Any vision of urban sustainability is incomplete without a commitment to human sustainability, yet many urban environments often create conditions that compromise children's sleep. These environments shape disparities in pediatric sleep health through multifaceted pathways, with socioeconomic and housing conditions serving as major drivers. Housing not only reflects socioeconomic status but also mediates children's sleep environments and their exposure to extreme weather events. However, urban-scale assessments of sleep disparities remain scarce due to limited population-level data on sleep health and environmental exposures. This study introduces the SLeep and Environmental Exposure evaluation framework for urban Populations (SLEEP), a bottom-up approach for assessing urban sleep health disparities in response to climate events (i.e., wildfire smoke) across 13 U.S. cities. SLEEP is further validated by comparing its results with sleep-related indicators from an independent nationwide dataset. Our results reveal substantial variation in pediatric sleep outcomes across cities, primarily driven by housing conditions. Children living in multifamily dwellings, overcrowded households, and rental units face elevated risks. Physical housing characteristics emerge as key determinants. These findings demonstrate how housing conditions amplify children's vulnerability to climate stressors, reinforcing sleep health disparities rooted in broader socioeconomic disadvantages.

To identify clinical characteristics that may be associated with persistence or progression of mild sleep-disordered breathing (SDB) in children who are observed without surgery. This is a secondary analysis of the control arm of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), which randomized 458 children aged 3.0 to 12.9 years with mild SDB (snoring with obstructive apnea–hypopnea index [oAHI] < 3 events/hour) to early adenotonsillectomy (eAT) versus watchful waiting with supportive care (WWSC). Participants were assessed at baseline and 12 months with the Pediatric Sleep Questionnaire–Sleep-Related Breathing Disorder (PSQ-SRBD) scale and polysomnography (PSG). We tested for factors predictive of either (1) PSG progression defined by a 12-month oAHI ≥ 3 or (2) symptom persistence or progression defined by a 12-month PSQ-SRBD score ≥ 0.33. A total of 234 participants were observed (mean age 6.2 years, 111 [47

Sleep health is a critical yet often overlooked dimension of pediatric patient recovery in hospitals. Conventional ventilation design primarily targets infection control and energy efficiency, with limited consideration of sleeppromoting environmental factors. Meanwhile, the growing prevalence of wildfire smoke exposure, now a major contributor to PM2.5 exposure in the United States, further challenges hospital indoor air quality (IAQ) and patient well-being. This study develops a sleep health-driven ventilation control framework to enhance hospital resilience to wildfire smoke while maintaining energy efficiency. The proposed approach integrates a pediatric sleep health model into Heating, Ventilation, and Air Conditioning (HVAC) operation strategies and is assessed using EnergyPlus simulations of a prototype hospital across 16 climate representative cities in the United States. Baseline and health-driven strategies were compared under varying air-side economizer and filtration configurations, assessed by obstructive sleep apnea (OSA) exceedance hours, energy consumption, and utility costs. Results show that the sleep health-driven strategy consistently improved IAQ, reducing OSA exceedance hours by up to 201 h (13.4%) and lowering energy use by up to 13.1 kWh/m2. Compared with the sleep health-driven only strategy, the strategy combined with economizer control achieved additional energy savings of up to 6.2%, with OSA exceedance hours increased slightly by 41 h. Higher filter efficiencies significantly reduced OSA exceedance hours but sometimes increased energy demand. Minimum Efficiency Reporting Value (MERV) 16 achieved the greatest energy reduction (6.9%), while High Efficiency Particulate Air (HEPA) filters increased energy use in 10 cities (0.7-6.3%) due to higher pressure drops. On average, utility cost savings reached USD 552 and USD 1,514 for MERV 14 and MERV 16, respectively. These findings demonstrate the potential of health-driven HVAC control to reduce operating costs and enhance hospital resilience to wildfire smoke across diverse climates.

