SLEEP

Pack, Allan I.; Zee, Phyllis C.

doi: 10.1093/sleep/29.10.1260pmid: 17068978

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doi: 10.1093/sleep/29.10.1263pmid: N/A

Abstract:This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodifi ed extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.

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doi: 10.1093/sleep/29.10.1277pmid: N/A

Summary:Bedtime problems and frequent night wakings are highly prevalent in infants, toddlers, and preschoolers. Evidence suggests that sleep disruption and/or insufficient sleep have potential deleterious effects on children's cognitive development, regulation of affect, attention, health outcomes, and overall quality of life, as well as secondary effects on parental and family functioning. Furthermore, longitudinal studies have demonstrated that sleep problems first presenting in infancy may become chronic, persisting into the preschool and school-aged years. A solid body of literature now exists supporting the use of empirically-based behavioral management strategies to treat bedtime problems and night wakings in infants, toddlers, and preschoolers. The following practice parameters present recommendations for the use of behavioral (i.e., non-pharmacological) treatments of bedtime problems and night wakings in young children (aged 0 – 4. years 11 months). A companion review paper1 on which the recommendations are based was prepared by a taskforce appointed by the Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM), and summarizes the peer-reviewed scientific literature on this topic. The authors of the review paper evaluated the evidence presented by the reviewed studies according to modified Sackett criteria.2 Using this information and a grading system described by Eddy3 (i.e., standard, guideline or option), the Standards of Practice Committee and Board of Directors of the American Academy of Sleep Medicine determined levels of treatment recommendation presented in the practice parameters below. These practice parameters provide 3 types of recommendations. First, recommendations are provided indicating that behavioral interventions are effective in the treatment of bedtime problems and night wakings in young children, producing reliable and significant clinical improvement in sleep parameters. Second, recommendations are made regarding specific behavioral therapies, including: (1) unmodified extinction, extinction with parental presence, and preventive parent education are all rated as individually effective therapies in the treatment of bedtime problems and night wakings (Standards), and (2) graduated extinction, bedtime fading/positive routines and scheduled awakenings are rated as individually effective therapies in the treatment of bedtime problems and night wakings but with less certainty (Guidelines). There was insufficient evidence to recommend standardized bedtime routines and positive reinforcement as single therapies. In addition, although behavioral therapies for bedtime problems and night wakings are often combined, there was insufficient evidence available to recommend one individual therapy over another or to recommend an individual therapy over a combination of therapies. Finally, recommendations are provided regarding the beneficial effects of behavioral treatments on secondary outcomes, including daytime functioning (child) and parental well-being.

Montgomery-Downs, Hawley E.; Gozal, David

doi: 10.1093/sleep/29.10.1282pmid: 17068981

AbstractStudy Objectives:Childhood sleep disorders are consistently shown to affect behavior and cognition, but first-night effects on these measures are generally unknown. We sought to examine how sleep in the home versus the laboratory differed among healthy toddlers and how such differences relate to standardized scores on assessments the morning following polysomnography.Design, Setting, and Participants:Twenty healthy 14-month-olds wore actigraphs during nighttime sleep at home for 5 nights preceding and during standard overnight laboratory polysomnography. The Bayley Scales of Infant Development (BSID-II) were administered once the morning after polysomnography.Measurements and Results:All subjects had normal polysomnography. Sleep-start times at home and during polysomnography did not differ, whereas, during polysomnography, subjects awoke earlier (p = .008, d = .58), their total sleep time (p <. 001, d = 1.1) and sleep efficiency (p = .004, d = .57) were reduced, and they had shorter sleep-bout lengths (p = .004, d = .03), less immobility (p = .003, d = .62), and greater average activity during sleep (p <. 001, d = .98). Standardized assessments were not affected by differences between home and polysomnography night sleep, but children with greater emotional regulation difficulty had a lower percentage of immobility (r = −0.67, p = .001) and increased sleep fragmentation (r = −0.60, p = .005) during polysomnography.Conclusions:Although sleep-onset times were preserved, sleep in the laboratory was disrupted, compared with at home. These differences did not affect standardized scores, but the magnitude of the difference was associated with worse emotional regulation. The effects of sleep disturbance during polysomnography, or the influence of poor emotional regulation on sleep in the laboratory, should be considered in studies of young children.

