Sleep and Childhood Concussion - Brain Injury. Often Problematic. Often Overlooked.

Following brain injury, sleep disorders are often overlooked in the care of children, teens and young adults. JR
Sleep disorders in children with traumatic brain injury: a case of serious neglect

1. Gregory Stores^1,* and
2. Rachel Stores²

Article first published online: 12 MAY 2013

"Findings in the following recent studies illustrate the frequent persistence of disturbed sleep, which clearly has implications for rehabilitation. Castriotta et al.[9] reported the presence of sleep disturbance in 46% of adult patients at least 3 months after TBI; Baumann et al.[10]described 72% of adults with TBI as having sleep disturbances 6 months after the injury that were not present before the accident; Fogelberg et al.[11] found persistent sleep difficulties in 44% of rehabilitation patients 1 year after TBI, and in the subsequent study by Baumann's group[12] such sleep problems were shown to be still present 3 years after injury in two-thirds of patients.

Studies of TBI and sleep disturbance in children are few, and the findings can be inconsistent.

 Using retrospective parental reports for pre-injury sleep and repeated prospective post-injury assessments up to 2 years, Beebe et al.[13] described children aged 6 to 12 years with severe TBI as being at increased risk for post-injury sleep problems compared with those with moderate TBI and a comparison group of children with only an orthopaedic injury. I

n contrast, a small group of 7- to 12-year-old children with a mild TBI 6 months before assessment were said to have greater sleep disturbance than children with orthopaedic injuries.[14] 

In a small-scale study, Kaufman et al.[15] found that adolescents who had suffered a minor head injury 3 years previously still complained of severe sleep disturbances and showed polysomnographic and actometry results in keeping with their complaints. 

Subsequently, researchers from the same group followed a larger number of adolescents who had suffered a minor head injury up to 6 years previously, and found that over a quarter still had subjective sleep disturbance.[16]

A more recent prospective study over 2 years of children aged up to 17 years of age who had experienced TBI confirmed a higher rate of sleep disturbance (with more prolonged duration) than comparison children who had experienced an orthopaedic injury.[17] 

Risk factors included pain, psychosocial factors, and mild TBI, which has been reported to be possibly more closely correlated with an increased likelihood of sleep disturbance than severe forms of TBI.[18] The counter-intuitive recurrent theme that mild TBI particularly seems to predispose to sleep disturbance is just one of the many current imponderables in this area of enquiry."

Aim

The aim of this study was to review the basic aspects of sleep disturbance in children with traumatic brain injury (TBI).

Method

A search was performed on reports of sleep disturbances in children who had suffered TBI. Adults with TBI were also considered to anticipate the nature and significance of such disturbances in younger patients. Types of reported sleep disturbance were noted and their possible aetiology and management considered.

Results

Sleep disturbance has consistently been associated with TBI but the literature suggests that this aspect of patient care is often inadequately considered and there has been little research on the subject, especially in relation to children. Excessive daytime sleepiness is often mentioned, less so insomnia and parasomnias, but there is little information about the specific sleep disorders underlying these problems.

Interpretation

Sleep disorders with potentially important developmental consequences have been neglected in the care of children with TBI. Screening for sleep problems should be routine and followed, if indicated, by a detailed diagnosis of the child's underlying specific sleep disorder, the possible aetiology of which includes neuropathology and potential medical, psychological, or psychiatric comorbidities. Appropriate assessments and modern treatment options are now well defined although generally underutilized. Further well-designed research is needed for which guidelines are available.

LINK to Full Article HERE

Information on Infant Sleep Often Is Inaccurate On Internet Searches

An interesting study looks at the reliability of health information found on the internet.

In 2010, 59% of the U.S. population used internet searches for health information, and parents searching for information regarding their children were among the top users. In 2011, the American Academy of Pediatrics (AAP) published recommendations for infant sleep safety to reduce the risk of sudden infant death syndrome (SIDS), suffocation, strangulation, and other accidental sleep-related deaths. However, according to a study scheduled for publication in The Journal of Pediatrics, Google internet searches related to infant sleep safety often do not reflect AAP recommendations.

Seventy-two percent of adults thought that they could believe most or all of the health information on the internet, and 70% of adults said that information that they found on the internet impacted their health or their actions pertaining to their health or the health of their children. According to Rachel Y. Moon, MD, pediatrician and SIDS researcher at Children’s National Medical Center, Washington, DC, “It is important for health care providers to realize the extent to which parents may turn to the internet for information about infant sleep safety and then act on that advice, regardless of the reliability of the source.”

Dr. Moon and colleagues from the University of South Carolina School of Medicine, Children’s National Medical Center, and George Washington University School of Medicine and Health Sciences checked the accuracy of information on infant sleep safety available on the internet, using Google, the top search engine in the U.S. Thirteen key phrases were created to reflect specific AAP recommendations for infant sleep safety, and the first 100 search engine websites were analyzed for each phrase (1300 websites total).

