Download Pediatric Sleep 2

A Good Night’s Sleep is Important !
Overcoming Sleep Problems in Children
William Wooten, III, MD
Pediatric Pulmonology and
Sleep Medicine
Brody School of Medicine, ECU
Sleep in Children
Questions to be
Answered…
• What constitutes normal sleep
in children?
• What are features of
sleep-disordered breathing in
children?
• Referral and treatment for
sleep problems – who, where,
and what?
What is Sleep Anyway?
“A naturally recurring state characterized by altered
consciousness with relatively inhibited sensory and
motor activity.”
When does sleep begin?
• Human sleep begins during
embryonic development
• Cycles of brain activity at 810 weeks gestation
• REM sleep develops around
28-32 weeks
Newborn Sleep Changes Rapidly
ACTIVE SLEEP (REM)
QUIET SLEEP (NON-REM)
Question
• Parents of a 2 month old boy complain that he is
not yet sleeping through the night from midnight
to 5 am.
• What is the correct response?
Question
• Parents of a 2 month old boy complain that he is
not yet sleeping through the night from midnight
to 5 am.
• What is the correct response?
Reassurance - Most babies “sleep through the
night” by 6-9 months of age.
Question
• Parents of a 2 month old boy complain that he is
not yet sleeping through the night from midnight
to 5 am.
• What is the correct response?
Reassurance - Most babies “sleep through the
night” by 6-9 months of age.
Sleep through the night defined as 5 hours of
uninterrupted sleep
Newborn Sleep
• Sleep onset REM (like narcolepsy)
until 6 months and indeterminate
sleep on EEG
• Sleep/wake cycle every 4 hours
• 80% of time spent sleeping
• Circadian rhythm matures
around 3-6 months of life
3-4 hr autonomous rhythm
3 months
4 months
Circadian rhythmicity
develops around 3-4
months of age
Synchronized sleep pattern
“Sleeping Through the Night”
Sleep Training Methods
Parent resources: “sleep training”
• Solve Your Child’s Sleep
Problems (Ferber)
• Healthy Sleep Habits, Healthy
Child (Weissbluth)
• On Becoming Babywise (Ezzo
and Bucknam)
Ferber method
“Progressive waiting” method
• Teach baby to soothe himself when
physically ready (at least 3-5 months)
• Put baby in bed awake, leave for
gradually longer periods of time
• Allows infant to develop sleep
associations
Weissbluth method
“Extinction” method
• Parents watch for sleep cues (ie
yawn, rubbing eyes)
• Soothe before putting in bed
• Extinction: “cry it out” indefinitely, up
to an hour for naps
• Earlier bedtime if sleep issues (to
prevent “over-tired” child)
Babywise method
• Feed infant on a strict 3-4 hour
schedule from birth regardless of
demand
• Baby should sleep through night
from 8-12 weeks
• AAP issued a statement that this
method is dangerous and should not
be followed
Recommended Sleep Times: National Sleep Foundation 2015
• Newborns (0-3 months): 14-17 hours each day (previously
it was 12-18)
• Infants (4-11 months): 12-15 hours (previously it was 1415)
• Toddlers (1-2 years): 11-14 hours (previously it was 12-14)
• Preschoolers (3-5): 10-13 hours (previously it was 11-13)
• School age children (6-13): 9-11 hours (previously it was
10-11)
• Teenagers (14-17): 8-10 hours (previously it was 8.5-9.5)
• Younger adults (18-25): 7-9 hours (new age category)
• Adults (26-64): 7-9 hours (no change)
• Older adults (65+): Sleep range is 7-8 hours (new age
category)
Naps – what is normal?
• 3 naps by age… 3 months
• 2 naps by age… 6-9 months
• 1 nap by age… 12-15 months
• 0 naps by age… 4-5 years
Infant Sleep Problems
• Parents of a 15 month old girl report that she
awakens multiple times at night. With awakenings,
mother picks her up, rocks her, and feeds her from a
bottle until she falls asleep.
• What is the diagnosis?
Infant Sleep Problems
• Parents of a 15 month old girl report that she
awakens multiple times at night. With awakenings,
mother picks her up, rocks her, and feeds her from a
bottle until she falls asleep.
• What is the diagnosis?
