sleep lecture (deepti singh)

Sleep Disorders in Children and AdolescentsDeepti Shenoi MD

ObjectivesTo gain an understanding of normal basic sleep physiology and pathology in children and adolescents To learn developmentally appropriate behavioral techniques for improving sleepTo obtain an understanding of options in pharmacotherapy for pediatric insomniaI would also like you to think of iatrogenic causes for sleep difficulties. Or how we can make things worse.

Stages of Sleep

General Sleep Stages

Typical sleep need for children and adolescents by developmental stageAge group Years Total sleep need

Infants 3 to 12 months 14 to 15 hoursToddlers 1 to 3 years 12 to 14 hoursPreschoolers 3 to 5 years 11 to 13 hoursSchool-aged 6 to 12 years 10 to 11 hoursAdolescents 12 to 18 years 8.5 to 9.5 hoursMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Sleep Time During DevelopmentThiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84

Newborns (0-3 months)

Sleep 10-18 hours per dayMany short sleep periods, with no differentiation between day and night.

Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Tips for newborns and infants (up to 6mo)Nighttime awakenings for changing and feeding should be quick and quietPlace baby in the crib before falling asleep (when drowsy)Avoid feeding the baby to sleepSimple bedtime routinesoothing activities in the same order every nightGOAL: Babies to fall asleep by themselves and learn to soothe themselves and go back to sleep if they wake up in the middle of the nightMindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28.

Toddlers (12 mo-3 yrs) and Preschoolers (3-5 yrs)Maintain a daily sleep schedule with regular naptimes and bedtimeEstablish a consistent bedtime routine.Bedroom should be quiet, comfortable, and darkHave the child fall asleep independently. Set limits that are consistent and enforced.Encourage use of a security object, such as a blanket or stuffed animal.

Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28.

School-Aged Children(6-12 yrs)

Same bedtime and wake-up on weekdays and weekendsA 20- to 30-minute bedtime routine that is the same every night.No caffeineNo TV in the bedroomThe child should spend time outside every day and get daily exerciseMindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28.

Adolescents (12-18 years)

Need 9-9.25 hours of sleep per night but studies show that most get 7 hours/nightOnset of puberty hormonal changes and shift in melatonin 2 hour shift in circadian rhythm phase (later sleep onset and morning wake time)Some experience a physiological need for a short sleep period in early afternoon


What to ask in a sleep evaluation?-- Sleep History

Bedtime: Evening activities, bedtime routinesNight-time: Latency to sleep onset, behaviors during the night, # and duration of awakeningsDaytime: Daytime sleepiness, naps, caffeine intake, psychological, social and family functioning

What to ask in a sleep evaluation?-- Sleep HygieneConsistent and appropriate sleep-wake scheduleSimilar schedule on weekdays and weekendsConsistent bedtime routine that involves same 3-4 activities every nightNo technology in the bedroom

BEARS screen (for kids 2-18y.o.)Bedtime problemsExcessive daytime sleepinessAwakenings during the nightRegularity of evening sleep time and morning awakeningsSleep related breathing problems or snoring

Common DisordersBehavioral Insomnia of ChildhoodInsufficient or Inadequate sleepDelayed Sleep Phase SyndromeSleep Disordered BreathingDisorders of ArousalMovement disorders

Behavioral Insomnia of ChildhoodManifests most commonly as bedtime resistance and/or frequent night wakings and occurs in approximately 10% to 30% of infants and toddlersSleep-onset Association TypeLimit-setting typeCombined Type


Insufficient or Inadequate SleepSleep deprivation can have a cumulative effect being late or missing school, falling asleep during school, fatigue, illness, and irritabilityPoll reports that 28% of high school students report falling asleep in school at least once a weekInsufficient sleep can be fatal for adolescents who fall asleep while driving. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Insufficient or Inadequate Sleep Signs that children or adolescents are not getting enough sleep include: (1) needing to be awakened for school or day care in the morning, (2) sleeping 2 hours more on weekends and vacations compared with weekdays, (3) falling asleep in school or at other inappropriate times, (4) behavior and mood differing on days after getting more sleepMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Delayed Sleep Phase SyndromeThe persons sleep-wake cycle is delayed by 2 or more hoursNight OwlsMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Delayed Sleep Phase Syndrome

Delayed Sleep Phase Syndrome-Treatment

Sleep hygieneShifting the internal clockPhase Advancement: When the difference between the actual and desired bedtime is less than 3 hours. Every night or two, go to sleep 15 minutes earlier.Phase Delay: When the difference is greater than 3 hours, delay sleep by 2-3 hours on successive nightsMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Sleep-Disordered BreathingCan range from primary snoring to obstructive sleep apnea syndrome (OSAS) and is related to signicant cognitive and behavioral sequelae, including learning, attention, concentration, hyperactivity, and aggressive behavior Incidence of habitual snoring has been reported at 3% to 12% of the general pediatric population, with OSAS seen in 1% to 3% of childrenMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

