Dissertations / Theses on the topic 'Pediatric sleep'

Disordered sleep affects 20-40% of children and adolescents. Such disorders can result in academic difficulties, emotional regulation difficulties, and decreased immune system functioning. Behavioral treatments are the empirically supported treatment for pediatric sleep problems. With most children getting yearly well-child visits, pediatric medical professionals are in an optimal position to identify sleep difficulties and refer children for treatment. However, research suggests that medical professionals receive limited formal education in disordered sleep, and they more frequently recommend medication over behavioral interventions. Therefore, referrals to psychologists for behavioral treatments may often be warranted. The factors that influence medical professionals’ referral decisions have not been investigated. The current study investigated factors implicated in referral behaviors including pediatric medical professionals’ knowledge, screening patterns, treatment preferences, and referral patterns in the area of pediatric behavioral disordered sleep. A total of 65 medical professionals were recruited to complete an online survey to investigate these factors. Results indicated that participants in the current study demonstrated significantly higher sleep knowledge and rates of screening than what was found in a previous study. Regarding predictors of sleep knowledge, taken together, specialty, years in practice, and screening behaviors significantly predicted sleep knowledge scores. Additionally, sleep knowledge of participants who indicated that a referral was necessary when presented with a hypothetical case example of a child presenting with disordered sleep was significantly lower than the sleep knowledge of those who did not refer. Further, rates of referral were significantly lower than reported in previous research. Confidence in managing sleep problems and rates of providing behavioral recommendations were also explored. Overall, results of the current study indicate that pediatric medical professionals may benefit from additional training in the area of pediatric behavioral sleep and increased awareness of appropriate referral sources. Further exploration into the influence of screening behaviors and treatment preferences on referral behavior is necessary.

Background: Obstructive sleep apnea has become recognized as one of the most common, under-diagnosed chronic diseases. Recently studies have shown increased numbers among the pediatric and adolescent population. OSA in children is associated with behavioral problems, poor school achievements, and in severe cases, pulmonary hypertension. OSA is often the Achilles heel of pediatric sedation and analgesic programs; during sedation, children with OSA have an increased vulnerability of their airway undergoing pharyngeal collapse and of having upper airway obstruction. Consequently, pediatric dentists who practice sedation dentistry should exercise extra precautions when treating patients with risk of sleep apnea. Currently there is no screening tool used in pediatric dentistry for diagnosing OSA during the pre-operative appointment or consultation for patients undergoing minimal and moderate oral conscious sedation. The purpose of this study was to develop and test a concise and easy-to-use questionnaire as a screening tool to aid in the diagnosis of OSA in pediatric patients. Materials and Methods: A retrospective chart review of 180 patients under the age of 18, who completed a polysomnogram at the VCU Center for Sleep Medicine between February 2011 and February 2013. A validated adult questionnaire, STOPBANG, was modified using more typical pediatric risk factors for OSA: presence of snoring (S), tonsillar hypertrophy (T1), tiredness; pESS>10 (T2), observed obstruction (O), neuroPsych-behavioral symptoms such as ADHD or daytime irritability (P), BMI percentile for age (B), age at diagnostic screening (A), presence of neuromuscular disorder (N), and presence of genetic/congenital disorder (G). A positive scoring from these variables was measured against the standard OSA measure, Apnea-Hypopnea Index. A multiple logistic regression analysis tested for relationships. Results: There was a statistically significant relationship P= .0007 for the S(T1)OPBANG scale, with a minimum of 4 variables needed to have a sensitivity of 57% and a specificity of 78%. There was also a statistically significant relationship P= .0040 for the S(T2)OPBANG, the cutoff>5 yielding sensitivity=36%, and specificity=90%. Only obstruction, BMI, and age showed a strong significant relationship to OSA. The presence of an obstruction was positively related to apnea (P = 0.0010). Most of the other components had an odds-ratio larger than one (indicating a nominally positive relationship). Conclusions: While both STOPBANG screening tools showed a statistically significant relationship, only obstruction, BMI, and age showed a predictive relationship to OSA. Consequently, consideration of other risk factors may be beneficial for future studies.

Sleep disorders are highly prevalent in children and adolescents, affecting approximately 25-40% of this population. Questions about sleep are among the most frequent concerns that parents raise to their child’s pediatric medical provider. Behavioral treatments are the empirically supported treatments for addressing behavioral disordered sleep, and pediatric medical providers often endorse using such strategies. However, given the time constraints of primary care visits, such strategies are delivered in a very brief format. Whether or not these recommendations result in a change in the child’s disordered sleep symptoms has not been explored. Further, it is likely that this brief recommendation format is effective for some patients but not others. For example, children with comorbid neurodevelopmental conditions, severe sleep problems, and anxiety are less likely to respond to brief sleep interventions, and, therefore, may require a more comprehensive, time-intensive behavioral intervention. The current study aimed to explore factors related to the efficacy of a brief behavioral intervention provided via telehealth. Thirteen parents completed all portions of the study. Three were parents of children between the ages of 8 to 15 years and 10 were parents of children between the ages of 4 to 7 years (M = 6.8; SD = 2.7). All parents identified as White mothers. All children were also identified as White with 38.5% being female. Due to small sample size, quantitative analyses were not appropriate, so a qualitative examination of the data was conducted to explore relationships among participant demographics, sleep hygiene behaviors, sleep knowledge, sleep symptom severity, anxiety symptoms, and effects of the intervention. Results indicated that 37.50% of parents accurately assessed whether their child had problematic sleep. Minor variations in sleep knowledge were observed between parents who accurately identified their child’s sleep problems and those who did not (7.67 and 6.40 out of 10, respectively). Overall, participants had an average initial sleep knowledge score of 6.68, an average follow up sleep knowledge score of 7.31, and an average change in knowledge score of 0.62. Regarding effects of the intervention on sleep symptom severity, the average initial sleep symptom severity score was 50.25, the average follow up sleep severity score was 48.77, and the average change in sleep severity score was -2.00. An examination of sleep hygiene characteristics highlighted that while 81.25% of participants endorsed having a bedtime routine, almost 70% reported that the routine included an electronic device. Differences in initial sleep symptom severity and sleep knowledge scores were noted between participants who did and did not include electronic devices in their bedtime routines. The clinical implications of these findings are discussed further. Differences in intervention efficacy between participants with and without ADHD was also examined, but differences were not apparent. Intervention acceptability and feasibility were also examined. The current study demonstrated that the intervention was feasible to deliver for most participants within 10 minutes and, therefore, would be conducive to a primary care setting. Additionally, parents reported high levels of satisfaction with the content, understandability, and comprehensiveness of the treatment, which is encouraging for parents’ willingness to utilize the intervention if it was available to them. This study acted as an important initial step to determining the feasibility and acceptability of a brief behavioral sleep intervention. Clinical implications and future directions are discussed.

Thesis (Ph. D.)--University of Kentucky, 2007.
Title from document title page (viewed on March 18, 2008). Document formatted into pages; contains: vii, 48 p. : ill. Includes abstract and vita. Includes bibliographical references (p. 37-45).

This study compared psychological and physiological differences between children diagnosed with migraine and their healthy peers. Physiological measures were obtained at baseline, after discussing an emotionally relevant stressor, and after recovery in 21 children with pediatric migraine and 32 healthy peers. Comparisons were also made on psychological measures investigating sleep problems, anxiety, and family stress. It was hypothesized that children with migraine compared to their peers 1) would report more sleep disturbances, anxiety, and family stress 2) would exhibit greater sympathetic activation at rest, in response to an emotional stressor, and after a recovery period and 3) that autonomic functioning would mediate the relation between the presence of pediatric migraine and sleep disturbances. Results indicated that the migraine group reported significantly greater anxiety compared to peers but there were no significant differences in sleep disturbances or family stress. Within the migraine group, migraine severity was significantly associated with total sleep disturbance and greater incidence of parasomnias, while migraine duration was significantly associated with greater night time awakenings. Migraine children also exhibited a significantly higher pulse rate compared to their peers at rest and a significantly higher diastolic blood pressure and marginally significant higher LF/HF ratio at recovery from an emotional stressor. These findings suggest that sleep disturbance and pediatric migraine are significantly related but the relation is unclear and warrants additional research. Results also indicate that children with migraine may experience more anxiety than peers. Of most interest, results suggest that children with migraine may experience a disinhibition of the autonomic nervous system characterized by a dominance of the sympathetic nervous system resulting in a longer recovery period following an emotional stressor.

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Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES
Introduction: The Pediatric obstructive sleep apnea screening tool is a short hierarchical 6-item questionnaire developed to evaluate sleep disordered breathing in 3 to 9 years old children. This set of questions allows to discriminate children at high risk of obstructive sleep apnea (OSA) and to screen which patients need promptly objective diagnostic tests and treatment. Objective: To validate the Pediatric Obstructive Sleep Apnea Screening Tool to be used in Brazil, in a Portuguese language version. Methods: The Brazilian version of the questionnaire was developed as following: a) translation; b) back-translation; c) conclusion of final version and d) pretesting. The questionnaire was applied previously to the polysomnography in 3 to 9 years old children included in the study from October 2015 until October 2016. Validity and reliability were the psychometric proprieties evaluated. The comparison between polysomnography results and the questionnaire`s cumulative score allowed the accuracy evaluation. Results: Sixty patients were included in the final sample. Accordingly to the polysomnography, 29 (48%) patients had normal apnea and hipopnea index and 31 (51,7%) presented abnormal results. The minimum O2 saturation level was significantly lower among children with OSA (p=0,021). Satisfactory concordance was observed between the apnea and hipopnea index and the questionnaire score. The Brand Altman bias plot was 0,1 for the difference between two measures, with 5,34 (IC95% 4,14 to 6,55) of upper limit agreement and -5,19 (IC95% -6,39 to -3,98) of the agreement lower limit. The questionnaire?s internal consistency calculated by Cronbach's alpha was 0,848 (IC95% 0,780-0,901). Conclusion: The Pediatric obstructive sleep apnea screening tool was translated and validated to an adequate Brazilian-Portuguese version. The questionnaire presented satisfactory results of reliability and concordance in relation to the apnea and hipopnea index.
Introdu??o: O Pediatric obstructive sleep apnea screening tool ? um question?rio com 6 itens de avalia??o de dist?rbios respirat?rios do sono em crian?as de 3 a 9 anos de idade. ? um instrumento de f?cil aplica??o que consegue discriminar as crian?as com maior risco para s?ndrome da apneia obstrutiva do sono (SAOS) e, consequentemente, que necessitam com maior brevidade de exames objetivos para o diagn?stico e do in?cio do tratamento. Objetivo: Validar o question?rio Pediatric obstructive sleep apnea screening tool para o seu uso no Brasil, em uma vers?o em portugu?s. Materiais e m?todos: A vers?o brasileira do question?rio foi desenvolvida a partir das seguintes etapas: a) tradu??o; b) retro-tradu??o; c) conclus?o da vers?o final e d) pr?-teste. A vers?o brasileira do question?rio foi aplicada previamente ao in?cio da polissonografia em pacientes de 3 a 9 anos que foram inclu?dos no estudo no per?odo de outubro de 2015 a outubro de 2016. As propriedades psicom?tricas avaliadas foram validade e confiabilidade. A acur?cia foi avaliada pela compara??o entre os resultados da polissonografia com o escore cumulativo do question?rio. Resultados: A amostra final do estudo foi composta por sessenta pacientes. Vinte e nove (48%) pacientes apresentaram ?ndices de apneia e hipopneia normais e 31 (51,7%) apresentaram resultados alterados conforme os resultados da polissonografia. A satura??o m?nima de O2 (p=0,021) foi significativamente menor entre os pacientes com s?ndrome de apneia obstrutiva do sono. O ?ndice de apneia e hipopneia apresentou concord?ncia satisfat?ria com os resultados do question?rio. Foi identificado um vi?s m?dio de 0,1 para a diferen?a entre as medidas, com um limite superior de 5,34 (IC95% 4,14 a 6,55) e um limite inferior de -5,19 (IC95% -6,39 a -3,98). A consist?ncia interna do question?rio avaliada pelo ? de Cronbach foi de 0,848 (IC95% 0,780-0,901). Conclus?o: O question?rio Pediatric obstructive sleep apnea screening tool foi traduzido e validado adequadamente para a vers?o em portugu?s brasileiro. O question?rio apresentou boa confiabilidade e concord?ncia com o ?ndice de apneia e hipopneia.

Pediatric sleep problems are among the most common pediatric health issues faced by families today. Sleep problems can have a deleterious impact on children's academics, behaviors, social-emotional development, health, and/or safety. Once sleep problems are identified and treated, many of the associated negative impacts can be ameliorated. The purpose of the current study was to examine prevalence rates of symptoms of sleep disorders in young children, and the relationship between these symptoms and various behavior problems. One hundred and four children, ages 2 to 5 years, attending a pediatric health clinic served as the participants in this study. Data on sleep disorder symptoms were derived from the Sleep Disorders Inventory for Students, Children's Form. The Child Behavior Checklist was used to measure internalizing and externalizing behaviors, and adaptive behavior was assessed through ratings on the Adaptive Behavior Assessment System, Second Edition. Results indicated that a total of 31% of the sampled children were at high risk for at least one type of sleep disorder. Children rated as high risk for having a sleep disorder displayed more externalizing and internalizing problems, as compared to children whose sleep was reported to be in the normal range. No significant differences were found between adaptive behavior scores and risk for having a sleep disorder. The implications of these results for school psychologists and directions for future practice and research are discussed.

Parents experience many stressful situations when their child is ill and needs medical care, irrespective of the child’s age, diagnosis or the severity of the illness. Poor sleep quality and negative mood decrease the parents’ ability to sustain attention and focus, to care for their ill child, and to cope with the challenges they face. The overall aim of this thesis was to evaluate sleep, mood, cortisol response, and sense of coherence (SOC) in parents caring for children in need of medical care, and to identify factors that may influence parents’ sleep. This thesis includes four original studies; two of these are quantitative, prospective, descriptive and comparative studies including parents (n=82) accommodated in six pediatric wards with their ill child, using questionnaires and sleep logs to measure sleep, mood and SOC, and saliva cortisol to measure cortisol response. A follow-up was performed four weeks later at home, after hospital discharge. The other two studies are qualitative, inductive and explorative interview studies, including parents (n=12) staying overnight with their preterm and/or ill infant in three neonatal intensive care units, and parents (n=15) with a child receiving hospital-based home care in two pediatric outpatient clinics. The interviews were analyzed with a phenomenographic method. Being together with one’s family seems beneficial for sleep and may decrease stress. The ability to stay with the child, in the hospital or at home, was highly appreciated by the parents. When caring for a child with illness, parents’ sleep quality was sufficient in the hospital; however, sleep quality improved further (p<0.05) at home after discharge. The parents reported frequent nocturnal awakenings in the hospital caused by the child, medical treatment and hospital staff. Concern and anxiety about the child’s health, and uncertainty about the future were stressors affecting the parents’ sleep and mood negatively. The parents had lower (p=0.01) morning awakening cortisol levels in the pediatric ward compared to at home, and parents accommodated for more than one night had lower (p<0.05) post-awakening cortisol levels compared to parents staying their first night. The findings of this thesis conclude that being together as a family is important for the parents’ sleep. The ability to be accommodated in the hospital and gather the family around the child may have given the parents time for relaxation and recovery, that in turn may lead to a less stressful hospital stay. When it is beneficial for the child, the whole family should be included in the pediatric care. Moreover, pediatric nurses must acknowledge parents’ sleep, in hospital and at home. Medical treatment and care at night should be scheduled and sleep promoted for the parents in order to maintain health and well-being in the family.

