romanian journal of pediatric sleep medicine

ISSN 0000-0000

ROMANIAN JOURNAL OF PEDIATRIC SLEEP MEDICINE

SOMNOLOGIE PEDIATRICĂ ROMANIAN JOURNAL OF PEDIATRIC SLEEP MEDICINE

PAGINA DE GARDA

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ISSN

- la adresa website - sa fie www.pedsleep.ro iar adresa de mail - [email protected]

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ROMANIAN JOURNAL OF PEDIATRIC SLEEP MEDICINE EDITOR IN CHIEF

ASSOCIATE EDITORS

Mihaela Oros, Bucuresti, Romania

Cristina Gianina Anghel, Bucuresti, Romania Lucia Baranga, Bucuresti, Romania Diana Barca, Bucuresti, Romania Ana Maria Bolchis, Bucuresti, Romania Niculina Butoianu, Bucuresti, Romania Alexandru Dina, Bucuresti, Romania Catrinel Iliescu, Bucuresti, Romania Daniela Ivascu, Bucuresti, Romania Liana Kobylinska, Bucuresti, Romania Ilinca Mihailescu, Bucuresti, Romania Cristina Momirla, Bucuresti, Romania Oana Tarta, Bucuresti, Romania

EDITORIAL BOARD Ioana Anca, Bucuresti, Romania Gheorghe Chiriac-Babei, Bucuresti, Romania Cristian Baicus, Bucuresti, Romania Daniela Boișteanu, Iasi, Romania Oliviero Bruni, Rome, Italy Marin Burlea, Iasi, Romania Carmen Burloiu, Bucuresti, Romania Paraschiva Cherecheș- Panta, Cluj, Romania Anca Coliță, Bucuresti, Romania Dana Craiu, Bucuresti, Romania Mihai Craiu, Bucuresti, Romania Oana Deleanu, Bucuresti, Romania Iuliana Dobrescu, Bucuresti, Romania Ștefan Dumitrache-Rujinski, Bucuresti, Romania Dan Gheorghe, Bucuresti, Romania Aviv Goldbart, Beer Sheva, Israell Diana Ionescu, Bucuresti, Romania Adelaida Iorgulescu, Bucuresti, Romania Reinhold Kerbl, Leoben, Austria Martin Konermann, Kassel, Germany Sorin Man, Cluj, Romania Mauro Manconi, Lugano, Switzerland Tamara Marcovici, Timisoara, Romania Florin Mihălțan, Bucuresti, Romania Ştefan Dan Mihăicuţă, Timisoara, Romania Ioana Munteanu, Bucuresti, Romania Roxana Nemes, Bucuresti, Romania Dumitru Orășeanu, Bucuresti, Romania Marina Otelea, Bucuresti, Romania Corina Paul, Timisoara, Romania Doina Anca Pleșca, Bucuresti, Romania Vasilica Plăiașu, Bucuresti, Romania Florina Rad, Bucuresti, Romania Hemant Sawnani, Cincinnati, USA Laurent Servais, Liege, Belgium Narong Simakajornboon, Cincinnati, USA Daniela Ștefănescu, Bucuresti, Romania Raluca Teleanu, Bucuresti, Romania Doina Todea, Cluj, Romania

Disclaimer The papers contained in each issue of the journal have been prepared and written by named authors and the views and opinions expressed do not reflect the official position of the Publisher, the Romanian Association for Pediatric Sleep Disorder and the Editors or institutions the authors are affiliated to. Accordingly the Publisher, the Romanian Association for Pediatric Sleep Disorder and the Editors are not responsible for the accuracy or otherwise of any papers and shall have no liability for any claims, damages or losses however arising from the contents of any papers or any use to which they may be put by any person. The fact that products and services are being advertised in this journal does not constitute any endorsement by the Publisher, the Romanian Association for Pediatric Sleep Disorder and the Editors, of the quality or value of such products or of the claims made by their manufacturer thereof.

Translation to and correction in English supervised by authorized translator, Florina Dulgheru

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Cuprins / Contents EDITORIAL 06 Cum am început... / How we started... Mihaela Oros

REVIEW 08 The International Pediatric Sleep Association, Oliviero Bruni 09 Sleep Medicine – an underprivileged field in Pediatrics, Reinhold Kerbl 10 Somnologia pediatrică – în sfârşit un capitol deschis şi la noi / Pediatric sleep medicine – a chapter finally open in the Romanian medicine, Florin Mihalţan

REZUMATE/ABSTRACT

1-a Conferinta de Somnologie Pediatrica “Tulburarile de somn la copii si adolescenti abordate multidisciplinar”, Sinaia, Romania, 4-6 Aprilie 2013/1st Pediatric Sleep Conference “Sleep disorders in children and adolescents multidisciplinary approach”, Sinaia, Romania, 4th – 6th of April 2013 16 Somnologia românească încotro? / Where is Romanian sleep medicine heading to?, Florin Mihalţan 17 Up to date from European Sleep Research Society, Dan Stefan Mihaicuta 18 Sleep disorders in children and adolescents. Reinhold Kerbl 20 Ce ascunde plansul excesiv la sugari? / What lies behind excessive crying in infants? Doina Anca Plesca, Sorina Chindris 22 Screening-ul tulburarilor de somn la copii / Screening for pediatric sleep disorder. Daniela Ştefănescu 21 Manifestari extradigestive in boala de reflux gastroesofagian / Extradigestive manifestations in gastroesophageal reflux. Marin Burlea

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24 Lessons from adults / Monitorizarea in ambulator a tulburarilor respiratorii din timpul somnului / Ambulatory monitoring of sleep-disordered breathing. Daniela Ivascu 26 Lessons from adults / Sindromul de obezitate hipoventilaţie. Prezentare de caz / Obesity hypoventilation syndrome. Case presentation. Oana Claudia Deleanu, Diana Pocora, Florin Mihalţan 28 Lessons from adults / Complicatii cardiovasculare ale SASO / Cardiovascular Complications of OSAS. Daniela Boisteanu, Raluca Vasiluta 30 Lessons from adults/ Complianta la tratament. Aspecte practice / Compliance with treatment. Practical aspects. Stefan Dumitrache-Rujinski 33 Tulburarile paroxistice de somn in patologia neuro-pediatrica / Paroxysmal sleep disorders in the neuropediatric pathology. Dana Craiu, Oana Tarţa, Cristna Moţoescu, Cristina Pomeran, Magda Budișteanu 34 Parasomniile copilului / Pediatric parasomnias. Raluca Teleanu 36 Dificultăţi de diagnostic într-un caz de narcolepsie / Diagnostic difficulties in a case of narcolepsy. Ioana Minciu, Mihaela Oros, Oana Tarta –Arsene, Daniela Ivascu 38 Tulburarile de somn la copiii cu boli neuromusculare / Sleep disorders in children with neuromuscular diseases. Oana TartaArsene, Niculina Butoianu, Ioana Minciu, Diana Barca, Dana Craiu 40 Pattern-ul tulburarilor de somn la pacientii cu ADHD si/ sau Tulburare de Spectru Autist / Sleep disorders pattern in patients with ADHD and/or Autism Spectrum Disorders. Ilinca Mihailescu, Cristina G Anghel, Florina Rad, Iuliana Dobrescu 42 Probleme de diagnostic si optiuni de tratament ORL in tulburarile respiratorii


de somn ale copilului / Diagnosis problems and ENT treatment options in pediatric sleepdisordered breathing. Dan Gheorghe 44 Adeno-Tonsillectomy in Children with Obstructive Sleep Related Breathing Disorders (SRBD). Magne Tvinnereim. 45 Tonsilectomia intracapsulara prin tehnica de radiofrecventa versus tonsilectomia clasica – rezultate pe un an de zile / Tonsillotomy using radiofrequency versus traditional tonsillectomy- one year study. Diana Ionescu 46 Enurezisul - tulburare de somn sau tulburare mictionala? / Enuresis - sleep or urinary disorder? Gheorghe Chiriac Babei, Cătălin Ion Chiriac Babei 48 Importanta factorilor ambientali in fiziologia somnului la copii si adolescenti / The importance of environmental factors in sleep physiology in children and adolescents. Marina Otelea 49 Fumat pasiv-tulburări de somn la copil / Passive smoking – pediatric sleep disorders. Ioana Munteanu, Florin Mihalţan 51 Exacerbarile nocturne ale bolilor respiratorii / Nocturnal exacerbations in respiratory diseases. Roxana Nemes 52 Obezitatea copilului si comorbiditatile ei / Childhood obesity and its comorbidities. Corina Paul, Iulian Velea 54 Tulburari de somn la copiii cu neoplazii / Sleep disorders in children with cancer. Anca Colita 56 Somnul – o povara genetica? / Sleep – a genetic burden? Vasilica Plaiasu

59 Ce este polisomnografia si care sunt indicatiile ei. Alte metode de investigare a tulburarilor de somn / What is polysomnography and what are its indications. Other methods of investigation of sleep disorders. Mihaela Oros 60 Tulburarile de somn la copil in practica medicului de familie. Studiu clinic intre anii 2002-2012 / Pediatric sleep disorders in family medicine practice. Clinical trial between 2002 and 2012. Valeria Herdea, Laura Comnea (Herdea), Lidia Soldea(Herdea), Alexandru Dan Herdea, Teodor Herdea 62 Ce trebuie sa stim despre indicatiile de CPAP/BiPAP la copiii cu tulburari respiratorii in timpul somnului / What we should know about the indications for CPAB/ BiPAP in children with sleep-disordered breathing. Mihaela Oros

STATE OF THE ART 64 Rinita alergica si tulburarile de somn - o legatura care trebuie recunoscuta / Allergic rhinitis and sleep disorders – a correlation that has to be acknowledged. Mihai Craiu

EXTRAS 68 Meeting calendar

BOOK REVIEW 75 Principles and practice of Pediatric Sleep Medicine 76 List of contributors 78 Information for authors

58 Reducerea progresiei miopiei la copii si adolescenti cu lentile de contact ortokeratologice purtate in timpul somnului / Reduction in myopia progression in children and adolescents with orthokeratology lenses worn during sleep. Daniela Goicea

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SOMNOLOGIE PEDIATRICĂ

EDITORIAL


Cum am inceput… După aproape 15 ani de când s-a deschis primul laborator de somnologie din România, într-un spital de adulţi, am început şi noi pediatrii să facem primele înregistrări de somn la copii, să tratăm şi apoi să-i monitorizăm pe măsură ce cresc. Nu e nimic neobişnuit ca somnologia pediatrică să se dezvolte urmând celei de adulţi. O pagină de istorie din cuprinsul acestei reviste, prin profesorul Oliviero Bruni, Preşedintele IPSA (International Pediatric Sleep Association), surprinde parcursul acesta la nivel internaţional. Şi la noi în ţară dezvoltarea somnologiei pediatrice parcurge acelaşi traseu, în primul rând de învăţare şi informare. Deşi uneori greu într-o societate aflată în permanentă tranziţie, cu siguranţă e mai uşor decât în trecut. E mai uşor pentru că deja există colegii noştri “de la adulţi” care au multă experienţă şi de la care am putut învăţa. Într-un domeniu ca acesta al somnologiei care abia de anul acesta prinde contur într-o competenţă aparte, bine definită, este nevoie de mult mai multe cuvinte pentru a vorbi despre munca colegilor noştri, despre generozitate, dedicare şi sacrificiu. “Lessons from adults” este legătura permanentă între vârsta pediatrică şi cea adultă atât în ceea ce priveşte patologia somnului cât şi prin colaborarea între specialiştii din cele două arii. E mai uşor şi pentru că există deja laboratoare de somnologie a căror dotare modernă şi standardizată permite şi studiile de somn la copii iar tehnologia pusă la dispoziţie de companiile de aparatură medicală este un suport continuu în acest sens. Pentru a crea însă cadrul specific vârstei pediatrice în ianuarie 2013 a fost constituită Asociaţia pentru Tulburările de Somn la Copii şi Adolescenţi, iar anul acesta apare primul număr din Jurnalul de Somnologie Pediatrică. Această revistă este dedicată medicilor ca un suport permanent şi constant de informare medicală şi care treptat va face trecerea de la structura generală din acest prim număr către articole de cercetare, editoriale şi cazuri clinice. Îi regăsim în paginile acestui număr, cum de altfel îi regăsim în tot ceea ce facem, pe cei care ne sunt mentori prin profesionalism, prin echipele pe care le-au format şi le au în preajmă în laboratoare de somn pediatrice din Europa şi US, prin activitatea ştiinţifică permanentă şi prin grija faţă de pacienţi. Acest prim număr inaugural al Jurnalului de Somnologie Pediatrică reprezintă un mod de a mulţumi tuturor celor care, cu generozitate şi cu încredere, au sprijinit şi au susţinut permanent dezvoltarea somnologiei pediatrice la noi în ţară. Deşi acest articol introductiv trebuia poate să sublinieze în special importanţa somnologiei pediatrice, articolele din revistă vor aduce cu siguranţă perspective diferite şi de multe ori nebănuite asupra acestei problematici. Nimic nu poate exista însă fără oamenii care construiesc şi le mulţumesc tuturor acestora – distinşi profesori, preşedinţi, cadre didactice la Universităţile de Medicină din diferite oraşe ale ţării cât şi clinicieni de diferite specialităţi medicale şi chirurgicale – care prin implicarea, generozitatea şi profesionalismul lor au susţinut şi susţin dezvoltarea somnologiei pediatrice în România. Dr. Mihaela Oros Presedinte Fondator Asociatia pentru Tulburari de Somn la Copii si Adolescenti Bucuresti, 2014

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EDITORIAL


How we started… After almost 15 years since the first Romanian sleep laboratory was opened in an adult hospital, we started as pediatricians to make the first sleep recordings in children, to treat and monitor them as they grow. There is nothing unusual in the fact that pediatric sleep medicine develops following adult sleep medicine. A page of history within this journal, written by Professor Oliviero Bruni, President of IPSA (International Pediatric Sleep Association), captures the way in which this journey unfolded at the international level. The development of pediatric sleep medicine follows the same path in our country, firstly by learning and becoming informed. Although the process is sometimes difficult in a society which is always under transition, it is definitely easier than it used to be. It is easier because we already have colleagues specialized in adult sleep medicine with a lot of experience from whom we had the opportunity to learn. In a field such as sleep medicine which only this year begins to take shape as a separate well-defined competency, much more words are needed to speak about our colleagues’ work, about their generosity, dedication, and sacrifice. ‘Lessons from adults’ represents the permanent link between pediatric and adult age with regard to sleep pathology and considering the permanent collaboration between specialists in the two fields. It is easier also because sleep labs already exist and they are endowed with modern and standardized equipment which allows the performance of sleep studies in children as well, and the technology provided by the medical device companies is a continuous support in this regard. However, in order to create the pediatric age-specific framework, in January 2013 the Romanian Association for Pediatric Sleep Disorder was founded, and this year the first issue of the Romanian Journal of Pediatric Sleep Medicine was released. This journal is dedicated to physicians as a permanent and constant medical information support which will gradually move from the general structure of this first issue to a more specialized structure comprising research articles, editorials, and clinical cases. Within the pages of this issue and throughout our entire activity, we will find the people who are our mentors through their professionalism, through the teams they have built and have around them in the pediatric sleep labs in Europe and US, and through their permanent scientific activity and care for patients. This inaugural issue of the Romanian Journal of Pediatric Sleep Medicine represents a way to thank all those who, by their generosity and confidence, have continuously encouraged and supported the development of pediatric sleep medicine in our country. Even if this introductory article was probably meant to underline especially the importance of pediatric sleep medicine, all the articles contained in the journal will surely bring different and often unexpected perspectives on this matter. However, nothing can exist without the constructive work of people. Therefore I thank all of them – distinguished professors, presidents, academics from Medicine Universities in various cities countrywide, as well as clinicians of different medical and surgical specialties, who by their implication, generosity and professionalism have supported and still support the development of pediatric sleep medicine in Romania. Mihaela Oros, M.D. Founding President Romanian Association for Pediatric Sleep Disorder Bucharest, 2014

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The International Pediatric Sleep Association The story of IPSA begins several years ago when a small group of pediatricians, child neurologists and psychologists interested in sleep started to join in informal meetings during the early ESRS congresses and in 1991 constituted the EPSC, as mentioned above. In 2003, André Kahn and the EPSC started to dream about an international pediatric sleep association. The creation of this international association was the project of André Kahn and was initiated by his efforts and by his dedication to the field of Pediatric Sleep Medicine but, unfortunately, shortly before his 61st birthday, André Kahn abruptly died on September 1st, 2004 in Brussels, at the end of his usual karate training session. Thus, during the last EPSC meeting in 2004 it was decided to abandon the EPSC and build up a new international association. This was not an easy step, since there were long debates about the nature of this association that was initially intended as a “clinically oriented” organization. Part of the questions related to the birth of the IPSA was that scientists have too many societies and too many fees to be paid, the fear that founders would have not had the strength and the power to build this association, the uncertainties about who would have really supported this initiative, and the worries about the financial support. However, the following year, during the World Association of Sleep Medicine (WASM) meeting in Berlin, the IPSA was founded on October 13th, 2005, with the crucial contribution of Christian Guilleminault. The by-laws were created stating the mission of IPSA that were: a) to promote basic and applied research in all areas of sleep in infants, children and adolescents; b) to provide topical information to the public about pediatric sleep; c) to increase the knowledge of pediatric sleep problems and their consequences; d) to promote teaching programs on pediatric sleep; e) to hold scientific meetings; f ) to provide information to the public about perspectives and applications of pediatric sleep research.

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The first board was elected and appointed in 2007, with the aim to represent nearly all the countries in the world in which Pediatric Sleep Medicine was pursued, for a four-years term, consisting of Oliviero Bruni as President, Christian Guilleminault as Vice-President and Patricia Franco as Secretary. The Board of Directors comprised Ronald Chervin, David Gozal, Avi Sadeh, Patricio Peirano, Magda Lahorgue-Nuñes, Rosemary Horne, and Daniel Ng. In 2007, IPSA has been affiliated with the Elsevier’s journal Sleep Medicine, an affiliate of the World Association of Sleep Medeicine (WASM) and, in 2009, it joined the Pediatric Sleep Medicine Conference. From 2007 to 2009 IPSA meetings were held as part of the WASM congresses but in 2010 the second IPSA congress was organized by Oliviero Bruni in Rome and was the first independent Congress of IPSA. The Congress was a huge success in terms of participants and high scientific quality, with 203 abstracts, 64 symposia , 1 Pediatric sleep course, 1 key-note lecture, and 34 countries represented worldwide. After this successful meeting it was decided to continue to have an IPSA meeting every two years in different parts of the world. The third IPSA meeting was held in Manchester (U.K.) in December 2012 and the next IPSA meeting will be held in Porto Alegre in 2014. Goals of the IPSA Congresses are and will be to lead to a substantial advancement of Pediatric Sleep Medicine, collecting the most renowned International speakers, and giving to all participants the opportunity to share knowledge in Sleep Medicine and research. In 2011, the second election renewed the Directors and the current board that will be in charge until 2014. Finally in 2012, with the help of Allan O’Bryan (WASM), the IPSA Foundation (a non-profit organization) has been created to raise funds from different sources, such as industries and

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pharmaceutical companies, in order to allow fundraising for scientific and charity purposes. The International Pediatric Sleep Association operates exclusively for scientific and educational purposes, and more specifically: • To promote basic and applied research in all areas of sleep in infants, children and adolescents. • To promote teaching programs on pediatric sleep, and the coordination of these programs among the different member and societies • To hold scientific meetings • To provide information to the public about

perspectives and applications of pediatric sleep research • To increase the knowledge of pediatric sleep problems and their consequences • To provide a forum for the exchange of information pertaining to pediatric sleep research To establish and maintain standards of reporting and classifying data in the field of pediatric sleep research Note: Extracted and adapted from: Bruni O, Ferri R. The emergence of paediatric sleep medicine. In: Chockroverty S, Billiard M (Eds.). Sleep Medicine. Springer, 2014, in press.

Sleep Medicine – an underprivileged field in Pediatrics Reinhold Kerbl Professor of Pediatrics and Adolescent Medicine, Leoben, Austria Abstract: Sleep disorders and sleep-related problems are quite common in childhood and adolescence. Between 10% and 40% of children and adolescents are reported to be affected by such disorders. Usually, pediatricians are well aware of sleeping problems in infancy and early childhood, however rarely feel competent enough to adequately manage these problems. Thus, parents usually collect recommendations from books, journals, friends, relatives and internet. In numerous cases, this kind of self-adopted therapy however remains unsuccessful. It is therefore essential that specialised pediatricians who are experienced in pediatric sleep medicine are available in every country. Around Europe, at presence pediatric sleep medicine represents a widely underprivileged field of Pediatrics. In contrast to pediatric cardiologists, pulmonologists, neuropediatricians etc. only few “somnologists” are available. In many cases their main field of daily routine is pulmonology, pediatric neurology, or neonatology. These colleagues frequently have collected their experience in sleep medicine without having passed a structured curriculum, mostly by self-training, and only very few colleagues have the privilege to work as full-time somnologists. To provide timely and adequate treatment of pediatric sleep disorders, it is necessary: 1) to nominate and promote colleagues for the subdiscipline „Pediatric Sleep Medicine” 2) to establish centers for the diagnosis and treatment of pediatric sleep disorders 3) to establish a curriculum for Pediatric Sleep Medicine 4) to increase general awareness about pediatric sleep disorders and the necessity of adequate treatment 5) to increase acceptance and reputation of colleagues working in this field Establishing Pediatric Sleep Medicine in Romania is an important contribution to general health provision for the pediatric population of this country, and many children and adolescents will benefit from the avoidance of adverse long-term consequences of sleep disorders.

