Introduction to Sleep Introduction to Sleep Problems in ChildrenProblems in Children

April Wazeka, M.D.

Respiratory Center for Children

Atlantic Health System

ObjectivesObjectives

Understand normal sleep in childrenReview common pediatric sleep disordersDiscuss proper treatment options for

childhood sleep disorders

IntroductionIntroduction

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.

Pediatric Sleep MedicinePediatric Sleep Medicine

Relatively new fieldFew pediatric sleep centersNow have new understanding of

associations between common childhood disorders and sleep

OverviewOverview

Sleep disorders in children are very common—approximately 25% of children ages 1-5 years of age

Pediatric knowledge expandingPresentation of sleep disorders different in

children than in adults– Varies with age and developmental stage

Sleep and BreathingSleep and Breathing

Some breathing disorders occur only during sleep

Virtually all respiratory disorders are worse during sleep than during wakefulness

Who needs sleep?Who needs sleep?

Mammalian Total Daily Sleep Time (in hours)

Giraffe 1.9 Roe deer 3.09Asiatic elephant 3.1 Pilot whale 5.3Human 8.0 Baboon 9.4Domestic cat 12.5 Laboratory rat 13.0Lion 13.5 Bats 19.9

BUT, exact function of sleep not well understood!

All mammals and birds “sleep” as we know what sleep to be.

Sleep “behavior” has also been observed in reptiles and insects

How much sleep do children need?How much sleep do children need?Sleep Duration from Infancy to Sleep Duration from Infancy to

AdolescenceAdolescence 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

Normal Sleep PhysiologyNormal 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

REM sleepREM sleepRapid eye movement or dream sleepBreathing erraticVariable RR and tidal volumeFrequent central apneasDecrease in intercostal and upper airway

muscle toneChildren have relatively more REM sleep

than adults

REM SleepREM 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.

DevelopmentDevelopment

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

DevelopmentDevelopment

Ossification of the sternum and vertebrae continues until 25 yrs of age

Results in a stiffer chest wallChest wall compliance = lung compliance

by 2 yrs of ageHowever, paradoxical inward rib cage

motion during inspiration in REM sleep is seen until almost 3 yrs of age

Upper AirwayUpper 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

Upper AirwayUpper 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.

ApneasApneas

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

Insomnia in Infants and ToddlersInsomnia in Infants and Toddlers

Sleep Onset Association DisorderColicNocturnal 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

Sleep Onset Association Sleep Onset Association DisorderDisorder

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!

Common FeaturesCommon 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

TreatmentTreatment

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)

Causes of Insomnia in the Causes of Insomnia in the Preschool and School-Aged ChildPreschool and School-Aged Child

Fears and nightmares Limit setting sleep behavior

disorder

Fears and NightmaresFears and NightmaresFears of “monsters” when awakeVivid, frightening dreams of villanous

creatures when asleepExperienced by >50% of childrenUsually begin at 3-5 years of age, decrease

with increasing age

TreatmentTreatment

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

Limit Setting Sleep DisorderLimit Setting Sleep Disorder

Exclusively a childhood sleep disorderCharacterized by:

– Stalling behaviors or refusal to go to bed at the desired time

– Associated with inadequate parental limit setting for a child’s behaviors

Common FeaturesCommon 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

Factors in Parental Failure to Set Factors in Parental Failure to Set LimitsLimits

Lack of understanding of the importance of setting limits

Inadequate knowledge of limit-setting techniques

Psychosocial factors

TreatmentTreatment

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

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

Treatment (Continued)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

Insomnia in AdolescenceInsomnia in Adolescence

More closely resembles adult disordersOften 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

TreatmentTreatment

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

Good Sleep HygieneGood 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

Pharmacologic treatment of Pharmacologic treatment of InsomniaInsomnia

Centuries ago opium-based laudanum given to children to keep babies quiet

AntihistaminesBenzodiazepinesZolpidem (Ambien)—not approved for

pediatric usage– Interacts with GABA-benzodiazepine receptor

complexes

Causes of Insomnia in Children Causes of Insomnia in Children of all Agesof 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

Treatment SuccessTreatment Success

Treatment FailureTreatment Failure

Restless Legs Syndrome (RLS)Restless Legs Syndrome (RLS)

Sensory-motor disorder involving the legsPrevalence approximately 4% of the

populationAge of onset can occur at any ageResults in sleep disturbance with difficulty

initiating and/or maintaining sleepCan be exacerbated by pregnancy, caffeine,

or iron deficiency

RLS-DiagnosisRLS-DiagnosisCriteria

– 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

RLSRLS

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

RLS in ChildrenRLS 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

RLS-TreatmentRLS-Treatment

Correct underlying medical cause, if present– Diabetes, uremia, anemia

Dopaminergic agents– Pramipexole (Mirapex)– Cardidopa-levodopa (Sinemet)

