1. Pediatric Neurology Quick Talks Sleep Disorders Michael Babcock Summer 2013

2. Scenario -4 yo boy -screaming at night -lasts 30 minutes -occurs about 2 hours after going to bed -inconsolable during crying, then falls back asleep -no bed wetting -no limb shaking -eyes closed -no sedation in the AM

3. Sleep Screen – BEARS B – Bedtime issues E – Excessive daytime sleepiness (can exhibit as motor over-activity, inattentiveness, irritability, oppositional defiance) A – night Awakenings R – Regularity and duration S – Snoring If concerns –Movements –Meds

4. Insomnia Onset or Maintenance? Usually behavioral Psychosocial Anxiety (separation) Depression Medical problems – chronic pain, GERD, breathing problems, medications

5. Insomnia Sleep onset Association –Prolonged night awakenings –Child has learned to fall asleep with Associations requiring parents – feeding, rocking, reading; can't self- soothe. –Tx – break connection; put child to be while drowsy but not asleep. Limit-setting subtype –Older children –Active resistance to bedtime –Verbal protests and repeated demands –Can manifest as fearful behavior (crying, clinging) –Usually due to caregiver inconsistency with bedtime rules –Can have medical underlying causes – asthma, medications, sleep disorder – RLS, anxiety. –Tx – caregiver enforces rules

6. Restless Leg Syndrome An urge to move legs, usually accompanied by unpleasant sensation in legs These symptoms: –Begin or worsen during rest/inactivity –Relieved by movement –Occur exclusively or predominantly in evening –Not solely accounted for as symptoms of another medical/behavioral condition Hx – children may have difficulty explaining this unpleasant feeling – pain should not be only feeling. Differential – Periodic leg movement disorder – actual leg movements during sleep without sensation – this can be due to other sleep disorders. Work-up – iron studies Tx – iron supplementation; off label use of gabapentin, benzo's, clonidine, dopamine agonist used less often in children.

7. Excessive daytime sleepiness A sleepy child may not appear sleepy – can be inattentive, hyperactive (trying to stay awake), aggressive, disruptive (sleep-deprived frontal cortex can't regulate emotion) Insufficient sleep – insomnia Inadequate sleep hygiene Medication side-effects Periodic limb movement disorder Idiopathic hypersomnia endocrine/metabolic problems Narcolepsy OSA

8. Narcolepsy –Excessive daytime sleepiness –Sleep paralysis –Hypnagogic hallucinations –Cataplexy Sudden loss of tone Precipitated by emotion (laughing, anger) REM creep –Dx – polysomnography, MSLT

9. Obstructive Sleep Apnea Excessive daytime sleepiness Symptoms – Snoring, with apneic pauses But also –Daytime nasal obstruction –Mouth breathing –Trouble eating/meat refusal –Behavior problems –Bed-wetting –Restless sleep –Sweaty sleep (needs fan on) –AM headache –Poor seizure control Who has OSA –2-3 % of normal development children have OSA –10% of normal children will be habitual snorers – don't have OSA –50% of children with Down's –~50% in obese children Why is it bad –Hypertension, CHF, stroke, diabetes, difficulty losing weight.

10. Parasomnias Disorders of Non-REM arousal –Sleep walking –Sleep terrors –Confusional arousals REM sleep disorders –Nightmares –Sleep paralysis –REM sleep behavior disorder Narcolepsy SSRI neurodevelopmental Sleep-related movement disorders –Rhythmic movement infants/toddlers Start at sleep onset Head rolling/head banging/body rocking –Bruxism –RLS/PLMD Hypnic starts –Brief jerks occurring with falling asleep/awakening –May have sensation of falling

11. Non-REM arousal parasomnias Usually during first 1/3 of night Usually only one event/night Increased arousals cause increased problems –OSA, RLS, GERD. Triggered by sleep deprivation, fever. Toddler and school-aged kids. Usually resolve with time –sleep-walking most likely to persist. Not tired the next day No stereotypic motor movements Last 5-30 minutes Differential – nocturnal seizures –Anytime during night, more often in transition periods –Last 30 seconds – 5 minutes –Multiple events nightly –Daytime seizures –Daytime irritability/lethargy –Older age of onset. Differential – panic attack, GERD. Dx -home videos, polysomnography or overnight EEG. Tx – low dose benzo.

12. References -Uptodate articles – pediatric sleep, NREM sleep disorders, parasomnias, narcolepsy, RLS