The electronic version of the thesis is a corrected version of the printed thesis.

This thesis has also been funded by Barnklinikens 60-årsfond, Filip SchelinsStiftelse, Riksföreningen för barnsjuksköterskor and Synskadades Riksförbund (Lyckopenningen).

Children with Autism Spectrum Disorder (ASD) have increased rates for sleep problems compared with typically developing children. Although physicians practicing in pediatric primary care settings have the potential to detect and address sleep problems at an early age, research investigating the sleep management practices of pediatricians in primary care is scant and does not particularly address children with ASD. This study investigated the frequency of sleep screening measures utilized by pediatric providers during well-child examinations, the most frequently recommended treatments, the barriers and facilitators to screening for sleep problems, and the perceived confidence of pediatricians with regard to screening for sleep problems in children ages 2-10 years with ASD. Survey data from members of the Hillsborough County Medical Association were collected and analyzed. Seventy-three percent of participants reported almost always screening for a sleep problem during well-child examinations. Findings indicate that pediatric healthcare providers acknowledge the importance of managing sleep problems in primary care settings. Barriers to screening for sleep problems during routine exams included lack of time, resources, and awareness of screening tools. Facilitators to screening for sleep problems during routine exams included shorter sleep screening tools and longer exams. Pediatric providers were moderately confident in their ability to manage sleep problems in primary care settings. A significant relationship was found between confidence level and a number of perceived barriers. Implications of the findings are discussed.

Mestrado em Enfermagem, Área de especialização: Enfermagem de Saúde Infantil e Pediátrica
Este relatório de estágio documenta a trajetória realizada durante o estágio final, fundamentado e refletindo a aquisição e o desenvolvimento de competências comuns e específicas do enfermeiro especialista em enfermagem de saúde infantil e pediátrica, bem como as competências de Mestre. Inerente ao processo de desenvolvimento de competências, demonstra se as atividades realizadas nos diferentes contextos de estágio, no âmbito da metodologia de projeto, tendo em conta as necessidades e especificidades de cada contexto, e a temática central do projeto. A temática do projeto, inscreve-se na linha de investigação Segurança e Qualidade de Vida e está relacionada com o Sono Infantil: Educar para Promover o Sono Saudável. Foram realizados estágios em diferentes contextos de assistência à criança e família, o que permitiu realizar diferentes atividades com vista à maximização da saúde da criança/jovem e família. O projeto foi desenvolvido com recurso à metodologia de projeto, metodologia essa reflexiva, baseada e suportada pela indagação participativa, desenvolvendo intervenções práticas. O sono infantil saudável corresponde à quantidade e à qualidade de sono adequado à faixa etária, primordial para o desenvolvimento infantil. Atualmente, não se respeita os ritmos circadianos do ser humano e existe muitas vezes uma tentativa de reprogramação do ritmo interno, devido às exigências da sociedade, mostrando-se assim uma temática da atualidade, o enfermeiro especialista em enfermagem de saúde infantil e pediátrica, tem uma intervenção abrangente, logo poderá ser um elemento fundamental no evitamento da privação de sono nos lactentes/crianças e jovens.
This traineeship report documents the trajectory carried out during the final stage, grounded and reflecting the acquisition and development of common and specific competences of nurses specialized in child and pediatric health nursing, as well as Master's competences. Inherent in the competency development process, the activities carried out in the different internship contexts within the scope of the project methodology are shown, taking into account the needs and specificities of each context and the central theme of the project. The theme of the project is in line with the research on Safety and Quality of Life and is related to the Infant Sleep: Educate to Promote Healthy Sleep. Internships were carried out in different contexts of child and family care, which allowed different activities to be carried out in order to maximize child / youth health and family health. The project was developed using the methodology of the project, a methodology that is reflexive, based and supported by the participatory inquiry, developing practical interventions. Healthy infant sleep corresponds to the quantity and quality of sleep appropriate to the age group, which is primordial for child development. Currently, the circadian rhythms of the human being are not respected and there is often an attempt to reprogram the internal rhythm, due to the demands of society, thus showing a thematic of the present time. The nurse specialist in pediatric and child health nursing, has a comprehensive intervention, could thus be a key element in avoiding sleep deprivation in infants / children and young people.

INTRODUÇÃO: Na população infantil, a presença da privação ou de alterações no padrão do sono interfere em diversos processos orgânicos, além de influenciar no comportamento e humor, no desempenho neuropsicomotor, na cognição e nos relacionamentos sociais e familiares, prejudicando sua qualidade de vida. Entre os métodos diagnósticos utilizados na investigação dos distúrbios do sono para essa população incluise a utilização de questionários. Estes são instrumentos de simples administração que facilitam o diagnóstico e determinam a presença de distúrbios do sono e parassônias em crianças. O Questionário do Sono de Reimão e Lefèvre (QRL) é um instrumento de avaliação subjetiva desenvolvido em território nacional, que validado, contribuirá para pesquisas clínicas e epidemiológicas, facilitando também a prática clínica do profissional que atua nessa área. OBJETIVOS: 1)verificar se as propriedades de validade (consistência interna e reprodutibilidade) do QRL permitem que este assuma o papel de um instrumento específico de avaliação de características e distúrbios do sono para a população infantil; 2)determinar a prevalência dos distúrbios do sono relacionados às crianças de três a cinco anos de idade e aos seus diferentes gêneros; 3)estabelecer as características do padrão de sono para crianças de três a cinco anos e; 4)conhecer os principais hábitos e rituais para dormir que crianças com essa faixa etária manifestam. MÉTODOS: Estudo prospectivo e observacional para a avaliação da consistência interna e reprodutibilidade do QRL. Para a avaliação da consistência interna, 60 crianças entre três e cinco anos de idade foram divididas em três subgrupos após diagnóstico médico: GICrianças com diagnóstico de distúrbio do sono; GII- Crianças sem a presença de qualquer distúrbio do sono; GIII- Crianças com ou sem a presença de distúrbio do sono. Os resultados do QRL foram comparados com o diagnóstico feito pelo médico neurologista especialista na área do sono. Para o estudo da reprodutibilidade, o questionário foi aplicado em 1021 crianças entre três e cinco anos de idade de creches municipais de São Paulo e reaplicado após um período que variou entre 14 e 21 dias. RESULTADOS: Os índices de correlação entre o QRL e o diagnóstico médico foram elevados nos três grupos estudados, com alta consistência interna (0,80 a 0,86) segundo Coeficiente Alfa de Cronbach. As questões do QRL apresentaram alta concordância para a reprodutibilidade (0,798 a 1,000) segundo coeficiente Kappa. O tempo total de sono variou entre 10 e 11 horas para as crianças entre três e cinco anos. A movimentação excessiva durante o sono (48,5%), o ronco (35,8%), sonolência diurna (33,2%) e enurese noturna (21,9%), foram os distúrbios com maior prevalência. A maior parte dos distúrbios do sono ocorreu diariamente, foram mais comuns ao gênero feminino e tenderam a diminuir com a idade. CONCLUSÕES: A consistência interna e a reprodutibilidade do QRL indicaram que esse é um instrumento adequado para avaliar a presença de distúrbios do sono na população infantil. A prevalência dos distúrbios do sono variou de acordo com o gênero, idade e frequência da manifestação
INTRODUCTION: The pediatric population, sleep deprivation and disturbance of sleep pattern influences several organic process, also influences behavior and mood, neuropsychomotor performance, cognition and relationships, and it is detrimental to quality of life. The diagnostic method used in this population also includes the use of questionnaires. Sleep questionnaires are instruments which easily assist to diagnose sleep disorders and parasomnias in children. Infant Sleep Questionnaire Reimão and Lefèvre (RLQ) is an instrument of subjective evaluation, developed in Brazil, and if validated, will be very helpful for clinical and epidemiologic research as well as for clinical practice. OBJECTIVES: Is to check validity (internal consistency and reproducibility) of RLQ and to verify if it could be used as specific instrument of evaluation of sleep disorders in children; To check prevalence of sleep disorders in children between three to five years old of both males and females; To establish characteristics of sleep patterns in children between three to five years old and recognize the habits and rituals used by these children to sleep. METHODS: Prospective and observational study for evaluation of internal consistency and reproducibility of RLQ. For the evaluation of internal consistency, 60 children were studied. Age ranged from 3 to 5 years old of both males and females. After medical diagnosis, they were divided in three subgroups: GI- Children with diagnosed sleep disorder; GII - Children without the presence of any sleep disorder; GIII - Children with or without sleep disorders. The results of RLQ were compared with reports from medical neurologist specialized in sleep disorders. For the reproducibility of RLQ, the questionnaire was applied twice to 1021 children between 3 and 5 years old, in public schools in Sao Paulo, during a period that ranged between 14 and 21 days. RESULTS: The questionnaire showed high reproducibility Kappa 0.798 to 1.0, the internal consistency was high for all three groups (080 to 0.86) second coefficient alpha Cronbach. The total sleep time ranged from 10 and 11 hours for children between 3 and 5 years old. The most frequently sleep disorders reported was restlessness during sleep (48.5), snoring (35.8 %), daytime sleepiness (33.2%) and enuresis (21.9 %). Most sleep disorders occurred daily, were more common in females and decreased with age. CONCLUSIONS: The internal consistency and reproducibility of RLQ suggested that this is an adequate instrument for evaluation of sleep disorders in children. The prevalence of sleep disorders varies with gender, age and frequency of this disorder

Mestrado em Enfermagem, Área de especialização: Enfermagem de Saúde Infantil e Pediátrica
Este relatório de estágio documenta a trajetória realizada durante o estágio final, fundamentado e refletindo a aquisição e o desenvolvimento de competências comuns e específicas do enfermeiro especialista em enfermagem de saúde infantil e pediátrica, bem como as competências de Mestre. Inerente ao processo de desenvolvimento de competências, demonstra se as atividades realizadas nos diferentes contextos de estágio, no âmbito da metodologia de projeto, tendo em conta as necessidades e especificidades de cada contexto, e a temática central do projeto. A temática do projeto, inscreve-se na linha de investigação Segurança e Qualidade de Vida e está relacionada com o Sono Infantil: Educar para Promover o Sono Saudável. Foram realizados estágios em diferentes contextos de assistência à criança e família, o que permitiu realizar diferentes atividades com vista à maximização da saúde da criança/jovem e família. O projeto foi desenvolvido com recurso à metodologia de projeto, metodologia essa reflexiva, baseada e suportada pela indagação participativa, desenvolvendo intervenções práticas. O sono infantil saudável corresponde à quantidade e à qualidade de sono adequado à faixa etária, primordial para o desenvolvimento infantil. Atualmente, não se respeita os ritmos circadianos do ser humano e existe muitas vezes uma tentativa de reprogramação do ritmo interno, devido às exigências da sociedade, mostrando-se assim uma temática da atualidade, o enfermeiro especialista em enfermagem de saúde infantil e pediátrica, tem uma intervenção abrangente, logo poderá ser um elemento fundamental no evitamento da privação de sono nos lactentes/crianças e jovens.
This traineeship report documents the trajectory carried out during the final stage, grounded and reflecting the acquisition and development of common and specific competences of nurses specialized in child and pediatric health nursing, as well as Master's competences. Inherent in the competency development process, the activities carried out in the different internship contexts within the scope of the project methodology are shown, taking into account the needs and specificities of each context and the central theme of the project. The theme of the project is in line with the research on Safety and Quality of Life and is related to the Infant Sleep: Educate to Promote Healthy Sleep. Internships were carried out in different contexts of child and family care, which allowed different activities to be carried out in order to maximize child / youth health and family health. The project was developed using the methodology of the project, a methodology that is reflexive, based and supported by the participatory inquiry, developing practical interventions. Healthy infant sleep corresponds to the quantity and quality of sleep appropriate to the age group, which is primordial for child development. Currently, the circadian rhythms of the human being are not respected and there is often an attempt to reprogram the internal rhythm, due to the demands of society, thus showing a thematic of the present time. The nurse specialist in pediatric and child health nursing, has a comprehensive intervention, could thus be a key element in avoiding sleep deprivation in infants / children and young people.

OBJETIVO: Crianças e adolescentes com câncer apresentam sintomas múltiplos que incluem fadiga, perturbações do sono, dor e náuseas. Esses sintomas estão associados à diminuição da qualidade de vida relacionada à saúde (QVRS). O objetivo desta pesquisa foi avaliar: a) fadiga, padrão de sono e QVRS de crianças e adolescentes hospitalizados com câncer; b) relações entre fadiga, padrão de sono e QVRS; c) fatores como idade, sexo, diagnóstico de câncer, motivo da internação, tempo em quimioterapia, uso de corticosteroides, níveis de hematócrito e hemoglobina e dias pós-quimioterapia que podem ter efeitos significativos na fadiga, sono e QVRS. PRESSUPOSTO TEÓRICO: A Teoria de Gerenciamento de Sintoma (TGS) foi utilizada para fundamentar esta pesquisa. TGS é constituída por três componentes que estão inter-relacionados: a experiência do sintoma, o gerenciamento do sintoma e resultados, que estão inseridas no contexto da pessoa, da saúde-doença e do meio ambiente. MÉTODO: O delineamento da pesquisa foi quantitativo, descritivo e transversal. Participantes preencheram a PedsQL(TM) Escala Multidimensional do Cansaço para mensuração da fadiga, Actigraph de pulso, por no mínimo três dias, como dispositivo para avaliação do padrão de sono e o PedsQL(TM) Inventário Pediátrico de Qualidade de Vida, Módulo Genérico e Módulo Câncer, para avaliação da QVRS. RESULTADOS: Participaram 38 crianças e adolescentes hospitalizados com câncer e em seguimento em um hospital público do interior paulista. Os resultados demonstraram escores muito baixos de fadiga (63,8 ± 18,5) e qualidade de vida (QVRS) (genérica: 61,1 ± 17,0; câncer: 59,1 ± 16,7). Duração do sono foi 3,4 ± 1,9 horas. Variações na fadiga podem ser explicadas por: 1) diagnóstico de tumores de sistema nervoso central, tempo em tratamento quimioterápico e QVRS total (câncer) (81,1%); 2) diagnóstico de sarcoma, tempo em tratamento quimioterápico, dores e machucados, ansiedade a procedimentos, dificuldades cognitivas e aparência física (89,6%); e 3) QVRS total (câncer) e duração do sono (74,7%). CONCLUSÕES: Crianças e adolescentes hospitalizados com câncer experienciam fadiga, distúrbios do sono e baixa QVRS. Enfermeiros precisam avaliar a fadiga, o sono e a QVRS. Futuros estudos são necessários para investigar estratégias de gerenciamento eficazes que podem diminuir a fadiga, melhorar o sono e aumentar a QVRS em crianças e adolescentes hospitalizadas com câncer
PURPOSE: Children and adolescents with cancer experience multiple symptoms, such as fatigue, sleep disturbance, pain, and nausea. These symptoms are associated with lower health-related quality of life (HRQoL). The purpose of this research was to examine: a) fatigue, sleep patterns, and HRQoL in hospitalized children and adolescents with cancer; b) relationships among fatigue, sleep patterns, and HRQoL; c) factors, such as age, gender, cancer diagnosis, reason for hospitalization, length of chemotherapy, use of dexamethasone, hematocrit and hemoglobin levels and days post-chemotherapy that may have significant effects on fatigue, sleep and HRQoL. THEORETICAL FRAMEWORK: The Symptom Management Theory (SMT) was used as a guiding framework for the research. SMT consists of three components that are interrelated: symptom experience, symptom management strategies and outcomes, which are embedded in the context of person, health/illness, and environment. METHODS: The research design was quantitative, descriptive and cross-sectional. Participants completed the PedsQL(TM) Multidimensional Fatigue Scale to measure fatigue, wore the wrist Actigraph for the minimum of three days to assess sleep patterns, and the PedsQL(TM) Pediatric Quality of Life Inventory (Generic and Cancer) to assess HRQoL. RESULTS: The participants were 38 children (9.7 ±1.3 age in years) and adolescents (14.8 ± 1.4 age in years) hospitalized with cancer at a public hospital in the interior of the State of São Paulo, Brazil. The results demonstrated low fatigue scores (63.8 ± 18.5) and quality of life (HRQoL) scores (generic: 61.1± 17.0; cancer: 59.1 ± 16.7). Sleep duration was 3.4 ± 1.9 hours. Variations in fatigue levels may be explained by: 1) a diagnosis of brain tumor, the length of chemotherapy and total HRQoL (81.1%); 2) a diagnosis of sarcoma, length of chemotherapy, pain and hurt, procedural anxiety, cognitive problems and physical appearance (89.6%); and 3) the total HRQoL (cancer) and sleep duration (74.7%). CONCLUSIONS: Hospitalized children and adolescents with cancer experience fatigue, sleep disturbance, and low HRQoL. Nurses need to assess fatigue, sleep, and HRQoL. Future studies are needed to investigate effective management strategies that may decrease fatigue, improve sleep, and increase HRQoL in hospitalized children and adolescents with cancer

