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pediatric Sleep disorders

sleep pattern and sleep disorders in children

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pediatric Sleep disorders

  1. 1. Pediatric Sleep Disorders Marwa Elhady lecturer of pediatrics Al-Azhar univerisity 2015
  2. 2. Objectives • Understand normal sleep in children • Review common pediatric sleep disorders • Discuss proper treatment options for childhood sleep disorders
  3. 3. The Sleep Cycle
  4. 4. The Sleep Cycle • Each sleep cycle 90 – 120 minutes • First REM period is shortest • Most NREM deep sleep occurs early • Most REM occurs late
  5. 5. Children’s Sleep Differs from Adults • More frequent REM • Earlier REM • More Total Hours of Sleep • Sleep disorders common in pediatrics than adults
  6. 6. REM & NREM Sleep by Age 0 2 4 6 8 10 12 14 16 18 1 - 3 M 3 - 5 M 6-23 M 2 - 3 Y 3 - 5 Y 5 - 9 Y 10-13 Y 14-18 Y 19-30 Y TotalHrsSleep Total daily sleep by age During childhood sleep accounts for 40% of the day At birth, REM ≈ 50% of total sleep, ↓ to 25% in adult
  7. 7.  prevalence ≈25% - 43%of children ages 1-5 years  interfere with daily patient and family functioning.  sleep problems cause significant emotional, behavioral, and cognitive dysfunction.  common among children with neurodevelopmental, medical and psychiatric disorders. Lehmkuhl et al.,2008
  8. 8. Owens, 2011
  9. 9. Sleep disorders divided into 3 categories: 1- Dyssomnias (# duration, timing of sleep)  Primary Insomnia  Primary Hypersomnia  Breathing-Related Sleep Disorder  Narcolepsy  Circadian Rhythm Sleep Disorder 2- Parasomnias (abnormal events during sleep)  Nightmare  Night Terrors  Sleep walking 3- Medical psychiatric disorders APA, 2013
  10. 10.  The clinical evaluation involves: obtaining a careful medical history assess for medical cause of sleep disturbance Current sleep patterns, including sleep duration, sleep-wake schedule, sleep habits, Nocturnal symptoms  Polysomnogram (PSG) record: EEG, EMG, EOG, Vital Signs and Other Physiologic ParametersOwens, 2011
  11. 11.  Difficult initiate or maintain sleep or early morning awake with difficult return to sleep  Occur 3 nights/week, for at least 3 months, despite sufficient time for sleep.  Not due to the effects of a substance  Not explained by mental/medical illness  Prevalence 1 – 6 % in pediatrics but higher in children with chronic med/psych conditions Czeisler et al., 201
  12. 12. Insomnia is subdivided into: 1. Sleep onset insomnia: difficulty falling asleep. 2. Sleep maintenance insomnia: frequent or sustained awakenings. 3. Sleep offset insomnia: early morning awakenings 4. Non-restorative sleep: persistent sleepiness despite adequate sleep duration Czeisler et al., 201
  13. 13. • Mainly treated with behavioral interventions • Media removal from bedroom • Avoid caffeine • Consistent bedtime routine and positive reinforcement from parents/caregivers • Correct the underlying med/psycho factors Treatment of insomnia Owens, 2011
  14. 14. prolonged sleep episodes, excessive sleepiness prolonged sleep > 9 h/day that is not refreshing Difficulty being fully awake after abrupt awakening The complaint is present for at least 6 months. Not due to med/psycho disorder Common in in late adolescence. American Academy of Sleep Medicine, 2001
  15. 15.  Obstructive Sleep Apnea (1 – 4 %) Results in blood oxygen desaturations  Upper Airway Resistance Syndrome Similar to OSA but not result in desaturations  Primary Snoring (7 – 12%) regular snoring without changes in sleep architecture, alveolar ventilation or oxygenation APA, 2013
  16. 16. • Periodic apneas due to sleep-related airway obstruction - ↓ patency (obstruction and/or ↓diameter) - ↑ collapsibility (↓ pharyngeal muscle tone) -↓ drive to breath (↓ central ventilatory drive) •Not all snorers have OSA Bradley and Floras,2009
  17. 17. Sequelae of OSA • Disrupt ventilation and sleep patterns • intermittent hypoxia and multiple arousals cause significant metabolic, CVS, neurocog/behavioral and academic morbidity • Daytime Sleepiness, Enuresis as short-term squeal • Pulmonary hypertension and right heart failure, FFT as long term sequel
  18. 18. Treatment of Sleep Apnea • Weight loss • Positional (sleep on one side or prone) • CPAP prevents obstruction by soft-tissue and keeps airway open • Surgical intervention (e.g., tonsiloadenectomy) • Avoid sedatives (which prevent reawakening to breath)
  19. 19.  uncontrollable excessive daytime sleep attacks interfere with normal daily functioning  Person goes directly into REM sleep  Common in adolescence & early adulthood  Genetic defect in hypothalamic orexin/hypocretin neurotransmitter  prevalence is 3-16/10,000 Owens, 2011
