- Sleep Medicine
Clinical Professor, Psychiatry and Behavioral Sciences - Sleep Medicine
Fellowship: Stanford University School of Medicine (1995) CA
Residency: Albert Einstein College of Medicine (1993) NY
Residency: Albert Einstein College of Medicine (1990) NY
Medical Education: Albert Einstein College of Medicine (1988) NY
Board Certification: American Board of Pediatrics, Sleep Medicine (2007)
Internship: New York Presbyterian Medical Center (1989) NY
Current Research and Scholarly Interests
Sleep Disorders in Adults and Children
Light Flashes to Treat Delayed Sleep Phase Disorder (DSPD)
Delayed Sleep Phase Disorder (DSPD) is a sleep disruption that commonly occurs in teens and manifests as a difficulty in waking up in the morning, going to sleep early enough at night, and daytime disturbances such as depression, fatigue, and restlessness. The purpose of this study is to determine if brief flashes of light, that are scheduled to occur during sleep, are effective in treating DSPD.
Stanford is currently not accepting patients for this trial. For more information, please contact Jamie Zeitzer, PhD, 650-493-5000 Ext. 62410.
Study of the Usability and Efficacy of a New Pediatric CPAP Mask
This study will evaluate a newly developed pediatric mask (known as Pixi) on children aged 2-7 using continuous positive airway pressure (CPAP), or Non-invasive ventilation (NIV) treatment. The participants will undergo a monitored sleep study, followed by a 7 night trial of the Pixi mask in the home environment. During the study usability will be measured through questionnaires filled in by the parent and clinician. The study hypothesis is that the usability of the mask will be superior to the patient's usual mask.
Stanford is currently not accepting patients for this trial. For more information, please contact Chia-Yu Cardell, (650) 721 - 7576.
- Dement's Sleep and Dreams
PSYC 135, PSYC 235 (Win, Spr)
- Independent Studies (5)
- Prior Year Courses
Adolescent sleep health and school start times: Setting the research agenda for California and beyond: A research summit summary: A research summit summary.
In fall 2019, California passed and signed into law SB328, the first US statewide legislation explicitly designed to protect adolescent sleep health by requiring most California public school districts to start no earlier than 8:00 AM for middle schools and 8:30 AM for high schools. Recognizing the unique opportunity presented by the bill's 3-year implementation period, a group of experts in adolescent sleep and school start times held a virtual summit on January 22-23, 2021 to (1)summarize the research on adolescent sleep and school start time change;(2)develop recommendations for relevant, refined, and innovative research areas and research questions;(3)provide input regarding research design, methodology, and implementation; and (4) offer a forum for networking, exchanging ideas, and establishing interdisciplinary research collaborations. Participants represented a multidisciplinary range of academic backgrounds including sleep and circadian biology, neuroscience, education, medicine, public health, mental health, safety, public policy, economics, implementation science, criminology, diversity studies, and science communication. This paper summarizes summit presentations regarding current knowledge on adolescent sleep health and school start times and key research recommendations from small group workshops on topics including research design and tools, methodological issues, sleep health disparities, logistical challenges in conducting school-based research, public-health impact, and novel and expanded approaches to research.
View details for DOI 10.1016/j.sleh.2021.10.008
View details for PubMedID 34991996
Variable negative external pressure-an alternative to continuous positive airway pressure for the treatment of obstructive sleep apnea: a pilot study.
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine
STUDY OBJECTIVES: To assess variable negative external pressure (vNEP) therapy using a range of pressures and varying collar sizes and shapes to identify combinations that improve the efficacy and comfort of this emerging therapy for obstructive sleep apnea (OSA).METHODS: This prospective, open-label pilot study included 28 eligible patients (71% men) having documented moderate OSA (apnea-hypopnea index 15 ≤ AHI ≤ 30) at one sleep clinic for an overnight, in-lab sleep trial. Each participant tested at least 2 of 6 available vNEP devices during sleep periods ≥2 hours. During the assessment of AHI by polysomnography, negative pressures of -20 to -35 cmH2O were adjusted to improve each patient's response. Participants' therapeutic preferences were assessed by a questionnaire and interviews.RESULTS: Twenty (71%) of the participants responded to vNEP therapy: excellent response (AHI ≤ 5 events/h) was observed in 14 (50%); 6 (21%) achieved a partial response (AHI ≤ 50% baseline). For the 20 responders, the therapy reduced the fraction of total sleep time when peripheral oxygen saturation SpO2 < 90% and improved minimum SpO2. Six patients experienced a minor, self-limited adverse event. Twenty-six participants (93%) stated that they would use vNEP nightly.CONCLUSIONS: In this pilot study vNEP therapy markedly improved AHI and oxygenation in most patients with moderate OSA. The majority of participants found vNEP comfortable and preferable to prevailing OSA therapies. Further development and studies of vNEP are warranted.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04718142; Study of Variable Negative External Pressure (vNEP) in Reducing Respiratory Event in Individuals With OSA; Unique Protocol ID: 20193101.
View details for DOI 10.5664/jcsm.9680
View details for PubMedID 34596039
- School start time: a public health crisis. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2020
- William C. Dement (1928-2020). Science (New York, N.Y.) 2020; 369 (6503): 512
Reminiscences of Michel Jouvet.
View details for PubMedID 30126684
Socioeconomic Impact of Pediatric Sleep Disorders.
Sleep medicine clinics
2017; 12 (1): 23-30
Pediatric disorders tend to affect the immediate support unit, adults and children. High costs for direct consumption of medical care are offset by early diagnosis and treatment of pediatric sleep disorders. Pediatric sleep disorders are underdiagnosed and undertreated. Attention-deficit/hyperactivity disorder may result from insufficient or fragmented sleep. Delaying school start time resulted in decreased car crashes in teen drivers and improved mood.