• Diagnosis: Behavioral Insomnia of Childhood:
Sleep Association Disorder
Behavioral Insomnia of Childhood
Sleep association disorder
• 6-36 months
• Delayed sleep onset and
awakenings
• Sleep onset becomes related
to external cues
• Parent rocking child to sleep,
drinking from a bottle
• Sleep will not occur without
cues
Behavioral Insomnia of Childhood
Limit setting sleep disorder
• >18 months
• Delayed bedtime; otherwise
normal sleep
• Parents unable to control
behaviors around bedtime or
awakenings
• Usually inadvertently
reinforce bad behaviors
• Inconsistent limit-setting
Behavioral Insomnia:
Tips for Parents
• Focus on bedtime
routine
• Be consistent and
predictable
• Good: Play with toys,
read books, take bath
• Bad: TV, electronics,
snacking after dinner
• Maintain regular
bedtime (not too late)
Behavioral Insomnia:
Tips for Parents
• Focus on environment
•
•
•
•
•
Keep things quiet
Dim lights
Maintain a restful sleeping space
Avoid games or activities in bed
Remove distractions
Behavioral Insomnia:
Tips for Parents
• Establish sleep associations
• Toy/object to crib with child,
not available during the day
• Don’t become a sleep
association… try to be “boring”
or “robot” parent after bedtime
Behavioral Insomnia:
Tips for Parents
• Remember to reward good behavior !
Get Rid of Bad Sleep
Associations!
No bottles in the crib !
… Can lead to cavities, GERD, aspiration
Get Rid of Bad Sleep
Associations!
Remember to think
about Caffeine…
Question
• Parents of a 3 year old girl are concerned about
awakenings at night when she sits up, mumbles a few
words and then goes back to sleep. This has been
happening almost every night for the past few
months and she does not seem to remember the
events.
• What would be appropriate to do next?
Question
• Parents of a 3 year old girl are concerned about
awakenings at night when she sits up, mumbles a few
words and then goes back to sleep. This has been
happening almost every night for the past few
months and she does not seem to remember the
events.
• What would be appropriate to do next?
• Ask about symptoms of sleep disorders,
Question
• Parents of a 3 year old girl are concerned about
awakenings at night when she sits up, mumbles a few
words and then goes back to sleep. This has been
happening almost every night for the past few
months and she does not seem to remember the
events.
• What would be appropriate to do next?
• Ask about symptoms of sleep disorders,
• Ensure safety of sleep environment,
Question
• Parents of a 3 year old girl are concerned about
awakenings at night when she sits up, mumbles a few
words and then goes back to sleep. This has been
happening almost every night for the past few
months and she does not seem to remember the
events.
• What would be appropriate to do next?
• Ask about symptoms of sleep disorders
• Ensure safety of sleep environment
…then,
Reassurance
Parasomnias – Normal or Not?
• Parasomnias are usually
normal in children
• If frequent, may indicate
condition causing arousal
• OSA
• Restless legs syndrome
• Seizures can be confused with
parasomnia
Parasomnias
Parasomnias: Disorders of Arousal
• Non-REM parasomnias
•
•
•
•
Confusional arousals
Night terrors
Sleepwalking
Sleep-related eating disorder
• REM parasomnias
• Nightmares
• REM behavior disorder
Disorders of Arousal
• Occur in NREM ,usually deep sleep (early night)
• Patient remains asleep during / following arousal
• No recollection of event
• Classic types:
• Confusional arousals
• Night terrors
• Sleepwalking
REM parasomnias
• Nightmares
• Occur during REM
• Usually occur LATE at night (early morning)
• Recollection of dream
• REM behavior disorder
•
•
•
•
Absence of normal REM atonia
Large movements and/or complex behaviors
“Acting out dreams” with recollection of dream when awakened
Associated with neurodevelopmental disorders and medications
Nightmares or Night Terrors?
• Nightmares
• Most often occurs late night/ early morning hours (REM sleep)
• Awakenings from sleep with frightening dreams
• Child responds to being consoled
• Night terrors
•
•
•
•
Usually occurs in the early night (non-REM)
Awakenings from sleep with crying, screaming
Child does not respond to being consoled
Will not remember in the morning
Nightmares and Fears: Tips
• Read happy books at bedtime,
avoid scary videos
• Bedtime ritual – should be quiet,
comforting
• Physical reassurance is helpful
• Child sleeping in your bed
• May work temporarily
• Often becomes a habit
• Be careful about “monster
hunts” and “monster sprays”
Question
• Parents of a 5 year old girl complain of heavy
snoring every night. Parents have witnessed
respiratory pauses during sleep. Tonsils are
enlarged. She has symptoms of ADHD and is on
stimulant medications.
• What is the suspected diagnosis?
Question
• Parents of a 5 year old girl complain of heavy
snoring every night. Parents have witnessed
respiratory pauses during sleep. Tonsils are
enlarged. She has symptoms of ADHD and is on
stimulant medications.
• What is the suspected diagnosis?
• Obstructive sleep apnea…
• What next?
