Pediatric Sleep Disorders And Sleep - PowerPoint Presentation

Slide1

Pediatric Sleep Disorders And Sleep hygeine

By Dr

Shamaita

gupta

Slide2

Ob

j

ectives

Understand

normal

sleep

in

children

Review

common

pediatric

sleep

disorders

Discuss proper treatment

options for

childhood sleep

disorders

Slide3

Sleep Cycle

Slide4

Duration of sleep cycle

Slide5

The sleep cycle

Each sleep

cycle

90 – 120

minutes

First

REM

period is

shortest

Most NREM deep sleep

occurs earlyMost REM occurs late

Slide6

Sleep Regulation

Regulated

by the combined action of two processes.The homeostatic process(

Process S

) - Rise

of sleep

pressure during

wakefulness and its dissipation during

sleep due to accumulation of adenosine and other sleep promoting

somnogens

during prolonged wakefulness

The second process refers to circadian

oscillations(Process C), which superimpose a nearly 24-h pattern on the sleep-wake cycle: by actively promoting wakefulness during the biological day and sleep during the biological night,i.e., during phases of melatonin secretion by the pineal gland. This rhythm is triggered and adjusted to the external light-dark cycle by external inputs like light(called zeitgebers) to the brain’s main circadian pacemaker, the suprachiasmatic nuclei (SCN) of the anterior hypothalamus.

Slide7

The changing trends of sleep patterns

Newborn

- up to 18 hours 1–12 months - 14–18 hours 1–3 years -12–15 hours 3–5 years - 11–13 hours 5–12 years - 9–11 hours

Adolescents - 9-10 hours

The REM sleep time decreases from birth(50%) to early childhood to adulthood(25-30%)

Irregularities of sleep patterns start in early childhood depending on school night and non school night bed times

Slide8

Pediatric sleep disorders

prevalence ≈25% - 43%of children ages

1-5 yearsi

n

t

er

f

e

r

e

w

it

h daily patient and family functioning.sleep pro

b

l

e

m

s

cau

se s

i

g

n

i

f

i

can

t

e

m

o

tio

na

l,

behavioral

, and cognitive

dysfunction.

c

o

mm

o

n

a

m

o

ng

children

w

i

th

m

ed

i

c

al, neurodevelopmental and

psychiatric

disorders

Slide9

Slide10

Most common causes of sleep abnormality:

Inadequate duration

(insufficient quantity)

Difficulty in initiating

Difficulty in maintaining sleep

Disrupted or fragmented sleep

(poor quality)

Less common causes of sleep abnormality

Inappropriate timing of sleep

Cicardian

rhythm disturbances

Excessive day time sleepiness

Slide11

Slide12

DSM-V classification

1-

Dyssomnias

(# duration, timing

of

sleep)

Primary Insomnia

Primary

Hypersomnia

Breathing-Related Sleep Disorder NarcolepsyCircadian Rhythm Sleep Disorder

2-

Parasomnias (abnormal events during

sleep)

Nightmare

Night

Terrors

Sleep

walking

3- Medical and Psychiatric disorders

Slide13

The clinical evaluation involves: obtaining

a

careful medical

history

assess

for

medical cause

of

sleep disturbance

Current

sleep patterns, including sleep duration,

sleep-wake schedule, sleep habits, Nocturnal symptomsPolysomnogram (PSG) record:EEG, EMG, EOG, Vital Signs and

Other Physiologic

Parameters

Slide14

Slide15

Insomnia

Difficult initiate

or maintain

sleep

or

early

morning

awake

with difficult

return to

sleep

Occur 3 nights/week, for at least 3 months,

despite sufficient

time

for

sleep.

Not

due

to the

effects

of a

substance

Not

explained

by mental/medical

illness

Prevalence

1 – 6 %

in

pediatrics

but higher

in

children

with chronic

med/psych

conditions

Slide16

Treatment of Insomnia

Mainly treated

with

behavioral

interventions

Media

removal

from

bedroom

Avoid

caffeineConsistent bedtime routine and positive reinforcement from parents/caregivers

Correct

the underlying med/psycho

factors

Slide17

Beavioral therapy(graduated extinction)

More

commonly in infants and toddlers

the problem

stems from learning to fall

asleep only

under certain conditions that require

the parent

to

intervene For

example, child must be rocked or fed

to fall asleep Child

does not learn to self-soothe during normal brief arousals between sleep cycles In pre-school age and older children, the problem is active resistance

to bedtime

rather than prolonged

wakings

during

the night

Systematic ignoring or “extinction” (

Unmodified

version is known as “crying it out

”) has been documented

to be a highly successful treatment, but difficult for parents to adhere to

.

