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Objectives. Understand normal sleep in childrenReview common pediatric sleep disordersDiscuss proper treatment options for childhood sleep disorders. Introduction. The average child spends almost half of his or her life asleepNewborns can sleep as much as 16 hours per dayRespiratory disorders during sleep are thus of special importance during childhoodMarcus, C. Sleep-disordered breathing in children. AJRCCM 2001; 164:16-30..
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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? 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
52. Parasomnias Unpleasant or undesirable motor, autonomic, or experiental phenomena that occur predominantly or exclusively during the sleep state
May be induced or exacerbated by sleep
Two types:
Primary
Secondary
53. Primary Parasomnias Disorders of arousal
REM sleep behavior disorder
Recurrent Hypnagogic Hallucinations/Sleep Paralysis
Bruxism
Rhythmic movement disorder
Periodic Limb movement disorder
Sleep starts
Sleeptalking
54. Rhythmic Movement Disorder (RMD) Sterotyped movements occurring at sleep onset or the end of sleep
Headbanging, headrolling, and bodyrocking
Common in first year of life, and decreases with age (rarely persists into adolescence or adulthood)
Incidence 60% at 9mos; 22% at 2 years; 5% at 5 years
Injuries infrequent
No apparent association between RMD and neuropsychiatric conditions, except in children with severe neurologic dysfunction
Rarely, headbanging can be sole manifestation of a seizure disorder
No treatment necessary in most cases
55. Periodic Limb Movement Disorder (PLMS) Prevalence and significance unknown in childhood
Characterized by periodic (every 20-40 seconds) and sustained (0.5-4.0 seconds) contractions of one or both anterior tibialis muscles
Often associated with unperceived arousals
Usually benign
Has been associated with metabolic disorders and childhood leukemia
Recent reports show linkage with ADHD
Picchietti Sleep 1999
56. Sleep Talking (Somniloquy) Common disorder
Can arise from REM or NREM sleep
May have a genetic component
Rarely of clinical significance
57. Disorders of Arousal Underlying process one of incomplete arousal
Seen more commonly in children than in adults
Sleepwalking
Confusional Arousals
Sleep Terrors
58. Sleepwalking Very common—40% in some studies
12% can persist for over 10 years
Individual gets up and walks about for short time (1-10 minutes)
Hard to discern if child is asleep
Inappropriate behavior is common (urinating in the corner or next to the toilet)
Child can be easily led back to bed
Older children usually awaken as event terminates
Agitation can occur
Amnesia common
Often + family history
Klackenberg G: Somnambulism in childhood—prevalence, course and behavioral correlations. Acta Paediatr Scand 71:495, 1982
59. Confusional Arousals
Typically seen in toddlers and preschool age children
Often confused with sleep terrors
Arousal typically starts with movements and moaning?progesses to crying and calling out, intense thrashing in the bed or crib
Can appear bizzare and frightening to parents
Child appears confused, agitated, or upset
60. Common Features Episodes can last up to 40 minutes (typically 5-15 minutes)
Begin gradually
The child does not recognize his/her parents
Vigorous attempts to awaken the child may not be successful—best not to intercede
Incidence 5-15% of children
Associated with amnesia
Family history typical
61. Sleep Terrors Uncommon in very young children
Seen more often in older children and adolescents
Incidence approximately 1% of children
Events begin precipitously, with crying and screaming
Eyes usually wide open, with tachycardia and diaphoresis
Facial expression of “fear”
Child may leave the bed and injure him or herself
Last only a few minutes
Most have amnesia; can have brief memory of event
62. Constitutional and Precipitating Factors for Arousals Constitutional
Genetic
Developmental
Sleep deprivation
Chaotic sleep schedule
Psychologic
Precipitating
OSA
GERD
Seizures
Fever
63. Common Features of Arousal Disorders Misperception of and unresponsive to environment
Automatic behavior
Retrograde amnesia
60% have positive family history
Pathophysiology
Occurs at transition from slow wave sleep to next sleep cycle
64. Arousal Disorders-Treatment Proper diagnosis and reassurance
Most cases benign and self-limited
Basic safety precautions
Regular sleep/wake schedule
Avoid sleep deprivation
No forcible intervention
Psychological stressors should be identified
Rarely: medications (benzodiazepines and tricyclic antidepressants) and relaxation and mental imagery
65. Secondary Parasomnias Neurologic
Seizures
Consider with stereotypical movements, recurrent dreams, unusual autonomic symptoms (stridor, choking, coughing)
Headaches
Muscle cramps
66. Sleepiness
67. Causes of Sleepiness Insufficient sleep
Schedule disorders
Obstructive sleep apnea
Epilepsy
Narcolepsy
Kleine-Levin Syndrome
Idiopathic Central Nervous System Hypersomnia
68. Clinical Manifestations of Sleepiness Excessive daytime somnolence
Falling asleep in inappropriate places and circumstances
Lack of relief of symptoms after additional sleep
Daytime fatigue
Inability to concentrate
Impairment of motor skills and cognition
Symptoms specific to etiology
69. Insufficient Sleep Most common cause of sleepiness at all ages!
Homework, television, and after-school employment and activities compete with the need for sleep
Parental influence on bedtime hour decreases from 50% at 10 years to <20% at 13 years*
Despite decreasing total sleep time, adolescents often need more sleep than do younger children
*Carskadon MA: Patterns of sleep and sleepiness in adolescents. Pediatrician 17:5, 1992
71. Behavioral Treatment of Inadequate Sleep Eliminate identifiable causes (sleep apnea, environmental disturbances)
Teach good sleep hygiene
Focus on target behaviors that interfere with sleep (erratic schedules, late night television, oppositional behavior)
Eliminate caffeine and stimulants in diet
Relaxation techniques, positive imagery at bedtime
73. Circadian Rhythm in Sleep Innate, daily fluctuation of sleep-wake states, generally linked to the 24 hour daily dark-light cycle.
