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Slide1

SLEEP DISORDERS IN CHILDREN AND ADOLESCENTS

Rebecca Cho, M.D.

Slide2

O B J E C T I V E S

Review of sleep architecture and physiology through life stages

Exploration of pediatric sleep disorders and comorbidities

Potential consequences of sleep disruption in development

Behavioral and pharmacological treatment options

Slide3

Normal 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.

Slide4

Normal 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.

Slide5

Normal Sleep Architecture

Stage 1 → Stage 2 → Stage 3 → Stage 4 → REM = one cycle

Cycle repeats through the night

NREM ≈ 75-80%, REM ≈ 20-25% of total sleep

First cycle ≈ 70-100 min; later cycles longer at 90-120 min

Stage 2 progressively dominates NREM and REM intervals get longer with subsequent cycles, while slow wave sleep largely disappears

Differences in sleep architecture through the ages

Sleep becomes less efficient w/ age

Newborns

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.

Slide6

Normal 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.

Slide7

Physiological 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.

Slide8

Why Do We Sleep??

Exact role of sleep or why we alternate

btwn

NREM and REM are unclear, but overwhelming evidence that lack of sleep or disrupted sleep architecture leads to negative outcomes

A lot of interest in research; some hypotheses have arisen

REM

Appears to be involved in memory consolidation; learning seems to intensify/

REM

Hippocampal neuronal activation in REM mirrors pattern of wake state

NE and 5HT

post-synaptic depolarization and long-term potentiation  may aid in temporary hippocampal memory storage, cognitive functioning, synaptic plasticity

NREM

Also appears to be associated w/ learning and memory; learning seems to intensify slow waves during NREM

May play role in differentiating/organizing important synapses from those that are underutilized, facilitate protein synthesis

Poe, Gina R., Walsh, Christine M.,

Bjorness

, Theresa E.

Cognitive Neuroscience of Sleep

.

Prog

Brain Res. 2010; 185:1-19.

Slide9

Pediatric Sleep Disorders

Obstructive sleep apnea

Sleep-related movement disorders

Parasomnias

Narcolepsy

Circadian rhythm disorders

Behavioral insomnia of childhood

Psychiatric causes

Medical causes

Slide10

Obstructive 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

Slide11

Obstructive Sleep Apnea

Has been associated w/ ADHD: proposed that

intermittent hypoxia + fragmented sleep  prefrontal dysfunction

Dx

:

polysomnography

+ pulse ox

Tx

:

Wt

loss

Adenotonsillectomy

if indicated

Nasal CPAP

Leukotriene receptor antagonists (

montelukast

)

Intranasal corticosteroids (fluticasone spray)

External nasal dilator strips

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan 15; 63(2): 277-28

Slide12

Sleep-related Movement Disorders

Rhythmic movement disorder

Periodic limb movement disorder in sleep

Restless leg syndrome

Relationship between ADHD and PLMS/RLS

Slide13

Rhythmic 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

Slide14

Rhythmic Movement Disorder

Most commonly seen in infants and children < 5 y/o

Usually occurs when child is sleeping;

occ

stage 1 or 2 sleep

prevalence in MR (

esp

older individuals)

Dx

: Thorough clinical

eval

+ video

polysomnography

to r/o other causes (e.g., seizures)

Tx

:

Supportive; spontaneous resolution w/ age in most cases

If movements

risk for injuries (

esp

head banging)

 provide safe environment (e.g., padding, protective helmets)

Metronome near bed

Allowing child to engage in rocking before bedtime (e.g., rocking on chair or rocking horse)

If severe, may trial low-dose

benzo

such as clonazepam

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide15

Periodic Limb Movements in Sleep (PLMS)

Involuntary brief jerking movements in 20-40 sec intervals

Lower > upper extremities

In children movements may be less apparent; instead may present as:

Growing pains

Leg discomfort

Disrupted sleep

Difficulties initiating/maintaining sleep

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide16

Periodic Limb Movements in Sleep (PLMS)

rate of

parasomnias

Dx

: Video

polysomnography

to r/o seizures/OSA, detailed

hx

Tx

options:

Fe supplementation (if low iron levels)

Dopaminergic agents (e.g.,

ropinirole

,

pramipexole

)

Clonazepam (limited data)

Bupropion (shown to be effective for adult PLMS)

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide17

Restless Leg Syndrome (RLS)

Frequently co-occurs w/ PLMS

May p/w nonspecific “growing pains” or leg discomfort

Criteria include:

Urge to move legs (may also involve upper

ext

)

Urge begins/worsens when sitting/lying/inactive

Urge partially or totally relieved upon movement of legs

Urge only occurs in evening/night or more severe than during daytime

Sleep onset or maintenance difficulties frequent; anxieties r/t discomfort may interfere w/ ability to achieve restful sleep

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide18

Restless 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

Slide19

Relationship Between ADHD & PLMS/RLS

Significant comorbidity

Possible hypotheses:

May be r/t impairment in DA pathway:

Fe

effectiveness of tyrosine hydroxylase 

DA production

Insufficient sleep in children (disrupted sleep commonly seen in those w/ PLMS & RLS) may manifest as hyperactivity, distractibility, inattention, impulsivity, cognitive impairments

ADHD-like

sx

may be diurnal manifestations of PLMS/RLS during daytime (difficulties staying seated or remaining inactive for extended periods of time and needing to move to decrease discomfort/urge)

Fe supplementation has been shown to improve both PLMS & RLS

sx

at nighttime and some research showing improved ADHD-like

sx

during daytime

Walters, Arthur S.,

Silvestri

,

Rosalia

,

Zucconi

, Marco,

Chandrashekariah

,

Ranju

,

Konofal

, Eric.

Review of the Possible Relationship and Hypothetical Links Between Attention Deficit Hyperactivity Disorder (ADHD) and the Simple Sleep-Related Movement Disorders,

Parasomnias

,

Hypersomnias

, and Circadian Rhythm Disorders

. J

Clin

Sleep Med. 2008 Dec 15; 4(6): 591-600.

Slide20

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

Slide21

Parasomnias

REM

parasomnias

No associated confusion, recall may be intact

Ex. nightmares, REM behavior d/o (more commonly seen in older adults), recurrent intermittent sleep paralysis

Should r/o underlying seizures

esp

if duration is very short, +repetitive/stereotypic movements, inconsistent pattern in episodes

Most common in children:

Sleepwalking

Night terrors

Nightmares

Nighttime enuresis

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide22

Sleepwalking (Somnambulism)

Pathogenesis unknown

Involves complex motor movements and cognitive functioning (e.g., ambulation, driving)

Most frequently seen in pubescent children (peak

prevalance

12 y/o) but can carry on to adulthood

First third of sleep

Triggered by psychological or physiological stress (e.g., sleep deprivation)

rates in those w/ comorbid OSA, 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

Slide23

Sleepwalking (Somnambulism)

Tx

:

Supportive, focus on ensuring child does not injure self during episode

Limit interference

Scheduled sleep awakenings

Psychotherapy (

esp

if episodes r/t stress)

Relaxation techniques

Pharmacotherapy:

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

Slide24

Night Terrors (Pavor Nocturnus)

First third of deep slow wave sleep

Sx

include:

Loud screaming and/or crying

Difficult to console

autonomic activity (e.g., tachycardia, tachypnea, sweating)

Intense feelings of panic/anxiety during episode

Lasts ≈ 15-30 min

Little to no recall of event

May co-occur w/ sleepwalking

Peak prevalence 3-7 y/o

Frequent +

FHx

May be triggered by fatigue, stress

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide25

Night Terrors (Pavor Nocturnus)