Alternative is to do this more gradually, with longer periods between checking on

child. Keep

contact brief and avoid picking child up

Slide18

Contd..

Also Known as Ferber Method

The child is allowed to cry for sometime before intervention is done by the parents

The time of intervention is gradually increased.

The child is taught to calm itself and fall asleep on its on

Sometimes a visit for a few minutes and a small pat on the bag is given

Slowly the crying time slowly decreases and the baby falls off to sleep on its own by 3-4days of extinction

However this method is criticised to be emotionally exhausting for both parents and the child.

Slide19

Hypersomnolence disorders

prolonged sleep episodes,

excessive

sleepiness

prolonged sleep

> 9

h/day

that

is not

refreshing

Difficulty being fully awake after abrupt awakening

The

complaint is present

for

at

least

6

months.

Not

due

to

med/psycho

disorder

Common

in in late

adolescence.

Slide20

Sleep disordered breathing

Obstructive Sleep

Apnea

(1

– 4

%)

Results in blood oxygen desaturations

Upper Airway

Resistance

Syndrome

Similar to OSA but not result in desaturationsPrimary Snoring (7 –

12%)

regular snoring without

changes in

sleep architecture, alveolar ventilation or

oxygenation

Slide21

Obstructive sleep apnea

Periodic

apneas

due

to sleep-related airway obstruction

↓

patency

(obstruction

and/or

↓diameter)

↑

collapsibility (↓ pharyngeal muscle tone)↓ drive to breath

(↓

central

ventilatory

drive)

Not

all

snorers have

OSA

Slide22

Sequelae of OSA

Disrupt

ventilation

and

sleep

patterns

intermittent

hypoxia and

multiple

arousals cause

significant metabolic,

CVS, neurocog/behavioral and academic morbidityDaytime Sleepiness, Enuresis

as short-term

squeal

Pulmonary

hypertension and right

heart failure,

FFT as long

term

sequel

Slide23

Treatment of Sleep Apnoea

Weight

loss

Positional (sleep

on one

side

or

prone

)

CPAP prevents

obstruction by soft-tissue and keeps airway open

Surgical

intervention

(e.g.,

tonsiloadenectomy

)

Avoid

sedatives (which

prevent reawakening

to

breath)

Slide24

Narcolepsy

uncontrollable excessive daytime sleep attacks interfere with normal

daily

functioning

Person

goes

directly

into

REM

sleep

Common

in adolescence & early adulthoodGenetic defect in hypothalamic orexin/hypocretin neurotransmitterprevalence is

3-16/10,000

Slide25

Symptoms

associated

with

narcolepsy

Slide26

Narcolepsy symptoms

Cataplexy

(pathognomonic

for

narcolepsy

)

Abrupt

bilateral partial

or

complete

loss of m. tone.triggered by intense positive emotion (e.g., laught)

last

for

seconds

to

minutes

with

complete

recovery

Hallucinations

(visual, auditory,

tactile)

occur

during transitions bet. sleep

and

wakefulness

At

sleep onset

→

hypnogogic

At

sleep

offset

→

hypnopompic

S

le

e

p

para

l

ys

i

s

:

i

nab

ili

t

y

t

o

m

ove

o

r

sp

e

a

k

f

or

s

e

c-

min at

sleep onset

or

offset; accompanies

hallucination

Slide27

Contd..

DD

Potential

causes of EDS:

Extrinsic

:

Secondary

to insufficient/fragmented

sleep

Intrinsic: CNS disorder with ↑ need for sleep.

Treatment

include:

Education

,

good

sleep

hygiene,

behavioral

changes (

eg

. Scheduled naps).

Medications

as

:

psychostimulants

and

modafinil

to control EDS.