Nasopharyngeal inflammation contributes to pediatric obstructive sleep apnea syndrome (OSAS). Intranasal corticosteroids (INCS) are used to treat pediatric OSAS; a randomized controlled trial showed an improvement in OSAS symptoms but without polysomnography or neurobehavioral outcome differences. There is a lack of data demonstrating an objective decrease in the nasal inflammatory biomarker profile associated with INCS. Hence, we evaluated the association of nasal inflammatory biomarker profile and response to INCS. Secondary analysis of a randomized controlled trial of INCS vs placebo in pediatric OSAS (n = 134). The difference in intranasal biomarkers (interleukin (IL)-4, IL-13, tumor necrosis factor-alpha) between the groups after 3 and 12 months was evaluated. The association of the nasal inflammatory biomarker profile and response to INCS was assessed. Multiple regression analysis was performed to identify clinical predictors of response to INCS. There were no statistically significant differences in the nasal IL-4, IL-13, and tumor necrosis factor-alpha levels between INCS and placebo groups after 3 and 12 months of treatment. Within the INCS group, there was no statistically significant change in the nasal IL-4, IL-13, and tumor necrosis factor-alpha levels after 3 months of therapy based on responder status. However, among those who received INCS, obesity and a higher obstructive apnea-hypopnea index at baseline were clinical predictors of greater obstructive apnea-hypopnea index after 3 months (P = .038 and .002, respectively). INCS did not affect the nasal inflammatory biomarker profile in children with OSAS, including the responders. In addition, INCS is not recommended as a treatment option in children with obesity or high obstructive apnea-hypopnea index at baseline. Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Steroids for Pediatric Apnea Research in Kids (SPARK); URL: https://clinicaltrials.gov/study/NCT02180672 ; Identifier: NCT02180672. Chidambaram AG, Cielo CM, Chervoneva I, Spergel JM, Tapia IE. Nasal biomarker inflammatory profile in response to intranasal corticosteroids in pediatric obstructive sleep apnea syndrome. J Clin Sleep Med. 2025;21(6):1033–1040.

INTRODUCTION:Individuals with Down syndrome (DS) are predisposed to obstructive sleep apnoea (OSA) due to craniofacial features (eg, midface hypoplasia, glossoptosis) and studies have shown that the prevalence of OSA in this population is markedly increased compared with that of typically developing children. Adenotonsillectomy is considered the first-line treatment for childhood OSA. However, persistent OSA is common, thus many children with DS are referred for positive airway pressure (PAP) therapy initiation; PAP appears to be an important aspect of living with DS. PAP has been shown to be highly effective in the general population for treating OSA and improving OSA-associated neurobehavioural symptoms, such as quality of life, behaviour, mood, daytime sleepiness and school performance. However, PAP as a treatment for OSA has not been well-studied in children with DS. Therefore, we designed a multicentre randomised controlled trial recruiting children with DS and OSA at three academic institutions, aged 6-18 years, referred for PAP initiation to treat OSA. METHODS AND ANALYSIS:86 participants will be randomised to a 6-month intensive behavioural intervention (INT) to improve PAP adherence versus standard clinical care and underwent standardised evaluations of quality of life, behaviour, attention, PAP adherence and healthcare utilisation at baseline, 6 months and 12 months. ETHICS AND DISSEMINATION:This study has been approved by the institutional review board at Children's Hospital of Philadelphia (IRB of record, IRB # 20-0 17 512). Cincinnati Children's Medical Center and University of Miami delegated IRB review and approval responsibility to Children's Hospital of Philadelphia through reliance agreements as mandated by National Institutes of Health (NIH). All participants will be minors; consent will be obtained from parents and assent from participants will be obtained when possible. The intervention tested in this trial is considered not greater than minimal risk, and no identifiable data will be reported. As required by the NIH, a data safety monitoring board (DSMB) has been formed, who will review and approve the protocol and any protocol changes prior to implementation. The study team will send biannual reports and hold a biannual meeting with the DSMB to review any safety and protocol concerns. Findings will be presented at national conferences pertinent to this topic and published in peer-reviewed medical journals. In addition, findings will be shared in the lay format with DS associations around the world and used for training of healthcare providers and trainees (R25HD118212). Further, data collected will be deposited in a repository (National Sleep Research Resource; sleepdata.org) after completion of the study to maximise use by scientific community. TRIAL REGISTRATION NUMBER:NCT04132999.

