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1 Pediatric Sleep Disorders Craig T. Nakamura, M.D. Z Z Z Z...

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Presentation on theme: "1 Pediatric Sleep Disorders Craig T. Nakamura, M.D. Z Z Z Z..."— Presentation transcript:

1 1 Pediatric Sleep Disorders Craig T. Nakamura, M.D. Z Z Z Z...

2 2 People who say they sleep like a baby usually don't have one. -- Leo J. Burke

3 3 TODAY’S OBJECTIVES: -- background -- obstructive sleep apnea -- sonambulism (sleep walking) -- night terrors -- sleep hygiene -- prevent everyone from falling asleep

4 4 Animal Sleep Times Brown Bat20 hours / day Tiger16 hours / day Ferret14.5 hours / day Platypus14 hours / day Cat12 hours / day Dog10.5 hours / day Pig8 hours / day Cow4 hours / day Giraffe2 hours / day Infant16 hours / day Adult8 hours / day Elderly5.5 hours / day Peds Pulmonologist4 hours / day

5 5 Average Sleep Times By Age AGE:Night Sleep (hours):Day Sleep (hours): 1 week month months months months months months years years years years years years years years years years8.25

6 6 Courtesy of the Perelman School of Medicine at the University of Pennsylvania Fatigue by State TOP TEN : 1. West Virginia 2. Tennessee 3. Kentucky 4. Oklahoma 5. Florida 6. Missouri 7. Georgia 8. Alabama 9. Mississippi 10. Louisiana

7 7 Courtesy of the Perelman School of Medicine at the University of Pennsylvania Sleep Disturbance by State

8 8 “Paying the Mortgage” Insufficient sleep  sleep debt (eventually must be “repaid”) affects immunity also nervous system important for cycling of growth hormone In adults, ↑ rate of automobile accidents by 3x

9 9 Sleep in Children

10 10 Sleep Induced Changes Sleep impairs ventilation in all children (sick or healthy): -- normal -- underlying respiratory illness -- CNS disease -- obstructive sleep apnea

11 11 Sleep Disorders in Children If diagnosed and treated early, morbidity can be avoided Therefore, important to recognize signs of sleep-disordered breathing: a)primary care providers b)teachers c)parents d) local postman

12 12 Sleep Stages

13 13 Sleep Stages 5 phases of sleep stages 1, 2, 3, 4, REM sleep 50%  stage 2 20%  REM sleep 30%  the other 3 stages progresion from stages 1 to REM ~ 90 to 110 min / total cycle then cycle starts again

14 14 Stage 1 Sleep light sleep drift in and out eyes move very slowly muscle activity slows when awaken, recall fragmented visual images sense of falling muscle contractions

15 15 Stage 2 Sleep eye movements stop brain waves become slower occasional bursts called sleep spindles

16 16 Stages 3 & 4 (Deep) Sleep no eye or muscle movements when awakened, groggy, disoriented bedwetting, night terrors, sleep walking Stage 3: extremely slow (delta) brain waves with smaller faster waves Stage 4: delta waves

17 17 REM Sleep rapid, irregular breathing eyes jerk rapidly limb muscles temporarily paralyzed heart rate & BP ↑ bizarre / illogical dreams first cycle 70 to 90 minutes penile erections HEH HEH. HE SAID, ERECTION.

18 18 Obstructive Sleep Apnea

19 19 Apnea: Greek word meaning “want of breath”

20 20 Obstructive Sleep Apnea Syndrome (OSAS) Disorder of breathing during sleep characterized by prolonged partial and / or intermittent complete upper airway obstruction that disrupts normal ventilation and patterns during sleep. First described in 1965

21 21 Obstructive Sleep Apnea adults: cessation for > 10 seconds children: cessation for 2 ½ missed breaths with apneas, oxygen levels ↓, carbon dioxide levels ↑ also causes arousals and fragmented sleep

22 22 Obstructive Sleep Apnea prevalence ~ 2% affects millions M = F more common with family history of OSAS ↑ in African Americans ↑ in children with chronic respiratory tract infections

23 23 Obstructive Sleep Apnea ↑ in children years of age same age of adenoidal & tonsillar hypertrophy continues through adolescence (especially with craniofacial anomalies, neurologic disorders, obesity)

24 24 Obstructive Sleep Apnea due to upper airway collapse can be due to: – anatomic factors – abnormal neuromuscular tone – both worse in REM sleep

25 25 OSAS: etiologic factors obesity craniofacial disorders esp. mid-face hypoplasia micrognathia ie. Pierre-Robin other -- Crouzon synd-- Aperts synd -- Down synd-- Achondroplasia -- Duchenne’s MD-- cerebral palsy -- Arnold Chiari malf-- Prader-Willi synd -- hypothyroidism-- choanal stenosis -- sickle cell anemia -- mucopolysaccharidosis

26 26 Obstructive Sleep Apnea: History predominant symptoms -- snoring -- labored breathing -- daytime somnolence -- difficulty in school important to ask about snoring, snorting, noisy breathing (gasping, grunting) note: parents frequently don’t volunteer this information

27 27 Other Historical Findings: labored breathing, retractions, paradoxical chest wall motion observed apneas restless sleep diaphoresis enuresis cyanosis unusual positions seated or neck hyper-extension daytime neurobehavioral abnormalities ADHD or sleepiness morning headaches from hypercapnia