TAD

and

SSRI

to

control REM-associated phenomena, such as

cataplexy

Slide28

Cicardian rhythm disorder

Circadian Rhythm Sleep Disorder caused by

mismatch

between sleep-wake schedule

required

by

a person’s environment and

his/her

circadian

sleep-wake

pattern.

Slide29

Delayed sleep phase syndrome

It

is a

circadian rhythm

disorder

significant

, persistent, intractable phase shift

in

sleep

wake

schedule (later sleep onset

and wake time)Patients has inability to get to sleep until the early morning, but little difficulty sleeping once

asleep

Interfere

with

school,

work

and

lifestyle

demands.

Common

in

adolescents

and

young adults

(7-16%)

Slide30

Treatment

Treatment

is

primarily

behavioral

Shifting

the

sleep-wake

schedule

to an

earlier

timeMaintaining the new schedule.→ Gradual shifting bedtime/wake time earlier by 15- 30 min

increments

→

Exposure

to light in

morning and avoidance

of

evening

light

exposure

Oral

melatonin

supplementation

in the

afternoon

or

early evening

is

effective

in

advancing

the

sleep

phase.

Slide31

Slide32

Sleep related movement disorder

Restless leg syndrome

:

Uncomfortable

sensations

in

the LL accompanied by irresistible

urge

to

move

legs →Disturbs

sleep→ Often mistaken as growing pains. Relieved only by movement only to recur on stopping movementPeriodic limb movement disorder: periodic, repetitive, brief (0.5-10

sec) highly stereotyped

limb

jerks

(rhythmic extension

of

big

toe and

dorsiflexion

at

ankle

)

→

Disrupts

sleep

.

Prevalence

in

children

is

8-12

%.

Diagnosis

of

PLMs requires overnight polysomnography

. Treated according to

severity (intensity,

frequency,

periodicity(<5/hour or more)) ,

degree

of

sleep

disturbance

,

daytime

sequelae.

Sleep related rhythmic movements:

repetitive

,

stereotyped,

rhythmic

movements

involve

large muscle

groups

. Like head banging, body rocking etc. may be seen in transition while going off to sleep. Treatment is reassurance to parents.

Slide33

Pediatric parasomnias

Episodic nocturnal

behaviors

involve

cognitive disorientation and autonomic

and skeletal

muscle

disturbance.

Slide34

Prevalence of parasomnias in pediatric age group

80

%

70

%

60

%

50

%

40

%

30

%20%10%0

%

Any sleep

sleep

night RLS nocturnal bruxism

walking talking terror enuresis

Slide35

Persistence of childhood parasomnias into adulthood

E

nu

r

e

s

i

s

Sleep

Terrors

B

r

u

x

i

s

m

Sleepwalking

0 5 10 15 20 25 35

Slide36

Nightmare

Sleep disorder

characterized

by high

arousal

and appearance

of

being

terrified

≈ 2/3 of all

kids experience

themCommon in preschoolers ages 3-6 yOccur during REM

sleep

Child believes them

to

be

real.

Slide37

Night terror

repeated

abrupt

awakenings

from sleep

characterized

by intense fear, panicky screams,

autonomic

symptoms (tachycardia, rapid breathing,

sweating),

absence

of

detailed dream recall, amnesia for the episode, and relative unresponsiveness to attempts to comfort the person.Lasts ~ 10 min

then returns

to

undisturbed

sleep

During Stage 3-4

of

NREM

sleep

(1st

third

of

night)

Prevalence

is

3–6.5% in

children.

can occur

at any

age.

Common in

male

resolves

spontaneously

Nocturnal administration

of

benzodiazepines

has

been

reported

to

be

beneficial

Slide38

Bruxism

involuntary, forceful grinding

of

teeth during

sleep

Up

to

88% of

children;

20 % of

adultsAny stage of sleepMay result in damage to the teeth

Periodicity

of 20 to 30

seconds.

May

represent

symptom different

disorders

Patient

is

usually

unaware

of the

problem

In severe cases,

rubber

tooth

guard

is

necessary.

Stress management

or

biofeedback.

