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STUDY OBJECTIVES: To carry out an analysis of leg movement activity during sleep in a polysomnography dataset of patients with multiple sclerosis (MS) in comparison to idiopathic restless legs syndrome (iRLS) and healthy controls. METHODS: In this cross-sectional, observational, instrumental study, 57 patients (males/females: 11/46; mean age 46.2 ± 10.2 years) with a diagnosis of MS underwent a telephone interview assessing the 5 standard diagnostic criteria for RLS and polysomnography. Sleep architecture and leg movement activity during sleep were subsequently compared: 1) 40 patients with MS without RLS (MS–RLS) vs 28 healthy controls; 2) 17 patients with MS with RLS (MS+RLS) vs 35 patients with iRLS; 3) MS+RLS vs MS–RLS. RESULTS: MS–RLS and MS+RLS presented increased sleep latency, percentage of sleep stage N1, and reduced total sleep time compared to healthy controls and iRLS, respectively. The periodic limb movements during sleep (PLMS) index was higher in MS–RLS than in healthy controls (P = .035) and lower in MS+RLS compared to iRLS (P = .024). PLMS in MS+RLS were less periodic, less often bilateral, and with shorter single movements compared to the typical PLMS in iRLS. CONCLUSIONS: MS is a risk factor for RLS, PLMS, and for a lower sleep quality in comparison to healthy patients. PLMS in MS+RLS are fewer and shorter if compared to iRLS. Our results suggest a dissociation between motor (PLMS) and sensory symptoms (RLS sensory component) in RLS secondary to MS, with possible treatment implications. CITATION: Ferri R, Sparasci D, Castelnovo A, et al. Leg movement activity during sleep in multiple sclerosis with and without restless legs syndrome. J Clin Sleep Med. 2022;18(1):11–20.

Study Objectives To address the hypothesis that periodic leg movements during sleep (PLMS) are more frequent in children with attention-deficit hyperactivity disorder (ADHD) when compared with typically developing (TD) children. To that end, we analyzed PLMS in a recent case–control study and conducted a systematic review and meta-analysis of PLMS frequency in children with ADHD and TD children. Methods In our case–control study, we compared the PLMS frequency of 24 children with ADHD (mean age 11 years, 17 males) to that of 22 age-matched typically developing (TD) children (mean age 10 years, 12 males). A subsequent meta-analysis included 33 studies that described PLMS frequency in groups of children with ADHD and/or groups of TD children. Results The case–control study did not show any differences in the frequency of PLMS between children with ADHD and TD children, a result that was consistent across a range of different definitions of PLMS, which in turn had a significant and systematic effect on PLMS frequency. The meta-analysis compared the average PLMS indices and the proportion of children with elevated PLMS indices between children with ADHD and TD children and across a number of analyses did not find any meta-analytic results that supported the hypothesis that PLMS are more frequent in children with ADHD. Conclusions Our results suggest that PLMS are not more frequent in children with ADHD compared with TD children. A finding of frequent PLMS in a child with ADHD should therefore be considered a separate disorder and prompt specific diagnostic and therapeutic strategies.

The mandibular advancement device (MAD) is a therapeutic option for obstructive sleep apnea syndrome (OSAS); however, for severe cases, it has a lower efficacy compared to continuous positive airway pressure (CPAP). This report aimed to present the efficacy of MAD in a patient with severe OSAS who refused CPAP. Video-polysomnography and polygraphy were performed before and after treatment, respectively. Three months after fitting and titrating the MAD, the apnea–hypopnea index was reduced from 56.2 events/h to 1.3 events/h and the minimum oxyhemoglobin saturation increased from 80% to 91%. Snoring time reduced from 75.2% to 0.2%. Our patient presented with low body fat, retrognathia, pharyngeal obstruction mainly along the anteroposterior axis and at the base of the tongue, and the ability to make wide protrusive movements with the jaw. In our opinion, these features could constitute a phenotype that may predict a positive response to MAD treatment even in severe cases of OSAS.

Anna Castelnovo,1– 3 Giuseppe Loddo,4 Federica Provini,5,6 Silvia Miano,1 Mauro Manconi1,2,7 1Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland; 2Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; 3University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; 4Department of Primary Care, Azienda USL di Bologna, Bologna, Italia; 5IRCSS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italia; 6Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italia; 7Department of Neurology, University Hospital, Inselspital, Bern, SwitzerlandCorrespondence: Anna Castelnovo Ospedale Civico Via Tesserete 46, Lugano, 6900, SwitzerlandEmail anna.castelnovo@eoc.chObjective/Background: Night terrors, sleepwalking and confusional arousals are behavioral manifestations of incomplete awakenings from sleep. According to international diagnostic criteria, these behaviors occur in the absence of any mental experience, or in the presence of very limited cognition or dream imagery (eg, a single visual scene). The aim of this study was to systematically and retrospectively investigate the mental content associated with sleep terrors and/or sleepwalking in both children and adults.Patients and Methods: Forty-five consecutive patients referred for a diagnosis of disorders of arousal (DOA) of all subtypes (sleepwalking/sleep terrors/confusional arousals) (25 adults: 30 ± 6 y, 15 females; 20 children: 10 ± 3 y, 6 females) underwent a detailed semi-structured interview about the mental content associated with their nocturnal episodes. The interview was comprehensive of specific questions about their subjective recall rate, several content details (characters, emotions, actions and setting/context), and hallucinatory or dissociative experiences during clinical episodes. Patients’ reports were classified for complexity (Orlinsky scale) and content (Hall and Van de Castle categories).Results: More than two-third of the children (n = 14) could not recall any mental activity associated with their episodes, whereas more than two-third (n = 16) of the adults recalled at least one mental experience. Half of the adult patients (n = 8) estimated that a specific mental content was subjectively present around 50% or more of the times. Seven adults and one child described clear and vivid hallucinatory experiences of “dreamed” objects or characters projected onto their real home environment, in the absence of any reality testing. Five adults and two children described one or more dissociative experiences. The content of the collected reports was dominated by dynamic actions acted out from a self-perspective, often with apprehension and in response to misfortune and danger, in a home-setting environment.Conclusion: These results suggest that current diagnostic criteria are tailored around the typical presentation of DOA in children, and do not always fit to adult patients with DOA. Furthermore, they support the concept that consciousness may reemerge in DOA patients during clinical episodes, in a peculiar dissociated, psychotic-like form.Keywords: somnambulism, confusional arousal, parasomnia, dream, consciousness, mental content, amnesia

