Rebecca Cho MD 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 ID: 774890
Download Presentation The PPT/PDF document " SLEEP DISORDERS IN CHILDREN AND ADOLESC..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
SLEEP DISORDERS IN CHILDREN AND ADOLESCENTS
Rebecca Cho, M.D.
Slide2O 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
Slide3Normal Sleep Architecture
NREMStage 1Transition stage where sleep usually begins, can be easily arousedAlpha waves, rhythmic = relaxed wakefulness≈ 1-7 min in HR and respirations, eyes move slowly under eyelidsStage 2Deeper 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 sleepFurther in HR and respirations, no eye movementSleep 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. 3rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Slide4Normal Sleep Architecture
Stages 3 and 4 (slow wave)Deepest sleep, highest arousal threshold, may be disoriented if awakenedStage 3 ≈ few min; stage 4 ≈ 20-40 minNo significant distinguishing pattern in shift from stage 3 to 4Primarily delta waves = high voltage slow wavesSlowest rates of breathing and HRREM Rapid eye movementAtonia, muscle paralysis safe expression of dreams Desynchronous low-voltage mixed frequency waves + mix of wave patterns seen in other sleep stages and wake stateSleep 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. 3rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Slide5Normal 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
Sleep up to 16-18
hrs
/day in broken segments lasting 2-4
hrs
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.
Slide6Normal Sleep Architecture
By 2-3
mos
Circadian rhythm, NREM, REM develops
Progressive consolidation of sleep,
naps, less total sleep required (14-15
hrs
)
Dreams more apparent by 12
mos
, content tends to be more vague
Children
Total sleep further
to 11-12
hrs
by 3-5 y/o, most napping stops also
Slow wave tends to dominate sleep cycle (w/ associated GH release)
May start having more vivid dreams, nightmares, content related to waking thoughts/fears/desires
Adolescents
Need
avg
8-10
hrs
/night
in slow wave sleep w/ onset of puberty and into adulthood
Frequent shifts in circadian rhythm due to social/environmental factors and potential biological/hormonal
Δs
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.
Slide7Physiological Δs in Sleep
Physiological ProcessNREMREMBrain activity from wakefulness in motor and sensory areas; otherwise similar to NREMHeart rate from wakefulness and variesBlood pressure from wakefulness up to 30 % and variesSympathetic nerve activity from wakefulness significantly from wakefulnessMuscle toneSimilar to wakefulnessAbsentBlood flow to brain from wakefulness from NREM, depending on brain regionRespiration from wakefulness and varies from NREM, but may show brief stoppages; cough suppressedAirway resistance from wakefulness and varies from wakefulnessBody temperatureRegulated at lower set point than wakefulness;; shivering initiated at lower set point than wakefulnessNot regulated; no shivering or sweating; temp drifts towards that of local environmentSexual arousalOccurs infrequently> than NREM
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.
Slide8Why 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.
