sleep tips for the primary care provider - amazon s3€¦ · sleep tips for the primary care...
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Sleep Tips for the Primary Care Provider Glenna Winnie, MD, D, ABSM Director Pediatric and Adolescent Sleep Center
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Overview
Normal sleep Strategies to prevent sleep disorders Signs and symptoms of sleep disorders Discuss things to do or not to do when
dealing with sleep disorders
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Definition of Sleep
A state of decreased responsiveness to outside and inside stimuli
An active process – brain and other organs are restored: “brain flush”
Must be safe to sleep By age 2, a child has spent
about 9500 hours sleeping versus 8000 hours awake
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The Stages of Sleep
Stage N1 (transition to sleep): lasts about 5 minutes, slow eye movements, easily awakened
Stage N2 (light sleep): first stage of true sleep , lasts 10 – 25 minutes, eye movement stops, heart rate slows, body temperature decreases
Stage N3 (deep sleep): difficult to awaken, slow large coordinated brain waves, blood directed away from brain and toward muscles
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The Stages of Sleep
REM Sleep (dreaming sleep): vivid dreams, rapid eye movements, irregular breathing, heart rate and blood pressure, muscles paralyzed except diaphragm and eyes
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Sleep Tip #1: Care About Sleep Sleep problems are a frequent
parental complaint Sleep affects every aspect of a child’s
development (physical, emotional, cognitive, social)
Sleep problems exacerbate virtually all psychiatric, developmental and psychosocial problems of childhood
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Why Should Providers Care about Sleep?
Adequate sleep is necessary for a child to function optimally
Sleep problems are common and chronic in children and adolescents (20-30%)
Pediatric sleep disorders are treatable Sleep problems are preventable
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Sleep Tip #2: Know How Much Sleep is Needed
NSF, AASM
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Prevention of Sleep Disorders
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Sleep Tip #3: Comfortable Safe Sleep Environment Keep noise down Use white noise, all night: fan or air purifier,
soft music, sound machine, white noise like static on radio (set between stations)
Temperature around 65 to 68 degrees Make sure the bed is comfortable! Decrease allergens in bedroom Treat snoring family members
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Sleep Tip #4: Children Need a Regular Sleep Schedule
Set a regular bedtime Have a regular nap schedule through pre-
school or kindergarten age Wake up at the same time every day Don’t sleep in late – take a short nap if
sleep was short Generally avoid naps – if needed, limit to 30
minutes
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Bedtime Routine
Everyone should have a bedtime routine!!!
Have a routine that is 15 – 30 minutes long, always the same, moving towards bed and lights out
Reserve the bedroom for sleeping
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Sleep Tip #5: Back to Sleep, Down to Sleep Longstanding recommendation for “back to
sleep” associated with decline in SIDS By 3-4 months of age, put child down before
child falls asleep - helps develop appropriate sleep onset associations
New AAP room sharing recommendations: 6 months and up to 12 months (evidence supports 3 months)
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Sleep Tip #6: Regulate the Sleep-Wake Cycle with Light
Sleep-wake cycle and body rhythms are controlled by the circadian clock
The clock has a slightly greater than 24 hour cycle
Melatonin helps regulate the circadian clock Melatonin production and the clock are most
powerfully regulated by light Other factors that regulate the clock are
exercise and eating
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Regulate the Sleep-Wake Cycle Increase light exposure during the day
– Spend time outside in daylight – Let light into home and workspace – No sunglasses in the morning – Use a light therapy box if needed
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Regulate the Sleep-Wake Cycle Decrease light exposure at night No visual electronics for at least one hour
before bedtime – Get the TV out of the bedroom – No reading from a backlit device
i.e. iPad, phone, computer (can use an eReader that needs external light)
Low–wattage bulbs for night reading Dark bedroom Use low nightlight, yellow or red, or
flashlight for getting up at night
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Sleep Tip #6: Exercise Improves Sleep Exercise 30 minutes daily Exercise in late afternoon Avoid vigorous exercise within 3 hours of
bedtime Exercise about 5 hours before bed is best to
help with sleep onset Exercise improves sleep quality, decreases
obstructive sleep apnea
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Signs and Symptoms of Sleep Disorders
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Sleep Tip #7: Daytime Sleepiness Is Not Normal Overt sleepiness in children and adolescents
is abnormal Insufficient sleep is most common cause Consider other medical disorders Consider medical and behavioral sleep
disorders: OSA, PLMD, narcolepsy, DSPS, behavioral insomnia of childhood, others
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Sleep Tip #8: Sleep Deprivation Has Many Effects Fatigue Moodiness, irritability, less ability to cope with
stress, difficulty making decisions Decreased creativity and problem-solving skills Concentration and memory problems Impaired motor skills and increased reaction time,
increased risk of accidents Weight gain Reduced immunity, increased infections Increased risk of diabetes, heart disease
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Signs & Symptoms of Sleep Deprivation/Disruption Needs an alarm clock/parent to
wake up Hard to get out of bed in the
morning Gets sleepy in school, lectures, warm rooms Gets drowsy after meals or when driving Needs to nap (after kindergarten) Falls asleep watching TV or relaxing Needs to sleep in on weekends Falls asleep within 5 minutes after going to bed