View details for DOI 10.1016/j.jsmc.2016.10.005
View details for PubMedID 28159094
Sleep-deprived motor vehicle operators are unfit to drive: a multidisciplinary expert consensus statement on drowsy driving
2016; 2 (2): 94–99
This article presents the consensus findings of the National Sleep Foundation Drowsy Driving Consensus Working Group, which was an expert panel assembled to establish a consensus statement regarding sleep-related driving impairment.The National Sleep Foundation assembled a expert panel comprised of experts from the sleep community and experts appointed by stakeholder organizations. A systematic literature review identified 346 studies that were abstracted and provided to the panelists for review. A modified Delphi RAND/UCLA Appropriateness Method with 2 rounds of voting was used to reach consensus.A final consensus was reached that sleep deprivation renders motorists unfit to drive a motor vehicle. After reviewing growing evidence of impairment and increased crash risk among drivers who obtained less than optimal sleep duration in the preceding 24 hours, the panelists recognized the need for public policy guidance as to when it is certainly unsafe to drive. Toward this end, the panelists agreed upon the following expert consensus statement: "Drivers who have slept for two hours or less in the preceding 24 hours are not fit to operate a motor vehicle." Panelists further agreed that most healthy drivers would likely be impaired with only 3 to 5 hours of sleep during the prior 24 hours.There is consensus among experts that healthy individuals who have slept for 2 hours or less in the preceding 24 hours are too impaired to safely operate a motor vehicle. Prevention of drowsy driving will require sustained and collaborative effort from multiple stakeholders. Implications and limitations of the consensus recommendations are discussed.
View details for PubMedID 28923267
Pediatric Sleep Pharmacology: A Primer.
Seminars in pediatric neurology
2015; 22 (2): 135-147
"What will you give my child to help him sleep?" is a common question parents ask and some health care providers abhor hearing. Entire families may suffer when one member does not sleep well. Poor sleep may complicate the management of other comorbid conditions. Health care providers may have received only limited education on sleep disorders and are frequently forced to choose between treatment options that are poorly studied in children. Fortunately, when addressed correctly, many children with chronic sleep disorders may improve their sleep and daytime behavior in a relatively short time. This review provides a framework to help understand the causes of poor sleep in children and the potential pharmacologic options.
View details for DOI 10.1016/j.spen.2015.03.002
View details for PubMedID 26072344
- Pediatric Sleep Pharmacology: A Primer SEMINARS IN PEDIATRIC NEUROLOGY 2015; 22 (2): 135-147
Evaluation of a new pediatric positive airway pressure mask.
Journal of clinical sleep medicine
2014; 10 (9)
The choice and variety of pediatric masks for continuous positive airway pressure (CPAP) is limited in the US. Therefore, clinicians often prescribe modified adult masks. Until recently a mask for children aged < 7 years was not available. This study evaluated apnea-hypopnea index (AHI) equivalence and acceptability of a new pediatric CPAP mask for children aged 2-7 years (Pixi; ResMed Ltd, Sydney, Australia).Patients aged 2-7 years were enrolled and underwent in-lab baseline polysomnography (PSG) using their previous mask, then used their previous mask and the VPAP III ST-A flow generator for ≥ 10 nights at home. Thereafter, patients switched to the Pixi mask for ≥ 2 nights before returning for a PSG during PAP therapy via the Pixi mask. Patients then used the Pixi mask at home for ≥ 21 nights. Patients and their parents/guardians returned to the clinic for follow-up and provided feedback on the Pixi mask versus their previous mask.AHI with the Pixi mask was 1.1 ± 1.5/h vs 2.6 ± 5.4/h with the previous mask (p = 0.3538). Parents rated the Pixi mask positively for: restfulness of the child's sleep, trouble in getting the child to sleep, and trouble in having the child stay asleep. The Pixi mask was also rated highly for leaving fewer or no marks on the upper lip and under the child's ears, and being easy to remove.The Pixi mask is suitable for children aged 2-7 years and provides an alternative to other masks available for PAP therapy in this age group.
View details for PubMedID 25142768
View details for PubMedCentralID PMC4153116
- Treatment of Sleep Disorders NEUROTHERAPEUTICS 2012; 9 (4): 685-686
Pediatric Sleep Pharmacology
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA
2012; 21 (4): 861-?
This article reviews common sleep disorders in children and pharmacologic options for them. Discussions of pediatric sleep pharmacology typically focus on treatment of insomnia. Although insomnia is a major concern in this population, other conditions of concern in children are presented, such as narcolepsy, parasomnias, restless legs syndrome, and sleep apnea.
View details for DOI 10.1016/j.chc.2012.08.001
View details for Web of Science ID 000311194100010
View details for PubMedID 23040905
- Chapter 34: the history of sleep medicine. Handbook of clinical neurology 2010; 95: 547-556
Pediatric Sleep Pharmacology
SEMINARS IN PEDIATRIC NEUROLOGY
2008; 15 (2): 79-90
This article reviews the most common pharmacologic options in the treatment of sleep disorders in children. Despite the high prevalence of sleep disorders in children, there is a paucity of education and information available on the pharmacologic management of sleep disorders in children. The principles of sleep physiology and pathophysiology that help provide more rational pharmacologic management are discussed. Medications are typically not Food and Drug Administration (FDA) approved for the pediatric age range or for the specific sleep disorder. Medications have a role for insomnia, narcolepsy, parasomnias, and sleep-related movement disorders. The available choices of hypnotics are reviewed. Medications to increase alertness of narcoleptics and decrease cataplexy are discussed. The use of dopaminergic agents for Restless Legs Syndrome is reviewed. The potential use of medication in sleep apnea is also reviewed. Pharmacologic guidelines need to be developed specifically for sleep disorders in children. Ideally, these guidelines should be FDA approved for the specific sleep disorder and for the pediatric age range. The development of easy to swallow, chewable or liquid forms of these medications are needed. Training programs should play the lead role in enhancing pediatricians' knowledge of the pharmacologic treatment of sleep disorders in children.