Heterogeneous cognitive deficits have been described in the spectrum of benign epilepsy with centro-temporal spikes, which strongly correlate with the intensity of interictal epileptiform discharges and its spreading, in particular during sleep, mostly within the perisylvian cognitive network. The aim of this review is to discuss current findings regarding the connection between sleep alterations and cognitive function in the spectrum of benign epilepsy with centro-temporal spikes. A longer sleep onset latency is the only evident sleep macrostructure alteration reported in the spectrum of benign epilepsy with centro-temporal spikes. On a microstructural level, a higher spike count of descending compared to ascending slopes of sleep cycles, an impairment of slow wave downscaling, and amplitude and slope of slow waves were found in the spectrum of benign epilepsy with centro-temporal spikes. Moreover, children with benign epilepsy with centro-temporal spikes had a reduced non-rapid eye movement sleep instability, in terms of cyclic alternating pattern, similar to that found in children with attention-deficit hyperactivity disorders and in children with obstructive sleep apnea and centro-temporal spike during sleep. Children with benign epilepsy with centro-temporal spikes have a known comorbidity with attention-deficit hyperactivity disorders and obstructive sleep apnea.Conclusion: Considering the common sleep microstructure alterations, the presence of attention deficit and hyperactivity and/or sleep apnea may be a considered warning sign in the case of benign epilepsy with centro-temporal spikes. What is Known: • Sleep related-cognitive deficits have been described in the spectrum of benign epilepsy with centro-temporal spikes. The degree of sleep alterations may predict the neurocognitive outcome, and help clinicians to choose the right treatment. What is New: • Considering the common sleep microstructure alterations, attention deficit and sleep apnea, may be a considered warning signs.

The analysis of sleep microstructure in attention deficit hyperactivity disorder (ADHD) revealed an under-representation of the EEG slow component during NREM sleep. Previous studies either excluded or did not characterize objectively sleep disorders, which notoriously affect sleep architecture. The present study aimed to investigate the cyclic alternating pattern in a real clinical sample of children with ADHD, in whom sleep disorders could be considered. Twenty-seven consecutively enrolled drug-naïve children (mean age, 10.53 years; nine females) and 23 controls (mean age, 10.22 years; 11 females) underwent a full sleep investigation, including attended video-polysomnography. Visual cyclic alternating pattern analysis was performed in a blinded way. Children with ADHD had one or more sleep disorders (a narcolepsy-like phenotype was found in two cases, sleep onset insomnia in three cases, arousal disorder in one case, movement disorder phenotype in six cases and obstructive sleep apnea in 11 cases, and six children had sleep-related epileptiform discharges). Children with ADHD and normal controls showed a similar microstructure with a cyclic alternating pattern rate of about 50%. Children with obstructive sleep apnea had a significantly higher cyclic alternating pattern rate during stage N3. Despite not reaching statistical differences, a lower cyclic alternating pattern rate and A1 index were found in children without epileptic abnormalities/obstructive sleep apnea. Our analysis might allow differentiation of the "primary form" of ADHD associated with a decrease of NREM instability from those forms associated with sleep apnea and epileptic activity.

Narcolepsy type 1 (NT1) is a disorder with well-established markers and a suspected autoimmune aetiology. Conversely, the narcoleptic borderland (NBL) disorders, including narcolepsy type 2, idiopathic hypersomnia, insufficient sleep syndrome and hypersomnia associated with a psychiatric disorder, lack well-defined markers and remain controversial in terms of aetiology, diagnosis and management. The Swiss Primary Hypersomnolence and Narcolepsy Cohort Study (SPHYNCS) is a comprehensive multicentre cohort study, which will investigate the clinical picture, pathophysiology and long-term course of NT1 and the NBL. The primary aim is to validate new and reappraise well-known markers for the characterization of the NBL, facilitating the diagnostic process. Seven Swiss sleep centres, belonging to the Swiss Narcolepsy Network (SNaNe), joined the study and will prospectively enrol over 500 patients with recent onset of excessive daytime sleepiness (EDS), hypersomnia or a suspected central disorder of hypersomnolence (CDH) during a 3-year recruitment phase. Healthy controls and patients with EDS due to severe sleep-disordered breathing, improving after therapy, will represent two control groups of over 50 patients each. Clinical and electrophysiological (polysomnography, multiple sleep latency test, maintenance of wakefulness test) information, and information on psychomotor vigilance and a sustained attention to response task, actigraphy and wearable devices (long-term monitoring), and responses to questionnaires will be collected at baseline and after 6, 12, 24 and 36 months. Potential disease markers will be searched for in blood, cerebrospinal fluid and stool. Analyses will include quantitative hypocretin measurements, proteomics/peptidomics, and immunological, genetic and microbiota studies. SPHYNCS will increase our understanding of CDH and the relationship between NT1 and the NBL. The identification of new disease markers is expected to lead to better and earlier diagnosis, better prognosis and personalized management of CDH., Journal of Sleep Research, 30 (5), ISSN:0962-1105, ISSN:1365-2869

Study Objectives To assess the frequency of restless legs syndrome (RLS), periodic limb movements during sleep (PLMS), and their overlap in a large sample of patients with multiple sclerosis (MS). To compare clinical and paraclinical findings among four subgroups of patients: RLS−/PLMS− (patients without RLS and PLMS), RLS+/PLMS− (patients with RLS and without PLMS), RLS−/PLMS (patients without RLS and with PLMS), and RLS+/PLMS+ (patients with both RLS and PLMS). Methods In this cross-sectional, observational, instrumental study, 86 patients (M/F: 27/59; mean age 48.0 ± 10.8 years) with a diagnosis of MS underwent a telephone interview assessing the five standard diagnostic criteria for RLS. Seventy-six participants underwent polysomnography (PSG) and maintenance of wakefulness test (MWT). Instrumental and clinical findings were subsequently statistically compared to investigate their association with RLS and PLMS index (PLMSI). Results RLS and PLMS (PLMSI ≥15/h) frequency in patients with MS were of 31.4% and 31.6%, respectively. Among patients with RLS, 37.5% had a PLMSI of at least 15/h. RLS−/PLMS+ group showed higher wake after sleep onset (p = 0.01), stage shifts per hour (p = 0.03), increased stage N1 (p = 0.03), and reduction in stage N3 (p = 0.01) compared to RLS−/PLMS−. RLS had no influence on clinical and PSG parameters (p = 0.45). Conclusions RLS is highly frequent in patients with MS. The frequency of PLMS is comparable to the general population. The low percentage of patients with RLS having a high PLMSI, together with the absence of correlation between RLS and female gender and older age, supports the existence of a distinct symptomatic form of RLS in MS.

