Pediatric obstructive sleep apnea—Dental professionals can play a crucial role

 Ongoing clinical research in the area of sleep disordered breathing has shown the benefit of a multidisciplinary team in treating these disorders.  Put simply,  sleep disorder treatment is not a one size fits all and you need many health care providers working together to find the right care plan.  These include the primary care provider, otolaryngologist, neurologist, pulmonologist, dentist/orthodontist, speech/occupational therapist and more.  This paper highlights the benefits of a multi-pronged strategy.

Abstract

The significant contribution of dental professionals to the management of selected adult obstructive sleep apnea (OSA) cases is understood. Among children, it has also been suggested that dental professionals may also help screen and manage this morbidity in selected cases. It has also been noted that our understanding of pediatric OSA lags significantly behind adult OSA. During the screening process for potential pediatric OSA cases, dental professionals may be quite helpful as specific craniofacial abnormalities have been previously associated with pediatric OSA, including Class II malocclusion, vertical facial growth and maxillary transversal deficiency. As dental professionals assess children more frequently than physicians, they can help screen sleep-disordered breathing signs and symptoms using validated questionnaires. In more advanced cases, orthodontists may be leading contributors to the management of selected cases where a craniofacial involvement is suspected. Rapid maxillary expansion and mandibular or maxillary anterior repositioning devices have been proposed as managing alternatives. So far, there is no substantial evidence if these approaches can be adopted to treat OSA fully or if the reported OSA signs and symptoms improvements observed in a selected group of patients are stable long-term. Nevertheless, dentists and orthodontists' integration into a transdisciplinary team should be encouraged to play a significant role. This review discusses dentists or orthodontists' potential contribution to screen and manage selective pediatric OSA patients as part of a transdisciplinary team.

Read abstract here.

New Narcolepsy Therapy?

Narcolepsy is a rare disorder associated with excessive sleepiness despite adequate sleep time.  A potentially highly efficacious therapy for narcolepsy, Xywav, is complicated by a difficult dosing regimen requiring twice nightly administration for optimal effect.  A new therapy in development by Avadel may provide a similar benefit in a once nightly dose.

 Avadel Pharmaceuticals plc, whose marketing application for narcolepsy drug candidate FT218 is under review by the US Food and Drug Administration (FDA), presented in eight posters at World Sleep 2022. FT218 is an investigational formulation of sodium oxybate designed to be taken once at bedtime for the treatment of excessive daytime sleepiness (EDS) or cataplexy in adults with narcolepsy.

Data presented at World Sleep 2022 include results from a discrete choice experiment designed to characterize and quantify drivers of preferences for attributes associated with oxybate treatments for narcolepsy, with a background survey providing patient and clinician perspectives on narcolepsy disease burden, treatment approaches, and satisfaction with current narcolepsy treatment options. New post-hoc data from the completed pivotal Phase 3 REST-ON clinical trial of FT218 and interim data from the ongoing RESTORE open-label extension/switch study of FT218 was also presented.

“We know that untreated narcolepsy can have a devastating effect on patients’ quality of life and ability to function and that additional treatment options would benefit patients and clinicians. Results from the discrete choice experiment identified that the overall driver of treatment choice for oxybate therapy is once-nightly dosing,” says Anne Marie Morse, DO, director of child neurology and pediatric sleep medicine at Geisinger Medical Center at Janet Weis Children’s Hospital, in a release. “Taken together with the robust clinical data already published, along with new post-hoc analyses from the pivotal trial and interim long-term data from the ongoing open-label study….FT218 shows great potential for patient care.”

Highlights from the Poster Presentations

• The discreet choice experiment confirmed that once-nightly dosing, when compared to twice-nightly dosing, was the most important attribute driving both patient and clinician preference for overall oxybate product choice, as well as patient quality of life and reduction of patient anxiety/stress.
• Dosing frequency was also viewed as a more important attribute as compared to other attributes assessed, including sodium content.
• In the REST-ON post-hoc analyses, FT218 demonstrated improvement in subjective measures of daytime sleepiness, sleep quality, and refreshing nature of sleep as early as week 1 with the 4.5 g starting dose, with even greater improvement at week 2 soon after starting the 6 g dose compared to placebo.
• Additional post-hoc analyses, stratified by narcolepsy type, as well as concomitant stimulant use, or without stimulants, demonstrated positive results that are generally consistent with previously reported positive endpoints from REST-ON and add to the existing body of evidence for FT218.
• In the first presentation of an interim safety analysis from the ongoing RESTORE study, FT218 has generally been well tolerated, with some participants receiving therapy for more than 18 months; no new safety signals have emerged.

