1. Pediatric Sleep Medicine:
A brief overview from A to Zzzzzz….

2. Introduction:
Sleep related upper airway problems are common in pediatrics
Behavioral sleep problems are also common
Underlying medical and anatomic problems increase the risk for and severity of these conditions
Involved testing, incomplete understanding and a general lack of “evidence” further complicates the diagnosis and management of pediatric sleep disorders

3. Why We Sleep Is Unknown, But A Good Night Sleep is Important:
Emotionally
Cognitively
Behaviorally
Performance
Family dynamics
Influence on health

4. The Biology of Sleep: Circadian System:
Circadian rhythms exist in all living things
Sleep-wake cycle is one of many examples
Circadian clock is located in the suprachiasmatic nucleus (SCN)
SCN neurons generate and maintain an oscillating rhythm via “clock” genes and their products

5. The Biology of Sleep:
The human Circadian rhythm is slightly longer than 24 hours and must be set or entrained to match our daily schedules
Light, physical activity and melatonin are the most potent “entrainers” (zeitgebers):
These can work to favor or oppose sleep
In general, when the rhythm is out of synch with scheduling demands, Circadian Rhythm Sleep Disorders are present

6. The Biology of Sleep: The Homeostatic System:
“Process S” (Sleep drive) is dependent upon the duration and quality of prior sleep and waking:
The longer you have been awake, the greater the drive to sleep and vice versa
After the main sleep period, the “homeostat” has been re-set and the drive to sleep is low
If there is an abnormality of sleep or if sleep is restricted, then Process S (the drive to sleep) will remain strong and the individual will be sleepy at inappropriate times

7. The Biology of Sleep:
Ideally the Circadian rhythm and Homeostatic drive are synchronized and the sleep-wake cycle is smooth and regular
In general:
“Circadian rhythm sleep disorders” occur when the circadian rhythm is desynchronized from the demands of everyday life
“Homeostatic or intrinsic sleep disorders” result from problems with sleep quality, quantity or regulation

8. Pediatric Sleep: What is normal?
Respiration during sleep:
Quiet and subtle
Sleep environment:
Infancy:
Back-to-Sleep
Safe crib
No co-sleeping
Rooming in for 6-months
No smoking
Childhood:
Quiet and comfortable
No stimulation
No electronics

9. General Sleep Hygiene:
Establish routine:
Consistent bedtime and wake up time
Consistent meals and naps
Bedtime ritual:
Transitional objects as age-appropriate
Increase exercise:
Not after dinner though…
Wind down period:
Quiet activity
Soft light
Sleep charts if needed

10. Sleep Hygiene: Is there any hope?
A large study (n=565) of pre-school children evaluating the use of healthy media on sleep quality and problems:
Risk factors for poor sleep include:
High levels of media use
Bedtime use of media
Frightening or violent media content
In this cohort problems with sleep latency were most commonly reported
Substitution of pro-social and educational media in a randomized study:
Resulted in fewer sleep problems over an 18-month follow up period
Garrison et al. Pediatrics 2012;130:

11. Sleep Hygiene: Is there any hope?
A small pilot study in adolescents aged years:
F.E.R.R.E.T. intervention:
Food
Emotions
Routine
Restrict
Environment
Timing
Short term improvements in sleep hygiene and other outcomes:
Sleep hygiene scores
Sleepiness scores
BMI z-scores
Tan et al. BMC Pediatrics 2012, 12:189

12. Tan et al. BMC Pediatrics 2012, 12:189
Theme
Rule 1
Rule 2
Rule 3
Food
No food or drink 30 minutes before bed
Avoid food and caffeine 3 hours before bed
No alcohol or smoking 3 hours before bed
Emotions
Set a time for thinking and planning each day
Wind down and relax 30 minutes before bed
Try not to worry, think or plan while in bed
Routine
Wake up and go to sleep same time each day
Turn lights on when you wake, Dim lights before bed
Keep the same sleep routine each day
Restrict
No electronics 30 minutes before bed
No exercise 3 hours before bed
Bed is for sleeping only
Environment
Comfortable bed clothes and bed
Light, temperature and noise
Keep clocks faced away from bed
Timing
Sleep for the recommended amount of time
Remember 30 minutes and 3 hours
Try to stick to the rules
Tan et al. BMC Pediatrics 2012, 12:189

