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
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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
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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
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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
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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
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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
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Sleep in School Age Children
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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
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◦ Rare naps
◦ Some have prolonged sleep latency
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Increasing pressure from schedule
◦ Earlier wake times, later bedtime from school
work/activities
Sleep Changes in Adolescence
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Delayed sleep onset
◦ Circadian: relative phase delay at puberty
◦ Environmental factors-music, computer, work
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Advanced wake times (sleep offset)
◦ Earlier school start time
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Decreased sleep/wake regularity
◦ Different weekday/weekend schedule
Sleep Changes in Adolescence
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Decreased daytime alertness
◦ ↑ sleep pressure, ↓ circadian output
Less parental “protection” of TST
 Leads to insufficient sleep
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◦ 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
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◦ Electronic babysitter, electronics in bedroom
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Family stresses
◦ Daycare, work schedules
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Adolescents “escape” parental controls
Insufficient Sleep Evaluation
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Question child and caregivers
◦ Signs/symptoms of sleepiness
 Sleeping, irritable, behavioral/focus issues
◦ Weekdays and weekends?
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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
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Bedtime routine
◦ Stimulating activities?
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Activities during the night
◦ Once down do they stay down?
◦ Fun activities during the night
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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
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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
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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
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Environmental issues
◦ Sleep location-bed-who’s?, couch, variable?
◦ Electronics, temperature, light, food
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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
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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
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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
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Hypersomnia
◦ Excessive daytime sleep despite normal
nocturnal sleep
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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
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Intrinsic Disorders of Sleepiness
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Narcolepsy
◦ EDS + cataplexy makes diagnosis
◦ Other symptoms: sleep paralysis, hypnagogic
hallucinations, disrupted nocturnal sleep
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Narcolepsy statistics
◦ Onset in second decade
◦ Diagnosis may take years to make
◦ 25-50/100,00 in US
Intrinsic Disorders of Sleepiness
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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
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◦ Necessary for diagnosis, to get medications
Intrinsic Disorders of Sleepiness
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History
◦ Amount of daytime sleep
◦ Where falling asleep- School, bus, bathroom,
meals, clinic?
PSG-looking for OSA, PLMs, seizure, etc
 MSLT
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◦ 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
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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
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Sleep Problems in ADHD
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Children with ADHD ↑ sleepiness vs nl
◦ Hyperactivity adaptive behavior for EDS
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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
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◦ ↓creativity, poor abstract thinking
◦ ↓memory, vigilance, attention, motor skills
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Sleep problems may mimic ADHD Sx
Sleep History: ‘BEARS”
Bedtime
 Excessive daytime sleepiness
 Awakenings: night or early morning
 Regularity and duration of sleep
 Snoring
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BEARS: Bedtime
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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
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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
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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
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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
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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