View details for DOI 10.1016/j.spen.2008.03.004
View details for Web of Science ID 000207789400006
View details for PubMedID 18555194
Reliability of respiratory polygraphy for the diagnosis of sleep apnea-hypopnea syndrome in children
ARCHIVOS DE BRONCONEUMOLOGIA
2008; 44 (6): 318-323
Overnight polysomnography (PSG) is the gold standard diagnostic tool for sleep apnea-hypopnea syndrome (SAHS) in children. The aim of the present study was to evaluate the usefulness of diagnostic respiratory polygraphy in children with clinically suspected SAHS referred to our sleep-disordered breathing clinic.We studied 53 children referred with clinical suspicion of SAHS; 29 (54.7%) were boys and the mean (SD) age was 6.4 (2.9) years. After a medical history was taken and a physical examination performed, patients underwent respiratory polygraphy (Edentec) simultaneously with overnight PSG in the sleep laboratory. The 2 diagnostic tools were compared using statistical analysis.SAHS was defined by an obstructive apnea-hypopnea index (OAHI) of 3 or more in overnight PSG and a respiratory disturbance index (RDI) of 3 or more in respiratory polygraphy. The rate of diagnostic agreement was 84.9%. The difference between the mean OAHI and RDI values was not significant (0.7 +/- 5.4; P=.34). The intraclass correlation coefficient between the OAHI and RDI was 89.4 (95% confidence interval, 82.4-93.7; P< .001). When receiver operating characteristic curves were calculated for the OAHI cutoff points used for the diagnosis of SAHS (> or =1, > or =3, and > or =5), the best RDI cutoff for all 3 OAHI values considered was found to be 4.6. When age strata were considered, in children 6 years or older the best RDI cutoff for the 3 OAHI values was 2.1. In children younger than 6 years the best RDI cutoff was 3.35 for OAHI > or =1 and 5.85 for OAHI > or =3 and > or =5.Respiratory polygraphy in the sleep laboratory is a valid method for the diagnosis of SAHS in children.
View details for Web of Science ID 000256900100006
View details for PubMedID 18559221
Efficacy of automated continuous positive airway pressure in children with sleep-related breathing disorders in an attended setting
2004; 113 (5): E412-E417
The purpose of this study was to evaluate the safety and efficacy of automated continuous positive airway pressure (Auto-CPAP) in children. Sleep-related breathing disorders (SRBDs) include the clinical spectrum of symptomatic chronic snoring, upper airway resistance syndrome, and obstructive sleep apnea. This spectrum occurs in adults and children. Less data are available for children despite recognition of the condition's prevalence. CPAP has been an established treatment for adults and children. Treatment with Auto-CPAP has been available for adults but has not been reported previously in children.A group of 14 children (8 months to 12 years old) was evaluated prospectively with baseline polysomnographic study and CPAP titration performed with Auto-CPAP under sleep technologist supervision.The results demonstrated that Auto-CPAP is sensitive and effective for children with obstructive sleep apnea in an attended setting. There was 1 subject who did not seem to tolerate Auto-CPAP, but when she was switched to conventional CPAP, she did not tolerate that either. In this subject, the mask never fit well. She was excluded from the analysis. All other patients had a decrease in the number of abnormal breathing events during sleep. The respiratory disturbance index decreased from a mean of 12.6 (SD: 12.4) to 2.6 (SD: 2.7) events per hour. The lowest oxygen saturation improved from a mean of 86% (SD: 10.8) to 93.6% (SD: 3.9).We conclude that Auto-CPAP is safe and effective in an attended environment. Auto-CPAP did not eliminate all the abnormal respiratory events. In subjects 1 and 14, the final respiratory index improved but remained >5 events per hour (5.9 and 7.7, respectively). We suspect that this was because of problems with the masks leaking, which illustrates the importance of follow-up and possible need for retitration in some patients. Proper mask fit is essential for successful treatment. Additional work is needed to evaluate its utility in the home setting. This study was designed to evaluate Auto-CPAP titration in an attended environment. It did not indicate information about the effectiveness in an unattended or home setting. We demonstrate that Auto-CPAP is able to detect abnormal breathing events during sleep in children and may provide the necessary pressure to correct these events. Auto-CPAP can be used safely for pressure titration in an attended setting. Auto-CPAP devices from different manufactures are commercially available for adults. These different devices may have different algorithms and sensitivities to detect abnormal breathing episodes. This study was performed with only 1 specific model of Auto-CPAP. Our results should not be extrapolated to other Auto-CPAP devices without empirical confirmation of the devices' ability to detect and correct events in children. Auto-CPAP can be an alternative treatment for SRBDS in the pediatric population. These results allow for speculation of possible applications for Auto-CPAP in children. A potential advantage of Auto-CPAP includes permitting the initiation of treatment while awaiting a standard CPAP titration. The variable pressure response of Auto-CPAP allows for treatment under different situations such as upper airway infections, different sleeping positions, and changes in weight. As the child grows, the amount of positive pressure needed to maintain airway patency may change. Auto-CPAP may be able to adjust to these changing pressure requirements. Auto-CPAP does not eliminate the need for periodic office visits and evaluations of the clinical course.
View details for PubMedID 15121982
Breathing patterns in prepubertal children with sleep-related breathing disorders
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
2004; 158 (2): 153-161
To investigate abnormal breathing patterns during sleep in prepubertal children using nonstandard polysomnographic patterns in association with an apnea-hypopnea scoring technique.Study participants included 400 children with suspected sleep-related breathing disorders and 60 control children. We analyzed clinical signs and symptoms at entry into the study and 3 months after otolaryngological treatment. We determined the frequency of predefined breathing patterns during sleep through blind analysis of polysomnograms obtained once in control subjects and twice in children referred to our clinic (before and after adenotonsillectomy), using the nasal cannula-pressure transducer system, mouth thermistor, esophageal manometry, microphone, and pulse oximetry. We also determined the relationship between breathing patterns during sleep and residual postsurgery symptoms. Further analysis was performed of symptoms and polysomnographic patterns in those children who underwent new treatment interventions due to persistence of symptoms and abnormal polysomnogram findings.Tachypnea, persistently elevated breathing effort, progressively increased breath effort, and discrete flattening of nasal airflow monitored with the nasal cannula-pressure transducer system without oxygen saturation decreases help determine disorder as much as apneas and hypopneas. Abnormal, nonstandard breathing patterns were associated with the same symptoms as those in children with apnea and hypopnea and were more commonly present when there was incomplete resolution of initial symptoms that led treating practitioners to request further treatment.Currently published polysomnographic scoring recommendations overlook common breathing abnormalities during sleep that are associated with clinical complaints.
