Sleep Disruption in Childhood Epilepsy
Introduction
My name is Alice Winsor1, and I am a PhD2 student working in the Centre for Human Brain Health3 and with the Richards Lab4 at the University of Birmingham5, under the supervision of Drs Andrew Bagshaw6 and Caroline Richards7. Our research is focused on investigating the mechanisms and impact of sleep disruption in children with epilepsy, with a particular focus on rolandic epilepsy8. This is a collaborative project with Birmingham Children’s Hospital9 and Worcestershire Royal Hospital10. Our overall aim is to improve the understanding of the interaction between epilepsy and sleep. To do this, we want to quantify how sleep is affected by and affects the daytime function, behaviour and quality of life of children with epilepsy.
Sleep and Epilepsy
Sleep and epilepsy have a strong and bidirectional association. Sleep disturbances are commonly experienced by children with epilepsy and can be due to multiple factors. These include seizures, which can disrupt the continuity of sleep, and lead to daytime sleepiness and an increased occurrence of further seizures the next day. Similarly, Anti-Epileptic Drugs (AEDs) can alter sleep architecture11 and induce drowsiness. There is also evidence that children with epilepsy are more likely to suffer from sleep disorders, such as parasomnias12 (e.g. sleep walking) and sleep-related breathing disorders.
There can also be more specific interactions between epilepsy and sleep that depend on sleep stage. For example, in Non-Rapid Eye Movement sleep, there are specific neurophysiological processes occurring which promote the spread of interictal13 epileptiform14 discharges (small pathological discharges characteristic of epilepsy occurring between seizures). AEDs have been suggested to facilitate arousal from sleep, which may partially account for the high density found in children with epilepsy and co-occurring sleep disorders e.g parasomnias. In Rapid Eye Movement15 sleep, these processes are inhibited making it less likely for the epileptiform discharges to be spread. Sleep deprivation can also reduce the threshold for the occurrence of a subsequent seizure and this risk is highest within the two days after sleep deprivation. Unfortunately, if sleep disturbances aren’t addressed, this cycle continues and can lead to exacerbation of seizures and later impairments in quality of life.
Figure 1. The cyclical interaction between sleep and epilepsy
Sleep disruption in children and adolescents with epilepsy: A systematic review and meta-analysis
Our team recently conducted a review which aimed to synthesise and collate previous studies which investigated sleep parameters in children with epilepsy compared to children without. It is hoped that by quantifying which aspects of sleep are affected in children with epilepsy, possible treatment options may be developed. The review included 19 studies comparing a total of 901 children with epilepsy to 1470 healthy children. We found significant differences between children with and without epilepsy across both subjective and objective measures of sleep. These include reduced sleep time, with children with epilepsy sleeping on average 34 minutes less compared to children without epilepsy. They also experienced significantly increased percentage of N2 sleep (part of REM sleep) and decreased sleep efficiency16 (the proportion of time spent asleep in relation to the amount of time spent in bed). Finally, we found that children with epilepsy had more frequent and severe sleep difficulties, specifically in the domains of night waking, parasomnias and Sleep Disordered Breathing17. These results illustrate that children with epilepsy are particularly vulnerable to sleep difficulties and further support the need for screening of sleep difficulties at the diagnosis stage to ensure they are identified early. This may help in seizure control, but also more generally in improving quality of life and mental wellbeing.
Figure 2. Meta-analytic findings comparing children with epilepsy (CWE) and children without epilepsy across various sleep parameters including total sleep time, sleep efficiency, sleep difficulties and sleep architecture
Research Visits
A major role of my PhD centres around recruitment of families and children with epilepsy for our study. This involves meeting with families whose children are attending a sleep video-EEG (video telemetry)18 at one of our participating hospitals. There I discuss what our research will involve, why it’s important and what both the child and parent will be required to do. If families agree to take part, they sign a consent and assent form for their child (if under 16). We provide parents with a questionnaire pack which provides us with information on their child’s behaviour, sleep, quality of life and seizures. I then provide the child with a wrist activity monitor called an Actiwatch19, which is worn for a period of two weeks and measures their habitual sleep patterns. Parents also complete a sleep diary for this period of time which helps us when analysing the data, in case there is anything unusual in sleep and wake up timings measured with the watch. After the families’ participation is complete, I am able to score the questionnaires and analyse the Actiwatch data, to provide them with a feedback report. This can be helpful in providing information about their child’s sleep and any particular areas of concern. We then signpost families to resources which can be used to improve sleep hygiene at home for both parents and children.
Dissemination of research
A really important aspect of our research is to provide a better understanding of the role of sleep in epilepsy. In order to achieve this aim, we actively take part in as wide a range of events as possible. Some of these include conferences such as the International League Against Epilepsy British branch20 annual scientific meeting, where we presented our review on sleep disruption in children and adolescents with epilepsy. We have also presented work at the launch of the Institute of Mental Health and Centre for Human Brain Health21. We also recently visited secondary schools across Birmingham, where we presented information on the importance of sleep for wellbeing in students. Brain Awareness Week22 and National Epilepsy Week23 are also great opportunities for us to share our message.
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