Jamie Neal, APRN 10/24/14

1. Insomnia and sleep hygiene: Making friends with the monsters under your bed and the voices in your head Jamie Neal, APRN 10/24/14

2. Objectives • Explain the importance of sleep • Describe the symptoms of insomnia • Identify treatment of insomnia • Describe the symptoms of restless leg syndrome (RLS) • Identify treatments for RLS • Describe good sleep hygiene techniques

3. Why is sleep important? • Insufficient sleep can lead to: • Mood disturbances • Irritability, emotional lability, depression, anger • Fatigue and daytime lethargy • Cognitive impairment • Memory, attention, concentration, decision making, problem solving • Daytime behavior problems • Over activity, impulsivity, noncompliance • Risk taking behaviors • Academic problems • Chronic tardiness, falling asleep in class • Use of stimulant meds • Other alertness enhancers like caffeine, nicotine

4. Sleep Requirements for kids • Infant 14-15 hrs • Toddler 12-14 hrs • Preschool 11-13 hr • School age 10-11hrs • Adolescents 9.5 hrs • Infant 12.7 hrs • Toddler 11.7 hrs • Preschool 10.3 hrs • School age 9.5 hrs • Adolescents 7 hrs By Age What they are really getting

5. What is insomnia? • Difficulty with sleep initiation, duration, consolidation or quality that occurs despite adequate time and opportunity for sleep and results in daytime impairment • Acute (adjustment) insomnia-short lived due to life circumstances (identifiable stressor) • i.e.: can’t fall asleep because of a test the next day, it’s the first day of school • Chronic insomnia-at least 3 nights a week for 3 months. • Can be associated with a comorbidity, but not always.

6. Types of Insomnia • Behaviorally induced • Insufficient sleep • Psycho physiologic • Paradoxical • Medical problems • Psychiatric conditions

7. Behavioral insomnia- sleep onset-association type • Relies on inappropriate sleep association • Usually presents with frequent night time awakenings • The process of falling asleep is associated with a specific habit, object, or setting • Child becomes unable to fall asleep within a reasonable time in the absence of these conditions • Examples: extended rocking, parent has to sleep with child or vice versa

8. Behavioral insomnia- limit setting type • Stalling or refusing to go to bed • When parent enforces limits, child falls asleep quickly • Problem arises when parent has trouble setting and maintaining limits and managing the stalling behavior (inconsistent) • Child’s stalling techniques are based on what they have learned will work • Examples: refusing to put on pajamas, get in bed, saying they are scared, need kisses, etc • Daytime anxiety may trigger night time fears

9. Night time fears • Bedtime or middle of the night fears • Begin in the preschool years, disappear age 5-6 • May be provoked by anxiety, stress, traumatic events • Treatments: • Try monster spray • Have a pet sleep in the room • Security objects • Night lights • Have the child involved in the solution

10. Nightmares • Frightening dreams that cause waking, are upsetting and require comfort • Start around age 2 • Treatment: think happy, pleasant thoughts at bedtime

11. Psycho physiologic insomnia • Heightened mental arousal and learned sleep-preventing associations • May be associated with emotional reactions • Hyper vigilant about sleep • Can complain of “racing main” • The more the person tries to sleep, the more irritated they become and the less able one is to fall asleep • People who sleep better when they are not in their own bedroom • May be associated with people who are overanxious about their overall health

12. Paradoxical insomnia • Complaints of severe insomnia that occurs in the face of a normal sleep study or without evidence of an objective sleep disturbance • The severity of the night time complaint is not matched by evidence of pathologic daytime sleepiness • still complain of being tired • may not be falling asleep at school, work • No other psychiatric illnesses • No suspicion of malingering • Overestimate of how long it takes to fall asleep and underestimate total sleep time

13. Insufficient sleep syndrome • Persistent failure to obtain the amount of sleep required to maintain normal levels of alertness and wakefulness • Voluntary but unintentional chronic sleep deprivation • Sleep history of the current sleep patterns reveals disparity between the amount of sleep they are getting and the amount of sleep they need!

