Insufficient Sleep in Children & Adolescents

1. Insufficient Sleep in Children & Adolescents Teresa M. Ward, RN, PhD Associate Professor Department of Family & Child Nursing University of Washington

2. Discuss recent National Sleep Foundation results regarding sleep disturbances in school-age children and adolescents. Describe the consequence of sleep disturbances and sleep disorders in children, adolescents, and their families. Describe sleep physiology and sleep patterns. Describe sleep disorders in school-age children and adolescents. Integrate sleep screening into routine health assessments. Objectives

3. Sleep in the News Insufficient Sleep Is a Public Health Epidemic, CDC http://www.cdc.gov/features/dssleep/ Seattle petition urges later start times for high schools, middle schools, Seattle Times, Feb 2014 Diagnosing the Wrong Deficit, NYT, April 2013 Teens Short On Sleep Have Higher Car Accident Risk, Study Find, Huffington Post, May 2013 Irregular Bedtimes Lead to Misbehaved Kids, TIME , Oct 2013 Research links later school start times to benefits for teens, StarTribune, March 2014 On Sleep Research, My Children Didn’t Get the Memo, NYT, July 2013 Up all night: Parents and kids are losing sleep to their devices, Today Health, March 2014

4. Top 5 complaints presented to primary care clinicians: Infants – up to 40% Preschool – 25% to 30% School-age – 15% Adolescents – 11% to 33% Prevalence of Sleep Disturbances Faruqui et al., 2011; Meltzer et al., 2010

5. National Sleep Foundation 2014 Results Estimates of nighttime sleep: • Children 6 to 10 years sleep ~ 8.9 hours/night • Children 11 to 12 years ~ 8.2 hours/night • Adolescents 13 to 14 years ~ 7.7 hours/night • Adolescents 15 to 17 years ~ 7.1 hours/night http://sleepfoundation.org/media-center/press-release/national-sleep-foundation-2014-sleep-america-poll-finds-children-sleep

6. 7 hours or less 8 hours 9 hours or more 80% 69% 70% 56% 60% 50% 42% 34% 40% 29% 29% 30% 23% 20% 10% 8% 10% 0% 6-11 years 12-14years 15-17 years Age Group Children’s Sleep Duration by age group National Sleep Foundation 2014 Results .

7. Electronics and Sleep National Sleep Foundation 2014 Results

8. Never leaves any electronic on Sometimes leaves ONE electronic device on Sometimes leaves TWO OR MORE electronic devices on 100% 57% 51% 49% 44% 33% 23% 20% 13% 7% 0% Excellent Good Fair or Poor Parent's rating of Child's Sleep Quality Sleep quality by number of electronic devices left on .

9. Reasons for Difficulty SleepingFindings: Reasons for Difficulty Sleeping National Sleep Foundation 2014 Results At least once Never 34% Evening activities 66% Children . 28% Homework 72% 18% Temperature 82% 15% Inside Noise 84% 8% Outside noise 92% 8% Light 92% 9% Pets 91% 0% 80% 90% 100% 10% 70% 20% 60% 40% 30% 50% 41% Evening activities Parents 59% 35% Temperature 65% 28% Inside Noise 72% 16% Outside noise 83% 13% Light 87% 18% Pets 82%

10. National Sleep Foundation 2014 Results Impact of Inadequate Sleep

11. Consequences of Insufficient Sleep • decrements in neurobehavioral function (attention span, slower reaction time) (Wahlstrom et al., 2014; Vedaa etal., 2012; Lufi, Tzischinsky, & Hadar 2011; Beebe et al., 2010; Carskadon et al., 1981) • increased risky behaviors & mental health challenges (depression) (Adrian et al., 2014; McKnight-Eily et al., 2011; Onyper, et al., 2012) • increased automobile accidents (Wahlstrom et al., 2014; Vorona et al., 2011; Pizza et al., 2010) • increased family stress(Johnson et al., 2009; Lopez-Wagner et al., 2008; Smaldone 2007) • increased screen time and electronic devices (Barlett, et al., 2013; Cain, Gradisar, 2010)