13. Pediatric Sleep: What is normal?
Typical sleep requirements throughout childhood:
Age group Age Sleep need
Infants 3 to 12 months hours
Toddlers 1 to 3 years hours
Preschoolers 3 to 5 years hours
School-aged 6 to 12 years hours
Adolescents 12 to 18 years hours
Meltzer and Mindell Psychiatr Clin N Am (2006)

14. Pediatric Sleep: What is normal?
Typical patterns of daytime sleep throughout childhood:
Age group Daytime Sleep
1 week 8 hours
1 month 7 hours
3 months 5-6 hours
6 months 3-4 hours
9 months hours
12 months 2-3 hours
18 months 2 hours
2-3 years 1-2 hours
Most children eliminate regular daytime naps between the age of 3-5 years

15. How much sleep are American children and adolescents getting?
Age Group Recommendation Study Finding
Infants (3-11 mo) h h
Toddlers (12-35 mo) h h
Preschoolers (3-6 yr) h h
School age (1st-5th grade) h h
Adolescents (6th-12th grade) 9.25 h 7 h
From the “Sleep in America Polls” 2004 & 2006

16. Adolescents Living the 24/7 Lifestyle:
Real world assessment of adolescent (n=100, aged years) technology and caffeine use:
66% had television in bedroom
30% had a computer in the bedroom
90% had a cell phone
79% had an MP-3 player
85% with caffeine intake
Self-reported activities after 9PM:
Watching TV
Text messaging
“On average, adolescents engaged in 4 technology activities after 9M”
Calamaro et al. Pediatrics 2009;e1005-e1010

17. Adolescents Living the 24/7 Lifestyle:
Multi-tasking was associated with worse sleep and daytime consequences:
20.6% of the cohort obtained 8-10 hours of sleep per night
33% of the cohort reported falling to sleep at school
More multi-taking was associated with lower sleep times and higher caffeine intake
Television in bedroom did not correlate with sleep time
Caffeine intake:
Timing was skewed to impair sleep:
6-8AM 18.7%
3-5PM 25.3%
6-8PM 21.3%
Calamaro et al. Pediatrics 2009;e1005-e1010

18. Pediatric Sleep Disorders: A working list
Normal sleep:
Developmental evolution throughout childhood
Usually defined by satisfied parents!
Behavioral sleep disorders:
Overlap syndrome with influence of cultural and societal norms
Usually defined by dissatisfied/frustrated parents!
Parasomnias or Transitional Disorders:
Usually defined by frightened parents!

19. Pediatric Sleep Disorders: A working list
Breathing disorders during sleep:
Broad spectrum of clinical syndromes and presentations
A number of common manifestations
Parents may be unaware of concerning symptoms!
Neurological disorders:
Less common in general
Children with special healthcare needs can be very challenging

20. Components of a Pediatric Sleep Evaluation: “BEARS”
Mnemonic for:
Bedtime
Excessive Daytime Sleepiness
Awakenings
Regularity
Snoring
Based on the four most common symptoms of pediatric sleep disorders:
Difficulty with sleep onset
Problems that disrupt sleep
Inability to awaken from sleep at the desired time
Daytime sleepiness
Rosen, GM: “Case-Based Analysis of Sleep Problems in Children” in Principles and Practice of Pediatric Sleep Medicine

21. Common Non-Respiratory Sleep Problems: A working list
Sleep talking
Bruxism
Night terrors
Rhythmic movements
Behavioral insomnia of childhood
Confusional arousals
Sleepwalking
Nightmares
Insomnia
Delayed Sleep Phase
Restless Leg Syndrome
Narcolepsy
Adapted from: Moore, M et al.: CHEST 2006;

22. Age Distribution of Common Non-Respiratory Sleep Problems:
Infant & Toddler (1-2 yrs):
Behavioral Insomnia of Childhood
Rhythmic Movements
Preschool (3-5 yrs):
Sleep Terrors
School age (6-12 yrs):
Insufficient Sleep
Bedtime Resistance
Sleep-Walking
Adolescence (13-18 yrs)
Delayed Sleep Phase
Narcolepsy
Adapted from: Moore, M et al.: CHEST 2006;