Geib, Lorena Teresinha Consalter; Aerts, Denise; Nunes, Magda Lahorgue

doi: 10.1093/sleep/29.10.1288pmid: 17068982

AbstractStudy Objectives:To evaluate sleep practices regarding maternal, infant, and socioeconomic factors in an infant population and to propose a scoring scale associated with high versus low risk of sudden infant death syndrome.Design:Cross-sectional, population-based study.Setting:Passo Fundo, Brazil.Participants:2,285 newborns.Interventions:Perinatal information was collected from the city health database, and a questionnaire regarding sleep practices was applied to the de facto mothers. The scale for classification of infant sleep practices in relation to high or low risk of sudden infant death syndrome was based on previous population studies. Cox regression, bivariate, and multivariate analyses were employed.Measurements and Results:Application of the score allowed detection of high-risk sleep practices in 42.4% of infants. The following variables maintained association with high-risk sleep practices: 6 or fewer visits in the antenatal clinic (p < .001), maternal age ≤ 20 years (p < .001), smoking during pregnancy (p = .041), disease during the first 2 months of life (p = .038), low birth weight (p = .049), and low socioeconomic status (p < .001); 90% of deceased infants and 75% of suspected sudden infant death syndrome cases were regularly exposed to high-risk sleep practices.Conclusions:High-risk sleep practices were widely observed in the study population. The significance of this study lies in the future application of this information via public health measures targeted at high-risk populations.

Patwardhan, Anjali A.; Larson, Martin G.; Levy, Daniel; Benjamin, Emelia J.; Leip, Eric P.; Keyes, Michelle J.; Wang, Thomas J.; Gottlieb, Daniel J.; Vasan, Ramachandran S.

doi: 10.1093/sleep/29.10.1301pmid: 17068983

AbstractStudy Objectives:We hypothesized that alterations in cardiac hemody-namics associated with obstructive sleep apnea-hypopnea (OSAH) would be reflected in higher natriuretic peptide levels. We examined the association of OSAH with natriuretic peptides in a community-based sample.Design:Cross-sectional, retrospective, observational study.Setting:Framingham Heart Study Offspring Cohort and Sleep Heart Health Study.Participants:Community-based sample of 623 individuals.Measurements:Full-montage home polysomnography was used to determine apnea-hypopnea index (AHI) and percentage of time with an oxyhemoglobin saturation < 90% (PctLt90). Sensitive immunoradiometric assays were used to measure plasma B-type (BNP) and N-terminal pro-atrial natriuretic peptide (NT-ANP). Multivariable regression was used to examine the relations between natriuretic peptides and indicators of OSAH, adjusting for age, sex, body mass index, and clinical covariates.Results:No statistically significant relations between OSAH indices andBNP were observed in the multivariable model. Compared with an AHI < 5, relative levels of 1.20, 0.88, and 0.91 were observed for AHI categories 5–15, 15–30, >30 events per hour, respectively. For NT-ANP, no significant relations were seen with AHI in the multivariable model (relative levels of 0.98, 0.91, and 0.90). An inverse association was observed between NT-ANP and PctLt90 in age- and sex-adjusted models (relative levels of 0.93, 0.87, and 0.80), although this association became statistically nonsignificant after adjusting for body mass index.Conclusion:Lack of association of natriuretic peptides with OSAH indices suggests that undiagnosed OSAH may not be associated with major alterations in left ventricular function, as reflected in morning natriuretic peptide levels.

Banno, Katsuhisa; Manfreda, Jure; Walld, Randy; Delaive, Kenneth; Kryger, Meir H.

doi: 10.1093/sleep/29.10.1307pmid: 17068984

AbstractSubjective Objectives:To document healthcare utilization 2 years after diagnosis in women with obstructive sleep apnea syndrome (OSAS).Design:Retrospective observational cohort study.Setting:Tertiary university-based medical center.Patients and Controls:Four hundred and fourteen women with OSAS were matched with 1404 women from the general population who served as controls.Interventions:Patients were treated with continuous positive airway pressure (CPAP) or were recommended weight loss alone.Measurements and Results:There were 231 treatment compliant (TC) patients, 91 patients not using CPAP (NCU), and 92 patients who were only recommended weight loss (WL). In the entire group, there was increase in fees of $123.43 ± $25.01 in the 2 years before diagnosis and a reduction of fees of $37.96 ± $21.35 in the 2 years after diagnosis (p < .0001). Physician claims increased in the 2 years before diagnosis by $111.22 ± 31.35 in TC and by $152.77 ± 59.55 in the NCU groups and then decreased in TC by $20.96 ± $26.60 (p < .01) and NCU by $72.20 ± 45.91 in the 2 years after diagnosis (p < .01). The fees in WL group did not change significantly. The number of clinic visits of the entire group increased in the 2 years before diagnosis by 2.32 ± 0.43 and decreased over the next 2 years by 1.48 ± 0.42 visits (p < .0001). There was an increase of clinic visits in the 3 subgroups in the 2 years before diagnosis (2.30 ± 0.57 in TC, 2.55 ± 0.99 in NCU, and 2.18 ± 0.82 in WL groups) followed by a reduction of clinic visits over the next 2 years (1.56 ± 0.55 fewer visits in TC [p < .0001], 1.70 ± 0.90 in NCU [p < .01], and 1.04 ± 0.90 in the WL group [p < .05] ).Conclusions:Healthcare utilization in women with OSAS increased in the years before sleep-clinic evaluation and then decreased in the following 2 years.

