What's new in sleep medicine

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

SLEEP-RELATED BREATHING DISORDERS

Mouth taping and obstructive sleep apnea (January 2025)

Social media has promoted mouth taping as a treatment for obstructive sleep apnea (OSA), but its efficacy is unclear. A recent study of 54 patients with OSA reported an increase in inspiratory flow during drug-induced sleep endoscopy (which simulates sleep) in the closed-mouth position compared with the open-mouth position [1]. However, in 22 percent of patients, mouth closure resulted in velopharyngeal obstruction that reduced inspiratory flow, which could be harmful during sleep. Further studies are needed before mouth taping can be routinely recommended for patients with OSA. (See "Obstructive sleep apnea: Overview of management in adults", section on 'Investigational'.)

INSOMNIA

Triage strategy for digital versus one-on-one cognitive behavioral therapy for insomnia (January 2025)

For patients with insomnia, digital/self-directed cognitive behavioral therapy for insomnia (CBT-I) can be more readily available compared with one-on-one CBT-I, but it may not be as effective for some. A recent randomized trial tested a stepped care strategy in which a triage checklist was used to direct patients to either early therapist-delivered CBT-I or digitally-delivered CBT-I with step-up to a therapist for inadequate responders [2]. Overall, the stepped care strategy resulted in greater reductions in insomnia severity and hypnotic medication use compared with access to digital CBT-I only. These results suggest that, in the context of a limited pool of CBT-I therapists, novel triage strategies may help match patients with the level of care most likely to meet their needs. (See "Cognitive behavioral therapy for insomnia in adults", section on 'Helping patients access CBT-I'.)

Masked taper for discontinuing benzodiazepines (December 2024)

For individuals who need to discontinue chronic benzodiazepines, the optimal tapering strategy to minimize withdrawal symptoms is unclear. In a recent randomized trial of 188 older adults with insomnia, a masked taper over nine weeks (ie, benzodiazepine pills with progressively increasing inert filler) plus augmented cognitive-behavioral therapy for insomnia (CBT-I, with exercises targeting expectations about the taper and placebo effects) increased the rate of benzodiazepine discontinuation at six months compared with an unmasked taper plus standard CBT-I (73 versus 59 percent) [3]. Although the results suggest that blinding patients to the taper rate may help improve benzodiazepine discontinuation, participants took relatively low doses at baseline (4 mg diazepam equivalents); thus, the efficacy of this strategy in other populations using higher doses, as in benzodiazepine use disorder, is uncertain. (See "Benzodiazepine use disorder", section on 'Taper rate'.)

CENTRAL DISORDERS OF HYPERSOMNOLENCE

Extended-release sodium oxybate in children with narcolepsy (November 2024)

Extended-release sodium oxybate, dosed once nightly at bedtime, has been approved by the US Food and Drug Administration for use in children with narcolepsy who are ≥7 years of age [4]. This formulation is more convenient than immediate-release sodium oxybate, which requires patients to be awoken in the middle of the night for a second dose. The lowest starting dose is 4.5 g; if there is concern that this dose is too high (eg, for children weighing <45 kg), we advise starting with the immediate-release formulation to allow for a lower starting dose and more flexible titration (table 1). (See "Management and prognosis of narcolepsy in children", section on 'Sodium oxybate'.)

PEDIATRIC SLEEP MEDICINE

Consensus guideline on melatonin for sleep in typically developing children (March 2025)

An international group of pediatric sleep experts has published a new consensus guideline on the use of melatonin for sleep in typically developing children [5]. The panel recommends performing a thorough clinical evaluation to rule out other causes of chronic insomnia before considering melatonin, using behavioral approaches before and along with melatonin, limiting duration to as short of a time period as possible and no longer than three to six months in most cases, and storing melatonin safely in locked containers out of the reach of children. The guideline provides typical dose ranges of melatonin by age, up to a maximum of 5 mg nightly in adolescents. Our approach is consistent with these guidelines. (See "Pharmacotherapy for insomnia in children and adolescents: A rational approach", section on 'Melatonin'.)

Tonsillotomy versus tonsillectomy for obstructive sleep apnea in children (January 2025)

Intracapsular tonsillectomy (also known as subtotal or partial tonsillectomy or "tonsillotomy") is increasingly used for the treatment of obstructive sleep apnea (OSA) in children, but its optimal role is unsettled. In a meta-analysis of 32 studies including 17 randomized trials of either tonsillotomy or traditional tonsillectomy in children with OSA, tonsillotomy was associated with improved recovery time and lower risk of postoperative complications but increased risk of tonsillar regrowth, recurrent OSA, and reoperation compared with traditional tonsillectomy [6]. Despite the high number of trials, the quality of the evidence remains limited by heterogeneity, high risk of bias, and lack of long-term follow-up. Further studies are needed to help identify individual patient characteristics predictive of long-term benefit from tonsillotomy. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Intracapsular tonsillectomy (tonsillotomy)'.)

GENERAL SLEEP MEDICINE

Accuracy of actigraphy for sleep stages (November 2024)

Actigraphy is very accurate for identifying periods of sleep (wake versus sleep) but has limited ability to identify stages of sleep. In a systematic review of eight validation studies that included mostly young, healthy adults, compared with polysomnography, actigraphy was approximately 40 percent accurate for discrimination of all five sleep stages [7]. Accuracy was slightly higher for three-class groupings (eg, wake, N1/N2, and N3/rapid eye movement sleep). Comparison across devices is difficult because staging algorithms vary and are often proprietary; further studies are needed to optimize actigraphy for sleep staging. (See "Actigraphy in the evaluation of sleep disorders", section on 'Validation and limitations'.)