23. Unique Aspects of Pediatric Sleep in Otherwise Healthy Infants and Children:
Another working list:
Delayed Settling
Trained Night Feeder
Trained Night Awakening
Developmental Night Awakening
Prolonged Routines
Curtain Calls
Bedtime Fears
Parasomnias
Management of these “problems” is facilitated by a good understanding of normal childhood development and confident supportive parenting skills

24. Night Terrors: Parent is terrified
Slow Wave Sleep:
Usually in the first or second cycle of sleep
Incidence ~5%, may be familial
Rare before mo
Can cluster
Self resolve by 8-10 yrs
Child is asleep:
Sympathetic output:
Sweating, thrashing, screaming
Child has no memory of the event

25. Night Terrors: Management: Reassure parents: Phase shift:
No need to awaken child
Safety
Avoid secondary gain
Phase shift:
Afternoon nap to decrease Stage 3 sleep
Awaken 1 hour into sleep
I do not favor medications:
Benzodiazepines

26. Nightmares: Child is terrified
Occur during REM periods:
Latter part of the night
Most common in preschoolers:
Learning about the “hard knocks” of life
Stress and other disruptions to routine
Child awakens and should remember dream:
Child is frightened

27. Nightmares: Child is terrified
Simple management:
Reassurance
Bedtime ritual and security object to prepare for good dreams
Brief intervention in child’s room
Avoid secondary gain
I do not favor medications
Complex management:
Counseling
Prazosin
Relaxation

28. Select features of Nightmares and Night Terrors:
Sudden onset
Autonomic nervous system activity
Behavioral manifestations of fear
Difficulty arousing the child
Confusion upon awakening
Amnesia of the episode
Dangerous behaviors
Recurrent episodes
Recall of a disturbing dream
Various emotions, but none will be good
Full awakening and alerting
Recall is good
Delayed return to sleep
Episodes occur in the latter half of the sleep period
Adapted from: ICSD 2nd ed: Diagnostic and Coding Manual. AASM; 2005

29. Behavioral Insomnia of Childhood:
Bedtime resistance
Frequent night time awakenings
10-30% of infants and toddlers
Sleep-onset association type:
Certain conditions must be met to facilitate sleep
Positive associations: Self comfort
Negative associations: External stimuli
Limit setting type:
Bedtime stalling or refusal
Combined type

30. Behavioral Insomnia of Childhood:
Sleep-onset association type:
Limit-setting type:
Falling asleep is an extended process
Falling asleep requires special conditions
When conditions are not met, sleep latency is prolonged and sleep is disrupted
Nighttime awakenings require caregiver intervention
Difficulty with sleep initiation and maintenance
Stalling and refusal to go to bed or return to bed after nighttime awakening
Caregiver cannot set limits to establish sleep hygeine
Adapted from: ICSD 2nd ed: Diagnostic and Coding Manual. AASM; 2005

31. Behavioral Insomnia of Childhood:
General treatment principles:
Not particularly evidence-based
Sleep hygiene:
Bedtime routine
Learn self-soothing
Extinction/Graduated extinction:
Ignore the behavior until it is extinguished:
Extinction burst
Learning about limits:
Parenting skills
Bedtime fading

32. Prolonged Routines and Curtain Calls:
May be a phase shift or limit setting issue:
Manage limits and increase daytime attention in general
Involve child in the plan
Parents need to “be strong:”
No escalation: Lead quietly back to bed
Reward positive behaviors:
Extra story the next night
Other systems
Physical barriers if needed:
Gates, locks
Parent sits outside door

33. Insufficient Sleep: Sleep deprivation: Clinical clues:
De-emphasis of sleep due to other commitments
Cumulative sleep debt results in:
Fatigue, mood changes, illness
School tardiness
Falling asleep in school
Sleepy driver accidents or fatalities
Clinical clues:
Needing to be awakened for school
Sleeping 2 hours or more on weekends and vacations
Falling asleep at inappropriate times
Behavior and mood differ after getting adequate sleep

34. Delayed Sleep Phase Syndrome:
Circadian rhythm disorder with delayed sleep-wake times:
2 or more hours
Interfering with daily schedules activities (school)
Most common in adolescents
Night owl syndrome:
Inability to fall asleep at “normal” time
Bedtimes of
Sleep onset/efficiency and quality are normal at this shifted time
Treatment is difficult:
Chronotherapy—phase advancement or phase delay
Melatonin to advance the circadian clock
Light therapy