28 28 OSA Findings hypertension -- systemic -- pulmonary failure to thrive adenoidal facies nasal obstruction mouth breathing hyponasal speech tongue size tonsils size soft palate size and shape

29 29 Obstructive Sleep Apnea gold standard  nocturnal full, observed polysomnogram (sleep study) rarely, multiple sleep latency test (MSLT) other studies much less helpful -- audiotapes -- nocturnal videotaping -- overnight pulse oximetry -- nap sleep study (1 hr) re-testing after T&A essential (~ 6 week post-op)

30 30 Obstructive Sleep Apnea questionaires to 7 th and 8 th graders 1,588 questionaires top 25% [HP] and bottom 25% [LP] frequent / loud snoring: 5 % HP / 13% LP Prior tonsillectomy / adenoidectomy: 7 HP / 24 LP (3.4 odds ratio) Conclusion: children with lower academic performance ↑ snoring and more likely to require T&A. “A learning debt that may hamper future performance” Gozal D et al. Pediatrics. 2001; 107(6):

31 31 Obstructive Sleep Apnea 297 first graders in lowest 10 th percentile sleep studies to assess for sleep-associated gas exchange abnormalities [SAGEA] SAGEA identified in 54 (18.1%) encouraged to Rx 24 underwent T&A [T&A] in T&A group, improvement by 0.5 no change in non-T&A group & those in top 90 th percentile Gozal D et al. Pediatrics. 1998; 102(3 pt 1):

32 32 Obstructive Sleep Apnea Conclusion: SAGEA is frequently present in poorly performing 1 st grade students in whom it adversely affects learning performance. The data suggest that a subset... could have SAGEA and may benefit from prospective medical evaluation and treatment. Gozal D et al. Pediatrics. 1998; 102(3 pt 1):

33 33 Obstructive Sleep Apnea surgical treatment – adenotonsillectomy adenoids can reappear – uvulopalatopharyngoplasty (UP3) – rarely tracheostomy – occasional recurrence other therapies – CPAP – BiPAP – lifestyle changes (ie. weight loss)

34 34 Z Z Z Z Z ! Primary Snoring in Children

35 35 Primary Snoring snore – a noise produced when breathing in (vibrates soft palate and uvula) snoring without sleep apneas 20% of normal children snore occasionally % snore every night OSAS only ~ 2% of snorers

36 36 Primary Snoring differs from primary snoring OSAS associated w/ complications primary snoring – 10% of children – not associated with OSA, arousals, or gas exchange abnormalities

37 37 Primary Snoring study on 1,144 3 rd grade school children snoring shown to be associated with poor academic performance in math and spelling in 3 rd grade school children Urschitz MS et al. Am J Respir Crit Care Med

38 38 Central apneas Sudden infant death syndrome (SIDS)

39 39 Sleepwalking (somnambulism)

40 40 Somnambulism typically pre-pubertal children highest years old (17%) can last into adulthood genotyping walking or moving during sleep potential for harm

41 41 Somnambulism difficulty arousing can be triggered by sleep disorder amnesia following first 3 rd of sleep episode slow wave sleep (stages 3 or 4)

42 42 Somnambulism get plenty of sleep develop calming bedtime ritual remove hazardous materials ground floor if possible reduce open windows occasionally hypnosis benzodiazepines Topamax?

43 43 Night Terrors

44 44 Night Terrors sudden arousal from slow wave sleep (stage 3 or 4); 1 st third of p.m. intense terror cry followed by autonomic changes tachycardia partial or total amnesia can occur nightly

45 45 Sleep Hygiene

46 46 Sleep Hygiene – habits / behaviors stimulants caffeine: coffee, tea, colas, cocoa, chocolate, medications nicotine exercise -- generally helpful -- avoid within 6 hours of bedtime

47 47 Sleep Hygiene – habits / behaviors alcohol slows brain waves initially, but disrupts sleep later (↓ REM sleep) avoid within 4 – 6 hours of bedtime

48 48 Sleep Hygiene environment comfortable bed, dark & quiet room mask / earplugs if necessary minimize changes diet heavy meals before disrupts light snack can help, especially milk and other dairy products (tryptophan)

49 49 Sleep Hygiene regular schedule reduce stress avoid long daytime naps reduce stimuli avoid clock-watching designate worry time

50 50 Sleep Hygiene sleep only when drowsy if unable to sleep, leave & return when sleepy maintain regular waking time limit bedroom activities avoid / reduce naps – limit to less than 1 hour – no later than 3 p.m. helpful tips:

51 51 Signs of problems too much time needed to help child fall asleep child wakes repeatedly behavior & mood are affected parents also lose sleep parent-child relationship starts to suffer

52 52 Three common problems sleep-onset association disorder ie. child requires rocking night-time eating / drinking disorder ie. frequently awakens for feeds limit-setting problems ie. refusing to go to bed or stalling children can get pretty creative

53 53 Sleep Hygiene in Children bedtime preparation can reduce anxiety 10 to 30 minutes of “special time” before bed should not be stimulating – ie. no wrestling or scary stories don’t extend length of “special time”

54 54 YAWN FACTS: -- lasts six seconds -- heart rate ↑ 30% -- 55% yawn within 5 min of seeing someone else -- the blind yawn after hearing someone else -- reading about yawning stimulates yawning -- fetuses yawn -- olympic athletes often yawn before competing - unknown cause - possible boredom  color test bar pattern 5.8 yawns / min  “MTV-like” video 3.4 yawns / min

55 55 THE END

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