Background and purpose Fatigue is amongst the most frequent and disabling symptoms of multiple sclerosis and a close relation between fatigue and sleep quality has been hypothesized. In this study the contribution of sleep disturbances measured by clinical and polysomnographic parameters to fatigue in multiple sclerosis was investigated. Methods This was a prospective instrumental study performed at the Neurocenter of Southern Switzerland. Demographic data and clinical characteristics including fatigue (as measured by the modified fatigue impact scale [MFIS]), neurological disability, psychiatric symptoms, medications and sleep‐related variables were collected at baseline visit and by a home full‐night polysomnography. The associations between sleep‐related variables and the MFIS were tested using partial correlations adjusted by demographic and sleep‐unrelated clinical factors. Results Seventy‐six patients were included in the study, of whom 53 (69.7%) had an MFIS ≥38 points (median 49.5, interquartile range 31.0–62.0). MFIS scores were positively associated with age, neurological disability, symptoms of depression and anxiety, and use of benzodiazepines and selective serotonin reuptake inhibitors. When adjusting for these variables, the presence of restless legs syndrome (RLS) (r = 0.37, p = 0.005) and periodic leg movements index (r = −0.33, p = 0.014) were associated with MFIS. Excessive daytime sleepiness, total sleep time, sleep efficiency, respiratory disturbances, and percentage of time spent in the different sleep stages (N1, N2, N3 and rapid eye movement) were not associated with fatigue. Conclusions Multiple sclerosis patients with a diagnosis of RLS had significantly higher global fatigue scores compared to those without RLS. Future studies should investigate whether medical treatment of RLS can ameliorate fatigue., Fatigue is amongst the most frequent and disabling symptoms of multiple sclerosis (MS), which is difficult to treat and negatively influences patients' quality of life. An investigation was done of whether clinical and polysomnographic measures of sleep quality influence fatigue in a large group of MS patients. It was observed that MS patients who also suffer from restless legs syndrome show significantly greater symptoms of fatigue, suggesting a potential causal link between these two entities and potential treatment implications.

Disorders of arousals are common sleep disorders characterized by complex motor behaviours that arise episodically out of slow-wave sleep. Psychological distress has long been associated with disorders of arousal, but this link remains controversial, especially in children andadolescents. The aim of this multi-centre study wasto characterize behavioural and emotional problems in a sample of children/adolescents with disorders of arousal, and toexplore their relationship with the severity of nocturnal episodes. The parents of 41 children/adolescents with a diagnosis of disorders of arousal (11.5±3.3years old, 61% males)and of a group of 41 age- and gender-matched control participants filled in the Child Behavior Checklist, along with the Sleep Disturbance Scale for Children and the Paris Arousal Disorders Severity Scale. Multilevel t-tests revealedsignificantly higher total scores and sub-scores of the Child Behavior Checklist for the patient group compared with the control group. Thirty-four percent of the patients obtained pathological total scores, and 12% of them borderline scores. The severity of emotional/behavioural problems in the patient group was positively correlated with the severity of the nocturnal episodes. Interestingly, children/adolescents with disorders of arousal also obtained higher excessive daytime sleepiness and insomnia symptoms sub-scores at the Sleep Disturbance Scale for Children. These results confirmed the hypothesis that behavioural/emotional problems are surprisingly common in children/adolescents with disorders of arousal. Further studies are warranted to investigate the causal relationship between pathological manifestations, subtler sleep abnormalities, and diurnal emotional/behavioural problems in children/adolescents with disorders of arousal.

In this chapter, we discuss sleep-related epilepsy, co-morbidity, differential diagnosis and the association with sleep disorders. The impairment of cognitive capabilities and the role of sleep-epileptic network are also additionally discussed. Some epilepsy syndromes occur primarily during sleep and others primarily upon awakening. The American Academy of Sleep Medicine uses the term sleep-related epilepsy (SRE) for the following epilepsies: sleep-related hypermotor epilepsy (SHE), benign focal epilepsy of childhood with centrotemporal spikes, Panayiotopoulos syndrome, tonic seizures of Lennox-Gastaut syndrome; electrical status epilepticus/continuous spike-waves during sleep and Landau-Kleffner syndrome. The majority of them have their onset during childhood and have a genetic component and a benign course. We describe the distinctive features of each epilepsy syndrome. Moreover, subjects with epilepsy may suffer from sleep disorder co-morbidities, from chronic insomnia to obstructive sleep apnoea syndrome, with significant impact on quality of life. In particular, the occurrence of sleep apnoea may be a challenge, as a sleep seizure may be misdiagnosed as sleep apnoea. Another significant co-morbidity, and differential diagnosis, includes sleep parasomnias. Over the last years, several new aspects have contributed to the understanding of sleep as a contributor to activation of interictal and ictal epileptic phenomena: the interrelationship between the sleep-wake circuitry and the different epileptic networks and the microstructure of sleep associated with epileptic activation, identified within the system of cyclic alternating pattern, and its implication on cognitive consequences of sleep epilepsy. All these new aspects may have strong implications for treatment and prognosis.