12. Knowledge about a child’s sleep problem alone is NOT enough Rather, a combination of the child’s sleep habits, family & parental caregiving characteristics, sleep environment and other social contexts are necessary. (Ward et al., 2007; Jenni etal., 2005 ) Children, adolescents & their families vary in their ability to cope and adapt to sleep problems. Sleep Disturbances Impact Families

13. Sleep in Early Childhood • Primary activity of the brain in early childhood (Dahl 1996) • By 2 years of age, the average child has spend almost 10,000 hours (nearly 14 months) asleep and approximately 7,500 hours (about 10 months) in all waking activities. • By early school age a child has spend more time asleep than in social interactions, exploring the environment, eating or any other single waking activity.(Dahl 1996)

14. Homeostatic and circadian process - endogenously driven rhythms (approx 24 hours) - Suprachiasmatic nucleus (SCN) internal biologic clock) - i.e. sleep-wake rhythms, body temperature, melatonin, prolactin, growth hormone Sleep Physiology Jenni & LeBourgeois 2006

15. Common Sleep Problems BEHAVIORAL Sleep Onset Association Disorder (SOAD) Limit Setting Delayed Sleep Phase Syndrome (DSPS) PARASOMNIAS - Sleep Terrors/ Night Terrors - Nightmares - Sleep Walking - Sleep Talking - Sleep Enuresis MEDICAL Sleep Disordered Breathing (SDB) Restless Leg Syndrome (RLS) Narcolepsy (adolescents)

16. Delayed Sleep Phase Syndrome Biological shift to later bedtimes and rise times • hormonal influence • extracurricular activities 7% of adolescents Hagenauer et al., 2009; Crowley et al., 2007; Carskadon et al., 1993

17. DSPS Treatment • Shift sleep cycle slowly • Phase advance 15 min earlier every few days • Sleep Hygiene (must change sleep habits!) • Relaxation techniques • Bright light exposure in morning • Parent or guardian support • Child motivated

18. Sleep Disordered Breathing (SDB) • Sleep Disordered Breathing (SDB) is a serious health concern1 associated with significant adverse health outcomes and high use of health care resources.2 • Spectrum of SDB: • - primary snoring • - upper airway resistance syndrome (UARS) • - obstructive sleep apnea (OSA) • Polysomnography (PSG) gold standard to diagnose SDB • *** Not all children who snore have SDB. Likewise not all children with enlarged tonsils and adenoids are diagnosed with SDB Lumeng JC, Chervin RD. (2008). Proc Am Thorac Soc. ; Halbower AC, Mahone EM. (2006). Sleep Med Rev.

19. Night time Symptoms Snoring Observed breathing pauses Gasping / choking Sweating • Restless sleeper (frequent tossing and turning, kicking) • Unusual position (neck hyperextension) • Mouth breather • Prolonged Bedwetting

20. Nasal speech Mouth breathing Excessive daytime sleepiness Morning headaches Daytime Symptoms • Hyperactive, difficulty focusing • Mood disturbances • Failure to Thrive

21. Family history Prematurity Craniofacial development (micrognathia, retrognathia) Chronic Allergies SDB Risk Factors • Unfavorable oronasal anatomy (turbinate hypertrophy, adenoidal and tonsillar hypertrophy) • Failure To Thrive (FTT) • Hypotonia • Obesity Urschitz et al., 2007; Arens & Marcus 2004; Marcus 2001

22. Sleep study (Polysomnography [PSG] Surgical - Tonsillectomy & adenoidectomy Non-Invasive Ventilation - CPAP/BiPAP Treatment of SDB

23. Restless Leg Syndrome (RLS) Sensorimotor disorder characterized by uncomfortable sensations in the legs with an urge to move the legs Etiology - Primary RLS: genetic - Secondary RLS: iron deficiency anemia, pregnancy, ESRD, polyneuropathy (Pichetti et al., 2013; Walters, Gabelia, & Frauscher 2012; Pichetti & Pichetti 2010)

