Introduction to Sleep Problems in Children

1. Introduction to Sleep Problems in Children April Wazeka, M.D. Respiratory Center for Children Atlantic Health System

3. Objectives Understand normal sleep in children Review common pediatric sleep disorders Discuss proper treatment options for childhood sleep disorders

4. Introduction The average child spends almost half of his or her life asleep Newborns can sleep as much as 16 hours per day Respiratory disorders during sleep are thus of special importance during childhood Marcus, C. Sleep-disordered breathing in children. AJRCCM 2001; 164: 16-30.

5. Pediatric Sleep Medicine Relatively new field Few pediatric sleep centers Now have new understanding of associations between common childhood disorders and sleep

6. Overview Sleep disorders in children are very common—approximately 25% of children ages 1-5 years of age Pediatric knowledge expanding Presentation of sleep disorders different in children than in adults Varies with age and developmental stage

7. Sleep and Breathing Some breathing disorders occur only during sleep Virtually all respiratory disorders are worse during sleep than during wakefulness

8. Who needs sleep? Mammalian Total Daily Sleep Time (in hours) Giraffe 1.9 Roe deer 3.09 Asiatic elephant 3.1 Pilot whale 5.3 Human 8.0 Baboon 9.4 Domestic cat 12.5 Laboratory rat 13.0 Lion 13.5 Bats 19.9 BUT, exact function of sleep not well understood!

9. How much sleep do children need?Sleep Duration from Infancy to Adolescence 492 patients followed with sleep questionnaires at 1,3,6,9,12, 18 and 24 months after birth, and at annual intervals until 16 years of age Total sleep duration decreased from an average of 14.2 hours (SD 1.9hrs) at 6 mos of age to an average of 8.1 hours (SD 0.8hrs) at 16 years of age Iglowstein et al Pediatrics Feb 2003; 111(2): 302-7

10. Normal Sleep Physiology Breathing is better awake than asleep! During sleep: Decrease in minute ventilation In children, respiratory rate (RR) decreases during sleep; in adults RR remains constant Functional residual capacity (FRC) decreases Upper airway resistance doubles

11. REM sleep Rapid eye movement or dream sleep Breathing erratic Variable RR and tidal volume Frequent central apneas Decrease in intercostal and upper airway muscle tone Children have relatively more REM sleep than adults

12. REM Sleep In neonates, active sleep (a REM-like state) can occur for up to two thirds of total sleep time, as compared with 20-25% of sleep time in adults Curzi-Dascalova L, Peirano P, Morel-Kahn F. Development of sleep states in normal premature and full-term newborns. Dev Psychobiol 1988; 21(5):431-444.

13. Development Chest wall and upper airway change during infancy and childhood in order to respond to the physiological needs of the developing child. Compliant chest wall in newborn In infancy, chest wall compliance is 3x the lung compliance Compliance? paradoxical rib cage motion during inspiration? increased work of breathing, especially during REM sleep when intercostal muscle activity is decreased

14. Development Ossification of the sternum and vertebrae continues until 25 yrs of age Results in a stiffer chest wall Chest wall compliance = lung compliance by 2 yrs of age However, paradoxical inward rib cage motion during inspiration in REM sleep is seen until almost 3 yrs of age

15. Upper Airway The upper airway changes during development in both structure and function To maintain FRC, infants do active glottic narrowing (laryngeal braking) until 6 to 12 mos of age In infants, larynx is located relatively cephalad, which allows the epiglottis to overlap the soft palate and make a better seal for sucking Predisposes infant to upper airway obstruction if nasopharynx is partially occluded

16. Upper Airway In males, the larynx increases in size and shape during puberty Testosterone-induced changes in upper airway morphology may in part explain the increased risk of OSA in males compared with females Prepubertal rates of OSA are similar Guilleminault C et al. Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr 1989;114:997-999.