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Sleep Tip #9: Hyperactive Behavior Is More Common
In children, excessive sleepiness more often manifests as increased activity, problems with focus and attention, and mood and behavior problems than as overt sleepiness
Excessive sleepiness is more likely to present as overt sleepiness in adolescents, although they too may show only mood and behavior problems
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Sleep Tip #10: Delayed Sleep Phase is Common in Teens
Delayed sleep phase circadian rhythm disorder is a shift of the sleep phase to a later period that conflicts with academic and work schedules and social norms, and is associated with daytime sleepiness
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Delayed Sleep Phase
Affects ~7% of adolescents Sleep in the morning to early afternoon,
cannot get up for school, feel best in evening or late at night, cannot fall asleep at normal bedtime
Usually presents as insomnia or excessive daytime sleepiness
Sleep quality itself is normal Is treatable with chronotherapy
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Sleep Tip #11: Restless Sleep Is Not Normal Children (and adults) should sleep quietly, shift
position occasionally during sleep Frequent motor activity before or during sleep
is abnormal Any cause for discomfort can cause restless
sleep Restlessness during sleep may be due to OSA,
PLMD, narcolepsy, and before sleep to RLS
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Sleep Tip #12: Snoring is Often a Sign of OSA 2-4% of children and teens have OSA Snoring, gasping, snorts, respiratory
pauses, paradoxical breathing Tossing and turning, restless sleep, hanging
out of bed, unusual sleep positions Hyperactivity, mood or behavior problems,
excessive sleepiness, depression Secondary or prolonged enuresis Headaches
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Things Not To Do, and Things To Do
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Sleep Tip #13: Avoid Drug Use for Sleep Disorders
Pediatricians often recommend medications for chronic sleep problems
Medication use is ineffective for long term treatment of sleep disorders in children
Melatonin does have an established role for sleep onset / circadian problems, but is not effective for wakings
Better to evaluate and treat underlying disorders, or refer for sleep medicine consult
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Sleep Tip #14: No School Excusal Due to Sleepiness
Inability to get up to attend school indicates a significant disorder, which may be a behavioral, psychiatric, medical, or sleep disorder, or a combination
Identification and treatment of that disorder is important
School excusal (except when acute medical disorder present) can impede treatment
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Sleep Tip #15: Follow AAP Clinical Practice Guidelines All children and adolescents should be screened
for snoring as part of routine health maintenance visits
Polysomnography should be performed if there is snoring and signs/symptoms of OSA – The presence of OSA cannot be determined from
history and physical alone – Polysomnogram determines severity of
OSA, allows risk stratification for surgery – Other disorders may be present, most often PLMD
Marcus et al. Pediatrics 2012;130(3):576-584
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AAP Clinical Practice Guidelines for OSA Adenotonsillectomy is the primary
treatment for OSA Postoperatively, high-risk patients
should be monitored as inpatients
Marcus et al. Pediatrics 2012;130(3):576-584
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Sleep Tip #16: Screen for Sleep Disorders with BEARS
Behavior or Bedtime problems Excessive daytime sleepiness Awakenings and Apnea Restless sleep and Regular sleep
schedule Snoring
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Minimum Screening
Ask about snoring (per AAP) Ask if child moves a lot during sleep Look at tonsils
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Sleep Tip #17: When to Order Polysomnography If you feel comfortable explaining
results to parents and: – When there are symptoms of OSA – Possible PLMD, especially in children with
behavior problems or ADHD
– Tracheostomy before decannulation – Evidence of SDB in child with ALTE
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Sleep Tip #18: Sleep Study is Sometimes Not Indicated
Trouble falling asleep Diagnosis or routine eval of seizures Seizures without sleep disorder Uncomplicated parasomnias Most ALTEs Oxygen adjustment in lung disease Ventilator adjustment in outpatient
sleep lab
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Sleep Tip #19: You Can Refer for Sleep Consult If you are concerned about OSA or PLMD but
are not comfortable doing eval or ordering and explaining sleep study results: – Persistent daytime sleepiness or fatigue – Frequent awakenings, early morning awakenings – Non-refreshing sleep, can’t get up in am – Loud snoring, especially with pauses – Restless sleep, lots of movement during sleep – Morning headaches or
severe headaches – Secondary enuresis
After T&A with persistent symptoms
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#19: When to Refer for Sleep Medicine Consult Any child with sleep problems not responsive
to simple interventions Excessive sleepiness in any child who does not
have severe obstructive sleep apnea Trouble with falling asleep, staying asleep,
frequent or prolonged awakenings, early morning awakenings
Leg discomfort or crawling sensations at night Restless sleep
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Summary
Normal sleep Strategies to prevent sleep disorders Signs and symptoms of sleep disorders Discussed things not to do or to do when
dealing with sleep disorders in children
You can have a positive long term impact on your patients and their families by addressing the child’s sleep problems!
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Thank you for your attention! Questions? Glenna Winnie, MD, D, ABSM 2730-D Prosperity Avenue, Fairfax 703-226-2290 205 E Hirst Road, Suite 303, Purcellville 540-751-1955 [email protected]