The burden of sleep disordered breathing in infants with Down syndrome referred to tertiary sleep center.

INTRODUCTION: Children with Down Syndrome (DS) are at high risk of sleep disordered breathing (SDB). We aimed to examine the burden of SDB in infants with DS referred to tertiary sleep center. METHODS: Infants (≤12 months old) with DS who underwent consecutive polysomnography (PSG) at a single academic sleep center over a 6-year period were included. obstructive sleep apnea (OSA) (obstructive apnea hypopnea index [oAHI]>1/hr), central sleep apnea (central apnea index > 5/h) and the presence of hypoventilation (% time spent with CO2 > 50 mmHg either by end-tidal or transcutaneous> 25% of total sleep time) and hypoxemia (time spent with O2 saturation <88% >5 min) were ascertained. RESULTS: A total of 40 infants were included (Mean age 6.6 months, male 66%). PSGs consisted of diagnostic (n = 13) and split night (n = 27, 68%) studies. All met criteria for OSA with mean oAHI 34.6/h (32.3). Central sleep apnea was present in 11 (27.5%) of infants. A total of 11 (27.5%) had hypoxemia. Hypoventilation was present in 10 (25%) infants. CONCLUSION: This study highlights the high prevalence of SDB in infants with DS referred to a sleep center, and supports early PSG assessment in this patient population.

A surface electrode adjacent to vagal nerve stimulator lead can aid in characterizing vagal nerve stimulator-mediated pediatric sleep-disordered breathing: a case series of 7 patients.

STUDY OBJECTIVES: The vagal nerve stimulator (VNS) is a nonpharmacological treatment for refractory epilepsy. A side effect of the VNS is sleep-disordered breathing. The purpose of this study was to demonstrate how a surface electrode placed over the VNS lead can help distinguish whether sleep-disordered breathing is due to VNS discharge. METHODS: Seven pediatric patients (aged 7.7 ± 2.2 years) with a VNS underwent a polysomnogram with an additional surface electrode on the left anterolateral neck to detect VNS discharge. The VNS-associated apnea-hypopnea index was calculated by determining the number of hypopneas and apneas occurring during VNS discharge. We evaluated the veracity of the VNS electrode by comparing signal duration and total number to those expected by programmed settings. We compared these findings to chin electromyogram signal change. RESULTS: Three patients had an obstructive pattern with VNS discharge, and 3 had an increase in respiratory rate without gas exchange abnormalities, including 1 with both patterns; 1 patient experienced no respiratory abnormalities. The mean obstructive apnea-hypopnea index was 8.2 ± 8.3 events/h. The mean VNS-associated apnea-hypopnea index was 4.8 ± 6.2 events/h and accounted for 46.9 ± 30.2% of the total obstructive apnea-hypopnea index. The additional electrode captured a statistically high percentage of expected discharges (94.7 ± 6.5%) compared to chin electromyogram (36.1 ± 35.8%; P < .05). CONCLUSIONS: We demonstrated that a surface electrode on the VNS lead can temporally coregister VNS discharges and enabled us to attribute sleep-disordered breathing to VNS stimulation in 4 patients. We propose that this sensor be standard procedure in patients with VNS undergoing polysomnogram. CITATION: Chan JHM, DelRosso LM, Ruth C, Wrede JE. A surface electrode adjacent to vagal nerve stimulator lead can aid in characterizing vagal nerve stimulator-mediated pediatric sleep-disordered breathing: a case series of 7 patients. J Clin Sleep Med. 2022;18(8):1973-1981.

Obstructive Apnea and Hypopnea Length in Normal Children and Adolescents.

(1) Background: Breathing is an essential function that requires both metabolic (or au-tomatic) and voluntary (behavioral) control during wakefulness but during sleep depends on metabolic control via peripheral and central chemoreceptors. Breathing during sleep disordered breathing also depends on the maturity of the neural centers and the strength of the respiratory muscles. We do not know if the response to apnea varies with age. (2) Methods: We measured the obstructive apneas and hypopneas during REM and NREM in polysomnography studies from children referred for snoring. Exclusion criteria: younger than 1 year of age, neuromuscular or syndrome comorbidity, oxygen or positive airway pressure, central apnea, and studies with loss of airflow sensors. (3) Results: Two-hundred-and-sixty-eight sleep studies were included. Mean age was 8.7 years (4.68 SD), range 1-18 years, 160 were male, and 108 were female. The 5th centile of apnea duration during NREM is above 8 s at all ages, with a tendency to increase in the oldest groups up to 10 s. During REM sleep, it shows a gradual increase from 6 s in the youngest children to 10 s in the oldest. (4) Conclusions: Apnea/hypopnea length increases with age in children and adolescents independently from sex or severity of OSA. Using adult criteria in teens seems to be accurate.

