sleep disorders in children and adolescents rebecca cho, m.d

SLEEP DISORDERS IN CHILDREN AND ADOLESCENTS Rebecca Cho, M.D.

O B J E C T I V E S Review of sleep architecture and physiology through life stages Exploration of pediatric sleep disorders and comorbidities Potential consequences of sleep disruption in development Behavioral and pharmacological treatment options

Normal Sleep Architecture NREM Stage 1 Transition stage where sleep usually begins, can be easily aroused Alpha waves, rhythmic = relaxed wakefulness 1-7 min in HR and respirations, eyes move slowly under eyelids Stage 2 Deeper sleep, more difficult to arouse 10-15 min initial cycle, longer with progressive cycles (45-55% total sleep) Sleep spindles and K-complexes memory consolidation, tranquil sleep Further in HR and respirations, no eye movement Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3 rd ed. West Sussex: Wiley-Blackwell, 2012. Print.

Normal Sleep Architecture Stages 3 and 4 (slow wave) o Deepest sleep, highest arousal threshold, may be disoriented if awakened o Stage 3 few min; stage 4 20-40 min o No significant distinguishing pattern in shift from stage 3 to 4 o Primarily delta waves = high voltage slow waves o Slowest rates of breathing and HR REM Rapid eye movement Atonia, muscle paralysis safe expression of dreams Desynchronous low-voltage mixed frequency waves + mix of wave patterns seen in other sleep stages and wake state Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3 rd ed. West Sussex: Wiley-Blackwell, 2012. Print.

Normal Sleep Architecture Stage 1 Stage 2 Stage 3 Stage 4 REM = one cycle Cycle repeats through the night NREM 75-80%, REM 20-25% of total sleep First cycle 70-100 min; later cycles longer at 90-120 min Stage 2 progressively dominates NREM and REM intervals get longer with subsequent cycles, while slow wave sleep largely disappears Differences in sleep architecture through the ages Sleep becomes less efficient w/ age Newborns o Sleep up to 16-18 hrs/day in broken segments lasting 2-4 hrs o No distinct stages, circadian rhythm not fully developed Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3 rd ed. West Sussex: Wiley-Blackwell, 2012. Print.

Normal Sleep Architecture By 2-3 mos o Circadian rhythm, NREM, REM develops o Progressive consolidation of sleep, naps, less total sleep required (14- 15 hrs) o Dreams more apparent by 12 mos, content tends to be more vague Children o Total sleep further to 11-12 hrs by 3-5 y/o, most napping stops also o Slow wave tends to dominate sleep cycle (w/ associated GH release) o May start having more vivid dreams, nightmares, content related to waking thoughts/fears/desires Adolescents o Need avg 8-10 hrs/night o in slow wave sleep w/ onset of puberty and into adulthood o Frequent shifts in circadian rhythm due to social/environmental factors and potential biological/hormonal s Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3 rd ed. West Sussex: Wiley-Blackwell, 2012. Print.

Physiological s in Sleep Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006.

Why Do We Sleep?? Exact role of sleep or why we alternate btwn NREM and REM are unclear, but overwhelming evidence that lack of sleep or disrupted sleep architecture leads to negative outcomes A lot of interest in research; some hypotheses have arisen REM Appears to be involved in memory consolidation; learning seems to intensify/ REM Hippocampal neuronal activation in REM mirrors pattern of wake state NE and 5HT post-synaptic depolarization and long-term potentiation may aid in temporary hippocampal memory storage, cognitive functioning, synaptic plasticity NREM Also appears to be associated w/ learning and memory; learning seems to intensify slow waves during NREM May play role in differentiating/organizing important synapses from those that are underutilized, facilitate protein synthesis Poe, Gina R., Walsh, Christine M., Bjorness, Theresa E. Cognitive Neuroscience of Sleep. Prog Brain Res. 2010; 185:1-19.