View details for PubMedID 14757607
Pediatric sleep pharmacology: you want to give my kid sleeping pills?
PEDIATRIC CLINICS OF NORTH AMERICA
2004; 51 (1): 117-?
There is a need for greater information about the pharmacologic management of sleep disorders in children. Pharmacologic guidelines must be developed specifically for sleep disorders in children. Ideally, these guidelines should be approved by the Food and Drug Administration for a specific sleep disorder or for the pediatric age range. This approval prevents physicians from being forced to prescribe medications as an "off label" indication. Development of easy-to-swallow, chewable, or liquid forms of these medications would be well received by parents everywhere. When these are not available, instructions for compounding these medications into a suspension by pharmacists are needed. Integration of behavioral and pharmacologic treatments may yield better patient outcomes. This approach requires pediatricians to have a comprehensive understanding of clinical sleep disorders in children. Training programs should play the lead role in enhancing pediatricians' knowledge of the pharmacologic treatment of sleep disorders in children.
View details for DOI 10.1016/S0031-3955(03)00179-2
View details for PubMedID 15008585
Abnormal blood pressure in prepubertal children with sleep-disordered breathing
2004; 55 (1): 76-84
The purpose of this study was to investigate the association between low blood pressure (BP) with mild symptoms of orthostatism, sleep-disordered breathing (SDB) and tilt test results in 7- to 12-y-old children. A retrospective chart review of 301 children, ages 7 to 12 y, was initially performed to evaluate the frequency of abnormal BP measurements. Then a prospective study was performed on 7- to 12-y-old prepubertal children with SDB, looking for both abnormal BP and mild orthostatism. All children had polysomnography. Those identified with abnormal (high or low) BP measurements (called "BP outliers") were studied with a new polysomnogram followed by a head-up tilt test as an indicator of autonomic activity. Four of the children with low BP were treated with nasal continuous positive airway pressure and received a second head-up tilt test 3.5 to 7 mo after starting treatment. The prospective study included 78 children, eight of whom were BP outliers. Seven of these outliers had low BP. Compared with all of the SDB subjects, SDB subjects with low BP and indicators of mild orthostatic hypotension had a significantly higher incidence of craniofacial dysmorphism, symptoms of SDB early in life, chronically cold extremities, and dizziness on standing up (chi2, p = 0.01 to 0.0001). They had a significantly greater drop in BP without evidence of autonomic neuropathy than all other children on head-up tilt testing (Kruskal-Wallis ANOVA with Bonferroni adjustment, p = 0.001 to 0.0001). However, the normotensive SDB controls also had significantly different BP drops than the normal controls (p = 0.0001). The four children placed on nasal continuous positive airway pressure had a nonsignificant trend toward normalization of tilt test response. SDB in prepubertal children can lead to different abnormal stimulation of the autonomic nervous system, with different impacts on BP. The severity and frequency of oxygen saturation drops during sleep, nonhypoxic increases in respiratory effort, and the duration of abnormal breathing are suspected of playing a role in the difference in autonomic nervous system stimulation.
View details for DOI 10.1203/01.PDR.0000099791.29621.62
View details for PubMedID 14605262
Sleep disordered breathing: Surgical outcomes in prepubertal children
2004; 114 (1): 132-137
To evaluate the treatment outcomes of sleep disordered breathing (SDB) in prepubertal children 3 months following surgical intervention.Retrospective investigation of 400 consecutively seen children with SDB who were referred to otolaryngologists for treatment.After masking the identities and conditions of the children, the following were tabulated: clinical symptoms, results of clinical evaluation and polysomnography at entry, the treatment chosen by the otolaryngologists, and clinical and polysomnographic results 3 months after surgery.Treatment ranged from nasal steroids to various surgical procedures. Adenotonsillectomy was performed in only 251 of 400 cases (68%). Four cases included adenotonsillectomy in conjunction with pharyngoplasty (closure of the tonsillar wound by suturing the anterior and posterior pillar to tighten the airway). Persistent SDB was seen in 58 of 400 children (14.5%), and an additional 8 had persistent snoring. Best results were with adenotonsillectomy.SDB involves obstruction of the upper airway, which may be partially due to craniofacial structure involvement. The goal of surgical treatment should be aimed at enlarging the airway, and not be solely focused on treating inflammation or infection of the lymphoid tissues. This goal may not be met in some patients, thus potentially contributing to residual problems seen after surgery. The possibility of further treatment, including collaboration with orthodontists to improve the craniofacial risk factors, should be considered in children with residual problems.
View details for PubMedID 14710009
Sleepwalking and sleep terrors in prepubertal children: What triggers them?