A circadian pattern in sleep-wake alternation is usually apparent by 6 weeks of age and becomes stable by 3 months of age
Most common cause of problems is due to extrinsic issues with scheduling
Rare causes of circadian disorders include hypothalamic dysfunction due to malformation or tumor, and blindness
74. Circadian Rhythm Sleep Disorders
Regular but inappropriate schedules
Sleep phase shifts
Delayed sleep phase
Advanced sleep phase
75. Advanced Sleep Phase Mainly in infants and toddlers
Relatively uncommon
Early bedtime and early awakening
“Morning Larks”
Treatment
Gradual delay of bedtime
Delay naps and mealtimes
Bright light at night, dim light in the morning
76. Delayed Sleep Phase Delay in sleep onset, late awakening
“Night owls”
Onset in adolescence
Male predominance
Sleep itself quantitatively and qualitatively normal
Genetic predisposition
77. Delayed Sleep Phase Differentiate from school avoidance, other sleep disorders
Diagnosis by sleep logs and actigraphy
Treatment
Bright light therapy 20-30 minutes upon awakening (8,000-10,000lux)
Strict sleep-wake schedule!
Melatonin 3 to 4 hours prior to desired sleep time
79. Melatonin Hormone synthesized from serotonin in the pineal gland
Provides human brain with signal for darkness
Suppressed by bright light
Regulates sleep-wake cycle
Has been shown to have sleep phase shifting properties
May be helpful in circadian rhythm disturbances
Has been used to regulate circadian rhythms in blind adults
80. Melatonin
Production unregulated—considered a food product
Dose: 1-5 mg PO QHS
Safety and efficacy not established in any age group
Ramelteon—newly approved melatonin agonist, not studied in children
Dose: 8mg PO QHS
82. Evaluation of Sleep Disorders History and physical
Sleep log
Blood work (drug screening, alcohol if indicated, anemia, metabolic)
Sleep study (OSA, neuromuscular disorders, craniofacial disorders, metabolic disorders, narcolepsy)
Multiple Sleep Latency Test (MSLT)
EEG
83. Sleep History Sleeping environment
Sleep position
Need for sleep aids (pacifier, rocking, patting, etc.)
Time into bed, sleep onset, and final morning awakening
ROS: snoring, mouth breathing, restless sleep, diaphoresis, GERD, abnormal behavior at night
Daytime behavior: irritability/hyperactivity/sleepiness
Number of daytime naps and their duration
Medications
Parental interventions
84. Physical Examination Height/Weight
Vital signs + BP
Evaluate for craniofacial abnormalities
Micrognathia
Dental malocclusion
Midface hypoplasia
Tonsillar size
Observe for behavioral signs of sleep disorders: inattentiveness, irritability, sleepiness, and mood swings.
85. Sleep Log
86. Diagnosis – Nocturnal Polysomnography Only diagnostic technique shown to quantitate the ventilatory and sleep abnormalities associated with sleep-disordered breathing
THE GOLD STANDARD!
87. Sleep Laboratory
89. Polysomnogram
90. Polysomnography Can be performed in children of any age
Should be scored and interpreted using age-appropriate criteria1
Can distinguish OSAS from primary snoring
Determines severity of OSAS and related gas exchange and sleep disturbances
May help determine operative risk
1 American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Resp Crit Care Med. 1996; 153:866-878.
91. Diagnosis- Audiotaping or Videotaping Studies have found sensitivities of 71-94%
Specificities of 29-80%
Positive predicted values of 50% and 75% for audiotaping, and 83% for videotaping
Struggle on audiotape more predictive than pauses
Negative predictive values 73-88%
Additional studies needed
Lamm C, Mandeli J, Kattan M. Evaluation of home audiotapes as an abbreviated test for obstructive sleep apnea syndrome (OSAS) in children. Pediatr Pulmonol. 1999;27:267-272.
92. Abbreviated Polysomnography Overnight oximetry
Useful if shows cyclic desaturation
PPV 97%; NPV 47%
Useful only in otherwise healthy children
Nap polysomnography
PPV 77-100%; NPV 17-49%
Can underestimate OSAS severity
Unattended home polysomnography
93. What is the role of the Pediatrician? Screening
Consider adding sleep questions to Review of Systems
Treat common disorders first
Refer to sleep specialist
Complex sleep disorders
When there is no improvement
94. Final Thoughts Childhood sleep disorders are common and can be associated with significant impairment of quality of life
Pediatricians play an important role in screening for and treating common pediatric sleep disorders
CHILD SLEEPS WELL=PARENT SLEEPS WELL=HAPPY PARENT AND CHILD
95. Resources American Academy of Sleep Medicine
http://aasmnet.org
National Sleep Foundation
http://www.sleepfoundation.org/
Star Sleeper
NIH website to promote healthy sleep in children with Garfield, contains teaching plans
http://www.nhlbi.nih.gov/health/public/sleep/starslp/