“In our first look at data from the interim analysis of the ongoing RESTORE study, we have affirmed that the tolerability of FT218 is in line with the well-established profile of sodium oxybate. We’re also pleased to share new results from our post-hoc analyses of the REST-ON trial that demonstrated clinically meaningful improvements with FT218 versus placebo in both subjective and objective measurements of narcolepsy symptoms, including EDS and disrupted nighttime sleep, with a dosing regimen preferred by patients and clinicians alike, consistent with our previous observations,” says Douglas Williamson, MD, chief medical officer of Avadel, in a release. “At Avadel, we believe in listening to patients to develop solutions that will have a meaningful impact on their symptoms. Our goal is to do just that for people living with narcolepsy, and we are working to bring FT218 to patients as a once-at-bedtime treatment option as quickly as possible.”

Read article here.

Sleep Awareness Week

This is Sleep Awareness Week.  Organizations such as the National Sleep Foundation routinely survey adults and find that sleep disorders are extraordinarily common and can significantly impact quality of life.  Sleep disorders in children and adolescents, though, are vastly underrecognized with between 20-30% of young children affected by disrupted sleep and 60-70% of adolescents experiencing reduced sleep time.  The effects can be numerous, including reduced cognitive function, mental health concerns, and increased metabolic and cardiovascular health risks.  A pediatric sleep specialist is NOT the sleep lab doctor.  A pediatric sleep clinic provides a comprehensive evaluation and treatment for all manners of sleep disorders to provide evidence based treatment recommendations for your entire health care team.

 To kick off Sleep Awareness Week, the National Sleep Foundation released the results from the 2022 Sleep in America Poll. The annual survey is one of the longest running records capturing Americans’ perceptions, attitudes, and behaviors around sleep. 

The 2022 Sleep in America Poll documents significant opportunities to improve daily activities that are associated with a range of positive sleep and health outcomes. Results show that many Americans are not getting bright light exposure during the day and are looking at screens around bedtime. In addition, many fall short of recommendations for exercise and take meals at inconsistent times.

Poll results show:

• Nearly half of Americans say they aren’t exposed to the recommended levels of bright light when indoors in the morning and afternoon.
• More than a third of Americans fall short of CDC’s recommendations for moderate or vigorous activity, another key factor in ensuring a sound sleep.
• Four in 10 Americans eat meals at inconsistent times, making it more difficult for their bodies to regulate the sleep/wake process.
• More than half of Americans indulge in screen time within an hour before bed or even while in bed.

“Over the last 31 years, the National Sleep Foundation has conducted the Sleep in America Poll to gain a better understanding of Americans’ sleep health and habits. These latest results highlight how people are doing with key daytime behaviors, knowing that what we do during the day and at night is important for sleep,” says John Lopos, CEO, National Sleep Foundation, in a release. “The best practices we continue to share can help you become your ‘Best Slept Self’— and by that we mean the radiant, positive feeling reflected in the way you look, feel, and navigate the day.”

Things you can do to help be your Best Slept Self:

• Increase exposure to bright light upon waking and throughout the afternoon.
• Help regulate your body’s sleep/wake process by eating meals at consistent times during the day and avoiding heavy meals 2-3 hours before bed.
• Avoid screentime at least one hour before bed.
• Make your bedroom a sleep-friendly space by keeping it cool, dark, and quiet.
• Follow recommended guidelines on proper exercise to improve overall health and your sleep. Aim for at least 20 minutes of exercise a day.
• Get the recommended hours of sleep per night. The National Sleep Foundation recommends 7-9 hours for most adults.

