Sleep Disorders in Children and Adolescents

1. Sleep Disorders in Children and Adolescents Deepti Shenoi MD

2. Objectives • To gain an understanding of normal basic sleep physiology and pathology in children and adolescents • To learn developmentally appropriate behavioral techniques for improving sleep • To obtain an understanding of options in pharmacotherapy for pediatric insomnia • I would also like you to think of iatrogenic causes for sleep difficulties. Or how we can make things worse.

3. Stages of Sleep

4. General Sleep Stages

5. Typical sleep need for children and adolescents by developmental stage Age group Years Total sleep need Infants 3 to 12 months 14 to 15 hours Toddlers 1 to 3 years 12 to 14 hours Preschoolers 3 to 5 years 11 to 13 hours School-aged 6 to 12 years 10 to 11 hours Adolescents 12 to 18 years 8.5 to 9.5 hours Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

6. Sleep Time During Development Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84

7. Newborns (0-3 months) • Sleep 10-18 hours per day • Many short sleep periods, with no differentiation between day and night. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

8. Tips for newborns and infants (up to 6mo) • Nighttime awakenings for changing and feeding should be quick and quiet • Place baby in the crib before falling asleep (when drowsy) • Avoid feeding the baby to sleep • Simple bedtime routine—soothing activities in the same order every night • GOAL: Babies to fall asleep by themselves and learn to soothe themselves and go back to sleep if they wake up in the middle of the night Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28.

9. Toddlers (12 mo-3 yrs) and Preschoolers (3-5 yrs) • Maintain a daily sleep schedule with regular naptimes and bedtime • Establish a consistent bedtime routine. • Bedroom should be quiet, comfortable, and dark • Have the child fall asleep independently. • Set limits that are consistent and enforced. • Encourage use of a security object, such as a blanket or stuffed animal. Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28.

10. School-Aged Children(6-12 yrs) • Same bedtime and wake-up on weekdays and weekends • A 20- to 30-minute bedtime routine that is the same every night. • No caffeine • No TV in the bedroom • The child should spend time outside every day and get daily exercise Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28.

11. Adolescents (12-18 years) • Need 9-9.25 hours of sleep per night but studies show that most get 7 hours/night • Onset of puberty hormonal changes and shift in melatonin  2 hour shift in circadian rhythm phase (later sleep onset and morning wake time) • Some experience a physiological need for a short sleep period in early afternoon Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

12. What to ask in a sleep evaluation?-- Sleep History Bedtime: Evening activities, bedtime routines Night-time: Latency to sleep onset, behaviors during the night, # and duration of awakenings Daytime: Daytime sleepiness, naps, caffeine intake, psychological, social and family functioning

13. What to ask in a sleep evaluation?-- Sleep Hygiene • Consistent and appropriate sleep-wake schedule • Similar schedule on weekdays and weekends • Consistent bedtime routine that involves same 3-4 activities every night • No technology in the bedroom

14. BEARS screen (for kids 2-18y.o.) • Bedtime problems • Excessive daytime sleepiness • Awakenings during the night • Regularity of evening sleep time and morning awakenings • Sleep related breathing problems or snoring

15. Common Disorders • Behavioral Insomnia of Childhood • Insufficient or Inadequate sleep • Delayed Sleep Phase Syndrome • Sleep Disordered Breathing • Disorders of Arousal • Movement disorders

16. Behavioral Insomnia of Childhood • Manifests most commonly as bedtime resistance and/or frequent night wakingsand occurs in approximately 10% to30% of infants and toddlers • Sleep-onset Association Type • Limit-setting type • Combined Type Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

17. Insufficient or Inadequate Sleep • Sleep deprivation can have a cumulative effect  being late or missing school, falling asleep during school, fatigue, illness, and irritability • Poll reports that 28% of high school students report falling asleep in school at least once a week • Insufficient sleep can be fatal for adolescents who fall asleep while driving. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

