Search

Transgender or gender-nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.This retrospective cross-sectional study utilized a large US-based administrative claims database (deidentified Optum Clinformatics Data Mart Database) to identify youth aged 12-25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (odds ratio = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (odds ratio = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (odds ratio = 3.1, 95% confidence interval 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (odds ratio = 0.5, 95% confidence interval 0.4, 0.7) relative to those not on GAT.This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. Gender identity and transition: relationships with sleep disorders in US youth.

Various thyroid pathologies are speculated to contribute to obstructive sleep apnea (OSA). The underlying mechanisms of the intricate relationship between OSA and thyroid structure and function, and whether thyroidectomy can alleviate OSA symptoms remain unclear. An assessment of the impact of thyroidectomy on OSA is warranted.A systematic review of four electronic databases (PubMed (Medline), Embase, the Cochrane library, and ClinicalTrials.gov) was performed up to February 2022. The primary outcomes were preoperative and postoperative Apnea/Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Berlin questionnaire scores, and continuous positive airway pressure (CPAP) use. A meta-analysis of continuous measures and odd ratios was conducted. Small-scale studies underwent a qualitative meta-analysis.Six cohort studies on 221 OSA patients who underwent thyroidectomies were included. The results showed that thyroidectomy was associated with significant reduction in postoperative AHI (Mean difference [MD], -6.39, 95% CI, -12.46 to -0.32), however, no significant association was found with CPAP withdrawal (Odd ratio [OR], 0.38, 95% CI, 0.12-1.18). Neither the Berlin questionnaire score (OR, 0.19, 95% CI, 0.03-1.17) nor the ESS improved postoperatively (MD, -1.04, 95% CI, -6.37 to 4.29).This meta-analysis provides a quantitative estimate for the effect of the thyroidectomy on OSA and suggests that thyroidectomy is associated with limited clinical improvement of polysomnographic measures. Future large-scale, well-designed prospective studies are necessary to validate these findings and to refine accordingly the preoperative assessment of both medical conditions individually and in combination.

Reut Gruber,1,2 Liron Salamon,3 Riva Tauman,4 Michal Al-Yagon3 1Department of Psychiatry, McGill University, Montreal, QC, Canada; 2Attention, Behaviour and Sleep Lab, Douglas Mental Health University Institute, Montreal, QC, Canada; 3Department of School Counseling and Special Education, Tel-Aviv University, Tel-Aviv, Israel; 4Sleep Disorders Center, Tel Aviv Souraski Medical Center, Tel Aviv, IsraelCorrespondence: Reut Gruber, Department of Psychiatry, McGill University, Montreal, QC, Canada, Email Reut.Gruber@Douglas.Mcgill.CaIntroduction: Delayed sleep phase syndrome (DSPS) and insomnia disorders are prevalent in adolescents and are comorbid with attention-deficit/hyperactivity disorder (ADHD), but only limited information is available regarding the prevalence of DSPS and insomnia in adolescents with ADHD. Moreover, previous studies comparing objective sleep parameters averaged the findings across all participants of each group (ADHD, control) regardless of each individual’s level of reported sleep disturbance. This might have resulted in inconsistency between information obtained by objective and subjective sleep measures in adolescents with ADHD. The objectives of the present study were 1) to compare the prevalence of risk for DSPS and insomnia in adolescents with ADHD and control adolescents in our samples; 2) to compare objectively measured sleep characteristics of adolescents with ADHD and controls while taking into consideration their levels of risk for DSPS or their level of insomnia; and 3) to compare the ADHD symptom levels of adolescents with moderate/high and low risk for DSPS or insomnia.Methods: Seventy-three adolescents (37 ADHD, 36 controls) aged 12– 15 years participated in a cross-sectional study. Actigraphy was used to characterize objective sleep parameters and parents’ or adolescents’ reports were used to characterize subjective sleep parameters.Results: Of the participants in the ADHD and control groups, 33.33% and 27%, respectively, had moderate/high levels of risk for DSPS. Adolescents in the high-risk group for DSPS had an objectively measured delayed sleep schedule and more variable sleep duration, time in bed, and sleep efficiency compared to adolescents in the low-risk group for DSPS, regardless of their ADHD diagnosis. Adolescents with higher levels of insomnia spent more time in bed and had more variable sleep efficiency compared to adolescents with no insomnia, regardless of their diagnosis.Conclusion: The prevalence of moderate/high risk for DSPS was similarly high in adolescents with ADHD and controls. Participants’ subjective reports of sleep disturbances were consistent with their objective sleep parameters when the type and level of subjectively defined sleep disturbance were considered. ADHD symptom levels were not different in adolescents with moderate/high or low risk for DSPS or insomnia.Keywords: delayed sleep phase, insomnia, subjective sleep measures, actigraphy

Giora Pillar,1 Murray Berall,2 Richard B Berry,3 Tamar Etzioni,1 Yaakov Henkin,4 Dennis Hwang,5 Ibrahim Marai,6,7 Faheem Shehadeh,6 Prasanth Manthena,8 Anil Rama,9 Rebecca Spiegel,10 Thomas Penzel,11 Riva Tauman12 1Sleep Laboratory, Carmel Medical Center and Technion Faculty of Medicine, Haifa, Israel; 2Center of Sleep and Chronobiology, University of Toronto, Toronto, ON, Canada; 3UF Health Sleep Center, University of Florida, Gainesville, FL, USA; 4Cardiology Department, Soroka Medical Center, Be’er Sheva, Israel; 5Kaiser Permanente San Bernardino County Medical Center, Fontana, CA, USA; 6Cardiology Department, Rambam Medical Center, Haifa, Israel; 7Baruch Padeh Medical Center and the Azrieli Faculty of Medicine in the Galilee, Poriya, Israel; 8Sleep clinic, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA; 9Sleep Clinic, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA; 10Department of Neurology and Sleep Center, Stony Brook University Hospital, Stony Brook, NY, USA; 11Charite Universitätsmedizin Berlin, Sleep Medicine Center, Berlin, Germany; 12Sleep Disorders Center, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelCorrespondence: Giora Pillar, Sleep Laboratory, Carmel Medical Center and Technion Faculty of Medicine, Haifa, 31096, Israel, Tel +972 4 8250258, Fax +972 48250699, Email gpillar@technion.ac.ilBackground: The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea and is widely used worldwide as an ambulatory diagnostic tool. While it records peripheral arterial tone (PAT) and not electrocardiogram (ECG), the ability of it to detect arrhythmias is unknown and was not studied previously. Common arrhythmias such as atrial fibrillation (AF) or premature beats may be uniquely presented while recording PAT/pulse wave.Purpose: To examine the potential detection of common arrhythmias by analyzing the PAT amplitude and pulse rate/volume changes.Patients and Methods: Patients with suspected sleep disordered breathing (SDB) were recruited with preference for patients with previously diagnosed AF or congestive heart failure (CHF). They underwent simultaneous WP and PSG studies in 11 sleep centers. A novel algorithm was developed to detect arrhythmias while measuring PAT and was tested on these patients. Manual scoring of ECG channel (recorded as part of the PSG) was blinded to the automatically analyzed WP data.Results: A total of 84 patients aged 57± 16 (54 males) participated in this study. Their BMI was 30± 5.7Kg/m2. Of them, 41 had heart failure (49%) and 17 (20%) had AF. The sensitivity and specificity of the WP to detect AF segments (of at least 60 seconds) were 0.77 and 0.99, respectively. The correlation between the WP derived detection of premature beats (events/min) to that of the PSG one was 0.98 (p< 0.001).Conclusion: The novel automatic algorithm of the WP can reasonably detect AF and premature beats. We suggest that when the algorithm raises a flag for arrhythmia, the patients should shortly undergo ECG and/or Holter ECG study.Keywords: home sleep apnea test, WatchPAT, obstructive sleep apnea, arrhythmia, atrial fibrillation