Sleep-disordered breathing (SDB) is frequent in patients with acute stroke. Little is known, however about the evolution of SDB after stroke. Most of our knowledge stems from smaller cohort studies applying limited cardiopulmonary sleep recordings or from cross-sectional data collected in different populations. This study aims to determine prevalence, type and intra-individual evolution of SDB based on full-night polysomnography (PSG) in acute stroke and 3 months thereafter. Furthermore, we aimed to identify predictors of SDB in the acute and chronic phase and to evaluate associations between SDB and functional outcome at 3 months (M3). A total of 166 patients with acute cerebrovascular events were evaluated by full PSG at baseline and 105 again at M3. The baseline prevalence of SDB (apnoea–hypopnoea index (AHI)>5·h−1) was 80.5% and 25.4% of the patients had severe SDB (AHI>30·h−1). Obstructive sleep apnoea was more prevalent than central sleep apnoea (83.8% versus 13%). Mean±SD AHI was 21.4±17.6·h−1and decreased significantly at M3 (18±16.4·h−1; p=0.018). At M3, 91% of all patients with baseline SDB still had an AHI>5·h−1 and in 68.1% the predominant type of SDB remained unchanged (78.9% in obstructive sleep apnoea and 44.4% in central sleep apnoea). The only predictors of SDB at baseline were higher age and body mass index and in the chronic phase additionally baseline AHI. Baseline AHI was associated with functional outcome (modified Rankin score >3) at M3. The high prevalence of SDB in acute stroke, its persistence after 3 months, and the association with functional outcome supports the recommendation for a rapid SDB screening in stroke patients., The high prevalence of SDB in acute stroke, its persistence after 3 months and its association with functional outcome support the recommendation for rapid SDB screening in stroke patients https://bit.ly/3bFWqV7

Age is presumably the essential factor in determining how humans sleep. Sleep patterns evolve in complex ways. This review is aimed to collect literature data about normal sleep, considering most relevant sleep studies published in the last decades, covering subjective and objective parameters, as well as neurophysiological studies on arousal development and sleep spectral analysis studies on sleep and brain maturation. According to subjective studies, sleep duration expresses the highest interindividual variability during the first years of life, becoming more stable across preschool and school ages, especially during weekend days or holidays. All these studies reported differences between sleep duration during weekday and weekend days, mostly due to earlier rise time for school time. Moreover, literature data showed a significant and worldwide decline in sleep duration and a later bedtime compared with the last century. Polysomnographic studies indicate that total sleep time in children older than 5 years did not really change with age, in contrast to what was generally suggested in several small studies. Changes seemed to be related to environmental factors rather than to biological changes. Studies about sleep microstructure (arousal levels, slow-wave activity, cyclic alternating pattern [CAP] analysis) need to be encouraged, considering the evident correlation between these sleep markers and sleep quality, brain maturation and cognition. Despite these evidences, there is a paucity of sleep normative data about CAP across developmental age, and many questions remain open about the scoring of arousals.

Although adenotonsillectomy is the first line treatment for children with obstructive sleep apnea syndrome (0SAS),1 improvement in objectively documented outcomes is often inadequate and a substantial number of children have residual disease. Early recognition and treatment of children with persistent OSAS is required to prevent long-term morbidity. The management of these children is frequently complex and a multidisciplinary approach is required as most of them have additional risk factors for OSAS and comorbidities. In this paper, we first provide an overview of children at risk for persistent disease following adenotonsillectomy. Thereafter, we discuss different diagnostic modalities to evaluate the sites of persistent upper airway obstruction and the currently available treatment options. Pediatr Pulmonol. 2017;52:699-709. © 2016 Wiley Periodicals, Inc.

Multiple sclerosis (MS) is a mainly demyelinating, autoimmune, and disabling neurological disease. In addition to well-known clinically evident symptoms such as coordination or motor problems, increasing attention has been posed to a constellation of less evident symptoms significantly contributing to the clinical impact of MS. Among others, sleep symptoms have been only recently explored. This systematic review summarizes objective sleep findings detected by using polysomnography and their relationship with clinical variables in MS patients. While it is well known that sleep disorders are frequent in MS, objective clinical data are still scarce. Literature based on subjective reports indicate sleep disorders as highly frequent in MS patients; however, objective data are still scarce. New large case-control instrumental investigations are warranted to establish the real objective entity and impact of sleep comorbidities.

Neck myoclonus (NM) is a frequent recently described sleep-related motor phenomenon occurring mainly during REM sleep with uncertain effect on sleep continuity. To better describe this phenomenon we studied 11 consecutive drug-free patients undergoing a video-polysomnographic (V-PSG) study who present at least 5 NM events in one single night of recording. All events were measured and checked for their association with rapid eye and leg movements, EEG arousals, awakenings and Bereitschaftspotential. One hundred and eighty-two motor events from 11 subjects were analyzed. Motor events were approximately 0.5 s in duration and occurred during REM sleep in 79.7% of the cases. Only 14.8% of the events were associated with rapid eye movements, 52.2% with leg movements, while approximately 80% of them were accompanied by an arousal or awakening. No EEG abnormalities and Bereitschaftspotential were observed. For its duration and its segregation in sleep, NM could be more appropriately named "sleep-related head jerks" (SRHJ). SRHJ should be recognized and its effect on sleep stability should be re-considered.

Introduction The aim of this study was to assess the prevalence of restless legs syndrome (RLS), periodic limb movements during sleep (PLMS) and their overlap in a large population of patients with multiple sclerosis (MS), and to compare clinical and paraclinical findings between patients with and without RLS/PLMS. Methods In this cross–sectional, observational, instrumental study, eighty-six patients (M/F: 27/59; mean age 48.0 ± 10.8 years) with a diagnosis of MS underwent a structured telephone interview assessing the five standard diagnostic criteria for RLS. Seventy-six participants underwent Video-polysomnography and Maintenance of Wakefulness Test (MWT). Instrumental and clinical findings were subsequently statistically compared to investigate their association with RLS and PLMS index (PLMSI). Results RLS and PLMS (PLMSI ≥15/h) prevalence in patients with MS was of 31.4% and 31.6% respectively. Among patients with RLS, 37.5% had a PLMSI ≥15/h. In the group with PLMS, 37.5% met all diagnostic criteria for RLS. No differences were found between patients with and without RLS (F = 0.99, p = 0.45), and between patients with and without a PLMSI ≥15/hour (F = 0.32 p = 0.94) on the pool of clinical and instrumental variables. Conclusion RLS is highly prevalent and severe in patients with MS. The prevalence of PLMS is comparable to the general population. The low percentage of patients with RLS having a high PLMSI, together with the absence of correlation between RLS and female gender and older age, support the existence of a distinct symptomatic form of RLS in MS. Support (if any)