Objective: Given the well-established association between epilepsy and sleep disturbance and the evidence suggesting the importance of sleep in memory consolidation, there is reason to investigate the relationship between sleep and rate of forgetting in children with epilepsy. This study aimed to investigate the relationship between sleep and forgetting in children with Genetic Generalised Epilepsy (GGE). Methods: Participants were 19 children with GGE (9-15 years old). Actigraphy, sleep diaries and standardised questionnaires were used to measure sleep over a week long period. Rate of forgetting was measured using neuropsychological tests at the beginning and end of the study week. Spearman’s correlation analysis was used to determine if poorer sleep was associated with poorer initial learning and rate of forgetting in verbal memory recall and recognition. Results: No association was found between sleep efficiency or duration and rate of forgetting. Measures of sleep disturbance were mixed, with sleep onset latency found to be associated with rate of forgetting on the Word Lists test. However, increased wake after sleep onset was associated with decreased rate of forgetting. Conclusions: Whilst there was limited evidence of a relationship between some actigraphic sleep parameters and rate of forgetting for verbal information, the results were mixed and likely biased by the small sample size. There is need for further research with a larger sample to establish the nature of the relationship between sleep and rate of forgetting in children with GGE.

Profiles of sleep disturbance and sleep quality of children with the specific neurodevelopmental disorders of Smith-Magenis syndrome (SMS), Angelman syndrome (AS), autism spectrum disorder (ASD) and tuberous sclerosis complex (TSC) and the relationships between behavioural and health characteristics, age and sleep were described in these groups. Interview data demonstrated that children with AS's sleep disturbance had a negative impact on both parents and children. A homogeneous sleep disturbance profile of severe night waking and early morning waking affected over 70% of children with SMS but more heterogeneous profiles were found for children with AS, TSC and ASD using cross-group questionnaire data comparisons and when compared to typically developing (TD) children. A heightened risk of sleep-related breathing disorders was identified for children with AS and SMS. Compared to TD children, children with SMS had significantly earlier morning wake times and children with AS and SMS had significantly earlier bedtimes according to actigraphy and sleep diary data. Increased daytime sleepiness in children with SMS was associated with increased overactivity and impulsivity. This thesis includes the largest samples of actigraphy data for children with SMS and AS to date. The importance of aetiology of intellectual disability in the profiling of sleep disturbance was evidenced. Areas for further assessment and intervention include sleep-related breathing disorders for children with AS and SMS and individualized assessment of circadian rhythm disorders for both groups.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior
A avaliaÃÃo de alteraÃÃes no comportamento do sono em crianÃas com e sem paralisia cerebral por meio de instrumento psicomÃtrico se faz importante, sendo o Infant Sleep Questionnaire (ISQ) um questionÃrio que avalia o relato dos pais sobre o comportamento do sono em crianÃas de 12 a 18 meses. Objetivou-se traduzir, adaptar e validar o ISQ para a versÃo brasileira com cuidadores de crianÃas com e sem paralisia cerebral. Estudo do tipo metodolÃgico, desenvolvido no NÃcleo de Tratamento e EstimulaÃÃo Precoce, no AmbulatÃrio Especializado de Pediatria e no Centro de Desenvolvimento Familiar da Universidade Federal do CearÃ. Seguiu as cinco etapas do processo de adaptaÃÃo transcultural: 1. TraduÃÃo inicial; 2. SÃntese da traduÃÃo; 3. TraduÃÃo de volta ao idioma original; 4. RevisÃo pelo Comità de Especialistas; e 5. Teste da versÃo prÃ-final com 10 cuidadores de crianÃas saudÃveis e com 10 de crianÃas com paralisia cerebral. ApÃs essa fase, o ISQ- versÃo brasileira foi aplicado a 50 cuidadores de crianÃas saudÃveis e 20 cuidadores de crianÃas com PC, totalizando uma amostra de 70 cuidadores. A validade de conteÃdo foi verificada por meio do julgamento de trÃs juÃzes e pelo Ãndice de validade de conteÃdo (IVC). A validade de construto foi analisada pela comparaÃÃo da pontuaÃÃo final do questionÃrio entre os grupos e da associaÃÃo dessa pontuaÃÃo com variÃveis sociodemogrÃficas do cuidador e clÃnicas da crianÃa. Considerou-se o intervalo de confianÃa de 95% (p<0,05) para todos os testes. Os dados foram coletados com o FormulÃrio para CaracterizaÃÃo dos Participantes e o ISQ- versÃo brasileira. O processo de adaptaÃÃo transcultural resultou em um instrumento vÃlido (IVC=0,93). Quanto a comparaÃÃo da pontuaÃÃo do ISQ- versÃo brasileira por grupos de cuidadores, a maioria das mÃdias das questÃes nÃo apresentou diferenÃa estatisticamente significante por grupo, exceto a questÃo cinco (p=0,046). Todavia, a chance da crianÃa com PC apresentar dificuldade para dormir à 2,6 vezes maior do que a da crianÃa saudÃvel e a mÃdia da pontuaÃÃo total do ISQ- versÃo brasileira mostrou-se mais elevada no grupo de cuidadores de crianÃas com PC (13,25), quando comparada a mÃdia do grupo de cuidadores das crianÃas saudÃveis (8,86), sendo essa comparaÃÃo entre as mÃdias estatisticamente significante (p=0,017). A testagem da confiabilidade indicou que os valores do Alpha de Conbrach, Coeficiente de Spearman-Brown e Coeficiente de Guttman Split-Half foram acima de 0,70 e a aplicaÃÃo do teste-reteste por meio do r de Spearman (p<0,001), teste de Wilcoxon (p>0,220) e McNemar (p=1,000) indicaram uma adequada estabilidade entre a primeira e segunda aplicaÃÃo das nove das dez questÃes do questionÃrio. O processo de traduÃÃo e adaptaÃÃo do ISQ-versÃo brasileira resultou em um instrumento adaptado, confiÃvel e vÃlido à lÃngua portuguesa adotada no Brasil.
A avaliaÃÃo de alteraÃÃes no comportamento do sono em crianÃas com e sem paralisia cerebral por meio de instrumento psicomÃtrico se faz importante, sendo o Infant Sleep Questionnaire (ISQ) um questionÃrio que avalia o relato dos pais sobre o comportamento do sono em crianÃas de 12 a 18 meses. Objetivou-se traduzir, adaptar e validar o ISQ para a versÃo brasileira com cuidadores de crianÃas com e sem paralisia cerebral. Estudo do tipo metodolÃgico, desenvolvido no NÃcleo de Tratamento e EstimulaÃÃo Precoce, no AmbulatÃrio Especializado de Pediatria e no Centro de Desenvolvimento Familiar da Universidade Federal do CearÃ. Seguiu as cinco etapas do processo de adaptaÃÃo transcultural: 1. TraduÃÃo inicial; 2. SÃntese da traduÃÃo; 3. TraduÃÃo de volta ao idioma original; 4. RevisÃo pelo Comità de Especialistas; e 5. Teste da versÃo prÃ-final com 10 cuidadores de crianÃas saudÃveis e com 10 de crianÃas com paralisia cerebral. ApÃs essa fase, o ISQ- versÃo brasileira foi aplicado a 50 cuidadores de crianÃas saudÃveis e 20 cuidadores de crianÃas com PC, totalizando uma amostra de 70 cuidadores. A validade de conteÃdo foi verificada por meio do julgamento de trÃs juÃzes e pelo Ãndice de validade de conteÃdo (IVC). A validade de construto foi analisada pela comparaÃÃo da pontuaÃÃo final do questionÃrio entre os grupos e da associaÃÃo dessa pontuaÃÃo com variÃveis sociodemogrÃficas do cuidador e clÃnicas da crianÃa. Considerou-se o intervalo de confianÃa de 95% (p<0,05) para todos os testes. Os dados foram coletados com o FormulÃrio para CaracterizaÃÃo dos Participantes e o ISQ- versÃo brasileira. O processo de adaptaÃÃo transcultural resultou em um instrumento vÃlido (IVC=0,93). Quanto a comparaÃÃo da pontuaÃÃo do ISQ- versÃo brasileira por grupos de cuidadores, a maioria das mÃdias das questÃes nÃo apresentou diferenÃa estatisticamente significante por grupo, exceto a questÃo cinco (p=0,046). Todavia, a chance da crianÃa com PC apresentar dificuldade para dormir à 2,6 vezes maior do que a da crianÃa saudÃvel e a mÃdia da pontuaÃÃo total do ISQ- versÃo brasileira mostrou-se mais elevada no grupo de cuidadores de crianÃas com PC (13,25), quando comparada a mÃdia do grupo de cuidadores das crianÃas saudÃveis (8,86), sendo essa comparaÃÃo entre as mÃdias estatisticamente significante (p=0,017). A testagem da confiabilidade indicou que os valores do Alpha de Conbrach, Coeficiente de Spearman-Brown e Coeficiente de Guttman Split-Half foram acima de 0,70 e a aplicaÃÃo do teste-reteste por meio do r de Spearman (p<0,001), teste de Wilcoxon (p>0,220) e McNemar (p=1,000) indicaram uma adequada estabilidade entre a primeira e segunda aplicaÃÃo das nove das dez questÃes do questionÃrio. O processo de traduÃÃo e adaptaÃÃo do ISQ-versÃo brasileira resultou em um instrumento adaptado, confiÃvel e vÃlido à lÃngua portuguesa adotada no Brasil.

Le sommeil, de par ses fonctions récupératrices, est essentiel à la vie. Pour autant, la modification du mode de vie et des comportements, tant sédentaires que nutritionnels, sont à l’origine d’une altération du sommeil, conduisant ensemble à des situations d’obésité. Cet excès pondéral s’accompagne fréquemment d’un syndrome d’apnées obstructives du sommeil (SAOS). Lorsque ces deux pathologies sont présentes, les troubles métaboliques s’aggravent et sont à l’origine d’une inflammation de bas grade. A notre connaissance, aucune étude ne s’est intéressée aux bénéfices d’un reconditionnement à l’exercice physique combiné à une modification des habitudes alimentaires, en dehors de ceux induits par la perte de poids, sur ces différents paramètres. L’objectif de ce travail de thèse a donc été, à partir d’une étude ancillaire, d’évaluer le sommeil d’adolescents obèses par polysomnographie (PSG) par comparaison à celui de sujets normo-pondérés. Dans l’étude principale, les effets d’un programme de 9 mois (reconditionnement à l’exercice, activités physiques adaptées, rééquilibre alimentaire) ont été évalués sur l’architecture et la durée du sommeil, le SAOS, les différents facteurs biologiques (inflammatoires, hormonaux, profils glucidique et lipidique) et sur les adaptations physiologiques à l’exercice musculaire, afin de mieux comprendre l’implication de l’endurance aérobie et des troubles du sommeil sur la santé cardio-métabolique. Trente-deux adolescents obèses (âge : 14,6 ans, z-score d’IMC= 4 ,7) ont été recrutés. Toutes les variables ont été analysées en pré et post-intervention. Les résultats montrent une durée de sommeil réduite chez les jeunes obèses avec un SAOS, diagnostiqué chez 58% d’entre eux, malgré une architecture du sommeil satisfaisante. En post-intervention, une perte de poids de 11 kg et une amélioration des paramètres d’adaptation à l’exercice maximal (PMA, VE, VO2pic…) ont été rapportées chez tous les sujets, que le SAOS soit encore, ou non, présent. En effet, ce syndrome s’est normalisé chez 46% d’entre eux. Par ailleurs, grâce à l’intervention, le sommeil s’est amélioré (qualité et quantité). Enfin, la protéine C-réactive basale du groupe SAOS, dont les valeurs atteignaient 11mg/l à l’admission, a considérablement diminué, accompagnée d’une baisse de la leptinémie et d’une hausse de l’adiponectinémie, pouvant expliquer le moindre risque cardio-métabolique. Nos résultats démontrent qu’à l’admission, l’inflammation est liée à l’obésité, alors qu’en post-intervention, sa baisse s’explique par l’augmentation de l’endurance aérobie, et ceci indépendamment du sexe, du poids, de la durée de sommeil et du SAOS. Bien que ce dernier n’ait pas été normalisé chez tous les sujets, sa prévention par l’exercice physique ainsi que celle des troubles métaboliques observés dans ces deux pathologies devrait faire partie intégrante de la prise en charge des jeunes obèses en vue d’atténuer le risque de morbi-mortalité cardiovasculaire à l’âge adulte
Sleep, through its restorative functions, is essential for life. However, lifestyle modifications, sedentary and unhealthy feeding behaviors trigger sleep curtailment and sleep disruption, leading together to weight gain. Obesity is usually associated with obstructive sleep apnea (OSA), and these two diseases both induce metabolic dysfunctions and low-grade systemic inflammation. To the best of our knowledge, no study has assessed the effects of exercise reconditioning and modified food habits on these parameters. The purpose of this work was to assess and compare, from an ancillary study, polysomnographic variables between obese adolescents and normal-weight (NW) controls. In the main study, the effects of a 9-month program (exercise reconditioning, adapted physical activities and modified food habits) on sleep architecture, sleep duration, OSA, biological factors (inflammatory, hormonal, carbohydrates and lipid profiles) and physiological adaptations at exercise were assessed, in order to a better understanding of the roles of cardiorespiratory fitness and sleep disorders on cardio-metabolic health. Thirty-two obese adolescents (age: 14.6 years, BMI z-score: 4.7) were recruited. Every parameters were assessed at admission and post-intervention. Short sleep duration and a high prevalence of OSA (58%) were observed at admission in obese adolescents despite a satisfying sleep architecture, compared with NW controls. Post-intervention, weight loss (11kg) and improved parameters of physiological adaptations at exercise (MAP, VE, VO2peak) were found in every subject and OSA was normalized in 46% of them. Sleep quantity and sleep quality were improved. Decreased C-reactive protein (6.78 vs 10.98 mg/l) and leptin concentrations, and increased adiponectin levels were found, and cardio-metabolic risk (CMR) was decreased. At admission, obesity explains by itself the systemic inflammation whereas the decrease in inflammation, post-intervention, is explained by enhanced cardiorespiratory fitness related to fat-free mass, after controlling for sex, weight loss, change in sleep duration and OSA. Prevention of OSA and metabolic dysfunctions by chronic exercise should be an integral part of the obesity management in youths in order to decrease the risk of cardiovascular morbi-mortality in adulthood