Effect of Telephone Call and Text Message Reminders on Patient Return to Acupuncture Follow-Up Treatment: A Pilot Randomized Controlled Trial.

Background: Telephone calls and text messages function as cues to elicit patient behavior. Objective: We tested the effect of telephone call and text message reminders on patient return to acupuncture follow-up treatment. Design: This is a randomized controlled trial. Setting and Subjects: We recruited adults visiting an acupuncture clinic for a new treatment consultation. Our sample contained 120 participants with 40 per study group. Interventions: Consenting patients were randomized to 1 of 3 study exposures: single voice call, single text message, or treatment as usual (TAU/no reminder). Exposures were sent 3 days after patient's initial treatment. Outcome Measures: Data from clinic charts were abstracted to quantify the absence/presence of a follow-up treatment return in the 30 days after initial treatment. Participants provided self-report of pain symptoms 10 and 30 days after initial treatment on the pain disability index (PDI) to measure change in PDI by return to follow-up treatment as a secondary outcome. Results: Telephone call (56%, P = 0.98) and text message (57%, P = 0.99) groups showed similar proportion of follow-up treatment returns compared with TAU group (57%). Presence of a follow-up appointment scheduled at the initial treatment predicted patient treatment return (odds ratio: 5.87, P < 0.01). Follow-up treatment return predicted reduced PDI scores at day 30 (ß = -3.09, P = 0.02). Conclusions: Adding a 1-time telephone call or text message reminder to standard clinic practice did not improve patient return to acupuncture follow-up treatment within 30 days of initial treatment. Scheduling a future appointment date at initial treatment visit may improve treatment return, and return attendance appears protective of pain disability in the short term.

Ambulatory blood pressure monitoring in children undergoing polysomnography.

Ambulatory blood pressure monitoring (ABPM) is recommended for the diagnosis of hypertension in children at high risk, such as children with obesity or obstructive sleep apnea (OSA). Nocturnal hypertension is highly predictive of cardiovascular outcomes. ABPM allows for early detection of nocturnal hypertension in children. Although OSA is the most common sleep disorder associated with hypertension, studies have also shown an increase in cardiovascular risk in adult patients with other sleep disorders; therefore, there is an imperative need to provide early diagnosis in children at high risk. In the present study, we evaluated the feasibility of using ABPM during polysomnography (PSG) in children referred for sleep disordered breathing to the Seattle Children's Hospital Sleep Disorders Center. A total of 41 children aged 7-18 years were included in this study. The ABPM monitor was worn for a mean (SD) of 10.2 (1.5) hr. No significant changes were seen in PSG parameters when ABPM was co-performed with PSG, including sleep efficiency and arousals. In total, 12 of the 41 patients were identified as having nocturnal hypertension. Our study is important in that it shows that concomitant use of ABPM during PSG can aid in the early identification of nocturnal hypertension in this population.

Restless sleep disorder in children with attention-deficit/hyperactivity disorder.

STUDY OBJECTIVES: Restless sleep is a very common parental complaint in children with attention-deficit/hyperactivity disorder (ADHD), but restless sleep has been seen in association with other comorbidities such as restless legs syndrome and obstructive sleep apnea. Restless sleep disorder (RSD) needs to be identified from other disorders when evaluating children with ADHD. In this study we aim to identify the prevalence of RSD in children with ADHD referred to our sleep center. METHODS: This is a retrospective study of children with ADHD who underwent polysomnography. The following diagnostic and descriptive data were obtained for each patient: age, sex, presence/absence of RSD, other sleep disorders, psychiatric comorbidities, and medications. RSD was diagnosed per diagnostic criteria. RESULTS: There were 66 children with ADHD. All of them underwent polysomnography, 17 were females, and 49 were males. Mean age was 11.6 years (± 3.6 standard deviation). The complaint of restless sleep was reported by the parents of 54 (81.1%) of the children; however, only 6 of them (9.1%) were diagnosed with RSD. Seventy-one percent had obstructive sleep apnea and 19.7% had restless legs syndrome. A significant number of patients had psychiatric comorbidities and were on various medications. CONCLUSIONS: Although restless sleep is a common complaint reported in 81.1% of children with ADHD, only 9.1% had RSD. Most causes of restless sleep are secondary and associated with other sleep disorders, psychiatric comorbidities, or medication use.