Overview of SDB - Questions
• What is sleep disordered breathing??
• Why is it important (and different) in children?
• What common conditions are associated with sleep
disordered breathing during childhood?
• How to reconcile different evaluation/treatment
guidelines for OSA in children (AASM, AAP, AAOHNSF)?
• What are new and emerging treatments for sleep apnea
in children?
What is SDB ?
• Sleep-disordered breathing Nonspecific, umbrella
term encompassing spectrum of respiratory
alterations during sleep
• Often refers to airway obstruction during sleep
• Primary snoring (PS)
• Upper airway resistance syndrome (UARS)
• Obstructive sleep apnea syndrome (OSAS)
• Also encompasses sleep related hypoventilation
syndromes and central sleep apnea
Spectrum of SDB in Children
• Obstructive sleep apnea syndrome
(OSAS) – Obstructive events, arousals
and gas-exchange abnormalities (O2,
CO2)
• Upper airway resistance syndrome
(UARS) – Flow limitation, arousals,
criteria not met for hypopneas
• Primary snoring - snoring NOT
associated with gas exchange
abnormalities or arousals.
OSA in Children is Important
• Obstructive sleep apnea (OSA): Repeated events of
partial or complete upper airway obstruction during
sleep. Diagnosed by polysomnography (PSG).
• Upper airway obstruction causes disruption of
ventilation and/or sleep structure (sleep fragmentation)
• Implications for developing nervous system:
neurobehavioral and cognitive problems (ADHD,
learning problems)
Pediatric OSA: Research Topic
“Pediatric Obstructive
Sleep Apnea”
on PubMed per year
“Adenoid facies”
http://radiopaedia.org
2 Peaks of OSA prevalence
Peak 1: Adenotonsillar hypertrophy (3-6 yr)
Peak 2: Obesity (adolescents)
0
3
6
9
12
15
18
Symptoms of SDB in Children
NIGHT symptoms
• Snoring, apnea, restlessness, night sweats
• Awakenings may precipitate disorders of arousal
(night terrors, confusional arousals, sleepwalking)
• Nocturnal enuresis –
• Children who snore and wet the bed are more likely to
have moderate to severe sleep apnea than those who
stay dry at night (Pediatric Research 2014)
Symptoms of SDB in Children
DAYTIME symptoms
• Neurocognitive impairment (poor school
performance)
• Behavior problems (aggression, irritability)
• Cardiovascular morbidity
• Changes in appetite, weight
Exam: SDB in children
• “Adenoid facies”
•
•
•
•
•
High-arched palate
Narrow nasal passages
Short upper lip
Crowded, prominent teeth
Small maxilla
• Mouth breathing leads to
molding of facial bones
“Adenoid facies”
http://radiopaedia.org
Exam: Modified Mallampati
Sitting position, tongue extended
Measures relationship of
soft palate to tongue
Scoring
Class I: Soft palate, uvula, fauces, pillars
visible.
Class II: Soft palate, uvula, fauces
visible.
Class III: Soft palate, base of uvula
visible.
Class IV: Only hard palate visible.
Exam: Tonsils
Tonsillar
pillars
Scoring
Grade 0: Tonsils absent
Grade 1: hidden behind pillars
Grade 2: Extend to pillars
Grade 3: Visible beyond pillars
Grade 4: Enlarged to midline
“kissing” tonsils
Exam: Tongue
Scalloping
Macroglossia
Ankyloglossia
Retrognathia / Micrognathia
Retrognathia / Micrognathia
Seen in genetic /
craniofacial conditions:
- Pierre Robin
- Treacher Collins
- Marfan’s
- Smith-Lemli Opitz
Retrognathia / Micrognathia
Retrognathia: Posterior
displacement of chin
(gnathion) compared to
the bridge of nose (nasion)
Micrognathia: Mandible
is smaller size than normal
(mandibular hypoplasia)
Exam: Overbite and Overjet
Overjet = Horizontal
Overbite = Vertical
Exam: High Arched Palate
Normal
Moderate
Mild
Severe
Treatment of OSA
Surgery
• Adenoidectomy and/or tonsillectomy
• Nasal turbinate reduction
CPAP
• Effective in overweight children or if surgery impossible
• May affect facial bone structure until age 11 yr
Orthodontics
• Rapid maxillary expansion – especially before 11-14 years of age
Weight loss
• Should always be encouraged if overweight / obese
Anti-inflammatory drugs
• Nasal corticosteroids
• Leukotriene antagonists (Singulair)
Treatment of OSA: Orthodontics
• Rapid maxillary palatal expansion
• Children have temporary gap between front teeth
• Usually 3 weeks to fully expand
Treatment of OSA: CPAP
PSG: Measuring Sleep Apnea
PSG – obstructive events
PSG – results (AHI)
• Apnea-hypopnea index (AHI)
• Number of events per hour of total sleep time.