Background Sleep difficulties have been reported in up to 85% of children with Attention Deficit hyperactivity disorder (ADHD). Children with ADHD exhibit commonly sensory modulation difficulties (SMD) and experience more significant functional difficulties. Sleep difficulties have also been associated with SMD. The aim of this study was to evaluate whether SMD are associated with sleep difficulties in children with ADHD. Methods We assessed sleep difficulties using the Children's Sleep Habits Questionnaire, and SMD using the Short Sensory Profile (SSP) questionnaire. A total of 25 children with ADHD and atypical sensory profiles, 13 children with ADHD and typical sensory profiles and 38 children used as controls (all children aged 8–11 years) were included. Results Sleep difficulties were detected in 86.4% of children with ADHD and atypical SSPs, as compared to 30.8% of children with ADHD and typical SSPs, and 16.7% of controls. A multivariate logistic regression revealed that children with ADHD and atypical SSPs had significantly increased odds for sleep difficulties as compared to controls (OR = 32.4; 95% CI 4.0–260.1, p = 0.001), while children with ADHD and typical SSPs were indistinguishable from controls. Suspected confounders (gender, age, mother's education, and stimulant therapy) did not contribute to sleep difficulties. Conclusion In this pilot study, SMD were associated with sleep difficulties in children with ADHD.

Background: Early diagnosis and treatment of sleep apnea in patients with atrial fibrillation (AF) is critical. The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea; however, studies using the WatchPAT device have thus far excluded patients with arrhythmias due to the potential effect of arrhythmias on the peripheral arterial tonometry (PAT) amplitude and pulse rate changes. Purpose: To examine the accuracy of the WP in detecting sleep apnea in patients with AF. Patients and Methods: Patients with AF underwent simultaneous WP and PSG studies in 11 sleep centers. PSG scoring was blinded to the automatically analyzed WP data. Results: A total of 101 patients with AF (70 males) were recruited. Forty-six had AF episodes during the overnight sleep study. A significant correlation was found between the PSG-derived AHI and the WP- derived AHI (r=0.80, p

Objective Studies have shown that chronobiological factors may adversely affect glycemic control in patients with type 2 diabetes mellitus (T2DM). Our objective was to assess the association of chronobiological disorders with glycemic control and neonatal birthweight in women with GDM. Design A prospective observational study was conducted. Setting Israel Population 208 women aged 18-45 years with a singleton pregnancy who were randomly selected from among women undergoing follow-up for GDM at the Maternal-Fetal Medicine Unit of a tertiary medical center in 2016 and 2017. Methods Nutrition, sleep, and lifestyle patterns were assessed from onset of GDM until birth along with glycemic control and obstetrical outcomes. Data were collected by structured interview and from the medical files. Main outcome measures Maternal glycemic control and large for gestational age (LGA) neonate. Results Multivariate analyses on a cohort of 208 women revealed suboptimal glycemic control which was associated with a late breakfast (RR=2.26; 95% CI 1.09-4.67). Any 10-g increase in carbohydrate intake in the evening increased the risk 1.19 times for suboptimal glycemic control (RR=1.19; 95% CI 1.003-1.42), and 2.14 times for poor sleep quality (RR=2.14; 95% CI 1.04-4.41). The adjusted relative risk for birthweight above the 85th percentile was associated with excessive of 10-g increase of carbohydrate intake in the morning (RR=1.70; 95%CI 1.30-2.23) and in the evening (RR=1.39; 95% CI 1.16-1.67). Conclusions Chronobiological disorders are associated with suboptimal glycemic control and large-for-gestational-age newborn in women with GDM.

Gestational diabetes mellitus is associated with an increased risk of maternal, fetal, and neonatal morbidities. Chronobiological disorders have recently been identified as risk factors for those morbidities. The disorders include chrononutritional disorders related to meal frequency and content according to the sleep-wake cycle, sleep disorders related to sleep quality, and chrono-obesity disorders, such as abnormal weight gain because of sleep deprivation and time of eating.This study aimed to assess whether a chrononutritional and sleep hygiene intervention can improve maternal glycemic control and reduce the proportion of large-for-gestational-age newborns among women with gestational diabetes mellitus.This randomized controlled trial included 103 women with gestational diabetes mellitus who were carrying a singleton fetus and assigned to either the intervention group (n=33) or the control group (n=70). The intervention group was assigned to a chrononutrition and sleep hygiene program, in addition to the usual care for gestational diabetes mellitus, from the time of diabetes mellitus diagnosis to birth, whereas the control group received the usual gestational diabetes mellitus care.The chrononutritional and sleep hygiene intervention significantly reduced the proportion of women with suboptimal glycemic control (80% of the plasma glucose values at target), after adjustment for maternal age, prepregnancy body mass index, gravidity, history of gestational diabetes mellitus, and large for gestational age (relative risk, 0.28; 95% confidence interval, 0.18-0.81). The effect of the intervention on balancing maternal glycemic control was mainly because of the decreased carbohydrate intake in the evening interval of the day (relative risk, 0.8; 95% confidence interval, 0.64-0.99). However, the intervention had no effect on the proportion of large-for-gestational-age newborns.The chrononutritional and sleep hygiene intervention can improve maternal glycemic control.

STUDY OBJECTIVES: Body position during sleep has been related to breathing in adults with obstructive sleep apnea (OSA). While sleep-disordered breathing is common, little information is available on the relation between sleep position and maternal breathing in pregnancy. We examined associations between the supine position, maternal breathing, and perinatal outcomes. METHODS: Women with a singleton, uncomplicated pregnancy were recruited and underwent an ambulatory overnight sleep study between 33 to 36 weeks using the Watch-PAT device. Their medical records were also reviewed. RESULTS: A total of 148 pregnant women were recruited (mean age: 33 ± 4 years; mean body mass index: 27.6 ± 4.0 kg/m(2)). They spent approximately one-half of their sleeping time in a supine position. The group’s mean apnea-hypopnea index (AHI) was 3.6 events/h in the supine position and 2.9, 2.6, and 2.1 events/h for the prone, right, and left positions, respectively. Median AHI and oxygen desaturation index were higher and SpO(2) nadir was lower in the supine versus nonsupine position (P < .0001, P < .0001, and P = .006, respectively). Peripheral oxygen saturation nadir was associated with the percentage of time spent sleeping in the supine position (P = .02). No correlations were found between supine sleep position and perinatal outcomes. There were no differences in the distributions of body positions between women with and those without OSA. CONCLUSIONS: Women in the third trimester of pregnancy with or without OSA spent large proportions of sleeping time in a supine position. Supine position was associated with more respiratory events and more and deeper oxygen desaturation events. They were not associated with perinatal outcomes. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Fetal Outcome of Sleep Disordered Breathing During Pregnancy; URL: https://clinicaltrials.gov/ct2/show/NCT00931099; Identifier: NCT00931099. CITATION: Dunietz GL, Sever O, DeRowe A, Tauman R. Sleep position and breathing in late pregnancy and perinatal outcomes. J Clin Sleep Med. 2020;16(6):955–959.