Down syndrome (DS) is the leading genetic cause of intellectual impairment and is often associated with obstructive sleep apnea (OSA). OSA frequently persists in this population despite adenotonsillectomy. Therefore, positive airway pressure (PAP) is commonly prescribed treatment of OSA in youth with DS, and often managed by medical providers, nurses and respiratory therapists (RT) with limited psychological support available. While children with DS encounter similar PAP implementation challenges as their typically developing peers, their neurodevelopmental differences can create additional barriers that may deter both caregivers and healthcare providers from pursuing PAP. This multicenter randomized-controlled trial evaluates whether the addition of psychological support improves PAP treatment outcomes compared to standard care (STD: physician, nurse, RT). Both groups participate in four structured telehealth visits over 6 months, with neurobehavioral and quality of life assessments conducted at baseline, 6, and 12 months. The intervention group receives supplemental behavioral assessment, personalized implementation strategies, and supportive follow-up calls. PAP adherence is the primary outcome to determine the effectiveness of psychological support in treatment success. Other baseline outcome measures include the parent-reported Pediatric Quality of Life Inventory Physical Score (PedsQLPhy), PedsQL Psychosocial Score (PedsQLPsy), and the NIH Toolbox 9 Hole Pegboard Dexterity Test (PDT). Twenty-six individuals have been randomized (male, N=14; White, N=19; Black, N=4; Asian, N= 2; Other, N=1; Hispanic, N=3). Mean±SD age is 11.8±3.6 years with a BMIz of 1.2±0.9 (BMI percentile=80.8±21.5). Baseline obstructive apnea hypopnea index is 16.1±12.6 events/hour and Epworth Sleepiness scores are 6.3±5.1. Baseline outcome scores were PedsQLPhy (68.6±18.5), PedsQLPsy (65.2±13.2), and PDT (Dominant Hand=48.5±23.2 seconds; Nondominant Hand=53.2±27.8 seconds). All participants successfully completed the Pegboard task. All participants completed titration polysomnogram except one in the STD who was unable to tolerate it. This ongoing trial will provide important insights into whether behavioral psychology support improves PAP adherence in youth with DS. Baseline data demonstrate moderate-to-severe OSA, normal DS quality of life scores, and impaired fine motor dexterity, though participants successfully completed all study procedures. These findings highlight both the significant clinical burden in this population and the feasibility of conducting complex interventional trials. National Heart Lung and Blood Institute (R33HL151253).

Non-invasive ventilation (NIV) has become an essential component of pediatric respiratory support, offering effective alternatives to invasive mechanical ventilation in both acute and chronic conditions. Advances in technology and a growing understanding of pediatric respiratory physiology have expanded the application of NIV across a range of clinical scenarios, from acute respiratory failure in the intensive care unit to long-term management of neuromuscular and sleep-related breathing disorders in outpatient settings. As part of a review series, in this part 2 we provide an overview of new and emerging modes of NIV, their recommended clinical applications and we will briefly discuss the available evidence in pediatrics.

The growing impact of climate change and escalating wildfire seasons has led to heightened ambient air pollution, potentially affecting children's sleep health. However, current epidemiological research often relies on outdoor weather data to model the environmental impacts on sleep health, potentially mischaracterizing the actual bedroom environment. To address these challenges, we conducted experiments to investigate the relationships among ambient, indoor, and personal exposure to PM2.5 concentrations and obstructive sleep apnea (OSA) in children. We employed computational fluid dynamics (CFD) simulations to assess how personal exposures are influenced by factors such as air distribution design, supply air temperature (T-sa), body shape, and sleep position. Our statistical analysis revealed notable associations between OSA severity as measured by obstructive apnea-hypopnea index (OAHI) and indoor PM2.5 concentrations (beta: 11.52; 95% CI: 5.07 to 17.96; p < 0.01) and personal PM2.5 exposures (beta: 18.92; 95% CI: 9.80 to 28.04; p < 0.001), with personal exposure demonstrating a stronger relationship. Our findings highlighted the critical role of T-sa and body shape in exacerbating personal exposure, as they could modify the bedding microenvironment around children's breathing zone during sleep. We assessed the effect of air filtration interventions on mitigating personal PM2.5 exposure and modulating OSA severity in children. Higher air filter efficiencies such as MERV14 or above can modulate severe OSA for more than 80% of the year. However, during wildfire episodes, because air filtration interventions alone may be insufficient, comprehensive strategies, including the potential use of air cleaners and personal protective equipment (PPE), are necessary to ensure children's health. Our research demonstrated that quantifying personal exposure is a more informative predictor than solely relying on ambient or indoor measures for estimating OSA in children.

