Pediatric Sleep Medicine : Mechanisms and Comprehensive Guide to Clinical Evaluation and Management

This book provides comprehensive coverage of all aspects related to pediatric sleep and its associated disorders. It addresses the ontogeny and maturational aspects of physiological sleep and circadian rhythms, as well as the effects of sleep on the various organ systems as a function of development. Organized into nine sections, the book begins with a basic introduction to sleep, and proceeds into an extensive coverage of normative sleep and functional homeostasis. Part three then concisely examines the humoral and developmental aspects of sleep, namely the emerging role of metabolic tissue and the intestinal microbiota in regulation. Parts four, five, and six discuss diagnoses methods, techniques in sleep measurement, and specific aspects of pharmacotherapy and ventilator support for the pediatric patient. Various sleep disorders are explored in part seven, followed by an in-depth analysis of obstructive sleep apnea in part eight. The book concludes with discussions on the presence of sleep issues in other disorders such as Down syndrome, obesity, cystic fibrosis, and asthma. Written by recognized leaders in the field, Pediatric Sleep Medicine facilitates an extensive learning experience for practicing physicians who encounter specific sleep-related issues in their practice. Preface Contents Contributors Part I: Basic Introduction to Sleep 1: Normal Sleep in Humans Introduction Sleep Neurobiology: The Basics Wakefulness NREM Sleep REM Sleep Sleep Architecture in Adults Changes in Sleep Architecture with Age Total Sleep Time (TST) Sleep Initiation, Maintenance, and Sleep Efficiency Sleep Architecture Changes in Circadian Rhythm with Age Normal Sleep–Wake Cycle: The Circadian Rhythm and Sleep Homeostasis Phase Advance, Reduced Circadian Amplitude, and Less Adaptation to Phase-Shift Sleep in Children Infants: 0–1 Year Toddlers: 1–5 Years Middle Childhood: 6–12 Years Adolescents: 12–18 Years Summary References Part II: Physiologic Regulation in Sleep and During Development 2: Control of Breathing During Sleep and Wakefulness in the Fetus, Newborn, and Child Introduction Influence of Sleep on the Respiratory Control System Control of Breathing in the Fetus Regulation of FBM by Chemoreflex Drives Hypoxic Drive and Peripheral Chemoreceptors Hypercapnic Drive and Central Chemoreceptors Control of Breathing in the Newborn Regulation of Breathing in Neonates in Relation to Sleep, Chemoreflex Drives Normoxic Breathing Pattern in Neonates in Relation to Sleep States Hypoxic Ventilatory Responses (HVR) in Neonates in Relation to Sleep State Hypercapnic Ventilatory Response (HcVR) in Neonates in Relation to Sleep State Alteration of Ventilatory Chemoreflexes in Neonates by Chronic Intermittent Hypoxia Sex and Control of Breathing at Neonatal Ages Respiratory Control in Older Children and Effects of Sleep State Respiratory Rate, Tidal Volume, and Minute Ventilation: Effects of Age and Sleep Ventilatory Response to Hypoxia and Hypercapnia: Effects of Age and Sleep References 3: Normal Respiratory Physiology During Wakefulness and Sleep in Children Introduction Lung Volumes Chest Wall—Developmental Changes Lung and Respiratory System Compliance—Developmental Changes Importance of FRC Contribution of Rib Cage Versus Abdomen to Tidal Volume—Effect of Sleep Dynamic Maintenance of End-Expiratory Lung Volume Paradoxical Inward Rib Cage Motion (PIRCM) During Inspiration Normal Response to Respiratory Mechanical Loading During Sleep Resistive Inspiratory Loading—Effect of Sleep Elastic Loading—Effects of Sleep Responses to Respiratory System Loading—Complete Airway Occlusion Summary References 4: Upper Airway and Motor Control During Sleep Introduction Anatomy of the Upper Airways Maturational Anatomy of the Upper Aerodigestive Tract Innervation of the Upper Airway Muscles