Sleep & Sleep Issues in the Pediatric Population Schmitz: xray. Sure. 5536387

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

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

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

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

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

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

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

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

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

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 pattern @ 34 wks GA and disappears by age 3 months. Term infant spends 50% in REM Term infant has REM @ 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…

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

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 **

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

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

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.

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

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

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.

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

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

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

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.

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

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

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

Treatment Of Nocturnal Enuresis Behavioral Modification Less drinks Double Voids @ night Timed Nighttime voids Alarm Systems

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”

“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

Periodic Limb Movement Disorder

Persistence of Childhood Parasomnias into Adolescence

Adolescent Sleep Public Safety Extracurriculars School Start times

Nocturnal Emissions Nocturnal penile erections throughout all life stages Occurs in utero Oigarche @ 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

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

Narcolepsy Begins in adolescence Triad of Symptoms Daytime Sleep Attacks Cataplexy Sleep Study Findings Normal total sleep time REM @ 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

Narcolepsy Somnogram

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.

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.