BenzodiazepinesOpiates

ParasomniasParasomnias

Unpleasant or undesirable motor, autonomic, or experiental phenomena that occur predominantly or exclusively during the sleep state

May be induced or exacerbated by sleepTwo types:

– Primary– Secondary

Primary ParasomniasPrimary Parasomnias

Disorders of arousal REM sleep behavior disorder Recurrent Hypnagogic Hallucinations/Sleep

Paralysis Bruxism Rhythmic movement disorder Periodic Limb movement disorder Sleep starts Sleeptalking

Rhythmic Movement Disorder Rhythmic Movement Disorder (RMD)(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

Periodic Limb Movement Periodic Limb Movement Disorder (PLMS)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

Sleep Talking (Somniloquy)Sleep Talking (Somniloquy)

Common disorderCan arise from REM or NREM sleepMay have a genetic componentRarely of clinical significance

Disorders of ArousalDisorders of Arousal

Underlying process one of incomplete arousal

Seen more commonly in children than in adults– Sleepwalking– Confusional Arousals– Sleep Terrors

SleepwalkingSleepwalking 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

Confusional ArousalsConfusional Arousals

Typically seen in toddlers and preschool age children

Often confused with sleep terrors Arousal typically starts with movements and

moaningprogesses 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

Common FeaturesCommon 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

Sleep TerrorsSleep 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

Constitutional and Precipitating Constitutional and Precipitating Factors for ArousalsFactors for Arousals

Constitutional– Genetic– Developmental– Sleep deprivation– Chaotic sleep schedule– Psychologic

Precipitating– OSA– GERD– Seizures– Fever

Common Features of Arousal Common Features of Arousal DisordersDisorders

Misperception of and unresponsive to environment

Automatic behaviorRetrograde amnesia60% have positive family historyPathophysiology

– Occurs at transition from slow wave sleep to next sleep cycle

Arousal Disorders-TreatmentArousal 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

Secondary ParasomniasSecondary Parasomnias

Neurologic– Seizures– Consider with stereotypical movements,

recurrent dreams, unusual autonomic symptoms (stridor, choking, coughing)

– Headaches– Muscle cramps

SleepinessSleepiness

Causes of SleepinessCauses of Sleepiness

Insufficient sleep Schedule disorders Obstructive sleep apnea Epilepsy Narcolepsy Kleine-Levin Syndrome Idiopathic Central Nervous System Hypersomnia

Clinical Manifestations of Clinical Manifestations of SleepinessSleepiness

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

Insufficient SleepInsufficient 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

Behavioral Treatment of Behavioral Treatment of Inadequate SleepInadequate 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

+ =

Circadian Rhythm in SleepCircadian 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

Circadian Rhythm Sleep Circadian Rhythm Sleep DisordersDisorders

Regular but inappropriate schedulesSleep phase shifts

– Delayed sleep phase– Advanced sleep phase

Advanced Sleep PhaseAdvanced Sleep Phase

Mainly in infants and toddlersRelatively uncommonEarly bedtime and early awakening“Morning Larks”Treatment

– Gradual delay of bedtime– Delay naps and mealtimes– Bright light at night, dim light in the morning

Delayed Sleep PhaseDelayed Sleep Phase

Delay in sleep onset, late awakening“Night owls”Onset in adolescenceMale predominanceSleep itself quantitatively and qualitatively

normalGenetic predisposition

Delayed Sleep PhaseDelayed 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

MelatoninMelatonin 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

MelatoninMelatonin

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

Evaluation of Sleep DisordersEvaluation 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

Sleep HistorySleep 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

Physical ExaminationPhysical 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.

Sleep LogSleep Log

Diagnosis – Nocturnal Diagnosis – Nocturnal PolysomnographyPolysomnography

Only diagnostic technique shown to quantitate the ventilatory and sleep abnormalities associated with sleep-disordered breathing

THE GOLD STANDARD!

Sleep LaboratorySleep Laboratory

PolysomnogramPolysomnogram

PolysomnographyPolysomnography

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.

Diagnosis- Audiotaping or Diagnosis- Audiotaping or VideotapingVideotaping

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.

Abbreviated Abbreviated PolysomnographyPolysomnography

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

What is the role of the What is the role of the Pediatrician?Pediatrician?

Screening– Consider adding sleep questions to Review of

Systems

Treat common disorders firstRefer to sleep specialist

– Complex sleep disorders– When there is no improvement

Final ThoughtsFinal 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

ResourcesResources

American Academy of Sleep Medicine http://aasmnet.orgNational 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/