NarcolepsyChronic neurologic disorder that involves excessive daytime sleepiness cataplexy (sudden loss of muscle control in response to strong emotional stimuli) hypnagogic hallucinations (vivid dreams at sleep onset) sleep paralysisautonomic behavior in which you continue to funtion, talk, clean but then have no recollection of performing task. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Narcolepsy Work upPolysomnography (PSG)Typically fall asleep rapidly with early REMMultiple sleep latency test (MSLT) Test subjects are given opportunities to sleep every two hours during the normal awake time and monitored to see how quickly they fall asleep and reach various stages of the sleep cycle.May provide clear evidence of narcolepsy, but in children, results are not always conclusive, and repeat studies may be necessary for a nal diagnosis

NarcolepsyIndividualized based upon symptoms.Treatment includes education, sleep hygiene, and pharmacologic interventionsDaytime Sleepiness:Sleep scheduling is essential, with a consistent bedtime, wake time, and good sleep hygieneChildren and adolescents who have narcolepsy may benet from a scheduled daily nap in the early afternoon.Stimulants are commonly used to treat daytime sedation including provigilAtomoxetine has also been used.Cataplexy: Cholinergic pathway mediatedmedications with anticholinergic properties are used to treat cataplexy, including clomipramine and imipramineMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Disorders of ArousalReferred as partial arousal parasomnias and include: confusional arousals, sleep terrors, sleep talking, and sleepwalkingDuring an event, although children are asleep, they may appear awake (eyes open), talk, or seem frightened or confused (eg, screaming in the case of sleep terrors)Typical parasomnias resolve spontaneously with children rapidly returning to a deep sleepMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Disorders of ArousalCommon feature: retrograde amnesiaStrong genetic component to partial arousal parasomnias, with a family history typically reportedPartial arousals are more likely to be triggered by insufficient sleep, a disruption to the sleep environment or sleep schedule, stress, illness, or certain medications (eg, chloral hydrate or lithium)


Sleep Terrors vs NightmaresThiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84

Comparison of Sleep Terrors and Nightmares

Factor

Sleep Terrors

Nightmares

Age

3 to 8 years

Any age

Gender

Male predominance

Either

Occurrence in Sleep Cycle

NREM

REM

Arousable?

No

Yes

Memory for Event

None

Yes

Exacerbated by Stress

Yes

Yes

REM = rapid eye movement, NREM = non-rapid eye movement

Disorders of ArousalTreatment: providing families with information about creating a safe sleep environment (eg, preventing windows from opening or putting alarms or bells on doors to alert if a sleep walker is up), education about the events, and how to interact with children appropriately during an eventAs some children may develop a fear of going to sleep and a prolonged sleep onset in turn increases the likelihood of an event occurring, parents should be encouraged to not discuss these events in the morning with the child or other children in the home


Restless Leg Syndrome and Periodic Limb Movement DisorderRLS manifests as uncomfortable sensations in the legs that worsen in the evening and with long periods of inactivity (eg, long car ride or movie)Sensations often are described as creepy-crawly or tingling feelings, most commonly in the legs, which can be alleviated temporarily with movement.PLMS are brief repetitive movements or jerks, lasting on average 2 seconds and occurring every 5 to 90 seconds during stages 1 and 2 of sleepPLMD occurs when PLMS are associated with frequent, but brief, arousals from sleepMeltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Restless Leg Syndrome and Periodic Limb Movement DisorderPharmacologic treatment for RLS and PLMD in children and adolescents may include benzodiazepine and dopaminergic medicationSome children who have RLS or PLMD have low iron/ferritin and many of these children and adolescents respond favorably to iron therapy At this time, there are no FDA-approved medications available to treat RLS and PLMD in children. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Sleep-Related Rhythmic Movement Disorders Include head banging and body rocking and are considered to be a sleep-wake transition disorder, occurring as children attempt to fall asleep at bedtime, naptime, or after a normal nighttime arousalcommon in infants (60% of 9 month olds), the behaviors tend to resolve spontaneously with development (only 8% of 4 year olds demonstrate these behaviors), but they can continue into adolescence and adulthood


Sleep-Related Rhythmic Movement Disorders Events typically last 5 to 15 minutes, but prolonged events can go for several hoursImportant to ensure safetyIn cases that result in injury, or when the behavior may be highly disruptive to others for a short duration (eg, family vacation or overnight sleepover), benzodiazepines may be indicated.Evaluation is recommended for severe cases or cases persisting past age 3Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76

Optimizing Treatment of Sleep ProblemsIdentification of the suspected causes of disrupted sleepInvolvement of the family by explaining the disorder and teaching them developmentally appropriate principles of sleep-wake organizationUse of behavioral treatments such as contracts to target specific behaviors that need to be changedAnders, TF, Eiben LA. Pediatric Sleep Disorders: A Review of the Past 10 Years. J Am Acad Child Adolesc Psychiatry. 1997;36:9-20.