  20. 20. Symptoms associated with narcolepsy Symptoms associated with narcolepsy
  21. 21. Cataplexy (pathognomonic for narcolepsy) Abrupt bilateral partial or complete loss of m. tone. triggered by intense positive emotion (e.g., laught) last for seconds to minutes with complete recovery Hallucinations (visual, auditory, tactile) occur during transitions bet. sleep and wakefulness At sleep onset → hypnogogic At sleep offset → hypnopompic Sleep paralysis: inability to move or speak for sec- min at sleep onset or offset; accompanies hallucination Owens, 2011
  22. 22. DD Potential causes of EDS: Extrinsic: 2ry to insufficient/fragmented sleep Intrinsic: CNS disorder with ↑ need for sleep. Treatment include: Education, good sleep hygiene, behavioral changes (eg. Scheduled naps). Medications as: • psychostimulants and modafinil to control EDS. • TAD and SSRI to control REM-associated phenomena, such as cataplexy Owens, 2011
  23. 23. Circadian Rhythm Sleep Disorder caused byCircadian Rhythm Sleep Disorder caused by mismatch between sleep-wake schedulemismatch between sleep-wake schedule required by a person’s environment andrequired by a person’s environment and his/her circadian sleep-wake pattern (e.g.,his/her circadian sleep-wake pattern (e.g., shift work).shift work).
  24. 24.  It is a circadian rhythm disorder  significant, persistent, intractable phase shift in sleep wake schedule (later sleep onset and wake time)  Patients has inability to get to sleep until the early morning, but little difficulty sleeping once asleep  Interfere with school, work and lifestyle demands.  Common in adolescents and young adults (7-16%) Owens, 2011
  25. 25. Treatment Treatment is primarily behavioral •Shifting the sleep-wake schedule to an earlier time •Maintaining the new schedule. → Gradual shifting bedtime/wake time earlier by 15- 30 min increments → Exposure to light in morning and avoidance of evening light exposure Oral melatonin supplementation in the afternoon or early evening is effective in advancing the sleep phase.
  26. 26.  Uncomfortable sensations in the LL accompanied by irresistible urge to move legs →Disturbs sleep  Severe leg pain is main symptom, missed as ‘growing pains’.  partially relieved by movement (walking, stretching, rubbing) but only as long as the motion continues.  Diagnosis of RLS is a clinical.  Prevalence in children is 1-6 % Khatwa and Kothare, 2010
  27. 27.  periodic, repetitive, brief (0.5-10 sec) highly stereotyped limb jerks (rhythmic extension of big toe and dorsiflexion at ankle).  occurring at 20 to 40 sec intervals.  occur mainly during sleep → Disrupts sleep  Prevalence in children is 8-12%
  28. 28.  Diagnosis of PLMs requires overnight polysomnography to document the characteristic limb movements with anterior tibialis EMG leads. Owens, 2011
  29. 29. Treatment according to: severity (intensity, frequency, periodicity) degree of sleep disturbance daytime sequelae •an index (PLMs per hr) < 5 → no treatment •index > 5 → promote good sleep hygiene → iron supplements if ferritin <50 •Medications that ↑ dopamine in CNS are effective in adults but limited data in children.
  30. 30.  repetitive, stereotyped, rhythmic movements involve large muscle groups.  include head banging, body rocking, head rolling  common in the 1st yr of life and disappear by age 4 yr  occur with the transition at sleep at bedtime.  It is a means of soothing themselves to sleep  significant injury is rare  not indicate neurological or psychological problem.  reassurance to the family Owens, 2011
  31. 31. • Episodic nocturnal behaviors involve cognitive disorientation and autonomic and skeletal muscle disturbance.
  32. 32. 0% 10% 20% 30% 40% 50% 60% 70% 80% A nySleepw alking SleeptalkingN ightTerrorsRestlessLegs Enuresis Bruxism
  33. 33. 0% 5% 10% 15% 20% 25% 30% Sleepwalking Bruxism Sleep Terrors Enuresis
  34. 34. • Sleep disorder characterized by high arousal and appearance of being terrified • ≈ 2/3 of all kids experience them • Common in preschoolers ages 3-6 y • Occur during REM sleep • Child believes them to be real. Owens, 2011
  35. 35.  repeated abrupt awakenings from sleep characterized by intense fear, panicky screams, autonomic symptoms (tachycardia, rapid breathing, sweating), absence of detailed dream recall, amnesia for the episode, and relative unresponsiveness to attempts to comfort the person.  Lasts ~ 10 min then returns to undisturbed sleep.