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Somnologia pediatrică – în sfârşit un capitol deschis şi la noi Florin Mihălţan Universitatea de Medicina si Farmacie „Carol Davila” Institutul de Pneumologie „Marius Nasta” Bucuresti

Primul numar al revistei de Somnologie Pediatrica aduna in paginile ei tumultul si emotiile primei Conferinte de Somnologie Pediatrica. Desfasurata la Sinaia in perioada 4-6 aprilie 2013, manifestarea a adunat toţi factorii interesaţi în lansarea acestei supraspecializări - zonă care pentru România înseamnă, de fapt, o speranţă pentru mulţi dintre copiii care au astfel de afecţiuni, dar și pentru părinţii acestora. Tematica abordata la aceasta prima Conferinta de Somnologie Pediatrica a adus in prim plan somnul - necesitate fiziologică la fel de importantă ca și alimentaţia sau respiraţia, încă de la momentul nașterii până la vârsta a treia. Evenimentul a demonstrat că somnul este şi un proces dinamic și că în timpul somnului creierul este activ. Cunoașterea acestor aspecte a permis participantilor o privire panoramică modernă pe măsura progreselor actuale în domeniul som nologiei pediatrice. Au fost zile pline cu titluri incitante şi cu speakeri talentaţi. Prima zi a programului știinţific a debutat cu un curs interesant, cu titlul: „Cum îmi folosesc punctele forte pentru a-mi atinge obiectivele în comunicare“, care face parte dintr‑un program de leadership cu durată de un an, oferit de „People Investment“, ţinut de un trainer cu experienţă - Giuliana Boicu. Manifestarea propriu-zisă a demarat cu două actualizări: prima a făcut o analiză a progreselor somnologiei românești („Somnologia românească, încotro?“ - Fl. Mihălţan), iar a doua a privit prin prisma acelorași criterii European Sleep Research

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Society („Up to date from European Sleep Research Society“ – D. Șt. Mihăicuţă). A urmat o trecere critică în revistă a medicinei somnului de către unul din invitaţii străini – Reinhold Kerbl (Austria), care a demonstrat că nu doar la noi, dar și în multe alte ţări acest domeniu este subevaluat și subprivilegiat în cadrul disciplinei de pediatrie. În următoarele zile a continuat schimbul de experienţă, prin prezenţa unor personalităţi marcante pediatrice și specialiști de renume în patologia de somn a adultului. A doua zi s-au abordat: „Tulburările somnului la copii și adolescenţi“ (Reinhold Kerbl), „Indicaţiile polisomnografiei și a altor metode de investigare a tulburărilor de somn“ (Mihaela Oros) și „Povara genetică a somnului“ (Vasilica Plăiașu). O idee interesantă a căpătat contur cu ocazia acestor zile - seria de prezentari „Lesson from adults“ prin care participantii au aflat din experienta specialistilor din patologia de somn la adulti, arie deja bine dezvoltata si in Romania cu specialisti si laboratoare in multe zone din tara. Au contribuit aici cu succes Dr. Oana Deleanu („Sindromul obezitate-hipoventilaţie”), Dr. Daniela Boișteanu („Complicaţii cardiovasculare ale SASO“), Dr. Ștefan Dumitrache Rujinski („Complianţa la tratament, aspecte practice“) si Dr. Daniela Ivașcu („Monitorizarea în ambulator a tulburărilor respiratorii din timpul somnului“). Perspectiva aceasta de continuum intre varsta pediatrica si cea adulta a fost cu atat mai apreciata cu cat alaturi de subiectele abordate din patologia somnului la adult au fost discutate intr-o maniera

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practica si interactiva si elementele specifice varstei pediatrice legate de screening-ul, diagnosticul si managementul acestor afectiuni. O alta mare calitate a acestei reuniuni a fost participarea multidisciplinară cu prezenta specialistilor in pediatrie, medicina de familie, neurologie pediatrica, ORL, psihologie si psihiatrie pediatrica, pneumologie, gastroenterologie, cardiologie, endocrinologie, oncologie, ATI, oftalmologie etc. Astfel, s-a vorbit de: „Obezitatea copilului și comorbidităţile asociate“ (Corina Paul), „Tulburările de somn la copii în practica medicului, studiu clinic între anii 2002-2012“ (Herdea Valeria și colab.), „Parasomniile copilului“ (Raluca Teleanu), „Tulburările de somn la copiii cu cancer“ (Anca Coliţă), „Pattern-ul tulburărilor de somn la pacienţii cu ADHD și/sau tulburare de spectru autist“ (Ilinca Mihăilescu și colab.), „Manifestările extradigestive ale refluxului gastro-esofagian la copii“ (Marin Burlea), „Exacerbările nocturne ale bolilor respiratorii“ (Roxana Nemeș), „Fumatul pasiv și tulburările de somn la copii, există o relaţie de cau zalitate?“ (Ioana Munteanu), „Reducerea miopatiei la copii și adolescenţi cu lentile de contact ortokeratologice purtate în timpul somnului“ (Daniela Goicea), „Fenomene paroxistice de somn în patologia neuropediatrică“ (Dana Craiu și colab.), Tulburarile de somn la copiii cu boli neuromusculare (Oana Tarta and colab.), Dificultăţi de diagnostic într-un caz de narcolepsie(Ioana Minciu si colab.), „Enurezisul – tulburare de somn sau tulburare micţională?“ (Ghe. Chiriac Babei), „Ce ascunde plânsul excesiv al sugarului?“ (Doina Anca Pleșca și colab.), Importanta factorilor ambientali in fiziologia somnului la copii si adolescenti (Marina Otelea), “Prezentare de caz “(Daniela Stefanescu) Un punct forte al manifestării a fost prezenţa unei sesiuni întregi cu participarea ORL-iștilor si a unui specialist ATI. Aici am remarcat expuneri ca: „Adenotonsilectomia la copii cu sindrom de apnee în somn de tip obstructiv“ (Magne TvinnereimNorvegia), „Tonsilectomia intracapsulara prin tehnica de radiofrecventa versus tonsilectomia

clasica – rezultate pe un an de zile“ (Diana Ionescu), „Probleme de diagnostic și opţiuni de tratament ORL în tulburările respiratorii de somn ale copilului“ (Dan Gheorghe), “Prevenirea riscului anestezic prin depistarea preoperatorie a tulburarilor respiratorii de somn la copii” (Valeria Vlasceanu). Prezenţa la această gală a somnologiei pediatrice a Președintelui Societăţii de Pediatrie – Prof. Marin Burlea și a decanei U.M.F. „Carol Davila“- Prof. Doina Pleșca, a reconfimat valoarea și importanţa acordată acestei tematici care poate schimba destinul multor copii cu astfel de afecţiuni nediagnosticate în România. În final, din experienţa acestor zile pline de somnologie pediatrică, toţi am avut de învăţat: s-a dovedit că există interes şi la noi în ţară, că primii paşi au fost făcuţi cu succes şi în România şi că s-au pus bazele formării unei noi generaţii de pionieri în acest domeniu care să ducă pe mai departe experienţa seniorilor. Succesul acestei conferinţe a deschis o uşă largă spre o nouă ediţie în 2014 care a avut loc in luna iunie in aceeasi locatie din Sinaia si unde participarea lectorilor internationali din US, Italia si Austria au facut accesibila experienta acestora intr-o maniera semiformala si extrem de interactiva. Asa cum Somnologia în România a parcurs un drum lung până la afirmare, apreciez ca Somnologia pediatrica este un domeniu in care deja s-au facut primii pasi si la noi in tara iar lansarea unei reviste de specialitate era un moment firesc in evolutia si dezvoltarea ulterioara.

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Pediatric sleep medicine – a chapter finally open in the Romanian medicine Florin Mihălţan “Carol Davila” University of Medicine and Pharmacy, “Marius Nasta” Institute of Pulmonology, Bucharest

The first issue of the Romanian Journal of Pediatric Sleep Medicine gathers the tumult and emotions of the first Pediatric Sleep Medicine Conference which was held in Sinaia between 4 and 6 April 2013. The event gathered all factors interested in launching this supraspecialization, which represents hope for many of the children in Romania with this type of diseases as well as for their parents. The topics approached in this first Pediatric Sleep Medicine Conference brought sleep to the attention of the participants – a physiological need as important as breathing or eating, from birth until third age. The event showed that sleep is also a dynamic process and that the brain is active during sleep. Knowing these aspects allowed the participants to have a modern overview in accordance with the current progress made in the field of pediatric sleep medicine. The days of the conference were filled with exciting topics and talented speakers. The first day of the scientific program started with an interesting course, entitled “Cum îmi folosesc punctele forte pentru a-mi atinge obiectivele în comunicare“, which is part of a one-year leadership training program provided by People Investment, and was held by an experienced trainer - Giuliana Boicu. The conference itself started with two topics for update: the first one showed an analysis of the progress made by the Romanian sleep medicine („Where is Romanian sleep medicine heading

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to?“ - Fl. Mihălţan), and the second one was a look at the European Sleep Research Society in terms of the same criteria („Up to date from European Sleep Research Society“ – D. Șt. Mihăicuţă). Then followed a critical review of sleep medicine made by one of the foreign guests – Reinhold Kerbl (Austria), who showed that this field is undervalued and underprivileged within pediatric specialty not only in Romania but in many other countries as well. During the following days the exchange of experience continued, through the presence of prominent personalities in pediatrics and renowned specialists in the adult sleep pathology. The second day, the following topics were approached: „ Sleep disorders in children and adolescents“ (Reinhold Kerbl), „ What is polysomnography and what are its indications. Other methods of investigation of sleep disorders“ (Mihaela Oros) and „ Sleep – a genetic burden?“ (Vasilica Plăiașu). An interesting idea took shape on the occasion of this event - the series of presentations under the name of Lesson from adults, which enabled the participants to learn from the experience of the specialists in adult sleep pathology, an area already well developed in Romania, with many specialists and laboratories throughout the country. Dr. Oana Deleanu („Obesity hypoventilation syndrome. Case presentation”), Dr. Daniela Boișteanu („Lessons from adults - Cardiovascular Complications of OSAS“), Dr. Ștefan Dumitrache Rujinski („Compliance with treatment. Practical aspects “)

REVIEWS


and Dr. Daniela Ivașcu („Ambulatory monitoring of sleep-disordered breathing “) successfully contributed to this series of presentations. This perspective of continuum between pediatric age and adult age was much appreciated, all the more so as the elements specific to the pediatric age regarding the screening, diagnosis and management of these diseases were discussed in a practical and interactive manner along with the topics from the adult sleep pathology. Another great quality of this reunion was the multidisciplinary participation with the presence of specialists in pediatrics, family medicine, pediatric neurology, ENT, pediatric psychology and psychiatry, pulmonology, gastroenterology, cardiology, endocrinology, oncology, AIC, ophthalmology etc. Therefore, the topics approached were: „Childhood obesity and its comorbidities “ (Corina Paul), „Pediatric sleep disorders in family medicine practice. Clinical trial between 2002 and 2012“ (Herdea Valeria and colab.), „Pediatric parasomnias“ (Raluca Teleanu), „ Sleep disorders in children with cancer“ (Anca Coliţă), „Sleep disorders pattern in patients with ADHD and/or Autism Spectrum Disorder“ (Ilinca Mihăilescu and colab.), „Extradigestive manifestations in gastroesophageal reflux in children” (Marin Burlea), „Nocturnal exacerbations in respiratory diseases“ (Roxana Nemeș), „Passive smoking – pediatric sleep disorders“ (Ioana Munteanu), „Reduction in myopia progression in children and adolescents with orthokeratology lenses worn during sleep“ (Daniela Goicea), „Paroxysmal sleep disorders in the neuropediatric pathology“ (Dana Craiu and colab.), Sleep disorders in children with neuromuscular diseases (Oana Tarta and colab.), Diagnostic difficulties in a case of narcolepsy (Ioana Minciu and colab.), „Enuresis - sleep or urinary disorder?” (Ghe. Chiriac Babei), „ What lies behind excessive crying in infants?“ (Doina Anca Pleșca și colab.) , “The importance of environmental factors in sleep physiology in

children and adolescents” (Marina Otelea), “Case study“(Daniela Stefanescu), A strong point of the event was a whole session of ENT participation and intensive care specialist. It included presentations such as: „ Adenotonsillectomy for Childhood with Obstructive Sleep Apnea” (Magne TvinnereimNorway), „Tonsillotomy using radiofrequency versus traditional tonsillectomy- one year study “ (Diana Ionescu), „Diagnosis problems and ENT treatment options in pediatric sleep-disordered breathing “ (Dan Gheorghe), “Preoperative anesthetic risk prevention by detecting respiratory sleep disorders in children” (Valeria Vlasceanu). The presence of Prof. Marin Burlea, President of the Romanian Pediatric Society, and Prof. Doina Pleșca, dean of the Carol Davila University of Medicine and Pharmacy at this gala of pediatric sleep medicine, reconfirmed the value and importance given to this field, which may change the fate of many children in Romania who experience this kind of undiagnosed diseases. Finally, we all had something to learn from the experience of these days filled with pediatric sleep medicine: they proved that there is interest in this field in our country, that the first steps have been successfully taken in Romania as well, and that a new generation of pioneers in the field is being established to continue the experience of seniors. The success of this conference opened a wide door towards a new edition in 2014 which took place in June at the same location in Sinaia, where the participation of international lecturers from US, Italy and Austria made their experience accessible in a semiformal and very interactive manner. Like Romanian sleep medicine which had come a long way until its acknowledgement, I estimate that the field of pediatric sleep medicine has already started to develop in our country as well, and launching a specialized journal is a natural step in its subsequent evolution and development.

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REZUMATE 1-a Conferinta de Somnologie Pediatrica “Tulburarile de somn la copii si adolescenti abordate multidisciplinar”, Sinaia, Romania, 4-6 Aprilie 2013 ABSTRACTS 1st Pediatric Sleep Conference “Sleep disorders in children and adolescents multidisciplinary approach”, Sinaia, Romania, 4th – 6th of April 2013

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REZUMATE / ABSTRACT


Somnologia românească încotro? • Florin Mihalţan Universitatea de Medicina si Farmacie „Carol Davila” Bucuresti, Institutul de Pneumologie „Marius Nasta” Bucuresti

Where is Romanian sleep medicine heading to? • Florin Mihalțan “Carol Davila” University of Medicine and Pharmacy, “Marius Nasta” Institute of Pulmonology, Bucharest

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Rezumat: Somnologia în România a parcurs un drum lung până la afirmare. Debutul s-a produs în 1997 cu primul laborator de somnologie din țară într-un moment când această specialitate dar și patologia pe care o acoperă era cvasinecunoscută. Au fost urcușuri și coborâșuri, au fost multiple probleme induse de lipsa recunoașterii acestei competențe de către Ministerul Sănătății, a Casei de Asigurări. Politicile și strategiile sunt descrise și analizate trasându-se în final și liniile directoare pentru viitor. În prezent există peste 80 de laboratoare, un interes major din partea companiilor de aparatură și o multitudine de medici care sunt doritori să participe la cursuri de formare. Cu toate acestea pașii care urmează să fie făcuți sunt mulți la număr și cu sprijinul tuturor probabil că vom reuși să aducem specialitatea acolo unde îi este locul. Cuvinte cheie: somnologie, competenţă

Abstract: Romanian sleep medicine has come a long way until its acknowledgement. The first sleep laboratory was founded in 1997, a time when there was almost no knowledge on this medical specialty or the pathology it deals with. There were ups and downs, multiple problems triggered by the lack of acknowledgement of this medical competence by the Ministry of Health, and the Health Insurance Fund. The policies and strategies have been described and analyzed and the guidelines have been drawn for the future. At present, there are over 80 sleep labs, a major interest coming from the companies which produce equipment, and a large number of physicians wishing to participate in training courses. Nevertheless, there are numerous steps yet to be taken, and with the support of all it is likely that we will succeed in bringing this specialty to its rightful place. Key words: sleep medicine, medical competence

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Societatea Europeana de Cercetare in Domeniul Somnului (ESRS) are ca scop promovarea tuturor activitatilor din domeniul somnologiei si a altor specialitati inrudite – activitati de cercetare stiintifica, articole de specialitate, programe de educatie. De asemenea ESRS isi propune formarea si trainingul unor specialisti in domeniul somnologiei si recunoasterea acestui domeniu ca si specialitate medicala in cat mai multe tari. In prezent in 27 de tari din Europa exista 130 de entree in care se desfasoara activitati clinice de cercetare in domeniul somnului. Este sustinuta unanim nevoia unor cercetari viitoare ale functiilor somnului, efectele deprivarii de somn asupra sanatatii.

The purpose of the European Sleep Research Society (ESRS) is to promote all activities in the field of sleep medicine and other related specialties – scientific research activities, specialized articles, and education programs. ESRS is also aiming to educate and train specialists in sleep medicine and make this field acknowledged as a medical specialty in as many countries as possible. At present, clinical sleep research activities are being conducted in 130 centers from 27 countries throughout Europe. There is unanimous support for the need to perform future research on sleep functions and the effects of sleep deprivation on human health.

Up to date from European Sleep Research Society • Dan Stefan Mihaicuta Universitatea de Medicina si Farmacie “V. Babes”, Clinica de Pneumologie, Timisoara

Up to date from European Sleep Research Society • Dan Stefan Mihaicuta University of Medicine and Pharmacy”V. Babes”, Pulmonology Clinic, Timisoara

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Sleep disorders in children and adolescents • Reinhold Kerbl Professor of Pediatrics and Adolescent Medicine, Leoben, Austria

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Abstract: According to the International Classification of Sleep Disorders (ICSD), more than 90 different sleep disorders do exist. Many of them may also occur in childhood and adolescence, and up to 40% of the pediatric population is affected by sleep disorders. As in adults, most disturbances constitute non-organic sleep disorders (inability to fall asleep, inablity to maintain sleep, disturbances of sleeping-waking pattern, parasomnias etc.) while organic sleep disorders (central and obstructive sleep apnea syndrome, hypoventilation syndrome, sleep-related seizures, narcolepsy etc.) represent a minority. Every age group has its characteristic sleep disorders. During early infancy, incompletely developed circadian rhythm may cause concern of parents, central and obstructive sleep apneas may be a contributing factor to SID (sudden infant death). In toddlers and pre-school children, hypertrophy of tonsils and adenoids may lead to obstructive sleep apnea syndrome (OSAS). In school-age and adolescence, daytime stressors, the (ab)use of modern media and phase delay as well as shortage of sleep duration may contribute to sleep disorders and disturbed daytime performance. Due to incomplete knowledge of professionals and nonprofessionals, many sleep problems remain inadequately treated for a long time, frequently leading to secondary complications. It is therefore essential that children and adolescents with sleep disorders contact pediatric sleep specialists as soon as possible. In non-organic sleep disorders, usually a behavioural approach is the therapy of choice, while in organic sleep disorders polysomnography in a pediatric sleep lab represents the gold standard of diagnosis. Pediatric sleep specialists have to know about the whole panel of pediatric sleep disorders. Following correct diagnosis, most pediatric sleep disorders can be effectively treated and normal life quality can be achieved.

