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Background  Breathing abnormalities are common in Rett syndrome (RTT), a pervasive neurodevelopmental disorder almost exclusively affecting females. RTT is linked to mutations in the methyl-CpG-binding protein 2 ( MeCP2 ) gene. Our aim was to assess the clinical relevance of apneas during sleep-wakefulness cycle in a population with RTT and the possible impact of apneas on circulating oxidative stress markers.    Methods  Female patients with a clinical diagnosis of typical RTT ( n  = 66),  MECP2  gene mutation, and apneas were enrolled (mean age: 12.5 years). Baseline clinical severity, arterial blood gas analysis, and red blood cell count were assessed. Breathing was monitored during the wakefulness and sleep states (average recording time: 13 ± 0.5 h) with a portable polygraphic screening device. According to prevalence of breath holdings, the population was categorized into the wakefulness apnea (WA) and sleep apnea (SA) groups, and apnea-hypopnea index (AHI) was calculated. The impact of respiratory events on oxidative stress was assessed by plasma and intra-erythrocyte non-protein-bound iron (P-NPBI and IE-NPBI, respectively), and plasma F 2 -isoprostane (F 2 -IsoP) assays.    Results  Significant prevalence of obstructive apneas with values of AHI &amp;gt; 15 was present in 69.7% of the population with RTT. The group with SA showed significantly increased AHI values &amp;gt; 15 ( p  = 0.0032), total breath holding episodes ( p  = 0.007), and average SpO 2  ( p  = 0.0001) as well as lower nadir SpO 2  ( p  = 0.0004) compared with the patients with WAs. The subgroups of patients with WA and SA showed no significant differences in arterial blood gas analysis variables ( p  &amp;gt; 0.089). Decreased mean cell hemoglobin (MCH) ( p  = 0.038) was observed in the group with WAs. P-NPBI levels were significantly higher in the group with WA than in that with SAs ( p  = 0.0001). Stepwise multiple linear regression models showed WA being related to nadir SpO 2 , average SpO 2 , and P-NPBI (adjusted  R  2  = 0.613, multiple correlation coefficient = 0.795  p  &amp;lt; 0.0001), and P-NPBI being related to average SpO 2 , blood PaCO 2 , red blood cell mean corpuscular volume (MCV), age, and topiramate treatment (adjusted  R  2  = 0.551, multiple correlation coefficient = 0.765,  p  &amp;lt; 0.0001).    Conclusion  Our findings indicate that the impact of apneas in RTT is uneven according to the sleep-wakefulness cycle, and that plasma redox active iron represents a potential novel therapeutic target.

frontiers in neurology

Breathing Abnormalities During Sleep and Wakefulness in Rett Syndrome: Clinical Relevance and Paradoxical Relationship With Circulating Pro-oxidant Markers