Motor Function of the Upper Airways Motor Function of the Upper Airway Muscles During Breathing Upper Airway Motor Responses to Subatmospheric Intraluminal Airway Pressure Mechanisms of Increased Upper Airway Resistance to Breathing During Sleep Control of Upper Airway Diameter During Central Apneas and Periodic Breathing Concluding Remarks References 5: Endocrinology of Sleep Introduction The Circadian System—A Brief Overview Interplays of the Endocrine System with Sleep and Circadian Rhythms Hypothalamic-Pituitary Axes and Sleep The Hypothalamic-Pituitary-Adrenal (HPA) Axis Hypothalamic Circadian Influence Circadian Activity of the Adrenal Glands Circadian Rhythmicity of the Glucocorticoid Receptors and Their Actions Influences of Sleep on HPA Axis Growth Hormone The Hypothalamic-Pituitary-Gonadal/Ovarian (HPG/HPO) Axis The Hypothalamic-Pituitary-Thyroid Axis Circadian Rhythmicity of the HPT Axis Sleep and the Thyroid Prolactin The Pineal Gland and Melatonin Endocrine Impact of Melatonin Action Insulin Secretion and Glucose Metabolism Melatonin and Prolactin Melatonin and Growth Hormone Melatonin and the HPG Axis Summary References 6: Thermoregulation and Metabolism Introduction Thermoregulation in Neonates and Infants Basic Principles Thermoregulatory Parameters and Sleep Stage Effects in the Thermoneutral Range Physiological Adjustments to Cold, and Sleep Stage Effects Physiological Adjustments to Heat, and Sleep Stage Effects Behavioral Thermoregulation Sleep Is Influenced by Non-thermoneutral Conditions Sleeping in a Cool Environment Sleeping in a Warm Environment Impacts of Thermal Transients on Sleep Sleeping at Thermoneutrality Temperature Circadian Rhythm in Infants and Its Relationship to Sleep Body Temperature Rhythm According to Sleep Body Temperatures and Sleep Onset Conclusion References 7: Sleep and Immunity Introduction The Function of Sleep Sleep Deprivation Immune System Sleep, Brain, and Immune System The Role of Sleep in Regulating the Immune System Effect of Sleep Deprivation on the Immune System Immune System Effect on Sleep Sleep During Infection References 8: Sleep and the Gastrointestinal System Sleep Related Changes in Upper Gastrointestinal Physiology Sleep and Gastroesophageal Reflux: Sleep Is a Vulnerable State for GERD GERD and OSA: Bidirectional Relationship? Laryngopharyngeal Reflux: LPR Modulation of Cardiorespiratory Events in Neonates and Infants: Role of Sleep and GER Protective Airway Reflexes Apnea of Prematurity (AOP) Brief Resolved Unexplained Event (BRUE) (Apparent Life-Threatening Event: ALTE) References 9: Circadian Rhythms in Children Endogenous Origin of Circadian Rhythm: The Circadian Timing System Examples of Interactions Between Circadian Timing System and the Environment Preterm Birth Chrononutrition Photoperiod at Birth Emergence and Consolidation of Circadian Sleep/Wake Cycle Circadian Sleep/Wake Cycle and the Two-Process Model of Sleep Regulation Developmental Changes According to the Two-Process Model of Sleep Regulation Individual Differences in Circadian Rhythm Conclusions References Part III: Sleep Mechanisms: Developmental Aspects 10: Developmental Aspects of Sleep Introduction Developmental Profile of Sleep Stressed Maternal Conditions Leading to Malformed S-W and Neurobehavioural Development in the Newborn Maternal Sleep Restriction Affecting Neural Development in the Newborn Micro-Architecture Based on Differences in Development of EEG Bands Clues From Modelling of Distribution Patterns of S-W Bouts During Development References 11: Humoral and Other Sleep-Promoting Factors Proinflammatory Cytokines Adipokines Gastrointestinal Hormones Prolactin Sleep Signaling by Metabolic Organs Conclusions References Part IV: Measurement of Sleep 12: Survey Tools and Screening Questionnaires to Pediatric Sleep Medicine Introduction Adolescent Sleep-Wake Scale Behavioral Evaluation of Disorders of Sleep (BEDS) (Fig. 12.1) Brief Infant Sleep Questionnaire (BISQ) Center for Epidemiological Studies Depression Scale for Children (CES-DC) (Fig. 12.2) Children’s Morningness-Eveningness Scale (Fig. 12.3) Children’s Sleep Habits Questionnaire (CSHQ) Cleveland Adolescent Sleepiness Questionnaire (CASQ) (Fig. 12.4) Pediatric Daytime Sleepiness Scale (PDSS) (Fig. 12.5) Pediatric Sleep Questionnaire (PSQ) Pictorial Sleepiness Scale Based on Cartoon Faces (Fig. 12.6) School Sleep Habits Survey (Fig. 12.7) Sleep Disorders Inventory for Students (SDIS): Children’s Form (SDIS-C) and Adolescent Form (SDIS-A) Tayside Children’s Sleep Questionnaire (TCSQ) Teacher’s Daytime Sleepiness Questionnaire (TDSQ) Adolescent Sleep Habits Survey BEARS Sleep Screening Tool Obstructive Sleep Apnea-18 (OSA-18) IF SLEEPY/I SLEEPY/I’M SLEEPY Questionnaires Obstructive Sleep Apnea-5 (OSA-5) (Table 12.1) Conclusion References 13: Pediatric Patients with Sleep Complaints: Initial Interview and Diagnostic Planning Introduction Screening for Sleep Disorders The Two Major Presenting Problems: Insomnia and Hypersomnia Start Simple Age Matters The First 5 minutes What Is the Chief Complaint at Night? What Else Is Going On in the Day? Supporting Data? The Sleepy Seven Sleep-Related Breathing Disorder Hypersomnia Sleep-Related Movement Disorders Parasomnia Insomnia Circadian Rhythm Sleep Disorder Miscellaneous The Bedroom and Bedtime Routines Current and Past Interventions Family and Social History The Physical Examination Decision-Making Know What Is Normal When Only Hand Holding May Be Needed Investigative Decisions Sleep-Related Breathing Disorder Hypersomnia Sleep-Related Movement Disorder Parasomnia Insomnia Circadian Rhythm Sleep Disorder Parting Thoughts References 14: Best Practices for Accommodating Children in the Polysomnography Lab: Enhancing Quality and Patient Experience Introduction Indications for Polysomnography in Children A Family-Centered Approach Preparing the Sleep Lab for Children and Families Scheduling and Considerations in the Pediatric Sleep Study Orders Medical History Information Needed for Planning PSG Planning and Preparatory Education for Families Emotional Preparation Special Needs Populations Physical Set Up, Protocols, Staffing During the Procedure Technologist Considerations: Initial Greeting and Hook-Up Safe Sleep Practices The PSG Procedure, Scoring, and PSG Interpretation After the PSG Procedure Patient Experience Quality Measures Conclusion References 15: Technologies in the Pediatric Sleep Lab: Present and Future Introduction Polysomnography Ambulatory Unattended Polysomnography Oximetry Capnography EEG Spectral Analysis Actigraphy Autonomic Signal Assessment ECG Analyses: HRV PAT PTT Sound Analyses Wrist Consumer-Wearable Activity Trackers Smart Phone Applications References 16: Upper Airway Imaging in Pediatric Obstructive Sleep Apnea Introduction Lateral Neck Radiography Cephalometry Magnetic Resonance Imaging (MRI) Normal-Weight Children Obese Children Children with DS Cine MRI Computerized Tomography (CT) Cone Beam CT (CBCT) Functional Respiratory Imaging (FRI) Normal-Weight Children Obese Children Children with DS (Long-Range) Optical Coherence Tomography Drug-Induced Sleep (Sedation) Endoscopy (DISE) Future Developments Summary References 17: Laboratory Tests in Pediatric Sleep Medicine Introduction Pediatric Obstructive Sleep Apnea Diagnostic Tests OSA-Associated Urinary Proteins High Sensitivity C-Reactive Protein (hs-CRP) OSA-Associated Inflammatory Biomarkers/Cardiovascular Biomarkers OSA-Associated Metabolic Biomarkers/Metabolic Morbidity Biomarkers Excessive Daytime Sleepiness in OSA Restless Leg Syndrome (RLS)/Periodic Leg Movement Disorder of Sleep (PLMDS) Iron-Related Markers Narcolepsy/Idiopathic Hypersomnia/Primary Excessive Sleepiness Orexin Levels in Cerebrospinal Fluid Thyroid Panel Human Leukocyte Antigen (HLA)-DQB1*06:02 References 18: The