Validity of the Pupillographic Sleepiness Test for the diagnosis of daytime sleepiness in children and adolescents and its relationship to sleepiness-associated outcomes

Hannah von Lukowicz; Christian F Poets; Tobias Peters; Barbara Wilhelm; Angelika Schlarb; Michael S Urschitz

doi:10.1016/j.sleep.2021.04.030

Validity of the Pupillographic Sleepiness Test for the diagnosis of daytime sleepiness in children and adolescents and its relationship to sleepiness-associated outcomes

Sleep Med. 2021 Jul:83:145-150. doi: 10.1016/j.sleep.2021.04.030. Epub 2021 Apr 28.

Authors

Hannah von Lukowicz¹, Christian F Poets², Tobias Peters³, Barbara Wilhelm³, Angelika Schlarb⁴, Michael S Urschitz⁵

Affiliations

¹ University Children's Hospital, Würzburg, Germany.
² Working Group on Pediatric Sleep Medicine, Department of Neonatology, University Children's Hospital, Tuebingen, Germany. Electronic address: christian-f.poets@med.uni-tuebingen.de.
³ Pupil Research Group, Centre for Ophthalmology, University Hospital, Tuebingen, Germany.
⁴ Department of Psychology, University of Bielefeld, Bielefeld, Germany.
⁵ Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.

PMID: 34015717
DOI: 10.1016/j.sleep.2021.04.030

Abstract

Objectives: To report validation data for the Pupillographic Sleepiness Test (PST) in children and adolescents, evaluate its applicability for diagnosing excessive daytime sleepiness and its relationship to sleepiness-associated outcomes.

Methods: A cross-sectional diagnostic test accuracy study was performed. Patients underwent three PST at 9 a.m. (T1), 11 a.m. (T2) and 1 p.m. (T3) plus the Multiple Sleep Latency Test (MSLT) on a single day. Additionally, two neurocognitive tests were performed and three questionnaires about quality of life, sleep-related self-efficacy and behavioural aspects completed. Gender-stratified z-values of the natural logarithm of the Pupillary Unrest Index (z-lnPUI) were correlated to Sleep Latency (SL) and Mean Sleep Latency (MSL) and to variables of neurocognitive tests and questionnaires using Spearman's rank correlation. Cut-off values were determined by receiver operating characteristic (ROC) analysis.

Results: 47 patients were recruited (median 10.6 years, range 6-18). Correlation between z-lnPUI and SL was r_T1 = -0.373 (p = 0.011); r_T2 = -0.320 (p = 0.028) and r_T3 = -0.336 (p = 0.022). Correlation between z-lnPUI and MSL was r_T1 = -0.338 (p = 0.020); r_T2 = -0.202 (p = 0.173); r_T3 = -0.117 (p = 0.433). ROC analysis showed an area under the curve of 90.7% and PUI cut-off values of 12.6 mm/min (boys) and 11.6 mm/min (girls). There were moderate correlations between z-lnPUI_T1 and reaction time and omission errors in neurocognitive tests (r = 0.394, p = 0.007 and 0.391, p = 0.008).

Conclusions: We found satisfactory correlations between PST and MSLT results. The z-lnPUI_T1 was related to MSL and objective measures of attention ability. Given this accuracy, the PST may be used as a screening tool for evaluating daytime sleepiness in children and adolescents. Corresponding gender-related reference values are now available.

Keywords: Alertness; Central nervous activation; Daytime sleepiness; Hypersomnia; Pupillography; Sleepiness testing.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Child
Cross-Sectional Studies
Disorders of Excessive Somnolence* / diagnosis
Female
Humans
Male
Quality of Life
Sleepiness*
Wakefulness