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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…