Sleep characteristics in children with Down syndrome - ScienceDirect

The Journal of Pediatrics

Volume 134, Issue 6, June 1999, Pages 755-760

The Journal of Pediatrics

https://doi.org/10.1016/S0022-3476(99)70293-3 Get rights and content

Abstract

Background: Obstructive sleep apnea syndrome is common in children with Down syndrome (DS). Little is known about sleep patterns, especially arousals, awakenings, and movements during sleep in children with DS. Objective: To determine the characteristics of sleep disorders in children with DS and to define the associations between respiratory disturbance and arousals, awakenings, and movements. Methods: The study included 23 children with DS, compared with 13 children with primary snoring. All underwent a 6- to 8-hour sleep study. Results: The respiratory disturbance index was significantly higher in the children with DS (2.8 ± 2.3 events/h vs 0.6 ± 0.4 events/h; P < .05). Sleep was significantly fragmented in children with DS, who had a significantly higher arousal/awakening (A/Aw) index (24.6 ± 7.9 events/h) compared with the comparison group (17.6 ± 4.0 events/h) (P < .02). A higher percentage of jerks associated with A/Aw and respiratory event-associated A/Aw was observed in patients with DS (45.2% ± 25% and 8.6% ± 6.4%, respectively) compared with the control patients (10.2% ± 4.5% and 1.5% ± 2.1%) (P < .02). The median length of occurrences of stage 2 sleep was 27% shorter in the DS group (P < .03). The number of shifts from “deeper” to “lighter” stages of non-rapid eye movement sleep was 30% greater (P < .02) in the DS group. Conclusion: Children with DS have significant sleep fragmentation, manifested by frequent awakenings and arousals, which are only partially related to obstructive sleep apnea syndrome. (J Pediatr 1999;134:755-60)

Section snippets

Study Population

Children with DS (n = 23) and 13 control patients (age range, 1 to 10 years) participated in the study. Children with DS were recruited from the Genetic Counseling Outpatient Clinic of the Soroka Medical Center or by referral from their family physician to our Sleep Wake Disorders Unit because of difficulties in breathing during sleep. Thirty families of children with DS were contacted and given detailed information about the purpose of the study; 27 agreed to participate, but only 23 completed

Study Population

The mean age in the DS group was 4.8 years, and the mean age in the comparison group was 5.1 years. Seven of the 13 children with DS had undergone adenoidectomy and/or tonsillectomy. Of these, 3 were diagnosed with mild and one with severe OSAS.

Sleep Characteristics

There were no statistically significant differences between the groups with respect to lights out time, time in bed, total sleep time, and sleep efficiency (Table I).

. Patients and sleep characteristics

Empty Cell	Comparison group (n = 13)	DS group (n = 23)
Age (y)
Mean

DISCUSSION

The results of this study suggest that children with DS have sleep abnormalities characterized by increased fragmentation, numerous awakenings and arousals, and periodic leg movements. These sleep abnormalities may be only partly explained by breathing difficulties, because they are found in children with DS with and without OSAS.

Acknowledgements

We thank Mrs Bruria Freidman for her expert technical assistance.