Pediatric Sleep Disorders Obstructive sleep apnea Sleep-related movement disorders Parasomnias Narcolepsy Circadian rhythm disorders Behavioral insomnia of childhood Psychiatric causes Medical causes

Obstructive Sleep Apnea SYMPTOMS Snoring Apneic episodes Diaphoresis Enuresis Waking up feeling unrested Daytime somnolence Morning HAs Cognitive dysfunction ETIOLOGY Adenotonsillar hypertrophy (most common) Obesity Craniofacial dysmorphology (e.g., Downs) Neuromuscular d/o (e.g., CP) RISK FACTORS Allergies Sinus problems AA ethnicity FHx of OSA

Obstructive Sleep Apnea Has been associated w/ ADHD: proposed that intermittent hypoxia + fragmented sleep prefrontal dysfunction Dx: polysomnography + pulse ox Tx: Wt loss Adenotonsillectomy if indicated Nasal CPAP Leukotriene receptor antagonists (montelukast) Intranasal corticosteroids (fluticasone spray) External nasal dilator strips Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan 15; 63(2): 277-28

Sleep-related Movement Disorders Rhythmic movement disorder Periodic limb movement disorder in sleep Restless leg syndrome Relationship between ADHD and PLMS/RLS

Rhythmic Movement Disorder AKA Jactatio Capitis Nocturna Repetitive, stereotyped movements, involvement of large muscle groups Head banging o stress o Lying in prone/supine position o Most common in 1 st yr o Boys > girls Head rolling o More common, progressively declines w/ age Body rocking o Child is usually on hands and knees rocking anterior posterior o More associated w/ pleasurable activities (e.g., listening to music) Hypothesized to be mechanism of self-stimulation/self-soothing (mimicking cradling/rocking by parents) Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Rhythmic Movement Disorder Most commonly seen in infants and children < 5 y/o Usually occurs when child is sleeping; occ stage 1 or 2 sleep prevalence in MR (esp older individuals) Dx: Thorough clinical eval + video polysomnography to r/o other causes (e.g., seizures) Tx: Supportive; spontaneous resolution w/ age in most cases If movements risk for injuries (esp head banging) provide safe environment (e.g., padding, protective helmets) Metronome near bed Allowing child to engage in rocking before bedtime (e.g., rocking on chair or rocking horse) If severe, may trial low-dose benzo such as clonazepam Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Periodic Limb Movements in Sleep (PLMS) Involuntary brief jerking movements in 20-40 sec intervals Lower > upper extremities In children movements may be less apparent; instead may present as: Growing pains Leg discomfort Disrupted sleep Difficulties initiating/maintaining sleep Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Periodic Limb Movements in Sleep (PLMS) rate of parasomnias Dx: Video polysomnography to r/o seizures/OSA, detailed hx Tx options: Fe supplementation (if low iron levels) Dopaminergic agents (e.g., ropinirole, pramipexole) Clonazepam (limited data) Bupropion (shown to be effective for adult PLMS) Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Restless Leg Syndrome (RLS) Frequently co-occurs w/ PLMS May p/w nonspecific growing pains or leg discomfort Criteria include: Urge to move legs (may also involve upper ext) Urge begins/worsens when sitting/lying/inactive Urge partially or totally relieved upon movement of legs Urge only occurs in evening/night or more severe than during daytime Sleep onset or maintenance difficulties frequent; anxieties r/t discomfort may interfere w/ ability to achieve restful sleep Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Restless Leg Syndrome (RLS) Tx: Behavioral interventions including strict sleep hygiene and reg physical activity If Fe levels low ( 50ng/dL + vit C to aid in absorption of Fe Pharmacological options only approvde for adults; includes benzos, clonidine, gabapentin, dopaminergic agents (need to monitor closely for sedation) Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Relationship Between ADHD & PLMS/RLS Significant comorbidity Possible hypotheses: May be r/t impairment in DA pathway: Fe effectiveness of tyrosine hydroxylase DA production Insufficient sleep in children (disrupted sleep commonly seen in those w/ PLMS & RLS) may manifest as hyperactivity, distractibility, inattention, impulsivity, cognitive impairments ADHD-like sx may be diurnal manifestations of PLMS/RLS during daytime (difficulties staying seated or remaining inactive for extended periods of time and needing to move to decrease discomfort/urge) Fe supplementation has been shown to improve both PLMS & RLS sx at nighttime and some research showing improved ADHD-like sx during daytime Walters, Arthur S., Silvestri, Rosalia, Zucconi, Marco, Chandrashekariah, Ranju, Konofal, Eric. Review of the Possible Relationship and Hypothetical Links Between Attention Deficit Hyperactivity Disorder (ADHD) and the Simple Sleep-Related Movement Disorders, Parasomnias, Hypersomnias, and Circadian Rhythm Disorders. J Clin Sleep Med. 2008 Dec 15; 4(6): 591-600.

