Robin M. Lloyd

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.

Adolescent Fatigue, POTS, and Recovery: A Guide for Clinicians

Many teenagers who struggle with chronic fatigue have symptoms suggestive of autonomic dysfunction that may include lightheadedness, headaches, palpitations, nausea, and abdominal pain. Inadequate sleep habits and psychological conditions can contribute to fatigue, as can concurrent medical conditions. One type of autonomic dysfunction, postural orthostatic tachycardia syndrome, is increasingly being identified in adolescents with its constellation of fatigue, orthostatic intolerance, and excessive postural tachycardia (more than 40 beats/min). A family-based approach to care with support from a multidisciplinary team can diagnose, treat, educate, and encourage patients. Full recovery is possible with multi-faceted treatment. The daily treatment plan should consist of increased fluid and salt intake, aerobic exercise, and regular sleep and meal schedules; some medications can be helpful. Psychological support is critical and often includes biobehavioral strategies and cognitive-behavioral therapy to help with symptom management. More intensive recovery plans can be implemented when necessary.

Characteristics of REM sleep behavior disorder in childhood.

STUDY OBJECTIVE To describe our experience regarding the clinical and polysomnographic features of REM sleep behavior disorder (RBD) in childhood. METHODS This was a retrospective chart review of children and adolescents with RBD and REM sleep without atonia. Demographics, and clinical and polysomnographic information were tabulated. Our findings were compared with those in the existing literature. RESULTS The 15 subjects identified (13 RBD and 2 having REM sleep without atonia) had a mean age at diagnosis of 9.5 years (range 3-17 years); 11/15 (73%) were male. Nightmares were reported in 13/15 and excessive daytime sleepiness in 6/15. Two children had caused bodily harm to bedmate siblings. Comorbidities, which were multiple in some subjects, included anxiety (8/15), attention deficit disorder (10/15), nonspecific developmental delay (6/15), Smith-Magenis syndrome (1/15), pervasive developmental disorder (1/15), narcolepsy (1/15), idiopathic hypersomnia (1/15), and Moebius Syndrome (1/15). Abnormal MRI scans were seen in 5/8 evaluated subjects. Treatments consisted of clonazepam (10/15), melatonin (2/15), and discontinuation of a tricyclic agent (1/15), with a favorable response in 11 of 13. Two of 15 patients with REM sleep without atonia did not require pharmacotherapy. CONCLUSIONS RBD in children may be associated with neurodevelopmental disabilities, narcolepsy, or medication use. It seems to be modestly responsive to benzodiazepines or melatonin. The etiology is distinct from that of common childhood arousal parasomnias and RBD in adults; congenital and neurodevelopmental disorders, medication effect, and narcolepsy coexisted in some, but none had an extrapyramidal neurodegenerative disorder.

AASM Scoring Manual Version 2.2 Updates: New Chapters for Scoring Infant Sleep Staging and Home Sleep Apnea Testing.

V 2.2 of the American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events was released on July 1, 2015. The Scoring Manual Editorial Board (previously the Scoring Manual Committee) would like to call attention to the most important changes. As discussed below, there are two new major chapters providing rules for the staging of infant sleep and scoring respiratory events in home sleep apnea testing (HSAT) studies. The new chapters were approved by the AASM Board of Directors to fi ll two obvious gaps in the Scoring Manual. The Scoring Manual Editorial Board would like to emphasize that any changes in the manual are instituted after long deliberation and consultation with area content experts. Version 2.2 of the Scoring Manual, for the fi rst time, includes rules for scoring sleep studies in term infants less than two months of age. This milestone acknowledges the importance of studying sleep across the lifespan, beginning with our youngest patients. The new scoring rules address sleep staging in infants and are based on the classic infant scoring rules of Anders et al.1 Development of these new rules benefi tted from expert consultation from Madeleine Grigg-Damberger, MD, and Mark Scher, MD. One important difference between the current manual and Anders is that sleep is now classifi ed into three stages: REM, NREM and transitional, as compared to the Anders classifi cation of active, quiet and indeterminate sleep. This new classifi cation was based on the physiologic similarities between active and REM sleep, and quiet and NREM sleep. Further, it was realized that young infants have stages of sleep that manifest elements of both REM and NREM sleep; hence, the term “transitional” rather than “indeterminate.” Note that respiratory events in infants should be scored using the standard AASM pediatric scoring criteria. Version 2.2 of the AASM Scoring Manual now also includes scoring rules for adult Home Sleep Apnea Testing (HSAT; chapter IX). The foundation for the development of these rules includes the work of the 2010 AASM Out-of-Center Task Force who developed the SCOPER (Sleep, Cardiovascular, Oximetry, Position, Effort, Respiratory) classifi cation system.2 This classifi cation system systematically evaluated available technology and evidence for diagnosing obstructive sleep apnea using portable devices. These new HSAT scoring rules allow for standardization of scoring and reporting data generated from HSAT AASM Scoring Manual Version 2.2 Updates: New Chapters for Scoring Infant Sleep Staging and Home Sleep Apnea Testing Richard B. Berry, MD1; Charlene E. Gamaldo, MD2; Susan M. Harding, MD3; Rita Brooks, MEd, RST, RPSGT4; Robin M. Lloyd, MD5; Bradley V. Vaughn, MD6; Carole L. Marcus, MBBCh7 1University of Florida, Gainesville, FL; 2Johns Hopkins University, Baltimore, MD; 3University of Alabama, Birmingham, AL; 4Capital Health, Hamilton, NJ; 5Mayo Clinic, Rochester, MN; 6University of North Carolina, Chapel Hill, NC; 7Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA

Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea

ABSTRACT Obstructive sleep apnea (OSA) is a prevalent disorder associated with a multitude of adverse outcomes when left untreated. There is significant heterogeneity in the evaluation and management of OSA resulting in variation in cost and outcomes. Thus, the goal for developing these measures was to have a way to evaluate the outcomes and reliability of the processes involved with the standard care approaches used in the diagnosis and management of OSA. The OSA quality care measures presented here focus on both outcomes and processes. The AASM commissioned the Adult OSA Quality Measures Workgroup to develop quality care measures aimed at optimizing care for adult patients with OSA. These quality care measures developed by the Adult OSA Quality Measures Workgroup are an extension of the original Centers for Medicare & Medicaid Services (CMS) approved Physician Quality Reporting System (PQRS) measures group for OSA. The measures are based on the available scientific evidence, focus on public safety, and strive to improve quality of life and cardiovascular outcomes for individual OSA patients. The three outcomes that were selected were as follows: (1) improve disease detection and categorization; (2) improve quality of life; and (3) reduce cardiovascular risk. After selecting these relevant outcomes, a total of ten process measures were chosen that could be applied and assessed for the purpose of accomplishing these outcomes. In the future, the measures described in this document may be reported through the PQRS in addition to, or as a replacement for, the current OSA measures group. The overall objective for the development of these measures is that implementation of these quality measures will result in improved patient outcomes, reduce the public health burden of OSA, and provide a measurable standard for evaluating and managing OSA.

Comorbidities in Infants with Obstructive Sleep Apnea

STUDY OBJECTIVE The clinical characteristics of obstructive sleep apnea (OSA) in infants have been insufficiently characterized. Our aim was to describe identifiable comorbidities in infants with obstructive sleep apnea, which may assist in recognizing these patients earlier in their disease course and help improve management. METHODS This was a single-center, retrospective study involving infants 0-17 months of age with a diagnosis of OSA on the basis of clinical features and nocturnal polysomnography (PSG) at the Mayo Clinic Center for Sleep Medicine between 2000 and 2011. Patients were excluded if they had central apnea accounting for greater than 50% of respiratory events. OSA severity was determined by the apnea-hypopnea index (AHI). RESULTS One hundred thirty-nine patients were included. Based upon the AHI, they were subdivided into mild (AHI <5; 30%), moderate (AHI 5-9; 30%), or severe (AHI >10; 40%) categories. Comorbidities included gastroesophageal reflux in 95/139 (68%), periodic limb movements in sleep in 59/139 (42%), craniofacial abnormalities in 52/139 (37%), neuromuscular abnormalities in 47/139 (34%), prematurity in 41/139 (29%), genetic syndromes in 41/139 (29%), laryngomalacia / tracheomalacia in 38/139 (27%), and epilepsy in 23/139 (17%) of subjects. Severity of OSA correlated with prematurity, having a genetic syndrome, or neuromuscular abnormality. Multispecialty evaluation was needed for 119/139 (86%). CONCLUSION Comorbidities in infants with OSA differ from those of older children. Based upon the comorbidities identified in our study population, it appears that appropriate management of infants with OSA requires a multidisciplinary approach involving genetics, gastroenterology, pulmonology, otolaryngology, neurology, and general pediatrics.

Efficacy of menopausal hormone therapy on sleep quality: systematic review and meta-analysis

Sleep complaints are reported by 40–60 % of menopausal women. Poor sleep is a risk factor for cardiovascular disease, diabetes, and obesity. The effect of menopausal hormone therapy on sleep quality is unclear. A systematic review and meta-analysis were conducted to summarize the efficacy of menopausal hormone therapy on self-reported sleep quality. Electronic databases (PubMed, Scopus, Ovid MEDLINE, EMBASE, EBM Reviews CENTRAL, and PsycInfo) were searched from 2002 to October 2015. Randomized trials assessing the effect of menopausal hormone therapy with a minimum follow up of 8 weeks were included. Titles, abstracts, and full texts were screened independently and in duplicate. Primary outcome included sleep items within a questionnaire, scale or diary. Standardized mean differences across trials were pooled using random-effects models. The search identified 424 articles, from which 42 trials were included. Seven trials at a moderate to high risk of bias enrolling 15,468 women were pooled in meta-analysis. Menopausal hormone therapy improved sleep quality in women who had vasomotor symptoms at baseline [standardized mean difference –0.54 (−0.91 to −0.18), moderate quality evidence]. No difference was noted when women without such symptoms were analyzed separately or combined. Across 31 sleep quality questionnaires, daytime dysfunction was the most evaluated sleep domain. Menopausal hormone therapy improves sleep in women with concomitant vasomotor symptoms. Heterogeneity of trials regarding study population, formulations, and sleep scales; limit overall certainty in the evidence. Future menopausal hormone therapy trials should include assessment of self-reported sleep quality using standardized scales and adhere to reporting guidelines.