2003; 111 (1)
To evaluate the clinical presentation and polysomnography of prepubertal children with repetitive sleep terrors and sleepwalking, to compare them with a control group, and to evaluate the treatment of associated sleep disorders.Patients with complaint of sleep terrors with or without sleepwalking were studied retrospectively. A control group was also recruited. Each subject received a standardized evaluation, which included the following: 1) Pediatric Sleep Questionnaire; 2) interview regarding child's medical and sociofamilial history, orthodontic history, schooling, psychological difficulties, medication intake, and family history of medical and sleep disorders; 3) general pediatric physical examination and neurologic, otolaryngological, and craniofacial examination by a specialist; 4) obtaining medical history on variables relevant to early life sleep disorders; 5) polysomnography, which included electroencephalogram (EEG; C3/A2, Fp1/T1, T1/O1, O1/C3, C4/A1, Fp2/T2, T2/O2, O2/C4), chin and leg electromyelogram, right and left electro-oculogram, and electrocardiogram (modified V2 lead); respiration was monitored with a nasal cannula/pressure transducer system, mouth thermistor, chest and abdominal bands, pulse oximeter, and neck microphone; respiratory effort was monitored with calibrated esophageal manometry; variables were collected on a computerized sleep system; and 6) available family members with a positive history of sleep terrors and sleepwalking received clinical evaluations similar to those used for index cases; they also underwent ambulatory monitoring with an Edentrace system, which monitors heart rate, body position, oro-nasal flow, chest impedance, breathing noises (neck microphone), and pulse oximetry. Movements are deduced from artifact, and leg movements may be recorded on one channel if the equipment is preset for such recording. Subjects used logs to record "lights out" time, "lights on" time, nocturnal awakenings, and other events that occurred during the night. All original and follow-up recordings were rescored by 2 of 4 randomly selected specialists who were blind to subject identity. Mann-Whitney U test was used for group comparison. Nonparametric chi2 test was used to compare percentages of symptoms in symptomatic children versus control children.Eighty-four children (5 with sleep terrors and 79 with both sleep terrors and sleepwalking) and 36 normal control children formed the studied population. All subjects were Tanner stage 1 (prepubertal). None of the control children had any parasomnias. Fifty-one (61%) of 84 children with parasomnia had a diagnosis of an additional sleep disorder: 49 with sleep-disordered breathing (SDB) and 2 with restless leg syndrome (RLS). Twenty-nine of the children with both parasomnia and SDB had a positive family history of parasomnias, and 24 of the 29 also had a positive family history of SDB. Of the 51 children with associated sleep disorders, 45 were treated. Forty-three of 49 children with SDB were treated with tonsillectomy, adenoidectomy, and/or turbinate revision, and 2 of 2 children with RLS were treated with Pramipexole, a dopamine agonist, at bedtime. Treatment of the precipitating sleep disorder eliminated parasomnias in all 45 children. In all 43 children who received surgery, polysomnography performed 3 to 4 months later indicated the disappearance of SDB. The recordings also showed an absence of confusional arousals. The number of EEG arousals significantly decreased from a mean of 9 +/- 2.6 EEG arousals > or =3 seconds/hour during total sleep time to 3 +/- 1.5. The number of EEG arousals > or =3 seconds during the first sleep cycle of slow wave sleep (stage 3-4 non-rapid eye movement sleep) decreased from 4 +/- 1.4 to 1 +/- 0.2. In all surgically treated cases, parents also reported subsequent absence of the parasomnia. The 2 symptomatic children who were treated with Pramipexole had a complete absence of confusional arousals on the follow-up recording and reported no parasomnia since treatment. The periodic limb movemia since treatment. The periodic limb movement syndrome arousal index (number of EEG arousals associated with periodic limb movement/hour) decreased from 11 and 16 to 0 and 0.2, respectively. Parasomnia persisted in the 6 children who were untreated for SDB. Surgeons had refused to perform surgery on these children because of lack of data on the relationship between parasomnia and SDB-related tonsil and adenoid enlargement.Children with chronic parasomnias may often also present SDB or, to a lesser extent, RLS. Furthermore, the disappearance of the parasomnias after the treatment of the SDB or RLS periodic limb movement syndrome suggests that the latter may trigger the former. The high frequency of SDB in family members of children with parasomnia provided additional evidence that SDB may manifest as parasomnias in children. Children with parasomnias are not systematically monitored during sleep, although past studies have suggested that patients with sleep terrors or sleepwalking have an elevated level of brief EEG arousals. When children receive polysomnographies, discrete patterns (eg, nasal flow limitation, abnormal respiratory effort, bursts of high theta or slow alpha EEG frequencies) should be sought; apneas are rarely found in children. Children's respiration during sleep should be monitored with nasal cannula/pressure transducer system and/or esophageal manometry, which are more sensitive than the thermistors or thermocouples currently used in many laboratories. The clear, prompt improvement of severe parasomnia in children who are treated for SDB, as defined here, provides important evidence that subtle SDB can have substantial health-related significance. Also noteworthy is the report of familial presence of parasomnia. Studies of twin cohorts and families with sleep terror and sleepwalking suggest genetic involvement of parasomnias. RLS and SDB have been shown to have familial recurrence. RLS has been shown to have genetic involvement. It remains to be investigated whether a genetic factor directly influences sleep terror and sleepwalking or instead influences other disorders that fragment sleep and lead to confusional arousals. Additional studies are needed to investigate the association between SDB and non-;rapid eye movement parasomnias in the general population.
View details for PubMedID 12509590
Sleep-disordered breathing and upper-airway anomalies in first-degree relatives of ALTE children
2001; 50 (1): 14-22
From 1985 through 1995, 348 infants aged 3 wk-3 mo were referred to the Stanford Sleep Clinic for "apparent life-threatening events" (ALTE). A small group of 48 infants with no history of sleep-disordered breathing (SDB) was also recruited and used as controls (they comprised group C). We conducted a systematic investigation of relatives (parents, siblings, and grandparents) of the infants, including a clinical evaluation, craniofacial investigation, and the completion of an extensive (189-question) validated sleep/wake questionnaire. All data were calculated before the subdivision of ALTE infants into two groups. The subdivision was based on a blind scoring of the infants' polygraphic recordings; 42.5% of the infants were negative for SDB (Group A), whereas 57.5% of the infants were positive for SDB (Group B). Groups A and C were not significantly different from each other. Forty-three percent of the relatives of Group B infants had been treated for SDB (with nasal CPAP, surgical or dental appliance treatments) compared with 7.1% of Group A relatives. Clinical investigation indicated a significantly higher presence of small upper airways in the families of infants with SDB. About twice as many relatives reported the presence of asthma in Group B compared with Group A. Naso-oro-maxillomandibular anatomic traits that may lead to small upper airways in parents may be risk factors for abnormal breathing during sleep in their infants.