Background Pathophysiological mechanisms active in inflammatory bowel disease (IBD), such as mucosal barrier repair, innate and adaptive immune responses, intestinal motility and gut microbiome, all exhibit diurnal variations. Chronic disruption of the molecular clock augments inflammatory response. We have shown that newly diagnosed, naïve to treatment, young IBD patients showed reduced clock gene expression in both inflamed and non-inflamed intestinal tissues and in peripheral White blood cells (WBCs). This reduction correlated with disease activity1. Our aim in the current study was to determine whether certain clock genes correlate with disease activity scores or inflammatory markers in Crohn’s disease (CD) vs. ulcerative colitis (UC). Methods Fourteen CD and 11 UC patients, 8–22 years old, were recruited. Patients were evaluated upon diagnosis and during medical treatment. Disease activity scores, C-reactive protein (CRP) and faecal calprotectin (Fcal) levels were measured and WBC were analysed for clock gene (CLOCK, BMAL1, CRY1, CRY2, PER1 and PER2) expression. Clock gene expression levels were correlated to disease activity scores (clinically active vs. remission), CRP levels (5 mg/l) and Fcal levels (250 μg/mg) in CD (21 samples) and UC patients (20 samples). Results In UC, CLOCK (p < 0.025), CRY1 (p < 0.033) and PER1 (p < 0.038) showed decreased expression when Fcal levels were >>250 μg/mg. When compared with the clinical status only BMAL1 showed reduced expression (p < 0.019). CRP levels showed no correlation with clock gene expression. In CD, CRP as well as the clinical status correlated with clock gene expression. Whereas CLOCK was reduced (p < 0.019), PER2 was induced (p < 0.005) when CRP levels were >5 mg/dl. Furthermore, CLOCK (p < 0.0005), PER1 (0.017) and PER2 (0.044) were reduced in CD patients with an active disease. However, Fcal did not correlate with clock gene expression. Conclusion Altered levels of certain clock genes were demonstrated in young CD and UC patients in relapse vs. remission and correlated with Fcal in UC patients and clinical status as well as CRP levels in CD patients. Reference

Study objectives To assess the accuracy of WatchPAT (WP—Itamar-Medical, Caesarea, Israel) enhanced with a novel systolic upstroke analysis coupled with respiratory movement analysis derived from a dedicated snoring and body position (SBP) sensor, to enable automated algorithmic differentiation between central sleep apnea (CSA) and obstructive sleep apnea (OSA) compared with simultaneous in-lab sleep studies with polysomnography (PSG). Methods Eighty-four patients with suspected sleep-disordered breathing (SDB) underwent simultaneous WP and PSG studies in 11 sleep centers. PSG scoring was blinded to the automatically analyzed WP data. Results Overall WP apnea-hypopnea index (AHI; mean ± SD) was 25.2 ± 21.3 (range 0.2–101) versus PSG AHI 24.4 ± 21.2 (range 0–110) (p = 0.514), and correlation was 0.87 (p

Background REM sleep (REMS) is considered vital for supporting well-being and normal cognition. However, it remains unclear if and how decreases in REMS impair cognitive abilities. Rare case studies of patients with REMS abolishment due to pontine lesions remain sporadic, and formal evaluation of cognitive status is lacking. In 1984, Lavie and colleagues described the case of Y.C. – a man with a pontine lesion and near-total absence of REMS who led a normal life. Here, we set out to re-evaluate this individual's REMS status 30 years after the original report, and formally assess his cognitive abilities. Methods Four whole-night polysomnographic sleep recordings were conducted to evaluate sleep architecture. Sleep scoring was performed according to the American Academy of Sleep Medicine (AASM) guidelines. Cranial Computed Tomography (CT) imaging was performed, as well as formal neuropsychological testing to evaluate cognitive functions. Results Y.C. averaged 4.5% of sleep time in REMS, corresponding to the 0.055 percentile of normal values for his age. Furthermore, residual REMS episodes were short and only occurred towards the end of the night. CT imaging revealed damage and metallic fragments in pons, cerebellum, and thalamus. Neuropsychological evaluation demonstrated average to high-average cognitive skills, normal memory, and motor difficulties including speech and left hand dyspraxia. Conclusions To our knowledge, this is the only case where REMS loss resulting from pontine lesion was re-evaluated after many years. We find a near-total absence of REMS with no signs of significant compensation throughout adult life, along with normal cognitive status. The results provide a unique perspective on the ongoing debate regarding the functional role of REMS in supporting cognition.

Sleep-disordered breathing (SDB) during pregnancy has been linked to adverse fetal outcomes. Since the intrauterine milieu plays a critical role in childhood growth, we explored the interactions between maternal SDB and offspring growth and adiposity patterns during infancy. Fifty-eight healthy women with uncomplicated pregnancies underwent an objective sleep study and laboratory evaluation during the third trimester, their offspring underwent a 3-year growth surveillance. The 14 (24.1%) women with SDB had a higher body mass index (BMI) (P = 0.003), elevated C-reactive protein levels (P = 0.003), and decreased HDL-cholesterol levels (P = 0.009) than the women without SDB. A general linear model evaluated the interactions between maternal SDB and offspring growth and adiposity measurements after controlling for gestational age and maternal and paternal BMIs. The offspring of mothers with SDB had a significantly smaller head circumference at birth (P = 0.004), with a distinctive pattern of catchup growth by the end of the first year of life (P = 0.018). Their growth pattern was distinguished by compromised birth weight-to-length, rapid catch-up growth, and an increase in both weight-to-length and triceps thickness by the age of three (P P = 0.001, respectively). Our findings suggest that maternal SDB during pregnancy affects head circumference growth and adiposity acquisition from birth through infancy.

