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PediatricSleep

Disorders

Craig T. Nakamura, M.D.

Z Z Z Z . . .

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People who saythey sleep like a baby

usually don't have one.  -- Leo J. Burke

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TODAY’S OBJECTIVES:-- background-- obstructive sleep apnea-- sonambulism (sleep walking)-- night terrors-- sleep hygiene-- prevent everyone from

falling asleep

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Animal Sleep TimesBrown Bat 20 hours / day

Tiger 16 hours / day

Ferret 14.5 hours / day

Platypus 14 hours / day

Cat 12 hours / day

Dog 10.5 hours / day

Pig 8 hours / day

Cow 4 hours / day

Giraffe 2 hours / day

Infant 16 hours / day

Adult 8 hours / day

Elderly 5.5 hours / day

Peds Pulmonologist 4 hours / day

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Average Sleep Times By AgeAGE: Night Sleep (hours): Day Sleep (hours):1 week 8.25 8.251 month 8.5 7.03 months 9.5 5.56 months 10.5 3.759 months 11.0 3.012 months 11.25 2.518 months 11.5 2.02 years 11.5 1.53 years 11.0 1.04 years 10.755 years 10.57 years 10.259 years 10.010 years 9.7513 years 9.2516 years 8.518 years 8.25

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Courtesy of the PerelmanSchool of Medicine at

the University of Pennsylvania

Fatigue by State

TOP TEN:1. West Virginia2. Tennessee3. Kentucky4. Oklahoma5. Florida6. Missouri7. Georgia8. Alabama9. Mississippi10. Louisiana

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Courtesy of the PerelmanSchool of Medicine at

the University of Pennsylvania

Sleep Disturbance by State

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“Paying the Mortgage”

• Insufficient sleep sleep debt(eventually must be “repaid”)

• affects immunity• also nervous system• important for cycling of growth

hormone• In adults, ↑ rate of automobile

accidents by 3x

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Sleep in Children

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Sleep Induced Changes

Sleep impairs ventilation in all children (sick or healthy):

-- normal-- underlying respiratory illness-- CNS disease-- obstructive sleep apnea

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Sleep Disorders in Children• If diagnosed and treated early,

morbidity can be avoided

• Therefore, important to recognize

signs of sleep-disordered breathing:

a) primary care providers

b) teachers

c) parents

d) local postman

12Sleep Stages

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Sleep Stages

5 phases of sleep stages 1, 2, 3, 4, REM sleep

50% stage 220% REM sleep30% the other 3 stages

progresion from stages 1 to REM~ 90 to 110 min / total cyclethen cycle starts again

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Stage 1 Sleep

light sleepdrift in and outeyes move very slowlymuscle activity slowswhen awaken, recall fragmented

visual imagessense of fallingmuscle contractions

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Stage 2 Sleep

eye movements stopbrain waves become sloweroccasional bursts called

sleep spindles

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Stages 3 & 4 (Deep) Sleep

no eye or muscle movementswhen awakened, groggy, disorientedbedwetting, night terrors, sleep walkingStage 3:

extremely slow (delta) brain waveswith smaller faster waves

Stage 4:delta waves

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REM Sleeprapid, irregular breathingeyes jerk rapidlylimb muscles temporarily paralyzedheart rate & BP ↑bizarre / illogical dreamsfirst cycle 70 to 90 minutespenile erections HEH HEH. HE SAID, ERECTION.

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Obstructive Sleep Apnea

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Apnea: Greek word meaning

“want of breath”

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Obstructive Sleep Apnea Syndrome (OSAS)

Disorder of breathing during

sleep characterized by

prolonged partial and / or

intermittent complete upper

airway obstruction that disrupts

normal ventilation and patterns

during sleep.

First described in 1965

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Obstructive Sleep Apnea

• adults:cessation for > 10 seconds

• children:cessation for 2 ½ missed breaths

• with apneas, oxygen levels ↓, carbon dioxide levels ↑• also causes arousals and

fragmented sleep

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Obstructive Sleep Apnea

• prevalence ~ 2%• affects millions• M = F• more common with family history of OSAS• ↑ in African Americans • ↑ in children with chronic respiratory tract infections

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Obstructive Sleep Apnea

• ↑ in children 2 - 6 years of age

• same age of adenoidal & tonsillar hypertrophy

• continues through adolescence(especially with craniofacial

anomalies, neurologic disorders, obesity)

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Obstructive Sleep Apnea• due to upper airway collapse

• can be due to:– anatomic factors– abnormal neuromuscular tone– both

• worse in REM sleep

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OSAS: etiologic factors

• obesity• craniofacial disorders

esp. mid-face hypoplasia• micrognathia

ie. Pierre-Robin• other

-- Crouzon synd -- Aperts synd -- Down synd -- Achondroplasia -- Duchenne’s MD -- cerebral palsy

-- Arnold Chiari malf -- Prader-Willi synd-- hypothyroidism -- choanal stenosis-- sickle cell anemia-- mucopolysaccharidosis

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Obstructive Sleep Apnea: History

• predominant symptoms-- snoring-- labored breathing-- daytime somnolence-- difficulty in school

• important to ask about snoring, snorting, noisy breathing (gasping, grunting)

• note: parents frequently don’t volunteer this information

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Other Historical Findings:

• labored breathing, retractions, paradoxical chest wall motion• observed apneas• restless sleep• diaphoresis• enuresis• cyanosis• unusual positions seated or neck hyper-extension• daytime neurobehavioral abnormalities