View details for PubMedID 11420413
Apparent life-threatening events, facial dysmorphia and sleep-disordered breathing
EUROPEAN JOURNAL OF PEDIATRICS
2000; 159 (6): 444-449
A standardized clinical evaluation and questionnaire was, beginning in 1985, applied to infants referred for an apparent life-threatening event (ALTE). All children who underwent this "core evaluation protocol" during a 10-year period were reviewed. Documentation of clinical complaints, symptoms and signs of sleep-disordered breathing, sleep/wake evaluation, systematic evaluation of the face and naso-oro-pharynx, nocturnal polygraphic recording, and systematic follow-up was conducted. A total of 346 infants had complete data sets, with a smaller group of 46 age-matched healthy infants as controls. A scorer blind to the clinical data analyzed the polygraphic investigation and divided the 346 referred into two groups. Group A, 42.6% of the population, included infants with no abnormal findings based on nocturnal polygraphic recording. These infants were no different from controls at initial evaluation and during follow-up. Group B, 57.4% of the population, included infants who had obstructive breathing during sleep which became more obvious over time. Two-thirds of these infants not only had clinical symptoms of sleep-disordered breathing but also had mild facial dysmorphia that could be seen clearly at 6 months of age.A subgroup of infants with apparent life-threatening events present an indication of a sleep-disordered breathing syndrome which is associated with a mild dysmorphia. This mild facial dysmorphia needs to be recognized early to distinguish these infants from other infants with apparent life-threatening events and to initiate appropriate treatment.
View details for Web of Science ID 000087421900010
View details for PubMedID 10867851
Pediatric sleep-related breathing disorders
AMERICAN JOURNAL OF OTOLARYNGOLOGY
2000; 21 (2): 98-107
Sleep-related breathing disorders (SRBD) can occur at any age. Obstructive sleep apnea, upper airway resistance syndrome and obstructive hypopnea syndrome all lie on the pathological continuum of SRBD. These disorders can have a great impact on a child's quality of life and can progress to significant complications. The symptoms, signs, work-up, and treatment of SRBD in children are discussed.
View details for Web of Science ID 000085933800005
View details for PubMedID 10758994
Narcolepsy in children: a practical guide to its diagnosis, treatment and follow-up.
2000; 2 (1): 1-9
Narcolepsy is a neurological syndrome characterised by daytime somnolence and cataplexy which often begins in childhood. Failing to recognise the condition may lead to mislabelling a child as lazy or depressed. The diagnostic criteria for narcolepsy vary with age. In children 8 years and older a Multiple Sleep Latency Test with an average latency of less than 8 minutes, and 2 or more sleep onset REM episodes supports the diagnosis. Human leucocyte antigen (HLA) marker DQbeta1 -0602 has been associated with narcolepsy. The current evidence supports the hypothesis that transmission of narcolepsy is multifactorial. with at least two genes, one of which is non-HLA related. The goal of all therapeutic approaches in narcolepsy is to control the narcoleptic symptoms and allow the patient to continue to fully participate in personal and academic activities. This usually requires a combination of behavioural therapy along with medication. Medications for patients with excessive sleepiness are usually stimulants, including amphetamines. However, a novel wake promoting agent, modafinil, is now available. Cataplexy can be controlled by medications with noradrenergic reuptake-blocking properties, such as clomipramine and fluoxetine, through their active metabolites. Increased awareness of narcolepsy is important to allow earlier diagnosis. Research on the effects different medications have, specifically on children with narcolepsy, has been very limited.
View details for PubMedID 10937454
Power spectral sleep EEG findings in patients with obstructive sleep apnea and upper airway resistance syndromes
14th International Congress of EEG and Clinical Neurophysiology
ELSEVIER SCIENCE BV. 1999: 113–120
View details for PubMedID 10689453
Sleep-disordered breathing in children
ANNALS OF MEDICINE
1998; 30 (4): 350-356
The first series of children with obstructive sleep apnoea syndrome was reported in 1976. Later it became apparent that children may have breathing disorders during sleep without frank apnoea or 'hypopnoeas'. This pattern could be detected by measuring the oesophageal pressure. This led to the concept of sleep-disordered breathing as a spectrum that combines obstructive sleep apnoea syndrome and the upper airway resistance syndrome. Studies that do not take into account this spectrum may misclassify symptomatic patients as 'primary snorers'. The exact prevalence of sleep-disordered breathing in children is unknown but may be as high as 11%. There is a familial predisposition to sleep-disordered breathing. Nasal obstruction and mouth breathing influence facial growth, which may further lead to difficulty in breathing while asleep. Symptoms include an increase in total sleep time, nonspecific behavioural difficulties, hyperactivity, irritability, bed-wetting and morning headaches. Clinical signs include failure to thrive, increased respiratory effort with nasal flaring and suprasternal or intercostal retractions. Also, abnormal paradoxical inward motion of the chest may occur during sleep. Excessive daytime sleepiness and obesity are not always present. Untreated children may develop cardiovascular complications. The condition is treatable with continuous or bilevel positive airway pressure, and may be cured with surgery.
View details for Web of Science ID 000076083500003
View details for PubMedID 9783833
Narcolepsy in prepubertal children
ANNALS OF NEUROLOGY
1998; 43 (1): 135-142
Narcolepsy was diagnosed in 51 children (29 boys). The age range was 2.1 to 11.8 years (mean, 7.9 +/- 3.1 years). A mean of three referrals was made before narcolepsy was considered. In 10 children, cataplexy was the presenting symptom. Thirty-eight children acknowledged sleep paralysis and 30 acknowledged hypnagogic hallucinations. All children had sleep studies; 31 exhibited rapid eye movement at sleep onset. The mean sleep latency was 1.5 minutes +/- 39 seconds on the Multiple Sleep Latency Test. All children had at least two sleep-onset rapid eye movement sleep episodes in this test. Forty-six children were HLA class II-positive for DQw6, and 45 were also positive for DRw15. Thirty (65%) families refused referrals to support and counseling groups. Teachers often refused to acknowledge a medical problem. During follow-up, all children presented at least once with depressive symptoms in reaction to their syndrome. Narcolepsy should be considered when evaluating children with behavioral and depressive symptoms.