Nocturnal Polysomnogram – Approaches to Recording, Scoring, and Interpretation in Infants and Children Indications for Nocturnal Polysomnography in Children Classification of Sleep Studies Advantages, Disadvantages, and Contraindications for Pediatric Level 1 Polysomnography Standards and Guidelines Used by Accredited Sleep Centers in the USA to Record and Score Nocturnal Pediatric Polysomnograms Child-Friendly Polysomnography Techniques Preparing a Child for In-Laboratory Polysomnogram Creating a Sleep Laboratory Welcoming to Children Applying Polysomnographic Sensors in Children Overnight Level 1 Pediatric Polysomnographic Recording Procedure Which Biophysiologic Signals Are Recorded in Level 1 Polysomnography and Why Electroencephalography (EEG) Electro-Oculography (EOG) Mentalis Electromyography (Chin EMG) Multiple Biological Signals Recorded to Assess Breathing During Sleep Thermal and Nasal Pressure Sensors Monitor Airflow Respiratory Effort Monitored Using Respiratory Inductance Plethysmography Pulse Oximetry Carbon Dioxide Monitoring (Capnometry) End-Tidal Carbon Dioxide Monitoring Transcutaneous Carbon Dioxide Monitoring Electrocardiography (ECG) Other Biological Variables Recorded During Level 1 PSG Split Night or Full Night Positive Airway Pressure Titration Level 1 PSG Capped Tracheostomy and Mechanical Ventilation Overnight Level 1 PSG Abbreviated 4-Hour Nap Level 1 PSG Scoring of Level 1 Nocturnal Polysomnogram First Done by Sleep Technologists Scoring Sleep/Wake States in Children 2 Months to 18 Years of Age The Dominant Posterior Rhythm of Wakefulness Develops with Age Drowsiness/Wake-Sleep Transition Scoring NREM 1 Sleep Recognizing and Scoring NREM 2 Sleep in a Nocturnal Polysomnogram in Children Scoring NREM 3 Sleep in Children Scoring REM Sleep in Children Scoring Arousals in Children of Ages 2 Months to 18 Years Scoring Respiratory Events in Children of Ages 2 Months to 18 Years Scoring Pediatric Periodic Limb Movements in Sleep Scoring REM Sleep Without Atonia Scoring Sleep/Wake States in Infants 0–2 Months of Age Crucial to Know the Infant’s Gestational and Chronological Age Technical Considerations When Recording Level 1 PSG in Infants 0–2 Months Old Scoring Sleep/Wake States in Infants 0–2 Months Old AASM Rules for Scoring Sleep/Wake States in Infants 0–2 Months Old Sleep Cycle Patterns in Infants 0–2 Months of Age Scoring Respiratory Events in Level 1 PSG in Infants of Ages 0–2 Months Is Challenging Review and Interpretation of Nocturnal Pediatric Polysomnograms Review Biocalibration, Hypnogram, and Technologist’s Comments Now Review the Video-Polysomnogram Once Reviewed and Revised, Generate a Report of the Polysomnogram Provide a Summary and Interpretation of the Polysomnogram Interpreting Pediatric Polysomnogram Cognizant Normative Data First Night Effect in Children Night-to-Night Variability in Pediatric Polysomnogram Normative Single Overnight Level 1 PSG Data for Pediatric Sleep Architecture and Arousals Normative Single Overnight Level 1 PSG Sleep-Related Respiratory Data Cutoff Values for Diagnosing OSA on PSG in Children of Ages 1–23 Months Excessive Periodic Limb Movements REM Sleep Without Atonia and REM Sleep Behavior Disorder Recognizing REM Sleep Behavior Episodes in Video-Polysomnography Summary References 19: Multiple Sleep Latency Test Multiple Sleep Latencies in Adults Introduction: Excessive Daytime Sleepiness (EDS) and Repercussions Subjective Diagnostic Methods Objective Diagnostic Methods Normative MSLT Data Factors Influencing MSLT Age Sleep Deprivation Stimulants or Drugs, Exercise, Meals Treatments Fourth or Fifth Nap Conditions During the Test Pathologies Influencing MSLT Central Hypersomnias Narcolepsy Idiopathic Hypersomnia Secondary Excessive Daytime Sleepiness Primary Insomnia Sleep-Related Breathing Disorders Sleep Fragmentation/Periodic Leg Movements Other Neurological Disorders Reliability