Depression, anxiety and tobacco use overlapping impediments to sleep in a national sample of college students

ABSTRACT Objectives: To examine how tobacco use and depression/anxiety disorders are related to disturbed sleep in college students. Participants: 85,138 undergraduate respondents (66.3% female, 74.5% white, non-Hispanic, ages 18–25) from the Spring 2011 American College Health Association–National College Health Assessment II database. Methods: Multivariate analyses of tobacco use (none, intermediate, daily) and mental health (diagnosed and/or symptomatic depression or anxiety) were used to predict sleep disturbance. Results: Daily tobacco use was associated with more sleep problems than binge drinking, illegal drug use, obesity, gender, and working >20 hours/week. Students with depression or anxiety reported more sleep disturbances than individuals without either disorder, and tobacco use in this population was associated with the most sleep problems. Conclusions: Tobacco use and depression/anxiety disorders are both independently associated with more sleep problems in college students. Students with depression and/or anxiety are more likely to be daily tobacco users, which likely exacerbates their sleep problems.

Effects of oral versus transdermal menopausal hormone treatments on self-reported sleep domains and their association with vasomotor symptoms in recently menopausal women enrolled in the Kronos Early Estrogen Prevention Study (keeps)

Objective: This study determined whether two different formulations of hormone therapy (HT): oral conjugated equine estrogens (o-CEE; 0.45 mg/d, n = 209), transdermal 17&bgr;-estradiol (t-E2; 50 &mgr;g/d, n = 201) plus cyclic progesterone (Prometrium, 200 mg) or placebo (PBO, n = 243) affected sleep domains in participants of the Kronos Early Estrogen Prevention Study. Methods: Participants completed the Pittsburgh Sleep Quality Index at baseline and during the intervention at 6, 18, 36, and 48 months. Global sleep quality and individual sleep domain scores were compared between treatments using analysis of covariance, and correlated with vasomotor symptom (VMS) scores using Spearman correlation coefficients. Results: Global Pittsburgh Sleep Quality Index scores (mean 6.3; 24% with score >8) were similar across groups at baseline and were reduced (improved sleep quality) by both HT (average change −1.27 [o-CEE] and −1.32 [t-E2]) when compared with PBO (−0.60; P = 0.001 [o-CEE vs PBO] and P = 0.002 [t-E2 vs PBO]). Domain scores for sleep satisfaction and latency improved with both HT. The domain score for sleep disturbances improved more with t-E2 than o-CEE or PBO. Global sleep scores significantly correlated with VMS severity (rs = 0.170, P < 0.001 for hot flashes; rs = 0.177, P < 0.001 for night sweats). Change in scores for all domains except sleep latency and sleep efficiency correlated with change in severity of VMS. Conclusions: Poor sleep quality is common in recently menopausal women. Sleep quality improved with both HT formulations. The relationship of VMS with domains of sleep suggests that assessing severity of symptoms and domains of sleep may help direct therapy to improve sleep for postmenopausal women.

DRESS following FIRES: A Clinical Conundrum

A previously healthy 2-year old Hmong girl presented to the Emergency Department with first time seizures during a febrile illness. Seizures continued for the next two weeks despite multiple antiepileptic agents. All initial cultures and evaluations were negative, and febrile infection related epilepsy syndrome (FIRES) was diagnosed. Three weeks into her hospital course, the patient developed a morbilliform rash on her thigh that became generalized. Concurrently, she developed fever and tachycardia. Laboratory studies demonstrated eosinophilia, an increase in ALT, AST, and direct/total bilirubin. CMV, EBV, and HHV-6 were negative. Skin biopsy showed lichenoid interface dermatitis. Clinical picture was suggestive of drug reaction with eosinophilia and systemic symptoms (DRESS). Topical and systemic steroids were started. Potential triggers for DRESS were discontinued. The patient deteriorated and cardiorespiratory failure occurred. She required ECMO for eight days. Patient gradually improved over the following weeks despite recurrent seizures and remained in the hospital for 283 days. FIRES is a rare and highly morbid condition in which patients develop status epilepticus in the setting of febrile illness that is often intractable to anticonvulsants and steroids. Typically no causative infection is identified. DRESS, another rare and potentially fatal condition, is a drug hypersensitivity reaction that includes eosinophilia, characteristic skin findings and potential involvement of liver, lungs, kidneys, or other organs. Allopurinol, antiepileptic agents, and antibiotics are the most frequently reported triggers. In this case report, we describe a patient who developed DRESS following FIRES, a sequence not previously described in the literature.