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Conferinta de Somnologie Pediatrica “Tulburarile de somn la copii si adolescenti abordate multidisciplinar”, Sinaia, Romania, 4-6 Aprilie 2013 “Sleep disorders in children and adolescents – multidisciplinary approach” with international participation, April 4 -6, 2013, Sinaia Romania

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Ce ascunde plânsul excesiv la sugari? • Doina Anca Pleșca1, Sorina Chindris2 1. Universitatea de Medicina si Farmacie “Carol Davila”, Clinica de Pediatrie si Neurologie, Spitalul Clinic de Copii “Victor Gomoiu”, București 2. Clinica de Pediatrie si Neurologie, Spitalul Clinic de Copii “Victor Gomoiu”, București

What lies behind excessive crying in infants? • Doina Anca Pleșca1, Sorina Chindris2 1. ”Carol Davila” University of Medicine and Pharmacy, Pediatrics and Neurology Clinic, “Victor Gomoiu” Children’s Clinical Hospital, Bucharest 2. Pediatrics and Neurology Clinic, “Victor Gomoiu” Children’s Clinical Hospital, Bucharest 20

Rezumat: Autorii abordează o tematică de actualitate, atât pentru lumea medicală cât și pentru parinţi, cu impact asupra viitoarelor achiziţii comportamentale și neurologice ale sugarului. Centrată pe complexitatea cuvântului “sugar”, lucrarea prezintă succinct variate etiologii care stau la baza plansului excesiv al acestuia. Sunt trecute în revistă diverse afecţiuni organice, factori de mediu sau biologici, greșeli alimentare, unele influenţe comportamentale ale părinţilor etc. Sunt propuse soluţii terapeutice diverse în vederea ameliorării plansului excesiv al sugarilor. Un element important îl reprezintă intervenţia precoce în modelarea interacţiunii părinte-copil, esenţiale pentru o solidă stabilitate emoţională și mentală a acestuia. Cuvinte cheie: tulburări de comportament, plâns excesiv, sugar

Abstract: The topic approached by the authors is currently of interest both to the medical community as well as parents, having an impact on the future behavioural and neurological acquisitions of the infant. The paper is built around the complex term “infant”, and briefly presents various etiologies that underlie infants’ excessive crying. Various organic diseases are mentioned, as well as environmental or biological factors, food mistakes, certain behavioural influences of parents, etc. Various treatment solutions are proposed in order to improve infant excessive crying. An important element is early intervention in the modelling of the parent-child interaction, which is essential for the emotional and mental stability of the child. Key words: behaviour disorders, excessive crying, infant

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Rezumat: Boala de reflux gastroesofagian (BRGE) este o entitate frecventă în pediatrie, care este încă subdiagnosticată (”boala mileniului trei”). Simptomele clinice polimorfice sunt dominate nu numai de vărsături postalimentare, ci în multe cazuri şi de simptome respiratorii (de la tuse nocturnă la episoade de apnee, wheezing recurent, pneumonie de aspiraţie şi chiar sindromul de moarte subită). Terapia BRGE este triplă: măsuri generale, terapie farmacologică şi chirurgicală. Drogurile inițiale (agenți prokinetici) au fost înlocuite în ultima perioadă cu inhibitorii pompei de protoni (IPP), deoarece acestea sunt considerate medicamente în măsură să determine dispariția simptomelor de reflux în cele mai multe cazuri. În cazul asocierii BRGE cu manifestări respiratorii, terapia cu IPP este controversată, literatura de specialitate rămânând a fi revizuită pentru a pune în lumină această boală complexă. Cuvinte cheie: reflux gastroesofagian, manifestări respiratorii, copil

Manifestări extradigestive în boala de reflux gastroesofagian la copil

Abstract: Gastroesophageal reflux disease (GERD) is a common pediatric condition that is still underdiagnosed (it is called ”the third millennium disease”). The clinical polymorphic symptoms are dominated not only by postfeeding vomiting, but in many cases also by respiratory symptoms (from nocturnal cough to apnea episodes, recurrent wheezing, aspiration pneumonia and even sudden death syndrome). GERD therapy is a triple therapy: general measures, pharmacological, and surgical treatment. Initial drugs (prokinetic agents) have been lately replaced by proton pump inhibitors (PPI), because they are considered to relieve reflux symptoms in most of the cases. When GERD is associated with respiratory manifestations, the PPI therapy remains under debate. The specialized literature is to be reviewed in order to shed light on this complex disease. Key words: gastroesophageal reflux, respiratory manifestations, children

Extradigestive manifestations in gastroesophageal reflux in children

• Marin Burlea Preşedinte Societatea Romana de Pediatrie

• Marin Burlea President of Romanian Pediatric Society

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Screening-ul tulburarilor de somn la copii • Daniela Ştefănescu Bucuresti

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Rezumat: Screening-ul este “o procedură scurtă de evaluare, concepută pentru depistarea copiilor care au nevoie de o evaluare sau diagnosticare aprofundată.” Scopul – diferențierea copiilor care sunt “probabil în regulă”, de cei care “necesită investigații suplimentare”. Întârzierea în dezvoltarea unui copil, ar trebui să ne îngrijoreze? O dezvoltare necorespunzătoare, poate conduce la incapacitatea copilului de a-și atinge potențialul său real. 16% dintre copii, au dizabilități de dezvoltare, dar numai 20%- 30% dintre ele, sunt depistate înainte de intrarea la scoală. Cabinetul medicului de familie este ideal pentru screening, prin poziția sa unică, fiind singurul loc unde sunt consultați majoritatea copiilor. Medicul de familie este singurul care oferă atât îngrijiri preventive cât și curative, centrate pe familie, inclusiv o evaluare medicală mai completă, atunci când screening-ul indică un copil cu risc de apariție a unei probleme de dezvoltare. Somnul este o necesitate fiziologică majoră, la fel de importantă ca respirația și alimentația, în timpul căruia se secretă de hormoni de creștere, se dezvoltă memoria, învățarea și creativitatea, acestea fiind doar unele din funcțiile sale. Tulburările de somn conduc la numeroase consecințe asupra sănătății și a stării de bine a copilului, precum dificultăți de învățare, probleme comportamentale, depresie, efecte asupra creșterii, etc. Depistarea lor precoce, prin chestionare și tehnici de screening, poate conduce la tratarea/intervenirea asupra dizabilității cu reducerea impactului asupra funcționării copilului și familiei. Cuvinte cheie: medic de familie, tulburări de somn, dificultăţi de învăţare

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Abstract: Screening is “a short evaluation procedure, created to identify the pediatric patients who need thorough evaluation or diagnosis.” Its purpose is to differentiate children who are “probably well” from those “requiring additional investigation”. Should the delay in child development concern us? An inappropriate development may lead to child’s incapacity to reach his real potential. 16% of children experience developmental disabilities, but only 20% - 30% of them are detected before school age. The family physician office is ideal for screening by its unique status, being the only place where the majority of children are examined. The family physicians are the only ones offering preventive as well as curative care, focused on the entire family, including a more complete medical assessment when screening shows a child at risk for a development problem. Sleep is a major physiological necessity, just as important as breathing and eating, during which growth hormones are secreted, memory, learning, and creativity develop, these being only a few of its functions. Sleep disorders lead to a large number of consequences for the child’s health and wellbeing, such as learning difficulties, behavioural problems, depression, effects on growth, etc. Their early detection, through questionnaires and screening techniques, may lead to treatment/intervention in case of occurrence of such a disability, thus reducing its impact on the child’s and his family’s functioning. Key words: family physician, sleep disorders, learning difficulties

Screening for pediatric sleep disorder. • Daniela Ştefănescu Bucharest

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Lessons from adults - Monitorizarea în ambulator a tulburărilor respiratorii din timpul somnului

Rezumat: Diagnosticul tulburărilor respiratorii din timpul somnului se poate face prin studiul somnului într-un laborator de somnologie, dar și prin folosirea echipamentelor portabile de monitorizare cardiorespiratorie la domiciliu, în acord cu teste prealabile, experienţa individuala și locul preferat. Poligrafia este un sistem mobil, înregistrarea se poate efectua în spital sau la domiciliu, având avantajul că pacienţii dorm în mediul lor obișnuit. Include un minim de 4 canale, semnale pentru fluxul respirator, frecvenţa cardiacă sau EKG și saturaţia în oxigen. Unele dispozitive înregistrează și sforăitul, poziţia corpului și mișcările picioarelor. Are rol de screening în depistarea apneei în somn. Cuvinte cheie: poligrafia, frecvenţa cardiacă, screening

• Daniela Ivașcu Clinica NewMedics, București

Lessons from adults - Ambulatory monitoring of sleep-disordered breathing • Daniela Ivașcu NewMedics Clinic, Bucharest

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Abstract: The diagnosis of sleep-disordered breathing may be achieved by the study of sleep in a sleep lab or by using portable equipment for home cardiorespiratory monitoring, depending on previous testing, individual experience and preferred location. The polygraphy is a mobile system, and the recording can be made in the hospital or at home where the advantage is that the patients sleep in their usual environment. It includes a minimum of 4 channels - respiratory signals, heart rate or ECG, and oxygen saturation. Some devices also record snoring, body position and leg movement. The polygraphy has a screening role in the detection of sleep apnea. Key words: polygraphy, heart rate, screening

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Lesson from adults-sindromul de obezitate hipoventilaţie. Prezentare de caz. • Oana Claudia Deleanu1, Diana Pocora2, Florin Mihalţan1 1. Universitatea de Medicina si Farmacie „Carol Davila” Bucuresti, Institutul de Pneumologie „Marius Nasta” Bucuresti 2. Institutul de Pneumologie „Marius Nasta” Bucuresti

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Rezumat: Premize: Sindromul de obezitate-hipoventilaţie (SOH) este caracterizat de prezenţa hipercapniei diurne la adulții obezi, în absenţa altor patologii care evoluează cu modificarea constantelor arteriale. Prevalența sa la adulți este doar estimată, iar etiologia hipercapniei este complexă și insuficient studiată. Deși este o patologie uşor de prevenit, în absenţa tratamentului, este însoţită de morbiditate şi mortalitate crescute. Cuprins: Datorită creşterii prevalenţei obezităţii, SOH este tot mai întâlnit în practica medicală curentă. La adulți, profilul pacientului cu SOH este conturat de sexul masculin, obezitate, simptomele tipice ale SASO (apnea nocturnă, sforăitul, somnolența diurnă) care se asociaza in 90% din cazuri și de manifestările tipice pentru hipercania cronică precum şi comorbidităţile asociate acestora. Tratamentul SOH cuprinde o serie de măsuri: scădere ponderală, oxigenoterapie – adesea insuficiente – şi tratament cu CPAP. În situaţia persistenţei hipoxemiei sau/şi a hipercapniei sub CPAP se indică ventilaţie noninvazivă (BiPAP cu sau fără funcţia AVAPS). Vom prezenta cazul unui tânăr de 24 de ani care prezintă SOH tipic, precum și evoluția acestuia sub tratament. Concluzii: Există foarte puţine studii privind prezența SOH în populația pediatrică; definițiile obezității pediatrice și a anomaliilor polisomnografice la copil rămân discrepante; doar studii foarte recente au demonstrat și la copii prezența unui răspuns ventilator alterat la hipercapnie. Dar, deși prezența SOH la copii este încă un subiect de dezbatere, consecințele acestei patologii la adultul tânăr (foarte recentul fost pacient pediatric), sunt severe și deloc neglijabile. Cuvinte cheie: obezitate, hipercapnie, ventilatie noninvazivă

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Abstract: Premises: Obesity hypoventilation syndrome (OHS) is characterized by the presence of daytime hypercapnia in obese adults, in the absence of other pathologies developing with the modification of arterial constants. Its prevalence in adults is only estimated, and the etiology of hypercapnia is complex and insufficiently studied. Though easy to prevent, in the absence of treatment this pathology is associated with increased morbidity and mortality. Content: Because of the increase in the prevalence of obesity, OHS is more and more common in current medical practice. In adults, the profile of the patient with OHS is characterized as male, with obesity and typical symptoms of OSAS (nocturnal apnea, snoring, daytime sleepiness) which in 90% of the cases are also associated with the specific manifestations of chronic hypercapnia as well as its related comorbidities. The treatment of OHS includes a series of measures such as weight loss, oxygen therapy, which are often insufficient, and CPAP therapy. If hypoxemia or/and hypercapnia persist under CPAP, noninvasive ventilation is indicated (BiPAP with or without AVAPS function). We will present the case and outcomes under treatment of a young man aged 24 who experiences typical OHS. Conclusion: There are very few studies on OHS in the pediatric population; the definitions of pediatric obesity and polysomnographic abnormalities in children remain discrepant; only very recent studies have shown the presence of an altered ventilatory response to hypercapnia in children as well. However, although the presence of OHS in children is still a subject of debate, the consequences of this pathology in the young adults (the very recently former pediatric patients) are severe and not negligible at all. Key words: obesity, hypercapnia, noninvasive ventilation

Lessons from adults - obesity hypoventilation syndrome. Case presentation. • Oana Claudia Deleanu1, Diana Pocora2, Florin Mihalţan1 1. “Carol Davila” University of Medicine and Pharmacy, “Marius Nasta” Institute of Pulmonology, Bucharest 2. „Marius Nasta” Institute of Pulmonology, Bucharest

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Lessons from adults - Complicaţii cardiovasculare ale SASO • Daniela Boișteanu1, Raluca Vasiluta2 1. Universitatea de Medicină și Farmacie “Gr.T.Popa”, Iași 2. Spitalul Clinic de Pneumologie Iași

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Rezumat: Sindromul de apnee obstructivă în somn (SASO) este o problemă complexă de sănătate publică, afectând 2-4% dintre barbaţi și 1-2% dintre femei în populația generala adultă. Afecţiunea este caracterizată prin episoade recurente de apnee în timpul somnului însoțite de hipoxie, fluctuații ale ritmului cardiac și tensiunii arteriale (TA), treziri frecvente, fragmentarea somnului, având ca rezultat hiperactivitatea sistemului nervos simpatic. Studii epidemiologice au confirmat faptul că SASO crește semnificativ riscul cardiovascular, independent de vârstă, sex, rasă si alţi factori de risc comuni. SASO a fost asociat cu numeroase afecţiuni cardiovasculare, printre care disfuncția endotelială, hipertensiunea arterială, boala coronariană, aritmii, insuficienţa cardiacă și accidente vascularecerebrale. S-au emis câteva teorii pentru a explica mecanismele riscului cardiovascular crescut în SASO, incluzând activarea simpatică, disfuncția endotelială, stresul oxidativ și inflamația. Asocierea dintre SASO și bolile cardiovasculare poate fi agravată prin prezența componentelor sindromului metabolic: obezitate, hipertensiune arterială, diabet zaharat și dislipidemie. SASO severă crește semnificativ riscul evenimentelor cardiovasculare fatale și non-fatale, iar tratamentul CPAP reduce acest risc. Cuvinte cheie: apneea obstructivă de somn, afecţiuni cardiovasculare, factori de risc, CPAP

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Abstract: Obstructive sleep apnea syndrome (OSAS) is a complex public health problem affecting 2-4% of men and 1-2% of women in the general adult population. It is characterized by recurrent episodes of sleep apnea accompanied by hypoxia, fluctuations in heart rate and blood pressure (BP), frequent arousal, and consequent sleep fragmentation, resulting in activation of the sympathetic nervous system. Epidemiological evidence confirmed that OSA significantly enhances cardiovascular risk, independent of age, sex, race and other common risk factors. OSA has been associated with numerous cardiovascular complications, including endothelial dysfunction, hypertension, coronary artery disease, arrhythmias, heart failure and stroke. Several theories have been postulated to explain the mechanisms behind increased cardiovascular risk in OSA, including sympathetic activation, endothelial dysfunction, oxidative stress and inflammation. The association between OSA and cardiovascular diseases may be compounded by the presence of elements of metabolic syndrome, such as obesity, hypertension, diabetes mellitus and dyslipidaemia. Severe OSAS significantly increases the risk of fatal and nonfatal cardiovascular events, and CPAP treatment reduces this risk. Key words: obstructive sleep apnoea, cardiovascular disease, risk factors, CPAP

Lessons from adults - Cardiovascular Complications of OSAS • Daniela Boișteanu1, Raluca Vasiluta2 1. University of Medicine and Pharmacy “Gr.T.Popa”, Iasi 2. Clinic of Pulmonary Diseases Iași

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Lessons from adults – complianţa la tratament. Aspecte practice. • Ştefan Dumitrache-Rujinski Universitatea de Medicina si Farmacie „Carol Davila” Bucuresti, Institutul de Pneumologie „Marius Nasta” Bucuresti

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Rezumat : Aderanţa (complianţa) la tratamentul CPAP este esenţială pentru obţinerea rezultatului așteptat în ceea ce privește prevenirea și/sau tratarea complicaţiilor sindromului de apnee în somn. Aderenţa la tratament depinde de mai mulţi factori printre care: importanţa simptomatologiei (este mai mare la pacienţii cu somnolenţă diurnă importantă), timpul petrecut de medic pentru a explica pacientului beneficiile utilizării corecte, respectiv riscurile neutilizării terapiei CPAP, timpul pe care medicul și/sau tehnicianul îl alocă instruirii pacientului în ceea ce privește tehnica corectă de aplicare a maștii și a utilizării CPAP, și, nu în ultimul rând, de găsirea celui mai potrivit dispozitiv și mod de operare adaptat nevoilor fiecărui pacient. Faptul că terapia cu CPAP nu este actualmente compensată de sistemul de asigurări de sănătate contribuie și el la aderanţa la tratament. Tehnologia actuala permite urmărirea nu numai a numărului de ore de utilizare a CPAP dar și înregistrarea parametrilor pe baza cărora se pot analiza valorile medii sau maxime ale presiunii de funcţionare, numărul de evenimente respiratorii reziduale (nerezolvate), pierderile aeriene, valorile saturaţiei în oxigen sau a indexului de desaturare sub terapia CPAP, elemente foarte utile în optimizarea tratamentului, identificarea și rezolvarea probemelor apărute, astfel încât să se îmbunătăţească aderenţa la terapia cu CPAP. Prezentarea are ca obiectiv abordarea acestor aspecte dintrun punct de vedere practic, bogat ilustrat, care decurge din activitatea curentă a unui laborator care se ocupă de această patologie. Cuvinte cheie: apnee în somn, CPAP, complianţă

REZUMATE / ABSTRACT


Abstract: Adherence to (compliance with) CPAP therapy is essential in order to obtain the expected outcome in the prevention and/ or treatment of the complications of sleep apnea syndrome. Adherence to treatment depends on several factors among which are the following: the importance of the symptomatology (is higher in patients with severe daytime sleepiness), the time spent by the doctor explaining to the patient the benefits of an accurate use of CPAP and the risks of not using this therapy, the time that the doctor and/or technician allocates for training the patients with respect to the correct technique for application of the CPAP mask and use of CPAP, and last but not least finding the most appropriate device and operation method adjusted to the particular needs of the patient. The fact that the CPAP therapy is not currently reimbursed by the health insurance system also contributes to the compliance with treatment. The current technology allows not only to follow the number of hours of CPAP use but also to record the parameters based on which one can analyze the average or maximum values of the functioning pressure, the number of residual respiratory events (unsolved), air loss, the values of the oxygen saturation or of the desaturation index under CPAP therapy, elements which are very useful for the optimization of treatment, identification and solving of the problems that occur, so that improvement is made in the adherence to CPAP therapy. The objective of the presentation is to approach these aspects from a practical and richly illustrated point of view which results from the current activity of a laboratory that deals with this pathology. Key words: sleep apnea, compliance, CPAP

Lessons from adults – compliance with treatment. Practical aspects. • Ştefan Dumitrache-Rujinski “Carol Davila” University of Medicine and Pharmacy, “Marius Nasta” Institute of Pulmonology, Bucharest

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Home Care

Calitatea somnului influenţează calitatea vieţii

Home Care

Somn mai bun = Viaţă mai bună! Messer România Gaz, Str. Delea Veche Nr. 24, Corp A, Et. 2–3, 024102, Sector 2, Bucureşti Tel: 021 327 36 24, int. 234; Fax: 021 327 36 26; E-mail: [email protected]; Web: www.messer.ro 32

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Rezumat: Tulburările paroxistice de somn sunt frecvente în patologia neuro-pediatrică și pun adesea probleme de diagnostic diferenţial. Această prezentare discută dificultăţile și metodele de diagnostic pozitiv și diferenţial a unora din fenomenele paroxistice de somn pornind de la cazuri concrete (diferenţierea epilepsiei mioclonice vs miocloniile benigne de somn, pavor nocturn vs coșmar sau de crize epileptice, fenomene automate în REM vs crize epileptice, fenomene psihiatrice vs crize epileptice, reflux gastroesofagian vs fenomene neurologice). Este subliniată valoarea unei anamneze corecte și a corelării cu examenul neurologic, a filmării acasă de către parinţi, a video-EEG efectuat în clinică (a consulturilor interdisciplinare în anumite cazuri de cauză psihiatrică, pediatrică, digestive). Sunt discutate pe scurt elemente teoretice de diferenţiere a entităţilor respective. Cuvinte cheie: fenomene paroxistice de somn, mioclonii, video-EEG

Abstract: Paroxysmal sleep disorders are common conditions in the neuropediatric pathology, and they often raise questions regarding differential diagnosis. This presentation illustrates the difficulties and methods of establishing positive and differential diagnosis for some of the paroxysmal sleep phenomena, starting from concrete cases (differentiation of myoclonic epilepsy vs benign sleep myoclonus, pavor nocturnus vs nightmare or epileptic seizures, automatic phenomena during REM vs epileptic seizures, psychiatric phenomena vs epileptic seizures, gastroesophageal reflux vs neurologic phenomena). It is of great importance to correctly conduct an anamnesis correlated with the neurologic examination, to have the episodes recorded by the parents at home, to perform an EEG-video monitoring in the clinic (to carry out interdisciplinary examinations in some cases of psychiatric, pediatric or digestive nature). The theoretical elements for differentiating the respective entities are also discussed. Key words: paroxysmal sleep disorders, myoclonus, EEG-video

