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

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

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

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

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

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

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

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

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

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;130:492-499

Sleep Hygiene: Is there any hope? A small pilot study in adolescents aged 10-18 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

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

Pediatric Sleep: What is normal? Typical sleep requirements throughout childhood: Age group Age Sleep need Infants 3 to 12 months 14-15 hours Toddlers 1 to 3 years 12-14 hours Preschoolers 3 to 5 years 11-13 hours School-aged 6 to 12 years 10-11 hours Adolescents 12 to 18 years 8.5-9.5 hours Meltzer and Mindell Psychiatr Clin N Am (2006) 1059-1076

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 2.5-3.5 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

How much sleep are American children and adolescents getting? Age Group Recommendation Study Finding Infants (3-11 mo) 14-15 h 12.7 h Toddlers (12-35 mo) 12-14 h 11.7 h Preschoolers (3-6 yr) 11-13 h 10.3 h School age (1st-5th grade) 10-11 h 9.5 h Adolescents (6th-12th grade) 9.25 h 7 h From the “Sleep in America Polls” 2004 & 2006

Adolescents Living the 24/7 Lifestyle: Real world assessment of adolescent (n=100, aged 12-18 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

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

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!

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

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

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; 1252-1262

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; 1252-1262

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

Night Terrors: Parent is terrified Slow Wave Sleep: Usually in the first or second cycle of sleep Incidence ~5%, may be familial Rare before 18-24 mo Can cluster Self resolve by 8-10 yrs Child is asleep: Sympathetic output: Sweating, thrashing, screaming Child has no memory of the event

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

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

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

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

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

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

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

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

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

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 0200-0300 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

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

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

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

“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;130:382-389

“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;130:382-389

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

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

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

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

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

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

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!

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

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

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

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 < .001. 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

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

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…

Recently Updated Clinical Practice Guideline: Clinical practice guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome: www.pediatrics.org/cgi/doi/10.1542/peds2012-1671 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

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;130:634-642

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