Obstructive sleep-disordered breathing includes a spectrum of clinical entities with variable severity ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). The clinical suspicion for OSAS is most often raised by parental report of specific symptoms and/or abnormalities identified by the physical examination which predispose to upper airway obstruction (e.g., adenotonsillar hypertrophy, obesity, craniofacial abnormalities, neuromuscular disorders). Symptoms and signs of OSAS are classified into those directly related to the intermittent pharyngeal airway obstruction (e.g., parental report of snoring, apneic events) and into morbidity resulting from the upper airway obstruction (e.g., increased daytime sleepiness, hyperactivity, poor school performance, inadequate somatic growth rate or enuresis). History of premature birth and a family history of OSAS as well as obesity and African American ethnicity are associated with increased risk of sleep-disordered breathing in childhood. Polysomnography is the gold standard method for the diagnosis of OSAS but may not be always feasible, especially in low-income countries or non-tertiary hospitals. Nocturnal oximetry and/or sleep questionnaires may be used to identify the child at high risk of OSAS when polysomnography is not an option. Endoscopy and MRI of the upper airway may help to identify the level(s) of upper airway obstruction and to evaluate the dynamic mechanics of the upper airway, especially in children with combined abnormalities. Pediatr Pulmonol. 2017;52:260-271. © 2016 Wiley Periodicals, Inc.

This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2–18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea–hypopnoea index (AHI) >5 episodes·h−1, those with an AHI of 1–5 episodes·h−1and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g.Down syndrome and Prader–Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).

Introduction Sleepwalking belongs to a family of disorders (Disorders of Arousal - DOA) that are thought to derive from incomplete arousals out of Non Rapid Eye Movement (NREM) sleep. At yet, our knowledge about the specific neural dynamics occurring during clinical episodes is limited and relies on one SPECT case study, four stereo-EEG case reports/series and one single high-density electro-encephalography (hdEEG) case report. We herein describe a single case captured by hdEEG. Report of Case We collected two consecutive sleep recordings (using a 256-channel hdEEG coupled with standard video-polysomnography) of a non-medicated, otherwise healthy, 13-year-old male, with a history of recurrent daily sleepwalking episodes. We visually identified 17 behavioral events during sleep stage 3 and divided them into two groups: clear clinical episodes (n = 7) and simple movements associated with burst of delta waves (n = 10). Source power topography in the delta range (1-4 Hz) was computed using LORETA. Source images during selected episodes were compared to 30 second-windows of baseline stage 3 sleep. Comparisons were performed using statistical non-parametric mapping with supra-threshold cluster tests. Events were associated with an increase of delta power over the right frontopolar prefrontal cortex (rPFC) / Broadman area 10 (BA10) at their onset. This finding was clearly observable even when considering only clear-cut events, followed by the involvement of the right dorsolateral and medial prefrontal cortex / BA9 and of the left superior temporal gyrus/ BA 22. Conclusion We were able to replicate a recently published case report by our group, where we highlighted the putative role of rPFC and PFC and prefronto-temporal circuit in DOA episodes. Intriguingly, we observed a lateralization of this effect, with a prominent right frontal involvement. Novel research has shown a physiological asymmetry in the generation of large slow waves between the two hemispheres. An increased right-left unbalance might prime behavioral episodes in DOA patients.

Objective A case-control study was performed to test the hypothesis that children with attention deficit hyperactivity disorder (ADHD) have chronic sleep deprivation and may be classified into specific sleep-related phenotypes. Methods Thirty outpatients with ADHD (nine females, mean age 10.1 ± 2.1 years) were recruited consecutively, and given a comprehensive sleep assessment, including blood exams, sleep questionnaires, laboratory video-polysomnographic recordings (v-PSG), multiple sleep latency tests, and one-week actigraphy. The PSG parameters were compared to those of 25 age-matched controls (12 females, mean age 10.34 ± 1.54 years) who underwent only the v-PSG. Results ADHD children were classified as follows: a narcolepsy-like phenotype was found in four; delayed sleep onset insomnia in five; obstructive sleep apnea (OSA) in 15; periodic limb movements in eight, and sleep epileptiform discharges in 10 children. All subjects had a total sleep time shorter than 9 h at actigraphy, ferritin levels lower than 60 mcg/L, and a history of sleep problems (mainly OSA and insomnia). Compared to controls, the ADHD group had a higher apnea-hypopnea index at PSG. Conclusions A full sleep assessment in children with ADHD confirmed the validity of the sleep phenotypes hypothesis, and revealed a much higher percentage of sleep problems than that found in the literature. Beyond the sleep phenotypes, all children reported a history of sleep problems and slept less than 9 h per night, indicating chronic sleep deprivation that should be evaluated as a possible unifying marker of ADHD.

ObjectiveTo define the prevalence, time course, and associated factors of periodic limb movements during sleep (PLMS) in patients with ischemic stroke or TIA.MethodsPatients enrolled in the prospective Sleep-Disordered Breathing in Transient Ischemia Attack (TIA)/Ischemic Stroke and Continuous Positive Airway Pressure (CPAP) Treatment Efficacy (SAS-CARE) study underwent a double polysomnographic investigation in the acute and chronic phases after stroke/TIA, together with a MRI brain scan and a 24-hour blood pressure evaluation. The prevalence of PLMS in patients was compared with that in a matched sample of randomly selected healthy controls from the HypnoLaus cohort. One hundred sixty-nine recordings were performed in the acute phase and 191 after 3 months (210 recordings were obtained from the same 105 patients in both phases) and were compared to those of 162 controls.ResultsThe mean number of PLMS per hour and the percentage of participants with a PLMS index >10 and >15 per hour were similar between patients and controls. PLMS remained stable from the acute to the chronic phase after stroke. Factors positively associated with PLMS were age, body mass index, and history of hypertension. Blood pressure over 24 hours and the burden of cerebrovascular damage were similar between the groups with PLMS and without PLMS.ConclusionsPLMS are equally frequent in patients with stroke/TIA and the general population. The absence of higher blood pressure values and of a greater vascular brain damage found in patients with PLMS compared to those without PLMS might be due to a greater use of antihypertensive medication among patients with PLMS, which corresponds to a higher prevalence of previous diagnosis of hypertension in these patients.