Indications of MSLT MSLT in Children Introduction Subjective Diagnostic Methods Objective Diagnostic Methods Factors Influencing MSLT Age-Puberty Sleep Restriction/Deprivation Stimulants or Treatments Pathologies Influencing MSLT Central Hypersomnia Narcolepsy Idiopathic Hypersomnia Secondary Excessive Daytime Sleepiness Obstructive Sleep Apnea Periodic Leg Movements Other Sleep Pathologies Attention-Deficit/Hyperactivity Disorder Indications of MSLT Conclusions References 20: Actigraphy Current Professional Recommendations for Clinical Use Validity of Actigraphy for Estimating Pediatric Sleep Clinical and Research Considerations When Not to Use Actigraphy When to Use Actigraphy Pediatric Actigraphy Considerations and Challenges Device Placement Artifact Recording Time Care and Return of the Device Reference Values Publishing and Reporting Consumer-Marketed Wearable Trackers References 21: Defining Normal in Pediatric Sleep: Some Thoughts and Things to Think About References Part V: Pharmacotherapy of Sleep Disorders in Children 22: Stimulants Introduction Amphetamines and Amphetamine-Like Compounds Pharmacological Effects Chemical Entities Pharmacokinetics Mechanisms of Action Pharmacodynamics Indications Side Effects Drug Abuse and Misuse Contraindications Management Dosage Initiation Monitoring Modafinil Pharmacological Effects Pharmacokinetics Mechanism of Action Indications Side Effects Management Contraindications Mazindol Other Waking Promoting Agents Pitolisant Pharmacological Effects Pharmacokinetics Mechanism of Actions Indications Side Effects Management Contraindications Sodium Oxybate Indications Side Effects Management Solriamfetol Conclusion References 23: Somnogenic Agents in Children Introduction Medical History Over-the-Counter Substances Used for Sleep Melatonin and Agonists Hypnotics Benzodiazepines Nonbenzodiazepine Hypnotics Conclusion References 24: Drugs which affect Sleep Introduction Analysis Sleep–Wake Disorders and Their Pharmacotherapy: An Ambiguous Perspective Insomnia Parasomnia Central Disorders of Hypersomnolence Circadian Rhythm Sleep–Wake Disorders Sleep-Related Breathing Disorders Sleep Apnea Sleep-Related Movement Disorders What Pediatric Somnologists Should Take into Consideration When Drugs Used in Common Pediatric Practice Impact Sleep Internal Medicine Surgery and Anesthesia Neurology and Psychiatry Vaccines Discussion References Part VI: Acute and Chronic Ventilatory Support in Children 25: Non-invasive Respiratory Support in Children with Sleep Disordered Breathing Introduction Continuous Positive Airway Pressure Bilevel Positive Pressure Ventilation Neuromuscular Diseases Congenital Central Hypoventilation Syndrome Hybrid Modes Neuromuscular Disease Obesity Hypoventilation Congenital Central Hypoventilation Syndrome High-Flow Nasal Cannula Therapy Supplementary Oxygen Conclusion References Part VII: Disorders of Sleep 26: Pediatric Insomnia: Etiology, Impact, Assessment, and Treatment Introduction Prevalence Etiology Impact Assessment Treatment Future Directions Summary References 27: Apnea of Infancy, Apparent Life-Threatening Events, and Sudden Unexplained Death in Infancy Apnea of Infancy Definition Physiology of Breathing in Early Infancy Pathophysiology Diagnostic Approaches: History and Examination Differential Diagnoses: Causes Management Apparent Life-Threatening Events (ALTE) Definition Pathophysiology Diagnostic Approaches: History and Examination Differential Diagnoses: Causes Management Sudden Unexplained Death in Infancy (SUDI) Definition Pathophysiology Diagnostic Approaches Differential Diagnosis Management Primary Prevention Creating a Safe Sleep Environment Illustrative Cases Apnea of Infancy: Case 1 Apnea of Infancy: Case 2 ALTE Case SUDI Case References 28: Apnea of Prematurity Introduction Significance Pathophysiology Hypoxic Ventilatory Depression CO2 Apneic Threshold Relationship Between