2. Objectives
• Understand normal sleep in children
• Review common pediatric sleep disorders
• Discuss proper treatment options for
childhood sleep disorders
4. The Sleep Cycle
• Each sleep cycle 90 – 120 minutes
• First REM period is shortest
• Most NREM deep sleep occurs early
• Most REM occurs late
5. Children’s Sleep Differs
from Adults
• More frequent REM
• Earlier REM
• More Total Hours of Sleep
• Sleep disorders common in pediatrics than
adults
6. REM & NREM Sleep by Age
0
2
4
6
8
10
12
14
16
18
1 - 3
M
3 - 5
M
6-23
M
2 - 3
Y
3 - 5
Y
5 - 9
Y
10-13
Y
14-18
Y
19-30
Y
TotalHrsSleep
Total daily sleep by age
During childhood sleep accounts for 40% of the day
At birth, REM ≈ 50% of total sleep, ↓ to 25% in adult
7. prevalence ≈25% - 43%of children ages 1-5
years
interfere with daily patient and family
functioning.
sleep problems cause significant emotional,
behavioral, and cognitive dysfunction.
common among children with
neurodevelopmental, medical and
psychiatric disorders.
Lehmkuhl et al.,2008
12. The clinical evaluation involves:
obtaining a careful medical history
assess for medical cause of sleep disturbance
Current sleep patterns, including sleep duration,
sleep-wake schedule, sleep habits, Nocturnal
symptoms
Polysomnogram (PSG) record: EEG, EMG, EOG,
Vital Signs and Other Physiologic ParametersOwens, 2011
13.
14.
15. Difficult initiate or maintain sleep or early
morning awake with difficult return to sleep
Occur 3 nights/week, for at least 3 months,
despite sufficient time for sleep.
Not due to the effects of a substance
Not explained by mental/medical illness
Prevalence 1 – 6 % in pediatrics but higher in
children with chronic med/psych conditions
Czeisler et al., 201
16. Insomnia is subdivided into:
1. Sleep onset insomnia: difficulty falling asleep.
2. Sleep maintenance insomnia: frequent or
sustained awakenings.
3. Sleep offset insomnia: early morning
awakenings
4. Non-restorative sleep: persistent sleepiness
despite adequate sleep duration
Czeisler et al., 201
17. • Mainly treated with behavioral interventions
• Media removal from bedroom
• Avoid caffeine
• Consistent bedtime routine and positive
reinforcement from parents/caregivers
• Correct the underlying med/psycho factors
Treatment of insomnia
Owens, 2011
18. prolonged sleep episodes, excessive sleepiness
prolonged sleep > 9 h/day that is not refreshing
Difficulty being fully awake after abrupt
awakening
The complaint is present for at least 6 months.
Not due to med/psycho disorder
Common in in late adolescence.
American Academy of Sleep Medicine, 2001
19. Obstructive Sleep Apnea (1 – 4 %)
Results in blood oxygen desaturations
Upper Airway Resistance Syndrome
Similar to OSA but not result in desaturations
Primary Snoring (7 – 12%)
regular snoring without changes in sleep
architecture, alveolar ventilation or oxygenation
APA, 2013
20. • Periodic apneas due to sleep-related airway
obstruction
- ↓ patency (obstruction and/or ↓diameter)
- ↑ collapsibility (↓ pharyngeal muscle tone)
-↓ drive to breath (↓ central ventilatory drive)
•Not all snorers have OSA
Bradley and Floras,2009
21. Sequelae of OSA
• Disrupt ventilation and sleep patterns
• intermittent hypoxia and multiple arousals cause
significant metabolic, CVS, neurocog/behavioral
and academic morbidity
• Daytime Sleepiness, Enuresis as short-term squeal
• Pulmonary hypertension and right heart failure,
FFT as long term sequel
22. Treatment of Sleep Apnea
• Weight loss
• Positional (sleep on one side or prone)
• CPAP prevents obstruction by soft-tissue and
keeps airway open
• Surgical intervention (e.g., tonsiloadenectomy)
• Avoid sedatives (which prevent reawakening to
breath)
23. uncontrollable excessive daytime sleep attacks
interfere with normal daily functioning
Person goes directly into REM sleep
Common in adolescence & early adulthood
Genetic defect in hypothalamic orexin/hypocretin
neurotransmitter
prevalence is 3-16/10,000
Owens, 2011
25. Cataplexy (pathognomonic for narcolepsy)
Abrupt bilateral partial or complete loss of m. tone.