  36. 36.  During Stage 3-4 of NREM sleep (1st third of night)  Prevalence is 3–6.5% in children.  can occur at any age.  Common in male  resolves spontaneously  Nocturnal administration of benzodiazepines has been reported to be beneficial
  37. 37. Nightmares Night Terrors Age 3 - 6 yrs 4 - 8 yrs Sleep Stage REM NREM (3/4) Time of Night Late Early State on waking Upset / Scared Disoriented Response to parents Consolable Unaware of Parents Return to Sleep Difficult Easy / Rapid Memory of Event occasional None
  38. 38.  involuntary, forceful grinding of teeth during sleep  Up to 88% of children; 20 % of adults  Any stage of sleep  May result in damage to the teeth  Periodicity of 20 to 30 seconds.  May represent symptom different disorders  Patient is usually unaware of the problem  In severe cases, rubber tooth guard is necessary. Stress management or biofeedback.
  39. 39. Begins during school age During NREM and REM sleep No treatment just reassurance
  40. 40. One or more waking from midnight to 5 am for at least four of seven nights per week for at least four consecutive weeks 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% All Infants Breastfed Infants 1-2 Yr Olds 4-5 Yr Olds Owens, 2011
  41. 41.  More than just walking around… Simple Behaviors Complex Behaviors  While sleepwalking, patient has a blank staring face, relatively unresponsive to others  confused or disoriented on being aroused.  Complete amnesia  Occur during Stage 3-4 Sleep; 1st third of night.
  42. 42.  Begins in ages 4-8 yrs  17% in children (4% of adults)  sleep-walking most likely to persist  it is important to institute safety precautions (use of gates, locking doors and windows, and bedroom door alarms).  No treatment is established, but may respond to benzodiazepines or sedating antidepressants at bedtime.
  43. 43.  During NREM sleep  May be restricted to Stage 3-4  Common in Males with Family History  prevalence is 30% at age 4 y 10% at age 6 y 5% at age 10 y 3% at age 12 y 1% at age 15 y. Owens, 2011
  44. 44.  Usually during first 1/3 of night  Usually only one event/night  Common in Toddler and school-aged kids.  prevalence rates 15% in children ages 3-13 yr.  co-occur with sleepwalking and sleep terrors  Usually resolve with time  Not tired the next day  No stereotypic motor movements  Last 5-30 minutes Stores, 2009
  45. 45.  parent education and reassurance  good sleep hygiene  avoidance of exacerbating factors such as sleep deprivation and caffeine.  Scheduled awakenings, parent wake the child 15 to 30 min before the time of first parasomnia episode.  Pharmacotherapy is rarely necessary, include benzodiazepines and tricyclic antidepressants. Stores, 2009
  46. 46. • Have a set bedtime and bedtime routine • Bedtime and wake-up time should be the same time on school & non-school nights. • No more than 1hour difference from one day to another. • Make the hour before sleep quiet time. • Avoid high-energy activities before bed. Owens, 2011
  47. 47. • Don't go to bed hungry, but avoid Heavy meals. • Avoid caffeine products before bedtime. • spend time outside every day and involve in regular exercise. • Keep bedroom quiet and dark with comfortable temperature • Don't use bedroom for punishment. Owens, 2011
  48. 48. • Naps should be short (no > 1hr) and scheduled in the early to midafternoon. • Keep TV out of child's bedroom. • Use bed for sleeping only. Don't study, read, watch TV on bed. • Relaxing, calm, enjoyable activities help you to get to sleep. • Smoking disturbs sleep. • Don't use sleeping pills Owens, 2011
  49. 49. Foods That Helps You Sleep BetterFoods That Helps You Sleep Better tryptophan in it convert to serotonin & melatonin which induces sleep, Ca, Mg helps m. relaxation Cherries rich source of melatonin rich in Vit. B6 for melatonin production Kale source of sleep inducing agents (K, Ca, Mg, Vit.B6) salmon & tunaOat
  50. 50. All Sleep Phenomenon could be a Seizure…
  51. 51.  Anything that is recurrent, stereotyped, and inappropriate may be manifestation of a seizure  Some forms of epilepsy occur more commonly during sleep than during wakefulness  Most often confused with sleep terrors,  More common in the first 2 hours of sleep, or around 4-6 am.  More common in kids than adults. Nocturnal seizuresNocturnal seizures
  52. 52. REFERENCES • Gerd Lehmkuhl, Alfred Wiater, Alexander Mitschke, Leonie Fricke-Oerkermann (2008): Sleep Disorders in Children Beginning School: Their Causes and Effects. Dtsch Arztebl Int; 105(47): 809–14 • Judith A. Owens (2011): sleep disorders in Nelson text book of pediatrics. Chapter17. • Bradley TD, Floras JS: Obstructive sleep apnoea and its cardiovascular consequences. Lancet 2009; 373:82-90. • Khatwa U, Kothare SV: Restless legs syndrome and periodic limb movements disorder in the pediatric population. Curr Opin Pulm Med 2010; 16:559-567. • Stores G: Aspects of parasomnias in children and adolescence. Arch Dis Child 2009; 94:63-69.

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