Presentation on theme: "Sleep disorders in children"— Presentation transcript:
1 Sleep disorders in children Dr Scott Burgess PhD FRACPPaediatric Respiratory and Sleep Physician
2 Outline / Learning objectives: Be able to describe thePathophysiologySymptomsPossible consequencesInvestigation (including role of sleep studies) andManagement of OSA in childrenGain and understanding of common non-respiratory sleep problems in children, in particularSleep onset associations disorder in young childrenSleep phase disorder in teenagersQuestions?
3 Why worry about sleep problems? Common – up to 30% of children are reported to have sleep problemImportant – can impact on...BehaviourDevelopmentGrowthMedical well-beingAdverse impact on parental mental healthTreatable – GPs have a crucial role to play.
4 Obstructive sleep apnoea OSA is characterised by:recurrent episodes of partial or complete upper airway obstruction during sleepdisruption of normal gas exchange (intermittent hypoxaemia or hypercapnoea)sleep fragmentation.
6 Frequency of SDB Snoring is a frequent symptom in children Approximately ¼ of children snore intermittentlyHabitual snoring (loud snoring reported to occur three of more times per week) reported by 10% parentsOSA affects approximately 2-3% of children.
7 PathophysiologyOSA is associated with narrowing or collapse of the upper airway during inspiration. Typically at the level of the soft palate and adenoids (Isono, Shimada et al. 1998).
8 Predisposing factors (1) Sleep state: REM sleep is associated with loss of pharyngeal muscle tone and a change in breathingAdenotonsillar hypertrophy: growth of adenoids and tonsils relative to the airway, 2-8 yearsShape, size and collapsibility of the airway: individual variation in the size and collapsibility of the airway, heritable factorExposure to cigarette smoke and recurrent viral URTIsPuberty: following puberty males developing longer upper airway, males > females post puberty.
9 Predisposing factors (2) Arousal threshold and breathing control: mechanoreceptors in the upper airway stimulated by increased respiratory effort cause arousal during apnoea. Blunted in children with OSAMedical conditions and syndromes may be associated with decreased airway tone and calibre (eg Down syndrome, Prader Willi, craniofacial abnormalities for example Pierre Robin)Medications and alcohol can reduce airway tone and respiratory driveObesity is associated with increased adipose tissue in the neck, decreased lung volumes and diaphragm excursion when supineObesity may even blunt respiratory drive normally stimulated by hormones such as Leptin.
10 Symptoms of OSA Snoring Snorting Laboured breathing / paradoxical chest wall movementWitnessed apnoeasSweatingRestless sleepMouth breathingSleeping with neck extended or other usual posturesHyperactivity, behavioural and cognitive problemsSleepiness.
11 Neurobehavioural consequences There is evidence that children with OSA have more behavioural problems than controlsPoor attentionConcentrationHyperactivityAggressive behaviouralMoodinessPoorer academic performanceReduced scores on psychometric testing (IQ) in school aged children.
12 Cardiovascular complications Episodes of obstruction are associated with autonomic activationSome, but not all studies, have reported an increase in systolic blood pressurePulmonary hypertension and right ventricular strain is a risk factor in severe OSAWeak risk factor for metabolic syndrome and cardiovascular diseaseCombination of OSA and morbid obesity is an increasing concern in relatively young children.
13 OSA DiagnosisBoth history and examination do not accurately predict sleep study findings:Illicit the history of above symptomsVideo recording of snoring and apnoeaExamination for nasal disease and increased tonsilsConsider in obese children and those with strong family historyRemember OSA in children with disorders of tone or upper airway.
17 Treatment of OSAMedical treatment of nasal disease: Nasal steroid +/- SingulairWeight lossCigarette smoke exposureImprove behavioural sleep problemsENT surgery: T’s and A’s, or other surgeryCPAP – second lineOther:Bi-level (CPAP > 15cm, mixed disease)Maxillary expansionTracheostomy.
18 Non-respiratory Sleep problems Inadequate sleepBehavioural insomnia of childhoodNightmares / bad dreams / night time fearsParasomnias (night terrors, sleep walking)Sleep phase syndromesPsychophysiological insomniaNarcolepsyRestless legs syndrome.
19 How much sleep do children need. Iglowstein. Pediatrics. 2003 How much sleep do children need? Iglowstein. Pediatrics p302 Lot of individual variation, below are averagesAge (years)Total Sleep% having day nap0.514.2100113.91.513.6213.296312.587411.850511.4356118710.610.4910.1109.99.6129.313148.7
21 Most common behavioural problems Sleep onset association (SOA)Refers to a requirement by the infant or child for certain things to be happening as they go off to sleepInterferes with their ability to independently go to sleepIncludes: being fed or patted to sleep, parent being presentParents commonly complain that their child wakes more frequently during nightNormal children wake multiple times overnightBut can put self back to sleepSOA – child cries until association is repeatedLimit setting type: Thus typically involves difficulties getting the child to go to bed and curtain calls.
22 Routines and sleep hygiene Set a bedtime that will allow adequate sleep durationConsistent routinesShould be clear to child when bedtime is coming upConsistent from night to night and between carersEnvironment: having TV in the child’s room and iPADs have been associated with increased difficulties falling asleep and less sleep time per nightAvoid caffeine containing drinks (USA 18% of preschoolers and 28% of younger school aged children drink at least one caffeinated beverage per day)Quiet activity before bed eg looking at picture book or reading.
23 Sleep associationGraduated withdrawal (controlled crying) vs extinctionNeed to have a planNeed to agree on a planNeed to be consistentStart at beginning of nightRepeat during night and day napsMonitor progressShould see progress over daysAdjuncts: Melatonin 1-2 mg 30 minutes before bed.
24 Delayed sleep phase disorder Second most common sleep disorder in adolescents (following inadequate sleep)5–10% of adolescentsPersistent delay of at least 2 h beyond the desired bedtime, resulting in disruptions to the adolescent’s functioningTrouble falling asleep (not anxious or worrying) but once asleep sleeps well and has trouble waking in time for schoolMelatonin (Circadin) 2mg 45 minutes before bed and natural light at ideal wake up timeNeed to be consistentIf extreme may need to move back slowly.
25 Resources Triple P (Positive parenting program) Parenting and Family Support Centre, UQ, PhChild Health Nurses and Early intervention serviceEllen Barron Centre – public inpatient unit (PCH)North West Private Hospital – Brisbane Nurture CentreQ-CLASS (www.qclass.com.au)Suresh and ScottBeth Shirley – GP with interest in infant sleep / settlingFiona Hudson – Psychologist with interest in sleepWesley sleep studies – short waiting list and covered by private insurance.