Introduction to Sleep Problems in Children

1. Introduction to Sleep Problems in Children April Wazeka, M.D. Respiratory Center for Children Atlantic Health System

3. Objectives • Understand normal sleep in children • Review common pediatric sleep disorders • Discuss proper treatment options for childhood sleep disorders

4. Introduction • The average child spends almost half of his or her life asleep • Newborns can sleep as much as 16 hours per day • Respiratory disorders during sleep are thus of special importance during childhood Marcus, C. Sleep-disordered breathing in children. AJRCCM 2001; 164: 16-30.

5. Pediatric Sleep Medicine • Relatively new field • Few pediatric sleep centers • Now have new understanding of associations between common childhood disorders and sleep

6. Overview • Sleep disorders in children are very common—approximately 25% of children ages 1-5 years of age • Pediatric knowledge expanding • Presentation of sleep disorders different in children than in adults • Varies with age and developmental stage

7. Sleep and Breathing • Some breathing disorders occur only during sleep • Virtually all respiratory disorders are worse during sleep than during wakefulness

8. Who needs sleep? • All mammals and birds “sleep” as we know what sleep to be. • Sleep “behavior” has also been observed in reptiles and insects Mammalian Total Daily Sleep Time (in hours) Giraffe 1.9 Roe deer 3.09 Asiatic elephant 3.1 Pilot whale 5.3 Human 8.0 Baboon 9.4 Domestic cat 12.5 Laboratory rat 13.0 Lion 13.5 Bats 19.9 BUT, exact function of sleep not well understood!

9. How much sleep do children need?Sleep Duration from Infancy to Adolescence • 492 patients followed with sleep questionnaires at 1,3,6,9,12, 18 and 24 months after birth, and at annual intervals until 16 years of age • Total sleep duration decreased from an average of 14.2 hours (SD 1.9hrs) at 6 mos of age to an average of 8.1 hours (SD 0.8hrs) at 16 years of age Iglowstein et al Pediatrics Feb 2003; 111(2): 302-7

10. Normal Sleep Physiology • Breathing is better awake than asleep! • During sleep: • Decrease in minute ventilation • In children, respiratory rate (RR) decreases during sleep; in adults RR remains constant • Functional residual capacity (FRC) decreases • Upper airway resistance doubles

11. REM sleep • Rapid eye movement or dream sleep • Breathing erratic • Variable RR and tidal volume • Frequent central apneas • Decrease in intercostal and upper airway muscle tone • Children have relatively more REM sleep than adults

12. REM Sleep In neonates, active sleep (a REM-like state) can occur for up to two thirds of total sleep time, as compared with 20-25% of sleep time in adults Curzi-Dascalova L, Peirano P, Morel-Kahn F.Development of sleep states in normal premature and full-term newborns. Dev Psychobiol 1988; 21(5):431-444.

13. Development • Chest wall and upper airway change during infancy and childhood in order to respond to the physiological needs of the developing child. • Compliant chest wall in newborn • In infancy, chest wall compliance is 3x the lung compliance • Compliance paradoxical rib cage motion during inspiration increased work of breathing, especially during REM sleep when intercostal muscle activity is decreased

14. Development • Ossification of the sternum and vertebrae continues until 25 yrs of age • Results in a stiffer chest wall • Chest wall compliance = lung compliance by 2 yrs of age • However, paradoxical inward rib cage motion during inspiration in REM sleep is seen until almost 3 yrs of age

15. Upper Airway • The upper airway changes during development in both structure and function • To maintain FRC, infants do active glottic narrowing (laryngeal braking) until 6 to 12 mos of age • In infants, larynx is located relatively cephalad, which allows the epiglottis to overlap the soft palate and make a better seal for sucking • Predisposes infant to upper airway obstruction if nasopharynx is partially occluded

16. Upper Airway • In males, the larynx increases in size and shape during puberty • Testosterone-induced changes in upper airway morphology may in part explain the increased risk of OSA in males compared with females • Prepubertal rates of OSA are similar Guilleminault C et al. Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr 1989;114:997-999.

17. Apneas • Central apneas common in infants and children • More prevalent during REM sleep • Normal infants can have central apneas up to 25 seconds in duration, associated with transient desats to the 80s • Clinical significance is dubious, unless they occur frequently or are associated with prolonged gas exchange abnormalities • Obstructive apneas are rare in normal children

23. Insomnia in Infants and Toddlers • Sleep Onset Association Disorder • Colic • Nocturnal eating (drinking) disorder • Recurrent awakenings with an inability to return to sleep without eating or drinking • Food allergy insomnia • Cow’s milk protein allergy with severe sleep disruption

24. Sleep Onset Association Disorder • Difficulty falling asleep and returning to sleep when specific environmental conditions are not present (i.e. bottle, pacifier, music, being rocked) • Perceived by parents as being a problem when: • Sleep onset delayed • Frequent attention needed to help child fall asleep • Child’s daytime mood or attention suffers • Parents are losing sleep!