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An at-home PSG study revealed that 44.4% of children with DS failed to enter REM sleep during a nap period, compared to 5.9% of TD children (Spanò et al., 2018). These findings are consistent with those of other PSG studies documenting greater respiratory disturbance, lower oxygen saturation levels, increased arousals, awakenings, and shifts from deeper to lighter stages of NREM in DS (Dyken, Lin-Dyken, Poulton, Zimmerman, & Sedars, 2003; Levanon et al., 1999). When comparing actigraphy data to other developmental groups, 95% of children with DS had sleep disturbances, compared to 67% in Williams syndrome (WS) and 57% in TD (Ashworth, Hill, Karmiloff-Smith, & Dimitriou, 2013).
Research conducted over the last century has suggested a role for sleep in the processes guiding healthy cognition and development, including memory consolidation. Children with intellectual and developmental disabilities (IDDs) tend to have higher rates of sleep disturbances, which could relate to behavior issues, developmental delays, and learning difficulties. While several studies examine whether sleep exacerbates daytime difficulties and attention deficits in children with IDDs, this chapter focuses on the current state of knowledge regarding sleep and memory consolidation in typically developing (TD) groups and those at risk for learning difficulties. In particular, this chapter summarizes the current literature on sleep-dependent learning across developmental disabilities, including Down syndrome, Williams syndrome, Autism Spectrum Disorder, and Learning Disabilities (Attention-Deficit/Hyperactivity Disorder and Dyslexia). We also highlight the gaps in the current literature and identify challenges in studying sleep-dependent memory in children with different IDDs. This burgeoning new field highlights the importance of considering the role of sleep in memory retention across long delays when evaluating children's memory processes. Further, an understanding of typical and atypical development can mutually inform recent theories of sleep's role in memory.
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Children with Down syndrome (DS) are at risk for sleep disorders including; obstructive sleep apnea (OSA). Although OSA is diagnosed by polysomnography (PSG), the practicality of PSG in DS is questionable. Further, OSA treatment efficacy in DS is largely unknown given the challenges of PSG. Our aims were to review (i) the feasibility of PSG, and (ii) the efficacy (improvement in obstructive apnea hypopnea index (OAHI)) of OSA treatment using follow-up PSG in DS.
Retrospective review of patients aged <21 years with DS who underwent PSG from October 2016 to June 2019. Successful PSG was determined using total sleep time (TST). PSG following treatment with adenotonsillectomy (AT) or positive airway pressure (PAP) was evaluated and compared to pre-treatment.
Among 248 patients with DS, only 11(4.4%) had unsuccessful PSG (TST<1h). Of the 237 successful studies (age: 7.9 ± 0.3y), average TST and sleep efficiency was 5.6 ± 0.1h and 79.5 ± 1.3%. 41 had post-AT PSG and 11(27%) achieved OSA cure (OAHI<2) with all demonstrating improved SE (p = 0.01) and OAHI (p = 0.0003). Multivariate analysis revealed only age was predictive (p = 0.003) of residual OSA post-AT. Of 24 children who underwent PAP titration, 20(83%) tolerated titration with improved OAHI (p = 0.01), however, no significant improvements in SE were observed.
In a large cohort of DS children, PSG was well tolerated. Following AT or PAP therapy, post treatment PSG confirmed efficacy, although residual OSA was identified. PSG is thus both feasible and useful in identifying OSA, OSA treatment response and should guide in decision making in children with DS.
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A single-center retrospective chart review of children with trisomy 21 who underwent AT was conducted from 1992 to 2019. The primary outcome was 30-day post-operative complication rate. Secondary outcomes included intraoperative complications, admission duration, emergency department visits, readmissions, reoperation rate and treatment failures.
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Research conducted with typically developing (TD) infants and children generally indicates that better habitual sleep and sleep after learning are related to enhanced memory. Less is known, however, about associations between sleep and recall memory in children with Down syndrome (DS).
The present study was conducted to determine whether parent-reported sleep problems were differentially associated with encoding, 1-month delayed recall memory, and forgetting over time in children with DS and those who were TD.
Ten children with DS (mean age = 33 months, 5 days) and 10 TD children (mean age = 21 months, 6 days) participated in a two-session study. At each session, recall memory was assessed using an elicited imitation paradigm. Immediate imitation was permitted at the first session as an index of encoding, and delayed recall was assessed 1 month later. In addition, parents provided demographic information and reported on child sleep problems.
Although parents did not report more frequent sleep problems for children with DS relative to TD children, regression-based moderation analyses revealed that more frequent sleep problems were associated with increased forgetting of individual target actions and their order by children with DS. Evidence of moderation was not found when examining encoding or delayed recall.
Although group differences were not found when considering parent-reported sleep problems, more frequent sleep problems were positively associated with increased forgetting by children with DS relative to those who were TD. Although future experimental work is needed to determine causality, these results suggest that improved sleep in children with DS might reduce forgetting, ultimately improving long-term recall memory.

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^☆: Supported by grant no. 89914101, from the Israeli Chief Scientist.

^☆☆: Reprint requests: Asher Tal, MD, Department of Pediatrics, Soroka University Medical Center, PO Box 151, Beer-Sheva, Israel 84101.

^★: 0022-3476/99/$8.00 + 0 9/21/98572

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