1. Sleep & Sleep Issues in the Pediatric Population
Schmitz: xray. Sure

2. Kids Sleep A lot
Sleep is a common discussion point among parents and doctors

3. Many Issues from birth to adolescence….
SIDS
Co-sleeping
Night-wakenings
Bed-wetting
Nightmares
Sleepwalking & Sleeptalking
Timing of High School start times…

4. Sleep Physiology Wakefulness REM Indeterminate NREM
Wakefulness: 50 % is alpha waves (8-13 cps) occipital, crescendo-decrescendo
Stage 1: 15 s of theta waves (3-7 cps) vertex
Stage 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 waves
Indeterminate
NREM

5. Wakefulness 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 tone
Stage 1

6. Stage 1 NREM  Waves Stage 2 NREM Sleep Spindles K-Complexes
Scored when >15 seconds of theta is seen, replacing an Alpha
Considered a transitional sleep stage
Very short duration

7. Stage 3 NREM
20-50 %  Waves
Stage 4 NREM
> 50 %  Waves

8. Conjugate Eye Movements
Stage REM
Alpha Waves
Conjugate Eye Movements
Tonic
low-voltage EEG
increased CBF
Poikilothermia
penile tumescence
Atonia
Phasic
Occipital EEG spikes
autonomic variability
muscle twitches

9. Sleep Stages Overnight
NREM is more common in the first part of sleep.
REM is more common in the latter half of sleep

10. Children’s Sleep Architecture Differs from Adults
More REM
Earlier REM
More frequent REM
More Total Hours of Sleep

13. Sleep in Preemies “Indeterminate Sleep” As gestational age increases…
Neither REM nor NREM
Characterized by “Delta Brushes” and temporal spikes
Predominant pattern at 34 wks
Disappears by 3 months of age
Benign neonatal myoclonia of sleep
SIDS
Central Apnea syndrome of infancy
Has 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 REM
Term infant has onset of sleep and briefer intervals of REM
Preemies have lower thresholds for arousal later in infancy
Rhythmic EEG patterns in the frontal lobe characterize the fullterm infant
Being born prematurely does not accelerate EEG maturation
As gestational age increases…
maximum EEG sleep activity switches from temporal to frontal
Indeterminate Sleep decreases
Synchrony between the 2 hemispheres increases
The preemie’s sleep legacy is easier arousal later on…

14. Normal Infant Sleep Patterns
18 hours a day, 50% REM, at birth
Infants start sleep with REM
Most sleep through night by 3 months
25 % still have not by 6 months of age
Naps
Usually 2 / day until 1st Birthday
2nd nap usually given up by age 3

15. Night 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 weeks
A community survey of 1158 families showed that 20% of 1- to 2-year-old children awakened five or more times a week.
Most experts agree
AAP
Ferber
Brazelton
Mindell
Sears
Promotion of Good Sleep Habits starts early
** Beware of bastardizations of Ferberizing **

16. SIDS Death of an infant under the age of 1 during sleep
90% under the age of 6 months
Usually during winter months
No known cause but many theories
Poor respiratory response to CO2
Poor blood pressure control
Inability to remove obstructions to breathing
Known associations
Sleeping on tummy
Smokers in the house
Not being breastfed

17. School-Age Sleep Issues
Bedtime Struggles
Associated with TV viewing behaviors
Parasomnias

18. Parasomnias Impressive Phenomena Positive Family History
Usually Deep NREM Sleep (Stages 3/4)
Common in childhood, decrease with age
Persistence into adulthood NOT a sign of psychopathology
Can be induced or precipitated by fever, sleep deprivation, and certain medications
febrile 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 cause
Pregnancy or menstruation, suggesting hormonal factors.

19. Prevalence of Parasomnias in Childhood
Persists
Sleeptalking (boys)
Restless Legs (girls)
Sleep Bruxism (boys)
These 3 still age 13 while other parasomnias decrease during childhood

20. Parasomnias Go Together
Sleeptalking
Sleepwalking
sleepwalking and somniloquy, night terrors (.21), somniloquy sleep bruxism
Bruxism
Night Terrors

21. Nightmares Extremely common Preschoolers ages 3-6 REM
2/3 of all kids experience them
Preschoolers ages 3-6
REM
Child believes them to be real.