triggered by intense positive emotion (e.g., laught)
last for seconds to minutes with complete recovery
Hallucinations (visual, auditory, tactile)
occur during transitions bet. sleep and wakefulness
At sleep onset → hypnogogic
At sleep offset → hypnopompic
Sleep paralysis: inability to move or speak for sec-
min at sleep onset or offset; accompanies hallucination
Owens, 2011
26. DD Potential causes of EDS:
Extrinsic: 2ry to insufficient/fragmented sleep
Intrinsic: CNS disorder with ↑ need for sleep.
Treatment include:
Education, good sleep hygiene, behavioral
changes (eg. Scheduled naps).
Medications as:
• psychostimulants and modafinil to control EDS.
• TAD and SSRI to control REM-associated
phenomena, such as cataplexy
Owens, 2011
27. Circadian Rhythm Sleep Disorder caused byCircadian Rhythm Sleep Disorder caused by
mismatch between sleep-wake schedulemismatch between sleep-wake schedule
required by a person’s environment andrequired by a person’s environment and
his/her circadian sleep-wake pattern (e.g.,his/her circadian sleep-wake pattern (e.g.,
shift work).shift work).
28. It is a circadian rhythm disorder
significant, persistent, intractable phase shift in sleep
wake schedule (later sleep onset and wake time)
Patients has inability to get to sleep until the early
morning, but little difficulty sleeping once asleep
Interfere with school, work and lifestyle demands.
Common in adolescents and young adults (7-16%)
Owens, 2011
29. Treatment
Treatment is primarily behavioral
•Shifting the sleep-wake schedule to an earlier time
•Maintaining the new schedule.
→ Gradual shifting bedtime/wake time earlier by 15-
30 min increments
→ Exposure to light in morning and avoidance of
evening light exposure
Oral melatonin supplementation in the afternoon or
early evening is effective in advancing the sleep phase.
30.
31. Uncomfortable sensations in the LL accompanied by
irresistible urge to move legs →Disturbs sleep
Severe leg pain is main symptom, missed as
‘growing pains’.
partially relieved by movement (walking, stretching,
rubbing) but only as long as the motion continues.
Diagnosis of RLS is a clinical.
Prevalence in children is 1-6 %
Khatwa and Kothare, 2010
32. periodic, repetitive, brief (0.5-10 sec) highly
stereotyped limb jerks (rhythmic extension of big
toe and dorsiflexion at ankle).
occurring at 20 to 40 sec intervals.
occur mainly during sleep → Disrupts sleep
Prevalence in children is 8-12%
33. Diagnosis of PLMs requires overnight
polysomnography to document the characteristic
limb movements with anterior tibialis EMG leads.
Owens, 2011
34. Treatment according to:
severity (intensity, frequency, periodicity)
degree of sleep disturbance
daytime sequelae
•an index (PLMs per hr) < 5 → no treatment
•index > 5 → promote good sleep hygiene
→ iron supplements if ferritin <50
•Medications that ↑ dopamine in CNS are effective in
adults but limited data in children.
35. repetitive, stereotyped, rhythmic movements involve
large muscle groups.
include head banging, body rocking, head rolling
common in the 1st yr of life and disappear by age 4 yr
occur with the transition at sleep at bedtime.
It is a means of soothing themselves to sleep
significant injury is rare
not indicate neurological or psychological problem.
reassurance to the family
Owens, 2011
36. • Episodic nocturnal behaviors involve cognitive
disorientation and autonomic and skeletal
muscle disturbance.
39. • Sleep disorder characterized by high arousal and
appearance of being terrified
• ≈ 2/3 of all kids experience them
• Common in preschoolers ages 3-6 y
• Occur during REM sleep
• Child believes them to be real.
Owens, 2011
40. repeated abrupt awakenings from sleep characterized
by intense fear, panicky screams, autonomic
symptoms (tachycardia, rapid breathing, sweating),
absence of detailed dream recall, amnesia for the
episode, and relative unresponsiveness to attempts to
comfort the person.
Lasts ~ 10 min then returns to undisturbed sleep.
