•Difficulties inducing sleep (12.7 %)
•Early morning awakenings (11.2 %)
•Daytime sleepiness (25 %)
•Snoring (14.7–46 %)
•Self-reported apneas (OR = 3.7)
•Restless sleep (26 %)
•Nocturnal awakenings (30 %)
•Apnea (3.8–6 %)
•Daytime tiredness (17–23.2 %)
These sleep disruptions are associated with significant morbidity. Numerous studies have found that children with poorly controlled asthma have overall lower quality of life with impairment in their social and academic activities and adverse effects on their psychological and emotional states. Presence of nocturnal symptoms is a particularly poor prognostic indicator. Asthmatic children with increased nocturnal symptoms have been found to have poorer sleep quality, more time awake at night, and lower scores on tests of daytime cognitive performance [5]. They have poorer school attendance and performance and their parents’ work attendances are negatively impacted as well [6].
Treatment for asthma-related sleep disturbances is simply improved asthma control. The importance of this must be emphasized, as about 34–40 % of asthmatic children experience nocturnal awakening, and those children with poorly controlled asthma are significantly more likely to have more nocturnal awakenings per week compared to their well-controlled counterparts [7]. Studies done in adolescents have also shown higher rates of sleep disturbances in those with severe asthma compared to those with mild asthma [8, 9]. Thus, an important part of the treatment includes: adjusting the patient’s medication regimen, educating the patient and family on medication compliance, and avoiding environmental triggers that may cause an acute exacerbation or worsen nocturnal symptoms.
Pitfalls
Asthma-related sleep disturbance may be challenging to distinguish from other common adolescent sleep disorders and they may be co-occurring as well.
Many youths presenting with sleep disturbances may also have undiagnosed asthma.
Learning Points
In asthmatic youths, a detailed history assessing medication compliance, potential environmental triggers, and presence of nocturnal asthma is crucial when asthma-related sleep disturbance is suspected.
Concurrent allergic rhinitis may be an important cause of sleep disturbances in asthmatics.
Presence of nocturnal asthma is a poor prognostic indicator for daytime functioning in children
Treatment for asthma-related sleep disturbances is adequate control of asthma.
Clinical Case 2
The patient is a 13-year-old girl who was recently diagnosed with obstructive sleep apnea (OSA ) and started on Continuous Positive Airway Pressure (CPAP) , now presenting with continued complaints of lethargy, daytime sleepiness, and poor concentration over the past several weeks. She initially presented about 3 months ago with similar symptoms and complaints of snoring and frequent night awakenings. A polysomnography (PSG) was done at that time which showed severe OSA. She subsequently underwent an adenotonsillectomy which failed to relieve her symptoms. As a result, she was started on CPAP about 2 months ago with marked improvement. However, over the past few weeks, she has begun to feel poorly again with additional complaints of muscle aches and constipation. She states that she is compliant with using CPAP every night, which her parents verify. Her compliance report shows a usage of 9–10 h with no residual sleep disordered breathing. She does sleep approximately 9.5 h every night. She denies any further daytime sleepiness, but continues to feel fatigued and unable to tolerate much physical activity in school.
On physical exam, she is an obese, prepubescent female who is short for her age. Her hair and skin appear dry and brittle. Her thyroid feels mildly enlarged on exam. Her neurological exam is otherwise unremarkable.
Complete blood count (CBC) and comprehensive metabolic panel (CMP) returned normal. Thyroid-stimulating hormone (TSH) returned elevated and free T4 was low. Patient also had high thyroid peroxidase (TPO) antibody levels. A diagnosis of autoimmune thyroiditis was made and she was subsequently started on thyroxine with resolution of her symptoms. She continues on CPAP for her OSA .
Discussion
This patient has OSA , most likely secondary to her hypothyroidism. OSA is a fairly common pediatric disorder, occurring in about 1–4 % of children and is particularly prevalent between the ages of 2 and 8 years [10]. In the pediatric population, it is usually secondary to lymphoid hyperplasia and adeno-tonsillar hypertrophy, so it often resolves with an adenotonsillectomy. However, OSA is also frequently associated with many other medical conditions such as hypothyroidism, as is the case here. Hypothyroidism is of special significance in the pediatric and adolescent population as it is the most common thyroid disorder. It is usually secondary to autoimmune thyroiditis, though may also be congenital or secondary to drugs or iodine deficiency.
