Pediatric Neurology Quick Talks

Sleep DisordersMichael Babcock

Summer 2013

Scenario

-4 yo boy-screaming at night-lasts 30 minutes-occurs about 2 hours after going to bed-inconsolable during crying, then falls back asleep-no bed wetting-no limb shaking-eyes closed-no sedation in the AM

Sleep Screen – BEARS

• B – Bedtime issues• E – Excessive daytime

sleepiness (can exhibit as motor over-activity, inattentiveness, irritability, oppositional defiance)

• A – night Awakenings• R – Regularity and duration• S – Snoring• If concerns

– Movements– Meds

Insomnia

• Onset or Maintenance?• Usually behavioral• Psychosocial• Anxiety (separation)• Depression• Medical problems – chronic pain,

GERD, breathing problems, medications

Insomnia

• Sleep onset Association– Prolonged night awakenings– Child has learned to fall

asleep with Associations requiring parents – feeding, rocking, reading; can't self-soothe.

– Tx – break connection; put child to be while drowsy but not asleep.

• Limit-setting subtype– Older children– Active resistance to bedtime– Verbal protests and repeated

demands– Can manifest as fearful

behavior (crying, clinging)– Usually due to caregiver

inconsistency with bedtime rules

– Can have medical underlying causes – asthma, medications, sleep disorder – RLS, anxiety.

– Tx – caregiver enforces rules

Restless Leg Syndrome

• An urge to move legs, usually accompanied by unpleasant sensation in legs

• These symptoms:– Begin or worsen during

rest/inactivity– Relieved by movement– Occur exclusively or

predominantly in evening– Not solely accounted for as

symptoms of another medical/behavioral condition

• Hx – children may have difficulty explaining this unpleasant feeling – pain should not be only feeling.

• Differential – Periodic leg movement disorder – actual leg movements during sleep without sensation – this can be due to other sleep disorders.

• Work-up – iron studies• Tx – iron supplementation; off

label use of gabapentin, benzo's, clonidine, dopamine agonist used less often in children.

Excessive daytime sleepiness

• A sleepy child may not appear sleepy – can be inattentive, hyperactive (trying to stay awake), aggressive, disruptive (sleep-deprived frontal cortex can't regulate emotion)

• Insufficient sleep – insomnia• Inadequate sleep hygiene• Medication side-effects• Periodic limb movement disorder• Idiopathic hypersomnia• endocrine/metabolic problems• Narcolepsy • OSA

Narcolepsy

• Narcolepsy– Excessive daytime sleepiness– Sleep paralysis– Hypnagogic hallucinations– Cataplexy

• Sudden loss of tone• Precipitated by emotion (laughing, anger)• REM creep

– Dx – polysomnography, MSLT

Obstructive Sleep Apnea

• Excessive daytime sleepiness• Symptoms – Snoring, with

apneic pauses• But also

– Daytime nasal obstruction– Mouth breathing– Trouble eating/meat refusal– Behavior problems– Bed-wetting– Restless sleep– Sweaty sleep (needs fan on)– AM headache– Poor seizure control

• Who has OSA– 2-3 % of normal

development children have OSA

– 10% of normal children will be habitual snorers – don't have OSA

– 50% of children with Down's– ~50% in obese children

• Why is it bad– Hypertension, CHF, stroke,

diabetes, difficulty losing weight.

Parasomnias

• Disorders of Non-REM arousal– Sleep walking– Sleep terrors– Confusional arousals

• REM sleep disorders– Nightmares– Sleep paralysis– REM sleep behavior disorder

• Narcolepsy• SSRI• neurodevelopmental

• Sleep-related movement disorders– Rhythmic movement

• infants/toddlers• Start at sleep onset• Head rolling/head

banging/body rocking– Bruxism– RLS/PLMD

• Hypnic starts– Brief jerks occurring with

falling asleep/awakening– May have sensation of falling

Non-REM arousal parasomnias

• Usually during first 1/3 of night• Usually only one event/night• Increased arousals cause increased problems

– OSA, RLS, GERD.• Triggered by sleep deprivation, fever.• Toddler and school-aged kids.• Usually resolve with time

– sleep-walking most likely to persist.• Not tired the next day• No stereotypic motor movements• Last 5-30 minutes

• Differential – nocturnal seizures– Anytime during night, more often

in transition periods– Last 30 seconds – 5 minutes– Multiple events nightly– Daytime seizures– Daytime irritability/lethargy– Older age of onset.

• Differential – panic attack, GERD.• Dx -home videos, polysomnography or

overnight EEG.• Tx – low dose benzo.

References

-Uptodate articles – pediatric sleep, NREM sleep disorders, parasomnias, narcolepsy, RLS