14. Medical causes of insomnia • Restless leg syndrome • Central apnea • Pain-low back pain, chronic pain • GI issues such as reflux • Arthritis • Endocrine issues such as hyperthyroidism • Neurological conditions such as Parkinson’s

15. Psychiatric causes of insomnia • Bipolar disorder • Depression • Insomnia can be a symptom of depression, especially middle of the night waking • Increased risk of severe insomnia in the face of major depressive disorder • Anxiety • Tension • Ruminating about past events • Worrying about future events • Feeling overwhelmed • Feeling over stimulated

16. Restless Legs Syndrome (RLS) • A sensory disorder characterized by an uncomfortable sensation in extremities accompanied by an urge to move the extremities while awake • Sensations relieved by movement (walking, rubbing, stretching, shaking, rocking) • Legs and arms can be affected • Episodes occur or are exacerbated by episodes of rest (sometimes with exercise) • Worse in the evening

17. Sensory RLS Symptoms in Children Ants, spiders, bugs crawling on legs “Lightening in my legs” Squeezing, tingling, itching, aching, or hurting “My legs feel wiggly” “My legs want to run” “My legs won’t stay still” “Lava running down my legs”

18. Mechanism of Iron in RLS/PLMD Low brain iron stores leads to disrupted dopamine synthesis in the CNS= reduction of dopamine availability within critical regions of the brain= development of RLS/PLMD

20. Risk Factors for RLS Genetic link, especially first degree relative Sleep deprivation Medical Conditions: iron deficiency anemia, end stage renal disease, hypothyroidism, DM Pregnancy Medications: antihistamines, antidepressants, antipsychotics, antiemetic Caffeine and alcohol may increase RLS symptoms

21. Treatment: Iron Supplementation • First line treatment in children with ferritin levels less than 50 ng/mL • Goal is to increase peripheral iron levels and to increase iron stores • Ferritin acts as a marker for the stored iron levels in the body • Goal for iron treatment is a ferritin between 50-70 ng/mL • Dose for oral iron : 3-6 mg/kg/day for 3 or 6 months • Iron is continued for 3 month intervals and iron and ferritin levels are assessed along with clinical improvement (improved RLS sensations, less difficultly with sleep onset, maintenance)

22. Iron Supplementation • Sounds easy, right? • Oral iron is poorly absorbed • Compliance with medications for many months is difficult • Liquid iron tastes bad! (We have them take it with orange or apple juice) • Calcium, magnesium, zinc all bind with iron and decrease absorption • Anti reflux medications decrease iron absorption • Side effects: most common is constipation • Iron toxicity a risk of acute iron overdose • Iron is not the same as lead!

23. Other RLS treatment • Dopamine agonists • Act like dopamine • Pramipexole (Mirapex) • Ropinirole (Requip) • First line treatment for adults (not FDA approved for kids) • Anticonvulsants • Gabapentin (off –label) • Alpha 2 agonists • Clonidine (short term use only)

24. Sleep-Friendly environment • Dim lights 1 hours before bed • Room darkening shades and curtains • Colors and decorations that are relaxing • Room temp between 60 and 67 degrees • Comfortable mattresses, pillows and sheets • Reduced noise with white noise or fan • Keep the TV off while asleep • Relaxing scents like lavender • National sleep foundation

25. Sleep hygiene reality… • Watching television is the most popular activity (76%) for adolescents in the hour before bedtime • surfing the internet/instant-messaging (44%) • talking on the phone (40%) • Nearly all adolescents (97%) have at least one electronic item in their bedroom. • 6th graders=2 items, 12th graders=4 • Adolescents with four or more items are 2x likely to fall asleep in school and while doing homework. • National Sleep Foundation 2006, 2011 Sleep in America Poll.

26. Electronics and sleep • 27% of parents of teens who leave electronic device ON rate their teen’s sleep as excellent • 53% of parents of teens who leave devices OFF rate their teen’s sleep as excellent • 17% of parents said that their child read or sent electronic communications after initially going to bed • On school nights, teens who leave their TV or iPod on get 1 hour less sleep than those who don’t • On school nights, teens who leave their phone on get 2 hours less sleep than those who don’t • National Sleep Foundation

27. More bad news about electronics and sleep • Kids using electronics as a sleep aid to relax at night have later weekday bedtimes fewer hours of sleep per week and report more daytime sleepiness • Teens with a TV in their bedroom have later bedtimes, more trouble falling asleep and shorter total sleep times • Texting and emailing after bedtime, even once per week, increases self-reported daytime sleepiness among teens • National Sleep Foundation

28. Treatment of insomnias • Improve the sleep hygiene! • Regular bedtime routine and bedtime • 1 hr of sunlight exposure early in the day • Regular physical activity • Dim lights in the evening • No stimulating activities (TV, video/computer games) for at least 1 hr prior to bedtime • No caffeine or chocolate, • Bath time earlier? • Relaxing activity when first getting in bed?