Slide9Pediatric Sleep Disorders
Obstructive sleep apnea
Sleep-related movement disorders
Parasomnias
Narcolepsy
Circadian rhythm disorders
Behavioral insomnia of childhood
Psychiatric causes
Medical causes
Slide10Obstructive Sleep Apnea
SYMPTOMSSnoringApneic episodesDiaphoresisEnuresisWaking up feeling unrestedDaytime somnolenceMorning HAsCognitive dysfunction
ETIOLOGYAdenotonsillar hypertrophy (most common)ObesityCraniofacial dysmorphology (e.g., Downs)Neuromuscular d/o (e.g., CP)
RISK FACTORS
Allergies
Sinus problems
AA ethnicity
FHx
of OSA
Slide11Obstructive 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
Slide12Sleep-related Movement Disorders
Rhythmic movement disorder
Periodic limb movement disorder in sleep
Restless leg syndrome
Relationship between ADHD and PLMS/RLS
Slide13Rhythmic Movement Disorder
AKA
Jactatio
Capitis
Nocturna
Repetitive, stereotyped movements, involvement of large muscle groups
Head banging
stress
Lying in prone/supine position
Most common in 1
st
yr
Boys > girls
Head rolling
More common, progressively declines w/ age
Body rocking
Child is usually on hands and knees rocking anterior
posterior
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
Slide14Rhythmic 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
Slide15Periodic 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
Slide16Periodic 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
Slide17Restless 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
Slide18Restless Leg Syndrome (RLS)
Tx
:
Behavioral interventions including strict sleep hygiene and
reg
physical activity
If Fe levels low (<50ng/
dL
) may consider supplementation (2mg/kg) w/ goal of
ing
> 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
Slide19Relationship 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
Slide21Parasomnias
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
Slide22Sleepwalking (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, Tourette’s, 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
Slide23Sleepwalking (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:
Benzos
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
Slide24Night 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
Slide25Night 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
Slide26Nightmares
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
Slide27Nocturnal 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
No h/o consistent dryness through night > 1-2
wks
Strong +
FHx
M > F
Neurodev
delay
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
Slide28Nocturnal Enuresis
Secondary enuresis
Wetting episodes occur after sustained period (6-12
mos
) of complete dryness
Majority of causes medical or psychological
Potential medical causes:
Constipation
DMI
UTIs
Seizures
Hyperthyroidism
Medication side effects
(antipsychotics)
Potential psychological causes
Death in the family
Abuse/trauma
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
Slide29Nocturnal 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
:
Limit fluid intake in the evening
Bedwetting alarm
Bladder stretching exercises
Positive reinforcement through awards
Responsibility training
Visual sequencing
Pharmacological agents:
DDAVP
Oxybutynin
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
Slide30Circadian 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
Slide31Circadian 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
Slide32Behavioral Insomnias of Childhood
Sleep-onset association disorder
Child has difficulties falling asleep independently
Relies on external interventions/circumstances; examples:
Rocking
TV
Being w/ parent
Being held
Sleeping in parents’ bed
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
Awakenings shortly before predicted time the child will awake and progressively
interval
btwn
awakenings
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
Slide33Behavioral 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
Slide34Psychiatric 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 child’s
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
Slide35Psychiatric 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
Slide36Psychiatric 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
Slide37Medical 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
CNS immaturity
Adaptive purpose of exercising infant lungs
Pain r/t gas
Cow’s milk allergy
Insufficient progesterone levels
Studies showing potential sleep disturbance (e.g.,
arousals and shorter duration of sleep), difficult temperament, sensitivities to
Δs
in sleep
sched
in children who have outgrown colic
Possbily
r/t parental
overresponsiveness
to child’s needs during colic
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
Slide38Medical 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
Slide39Sleep 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
Bath, PJs
Reading/humming
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
Slide40Sleep Hygiene
Assist infant in learning to independently fall asleep in their own bed and remove parental presence as much as possible
Study by Anders and Keener showed 50% infants at 2
mos
old able to fall asleep after arousal on their own
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
Warm blankets
Supine sleep position
Humidifier
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
Slide41Sleep 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
Slide42General 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.