41. During Stage 3-4 of NREM sleep (1st third of night)
Prevalence is 3–6.5% in children.
can occur at any age.
Common in male
resolves spontaneously
Nocturnal administration of benzodiazepines has
been reported to be beneficial
42. 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 occasional None
43. involuntary, forceful grinding of teeth during sleep
Up to 88% of children; 20 % of adults
Any stage of sleep
May result in damage to the teeth
Periodicity of 20 to 30 seconds.
May represent symptom different disorders
Patient is usually unaware of the problem
In severe cases, rubber tooth guard is necessary.
Stress management or biofeedback.
45. One or more waking from midnight to 5 am
for at least four of seven nights per week for
at least four consecutive weeks
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
All Infants Breastfed
Infants
1-2 Yr
Olds
4-5 Yr
Olds
Owens, 2011
46. More than just walking around…
Simple Behaviors
Complex Behaviors
While sleepwalking, patient has a blank staring
face, relatively unresponsive to others
confused or disoriented on being aroused.
Complete amnesia
Occur during Stage 3-4 Sleep; 1st
third of night.
47. Begins in ages 4-8 yrs
17% in children (4% of adults)
sleep-walking most likely to persist
it is important to institute safety precautions (use
of gates, locking doors and windows, and bedroom
door alarms).
No treatment is established, but may respond to
benzodiazepines or sedating antidepressants at
bedtime.
48. During NREM sleep
May be restricted to Stage 3-4
Common in Males with Family History
prevalence is 30% at age 4 y
10% at age 6 y
5% at age 10 y
3% at age 12 y
1% at age 15 y.
Owens, 2011
49. Usually during first 1/3 of night
Usually only one event/night
Common in Toddler and school-aged kids.
prevalence rates 15% in children ages 3-13 yr.
co-occur with sleepwalking and sleep terrors
Usually resolve with time
Not tired the next day
No stereotypic motor movements
Last 5-30 minutes
Stores, 2009
50. parent education and reassurance
good sleep hygiene
avoidance of exacerbating factors such as sleep
deprivation and caffeine.
Scheduled awakenings, parent wake the child 15 to
30 min before the time of first parasomnia episode.
Pharmacotherapy is rarely necessary, include
benzodiazepines and tricyclic antidepressants.
Stores, 2009
51. • Have a set bedtime and bedtime routine
• Bedtime and wake-up time should be the
same time on school & non-school nights.
• No more than 1hour difference from one
day to another.
• Make the hour before sleep quiet time.
• Avoid high-energy activities before bed.
Owens, 2011
52. • Don't go to bed hungry, but avoid Heavy
meals.
• Avoid caffeine products before bedtime.
• spend time outside every day and involve
in regular exercise.
• Keep bedroom quiet and dark with
comfortable temperature
• Don't use bedroom for punishment.
Owens, 2011
53. • Naps should be short (no > 1hr) and
scheduled in the early to midafternoon.
• Keep TV out of child's bedroom.
• Use bed for sleeping only. Don't study,
read, watch TV on bed.
• Relaxing, calm, enjoyable activities help
you to get to sleep.
• Smoking disturbs sleep.
• Don't use sleeping pills
Owens, 2011
54. Foods That Helps You Sleep BetterFoods That Helps You Sleep Better
tryptophan in it convert to serotonin & melatonin which induces sleep, Ca, Mg helps
m. relaxation
Cherries rich source
of melatonin
rich in Vit. B6 for
melatonin production
Kale
source of sleep inducing agents (K, Ca,
Mg, Vit.B6)
salmon & tunaOat
56. Anything that is recurrent, stereotyped, and
inappropriate may be manifestation of a seizure
Some forms of epilepsy occur more commonly
during sleep than during wakefulness
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.
Nocturnal seizuresNocturnal seizures
57. REFERENCES
• Gerd Lehmkuhl, Alfred Wiater, Alexander Mitschke, Leonie
Fricke-Oerkermann (2008): Sleep Disorders in Children
Beginning School: Their Causes and Effects. Dtsch Arztebl Int;
105(47): 809–14
• Judith A. Owens (2011): sleep disorders in Nelson text book of
pediatrics. Chapter17.
