pediatric sleep disorders
TRANSCRIPT
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Sleep & Sleep Issues in the Pediatric Population
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Kids Sleep A lot
• Sleep is a common discussion point among parents and doctors
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Many Issues from birth to adolescence….
• SIDS
• Co-sleeping
• Night-wakenings
• Bed-wetting
• Nightmares
• Sleepwalking & Sleeptalking
• Timing of High School start times…
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Sleep Physiology
Wakefulness REM
Indeterminate NREM
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Wakefulness
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Stage 1 NREM• Waves
Stage 2 NREM• Sleep Spindles• K-Complexes
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Stage 3 NREM• 20-50 % Waves
Stage 4 NREM• > 50 % Waves
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Stage REM Alpha Waves
Conjugate Eye Movements
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Sleep Stages Overnight
NREM is more common in the first part of sleep. REM is more common in the latter half of sleep
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Children’s Sleep Architecture Differs from Adults
• More REM• Earlier REM• More frequent REM • More Total Hours of Sleep
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REM & NREM Sleep by Age
02468
1012141618
1 - 3M
3 - 5M
6-23M
2 - 3Y
3 - 5Y
5 - 9Y
10-13Y
14-18Y
19-30Y
Tot
al H
rs S
leep
Total Daily Sleep by Age
02468
1012141618
1 - 3M
3 - 5M
6-23M
2 - 3Y
3 - 5Y
5 - 9Y
10-13Y
14-18Y
19-30Y
Tot
al H
rs S
leep
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Sleep in Preemies• “Indeterminate Sleep”
– Neither REM nor NREM
– Characterized by “Delta Brushes” and temporal spikes
– Predominant pattern at 34 wks
– Disappears by 3 months of age
• As gestational age increases…– maximum EEG sleep activity switches from temporal to frontal– Indeterminate Sleep decreases– Synchrony between the 2 hemispheres increases
• The preemie’s sleep legacy is easier arousal later on…
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Normal Infant Sleep Patterns
• 18 hours a day, 50% REM, at birth
• Infants start sleep with REM
• Most sleep through night by 3 months– 25 % still have not by 6 months of age
• Naps– Usually 2 / day until 1st Birthday– 2nd nap usually given up by age 3
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Night Wakenings
0%5%
10%15%20%25%30%35%40%45%50%
All Infants BreastfedInfants
1-2 YrOlds
4-5 YrOlds
Promotion of Good Sleep Habits starts early
** Beware of bastardizations of Ferberizing **
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SIDS• Death of an infant under the age of 1 during sleep
– 90% under the age of 6 months– Usually during winter months
• No known cause but many theories– Poor respiratory response to CO2– Poor blood pressure control– Inability to remove obstructions to breathing
• Known associations– Sleeping on tummy– Smokers in the house– Not being breastfed
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School-Age Sleep Issues
• Bedtime Struggles– Associated with TV viewing behaviors
• Parasomnias
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Parasomnias
• Impressive Phenomena• Positive Family History• Usually Deep NREM Sleep (Stages 3/4)• Common in childhood, decrease with age
– Persistence into adulthood NOT a sign of psychopathology
• Can be induced or precipitated by fever, sleep deprivation, and certain medications
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Prevalence of Parasomnias in Childhood
0%10%20%30%40%50%60%70%80%
Persists
PersistsPersists
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Parasomnias Go Together
Sleepwalking Sleeptalking
Night Terrors Bruxism
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Nightmares
• Extremely common– 2/3 of all kids experience them
• Preschoolers ages 3-6
• REM
• Child believes them to be real.
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Night Terrors
• 5 % of pre-schoolers.• Starts between ages 4-12 and resolves
spontaneously• Increased FHx of enuresis / sleepwalking in 1st
degree relatives• During Stage 3-4 during 1st third of night.• Sits upright, stares, appears frightened, screams,
cries, autonomic arousal, unresponsiveness– Lasts ~ 10 minutes then child returns to undisturbed
sleep. No recall.
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Night Terrors
• Not associated with psych problems in childhood; although in adults, associated with PTSD, panic disorders
• If disruptive or occur daily, can try Benzo qhs.
• Sometimes can be manifestation of seizures
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Nightmares Night Terrors
Age 3 - 6 yrs 4 - 8 yrs
Sleep Stage REM NREM (3/4)
Time of Night Late Early
State on waking Upset / Scared Disoriented
Response to parents Consolable
Unaware of Parents
Return to Sleep Difficult Easy / Rapid
Memory of Event Vivid None
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Sleep Bruxism
• Up to 88% of children; 20 % of adults
• Any stage of sleep
• May result in damage to the
• Periodicity of 20 to 30 seconds.
• Malocclusion plays no role in bruxism
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Sleeptalking
• Begins during school age
• NREM and REM sleep
• No treatment
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Sleepwalking
• More than just walking around…– Simple Behaviors– Complex Behaviors
• Begins in ages 4-8 yrs and resolves spontaneously by adolescence.
• 10 % of children (2.5 % of adults)• Positive Family History • Stage 3-4 Sleep; 1st third of night.
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Nocturnal Enuresis
• NREM sleep• May be restricted to Stage 3-4• Increased bladder pressures during deep
sleep• Males with Family History• 15% of 5 year olds• 10% cure per year, with 3-5% of
adolescents
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Treatment Of Nocturnal Enuresis
• Behavioral Modification• Less drinks• Double Voids @ night• Timed Nighttime voids
• Alarm Systems
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Sleep Motor Phenomena• Hypnic Jerks• Body Rocking• Restless Legs Syndrome
– “Periodic Limb Movement Disorder”– Parathesias and desire to move the legs– Stage 1-2 NREM Sleep– More common in children than recognized
• 40% start in childhood
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“Restless Legs Syndrome”
– “Periodic Limb Movement Disorder”
– Stage 1-2 NREM Sleep– More common in children than recognized
• 40% start in childhood
– Secondary Causes• Anemia, Pregnancy, Uremia, Neuropathy
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Periodic Limb Movement Disorder
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Persistence of Childhood Parasomniasinto Adolescence
0% 5% 10% 15% 20% 25% 30%
Sleepwalking
Bruxism
Sleep Terrors
Enuresis
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Adolescent Sleep
• Public Safety
• Extracurriculars
• School Start times
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Nocturnal Emissions
• Nocturnal penile erections throughout all life stages– Occurs in utero
• Oigarche @ 13 yrs, 2 months
• Sexual dream causes ejaculation– How common?
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Delayed Sleep Phase Syndrome
• Excessive Daytime Sleepiness or typically as the sum of its complications
• Patients complain of inability to get to sleep until the early morning hours, but little difficulty sleeping once asleep
Melatonin
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Narcolepsy
• Begins in adolescence
• Triad of SymptomsDaytime Sleep Attacks
Cataplexy
HypnagognicHallucinations
• Sleep Study Findings–Normal total sleep time –REM @ onset of sleep–Decreased latency
• Highest HLA-disease linkage in medicine
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Narcolepsy Somnogram
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Obstructive Sleep Apnea
• Periodic apneas due to sleep-related airway obstruction– Large adenoids– Obesity– Not all snorers have OSA
• Daytime Sleepiness in the short-term
• Pulmonary hypertension and right heart failure in the long term
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All Sleep Phenomenon can be a Seizure…
• Anything that is recurrent, stereotyped, and inappropriate may be the manifestation of a seizure
• Most often confused with sleep terrors,• More common in the first 2 hours of sleep,
or around 4-6 am. • More common in kids than adults.
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