Transcript Polysomnography I

Sleep in the Pre-teen Years
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Pre-school (3 to 5 years)
• Sleep needs: 11 to 12 hours
• Naps: Decrease from one a day to none
• Clinical Issues: Sleep onset and sleep
maintenance problems are common
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Pre-pubertal (6 to 12 years)
• Sleep needs: 9 to 11 hours
• Naps: Daytime naps are infrequent
• Delayed sleep-wake timing – later bed times
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Age-related Changes of Parent
Reported Sleep Times
From Iglowstein et al 2003
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Polysomnographically Determined
Age-related Changes of Sleep Time
From Coble et al. 1984
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Sleep Architecture Changes
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3
48.1
50
Percent SWS
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58.5
42.9
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40
35.5
30
20
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Number of Arousals
60
3.5
2.6
2.5
2
1.7
1.5
1.5
1.2
1
0.5
0
0
5-7
8-9
10-11
Age
12-13
14-16
5-7
8-9
10-11
12-13
14-16
Age
From Quan et al 2003
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Age-related Changes in
Napping Frequency and Duration
Acebo et al. SLEEP 2005
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Estimated Prevalence of Sleep
Disorders in Children
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Insufficient sleep – 10% (higher in teens – up to 33%)
• Behaviorally based - 25%
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Sleep related breathing disorders - 2%
Narcolepsy – 0.05%
Sleep/wake timing (delayed sleep phase) - 7% teens
Parasomnias
• Nightmares – 10-50%
• Night terrors 2 - 3%
• Sleep walking 5%
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Rhythmic movement disorder 3 -15%
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Developmental Overview of
Common Non-respiratory Sleep Problems
Newborn/
Young Infant
Older Infant
& Toddler
Pre-schooler
School Age
Teenager
Usually normal
Night wakings
Night wakings
Insufficient sleep
Developmental
Difficulty settling
Self limited
Night terrors
Bedtime
resistance
Bedtime
resistance
Insufficient
sleep
Night terrors
Sleep walking
Sleep walking
Enuresis
Delayed sleep
phase
Rhythmic
movements
Bruxism
Narcolepsy
Rhythmic
movements
Bedtime fears
Nightmares
Bedtime fears
Nightmares
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Insomnia
Complaint of:
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Difficulty initiating sleep (bedtime resistance)
Maintaining sleep (inability to sleep independently)
Daytime impairment:
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Inattention, mood disturbance
Problems with memory and concentration
Impaired performance (at school in children)
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Behavioral Insomnia of Childhood
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Symptoms meet criteria of insomnia
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Pattern consistent with either:
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Sleep-onset association type
Limit-setting type
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Behavioral Insomnia of Childhood
Evaluation
• History
• Precise description of the problem
• Parent response and interaction with child
• Typical night, not extremes
• Careful description of bedtime routines,
including naps
• Evaluate the 24 hour schedule
(weekday, weekend, vacation)
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Behavioral Insomnia of Childhood
Sleep-onset Association Type
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Child begins to associate sleep
onset with circumstances that
are problematic and
demanding of the caregiver
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Child unable to fall asleep
without these associations
either at initial sleep onset or
during nocturnal awakenings
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Treatments for
Sleep-onset Association Type
Education
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Awakenings during the
night are normal
Sleep onset
associations are
learned
Sleep onset
associations are
present at all ages
New sleep onset
associations can be
taught
Behavioral treatment
• Place child in crib/bed awake
and leave room
• If child is upset, return to
comfort
• Do not pick up the child;
comfort verbally
• Stay in room briefly, leave
before child sleeps
• Increase time between
responses
• Same routine for awakenings
and naps
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Treatments for
Sleep-onset Association Type
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Usual response between
3 to 5 nights
If symptoms persist,
consider:
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Instructions not followed
Co-existing problems
Error in diagnosis
More time needed
Modifying the technique
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Modified techniques:
• Eliminate associations in
stages
• Parents present longer
• Limit physical contact
• Gradually withdraw
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Behavioral Insomnia of Childhood
Limit-setting Type
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Refusal to go to bed
at an appropriate time
or following a
nighttime awakening
Insufficient or
inappropriate limit
setting demonstrated
by the caregiver
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Behavioral Insomnia of Childhood
Limit-setting Type: Favorite Delay Tactics
“Mommy …”
“Daddy, I need…”
• I’m hot.
• I’m cold.
• I’m scared.
• I’m not sleepy.