Apnea, Bradycardia, and Desaturation Changes in Lung Volume, Apnea, and Desaturation The Role of Feeding and Gastroesophageal Reflux Chest Wall Distortion, Anatomic Dead Space, and Diaphragmatic Fatigue Treatment Head-Elevated Positioning Nasal Respiratory Support Systems Caffeine Doxapram Interventions to Reduce IH Independent of Apnea References 29: Disorders of Respiratory Control and Central Hypoventilation Syndromes Introduction Definitions Pathophysiology Differential Diagnosis Congenital Central Hypoventilation Syndrome (CCHS) ROHHAD/ROHHADNET Clinical Management Chiari Malformation and Myelomeningocele Clinical Presentation Clinical Management Prader-Willi Syndrome Clinical Respiratory Features Clinical Management Achondroplasia Clinical Respiratory Features Management Leigh Syndrome Joubert Syndrome Clinical Management Familial Dysautonomia Clinical Respiratory Features Acquired Central Hypoventilation Syndromes Management Illustrative Case References 30: Disorders of Excessive Sleepiness Introduction Narcolepsy Definitions Epidemiology Pathophysiology Clinical Features Differential Diagnosis Diagnostic Approach Management Illustrative Case Idiopathic Hypersomnia Definitions Epidemiology Pathophysiology Clinical Features Differential Diagnosis Diagnostic Approaches Management Prognosis Kleine-Levin Syndrome Definitions Epidemiology Pathophysiology Clinical Features Diagnostic Approach Management Prognosis Insufficient Sleep Syndrome Definitions Epidemiology Etiology Pathophysiology Clinical Features Differential Diagnosis Diagnostic Approach Management Illustrative Case References 31: Restless Legs Syndrome and Periodic Leg Movements of Sleep Definitions Pathophysiology Diagnostic Approaches Differential Diagnosis Management Illustrative Cases Case 1 Case 2 References 32: Circadian Sleep Disorders Definitions and Background Pathophysiology Diagnosis Summary of Disorders and Diagnostic Approaches Differential Diagnosis Treatment Consistent Light/Dark Timing Prescribed Sleep/Wake Scheduling Resetting Agents DSWPD ASWPD N24SWD ISWRD Illustrative Cases Case One Clinical History Physical Exam Discussion Treatment Options Outcome Case Two Clinical History Physical Exam Discussion Outcome References 33: Parasomnias Definitions of Parasomnia NREM-Related Parasomnias Diagnostic Approaches to NREM Parasomnia Disorders of Arousal From NREM Sleep Confusional Arousal Sleepwalking Sleep Terrors Sleep-Related Eating Disorder (SRED) Pathophysiology of NREM Parasomnias Differential Diagnosis of NREM Parasomnia REM Parasomnias Sleep-Related Hypermotor Epilepsy Management of NREM Parasomnia Non-pharmacological Treatment Pharmacological Treatment REM-Related Parasomnias REM Sleep Behavior Disorder (RBD) Recurrent Isolated Sleep Paralysis Nightmare Disorder Other Parasomnias Exploding Head Syndrome (EHS) Sleep-Related Hallucinations Sleep Enuresis Nocturnal Panic Attacks Illustrative Cases Case 1 References Part VIII: Obstructive Sleep Apnea 34: Obstructive Sleep Apnea: Definition First Description and Consensus Definitions for Obstructive Sleep Apnea in Pediatrics Additional Elements of Sleep-Related Respiratory Disturbance Not in the Definitions A Look Forward: Challenges to Define Early Signals of Pediatric OSA References 35: Pathophysiology of Obstructive Sleep Apnea Syndrome in Childhood Introduction Pharyngeal Development Pharyngeal Anatomy Anatomic Considerations Infancy Craniofacial Anomalies Altered Soft Tissue Size Neurological Disorders Childhood Anatomical Assessment of the Upper Airway Airway Size Region of Vulnerability and Overlap Region Airway Dynamics Depicted by MRI Soft Tissues Craniofacial Structure Childhood Obesity Adolescence Summary of Anatomic Considerations Functional Considerations Central Ventilatory Drive Ventilatory Response to Inspiratory Resistive Loading Arousals from Sleep Upper Airway Neuromotor Tone Upper Airway Sensation Summary