17. Apneas Central apneas common in infants and children More prevalent during REM sleep Normal infants can have central apneas up to 25 seconds in duration, associated with transient desats to the 80s Clinical significance is dubious, unless they occur frequently or are associated with prolonged gas exchange abnormalities Obstructive apneas are rare in normal children

23. Insomnia in Infants and Toddlers Sleep Onset Association Disorder Colic Nocturnal eating (drinking) disorder Recurrent awakenings with an inability to return to sleep without eating or drinking Food allergy insomnia Cow’s milk protein allergy with severe sleep disruption

24. Sleep Onset Association Disorder Difficulty falling asleep and returning to sleep when specific environmental conditions are not present (i.e. bottle, pacifier, music, being rocked) Perceived by parents as being a problem when: Sleep onset delayed Frequent attention needed to help child fall asleep Child’s daytime mood or attention suffers Parents are losing sleep!

25. Common Features Prolonged crying at bedtime or at awakening if parents do not respond in the usual manner Rapid sleep onset once usual conditions are established

26. Treatment Make child feel safe and comfortable when alone Place child in crib and leave the room Return after a few minutes to comfort—verbally ONLY, do not pick child up Stay in the room no more than 1-2 minutes Gradual withdrawal of parent from the child’s room Best to start training children at approximately 6 months of age (age at which they should sleep through the night)

28. Causes of Insomnia in the Preschool and School-Aged Child Fears and nightmares Limit setting sleep behavior disorder

30. Fears and Nightmares Fears of “monsters” when awake Vivid, frightening dreams of villanous creatures when asleep Experienced by >50% of children Usually begin at 3-5 years of age, decrease with increasing age

31. Treatment Reassurance In a truly anxious child, exploration of underlying causes may be indicated Milder fears may respond to supportive firmness, if in a stable social setting Parents should provide clear cut reassurance and consistent bedtime routine Relaxation techniques for the child may be helpful

32. Limit Setting Sleep Disorder Exclusively a childhood sleep disorder Characterized by: Stalling behaviors or refusal to go to bed at the desired time Associated with inadequate parental limit setting for a child’s behaviors

33. Common Features Child usually >2 years of age and out of a crib Repetitive requests, complaints, and stalling by the child despite physiological readiness for sleep Frequent refusal to stay in bed or in bedroom No parental enforcement of consistent bedtime rules Possible recurrence of behaviors after nighttime awakenings Sleep itself is usually of normal quality and duration

34. Factors in Parental Failure to Set Limits Lack of understanding of the importance of setting limits Inadequate knowledge of limit-setting techniques Psychosocial factors

36. Treatment Parental education Regular bedtime ritual with a definite endpoint Gate or door closure: this is a passive limit setter Parents to be supportive and controlled, not punitive Parents should be nearby when the door is closed, and time closed should be increased gradually

37. Once child is convinced of parental ability to enforce limits consistently, typically nighttime disruption ceases rapidly

38. Treatment (Continued) If the child is fearful, it may be necessary for parents to stay in the room, but continue to set limits If parent and child share the same bed, then the parent may need to leave the room until the child accepts the rules imposed upon sleeping In older children use of positive behavior modification with rewards Starting with a later bedtime can help at the beginning of the process Psychosocial problems should be addressed

39. Insomnia in Adolescence More closely resembles adult disorders Often due to extrinsic factors Stress Anxiety Psychological disorders Sleep disturbances can be first sign of major psychological disturbances, such as schizophrenia, anorexia, and bipolar disorder

40. Treatment Improved sleep hygiene Normalization of sleep schedule Decreased use of alcohol and other drugs Sleep restriction therapy Relaxation training Biofeedback Psychotherapy Medications rarely indicated—at best a temporary fix

41. Good Sleep Hygiene Measures that promote sleep Avoidance of caffeinated beverages, alcohol, and tobacco in the evening No intense mental activities or exercise close to bedtime Avoid daytime naps and excessive time spent in bed Adherence to a regular sleep-wake schedule