Tulburările paroxistice de somn în patologia neuro-pediatrică • Dana Craiu, Oana Tarţa, Cristina Moţoescu, Cristina Pomeran, Magda Budișteanu Spitalul Clinic “Prof. Dr. Alexandru Obregia” București

Paroxysmal sleep disorders in the neuropediatric pathology • Dana Craiu, Oana Tarţa, Cristina Moţoescu, Cristina Pomeran, Magda Budișteanu “Prof. Dr. Al. Obregia” Clinical Hospital, Bucharest

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Parasomniile copilului • Raluca Ioana Teleanu Universitatea de Medicina si Farmacie „Carol Davila”, Secţia de Neurologie Pediatrică Spitalul Clinic de Copii „Dr Victor Gomoiu”, București

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Rezumat: Parasomniile sunt tulburări disruptive de somn care pot apărea la adormire, în timpul somnului sau la trezire. Ele sunt clasificate în parasomnii asociate cu somnul NON-REM (pavorul nocturn, automatismul ambulator nocturn, trezirile confuzionale), parasomnii asociate cu somnul REM (coșmarul, paraliziile de somn, tulburările de somn REM) și alte parasomnii (enurezis, halucinaţii hipnagogice - hipnapompice, tulburare de alimentaţie legată de somn) . Evenimentele sunt mai frecvente la copiii cu vârstă de gradiniţă, apoi incidenţa lor scade treptat dupa primul deceniu de viata. Calitatea somnului la acești copii în general rămâne neafectată, dar aceste evenimente nocturne produc îngrijorare din partea familei și a copilului. Manifestarile pot fi confundate cu crizele epileptice; astfel, este important stabilirea unui diagnostic corect. Uneori, parasomniile sunt simptome izolate care survin la un copil sănătos, dar uneori coexistă cu o afectare neurologică, psihiatrică sau altă patologie medicala asociată. Factorii declanșatori cunoscuţi sunt: apneea obstructivă de somn, sindromul picioarelor neliniștite, refluxul gastro-esofagian, iar tratamentul corect al acestor afecţiuni ajută la ameliorarea manifestărilor. Managementul constă de obicei din tratarea cauzei principale a parasomniei, asigurarea unui ritual corect de somn, iar la adolescenţi, evitarea unor substanțe psihoexcitante (cofeina, alcool, etc). În cazul în care manifestările de somn devin frecvente și afectează calitatea vieţii copilului, tratamentul medicamentos este necesar. Cuvinte cheie: parasomnii, crize epileptice, tratament medicamentos

REZUMATE / ABSTRACT


Abstract: Parasomnias are disruptive sleep disorders that occur while falling asleep, sleeping or during arousal from sleep. They are classified as parasomnias associated with non-REM sleep (nocturnal terrors, nocturnal ambulatory automatism, confusional arousals), parasomnias associated with REM sleep (nightmares, sleep paralysis, REM sleep disorders) and other parasomnias (enuresis, hypnagogic and hypnopompic hallucinations, sleeprelated eating disorder). These events are more common in preschool children, and their incidence decreases gradually after the first decade of life. Generally, the quality of sleep in these children remains unaffected, but these nocturnal events cause concern in the family and child. The manifestations may be mistaken for epileptic seizures; therefore it is important to establish an accurate diagnosis. Sometimes, parasomnias are isolated symptoms that occur in a healthy child, but there are times when they coexist with a neurologic or psychiatric condition, or with another associated pathology. The known factors causing parasomnias are: obstructive sleep apnea, restless legs syndrome, gastroesophageal reflux, and the correct treatment of these diseases helps to improve symptoms. The management of parasomnias usually consists in treating the main cause of the parasomnia, ensuring a correct bedtime routine, and in adolescents it is important to avoid use of stimulating substances (caffeine, alcohol, etc). If the sleep-related manifestations become common, affecting child’s quality of life, medical management is required. Key words: parasomnias, epileptic seizures, medical treatment

Pediatric parasomnias • Raluca Ioana Teleanu “Carol Davila” University of Medicine and Pharmacy, Pediatric Neurology Department „Dr. V. Gomoiu” Children’s Hospital, Bucharest

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Dificultăţi de diagnostic într-un caz de narcolepsie • Ioana Minciu1, Mihaela Oros2, Oana Tarţa –Arsene1, Daniela Ivașcu3 1. Clinica Neurologie Pediatrică Spital Clinic de Psihiatrie “Al Obregia”, Bucuresti 2. Clinica de Pediatrie Medicover, București 3. Clinica NewMedics, București

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Rezumat: Introducere. Narcolepsia este o boală rară caracterizată de disfuncţia şi tulburarea de reglare a somnului REM, determinată de predispoziţia genetică, funcţionarea anormală a neurotransmiţătorilor cerebrali şi imunomodularea anormală. Este clinic caracterizată de episoade de somnolenţă diurnă, cataplexie, halucinaţii de adormire sau trezire, paralizii de somn. Prezentarea cazului. Se prezintă cazul unui copil de sex masculin în vârstă de 12 ani cu intelect normal, neurologic normal care se internează în octombrie 2012 pentru un episod paroxistic survenit în somn urmat de o stare confuzională prelungită (2 ore),şi halucinaţii vizuale. În 2008 copilul prezentase un episod asemănător cu durata >10 min care a fost considerat epileptic. Probele toxicologice CT cerebral , EEG intercritic au fost normale atunci şi copilul a primit tratament aproape 2 ani cu Valproat de Na (Depakine), apoi acesta a fost scos în 2010. În 2012 EEGul intrecritic a fost normal, IRM cerebral normal. S-a reintrodus tratamentul antiepileptic şi copilul începe să prezinte din veghe episoade foarte frecvente bruşte de “moleşeală şi somn” cu durata variabilă, dificultăţi de trezire matinală, uneori “comportament ciudat” de scurtă durată după trezire sau la adormire cu amnezia perioadei. Aceste manifestări aduc pertubări mari în viaţa şcolară a copilului dar şi în viaţa familiei. Manifestările de tip hipoton din veghe sunt văzute de medic şi înregistrarea EEG concomitentă infirmă natura lor epilepică, ridicând suspiciunea unor manifestări psihogene sau a unor tulburări de somn. EEG-ul de somn confirmă o dissomnie prin prezenţa somnului REM în procent ridicat, fapt confirmat apoi de înregistrările polisonmografice şi MSLT (multiple sleep latency test). Diagnosticul este în acest moment de narcolepsie şi copilul primeste tratament cu Metil fenidat cu evoluiţie ameliorată. Concluzie: Nu toate manifestările paroxistice cu stare confuzională asociată sunt epileptice şi o anamneză atentă poate ajuta mult diagnosticul mai rapid al unor manifestări paroxistice care perturbă intens viaţa pacientului şi familiei. Cuvinte cheie: narcolepsia, EEG, manifestări paroxistice

REZUMATE / ABSTRACT


Abstract: Inroduction. Narcolepsy is a rare disease characterized by REM sleep regulation dysfunction and disorder, determined by genetic predisposition, abnormal functioning of the brain neurotransmitters and abnormal immunomodulation. It is clinically characterized by daytime sleepiness episodes, cataplexy, hallucinations while falling asleep or during arousal from sleep, sleep paralysis. Case presentation. We hereby present the case of a male child aged 12 with normal intellect, normal neurologic functioning, who is admitted in the hospital in October 2012 for a paroxysmal episode occurred during sleep and followed by a prolonged confusional state (2 hours), and visual hallucinations. In 2008, the child experienced a similar episode of >10 minutes which was considered to be of epileptic nature. The results of the toxicological tests, head CT, intercritical EEG were normal at that time, and the child received treatment with Navalproat (Depakine) for almost 2 years, then the treatment was discontinued in 2010. In 2012 the result of the intercritical EEG was normal and so was the result of the head MRI. The antiepileptic treatment was reintroduced, and while awake, the child started to experience very frequent and sudden episodes of “drowsiness and sleepiness” with variable duration, difficult morning arousal from sleep, and sometimes after waking up or while falling asleep, he would experience short episodes of “unusual behaviour” that he would later on not remember. These modifications cause great disturbance in the child’s school life but also in his family’s life. The hypotonic manifestations occurred during wakefulness are observed by the doctor and the concomitant EEG recording excludes an epileptic nature, raising suspicion of psychogenic manifestations or sleep disorders. The sleep EEG confirms dysomnia due to the presence of a high percentage of REM sleep, fact reconfirmed by the subsequent polysomnographic recordings and MSLT (multiple sleep latency test). The present diagnosis is narcolepsy and the child is receiving treatment with Methylphenidate showing improved outcomes. Conclusion: Not all paroxysmal manifestations associated with confusional state are of epileptic origin, and an accurate anamnesis may be of much help in determining early diagnosis of paroxysmal episodes that intensely disturb the life of the patient and his family. Key words: narcolepsy, EEG, paroxysmal manifestations

Diagnostic difficulties in a case of narcolepsy • Ioana Minciu1, Mihaela Oros2, Oana Tarţa –Arsene1, Daniela Ivașcu3 1. Pediatric Neurology Clinic, Dr. Al. Obregia Clinical Hospital for Psychiatry, Bucharest 2. Medicover Pediatric Clinic, Bucharest 3. NewMedics Clinic, Bucharest

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Tulburările de somn la copiii cu boli neuromusculare • Oana Tarţa-Arsene, Niculina Butoianu, Ioana Minciu, Diana Bârca, Dana Craiu Spitalul Clinic de Psihiatrie “Prof. Dr. Al. Obregia”, București

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Rezumat: Bolile neuromusculare la copil sunt afecţiuni frecvent întâlnite care necesită abordare multidisciplinară: neurologie pediatrică, pediatrie, cardiologie, pneumologie, ortopedie, gastroenterologie, kinetoterapie. Aceste boli pot debuta la orice vârsta a copilăriei, de la sugar la adolescent. Din punct de vedere clinic sunt caracterizate printrun tablou comun: deficit motor însoţit de hipotonie musculară și tulburări de reflectivitate. În funcţie de tipul bolii, fiecare pacient are o evoluţie particulară, asociind în timp cel mai frecvent afectare cardiacă, respiratorie, ortopedică. Astfel, problemele respiratorii asociate sunt de tipul tusei ineficiente, dezvoltare insuficientă a plamânilor și a cutiei toracice, toate acestea asociind infecţii recurente. Dintre acestea, tulburările de somn de tipul hipoventilaţiei reprezintă primul semn de afectare pulmonară astfel având posibilitatea de a trata eficient problemele asociate și prevenind cât mai precoce complicaţiile acestora. În cadrul acestei prezentări autorii prezintă principalele boli neuromusculare la copil cu semnele clinice și evoluţia particulară, subliniind afectarea somnului ca semn precoce de implicare respiratorie și importanţa efectuării studiului somnului la copiii cu această patologie. Cuvinte cheie: boli neuromusculare, tulburări de somn, copil, polisomnografie

REZUMATE / ABSTRACT


Abstract: Pediatric neuromuscular diseases are common conditions that require a multidisciplinary approach: pediatric neurology, pediatrics, cardiology, pulmonology, orthopedics, gastroenterology, kinetotherapy. The onset of these diseases may be found at any age of childhood, from infancy to adolescence. Clinically, they are characterized by a common framework comprising motor deficits accompanied by hypotonia and reflectivity disorders. Depending on their type, these diseases develop differently in each patient, and become associated in time most frequently with cardiac, respiratory, and orthopedic impairment. Thus, among the associated respiratory problems are: inefficient cough, insufficient development of lungs and rib cage, all of which are associated with recurrent infections. Among them, sleep disorders such as hypoventilation represent the first sign of pulmonary impairment, giving us the possibility to treat the associated problems efficiently and to prevent the occurrence of their complications as early as possible. The authors present the main pediatric neuromuscular diseases and their particular signs and development, underlining sleep impairment as an early sign of respiratory implication, and the importance of sleep study in children with this condition. Key words: neuromuscular diseases, sleep disorders, children, polysomnography

Sleep disorders in children with neuromuscular diseases • Oana Tarţa-Arsene, Niculina Butoianu, Ioana Minciu, Diana Bârca, Dana Craiu “Prof. Dr. Al. Obregia” Clinical Hospital for Psychiatry, Bucharest

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Pattern-ul tulburărilor de somn la pacienţii cu ADHD și/ sau Tulburare de Spectru Autist • Ilinca Mihailescu, Cristina G Anghel, Florina Rad, Iuliana Dobrescu Spitalul Clinic de Psihiatrie „Prof. Dr. Al. Obregia”, București

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Rezumat: Obiective. Obiectiv primar: identificarea unori pattern-uri anormale ale somnului la copiii cu ADHD sau TSA. Obiective secundare: compararea celor două patologii din punct de vedere ale profilului de somn (diferenţe și asemănări), identificarea unor factori agravanţi ale acestor modificări (ex: rutina de adormire sau igiena a somnului deficitare, fragmentarea somnului, treziri nocturne, probleme respiratorii, bruxism etc.) Metode: Un lot de subiecţi cu TSA (nA = 30), un lot de subiecţi cu ADHD (nB = 30) și un lot martor de subiecţi sănătoși (nc = 30). Subiectii incluși în loturile A si B reprezintă cazuri internate în Spitalul de Psihiatrie “Prof. Dr. Al. Obregia”. În ambele loturi s-a aplicat scala Albany (“Albany Sleep Problems Scale”) reprezentantului legal al copilului (părinte/ tutore). Rezultate: Trezirile nocturne, somnul agitat (mișcările membrelor), vorbitul în timpul somnului și necesitatea utilizării medicaţiei hipnoinductoare au fost principalele probleme identificate până acum în ambele loturi. În plus, în lotul de subiecţi cu ADHD au fost raportate frecvent probleme legate de rutina de adormire (ex: lipsa unui program regulat de somn) și hipersomnolenţa diurnă. Finalizarea rezultatelor obţinute este în progres. Concluzii: Modificările calitative ale somnului sunt comune în rândul pacienţilor cu ADHD sau TSA, fapt ce ar putea explica necesitatea utilizării unei medicaţii adjuvante. Măsurarea obiectivă a acestor pattern-uri (ex: polisomnografie) reprezintă o etapă necesară în viitor pentru investigarea tulburărilor de somn în Tulburarile de Spectru Autist și ADHD. Cuvinte cheie: rutina de adormire, tulburari de somn, ADHD, TSA

REZUMATE / ABSTRACT


Abstract: Objectives. Primary objective: identifying abnormal sleep patterns in children with ADHD or ASD. Secondary objectives: comparing the two pathologies from the point of view of the sleep profile (differences and resemblances), identifying the aggravating factors of these modifications (e.g. inappropriate bedtime routine or sleep hygiene, sleep fragmentation, nocturnal awakenings, breathing problems, bruxism etc.) Methods: A cohort of subjects with ASD (nA = 30), a group of patients with ADHD (nB = 30) and a control group of healthy subjects (nc = 30); Subjects included in groups A and B represent cases admitted to Dr. Al. Obregia Hospital for Psychiatry. Albany Sleep Problems Scale was applied to the children’s legal representatives (parent/tutor) in both lots. Results: Nocturnal awakenings, agitated sleep (limb movement), speaking during sleep and the need for hypnosis induction drugs have been the main problems identified so far in both groups. Moreover, problems related to bedtime routine (e.g. lack of a regular sleep schedule) and diurnal hypersomnolence have been frequently reported in the group of patients with ADHD. Completion of findings is still in progress. Conclusion: Sleep qualitative modifications are common in patients with ADHD or ASD, which could explain the necessity for adjuvant medication. The objective measurement of these patterns (e.g. polysomnography) represents a necessary stage in the future for the investigation of sleep disorders in ASD and ADHD patients. Key words: bedtime routine, sleep disorders, ADHD, ASD

Sleep disorders pattern in patients with ADHD and/or Autism Spectrum Disorders • Ilinca Mihailescu, Cristina G Anghel, Florina Rad, Iuliana Dobrescu Child and Adolescent Psychiatry “Prof. Dr. Al. Obregia” Clinical Hospital, Bucharest

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Probleme de diagnostic și opţiuni de tratament ORL în tulburările respiratorii de somn ale copilului

Rezumat: Tulburările de somn prin obstrucţie respiratorie reprezintă o preocupare centrala în patologia ORL pediatrică. Datorită cazuisticii bogate, autorul prezintă concluzii practice legate de diagnosticarea corectă a obstrucţiei respiratorii a copilului și protocolul terapeutic folosit în practica curentă. Sunt evidenţiate dificultăţile, confuziile generate de lucrul cu copilul mic și este subliniat rolul medicului ORL în cadrul algoritmului terapeutic al acestei patologii. Cuvinte cheie: obstrucţie respiratorie, ORL

• Dan Gheorghe Spitalul Clinic de Urgenta pentru Copii „M. S. Curie” București

Diagnosis problems and ENT treatment options in pediatric sleep-disordered breathing • Dan Gheorghe “M.S.Curie” Childrens Hospital Bucharest 42

Abstract: Obstructive sleep disordered breathing represents a central topic in pediatric ENT. Due to the large number of patients seen in medical practice, the author presents a few conclusions upon the correct diagnosis of chronic respiratory obstruction in children and some useful therapeutic recommendations in daily practice. He marks the difficulties and the confusions generated by work with small children and stresses the role of ENT medicine in treating this common disease. Key words: respiratory obstruction, ENT

REZUMATE / ABSTRACT


Rezumat: Enurezisul este cauză de jenă familială, marcă a inconştientului personal dar şi a eului social. Atrage eșecuri diverse, dar în primul rând de inserţie socială. Enurezisul, simptom pregnant, jenant, care ruşinează, poate fi manifestarea unei etiologii multiple. Vorbim astăzi de o condiţionare genetică, de o sinteză – expresie inadecvată de ADH, disfuncţii metabolice complexe sau malformativ – sindromul de coardă terminală. Pornind de la “a dormi egal a muri puţin” autorii evidenţiază anumite legături certe între tulburările de somn ale copilului şi incidenţa enurezisului “primar” nocturn. Enurezisul rămâne astăzi o problema socială complexă chiar daca progresele în diagnosticul şi tratamentul afecţiunii au cunoscut un salt uriaş. Constatăm o scădere a adresabilităţii către medic cel puţin aparent deoarece probabil în vâltoarea vieţii cotidiene restricţiile de program și alimentaţie impuse pentru succesul tratamentului dezarmează aparţinătorii şi duc la o atitudine pasivă a acestora, lasând copilul pradă unui zbucium surd. Concluzia expunerii poate fi exprimată succint ca singura modalitate de abordare a copilului fiind cea holistică pluridisciplinară bazată pe o echipă constituită ad-hoc pe baza aderenţei de inters astfel încât să devină din travaliu un mobil. Cuvinte cheie: tulburari de micţiune, enurezis

Abstract: Enuresis is a cause for family discomfort, a mark of the unconscious as well as social self. It triggers various types of failure, but mostly related to social integration. Enuresis is a pregnant, discomforting and embarrassing symptom that may be the manifestation of a multiple etiology. Today we speak of a genetic conditioning, a synthesis – an inadequate expression of ADH, complex or malformative metabolic dysfunctions – the tethered cord syndrome. Starting from the saying “sleeping is a little bit like dying” the authors illustrate certain connexions between pediatric sleep disorders and the incidence of nocturnal primary enuresis. Nowadays, enuresis remains a complex social matter even though huge progress has been made in the diagnosis and treatment of this disease. One can observe, at least apparently, a decrease in the addressability of this issue to physicians, probably because in the whirlpool of daily life, the schedule and food restrictions imposed for a successful treatment disarm caregivers, leading to a passive attitude that leaves the child alone in his struggle with this condition. The conclusion is briefly the following: the only way to approach pediatric enuresis is a multidisciplinary holistic method based on a team formed ad hoc according to the individual interest in the matter, so that the issue turns from struggle into a purposeful set of actions. Key words: urinary disorder, enuresis

Enurezisul tulburare de somn sau tulburare micţonală? • Chiriac Babei Gheorghe1, Chiriac Babei Cătălin Ion2 1. Spitalul Medicover București 2. Spital clinic de Urgenţă pentru Copii “Grigore Alexandrescu” Bucureşti

Enuresis - sleep or urinary disorder? • Chiriac Babei Gheorghe1, Chiriac Babei Cătălin Ion2 1. Medicover Hospital, Bucharest 2. Grigore Alexandrescu Clinical Emergency Children’s Hospital, Bucharest

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AdenoTonsillectomy in Children with Obstructive Sleep Related Breathing Disorders (SRBD) • Magne Tvinnereim, MD., Ph.D. Specialist in Oto-rhino-Laryngology. International Accredited Sleep – specialist CEO of Eurosleep Intl. & Spiromedical ltd.