Pharmocotherapy of Pediatric Insomnia: General GuidelinesReminder: In almost all cases, medication is neither the first treatment of choice, nor the sole treatment for childrenMedication should be used in combination with non-pharmacological strategies as these have been shown to have long-lasting effectsTreatment selection - best match between clinical circumstances and individual properties of medicationsMedications should be closely monitored for emerging side effects

Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: General GuidelinesPresence of both medically and behaviorally-based sleep disorders must be assessedMedications should be used in caution in situations where there may be potential drug-drug interactionsNon-prescription and over-the-counter medication use should be assessed


Pharmocotherapy of Pediatric InsomniaAntihistamines: Prescription (hydroxyzine) and OTC (diphenhydramine)Bind to H1 receptors in the CNSRapidly absorbedSide effects: daytime drowsiness, cholinergic effects, paradoxical excitation


Pharmocotherapy of Pediatric Insomnia: MelatoninMelatonin: hormone secreted by pineal gland in response to decreased light, mediated through suprachiasmatic nucleus; mechanism of commercially available melatonin is to supplement endogenous pineal hormoneClinical uses for melatonin are principally in normal children with acute or chronic circadian rhythm disturbances and in children with special needs (blindness, Rett syndrome)Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: MelatoninPlasma levels peak within 1 hour of administrationGenerally safe but potential side effects include suppression of hypothalamic-gonadal axis (i.e. could trigger precocious puberty upon discontinuationNot regulated by FDAReported doses: 1 mg in infants, 2.5-3 mg in older children, 5 mg in adolescentsOwens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: Herbal PreparationsValerian Root, St. Johns Wort, and Humulus lupulus - some evidence of efficacy in adult and/or pediatric studiesLemon balm, chamomile, and passion flower - limited to no evidenceKava kava, Tryptophan - assoc. with significant safety concerns (e.g. hepatotoxicity and eosinophilic myalgia syndrome, respectively) Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: BenzodiazepinesHypnotic effect mediated at GABA Type A receptors in the brainThey shorten sleep- onset latency, increase total sleep time, and improve non-REM sleep maintenance; most disrupt slow-wave sleep.Use of longer- acting BZDs may lead to morning hangover, daytime sleepiness, and compromised daytime functioning. Anterograde amnesia and disinhibition may also occur.Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: BenzodiazepinesRisk for habituation or addiction with these medications, as well as withdrawal phenomenaUsed for short-term or transient insomnia or in clinical situations in which their other properties (e.g., anxiolytic) are advantageousBZDs are occasionally used to treat intractable partial arousal parasomnias (e.g., sleep terrors) in children because of their slow-wave sleep suppressant effects. Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: Melatonin Receptor AgonistRamelteon (Rozerem): a synthetic melatonin receptor agonist, acting selectively at the MT1 and MT2 receptorsApproved for use in sleep initiation insomnia, and shows moderate efficacy in reducing sleep-onset latency (in adults)Two single pediatric case reports have reported efficacy in autistic childrenOwens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.

Pharmocotherapy of Pediatric Insomnia: -AgonistClonidine: central 2-agonist that decreases adrenergic toneone of the most widely used medications for insomnia in pediatric and child psychiatry practice, particularly in children with sleep- onset delay and ADHDsafety and efficacy in children with ADHD and sleep problems is limited to descriptive studies


Pharmocotherapy of Pediatric Insomnia: -AgonistClonidine is rapidly absorbed with onset of action within 1 hour and peak effects in 2-4 hoursTolerance often develops necessitating increase in doseDiscontinuation may lead to rebound in REM and slow-wave sleepPossible side effects include: hypotension and bradycardia, anticholinergic effects, irritability, and dysphoria; rebound hypertension may occur on abrupt discontinuationAvoid in patients with diabetes and Raynaud syndrome


Pharmocotherapy of Pediatric Insomnia: Atypical AntidepressantsTrazodone: one of the most sedating antidepressants because it both inhibits binding of serotonin and blocks histamine receptorsSuppressant effects on REM and may increase slow-wave sleepMorning hangover is a common side effectAssociated with reports of priapism in the 50- to 150-mg dose range