• I’m thirsty.
• My tummy hurts.
• I hear something.
• I have to go to the bathroom.
• Fix my blanket.
• I need to be tucked in again.
• A drink.
• One more kiss.
• One more hug.
• The light on.
• The light off.
• To tell you something
• A band-aid.
• My mommy.
• You to cover me up.
• You to rub my back.
• A tissue.
• Some medicine
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Behavioral Insomnia of Childhood
Limit-setting Type
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Bedtime refusals, stalling
and repeated demands
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May also occur at
naptime and nighttime
wakings
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May be straightforward
or complex
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Treatment of Limit-setting Type
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Emphasize the importance of
limit-setting
Teach general limit-setting
guidelines (day as well as
night)
Specific and individualized
techniques (gate, progressive
door closure)
Positive reinforcement (star
chart)
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Pediatric Obstructive Sleep Apnea
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Sleep Disordered Breathing
Spectrum of conditions determined by relative
amount of upper airway obstruction:
(CIRCLES DISPLAY INCREASING UPPER AIRWAY OBSTRUCTION)
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PS - Primary snoring:
NOISY BREATHING
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UARS - Upper airway resistance syndrome:
NOISY BREATHING + DISTURBED SLEEP
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OH - Obstructive hypoventilation:
NOISY BREATHING ± DISTURBED SLEEP +  CO2 and/or  SaO2
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OSA - Obstructive sleep apnea:
NOISY BREATHING ± DISTURBED SLEEP +  CO2 and/or  SaO2 + ABSENCE OF AIRFLOW
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OSA Epidemiology
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Snoring in children:
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7% - 10% Habitual snorers
20% Intermittent snorers
OSA – 1% to 3% of preschool children
Peaks ages two to five years
Gender distribution: M:F ratio approximately
equal in children
Prevalence is higher among African
Americans
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Cross-Section of Oropharynx
Nasal
obstruction
Micro- or
retrognathia
Tonsillar
hypertrophy
Large
tongue
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Pathophysiology of OSA
Structural factors
• Adenotonsillar hypertrophy
• Craniofacial abnormality
• Obesity
Neuromotor tone
• Cerebral palsy
• Genetic diseases
OSA
Other factors
• Genetic
• Hormonal
•?
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Risk Factors
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Adenotonsillar hypertrophy
Craniofacial anomalies
Down syndrome
Obesity
Neurologic disorders
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Tonsillar Hypertrophy
The degree of tonsillar hypertrophy may
not correlate with the presence of OSAS
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Clinical Features
Nocturnal Symptoms
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Loud snoring
Observed apneic pauses
Snorting / gasping / choking
Restless sleep
Diaphoresis
Paradoxical chest wall movement
Abnormal sleeping position
Secondary enuresis
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Clinical Features
Diurnal Symptoms
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Daytime somnolence
Behavioral / school problems
Difficulty awakening in AM
Morning headaches
Nasal congestion
Mouth breathing
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Pediatric Polysomnography
EEG
EOG
Nasal EtCO2
Nasal Oral Airflow
Chin EMG (2)
Microphone
Sao2
EKG
Tech Observer
Video Camera
Respiratory Effort
Documents arousals,
parasomnias, abnormal
sleeping position, and attends
to any technical problem
Leg EMG (2)
Record behavior
Courtesy of Dr. Carol Rosen
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Consequences of Pediatric OSA
• Effects on growth
• Neurocognitive morbidity
• Cardiovascular consequences
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Neurocognitive Morbidity
• Hyperactivity, inattention, aggression
• Impaired school performance
• Daytime sleepiness
• Depression
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Cardiovascular Consequences
• Pulmonary Hypertension
• Cor Pulmonale
• Systemic Hypertension
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Cor Pulmonale in OSAS
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Blood Pressure in OSAS
Marcus et al. Am J Respir Crit Care Med 1998
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Positive Airway Pressure
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Children on CPAP
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Special Considerations for CPAP in
Children
• Need wide variety of mask sizes and styles
to fit children
• Compliance may be enhanced by behavioral
techniques
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Empowerment
Positive reinforcement
Desensitization
Role modeling
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Childhood Parasomnias
Undesirable events or experiences
occurring:
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At entry into sleep
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Within sleep
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During arousal from sleep
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Parasomnia Classification
• Disorders of Arousal (from NREM sleep)
• Parasomnias Associated with REM Sleep
• Other Parasomnias
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Disorders of Arousal
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Arousals from NREM sleep
First half of night, typically short duration
Prolonged or multiple episodes may occur
Confusion / automatic behavior
Difficult to awaken during event
Fragmented imagery
Rapid return to sleep after event
Amnesia of events
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Confusional Arousals
Clinical Characteristics:
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Occur on arousal from NREM sleep
May not recognize parents
May cry, yell, or moan
Speech often unintelligible,
sounds like words
Most common words: “No, No!”