42. Pharmacologic treatment of Insomnia Centuries ago opium-based laudanum given to children to keep babies quiet Antihistamines Benzodiazepines Zolpidem (Ambien)—not approved for pediatric usage Interacts with GABA-benzodiazepine receptor complexes

43. Causes of Insomnia in Children of all Ages Environmental-induced sleep disorders Travel, noise, distractions, light Insomnia associated with: Medical disorders Asthma, GERD, chronic otitis media, atopic dermatitis, infantile colic Neurological disorders Sleep time can be dramatically reduced and circadian function abnormal Mental disorders (social stressors) Most common is anxiety

44. Treatment Success

45. Treatment Failure

46. Restless Legs Syndrome (RLS) Sensory-motor disorder involving the legs Prevalence approximately 4% of the population Age of onset can occur at any age Results in sleep disturbance with difficulty initiating and/or maintaining sleep Can be exacerbated by pregnancy, caffeine, or iron deficiency

47. RLS-Diagnosis Criteria Major Desire to move the limbs, usually associated with paresthesia or dysesthesia Motor restlessness Worsening of symptoms at rest, with at least partial relief with activity Worsening of symptoms at night time Ancillary: Involuntary movements Neurologic examination Clinical course Sleep disturbance Family history

48. RLS Sensory manifestations Disagreeable feelings: creeping, crawling, tingling, burning, painful, aching, cramping, or itching sensations Occur mostly between the knees and ankles Differential diagnosis Neurologic disorders, medical disorders, drugs

49. RLS in Children Study by Chervin et al*: Community based survey of 866 children ages 2 to 13.9 years Relationship found between significant hyperactivity and periodic limb movement scores, and between hyperactivity and restless legs Study of 11 children referred to a pediatric neurology clinical with a diagnosis of growing pains--10/11 met clinical criteria for RLS** * Chervin et al. Associations between symptoms of inattention, hyperactivity, restless legs, and periodic leg movements. Sleep 2002;25:213-8. **Rajaram et al Sleep 2004

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

52. Parasomnias Unpleasant or undesirable motor, autonomic, or experiental phenomena that occur predominantly or exclusively during the sleep state May be induced or exacerbated by sleep Two types: Primary Secondary

53. Primary Parasomnias Disorders of arousal REM sleep behavior disorder Recurrent Hypnagogic Hallucinations/Sleep Paralysis Bruxism Rhythmic movement disorder Periodic Limb movement disorder Sleep starts Sleeptalking

54. Rhythmic Movement Disorder (RMD) Sterotyped movements occurring at sleep onset or the end of sleep Headbanging, headrolling, and bodyrocking Common in first year of life, and decreases with age (rarely persists into adolescence or adulthood) Incidence 60% at 9mos; 22% at 2 years; 5% at 5 years Injuries infrequent No apparent association between RMD and neuropsychiatric conditions, except in children with severe neurologic dysfunction Rarely, headbanging can be sole manifestation of a seizure disorder No treatment necessary in most cases

55. Periodic Limb Movement Disorder (PLMS) Prevalence and significance unknown in childhood Characterized by periodic (every 20-40 seconds) and sustained (0.5-4.0 seconds) contractions of one or both anterior tibialis muscles Often associated with unperceived arousals Usually benign Has been associated with metabolic disorders and childhood leukemia Recent reports show linkage with ADHD Picchietti Sleep 1999

56. Sleep Talking (Somniloquy) Common disorder Can arise from REM or NREM sleep May have a genetic component Rarely of clinical significance

57. Disorders of Arousal Underlying process one of incomplete arousal Seen more commonly in children than in adults Sleepwalking Confusional Arousals Sleep Terrors

58. Sleepwalking Very common—40% in some studies 12% can persist for over 10 years Individual gets up and walks about for short time (1-10 minutes) Hard to discern if child is asleep Inappropriate behavior is common (urinating in the corner or next to the toilet) Child can be easily led back to bed Older children usually awaken as event terminates Agitation can occur Amnesia common Often + family history Klackenberg G: Somnambulism in childhood—prevalence, course and behavioral correlations. Acta Paediatr Scand 71:495, 1982

