Presentation on theme: "Sleep & Sleep Issues in the Pediatric Population"— Presentation transcript:
1Sleep & Sleep Issues in the Pediatric Population Schmitz: xray. Sure
2Kids Sleep A lotSleep is a common discussion point among parents and doctors
3Many Issues from birth to adolescence…. SIDSCo-sleepingNight-wakeningsBed-wettingNightmaresSleepwalking & SleeptalkingTiming of High School start times…
4Sleep Physiology Wakefulness REM Indeterminate NREM Wakefulness: 50 % is alpha waves (8-13 cps) occipital, crescendo-decrescendoStage 1: 15 s of theta waves (3-7 cps) vertexStage 2: Sleep Spindles appear (12-14 cps) lasting ½ to 3 s. K Waves (sharp slow waves). If a K wave or spindle not seen in 3 minutes, it’s Stage 1.Stage 3: 20-50% delta waves (0.5-2 cps)Stage 4: > 50% delta wavesIndeterminateNREM
5Wakefulness EOG (LOC) EOG (ROC) EEG (C3-A2) EEG (O1-A2) EMG (submental)Awake: >50% of each epoch contains alpha activity. Slow rolling eye movements or eye blinks will be seen in the EOG channels Relatively high submental EMG muscle toneStage 1
6Stage 1 NREM Waves Stage 2 NREM Sleep Spindles K-Complexes Scored when >15 seconds of theta is seen, replacing an AlphaConsidered a transitional sleep stageVery short duration
13Sleep in Preemies “Indeterminate Sleep” As gestational age increases… Neither REM nor NREMCharacterized by “Delta Brushes” and temporal spikesPredominant pattern at 34 wksDisappears by 3 months of ageBenign neonatal myoclonia of sleepSIDSCentral Apnea syndrome of infancyHas 3rd pattern in addition to REM/NREM called indeterminate sleep. Predominant 34 wks GA and disappears by age 3 months.Term infant spends 50% in REMTerm infant has onset of sleep and briefer intervals of REMPreemies have lower thresholds for arousal later in infancyRhythmic EEG patterns in the frontal lobe characterize the fullterm infantBeing born prematurely does not accelerate EEG maturationAs gestational age increases…maximum EEG sleep activity switches from temporal to frontalIndeterminate Sleep decreasesSynchrony between the 2 hemispheres increasesThe preemie’s sleep legacy is easier arousal later on…
14Normal Infant Sleep Patterns 18 hours a day, 50% REM, at birthInfants start sleep with REMMost sleep through night by 3 months25 % still have not by 6 months of ageNapsUsually 2 / day until 1st Birthday2nd nap usually given up by age 3
15Night Wakenings Promotion of Good Sleep Habits starts early One or more waking from midnight to 5 am 4/7 days Night waking that is defined as waking and crying once or more between midnight and 5 AM at least four of seven nights per week for at least four consecutive weeksA community survey of 1158 families showed that 20% of 1- to 2-year-old children awakened five or more times a week.Most experts agreeAAPFerberBrazeltonMindellSearsPromotion of Good Sleep Habits starts early** Beware of bastardizations of Ferberizing **
16SIDS Death of an infant under the age of 1 during sleep 90% under the age of 6 monthsUsually during winter monthsNo known cause but many theoriesPoor respiratory response to CO2Poor blood pressure controlInability to remove obstructions to breathingKnown associationsSleeping on tummySmokers in the houseNot being breastfed
17School-Age Sleep Issues Bedtime StrugglesAssociated with TV viewing behaviorsParasomnias
18Parasomnias Impressive Phenomena Positive Family History Usually Deep NREM Sleep (Stages 3/4)Common in childhood, decrease with agePersistence into adulthood NOT a sign of psychopathologyCan be induced or precipitated by fever, sleep deprivation, and certain medicationsfebrile illness, alcohol, prior sleep deprivation, and emotional stress.Medication-induced: sedative/hypnotic agents, neuroleptic drugs, minor tranquilizers, stimulants, and antihistamines, often in combination with each other.Magnesium deficiency has been suggested as a causePregnancy or menstruation, suggesting hormonal factors.
19Prevalence of Parasomnias in Childhood PersistsSleeptalking (boys)Restless Legs (girls)Sleep Bruxism (boys)These 3 still age 13 while other parasomnias decrease during childhood
20Parasomnias Go Together SleeptalkingSleepwalkingsleepwalking and somniloquy, night terrors (.21), somniloquy sleep bruxismBruxismNight Terrors
21Nightmares Extremely common Preschoolers ages 3-6 REM 2/3 of all kids experience themPreschoolers ages 3-6REMChild believes them to be real.
