Introduction to Sleep Problems in Children - PowerPoint PPT Presentation

Loading...

PPT – Introduction to Sleep Problems in Children PowerPoint presentation | free to download - id: 18e7a-MTY2Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Introduction to Sleep Problems in Children

Description:

Newborns can sleep as much as 16 hours per day. Respiratory disorders during sleep are thus of special importance during childhood ... – PowerPoint PPT presentation

Number of Views:1305
Avg rating:3.0/5.0
Slides: 96
Provided by: J39
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Introduction to Sleep Problems in Children


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

2
(No Transcript)
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
    commonapproximately 25 of children ages 1-5
    years of age
  • Pediatric knowledge expanding
  • Presentation of sleep disorders different in
    children than in adults
  • Varies with age and developmental stage

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?
  • All mammals and birds sleep as we know what
    sleep to be.
  • Sleep behavior has also been observed in
    reptiles and insects
  • Mammalian Total Daily Sleep Time (in hours)
  • Giraffe 1.9 Roe deer 3.09
  • Asiatic elephant 3.1 Pilot whale 5.3
  • Human 8.0 Baboon 9.4
  • Domestic cat 12.5 Laboratory rat 13.0
  • Lion 13.5 Bats 19.9
  • BUT, exact function of sleep not well understood!

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 1989114997-999.

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

18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
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
  • Cows 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
  • Childs 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 comfortverbally
    ONLY, do not pick child up
  • Stay in the room no more than 1-2 minutes
  • Gradual withdrawal of parent from the childs
    room
  • Best to start training children at approximately
    6 months of age (age at which they should sleep
    through the night)

27
(No Transcript)
28
Causes of Insomnia in the Preschool and
School-Aged Child
  • Fears and nightmares
  • Limit setting sleep behavior disorder

29
(No Transcript)
30
Fears and Nightmares
  • Fears of monsters when awake
  • Vivid, frightening dreams of villanous creatures
    when asleep
  • Experienced by gt50 of children
  • Usually begin at 3-5 years of age, decrease with
    increasing age

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 childs behaviors

33
Common Features
  • Child usually gt2 years of age and out of a crib
  • Repetitive requests, complaints, and stalling by
    the child despite physiological readiness for
    sleep
  • Frequent refusal to stay in bed or in bedroom
  • No parental enforcement of consistent bedtime
    rules
  • Possible recurrence of behaviors after nighttime
    awakenings
  • Sleep itself is usually of normal quality and
    duration

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

35
(No Transcript)
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 indicatedat 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 200225213-8.
  • 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

51
(No Transcript)
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 common40 in some studies
  • 12 can persist for over 10 years
  • Individual gets up and walks about for short time
    (1-10 minutes)
  • Hard to discern if child is asleep
  • Inappropriate behavior is common (urinating in
    the corner or next to the toilet)
  • Child can be easily led back to bed
  • Older children usually awaken as event terminates
  • Agitation can occur
  • Amnesia common
  • Often family history
  • Klackenberg G Somnambulism in childhoodprevalenc
    e, course and behavioral correlations. Acta
    Paediatr Scand 71495, 1982

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
    successfulbest 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 lt20 at 13 years
  • Despite decreasing total sleep time, adolescents
    often need more sleep than do younger children
  • Carskadon MA Patterns of sleep and sleepiness
    in adolescents. Pediatrician 175, 1992

70
(No Transcript)
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

72


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

78
(No Transcript)
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 unregulatedconsidered a food product
  • Dose 1-5 mg PO QHS
  • Safety and efficacy not established in any age
    group
  • Ramelteonnewly approved melatonin agonist, not
    studied in children
  • Dose 8mg PO QHS

81
(No Transcript)
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/sleep
    iness
  • 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
88
(No Transcript)
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
    153866-878.

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. 199927267-272.

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 WELLPARENT SLEEPS WELLHAPPY 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/stars
    lp/
About PowerShow.com