Non-REM sleep instability in children with restless sleep disorder.

STUDY OBJECTIVES: Restless sleep disorder (RSD) is a newly recognized condition characterized by motor movements involving large muscle groups with frequent repositioning or bed sheets disruption. We analyzed cyclic alternating pattern (CAP) in these children, a marker of sleep instability that might be associated with the motor episodes of RSD and may play a role in their daytime symptoms. METHODS: Polysomnographic recordings from thirty-eight children who fulfilled RSD diagnostic criteria (23 boys and 15 girls), 23 children with restless legs syndrome (RLS, 18 boys and 5 girls) and 19 controls (10 boys and 9 girls) were included. For CAP analysis, a previously developed, highly precise automated system, based on a deep learning recurrent neural network, was used. RESULTS: Age and gender were not statistically different between groups. RSD patients showed a lower percentage of A3 CAP subtypes than controls (median 9.8 vs. 18.2, p = 0.0089), accompanied by shorter duration of the B phase of the CAP cycle (median 28.2 vs. 29.8 in controls, 30.2 in RLS, p = 0.005) and shorter CAP cycle duration than both controls and RLS subjects (median 33.8 vs. 35.0 in controls, 35.8 in RLS, p = 0.002). Finally, RSD children also showed a longer duration of CAP cycle sequences, when compared to controls (median 172.7 vs. 141.9, p = 0.0063). CONCLUSIONS: In conclusion, our study indicates that NREM sleep EEG shows an increased instability in RSD; these findings add to the current knowledge on the mechanisms of this newly recognized sleep disorder and suggest that sleep instability might be a favoring mechanism for the emergence of the motor episodes characterizing RSD.

Demographic and Clinical Factors Associated with Patient Adherence to Acupuncture Treatment.

Objectives: Acupuncture uses needle stimulation upon the body's meridian points to alleviate physical and psychologic symptoms. In clinical practice, acupuncturists often recommend patients to attend follow-up treatment to achieve cumulative benefit over time. Adherence to acupuncture treatment was studied, and demographic and clinical factors were tested that may predict adherence. Design and subjects: A retrospective chart review at an acupuncture teaching clinic was conducted using data from 2014, where patients routinely received recommendations to return for follow-up visits to continue their management of the same health condition. A total of 131 patients were included with an initial consultation in this analysis (mean age = 43 ± 15, 40% male). Outcome measures: Rates of adherence to acupuncture follow-up treatment were determined by tracking whether patients had any subsequent follow-up visits in 30 days after their initial consultation. Demographic and clinical characteristics that differed between adherers (≥1 follow-up visit) and nonadherers (no follow-up visit) were then tested. Among the adherer sample, the authors tested whether these characteristics were associated with a higher number of follow-up visits was tested. Results: Half (50%) of the patient sample adhered to ≥1 follow-up visits in 30 days after their initial consultation. Patients reporting multiple chief complaints were more likely to have a follow-up visit than those with a single complaint (63% vs. 42%, p = 0.02). Receipt of a treatment plan (incidence rate ratio [IRR]: 1.37, p = 0.02) and first follow-up visit within 7 days of initial treatment (IRR: 1.42, p = 0.01) were associated with a higher number of follow-up visits among adherers, after adjusting for covariates. The predicted number of follow-up visits for patients with a treatment plan was 2.5 (standard error [SE] = 0.3) and that for those without a treatment plan was 1.8 (SE = 0.2) among adherers. Conclusion: The rate of return to an acupuncture clinic for follow-up treatment was low (50%). Patient adherence to acupuncture follow-up treatments may be improved by clinical administrative protocols that formalize treatment plans and appointment scheduling.