Of 1300 website results, 43.5% provided accurate information, 28.1% provided inaccurate information, and 28.4% provided information that was not relevant to infant sleep safety. When the websites that were not relevant were excluded, 60.8% of the websites provided accurate information. The key search phrases with the highest percentage of accurate information were “infant cigarette smoking,” “infant sleep position,” and “infant sleep surface”; those with the highest percentage of inaccurate information were “pacifier infant,” “infant home monitor,” and “infant co-sleeping.”

The most common types of websites resulting from the key search phrases were company/interest groups, retail product reviews, and educational websites. Government and organizational websites had the highest percentage of accurate information (80.1% and 72.5%, respectively). Blogs, retail product reviews, and individuals’ websites had the highest percentage of inaccurate information regarding infant sleep safety (30.9%, 36.2%, and 45.5%, respectively). News websites were accurate only one-half of the time.

Read more here

Snoring Tots May Develop Behavioral Issues Later

How do we raise awareness among pediatricians, teachers, psychologists and psychiatrists? - Dr. R

Snoring Tots May Develop Behavioral Issues Later

Study found those who had worst sleep problems seemed most at risk

March 5, 2012

By Jenifer Goodwin
HealthDay Reporter

MONDAY, March 5 (HealthDay News) -- Infants and toddlers who snore or have other breathing issues while sleeping are more likely to develop behavioral problems by the age of 7, new research suggests.

Those issues can include hyperactivity and inattention, emotional problems such as anxiety and depression, conduct problems such as rule-breaking and aggressiveness and problems with peer relationships, researchers said.

The study is published online March 5 and in the April print issue of Pediatrics.

The researchers assessed more than 11,000 children in England, who were followed for six years, beginning when the kids were 6 months old.

Parents were asked about snoring, mouth breathing and witnessed apnea -- when a child takes abnormally long pauses in breathing during sleep -- at various points throughout infancy and childhood. Taken together, those symptoms are called sleep-disordered breathing.

Parents also filled out questionnaires about their child's behavior at the ages of 4 and 7.

Those who had the worst sleep-disordered breathing were almost twice as likely to have behavioral issues at age 7 as kids whose breathing was normal. Kids were considered to have behavioral issues if their parent's ratings were in the top 10 percent, relative to kids their age, for problem behaviors.

"Parents should pay close attention to their child's sleep, and if you think something is going on you should consult a pediatrician or a sleep specialist," said study author Karen Bonuck, a professor of family and social medicine at Albert Einstein College of Medicine of Yeshiva University in New York City.

The research showed only an association between sleep-disordered breathing and behavioral problems, not causality. However, there could be several reasons for the connection, Bonuck said.

By interfering with the quality of rest, sleep-disordered breathing leaves kids overtired. That may contribute to behavioral issues, such as being easily distracted, hyperactivity and irritability.

Previous research has also suggested that sleep-disordered breathing affects brain physiology via a lack of oxygen to the brain, carbon dioxide buildup and abnormal gas exchanges, Bonuck explained. For children, that may have a long-lasting impact.

"We are sleeping to restore our brains, and sleep-disordered breathing interferes with that process," Bonuck explained. "For kids, these are critical periods in brain development."

Heidi Connolly, division chief for pediatric sleep medicine at University of Rochester Medical Center in New York, said the study adds to a growing body of research showing that snoring, mouth breathing and sleep apnea in children should be taken seriously.

"These findings echo many of the other studies that show having sleep apnea and symptoms of snoring are bad for neurodevelopmental outcomes in children," Connolly said.

While snoring is a symptom of sleep apnea, it can have other causes, such as nasal allergies. Other studies suggest that even snoring alone, without apnea, can cause kids to do worse developmentally, she added.

"We need to think of that in primary care settings, and screen children for snoring," she said. "Kids who snore need to be evaluated and treated promptly, as you would any other medical condition."

Snoring occurs when the palate and the base of the tongue vibrate against each other. In sleep apnea, the airway is blocked. When kids try to breathe, negative pressure squeezes the airway shut, Connolly explained. That causes kids to wake up partially to take a breath.

Obesity is a major risk factor for sleep apnea in children, but normal-weight kids can get it, too.

"If your child is snoring on a nightly basis, not just when they are exposed to tobacco smoke or they have a cold or they just hung out with the neighbors' cat that they're allergic to, those children need to be evaluated for sleep apnea," Connolly said.

Treatments can include removing the tonsils and adenoids; topical nasal steroids or other anti-inflammatory medications; weight loss; and continuous positive airway pressure (CPAP) devices.

The researchers broke down kids with sleep-disordered symptoms into four groups: those whose symptoms were the worst at 6 months of age and then abated; 18 months and then abated; those whose symptoms didn't start until they were about 3.5 years old and then persisted; and those whose symptoms peaked at 2.5 years of age and persisted.

Nearly all four groups had an increased risk of various problems, including emotional, conduct and peer issues.

For example, at age 7, kids with "worst" sleep-breathing problems were 85 percent more likely to hyperactive, about 60 percent more likely to have emotional or conduct problems and nearly 40 percent more likely to have peer difficulties.

Children whose symptoms peaked early -- at 6 months or 18 months -- were 40 percent to 50 percent more likely to have behavioral problems at age 7, compared with normally breathing children.

More information

The American Sleep Apnea Association has more on sleep apnea in children.