22. Night Terrors 5 % of pre-schoolers.
Starts between ages 4-12 and resolves spontaneously
Increased FHx of enuresis / sleepwalking in 1st degree relatives
During Stage 3-4 during 1st third of night.
Sits upright, stares, appears frightened, screams, cries, autonomic arousal, unresponsiveness
Lasts ~ 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, autonomic
arousal (tachycardia, rapid breathing, and sweating), absence of detailed dream recall, amnesia for the episode, and relative
unresponsiveness to attempts to comfort the person. [87] [88] Because sleep terrors occur primarily during delta sleep, they
usually take place during the first third of the night. These episodes may cause distress or impairment, especially for caretakers
who 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 usually
begins between the ages of 4 and 12 years and resolves spontaneously during adolescence. It is more common in boys than in
girls. It does not appear to be associated with psychiatric illness in children. In adults, it usually begins between 20 and 30
years of age, has a chronic undulating course, is equally common in men and women, and may be associated with psychiatric
disorders, such as posttraumatic stress disorder, generalized anxiety disorder, borderline personality disorder, and others. An
increased frequency of enuresis and somnambulism has been reported in the first-degree relatives of patients with night
terrors.
Treatment
Nocturnal administration of benzodiazepines has been reported to be beneficial, perhaps because these drugs suppress delta
sleep, the stage of sleep during which sleep terrors typically occur.
1% of adults

23. Night Terrors
Not associated with psych problems in childhood; although in adults, associated with PTSD, panic disorders
If disruptive or occur daily, can try Benzo qhs.
Sometimes can be manifestation of seizures

24. Nightmares Night Terrors
Age
3 - 6 yrs
4 - 8 yrs
Sleep Stage
REM
NREM (3/4)
Time of Night
Late
Early
State on waking
Upset / Scared
Disoriented
Response to parents
Consolable
Unaware of Parents
Return to Sleep
Difficult
Easy / Rapid
Memory of Event
Vivid
None

25. Sleep Bruxism Up to 88% of children; 20 % of adults Any stage of sleep
May result in damage to the
Periodicity of 20 to 30 seconds.
Malocclusion plays no role in bruxism
The force of nocturnal bruxism actually may exceed what is possible with conscious clenching
reminiscent of periodic limb movements during sleep
bruxism actually may represent the symptom of a number of different disorders, including orofacial dyskinesia, mandibular dystonia, and tremor.

26. Sleeptalking Begins during school age NREM and REM sleep No treatment
Bilingual sleeptalking kids talk in their dominant language

27. Sleepwalking More than just walking around…
Simple Behaviors
Complex Behaviors
Begins in ages 4-8 yrs and resolves spontaneously by adolescence.
10 % of children (2.5 % of adults)
Positive Family History
Stage 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 first
third of the night. While sleepwalking, the patient has a blank staring face, is relatively unresponsive to others, and may be
confused or disoriented initially on being aroused from the episode. Although the person may be alert after several minutes of
awakening, complete amnesia for the episode is common the next day. Sleepwalking may cause considerable distress, for
example, if a child cannot sleep away from home or go to camp because of it. By DSM-IV definition, pure sleepwalking is
excluded if it occurs as a result of a medication or substance or is due to a medical disorder. However, sleepwalking may be
an 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 walking
around 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 going
through 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% of
somniloquists also walked during their sleep
Whereas about 10% to 30% of children have at least one sleepwalking episode, only about 1% to 5% have repeated
episodes. The disorder most commonly begins between the ages of 4 and 8 years and usually resolves spontaneously during
adolescence. Genetic factors may be involved, because sleepwalkers are reported to have a higher than expected frequency
of first-degree relatives with either sleepwalking or sleep terrors. [91] Sleepwalking may be precipitated in affected patients by
gently sitting them up during sleep, by fever, or by sleep deprivation. Adult onset of sleepwalking should prompt the search for
possible medical, neurological, psychiatric, pharmacological, or other underlying causes, such as nocturnal epilepsy.
Treatment
No treatment for sleepwalking is established, but some patients respond to administration of benzodiazepines or sedating
antidepressants at bedtime. The major concern should be the safety of the sleepwalker, who may injure herself or himself or
someone else during an episode