• Bradley TD, Floras JS: Obstructive sleep apnoea and its
cardiovascular consequences. Lancet 2009; 373:82-90.
• Khatwa U, Kothare SV: Restless legs syndrome and periodic
limb movements disorder in the pediatric population. Curr
Opin Pulm Med 2010; 16:559-567.
• Stores G: Aspects of parasomnias in children and adolescence.
Arch Dis Child 2009; 94:63-69.
Notas del editor
During sleep:
Decrease in minute ventilation
In children, respiratory rate (RR) decreases during sleep; in adults RR remains constant
Functional residual capacity (FRC) decreases
Upper airway resistance doubles
Between ages 2 and 5, children spend equal amounts of time asleep and awake
American psychological association,
Difficulty initiating sleep means that the subjective sleep latency is greater than 20-30 minutes. Difficulty maintaining sleep is the subjective time awake after sleep onset is longer than 20-30 minutes. There is no standard definition of early morning awakening, but it usually requires awakening 30 minutes before the scheduled time or before total sleep time reaches 6.5 hours.
Behavioral insomnia (sleep onset association insomnia): the child learns to fall asleep only under certain conditions or associations which typically require parental presence, such as being rocked or fed, and does not develop the ability to self-soothe. During the night, when the child experiences the type of brief arousal that normally occurs at the end of a sleep cycle (every 60-90 minutes in infants) or awakens for other reasons, he is not able to get back to sleep without those same conditions being present , resulting in insufficient sleep (for both child and parent).
Bedtime problems, including stalling and refusing to go to bed, are more common in preschool-aged and older children. In some cases the child&apos;s resistance at bedtime is due to an underlying problem in falling asleep that is caused by other factors (medical conditions, such as asthma or medication use; a sleep disorder, such as restless legs syndrome; or anxiety) or a mismatch between the child&apos;s intrinsic circadian rhythm (“night owl”) and parental expectations.
American Academy of Sleep Medicine
Viral infections have preceded or accompanied hypersomnolence in 10% of cases, sometimes several months after the infection. Head trauma can result in hypersomnolence within 6-18 months after injury. An autosomal dominant mode of inheritance occurs in a subset of familial cases
(difference between current sleep onset and desired bedtime) may require “chronotherapy,” which involves delaying bedtime and wake time by 2-3 hr daily to every other day.
a neurologic sensory disorder, characterized by
Genetic
Dopaminergic dysfunction
Iron deficiency
Clinical Manifestations
The partial arousal parasomnias have several features in common. Because they typically occur at the transition out of “deep” or SWS, partial arousal parasomnias have clinical features of both the awake (ambulation, vocalizations) and the sleeping (high arousal threshold, unresponsiveness to the environment) states; there is usually amnesia for the events. The typical timing of partial arousal parasomnias during the first few hours of sleep is related to the predominance of SWS in the first third of the night; the duration is typically a few minutes (sleep terrors) to an hour (confusional arousals). Sleep terrors are sudden in onset and characteristically involve a high degree of autonomic arousal (i.e., tachycardia, dilated pupils), while confusional arousals typically arise more gradually from sleep, may involve thrashing around but usually not displacement from bed, and are often accompanied by slow mentation on arousal from sleep (“sleep inertia”). Sleepwalking may be associated with safety concerns (e.g., falling out of windows, wandering outside). Avoidance of, or increased agitation with, comforting by parents or attempts at awakening are also common features of all partial arousal parasomnias.
Sleeptalking (boys)
Restless Legs (girls)
Sleep Bruxism (boys)
These 3 still common @ age 13 while other parasomnias decrease during childhood
Slow-wave sleep (SWS)
Characteristics:
(1)Abrupt awakening from sleep, usually beginning with a panicky scream or cry.
(2)Intense fear and signs of autonomic
arousal
(3)Unresponsive to efforts from other to calm
client
(4)No detailed dream recalled
(5)Amnesia for episode
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
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.
Bilingual sleeptalking kids talk in their dominant language
the prevalence of children who regularly sleepwalk is approximately 17%, and 3-4% have frequent episodes. Sleepwalking may persist into adulthood, with the prevalence in adults of about 4%. The prevalence is approximately 10 times greater in children with a family history of sleepwalking.
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
The major concern should be the safety of the sleepwalker, who may injure herself or himself or
someone else during an episode
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.