Two categories which differ in course of illness and

tx

approach

Type A

Common

Benign, self-limiting

No

tx

required, parent reassurance

Type B

Much less common

Frequently r/t trauma

Tends to be persistent throughout life

Resistant to

tx

Tx

options include low dose

benzos

(diazepam 2-5mg),

impramine

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide26

Nightmares

Common in both children and adults, but most common in children 3-6 y/o; persistence beyond this may warrant further exploration for underlying trauma, anxiety, mood disorder

Must distinguish from night terrors

Recall intact, not associated w/ confusion

Second half of sleep in REM

Tx

:

Reassurance for parents

CBT (e.g., progressive muscle

relaxation, dream scripting)

Pharmacotx

for trauma-related

nightmares (e.g.,

prazosin

,

clonidine)

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide27

Nocturnal Enuresis

DSM V: Repeated involuntary bedwetting while sleeping ≥ 2x/

wk

for 3 consecutive

mos

or cause significant distress/impairment in child

Toilet training complete by 4-5 y/o for most children

Occurs proportionally throughout diff sleep stages

Not associated w/ sleep disruption or arousal

Two categories

Primary enuresis

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

Slide28

Nocturnal 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

Slide29

Nocturnal Enuresis

Extensive medical

eval

beyond PE and UA not necessary unless H&P c/w underlying medical d/o

Tx

Behavioral modification first line

tx

:

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

Slide30

Circadian Rhythm Disorders

Delayed sleep phase syndrome

Sleep schedule lags behind environmentally expected sleep schedule

May be 2/2 genetics or habit

Teens > children

Tx

:

Systematc

sleep deprivation

Motivational phase delay: When child has difficulties falling asleep and waking up 2/2 distress r/t daytime event (most commonly school); not due to physiological

dyssynchrony

of circadian rhythm, must target underlying issue causing distress

Phase advance

Sleep schedule is earlier than environmentally expected sleep schedule

Less common than sleep delay

Tx

: Progressively delay sleep time by 30-60 min at a time, shift activities later in the day (e.g., dinner time), until schedule adjusts

Tends to be easier to achieve due to 25-hr cycle of circadian rhythm

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide31

Circadian Rhythm Disorders

Irreg

sleep/wake patterns w/o consistent phase delay or phase advance

Caused by

irreg

schedules and lack of consistent structure at home

Tx

focuses on helping parents develop structure in the home

Some children may have shorter sleep cycles; these children generally do not have difficulties falling asleep or waking up in the AM

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide32

Behavioral 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

Slide33

Behavioral Insomnias of Childhood

Limit-setting disorder

Child repeatedly refuses to go to sleep at bedtime and parent allows them to stay up later

Allows excessive/

dev

inappropriate napping

Combined type = Sleep onset association disorder + limit setting disorder

Feeding-related disorder

Child must be fed when awakening from sleep in order to fall back asleep

Causes further disruptions in sleep r/t discomfort from bladder distention, diaper soiling

Poor sleep hygiene

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide34

Psychiatric Causes

Depression/mood disorders

 sleep issues

Early morning awakenings,

incr

sleep latency, interruptions/arousals,

need for sleep, changes in sleep architecture

Tx

underlying condition in addition to relaxation techniques, positive reinforcement strategies, limit setting, consistent bedtime schedules/routines

Anxiety

Tx

underlying condition in addition to

behavioral/environmental interventions

At times strict limit setting may worsen

anxieties/fears so parents must show

understanding and compassion for 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

Slide35

Psychiatric Causes

PTSD

Associated w/ specific

parasomnias

(e.g., nightmares, night terrors, enuresis)

Type 1: Acute specific trauma resulting in

hyperautonomic

arousal and

insomnia

Type 2: Chronic trauma associated w/

hypersomnia

Tx

for nightmares should be oriented more behaviorally (e.g., using dream scripting and trauma-focused CBT)

vs

meds such as

prazosin

given limited studies

ADHD

Sleep issues hypothesized to be r/t combo of

hypoarousal

during day + compensatory hyperactivity to combat daytime

hypoarousal

and then inability to calm down at bedtime to fall asleep

Other factors include disruptions in baseline circadian rhythm, sensory integration difficulties, stimulant rebound effects, comorbid psychiatric d/o (e.g., anxiety)