35. The Spectrum of Pediatric Sleep Disordered Breathing:
Central Sleep Apnea Syndromes:
May or may not be developmental
CNS Disorders
Hypoventilation Syndromes:
Congenital Central Hypoventilation Syndrome
Neuromuscular
Respiratory Dysrhythmia Syndromes:
May be developmental
Awake respiration may or may not be normal
Laboratory studies may actually be helpful

36. The Spectrum of Pediatric Sleep Disordered Breathing:
Airway Obstructive Syndromes
A number of conditions which are possibly interrelated:
Primary snoring
Upper airway resistance syndrome
Obstructive sleep apnea syndrome
All three are manifest by snoring
Respiration during wakefulness usually normal
Routine laboratory studies not generally helpful

37. Primary Snoring:
Defined as snoring in the absence of apnea, gas exchange abnormalities or arousals
Snoring is a common “symptom:”
Up to 10% of children snore regularly
The majority have Primary Snoring
Consequences of Primary Snoring are unclear:
No evidence of progression to OSA…
Some developmental consequences are proposed
No treatment is currently recommended

38. “He snores just like his father!” Maybe that is not so cute…
A large cohort study (n=249 parent-child pairs) evaluated snoring in preschool children:
Parental report of loud snoring more than twice weekly that was absent (no snoring), transient (snoring at age 2 but not age 3) or persistent (snoring at both ages):
Non-snorers: 68%
Transient snorers: 23%
Persistent snorers: 9%
Beebe et al.: Pediatrics 2012;130:

39. “He snores just like his father!” Maybe that is not so cute…
Risk factors for snoring:
Higher BMI
Pre and post natal tobacco smoke exposure
African American race
Lower parental education and family income
Absent or shorter duration of breast feeding
Persistent snoring was associated with adverse behavioral and developmental outcomes:
Behavioral:
Hyperactivity
Depression
Attention
Beebe et al.: Pediatrics 2012;130:

40. Upper Airway Resistance Syndrome:
Defined as a syndrome of snoring and prolonged partial upper airway obstruction:
Repetitive episodes of increased work of breathing that leads to arousal:
Diagnosed by polysomnogram with evidence of increased work of breathing (paradoxical breathing) and arousal
Apnea, hypopnea and gas exchange abnormality are generally absent
Treatment options are the same as those for obstructive sleep apnea syndrome

41. Obstructive Sleep Apnea Syndrome:
A syndrome occurring during sleep characterized by:
Obstructive apnea
Partial upper airway obstruction
Hypoventilation
Hypoxemia
Incidence thought to be 1-3% of all children:
Up to 40% of specialty referred patients with snoring
Obstructive apnea with desaturation

42. Obstructive Sleep Apnea:
Imbalance of forces:
Airway opening and closing pressures
An imbalance between these forces balance due to anatomic or neuromuscular factors results in inappropriate airway closure
Retropalatal
Retroglossal
Katz, ES: Proc Am Thorac Soc Vol 5, 2008

43. Approaching the Patient with Possible Sleep Disordered Breathing:
Sleep & Developmental History
Co-existing conditions
Physical Examination:
Growth parameters
Upper airway anatomy and patency
Heart sounds
Chest wall configuration
Awake gas exchange
Potential testing:
Chest and airway/neck films
ECG
Blood tests are usually normal
Specialized testing
Rating tonsil hypertrophy

46. Adenotonsillar Hypertrophy:
Most common “cause” of OSA in children
Most prevalent in young school age children:
Related to normal lymphoid hyperplasia ages 2-6 years
Tonsil and adenoid size related to severity but not presence of OSA
Most common reason for referral to our lab

47. Diagnosis of Obstructive Sleep Apnea Syndrome:
Literature supports the benefits of early diagnosis and treatment
Obstructive sleep apnea cannot be diagnosed based upon history and physical exam alone:
Sleep history should be obtained
Screen for symptoms of OSA
Physical examination features
Polysomnography is the “gold standard:”
Expensive, but cost-effective when used correctly

48. Symptoms of Pediatric Obstructive Sleep Apnea Syndrome:
Nocturnal:
Symptoms correlate with severity:
Snoring
Labored breathing
Sweating
Restless sleep
Unusual sleep position
Enuresis
Normal breathing during sleep in a child should be a subtle finding!