Importance:The impact of adenotonsillectomy on blood pressure (BP) in children with mild obstructive sleep-disordered breathing (oSDB) remains unclear. Objective:To compare BP trajectories in children with mild oSDB randomized to early adenotonsillectomy (eAT) vs watchful waiting with supportive care (WWSC). Design, Setting, and Participants:This was a secondary outcome exploratory analysis of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), a randomized clinical trial where children aged 3 to 12.9 years with snoring and mild oSDB (Obstructive Apnea-Hypopnea Index <3 with tonsillar hypertrophy [Brodsky scale grade ≥2]) were randomized to eAT vs WWSC and followed up for 12 months. PATS was conducted across 7 tertiary pediatric centers in the US. Participants were recruited from June 29, 2016, to February 1, 2021. Data were analyzed between July and November 2024. Interventions:eAT vs WWSC. Main Outcomes and Measures:The outcomes of interest were 12-month changes in BP percentiles from baseline and the moderating effect of covariates on these changes. BP was measured with an automated oscillometric BP device at baseline, 6 months, and 12 months after randomization. The treatment effect on BP trajectories was evaluated using mixed-effect models. Results:Of 458 participants included in the analysis, the mean (SD) age was 6.1 (2.3) years, 230 (50.2%) were female, and 169 (36.9%) had overweight/obesity. Mean (SD) baseline systolic BP (SBP) and diastolic BP (DBP) percentiles were 60.62 (25.22) and 53.86 (21.05), respectively, and 231 participants (50.4%) underwent eAT. From baseline to 12 months, SBP and DBP decreased in the eAT group but increased in the WWSC group. The between-group difference in changes from baseline for SBP was -9.02 (95% CI, -14.77 to -3.28) and for DBP was -6.53 (95% CI, -11.02 to -2.03). Moderation analysis showed that the effect of eAT on DBP was greater among children with body mass index higher than the 85th percentile, with an interaction effect estimate of -10.40 (95% CI, -19.69 to -1.12; P = .03). Conclusion and Relevance:In this exploratory analysis of the PATS randomized clinical trial, BP trajectories differed by treatment arm. eAT led to decreases in SBP and DBP percentiles, while WWSC led to increases. Children with overweight/obesity benefited more from eAT than children without. Trial Registration:ClinicalTrials.gov Identifier: NCT02562040.

Childhood sleep disordered breathing (SDB) is highly prevalent and associated with poor neurobehavioral outcomes, underscoring the importance of early identification. However, most outpatient settings, including primary care, lack feasible tools to identify SDB symptoms and support referrals for further evaluation. This pilot study evaluated the initial adoption, reach, acceptability, and initial effectiveness of an electronic health record (EHR)-based primary care clinical decision support (CDS) tool for the management of abnormal SDB screening results. The CDS was iteratively developed and deployed in all well child visits at 4 primary care sites from 06/2022-06/2023. Those with reported habitual snoring (≥3 nights/week) received 2-3 age-based questions about labored breathing/gasping, mouth breathing, and bed-wetting, drawn from validated SDB measures. A best practice alert (BPA) appeared when ≥1 of the additional questions were endorsed, with a prompt to refer to specialty care (sleep or otolaryngology) for further assessment, in line with pediatric guidelines. Retrospective electronic health record data were drawn to examine outcomes during the implementation year. Chi-squared tests examined BPA activation and referrals. Primary care clinicians rated CDS acceptability using the System Usability Scale. A total of 49,125 unique children (6 months-18 years, 51% boys, 51% African American/Black, 5% Asian, 5% Hispanic/Latine, 31% White) were screened for SDB in >90% of well visits, reflecting high adoption. Thirteen percent (n=6257) endorsed habitual snoring. Of the habitually snoring children, the BPA fired for 60% (n=3748) who had ≥1 additional SDB symptom endorsed (i.e., reach). BPA activation was significantly associated with specialty care referrals (p = <.001), with 41% (1524/3748) of snoring children with ≥1 additional symptom referred to specialty care. Of 19 clinician respondents, 68% agreed/strongly agreed to feeling satisfied with the CDS, while 84% agreed/strongly agreed that it was easy to use and helped initiate discussions with families. Findings indicate high reach and adoption of CDS for SDB in primary care, with evidence of good acceptability and preliminary effectiveness in supporting specialty care referrals for symptomatic children. Further research is warranted to evaluate the long-term impact of the CDS on patient outcomes and healthcare efficiency. Children’s Hospital of Philadelphia Chair’s Initiative Round 8 (AAW)