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Sleep Terrors
• Peak age: 5-7 years
• Prevalence rate of 2.0 - 6.5%
• Most will later sleepwalk
• Usual duration in children:- 4 years
• 50% end by age 8
• 36% continue into adolescence
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Sleep Terrors
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Begin abruptly from NREM sleep
Episodes of agitation and apparent terror
Heralded by a blood-curdling scream or cry
Followed by confusion, agitation and autonomic
disturbances
• Patient difficult to arouse
• If patient can be awakened, may describe:
• Vague sense of terror
• Isolated or fragmented dream imagery
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Sleepwalking
Clinical Characteristics
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Quiet wandering (injury unlikely)
Agitated wandering (injury more likely)
Behaviors of variable complexity
Inappropriate behaviors
Most sleepwalkers have few daytime effects
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Disorders of Arousal: Treatment
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Allow episodes to run their course:
• Interfere only to prevent injury
• May try to lead the patient calmly to bed
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Emphasize sleep hygiene
Secure the bedroom to prevent injury:
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Consider ground floor bedrooms
Window and door locks, pad bedrails
Remove sharp objects or toys on bedroom floor
Alarms or barriers at door/stairs
Medications may be necessary in severe cases
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Parasomnias Associated with REM
Sleep
• Nightmares
• Sleep paralysis
• REM Sleep Behavior Disorder
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Nightmares
• 75% of children experience nightmares
• 10 - 50% of children have nightmares
severe enough to disturb their parents
• Proportion of children reporting nightmares
reaches a peak around ages 6-10 years
and decreases thereafter
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Nightmares
Clinical Characteristics:
• Usually during last half of night
• Complex dream mentation: –
“Good dream gone bad”
• Emotional reaction more significant
than autonomic response
• Fully alert upon awakening
• Responsive to comforting
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Nightmares
Precipitating Factors:
• Anxiety / Stress
• Personality – association with creativity
• Post-traumatic stress disorder
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Nightmares and PTSD
When there is a history of significant physical
or psychological trauma, recurrent nightmares
may occur and are likely a symptom of
Posttraumatic Stress Disorder (PTSD)
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Nightmares of PTSD
• Trauma-related nightmares are the most
consistent problem reported by Posttraumatic
disorder (PTSD) patients
• Nightmares are present in up to 80% of PTSD
patients (usually beginning within three months
of the trauma)
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Nightmares
Treatment:
• Explanation and reassurance
• Sleep hygiene
• Behavioral therapies
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Nightmares & Sleep Terrors
Nightmares
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REM sleep
Most common parasomnia
2nd half of night
Delayed return to sleep
Easily comforted
Detailed narrative
description of episode
Mild autonomic activity
Alert upon awakening
Sleep Terrors
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NREM sleep
2.0 - 6.5% prevalence
1st half of night
Rapid return to sleep
Resists comforting
Fragmented recall /
amnesia
Intense autonomic activity
Confusion on waking
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Pediatric RLS: Prevalence
“Night-Walkers” Survey
• 138 adults with RLS (mean age 60 years)
• 18% reported symptoms began before age 10 years
• 25% reported symptoms began before age 20 years
• Childhood RLS case reports
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Pediatric RLS: Clinical features
• Attention sought for “growing pains”
• These present as:
• Sleep onset problems
• Sleep maintenance problems
• Daytime irritability and attention problems
may occur, likely due to sleep deprivation
• Family history is positive for RLS
• Iron deficiency may play a role as in adults
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Pediatric RLS
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An urge to move legs, caused by discomfort
as described in child’s own words
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Begins or worsens during periods of inactivity
Partially or totally relieved by movement
Worse in the evening or night
Biological parent / sibling with definite RLS
Periodic limb movements of 5 or more per
hour of sleep on PSG
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Pediatric RLS: Treatment
• Strict sleep hygiene is necessary to avoid
sleep deprivation
• Limiting setting often required (day and at
bedtime)
• Treatment of iron deficiency
• Medications:
• Clonazepam 0.25 to 1.0 mg qHS
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