18. Insufficient or Inadequate Sleep • Signs that children or adolescents are not getting enough sleep include: • (1) needing to be awakened for school or day care inthe morning, • (2) sleeping 2 hours more on weekends and vacations comparedwith weekdays, • (3) falling asleep in school or at other inappropriate times, • (4) behavior and mood differing on days after getting more sleep Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

19. Delayed Sleep Phase Syndrome • The person’s sleep-wake cycle is delayed by 2 or more hours • “Night Owls” Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

20. Delayed Sleep Phase Syndrome

21. Delayed Sleep Phase Syndrome-Treatment • Sleep hygiene • Shifting the internal clock • Phase Advancement: When the difference between the actual and desired bedtime is less than 3 hours. Every night or two, go to sleep 15 minutes earlier. • Phase Delay: When the difference is greater than 3 hours, delay sleep by 2-3 hours on successive nights Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

22. Sleep-Disordered Breathing • Can range from primary snoring toobstructive sleep apnea syndrome (OSAS) and is related to significant cognitiveand behavioral sequelae, including learning, attention, concentration, hyperactivity, and aggressive behavior • Incidence of habitual snoring has been re-ported at 3% to 12% of the general pediatric population, with OSAS seen in 1%to 3% of children Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

23. Narcolepsy • Chronic neurologic disorder that involves excessive daytimesleepiness • cataplexy (sudden loss of muscle control in response to strong emotional stimuli) • hypnagogic hallucinations (vivid dreams at sleep onset) • sleepparalysis • autonomic behavior in which you continue to funtion, talk, clean…… but then have no recollection of performing task • . Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

24. Narcolepsy Work up • Polysomnography (PSG) • Typically fall asleep rapidly with early REM • Multiplesleep latency test (MSLT) • Test subjects are given opportunities to sleep every two hours during the normal awake time and monitored to see how quickly they fall asleep and reach various stages of the sleep cycle. • May provide clear evidence of narcolepsy, but inchildren, results are not always conclusive, and repeat studies may be necessaryfor a final diagnosis

25. Narcolepsy • Individualized based upon symptoms. • Treatment includes education, sleep hygiene, and pharmacologicinterventions • Daytime Sleepiness: • Sleep scheduling is essential, with a consistent bedtime,wake time, and good sleep hygiene • Children and adolescents who have narcolepsy may benefit from a scheduled daily nap in the early afternoon. • Stimulants are commonly used to treat daytime sedation including provigil • Atomoxetine has also been used. • Cataplexy: Cholinergic pathway mediated • medications with anticholinergic properties are used to treat cataplexy, including clomipramine and imipramine Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

26. Disorders of Arousal • Referred as partial arousal parasomnias and include: confusional arousals, sleep terrors, sleep talking, and sleepwalking • Duringan event, although children are asleep, they may appear awake (eyes open),talk, or seem frightened or confused (eg, screaming in the case of sleep terrors) • Typical parasomnias resolve spontaneously withchildren rapidly returning to a deep sleep Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

27. Disorders of Arousal • Common feature: retrograde amnesia • Strong genetic component to partial arousal parasomnias, with a family history typically reported • Partial arousals are more likely to be triggered by insufficient sleep, a disruption to the sleep environment or sleep schedule, stress, illness,or certain medications (eg, chloral hydrate or lithium) Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

28. Sleep Terrors vs Nightmares Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84

29. Disorders of Arousal • Treatment: providing families withinformation about creating a safe sleep environment (eg, preventing windowsfrom opening or putting alarms or bells on doors to alert if a sleep walker isup), education about the events, and how to interact with children appropriately during an event • As some children may develop a fear of goingto sleep and a prolonged sleep onset in turn increases the likelihood of an event occurring, parents should be encouraged to not discuss these events in the morning withthe child or other children in the home Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

30. Restless Leg Syndrome and Periodic Limb Movement Disorder • RLS manifests as uncomfortable sensations in the legs that worsenin the evening and with long periods of inactivity (eg, long car ride or movie) • Sensations often are described as creepy-crawly or tingling feelings, mostcommonly in the legs, which can be alleviated temporarily with movement. • PLMS are briefrepetitive movements or jerks, lasting on average 2 seconds and occurring every5 to 90 seconds during stages 1 and 2 of sleep • PLMD occurs whenPLMS are associated with frequent, but brief, arousals from sleep Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