Sleep disordered breathing (SDB) and insufficient sleep are common in early childhood and linked to neurobehavioral functioning, highlighting the importance of screening for these sleep problems. However, few studies have examined variation in multi-method evaluations of these concerns. This study compared caregiver-reported symptoms of child SDB and sleep duration to subsequent polysomnography (PSG) and actigraphy. Data from 95 3-5-year-olds (43% boys, 49% Black, 51% Non-Latine White; 96% maternal caregiver) were drawn from a larger study. Caregivers reported on symptoms of child SDB using the Pediatric Sleep Questionnaire (PSQ) and on insufficient sleep using the Brief Child Sleep Questionnaire (BCSQ). Preschoolers were initially categorized into 4 groups based on measure cut-offs and sleep duration guidelines: (A) SDB only (PSQ score □0.33 clinical cut-off, total 24-hour sleep duration >=10 hours); (B) insufficient sleep only (PSQ < 0.33, total sleep duration < 10 hours); (C) both SDB and insufficient sleep (PSQ □0.33, total sleep duration < 10 hours); (D) no sleep problems. Children then completed PSG scored according to diagnostic guidelines and # nights/weeks of actigraphy scored using validated procedures with daily sleep diaries. Based on initial caregiver-report, 29 (31%) preschoolers had SDB only (A); 10 (11%) had insufficient sleep only (B); 13 (14%) had both SDB and insufficient sleep (C); and 43 (45%) had no sleep problems (D). After PSG/actigraphy, 62% were reassigned from their initial caregiver-reported group. Twenty-one percent were reassigned based on PSG results only, 27% reassigned based on actigraphy only, and 14% reassigned based on both actigraphy and PSG. Initially, based on caregiver-report, the largest group (45%) were the no sleep problem group (D). However, after PSG and actigraphy, the no sleep problem group (D) only reflected 21% of the sample. Importantly, after PSG and actigraphy, the group reflecting co-occurring SDB and insufficient sleep (C) increased from 14% to 38% of the sample. Early childhood sleep-disordered breathing and insufficient sleep may be underrecognized when based on caregiver report compared to more objective measures. Additional multi-method studies with early childhood samples may be needed to re-evaluate caregiver report-based clinical cutoffs for sleep issues in young children. R01HL163798 (AAW)

Obstructive sleep apnoea (OSA) affects 1-5% of the paediatric population, including 55-90% of children with Down syndrome (DS), and has been associated with negative effects on neurocognitive development, cardiovascular health, immune development and quality of life. In-lab attended polysomnography (PSG) is currently the gold standard for the diagnosis of OSA in children, but it poses challenges due to the burden on families and limited testing facilities. Home sleep apnoea testing (HSAT), an unattended sleep test done at home, is an accepted alternative for adults but lacks sufficient evidence to be used clinically for the evaluation of OSA in children. HSAT may be especially beneficial for children with DS or others with sensory issues or those who struggle with sleeping in a laboratory setting overnight. This single-centre trial compares HSAT to PSG for the diagnosis of OSA in children, including those with DS. The trial will enrol 317 children 5-12 years old, including approximately 100 with DS. The primary outcome is the diagnostic accuracy of HSAT compared with PSG for OSA evaluated through ROC. Secondary outcomes include the agreement between HSAT and PSG for therapeutic decision-making and comparison of preference and acceptability of HSAT versus PSG. This trial seeks to evaluate HSAT as an alternative diagnostic tool for paediatric OSA, potentially expanding testing options for clinicians and families. This study has been approved by the Institutional Review Board at Children's Hospital of Philadelphia (#21-0 19 533). Informed consent will be obtained from all participants, and no identifiable data will be reported. NCT05382754.