Krakow, Barry

doi: 10.1093/sleep/29.10.1313pmid: 17068985

AbstractStudy Objectives:To develop clinical guideposts to identify patients with salient nightmare conditions.Design:Prevalence data from a retrospective chart review on a consecutive series of sleep patients to assess how or whether those with nightmares (1) rank nightmare complaints compared to other sleep complaints, (2) link nightmares to disrupted sleep, (3) report worse sleep symptoms and health outcomes compared to other sleep patients, and (4) endorse criteria for a salient nightmare condition on the Disturbing Dream and Nightmare Severity Index.Setting:Two community sleep facilities: private sleep medical center and a hospital-based sleep lab.Patients:Seven hundred eighteen patients presenting at intake: sleep center (n = 620); sleep lab (n = 98).Measurements and Results:Standard sleep parameters and various health outcomes were assessed with self-report measures. Of 718 sleep patients, 186 ranked a nightmare complaint among their sleep problems, of whom 117 linked their bad dreams to disrupted sleep, suggesting a potential salient nightmare condition. Compared to all other sleep patients, these 117 cases demonstrated consistent significant patterns of worse or more prevalent problems with self-reported sleep indexes, insomnia, sleep quality, sleep-fragmentation factors, sleep-related daytime impairment, psychiatric history, medical comorbidity, and parasomnias. The Disturbing Dream and Nightmare Severity Index identified those with salient nightmare complaints and correlated with worse sleep and health outcomes.Conclusions:At 2 sleep medical facilities, 16% of patients presented with an apparent salient nightmare condition, and these patients were identified with simple clinical guideposts, which could be incorporated at intake in various sleep medicine settings.

Gagnon, Jean-François; Petit, Dominique; Fantini, Maria Livia; Rompré, Sylvie; Gauthier, Serge; Panisset, Michel; Robillard, Alain; Montplaisir, Jacques

doi: 10.1093/sleep/29.10.1321pmid: 17068986

AbstractStudy Objective:To determine the frequency of rapid eye movement (REM) sleep behavior disorder (RBD) and REM sleep without atonia among patients with Alzheimer disease and control subjects.Design:Overnight polysomnography.Settings:Sleep laboratory.Patients:Fifteen patients with probable Alzheimer disease (mean age ± SD, 70.2 ± 5.6) and 15 age-matched healthy control subjects (mean age ± SD, 67.9 ± 5.4).Intervention:N/A.Results:Four patients with Alzheimer disease presented REM sleep without atonia. One of these patients had all the polysomnographic features of RBD, including behavioral manifestations during REM sleep.Conclusion:RBD is rare, but REM sleep without atonia is relatively frequent in patients with probable Alzheimer disease, a tauopathy.

González, Mónica M.C.; Aston-Jones, Gary

doi: 10.1093/sleep/29.10.1327pmid: 17068987

AbstractStudy Objectives:Noradrenergic locus coeruleus (LC) neurons regulate arousal. Previous studies have shown that noradrenergic LC neurons exhibit a circadian rhythm in impulse activity, which peaks during the active period. This is mediated by an indirect circuit projection from the supra-chiasmatic nucleus (SCN) to the LC. Here we sought to evaluate the hypothesis that the LC regulates the circadian properties of the sleep-wake cycle.Design:Sprague-Dawley rats maintained on a light-dark (LD) schedule or in constant darkness (DD) for 3 to 4 weeks were treated with DSP-4, a neurotoxic agent specific for noradrenergic-LC projections. Vigilance states were analyzed before and 3 weeks after LC lesion. The DSP-4 lesion was verified by immunohistochemistry of noradrenergic fibers in the frontal cortex.Setting:University of Pennsylvania.Patients or Participants:N/A.Interventions:N/A.Measurements and Results:DSP-4 decreased the amplitude of thesleep-wake rhythm in LD animals by significantly decreasing wakefulness and increasing sleep during the active period. However, DSP-4 had no effect on the sleep-wake cycle of DD animals. Moreover, DD itself decreased the amplitude of the sleep-wake cycle similar to that of the neurotoxic lesion of the noradrenergic system in LD animals. Analysis of noradrenergic fiber staining in the frontal cortex revealed that this effect was associated with fewer fibers or boutons in nonlesioned DD rats than in nonlesioned LD animals.Conclusions:Noradrenergic LC neurons provide a circadian regulation of the sleep-wake cycle, and the maintenance of LC function depends on light exposure. Light deprivation induces a loss of noradrenergic fibers, which in turn decreases the amplitude of the sleep-wake rhythm.