22Night Terrors 5 % of pre-schoolers. Starts between ages 4-12 and resolves spontaneouslyIncreased FHx of enuresis / sleepwalking in 1st degree relativesDuring Stage 3-4 during 1st third of night.Sits upright, stares, appears frightened, screams, cries, autonomic arousal, unresponsivenessLasts ~ 10 minutes then child returns to undisturbed sleep. No recall.This disorder is defined as repeated abrupt awakenings from sleep characterized by intense fear, panicky screams, autonomicarousal (tachycardia, rapid breathing, and sweating), absence of detailed dream recall, amnesia for the episode, and relativeunresponsiveness to attempts to comfort the person.   Because sleep terrors occur primarily during delta sleep, theyusually take place during the first third of the night. These episodes may cause distress or impairment, especially for caretakerswho witness the event. Sleep terrors may also be called night terrors, pavor nocturnus, or incubus.The prevalence of the disorder is estimated to be about 1% to 6% in children and less than 1% adults. In children, it usuallybegins between the ages of 4 and 12 years and resolves spontaneously during adolescence. It is more common in boys than ingirls. It does not appear to be associated with psychiatric illness in children. In adults, it usually begins between 20 and 30years of age, has a chronic undulating course, is equally common in men and women, and may be associated with psychiatricdisorders, such as posttraumatic stress disorder, generalized anxiety disorder, borderline personality disorder, and others. Anincreased frequency of enuresis and somnambulism has been reported in the first-degree relatives of patients with nightterrors.TreatmentNocturnal administration of benzodiazepines has been reported to be beneficial, perhaps because these drugs suppress deltasleep, the stage of sleep during which sleep terrors typically occur.1% of adults
23Night TerrorsNot associated with psych problems in childhood; although in adults, associated with PTSD, panic disordersIf disruptive or occur daily, can try Benzo qhs.Sometimes can be manifestation of seizures
24Nightmares Night Terrors Age3 - 6 yrs4 - 8 yrsSleep StageREMNREM (3/4)Time of NightLateEarlyState on wakingUpset / ScaredDisorientedResponse to parentsConsolableUnaware of ParentsReturn to SleepDifficultEasy / RapidMemory of EventVividNone
25Sleep Bruxism Up to 88% of children; 20 % of adults Any stage of sleep May result in damage to thePeriodicity of 20 to 30 seconds.Malocclusion plays no role in bruxismThe force of nocturnal bruxism actually may exceed what is possible with conscious clenchingreminiscent of periodic limb movements during sleepbruxism actually may represent the symptom of a number of different disorders, including orofacial dyskinesia, mandibular dystonia, and tremor.
26Sleeptalking Begins during school age NREM and REM sleep No treatment Bilingual sleeptalking kids talk in their dominant language
27Sleepwalking More than just walking around… Simple BehaviorsComplex BehaviorsBegins in ages 4-8 yrs and resolves spontaneously by adolescence.10 % of children (2.5 % of adults)Positive Family HistoryStage 3-4 Sleep; 1st third of night.This disorder is characterized by repeated episodes of motor behavior initiated in sleep, usually during delta sleep in the firstthird of the night. While sleepwalking, the patient has a blank staring face, is relatively unresponsive to others, and may beconfused or disoriented initially on being aroused from the episode. Although the person may be alert after several minutes ofawakening, complete amnesia for the episode is common the next day. Sleepwalking may cause considerable distress, forexample, if a child cannot sleep away from home or go to camp because of it. By DSM-IV definition, pure sleepwalking isexcluded if it occurs as a result of a medication or substance or is due to a medical disorder. However, sleepwalking may bean idiosyncratic reaction to specific drugs, including tranquilizers and sleeping pills.Most behaviors during sleepwalking are routine and of low-level intensity, such as sitting up, picking the sheets, or walkingaround the bedroom. More complicated behaviors may also occur, however, such as urinating in a closet, leaving the house,running, eating, talking, driving, or even committing murder. A real danger is that the individual will be injured by goingthrough a window or falling from a height.Can cause distress (ie. Can’t go to camp or to sleepover)sitting up, picking the sheets, walking around bedroom.More complicated ones: urinating in closet, leaving the house, eating, talking, driving, committing murder. Falls are a concern.At age 11 years, 81% percent of sleepwalkers talked in their sleep, while 16% ofsomniloquists also walked during their sleepWhereas about 10% to 30% of children have at least one sleepwalking episode, only about 1% to 5% have repeatedepisodes. The disorder most commonly begins between the ages of 4 and 8 years and usually resolves spontaneously duringadolescence. Genetic factors may be involved, because sleepwalkers are reported to have a higher than expected frequencyof first-degree relatives with either sleepwalking or sleep terrors.  