View details for Web of Science ID 000071504600021
View details for PubMedID 9450782
Obstructive sleep apnea surgery: Risk management and complications
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
1997; 117 (6): 648-652
Hypoxemia, hypertension, airway obstruction, and death have been associated with surgery for obstructive sleep apnea syndrome (OSAS). Patient analysis was undertaken to identify potential factors that could affect risk-management outcome.One hundred eighty-two consecutively treated patients with OSAS undergoing 210 procedures were evaluated. Fifty-four factors were analyzed.Group characteristics included a mean age of 48.2 years, a mean respiratory disturbance index of 42.3, and a mean low oxyhemoglobin desaturation (LSAT) of 77.5%. Surgery included a combination of uvulopalatopharyngoplasty (162 patients; 77%) and maxillofacial procedures (173 patients; 82%). Patients with a respiratory disturbance index greater than 40 and an LSAT less than 80% (117 patients; 64%) were maintained on nasal continuous positive airway pressure. Thirty-nine patients (18.6% had difficult intubations. There was a positive correlation (p > 0.001) of difficult intubations, neck circumference (> 45.6 cm) and skeletal deficiency (Sella-Nasion-Point B < 75 degrees). All tubes were removed with the patient awake in the operating room with two transient episodes of airway obstruction. One hundred forty-eight of the patients (70.5%) required postoperative intravenous antihypertensive medications. Patients with a preoperative history of hypertension had a significantly increased risk (p > 0.01) of requiring intraoperative and postoperative intravenous antihypertensive medications. The mean hospital stay was 2.2 days (SD +/- 0.9). Analgesia was achieved with intravenous morphine sulfate or meperidine HCl (intensive care unit) and oral oxycodone (non-intensive care unit). There were no significant oxyhemoglobin desaturations, irrespective of severity of OSAS or obesity (mean LSAT day 1, 94.8% (SD +/- 2.4); mean LSAT day 2, 95.5% (SD +/- 1.6)). Complications included postoperative bleeding (n = 4), infection (n = 5), seroma (n = 3), arrhythmia (n = 4), angina (n = 1), and loss of skeletal fixation (n = 1).Intraoperative airway risks can be reduced by use of fiberoptic intubation in patients with increased neck circumference and skeletal deficiency. Patients with OSAS are at a significantly increased risk for hypertension. Nasal continuous positive airway pressure eliminated the postoperative risk of hypoxemia, which allowed the use of adequate parenteral or oral analgesics.
View details for PubMedID 9419093
Public health impact and treatment of insomnia
1997; 12: S31-S39
View details for Web of Science ID A1997WH97900005
Public health impact and treatment of insomnia.
1997; 12: 31-39
A growing number of people are concerned about their sleep in the United States. There are an estimated 40 million US citizens with chronic sleep disorders. The cost to society of sleep disorders has been estimated at greater than $90 billion US dollars. Despite this enormous cost to society, there remains a pervasive lack of attention provided to medical management of this problem. This is compounded by inadequate funding of sleep disorders research. There are treatments available to improve insomnia. These include different behavioral and pharmacologic regimes that can be used separately or in combination. Successful treatment requires thorough knowledge of the differential diagnosis of insomnia. The greatest public health challenge in the management of insomnia is how to develop effective educational programs that will allow the general public to improve their sleep. This will require greater cooperation from primary care providers and the government. Sleep disorders are the most important public health problem not being addressed in the United States.
View details for PubMedID 19698572
Recognition of sleep-disordered breathing in children
1996; 98 (5): 871-882
To determine whether upper airway resistance syndrome (UARS) can be recognized and distinguished from obstructive sleep apnea syndrome (OSAS) in prepubertal children based on clinical evaluations, and, in a subgroup of the population, to compare the efficacy of esophageal pressure (Pes) monitoring to that of transcutaneous carbon dioxide pressure (tcPCO2) and expired carbon dioxide (CO2) measurements in identifying UARS in children.A retrospective study was performed on children, 12 years and younger, seen at our clinic since 1985. Children with diagnoses of sleep-disordered breathing were drawn from our database and sorted by age and initial symptoms. Clinical findings, based on interviews and questionnaires, an orocraniofacial scale, and nocturnal polygraphic recordings were tabulated and compared. If the results of the first polygraphic recording were inconclusive, a second night's recording was performed with the addition of Pes monitoring. In addition, simultaneous measurements of tcPCO2 and endtidal CO2 with sampling through a catheter were performed on this second night in 76 children. These 76 recordings were used as our gold standard, because they were the most comprehensive. For this group, 1848 apneic events and 7040 abnormal respiratory events were identified based on airflow, thoracoabdominal effort, and Pes recordings. We then analyzed the simultaneously measured tcPCO2 and expired CO2 levels to ascertain their ability to identify these same events.The first night of polygraphic recording was inconclusive enough to warrant a second recording in 316 of 411 children. Children were identified as having either UARS (n = 259), OSAS (n = 83), or other sleep disorders (n = 69). Children with small triangular chins, retroposition of the mandible, steep mandibular plane, high hard palate, long oval-shaped face, or long soft palate were highly likely to have sleep-disordered breathing of some type. If large tonsils were associated with these features, OSAS was much more frequently noted than UARS. In the 76 gold standard children, Pes, tcPCO2, and expired CO2 measurements were in agreement for 1512 of the 1848 apneas and hypopneas that were analyzed. Of the 7040 upper airway resistance events, only 2314 events were consonant in all three measures. tcPCO2 identified only 33% of the increased respiratory events identified by Pes; expired CO2 identified only 53% of the same events.UARS is a subtle form of sleep-disordered breathing that leads to significant clinical symptoms and day and nighttime disturbances. When clinical symptoms suggest abnormal breathing during sleep but obstructive sleep apneas are not found, physicians may, mistakenly, assume an absence of breathing-related sleep problems. Symptoms and orocraniofacial information were not useful in distinguishing UARS from OSAS but were useful in distinguishing sleep-disordered breathing (UARS and OSAS) from other sleep disorders. The analysis of esophageal pressure patterns during sleep was the most revealing of the three techniques used for recognizing abnormal breathing patterns during sleep.