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In the last decades adeno-tonsillectomy in children have switched from having an infectious perspective towards adenotonsillar hypertrophy causing different degrees of pharyngeal narrowing, giving a wide variety of symptoms. Besides heroic snoring and apneas, mouth breathing, sweating, enuresis, turning and tossing can be observed. During daytime, EDS, headache, failure to thrive and behavioral problems like hyperactivity, aggressiveness and learning problems are frequently reported. Symptoms like these usually lead to the diagnosis together with thorough ENT-examination including objective grading of tonsil size and evaluation of the skeletal features. Differential diagnostic etiologic factors are laryngomalacia and different syndroms (Down’s, Pierre Robin, Crouzon, Apert’s, DiGeorge, Treacher Collins,Prader Willi, Goldenhars, Hunters, Bechwith Wiedemann.) Breathing through a narrow pharynx may result in increased Respiratory Effort and EEG Arousals. Respiratory Effort Related Arousals (RERA) are therefore included in the diagnosis by, AASM 2007: SRBD = RERA + OSAS. The recommended diagnostic tools are PSG and esophageal manometry, but availability are extremely restricted. The milder forms of SRBD in children have a prevalence of 7-10%. OSA is found in 1-2%, defined by an AI of 1 or AHI on 5+, and the obstructive events lasting for at least 5 or 10 seconds in children below or above 9 years respectively. Unlike in adults there is no male predominance, but with the peak prevalence at ages 2 – 8. Indications for adeno-tonsillectomy are: • PSG confirmed SRBD • Children with large tonsils and symptoms of disturbed sleep • Syndrome children with large tonsils and adenoids, supplemented by sleep nasendoscopy The success rates of surgery varies in the literature (50 – 90%). Rapid catch up of growth and weight gain, increased GH release, improved QOL and school performance are most often reported. Furthermore, non REM SRBD’s responds better than REM SRBD’s. As the facial skeleton develops at the age around six, late diagnosis, treatment as well as lack of proper follow up can give disastrous results, including skeletal malformations and serious SRBD. Meticulous follow up of patients with persisting symptoms are mandatory, then with PSG and esophageal manometry included.

REZUMATE / ABSTRACT


Obiective Autorii isi propun sa compare cele 2 tehnici operatorii (tonsilotomia prin radiofrecventa versus operatia clasica de tonsilectomie). Material si metoda Studiu este realizat la sectia orl, a Spitalului Victor Gomoiu Bucuresti, pe durata unui an de zile si cuprinde 100 de copii cu varste cuprinse intre 3 si 17 ani care au fost supusi diferitelor tipuri de interventii chirurgicale mentionate. Rezultate Lotul cu apnee obstructiva de somn, operat cu radiofrecventa a prezentat mai putine complicatii post operatorii(durere, sangerare) necesitand o administrare redusa a medicatiei. La 10 zile post operator, peste 80% din acesti copii erau complet vindecati. In cazul copiilor care sufereau de amigdalite recurente, metoda clasica s-a dovedit a fi mai eficienta in timp. Ronhopatiile s-au diminuat in procente relative egale Concluzie Tonsilotomia prin radiofrecventa poate fi o metoda eficienta de tratament chirurgical ce reduce complicatiile post operatorii pentru copii cu apnee obstructiva de somn

Objective The authors propose to compare the two surgical methods (tonsillotomy using radiofrequency versus traditional tonsillectomy) Material and method The study is realized at ENT clinic, Victor Gomoiu Hospital, during one year with one hundred children between 3 and 17 years of age who were randomized to either surgical methods Results The group with obstructive sleep apnea operated with radiofrequency showed less post operative complications (pains, bleeding), with less need of the prescribed drugs. After 10 days, more than 80% children from this group were completely healed. For the children with recurrent tonsillitis the surgical classic method showed the best efficiency. The effect of snoring was the same for both groups. Conclusion Tonsillotomy using radiofrequency could be an efficient surgical treatment method for tonsil surgery with much less postoperative morbidity for the children with obstructive sleep apnea

Tonsilectomia intracapsulara prin tehnica de radiofrecventa versus tonsilectomia clasica – rezultate pe un an de zile • Diana Ionescu Spitalul Clinic de Copii „Dr. Victor Gomoiu”, Bucuresti

Tonsillotomy using radiofrequency versus traditional tonsillectomy- one year study • Diana Ionescu Childrens Hospital „Dr. Victor Gomoiu” Bucharest

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Enurezisul tulburare de somn sau tulburare micţonală? • Chiriac Babei Gheorghe1, Chiriac Babei Cătălin Ion2 1. Spitalul Medicover București 2. Spital clinic de Urgenţă pentru Copii “Grigore Alexandrescu” Bucureşti

Enuresis - sleep or urinary disorder? • Chiriac Babei Gheorghe1, Chiriac Babei Cătălin Ion2 1. Medicover Hospital, Bucharest 2. Grigore Alexandrescu Clinical Emergency Children’s Hospital, Bucharest

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Rezumat: Enurezisul este cauză de jenă familială, marcă a inconştientului personal dar şi a eului social. Atrage eșecuri diverse, dar în primul rând de inserţie socială. Enurezisul, simptom pregnant, jenant, care ruşinează, poate fi manifestarea unei etiologii multiple. Vorbim astăzi de o condiţionare genetică, de o sinteză – expresie inadecvată de ADH, disfuncţii metabolice complexe sau malformativ – sindromul de coardă terminală. Pornind de la “a dormi egal a muri puţin” autorii evidenţiază anumite legături certe între tulburările de somn ale copilului şi incidenţa enurezisului “primar” nocturn. Enurezisul rămâne astăzi o problema socială complexă chiar daca progresele în diagnosticul şi tratamentul afecţiunii au cunoscut un salt uriaş. Constatăm o scădere a adresabilităţii către medic cel puţin aparent deoarece probabil în vâltoarea vieţii cotidiene restricţiile de program și alimentaţie impuse pentru succesul tratamentului dezarmează aparţinătorii şi duc la o atitudine pasivă a acestora, lasând copilul pradă unui zbucium surd. Concluzia expunerii poate fi exprimată succint ca singura modalitate de abordare a copilului fiind cea holistică pluridisciplinară bazată pe o echipă constituită ad-hoc pe baza aderenţei de inters astfel încât să devină din travaliu un mobil. Cuvinte cheie: tulburari de micţiune, enurezis

Abstract: Enuresis is a cause for family discomfort, a mark of the unconscious as well as social self. It triggers various types of failure, but mostly related to social integration. Enuresis is a pregnant, discomforting and embarrassing symptom that may be the manifestation of a multiple etiology. Today we speak of a genetic conditioning, a synthesis – an inadequate expression of ADH, complex or malformative metabolic dysfunctions – the tethered cord syndrome. Starting from the saying “sleeping is a little bit like dying” the authors illustrate certain connexions between pediatric sleep disorders and the incidence of nocturnal primary enuresis. Nowadays, enuresis remains a complex social matter even though huge progress has been made in the diagnosis and treatment of this disease. One can observe, at least apparently, a decrease in the addressability of this issue to physicians, probably because in the whirlpool of daily life, the schedule and food restrictions imposed for a successful treatment disarm caregivers, leading to a passive attitude that leaves the child alone in his struggle with this condition. The conclusion is briefly the following: the only way to approach pediatric enuresis is a multidisciplinary holistic method based on a team formed ad hoc according to the individual interest in the matter, so that the issue turns from struggle into a purposeful set of actions. Key words: urinary disorder, enuresis


• • • • • •

Oxigenoterapie Aparate pentru diagnosticul şi tratamentul Sindromului de Apnee în Somn Aparate pentru ventilaţie mecanică invazivă şi non invazivă la domiciliu Spirometre şi pulsoximetre Nebulizatoare pentru terapia cu aerosoli Spacere pentru administrarea produselor de astm

Linde Gaz Romania SRL Timisoara 300136, Avram Imbroane nr. 9 Tel +40.256 300 700, Fax +40.256 225 608 Bucuresti 077090, Autostrada A1 Bucuresti – Pitesti km 11,4 Tel +40.21.318–1921, Fax +40.21.318–1920 Iasi: Str. Fundac Gavril Muzicescu, nr. 2, Tel +40.731.770–850

Oradea, Panait Cerna nr. 10–12 Tel +40.733. 770–554 Constanta, Al. Lapusneanu nr. 95, bl. LV31, sc C, ap 41 Tel +40.727. 727–048 Targu Mures, Arany Ianos nr. 54 Tel +40.725. 352–778 www.linde.ro

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Importanţa factorilor ambien tali în fiziologia somnului la copii și adolescenţi • Marina Oţelea Universitatea de Medicina si Farmacie „Carol Davila” București

The importance of environmental factors in sleep physiology in children and adolescents • Marina Oţelea “Carol Davila” University of Medicine and Pharmacy Bucharest 48

Rezumat: Somnul este influenţat de mediul în care se desfășoară, atât in ceea ce priveste calitatea, cât și durata și ciclicitatea perioadei de somn-veghe. Lucrarea și-a propus să sintetizeze principalele date din literatura de specialitate publicate până în prezent privind sursele de poluare a habitatului. Este descrisă influenţa microclimatului, a diferitelor metode de încălzire, a zgomotului, luminii, precum și a noxelor chimice și biologice (fungi, alergeni) asupra calităţii somnului. Un rol aparte este dedicat factorilor psiho-socio-emoţionali și a unor comportamente culturale ale copiilor si adolescenţilor (reţele de socializare, jocuri) asupra somnului. În finalul lucrarii sunt menţionate o serie de intervenţii de educaţie pentru un somn sănătos, precum și recomandările actuale ce derivă din datele prezentate. Cuvinte cheie: poluare, somn sănătos,copii

Abstract: Sleeping is influenced by the environment where it takes place; the environments influences the quality, the duration and the sleep-wake pattern. The presentation gathers the main data from the specialized literature published so far, related to the habitat pollution sources. It describes the influence that the microclimate, the various heating methods, noise, light, as well as chemical and biological emissions (fungi, allergens) have on the quality of sleep. Special attention is paid to the psychological, social and emotional factors, and some types of cultural behaviour in children and adolescents (social networks, games) that have effects on sleep. The work ends by mentioning a series of education interventions required for a healthy sleep and the current recommendations based on the data presented. Key words: pollution, healthy sleep, children

REZUMATE / ABSTRACT


Rezumat: Somnul insuficient devine o problemă de sănătate publică prin consecinţele sale: obezitate, diabet zaharat şi boli cardiovasculare ce caracterizează lumea modernă. Fumatul este în general asociat tulburărilor de somn de tipul: scurtarea acestuia, dificultăţi în iniţierea şi menţinerea lui, sforăit şi somnolenţă diurnă. Aceste tulburări sunt de 2 ori mai frecvente la fumători, indiferent de sex, ednie, asocierea cu alcoolul sau IMC . În mecanismul de producere este implicată nicotina care stimulează eliberarea de dopamină şi serotonină la nivel cerebral determinând tulburări ale somnului. Expunerea la fumul de ţigară a nefumătorului îl face pe acesta să experimenteze aceleaşi efecte ale sevrajului nicotinic în timpul nopţii . La copil sindromul de dezvoltare intrauterină insuficientă (810%) este asociat cu tulburări de somn la copii cu vârste intre 4-7 ani, iar la cei cu greutate sub 1500 mg aceste tulburările pot persista şi în adolescenţă (întârzierea iniţierii somnului). Fumatul matern în timpul sarcinii este cel mai frecvent asociat cu acest sindrom. Tulburările de somn apar la copii cu mame fumătoare indiferent de numărul de ţigări, cu repercursiuni asupra dezvoltării cerebrale, cu modificări fiziologice şi comportamentale ulterioare. Cuvinte cheie: fumat matern, nicotina, copil

Abstract Insufficient sleep is becoming a public health issue because of its consequences: obesity, diabetes, and cardiovascular diseases that characterize modern world. Smoking is generally associated with sleep disorders such as: shortened sleep duration, difficulties in initiating and maintaining sleep, snoring and daytime sleepiness. These disorders are twice as common in smokers irrespective of gender, ethnicity, association with alcohol or BMI. Nicotine is involved in their occurrence mechanism, because it stimulates dopamine and serotonin release in the brain, thus determining sleep disorders. Non-smokers’ exposure to tobacco smoke makes them experience the same effects of nicotine withdrawal during the night. The intrauterine growth restriction syndrome (8-10%) is associated with sleep disorders in children between 4 and 7 years of age, and in children whose weight is below 1500mg these disorders may persist also during adolescence (delay in sleep initiation). Maternal smoking during pregnancy is the most common element associated with this syndrome. Sleep disorders occur in children with smoking mothers irrespective of the number of cigarettes smoked, with consequences for the brain development, and with subsequent physiological and behavioural modifications. Key words: Maternal smoking, nicotine, children

Fumat pasivtulburări de somn la copil • Ioana Munteanu1, Florin Mihalţan2 1. Institutul de pneumologie „Marius Nasta” Bucureşti 2. Universitatea de Medicina si Farmacie „Carol Davila” Bucuresti, Institutul de Pneumologie „Marius Nasta” Bucuresti

Passive smoking – pediatric sleep disorders • Ioana Munteanu1, Florin Mihalțan2 1. “Marius Nasta” Institute of Pulmonology Bucharest 2. “Carol Davila” University of Medicine and Pharmacy, “Marius Nasta” Institute of Pulmonology, Bucharest 49


REZUMATE / ABSTRACT


Somnul copiilor şi DHA Şi copii pot avea probleme de somn ce sunt asociate cu o stare de sănătate precară şi cu probleme de comportament și cognitive. Somnul este esențial pentru starea generală de sănătate a copiilor, iar lipsa unui somn bun poate duce la deteriorarea sănătăţii, a funcționării cognitive şi emoţionale, la deficit de atenție şi tulburări de hiperactivitate (ADHD). Un studiu randomizat, controlat pe un eșantion de copii sănătoși cu vârsta cuprinsă între 7-9 ani din şcoli din Marea Britanie a urmărit legătura dintre concentraţiile de acizi graşi din sânge şi problemele de somn la aceşti copii. Copii au fost evaluaţi obiectiv pe baza unor Chestionare de evaluare a obiceiurilor de somn (despre nr. de treziri pe noapte, durata somnului, etc.) şi s-a observat că în circa 40% din cazuri, copiii aveau probleme clinice de somn. Tratamentul a fost suplimentarea dietei cu acizi graşi Omega-3 DHA (omega-3 acid docosahexaenoic), iar efectele au fost încurajatoare – s-a constatat, în medie, cu şapte mai puţine episoade de trezire și mai mult somn pe noapte cu 58 minute. Importanța acizilor grași cu lanț lung polinesaturaţi (LC-PUFA) pentru inițierea și menținerea unui somn bun sunt cunoscute de mult timp. Din studiile efectuate cu acizi grași a rezultat că acizii grași omega-3 sunt mai eficienţi pentru problemele de somn, iar la pacienţii cu insomnie nu s-au găsit beneficii de la suplimentarea cu omega-6 acidul linoleic (LA). Dar suplimentarea cu acizi graşi Omega-3 a dietei femeilor gravide a condus la un somn mai bun la bebeluşii lor. Mecanismul ar fi următorul: Acidul arahidonic (AA) este un precursor 50 de prostaglandina D2 pentru iniţierea somnului, iar DHA pare esențial

pentru reglarea somnului. Dovezile sugerează că echilibrul de DHA și AA din glanda pineală reglementează producția de melatonină, iar DHA e necesar pentru o enzimă care transformă serotonina în melatonină. În conformitate cu aceste mecanisme, studiile epidemiologice au găsit că nivelurile mai ridicate de acizi graşi omega-3 sunt asociate cu mai puține probleme de somn la copii, dar și la adulți și copii cu ADHD. DHA a fost de asemenea asociat cu tulburări de somn şi apnee mai puțin severe. Uleiurile de peşte LYSI sunt renumite pentru puritatea şi eficienţa lor, Uleiul din ficat de cod islandez fiind cel mai cunoscut pentru aceste caracteristici. Datorită calităţii sale excepţionale, Uleiul din Ficat de Cod pentru copii LYSI se poate administra chiar şi la copiii foarte mici, iar gustul bun şi administrarea uşoară a lichidului, cu linguriţa, îl face accesibil atât copiilor, cât şi persoanelor cu sensibilitate la înghiţire şi persoanelor vârstnice. Conţinut ridicat de DHA mai găsim şi în Omega-3 chewable LYSI, Omega-3 LYSI ulei pur de peşte şi în Omega-3 forte LYSI(pentru adulţi). Puteti descoperi virtuţile acestor uleiuri pentru sănătatea dv. şi a pacientilor dv, găsindu-le în farmacii, plafare şi în magazinul nostru online www.sagasanatate.ro, cu oferte speciale şi produse BONUS. Un somn bun face copii fericiţi!

REZUMATE / ABSTRACT


Rezumat: Identificarea simptomelor nocturne în bolile respiratorii trebuie să preocupe orice clinician în abordarea corectă a diagnosticului, severităţii, nivelului de control (pentru astm) și conduitei terapeutice. Mecanismele fiziopatologice și factorii ce pot favoriza apariţia acestor simptome nocturne sunt variabile: poziţia de clinostatism, asocierea BRGE, ritm hormonal circadian, drenaj sinusal, predominanţa stimulării vagale etc. Prezenţa concomitentă a unor factori de risc: obezitate, modificări cranio-faciale, istoric familial etc. contribuie suplimentar la aparitia simptomatologiei respiratorii în timpul somnului. Astmul nocturn, sindromul de apnee în somn obstructiv, crupul laringian, astmul cu simptome nocturne la gravide și implicaţiile acestora sunt doar o parte a afecţiunilor respiratorii ce vor fi abordate. Cuvinte cheie: boli respiratorii, factori de risc

Exacerbările nocturne ale bolilor respiratorii

Abstract: Identification of nocturnal symptoms in the respiratory diseases should concern any clinician in the approach to diagnosis, severity, level control (for asthma) and therapeutic recommendations. Pathophysiological mechanisms and factors that may promote the appearance of these symptoms are variable: position of clinostatism, GERD (gastro esophageal reflux disease), circadian hormonal rhythms, sinus drainage, stimulation of vagal predominance The existence of simultaneous risk factors: obesity, cranio-facial changes, family history, etc. contribute to the occurrence of respiratory symptoms during sleep. Nocturnal asthma, syndrome of obstructive sleep apnea, croup, asthma with laryngeal nocturnal symptoms in pregnant women and their implications are only part of the respiratory diseases to be addressed. Key words: respiratory diseases, risk factors

Nocturnal exacerbations in respiratory diseases

• Roxana Nemeș Institutul de Pneumologie “Marius Nasta” București

• Roxana Nemeș Institute of Pulmonology “Marius Nasta” Bucharest

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Obezitatea copilului și comorbidităţile ei • Corina Paul1, Iulian Velea2 1,2. Universitatea de Medicina si Farmacie “Victor Babeș” Timișoara

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Rezumat: Obezitatea copilului reprezintă o problema cu implicaţii atât medicale cât și psihologice. Apariţia obezităţii la vârsta copilăriei se asociază cu un risc crescut de obezitate la vârsta adultă și cu toate consecinţele clinice ce implică în special sistemul cardiovascular și cel metabolic. Sindromul de apnee în somn (OSAS) se întâlnește frecvent la copiii obezi; acesta poate amplifica tulburările cardiovasculare și metabolice deja instalate. Diagnosticul și tratamentul precoce al OSAS la copiii obezi pare să diminue consecinţele cardiace și metabolice la acești copii. Autorii prezintă aspecte epidemiologice, etiopatogenice și clinice în obezitatea copilului și comorbidităţile ei, inclusiv sindromul de apnee în somn. Sunt luate în discuţie rezultate ale studiilor din ultimii ani privind implicarea OSAS ca mediator al insulinorezistenţei, dislipidemiei, hipertensiunii și inflamaţiei prin intermediul activării sistemului simpatic, prin hipoxie intermitentă și prin fragmentarea și/sau reducerea duratei somnului. Aceste modificari apărute la vârsta copilăriei predispun copilul obez la comorbidităţi cu atât mai severe cu cât vârsta la care se instalează este mai fragedă. Se recomandă ca managementul copilului obez să fie realizat de către o echipă multidisciplinară care să includă pediatri cu experientă în endocrinologie și nutriţie, cardiologie, pneumologie, ORL precum și un psiholog cu preocupări in domeniu. Cuvinte cheie: obezitatea copilului, sindromul de apnee în somn, echipă multidisciplinară