Background The intrauterine environment affects growth and adiposity acquisition from the fetal period until adulthood. Mild sleep disordered breathing (SDB) during pregnancy is a common underdiagnosed medical condition in healthy women. We aimed to investigate the interaction between maternal isolated SDB during the third trimester of pregnancy and the offspring’s growth and adiposity during the first three years of life. Methods Healthy pregnant women in the third trimester of an uncomplicated singleton pregnancy who were followed at the low-risk obstetric surveillance clinic of our hospital were recruited between 4/2013 and 5/2016. They were followed from enrollment until their offspring was three years old. During their third trimester of pregnancy, they underwent an ambulatory overnight sleep study by means of a validated sleep technology [SDB defined as apnea hypopnea index (AHI) ≥5]. Fasting blood samples were drawn on the following morning for glucose, insulin, HbA1c, lipid profile and C-reactive protein (CRP) levels. The offspring’s growth (length, weight and head circumference) and adiposity (subscapular and triceps skinfolds) parameters were measured at birth, 1 and 4 months, and 1, 2, and 3 years of age. Growth parameters were presented as standard deviation scores using the CDC growth charts. A general linear model was used to evaluate the interaction between maternal SDB and her offspring’s growth and adiposity measurements, after controlling for gestational week at delivery and maternal and paternal body mass index (BMI). Results Fourteen of 58 women (24.1%) were diagnosed with SDB (AHI range 5.3–14.7). They had a significantly higher mean BMI during the third trimester of pregnancy (30.1 ± 3.9 vs 27.2 ± 3.5, P = 0.011), elevated CRP levels, and decreased HDL-cholesterol levels (6.39 ± 2.29 mg/L vs 4.28 ± 2.15 mg/L, P = 0.003 and 67 ± 14 mg/dl vs 82 ± 19 mg/dl, P = 0.009, respectively) compared to women with normal sleep study results. Offspring of mothers with SDB had a smaller mean head circumference SDS at birth (-0.95 ± 0.70 vs -0.30 ± 0.71, P = 0.004), with a distinctive pattern of catchup growth by the end of the first year of life (P = 0.018). They also had increased mean adiposity at birth measured by triceps and subscapular skinfolds (6.8 ± 1.8 mm vs 5.4 ± 1.2 mm, P =0.002 and 5.8 ± 1.3 mm vs 5.0 ± 1.0 mm, P =0.019, respectively), with a distinctive pattern of increased triceps thickness at age 3 years (P = 0.001). There was no significant difference in offspring length or weight between groups. Conclusions Our findings suggest that isolated maternal SDB during pregnancy affected longitudinal head circumference growth and adiposity acquisition in the fetus and during the first three years of life.

Background Sleep and feeding difficulties are two common disorders in early childhood. It has been shown that feeding difficulties are more common among children with sleep disorders and vice versa. Since a child's characteristics play a substantial role in these two conditions, we aimed to investigate the sensory profile of infants and toddlers with behavioral insomnia (BI) or feeding disorders (FDs) in comparison with healthy age-matched controls. Methods Children aged 7–36 months with BI or FD were recruited from the sleep and feeding disorders clinics. Healthy controls were recruited from well-baby clinics. Parents completed a questionnaire which included demographics and socioeconomic status, as well as a sensory profile evaluation using the Infant/Toddler Sensory Profile (ITSP). Results Twenty-five children with BI, 28 with FDs and 32 controls were recruited. Oral processing scores were significantly lower in both BI and FD groups vs the controls ( p = 0.015 and 0.001, respectively). Auditory processing scores were lower in the FD group vs the controls ( p = 0.028). The scores of three out of the four ITSP sensory quadrants (Low Registration, Sensory Sensitivity, and Sensation Avoiding) were significantly lower in the FD group vs the controls ( p = 0.027, 0.025, and 0.001, respectively), and in one quadrant (Sensation Avoiding) in the BI group vs the controls ( p = 0.037). Conclusions There were considerable differences in sensory processing, as reported by parents between children with BI and those with FDs compared to healthy controls, most often in the direction of the ‘hypersensitive' profile. These differences may underlie the development and partially explain the coexistence of the two disorders. Sensory profile may be a target of intervention as part of the management of sleep and feeding disorders in early childhood.

Introduction The currently available questionnaires based on parental reporting of OSA symptoms include large number of items and are not sufficient to the diagnosis and assessment of OSA severity. We aimed to evaluate a simple 2-item questionnaire regarding parental concern as a predictor of the severity of OSA in children as measured by polysomnography. Methods Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child’s breathing. Results Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Significant correlations were found between the need for surgery score and the apnea-hypopnea index (r=0.22, P = .029), as well as the mean SpO2 levels (r=-0.24, P = .02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P = .003). The need for surgery score and the child’s age were the only predictors for moderate-severe OSA (P = .01 and P = .043, respectively). Conclusion Querying parents on their perception of their child’s need for surgery is a sensitive, practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG. Support

Alterations in sleep patterns are among a multitude of physiologic changes occurring during pregnancy. In this chapter, we review the most common sleep disorders in pregnancy among them Sleep disordered breathing, Restless leg syndrome and Insomnia. Sleep disordered breathing is a spectrum of abnormal respiration during sleep which develops during pregnancy due to reduction in the upper airway size, increased fluid retention, weight gain and changes in lung mechanics. Data from recent years suggest that SDB during pregnancy increases the risk of gestational hypertensive disorders, gestational diabetes, increased birth weight and adiposity as well as increased risk for preterm birth. Restless leg syndrome commonly develops in late pregnancy, with a recovery around delivery and is mostly treated by reassurance, nonpharmacological treatment or medications such as Iron supplementation. Insomnia, short sleep duration, and reduced sleep quality are common in pregnant women and related to musculoskeletal discomfort, heartburn, nocturia and uterine contractions. These are associated with increased risk for gestational diabetes, preterm deliveries, high rates of caesarian deliveries, and depression. In conclusion, data from recent years indicate that sleep disorders are not “Normal” during pregnancy and are associated with adverse maternal and fetal outcomes. Improved awareness of healthcare providers is warranted.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Introduction An accepted screening question for Obstructive Sleep Apnea (OSA) in children is “Does your child snore”. However, this has no correlation to severity. The purpose of this study is to evaluate a simple 2-item questionnaire that reflects the degree of parental concern to predict the severity of Obstructive Sleep Apnea (OSA) in children as measured by Polysomnography (PSG). Methods Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire that we devised and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child's breathing. Both questionnaires were compared to PSG results. Results Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Correlations were found between the need for surgery score and the apnea-hypopnea index (r = 0.22, P = .029), as well as the mean SpO2 levels (r = −0.24, P = .02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P = .003). The need for surgery score was the only predictor for moderate-severe OSA (P = .039). Conclusion Querying parents on their perception of their child's need for surgery is a practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG.

Sleep disruption modifies the immune system and can trigger flares of inflammatory bowel diseases (IBD). Changes in expression of clock genes have been reported in patients with IBD. We investigated whether a change in the circadian clock is an early event in development of IBD.We performed a prospective study of patients younger than 21 years old who underwent diagnostic endoscopies at the pediatric and adult gastroenterology units at the Tel Aviv Sourasky Medical Center from August 2016 through August 2017. Questionnaires were completed by 32 patients with IBD (8-21 years old) and 18 healthy individuals (controls) that provided data on demographics, sleep, disease activity scores. We also obtained data on endoscopic scores, anthropometric parameters, blood level of C-reactive protein (CRP), and fecal level of calprotectin. Peripheral blood and intestinal mucosa samples were analyzed for expression levels of clock gene (CLOCK, BMAL1, CRY1, CRY2, PER1, and PER2).Levels of CRP and fecal calprotectin were significantly higher in patients with IBD compared with controls (P.05). Expression levels of clock genes (CLOCK, CRY1, CRY2, PER1, and PER2) were significantly lower in inflamed intestinal mucosa from patients compared with intestinal mucosa from controls (P.05). Expression levels of all clock genes except for PER2, were also significantly lower in non-inflamed intestinal mucosal tissues from patients compared with controls (P.05). Expression levels of clock genes (CLOCK, BMAL1, CRY1, CRY2, PER1 and PER2) were lower in white blood cells from patients with IBD compared with controls. This reduction was greater in white blood cells from patients with ulcerative colitis than in patients with Crohn's disease.Young, newly diagnosed, untreated patients with IBD have reduced expression of clock genes in inflamed and non-inflamed intestinal mucosal samples, and also in blood cells, compared with healthy individuals. Alterations in expression of clock genes might be an early event in IBD pathogenesis. ClinicalTrials.gov Identifier: NCT03662646.