Although the psychomotor vigilance task (PVT) is commonly used in adult sleep research, normative data for PVT performance in children have not been published and performance in children with sleep disordered breathing (SDB) has not been explored. This report describes PVT performance among children participating in the Tucson Children's Assessment of Sleep Apnea (TuCASA). A community-based sample of 360 Caucasian and Hispanic children completed a standard PVT trial. Participants were 48% female and 36% Hispanic; mean age was 8.9 years. Children with respiratory disturbance index (RDI) >1 event/hour and those with parent-reported sleep problems were excluded from the normative analysis. Among normal sleepers, performance on several measures improved with increasing age and differed between boys and girls. No ethnic differences were detected. Among children with SDB, no differences in performance were identified. Age and gender differences in PVT performance must be considered when the PVT is utilized in pediatric populations.

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Innumerable studies have focused been reported on the sleep spindles (SS), Sharp Vertex Waves (SVW) and REM, NREM Sleep as indicators interpreting EEG patterns in children. However, Frequency and Amplitud Gradient (FAG) is rarely cited sleep parameter in children,that occurs during NREM Sleep. It was first described by Slater and Torres, in 1979, but has not been routinely evaluated in EEG reports. The aim of this study was to assess the absence of SS, SVW and FAG, as an indication of neurological compromise in children. The sample consisted of 1014 EEGs of children referred to the Clinical Neurophysiology Laboratory, Hospital Universit?rio de Bras?lia (HUB), from January 1997 to March 2003, with ages ranging from 3 months to 12 years old, obtained in spontaneous sleep or induced by choral hydrate. The study was transversal and analytical, in which, visual analysis of EEG traces was perfumed individually and independently by two electroencephalographers without prior knowledge of the EEG study or neurological findings. After EEG selection, the investigators analyzed the medical reports in order to define and correlate neurological pattern was classified according to the presence or absence of neurological compromise, as Normal Neurological Pattern (NNP), and Altered Neurological Pattern (ANP) respectively. From the visual analysis of the EEG(s), it was possible to characterize 6 parameters: 1- FAG present (64,1%); 2- FAG absent (35,9%); 3 - normal SS (87,9%); 4 - altered SS s (12,1%); 5 - normal SVW s (95,7%); 6 - altered SVW s (4,3%). The prevalence of well-formed FAG is found in the 3 months to 5 years age group in the children with NNF. FAG was totally absent from the age of 10 years. When comparing the three sleep graphielements, it was observed that SVW and SS were predominant in children with NNF. However, FAG absent was more prevalent in the ANF than in altered SS an SVW. The statistical analysis showed that there is a strong association of FAG absent, with isolated alteration, in ANF patients, in that the prevalence ratio was 6,60. The association becomes stronger when FAG absent + altered SS(s) is considered (RP= 6,68). Chi-square test, corrected by Yates technique, showed a highly significant relation for FAG ρ= 0,00000001, for error X of 5%, or else the 95% confidence interval (ρ<0,05). Thus, the FAG absent were more expressive in ANF patient than altered SS(s) and SVW(s). The association becomes stronger in order to establish a prognostic relation, when the FAG is combined with the SS. The results os this study allow us to affirm that the FAG, when absent at ages ranging from 3 months to 5 years , is an indication of neurological compromise. FAG is an age-dependent EEG parameter and incorporated systematically, in the interpretation criteria of the EEG of children s sleep, not only in the maturational point of view, but also neurological disturbances with encephalic compromise
In?meras pesquisas t?m focalizado periodicamente os fusos do sono (FS), as ondas agudas do v?rtex (OAV), o complexo K e o padr?o do sono REM e NREM como indicadores de avalia??o eletrencefalogr?fica da inf?ncia. O GFA ? um padr?o EEG do sono de crian?as que ocorre durante o sono NREM, raramente citado na literatura, e que, descrito pela primeira vez por Slater e Torres, em 1979, e n?o devidamente valorizado na rotina dos laudos EEG. Nas montagens referenciais ? caracterizado por uma progressiva diminui??o de voltagem e aumento de freq??ncia na dire??o p?stero-anterior. O objetivo desta tese, foi analisar o gradiente de freq??ncia e amplitude, um padr?o EEG do sono de crian?as que ocorre durante o sono NREM; estudar os fusos do sono(FS), ondas agudas do v?rtex (OAV), como indicadores de comprometimento neurol?gico. A popula??o de estudo constitui-se de 1014 EEG de crian?as atendidas no Laborat?rio de Neurofisiologia Cl?nica do Hospital Universit?rio de Bras?lia (HUB) no per?odo de janeiro de 1997 a mar?o de 2003, nas faixas et?rias de 3 meses a 12 anos de idade, obtidos em sono espont?neo ou induzido por hidrato de cloral. O tipo de ensaio foi transversal-anal?tico, onde os EEG foram avaliados independentemente por 2 examinadores sem pr?vio conhecimento do padr?o neurol?gico e da indica??o cl?nica. Ap?s an?lise visual do EEG, foram pesquisados os prontu?rios m?dicos de todas as crian?as inclu?das no estudo, a fim de definir e associar o padr?o neurol?gico com os par?metros fusos do sono, ondas agudas do v?rtex, e GFA. O padr?o neurol?gico foi classificado segundo a presen?a ou aus?ncia de comprometimento neurol?gico em padr?o neurol?gico normal (PNN) e padr?o neurol?gico anormal (PNA), respectivamente. Com base na an?lise visual dos EEG, foi caracterizado o GFA em duas categorias: 1) GFA presente (64,1%); 2) GFA ausente ( 35,9%); 3) FS normais (87,9%); 4) FS alterados (12,1%); 5) OAV normais (95,7%); 6) OAV alteradas (4,3%). A melhor express?o do GFA presente com PNN ocorreu nas faixas et?rias de 3 meses a 5 anos. Observou-se tamb?m que o GFA torna-se ausente a partir dos 10 anos de idade em crian?as com PNN. Comparando os 3 grafoelementos do sono, as OAV e FS, foram respectivamente predominantes nas crian?as com PNN. A an?lise estat?stica mostrou que existe uma forte associa??o de aus?ncia de GFA, como altera??o isolada, nos pacientes com PNA, uma vez que a raz?o de preval?ncia foi de 6,60. A associa??o torna-se mais forte, quando se considerou GFA ausente + FS alterados (RP=11,9) e GFA ausente + FS alterados + OAV alterados (RP= 6,68). O teste do qui-quadrado, com corre??o pela t?cnica de Yates, mostrou uma rela??o altamente significativa, quando envolvido o GFA. Assim, o GFA ausente foi mais expressivo no PNA que os FS e as OAV alterados. A associa??o se torna ainda mais forte a ponto de estabelecer uma rela??o com valor progn?stico, quando o GFA se encontra-se combinado com o FS. Embora estatisticamente significante, n?o houve associa??o quando as OAV se encontra isoladas em compara??o aos demais par?metros. Os dados obtidos neste estudo permitem afirmar que, entre os grafo- elementos do sono, o GFA, quando ausente nas faixas et?rias de 3 meses a 5 anos, ? um indicador de comprometimento neurol?gico, sendo tal conclus?o mais expressiva do que os par?metros FS e OAV. O GFA ? um par?metro idade dependente e deve ser valorizado e incorporado, sistematicamente, aos crit?rios de interpreta??o do tra?ado EEG do sono de crian?as, tanto no ponto de vista da avalia??o maturacional como dos dist?rbios neurol?gicos com comprometimento encef?lico

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Introduction: Sleep disorders are not only a problem in Brazil, has become a worldwide public health condition, affecting people physically and emotionally, and even putting them in danger of life. Objectives: To identify, analyze and compare habits and sleep disturbances (SD) in a sample of students from municipal schools in a midsize city in the state of Sao Paulo. Method: A study descriptive, qualitative-quantitative, with data collection conducted between November and December 2009, 188 children between six and 11 years of municipal schools in the city of Sao Jose do Rio Preto, SP, from screenplay data demographic questions about sleep habits and the Sleep Disorders Scale for Children (EDSC), completed by the parents / caregivers. The same was conducted within the standards required by the Helsinki Declaration, Resolution 196/96 of the National Health Council (NHC) and approved by the ethics committee of the Faculty of Medicine of São José do Rio Preto (Number 316/269). Results: Overall, the results indicate that the prevalence of SD in the sample school Sao Jose do Rio Preto, hit rate higher than that reported in literature with greater frequency among those who studied in the morning, consistent with research area, and whose parents / caregivers are considered mulatto. Students belonging to families with more members showed a greater tendency to Sleep Disordered Breathing (SDB), those taking medication for SED, and those who complained of pain or discomfort, for all SD. Boys were more SD, poor sleep habits healthy and more probability to Sleep Hyperhidrosis (HS) and enuresis, compared to girls in the study, was found increased occurrence and association between HS and SDB. Students with behavioral problems, expulsion and insufficient grade school tended to some SD specific, indicating a relationship between the variables. With regard to the habits that influence the quality of sleep, significant amount of students took plenty of fluids, including milk, close to bedtime, some children from school B responded in the affirmative to play strong, and the school A to the games video game or computer. After lying down, was the high amount of which were sporadic use of television and slept without turning it off, irregularities in the time and place to sleep were also identified in both institutions, as well as the permanence of parents / caregivers in the room until the child fall asleep. Conclusions: The SH, SD poorly addressed by the scientific literature was identified with high frequency in the population studied, and the SDB. Participants who showed sleep habits that were unfavorable constitute a significant portion of the sample, that may be influencing both the quantity and quality of sleep, increasing the risks related to diseases, as well as interfering with the development of intellectual abilities and school behavior. More detailed studies on SH as well as surveys are suggested, and specialty specific assistance programs should be developed and deployed for this community.
Introdução: Distúrbios do sono (DS) constituem um problema não só no Brasil, já se tornou condição de saúde pública mundial, prejudicando as pessoas, física e emocionalmente, e até colocando-as em perigo de vida. Objetivos: Identificar, analisar e comparar hábitos e distúrbios do sono em uma amostra de alunos da rede municipal de ensino de uma cidade de médio porte do interior do estado de São Paulo. Método: Pesquisa descritiva, qualiquantitativa, com coleta de dados realizada entre novembro e dezembro de 2009, em 188 crianças entre seis e 11 anos, de escolas municipais da cidade de São José do Rio Preto, São Paulo, a partir de um Roteiro de dados demográficos, Questões sobre hábitos do sono e Escala de Distúrbios do Sono para Crianças (EDSC), preenchidos pelos pais/responsáveis. A mesma foi conduzida dentro dos padrões exigidos pela Declaração de Helsinque, Resolução 196/96 do Conselho Nacional de Saúde e aprovada pela comissão de ética da Faculdade de Medicina de São José do Rio Preto - Parecer n° 316/269. Resultados: No geral, a prevalência de DS da amostra em escolares de São José do Rio Preto, SP, atingiu índice superior ao relatado pela literatura, com maior frequência entre os que estudavam no período matutino, e os cujos pais/responsáveis se consideraram pardos. Escolares pertencentes a famílias com maior número de integrantes demonstraram maior tendência para Distúrbio Respiratório do Sono (DRS), os que tomavam remédio, para Sonolência Excessiva Diurna (SED), e aqueles que apresentavam queixa de dor ou incômodo, para todos os DS. Os meninos apresentaram mais DS, hábitos desfavoráveis ao sono saudável e maior tendência para Hiperhidrose do Sono (HS) e enurese, quando comparados às meninas do estudo; foi verificada maior ocorrência e associações entre HS e DRS. Escolares com problemas de comportamento, notas insuficientes e expulsão, demonstraram tendência para alguns DS específicos, indicando uma estreita relação entre as variáveis. Com relação aos hábitos que influenciam a qualidade do sono, quantidade significativa de escolares tomava muito líquido, incluindo o leite, próximo da hora de dormir, algumas crianças da escola B responderam de forma afirmativa às brincadeiras vigorosas, e os da escola A aos jogos de vídeo game ou computador. Após deitar, foi alta a quantidade dos que faziam uso esporádico da televisão e que dormiam sem desligá-la, irregularidades quanto ao horário e local para dormir também foram identificadas em ambas as instituições, bem como a permanência de pais/responsáveis no quarto até a criança adormecer. Conclusões: A HS, DS pouco abordado pela literatura científica, foi identificada com alta frequência na população estudada, bem como o DRS. Participantes que mostraram hábitos considerados desfavoráveis ao sono constituem parcela significativa da amostra, que podem estar influenciando tanto a quantidade quanto a qualidade do sono, aumentando os riscos relacionados às doenças, bem como interferindo no desenvolvimento das capacidades intelectuais e do comportamento escolar. Estudos mais detalhados sobre HS, bem como inquéritos populacionais são sugeridos, e programas específicos de intervenções especializadas devem ser elaborados e implantados para este público.