Medication
Dosing
Safety Concerns
Pearls
Alpha-agonists (clonidine,
guanfacine
)
PO clonidine 0.05mg QHS (titrated by 0.05mg q5days)
PO
guanfacine
0.5mg QHS (gradual titration by 0.5mg q5days)
Cardiovascular risk at higher doses and overdose
Guanfacine
less sedating and has less anticholinergic/CV side effects
vs
clonidine
Guanfacine
helpful in comorbid seizure d/o due to anticonvulsant effects; newer longer-acting formulation can be helpful in
tx
of ADHD and help w/ sleep maintenance
REM suppression may occur, resulting in REM rebound upon d/c
Often prescribed to target sleep onset delay in children w/ ADHD
General Psychopharmacology
MedicationDosingSafety ConcernsPearlsMelatonin and its receptor agonists (e.g. ramelteon)Clear dosing guidelines for melatonin unavailable in children 0.5-3mg/day (administered 2-3 hrs prior to sleep onset) Possible suppression of the hypothalamic-gonadal axis (caution in children w/ delayed puberty)Often prescribed to target sleep onset delay in children w/ ADHD and dev d/o More useful for chronobiotic rather than hypnotic properties (thus, useful in circadian rhythm sleep d/o) Effective doses may be higher in children w/ dev d/o (up to 10mg/day) Ramelteon (melatonin-receptor agonist) has limited data for use in children New agents (Agomelatine) can have potential uses in tx of comorbid anxiety and insomnia (due to melatonin agonist and 5HT antagonist properties)
Moturi
,
Sricharan
, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders
. Psychiatry (
Edgmont
). 2010 Jun; 7(6): 24-37.
Slide44General Psychopharmacology
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Medication
Dosing
Safety Concerns
Pearls
Antihistamines
Diphenhydramine (0.5mg/kg up to max dose 25mg/day)
Hydroxyzine (0.5mg/
lb
)
Daytime drowsiness, dry mouth, urinary retention, paradoxical hyperactivity, cardiac toxicity in overdose
Sedative effects through H1 receptor blocking properties
Dev
of tolerance requiring escalating doses
Anxiolytic and anticholinergic properties of antihistamines can potentiate substance abuse in adolescents
Benzodiazepines and benzodiazepine-receptor agonists (
zaleplon
,
zolpidem
,
eszopiclone
)
Ultra-short half-life (
zaleplon
, 1-2hrs); short half-life (
zolpidem
, 2-3hrs); intermediate to long half-life (
eszopiclone
, 6hrs)
Behavioral
disinhibition
and agitation w/ aggression and impulsivity, paradoxical hyperactivity
Limited use in children 2/2 potential for abuse; none are approved for use in children by FDA
Benzodiazepine-receptor
agonsists
have been shown to induce complex sleep-related behaviors (e.g., sleep eating and sleep walking); longer-acting medications (e.g.,
eszopiclone
) are used mostly in adults 2/2 lack of
dev
of tolerance
General Psychopharmacology
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Medication
Dosing
Safety Concerns
Pearls
Antidepressants
Trazodone
at lower doses (12.5-50mg/day)
TCAs (amitriptyline,
nortriptyline
)
Priapism w/
trazodone
;
tx
-emergent anxiety and agitation; exacerbation of
sx
of RLS w/ TCAs; significant
cardiotoxicity
in overdose
Most TCAs are potent REM sleep suppressants and suppress slow wave sleep
Should be used at the lowest possible doses to avoid cardiac side effects
Sedating antidepressants (e.g., mirtazapine) have limited data in children; REM suppression by mirtazapine appears to be minimal
Herbal supplements
Chamomile, lavender, tryptophan, kava kava
Necrotizing hepatitis (kava kava); eosinophilia myalgia syndrome (tryptophan)
Use of herbal supplements have limited-to-no evidence of efficacy
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
Children’s Sleep Habits Questionnaire (CSHQ)
Vaildated
for 4-12 y/o
33 items (41 points cut off)
http://www.education.uci.edu/childcare/pdf/questionnaire_interview/Childrens%20Sleep%20Habits%20Questionnaire.pdf
Adolescent Sleep Hygiene Scale
12-18 y/o
28 items (no specific scoring)
Dev
for evaluating healthy teens
http://sleep.colorado.edu/sites/default/files/ASHS_website_130303.pdf
Slide47Evaluation for Sleep Disorders
Medical work-upVS including BMIFocused or comprehensive PE Labs (e.g., Fe levels)Polysomnography if suspecting primary sleep d/oEvaluation 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 Complaint
Exploring 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
Slide48Evaluation for Sleep Disorders
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-3
Sleep Complaint
Exploring 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)
Slide49Ramifications 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
O’Brien, 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