of Functional Consideration Biomechanical Considerations Additional Considerations Edema Myopathy Gender Genetics Research Questions References 36: Obstructive Sleep Apnea: Clinical Presentation and Differential Diagnosis Clinical Presentation Clinical History Physical Examination Differential Diagnosis References 37: Surgical Treatment of Pediatric Obstructive Sleep Apnea Introduction Adenotonsillectomy Preoperative Evaluation in Children with Persistent OSA Drug-Induced Sleep Endoscopy Cine MRI Nasal and Nasopharyngeal Surgery Oropharyngeal Surgery Surgery to Address Tongue Base Collapse Tongue Base Reduction Tongue Repositioning Procedures Supraglottoplasty Tracheostomy Perioperative Considerations in Pediatric OSA Conclusion References 38: Obstructive Sleep Apnea: Treatment – Anti-inflammatory Therapy Introduction Mechanisms of Action Nasal Corticosteroids Montelukast Comparison of Treatment Efficacy: Nasal Corticosteroids Versus Montelukast Combination Therapy of Nasal Corticosteroids and Montelukast Side Effects Anti-inflammatory Medications After Adenotonsillectomy Identification of Patients Susceptible for Medical Treatment Conclusions References 39: Pediatric Obstructive Sleep Apnea: Orthodontic Management Pathophysiology Assessment in an Oral Health Office Assessment of Craniofacial Features, Airway Space, and Weight Differences in Syndromic Children Screening of POSA: Prediction of Likely Presence or Absence by Oral Health Professionals – Clinical and Imaging Assessment Management of POSA by Oral Health Providers Indication Maxillary Expansion Mandibular Repositioning Maxillary Advancement Other Considerations Specific Craniofacial Diagnosis Prior OSA Management Outcomes of Orthodontic-Orthopedic Approaches MAD Appliances RME Appliances Prediction of Orthodontic-Orthopedic Management Outcomes Follow-Up Success Rates of Treatment Recurrence of Craniofacial Discrepancies Guiding Recommendation on Long-Term Reassessments References 40: Myofunctional Approaches to Pediatric Sleep Medicine Introduction Craniofacial Growth and SDB Orofacial Myofunctional Evaluation Orofacial Myofunctional Exercises Obstructive SDB and Orofacial Myofunctional Therapy Other New Evidences Conclusions References 41: Illustrative Clinical Cases Case #1 ADHD and Delayed Sleep-Wake Phase Syndrome with RLS Biographic Data Chief Complaint Family History Personal History Sleep-Specific History General Examination Complementary Tests Performed Using Melatonin with Tryptophan and Vitamin B6 Conclusion Case #2 Epilepsy and Sleep Disturbances (Insomnia) Biographic Data Sleep-Specific History Evolution Conclusion Case #3 Central Congenital Hypoventilation Syndrome (Late Onset) Specific Sleep History Central Sleep Apnea (CSA) Congenital Central Hypoventilation Syndrome (CCHS): Late Onset Case #4 Narcolepsy Case #5 OSA and ADHD Case #6 Behavioral Insomnia of Childhood Case #7 Sleep and Seizure Disorder References Part IX: Sleep in Other Disorders 42: Sleep-Disordered Breathing in Neuromuscular Diseases Introduction Pathophysiology and Clinical Presentation Sleep Studies in NMD: Findings Spinal Muscular Atrophy Duchenne Muscular Dystrophy Congenital Muscular Dystrophy Spinal Cord Injury Other Diseases Management Approaches Nocturnal Ventilation Diurnal Ventilation Interfaces for Ventilation Mask Interface Mouthpiece Tracheostomy Conclusions References 43: Obstructive Sleep Apnea and Asthma Introduction Epidemiology Prevalence of Asthma and OSA Severity of Asthma and OSA Common Clinical Features Obesity, Allergic Rhinitis, GERD, and Inflammation Mechanisms of Increased Risk of OSA in Asthma Clinical Implications Treatment Conclusion References 44: Cystic Fibrosis Case Vignette Introduction Insufficient Sleep and Poor Sleep Quality Obstructive Sleep Apnea (OSA) Abnormalities in Gas Exchange Nocturnal Hypoxemia Nocturnal Hypercapnia Effects on Sleep Quality Etiologies for Poor Sleep