Objective Large-scale connectivity, especially interhemispheric connections, plays a crucial role for recovery after stroke. Here we used methods from information theory to characterize interhemispheric information flow in wake- and sleep-EEG after cerebral ischemia. Methods 34 patients with unilateral ischemic stroke were included. Symbolic Transfer Entropy (STE) was applied between bipolar EEG signals on the left and the right cerebral hemisphere during polysomnographic recordings in the acute phase and 3 months after stroke. Results In the acute phase, we found a sleep stage-dependent preferred interhemispheric asymmetry: during non-REM sleep the information flow was predominantly directed from the contralesional toward the ipsilesional hemisphere. This effect was greatly reduced in a follow-up recording 3 months after stroke onset. Conclusion Our findings are consistent with functional imaging studies showing a transient hyperactivity of contralesional areas after stroke. We conclude that STE is a robust method for detecting post-stroke connectivity reorganizations, and that sleep stages have to be taken into account when assessing functional connectivity. Significance EEG is more widely available than functional MRI. Future studies will have to confirm whether EEG derived STE can be useful in a clinical setting during rehabilitation after stroke.

Sleep-related rhythmic movements (SRRMs) are typical in infancy and childhood, where they usually occur at the wake-to-sleep transition. However, they have rarely been observed in adults, where they can be idiopathic or associated with other sleep disorders including sleep apnea. We report a case series of 5 adults with sleep-related rhythmic movement disorder, 4 of whom had a previous history of SRRMs in childhood. SRRMs mostly occurred in consolidated sleep, in association with pathological respiratory events, predominantly longer ones, especially during stage R sleep, and recovered in 1 patient with continuous positive airway pressure therapy. We hypothesize that sleep apneas may act as a trigger of rhythmic motor events through a respiratory-related arousal mechanism in genetically predisposed subjects.

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1–23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms (e.g.snoring) and/or conditions predisposing to SDB (e.g.mandibular hypoplasia) as well as children with SDB and complex conditions (e.g.Down syndrome, Prader–Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions (e.g.supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1–23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep.

Chronobiology is a science that studies the physiology and pathology of circadian phenomena. In the last 50 years, numerous studies have been published on sleep changes during puberty and adolescence, which largely consist of delays in the timing of sleep. The most notable consequence of these shifts is a sleep debt due to a forced early wake-up during school days, despite no change in sleep requirements (around 9 h), and diurnal hypersomnolence. All these changes explain why teenagers are particularly vulnerable to delayed sleep phase syndrome, which is known to peak during adolescence (prevalence ranging from 7 % to 16 % compared with 0.15 % during adulthood). Advanced sleep phase disorder (ASPD), delayed sleep-wake phase disorder (DSWPD), irregular sleep-wake rhythm (ISWR), and the non-24-h sleep-wake syndrome or free-running disorder (non-entrained type) are referred to as “endogenous” circadian rhythm sleep disorders. The clinical features of each sleep circadian disorder are discussed together with the recommended treatment. Pediatric categories of subjects that are at risk of developing circadian disorders, such as those with a developmental disability, autism, attention-deficit hyperactivity disorders, and mood disorders, are investigated. Lastly, two case reports that provide examples of clinical practice are also presented.

Objective Benzodiazepines (BZDs) are the most commonly prescribed compounds in insomnia. A long-term of BZDs use may cause dependence and abuse. The aim of this study was to evaluate sleep architecture and microstructure (in terms of cyclic alternating pattern – CAP – analysis and of sleep EEG power spectral analysis) in a group of long-term users of high doses of BZDs for their primary chronic insomnia. Methods Twenty patients consecutively admitted at the Sleep Centre for drug discontinuation and 13 matched healthy controls underwent a full nocturnal video-polysomnographic recording, after one adaptation night. Results Significant differences were found in time in bed, REM sleep latency and sleep stage 1% which were increased in patients compared to controls, while CAP rate was dramatically decreased. During NREM sleep, patients showed a clear decrease in the relative power of delta band. Conclusions Our data demonstrate that in adults with chronic insomnia, long-term use of high doses of BZDs induces a severe disruption of sleep microstructure, while sleep architecture seems to be much less affected. Significance The long term use of high doses of BZDs for chronic insomnia induces a marked depression of slow wave activity and of its physiological instability.

Summary Background and methods We present the preliminary results of a prospective case–control sleep study in children with a diagnosis of attention-deficit hyperactivity disorder (ADHD). A deep sleep assessment including sleep questionnaires, sleep habits, a video-polysomnographic recording with full high-density electroencephalography (EEG) and cardiorespiratory polygraphy, multiple sleep latency test, and 1-week actigraphic recording were performed to verify whether children with ADHD may be classified into one of the following five phenotypes: (1) hypoarousal state, resembling narcolepsy, which may be considered a “primary” form of ADHD; (2) delayed sleep onset insomnia; (3) sleep-disordered breathing; (4) restless legs syndrome and/or periodic limb movements; and (5) sleep epilepsy and/or EEG interictal epileptiform discharges. Results Fifteen consecutive outpatients with ADHD were recruited (two female, mean age 10.6 ± 2.2, age range 8–13.7 years) over 6 months. The narcolepsy-like sleep phenotype was observed in three children, the sleep onset insomnia phenotype was observed in one child, mild obstructive sleep apnea was observed in three children, sleep hyperkinesia and/or PLMs were observed in five children, while IEDs and or nocturnal epilepsy were observed in three children. Depending on the sleep phenotype, children received melatonin, iron supplementation, antiepileptic drugs, or stimulants. Conclusions Our study further highlights the need to design an efficient sleep diagnostic algorithm for children with ADHD, thereby more accurately identifying cases in which a full sleep assessment is indicated.