Several studies have cited an increased prevalence of OSA in hypothyroidism . It has been theorized that this is likely a result of obesity, macroglossia, upper respiratory tract myopathy, deposition of mucopolysaccharides in the upper respiratory tract, and decreased central ventilatory control [11, 12]. However, it remains controversial whether or not to screen for hypothyroidism in patients presenting with OSA given that there is a subset of the population with both disorders [13]. Furthermore, OSA and hypothyroidism have overlapping clinical pictures which may make it difficult to distinguish between the two (Table 8.2). Nevertheless, though it is accepted that there is a significantly higher occurrence of sleep apnea in hypothyroid patients, the inverse has not found to be true, with several studies finding no significant difference in the prevalence of hypothyroidism between patients with sleep apnea and the general population [14]. Thus, current guidelines do not recommend screening for hypothyroidism in patients with OSA [15].
Table 8.2
Obstructive sleep apnea (OSA) and hypothyroidism clinical features
Clinical | OSA | Hypothyroidism |
|---|---|---|
Obestiy | Yes | Yes |
Sleepiness | Variable in children, hyperactive | Mostly fatigue |
Snoring | Most of the time | Variable, present if OSA |
Thyroid levels | Normal | Abnormal |
Enlarged thyroid | No | Variable |
Systemic manifestations | None usually | Constipation, slow reflexes, brittle hair, sensitivity to cold increased |
Depression | At times if severe | Frequent |
Cognition | Decreased attention, hyperactive, irritable | Impaired memory if severe, irritable |
It is unclear whether the treatment of the hypothyroidism with thyroid hormone replacement therapy leads to improvement of sleep apnea in patients with hypothyroidism-associated OSA. Several studies have been done with contrasting results, with some researchers reporting resolution of OSA after thyroxine treatment and others reporting persistent apnea with continued CPAP requirement in spite of correction of thyroid abnormalities [16, 17]. In any case, treatment for hypothyroidism-associated OSA should be no different from the typical management of the two disorders when they occur independently.
Pitfalls
OSA and hypothyroidism may be challenging to distinguish as patients often have overlapping symptoms and the two also frequently occur together.
Patients with OSA do not need to be screened for hypothyroidism unless there is increased clinical suspicion.
It is unclear whether adequate thyroid replacement therapy leads to improvement of OSA symptoms.
Learning Points
There is an increased prevalence of OSA in patients with hypothyroidism than the general population, so clinicians should screen for OSA by taking a thorough history.
Treatment of hypothyroidism-associated OSA is simply treatment of hypothyroidism and of OSA.
Clinical Case 3
Sixteen year-old girl who presents with his mother due to exacerbation of migraine headaches for the last two months. She has had headaches since age 11. These headaches are throbbing, unilateral (either left or right side), associated with nausea and, at times, vomit. She mentions phonophobia and photophobia associated with them. The typical headaches occur, at least, once a week and last from 4–12 h if untreated, but she also has chronic daily headaches , which may last the whole day if untreated. In the past, the headaches occurred once or twice a year. She has tried acetaminophen and ibuprofen for these headaches with no success. She has been given butalbital/acetaminophen/caffeine tablets with resolution of her headaches, but these return quickly after the effect wears off. She takes this medication several times a day. She was recommended to take valproic acid for headache prevention, but she did not like the side effects profile and she did not take it.
Her mother and paternal aunt have a history of migraines. Her past medical history is significant for having heavy menstrual periods since 1 year ago and significant weight gain. She sleeps from 10–11 PM and she does not have any problems to fall or stay asleep. She wakes up at 7:00 AM with help of an alarm clock. She snores loudly every night and she is very restless sleeper. She has noted being more tired lately. Her Epworth Sleepiness Scale (ESS) is 10/24. There has been a minor decrease in grades at school and she seems irritable at times.
Her physical exam is normal, except for her weight at 95 kg; height is 152.4 cm. This accounts for a BMI of 40.9. Upon more questioning, she also admits feeling a “crawly” feeling in legs at night or when sitting quietly. She feels better moving the legs.
Discussion
The intimate connection between sleep and headaches has been recognized for centuries. Pain stimuli and pain disorders may affect sleep quality and quantity. One of the most common triggers for headaches is sleep deprivation [18, 19], and it is well-known that sleep can terminate migraine attacks [18].
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