Este relatório é o resultado do trabalho desenvolvido ao longo de todo o percurso académico do Mestrado em Enfermagem em Associação na Área de Especialização de Enfermagem de Saúde Infantil e Pediátrica para a obtenção do grau de Mestre em Enfermagem na referida área científica. Com a elaboração do presente relatório de estágio, onde está integrado o projeto desenvolvido, pretendemos fazer uma análise e reflexão sobre as competências comuns e específicas do enfermeiro especialista assim como as competências de mestre em enfermagem na área de enfermagem de saúde infantil e pediátrica, desenvolvidas ao longo do Estágio I e do Estágio Final. Ao longo da realização dos estágios I e final, tivemos a oportunidade de desenvolver um projeto, que integrou a linha de investigação “segurança e qualidade de vida”, e seguiu as etapas da metodologia de projeto. O problema por nós identificado, através da observação e mediante a utilização de um questionário, como instrumento de colheita de dados, incidiu na promoção do sono/repouso do lactente, destacando a importância do controlo do ruído ambiente na promoção do mesmo. Deste modo, propusemo-nos a: sensibilizar os enfermeiros que prestam cuidados em pediatria e os pais/pessoas significativas dos lactentes relativamente a esta problemática, de modo a minimizar as consequências negativas que o ruído ambiente tem sobre o sono/repouso das crianças, elaborar uma norma de procedimento de enfermagem de modo a uniformizar os cuidados prestados às crianças/adolescentes no Serviço de Pediatria e na Unidade de Urgência Pediátrica de forma a controlar/reduzir os níveis de ruído ambiental, contribuindo deste modo para a promoção do sono/conforto das crianças no primeiro ano de vida A consecução dos objetivos delineados, permitiu-nos contribuir para a qualidade dos cuidados e a excelência no exercício da profissão, tendo por base uma prática baseada na evidência científica, integrando os conhecimentos teóricos e práticos adquiridos enquanto Mestres em Enfermagem de Saúde Infantil e Pediátrica; ABSTRACT: Promotion of sleep/rest of the child during the first year of life: the importation of envi-ronmental noise This report is the result of the work done throughout the academic career of the Master's degree in nursing in association in the area of Childs Health and Pediatrics Spe-cialization’s to obtaining the Master's degree in nursing in that specific scientific area. With the preparation of this report, where's integrated the intervention project de-veloped, we want to do an analysis and reflection on the common and specific skills of the specialist nurse as well as the master skills in nursing in the area of nursing Childs Health and Pediatrics, developed along the internship I and final internship. Throughout the implementation of the internship I and final, we had the oppor-tunity to develop an intervention project, which integrated the research line "safety and quality of life", and followed the steps of design methodology. The problem we identi-fied, through observation and through the use of a questionnaire, as a tool for data collec-tion, focused on sleep/rest promotion of the infant, highlighting the importance of the control of environmental noise in the promotion of it. Thus, we proposed to: raise awareness of nurses who provide care in Pediatrics, and parents/significant people of infants in relation to this issue, in order to minimize the negative consequences that the ambient noise has on sleep/rest of children; develop a standard of nursing procedure in order to standardize the care provided to children/ado-lescents in the service of Pediatrics and Pediatric Emergency Unit to control/reduce en-vironmental noise levels, contributing in this way to the promotion of sleep/comfort of the children in the first year of life. The objectives outlinde allowed us to contribute to the equality of care and excel-lence in the practice of the profession, on the basis of a praxis based on scientific evi-dence, integrating theoretical and pratical knowledge acquired while Nursing Master De-gree – Childs Health and Pediatrics.

碩士
元培科技大學
放射技術研究所
97
Obstructive sleep apnea syndrome (OSAS) is a frequent sleep disorder in children and is highly related to the anatomy of upper airway. Cephalometry is a useful tool for evaluation of craniofacial skeletal and soft tissue structure of upper airway in OSAS patients. The goal of this study is to use MATLAB which is a semi-automatic measurement system to obtain the cephalometric parameters and analyze the correlation between cephalometric parameters and apnea-hypopnea index (AHI). The parameters of 66 children age from 4 to 15 years with OSAS were analyzed. All patients underwent polysomnographic (PSG) and cephalometric examinations. The study collected cephalometric parameters of 9 angles, 9 lines, and 2 ratios. Additionally, tonsillar sizes were graded. The hyoid position (Gn-Go-H and MP-H) were positively correlated to AHI scores (p=0.002, p< 0.001). The intermaxillary angle (PNSANS-GoGn) was positively correlated to AHI scores (p=0.031). Relative hyoid distance (GoGn-H/GoGn) was also positively correlated to AHI scores (p<0.001). The adenoid and tonsillar hypertrophy were positively correlated to AHI scores (p=0.015, p=0.009). Using MATLAB can obtain cephalometric parameters of pediatric OSAS more efficiently. There is significant correlation between cephalometric variables and AHI scores. Cephalometric is a simple tool to evaluate upper airway anatomy and could further facilitate the diagnosis and treatment of pediatric OSAS.

碩士
國立臺灣大學
流行病學與預防醫學研究所
102
Background: Obstructive sleep apnea syndrome (OSAS) is an upper airway disorder. Over-night polysomnography is the “gold standard” for the diagnosis of pediatric OSAS. Information from objective and subjective measures for children with OSAS helps clinicians in decision making. Purpose: To assess diagnostic abilities of objective measures, subjective measures, and combined objective and subjective measures in detecting pediatric obstructive sleep apnea syndrome, and to compare performance difference and clinical utilities between objective measures, subjective measures, and combined objective and subjective measures for detection of pediatric OSAS. Study Design: Cross-sectional study. Methods: Children aged 2-18 years were recruited. Children were assessed objectively for tonsil size, adenoid size, and obesity; tonsils were graded by otolaryngologist using the scheme by Brodsky et al.; adenoid size was measured based on a lateral cephalometric radiographs (Fujioka method); obesity was determined by a measure of body mass index percentile of each child. Subjective measures for symptoms were recorded using a standard sheet. Objective measures significantly correlated with OSAS were put into the objective model, whereas subjective measures into the subjective model. Accordingly, objective and subjective measures significantly correlated with OSAS were served as the combined model. Diagnosis of OSAS was made by polysomnography. Diagnostic performances of models in detecting OSAS were analyzed by model fit, discrimination (C-index), calibration (Hosmer-Lemeshow test), and reclassification. The model was internal validated using the leave-one-out cross-validation, bootstrapping method, and k-fold cross-validation. Results: In total, 222 children were enrolled. Objective model included tonsil hypertrophy, adenoid hypertrophy, and obesity, whereas subjective model included snoring frequency, snoring duration, awaken, and breathing pause. The chi-square test was significant in the objective model, subjective model, and the combined model (P < 0.001). The C-index was 0.84 for the combined model, which was significantly differed from that in the objective model (0.78, P = 0.0032) and the subjective model (0.72, P = 0.0001). The Hosmer-Lemeshow test showed adequate fit (P > 0.05) for all models. Compared to objective model or subjective model, the combined model correctly reclassified 10.3% (P = 0.044) and 21.9% (P = 0.003) of all subjects. Internal validation of the combined model showed fair model performance and no obvious over-fitting. Conclusions: Overall performance of combined objective and subjective measures, as compared with objective measures or subjective measures alone, offer incremental utility in detecting OSAS. This finding provides the rationale to combine both objective and subjective measures in developing a screen tool for pediatric OSAS.

Au, Chun Ting.
Thesis (M.Phil.)--Chinese University of Hong Kong, 2007.
Includes bibliographical references (leaves xxvii-lv).
Abstracts in English and Chinese.
ACKNOWLEDGEMENTS --- p.i
ABSTRACT
In English --- p.ii
In Chinese --- p.v
LIST OF TABLES --- p.vii
ABBREVIATIONS
For Units --- p.ix
For Prefixes of the international system of units --- p.ix
For Terms commonly used in the report --- p.x
STATEMENT OF WORK DONE --- p.xvi
Chapter CHAPTER 1 --- Overview of Childhood Obstructive Sleep Apnea Syndrome (OSAS)
Chapter 1.1. --- Clinical Features of Childhood OSAS --- p.1
Chapter 1.2. --- Definition of Childhood OSAS --- p.2
Chapter 1.3. --- Prevalence of Childhood OSAS --- p.3
Chapter 1.4. --- Pathophysiology --- p.4
Chapter 1.5. --- Risk Factors --- p.6
Chapter 1.6. --- Diagnosis --- p.10
Chapter 1.7. --- Treatment
Chapter 1.7.1. --- Tonsillectomy and Adenoidectomy (T&A) --- p.12
Chapter 1.7.2. --- Continuous Positive Airway Pressure (CPAP) --- p.14
Chapter 1.7.3. --- Corticosteroids --- p.15
Chapter 1.7.4. --- Leukotriene Receptor Antagonist --- p.16
Chapter 1.8. --- Complications of Childhood OSAS
Chapter 1.8.1. --- Growth Failure --- p.17
Chapter 1.8.2. --- Neurocognitive Abnormalities --- p.19
Chapter 1.8.3. --- Cardiovascular Abnormalities --- p.20
Chapter CHAPTER 2 --- Cardiovascular Complications of OSAS in Adults (Literature Review)
Chapter 2.1. --- Acute Effects of OSAS on Cardiovascular System --- p.21
Chapter 2.2. --- Chronic Effects of OSAS on Cardiovascular System --- p.23
Chapter 2.3. --- Hypertension --- p.24
Chapter 2.4. --- Heart Failure --- p.28
Chapter 2.5. --- Pulmonary Hypertension --- p.30
Chapter 2.6. --- Arrhythmias --- p.31
Chapter 2.7. --- Cardiac Ischemia and Vascular Disease --- p.33
Chapter 2.8. --- Stroke --- p.34
Chapter CHAPTER 3 --- Cardiovascular Complications of Childhood OSAS (Literature Review)
Chapter 3.1. --- Blood Pressure --- p.37
Chapter 3.2. --- Ventricular Structure and Function --- p.40
Chapter 3.3. --- Arterial Distensibility --- p.42
Chapter 3.4. --- Heart Rate Variability --- p.42
Chapter CHAPTER 4 --- Ambulatory Blood Pressure in Children with OSAS
Chapter 4.1. --- Introduction --- p.44
Chapter 4.2. --- Methods
Chapter 4.2.1. --- Subjects and Study Design --- p.46
Chapter 4.2.2. --- Polysomnography (PSG) --- p.47
Chapter 4.2.3. --- Ambulatory Blood Pressure Measurement (ABPM) --- p.49
Chapter 4.2.4. --- Statistical Analysis --- p.50
Chapter 4.3. --- Results
Chapter 4.3.1. --- Subject Characteristics --- p.52
Chapter 4.3.2. --- Blood Pressure during Wakefulness --- p.55
Chapter 4.3.3. --- Blood Pressure during Sleep --- p.57
Chapter 4.4. --- Discussion --- p.62
Chapter 4.5. --- Conclusion --- p.70
Chapter CHAPTER 5 --- Cardiac Remodeling and Dysfunction in Children with OSAS
Chapter 5.1. --- Introduction --- p.71
Chapter 5.2. --- Methods
Chapter 5.2.1. --- Subjects and Study Design --- p.72
Chapter 5.2.2. --- Polysomnography (PSG) --- p.74
Chapter 5.2.3. --- Conventional Echocardiography --- p.75
Chapter 5.2.4. --- Tissue Doppler Imaging --- p.76
Chapter 5.2.5. --- Statistical Analysis --- p.77
Chapter 5.3. --- Results
Chapter 5.3.1. --- Study Population --- p.79
Chapter 5.3.2. --- Polysomnographic Findings --- p.79
Chapter 5.3.3. --- Echocardiographic Findings
Chapter 5.3.3.1. --- Right Ventricle --- p.81
Chapter 5.3.3.2. --- Left Ventricle --- p.83
Chapter 5.3.4. --- Treatment Effect --- p.86
Chapter 5.4. --- Discussion --- p.90
Chapter 5.5. --- Conclusion --- p.95
Chapter CHAPTER 6 --- Conclusion --- p.96
APPENDIX I Hong Kong Children Sleep Questionnaire (Chinese) --- p.xvii
APPENDIX II Hong Kong Children Sleep Questionnaire (English) --- p.xxii
REFERENCES --- p.xxvii

碩士
國立陽明大學
護理學系
105
The aim of this study was to investigate the correlation of stress, anxiety and sleep quality among primary caregivers of children in intensive care units in China. METHODS: A cross-sectional descriptive study was conducted. A total of 147 pri-mary caregivers were collected from the Pediatric Intensive Care Unit (PICU) of Tai-pei Medical Center(Taipei, Danshui and Hsinchu), the use of structural questionnaire to collect information, research scale includes:(A) Basic Tables of Population Attrib-utes of Sick Children and Primary Caregivers; (B) Chinese Version of the Parental Stressor Scale: Pediatric Intensive Care Unit(PSS:PICU);(C) Chinese version of the State-Trait Anxiety Inventory;(D) Pittsburgh Sleep Quality Index (PSQI), the data were analyzed by descriptive statistical analysis, t test, Pearson product difference correlation and multiple regression with SPSS Windows version 18. The results of the study show that the main caregivers in the stress source scale items in the study before the results of five: "8. See the baby who placed the pipeline, such as: the endotracheal tube, nasogastric tube or use the respirator, (M = 3.27, SD = 1.24) ,"32.when the baby showed pain or pain-like appearance (M = 3.32, SD = 1.20) ,"34. When the baby can not speak due to intubation or crying sound, let me feel" (M = 3.14, SD = 1.58), "10. See the baby who was examined (such as pumping spinal fluid, ascites, etc.) (M = 3.07, SD = 1.61), "20. When the baby cries, I can not accompany him and make me feel" (M = 3.03, SD = 1.22). Comparing the differences in parental stress, the study found that the main caregivers were the most painful in tracheal intubation, followed by the degree of pain in the child, the appearance of the child and the noise of the unit. The relationship between the main attributes of caregivers and their stress: (1) The statistic of "relational identity" was significant at the change of caregiver role, in-dicating that the change of caregiver's basic attribute and caregiver role was obvious The relationship between parental self-esteem and parental self-esteem was signifi-cantly higher than that of the other three. The main caregiver's gender "and" relation-ship's identity "statistically significant level, indicating that the main caregiver" gender "and" relationship between identity "and the context Anxiety was significantly associ-ated with the existence of the mother's situation anxious than father. (2) There was a significant correlation between "age of the child" and "hospitalization expectation" in the communication of nurses, and there was a clear correlation between the "child age" and the "expected hospitalization" The expectation of hospitalization was significantly higher than that of caregiver stress, indicating that the basic attributes of "expected hospitalization" and overall caregiver stress were significant There was a significant association between those who were not expected to be hospitalized and those with a higher degree of stress than expected. (3) Increasing caregiver stress and understand-ing the impact factors of sleep quality of primary caregivers when the patient is in the intensive care unit where the primary caregiver loses parents' role, messages and un-certainty about the outcome, as a result of which the regression coefficient is signifi-cant (Β = .21, p <.01), and "situational anxiety" (β = .25, p <.01), indicating that these variables had a positive Related.Therefore, when the number of weeks of pregnancy and the greater the child's caregiver at the higher level of perceived anxiety situations, the caregiver's quality of sleep scores will be higher, on behalf of the poorer quality of sleep. DISCUSSION: The results of this study were in agreement with several litera-ture studies. The study found that the age, educational attainment and income of pri-mary caregivers were no longer a source of stress, "age of caregiver" and "stress" at all levels and (Segre, 2014; Brooten et al., 1988; Rogers et al., 2013, & Vanderbilt, 2009). The overall correlation coefficient was not significant. Age, educational attainment and income were not significantly associated with negative affect.In addition, qualita-tive findings were consistent with the impact of PICU on primary caregivers (Colville, 2009). PSS: PICU used in Haines (1995) between intensive care unit intubation and primary caregivers of non-intubated sick children, witnessing medical procedures and multiple medical piping appearances on children are highly related to their stress, and the mother's Stress and anxiety were significantly higher than those of fathers (Lefkowitz, Baxt, & Evans, 2010; Pinelli et al., 2008; Segre; McCabe; Siewert, 2014). In line with a number of studies, when caregivers are deprived of parental roles, mes-sages, and prognosis uncertainties increase the caregiver pressure when the child is admitted to the intensive care unit, effective communication and support from the caregiver can reduce the number of primary caregivers Pressure (Lefkowitz, Baxt, Evans, 2010; Colville, Pierce, 2012).Furthermore, the results of this study found that the higher the stress of the caregiver, the higher the age of the caregiver. For example, disease severity: lack of intelligence, cerebral palsy, spina bifida, retardation, limb dis-orders, etc., the parent's feelings of parental stress will be (Als, Nadel, Cooper, et al. 2016; Abidin, 1990). Parents of children with chronic or congenital conditions also experience higher parental stress than parents of average children (Garralda, Gledhill, Nadel, et al., 2009; Goldberg, Morris, Simmons & Fowler, 1990;You,1993) CONCLUSIONS: The results of this study found that stressors (high) and sleep quality (low) in the primary caregivers were associated with an increased number of pro- cesses in the intensive care unit (number of weeks of gestation). Due to the envi-ronmental noise in the ICU and the stress and anxieties experienced by the patient, the child care team should provide the primary caregiver with appropriate knowledge and psychological support for the critical care of the child, Reduce the stress and anxiety of the primary caregiver, and thus expect to maintain their sleep quality.

