h). Twenty-hour urinary free cortisol and 24-hour urinary catecholamines were not associated with BP. CONCLUSIONS: BP in children varies with sleep stage. OSA is associated with systolic hypertension, higher BP during rapid eye movement sleep, as well as elevation of diastolic BP and blunted BP changes with sleep.

The role of polysomnography in tracheostomy decannulation of children with bronchopulmonary dysplasia.

BACKGROUND: Patients with bronchopulmonary dysplasia (BPD) may require tracheostomy for long-term mechanical ventilation. Polysomnography (PSG) may predict successful decannulation in children, however it is unclear how this success compares with children without a PSG. To better evaluate this role, we compared decannulation outcomes between tracheostomy-dependent children with BPD who underwent PSG before decannulation to those who did not. METHODS: This is a retrospective cohort study between 1 January 2007 and 1 June 2017 of tracheostomy-dependent children with BPD who were clinically considered for decannulation. Patient demographics, PSG results, and medical comorbidities were abstracted from medical records and compared between groups. Decannulation outcomes were compared between children with BPD who underwent PSG before decannulation and those who did not. RESULTS: One hundred twenty-five patients with BPD were considered for tracheostomy decannulation. Forty-six (37%) had a pre-decannulation PSG while 79 (63%) did not. Nineteen (41%) patients did not undergo decannulation within 6 months of the PSG. One (3%) patient with pre-decannulation PSG failed decannulation. Four (5%) patients without pre-decannulation PSG failed decannulation. Nineteen patients with PSG and no decannulation had significantly higher obstructive apnea-hypopnea index (OAHI) (13.62 vs 2.68 events per hour, P = 0.004), higher end-tidal CO 2 max (52.84 vs 48.03 mm Hg, P = 0.035), and were older at PSG (median age, 6.04 vs 4.04 years, P = 0.008). CONCLUSIONS: While successful decannulation can be achieved without a PSG in some patients, PSG is a valuable tool to identify BPD patients undergoing clinical evaluation for decannulation who would benefit from treatment of OSA before decannulation.

Accuracy of a smartphone application in estimating sleep in children.

PURPOSE: Chronic sleep problems can lead to difficulties for both the individual and society at large, making it important to effectively measure sleep. This study assessed the accuracy of an iPhone application (app) that could potentially be used as a simple, inexpensive means to measure sleep over an extended period of time in the home. METHODS: Twenty-five subjects from the ages of 2-14 who were undergoing overnight polysomnography (PSG) were recruited. The phone was placed on the mattress, near their pillow, and recorded data simultaneously with the PSG. The data were then downloaded and certain parameters were compared between the app and PSG, including total sleep time, sleep latency, and time spent in various defined "stages." RESULTS: Although there seemed to be a visual relationship between the graphs generated by the app and PSG, this was not confirmed on numerical analysis. There was no correlation between total sleep time or sleep latency between the app and PSG. Sleep latency from the PSG and latency to "deep sleep" from the app had a significant relationship (p = 0.03). No combination of PSG sleep stages corresponded with app "stages" in a meaningful way. CONCLUSIONS: The Sleep Cycle App may have value in increasing the user's awareness of sleep issues, but it is not yet accurate enough to be used as a clinical tool.

Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion.

ABSTRACT: Members of the American Academy of Sleep Medicine developed consensus recommendations for the amount of sleep needed to promote optimal health in children and adolescents using a modified RAND Appropriateness Method. After review of 864 published articles, the following sleep durations are recommended: Infants 4 months to 12 months should sleep 12 to 16 hours per 24 hours (including naps) on a regular basis to promote optimal health. Children 1 to 2 years of age should sleep 11 to 14 hours per 24 hours (including naps) on a regular basis to promote optimal health. Children 3 to 5 years of age should sleep 10 to 13 hours per 24 hours (including naps) on a regular basis to promote optimal health. Children 6 to 12 years of age should sleep 9 to 12 hours per 24 hours on a regular basis to promote optimal health. Teenagers 13 to 18 years of age should sleep 8 to 10 hours per 24 hours on a regular basis to promote optimal health. Sleeping the number of recommended hours on a regular basis is associated with better health outcomes including: improved attention, behavior, learning, memory, emotional regulation, quality of life, and mental and physical health. Regularly sleeping fewer than the number of recommended hours is associated with attention, behavior, and learning problems. Insufficient sleep also increases the risk of accidents, injuries, hypertension, obesity, diabetes, and depression. Insufficient sleep in teenagers is associated with increased risk of self-harm, suicidal thoughts, and suicide attempts. COMMENTARY: A commentary on this article apears in this issue on page 1439.

Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine.

ABSTRACT: Sleep is essential for optimal health in children and adolescents. Members of the American Academy of Sleep Medicine developed consensus recommendations for the amount of sleep needed to promote optimal health in children and adolescents using a modified RAND Appropriateness Method. The recommendations are summarized here. A manuscript detailing the conference proceedings and the evidence supporting these recommendations will be published in the Journal of Clinical Sleep Medicine.

Event-related potentials reveal the relations between feature representations at different levels of abstraction.

In this paper, we use behavioural methods and event-related potentials (ERPs) to explore the relations between informational and instantiated features, as well as the relation between feature abstraction and rule type. Participants are trained to categorize two species of fictitious animals and then identify perceptually novel exemplars. Critically, two groups are given a perfectly predictive counting rule that, according to Hannah and Brooks (2009. Featuring familiarity: How a familiar feature instantiation influences categorization. Canadian Journal of Experimental Psychology/Revue Canadienne de Psychologie Expérimentale, 63, 263-275. Retrieved from http://doi.org/10.1037/a0017919), should orient them to using abstract informational features when categorizing the novel transfer items. A third group is taught a feature list rule, which should orient them to using detailed instantiated features. One counting-rule group were taught their rule before any exposure to the actual stimuli, and the other immediately after training, having learned the instantiations first. The feature-list group were also taught their rule after training. The ERP results suggest that at test, the two counting-rule groups processed items differently, despite their identical rule. This not only supports the distinction that informational and instantiated features are qualitatively different feature representations, but also implies that rules can readily operate over concrete inputs, in contradiction to traditional approaches that assume that rules necessarily act on abstract inputs.

Insulin-like growth factor-I and insulin-like growth factor binding protein-1 are related to cardiovascular disease biomarkers in obese adolescents.

CONTEXT: Insulin-like growth factor (IGF)-I and IGF binding protein (IGFBP)-1 have been linked to cardiovascular disease (CVD) risk and pathophysiology in adults, but there are limited data in youth. OBJECTIVE: The aim of the study was to examine the relationship between IGF and IGFBP-1 with traditional and non-traditional CVD risk factors including inflammatory markers and body composition in an obese pediatric cohort. DESIGN: A cross-sectional study. SETTING: The study was carried out at a university children's hospital. SUBJECTS: Sixty-one obese non-diabetic adolescents. OUTCOMES: Fasting IGF-I, IGFBP-1, lipoprotein profiles, high-sensitivity C-reactive protein (hsCRP), and total adiponectin as well as insulin sensitivity measures, blood pressure (BP), and anthropometrics. RESULTS: IGFBP-1 was negatively associated with insulin sensitivity measures, body mass index (BMI), and diastolic BP in males. IGF-I was negatively associated with hsCRP (r = -0.479, p < 0.0005), and IGFBP-1 was positively associated with adiponectin (r = 0.545, p < 0.0005). The IGF-I/CRP and IGFBP-1/adiponectin associations remained significant when controlling for both BMI and insulin sensitivity index (SI ). Both IGF-I and IGFBP-1 were negatively associated with waist circumference (r = -0.327 and r = -0.275, respectively) and sagittal abdominal diameter (r = -0.333 and r = -0.371, respectively), while IGFBP-1 was negatively associated with fat mass (r = -0.347, p = 0.01) as well as neck circumference and fat-free mass in males. Controlling for BMI z-score and SI , IGFBP-1 remained negatively associated with diastolic blood pressure (r = 0.706, p = 0.001 and neck circumference (r = -0.548, p = 0.15) in males. CONCLUSIONS: IGF-I and IGFBP-1 associate with CVD risk markers and may add to clinical assessments of cardiometabolic dysfunction in youth.