31. Restless Leg Syndrome and Periodic Limb Movement Disorder • Pharmacologic treatment for RLS and PLMD in children and adolescentsmay include benzodiazepine and dopaminergic medication • Some children who have RLS or PLMD have low iron/ferritin and many ofthese children and adolescents respond favorably to iron therapy • Atthis time, there are no FDA-approved medications available to treat RLS andPLMD in children. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

32. Sleep-Related Rhythmic Movement Disorders • Include head banging and body rocking and are consideredto be a sleep-wake transition disorder, occurring as children attempt to fallasleep at bedtime, naptime, or after a normal nighttime arousal • common in infants (60% of9 month olds), the behaviors tend to resolve spontaneously with development(only 8% of 4 year olds demonstrate these behaviors), but they can continueinto adolescence and adulthood Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

33. Sleep-Related Rhythmic Movement Disorders • Events typically last 5 to 15 minutes,but prolonged events can go for several hours • Important to ensure safety • In cases that result in injury, or when the behavior may be highly disruptive to others for a short duration (eg, family vacation or overnight sleepover), benzodiazepines may beindicated. • Evaluation is recommended for severe cases or cases persisting past age 3 Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

34. “Optimizing” Treatment of Sleep Problems • Identification of the suspected causes of disrupted sleep • Involvement of the family by explaining the disorder and teaching them developmentally appropriate principles of sleep-wake organization • Use of behavioral treatments such as contracts to target specific behaviors that need to be changed Anders, TF, Eiben LA. Pediatric Sleep Disorders: A Review of the Past 10 Years. J Am Acad Child Adolesc Psychiatry. 1997;36:9-20.

35. Pharmocotherapy of Pediatric Insomnia: General Guidelines • Reminder: In almost all cases, medication is neither the first treatment of choice, nor the sole treatment for children • Medication should be used in combination with non-pharmacological strategies as these have been shown to have long-lasting effects • Treatment selection - best match between clinical circumstances and individual properties of medications • Medications should be closely monitored for emerging side effects Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

36. Pharmocotherapy of Pediatric Insomnia: General Guidelines • Presence of both medically and behaviorally-based sleep disorders must be assessed • Medications should be used in caution in situations where there may be potential drug-drug interactions • Non-prescription and over-the-counter medication use should be assessed Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

37. Pharmocotherapy of Pediatric Insomnia • Antihistamines: Prescription (hydroxyzine) and OTC (diphenhydramine) • Bind to H1 receptors in the CNS • Rapidly absorbed • Side effects: daytime drowsiness, cholinergic effects, paradoxical excitation Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

38. Pharmocotherapy of Pediatric Insomnia: Melatonin • Melatonin: hormone secreted by pineal gland in response to decreased light, mediated through suprachiasmatic nucleus; mechanism of commercially available melatonin is to supplement endogenous pineal hormone • Clinical uses for melatonin are principally in normal children with acute or chronic circadian rhythm disturbances and in children with special needs (blindness, Rett syndrome) Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

39. Pharmocotherapy of Pediatric Insomnia: Melatonin • Plasma levels peak within 1 hour of administration • Generally safe but potential side effects include suppression of hypothalamic-gonadal axis (i.e. could trigger precocious puberty upon discontinuation • Not regulated by FDA • Reported doses: 1 mg in infants, 2.5-3 mg in older children, 5 mg in adolescents Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

40. Pharmocotherapy of Pediatric Insomnia: Herbal Preparations • Valerian Root, St. John’s Wort, and Humulus lupulus - some evidence of efficacy in adult and/or pediatric studies • Lemon balm, chamomile, and passion flower - limited to no evidence • Kava kava, Tryptophan - assoc. with significant safety concerns (e.g. hepatotoxicity and eosinophilic myalgia syndrome, respectively) Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