ADHD or sleepiness• morning headaches from hypercapnia

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OSA Findings• hypertension

-- systemic

-- pulmonary• failure to thrive• adenoidal facies• nasal obstruction• mouth breathing• hyponasal speech• tongue size• tonsils size• soft palate size and

shape

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Obstructive Sleep Apnea

• gold standard nocturnal full, observedpolysomnogram (sleep study)• rarely, multiple sleep latency test (MSLT)• other studies much less helpful -- audiotapes

-- nocturnal videotaping-- overnight pulse oximetry-- nap sleep study (1 hr)

• re-testing after T&A essential (~ 6 week post-op)

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Obstructive Sleep Apnea

• questionaires to 7th and 8th graders• 1,588 questionaires• top 25% [HP] and bottom 25% [LP]• frequent / loud snoring: 5 % HP / 13% LP• Prior tonsillectomy / adenoidectomy:

7 HP / 24 LP (3.4 odds ratio)• Conclusion: children with lower academic

performance ↑ snoring and more likely to require T&A. “A learning debt that may hamper future performance”

Gozal D et al. Pediatrics. 2001; 107(6):1394-1399.

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Obstructive Sleep Apnea

• 297 first graders in lowest 10th percentile

• sleep studies to assess for sleep-associated gas exchange abnormalities [SAGEA] • SAGEA identified in 54 (18.1%)• encouraged to Rx• 24 underwent T&A [T&A] • in T&A group, improvement by 0.5• no change in non-T&A group & those in top

90th percentile

Gozal D et al. Pediatrics. 1998; 102(3 pt 1):616-620.

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Obstructive Sleep Apnea

Conclusion:

SAGEA is frequently present in poorly performing 1st grade students in whom it adversely affects learning performance.

The data suggest that a subset. . . could have SAGEA and may benefit from prospective medical evaluation and treatment.

Gozal D et al. Pediatrics. 1998; 102(3 pt 1):616-620.

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Obstructive Sleep Apnea

• surgical treatment

– adenotonsillectomy

adenoids can reappear– uvulopalatopharyngoplasty (UP3)– rarely tracheostomy– occasional recurrence

• other therapies– CPAP– BiPAP– lifestyle changes (ie. weight loss)

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Z Z Z Z Z !

Primary Snoring in Children

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Primary Snoring

• snore – a noise produced when breathing in (vibrates soft

palate and uvula)

• snoring without sleep apneas

• 20% of normal children snore

occasionally

• 7 - 10% snore every night

• OSAS only ~ 2% of snorers

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Primary Snoring

• differs from primary snoring

• OSAS associated w/ complications• primary snoring – 10% of children– not associated with OSA, arousals, or gas

exchange abnormalities

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Primary Snoring

• study on 1,144 3rd grade schoolchildren

• snoring shown to be associated with poor academic

performance in math and spelling in 3rd grade school children

Urschitz MS et al. Am J Respir Crit Care Med. 2003.

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Central apneas

Sudden infant death syndrome (SIDS)

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Sleepwalking(somnambulism)

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Somnambulism

• typically pre-pubertal children• highest 11-12 years old (17%)• can last into adulthood• genotyping

• walking or moving during sleep• potential for harm

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Somnambulism

• difficulty arousing

• can be triggered by sleep disorder

• amnesia following

• first 3rd of sleep episode

• slow wave sleep (stages 3 or 4)

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Somnambulism

• get plenty of sleep• develop calming bedtime ritual• remove hazardous materials• ground floor if possible• reduce open windows• occasionally hypnosis• benzodiazepines• Topamax?

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NightTerrors

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Night Terrors

• sudden arousal from slow wave sleep (stage 3 or 4); 1st third of p.m.• intense terror

cry followed by autonomic changes

• tachycardia• partial or total amnesia• can occur nightly

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SleepHygiene

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Sleep Hygiene – habits / behaviors

• stimulantscaffeine: coffee, tea, colas, cocoa, chocolate,

medications

nicotine

• exercise

-- generally helpful-- avoid within 6 hours of bedtime

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Sleep Hygiene – habits / behaviors

• alcoholslows brain waves initially, but disrupts

sleep later (↓ REM sleep)avoid within 4 – 6 hours of bedtime

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Sleep Hygiene• environment

comfortable bed, dark & quiet room

mask / earplugs if necessary

minimize changes

• dietheavy meals before disrupts

light snack can help, especially milk and

other dairy products (tryptophan)

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Sleep Hygiene

• regular schedule

• reduce stress

• avoid long daytime naps

• reduce stimuli

• avoid clock-watching

• designate worry time

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Sleep Hygiene

• sleep only when drowsy• if unable to sleep, leave

& return when sleepy• maintain regular waking time• limit bedroom activities • avoid / reduce naps – limit to less than 1 hour– no later than 3 p.m.

helpful tips:

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Signs of problems

• too much time needed to help child fall asleep

• child wakes repeatedly• behavior & mood are affected • parents also lose sleep• parent-child relationship starts to suffer

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Three common problems

• sleep-onset association disorderie. child requires rocking

• night-time eating / drinking disorderie. frequently awakens for feeds

• limit-setting problemsie. refusing to go to bed or stalling

children can get pretty creative

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Sleep Hygiene in Children

• bedtime preparation can reduceanxiety

• 10 to 30 minutes of “special time” before bed

• should not be stimulating– ie. no wrestling or scary stories

• don’t extend length of “special time”

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YAWN FACTS:

-- lasts six seconds-- heart rate ↑ 30%-- 55% yawn within 5 min of seeing someone else-- the blind yawn after hearing someone else-- reading about yawning stimulates yawning-- fetuses yawn-- olympic athletes often yawn before competing

- unknown cause- possible boredom color test bar pattern

5.8 yawns / min “MTV-like” video

3.4 yawns / min

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THEEND