49. Symptoms of Pediatric Obstructive Sleep Apnea Syndrome:
Daytime:
May be absent
Mouth breathing
Nasal obstruction
Hyponasal speech
Increased attention being given
to neurobehavioral aspects of OSA:
Attention problems
Learning problems
Behavior problems
Hyperactivity
Mouth breathing in
adenoidal hypertrophy

50. Complications of Pediatric Obstructive Sleep Apnea Syndrome:
Growth related:
Failure to thrive reported:
Increased work of breathing
Decreased growth hormone secretion
Cardiopulmonary:
Pulmonary hypertension
Cor pulmonale
Systemic hypertension
Right or left ventricular hypertrophy

51. Treatment of Pediatric Obstructive Sleep Apnea Syndrome:
Healthy children:
Adenotonsillectomy is usually curative:
Post-operative risk factors well documented
Mild OSA:
Intranasal Steroids
Montelukast
Antihistamines
Other items to address:
Chronic or allergic rhinitis
Co-morbidities:
Obesity
Asthma
Tonsillar hyperplasia and infection

52. Adenoid size (adenoidal/nasopharyngeal ratio) significantly decreased with montelukast.
Adenoid size (adenoidal/nasopharyngeal ratio) significantly decreased with montelukast. The ratio decreased from 0.81 ± 0.04 before (pre) to 0.57 ± 0.04 after (post) treatment; P < In contrast, children who received placebo displayed no significant changes. Star indicates a significant difference between pre and post values.
Goldbart A D et al. Pediatrics 2012;130:e575-e580
©2012 by American Academy of Pediatrics

53. Montelukast treatment resulted in a significant improvement in the OAI
Montelukast treatment resulted in a significant improvement in the OAI. The pretreatment average of 3.7 ± 1.6 before (pre) dropped to 1.9 ± 1.0 after (post) treatment; P < .05.
Montelukast treatment resulted in a significant improvement in the OAI. The pretreatment average of 3.7 ± 1.6 before (pre) dropped to 1.9 ± 1.0 after (post) treatment; P < .05. In contrast, 12 weeks of placebo treatment did not significantly change the OAI; means: 3.5 ± 1.6 (pre) vs 3.7 ± 1.0 (post) treatment; P = .75. Star indicates a significant difference between pre and post values.
Goldbart A D et al. Pediatrics 2012;130:e575-e580
©2012 by American Academy of Pediatrics

54. Treatment of Pediatric Obstructive Sleep Apnea Syndrome:
Nasal mask ventilation:
CPAP/BiPAP®
Can be implemented post-operatively if needed
Supplemental oxygen:
Use with caution
Devices:
Not well studied
Efficacy and safety unknown…

55. Recently Updated Clinical Practice Guideline:
Clinical practice guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome:
All children should be screened for snoring
PSG should be performed for snoring and symptoms/signs of OSAS
Adenotonsillectomy is recommended as first-line treatment of patients with ATH
High risk patients should be monitored as inpatients post-operatively
Patients should be re-evaluated post-operatively
CPAP is recommended
Weight loss is recommended
Intranasal corticosteroids are an option in mild OSAS

56. The diagnosis and management of pediatric sleep disorders is important!
A large (~11,000) cohort study evaluated sleep disordered breathing (SDB) and behavioral sleep problems (BSP) in children:
SDB defined by:
Snoring, Witnessed apnea, Mouth breathing
BSP defined by:
Evaluation of sleep behaviors
“A history of either SDB or BSP in the 1st 5-yrs of life was associated with the need for SEN at 8 yrs of age. Findings highlight the need for pediatric sleep disorder screening”
Bonuck et al.: Pediatrics 2012;130:

57. Some Final Thoughts: Sleep disordered breathing common in pediatrics:
OSA is just one example
Many underlying medical conditions can affect sleep
Behavioral sleep problems are also common:
Treatment can be challenging
Sleep hygiene is critical
Important outcomes require clarification
Lean CPAP Patient