28. Nocturnal Enuresis NREM sleep May be restricted to Stage 3-4
Increased bladder pressures during deep sleep
Males with Family History
15% of 5 year olds
10% cure per year, with 3-5% of adolescents

29. Treatment Of Nocturnal Enuresis
Behavioral Modification
Less drinks
Double night
Timed Nighttime voids
Alarm Systems

30. Sleep Motor Phenomena Hypnic Jerks Body Rocking Restless Legs Syndrome
“Periodic Limb Movement Disorder”
Parathesias and desire to move the legs
Stage 1-2 NREM Sleep
More common in children than recognized
40% start in childhood
ADHD Misdiagnoses
“Pepsi in the veins”

31. “Restless Legs Syndrome”
“Periodic Limb Movement Disorder”
Stage 1-2 NREM Sleep
More common in children than recognized
40% start in childhood
Secondary Causes
Anemia, Pregnancy, Uremia, Neuropathy
12-20% of pregnant women
Cured by renal transplant

32. Periodic Limb Movement Disorder

33. Persistence of Childhood Parasomnias into Adolescence

34. Adolescent Sleep
Public Safety
Extracurriculars
School Start times

35. Nocturnal Emissions
Nocturnal penile erections throughout all life stages
Occurs in utero
13 yrs, 2 months
Sexual dream causes ejaculation
How common?
Watching porno movie before sleep doesn’t increase NPE’s
Some older men get Sleep Related Painful Erections

36. Delayed Sleep Phase Syndrome
Excessive Daytime Sleepiness or typically as the sum of its complications
Patients complain of inability to get to sleep until the early morning hours, but little difficulty sleeping once asleep
B-12
Melatonin

37. Narcolepsy Begins in adolescence Triad of Symptoms
Daytime Sleep Attacks
Cataplexy
Sleep Study Findings
Normal total sleep time
onset of sleep
Decreased latency
Highest HLA-disease linkage
in medicine
90% of individuals with narcolepsy carrying the HLA-DR2/DQ1 (under current
nomenclature HLA-DR15 and HLA-DQ6) gene (found in fewer than 30% of the general population). [1] This association is
present 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 as
laughter, anger, excitement, delight, or surprise, occurs in 65% to 70% of patients with narcolepsy. Although the muscle
weakness of cataplexy may be complete, resulting in the individual falling down or being forced to sit, it more commonly is
milder and more focal in nature, taking the form of facial sagging, slurred speech, more localized weakness of an extremity, or
the 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 of
respiration 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.
Hypnagognic
Hallucinations

38. Narcolepsy Somnogram

39. Obstructive Sleep Apnea
Periodic apneas due to sleep-related airway obstruction
Large adenoids
Obesity
Not all snorers have OSA
Daytime Sleepiness in the short-term
Pulmonary hypertension and right heart failure in the long term
19% of women and 30% of men are chronic heavy snorers considerably in excess of the rate of sleep apnea.

40. All Sleep Phenomenon can be a Seizure…
Anything that is recurrent, stereotyped, and inappropriate may be the manifestation of a seizure
Most 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 parasomnia
disorders. Nocturnal seizures may at times be confused with sleep terror, REM sleep behavior disorder, paroxysmal
hypnogenic dystonia, or nocturnal panic attacks. [95] They may take the form of generalized convulsions or may be partial
seizures with complex symptoms. Nocturnal seizures are most common at two times: the first 2 hours of sleep, or around 4 to
6 AM. They are more common in children than in adults. The chief complaint may be only disturbed sleep, torn up bedsheets
and blankets, morning drowsiness (a postictal state), and muscle aches. Some patients never realize they suffer from nocturnal
epilepsy until they share a bedroom or bed with someone who observes a convulsion.
Nocturnal Paroxysmal Dystonia, nocturnal laryngospasm, etc.