Obstructive sleep-disordered breathing includes a spectrum of clinical entities with variable severity ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). The clinical suspicion for OSAS is most often raised by parental report of specific symptoms and/or abnormalities identified by the physical examination which predispose to upper airway obstruction (e.g., adenotonsillar hypertrophy, obesity, craniofacial abnormalities, neuromuscular disorders). Symptoms and signs of OSAS are classified into those directly related to the intermittent pharyngeal airway obstruction (e.g., parental report of snoring, apneic events) and into morbidity resulting from the upper airway obstruction (e.g., increased daytime sleepiness, hyperactivity, poor school performance, inadequate somatic growth rate or enuresis). History of premature birth and a family history of OSAS as well as obesity and African American ethnicity are associated with increased risk of sleep-disordered breathing in childhood. Polysomnography is the gold standard method for the diagnosis of OSAS but may not be always feasible, especially in low-income countries or non-tertiary hospitals. Nocturnal oximetry and/or sleep questionnaires may be used to identify the child at high risk of OSAS when polysomnography is not an option. Endoscopy and MRI of the upper airway may help to identify the level(s) of upper airway obstruction and to evaluate the dynamic mechanics of the upper airway, especially in children with combined abnormalities. Pediatr Pulmonol. 2017;52:260-271. © 2016 Wiley Periodicals, Inc.

The behavioral pediatric insomnia is the most common pediatric sleep disorder (approximately 30 % of children have suffered of this disorder by the second year of life), characterized by difficulty of falling asleep and multiple nocturnal awakenings. This disorder is also frequently complained by parents or caregivers of ASD children, with a prevalence up to 50 % of cases. Nocturnal agitation, cosleeping, poor sleep hygiene, and early final awakening have been often reported. In ASD, insomnia is associated to an early alteration of physiological circadian rhythms and melatonin secretion. Furthermore, in a minority of cases, behavioral insomnia can anticipate or be in comorbidity with other major sleep problems such as restless legs syndrome, periodic limb movements during sleep, obstructive sleep apneas, bruxism, and epilepsy. After excluding the presence of other major sleep disorders, the best treatment of behavioral insomnia in children with ASD is behavioral cognitive therapy and sleep hygiene, associated with melatonin.

Research Findings, 12 In the last decades, many studies have investigated the association between attention-deficit hyperactivity disorder (ADHD) and sleep problems, reported in a percentage ranging from 25% to 50% of cases (Corkum, Tannock, & Moldofsky, 1998). This relationship is still poorly understood because sleep problems include a wide range of specific sleep disorders, from insomnia to hypersomnia. Indeed, a better characterization and understanding of the specific sleep disorders underlying these complaints in children with ADHD is needed (Owens, 2005). The complexity of this issue is also due to the heterogeneity of the studies on sleep in pediatric ADHD (subjective studies based on sleep questionnaires fulfilled by caregivers or objective studies based on actigraphic and polysomnographic recordings), and the contradictory results reported. Caregivers are worried mostly about insomnia, bedtime resistance, difficulties with morning awakenings, snoring, and daytime sleepiness. Objective data showed an increase in sleep onset latency (actigraphic studies) or a decreased time to fall asleep during daytime with daytime somnolence (as measured by the Multiple Sleep Latency Test), a decreased amount of sleep time, an increased number of apneahypopnea during sleep and of movements during sleep (polysomnographic studies) (Cortese, Faraone, Konofal, & Lecendreux, 2009). Sleep instability in children with ADHD might also be a consequence of the increased rate of EEG-interictal discharges during sleep or of epilepsy (Silvestri et al., 2007). Finally, sleep-disordered breathing (SDB) is a well-known sleep disorder that is associated with diurnal neurobehavioral problems, such as ADHD, learning problems, behavioral disorders, and hypersomnolence. Intermittent hypoxia during sleep and sleep fragmentation due to sleep apnea are implicated in the pathogenesis of the diurnal neurobehavioral consequences of SDB (Kheirandish & Gozal, 2006). Paradoxically, while many studies have hypothesized the presence of an arousal dysfunction in ADHD, few data have been collected on the analysis of arousals in children with ADHD. The analysis of arousals has many clinical implications: An increased level of arousability might be related to sleep fragmentation, and excessive arousals from sleep may impair cognitive development, as well may low levels of arousability. Arousals are important components of sleep structure and are defined as transient intrusions of wakefulness during sleep and are closely correlated with the recovery function of sleep. Presented below is

Overnight polysomnography (PSG) is an expensive procedure which can only be used in a minority of cases, although it remains the gold standard for the diagnosis of sleep disordered breathing (SDB). The objective of this study was to develop a simple, PSG-validated tool to screen SDB, thus reducing the use of PSG. For every participant we performed PSG and a sleep clinical record was completed. The sleep clinical record consists of three items: physical examination, subjective symptoms and clinical history. The clinical history analyses behavioural and cognitive problems. All three items were used to create a sleep clinical score (SCS). We studied 279 children, mean ± SD age 6.1 ± 3.1 years, 63.8% male; 27.2% with primary snoring and 72.8% with obstructive sleep apnoea (OSA) syndrome. The SCS was higher in the OSA syndrome group compared to the primary snoring group (8.1 ± 9.6 versus 0.4 ± 0.3, p

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common childhood-onset neuropsychiatric conditions. Despite extensive research, the etiopathophysiological factors underlying ADHD are not completely understood. It has been suggested that iron deficiency may contribute to ADHD symptoms severity. Whereas evidence from studies based on serum ferritin measures, a marker of peripheral iron status, is somewhat mixed, preliminary recent evidence suggests a deficiency of brain iron in individuals with ADHD. Therefore, it has been proposed that either a deficiency of peripheral iron or a dysfunction of the blood-brain barrier, in the presence of normal peripheral iron levels, may contribute to low brain iron levels, which, in turn, would increase the risk for ADHD symptoms in a subgroup of individuals with this disorder. It has also been found that individuals with ADHD may be at increased risk of severe cardiovascular events during treatment with ADHD drugs, although the extent to which this occurs in ADHD patients compared to non-ADHD individuals is still matter of investigation. Since iron depletion has been recently reported as a risk factor for adverse prognosis in heart failure, iron deficiency might contribute both to ADHD symptoms severity before treatment and to increased risk of severe cardiovascular events during treatment with ADHD drugs in a selected subgroup of patients. Therefore, we hypothesize that the effective treatment of iron deficiency might lead both to improvement of ADHD symptoms severity and to a decrease of the risk of cardiovascular events during treatment with ADHD drugs. If empirical studies confirm this hypothesis, the clinician would be advised to systematically check iron status and effectively treat iron deficiency before starting a pharmacological treatment with ADHD drugs.