24. RLS Symptoms: - urge to move the legs that begins or worsens when sitting or lying down - urge to move legs worse in the evening or at night - urge to move is partially or totally relived by movement Diagnosis • self report of symptoms & sleep study are necessary Treatment • check CBC, serum ferritin levels (<50) • supplemental iron, or folate, B12

25. Sleep History Medical History Nocturnal Behaviors Daytime Behavior - teacher & parent report Assessment of Sleep Disorders Owens & Dalzell 2005; Lewanski, Ward, & Palermo 2011

26. Screening Tool: BEARS Bedtime problems SCHOOL-AGE (6-12 years) • Does your child have any problems at bedtime? (P) • Do you have any problems going to bed? (C) ADOLESCENT (13-18 years) • Do you have problems falling asleep at bedtime? Excessive daytime sleepiness SCHOOL-AGE (6-12 years) • Does your child have difficulty waking in the morning, • seem sleepy during the day or take naps? (P) • Do you feel tired a lot? (C) ADOLESCENT (13-18 years) • Do you feel sleepy a lot during the day? in school? while driving? (C)

27. BEARS continued Awakenings during the night SCHOOL-AGE (6-12 years) • Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? (P) • Do you wake up a lot at night? Have trouble getting back to sleep? (C) ADOLESCENT (13-18 years) • Do you wake up a lot at night? Have trouble getting back to sleep? (C) Regularity and duration of sleep SCHOOL-AGE (6-12 years) • What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep? (P) ADOLESCENT (13-18 years) • What time do you usually go to bed on school nights? • How much sleep do you usually get? (C) Weekends?

28. BEARS continued Sleep Disordered Breathing SCHOOL-AGE (6-12 years) • Does your child have loud or nightly snoring or any • breathing difficulties at night? (P) ADOLESCENT (13-18 years) • Does your teenager snore loudly or nightly? (P) Owens & Dalzell, Sleep Medicine, 2005 http://illinoisaap.org/wp-content/uploads/BEARS.-Spruyt-third-of-three.pdf

29. Diagnosis Polysomnography (PSG) • overnight sleep study in an accreditedpediatric sleep center Multiple Sleep Latency Test (MSLT) • completed after a PSG to diagnose narcolepsy Actigraphy • sleep watch that is worn for several days or weeks to assess sleep patterns Radiographs • Lateral Neck X-Ray • MRI

30. Polysomnography (PSG)

31. PSG HOOK-UP

32. Actigraphy

33. Sleep Hygiene • Consistent & clear bedtime routines and bedtime rules • Set clear limits and follow through • Do not ask questions (i.e. ready for bed? Rather time for bed) • Limit use of technology before bedtime and in the bedroom

34. Seattle Children’s Hospital, Pediatric Sleep Disorders Center, Division of Pulmonary Medicine Dr. Maida Chen, & Amber McAfee, RN, APRN Swedish Medical Center, Pediatric Sleep Disorders Center, Division of Pulmonary Medicine Dr. Preetam Bandla When to Refer

35. Resources for Families, Children, & Adolescents National Sleep Foundation (bilingual) http://www.sleepfoundation.org www.sleepforkids.org http://kidshealth.org/teen http://www.aasmnet.org/spanishbrochures.aspx

36. Resources for Clinicians • Accredited pediatric sleep centers in your area can be found here www.aasmnet.org click on patients and public and find a sleep center http://sleepfoundation.org/ www.sleepeducation.com http://www.aasmnet.org/practiceparameters.aspx?cid=100

37. Primary care provider Social work Nurses, Psychologists, Neurologists, Psychiatrists Child life specialist Dietician Behavioral health team Childcare Teachers/Teachers/educators Sleep specialist Sleep lab staff, CPAP coordinator Multidisciplinary Team