Parasomnias Largely seen in children Condition appears to spontaneous resolve w/ age, hypothesized to be 2/2 CNS immaturity Generally benign, though may be more impairing esp in older children if interfering w/ social functioning (e.g., sleepovers) NREM parasomnias: AKA arousal disorders, result from sudden awakening from deep slow wave sleep, causing confusion and retrograde amnesia Generally do not tend to respond to external stimuli May be autonomic/motor hyperactivity (e.g., repetitive movements during sleep) Often +FHx Ex. sleepwalking, night terrors Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Parasomnias REM parasomnias No associated confusion, recall may be intact Ex. nightmares, REM behavior d/o (more commonly seen in older adults), recurrent intermittent sleep paralysis Should r/o underlying seizures esp if duration is very short, +repetitive/stereotypic movements, inconsistent pattern in episodes Most common in children: Sleepwalking Night terrors Nightmares Nighttime enuresis Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Sleepwalking (Somnambulism) Pathogenesis unknown Involves complex motor movements and cognitive functioning (e.g., ambulation, driving) Most frequently seen in pubescent children (peak prevalance 12 y/o) but can carry on to adulthood First third of sleep Triggered by psychological or physiological stress (e.g., sleep deprivation) rates in those w/ comorbid OSA, Tourettes, migraines Uncommonly violent/aggressive behaviors, but may become combative and agitated if attempted to be restrained during episode Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Sleepwalking (Somnambulism) Tx: Supportive, focus on ensuring child does not injure self during episode Limit interference Scheduled sleep awakenings Psychotherapy (esp if episodes r/t stress) Relaxation techniques Pharmacotherapy: o Benzos o Antidepressants (only case studies, some may worsen condition 2/2 impairment in REM sleep) Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Night Terrors (Pavor Nocturnus) First third of deep slow wave sleep Sx include: Loud screaming and/or crying Difficult to console autonomic activity (e.g., tachycardia, tachypnea, sweating) Intense feelings of panic/anxiety during episode Lasts 15-30 min Little to no recall of event May co-occur w/ sleepwalking Peak prevalence 3-7 y/o Frequent +FHx May be triggered by fatigue, stress Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Night Terrors (Pavor Nocturnus) Two categories which differ in course of illness and tx approach Type A Common Benign, self-limiting No tx required, parent reassurance Type B Much less common Frequently r/t trauma Tends to be persistent throughout life Resistant to tx Tx options include low dose benzos (diazepam 2-5mg), impramine Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Nightmares Common in both children and adults, but most common in children 3-6 y/o; persistence beyond this may warrant further exploration for underlying trauma, anxiety, mood disorder Must distinguish from night terrors Recall intact, not associated w/ confusion Second half of sleep in REM Tx: Reassurance for parents CBT (e.g., progressive muscle relaxation, dream scripting) Pharmacotx for trauma-related nightmares (e.g., prazosin, clonidine) Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Nocturnal Enuresis DSM V: Repeated involuntary bedwetting while sleeping 2x/wk for 3 consecutive mos or cause significant distress/impairment in child Toilet training complete by 4-5 y/o for most children Occurs proportionally throughout diff sleep stages Not associated w/ sleep disruption or arousal Two categories Primary enuresis o No h/o consistent dryness through night > 1-2 wks o Strong +FHx o M > F o Neurodev delay o Probable delayed bladder control maturation, bladder irritation, primary detrusor muscle contraction Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Nocturnal Enuresis Secondary enuresis o Wetting episodes occur after sustained period (6-12 