REZUMATE / ABSTRACT


Abstract: Childhood obesity represents a problem which has medical as well as psychological implications. The occurrence of obesity in childhood is associated with an increased risk of obesity in adulthood and with all the related clinical consequences which involve especially the cardiovascular and metabolic systems. Sleep apnea syndrome (OSAS) is common in obese children; it may increase the severity of already existing cardiovascular and metabolic disorders. Early diagnosis and treatment of OSAS in children with obesity seem to diminish the cardiac and metabolic consequences for these children. The authors present epidemiological, etiopathological and clinical aspects in childhood obesity and its comorbidities, including sleep apnea syndrome. They take into account findings of studies conducted over the last few years regarding OSAS involvement as mediator of insulin resistance, dyslipidemia, hypertension and inflammation by activation of the sympathetic nervous system, by intermittent hypoxia and by fragmentation and/or reduction of sleep duration. These modifications occurring in childhood predispose the obese children to comorbidities whose degree of severity increases as the age of their onset is younger. It is recommended that the management of obese children is carried out by a multidisciplinary team which includes pediatricians with experience in endocrinology and nutrition, cardiology, pulmonology, ENT as well as a psychologist with expertise in this field. Key words: childhood obesity, sleep apnea syndrome, multidisciplinary team

Childhood obesity and its comorbidities • Corina Paul1, Iulian Velea2 1,2. “Victor Babeș” University of Medicine and Pharmacy, Timișoara

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Tulburări de somn la copiii cu neoplazii • Anca Coliţa Universitatea de Medicina si Farmacie “Carol Davila” București

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Rezumat: La copiii cu neoplazii tulburările de somn sunt frecvente și survin direct din cauza lezarii sistemului nervos (tumori cerebrale, neurochirurgie, radioterapie craniană, hidrocefalie) sau indirect datorită efectelor secundare ale chimioterapiei, fatigabilitate asociată cancerului, durere, convulsii, obezitate, endocrinopatii, medicaţie. Academia Americana de Somnologie a împărţit tulburările de somn în cinci categorii majore: 1)Tulburări de iniţiere și menţinere a somnului (insomnia); 2)Tulburări respiratorii în somn (apne de somn); 3)Somnolenţa excesivă (hipersomnia); 4)Tulburări ale ciclului de somn-veghe ( ritmului circadian); 5) Alte tulburări asociate somnului, stadiilor somnului, sau treziri incomplete (parasomnii). Tulburările de somn pot fi exacerbate de sindroamele paraneoplazice asociate metabolismului steroid și de simptome asociate invaziei tumorale, cum sunt leziunile de drenaj, tulburări gastrointestinale (GI) și genitourinare (GU), durere, febră, tuse, dispnee, prurit si fatigabilitate. Medicaţia – inclusiv corticoterapia, neurolepticele pentru greaţă și vărsături, precum și alţi factori asociaţi tratamentului, pot altera cursul normal al somnului. La adulţi, între 30-70% din rândul pacienţilor nou diagnosticaţi sau trataţi pentru cancer, au tulburări de somn, procente aproape duble faţă de restul populaţiei. Nu au fost efectuate studii prospective asupra tulburărilor de somn la copii cu cancer; astfel o prevalenţă exactă a tulburărilor de somn la acești copii este necunoscută. Somnolenţa diurnă excesivă (EDS- Excessive daytime sleepiness) este cea mai frecventă tulburare de somn la copiii cu cancer, mai ales la cei cu tumori cerebrale. Dexametazona folosită în tratamentul de consolidare la pacienţii cu leucemie limfoblastică acută este asociată cu tulburări de somn și de comportament. La copiii spitalizaţi somnul este frecvent înterupt din cauza orarului de administrare a medicaţiei, a rutinelor de îngrijire și a colegilor de cameră, care pot sa fie singura cauză sau să se adauge la alte tulburări ale ritmului circadian. Alţi factori care influenţează ciclul de somn veghe în spital sunt vârsta pacienţilor, durerea și anxietatea, zgomotul de fond și temperatura. Tulburările de somn influenţează rezultatele terapiei și ale măsurilor suportive.Copiii cu tulburări de somn ușoare sau moderate sunt iritabili, se concentrează cu dificultate, sunt mai necomplianţi la protocoalele de tratament, au alterată capacitatea de a lua decizii sau de a interacţiona. Depresia și anxietatea sunt de asemenea cauze de tulburări de somn. Măsurile suportive sunt orientate către îmbunătăţirea calităţii vieţii și a somnului. Cuvinte cheie: sindroame paraneoplazice, ciclul somn-veghe, tulburări de somn, depresie, anxietate

REZUMATE / ABSTRACT


Abstract: Sleep is often disturbed in children with cancer either by direct result of brain injury (brain tumor, neurosurgery, cranial radiation therapy, hydrocephaly) or by indirect result of chemotherapy, cancer related fatigue, pain, seizures, obesity, endocrinopathies, medication. Five major categories of sleep disorders have been defined by the Sleep Disorders Classification Committee of the American Academy of Sleep Medicine : 1)Disorders of initiating and maintaining sleep (insomnias), 2) Sleep-related breathing disorders (sleep apnea), 3) Disorders of excessive somnolence (hypersomnias), 4) Disorders of the sleep-wake cycle (circadian rhythm sleep disorders), 5) Dysfunctions associated with sleep, sleep stages, or partial arousals (parasomnias). Sleep disturbances may be exacerbated by paraneoplastic syndromes associated with steroid production and by symptoms associated with tumor invasion, such as draining lesions, gastrointestinal (GI) and genitourinary (GU) alterations, pain, fever, cough, dyspnea, pruritus, and fatigue. Medications — including, corticosteroids, neuroleptics for nausea and vomiting, as well as other treatment factors can negatively impact sleep patterns. In adults, sleep disturbances are reported in 30%-75% of newly diagnosed or recently treated cancer patients, a rate that is almost double that of the general population. There have been no prospective studies of sleep problems in children with cancer; therefore, the exact prevalence of sleep problems in children with cancer is unknown. Excessive daytime sleepiness (EDS) is the most common sleeping disorder in children with cancer, particularly among children with brain tumors. Dexamethasone use during the consolidation therapy for patients with acute lymphoblastic leukemia is associated with sleep disorders and behavioral modifications. The sleep of hospitalized children is likely to be frequently interrupted by treatment schedules, hospital routines, and roommates, which singularly or collectively alter the sleep-wake cycle. Other factors influencing sleep-wake cycles in the hospital setting include patient age, comfort, pain, and anxiety; and environmental noise and temperature. Consequences of sleep disturbances can influence outcomes of therapeutic and supportive care measures. The child with mild to moderate sleep disturbances may experience irritability and inability to concentrate, which may in turn affect the patient’s compliance with treatment protocols, ability to make decisions, and relationships with significant others. Depression and anxiety can also be caused by sleep disturbances. Supportive care measures are directed toward promoting quality of life and adequate rest. Key words: paraneoplastic syndromes, sleep-wake cycle, sleep disorders, depression, anxiety

Sleep disorders in children with cancer • Anca Coliţa “Carol Davila” University of Medicine and Pharmacy Bucharest

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Somnul – o povară genetică? • Vasilica Plăiașu Institutul pentru Ocrotirea Mamei si Copilului ”Alfred Rusescu”, București

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Rezumat: Somnul și starea de veghe reprezintă comportamente complexe care sunt influenţate de numeroși factori genetici și de mediu. Tulburările de somn influenţează activitatea zilnică, pot afecta sănătatea și longevitatea, cu impact dramatic la nivel medical, social și economic. Descifrarea mecanismelor moleculare ale somnului și identificarea bazelor genetice ale tulburărilor de somn sunt principalele strategii actuale de cercetare în domeniul somnologiei. Bolile monogenice care determină tulburari de somn sunt rare, iar majoritatea bolilor comune care afectează somnul sunt complexe, implicând susceptibilitatea genetică, efectele de mediu, interacţiunile intergenice, respectiv între genă și mediu. Studiile familiale și pe gemeni au indicat o influenţă importantă a factorilor genetici în apariţia tulburărilor de somn. Orice disfuncţie în expresia și reglarea somnului produce o tulburare complexă de somn care necesită investigaţii integrate clinice și de laborator. Tulburările de somn reprezintă un fenomen comun și interesează toate grupele de vârstă. Dar există și sindroame genetice, cu o bază genetică binecunoscută, care asociază în tabloul clinic modificări ale duratei și calităţii somnului. Afecţiuni precum sindromul Smith-Magenis, sindromul Angelman, sindromul Rett, sindromul Prader-Willi, sindromul Kleine-Levin, sindromul Smith-Lemli-Opitz, acondroplazia sunt exemple de boli genetice rare care asociază tulburări de somn. Diagnosticul acestor conditii este suspectat clinic, susţinut prin analize genetice specifice, iar managementul cazurilor este complex, multidisciplinar, incluzând și specialiști în patologia somnului. Tulburările de somn de cauză monogenică (ex. insomnia familială fatală, sindromul de fază de somn avansat, insomnia primară) sunt rar întâlnite în practică, dar produc alterari severe ale somnului, iar riscul de recurenţă este mare. Consilierea genetică este extrem de importantă pentru profilaxia noilor cazuri în familiile afectate de tulburări ale somnului. Cuvinte cheie: sindroame genetice, susceptibilitatea genetică, insomnia.

REZUMATE / ABSTRACT


Abstract: Sleep and wakefulness represent complex behaviours influenced by a large number of genetic and environmental factors. Sleep disorders influence daily activities, they may affect health and longevity, having a dramatic medical, social and economic impact. Deciphering the molecular mechanisms of sleep and identifying the genetic basis of sleep disorders are the main current research strategies in the field of sleep medicine. Monogenic diseases causing sleep disorders are rare, and the majority of common diseases which affect sleep are complex, involving genetic predisposition, environmental effects, intergenic interactions, and interactions between genes and the environment, respectively. The clinical trials performed in families and twins show an important influence of the genetic factors on the occurrence of sleep disorders. Any dysfunction in sleep expression and regulation causes a complex sleep disorder which requires integrated clinical and laboratory investigations. Sleep disorders represent a common phenomenon which is encountered in all age groups. However, there are also genetic syndromes, with a well-known genetic basis, whose clinical framework associates modifications of both duration and quality of sleep. Conditions such as Smith-Magenis syndrome, Angelman syndrome, Rett syndrome, Prader-Willi syndrome, Kleine-Levin syndrome, Smith-Lemli-Opitz syndrome, achondroplasia are examples of rare genetic conditions which involve sleep disorders. The diagnosis of these diseases is suspected clinically and supported by specific genetic testing, and their case management is complex, multidisciplinary, including also specialists in sleep pathology. Monogenic sleep disorders (e.g. fatal familial insomnia, advanced sleep phase disorder, primary insomnia) are rarely encountered in practice, but they cause severe sleep impairment, and have a high recurrence risk. Genetic counselling is extremely important for the prophylaxis of new cases in the families affected by sleep disorders. Key words: genetic syndromes , genetic predisposition, insomnia

Sleep – a genetic burden? • Vasilica Plăiașu Institute for Mother and Child Care “Alfred Rusescu”, Bucharest

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Reducerea progresiei miopiei la copii și adolescenţi cu lentile de contact ortokeratologice purtate în timpul somnului • Daniela Goicea Clinica Focus Optic București

Reduction in myopia progression in children and adolescents with orthokeratology lenses worn during sleep • Daniela Goicea Focus Optic Clinic, Bucharest

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Rezumat: Miopia afectează un sfert din populatia globului, iar până în 2020 se estimează o creștere a numărului de miopi până la o treime. Apariţia și evoluţia miopiei sunt influenţate atât de factori genetici cât și de mediu. Un copil care are ambii părinţi miopi are un risc de 80% de a deveni miop. Urbanizarea și activităţile la aproape, cum ar fi cititul și lucrul la calculator, cresc incidenţa miopiei. La copil miopia crește în medie cu 0.5 dioptrii/an. De exemplu, un copil cu o miopie de -1.0 D la 8 ani ar putea ajunge la -5.0 D la 16 ani. Miopia mare este asociată cu dublarea riscului de afecţiuni oculare grave, cum ar fi dezlipirea de retină și glaucomul. Prin urmare, reducerea progresiei miopiei are importanţa covârșitoare, în special la copii. O posibilitate este portul lentilelor de contact ortokeratologice în timpul somnului. Ortokeratologia presupune remodelarea corneei cu ajutorul lentilelor de contact rigide, cu design special, în timpul nopţii, având ca efect vedere clară fara ochelari sau lentile de contact în timpul zilei. Tratamentul este complet reversibil și neinvaziv. Studiile arată că purtarea lentilelor de contact ortokeratologice poate reduce progresia miopiei cu 50%. Cuvinte cheie: miopia, lentile de contact, ortokeratologie

Abstract: Myopia affects a quarter of the world population, and until 2020 there is an estimation of an increase in the number of myopic individuals up to a third. The occurrence and evolution of myopia are influenced by genetic factors as well as the environment. A child whose both parents are myopic has an 80% risk of becoming myopic himself, as well. Urbanization and close up activities, such as reading and computer work, increase the incidence of myopia. Myopia increases by an average of 0.5 diopters/year in children. For instance, a child with -1.0 D myopia at the age of 8 might get to -5.0 D at 16. High myopia is associated with the doubling of the risk for severe eye diseases, such as retinal detachment and glaucoma. Therefore, the reduction of myopia progression is of great importance especially in children. One way to do this is wearing orthokeratology lenses during sleep. Orthokeratology implies the remodelling of the cornea by wearing specially designed rigid contact lenses during the night, with clear vision effect without glasses, or wearing contacts during the day. The treatment is completely reversible and noninvasive. Studies have shown that wearing orthokeratology lenses may reduce myopia progression by 50%. Key words: myopia, contact lenses, orthokeratology

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Rezumat: Pentru diagnosticul tulburărilor respiratorii în timpul somnului, istoricul pacientului și examinarea fizică reprezintă factori puțin relevanți de prognostic, iar evaluarea funcției respiratorii în timpul stării de veghe nu este de ajutor pentru depistarea modificărilor în schimbul de gaze din timpul somnului. Polisomnografia (PSG) reprezintă o extensie a evaluării clinice care furnizează date fiziologice importante cu privire la multe aspecte, în principal ale funcției respiratorii în timpul somnului. PSG este recomandată ca investigaţie de elecţie la copiii cu suspiciune de SASO. Alte indicaţii pentru PSG o constituie bolile neuromusculare, bolile pulmonare cronice, apneea centrală, titrarea CPAP, parasomniile, periodic limb movement disorder (PLMS), somnolenţa excesivă diurnă (ex: narcolepsia). Daca polisomnografia nu este disponibilă, se pot recomanda alte investigaţii alternative: înregistrarea video în timpul nopţii, pulsoximetria nocturnă, PSG în ambulator. Este necesar ca echipamentele și regulile de interpretare sa fie adaptate vârstei, iar rezultatele obţinute la PSG să fie integrate cu observaţia clinică. Cuvinte cheie: polisomnografie, funcţia respiratorie, somnolenţa diurnă.

Abstract: Patient history and physical examination are poor predictors of sleep-disordered breathing, and the assessment of the respiratory function during wakefulness is not helpful in detecting altered gas exchange during sleep. Polysomnography (PSG) represents an extension of the clinical evaluation, providing important physiological data on many aspects regarding mainly the respiratory function during sleep. PSG is indicated as elective investigation when the clinical assessment suggests the diagnosis of obstructive sleep apnea syndrome in children. Other indications for PSG are neuromuscular disease, chronic pulmonary disease, central sleep apnea, CPAP titration, parasomnias, Periodic Limb Movement Disorder (PLMS), excessive daytime sleepiness (e.g. narcolepsy). If polysomnography is not available, clinicians may order alternative diagnostic tests: nocturnal video recording, nocturnal oximetry, ambulatory polysomnography. It is necessary that the equipment and the rules of interpretation are adjusted to age, and the PSG findings are integrated with the clinical evaluation. Key words: polysomnography, respiratory function, daytime sleepiness.

Ce este polisomno grafia si care sunt indicatiile ei. Alte metode de investigare a tulburarilor de somn • Mihaela Oros Clinica de Pediatrie Medicover, București

What is polysom nography and what are its indications. Other methods of investigation of sleep disorders • Mihaela Oros Medicover Pediatric Clinic, Bucharest

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Tulburările de somn la copil în practica medicului de familie. Studiu clinic între anii 2002-2012 • Herdea Valeria, Herdea(Comnea) Laura, Herdea Teodor, Herdea(Soldea) Lidia, Herdea Alexandru-Dan Bucuresti

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Rezumat: Introducere: Frecvenţa mare a tulburărilor legate de somn la copil, în practica de medicină de familie, cu impact major asupra dezvoltării armonioase a acestuia, provocările impuse de găsirea unor soluţii de prevenire și tratament optimizat, pentru pacienţii proprii, au determinat demararea prezentului studiu. Scopul: Studiul a urmarit identificarea cauzelor responsabile de frecventa crescuta a a tulburarilor legate de somn la copil , posibilitatile de profilaxie, diagnostic corect si tratament ţintit, rata de apariţie a complicaţiilor cu impact asupra calităţii vieţii pacienţilor, în condiţiile în care în ultimii ani, accesibilitatea populaţiei la serviciile medicale a crescut. Obiective: 1.Cuantificarea problematicii tulburărilor de somn la copil, în practica de cabinet; 2.Studiul relaţiei cauză - efect, în patologia somnului la copiii urmariţi.Caz clinic; 3.Analiza de impact a metodelor de profilaxie, diagnostic și tratament precoce în îmbunătătirea prognosticului quo ad vitam la pacienţii cu tulburări de somn (fisa de inerventie); 4.Echipa interdisciplinară. Proiectare si metode: În intervalul 2003-2012, au fost efectuate în cadrul cabinetului 107.822 de consultaţii-copii și adulţi. Dintre aceștia, serviciilor medicale li se adresează aprox 71,5% copiii sub 18 ani. Circa 20% vin doar pentru acuze legate de somn. O analiză a acestor tulburări a relevat multiple cauze: 34,5% sunt de cauză organică (34% epilepsie, 26% inclusi în sindroamele de tulburări funcţionale cerebrale, 2,5% tumori, 8% stari posttraumatice, 15,5% patologie infectioasă, 7% boli autoimmune, 7% alte cauze) iar 65,5% sunt funcţionale. Sunt prezentate aspecte ale muncii de cabinet de medicină de familie: algoritmul de abordare al pacientului, modelul fișei de intervenţie la caz (monitorizare), aspecte legate de distribuţia pe vârstă, sexe, apartenenţa socio-economică, școlarizare, comorbidităţi, tratamente urmate, problemele colaborării interdisciplinare - provocări și rezultate. Concluzii: 1.În ultimii 10 ani adresabilitatea către serviciile medicale, în problematica tulburărilor de somn a crescut cu peste 15%; 2.Paleta de afecţiuni, pentru care “tulburarea de somn” reprezintă doar un vârf de iceberg este vastă și îngrijirea lor extrem de reponsabilizantă pentru medicul de familie; 3.Este importantă dezvoltarea unui sistem de up-grade educaţional, în rândul cadrelor medicale-medici și asistenţi medicali, parinţi, aparţinători și nu în ultimul rând al pacienţilor înșiși, pentru prezentare, depistare activă precoce, diagnostic si monitorizare, întrucât implicaţiile pe termen lung a tulburărilor de somn sunt împovărătoare și de cele mai multe ori cu impact asupra întregii existenţe a individului. Cuvinte cheie: tulburări de somn, medicină de familie, servicii medicale, depistare activă precoce.