Ng, Mei.
Thesis (M.Phil.)--Chinese University of Hong Kong, 2010.
Includes bibliographical references (leaves xvi-xlviii).
Abstracts in English and Chinese.
ACKNOWLEDGEMENTS --- p.i
ABSTRACT
In English --- p.ii
In Chinese --- p.iv
LIST OF TABLES --- p.vi
LIST OF FIGURE --- p.viii
ABBREVIATIONS
For Units --- p.ix
For Prefixes of the International System of Units --- p.ix
For Terms Commonly Used --- p.X
Chapter CHAPTER 1 --- Overview of Childhood Obstructive Sleep Apnoea Syndrome (OSAS)
Chapter 1.1 --- Prevalence --- p.1
Chapter 1.2 --- Clinical Features --- p.3
Chapter 1.3 --- Definitions and Cutoffs --- p.4
Chapter 1.4 --- Pathophysiology --- p.6
Chapter 1.5 --- Risk Factors
Chapter 1.5.1 --- Gender --- p.8
Chapter 1.5.2 --- Obesity --- p.9
Chapter 1.5.3 --- Adenotonsillar Hypertrophy --- p.10
Chapter 1.5.4 --- Genetic --- p.11
Chapter 1.5.5 --- Atopic Diseases --- p.12
Chapter 1.6 --- Complications
Chapter 1.6.1 --- Neurobehavioural Deficits --- p.13
Chapter 1.6.2 --- Growth Defects --- p.14
Chapter 1.6.3 --- Metabolic Disorders --- p.16
Chapter 1.6.4 --- Systemic inflammation --- p.17
Chapter 1.6.5 --- Cardiovascular Consequences --- p.19
Chapter 1.7 --- Diagnosis --- p.20
Chapter 1.8 --- Treatment
Chapter 1.8.1 --- Surgical Treatment --- p.22
Chapter 1.8.2 --- Continuous Positive Airway Pressure (CPAP) --- p.24
Chapter 1.8.3 --- Corticosteroids --- p.24
Chapter 1.8.4 --- Leukotriene Receptor Antagonist --- p.25
Chapter 1.8.5 --- Oral Appliances --- p.26
Chapter 1.8.6 --- Weight Control --- p.27
Chapter CHAPTER 2 --- OSAS and Cardiovascular Complications in Adults
Chapter 2.1 --- Mechanism
Chapter 2.1.1 --- Acute Cardiovascular Responses --- p.28
Chapter 2.1.2 --- Chronic Cardiovascular Responses --- p.29
Chapter 2.2 --- Hypertension
Chapter 2.2.1 --- Epidemiological and Clinical Data --- p.31
Chapter 2.2.2 --- Characteristics --- p.32
Chapter 2.2.3 --- Mechanisms --- p.33
Chapter 2.2.4 --- Treatment --- p.34
Chapter 2.3 --- Heart Failure --- p.35
Chapter 2.4 --- Stroke --- p.37
Chapter 2.5 --- Cardiac Arrhythmias --- p.39
Chapter 2.6 --- Myocardial Ischemia and Vascular Disease --- p.41
Chapter 2.7 --- Pulmonary Hypertension --- p.43
Chapter CHAPTER 3 --- OSAS and cardiovascular complication in children
Chapter 3.1 --- Blood Pressure --- p.45
Chapter 3.2 --- Ventricular Hypertrophy and Dysfunctions --- p.48
Chapter 3.3 --- Heart Rate Variability --- p.50
Chapter 3.4 --- Arterial Tone --- p.51
Chapter 3.5 --- Endothelial Function --- p.51
Chapter CHAPTER 4 --- Longitudinal follow-up study of children with OSAS - a cardiovascular perspective
Chapter 4.1 --- Introduction --- p.53
Chapter 4.2 --- Methods
Chapter 4.2.1 --- Subjects and Study Design --- p.57
Chapter 4.2.2 --- Polysomnography --- p.59
Chapter 4.2.3 --- Ambulatory Blood Pressure Measurement --- p.61
Chapter 4.2.4 --- Statistical Analysis --- p.62
Chapter 4.3 --- Results
Chapter 4.3.1 --- Subject Characteristics --- p.64
Chapter 4.3.2 --- Blood Pressure During Wakefulness --- p.71
Chapter 4.3.3 --- Blood Pressure During Sleep --- p.76
Chapter 4.3.4 --- Nocturnal Blood Pressure Dipping --- p.83
Chapter 4.3.5 --- Blood Profile --- p.86
Chapter 4.4 --- Discussion --- p.87
Chapter 4.5 --- Conclusion --- p.99
Reference List --- p.xvi

Le sommeil, de par ses fonctions récupératrices, est essentiel à la vie. Pour autant, la modification du mode de vie et des comportements, tant sédentaires que nutritionnels, sont à l’origine d’une altération du sommeil, conduisant ensemble à des situations d’obésité. Cet excès pondéral s’accompagne fréquemment d’un syndrome d’apnées obstructives du sommeil (SAOS). Lorsque ces deux pathologies sont présentes, les troubles métaboliques s’aggravent et sont à l’origine d’une inflammation de bas grade. A notre connaissance, aucune étude ne s’est intéressée aux bénéfices d’un reconditionnement à l’exercice physique combiné à une modification des habitudes alimentaires, en dehors de ceux induits par la perte de poids, sur ces différents paramètres. L’objectif de ce travail de thèse a donc été, à partir d’une étude ancillaire, d’évaluer le sommeil d’adolescents obèses par polysomnographie (PSG) par comparaison à celui de sujets normo-pondérés. Dans l’étude principale, les effets d’un programme de 9 mois (reconditionnement à l’exercice, activités physiques adaptées, rééquilibre alimentaire) ont été évalués sur l’architecture et la durée du sommeil, le SAOS, les différents facteurs biologiques (inflammatoires, hormonaux, profils glucidique et lipidique) et sur les adaptations physiologiques à l’exercice musculaire, afin de mieux comprendre l’implication de l’endurance aérobie et des troubles du sommeil sur la santé cardio-métabolique. Trente-deux adolescents obèses (âge : 14,6 ans, z-score d’IMC= 4 ,7) ont été recrutés. Toutes les variables ont été analysées en pré et post-intervention. Les résultats montrent une durée de sommeil réduite chez les jeunes obèses avec un SAOS, diagnostiqué chez 58% d’entre eux, malgré une architecture du sommeil satisfaisante. En post-intervention, une perte de poids de 11 kg et une amélioration des paramètres d’adaptation à l’exercice maximal (PMA, VE, VO2pic…) ont été rapportées chez tous les sujets, que le SAOS soit encore, ou non, présent. En effet, ce syndrome s’est normalisé chez 46% d’entre eux. Par ailleurs, grâce à l’intervention, le sommeil s’est amélioré (qualité et quantité). Enfin, la protéine C-réactive basale du groupe SAOS, dont les valeurs atteignaient 11mg/l à l’admission, a considérablement diminué, accompagnée d’une baisse de la leptinémie et d’une hausse de l’adiponectinémie, pouvant expliquer le moindre risque cardio-métabolique. Nos résultats démontrent qu’à l’admission, l’inflammation est liée à l’obésité, alors qu’en post-intervention, sa baisse s’explique par l’augmentation de l’endurance aérobie, et ceci indépendamment du sexe, du poids, de la durée de sommeil et du SAOS. Bien que ce dernier n’ait pas été normalisé chez tous les sujets, sa prévention par l’exercice physique ainsi que celle des troubles métaboliques observés dans ces deux pathologies devrait faire partie intégrante de la prise en charge des jeunes obèses en vue d’atténuer le risque de morbi-mortalité cardiovasculaire à l’âge adulte
Sleep, through its restorative functions, is essential for life. However, lifestyle modifications, sedentary and unhealthy feeding behaviors trigger sleep curtailment and sleep disruption, leading together to weight gain. Obesity is usually associated with obstructive sleep apnea (OSA), and these two diseases both induce metabolic dysfunctions and low-grade systemic inflammation. To the best of our knowledge, no study has assessed the effects of exercise reconditioning and modified food habits on these parameters. The purpose of this work was to assess and compare, from an ancillary study, polysomnographic variables between obese adolescents and normal-weight (NW) controls. In the main study, the effects of a 9-month program (exercise reconditioning, adapted physical activities and modified food habits) on sleep architecture, sleep duration, OSA, biological factors (inflammatory, hormonal, carbohydrates and lipid profiles) and physiological adaptations at exercise were assessed, in order to a better understanding of the roles of cardiorespiratory fitness and sleep disorders on cardio-metabolic health. Thirty-two obese adolescents (age: 14.6 years, BMI z-score: 4.7) were recruited. Every parameters were assessed at admission and post-intervention. Short sleep duration and a high prevalence of OSA (58%) were observed at admission in obese adolescents despite a satisfying sleep architecture, compared with NW controls. Post-intervention, weight loss (11kg) and improved parameters of physiological adaptations at exercise (MAP, VE, VO2peak) were found in every subject and OSA was normalized in 46% of them. Sleep quantity and sleep quality were improved. Decreased C-reactive protein (6.78 vs 10.98 mg/l) and leptin concentrations, and increased adiponectin levels were found, and cardio-metabolic risk (CMR) was decreased. At admission, obesity explains by itself the systemic inflammation whereas the decrease in inflammation, post-intervention, is explained by enhanced cardiorespiratory fitness related to fat-free mass, after controlling for sex, weight loss, change in sleep duration and OSA. Prevention of OSA and metabolic dysfunctions by chronic exercise should be an integral part of the obesity management in youths in order to decrease the risk of cardiovascular morbi-mortality in adulthood

A apneia obstrutiva do sono é nos dias de hoje um distúrbio respiratório com consequências graves que afectam a qualidade de vida das pessoas. A percentagem de casos em crianças de idade pré-escolar é de cerca de 1-3%. A Polissonografia é actualmente a técnica mais utilizada para o estudo do sono, durante uma noite completa num hospital, em que inúmeros sinais vitais da criança estão continuamente a ser monitorizados. O reduzido número de hospitais pediátricos com este tipo de exame, a sua complexidade e custos elevados, promovem o desenvolvimento de novos dispositivos. O Sleep@Home é um sistema inovador e não invasivo, em que as crianças podem ser monitorizadas a partir de suas casas, e a aquisição dos sinais é transmitida remotamente para a unidade de saúde onde os dados podem ser consultados. O objectivo deste sistema não é substituir a PSG, mas ser utilizado como um dispositivo de rastreio menos estranho para as crianças. Para isso é necessária a realização de mais testes clínicos a fim de validar o sistema. Palavras-chave (Tema): Síndrome da Apneia Obstrutiva do Sono, saturação de oxigénio, frequência cardíaca, monitorização no domicílio, apoio ao diagnóstico, crianças. Palavras-chave (Tecnologias): Oxímetro, câmara de vídeo, bandas de esforço respiratório, microfone.

