objectives outline normal developmental changes in sleep from infancy through adolescence describe...
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ObjectivesObjectivesOutline normal developmental
changes in sleep from infancy through adolescence
Describe the causes of daytime sleepiness affecting children
Outline the clinical evaluation of daytime sleepiness in children and adolescents
Young Children Sleep A Young Children Sleep A LotLotBy age 2y, average child has spent
9500 h (approx. 13 months) asleep vs 8000 h awake
Between 2-5 y, time asleep = time awake
In school-age children, sleep occupies 40% of the 24 h day
Sleep is the primary activity of the brain during early development
Appropriate Duration of Sleep Appropriate Duration of Sleep by Ageby Age
RealityReality
Sleep Dysfunction In Sleep Dysfunction In ChildrenChildren
Insufficient SleepSleep deprivation
Fragmented SleepSleep disruption
Excessive Daytime Sleepiness
Primary Disorders of EDS
Sleep in NewbornsSleep in Newborns
3 sleep states in term newborns: active, quiet and indeterminate; enter sleep thru active (REM)
Total sleep time: 16-20 hours/day with equal amounts day and night
Sleep episodes 3-4 hours/1-2 hours awake; breast fed-more frequent wakings
Sleep in InfantsSleep in InfantsCritical sleep reorganization at 8-
12 weeks; establish diurnal cycleDevelop NREM sleep by 6
months; decreased REMAt 6 months: TST is 13-14 hours;
sleep episodes 6-8 hours70-80% sleep through the night at 9 months
Sleep in ToddlersSleep in Toddlers
Total sleep time – 12-14 hoursMost give up second nap at 1 yearDevelopmental issues: separation
anxiety→nightime fears, mastery of independent skills→power struggles
Sleep problems common-20-40%Importance of bedtime routines,
transitional objects
Sleep in Pre-SchoolersSleep in Pre-SchoolersTST-11-12 hours/dayMany give up regular daytime
nap by age 4-5 yearsSignaled night wakings occur
frequently; role of parental reinforcement
Sleep problems may become chronic
Sleep in School Age Sleep in School Age ChildrenChildrenTotal sleep time 9-11 hours
◦10-11 hours in 6-7 y.o. ↓9.5 hours in adoles.
Stable sleep pattern night to nightLow level of daytime sleepiness
◦Rare naps◦Some have prolonged sleep latency
Increasing pressure from schedule◦Earlier wake times, later bedtime
from school work/activities
Sleep Changes in Sleep Changes in AdolescenceAdolescenceDelayed sleep onset
◦Circadian: relative phase delay at puberty
◦Environmental factors-music, computer, work
Advanced wake times (sleep offset)◦Earlier school start time
Decreased sleep/wake regularity◦Different weekday/weekend schedule
Sleep Changes in Sleep Changes in AdolescenceAdolescenceDecreased daytime alertness
◦↑ sleep pressure, ↓ circadian output Less parental “protection” of TSTLeads to insufficient sleep
◦Most need 9-9.5 hours◦Average high school student sleeps
only 7 1/4 hours
Causes of EDS-Insufficient Causes of EDS-Insufficient SleepSleepCommon problem in 24/7 societyMore fun activities at night
◦Electronic babysitter, electronics in bedroom
Family stresses◦Daycare, work schedules
Adolescents “escape” parental controls
Insufficient Sleep Insufficient Sleep EvaluationEvaluationQuestion child and caregivers
◦Signs/symptoms of sleepiness Sleeping, irritable, behavioral/focus issues
◦Weekdays and weekends?Duration/quality of sleep-day and
night◦What time in bed, what time asleep
Sleep diary can be very informative!
◦Rise time-hard to get up?◦Weekday vs weekend schedule
Insufficient Sleep Insufficient Sleep EvaluationEvaluationBedtime routine
◦Stimulating activities?Activities during the night
◦Once down do they stay down?◦Fun activities during the night
Child who won’t sleep or never sleeps◦Limit setting disorder◦Sleep onset association disorder◦Anxiety issues
Sleep Onset Association Sleep Onset Association DisorderDisorderChild learns to fall asleep under
certain conditions which are usually present at bedtime (parent in room, rocking); no problems settling when conditions met
Child continues to require conditions during normal nighttime arousals in order to fall back to sleep
Absence of those conditions results in prolonged night wakings
Limit Setting Sleep Limit Setting Sleep DisorderDisorderParents unable to set consistent
bedtime rules→bedtime struggles, bedtime refusal, protests, requests, excuses
Results in prolong sleep onset latency; most common in 2-6 year olds
Behavioral Sleep Disorders: Behavioral Sleep Disorders: ManagementManagementPreventative education for parentsSOAD-child needs to learn to fall
asleep in reproducible conditionsLSSD-family needs help with setting
limits and consequencesProblems will wax and wane and re-
training is necessary
Disrupted Nocturnal SleepDisrupted Nocturnal SleepEnvironmental issues
◦Sleep location-bed-who’s?, couch, variable?