Introduction: Moderate to severe obstructive sleep-disordered breathing (oSDB) in children has been associated with elevated blood pressure (BP) and hypertension (HTN). While adenotonsillectomy has been shown to benefit children with elevated BP, its impact in children with only mild oSDB, remains unclear. Study Design and Methods: We conducted a secondary outcome analysis of the Pediatric Adenotonsillectomy Trial for Snoring, a randomized clinical trial that enrolled 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (oAHI) < 3/hour. Children were randomized to early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC) and followed for 12 months. Systolic BP (SBP) and diastolic BP (DBP) measurements were collected at baseline, 6 months, and 12 months during daytime research visits. We hypothesized that 12-month BP trajectories would differ between study arms. The treatment effect on BP changes was evaluated using mixed-effects models. A P < 0.05 was considered significant. Results: Of the 458 participants analyzed, 230 (50.2%) were female, 122 (26.6%) Black, and 169 (36.9%) had overweight/obesity (BMI > 85th percentile). A total of 394 (86%) children completed the 12-month follow-up and 231 (50.3%) underwent eAT. Baseline mean SBP was slightly higher in the eAT group, although both groups means were within the normal range (eAT: 63.6th percentile [23.02 SD] vs. WWSC: 57.6th percentile [26.97 SD]). Mean DBP values were similar between the intervention arms (eAT: 55.4th percentile [20.50 SD] vs. WWSC 52.2nd percentile [21.51]). Both SBP and DBP decreased significantly in the eAT group compared to WWSC (difference between groups: -9.02 for SBP, P = 0.002, 95% CI [-14.77 to -3.28]; and -6.53 for DBP, P = 0.005, 95% CI [-11.02 to -2.03]). Moderation effect analysis indicated that children with overweight/obesity had a larger decrease in DBP percentile following eAT compared to children with a normal BMI at 12 months (-10.41, P = 0.028, 95% CI [-19.69 to -1.12]). At baseline, 53 children (12.2%) had elevated SBP (>90th percentile) and 22 (5.1%) had elevated DBP; 25 (5.8%) had systolic HTN (>95th percentile), and 9 (2.1%) had diastolic HTN. Conclusion: Children with mild oSDB treated with eAT vs. WWSC experienced divergent SBP and DBP trajectories at 12 months, with children in the eAT group experiencing a significant reduction in both SBP and DBP. Moderation effect analysis suggests that children with overweight/obesity may derive greater BP-lowering benefits from adenotonsillectomy.

Children with Down Syndrome (DS) are more likely to have multi-system comorbidities leading to more frequent hospitalizations than the general population. We aim to evaluate whether racial differences contribute to hospitalization outcomes and mortality among children with DS. Hospital discharge records were obtained for children (< 21 y) with DS hospitalized between 2006 and 2019 from the Kid’s Inpatient Database. The primary exposure was the Black race. Primary outcomes were invasive mechanical ventilation (IMV) and mortality. Secondary outcomes were non-invasive mechanical ventilation (NIMV), length of hospital stay (LOS), and inflation-adjusted cost of hospitalization (IACH). Multivariable logistic regression models were used to ascertain associations between Black race and outcomes. Among 163,870 hospitalizations in children with DS, 16,208 (9.89