Study objectives Obstructive sleep apnea (OSA) during pregnancy has been associated with adverse maternal outcomes. However, the effect of maternal OSA on fetal growth is less clear. The placenta is a critical organ for fetal growth and development and the principal determinant of birthweight. We aimed to investigate the effect of maternal OSA on placental growth and function. Methods Placentas of women recruited to a prospective longitudinal study were consecutively obtained immediately after delivery. Each placenta was measured for length, width, and thickness. Total RNA was isolated for gene expression analysis of VEGF, VEGF receptor, PIGF, and leptin. Histological and morphometric evaluations of the placenta were performed. Results A total of 53 placentas were investigated. Ten women (19%) had OSA, and the weight of their placentas was significantly higher compared with the placentas of the controls (526.1 ± 83.9 vs. 425.7 ± 95.5 g, p = 0.004). There was a significant positive correlation between placental weight and the log apnea-hypopnea index even after controlling for maternal body mass index (BMI; r = 0.31, p = 0.04). The birthweight/placental weight ratio was significantly lower in women with OSA compared with controls (p = 0.03). Placental weight and newborn triceps adiposity thickness correlated positively after controlling for maternal BMI (r = 0.29, p = 0.04). Leptin expression was 1.8-fold higher in placentas of women with OSA compared with controls (p = 0.02). No histological differences were found between the groups. Conclusions Maternal OSA is associated with increased placental weight that correlated with OSA severity and neonatal adiposity independently of maternal BMI. Placental leptin overexpression may mediate/underlie the above findings.Trial Registration: Clinical Trials NCT00931099.

The prevalence of obstructive sleep apnea (OSA) during pregnancy is rising. OSA during pregnancy has been associated with hypertensive disorders of pregnancy and gestational diabetes. The effect of maternal OSA on the fetus, particularly on fetal growth, is less apparent. Most of the currently available human data is based on non-objective assessment of OSA and includes heterogeneous populations with inadequate control on confounders, such as maternal obesity and pregnancy complications. Using objective tools in non-obese women with uncomplicated pregnancies, we aimed to investigate the association between maternal OSA and fetal growth. A total of 155 non-obese pregnant women were recruited. Birth-weight percentile of the newborns of women with mild OSA was significantly higher compared with the newborns of non-OSA controls (72% vs. 57%, respectively, P P = 0.02 for both). The proportion of large for gestational age (LGA) newborns was higher among women with OSA compared with controls (28% vs. 8%, respectively, P = 0.04). Our results suggest that maternal OSA during the third trimester of pregnancy - even in a mild form -is associated with accelerated fetal growth.

Inflammation plays a role in the pathogenesis and consequences of sleep-disordered breathing (SDB). The nasal mucosa and paranasal sinuses produce high levels of nitric oxide (NO). In asthma, exhaled NO is a marker of airway inflammation. There is only limited information whether nasal NO (nNO) accompanies also chronic upper airway obstruction, specifically, SDB. The objective of this study was to investigate nNO levels in children with SDB in comparison to healthy non-snoring children. Nasal NO was measured in children who underwent overnight polysomnographic studies due to habitual snoring and suspected SDB and in healthy non-snoring controls. One hundred and eleven children participated in the study: 28 with obstructive sleep apnea (OSA), 60 with primary snoring (PS), and 23 controls. Nasal NO levels were significantly higher in children with OSA and PS compared to controls (867.4 ± 371.5, 902.0 ± 330.9, 644.1 ± 166.5 ppb, respectively, p = 0.047). No difference was observed between children with OSA and PS. No correlations were found between nNO levels and any of the PSG variables, nor with age, BMI percentile or tonsils size. Compared to healthy controls, nNO is increased in children with SDB, but it is not correlated with disease severity. This is probably due to the local mechanical processes and snoring.

Obesity, obstructive sleep apnea (OSA), and type 2 diabetes mellitus (T2DM) are associated with chronic low-grade inflammation and oxidative stress. In adults, increased lipid peroxidation, a marker of oxidative stress, was found in both metabolic syndrome and OSA. Studies on oxidative stress in children with T2DM and OSA are scarce. Plasma oxidized low-density lipoprotein (Ox-LDL) levels were evaluated in obese children and adolescents with/without T2DM, and the contribution of OSA to oxidative stress was investigated. Ten patients with T2DM, 8 with impaired glucose tolerance (IGT), and 20 body mass index-standard deviation score (BMI-SDS)-matched non-diabetic children (controls) were studied. They all underwent overnight polysomnography. Fasting plasma concentrations of Ox-LDL were measured and compared to the glycemic status and to the presence of OSA. Fourteen patients (36%) were diagnosed with OSA and 21 (55%) with hypertension. There were no significant group differences in plasma Ox-LDL levels or between patients with/without OSA. Plasma Ox-LDL levels were significantly higher among patients with hypertension compared to controls (P = 0.01), while they correlated with homeostasis model assessment (P = 0.02), BMI-SDS (P = 0.049), and systolic blood pressure (P = 0.002). The findings of this pilot study suggest that increased lipid peroxidation is associated with insulin resistance and hypertension in obese children and adolescents, while OSA has most likely minor influence.

Objectives Seven years after the introduction of the pneumococcal conjugate vaccines (PCV) in Israel, its effect on the incidence and severity of episodes of acute mastoiditis (AM) remains unclear. The primary objective of this study was to determine the incidence of AM and describe its clinical features in children during the years that followed the introduction of the PCV13 in comparison with the pre-PCV period. Methods Included in this retrospective comparative case series were all pediatric patients diagnosed with AM between Jan. 2007 and Dec. 2015 in one tertiary medical center. The patients were divided into 3 groups: pre-PCV, post-PCV7 (July 2009 through Dec. 2010) and post-PCV13 (Jan. 2011 through Dec. 2015). The patients' medical records were reviewed, and data on age at presentation, gender, presenting signs, bacterial ear cultures, hospitalization course, complications, surgical interventions, inflammatory response and outcome were retrieved and compared between the groups. Comparison was made between the pre-PCV and the post-PCV13 groups. Results 216 children were identified for analysis, 80 children in the pre-PCV period, 31 in the post-PCV7 period and 105 in the post-PCV13 period. Their mean age was 2.6 years. The number of AM cases per 1000 visits at the emergency room decreased by 46% in the post-PCV13 period compared to the pre-PCV period. There was no difference in the rate of AM between the post-PCV7 and post-PCV13 periods. No differences were found in age, gender, hospitalization length, C-reactive protein level, white blood cell count, rate of surgical interventions (mastoidectomy and incision and drainage) and rate of complications between the 3 groups. Conclusion The incidence of AM was lower in the post-PCV13 period compared to the pre-PCV period. The rate of AM complications, however, has not changed, nor has the number of mastoidectomies.