RESUMO: Enquadramento: O sono é cada vez mais reconhecido como um fator determinante na Saúde Infantil porque, quando desadequado, pode ter consequências na regulação emocional e do comportamento, nas funções cognitivas, no rendimento académico, na regulação do peso e no risco de lesões acidentais. Os hábitos e problemas do sono das crianças portuguesas não se encontram ainda bem caracterizados. Este conhecimento é importante para o desenvolvimento da investigação e para a promoção da saúde nesta área. Objetivos: Adaptar e validar o Children's Sleep Habits Questionnaire (CSHQ) para a cultura portuguesa; Caracterizar os hábitos de sono de uma amostra de crianças dos 2 aos 10 anos tendo em vista a obtenção de dados de referência; Estimar a prevalência dos problemas do sono na perspetiva dos pais; Avaliar se existem diferenças nos hábitos e problemas do sono entre as regiões de média-alta e baixa densidade populacional; Identificar potenciais consequências dos problemas do sono. Métodos: Foi realizado um estudo transversal, descritivo e correlacional. A versão portuguesa do questionário (CSHQ-PT) foi desenvolvida de acordo com as orientações previamente publicadas e validada numa amostra de 315 crianças dos 2 aos 10 anos. Para o estudo dos hábitos e problemas do sono, o CSHQ-PT foi distribuído aos pais de 2257 crianças recrutadas em 17 zonas de agrupamentos escolares (15 escolhidos de forma aleatória) das áreas da Grande Lisboa, Península de Setúbal e Alentejo, compreendendo zonas litorais e do interior, e de alta, média e baixa densidade populacional. Foram obtidos 1450 (64%) questionários válidos. Resultados: O CSHQ-PT mostrou propriedades psicométricas semelhantes às das versões de outros países e adequadas para a investigação. A avaliação dos hábitos de sono nos dias de semana mostrou que as crianças se deitam, em média, pelas 21h 44m (DP 38 min.). A necessidade da companhia dos pais para adormecer diminui com a idade, ocorrendo em 49% das crianças aos 2-3 anos e 10% aos 9-10 anos. O hábito de adormecer a ver televisão foi descrito em 15,8% das crianças. O tempo total de sono diário diminui com a idade, com uma diferença mais marcada dos 2 para os 3 anos e dos 3 para os 4 anos, quando a sesta se torna menos frequente. No fim de semana, 25% das crianças dormia pelo menos mais uma hora. As diferenças nos hábitos de sono entre regiões de média-alta e de baixa densidade populacional foram reduzidas, sem reflexo na duração média do sono. Considerando valores de referência de outros países, verificou-se que 10% das crianças estudadas tinha uma duração do sono dois desvios-padrão abaixo da média esperada para a idade. A prevalência dos problemas do sono na perspetiva dos pais foi de 10,4%, sem diferenças significativas entre classes etárias, subgrupos de nível educacional dos pais, nem entre zonas de média-alta e baixa densidade populacional. Estes problemas do sono mostraram-se associados, sobretudo, à duração do sono insuficiente, resistência em ir para a cama, dificuldade em adormecer sozinho, despertares noturnos frequentes e ocorrência de parassónias. A baixa prevalência de problemas do sono identificados pelos pais contrasta com cotações elevadas no CSHQ-PT que traduzem comportamentos-problema mais frequentes, que são bem aceites por alguns pais. O Índice de Perturbação do Sono foi mais elevado nas famílias com menor nível educacional. Em análise multivariada mostraram valor preditivo para a sonolência diurna: o tempo total de sono diário, a diferença da duração do sono noturno durante a semana e no fim de semana, a frequência de algumas parassónias e o hábito de adormecer a ver televisão. O rendimento escolar mostrou associação com os problemas do sono, que são mais frequentes nas crianças com dificuldades escolares e hiperatividade/problemas de atenção. A relação entre estas variáveis é complexa. Conclusões: Este estudo mostrou que os problemas comportamentais do sono e a privação de sono são frequentes na população estudada. Estes problemas têm consequências, uma vez que correspondem a uma frequência mais elevada de sintomas de sonolência diurna, por comparação com outros países. Perante este cenário, é muito importante reforçar a promoção de hábitos de sono saudáveis e continuar a estudar as consequências do sono desadequado nas crianças portuguesas. -----------ABSTRACT:Framework: Sleep is increasingly being recognized as important to Child Health, for inadequate sleep may impact behavioral and emotional regulation, cognitive functions, academic performance, weight regulation and the risk of accidental injuries. The sleep habits and sleep problems of Portuguese children are not well characterized. This knowledge is important to support further studies and health promotion actions. Objectives: Develop and validate a Portuguese version of the Children's Sleep Habits Questionnaire (CSHQ-PT); Characterize the sleep habits and problems in a sample of Portuguese children from the ages of 2 to 10 for future reference; Estimate the prevalence of parent-defined sleep problems; Assess whether there are differences in sleep habits and problems between regions of medium-high and low population densities; Identify potential consequences of sleep problems. Methods: We conducted a cross-sectional, descriptive and correlational study. The Portuguese version of the questionnaire (CSHQ-PT) was developed according to published guidelines and validated in a sample of 315 children from 2 to 10 years old (y.o.). In order to study sleep habits and problems we delivered the CSHQ-PT to 2257 children recruited from 17 school districts (15 were chosen randomly) in areas with low, medium and high population densities, including coastline and inland regions. 1450 (64%) valid questionnaires were obtained. Results: The CSHQ-PT demonstrated psychometric properties that were similar to the versions from other countries and adequate for research. The evaluation of sleep habits showed that on schooldays children go to bed, on average, at 21h 44m (SD 38 min.). The need of having the parent in the room at bedtime decreases with the age of the child, occurring in 49% of children with 2-3 y.o. and 10% of children between 9 and 10 y.o. The habit of going asleep while watching TV was reported in 15,8% of the children. Total sleep time diminishes with the age of the child, having a major decrease from 2 to 3 y.o. and from 3 to 4 y.o., along with less frequent naps. During the weekend, 25% of the children sleep at least one extra hour. Considering reference values from other series, we found that 10% of the children had a sleep duration two standard deviations below the mean for the age. The differences in sleep habits between regions of medium-high and low population densities are few, and there are no differences in average sleep durations. The prevalence of parent-defined sleep problems was 10.4%. There were no significant differences between age classes, parent education subgroups or between regions of medium-high and low population densities. These sleep problems were associated with insufficient sleep duration, bedtime resistance, difficulty in falling asleep alone, frequent night awakenings and the occurrence of parasomnias. The low prevalence of parent-defined sleep problems contrasts with high CSHQ scores meaning that problematic behaviors are more frequent, but acceptable to some parents. The Sleep Disturbance Score was higher in families with a lower educational level. In multivariate analysis, the following factors predicted the daytime somnolence score: total sleep time, the difference in night sleep duration between the weekend and school days, the frequency of some parasomnias and the habit of falling asleep while watching TV. School achievement showed a negative correlation with the sleep problems, which are more frequent in children with school difficulties and hyperactivity/attention problems. The relationship between these variables is complex. Conclusions: This study evidenced that behavioral sleep problems and sleep deprivation are common in our population. These sleep problems have consequences as they correspond to more symptoms of excessive daytime somnolence comparing to other countries. Therefore, we reinforce the importance of promoting healthy sleep habits and further study the consequences of inadequate sleep in Portuguese children.

As doenças alérgicas respiratórias pediátricas são cada vez mais frequentes e têm impactos significativos para as crianças e suas famílias, levando a que a família se tenha de adaptar às exigências da condição de saúde dos seus filhos. Reconhecendo o papel da família para o controlo destas doenças, tem sido salientada a importância de compreender a adaptação das próprias famílias e também a necessidade de utilizar indicadores positivos. O presente estudo teve como objetivo compreender o bem-estar de famílias de crianças com doenças alérgicas, considerando o papel de variáveis individuais, parentais e familiares e ainda o papel da qualidade do sono da criança na relação entre estes fatores e o bem-estar da família. Participaram neste estudo 139 pais/cuidadores de crianças com doenças alérgicas respiratórias (asma ou rinite), que preencheram questionários para avaliar o temperamento, fatores de resiliência da família, a satisfação conjugal, a autorregulação parental, o bem-estar familiar e a severidade da asma. Foram também recolhidos dados sociodemográficos e clínicos. Os resultados apoiaram a importância dos recursos parentais e familiares para o bem-estar familiar, assim como a relevância de considerar outros indicadores de saúde e funcionamento da criança, neste caso a qualidade do sono, para compreender o bem-estar das famílias. Os recursos familiares revelaram ser fatores positivos da família que contribuem para a perceção de bem-estar familiar pelos cuidadores. O subsistema conjugal e a autorregulação parental também se relacionaram com o bem-estar familiar revelando que ambos influenciam o modo como se responde aos desafios da paternidade. A qualidade do sono foi ainda mediadora e moderadora na relação entre os recursos familiares e o bem-estar familiar. Os resultados encontrados sugerem recursos potenciais para a adaptação dos pais e também áreas de vulnerabilidade. A abordagem de fatores do sistema familiar e a consideração da qualidade do sono podem ser cruciais para promover o bem-estar de famílias de crianças com doenças alérgicas respiratórias.
Pediatric respiratory allergic diseases are increasingly common and affect children and their families, leading to families having some change in the health conditions of their children. Recognizing the role of the family in controlling these diseases, the importance of understanding families’ adaptation and the need to use positive indicators has been highlighted. The present study aimed to understand children with allergic diseases well-being, considering the role of individuals, parents and family members and the role of children's sleep quality in the relationship between these factors and family well-being. 139 children with respiratory diseases (asthma or rhinitis) parents/caregivers participated in this study by completing questionnaires to measure temperament, family resilience factors, marital satisfaction, parental self-regulation, family well-being and asthma severity. Sociodemographic and clinical data were also collected. The results support the importance of parental and family resources for family well-being, as well as the importance of considering other child health indicators and functioning, in this case, sleep quality to understand families well-being. Family resources revealed positive family factors that contribute to the caregivers' perception of family well-being. The marital subsystem and parental self-regulation were also related to family well-being, revealing that both influence the way we respond to parenting challenges. Sleep quality was also mediating and moderating in the relationship between family resources and family well-being. The results suggest potential resources for parents’ adaptation as well as the areas of vulnerability. Addressing family system factors and considering sleep quality can be crucial in promoting the well-being of children with allergical diseases families.

L’annonce d’un diagnostic de cancer provoque souvent une forte réaction émotionnelle et un stress important tant chez les adultes que chez les adolescents et leurs parents. Certains d’entre eux cherchant à soulager cette détresse se tournent vers des méthodes alternatives positives de gestion de stress, dans le but d’atténuer les effets psychologiques indésirables du cancer. Les thérapies ciblant à la fois le corps et l’esprit gagnent en popularité dans ces populations. Une avenue prometteuse est la méditation de pleine conscience (MPC), inspirée de la philosophie bouddhiste et adaptée dans le cadre d’interventions thérapeutiques pour améliorer la qualité de vie des patients souffrant de maladies chroniques. À ce jour, des études dans le domaine de la santé ont suggéré que la MPC pouvait avoir des effets bénéfiques sur les symptômes et la gestion de plusieurs maladies chroniques dont le cancer, faisant d’elle une avenue thérapeutique intéressante dans le traitement des effets psychologiques indésirables liés à ces maladies. La recherche émergente en pédiatrie suggère des effets comparables chez les enfants et adolescents. L’objectif de la présente thèse a été de développer un essai clinique randomisé visant à évaluer les effets de la MPC sur la qualité de vie, le sommeil et l’humeur chez des adolescents atteints de cancer, en documentant les étapes d’implantation du projet, les embuches qui ont été rencontrées durant son implantation et les résultats obtenus. La thèse est présentée sous la forme de deux articles scientifiques. Le premier article présente la méthodologie qui avait été planifiée pour ce projet mais qui n’a pu être réalisée en raison d’embuches rencontrées dans la complétion de ce pilote. Ainsi, les étapes préliminaires du développement de ce projet de recherche, en accordant une place prépondérante au manuel d’intervention rédigé à cette fin. La mise en place et la structure de ce projet, nommément le devis méthodologique employé, la taille d’échantillon visée, les méthodes de recrutement mises en place et les stratégies de randomisation prévues, sont décrites en détail dans cet article. Pour les fins de ce projet, un manuel d’intervention de MPC a été rédigé. L’intervention en MPC, menée par deux instructeurs formés en MPC, s’est échelonnée sur une durée de huit semaines, à raison d’une séance d’une heure trente par semaine. Une description détaillée de chaque séance est incluse dans cet article, dans un but de dissémination du protocole de recherche. Des analyses intragroupe serviront à évaluer l’impact de l’intervention en méditation de pleine conscience sur la qualité de vie, le sommeil et l’humeur pré-à-post intervention et au suivi à six mois. Des analyses intergroupes prévues sont décrites afin de comparer les effets de l’intervention entre les participants du groupe contrôle et du groupe expérimental. Les limites potentielles de ce projet, notamment la participation volontaire, le risque d’attrition et la petite taille d’échantillon sont décrites en détail dans cet article. Le deuxième article présente, dans un premier temps, le déroulement du projet de recherche, en mettant en lumière les embuches rencontrées dans son implantation. Ainsi, les leçons à tirer de l’implantation d’un tel essai clinique en milieu hospitalier au Québec sont décrites selon trois axes : 1) les défis liés au recrutement et à la rétention des participants; 2) l’acceptabilité et la compréhensibilité de l’intervention en pleine conscience; et 3) le moment où l’intervention s’est déroulée (timing) et l’impact sur l’engagement requis des participants dans le projet. Durant une période de recrutement de neuf mois, 481 participants potentiels ont été filtrés. 418 (86,9 %) d’entre eux ont été exclus. 63 participants potentiels, vivant à moins d’une heure de Montréal, ont été approchés pour prendre part à ce projet. De ce nombre, seulement 7 participants (1,4%) ont accepté de participer aux rencontres de MPC et de compléter les mesures pré-post intervention. Un bassin d’éligibilité réduit, ainsi que des taux de refus élevés et des conflits d’horaire avec les activités scolaires ont eu un impact considérable sur la taille d’échantillon de ce projet et sur l’absentéisme des participants. Malgré l’intérêt manifeste des équipes médicales pour la recherche psychosociale, les ressources requises pour mener à terme de tels essais cliniques sont trop souvent sous- estimées. Les stratégies de recrutement et de rétention des participants méritent une attention spéciale des chercheurs dans ce domaine. Dans un deuxième temps, le deuxième article de cette thèse a pour objectif de présenter les résultats de l’intervention en MPC chez des jeunes ayant le cancer, en examinant spécifiquement l’impact de l’intervention sur la qualité de vie, le sommeil et l’humeur des jeunes pré-post intervention et lors du suivi à six mois. Faisant écho aux embuches décrites préalablement décrites, les analyses statistiques n’ont permis de déceler aucun effet statistiquement significatif de notre intervention. Aucune différence significative n’est notée entre les participants du groupe expérimental et les participants du groupe contrôle. Les difficultés rencontrées dans de la complétion des devoirs et de la pratique de techniques de méditation entre les séances, décrites en détail cet article, expliquent en partie ces résultats. Globalement, le contexte développemental spécifique à l’adolescence, ayant possiblement eu un impact sur l’adhérence des participants à la thérapie proposée et à leur motivation à prendre part aux rencontres, les scores sous-cliniques lors du premier temps de mesure, l’impact du soutien social inhérent au contexte de thérapie de groupe, ainsi que les caractéristiques personnelles des thérapeutes, pourraient avoir influencé les résultats de ce pilote. Les résultats de ce projet pilote nous laissent croire que la prudence est de mise dans la généralisation des bienfaits et de l’efficacité de la pleine conscience observés chez les adultes atteints de cancer dans son application aux adolescents en oncologie. En conclusion, la présente thèse contribue à enrichir la recherche dans le domaine de la MPC chez les jeunes en questionnant néanmoins la pertinence d’une telle intervention auprès d’une population d’adolescents souffrant de cancer. Ainsi, il convient d’analyser les résultats obtenus en tenant compte des limites méthodologiques de ce projet et de poser un regard critique sur la faisabilité et la reproductibilité d’un projet d’une telle envergure auprès d’une même population. Les leçons tirées de l’implantation d’un tel projet en milieu hospitalier pédiatrique se sont avérées d’une importance centrale dans sa complétion et feront partie intégrante de toute tentative de réplication. D’autres essais cliniques de cette nature seront inévitablement requis afin de statuer sur l’efficacité de la MPC chez des adolescents atteints cancer et sur la faisabilité de l’implantation de cette méthode d’intervention auprès d’une population pédiatrique hospitalière.
News of a cancer diagnosis often elicits a strong emotional reaction in teenagers and their parents. To address these emotional challenges, various psychosocial approaches have been developed, including mind-body therapies. Mindfulness-based meditation, inspired from the Buddhist tradition, and adapted to improve quality of life in patients suffering from chronic illnesses, constitutes a promising option. Altogether, authors have suggested that mindfulness meditation could have beneficial effects on physical and psychological symptoms among adults with different chronic illnesses, namely cancer, and could hence be an interesting therapeutic avenue in the treatment of these conditions. The emerging research in pediatrics is suggesting similar effects in children and adolescents. The goal of this thesis was to develop a randomized clinical trial with the aim to evaluate the effects of a mindfulness- based intervention on quality of life, sleep and mood in adolescents with cancer, while documenting lessons learned from this experience and obtained results. This thesis is comprised of two scientific articles. The first article presents the initial study protocol that was planned for this study, although this could not be implemented because of multiple feasibility challenges that were met along the way. Preliminary steps in developing this research project, giving prominence to its intervention manual. The structure of the project, namely the choice of design and participant flow, the targeted sample size, along with recruitment and randomization strategies, are described in this article. For the purposes of this project, an intervention manual was written. The mindfulness-based intervention, given by two trained instructors, comprised of eight weekly sessions, lasting 90 minutes each. A detailed description of each weekly session was included in this article, in order to foster the dissemination of our research protocol. The second article is firstly based on our experience of carrying out a mindfulness- based clinical trial with a group of teenagers treated for cancer. While the initial goal of the trial was to expand the field of mindfulness research of youth with cancer, it became clear that much was to be learned from the challenges we met along the way. The goal of this article was therefore to document lessons learned from completing this trial to improve feasibility of future similar trials. Our findings are described in terms of the challenges encountered according to the following three categories: 1) recruitment and retention challenges; 2) treatment acceptability; 3) timing and commitment. Over 9 months of recruitment, 481 youth were screened for participation in the present project. Of these, 418 (86,9 %) were excluded. Of the 63 that were approached, only 7 (1,4%) agreed to participate in the project, gave consent and provided a complete dataset. A narrow pool of eligible participants, along with high refusal rates, scheduling conflicts with school and absenteeism had a significant impact on sample size in this project. Although there is manifest interest from the medical care community and scientific merit to conducting clinical trials, the resources needed for implementing these types of projects are often underestimated. Effective recruitment and retention merits particular attention. Secondly, this article presents results of our mindfulness-based intervention in adolescents with cancer, specifically in terms of quality of life, sleep and mood. Participants from the experimental group completed follow-up measures. Testing revealed no significant differences on any variable between participants from the experimental group and participants from the control group pre-to-post assessment. This could be explained by a lack of exposure to mindfulness techniques following the eight weeks program, limiting the generalization potential beyond therapy sessions. Moreover, encountered difficulties with homework, previously mentioned, could explain the absence of a mindfulness skills acquisition. Globally, our results could be explained by the inherent developmental changes of adolescence, impacting participants’ openness and adherence to mindfulness. Sub-clinical psychological symptoms could also strongly impact the usefulness of mindfulness meditation in youth with cancer. Data from this pilot study suggests that caution is required in generalizing the results used to determine the effectiveness of mindfulness interventions in adults with cancer, as they are not a guarantee of success and effectiveness for adolescent oncology populations. In conclusion, the present thesis helps advance the state of knowledge in mindfulness and youth research, namely by presenting data that questions the relevance of mindfulness interventions for teenagers with cancer. It is necessary to be cautious in analysing results from this thesis, especially when taking into consideration the methodological limitations that were faced in its completion and their impact on feasibility and reproducibility of such a project on a larger scale. Thus, lessons learned from the implementation of a mindfulness intervention project in pediatric oncology were of crucial importance in the completion of this project and will be an essential part of any attempt to replicate a project of this nature. Further research in this field will be necessary to conclude whether mindfulness interventions are beneficial for teenagers with cancer and whether they are feasible with pediatric populations.