• OSA severity (pediatric vs adult)
• Mild : AHI 1-5 (adult 5-15)
• Moderate : AHI 5-10 (adult 15-30)
• Severe : AHI >10 (adult >30)
Primary snoring
• Primary snoring: frequent snoring NOT associated with
gas exchange abnormalities or frequent arousals.
• Cannot be differentiated from OSA without PSG.
• Prevalence of habitual snoring (>3x per week) is 10-15% of
children (Lumeng et al 2008).
• Studies have found clinical consequences in children who
snore, even without sleep apnea on PSG…
Snoring and Reduced IQ?
• IQ scores ~10 points lower in PS compared to
controls. Impairments in verbal knowledge and
language development (Blunden et al 2000,
Bourke et al 2003, Kohler et al 2009)
• Lower scores in reading and arithmetic (Bourke et
al 2011)
• 10x risk of daytime sleepiness compared to
controls, compared to 5x risk in OSA. (Brockman
2012)
Primary snoring – Behavioral
effects
• Children with PS have cognitive impairment
SIMILAR to those with moderate to severe OSA
• Children with PS appear to have MORE behavioral
problems, inattention and daytime sleepiness than
those with mod/severe OSA (Bourke 2011, Jackman
2012, Brockman 2012)
Hypoxia-Arousal
or another Mechanism ?
• Number of desaturations >3% linked to
impairments in working memory, attention and IQ
• Number of arousals associated with daytime
sleepiness, sleep fragmentation
• In PS, cognitive and behavioral problems occur
without desaturations or arousals
• Does PSG have poor sensitivity to detect meaningful
EEG or O2 changes? Does PS represent another
phenotype or mechanism? More research needed…
Cognitive Effects of Snoring ?
• Preschool children appear to have equivalent
cognitive scores in all SDB severity groups
• Neuroplasticity – is there a protective mechanism ?
• Is there a cumulative effect ?
• Studies have limitations
•
•
•
•
Variability in PSG and scoring criteria
Disease overlap – OSA, ADHD, asthma
Recruitment bias – who wants a free sleep study?
Few studies in preschool population
Where to Refer for SDB?
• Guidelines for screening and management for sleep
disordered breathing in children
• American Academy of Sleep Medicine (AASM) 2011
• American Academy of Otolaryngology-HNS (AA-OHNS)
2011
• American Academy of Pediatrics (AAP) 2012
• Guidelines similar, but with differences
AASM Practice Parameters
- PSG indicated when clinical assessment suggests OSA
- PSG indicated in children being considered for
adenotonsillectomy to treat OSA
- PSG indicated after treatment of OSAS following AT in
mild OSA with residual symptoms and in all with
mod/severe OSA, obesity, craniofacial or neurologic
disorders
AA-OHNS
AA-OHNS Guideline for PSG
• PSG indicated in certain children with SDB:
• Obesity, Trisomy 21, Craniofacial or Neuromuscular disorders,
Sickle cell disease, Mucopolysaccharidosis
• Advocate for PSG:
• Need for surgery uncertain
• Discrepancy between tonsillar size and reported symptoms
AA-OHNS Guidelines
• Surgery considerations
• PSG results should be communicated to
anesthesiologist prior to induction
• Criteria for admission after AT
• Any child younger than age 3
• Severe OSA (AHI >10/hr and/or O2 nadir <80%)
AAP Clinical Practice Guideline
AAP Clinical Practice Guideline
- All children/adolescents should be screened for snoring
- PSG performed in children with snoring and
symptoms/signs of OSAS.
- If PSG not available, consider alternative diagnostic tests
or specialist referral
- Adenotonsillectomy recommended treatment in patients
with adenotonsillar hypertrophy
- High risk patients should be monitored as inpatients
postoperatively
AAP Clinical Practice Guideline
OSA diagnosed
NO
Adenotonsillar
hypertrophy YES
Obesity?
NO
YES
NO
Clinical judgment
CPAP
Adenotonsillectomy
Referral for SDB in Children
Since guidelines differ,
Primary MD has to determine best practice for referral
Primary MD
ENT
Sleep MD
Open communication between providers is always helpful…
Referral for SDB in Children
ENT
Sleep MD
Primary MD
Guideline consensus…
• In children, in-lab standard PSG recommended
compared to unattended PSG or oximetry
• AT is first line treatment for OSA in children with AT
hypertrophy
• CPAP is an alternative to AT if surgery is not indicated
Success after
childhood…