Slide39

Sleep talking

Begins

during school

age



During

NREM and REM

sleep



No

treatment just reassuranceNight wakeningOne or more waking from midnight to 5 am for at least four

of seven nights per

week

for at least four consecutive

weeks

Slide40

Sleep walking

More

than

just

walking

around…

Simple

Behaviors

and

Complex

BehaviorsWhile sleepwalking, patient has a blank staring face, relatively unresponsive to others. confused or disoriented

on

being

aroused.

Complete

amnesia

Occur

during

Stage

3-4 Sleep;

1

st

third

of

night

.

Begins

in

ages

4-8

yrs

.

17

% in

children

(4% of

adults)

sleep-walking

most

likely

to persist

it is

important

to

institute safety precautions (use

of gates,

locking

doors and

windows,

and

bedroom door

alarms).

No

treatment

is

established, but

may

respond

to

benzodiazepines

or

sedating antidepressants

at

bedtime.

Slide41

Non REM confusional arousal parasomnia

Usually during first

1/3 of

night

Usually

only one

event/night

Common in

Toddler

and

school-aged kids.prevalence rates 15% in children ages 3-13 yr.co-occur with sleepwalking and

sleep

terrors

Usually resolve

with

time

Not tired the next

day

No stereotypic

motor

movements

Last

5-30

minutes

Slide42

Treatment of Parasomnias

parent education

and

reassurance

good

sleep

hygiene

avoidance

of

exacerbating factors such

as sleep deprivation and caffeine.

Scheduled awakenings,

parent

wake

the

child

15

to

30 min

before

the time of

first parasomnia

episode.

Pharmacotherapy

is

rarely necessary, include

benzodiazepines

and

tricyclic

antidepressants.

Slide43

Sleep hygiene for toddlers

Make sure the baby is not hungry when you put him to bed.

Feed the baby right before bedtime so he or she is not hungry when put to bed.

Place the child in bed when he is sleepy but not yet asleep. Make sure your child is still awake when he is put down for naps and at bedtime.

Placing the baby in bed while he is still awake lets him learn to fall asleep on his own.

P

lace the child on his back when putting him to bed, up to one year of age .

Have a nighttime routine and a regular sleep schedule.

Set a bedtime for

te

child. Be sure to stick with the time selected by putting the baby to bed at the same time every night.

Start a nighttime routine that includes feeding, bath, bedtime story, etc.

Do not let the child nap for too long or too late in the day. Try to limit naps to no more than 3 hours. Also, make sure the child is awake from the

afternoon nap by 4 pm. Children who sleep later than 4 pm may not be ready to go back to sleep when it is their bedtime.

Do not put the child in bed with a bottle or cup. Sleeping with milk or juice in the mouth can lead to cavities and tooth decay.

Slide44

Sleep hygiene for children

Have a set bedtime and bedtime routine

Bedtime

and

wake-up

time should be the

same time

on school & non-school

nights.

No

more

than 1hour difference from one day to another.Make the hour before sleep quiet time.

Avoid high-energy

activities

before

bed.

Slide45

Contd…

D

o

n

'

t

put the child

to

be

d

hu

ngry, but avoid Heavy meals.

spend

time

outside

every day and

involve in

regular

exercise.

Keep bedroom quiet and dark

with

comfortable

temperature

Don't use bedroom

for

punishment

Naps should

be

short (no > 1hr) and scheduled

in the

early

to

midafternoon

.

Keep TV out of

child's

bedroom.

Use

bed for sleeping

only.

Don't

study,

read,

watch TV

on

bed.

Relaxing,

calm, enjoyable

activities help

you

to get to

sleep.

Slide46

Sleep hygiene for adolescents

Budgeting eight hours of sleep into your daily schedule and keeping that same schedule on both weekdays and weekends.

Creating a consistent pre-bed routine to help with

relaxation and falling asleep fast

.

Avoiding

caffeine

and energy drinks, especially in the afternoon and evening.

Putting away electronic devices for at least a half-hour before bed and keeping them on silent mode to avoid checking them during the night.

Slide47

Contd..

Setting up your bed with a supportive

mattress

and

pillows

.

Keeping your bedroom

cool

, dark, and quiet.

Smoking and alcohol disturbs sleep

Use bed only for sleep

Regular exercise

Regular meals before going off to sleep.Avoid catch up sleep in weekends.Do not use sleeping pills

Slide48

The End