Background Enlarged tonsils and adenoids are the major etiology of obstructive sleep apnea (OSA) in children. Lymphatic hyperplasia is common to both OSA and celiac disease. We aimed to investigate the effect of a gluten-free diet on OSA symptoms in children with celiac disease. Methods Children with celiac disease aged 2–18 years were prospectively recruited before the initiation of a gluten-free diet. Children with negative celiac serology who underwent gastrointestinal endoscopies for other indications served as controls. All participants completed a validated OSA-related symptoms questionnaire and the pediatric sleep questionnaire (PSQ) at baseline and 6 months later. Results Thirty-four children with celiac disease (mean age 6.6 ± 3.5 years) and 24 controls (mean age 7.3 ± 4.6 years, P = 0.5) were recruited. There were no significant differences in gender, body mass index or season at recruitment between the two groups. The rate of positive PSQ scores was higher (more OSA-related symptoms) in the control group compared to the celiac group, both at recruitment and at the 6-month follow-up (33.3% vs. 11.8%, P = 0.046, and 16.7% vs. 0, P = 0.014, respectively). PSQ scores improved significantly in both groups at the 6-month follow-up (P

Pediatric obstructive sleep apnea (OSA) is associated with cardiovascular consequences, including accelerated atherosclerosis and endothelial dysfunction. Increased lipid peroxidation, a marker of oxidative stress, has been identified in adults with OSA in a severity-dependent manner, with attenuation following treatment with continuous positive airway pressure therapy. Studies on oxidative stress in children with OSA are sparse and results are inconclusive. The objective of this study was to compare lipid peroxidation in children with OSA to non-OSA children.A prospective cross-sectional study of 26 children with polysomnography-confirmed OSA (oAHI ≥ 5/h TST) was conducted. Thirty age- and body mass index z-score-matched children with primary snoring (PS) served as a comparison group (oAHI ≤ 1/h TST). Fasting blood samples were obtained on the morning following the sleep study. Plasma oxidized low-density lipoprotein (oxLDL) concentrations were measured by enzyme-linked immunosorbent assay.There were no group differences in patient characteristics and their lipid profiles. The mean oxLDL levels of the OSA group were significantly higher than those of the comparison group (53.1 ± 13.0 vs. 45.7 ± 10.0 U/L, respectively, p = 0.02). There was a significant positive correlation between plasma oxLDL and the apnea hypopnea index (r = 0.29, p = 0.03) and between oxLDL and the oxygen desaturation index (r = 0.51, p = 0.003), and a significant negative correlation between SpO2 nadir and oxLDL (r = -0.29, p = 0.03).OSA in children is associated with increased lipid peroxidation in a severity-dependent manner. Lipid peroxidation levels correlate with the degree of intermittent hypoxia.

Obstructive sleep apnea (OSA) is a risk factor for insulin resistance and type 2 diabetes mellitus (T2DM) in adults. Data in children are limited. The aim was to study the frequency and severity of OSA and its association with cardiometabolic risk factors in obese children and adolescents with and without T2DM. In this prospective cross-sectional study, obese children and adolescents with and without T2DM underwent polysomnography and blood tests for fasting lipids, insulin, glucose, liver functions, and C-reactive protein. All participants completed a questionnaire on past and present sleep-disordered breathing (SDB). Results were compared between T2DM and obese non-diabetic controls matched for body mass index–standard deviation score (BMI–SDS) and also according to the glycemic status: T2DM, impaired glucose tolerance (IGT), and normal glycemic control. Eleven patients with T2DM (age 15.9 ± 3.6 years) and 30 BMI–SDS matched non-diabetic subjects (age 12.7 ± 3.0 years) were studied. Among the entire cohort, 45 % had a history of snoring, 26 % reported apneic episodes during sleep, and 65 % had daytime fatigue. There were no significant between-group differences in SDB history or abnormal polysomnographic results [apnea–hypopnea index (AHI) >5/h]. The percentage of subjects with AHI >5/h was 45.5 % in T2DM patients, 25 % in obese patients with IGT, and 18.2 % in obese patients without IGT, although the difference was not statistically significant (p = 0.25). Plasma C-reactive protein levels were related to both glycemic status and OSA severity. The severity of OSA in obese children and adolescents is unrelated to the presence of diabetes. OSA may play a minor role in the development and progression of T2DM in children and adolescents. Further studies in larger cohorts are required.

To compare sleep quality and sleep-wake pat- terns in parents of children with type 1 diabetes before routine use of the continuous glucose monitoring system (CGMS) and while using it. Thirteen parents completed the Pittsburg Sleep Quality Index (PSQI), a 7-day sleep diary, and wore an actigraph (a wristwatch-size motion detector) during the night for 1 week before pediatric use of CGMS and 4-8 weeks after initiating routine use of the CGMS. Mean age of parents (ten mothers, three fathers) was 39 (range 32-47) years; mean age of children was 9.3 years (range 5.5-16.5 years); mean disease duration was 3.4 (range 0.6-11.2) years. PSQI total score demonstrated similar quality of sleep with and without use of the CGMS (4.6 and 4.9, respectively, p = 0.45). Six of the 13 parents reported severe sleep problems (PSQI C 5) with and without the CGMS. The sleep diary indicated a greater number of awakening episodes during CGMS use than without the CGMS (1.6 and 1, respectively, p = 0.03), and actigraphy documented an increase in the number of wake bouts (22.9 and 19.7, p = 0.03) as well as in total wake time (48.3 and 42.2 min, p = 0.03) during CGMS use as compared with the period prior to CGMS use. Although self-perception of sleep quality remained unchanged, CGMS use appeared to affect actual parental sleep conti- nuity somewhat negatively. This should be made clear to parents who may hold expectations of improvement in sleep quality following initiation of CGMS use.

Pregnancy is associated with profound changes in sleep. Up to 75% of pregnant women experience some form of sleep disruption during pregnancy. The emerging data from recent years suggests that sleep disturbances may represent a novel contributor to adverse pregnancy outcomes and that sleep disorders during pregnancy may affect both maternal and fetal outcomes. In spite of the increased awareness, information specifically addressing sleep disturbances and fetal outcomes is limited. The current review summarizes the existing published literature on the effect of short sleep duration, poor quality sleep and sleep-disordered breathing (SDB) on the developing fetus.