29. Naps • Naps may help to improve: • Alertness • Performance • Memory recall • Short nap(under 45 minutes) • Only if no sleep onset/ maintenance problems Ficca et.al., Sleep Medicine Reviews, 2010 Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006

30. Light and Sleep • Exposure to light before sleep can inhibit production of melatonin • Decrease/avoid light at night • Increase exposure during the day Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006 Bonnefond et al., Industrial Health, 2004

31. Sleep aids • Melatonin • Sleep Time Tea • Natural supplements • Marley’s Mellow Mood • Lazy Cakes

32. Melatonin • Secreted by pineal gland • Tryptophan → 5HTP → serotonin → melatonin • Natural melatonin levels rise at night about 1-2 hours prior to bedtime • Give melatonin 1-2 hours prior to bedtime • Adult doses range from 0.3mg to 10mg • NSF warns against using in patients with immune system disorders, cancers, taking corticosteroids or immune suppressants

33. Melatonin and kids • Not regulated by FDA • Considered dietary supplement • Works best in children with • Circadian rhythm disorders • Mid-line brain defects such as agenesis of the corpus callosum • Blindness • ADHD • Autism

34. Marley’s Mellow Mood

35. Lazy cake relaxation brownies

36. Healthy sleep tips • Stick to the same bedtime and wake time, even on the weekends • Have a relaxing bedtime ritual • Avoid naps, especially in the afternoons • Exercise daily • Adjust your sleep environment • Sleep on a comfy bed • Use bright light to help manage your circadian rhythm • Avoid alcohol, cigarettes and heavy meals in the evening • Give yourself some wind down time • Go to another room and do something relaxing until you are tired

37. Things that won’t help • Scaring your child to sleep i.e.: the bogeyman • Talking negatively about ghosts • Letting kids watch scary movies, TV shows • Discussing vampires, werewolves and zombies • Letting kids play scary video games

38. Goya 1797 Que Viene el Coco (Here comes the bogeyman)

39. The boogeyman – German/English • An imaginary creature used to scare children into behaving well • Aka “If you don’t go to bed right now, the boogeyman is going to get you” • There is a similar creature in many cultures and countries • Usually male • He has a sack to carry naughty children away

40. Resources for Parents • Guide to Your Child’s Sleep. • George J. Cohen, M.D., F.A.A.P. • Take Charge of Your Child’s Sleep. • Judy Owens, M.D., and Jodi Mindell, Ph.D. • Sleeping Through the Night. • Jodi Mindell, Ph.D.

41. References • American Academy of Pediatrics Section on Pediatric Pulmonology. 2011. Pediatric Pulmonology. American Academy of Pediatrics. • American Academy of Sleep Medicine. 2005. The international classification of sleep disorders. 2nd edition. American Academy of sleep medicine. • Mindell, J.A & Owens, J.A. 2003. A clinical guide to pediatric sleep: diagnosis and management. 2nd edition. Wolters Kluwer. • Sheldon, S.H., Ferber, R., Kryger, M.H. 2005. Principles and practice of pediatric sleep medicine. Elsevier Inc. • Panitch, H.B. 2005. Pediatric Pulmonology The Requisites in Pediatrics. Elsevier Inc.

42. References • EggermontS., & Van den Bulck J. 2006. Nodding off or switching off? The use of popular media as a sleep aid in secondary-school children. Journal of Paediatrics Child Health. Vol 42 (7-8) pp 428-433b • Shochat, T., Flint-Bretler O., &Tzischinsky O. 2010. Sleep patterns, electronic media exposure and daytime sleep-related behaviours among Israeli adolescents. Acta Paediatrics Vol 99 (9) pp 1220-1223 • Pelayo, R., & Dubik, M. 2008. Pediatric Sleep Pharmacology. Semin Pediatr Neuro. 15: 79-90. • Picchietti, D., Allen, R.P., Walters, A.S., Davidson, J.E.Myers, A., et al. 2007. Pediatrics. Restless legs syndrome: Prevalence and impact in children and adolescents the pediatric REST study. 120; 253-266

43. Thank you! cgon445 Related topics: shops,