Introduction to Sleep Problems in Children

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Introduction to Sleep Problems in Children

• April Wazeka, M.D.
• Respiratory Center for Children
• Atlantic Health System

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Objectives

• Understand normal sleep in children
• Review common pediatric sleep disorders
• Discuss proper treatment options for childhood
  sleep disorders

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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.

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Pediatric Sleep Medicine

• Relatively new field
• Few pediatric sleep centers
• Now have new understanding of associations
  between common childhood disorders and sleep

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Overview

• Sleep disorders in children are very
  commonapproximately 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

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Sleep 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?

• All mammals and birds sleep as we know what
  sleep to be.
• Sleep behavior has also been observed in
  reptiles and insects

• 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!

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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

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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

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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

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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.

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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

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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

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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

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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 1989114997-999.

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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

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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
• Cows milk protein allergy with severe sleep
  disruption

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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
• Childs daytime mood or attention suffers
• Parents are losing sleep!

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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

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Treatment

• Make child feel safe and comfortable when alone
• Place child in crib and leave the room
• Return after a few minutes to comfortverbally
  ONLY, do not pick child up
• Stay in the room no more than 1-2 minutes
• Gradual withdrawal of parent from the childs
  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 Preschool and
School-Aged Child

• Fears and nightmares
• Limit setting sleep behavior disorder

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Fears and Nightmares

• Fears of monsters when awake
• Vivid, frightening dreams of villanous creatures
  when asleep
• Experienced by gt50 of children
• Usually begin at 3-5 years of age, decrease with
  increasing age

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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

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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 childs behaviors

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Common Features

• Child usually gt2 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 Limits

• Lack of understanding of the importance of
  setting limits
• Inadequate knowledge of limit-setting techniques
• Psychosocial factors

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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

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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)

• 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 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

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Treatment

• Improved sleep hygiene
• Normalization of sleep schedule
• Decreased use of alcohol and other drugs
• Sleep restriction therapy
• Relaxation training
• Biofeedback
• Psychotherapy
• Medications rarely indicatedat best a temporary
  fix

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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

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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

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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

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Treatment Success
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Treatment Failure
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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

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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

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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

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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 200225213-8.
• Rajaram et al Sleep 2004

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RLS-Treatment

• Correct underlying medical cause, if present
• Diabetes, uremia, anemia
• Dopaminergic agents
• Pramipexole (Mirapex)
• Cardidopa-levodopa (Sinemet)
• Benzodiazepines
• Opiates

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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

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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

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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

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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

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Sleep Talking (Somniloquy)

• Common disorder
• Can arise from REM or NREM sleep
• May have a genetic component
• Rarely of clinical significance

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Disorders 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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Sleepwalking

• Very common40 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 childhoodprevalenc
  e, course and behavioral correlations. Acta
  Paediatr Scand 71495, 1982

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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

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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
  successfulbest not to intercede
• Incidence 5-15 of children
• Associated with amnesia
• Family history typical

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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

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Constitutional and Precipitating Factors for
Arousals

• Constitutional
• Genetic
• Developmental
• Sleep deprivation
• Chaotic sleep schedule
• Psychologic
• Precipitating
• OSA
• GERD
• Seizures
• Fever

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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

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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

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Secondary Parasomnias

• Neurologic
• Seizures
• Consider with stereotypical movements, recurrent
  dreams, unusual autonomic symptoms (stridor,
  choking, coughing)
• Headaches
• Muscle cramps

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Sleepiness
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Causes 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 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

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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 lt20 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 175, 1992

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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

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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

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Circadian Rhythm Sleep Disorders

• Regular but inappropriate schedules
• Sleep phase shifts
• Delayed sleep phase
• Advanced sleep phase

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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

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Delayed Sleep Phase

• Delay in sleep onset, late awakening
• Night owls
• Onset in adolescence
• Male predominance
• Sleep itself quantitatively and qualitatively
  normal
• Genetic predisposition

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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

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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

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Melatonin

• Production unregulatedconsidered a food product
• Dose 1-5 mg PO QHS
• Safety and efficacy not established in any age
  group
• Ramelteonnewly approved melatonin agonist, not
  studied in children
• Dose 8mg PO QHS

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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

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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/sleep
  iness
• Number of daytime naps and their duration
• Medications
• Parental interventions

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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.

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Sleep Log
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Diagnosis Nocturnal Polysomnography

• Only diagnostic technique shown to quantitate the
  ventilatory and sleep abnormalities associated
  with sleep-disordered breathing
• THE GOLD STANDARD!

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Sleep Laboratory
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Polysomnogram
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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
  153866-878.

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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. 199927267-272.

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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

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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

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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 WELLPARENT SLEEPS WELLHAPPY PARENT
  AND CHILD

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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/stars
  lp/