introduction to sleep problems in children april wazeka, m.d. respiratory center for children...
TRANSCRIPT
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Introduction to Sleep Introduction to Sleep Problems in ChildrenProblems in Children
April Wazeka, M.D.
Respiratory Center for Children
Atlantic Health System
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ObjectivesObjectives
Understand normal sleep in childrenReview common pediatric sleep disordersDiscuss proper treatment options for
childhood sleep disorders
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IntroductionIntroduction
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.
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Pediatric Sleep MedicinePediatric Sleep Medicine
Relatively new fieldFew pediatric sleep centersNow have new understanding of
associations between common childhood disorders and sleep
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OverviewOverview
Sleep disorders in children are very common—approximately 25% of children ages 1-5 years of age
Pediatric knowledge expandingPresentation of sleep disorders different in
children than in adults– Varies with age and developmental stage
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Sleep and BreathingSleep and Breathing
Some breathing disorders occur only during sleep
Virtually all respiratory disorders are worse during sleep than during wakefulness
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Who needs sleep?Who needs sleep?
Mammalian Total Daily Sleep Time (in hours)
Giraffe 1.9 Roe deer 3.09Asiatic elephant 3.1 Pilot whale 5.3Human 8.0 Baboon 9.4Domestic cat 12.5 Laboratory rat 13.0Lion 13.5 Bats 19.9
BUT, exact function of sleep not well understood!
All mammals and birds “sleep” as we know what sleep to be.
Sleep “behavior” has also been observed in reptiles and insects
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How much sleep do children need?How much sleep do children need?Sleep Duration from Infancy to Sleep Duration from Infancy to
AdolescenceAdolescence 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
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Normal Sleep PhysiologyNormal 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
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REM sleepREM sleepRapid eye movement or dream sleepBreathing erraticVariable RR and tidal volumeFrequent central apneasDecrease in intercostal and upper airway
muscle toneChildren have relatively more REM sleep
than adults
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REM SleepREM 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.
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DevelopmentDevelopment
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
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DevelopmentDevelopment
Ossification of the sternum and vertebrae continues until 25 yrs of age
Results in a stiffer chest wallChest wall compliance = lung compliance
by 2 yrs of ageHowever, paradoxical inward rib cage
motion during inspiration in REM sleep is seen until almost 3 yrs of age
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Upper AirwayUpper 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
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Upper AirwayUpper 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.
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ApneasApneas
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
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Insomnia in Infants and ToddlersInsomnia in Infants and Toddlers
Sleep Onset Association DisorderColicNocturnal 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
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Sleep Onset Association Sleep Onset Association DisorderDisorder
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!
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Common FeaturesCommon 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
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TreatmentTreatment
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)
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Causes of Insomnia in the Causes of Insomnia in the Preschool and School-Aged ChildPreschool and School-Aged Child
Fears and nightmares Limit setting sleep behavior
disorder
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Fears and NightmaresFears and NightmaresFears of “monsters” when awakeVivid, frightening dreams of villanous
creatures when asleepExperienced by >50% of childrenUsually begin at 3-5 years of age, decrease
with increasing age
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TreatmentTreatment
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
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Limit Setting Sleep DisorderLimit Setting Sleep Disorder
Exclusively a childhood sleep disorderCharacterized by:
– Stalling behaviors or refusal to go to bed at the desired time
– Associated with inadequate parental limit setting for a child’s behaviors
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Common FeaturesCommon 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
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Factors in Parental Failure to Set Factors in Parental Failure to Set LimitsLimits
Lack of understanding of the importance of setting limits
Inadequate knowledge of limit-setting techniques
Psychosocial factors
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TreatmentTreatment
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
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Once child is convinced of parental ability to enforce limits consistently, typically nighttime disruption ceases rapidly
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Treatment (Continued)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
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Insomnia in AdolescenceInsomnia in Adolescence
More closely resembles adult disordersOften 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
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TreatmentTreatment
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
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Good Sleep HygieneGood 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
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Pharmacologic treatment of Pharmacologic treatment of InsomniaInsomnia
Centuries ago opium-based laudanum given to children to keep babies quiet
AntihistaminesBenzodiazepinesZolpidem (Ambien)—not approved for
pediatric usage– Interacts with GABA-benzodiazepine receptor
complexes
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Causes of Insomnia in Children Causes of Insomnia in Children of all Agesof 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
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Treatment SuccessTreatment Success
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Treatment FailureTreatment Failure
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Restless Legs Syndrome (RLS)Restless Legs Syndrome (RLS)
Sensory-motor disorder involving the legsPrevalence approximately 4% of the
populationAge of onset can occur at any ageResults in sleep disturbance with difficulty
initiating and/or maintaining sleepCan be exacerbated by pregnancy, caffeine,
or iron deficiency
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RLS-DiagnosisRLS-DiagnosisCriteria
– 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
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RLSRLS
