CLINICAL REVIEW
Neuropsychological morbidity linked to childhood sleep-disordered breathing

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Summary

Understanding the long-term neuropsychological consequences of sleep disorders in children poses a significant challenge to researchers. Since children are in a state of rapidly changing cognition and neurobehavioral function, impacts on development may have profound consequences. Recent studies now demonstrate that mild sleep apnea and snoring, once considered within the spectrum of normal sleep patterns, are associated with deficits of neuropsychological function. Preliminary data suggest that some of these cognitive deficits may be reversible following treatment of mild sleep apnea in children; however, factors such as age at treatment, duration of sleep disordered breathing, pre-morbid intellectual level, socioeconomic status, or the effectiveness of treatment may adversely affect long-term outcome. Furthermore, it is imperative that researchers determine whether the developing brain exhibits critical periods of plasticity during which episodes of sleep-disordered breathing might cause long-term or permanent neuropsychological effects.

Section snippets

Childhood sleep-disordered breathing

Sleep-disordered breathing (SDB) is the result of partial or complete airway obstruction causing sleep fragmentation and/or a disruption in ventilation. The pathophysiology of childhood SDB is considered a combination of mechanical obstruction of the pharyngeal space and a disorder of activation of neuromuscular tone which would normally dilate that space.1 Reports on the prevalence of obstructive sleep apnea (OSA) in children range from 2 to 4%,2 however, habitual snoring, which may be part of

Definition of obstructive sleep-disordered breathing; evolving concepts

The ‘standard’ measure of sleep disturbance is performed with the polysomnogram, a gross compilation of indices of sleep–wake states, respiratory and cardiac activity, oxygen saturation, carbon dioxide tension (frequently measured in pediatric labs) and body movement. Although individual sleep labs have established criteria defining sleep apnea and more importantly, obstructive SDB, there is still a lack of consensus on the standard criteria which should be used to define SDB or the level of

Evidence for neuropsychological dysfunction associated with childhood sleep-disordered breathing

There is significant evidence of behavior dysfunction associated with symptomatic childhood SDB, based on subjective data provided by parents.31 Parents and teachers commonly report behavior changes including aggression, impulsivity, hyperactivity, or decreased attention.13, 11, 32, 33, 34, 35, 36 These studies provide initial evidence for dysfunction and underscore the need for objective measurements of performance, in order to detect and quantify these deficits. Measuring the cognitive impact

Proposed mechanism of cerebral injury in sleep disordered breathing

SDB is associated with cognitive impairment, but a causal association has yet to be clearly established. Whether sleep apnea causes brain damage, or pre-existing brain injury causes sleep apnea is unclear.44, 45 Further investigation is required to determine the mechanism of brain injury associated with sleep apnea, and which neuropsychological deficits might be amenable to treatment.

SDB is characterized by sleep fragmentation, multiple arousals or awakenings, sleepiness, prolonged or

Timing of OSA insult, plasticity of the developing brain

An important area of future research lies in the question of whether the developing brain exhibits critical periods of plasticity during episodes of SDB that might cause long term or permanent neuropsychological effects. As noted by John Carroll in regards to the development of the respiratory system,73 developmental plasticity is defined as alterations induced by an experience during a critical period of development causing a lasting effect where the same experience occurring outside the

Treatment studies in childhood OSA

Treatment of OSA in adults with sleep apnea has been reported to improve measures of vigilance and attention; however, these deficits are similar to those resulting from sleep deprivation, suggesting that treatment in part targets the sleepiness resulting from OSA. It is unclear whether treatment can improve deficits associated with long-term brain injury or alterations of brain morphology. Many studies of adult OSA show conflicting treatment results of deficits of attention, executive

Significance: identifying children at risk for neuropsychological impairments

Childhood sleep apnea has a prevalence of 2–4% and childhood snoring is even more common with a reported prevalence ranging 5–21%.3, 4 Given the large number of children and teenagers with months or years of SDB symptoms referred to pediatric sleep centers, there is a potentially large unrecognized population of children with long-standing consequences of OSA. Children are presently vastly understudied due to a lack of recognition of sleep disorders by health providers and parents, and due to

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