Pharmocotherapy of Pediatric Insomnia: Atypical AntidepressantsMirtazepine (Remeron) 2-adrenergic 5- hydroxytryptamine receptor agonist with a high degree of sedationShown to decrease sleep- onset latency, increase sleep duration, and reduce wake after sleep onset in adults with and w/o major depression with little effect on REM


Pharmocotherapy of Pediatric InsomniaSSRIs: may cause sleep-onset delay and sleep disruption (Fluoxetine) and sedation (Fluvoxamine, Paroxetine, Citalopram)SSRIs suppress REM sleep and often prolong REM onset while increasing the number of REMsMost increase sleep-onset latency and decrease sleep efficiency (time asleep/time in bed)Selective serotonin reuptake inhibitors frequently are associated with motor restlessness and may exacerbate preexisting RLS and periodic limb movements

Pharmocotherapy of Pediatric InsomniaOther classes which have reportedly been used include mood stabilizers/anticonvulsants (e.g., carbamazepine, valproic acid, topiramate, gabapentin), atypical antipsychotics (e.g. risperidone, olanzapine, quetiapine), and chloral hydrate.These meds should be used with caution as there are no or limited date on safety and tolerability.Sedating effects may interfere with daytime functioning and learningAtypical antipsychotics may cause weight gain and worsen Obstructive Sleep Apnea; also tend to suppress REM sleep and increase motor restlessness during sleepChloral Hydrate and Barbiturates are not indication for use in children due to significant side effects (inc. hepatotoxcity)


The End

**In newborns, the amount of sleep is divided fairly equally between night and day. In the normal infant, nighttime sleep gradually becomes consolidated over the first year into a single uninterrupted block of time, and daytime sleep gradually decreases over the first three years.

Infants spend about 50% of their sleep time in NREM and 50% in REM sleep

**Bedtime: evening activities, such as television viewing, computer use and studying, followed by bedtime routines. Bedtime difficulties, including bedtime stalling,bedtime refusal, bedtime fears, and inability to fall asleep independently need to be assessed

Nighttime: e latency to sleep onset, behaviours during the night, and the number and duration of night-time awakenings. Details should also be collected about abnormal events during sleep, such as night terrors, confusional arousals, respiratory disturbances, seizures and enuresis. Furthermore, the bedroom environment should be considered as a potential contributor to sleep difficulties, including room temperature, noise and comfort level.

Daytime: wake time and daytime sleepiness. It is important to understand that daytime sleepiness is often manifested differently across thedevelopmental span. For example, younger children andschool-aged children often present with overactivity and difficulties with behavioural and emotional regulation, rather than the more typical lethargy seen in adolescents. naps, meals,

medications and caffeine intake.

Overall daytime functioning should also be assessed,including school performance, psychological functioning,social functioning and family functioning. Life events, from the birth of a sibling to a recent move or family death, can lead to sleep problems. Family tension, due to such issues as financial or marital difficulties can also contribute to sleep difficulties. Note that often children, and especially adolescents, are much more aware of family tensions than parents recognise*May miss kids with PLMD, RLS, or other parasomnias*Instead of going to sleep at 10PM and waking up at 7AM, the person might go to sleep at 12AM, and then have difficulty waking up at 7AM. Night owls. It usually develops during adolescence, but it can develop in children. Likely and exaggerated response to the normal shift in sleep times that occur during adolescence. All adolescents have a shift in their clock after puberty for about 2 hours.

**Phase advancement involves moving the bedtime earlier by 15 minutes on successive nights. If the individual usually falls asleep at 12:30, then bedtime is set for 12:15 for one or two nights, 12:00 for one to two nights, and so on.

Phase delay is chosen if their naturally occurring bedtime is 3 or more hours later than desired. Bedtimeis delayed by 2 to 3 hours on successive nights. For example, if one usually falls asleep at 2 AM, bedtime is delayed until 4 AM on night one, 6AM on night two, and so on until the desired bedtime is reached (e.g.,10:30 PM). Given that it is much easier for the body to adjust to a laterbedtime than an earlier one, it is often recommended to delay bedtime rather than try to advance it.*Catastrophisosel the situation with me.

Article in sleep. Took a grade school and did a sleep study on all the risks to determine risk or sleep disorder breathing and determined a strong linear relationship between waist circumference and BMI. What does that mean for patients we might treat.Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009 Jun 1;32(6):715-6. *I have never used in infants and only have used 3mg in older children and adolescents.

sleep lecture (deepti singh)

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