Sleepwalking may be precipitated in affected patients bygently sitting them up during sleep, by fever, or by sleep deprivation. Adult onset of sleepwalking should prompt the search forpossible medical, neurological, psychiatric, pharmacological, or other underlying causes, such as nocturnal epilepsy.TreatmentNo treatment for sleepwalking is established, but some patients respond to administration of benzodiazepines or sedatingantidepressants at bedtime. The major concern should be the safety of the sleepwalker, who may injure herself or himself orsomeone else during an episode
28Nocturnal Enuresis NREM sleep May be restricted to Stage 3-4 Increased bladder pressures during deep sleepMales with Family History15% of 5 year olds10% cure per year, with 3-5% of adolescents
29Treatment Of Nocturnal Enuresis Behavioral ModificationLess drinksDouble nightTimed Nighttime voidsAlarm Systems
30Sleep Motor Phenomena Hypnic Jerks Body Rocking Restless Legs Syndrome “Periodic Limb Movement Disorder”Parathesias and desire to move the legsStage 1-2 NREM SleepMore common in children than recognized40% start in childhoodADHD Misdiagnoses“Pepsi in the veins”
31“Restless Legs Syndrome” “Periodic Limb Movement Disorder”Stage 1-2 NREM SleepMore common in children than recognized40% start in childhoodSecondary CausesAnemia, Pregnancy, Uremia, Neuropathy12-20% of pregnant womenCured by renal transplant
33Persistence of Childhood Parasomnias into Adolescence
34Adolescent SleepPublic SafetyExtracurricularsSchool Start times
35Nocturnal EmissionsNocturnal penile erections throughout all life stagesOccurs in utero13 yrs, 2 monthsSexual dream causes ejaculationHow common?Watching porno movie before sleep doesn’t increase NPE’sSome older men get Sleep Related Painful Erections
36Delayed Sleep Phase Syndrome Excessive Daytime Sleepiness or typically as the sum of its complicationsPatients complain of inability to get to sleep until the early morning hours, but little difficulty sleeping once asleepB-12Melatonin
37Narcolepsy Begins in adolescence Triad of Symptoms Daytime Sleep AttacksCataplexySleep Study FindingsNormal total sleep timeonset of sleepDecreased latencyHighest HLA-disease linkagein medicine90% of individuals with narcolepsy carrying the HLA-DR2/DQ1 (under currentnomenclature HLA-DR15 and HLA-DQ6) gene (found in fewer than 30% of the general population).  This association ispresent to varying degrees in different ethnic populations and represents the highest disease-HLA linkage known in medicine.Cataplexy, the sudden loss of muscle tone, typically triggered by emotion, such aslaughter, anger, excitement, delight, or surprise, occurs in 65% to 70% of patients with narcolepsy. Although the muscleweakness of cataplexy may be complete, resulting in the individual falling down or being forced to sit, it more commonly ismilder and more focal in nature, taking the form of facial sagging, slurred speech, more localized weakness of an extremity, orthe feeling that one's knees may ''give way."Sleep paralysis is experienced by up to 60% of patients with narcolepsy and consists of total-body paralysis, with sparing ofrespiration and EMs. It lasts from seconds to minutes and is very frightening to the patient.Hypnagogic (at sleep onset) and hypnopompic (upon awakening) hallucinations are seen in 12% to 50% of cases.HypnagognicHallucinations
39Obstructive Sleep Apnea Periodic apneas due to sleep-related airway obstructionLarge adenoidsObesityNot all snorers have OSADaytime Sleepiness in the short-termPulmonary hypertension and right heart failure in the long term19% of women and 30% of men are chronic heavy snorers considerably in excess of the rate of sleep apnea.
40All Sleep Phenomenon can be a Seizure… Anything that is recurrent, stereotyped, and inappropriate may be the manifestation of a seizureMost often confused with sleep terrors,More common in the first 2 hours of sleep, or around 4-6 am.More common in kids than adults.Some forms of epilepsy occur more commonly during sleep than during wakefulness and may be associated with parasomniadisorders. Nocturnal seizures may at times be confused with sleep terror, REM sleep behavior disorder, paroxysmalhypnogenic dystonia, or nocturnal panic attacks.  They may take the form of generalized convulsions or may be partialseizures with complex symptoms. Nocturnal seizures are most common at two times: the first 2 hours of sleep, or around 4 to6 AM. They are more common in children than in adults. The chief complaint may be only disturbed sleep, torn up bedsheetsand blankets, morning drowsiness (a postictal state), and muscle aches. Some patients never realize they suffer from nocturnalepilepsy until they share a bedroom or bed with someone who observes a convulsion.Nocturnal Paroxysmal Dystonia, nocturnal laryngospasm, etc.