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
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RLS in ChildrenRLS 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
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RLS-TreatmentRLS-Treatment
Correct underlying medical cause, if present– Diabetes, uremia, anemia
Dopaminergic agents– Pramipexole (Mirapex)– Cardidopa-levodopa (Sinemet)
BenzodiazepinesOpiates
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ParasomniasParasomnias
Unpleasant or undesirable motor, autonomic, or experiental phenomena that occur predominantly or exclusively during the sleep state
May be induced or exacerbated by sleepTwo types:
– Primary– Secondary
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Primary ParasomniasPrimary Parasomnias
Disorders of arousal REM sleep behavior disorder Recurrent Hypnagogic Hallucinations/Sleep
Paralysis Bruxism Rhythmic movement disorder Periodic Limb movement disorder Sleep starts Sleeptalking
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Rhythmic Movement Disorder Rhythmic Movement Disorder (RMD)(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
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Periodic Limb Movement Periodic Limb Movement Disorder (PLMS)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
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Sleep Talking (Somniloquy)Sleep Talking (Somniloquy)
Common disorderCan arise from REM or NREM sleepMay have a genetic componentRarely of clinical significance
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Disorders of ArousalDisorders of Arousal
Underlying process one of incomplete arousal
Seen more commonly in children than in adults– Sleepwalking– Confusional Arousals– Sleep Terrors
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SleepwalkingSleepwalking 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
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Confusional ArousalsConfusional Arousals
Typically seen in toddlers and preschool age children
Often confused with sleep terrors Arousal typically starts with movements and
moaningprogesses 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
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Common FeaturesCommon 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
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Sleep TerrorsSleep 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
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Constitutional and Precipitating Constitutional and Precipitating Factors for ArousalsFactors for Arousals
Constitutional– Genetic– Developmental– Sleep deprivation– Chaotic sleep schedule– Psychologic
Precipitating– OSA– GERD– Seizures– Fever
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Common Features of Arousal Common Features of Arousal DisordersDisorders
Misperception of and unresponsive to environment
Automatic behaviorRetrograde amnesia60% have positive family historyPathophysiology
– Occurs at transition from slow wave sleep to next sleep cycle
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Arousal Disorders-TreatmentArousal 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
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Secondary ParasomniasSecondary Parasomnias
Neurologic– Seizures– Consider with stereotypical movements,
recurrent dreams, unusual autonomic symptoms (stridor, choking, coughing)
– Headaches– Muscle cramps
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SleepinessSleepiness
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Causes of SleepinessCauses of Sleepiness
Insufficient sleep Schedule disorders Obstructive sleep apnea Epilepsy Narcolepsy Kleine-Levin Syndrome Idiopathic Central Nervous System Hypersomnia
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Clinical Manifestations of Clinical Manifestations of SleepinessSleepiness
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
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Insufficient SleepInsufficient 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
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Behavioral Treatment of Behavioral Treatment of Inadequate SleepInadequate 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
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+ =
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Circadian Rhythm in SleepCircadian 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
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Circadian Rhythm Sleep Circadian Rhythm Sleep DisordersDisorders
Regular but inappropriate schedulesSleep phase shifts
– Delayed sleep phase– Advanced sleep phase
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Advanced Sleep PhaseAdvanced Sleep Phase
Mainly in infants and toddlersRelatively uncommonEarly bedtime and early awakening“Morning Larks”Treatment
– Gradual delay of bedtime– Delay naps and mealtimes– Bright light at night, dim light in the morning
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Delayed Sleep PhaseDelayed Sleep Phase
Delay in sleep onset, late awakening“Night owls”Onset in adolescenceMale predominanceSleep itself quantitatively and qualitatively
normalGenetic predisposition
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Delayed Sleep PhaseDelayed 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
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MelatoninMelatonin 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
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MelatoninMelatonin
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
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Evaluation of Sleep DisordersEvaluation 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
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Sleep HistorySleep 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
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Physical ExaminationPhysical 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.
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Sleep LogSleep Log
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Diagnosis – Nocturnal Diagnosis – Nocturnal PolysomnographyPolysomnography
Only diagnostic technique shown to quantitate the ventilatory and sleep abnormalities associated with sleep-disordered breathing
THE GOLD STANDARD!
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Sleep LaboratorySleep Laboratory
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PolysomnogramPolysomnogram
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PolysomnographyPolysomnography
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.
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Diagnosis- Audiotaping or Diagnosis- Audiotaping or VideotapingVideotaping
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.
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Abbreviated Abbreviated PolysomnographyPolysomnography
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
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What is the role of the What is the role of the Pediatrician?Pediatrician?
Screening– Consider adding sleep questions to Review of
Systems
Treat common disorders firstRefer to sleep specialist
– Complex sleep disorders– When there is no improvement
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Final ThoughtsFinal 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
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ResourcesResources
American Academy of Sleep Medicine http://aasmnet.orgNational 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/