Objective Non-REM sleep is characterized by a physiologic oscillating pattern that exhibits different levels of arousal, coded as cyclic alternating pattern. The aim of this study was to analyze the development of cyclic alternating pattern parameters in a group of infants with apparent life-threatening events. Methods A total of 26 infants with apparent life-threatening events (14 females, mean age 3.4 months, 2.37 S.D., age range 0.5–9 months) were studied while they slept in the morning between feedings, by means of a 3-h video-electroencephalographic–polygraphic recording. Sleep was visually scored using standard criteria. The control group was composed of 36 healthy infants (16 females, mean age 3.2 months, 2.17 S.D., age range 0.5–9 months). Results Children with apparent life-threatening events showed an increased frequency of periodic breathing, gastroesofageal reflux and of other risk conditions. They presented also an increased obstructive apnoea/hypopnea index. A full NREM sleep development was found in a significantly smaller percentage of patients, and they showed a significant reduction of the percentage of REM sleep, of cyclic alternating pattern A1 subtypes, an increased percentage of A2 and A3 subtypes and increased index of A2, A3 subtypes and arousal, compared to normal controls. Cyclic alternating pattern rate showed a significant positive correlation with age, only in controls. Conclusions Our results show a higher level of arousal and an increased non-REM sleep discontinuity in babies with apparent life-threatening events, compared to controls. Significance The enhanced mechanism of arousal might counteract life-threatening events and represent an important neurophysiologic distinction from future victims of sudden infant death syndrome who also experience similar events.

Different moderators/mediators of risk are involved in developmental dyslexia (DD), but data are inconsistent. We explored the prevalence of season of birth and its association with gender and age of school entry in an Italian sample of dyslexic children compared to an Italian normal control group. The clinical sample included 498 children (345 boys, mean age 10.3 ± 2.1 years) with DD, the control sample 1,276 children (658 boys, mean age 10.8 ± 2.2 years) from four elementary schools from the same urban area, and with the same socio-economic status level. A prevalence of birth in autumn was found among children with DD compared to controls (34% versus 24%, p

Cyclic alternating pattern (CAP) has now been studied in different age groups of normal infants and children, and it is clear that it shows dramatic changes with age. In this review we first focus on the important age-related changes of CAP from birth to peripubertal age and, subsequently, we describe the numerous studies on CAP in developmental clinical conditions such as pediatric sleep disordered breathing, disorders of arousal (sleep walking and sleep terror), pediatric narcolepsy, learning disabilities with mental retardation (fragile-X syndrome, Down syndrome, autistic spectrum disorder, Prader-Willi syndrome) or without (dyslexia, Asperger syndrome, attention-deficit/hyperactivity disorder). CAP rate is almost always decreased in these conditions with the exception of the disorders of arousal and some cases of sleep apnea. Another constant result is the reduction of A1 subtypes, probably in relationship with the degree of cognitive impairment. The analysis of CAP in pediatric sleep allows a better understanding of the underlying neurophysiological mechanisms of sleep disturbance. CAP can be considered as a window into pediatric sleep, allowing a new vision on how the sleeping brain is influenced by a specific pathology or how sleep protecting mechanisms try to counteract internal or external disturbing events.

Mutations of the DCX gene (Xp22.3) cause X-linked lissencephaly in males and double cortex syndrome (DCS) or subcortical band heterotopia (SBH) in females. SBH is characterized by bilateral bands of grey matter interposed in the white matter between the cortex and the lateral ventricles. The main clinical manifestation in patients with SBH is epilepsy, which may be partial or generalized and is intractable in approximately 65% of the patients. An association of periodic limb movements (PLMs) and SBH has not been documented previously. We describe a 2-year-old girl affected by SBH with epilepsy and periodic limb movements (PLMs), in whom a novel "de novo" missense substitution, Met1Val (M1V), was identified in the DCX gene. Physiopathological links between PLMs and SBH are discussed.

Aim The purpose of this review was to examine the possible pathophysiological links between epilepsy, cognition, sleep macro- and microstructure, and sleep disorders to highlight the contributions and interactions of sleep and epilepsy on cognitive functioning in children with epilepsy. Method PubMed was used as the medical database source. No language restriction was placed on the literature searches, and citations of relevant studies in the paediatric age range (0–18y) were checked. Studies including a mixed population but with a high percentage of children were also considered. Results The searches identified 223 studies. One reviewer scanned these to eliminate obviously irrelevant studies. Three reviewers scanned the remaining 128 studies and their relevant citations. The review showed that several factors could account for the learning impairment in children with epilepsy: aetiology, electroencephalographic (EEG) discharges, and persistence and circadian distribution of seizures, etc. EEG discharges may affect cognition and sleep, even in the absence of clinical or subclinical seizures. The sleep deprivation and/or sleep disruption affect the neurophysiological and neurochemical mechanisms important for the memory–learning process, but also influence the expression of EEG discharges and seizures. Learning and memory consolidation can take place over extended periods, and sleep has been demonstrated to play a fundamental role in these processes through neuroplastic remodelling of neural networks. Epilepsy and EEG paroxysms may affect sleep structure, interfering with these physiological functions. Interpretation Improvement in the long-term cognitive–behavioural prognosis of children with epilepsy requires both good sleep quality and good seizure control. The antiepileptic drug of choice should be the one that interferes least with sleep structure and has the best effect on sleep architecture – thus normalizing sleep instability, especially during non-rapid eye movement sleep.

We describe an obese child with severe obstructive sleep apnea syndrome in whom nocturnal frontal lobe seizures developed within a week after therapy was started with continuous positive airway pressure. The video polysomnographic study after the onset of nocturnal episodes showed 3 seizures: 2 starting from slow-wave sleep when he was sleeping with continuous positive airway pressure, and 1 from stage 2 non—rapid eye movement sleep when he was sleeping without continuous positive airway pressure. Cyclic alternating pattern analysis during the video polysomnography recorded after the onset of nocturnal seizures disclosed a high cyclic alternating pattern rate during slow-wave sleep, and the recording obtained after antiepileptic therapy began showed a low cyclic pattern analysis rate. In this child, we describe the non—rapid eye movement sleep instability induced by continuous positive airway pressure therapy might have had a role in triggering the nocturnal seizures.