59. Confusional Arousals Typically seen in toddlers and preschool age children Often confused with sleep terrors Arousal typically starts with movements and moaning?progesses to crying and calling out, intense thrashing in the bed or crib Can appear bizzare and frightening to parents Child appears confused, agitated, or upset

60. Common Features Episodes can last up to 40 minutes (typically 5-15 minutes) Begin gradually The child does not recognize his/her parents Vigorous attempts to awaken the child may not be successful—best not to intercede Incidence 5-15% of children Associated with amnesia Family history typical

61. Sleep Terrors Uncommon in very young children Seen more often in older children and adolescents Incidence approximately 1% of children Events begin precipitously, with crying and screaming Eyes usually wide open, with tachycardia and diaphoresis Facial expression of “fear” Child may leave the bed and injure him or herself Last only a few minutes Most have amnesia; can have brief memory of event

62. Constitutional and Precipitating Factors for Arousals Constitutional Genetic Developmental Sleep deprivation Chaotic sleep schedule Psychologic Precipitating OSA GERD Seizures Fever

63. Common Features of Arousal Disorders Misperception of and unresponsive to environment Automatic behavior Retrograde amnesia 60% have positive family history Pathophysiology Occurs at transition from slow wave sleep to next sleep cycle

64. Arousal Disorders-Treatment Proper diagnosis and reassurance Most cases benign and self-limited Basic safety precautions Regular sleep/wake schedule Avoid sleep deprivation No forcible intervention Psychological stressors should be identified Rarely: medications (benzodiazepines and tricyclic antidepressants) and relaxation and mental imagery

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

66. Sleepiness

67. Causes of Sleepiness Insufficient sleep Schedule disorders Obstructive sleep apnea Epilepsy Narcolepsy Kleine-Levin Syndrome Idiopathic Central Nervous System Hypersomnia

68. Clinical Manifestations of Sleepiness Excessive daytime somnolence Falling asleep in inappropriate places and circumstances Lack of relief of symptoms after additional sleep Daytime fatigue Inability to concentrate Impairment of motor skills and cognition Symptoms specific to etiology

69. Insufficient Sleep Most common cause of sleepiness at all ages! Homework, television, and after-school employment and activities compete with the need for sleep Parental influence on bedtime hour decreases from 50% at 10 years to <20% at 13 years* Despite decreasing total sleep time, adolescents often need more sleep than do younger children *Carskadon MA: Patterns of sleep and sleepiness in adolescents. Pediatrician 17:5, 1992

71. Behavioral Treatment of Inadequate Sleep Eliminate identifiable causes (sleep apnea, environmental disturbances) Teach good sleep hygiene Focus on target behaviors that interfere with sleep (erratic schedules, late night television, oppositional behavior) Eliminate caffeine and stimulants in diet Relaxation techniques, positive imagery at bedtime

73. Circadian Rhythm in Sleep Innate, daily fluctuation of sleep-wake states, generally linked to the 24 hour daily dark-light cycle. A circadian pattern in sleep-wake alternation is usually apparent by 6 weeks of age and becomes stable by 3 months of age Most common cause of problems is due to extrinsic issues with scheduling Rare causes of circadian disorders include hypothalamic dysfunction due to malformation or tumor, and blindness

74. Circadian Rhythm Sleep Disorders Regular but inappropriate schedules Sleep phase shifts Delayed sleep phase Advanced sleep phase

75. Advanced Sleep Phase Mainly in infants and toddlers Relatively uncommon Early bedtime and early awakening “Morning Larks” Treatment Gradual delay of bedtime Delay naps and mealtimes Bright light at night, dim light in the morning

76. Delayed Sleep Phase Delay in sleep onset, late awakening “Night owls” Onset in adolescence Male predominance Sleep itself quantitatively and qualitatively normal Genetic predisposition