25. Common Features • Prolonged crying at bedtime or at awakening if parents do not respond in the usual manner • Rapid sleep onset once usual conditions are established

26. Treatment • Make child feel safe and comfortable when alone • Place child in crib and leave the room • Return after a few minutes to comfort—verbally ONLY, do not pick child up • Stay in the room no more than 1-2 minutes • Gradual withdrawal of parent from the child’s room • Best to start training children at approximately 6 months of age (age at which they should sleep through the night)

28. Causes of Insomnia in the Preschool and School-Aged Child • Fears and nightmares • Limit setting sleep behavior disorder

30. Fears and Nightmares • Fears of “monsters” when awake • Vivid, frightening dreams of villanous creatures when asleep • Experienced by >50% of children • Usually begin at 3-5 years of age, decrease with increasing age

31. Treatment • Reassurance • In a truly anxious child, exploration of underlying causes may be indicated • Milder fears may respond to supportive firmness, if in a stable social setting • Parents should provide clear cut reassurance and consistent bedtime routine • Relaxation techniques for the child may be helpful

32. Limit Setting Sleep Disorder • Exclusively a childhood sleep disorder • Characterized by: • Stalling behaviors or refusal to go to bed at the desired time • Associated with inadequate parental limit setting for a child’s behaviors

33. Common Features • Child usually >2 years of age and out of a crib • Repetitive requests, complaints, and stalling by the child despite physiological readiness for sleep • Frequent refusal to stay in bed or in bedroom • No parental enforcement of consistent bedtime rules • Possible recurrence of behaviors after nighttime awakenings • Sleep itself is usually of normal quality and duration

34. Factors in Parental Failure to Set Limits • Lack of understanding of the importance of setting limits • Inadequate knowledge of limit-setting techniques • Psychosocial factors

36. Treatment • Parental education • Regular bedtime ritual with a definite endpoint • Gate or door closure: this is a passive limit setter • Parents to be supportive and controlled, not punitive • Parents should be nearby when the door is closed, and time closed should be increased gradually

37. Once child is convinced of parental ability to enforce limits consistently, typically nighttime disruption ceases rapidly

38. Treatment (Continued) • If the child is fearful, it may be necessary for parents to stay in the room, but continue to set limits • If parent and child share the same bed, then the parent may need to leave the room until the child accepts the rules imposed upon sleeping • In older children use of positive behavior modification with rewards • Starting with a later bedtime can help at the beginning of the process • Psychosocial problems should be addressed

39. Insomnia in Adolescence • More closely resembles adult disorders • Often due to extrinsic factors • Stress • Anxiety • Psychological disorders • Sleep disturbances can be first sign of major psychological disturbances, such as schizophrenia, anorexia, and bipolar disorder

40. Treatment • Improved sleep hygiene • Normalization of sleep schedule • Decreased use of alcohol and other drugs • Sleep restriction therapy • Relaxation training • Biofeedback • Psychotherapy • Medications rarely indicated—at best a temporary fix

41. Good Sleep Hygiene • Measures that promote sleep • Avoidance of caffeinated beverages, alcohol, and tobacco in the evening • No intense mental activities or exercise close to bedtime • Avoid daytime naps and excessive time spent in bed • Adherence to a regular sleep-wake schedule

42. Pharmacologic treatment of Insomnia • Centuries ago opium-based laudanum given to children to keep babies quiet • Antihistamines • Benzodiazepines • Zolpidem (Ambien)—not approved for pediatric usage • Interacts with GABA-benzodiazepine receptor complexes

43. Causes of Insomnia in Children of all Ages • Environmental-induced sleep disorders • Travel, noise, distractions, light • Insomnia associated with: • Medical disorders • Asthma, GERD, chronic otitis media, atopic dermatitis, infantile colic • Neurological disorders • Sleep time can be dramatically reduced and circadian function abnormal • Mental disorders (social stressors) • Most common is anxiety

44. Treatment Success

45. Treatment Failure

46. Restless Legs Syndrome (RLS) • Sensory-motor disorder involving the legs • Prevalence approximately 4% of the population • Age of onset can occur at any age • Results in sleep disturbance with difficulty initiating and/or maintaining sleep • Can be exacerbated by pregnancy, caffeine, or iron deficiency

47. RLS-Diagnosis • Criteria • Major • Desire to move the limbs, usually associated with paresthesia or dysesthesia • Motor restlessness • Worsening of symptoms at rest, with at least partial relief with activity • Worsening of symptoms at night time • Ancillary: • Involuntary movements • Neurologic examination • Clinical course • Sleep disturbance • Family history

48. RLS • Sensory manifestations • Disagreeable feelings: creeping, crawling, tingling, burning, painful, aching, cramping, or itching sensations • Occur mostly between the knees and ankles • Differential diagnosis • Neurologic disorders, medical disorders, drugs

49. RLS in Children • Study by Chervin et al*: • Community based survey of 866 children ages 2 to 13.9 years • Relationship found between significant hyperactivity and periodic limb movement scores, and between hyperactivity and restless legs • Study of 11 children referred to a pediatric neurology clinical with a diagnosis of growing pains--10/11 met clinical criteria for RLS** * Chervin et al. Associations between symptoms of inattention, hyperactivity, restless legs, and periodic leg movements. Sleep 2002;25:213-8. **Rajaram et al Sleep 2004

50. RLS-Treatment • Correct underlying medical cause, if present • Diabetes, uremia, anemia • Dopaminergic agents • Pramipexole (Mirapex) • Cardidopa-levodopa (Sinemet) • Benzodiazepines • Opiates