Crystal structures of eight mono-methyl alkanes (C26-C32) via single-crystal and powder diffraction and DFT-D optimization.

The crystal structures of eight mono-methyl alkanes have been determined from single-crystal or high-resolution powder X-ray diffraction using synchrotron radiation. Mono-methyl alkanes can be found on the cuticles of insects and are believed to act as recognition pheromones in some social species, e.g. ants, wasps etc. The molecules were synthesized as pure S enantiomers and are (S)-9-methylpentacosane, C26H54; (S)-9-methylheptacosane and (S)-11-methylheptacosane, C28H58; (S)-7-methylnonacosane, (S)-9-methylnonacosane, (S)-11-methylnonacosane and (S)-13-methylnonacosane, C30H62; and (S)-9-methylhentriacontane, C32H66. All crystallize in space group P21. Depending on the position of the methyl group on the carbon chain, two packing schemes are observed, in which the molecules pack together hexagonally as linear rods with terminal and side methyl groups clustering to form distinct motifs. Carbon-chain torsion angles deviate by less than 10° from the fully extended conformation, but with one packing form showing greater curvature than the other near the position of the methyl side group. The crystal structures are optimized by dispersion-corrected DFT calculations, because of the difficulties in refining accurate structural parameters from powder diffraction data from relatively poorly crystalline materials.

Relationship between sleep, sleep apnea, and neuropsychological function in children with Down syndrome.

PURPOSE: To determine whether sleep and sleep disordered breathing (SDB) contribute to the neuropsychological deficits of patients with Down syndrome, and whether treatment of SDB results in improvement in cognitive function. METHODS: In this cohort study, 25 children with Down syndrome underwent overnight polysomnography (PSG), Multiple Sleep Latency Testing (MSLT), and a battery of neuropsychological tests. Patients with SDB underwent a follow up PSG after treatment. All patients repeated the neuropsychological tests 13 months later. RESULTS: At baseline, there was no relationship between SDB and performance on the neuropsychological tests. However, total sleep time and sleep latency were related to tests of cognitive ability (p < 0.05) and comprehension (p < 0.01). The amount of time in slow-wave sleep correlated with tests of achievement (p < 0.01), and adaptive behavior (p < 0.01). Ten patients had SDB confirmed on PSG. Five of these patients were treated successfully with adenotonsillectomy and/or continuous positive airway pressure. The five who did not tolerate treatment were deficient in tests of adaptive behavior (Vineland p < 0.05) visual-motor integration (Beery p < 0.01) and achievement (Woodcock-Johnson p < 0.05) compared to those successfully treated. After treatment the patients improved in ratings of attention (Conners p < 0.05). CONCLUSIONS: Although SDB is common in children with Down syndrome, it is not a major contributor to their cognitive deficits. Cognitive function is related to the amount of sleep and particularly slow wave sleep. Successful treatment of SDB may improve their attention.

Prevalence of periodic limb movements during sleep in normal children.

STUDY OBJECTIVES: Although the American Academy of Sleep Medicine (AASM) mandates that periodic limb movements during sleep (PLMS) be scored on every polysomnogram, and considers a periodic limb movement index (PLMI) > 5/h abnormal in children, there is a lack of community-derived data regarding the prevalence of PLMS in children, and no data to support this cutoff value. Therefore, the aim of this study was to determine the prevalence of PLMS in a sample of normal children. DESIGN: Retrospective study. PARTICIPANTS: 195 healthy, non-snoring children aged 5-17 years, recruited from the community, who underwent polysomnography for research purposes. METHODS: PLMS were scored using the AASM 2007 criteria. MEASUREMENTS AND RESULTS: The group age (median [IQR]) was 12.9 [10-15] years, and 58% were male. Sleep architecture was normal, and the obstructive apnea hypopnea index was 0.1 [0-0.3]/h. The median PLMI was 0/h, ranging from 0 to 35.5/h. Fifteen (7.7%) subjects had a PLMI > 5/h, and only 3 (1.5%) met the adult pathologic criterion of more than 15/h. Use of the 95th percentile PLMI cutoff of 7.2/h produced little difference in categorization between groups. Children with a PLMI > 5/h had a higher arousal index than those with a lower PLMI (11.6 [8.8-14.6] vs 8.1 [6.1-9.9]/h, respectively, P = 0.003). CONCLUSIONS: This study provides normative data to the field and supports the clinical periodic limb movement index cutoff of > 5/h based on both prevalence and the correlate of increased sleep fragmentation. Periodic limb movements during sleep are infrequent in normal children recruited from the community. CITATION: Marcus CL, Traylor J, Gallagher PR, Brooks LJ, Huang J, Koren D, Katz L, Mason TB, Tapia IE. Prevalence of periodic limb movements during sleep in normal children.