View details for Web of Science ID A1996VR46600003
View details for PubMedID 8909480
Development of circadian rhythmicity of temperature in full-term normal infants
NEUROPHYSIOLOGIE CLINIQUE-CLINICAL NEUROPHYSIOLOGY
1996; 26 (1): 21-29
Twelve full-term infants (7 girls and 5 boys) with normal neurological, behavioral and somatic development were followed at regular intervals during the first 5 months of life to appreciate the development of circadian rectal temperature rhythmicity. Activity and temperature (oral at birth, rectal thereafter) were monitored for a minimum of 60 hours on seven separate occasions: at birth, 3 weeks, 6 weeks, 8 weeks, 10 weeks, 16 weeks and 20 weeks of age. Activity was measured using an actigraph worn on the infant's wrist, and rectal temperature was measured using a rectal probe attached to a portable microprocessor (Vitalog TM). Data points were collected every 2 minutes. No fewer than ten infants were monitored at each session, and no infant missed more than one session. Missing recordings were due to equipment malfunctions, probe expulsions and minor health problems. Six infants out of 12 were successfully monitored at each of the first four sessions, from birth to 8 weeks of age inclusively, and two subjects were successfully monitored at all seven sessions. Periodic regression analysis was performed by least squares curve fit with secondary analysis of variance. Analysis of covariance was performed on repeated measures. There was no evidence of rectal temperature circadian rhythmicity at 3 weeks. Two infants demonstrated a circadian rhythmicity at 6 weeks, and all infants had a circadian rhythmicity at 10 weeks post-natal age. At the time of the first observance of circadian rhythmicity of rectal temperature, the mean delta in temperature from peak to trough was 0.6 +/- 0.3 degrees C. This delta was greater at the 16th week, with a mean value of 1.2 +/- 0.3 degrees C. The trough was seen during the first part of the long nocturnal inactivity period. Circadian rhythmicity of rectal temperature was always observed in the studied subjects before the establishment of a consolidated, long daytime wake period.
View details for Web of Science ID A1996UK72800004
View details for PubMedID 8657095
HOME NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE IN INFANTS WITH SLEEP-DISORDERED BREATHING
JOURNAL OF PEDIATRICS
1995; 127 (6): 905-912
To review our experience with home nasal continuous positive airway pressure (CPAP) in infants with small upper airways and abnormal breathing during sleep.Seventy-four infants with sleep-disordered breathing and narrow upper airways, as identified by nocturnal polygraphic recording and endoscopic evaluation, were treated at home with nasal CPAP. Infants with craniofacial anomalies and trisomy 21, and infants who had been referred to us as having had "apparent life-threatening events," made up the majority of the population. Because of the rapid growth of infants, regular follow-up visits were scheduled to adjust CPAP and mask size.Seventy-two infants were successfully treated at home with nasal CPAP; there were two failures. Follow-up lasted from 5 months to 12 years. Compliance was not a problem, but home nasal CPAP was prescribed only for infants who lived close to our center and whose families and pediatricians were willing to support compliance.Home nasal CPAP requires careful, in-laboratory titration and regular follow-up to adjust both pressure and mask size. With the support of families and pediatricians, home nasal CPAP can be an effective treatment for infants with upper airway respiratory problems during sleep. In many cases, it can provide an interim solution, enabling physicians to plan surgery at an appropriate time and giving infants time to grow before having to undergo surgical stress.
View details for Web of Science ID A1995TK14900009
View details for PubMedID 8523187
- ADULT OBSTRUCTIVE SLEEP-APNEA WITH SECONDARY ENURESIS WESTERN JOURNAL OF MEDICINE 1995; 163 (5): 478-480
NONDRUG TREATMENT TRIALS IN PSYCHOPHYSIOLOGICAL INSOMNIA
ARCHIVES OF INTERNAL MEDICINE
1995; 155 (8): 838-844
Due to a variety of potential problems with long-term hypnotic use, patients and treating physicians often try to avoid drugs in the treatment of psychophysiologic insomnia and to use nondrug treatment strategies, but these treatments must bring relief within a limited amount of time to be acceptable to patients.Thirty patients participated in the study. All had, for a minimum of 6 months, the complaint of less than 6 hours total sleep time per night in conjunction with either: (1) spending more than 30 minutes in bed before falling asleep, or (2) awakening during the night within 2 hours of sleep onset with difficulty returning to sleep. All subjects had the associated complaint of daytime impairment and none had used hypnotics for at least 3 months. Patients were randomly assigned to three parallel treatment groups: structured sleep hygiene, structured sleep hygiene with late afternoon moderate exercise, and structured sleep hygiene with early morning light therapy. Patients responded to questionnaires and filled out sleep logs. In addition, they underwent clinical evaluation, structured interviews, nocturnal monitoring, and actigraphy. The analyzed variables before and at the end of treatment were those derived from sleep logs and actigraphy.All subjects showed a trend toward improvement, independent of the treatment received, but only the "structured sleep hygiene with light treatment" showed statistically significant improvement at the end of the trial.Patients with chronic psychophysiologic insomnia may benefit from a nondrug treatment approach. Light therapy appears particularly promising.
View details for Web of Science ID A1995QU59400008
View details for PubMedID 7717792