La santé maternelle et la santé pédiatrique font partie des priorités de santé publique mondiale. La présente thèse a pour objectif d’élargir les connaissances portant sur l’influence de la santé maternelle durant la grossesse sur la santé pondérale et cardiométabolique de la population pédiatrique. Une première étude a montré qu’une exposition intra-utérine à une ou plusieurs conditions gestationnelles sous-optimales (diabète gestationnel, désordres hypertensifs de la grossesse, tabagisme maternel durant la grossesse) avait un effet délétère sur la santé pondérale et cardiométabolique de la population pédiatrique et que cet effet était spécifique au sexe. Une seconde étude a montré que l’efficacité mécanique et l’oxydation des substrats énergétiques (lipides et glucides) au repos et durant l’exercice ne sont pas altérées dans cette population en comparaison avec les enfants non exposés. Ainsi, ce résultat suggère que d’autres mécanismes seraient à l’origine des effets délétères des conditions gestationnelles sous-optimales sur la santé pondérale et cardiométabolique de cette population. Enfin, la troisième étude a montré que seule l’activité physique d’intensité légère réduisait l’effet délétère d’une exposition intra-utérine à plus d’une condition gestationnelle sous-optimale sur le taux de cholestérol à lipoprotéine de haute densité chez les garçons. De plus, une durée de sommeil correspondant aux recommandations canadiennes actuelles n’avait pas d’effet protecteur vis-à-vis du risque d’obésité abdominale (enfants) et d’obésité (filles) dans le contexte d’une exposition au tabagisme maternel durant la grossesse. Par ailleurs, les autres saines habitudes de vie telles que l’activité physique d’intensité moyenne à élevée et une alimentation riche en fruits et légumes, en produits laitiers et en produits céréaliers n’ont pas contrecarré les effets délétères d’une exposition intra-utérine à une ou plusieurs conditions gestationnelles sous-optimales sur la santé pondérale et cardiométabolique des enfants. L’ensemble de ces résultats souligne l’importance de la santé maternelle durant la grossesse pour la santé pondérale et cardiométabolique de la population pédiatrique. Par ailleurs, étant donné que ces effets délétères ne sont que peu contrecarrés par les habitudes de vie durant l’enfance, il reste important de continuer les efforts de prévention et de prise en charge des conditions gestationnelles sous-optimales auprès des femmes enceintes qui les présentent. En terminant, il est important de continuer à explorer les mécanismes sous-jacents à ces effets délétères et à déterminer si des interventions en habitudes de vie peuvent prévenir l’obésité et les facteurs de risque cardiométaboliques dans cette population.
Maternal and children’s health are major worldwide public health concerns. The current thesis aimed to explore the impact of maternal health during pregnancy on children’s and adolescents’ health and included three original research projects. The first study found that a prenatal exposure to independent or combined suboptimal gestational factors (SGF : gestational diabetes mellitus, hypertensive disorders during pregnancy, maternal smoking during pregnancy) was positively associated with obesity and cardiometabolic risk factors in children around puberty, and these associations were sex-dependent. The second study found that children exposed to one SGF display a similar physiological response in terms of mechanical efficiency and substrate oxidation at rest and during exercise (submaximal and maximal) in comparison with non-exposed children. The third study of the thesis found that light-intensity physical activity reduced the adverse impact of prenatal exposure to combined SGF on high density lipoprotein-cholestrol levels in boys. A sleep duration within the range of the current Canadian recommendations for sleep did not mitigate the risk of high waist circumference (children) and obesity (girls) in a context of exposure to maternal smoking during pregnancy. Furthermore, other lifestyle factors such as moderate-to-vigorous physical activity and a healthy diet (intakes of: fruits and vegetables, grains, and dairy products), did not mitigate the adverse impact of a prenatal exposure to independent or combined SGF on children’s risk of obesity and cardiomeatbolic outcomes. Taken together, these results suggest that it is important to continue maternal SGF prevention and management programs to provide optimal health for children. Moreover, future studies should also develop and evaluate the impact of lifestyle habits interventions to design future prevention strategies during childhood and adolescence to reduce obesity and cardiometabolic risk factors in this population.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
RESUMOIntrodução: A acessibilidade a cuidados de saúde mais diferenciados possibilitou o aumento da esperança média de vida em patologias com prognósticos anteriormente reservados, embora frequentemente com aumento das co-morbilidades. Deste modo, as crianças dependentes de tecnologia no domicílio, têm vindo a aumentar, com implicações no tipo de vigilância e assistência dos seus cuidadores. Objetivos: avaliação da qualidade do sono e qualidade de vida (QdV) de cuidadores de crianças/adolescentes com doença crónica complexa (DCC) e necessidade de ventilação mecânica domiciliária (VMD), relacionando-as com características sociodemográficas e clínicas. Materiais e Métodos: Estudo prospetivo, exploratório e observacional, incluindo pais/cuidadores de crianças/adolescentes com DCC, sob VMD. Utilizaram-se como instrumentos de avaliação o PSQI-PT e o WHOQOL-Bref, validados para a população portuguesa, complementados com variáveis clínicas e sociodemográficas. Período: Outubro/2018-Janeiro/2019. Obteve-se consentimento informado escrito. Análise estatística: IBM SPSS Statistics ®, versão 25 (nível de significância: 5%).Resultados: Responderam ao questionário 36 cuidadores (86,1% eram mães; idade média de 42 anos), sendo que 33 preencheram o PSQI e 35 o WHOQOL-Bref; 16,7% dos cuidadores apresentava doença crónica e 22,2% patologia/distúrbio do sono. As crianças/adolescentes com DCC pertenciam maioritariamente ao género masculino (66,7%), com predomínio de adolescentes (58,3% na faixa 11-18 anos) e o principal grupo diagnóstico foi o genético/polimalformativo (41,7%).Verificou-se uma discrepância entre a qualidade subjetiva do sono (“Boa” em 63,6%) e a pontuação global final do PSQI, mostrando “Má Qualidade do Sono” em 72,4%. Salienta-se elevada percentagem de sonolência/disfunção diurnas (75%). O valor geral mediano da QdV foi de 87; 48,6% considerou a sua QdV como “Boa ou Muito Boa”. O domínio das relações sociais foi o que obteve pontuação mais baixa.Cuidadores de doentes com patologia respiratória apresentaram valores inferiores de qualidade do sono, enquanto hipoventilação central apresentaram valores inferiores de QdV. Não foram registadas variações significativas com a frequência de estabelecimento escolar, autonomia para as atividades diárias ou interface utilizado. Apesar de não se demonstrar correlação, o aumento de horas diárias de VMD na criança/adolescente parece condicionar qualidade de sono inferior nos cuidadores. Como esperado, os cuidadores com patologia/distúrbio do sono relataram pior qualidade do sono.Discussão e Conclusão: A qualidade de sono dos cuidadores pareceu ser negativamente afetada pela necessidade de VMD, ao contrário da QdV, que não registou alterações, embora o domínio social tenha sido o mais afetado. Os valores encontrados estão de acordo com a literatura e devem alertar as equipas assistenciais para a sobrecarga e risco de exaustão dos cuidadores de crianças com elevada dependência de tecnologia.
ABSTRACTBackground: Better health care and accessibility leads to the rise of many pediatric chronic diseases, with increased life expectancy, even though the upcoming comorbidities. This way, children with specialized health care needs, dependents on domiciliary technology, have been rising, with implications on the caregivers’ type of vigilance/assistance and impact on personal, familiar and social dynamics. The main aims of this study were the quality of sleep and life evaluation of children/adolescents with complex chronic disease and home mechanical ventilation caregivers’, linking them to sociodemographic and clinical characteristics. Methods: A prospective, exploratory and observational study was taken. The sample consisted of parents/caregivers of children/adolescents with complex chronic disease and home mechanical ventilation. As evaluation instruments, we used the PSQI and the WHOQOL-Bref, both validated to the Portuguese population. They were complemented with other sociodemographic variables. Study period: October/2018 to January/2019. We conducted the data analysis with IBM SPSS Statistics ® software, version 25, with a significance level of 5%.Results: We had 36 caregivers responding to the questionnaire (86,1% were mothers, mean age of 42 years), with 33 responding to PSQI and 35 to WHOQOL-Bref; 16,7% of the caregivers had chronic disease and 22,2% had sleep pathology/disturbance. Children/adolescents with chronic complex disease were mainly male (66,7%) and adolescents (58,3% between 11 and 18 years). The principal diagnosis group was genetic/polymorphic syndrome. There was a difference between sleep subjective quality (‘Good’ in 63,6%) and PSQI final global score, with 72,4% being ‘poor sleepers’ and a high percentage of somnolence and diurnal dysfunction (75%). The quality of life general median score was 87 and 48,6% classified their own quality of life as ‘Good or Very good’. Social relations domain was the one who get the lowest scores. Caregivers of children with respiratory pathology had the lowest scores in quality of sleep and caregivers of children with central hypoventilation had the lowest score in quality of life. There was no significant differences between school attendance, daily activities autonomy or ventilation forms. Although the correlation was not demonstrated, a superior daily number of ventilation hours seemed to predict worse caregiver sleep quality. As we expected, caregivers with sleep pathology/disorders had the worst sleep quality.Discussion and Conclusions: Caregivers’ sleep quality seemed to be negatively affected by domiciliary mechanical ventilation needs. In the other side, quality of life did not registered any changes, even though the social domain was the one who get the lowest scores. These results are similar to the ones found on the literature and should alert care teams to the burden and exhaustion risk of caregivers of children highly dependent on technology.

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014
Introduction: Sleep is influenced by biopsychological factors and by the cultural, social and familiar environment. Inadequate sleep causes cognitive, behavioral and emotional problems in children. The aim was to compare sleep between preschool (PS) and school (S) aged children. Materials and Methods: The Children’s Sleep Habits Questionnaire-PT was applied to children aged three to ten years old. Descriptive and comparative statistics - SPSS® 21. Significance level of 5%. Results: 185 questionnaires. Calculated mean wakeup time, bedtime and sleep duration were similar to reference values from portuguese children. S children woke up 13 minutes earlier (p <0,01) and slept 14 minutes less (p <0,01) during the week. The prevalence of parent reported sleep problems was 14,3% in the PS group and 12,2% in the S group, in contrast with the obtained scores: 41% and 30,3%, respectively, presented a sleep disturbance index ≥ 48. The problems with the highest scores were: daytime sleepiness and bedtime resistance. Most sleep habits presented an higher prevalence in PS; bedtime resistance had significantly higher score in this age group (p <0,05). Conclusion: Parents have poor perception of sleep. Both age groups sleep less than recommended. Sleep problems are prevalent in children and should be actively investigated. It’s necessary to educate parents about healthy sleep.
Introdução: O sono é influenciado por fatores biopsicológicos e pelo meio sociocultural e familiar. Sono inadequado causa problemas cognitivos, comportamentais e emocionais em crianças. O objetivo foi comparar o sono em crianças em idade pré-escolar (PEsc) e escolar (Esc). Material e Métodos: Aplicação do questionário CSHQ – Children’s Sleep Habits Questionnaire-PT a crianças entre três e dez anos. Estatística descritiva e comparativa - SPSS® 21. Nível de significância 5%. Resultados: 185 questionários. As médias horárias foram semelhantes a valores de referência para a população portuguesa. As crianças Esc acordaram 13 minutos mais cedo (p <0,01) e dormiram menos 14 minutos (p <0,01) na semana. A prevalência de problemas do sono referidos pelos pais foi 14,3% no PEsc e 12,2% no Esc, contrastando com as cotações: 41% e 30,3%, respetivamente, apresentaram índice de perturbação do sono ≥48. As cotações mais elevadas coincidiram: sonolência diurna e resistência em ir para a cama. A maioria dos hábitos de sono apresentou maior prevalência no PEsc; resistência em ir para a cama teve cotação significativamente superior neste grupo (p <0,05). Conclusão: Os pais têm má perceção do sono. Ambos os grupos têm uma quantidade de sono inferior ao desejável. Os problemas de sono são prevalentes nas crianças e devem ser pesquisados ativamente. É necessário educar os pais para hábitos de sono saudáveis.