REZUMATE / ABSTRACT


Abstract: Introduction: The present study was conducted as a result of the high incidence of pediatric sleep disorders in family medicine practice, with a major impact on the harmonious child development, and because of the challenges imposed by finding solutions for prevention and optimized treatment for our patients. Goal: The study aimed to identify the causes responsible for the increased incidence of pediatric sleep-related disorders, the possibilities of prevention, correct diagnosis and targeted treatment, the incidence rate of the complications with impact on the patient quality of life, given that the accessibility of population to medical services has increased over the past few years. Objectives: 1.Quantification of the pediatric sleep disorder issue, in the physician office daily practice; 2.Study of the cause and effect relationship in the sleep pathology in children undergoing follow-up. Clinical case; 3.The impact analysis of early prevention, diagnosis and treatment methods in the improvement of quo ad vitam prognostic in patients with sleep disorders. (intervention sheet); 4.Interdisciplinary team Designing and methods: Between 2003 and 2012, there were 107.822 doctor’s visits – children and adults, about 71.5% of whom are children aged under 18. About 20% of them came only with sleep-related complaints. An analysis of these disorders revealed multiple causes: 34.5% have an organic origin (34% epilepsy, 26% brain functional disorders syndrome, 2.5% tumors, 8% posttraumatic state, 15.5% infectious disease, 7% autoimmune disease, 7% other causes) and 65.5% are functional. We will present aspects related to the family medicine office work: the algorithm of patient approach, the template of the case intervention (follow-up) sheet, aspects related to the distribution according to age, gender, social and economic status, education, comorbidities, treatments taken, the issues regarding interdisciplinary collaboration, challenges and results. Conclusions: 1.The addressability of the sleep disorders to health services increased by more than 15% over the past 10 years; 2.There is a wide range of diseases for which sleep disorders represent just the tip of the iceberg, and providing medical care for these diseases puts great responsibility on the family physicians; 3.It is important to develop an educational upgrade system among health-care professionals – doctors and nurses, parents, caregivers, and last but not least among patients, in order for the problem to be addressed, early and actively detected, diagnosed and monitored, as the long-term implications of sleep disorders are burdensome and most of the times with impact on the entire individual existence. Key words: sleep disorders, family medicine, medical services, early and actively detected

Pediatric sleep disorders in family medicine practice. Clinical trial between 2002 and 2012 • Herdea Valeria, Herdea (Comnea) Laura, Herdea Teodor, Herdea (Soldea) Lidia, Herdea Alexandru-Dan Bucharest

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REZUMATE / ABSTRACT


Ce trebuie sa știm despre indicaţiile de CPAP/BiPAP la copiii cu tulburări respiratorii în timpul somnului • Mihaela Oros Clinica de Pediatrie Medicover, București

What we should know about the indications for CPAP/BiPAP in children with sleep-disordered breathing • Mihaela Oros Medicover Pediatric Clinic, Bucharest

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Rezumat: La copiii cu tulburări respiratorii în timpul somnului strategiile de tratament sunt adresate mecanismelor ce stau la baza acestora. Adenoamigdalectomia este terapia de primă linie pentru OSAS la copil, însă până la 50-75% dintre copiii pot avea IAH rezidual. Pentru identificarea IAH rezidual este indicată PSG postoperatorie în special la copiii cu forme severe. Terapia cu CPAP este o opţiune pentru cei care nu au indicaţie chirurgicală sau nu răspund la tratamentul chirurgical. Este utilizat temporar în OSAS severe asociate cu sindroame genetice, obezitate, paralizie cerebrală, afecţiuni neurologice sau musculare. La pacienţii cu boli neuromusculare iniţierea ventilaţiei noninvazive în stadiul precoce, cu hipercapnie doar în timpul nopţii, crește calitatea vieţii și întârzie apariţia hipercapniei diurne. Pentru titrare este indicată polisomnografia. La copii terapia cu CPAP/BiPAP necesită mai multe ore de somn comparativ cu adultul si include training-ul părinţilor. Cuvinte cheie: OSAS, copil, boli neuromusculare

Abstract: The treatment strategies in children with sleep-disordered breathing address the underlying mechanisms of these disorders. Adenotonsillectomy is the first-line treatment for OSAS in children, but up to 50-75% of the cases may experience residual IAH. In order to identify residual IAH, postoperative PSG is indicated especially in children with severe forms. CPAP therapy represents an option for those who don’t have indication for surgery or don’t respond to surgical treatment. CPAP is used temporarily in severe OSAS associated with genetic syndromes, obesity, cerebral palsy, neurologic or muscular diseases. The initiation of noninvasive ventilation in the early stage of the disease, with hypercapnia only during the night, increases the quality of life and delays occurrence of daytime hypercapnia in patients with neuromuscular diseases. For titration polysomnography is indicated. CPAP/BiPAP therapy in children requires more hours of sleep than in adults and includes also parents’ training. Key words: OSAS, children, neuromuscular diseases

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A 2-a Conferinţă de Somnologie Pediatrică cu participare internationala, 12 - 15 iunie 2014, Sinaia, Romania The 2nd Conference of Pediatric Sleep Medicine with international participation, June 12 – 15, 2014, Sinaia Romania

Sinaia, Romania, 2014 ar fi bine aici sa scriem .... congresul... conferinta.... 63


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Rinita alergica si tulburarile de somn - o legatura care trebuie recunoscuta • Mihai Craiu Universitatea de Medicina si Farmacie “Carol Davila”, Institutul pentru Ocrotirea Mamei si Copilului ”Alfred Rusescu”, București

Figura 1 – Preșcolar de sex feminin, 5 ani cu RA severă având cearcăne palpebrale violacee, linii Morgan-Dennie și umbră nazală indusă de prurit („allergic salute”) / Female preschooler, aged 5, with severe AR, having violet eye shadows, Morgan- Dennie lines and „allergic salute”

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Introducere Rinita, atât cea alergică cat și cea nealergică, este extrem de frecvent întâlnită la copii, in condițiile creșterii constante a gradului de urbanizare al populației, in paralel cu accentuarea globală a poluării și cu schimbările condițiilor de macro și microclimat. In ciuda frecventei extrem de crescute a rinitei alergice la copiii din țările dezvoltate, afecțiunea este deseori ignorată de părinți și minimalizată de medic [1]. In pofida acestei abordări simplificatoare, afectarea căii aeriene din rinită contribuie semnificativ la pierderea controlului sau la agravarea astmului, la unii pacienți (conceptul lansat de Prof Jean Bousquet „united airways disease” [2]). Aceste două elemente (frecventa ridicată a unei boli privita ca trivială, rolul in evoluția și agravarea astmului) au fost motivul elaborării ghidului ARIA de către un numeros grup de experți in domeniul alergologiei, pneumologiei, ORL, somnologiei, etc [2]. Din păcate implementarea recomandărilor ghidului ARIA este neomogenă și încă insuficient de dezvoltată, fiind necesare eforturi de popularizare ale acestor recomandări cu ajutorul unor mijloace educaționale adecvate nivelului de comunicare actuală, dominat de formatul electronic și de interacțiunea virtuală cu ajutorul motoarelor de căutare de pe internet[3]. Rinita alergică Rinita alergică (RA) este situată la capătul spectrului unei afecțiuni sistemice [4], care reflectă mecanisme patogenice nu numai ale întregii căi aeriene [„united airways disease”] ci ale întregului organism [inflamația eozinofilică, IgE mediată]. Rinita alergică trebuie privită ca un semnal al unor procese care ar putea să afecteze întregul organism. Preocupările pentru studiul RA sunt numeroase și se reflectă in cele aproape 22000 de articole din PubMed [5]. Pneumologul pediatru ar trebui să fie implicat activ in recunoașterea și managementul RA deoarece există o strânsă conexiune intre astm (cea mai frecventă boală cronică a copilului [6]) și RA după cum o dovedesc cele peste 9500 de articole PubMed. Prevalenta asocierii dintre rinita alergică și astm este înaltă, in jur de 21-64% [7], iar a RA „izolata” este variabilă in funcție de mulți factori [genotip, climat, expunere ambientală, etc] având valori maxime in jur de 2/3 din toți pacienții atopici [8]. 25% din pacienții cu RA au și conjunctivită manifestă [7]. La copilul cu RA trebuie in mod activ căutate atât comorbiditatile posibile (astm, conjunctivită) dar și posibilele complicații (otita medie seroasă, sinuzită, tulburări de somn, anomalii dento-faciale). Recunoașterea RA se poate face de către medicul de familie, urmărind cele mai frecvente simptome asociate. Frecventa acestora este întâlnită in cursul unei luni cu intensitate mare a bolii (worst month score) in 43% din zile pentru rinoree apoasă, 41% congestie nazală, 37% strănut, 35% prurit nazal, 16% lacrimare excesivă, 15% tuse reflexă, 14% prurit ocular, 14% diminuarea capacității olfactive, 12% senzație de gâdilat in gat si 8% cefalee. Acestora li se pot asocia și semne evocatorii: edem palpebral cu tentă violacee, desen vascular vizibil și linii palpebrale Morgan-Dennie (figura 1), secreții seroase ce se scurg din cavum (sindrom descendent, post-nasal drip syndrome, in 18% din zile), și

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creastă nazală indusă de pruritul nazal repetitiv, de obicei cu dosul palmei sub forma unei mișcări ascendente de ștergere (figura 2). Manifestări clinice care nu sunt de obicei asociate RA (conform ghidului ARIA[2]): manifestări nazale unilaterale, obstrucție nazală izolată, fără alte simptome, rinoree purulentă, durere locală, epistaxis recurent și anosmie. Deseori pacienții cu rinită alergică au tulburări de somn. Printre tulburările de somn descrise la copiii alergici sunt dissomniile și parasomniile (opoziția la adormire, somn întrerupt și tulburări respiratorii în cursul somnului]. Afecțiunile alergice asociate cel mai des cu opoziția la adormire sunt alergia alimentară și dermatita atopică, iar rinita alergică a fost cel mai frecvent asociată cu sforăitul și cu trezirile nocturne [9]. Calitatea vieții acestor copii este modificată și are impact asupra întregii familii deoarece și calitatea somnului părinților lor este modificată. Un studiu recent [10] a dovedit o scădere semnificativă a calității somnului la părinții copiilor cu rinită sau astm (Pittsburg Sleep Quality Index [PSQI] cu o valoare medie de 6.6, 75% din părinții acestor copii având un scor mai mare sau egal cu 5). In mod interesant aproape toți acești părinți [91%] nu au relatat în mod spontan medicului despre calitatea proastă a somnului propriilor copii [9]. Tulburările de somn există mai frecvent la pacienții atopici cu astm sau rinită, decât la non-atopici, chiar și în absenta obezității, care era considerată în trecut ca fiind un factor major de risc [11]. Apneea obstructivă de somn [OSA – obstructive sleep apnea] coexistă deseori cu afecțiunile alergice, în special cu astmul. La copii cu OSA rinita este descrisă la aproape jumătate din pacienți – 43% [12]. La pacienții astmatici cu OSA magnitudinea desaturărilor în faza de somn REM și OAHI (Obstructive apnea-hypopnea index) sunt mai severe decât la cei care au doar OSA și nu au astm [11]. La copii cu OSA și rinită deși nu există un indice de apnee-hipopnee mai mare (OAHI), în general, pe durata somnului REM, acesta (OAHI) este semnificativ crescut [12]. In cazul în care există suspiciunea de diagnostic pacientul cu RA trebuie abordat de o echipă multidisciplinară [ORL-ist, pneumolog, alergolog, somnolog] pentru a putea încadra severitatea și tipul acesteia (rinită intermitentă/persistentă, rinită ușoară/severă) și pentru a putea personaliza tratamentul necesar și pentru a putea aborda familia în ansamblul ei. Concluzii Rinita alergică trebuie suspectată la un copil alergic si trebuie în mod activ căutată la pacienții astmatici (deoarece aceștia ar putea pierde controlul bolii daca au RA netratată), la cei cu tuse cronică si la cei cu tulburări de somn (OSA). Planul de acțiune în fata acestor pacienți presupune o abordare personalizată, prin colaborarea mai multor specialiști - pneumolog, alergolog, ORL-ist, somnolog, etc si vizează familia acestor pacienți în ansamblul ei. Metodele de abordare ale familiei și pacientului trebuie să reflecte progresul noilor mijloace de comunicare ale epocii virtuale și internetului.

Figura 2 – Creastă nazală transversală (allergic salute) indusă de pruritul nazal repetitiv / Transverse nasal crest (“allergic salute”) induced by the repetitive nasal itching

Figura 3 – Sindrom descendent (de notat lipsa hiperemiei marcate evocatorii pentru un proces infecțios, aspectul „granulos” al orofaringelui și secrețiile sero-mucoase ce se scurg din cavum / Postnasal drip syndrome (one must note the lack of the infectious-suggesting hyperemia, the granules aspect of the oropharinx and the sero-mucous secretions dripping from the cavum)

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Allergic rhinitis and sleep disorders – a correlation that has to be acknowledged • Mihai Craiu “Carol Davila” University of Medicine Bucharest, Institute for Mother and Child Care “Alfred Rusescu” Bucharest

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Introduction Both allergic and non-allergic rhinitis are extremely common in children, given the constant urbanizing of the population, corroborated with the increase in global pollution and the microand macro- climate changes. Despite its increased frequency in developed countries, allergic rhinitis in children is often ignored by the parents and down-staged by the doctors [1]. Regardless of this simplified approach, the airways pathology in rhinitis is a main contributor to decompensating or aggravating asthma in some patients (Prof Jean Bousquet even proposes the concept of “united airways disease” [2]). These two elements (the high incidence of a trivially regarded disease and its role in the evolution and aggravation of asthma) have determined a group of experts in allergology, respiratory diseases specialists, ENT, somnology etc. to develop the ARIA guide [2]. Unfortunately, implementing the recommendations of the ARIA guide remains inhomogeneous and insufficiently developed. Marketing efforts are much needed to make these guidelines available through adequate educational means, such as an electronic format and the availability of a visual interaction through internet search engines [3]. Allergic rhinitis Allergic rhinitis (AR) represents the edge of the spectrum of a systemic disorder [4] that reflects pathogenic mechanisms that involve not only the whole airways [„united airways disease”], but also the entire body [IgE mediated eosinophilic inflammation] it must be regarded as a series of process that might affect the whole body. The concern for the study of AR is extensive, with nearly 22000 articles on Pub Med dealing with this topic [5]. The pediatric respiratory diseases specialist should be actively involved in recognizing and managing AR, given the strong connection between asthma (the most frequent disease in children [6]) and AR, as it has been shown in over 9500 PubMed articles. The prevalence of the AR-asthma association has been found to be high, between 21-64% [7], by several studies. Isolated AR is variable depending on various factors (genotype, climate, environmental exposure, etc.) with a maximal value around 2/3 of the patients with atopic terrain [8]. 25% of the AR patients also had manifest conjunctivitis [7]. In children with AR it is important to search for both possible comorbidities (asthma, conjunctivitis), as well as for possible complications (serous otitis media, sinusitis, sleep disorders, dental and facial abnormalities). The general practitioner should include AR in differential diagnosis with a high index of suspicion when confronted with recurrent respiratory symptoms. They occur frequently in months with a high intensity of the disease (“worst month score”), with 43% of the AR patients having watery rhinorrhea, 41% having nasal congestion, 37% sneezing, 35% having nasal itching, 16% with excessive tearing, 15% with reflex coughing, 14% with eyes itching, 14% with hypoosmia, 12% with tickly throat sensation and 8% with headaches. Suggestive symptoms might accompany these features: purplish eye lid edema, visible blood vessels and Morgan-Dennie eye lid lines (fig.1), serous secretions dripping from the cavum (descendent, post-nasal drip syndrome, in 18% of

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days), and nasal crest induced by the repeated nose itch, usually by the back of the hand through and upper wiping movement (“allergic salute”) (fig.2) Clinical symptoms that are not usually associated with AR (according to the ARIA guide[2]): unilateral nasal symptoms, isolated nasal obstruction, with no other symptoms, suppurative rhinorrhea, local pain, recurring epistaxis and anosmia. Rhinitis patients often have sleep disorders. Dissomnias and parasomnias (opposition to sleep, fragmented sleep, breathing disorders during sleep) are some of the sleep disorders of allergic children. The most commonly associated allergic disorders with refusal to go to sleep are the food allergy and atopic dermatitis. Allergic rhinitis is most commonly associated with snoring and frequent waking-ups during the night [9]. The quality of life of these children is modified and this affects the whole family, as the quality of the parents’ sleep might also be altered. A recent study [10] has shown a marked decrease in the sleep quality of parents of children with asthma or rhinitis (Pittsburg Sleep Quality Index [PSQI] was applied, with an average result of 6.6, 75% of the parents of children with these pathologies having scores of 5 or more). Interestingly, a vast majority of these parents (91%) did not spontaneously tell their doctor about their children’s poor sleep [9]. Sleep disorders are more frequent in atopic patients with asthma or rhinitis than in non-atopic ones, even in the absence of obesity, which had previously been considered a major risk factor [11]. Obstructive sleep apnea (OSA) often coexists with allergic disorders, especially with asthma. Some studies have described rhinitis in almost half (43%) of the OSA patients [12]. In OSA asthmatic patients, the magnitude of REM desaturations and the obstructive apnea-hypopnea index (OAHI) are higher than in those with OSA, only [11]. In children with OSA and AR, even if OAHI is not globally higher, it does increase significantly during REM sleep [12]. If AR is suspected, the case should be approached by a multidisciplinary team (ENT specialist, pneumologist, allergologist, sleep pathology specialist) in order to determine the severity and the type of the disorder (intermittent/persistent rhinitis, easy or severe form) and to be able to personalize the treatment and the family approach. Conclusions Allergic rhinitis should be suspected in allergic children and it must systematically be researched in asthma patients (as they might not be able to achieve control of their disorder if AR is left untreated), in patients with chronic cough and in those with sleep disorders (OSA). The action plan for these patients involves a personalized approach, through the collaboration of several specialists - allergologist, ENT, respiratory diseases and sleep disorders specialists, etc. – in order to address the patient’s whole family. This approach should also reflect progress of the new communication means in the internet virtual era.

Bibliography 1. Chawes BL – Upper and lower airway pathology in young children with allergic- and nonallergic rhinitis. Dan Med Bull. 2011;58(5):B4278 2. Brozek JL, Bousquet J, Baena-Cagnani CE et al – Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010;126(3):466-76. 3. König V, Mösges R.J – A model for the determination of pollen count using google search queries for patients suffering from allergic rhinitis. Allergy (Cairo). 2014:381983. Epub 2014 Jun 19. 4. Morjaria JB et al – Preventing progression of allergic rhinitis to asthma. Curr Allergy Asthma Rep. 2014;14(2):412. 5. *** - Allergic Rhinitis in PubMed in http:// www.ncbi.nlm.nih.gov/pubmed/?term=allergic+ rhinitis accessed on the 15th of August 2014. 6. Papadopoulos NG et al – International consensus on (ICON) pediatric asthma. Allergy 2012;67(8):976-97. 7. Kim HY et al – Prevalence and comorbidity of allergic diseases in preschool children. Korean J Pediatr. 2013;56(8):338-42. 8. Hong S et al – The prevalence of atopic dermatitis, asthma, and allergic rhinitis and the comorbidity of allergic diseases in children. Environ Health Toxicol. 2012 ;27:e2012006. 9. Wasilewska J, Kaczmarski M et al – [Sleep disorders in childhood and adolescence, with special reference to allergic diseases]. Pol Merkur Lekarski. 2009;26(153):188-93. 10. Ridolo E, Caffarelli C et al – Quality of sleep in allergic children and their parents. Allergol Immunopathol (Madr). 2014 Jun 16. pii: S03010546(14)00054-8. doi: 10.1016/j.aller.2014.01.004. [Epub ahead of print] 11. Guttierez MJ, Zhu J et al – Nocturnal phenotypical features of obstructive sleep apnea (OSA) in asthmatic children. Pediatr Pulmonol. 2013;48(6):592-600. doi: 10.1002/ppul.22713. Epub 2012 Nov 30 . 12. Huseni S, Guttierez MJ et al – The link between rhinitis and rapid-eye-movement sleep breathing disturbances in children with obstructive sleep apnea. Am J Rhinol Allergy. 2014;28(1):e56-61.

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MEETINGS CALENDAR 28-30 august 2014, Vama, Bucovina Protocoale in Boli Respiratorii 6-10 septembrie 2014, Munich, Germany European Respiratory Society International Congress 16–20 septembrie 2014, Tallinn, Estonia 22nd Congress of the European Sleep Research Society ESRS event 8-11 octombrie 2014, Hotel Ramada, Sibiu Congresul Societatii Romane de Pneumologie 30 octombrie - 1 noiembrie 2014, Hotel International, Iasi Conferinta Zilele Pediatriei Iesene “N.N. Trifan”, ed. a XXVII-a 20-21 noiembrie 2014, Hotel International, Oradea Conferinta de Boli Pulmonare Rare - prima editie 16-19 aprilie 2015, Budapest CoPedia 2015 - 2nd World Congress on Controversis in Pediatrics 16-18 aprilie 2015, Barcelona, Spain ESRS event Sleep and Breathing 6-10 June 2015, Seatle, US Sleep 2015 19-20 iunie 2015, Budapest Pneumo Update Europe 2015 29 June - 03 July 2015, Lugano, Switzerland 3rd Alpine Sleep Summer School (ASSS) A course in sleep medicine 17 September 2014, Vienna , Austria Austrian Society for Pediatrics and adolescent medicine 52nd annual meeting 26-30 septembrie 2015, Budapest European Respiratory Society Congress 2015 17-21 October 2014, Barcelona, Spania 5th Congress of the European Academy of Paediatric Societies (EAPS 2014) 31 Oct – 3 Nov 2015, Istanbul, Turkey, ESRS event, Worldsleep 2015 - 7th World Congress of the World Sleep Federation

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BOOK REVIEW


Stephen H. Sheldon is DO, FAAP, Professor, Pediatrics, Northwestern University Feinberg School of Medicine; Director, Sleep Medicine Center, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois. His research and practice explore sleep disorders in children, while his advocacy efforts encourage a new model for this field—one that establishes this discipline by medical school training, specific residencies, increased fellowships, devoted associations, clinical certifications, and awareness campaigns. Richard Ferber, MD, Professor of Medicine, Yale School of Medicine, Pulmonary, Critical Care and Sleep Medicine, New Haven, Connecticut. He has been researching sleep and sleep disorders in children for over 20 years. He is best known for his methods—popularly called Ferberization—which purport to teach young infants to learn how to fall asleep on their own. Meir H. Kryger, MD, Associate Professor of Neurology, Harvard Medical School Director, Center for Pediatric Sleep Disorders Children’s Hospital Boston. His research has spanned all areas of sleep breathing disorders. He has published more than 200 research articles and book chapters. He established the first laboratory to study patients with sleep breathing problems in Canada, and was the first to diagnose and report obstructive sleep apnea in North America. David Gozal, MD, Professor and Chairman, Department of Pediatrics, Comer Children’s Hospital, The University of Chicago, is a leading expert in the treatment of pediatric sleep disorders, the developmental neurobiology of respiratory control, and sleep-disordered breathing. He is known as a pioneer in the study of childhood sleep problems, and the relationships between sleep disorders and neurobehavioral, cardiovascular, and metabolic disease. In a recent interview, Dr. Sheldon said: “When it comes to children, sleep is as important as food. Sleep is not a passive process but an active one, and we all do better when we sleep well. If you just look at growth and development, we know that sleep is a neurodevelopmental process, similar to walking and talking. And just like children can’t walk or talk like adults, they can’t sleep like adults.” (http://www.sleepreviewmag.com/2013) Knowing this, an expanded understanding of the pathophysiology, epidemiology, clinical evaluation methods and treatment options of common pediatric sleep disorders, is the key to a rational approach to the diagnosis and management of these children in clinical settings. The book helps to separate practice of pediatric sleep medicine from the sphere of adult medicine and represent additional meaningful steps in the development of pediatric sleep medicine as a distinct discipline. The book is structured in 2 parts – one part which contains information about principles and basic science of pediatric sleep medicine, and another part describing practical and clinical science in sleep-related disturbances that are most prevalent in the pediatric population. The 49 chapters of this book compile the expertise of the leading pediatric sleep researchers and clinicians in the field of sleep medicine. This edition contains new and expanded chapters regarding sleep related breathing disorders, parasomnias, differential diagnosis of pediatric sleep disorders, hypersomnia, school start times and their implications, and the evaluation and management of circadian rhythm disturbances. It also includes extensive information about obstructive sleep apnea, diagnosis and treatment, evaluation and management of sleepy children, evaluation and management of circadian rhythm abnormalities, and pharmacology. This book is the most comprehensive source for diagnosing and managing sleep disorders in children. Newly updated, this medical reference book is internationally recognized as the definitive resource for any health practitioner who treats children, providing absolute guidance on virtually all of the sleep-associated problems encountered in pediatric patients.