Relationship between sleep and pain in adolescents with juvenile primary fibromyalgia syndrome.

STUDY OBJECTIVES: To investigate sleep quality in adolescents with juvenile primary fibromyalgia syndrome (JPFS) and determine whether sleep abnormalities, including alpha-delta sleep (ADS), correlate with pain intensity. We hypothesized that successful treatment for pain with exercise therapy would reduce ADS and improve sleep quality. DESIGN: Single-center preintervention and postintervention (mean = 5.7 ± 1.0 weeks; range = 4.0-7.3 weeks) observational study. PATIENTS: Ten female adolescents (mean age = 16.2 ± 0.65 SD yr) who met criteria for JPFS and completed treatment. INTERVENTIONS: Multidisciplinary pain treatment, including intensive exercise therapy. MEASUREMENTS AND RESULTS: Pain and disability were measured by a pain visual analog scale (VAS) and the functional disability inventory. Subjective sleep measures included a sleep VAS, an energy VAS, and the School Sleep Habits Survey. Objective sleep measures included actigraphy, polysomnography (PSG), and the Multiple Sleep Latency Test. Baseline PSG was compared with that of healthy age- and sex-matched control patients. At baseline, patients had poorer sleep efficiency, more arousals/awakenings, and more ADS (70.3% of total slow wave sleep [SWS] versus 21.9% SWS, P = 0.002) than controls. ADS was unrelated to pain, disability, or subjective sleep difficulty. After treatment, pain decreased (P = 0.000) and subjective sleep quality improved (P = 0.008). Objective sleep quality, including the amount of ADS, did not change. CONCLUSIONS: Although perceived sleep quality improved in adolescents with JPFS after treatment, objective measures did not. Our findings do not suggest exercise therapy for pain improves sleep by reducing ADS, nor do they support causal relationships between ADS and chronic pain or subjective sleep quality.

Accuracy of computer algorithms and the human eye in scoring actigraphy.

PURPOSE: The purpose of this study is to determine the optimal scoring method and parameter settings of actigraphy by comparison to simultaneous polysomnography (PSG). METHODS: Fifteen studies of simultaneous PSG and actigraphy were completed in adolescents (mean age = 16.3 years) and analyzed. Scoring actigraphy by the human eye was compared to a commercial computerized algorithm using various parameters. The PSG was considered the reference standard. RESULTS: There was a better correlation between actigraphy and PSG sleep start/end, total sleep time, wake after sleep onset, and sleep efficiency when the rest period was determined by the human (mean r = 0.640) rather than auto-set by the software (r = 0.406). The best results came when the rest intervals were set based on the PSG (r = 0.694). Scoring the printed actogram by the human eye was superior to the auto analyses as well (r = 0.575). Higher correlations and lower biases were obtained from lower wake threshold settings (low and medium) and higher immobility times (10 and 15 min). CONCLUSIONS: Visual scoring by simple inspection of the actigraphy tracing had a reasonable correlation with the gold standard PSG. Accurate determination of the rest interval is important in scoring actigraphy. Scoring actigraphy by the human eye is superior to this computer algorithm when auto-setting major rest periods. A low wake threshold and 10-15 min of immobility for sleep onset and sleep end yield the most accurate computerized results. Auto-setting major rest intervals should be avoided to set start/end of rest intervals; adjustments for artifacts and/or a sleep diary for comparison are helpful.