If behavioral interventions ineffective/suboptimal, trial melatonin/alpha-agonist

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide36

Psychiatric Causes

5 factors seen in children w/ sleep issues > than those w/o

Family member who has experienced an accident/illness

Unaccustomed absence of mother

Mother w/ depressed mood

Co-sleeping

Maternal ambivalence towards child

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide37

Medical Causes

Colic

Prolonged episodes of inconsolable crying, fussiness, and hypertonia (e.g., fist clenching, writhing/twisting movements, flapping, grimacing facial expressions)

Usually

dev

by 2-3

wks

old, resolves by 4

mos

Hypotheses on etiology

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

Slide38

Medical Causes

Medication side effects

Sedative/hypnotics: Associated w/ sleepwalking

episdes

, in particular non-

benzos

(e.g.,

zolpidemn

,

eszopiclone

)

Sedative/hypnotics and antihistamines may cause residual daytime sedation

Antibiotics

Beta-blockers: Suppress nighttime melatonin secretion

Steroids: Cause imbalance in adrenal glands

SSRIs: Suppress REM sleep; some may also

incr

sleep latency and/or frequency of awakenings/arousals

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide39

Sleep Hygiene

Integral part of

tx

for any sleep d/o

Some differences depending on age

Infants:

Fragmented and

irreg

sleep pattern c/w

nl

dev

for newborns (up to 3-6

mos

old) so parents should limit interference w/ sleep unless needed (e.g., getting on a plane)

As infant begins to consolidate sleep at night and responding more to external cues for sleep, parents should incorporate additional cues (e.g., waking them up earlier from daytime naps, minimizing disruptions at night while changing diapers by using low light)

Begin bedtime routine to help infant experience calm before sleep and ensure consistent routine in same order on nightly basis

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

Slide40

Sleep 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

Slide41

Sleep Hygiene

Older children/adolescents

Parents must reinforce consistent sleep

sched

, even on

wknds

Bedroom should be reserved for bedtime ritual and sleeping only; no TVs, games, toys, computers, tablets, phones, etc.

Child should fall asleep in their own bed and alone

Avoid excessive physical activity near bedtime, though

reg

exercise earlier in the day may promote sleep

No daytime naps

Avoid caffeine or other stimulating substances

Avoid heaving eating or excessive drinking prior to bedtime

Avoid lying in bed unless sleepy

Provide cool, dark, quiet room

Must distinguish resistance to sleep from legitimate anxieties (e.g., school) b/c strict limit setting may exacerbate fears/worries; if this is the case must target underlying issue

Moturi

,

Sricharan

, Avis, Kristin.

Assessment and treatment of common pediatric sleep disorders

. Psychiatry (

Edgmont

). 2010 Jun; 7(6): 24-37.

Thiedke

, C. Carolyn.

Sleep disorders and sleep problems in childhood

. Am

Fam

Physician. 2001 Jan; 63(2): 277-285

Slide42

General Pyschopharmacology

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

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

Slide43

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.

Slide44

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

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

Slide45

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

Slide46

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

Slide47

Evaluation 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

Slide48

Evaluation for Sleep Disorders

Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-3

Sleep 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)

Slide49

Ramifications of Sleep Deprivation

Neurocognitive

Deficits in attention, memory, learning

Hyperactivity/impulsivity (more common in younger children)

Deficits in executive functioning

Daytime sedation

Psychological

Depression/mood

lability

Irritability

Oppositionality

Anxiety

Fatigue/weakness

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

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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

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sleep disorders common psychiatry sleep disorders common psychiatry pediatric 2010 treatment sricharan jun edgmont assessment kristin avis moturi childhood

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