Rapid eye movement (REM) sleep plays a critical role in neurodevelopment, yet current measures lack the sensitivity to capture age-specific REM dynamics that reflect evolving neural architecture. Chaos analytics involves analyzing complex, nonlinear, and dynamic systems where traditional methods may fail to capture the underlying patterns. Recurrence Analyses is one primary method of visualizing and quantifying this alternating complex pattern of “chaos” and “order” that recur. We established Multilevel Heterogeneous Recurrence Analysis (MHRA) to increase specificity and quantification of complex EEG patterns. MHRA offers a flexible framework for uncovering dynamic brain characteristics across multiple scales. With recurrence-based approach using chaos-driven metrics, we described age-specific REM sleep micro- and macrostructural features in pediatric populations. REM sleep data from children and adolescents aged 6–18 years were analyzed using MHRA. For microstructural analysis, electroencephalogram (EEG) signals were extracted from REM epochs, normalized, and analyzed to quantify dynamic properties within each epoch. For macrostructural analysis, sleep stages (Wake, N1, N2, N3, REM) were segmented into 30-second epochs, producing symbolic sequences to represent stage transitions throughout the night. MHRA was applied to visualize dynamic recurrence patterns using Heterogeneous Recurrence Plots and Fractal Maps. Machine learning techniques were integrated to identify age-specific features across the micro- and macrostructural levels. Principal Component Analysis was performed to identify and explore age-related variations in REM EEG micro- and macrostructural features across pediatric age groups. The analysis revealed that the extracted REM micro- and macrostructural dynamics exhibited clear and distinct age-related patterns among children and adolescents aged 6 to 18 years. These findings demonstrate that the proposed methods successfully captured age-specific neurodevelopmental signatures, reflecting the evolving characteristics of REM sleep across developmental stages. Our findings suggest that both micro- and macrostructures of REM sleep contain distinct developmental signatures across different age groups. This methodology offers promise as a diagnostic tool for detecting atypical neurodevelopment early in life, potentially enabling earlier therapeutic interventions and improved outcomes for children with developmental concerns.

The literature indicates that health care utilization (HCU) of children with untreated moderate-to-severe obstructive sleep apnea is greater than that of matched controls before diagnosis, and treatment is associated with a decline in HCU not observed in those who remain untreated. Research on this topic has been limited to retrospective analyses and observational cohort studies; little is known about HCU among the many children with snoring and mild sleep-disordered breathing (SDB). To determine whether adenotonsillectomy in comparison with watchful waiting with supportive care is associated with fewer health care encounters and prescriptions. This randomized clinical trial, Pediatric Adenotonsillectomy Trial for Snoring (PATS), was a 12-month, parallel-arm trial conducted from 2016 to 2022 in tertiary care centers in the United States. Participants were recruited from otolaryngology, sleep, pulmonary, or general pediatric clinics; aged 3 to 13 years; diagnosed with mild SDB; had a tonsillar hypertrophy grade of 2 or more; and had a body mass index z score less than 3. Children referred from a clinician outside of the local electronic medical record system were excluded. Data analysis was conducted from June 2022 to April 2024. Early adenotonsillectomy. Evaluation of HCU was a prespecified secondary aim of PATS. Total encounters and total prescriptions over the 12 months after randomization were analyzed. Among 459 children who were randomized, the analytic sample included 381 children, after excluding those referred from outside the local electronic medical record system. The median (IQR) age was 6 (4-8) years; 192 participants (50%) were female and 189 (50%) male. Adenotonsillectomy was associated with a 32% reduction in total health care encounters (mean difference, −1.25 per participant per year; 95% CI, −1.96 to −0.53) and a 48% reduction in prescriptions (mean difference, −2.53 per participant per year; 95% CI, −4.12 to −0.94). The difference in encounters was primarily driven by fewer office visits and outpatient procedures rather than by reduced hospitalizations or urgent care visits. This study found that adenotonsillectomy was associated with reduced all-cause HCU in children with mild SDB, supporting early intervention for children with mild SDB. Future research focused on the cost effectiveness of adenotonsillectomy for pediatric SDB is warranted. ClinicalTrials.gov Identifier: NCT02562040