Impact of Sleep Disturbances Treatment of Sleep Disorders Conclusions and Implications for Clinical Practice References 45: Bronchopulmonary Dysplasia Introduction Definition of BPD New Directions: New Definition, New Studies New BPD Definition (Table 45.2) Pathophysiology Inflammation Infection Immaturity Ventilator Injury Pressure/Volume Current Management Strategies Medications Steroids Long-Term Implications Outpatient Management Strategies References 46: Down Syndrome Introduction Sleep Disturbance in Children with Down Syndrome Sleep-Disordered Breathing in Children with Down Syndrome Epidemiology Evaluation and Diagnosis Morbidity and Management Conclusion References 47: Sleep in Obese Children and Adolescents Introduction Sleep Duration and Obesity Sleep Quality, Sleep Timing, Sleep Variability, and Obesity Sleep Timing and Obesity Sleep Variability, Sleep Quality, and Obesity Obstructive Sleep Apnea (OSA) Obesity Hypoventilation Syndrome Sleep Interventions and Health in Youth References 48: Sleep in Sickle Cell Disease Introduction Pathophysiology Nocturnal Hypoxemia Oxidative Stress Nitric Oxide Bioavailability Inflammatory Cascade Activation Cell Adhesion Molecules Autonomic Nervous System Imbalance Clinical Manifestations Sleep Quality and Duration Pain and Sleep Quality Respiratory Manifestations Upper Airway Obstruction and OSA Lower Airway Obstruction and Asthma Cardiovascular Disease Pulmonary Hypertension Left Ventricular Dysfunction Neurological Complications Urological Complications Priapism Nocturnal Enuresis Erectile Dysfunction Summary References 49: Epilepsy and Sleep, Common Bedfellows Introduction Sleep-Wake State and Circadian Rhythm Effects on EEG, Seizures, and Cortical Excitability Epilepsy Syndromes and Sleep Epilepsy Treatment and Sleep Sudden Unexplained Death in Epilepsy Patients Epilepsy and Comorbid Sleep Disorders References 50: Autism Spectrum Disorder Autism Spectrum Disorder Defined Epidemiology of Sleep Problems in ASD Prevalence Developmental Course Correlates Predictors and Consequences Sleep in Autism – Ontogeny of Sleep Problems in ASD Neurobiological Mechanisms Medical Contributors Environmental and Behavioral Contributors Assessment Objective Measures Polysomnography Actigraphy Subjective Measures Questionnaires Sleep Diaries Assessment Considerations Treatment – Practice Pathway Sleep Disorders Insomnia Development and Risk Factors Assessment Treatment Circadian Rhythm Disorders Development and Risk Factors Assessment and Treatment Sleep-Disordered Breathing Development and Risk Factors Assessment and Treatment Sleep Movement Disorders Development and Risk Factors Assessment and Treatment Parasomnias Development and Risk Factors Assessment and Treatment Bruxism Development and Risk Factors Assessment and Treatment Summary, Conclusions, and Future Directions References 51: Sleep and Attention-Deficit/Hyperactivity Disorder Introduction ADHD and Sleep-Onset Insomnia/Sleep Delayed Phase Syndrome (SDPS) ADHD and Narcolepsy-Like Symptoms ADHD and OSA ADHD Sleep and Epilepsy ADHD and RLS/PLMs Effect of ADHD Therapy on Sleep and the Effect of Sleep Therapy on ADHD Symptomatology Conclusion References 52: Sleep and Mood Disorder Introduction of Sleep, Behavior, and Mood Sleep and Psychiatry Study of Sleep in Psychiatric Disorders Sleep and Depressive Disorders Sleep and Bipolar Disorder Sleep and Suicide Sleep, Mood, and Early Intervention Conclusion References 53: Prader–Willi Syndrome Introduction Genetics Clinical Manifestations Sleep and Respiration in PWS Patients Growth Hormone Therapy and PWS Summary References 54: Craniofacial Syndromes Historical Perspective and General Considerations Specific Craniofacial Conditions Cleft Lip/Palate Without Micrognathia Diagnosis/Treatment Micrognathia with or Without Cleft Palate Presentation/Evaluation Nonsurgical Management Surgical Airway Management Syndromes with Other