PRINCIPLES AND PRACTICE OF PEDIATRIC SLEEP MEDICINE Stephen H. Sheldon, Meir H. Kryger, Richard Ferber, David Gozal Elsevier Inc., 2014

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Oliviero Bruni Associate Professor of Child Neurology and Psychiatry President of the International Pediatric Sleep Association Pediatric Field Editor – Sleep Medicine Dept of Social and Developmental Psychology Sapienza University - Rome (Italy)

It is my pleasure to present the \\\ Congress of the International Pediatric Sleep Association (IPSA), which will be held in Porto Alegre (Brazil) 3-5 December 2014. The importance of sleep for health, learning and psychomotor development in infancy, childhood and adolescence has been emphasized in the pediatric research in the last two decades and it has become more and more evident that ensuring a good sleep during development is of key importance for a later healthy life. The IPSA Congress is an influential forum for sleep practitioners from around the world to network and exchange views, whilst learning from world-class researchers about the latest scientific and clinical developments in the field. The success of the last two Congresses in Rome 2010 and Manchester 2012 has highlighted the magnitude of Pediatric Sleep Medicine in the scientific community and we hope that the 2014 Congress will provide a perfect balance between didactic and practical needs, in order to provide the technical knowhow and up-todate knowledge that will enable participants to improve their practice. As traditional for IPSA, the most renowned International opinion leaders in the field of Pediatric Sleep Medicine speakers will join the Congress and will highlight the recent significant advances in both basic science and clinical sleep medicine during development. I hope that the world paediatric sleep community will gather together in the lively city of Porto Alegre to celebrate the best clinical practice and the latest advances in Pediatric Sleep Medicine.

Oliviero Bruni

President of the International Pediatric Sleep Association

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List of Contributors Ioana Anca, MD, PhD Professor, University of Medicine and Pharmacy “Carol Davila”, Institute for Mother and Child Care “Prof. Dr. Alfred Rusescu”, Bucharest, Romania Cristina Gianina Anghel, MD, PhDc • Assistant Professor Child and Adolescent Psychiatry, University of Medicine and Pharmacy “Carol Davila” • Specialist Doctor in Child and Adolescent Psychiatry Department “Prof. Dr. Al. Obregia” , Hospital of Psychiatry, Bucharest, Romania Gheorghe Chiriac-Babei, MD, PhD Lecturer, Pediatrician and nephrologist, Certified in Pediatric nephrology and dialysis, Medical Director Medicover Hospital Bucharest, Romania Cristian Baicus, MD, PhD Professor, University of Medicine and Pharmacy “Carol Davila” Internal Medicine, Colentina Hospital, Bucharest, Romania Lucia Baranga, MD Pediatric specialist, Medicover Pediatric Clinic, Bucharest, Romania Diana Barca, MD, PhDc Assistant Professor, University of Medicine and Pharmacy “Carol Davila” Specialist, Pediatric Neurology, Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania Daniela Boișteanu, MD, PhD Associate Professor, University of Medicine and Pharmacy “Gr.T.Popa”, Certified in Sleep Medicine, Clinic of Pulmonary Diseases Iași, Romania Ana Maria Bolchis, MD Pediatric specialist, Medicover Pediatric Clinic, Bucharest, Romania Oliviero Bruni, MD Associate Professor of Child Neurology and Psychiatry, President of the International Pediatric Sleep Association, Pediatric Field Editor – Sleep Medicine, Dept of Social and Developmental Psychology, Sapienza University, Rome, Italy Magdalena Budisteanu, MD, PhD Lecturer, University of Medicine and Pharmacy “Titu Maiorescu”, Senior Physician, Pediatric Neurology Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania Marin Burlea, MD, PhD Professor, President of Romanian Pediatric Society Iasi, Romania Carmen Burloiu, MD, PhD Senior Physician, Pediatric Neurology Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest Niculina Butoianu, MD, PhD Assistant Professor, University of Medicine and Pharmacy “Carol Davila”, Senior Physician, Pediatric Neurology Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania

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Dana Craiu, MD, PhD Professor of Pediatric Neurology, University of Medicine and Pharmacy “Carol Davila”, Senior Physician, Pediatric Neurology Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania Mihai Craiu, MD, PhD Associate Professor, “ University of Medicine and Pharmacy “Carol Davila”, Certified in Pediatric pulmonology Head of IInd Pediatric Clinic, Head of Emergency Department, Institute for Mother and Child Care “Prof. Dr. Alfred Rusescu”, Bucharest, Romania Oana Deleanu, MD, PhDc Assistant Professor, University of Medicine and Pharmacy “Carol Davila”, Certified in Sleep Medicine, President of SSVNI, “Marius Nasta” Institute of Pulmonology, Bucharest, Romania Alexandru Dina Physiotherapists, Master Of Physiotherapy Medicover Pediatric Clinic, Bucharest, Romania Iuliana Dobrescu, MD, PhD Professor Child and Adolescent Psychiatry, University of Medicine and Pharmacy “Carol Davila”, Head of Child and Adolescent Psychiatry Department “Prof. Dr. Al. Obregia” Hospital of Psychiatry, Honorary President of Romanian Association of Child and Adolescent Psychiatry and Allied Professions (RACAPAP), Bucharest, Romania Ștefan Dumitrache-Rujinski, MD, PhD Assistant Professor, University of Medicine and Pharmacy “Carol Davila”, Certified in Sleep Medicine, “Marius Nasta” Institute of Pulmonology, Bucharest, Romania Dan Gheorghe, MD, PhD Associate Professor, University of Medicine and Pharmacy “Carol Davila”, ENT Clinic, “M.S.Curie” Hospital, Bucharest, Romania Daniela Goicea, MD Ophthalmologists, Focus Optic Bucharest, Romania Aviv D. Goldbart, MD, MSc Department of Pediatrics, Pediatric Pulmonary and Sleep Research Laboratory, Sleep-Wake Disorders Center, Soroka University Medical Center,Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel Valeria Herdea, MD Senior General Practitioner, Private Practice Bucharest, Romania Alexandru Dan Herdea, MD Student “ University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania Catrinel Iliescu, MD, PhD Assistant Professor, University of Medicine and Pharmacy “Carol Davila” Senior Physician, Pediatric Neurology, Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania

Paraschiva Chereches-Panta, MD, PhD Lecturer, University of Medicine and Pharmacy “Iuliu Hatieganu”, IIIrd Pediatric Clinic, Cluj – Napoca, Romania

Diana Ionescu, MD, PhD Head of ENT Department Childrens Hospital “Dr. Victor Gomoiu” Bucharest, Romania

Sorina Chindris, MD Pediatrician, Pediatrics and Neurology Clinic, “Victor Gomoiu” Children’s Clinical Hospital, Bucharest

Adelaida Iorgulescu, MD ENT Clinic , Childrens Hospital “Grigore Alexandrescu”, Bucharest, Romania

Anca Colita, MD, PhD Associate Professor, University of Medicine and Pharmacy “Carol Davila”, Pediatric Clinic, Fundeni Clinical Institute, Bucharest, Romania

Daniela Ivascu, MD Specialist in pulmonology, “New Medics” Clinic Bucharest, Romania

Comnea Laura, MD General Practitioner, Private Practice Bucharest, Romania

Reinhold Kerbl, MD Professor of Pediatrics and Adolescent Medicine Leoben, Austria


Liana Kobylinska, MD Resident in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department “Prof. Dr. Al. Obregia” Hospital of Psychiatry, Bucharest, Romania

Vasilica Plăiașu, MD, PhD Clinical Genetics, Genetics Department, Institute for Mother and Child Care “Prof. Dr. Alfred Rusescu”, Bucharest, Romania

Martin Konermann, MD, PhD Professor Internal Medicine, Cardiologie, Angiologie, Intensive care, Sleep Medicine, Kassel, Germany

Diana Pocora, MD Resident in pulmonology,“Marius Nasta” Institute of Pulmonology, Bucharest, Romania

Sorin Man, MD, PhD Associate Professor, University of Medicine and Pharmacy “Iuliu Hatieganu”, IIIrd Pediatric Discipline, Certified in Pediatric pulmonology, Cluj– Napoca, Romania Mauro Manconi, MD, PhD Head of Sleep and Epilepsy Center Neurocenter of Southern Switzerland Regional Hospital of Lugano (EOC), Lugano, Switzerland Tamara-Marcela Marcovici MD, PhD Lecturer, University of Medicine and Pharmacy “Victor Babes”, Pediatrician, Certified in Pediatric respiratory medicine, “Louis Turcanu” Children’s Emergency Hospital, Timisoara, Romania Florin Mihaltan, MD, PhD Professor, University of Medicine and Pharmacy “Carol Davila”, Certified in Sleep Medicine, National Coordinator of Sleep Training Program, “Marius Nasta” Institute of Pulmonology, Bucharest Stefan Dan Mihaicuta, MD, PhD, FCCP Sleep Medicine Expert , University of Medicine and Pharmacy “Victor Babes”, Pulmonolgy Clinic, Timisoara, Romania Ilinca Mihailescu, MD, PhDc Resident in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department “Prof. Dr. Al. Obregia” Hospital of Psychiatry, Bucharest, Romania Crenguta Momirla, MD Pediatric specialist, Medicover Pediatric Clinic, Bucharest, Romania Cristina Motoescu, MD, PhD Assistant Professor, University of Medicine and Pharmacy “Carol Davila”, Senior Physician Pediatric Neurology Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania Ioana Munteanu, MD, PhD Senior physician in pulmonology, “Marius Nasta” Institute of Pulmonology, Bucharest, Romania Roxana Nemes, MD, PhD Senior physician in pulmonology, Scientific researcher Head of Pulmonary Function Test Department “Marius Nasta” Institute of Pulmonology, Bucharest, Romania Dumitru Oraseanu, MD, PhD Professor, University of Medicine and Pharmacy “Carol Davila”, Childrens Hospital “Grigore Alexandrescu”, Bucharest, Romania Mihaela Oros, MD, PhDc Pediatrician, Certified in Sleep Medicine, Certified in Pediatric respiratory medicine Head of Medicover Pediatric Clinic, Bucharest, Romania Marina Otelea, MD, PhD Associate lecturer, Physiopathology II, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania Corina Paul, MD, PhD Lecturer, University of Medicine and Pharmacy “Victor Babes”, Clinic II Pediatrics - Clinical Emergency County Hospital, Timisoara, Romania

Cristina Pomeran, MD, PhDc Specialist in Pediatric Neurology, Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania Florina Rad, MD, PhD Assistant Professor Child and Adolescent Psychiatry, University of Medicine and Pharmacy “Carol Davila”, Specialist Doctor in Child and Adolescent Psychiatry Department “Prof. Dr. Al. Obregia” Hospital of Psychiatry, Bucharest, Romania Hemant Sawnani, MD Assistant Professor, Division of Pulmonology and Section of Sleep Medicine The Comprehensive Neuromuscular Program Cincinnati Children’s Hospital Medical Center, USA Laurent Servais, MD, PhD Child Neurologist Institut de Myologie Paris, France Narong Simakajornboon, MD Professor, Division of Pulmonary Medicine Director, Sleep Disorders Center Director, Sleep Fellowship Training Program Cincinnati Children’s Hospital Medical Center, USA Daniela Stefanescu, MD General Practitioner, Trainer, Bucharest, Romania Soldea Lidia, MD Resident in nutrition and metabolic disease, Bucharest, Romania Oana Tarta-Arsene, MD, PhD Assistant Professor, University of Medicine and Pharmacy “Carol Davila” Senior Physician, Pediatric Neurology, Pediatric Neurology Clinic, “Al. Obregia” Hospital, Bucharest, Romania Raluca Teleanu, MD, PhD Associate Professor, University of Medicine and Pharmacy “Carol Davila”, Head of Pediatric Neurology Department Childrens Hospital “Victor Gomoiu”, Bucharest, Romania Doina Adina Todea, MD, PhD Associate Professor, University of Medicine and Pharmacy “Iuliu Hatieganu”, Certified in Sleep Medicine, Sleep Laboratory Coordinator, Clinical Hospital of Pneumology “Leon Daniello”, Cluj–Napoca, Romania Magne Tvinnereim, MD, Ph.D Specialist in Oto-rhino-Laryngology International Accredited Sleep specialist CEO of Eurosleep Intl. & Spiromedical ltd. Norway Raluca Vasiluta, MD Clinic of Pulmonary Diseases Iași, Romania Iulian Velea, MD, PhD Associate Professor, University of Medicine and Pharmacy “ Victor Babes” Timisoara Clinic II Pediatrics - Clinical Emergency County Hospital Timisoara, Romania

Doina Anca Plesca, MD, PhD Professor, Department of Pediatric and Pediatric Neurology University of Medicine and Pharmacy “ Carol Davila”, Childrens Clinical Hospital “Victor Gomoiu”, Bucharest, Romania

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INFORMATION FOR AUTHORS Purpose The Romanian Journal of Pediatric Sleep Medicine is the official publication of the Romanian Association for Pediatric Sleep Disorders. The Romanian Association for Pediatric Sleep Disorders aims to develop scientific, research and medical training activities in order to build and expand the knowledge of pediatric sleep disorders in Romania. Types of manuscripts The journal is published two times per year and papers are accepted for publication in English and Romanian language. There are several categories of material: editorial, original articles (clinical and basic research), case presentations, reviews, letters to the editor, advertisements. Authors are invited to submit manuscripts electronically via email: journal@....... Manuscript format The text should be in single-column format. Keep the layout of the text as simple as possible. Most formatting codes will be removed and replaced on processing the article. Do not break and hyphenate words. Use the word processor’s options only to justify or center text, bold face, italics, underline, subscripts, and superscripts. Do not embed “graphically designed” equations or tables, but prepare these using the Word processor’s facility. Do not import the figures or tables into the text file but, instead, indicate their approximate locations directly in the electronic text and on the manuscript. Footnotes in text are not permitted. Italics are used for expressions of Latin origin. Abbreviations (except standard units of measurement) should be identified on first use. Introduce an abbreviation only when the same term occurs three or more times. Pages should be numbered consecutively and organized as follows: Title, Abstract and Keywords, Main text, Acknowledgments, References, Tables, Figures, Graphics and Schemes (with captions). Title The title page should include: (1) – title of the article, short and descriptive; (2) – first name and last name of each author; (3) – names of departments and institutions with which authors are associated; (4) – postal address, phone/fax numbers, and e-mail of the corresponding author. Ensure that phone and fax numbers (with country and area code) are provided in addition to the e-mail and the complete postal address. Abstract and Keywords A concise abstract of less than 250 words is required. The abstract should briefly state the purpose of the research, the main results and major conclusions. The abstract is presented separately from the article, so it must be able to stand alone. At the end of the abstract provide a maximum of 6 keywords. Abbreviations should not be used in the abstract. Main text The manuscript should be written clearly and concisely. The author is responsible for providing the correct nomenclature, which must be consistent and unambiguous. The text should be arranged in the following order: Introduction, Materials and Methods, Results, Discussion, and Conclusions. Each section should be clearly marked by a separate, numbered heading and may be numbered down to the third order. The introduction should be a brief overview of the topic. The body of the text should describe the topic in an orderly manner, using subheadings to divide the various sections. A few summary paragraphs should conclude the paper. Be sure to display line number (1, 2 , 3, and so forth) in the left margin of the manuscript. Acknowledgments Place acknowledgments, including information on grants received, before the references, in a separate section, and not as a footnote on the title page. References Responsibility for the accuracy of bibliographic citations lies entirely with the authors. Please ensure that every reference cited in the text is also present in the reference list (and vice versa). Any references cited in the abstract must be given in full. Unpublished results and personal communications should not be in the reference

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list, but may be mentioned in the text. Citation of a reference as “in press” implies that the item has been accepted for publication. References (indicated by numbers in square brackets) should be cited in consecutive order of their appearance in the text. The complete references must be reproduced at the end of the manuscript. List names of all the authors. References should be typed in the following style: For journals: Author’s name. (Year of publication). Title of article. Title of Journal, volume number (issue number), pages. For books: author’s name (Year of publication), Title of book. Editor, pages. Tables, Figures and Schemes Tables, Figures and Schemes are to be typed in this order, on separate pages at the end of the manuscript. Ensure that each illustration or table has a caption attached, which should comprise a brief title and a description. Keep text in the illustrations to a minimum, but explain all symbols and abbreviations used. Tables should be on separate sheets, one table per sheet, and should bear a short descriptive title. Number tables consecutively, in accordance with their appearance in the text. Place footnotes to tables below the table body and indicate them with superscript lowercase letters. Avoid vertical rules and shading. Be sparing in the use of tables and ensure that the data presented in tables do not duplicate results described elsewhere in the article. Figures and Schemes should be cited and consecutively numbered with Arabic numerals, according to their order of appearance in the main text. Mark the appropriate position of a figure/scheme in the text. Graphics and schemes are suitable for mention as figures. Ensure that high-resolution graphics files are provided, even if the graphic appears as part of your normal word-processed text file. Peer-reviewed The following types of contribution to the journals are peerreviewed: Articles, Technical Reports, Analysis, Reviews and Insight articles. All forms of published correction may also be peer-reviewed at the discretion of the editors. Other contributed articles are not usually peer-reviewed. Nevertheless, articles published in these sections, particularly if they present technical information, may be peer-reviewed at the discretion of the editors. For any general questions and comments about the peer-review process, the journal or its editorial policies that are not addressed here, we encourage reviewers to contact us. Questions about a specific manuscript should be directed to the editor who is handling the manuscript. Proofs Unless indicated otherwise, proofs are sent to the corresponding author and should be returned with the least possible delay. Alterations other than the correction of printer’s errors are charged to the author. Copyright In case the paper is accepted for publication, copyright will be transferred to the Romanian Journal of Pediatric Sleep Medicine. Authors must agree to undertake all responsibility for the scientific content and originality of the paper; the Romanian Journal of Pediatric Sleep Medicine will take no responsibility whatsoever in this respect. It is the author’s responsibility to obtain permission to reproduce illustrations, tables, etc. from other publications. Conflicts of interest Authors must state all possible conflicts of interest in the manuscript, including financial, consulting, institutional and other relationships that might lead to bias or a conflict of interest. If there is no conflict of interest, this should also be explicitly stated as none declared. All sources of funding should be acknowledged in the manuscript. All relevant conflicts of interest and sources of funding should be included in the “Acknowledgements” section in the manuscript. Summary: - send the material in electronic format in both Romanian and English - use 1.5 line spacing for the entire text - attach an abstract of less than 250 words at the beginning of the paper - include a statement of agreement by all authors as to the content of the paper - include a commercial interest and financial disclosure statement - fulfill the manuscript preparation and submission requirements - papers that do not meet these criteria will not be accepted for publication


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