mos) of complete dryness o Majority of causes medical or psychological o Potential medical causes: a.Constipation b.DMI c.UTIs d.Seizures e.Hyperthyroidism f.Medication side effects (antipsychotics) o Potential psychological causes a.Death in the family b.Abuse/trauma c.Severe bullying Sleep apnea proposed to be possible cause of both primary and secondary nocturnal enuresis; studies show adenotonsillectomy significantly or relieves enuretic episodes Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Nocturnal Enuresis Extensive medical eval beyond PE and UA not necessary unless H&P c/w underlying medical d/o Tx Behavioral modification first line tx: o Limit fluid intake in the evening o Bedwetting alarm o Bladder stretching exercises o Positive reinforcement through awards o Responsibility training o Visual sequencing Pharmacological agents: o DDAVP o Oxybutynin o TCAs if refractory Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Circadian Rhythm Disorders Delayed sleep phase syndrome Sleep schedule lags behind environmentally expected sleep schedule May be 2/2 genetics or habit Teens > children Tx: Systematc sleep deprivation Motivational phase delay: When child has difficulties falling asleep and waking up 2/2 distress r/t daytime event (most commonly school); not due to physiological dyssynchrony of circadian rhythm, must target underlying issue causing distress Phase advance Sleep schedule is earlier than environmentally expected sleep schedule Less common than sleep delay Tx: Progressively delay sleep time by 30-60 min at a time, shift activities later in the day (e.g., dinner time), until schedule adjusts Tends to be easier to achieve due to 25-hr cycle of circadian rhythm Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Circadian Rhythm Disorders Irreg sleep/wake patterns w/o consistent phase delay or phase advance Caused by irreg schedules and lack of consistent structure at home Tx focuses on helping parents develop structure in the home Some children may have shorter sleep cycles; these children generally do not have difficulties falling asleep or waking up in the AM Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Behavioral Insomnias of Childhood Sleep-onset association disorder Child has difficulties falling asleep independently Relies on external interventions/circumstances; examples: o Rocking o TV o Being w/ parent o Being held o Sleeping in parents bed o Having bottle Esp prevalent for infants who then associate falling asleep w/ parental support; then when waking up mid sleep has difficulties going back to sleep on his/her own Tx o Awakenings shortly before predicted time the child will awake and progressively interval btwn awakenings o Remove the external cues, allow child to learn to sleep on their own Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Behavioral Insomnias of Childhood Limit-setting disorder Child repeatedly refuses to go to sleep at bedtime and parent allows them to stay up later Allows excessive/dev inappropriate napping Combined type = Sleep onset association disorder + limit setting disorder Feeding-related disorder Child must be fed when awakening from sleep in order to fall back asleep Causes further disruptions in sleep r/t discomfort from bladder distention, diaper soiling Poor sleep hygiene Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Psychiatric Causes Depression/mood disorders sleep issues Early morning awakenings, incr sleep latency, interruptions/arousals, need for sleep, changes in sleep architecture Tx underlying condition in addition to relaxation techniques, positive reinforcement strategies, limit setting, consistent bedtime schedules/routines Anxiety Tx underlying condition in addition to behavioral/environmental interventions At times strict limit setting may worsen anxieties/fears so parents must show understanding and compassion for childs distress and set limits more gradually in these cases Alcohol/drug abuse Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Psychiatric