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Pediatric Neurology Quick Talks

Sleep Disorders Michael Babcock Summer 2013. Pediatric Neurology Quick Talks. -4 yo boy -screaming at night -lasts 30 minutes -occurs about 2 hours after going to bed -inconsolable during crying, then falls back asleep -no bed wetting -no limb shaking -eyes closed

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Pediatric Neurology Quick Talks

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  1. Sleep Disorders Michael Babcock Summer 2013 Pediatric Neurology Quick Talks

  2. -4 yo boy -screaming at night -lasts 30 minutes -occurs about 2 hours after going to bed -inconsolable during crying, then falls back asleep -no bed wetting -no limb shaking -eyes closed -no sedation in the AM Scenario

  3. Sleep Screen – BEARS • B – Bedtime issues • E – Excessive daytime sleepiness (can exhibit as motor over-activity, inattentiveness, irritability, oppositional defiance) • A – night Awakenings • R – Regularity and duration • S – Snoring • If concerns • Movements • Meds

  4. Insomnia • Onset or Maintenance? • Usually behavioral • Psychosocial • Anxiety (separation) • Depression • Medical problems – chronic pain, GERD, breathing problems, medications

  5. Limit-setting subtype • Older children • Active resistance to bedtime • Verbal protests and repeated demands • Can manifest as fearful behavior (crying, clinging) • Usually due to caregiver inconsistency with bedtime rules • Can have medical underlying causes – asthma, medications, sleep disorder – RLS, anxiety. • Tx – caregiver enforces rules Insomnia • Sleep onset Association • Prolonged night awakenings • Child has learned to fall asleep with Associations requiring parents – feeding, rocking, reading; can't self-soothe. • Tx – break connection; put child to be while drowsy but not asleep.

  6. Hx – children may have difficulty explaining this unpleasant feeling – pain should not be only feeling. Differential – Periodic leg movement disorder – actual leg movements during sleep without sensation – this can be due to other sleep disorders. Work-up – iron studies Tx – iron supplementation; off label use of gabapentin, benzo's, clonidine, dopamine agonist used less often in children. Restless Leg Syndrome • An urge to move legs, usually accompanied by unpleasant sensation in legs • These symptoms: • Begin or worsen during rest/inactivity • Relieved by movement • Occur exclusively or predominantly in evening • Not solely accounted for as symptoms of another medical/behavioral condition

  7. Excessive daytime sleepiness • A sleepy child may not appear sleepy – can be inattentive, hyperactive (trying to stay awake), aggressive, disruptive (sleep-deprived frontal cortex can't regulate emotion) • Insufficient sleep – insomnia • Inadequate sleep hygiene • Medication side-effects • Periodic limb movement disorder • Idiopathic hypersomnia • endocrine/metabolic problems • Narcolepsy • OSA

  8. Narcolepsy • Narcolepsy • Excessive daytime sleepiness • Sleep paralysis • Hypnagogic hallucinations • Cataplexy • Sudden loss of tone • Precipitated by emotion (laughing, anger) • REM creep • Dx – polysomnography, MSLT

  9. Who has OSA 2-3 % of normal development children have OSA 10% of normal children will be habitual snorers – don't have OSA 50% of children with Down's ~50% in obese children Why is it bad Hypertension, CHF, stroke, diabetes, difficulty losing weight. Obstructive Sleep Apnea • Excessive daytime sleepiness • Symptoms – Snoring, with apneic pauses • But also • Daytime nasal obstruction • Mouth breathing • Trouble eating/meat refusal • Behavior problems • Bed-wetting • Restless sleep • Sweaty sleep (needs fan on) • AM headache • Poor seizure control

  10. Sleep-related movement disorders Rhythmic movement infants/toddlers Start at sleep onset Head rolling/head banging/body rocking Bruxism RLS/PLMD Hypnic starts Brief jerks occurring with falling asleep/awakening May have sensation of falling Parasomnias • Disorders of Non-REM arousal • Sleep walking • Sleep terrors • Confusional arousals • REM sleep disorders • Nightmares • Sleep paralysis • REM sleep behavior disorder • Narcolepsy • SSRI • neurodevelopmental

  11. Differential – nocturnal seizures Anytime during night, more often in transition periods Last 30 seconds – 5 minutes Multiple events nightly Daytime seizures Daytime irritability/lethargy Older age of onset. Differential – panic attack, GERD. Dx -home videos, polysomnography or overnight EEG. Tx – low dose benzo. Non-REM arousal parasomnias • Usually during first 1/3 of night • Usually only one event/night • Increased arousals cause increased problems • OSA, RLS, GERD. • Triggered by sleep deprivation, fever. • Toddler and school-aged kids. • Usually resolve with time • sleep-walking most likely to persist. • Not tired the next day • No stereotypic motor movements • Last 5-30 minutes

  12. References -Uptodate articles – pediatric sleep, NREM sleep disorders, parasomnias, narcolepsy, RLS

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