To investigate (1) maternal cognitions regarding infant's sleep and feeding and maternal depression among mothers of children with behavioral insomnia, feeding disturbances and healthy controls, and (2) the association between maternal cognitions about sleep and those about feeding.Children 6-36 months of age with either behavioral insomnia or feeding disorders were recruited. Children 6-36 months of age who attended the well-baby clinics were recruited and served as controls. The participants' mothers completed three questionnaires on their cognitions/perceptions of their child's sleep and feeding habits and about their own feelings of depression.A total of 230 children (31 with behavioral insomnia, 29 with feeding disorders, 170 controls) were enrolled. Their mean age was 16.1 ± 7.6 months. Maternal cognitions/perceptions about sleep (maternal cognition infant sleep questionnaire, MCISQ) did not differ significantly between the behavioral insomnia group and the feeding disorders group. The MCISQ score was significantly higher in the behavioral insomnia group compared with controls (P.02). Mothers of children with feeding disorders reported being significantly more frustrated or anxious when they fed their child (P.0005), less confident about their child getting enough food (P.0005), and less confident in their ability to manage their child's behavior at mealtime (P.02) compared to the controls. Significant positive correlations were found between the MCISQ scores and the Beck Depression Inventory scores (r = 0.29, P.0002), and between the MCISQ scores and the maternal cognitions of their child's feeding scores (r = 0.26, P.0002). The latter remained significant after controlling for maternal depression (r = 0.25, P.002).Mothers of children with either behavioral insomnia or feeding disorders differ significantly from mothers of controls regarding their cognitions about sleep and feeding. Maternal cognitions about infant sleep behavior correlated with their cognitions about infant feeding. Maternal cognitions are a modifiable factor that may serve as a target for intervention in both sleep and feeding disorders in children.

Sleep has been shown to impact glucose regulation, and may be altered in persons with type 1 diabetes (T1D).To assess sleep characteristics in T1D patients and the possible association between sleep disturbances and diabetes-related variables.In a cross-sectional study in 154 young patients with T1D and 154 age-range-matched nondiabetic controls subjective sleep characteristics were assessed using validated questionnaires: Sleep Disturbance Scale for Children (SDSC), Adolescent Sleep-Wake Scale (ASWS), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS). Clinical and disease-related variables were obtained from medical charts.Sleep disorders were frequent in all age groups, with no significant difference in prevalence or total scores of the SDSC, ASWS, PSQI, or ESS between the patients and the controls. In T1D children, SDSC score was significantly higher in those using continuous glucose monitoring (CGM) vs glucose meters (P = .042). The score of disorders related to "initiating and maintaining sleep" was significantly higher in those treated with pumps vs patients treated with injections (P = .014), in those using CGM vs glucose meters (P = .02), and in those with nocturnal hypoglycemia vs those without (P = .023). The percentage of children with excessive daytime sleepiness was significantly lower in patients vs controls (P = .035). No significant differences were found in the other two age groups.The prevalence of sleep disorders among most of the young T1D patients was no higher than in the nondiabetic population. Studies using objective sleep measures are warranted to further assess sleep quality in T1D patients.

It has been suggested that sleep disordered breathing (SDB) during pregnancy may adversely influence maternal as well as fetal well being.To examine the effect of maternal SDB on neonatal neurological examination and perinatal complications.Pregnant women of singleton uncomplicated pregnancies were prospectively recruited from a community and hospital low risk obstetric surveillance. All participants completed a sleep questionnaire in the second trimester and underwent ambulatory sleep evaluation (WatchPAT, Itamar Medical, Caesarea, Israel). They were categorized as SDB (apnea hypopnea index5) and non-SDB. Maternal and newborn records were reviewed and a neonatal neurologic examination was conducted during the first 48 hours.The study group included 44 women and full-term infants; 11 of the women (25%) had SDB. Mean maternal age of the SDB and non-SDB groups was 32.3 ± 2.8 and 32.5 ± 4.7 years, respectively (P = 0.86). Mean body mass index before the pregnancy in the SDB and non-SDB groups was 25.8 ± 4.7 and 22.0 ± 2.5 kg/m2, respectively (P = 0.028). No differences were found between infants born to mothers with SDB and non-SDB in birth weight (3353.8 ± 284.8 vs. 3379.1 ± 492.4 g), gestational age (39.5 ± 0.9 vs. 39.2 ± 1.5 weeks), 5 minute Apgar scores (9.8 ± 0.6 vs. 9.9 ± 0.3), and neurologic examination scores (95.2 ± 3.9 vs. 94.6 ± 4.1). P value for all was not significant.Our preliminary results suggest that maternal mild SDB during pregnancy has no adverse effect on neonatal neurologic examination or on perinatal complications.

OBJECTIVE To investigate fractional exhaled nitric-oxide (FeNO) levels in children with Crohn's disease (CD) and ulcerative colitis (UC) and their correlation to disease activity. MATERIALS AND METHODS Children with CD and UC (aged 8-18 years) and age-matched healthy controls without respiratory symptoms were recruited. Disease activity was assessed using validated scores. All children performed spirometry and FeNO tests and the association between intestinal disease parameters and pulmonary functions was studied. RESULTS Thirty-five children with CD, nine with UC, and 24 healthy controls were enrolled. The mean FeNO level was higher in children with CD compared with the controls. Increased FeNO levels (>23 parts per billion) were more common among CD and UC compared with healthy children (46, 33, and 0%, respectively, P

Adenotonsillectomy is the recommended treatment for children with obstructive sleep apnea (OSA). Since adenoidectomy alone may be associated with significantly lower morbidity, mortality, and cost, we aimed to investigate whether adenoidectomy alone is a reasonable and appropriate treatment for children with OSA.Five-hundred fifteen consecutive children diagnosed with moderate-to-severe OSA (apnea-hypopnea index5) based on polysomnography and who underwent adenoidectomy or adenotonsillectomy were reevaluated after 17-73 months (mean 41) for residual or recurrent OSA using a validated questionnaire (Pediatric Sleep Questionnaire, PSQ). Failure of OSA resolution was defined as a positive mean PSQ score ≥ 0.33. Contribution of age, obesity, tonsil size, and OSA severity at baseline to adenoidectomy or adenotonsillectomy failure was examined.Positive PSQ score occurred in 15% of the entire sample and was not influenced by age or gender. No difference in failure rate was observed between adenoidectomy and adenotonsillectomy for children who were not obese with apnea-hypopnea index10 and had small tonsils (3). Children with apnea-hypopnea index ≥ 10 and/or tonsil size ≥ 3 showed a higher failure rate after adenoidectomy compared to adenotonsillectomy (20% versus 9.8%, p = 0.028).We suggest that subjective, long term outcomes of adenoidectomy are comparable to those of adenotonsillectomy in non-obese children under 7 years old with moderately OSA and small tonsils. Hence, adenoidectomy alone is a reasonable option in some children. Future prospective randomized studies are warranted to define children who may benefit from adenoidectomy alone and those children in whom adenoidectomy alone is unlikely to succeed.

A small number of studies have, thus far, evaluated the association between maternal snoring and fetal growth revealing conflicting results. No study has compared fetal growth between women with habitual snoring who snored before pregnancy and women with habitual snoring that started to snore during pregnancy. Objectives: To examine the effect of maternal snoring on fetal outcome and to investigate the differences between “chronic snorers” and “new-onset snorers”. Methods: Women of singleton, uncomplicated, full-term pregnancies completed a questionnaire. Obstetric and labor records were reviewed. Newborn records were reviewed for gestational age, birth weight, Apgar score and gender. Results: 246 low risk women were studied. Mean BMI at the beginning of pregnancy was 22.3 ± 3.5 kg/m 2 . 32% reported habitual snoring. Of those, 26% were chronic snorers and 74% were new-onset snorers. Neither significant difference in fetal growth was found between snorers and nonsnorers nor between chronic snorers and new-onset snorers. Increased rate of nulliparous women was found in new-onset snorers compared with both chronic snorers and non-snorers (54 vs. 25 and 29% respectively; p = 0.001). Conclusions: In pregnant women with no apparent risk factors, maternal snoring does not affect fetal growth. No differences in maternal charac teristics or fetal outcome were found between chronic snorers and new-onset snorers.