Causes PTSD Associated w/ specific parasomnias (e.g., nightmares, night terrors, enuresis) Type 1: Acute specific trauma resulting in hyperautonomic arousal and insomnia Type 2: Chronic trauma associated w/ hypersomnia Tx for nightmares should be oriented more behaviorally (e.g., using dream scripting and trauma-focused CBT) vs meds such as prazosin given limited studies ADHD Sleep issues hypothesized to be r/t combo of hypoarousal during day + compensatory hyperactivity to combat daytime hypoarousal and then inability to calm down at bedtime to fall asleep Other factors include disruptions in baseline circadian rhythm, sensory integration difficulties, stimulant rebound effects, comorbid psychiatric d/o (e.g., anxiety) If behavioral interventions ineffective/suboptimal, trial melatonin/alpha-agonist Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Psychiatric Causes 5 factors seen in children w/ sleep issues > than those w/o Family member who has experienced an accident/illness Unaccustomed absence of mother Mother w/ depressed mood Co-sleeping Maternal ambivalence towards child Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Medical Causes Colic Prolonged episodes of inconsolable crying, fussiness, and hypertonia (e.g., fist clenching, writhing/twisting movements, flapping, grimacing facial expressions) Usually dev by 2-3 wks old, resolves by 4 mos Hypotheses on etiology o CNS immaturity o Adaptive purpose of exercising infant lungs o Pain r/t gas o Cows milk allergy o Insufficient progesterone levels Studies showing potential sleep disturbance (e.g., arousals and shorter duration of sleep), difficult temperament, sensitivities to s in sleep sched in children who have outgrown colic o Possbily r/t parental overresponsiveness to childs needs during colic o Target by educating parents on importance of strict sleep hygiene Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Medical Causes Medication side effects Sedative/hypnotics: Associated w/ sleepwalking episdes, in particular non-benzos (e.g., zolpidemn, eszopiclone) Sedative/hypnotics and antihistamines may cause residual daytime sedation Antibiotics Beta-blockers: Suppress nighttime melatonin secretion Steroids: Cause imbalance in adrenal glands SSRIs: Suppress REM sleep; some may also incr sleep latency and/or frequency of awakenings/arousals Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Sleep Hygiene Integral part of tx for any sleep d/o Some differences depending on age Infants: Fragmented and irreg sleep pattern c/w nl dev for newborns (up to 3-6 mos old) so parents should limit interference w/ sleep unless needed (e.g., getting on a plane) As infant begins to consolidate sleep at night and responding more to external cues for sleep, parents should incorporate additional cues (e.g., waking them up earlier from daytime naps, minimizing disruptions at night while changing diapers by using low light) Begin bedtime routine to help infant experience calm before sleep and ensure consistent routine in same order on nightly basis o Bath, PJs o Reading/humming o Changing diapers Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Sleep Hygiene Assist infant in learning to independently fall asleep in their own bed and remove parental presence as much as possible o Study by Anders and Keener showed 50% infants at 2 mos old able to fall asleep after arousal on their own o Allow infant to attempt to fall asleep on their own even if crying upon arousal If prolonged crying, parents may come to child and make eye contact to show support but no other interventions, and progressively increase interval of parental presence w/ subsequent arousals By 6 mos need for nighttime feeding no longer present Start weaning nighttime feeding over 1-2 wks to avoid feeding-related d/o Ensure comfortable environment for sleep o Warm blankets o Supine sleep position o Humidifier o Breathe Right strips for nasal congestion Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