The Sleep in America Poll is fielded annually and results are shared during National Sleep Foundation’s Sleep Awareness Week. Sleep Awareness Week runs Sunday, March 13 through March 19. NSF independently produces Sleep Awareness Week, the Sleep in America Poll, and all related official educational content.

Sleep Awareness Week 2022 is supported by unrestricted funds from Jazz Pharmaceuticals, Eisai, Inc., Avadel Pharmaceuticals, Graber, Harmony Biosciences, Huckleberry, Idorsia, and PureCare. 

Read article here.

Helping High Risk Infants and Parents Sleep Better: ATS Guidelines for Outpatient Care of Premature Infants

Premature infants, particularly born before 30 weeks gestation who have been given a diagnosis of chronic lung disease, bronchopulmonary dysplasia, or post-prematurity respiratory disease face significant challenges in transition from the NICU environment to life at home.  The lack of guidelines to help focus care and quality medical literature differentiating outcomes is stark.  Parents and physicians need tools to care for these high risk infants. These new ATS guidelines nicely evaluate the role of inhaled medications, swallowing assessment, airway endoscopy, and especially sleep testing and provide timely recommendations.

Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

New recommendations are available to help guide physicians who must determine when and how to treat infants, children and adolescents with post-prematurity respiratory disease (PPRD). The American Thoracic Society has published an official clinical practice guideline in which a multidisciplinary panel of experts provide 13 conditional recommendations on the diagnostic testing and clinical management of these young people. The complete guideline detailing these recommendations was posted online ahead of print in the American Journal of Respiratory and Critical Care Medicine.

Worldwide, approximately 12 million infants—10 percent of live births—are born prematurely and are at risk for respiratory disease, the most common of which is bronchopulmonary dysplasia (BPD). However, all premature infants, even those who do not meet the criteria for having BPD, may develop poor respiratory health later in life with signs and symptoms including cough, recurrent wheezing, exercise intolerance, low blood oxygen (hypoxemia) and reduced pulmonary function. These individuals are classified as having PPRD.

Read article here.

Sleepless in Lockdown

The impact of lockdown on sleep patterns of children and adolescents with ADHD

Among the consequences of COVID 19 lockdowns and extended virtual learning, a deterioration in sleep-wake patterns especially among at risk children was anticipated and now confirmed in this Italian study surveying parents with children with ADHD.   Children an adolescents were more likely to have delayed sleep time, anxiety, awakenings, and daytime sleepiness. Unfortunately, many of the maladaptive sleep patterns may take longer to reverse and require a concerted sleep strategy.

ABSTRACT

STUDY OBJECTIVES:

The current study examined the impact of home confinement (lockdown) because of the COVID-19 pandemic on the sleep patterns of children and adolescents with attention-deficit hyperactivity disorder (ADHD).

METHODS:

Nine hundred ninety-two parents of children and adolescents with ADHD filled out an anonymous online survey through the ADHD family association website. The survey investigated the sleep patterns and disturbances (using a modified version of the Sleep Disturbance Scale for Children) and screen exposure time before and during lockdown.

RESULTS:

During lockdown, 59.3% of children and 69.4% of adolescents with ADHD reported a change of bedtime, with a significant increase in patients with ADHD who went to sleep at 11 pm or later. Sleep duration, in contrast, resulted in 2 opposing processes with more children and adolescents sleeping either less than 6 hours/night or 10–11 hours/night. Among children and adolescents, respectively, 19.9% and 22% slept less than they did before lockdown, whereas 21.4% and 27.4% slept for more hours. Bedtime delay and decreased sleep duration were associated with an increase in screen time exposure. Moreover, patients with ADHD reported an increase in sleep disturbances when compared to their previous condition, mainly including difficulties falling asleep, anxiety at bedtime, night awakenings, nightmares, and daytime sleepiness.

CONCLUSIONS:

Lockdown impacted sleep-wake rhythms by strengthening the maladaptive sleep patterns reported in usual-life conditions in children and adolescents with ADHD.

CITATION:

Bruni O, Giallonardo M, Sacco R, Ferri R, Melegari MG. The impact of lockdown on sleep patterns of children and adolescents with ADHD. J Clin Sleep Med. 2021;17(9):1759–1765

Read abstract here.