◦Electronics, temperature, light, foodWhat to do?
◦Importance of bedtime routine◦Regular sleep location-quiet, dark◦No electronics-TV, phone, games◦No food◦No reason to be up!
Disrupted Nocturnal SleepDisrupted Nocturnal SleepIssues intrinsic to child
◦OSA-Hx of snoring, gasping or observed apnea Consider sleep study
◦Leg movements-Family history of RLS Ask RLS questions to caregiver/child Treat clinically or consider PSG
◦Parasomnias-clinical history Sleep walking, confusional arousals, night
terrors No sleep study needed usually
Causes of Daytime Causes of Daytime SleepinessSleepinessMedications
◦Many associated with daytime sleepiness
◦Anti-epileptic medications◦Medications to treat muscle spasm◦Psychotropic medications◦Antihistamines
Caffeine-sleep disruption, PLMs
Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessHypersomnia
◦Excessive daytime sleep despite normal nocturnal sleep
Narcolepsy◦EDS – may have co-existing sleep
disordersAbnormal brain regulation of
sleep/wakeDiagnosis of exclusion after ruled out
insufficient sleep or disrupted sleep
Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessNarcolepsy
◦EDS + cataplexy makes diagnosis◦Other symptoms: sleep paralysis,
hypnagogic hallucinations, disrupted nocturnal sleep
Narcolepsy statistics◦Onset in second decade◦Diagnosis may take years to make◦25-50/100,00 in US
Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessHypersomnia
◦Similar issues as in narcolepsy◦Lack other symptoms seen in narcolepsy◦Kleine-Levin, menstrual associated
Diagnosis made by history + PSG/MSLTPSG to look for other sleep disordersMSLT quantifies daytime sleepiness
◦Necessary for diagnosis, to get medications
Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessHistory
◦Amount of daytime sleep◦Where falling asleep- School, bus,
bathroom, meals, clinic?PSG-looking for OSA, PLMs, seizure,
etcMSLT
◦Daytime studied to quantify sleepiness◦5 naps 2 hours apart looking for sleep
and REM
Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessTreatmentConsider referral to sleep expert
◦ Determine exact diagnosis, treat other sleep disorders
◦ Arrange appropriate testing◦ Determine appropriate medication regimen
Stimulants, treatment for cataplexyMaximize nocturnal sleepScheduled daytime napsSchedule important tests/activities during
periods of maximal alertness
Circadian Rhythm DisordersCircadian Rhythm Disorders
Child’s internal clock for sleep/wake behavior conflicts with family expectations
Delayed sleep phase◦May be transient (jet lag) or persistent (night
owl)◦Sleep onset and offset delayed, but regular◦Difficulty am waking and daytime sleepiness◦Rx: strict and controlled sleep/wake
schedule, delayed bedtime/gradual phase advance, chronotherapy, bright light therapy, melatonin
Sleep Problems in ADHDSleep Problems in ADHDChildren with ADHD ↑ sleepiness
vs nl◦Hyperactivity adaptive behavior for
EDSMedication role in sleep problems
◦Stimulant side effects-↑sleep latency, nocturnal awakenings, ↓total sleep time
◦“Wearing off” in evening→rebound increase in arousal and hyperactivity
Signs of Sleepiness???Signs of Sleepiness???
Signs of SleepinessSigns of SleepinessSleepy behaviorImpulsivity, hyperactivity,
aggressivenessLabile mood and inattentionNeurocognitive deficits
◦↓creativity, poor abstract thinking◦↓memory, vigilance, attention, motor
skillsSleep problems may mimic ADHD
Sx
Sleep History: ‘BEARS”Sleep History: ‘BEARS”BedtimeExcessive daytime sleepinessAwakenings: night or early
morningRegularity and duration of sleepSnoring
BEARS: BEARS: BBedtimeedtimeWhat happens at sleep onset
◦Difficulty going to bed or falling asleep
◦What happens at bedtime◦What keeps the child from falling
asleep◦Is the child anxious at bedtime
BEARS: BEARS: EExcessive Daytime xcessive Daytime SleepinessSleepinessWhat is the extent of daytime
sleepiness◦Difficulty waking in am◦Does the child act sleepy or seem
overtired◦Behavior when overtired◦Daytime naps◦Any similar history in family
members
BEARS: BEARS: AAwakeningswakeningsCharacterize extent and content
of awakenings◦Does the child have trouble waking
up at night◦What awakens the child◦Behavior when awake at night◦Does the child leave their bed after
awakenings
BEARS: BEARS: RRegularity and egularity and Duration of SleepDuration of SleepCharacterize sleep habits
◦Bedtime and wake time Weekdays vs. weekends
◦Does the child get enough sleep◦How much sleep does the child need
BEARS: BEARS: SSnoringnoring
Screen for OSA◦Does the child snore at night
How loud, how often
◦Does the child gasp, choke or stop breathing
◦Is the child a restless sleeper or sweaty
◦Anyone else at home snoring
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