Q&A: Epilepsy in children negatively affects sleep duration, quality

Children with epilepsy experienced more sleep-related problems such as night waking, parasomnias and sleep-disordered breathing than children without epilepsy, according to a meta-analysis published in Sleep Medicine Reviews.

The analysis, which included 19 studies that compared a total of 901 children with epilepsy and 1,470 healthy children, also revealed “decreased sleep efficiency” in children with epilepsy compared with healthy children. According to the researchers, the results suggested that screening patients for sleep-related issues “should be an integral part” of diagnosing epilepsy to effectively manage those issues.

Healio Neurology spoke with Alice Winsor, MSc, BSc, a doctoral researcher in the Center for Human Brain Health at the University of Birmingham in the United Kingdom, about the ways in which the study results may affect clinical practice, as well as the unmet needs in pediatric epilepsy.

Healio Neurology: What prompted this research?

Winsor: This research is part of a wider project investigating sleep in children with rolandic epilepsy, which is an epilepsy type that is considered ‘benign’ in terms of its clinical course due to the low seizure count and the fact that seizures typically remit during the adolescent years. However, this group of children often report an increased prevalence of psychopathologies, including depression and anxiety, reduced academic performance and poorer quality of life. As sleep and epilepsy are known to interact, and given that sleep has a widespread impact on various areas of functioning, our research hypothesizes that sleep disruption may be a factor that underlies many of the adverse impacts of epilepsy on both children and their families. This is not only seen in this epilepsy type but across epilepsies, whether seizures predominantly occur during sleep or not. Our research aims to quantify what areas of sleep children with epilepsy appear to show disturbances in and how these issues impact wider quality of life.

Healio Neurology: What is currently known about the bidirectional relationship between epilepsy and sleep?

Winsor: The association between sleep and epilepsy is underpinned by various mechanisms. When looking at the influence of epilepsy on sleep, seizures can disrupt transitions through the sleep/wake cycle, resulting in sleep deprivation and daytime drowsiness, and increase the propensity for another seizure to occur. Interictal epileptic discharge — EEG manifestations that occur between seizures — have been found to promote arousals from sleep and ultimately interfere with normal sleep patterns. Another precipitating factor in sleep difficulties includes the medical treatment of epilepsy itself because antiepileptic drugs (AEDs) can alter sleep architecture and increase fatigue.

In looking at the influence of sleep on epilepsy, non-rapid eye movement (NREM) sleep can serve as an activating environment to an epileptic brain, increasing the occurrence and use of AEDs, whereas the desynchronized state in rapid eye movement (REM) sleep exerts an opposite influence. Reduced sleep duration can have various effects on interictal epileptic discharges, altering their frequency and shape in childhood epilepsies. Circadian rhythmicity has also been found to exert a modulating influence on seizure timing in different epilepsies along with various other factors, including type of epilepsy or seizure and age of onset.

Healio Neurology: What did your literature analysis highlight about the negative effects of this relationship?

Winsor: Our literature analysis highlighted the negative effects of epilepsy on various aspects of sleep. We found that across both objective and parent report measures, children with epilepsy were observed to be more vulnerable to sleep disturbances compared with children without epilepsy. Moreover, children with epilepsy slept, on average, 34 minutes less per night than those without epilepsy. They also had significantly worse and more frequent sleep problems, including night waking, parasomnias and sleep-disordered breathing. Further, children with epilepsy had lower sleep quality, which was defined as the portion of time spent asleep when in bed. Finally, in terms of sleep stages, children with epilepsy showed a reduced percentage of REM sleep and a higher percentage of light sleep (NREM2), indicating disturbances in the continuity of the sleep cycle.

Healio Neurology: What do providers do, if anything, to integrate sleep hygiene into epilepsy care?

Winsor: Based on the findings of our review, whereby both objective measures of sleep (actigraphy) and parent-reported measures (questionnaires) correlated well, we believe that characterizing sleep habits at diagnosis gives clinicians the opportunity to manage epilepsy better. We recommend either of the sleep assessments discussed above be integrated into clinical practice, depending on the ease of application. These assessments can help provide a more comprehensive measure of sleep hygiene, while recognizing and effectively treating sleep problems may help reduce recurrent seizures and improve functioning.

Healio Neurology: What are the greatest unmet needs in this setting?

Winsor: Various areas of priorities in pediatric epilepsy care have been highlighted in previous research. The most consistent area that has been identified is the need to include a broader set of treatment outcomes. These include not only seizure control, which is extremely important, but also inclusion of behavioral, academic, social and mental functioning. A more holistic approach to epilepsy management may help to improve wider quality of life for the child. Further, epilepsy can have systemic effects on the wider family. Families have identified a lack of detailed information, specifically concerning co-occurring conditions and emotional support, which can compromise the families’ ability to access specific services. More support regarding an understanding of the wider impacts of their child’s epilepsy and how to cope with adjustments can improve overall wellbeing for families.

Healio Neurology: What additional research is needed to improve sleep-related issues for children with epilepsy?

Winsor: Our current research points toward an interaction of co-occurring conditions with sleep, such as neurodevelopmental disorders including autism and ADHD. More research is needed concerning this relationship and the impact of addressing these conditions on quality of life. Our literature analysis also highlighted that future research should aim to extend current findings to investigate whether poor quality of sleep with co-occurring epilepsy has a greater consequence on quality of life, academic attainment and mental health compared with healthy children. Finally, studies should also aim to develop interventions to investigate whether improving sleep habits has an impact on health-related quality of life and seizure outcomes.

Reference:

Winsor AA, et al. Sleep Med Rev. 2021;doi:10.1016/j.smrv.2021.101416.