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AASM Membership Sections Newsletter
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Issue #6
American Academy
of Sleep Medicine
He specializes in the comprehensive management of sleep
disorders in children and infants, with a special interest in the
treatment of children needing home ventilation. Also an active
physician scientist, Dr. Bandla’s research has focused on
Sleep Medicine education for medical trainees and pediatric
sleep disorders associated with other health conditions,
including obesity, cystic fibrosis and gastroesophageal reflux
disease (GERD).
Kiran Maski, MD
Dr. Kiran Maski, MD, is an Instructor in the Departments
of Neurology at Boston Children’s Hospital and Harvard
Medical School in Boston, MA. She trained in pediatrics at
Tufts-New England Medical Center and completed a child
neurology residency and sleep fellowship at Boston Children’s
Hospital. Her research interests include central hypersomnia
conditions, as well as the effects of sleep disorders on
cognition and daytime behavior in children.
Althea Robinson-Shelton, MD
Dr. Althea Robinson-Shelton, MD, is an Assistant Professor
in the Department of Neurology at Vanderbilt University in
Nashville, TN. She completed a Clinical Neurophysiology
Fellowship with an emphasis in epilepsy in 2009 and then
continued further training in sleep medicine with an emphasis
in pediatrics at Vanderbilt University. Her research interests
include studying the mechanisms of sleep and epilepsy in
children, especially children in underserved populations and
with early onset narcolepsy. She is currently conducting
research on neuro-psychiatric and neuro-behavioral disorders
associated with childhood onset narcolepsy.
Nanci Yuan, MD
Dr. Nanci Yuan, MD, is also starting her second year as a
member of the Childhood Sleep Disorders and Development
Section. She is an Associate Professor at Lucile Packard
Children’s Hospital at Stanford where she is the Medical
Director for their Pediatric Sleep Center. Her research
interests are concentrated on the pulmonary complications
due to neuromuscular disease, cerebral palsy/hypertonicity,
scoliosis and sleep disorders in the pediatric population. ■
References
1. Adolescent Sleep Working Group Committee on Adolescence
and Council on School Start Times for Adolescents. Pediatrics
2014 Sep; 134:642
2. Wahlstrom K, Dretzke B, Gordon M, Peterson K, Edwards K,
Gdula J. Examining the Impact of Later School Start Times on
the Health and Academic Performance of High School Students:
A Multi-Site study. Center for Applied Research and Educational
Improvement. St Paul, MN: University of Minnesota: 2014
Difficulty in Diagnosing Narcolepsy in Children
By Dr. Kiran Maski, MD
An 8-year-old, obese, African-American boy presented to a
pediatric sleep clinic because of a one-year history of sleepiness,
fatigue and snoring. He had undergone an adenotonsillectomy 3
months prior for concern of obstructive sleep apnea. No sleep study
had been done prior to surgery. His typical sleep times were 8 PM to
7 AM (10 PM to 7 AM on weekends) without reported wakings. At
night, parents observed persistent snoring with witnessed gasping
and pausing in breathing. The parents also reported concern about
worsening sleepiness despite the adenotonsillectomy. Specifically, he
was falling asleep in class, in the cafeteria during lunch and taking
long naps after school. The patient denied restless limb symptoms,
hypnogogic hallucinations, sleep paralysis and cataplexy. Parents
reported no witnessed parasomnia-like behaviors, nightmares or
dream enactment, though he was described as a restless sleeper. Past
medical history was unremarkable with the exception of obesity with
rapid weight gain noted over the course of the last year and GERD. He
was on no medications. Family history was notable for father having
obstructive sleep apnea treated with CPAP and residual daytime
sleepiness.
Physical Exam:
BMI was 35 kg/m2. HEENT: Mallampati 3 and no
tonsils visualized. Neuro, cardiac and pulmonary exams were normal.
Testing:
In 2012, a diagnostic PSG (Figure 1) was conducted for
the evaluation of obstructive sleep. On the night of the study, the
parents reported that the patient slept his typical weekday schedule
the night prior (8 PM to 7 AM schedule). Lights off was 9:02 PM. The
sleep latency was 1.6 minutes and REM latency was 2 minutes. Sleep
efficiency and sleep maintenance were 97% each and only 10 minutes
of WASO noted. The patient had 15% N1, 45% N2, 21% N3 and 19%
REM sleep. Arousal index was mildly increased at 12/hour (<10/hour
is considered normal). Only one obstructive hypopnea was noted
and 11 respiratory effort-related arousals were noted (RDI=1.5/hour).
Oxygen and carbon dioxide levels were within normal range. The
periodic limb movement index was markedly increased at 27/hour
with an associated arousal index of 2.8/hour.
Course:
In a follow-up clinic visit 2 weeks after the study, the family
was told that mild upper airway resistance syndrome and periodic
limb movements of sleep may be contributing to symptoms of
daytime sleepiness and fatigue. Serum ferritin level was checked and
was 22.5 ng/ml. The patient was advised to keep consistent wake and
sleep schedules on weekdays to weekends, lose weight and to start iron
supplementation at a dose of 2 mg/kg/day of elemental iron. Follow-
up was scheduled for 3 months later for reassessment of symptoms
with this treatment plan; however, the patient and family did not
return for this scheduled visit.
