Transcript Slide 1
Objectives
Outline 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 Lot
By 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 by Age
Reality
Sleep Dysfunction In Children
Insufficient Sleep
Sleep deprivation
Fragmented Sleep
Sleep disruption
Excessive Daytime Sleepiness
Primary Disorders of EDS
Daytime Sleepiness in Children:
Impact
Sleep 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 Infants
Critical sleep reorganization at 8-12
weeks; establish diurnal cycle
Develop NREM sleep by 6 months;
decreased REM
At 6 months: TST is 13-14 hours; sleep
episodes 6-8 hours
70-80% sleep through
the night at 9 months
Sleep in Toddlers
Total sleep time – 12-14 hours
Most give up second nap at 1 year
Developmental 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-Schoolers
TST-11-12 hours/day
Many give up regular daytime nap by age
4-5 years
Signaled night wakings occur frequently;
role of parental reinforcement
Sleep problems may become chronic
Sleep in School Age Children
Total sleep time 9-11 hours
◦ 10-11 hours in 6-7 y.o. ↓9.5 hours in adoles.
Stable sleep pattern night to night
Low 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 Adolescence
Delayed 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 Adolescence
Decreased daytime alertness
◦ ↑ sleep pressure, ↓ circadian output
Less parental “protection” of TST
Leads to insufficient sleep
◦ Most need 9-9.5 hours
◦ Average high school student sleeps only
7 1/4 hours
Causes of EDS-Insufficient Sleep
Common problem in 24/7 society
More fun activities at night
◦ Electronic babysitter, electronics in bedroom
Family stresses
◦ Daycare, work schedules
Adolescents “escape” parental controls
Insufficient Sleep Evaluation
Question 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 Evaluation
Bedtime 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 Disorder
Child 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 Disorder
Parents 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: Management
Preventative education for parents
SOAD-child needs to learn to fall asleep in
reproducible conditions
LSSD-family needs help with setting limits
and consequences
Problems will wax and wane and re-training
is necessary
Disrupted Nocturnal Sleep
Environmental issues
◦ Sleep location-bed-who’s?, couch, variable?
◦ Electronics, temperature, light, food
What to do?
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Importance of bedtime routine
Regular sleep location-quiet, dark
No electronics-TV, phone, games
No food
No reason to be up!
Disrupted Nocturnal Sleep
Issues 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 Sleepiness
Medications
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Many associated with daytime sleepiness
Anti-epileptic medications
Medications to treat muscle spasm
Psychotropic medications
Antihistamines
Caffeine-sleep disruption, PLMs
Intrinsic Disorders of Sleepiness
Hypersomnia
◦ Excessive daytime sleep despite normal
nocturnal sleep
Narcolepsy
◦ EDS – may have co-existing sleep disorders
Abnormal brain regulation of sleep/wake
Diagnosis of exclusion after ruled out
insufficient sleep or disrupted sleep
Intrinsic Disorders of Sleepiness
Narcolepsy
◦ 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 Sleepiness
Hypersomnia
◦ Similar issues as in narcolepsy
◦ Lack other symptoms seen in narcolepsy
◦ Kleine-Levin, menstrual associated
Diagnosis made by history + PSG/MSLT
PSG to look for other sleep disorders
MSLT quantifies daytime sleepiness
◦ Necessary for diagnosis, to get medications
Intrinsic Disorders of Sleepiness
History
◦ Amount of daytime sleep
◦ Where falling asleep- School, bus, bathroom,
meals, clinic?
PSG-looking for OSA, PLMs, seizure, etc
MSLT
◦ Daytime studied to quantify sleepiness
◦ 5 naps 2 hours apart looking for sleep and
REM
Intrinsic Disorders of Sleepiness
Treatment
Consider referral to sleep expert
◦ Determine exact diagnosis, treat other sleep
disorders
◦ Arrange appropriate testing
◦ Determine appropriate medication regimen
Stimulants, treatment for cataplexy
Maximize nocturnal sleep
Scheduled daytime naps
Schedule important tests/activities during periods of
maximal alertness
Circadian 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 ADHD
Children with ADHD ↑ sleepiness vs nl
◦ Hyperactivity adaptive behavior for EDS
Medication 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
Sleepy behavior
Impulsivity, hyperactivity, aggressiveness
Labile mood and inattention
Neurocognitive deficits
◦ ↓creativity, poor abstract thinking
◦ ↓memory, vigilance, attention, motor skills
Sleep problems may mimic ADHD Sx
Sleep History: ‘BEARS”
Bedtime
Excessive daytime sleepiness
Awakenings: night or early morning
Regularity and duration of sleep
Snoring
BEARS: Bedtime
What happens at sleep onset
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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: Excessive Daytime
Sleepiness
What is the extent of daytime sleepiness
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Difficulty waking in am
Does the child act sleepy or seem overtired
Behavior when overtired
Daytime naps
Any similar history in family members
BEARS: Awakenings
Characterize 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: Regularity and Duration of
Sleep
Characterize sleep habits
◦ Bedtime and wake time
Weekdays vs. weekends
◦ Does the child get enough sleep
◦ How much sleep does the child need
BEARS: Snoring
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