OBJECTIVE: Behavioral insomnia and feeding difficulties are 2 prevalent conditions in healthy young children. Despite similarities in nature, etiology, prevalence, and age distribution, the association between these 2 common disorders in young children has not been examined thus far. PATIENTS AND METHODS: Children aged 6 to 36 months with either behavioral insomnia or feeding disorders were recruited. Children aged 6 to 36 months who attended the well-care clinics were recruited and served as controls. Sleep and feeding were evaluated by using a parental questionnaire. RESULTS: Six hundred eighty-one children were recruited. Fifty-eight had behavioral insomnia, 76 had feeding disorders, and 547 were controls. The mean age was 17.0 ± 7.6 months. Parents of children with feeding disorders considered their child's sleep problematic significantly more frequently compared with controls (37% vs 16%, P = .0001 [effect size (ES): 0.66]). They reported shorter nocturnal sleep duration and delayed sleep time compared with controls (536 ± 87 vs 578 ± 88 minutes, P = .0001) and 9:13 ± 0.55 pm vs 8:26 ± 1.31 pm, P = .003). Parents of children with behavioral insomnia described their child's feeding as “a problem” more frequently compared with controls (26% vs 9%, P = .001 [ES: 0.69]). They reported being more concerned about their child's growth (2.85 ± 1.1 vs 2.5 ± 1.0, P = .03) and reported higher scores of food refusal compared with controls (3.38 ± 0.54 vs 3.23 ± 0.44, P = .04). CONCLUSIONS: Problematic sleep and feeding behaviors tend to coexist in early childhood. Increased awareness of clinicians to this coexistence may allow early intervention and improve outcome.

OBSTRUCTIVE SLEEP APNEA (OSA) IS A RELATIVELY HIGHLY PREVALENT CONDITION IN CHILDREN AND HAS RECENTLY EMERGED AS MAJOR CAUSE OF neurobehavioral dysfunction and cardiovascular morbidity. In adults affected with OSA, excessive daytime sleepiness (EDS) is extremely frequent and accounts for one of the most important symptoms prompting medical referral for evaluation and treatment. However, the prevalence of EDS in children with OSA is somewhat unclear and probably depends on the perceptions of caretakers, since children are unlikely to verbalize such symptoms. In a 1995 study, parental reports in children being evaluated for suspected OSA initially indicated that only a small minority of these children (7%) present symptoms compatible with EDS.1 In contrast, more recent studies using questionnaires that included more specific questions on behaviors associated with EDS suggested that the frequency of EDS may revolve around the 20% to 50% of all children.2 When sleepiness was measured using the Multiple Sleep Latency Test (MSLT), approximately 13 to 20% of nonobese children fulfilling the criteria for OSA displayed EDS, whereas 40% to 60% of obese children with OSA fulfilled MSLT criteria of EDS.3–5 One of the major questions emanating from the aforementioned studies was whether polysomnographic measures could provide insights and identify increased risk for having EDS in children with OSA. To this effect, the magnitude of sleep fragmentation induced by OSA was quantified in both children and adults and allowed for development of a numerical algorithm, i.e., the sleep pressure score (SPS), that would theoretically indicate a putative threshold for disruption of sleep homeostasis such that further sleep disruption would then be theoretically met with increased EDS.6,7 Of note, the SPS derived from the arousal indices in each individual overnight sleep study seemed to confer improved prediction for the occurrence of both cognitive and behavior disturbances in snoring children.8 Notably, working under similar assumptions, Chervin and colleagues showed the presence of respiratory cycle-related electroencephalographic spectral changes in patients with OSA that seemed to correlate with EDS measures.9 Tumor necrosis factor (TNF)-α is one of the most important cytokines involved in sleep regulation.10 For example, injection of TNF-α induces physiologic sleep and increases the time spent in non-rapid eye movement phase. In addition, TNF-α levels follow a circadian variation and are increased after sleep deprivation; inhibition of TNF-α receptors in the brain is accompanied by the suppression of spontaneous non-rapid eye movement sleep. It is now well established that TNF-± levels are elevated in adults patients with OSA, and, in fact, circulating TNF-α levels have been proposed as a biologic marker of EDS. Indeed, Vgontzas and colleagues demonstrated that neutralizing TNF-α activity by administration of etanercept is associated with significant reductions in EDS in adult patients with OSA.11 We therefore conducted the present study to assess whether TNF-α levels are elevated in children with OSA and, if so, to determine whether specific demographic characteristics or polysomnographic measures would account for the variance in morning TNF-α plasma concentrations. We also examined whether the presence of EDS, as determined by MSLT, is associated with increased TNF-α levels in children with OSA and whether improved MSLT and TNF-α levels would emerge after surgical treatment of OSA.

Associations between SDB, the metabolic syndrome, and circulating levels of adipokines have emerged in adults but have not been examined in snoring children, who, in contradistinction to adults, display insulin resistance and lipid abnormalities as a function of adiposity rather than SDB. Therefore, we aimed to examine associations between circulating adipokines levels, insulin resistance, and measures of SDB in children.Prospective study.Polysomnographic evaluation and assessment of plasma levels of leptin, adiponectin, resistin, glucose, insulin, and CRP.130 children (mean age 8.2 +/- 2.8 years; 39% obese) were studied.Log adiponectin levels were lower in obese than nonobese children (3.8 +/- 0.31 vs 4.0 +/- 0.30 corresponding to 8,381.4 +/- 5,841.0 vs 12,853.2 +/- 7,780.2 ng/ml, P0.0001) and were inversely correlated with BMI Z scores (r = -0.47, P0.0001) but not with log AHI. Log leptin concentrations were higher in the obese group than the nonobese group (4.2 +/- 0.32 vs 3.4 +/- 0.57 corresponding to 19,542.6 +/- 13,643.6 vs 5,875.5 +/- 8,425.7 pg/ml, P0.0001), correlated with BMI Z scores (r = 0.64, P0.0001), and were significantly lower in children with AHIor = 1/hr than children with AHI1/hr (P = 0.006) and in children with SpO2 nadiror = 90% than children with SpO2 nadir90%, even after controlling for BMI Z score (P0.03). No significant differences were found in log resistin levels as a function of obesity or AHI. Significant correlations between log adiponectin levels and log Insulin/Glucose (I/G) ratios (-0.28, P = 0.006) and between log leptin levels and log I/G ratios (r = 0.66, P0.0001) emerged.In close agreement with the absence of a measurable effect of SDB on insulin resistance in children, circulating adipokines levels are primarily attributable to the ponderal index. However, SDB and associated hypoxemia may contribute to the elevation of leptin levels.