Sleep Hygiene Older children/adolescents Parents must reinforce consistent sleep sched, even on wknds Bedroom should be reserved for bedtime ritual and sleeping only; no TVs, games, toys, computers, tablets, phones, etc. Child should fall asleep in their own bed and alone Avoid excessive physical activity near bedtime, though reg exercise earlier in the day may promote sleep No daytime naps Avoid caffeine or other stimulating substances Avoid heaving eating or excessive drinking prior to bedtime Avoid lying in bed unless sleepy Provide cool, dark, quiet room Must distinguish resistance to sleep from legitimate anxieties (e.g., school) b/c strict limit setting may exacerbate fears/worries; if this is the case must target underlying issue Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285

General Pyschopharmacology First-line tx is always behavioral/environmental/sleep hygiene!!!! Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.

General Psychopharmacology Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.

Evaluation for Sleep Disorders Etiology of pediatric sleep d/o usually multifactorial Detailed hx most important Record sleep diary for 2 wks (e.g., http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf) Questionnaires Childrens Sleep Habits Questionnaire (CSHQ) o Vaildated for 4-12 y/o o 33 items (41 points cut off) o http://www.education.uci.edu/childcare/pdf/questionnaire_interview/C hildrens%20Sleep%20Habits%20Questionnaire.pdf Adolescent Sleep Hygiene Scale o 12-18 y/o o 28 items (no specific scoring) o Dev for evaluating healthy teens o http://sleep.colorado.edu/sites/default/files/ASHS_website_130303.pdf

Evaluation for Sleep Disorders Medical work-up VS including BMI Focused or comprehensive PE Labs (e.g., Fe levels) Polysomnography if suspecting primary sleep d/o Evaluation of Sleep Complaints and Pertinent Clinical Hx: Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Sleep ComplaintExploring Pertinent History Habitual bedtimes (sleep onset/offset on wkdays and wknds/holidays) Time taken to sleep onset; desired bedtime Duration, frequency, and severity of complaints Difficulty falling asleep Inappropriate nap schedules FHx Negative associations (fears, worries) w/ distressing sensorimotor sx of restless leg syndrome, nightmares Difficulty sleeping through the night (nighttime awakenings, early morning awakening); activities during the awakenings Difficulty staying asleep (and/or multiple nocturnal awakenings) early morning awakenings Screen for mood and anxiety sx Screen for primary sleep disorders (sleep apnea) FHx Use of alerting substances at bedtime

Evaluation for Sleep Disorders Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-3 Sleep ComplaintExploring Pertinent History Total duration of nocturnal sleep Quality of morning awakenings Difficulty to stay awake in the classroom, while driving, watching TV, eating meals Persistent use of stimulants (e.g., nicotine, caffeine) to stay awake Excessive daytime sleepiness Exploring other potential sx associated w/ disorders of excessive sleepiness (e.g., cataplexy, sleep paralysis, sleep attacks, hallucinations) Daytime consequences of sleepiness (e.g., poor academic performance, learning difficulties, impaired concentration, disruptive behaviors, mood sx) FHx Medication use (long-acting psychotropic meds w/ hangover effects) Substance use (alcohol and other illicit drugs, OTC meds) Occupation (odd hrs at employment, shift-work schedules) Social environment (co-sleeping/sharing bedroom, sleep patterns of parents and other children, pets in bedroom) Poor sleep routine and sleep hygiene due to environment and psychosocial variables Housing (light, noise, temp) Activities at bedtime (computer/telephone, HW completion, TV viewing) Substance use (alcohol and other illicit drugs, caffeine intake, nicotine use, OTC meds) Parental involvement (limit setting, adult supervision)

Ramifications of Sleep Deprivation Neurocognitive Deficits in attention, memory, learning Hyperactivity/impulsivity (more common in younger children) Deficits in executive functioning Daytime sedation Psychological Depression/mood lability Irritability Oppositionality Anxiety Fatigue/weakness OBrien, Louise M. The neurocognitive effects of sleep disruption in children and adolescents. Child and Adolescent Clinics of North America. 2009 Oct; 18(4): 813-823

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sleep disorders in children and adolescents rebecca cho, m.d

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