41. Pharmocotherapy of Pediatric Insomnia: Benzodiazepines • Hypnotic effect mediated at GABA Type A receptors in the brain • They shorten sleep-onset latency, increase total sleep time, and improvenon-REM sleep maintenance; most disrupt slow-wavesleep. • Use of longer-acting BZDs may lead to morninghangover,daytimesleepiness, and compromised daytime functioning.Anterograde amnesia and disinhibition may also occur. Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

42. Pharmocotherapy of Pediatric Insomnia: Benzodiazepines • Risk for habituation or addiction with thesemedications, as well as withdrawal phenomena • Used for short-term or transient insomnia or inclinical situations in which their other properties (e.g.,anxiolytic) are advantageous • BZDs are occasionally used to treat intractable partial arousal parasomnias (e.g., sleep terrors) in children because of theirslow-wave sleep suppressant effects. Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

43. Pharmocotherapy of Pediatric Insomnia: Melatonin Receptor Agonist • Ramelteon (Rozerem): a synthetic melatonin receptor agonist, acting selectively at the MT1 and MT2receptors • Approved for use in sleepinitiation insomnia, and shows moderate efficacy inreducing sleep-onset latency (in adults) • Two single pediatriccase reports have reported efficacy in autistic children Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

44. Pharmocotherapy of Pediatric Insomnia: -Agonist • Clonidine: central 2-agonist that decreases adrenergic tone • one of the most widelyused medications for insomnia in pediatric and childpsychiatry practice, particularly in children with sleep-onset delay and ADHD • safety and efficacy in children withADHD and sleep problems is limited to descriptivestudies Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

45. Pharmocotherapy of Pediatric Insomnia: -Agonist • Clonidine is rapidly absorbed with onset of action within 1 hour and peak effects in 2-4 hours • Tolerance often develops necessitating increase in dose • Discontinuation may lead to rebound in REM and slow-wave sleep • Possible side effects include: hypotension and bradycardia, anticholinergiceffects, irritability, and dysphoria; rebound hypertensionmay occur on abrupt discontinuation • Avoid in patients with diabetes and Raynaud syndrome Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

46. Pharmocotherapy of Pediatric Insomnia: Atypical Antidepressants • Trazodone: one of themost sedating antidepressants because it both inhibitsbinding of serotonin and blocks histamine receptors • Suppressant effects on REM and mayincrease slow-wave sleep • “Morning hangover”is acommon side effect • Associated with reportsof priapism in the 50- to 150-mg dose range Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

47. Pharmocotherapy of Pediatric Insomnia: Atypical Antidepressants • Mirtazepine (Remeron) 2-adrenergic 5-hydroxytryptamine receptor agonist with a high degreeof sedation • Shown to decrease sleep-onset latency, increase sleep duration, and reduce wakeafter sleep onset in adults with and w/o major depression with little effect on REM Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

48. Pharmocotherapy of Pediatric Insomnia • SSRI’s: may cause sleep-onset delay and sleep disruption (Fluoxetine) and sedation (Fluvoxamine, Paroxetine, Citalopram) • SSRI’s suppress REM sleep and often prolong REM onset while increasing the number of REMs • Most increase sleep-onset latency and decrease sleep efficiency (time asleep/time in bed) • Selective serotonin reuptake inhibitors frequently are associated with motor restlessness and may exacerbate preexisting RLS and periodic limb movements

49. Pharmocotherapy of Pediatric Insomnia • Other classes which have reportedly been used include mood stabilizers/anticonvulsants (e.g., carbamazepine, valproic acid, topiramate, gabapentin), atypical antipsychotics (e.g. risperidone, olanzapine, quetiapine), and chloral hydrate. • These meds should be used with caution as there are no or limited date on safety and tolerability. • Sedating effects may interfere with daytime functioning and learning • Atypical antipsychotics may cause weight gain and worsen Obstructive Sleep Apnea; also tend to sup- press REM sleep and increase motor restlessness during sleep • Chloral Hydrate and Barbiturates are not indication for use in children due to significant side effects (inc. hepatotoxcity) Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

50. The End