77. Delayed Sleep Phase Differentiate from school avoidance, other sleep disorders Diagnosis by sleep logs and actigraphy Treatment Bright light therapy 20-30 minutes upon awakening (8,000-10,000lux) Strict sleep-wake schedule! Melatonin 3 to 4 hours prior to desired sleep time

79. Melatonin Hormone synthesized from serotonin in the pineal gland Provides human brain with signal for darkness Suppressed by bright light Regulates sleep-wake cycle Has been shown to have sleep phase shifting properties May be helpful in circadian rhythm disturbances Has been used to regulate circadian rhythms in blind adults

80. Melatonin Production unregulated—considered a food product Dose: 1-5 mg PO QHS Safety and efficacy not established in any age group Ramelteon—newly approved melatonin agonist, not studied in children Dose: 8mg PO QHS

82. Evaluation of Sleep Disorders History and physical Sleep log Blood work (drug screening, alcohol if indicated, anemia, metabolic) Sleep study (OSA, neuromuscular disorders, craniofacial disorders, metabolic disorders, narcolepsy) Multiple Sleep Latency Test (MSLT) EEG

83. Sleep History Sleeping environment Sleep position Need for sleep aids (pacifier, rocking, patting, etc.) Time into bed, sleep onset, and final morning awakening ROS: snoring, mouth breathing, restless sleep, diaphoresis, GERD, abnormal behavior at night Daytime behavior: irritability/hyperactivity/sleepiness Number of daytime naps and their duration Medications Parental interventions

84. Physical Examination Height/Weight Vital signs + BP Evaluate for craniofacial abnormalities Micrognathia Dental malocclusion Midface hypoplasia Tonsillar size Observe for behavioral signs of sleep disorders: inattentiveness, irritability, sleepiness, and mood swings.

85. Sleep Log

86. Diagnosis – Nocturnal Polysomnography Only diagnostic technique shown to quantitate the ventilatory and sleep abnormalities associated with sleep-disordered breathing THE GOLD STANDARD!

87. Sleep Laboratory

89. Polysomnogram

90. Polysomnography Can be performed in children of any age Should be scored and interpreted using age-appropriate criteria1 Can distinguish OSAS from primary snoring Determines severity of OSAS and related gas exchange and sleep disturbances May help determine operative risk 1 American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Resp Crit Care Med. 1996; 153:866-878.

91. Diagnosis- Audiotaping or Videotaping Studies have found sensitivities of 71-94% Specificities of 29-80% Positive predicted values of 50% and 75% for audiotaping, and 83% for videotaping Struggle on audiotape more predictive than pauses Negative predictive values 73-88% Additional studies needed Lamm C, Mandeli J, Kattan M. Evaluation of home audiotapes as an abbreviated test for obstructive sleep apnea syndrome (OSAS) in children. Pediatr Pulmonol. 1999;27:267-272.

92. Abbreviated Polysomnography Overnight oximetry Useful if shows cyclic desaturation PPV 97%; NPV 47% Useful only in otherwise healthy children Nap polysomnography PPV 77-100%; NPV 17-49% Can underestimate OSAS severity Unattended home polysomnography

93. What is the role of the Pediatrician? Screening Consider adding sleep questions to Review of Systems Treat common disorders first Refer to sleep specialist Complex sleep disorders When there is no improvement

94. Final Thoughts Childhood sleep disorders are common and can be associated with significant impairment of quality of life Pediatricians play an important role in screening for and treating common pediatric sleep disorders CHILD SLEEPS WELL=PARENT SLEEPS WELL=HAPPY PARENT AND CHILD

95. Resources American Academy of Sleep Medicine http://aasmnet.org National Sleep Foundation http://www.sleepfoundation.org/ Star Sleeper NIH website to promote healthy sleep in children with Garfield, contains teaching plans http://www.nhlbi.nih.gov/health/public/sleep/starslp/