Down syndrome (DS) is a prevalent neurogenetic condition that impacts thousands of individuals, their families, and their communities each year. Due to the relatively high prevalence of DS and co-occurring conditions associated with this diagnosis, it is increasingly becoming the focus of clinical trials. In an effort to review the scope of interventions for this population across time, we reviewed ClinicalTrials.gov for clinical trials being conducted in DS. The goal was to evaluate the targets of clinical trials with individuals with DS, describe changes with the onset of the INCLUDE project, and identify gaps in clinical trial targets with individuals with DS. Across 138 clinical trials related to DS registered on ClinicalTrials.gov, the following target condition emerged (with some trials targeting more than one condition): motor functioning (n = 46), cognition (n = 24), Alzheimer's disease (n = 17), sleep (n = 12), adaptive daily living skills (n = 11), leukemia (n = 10), communication (n = 7), prenatal (n = 4), dental (n = 3), Attention Deficit Hyperactivity Disorder (n = 3), and other (n = 13; any category with <3 registered trials). Collectively, across these conditions, the number and variety in clinical trials in DS have increased substantially post-INCLUDE. Implications and future directions across each area of research are discussed.

Importance:The literature indicates that health care utilization (HCU) of children with untreated moderate-to-severe obstructive sleep apnea is greater than that of matched controls before diagnosis, and treatment is associated with a decline in HCU not observed in those who remain untreated. Research on this topic has been limited to retrospective analyses and observational cohort studies; little is known about HCU among the many children with snoring and mild sleep-disordered breathing (SDB). Objective:To determine whether adenotonsillectomy in comparison with watchful waiting with supportive care is associated with fewer health care encounters and prescriptions. Design, Setting, and Participants:This randomized clinical trial, Pediatric Adenotonsillectomy Trial for Snoring (PATS), was a 12-month, parallel-arm trial conducted from 2016 to 2022 in tertiary care centers in the United States. Participants were recruited from otolaryngology, sleep, pulmonary, or general pediatric clinics; aged 3 to 13 years; diagnosed with mild SDB; had a tonsillar hypertrophy grade of 2 or more; and had a body mass index z score less than 3. Children referred from a clinician outside of the local electronic medical record system were excluded. Data analysis was conducted from June 2022 to April 2024. Intervention:Early adenotonsillectomy. Main Outcomes and Measures:Evaluation of HCU was a prespecified secondary aim of PATS. Total encounters and total prescriptions over the 12 months after randomization were analyzed. Results:Among 459 children who were randomized, the analytic sample included 381 children, after excluding those referred from outside the local electronic medical record system. The median (IQR) age was 6 (4-8) years; 192 participants (50%) were female and 189 (50%) male. Adenotonsillectomy was associated with a 32% reduction in total health care encounters (mean difference, -1.25 per participant per year; 95% CI, -1.96 to -0.53) and a 48% reduction in prescriptions (mean difference, -2.53 per participant per year; 95% CI, -4.12 to -0.94). The difference in encounters was primarily driven by fewer office visits and outpatient procedures rather than by reduced hospitalizations or urgent care visits. Conclusions and Relevance:This study found that adenotonsillectomy was associated with reduced all-cause HCU in children with mild SDB, supporting early intervention for children with mild SDB. Future research focused on the cost effectiveness of adenotonsillectomy for pediatric SDB is warranted. Trial Registration:ClinicalTrials.gov Identifier: NCT02562040.

Examine sleep patterns in children with sleep-disordered breathing (SDB) who habitually bedshare. We evaluated associations of bedsharing with parent-reported (n = 457) and actigraphy-based (n = 258) sleep patterns in a diverse child sample (mean age 6.6 ± 2.3 years, range 3.0–12.9) with mild SDB using baseline data from the Pediatric Adenotonsillectomy Trial for Snoring. Multivariable linear regressions examined associations between sleep patterns and bedsharing, adjusting for sociodemographic, child, and parent/environmental factors. Moderation effects were investigated using interaction terms. Analyses were stratified by age, categorizing children as younger (< 6) and older (≥ 6) years. Bedsharing rates were 38 Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/study/NCT02562040 ; Identifier: NCT02562040. Ibrahim S, Ievers-Landis CE, Taylor HG, et al. Bedsharing sleep characteristics in children with mild sleep-disordered breathing. J Clin Sleep Med. 2025;21(2):237–247.