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Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S63 0021-7557/02/78-Supl.1/S63 Jornal de Pediatria Copyright © 2002 by Sociedade Brasileira de Pediatria REVIEW ARTICLE Sleep disorders Magda Lahorgue Nunes* Abstract Objective: the aim of this article is to review and update the knowledge about sleep disorders in childhood. Sources: normal sleep ontogenesis and therapeutics for the most prevalent sleep disorders were reviewed. The text was based on classical articles and books and on Medline (publications from 2000 and 2001) using the key words sleep disorders and childhood. the article was structured on descriptive topics containing definition of the sleep disorder, age, clinical presentation and therapeutics. Summary of the findings: sleep disorders are frequent concerns referred in pediatrics outpatient clinics, and a correct diagnosis is the main goal to establish therapeutic procedures. Conclusions: in the majority of cases clinical history is sufficient to establish diagnosis and assuring parents of the benign evolution of the symptoms the better treatment. J Pediatr (Rio J) 2002; 78 (Supl.1): S63-S72: sleep disorders, childhood, sudden infant death syndrome, apnea. Introduction Sleep disorders are very common among pediatric patients. However, in most cases, they can be diagnosed through a good anamnesis, showing parents the disorders are benign and allowing for appropriate treatment.1-3 Most sleep disorders affect both adults and children, but their manifestation is different. Possibly, only colics and the infant sudden infant death syndrome (SIDS) are exclusive childhood sleep disorders;2 other disorders can occur at any age, although some are more predominant during childhood. This article aims at showing the normal aspects of sleep ontogeny since, in some cases, we can establish treatment if we know the normal sleep patterns. In addition, the article reviews therapeutic management of the most prevalent childhood sleep disorders. Normal sleep pattern from the neonatal period to adolescence Circadian rhythms are already established in the perinatal period. Newborns have their sleep pattern within the ultradian rhythm (<24hours), therefore, sleep acquires a circadian rhythm only after the neonatal period (equivalent to 24 hours). * Associate Professor of Neurology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) School of Medicine. S63 S64 Jornal de Pediatria - Vol. 78, Supl.1, 2002 Sleep disorders - Nunes ML At birth, newborns have periods of 3-4 hours of continuous sleep, alternated with approximately one waking hour. This rhythm is continuous during night and day. In the neonatal period, the alternation between sleep stages lasts 50-60 minutes, the cycle starts with REM and, the more premature the newborn is, the longer the REM stage. In the first month of life, the adaptation of the sleep-wake cycle to the night-day cycle begins. At the end of the first month of life, nighttime sleep periods are longer. afternoon), which do not exceed two hours. At the age of three, usually only the afternoon nap is necessary. At this age, infants have the adult REM sleep pattern, which should be at most 25% of the total sleep time. Important structural changes in sleep architecture occur during the third month of life, sleep begins with the NREM stage, and up to the sixth month of life, 90% of infants will have already undergone such change. At this age, the longest uninterrupted sleep period does not usually exceed 200 minutes. In adolescence, there is a reduction in nighttime sleep pattern (on average 7 hours of sleep), but there is a difference between sleep hours on schooldays and weekends. The increase in the total sleep time on weekends reflects a compensation for reduced hours of sleep during schooldays. After the age of five, nighttime sleep should be already consolidated and there are no longer daytime sleep periods. Between five and ten years, there is a gradual reduction of total sleep time, and the adult sleep pattern is reached (± 8 hours). The average sleep in 24 hours, the percentage between REM/NREM sleep and the establishment of consistent nighttime sleep and daytime wakefulness patterns are associated with growth and are shown in Table 1.3-7 In the sixth month of life, the longest period of uninterrupted sleep does not exceed six hours. The night is split into two continuous sleep periods, alternated with one waking period. During the day, wakefulness begins to consolidate, but it is already interrupted by daytime sleep. Sleep disorders Between the ninth and tenth months, infants sleep on average 9-10 hours during the night and 2-3 hours during the day, including two naps. Infant apnea - apparent life-threatening events (ALTE) Infant apnea consists of an unknown respiratory arrest during 20 or more seconds, or sometimes less than that, associated with bradycardia, cyanosis, paleness and hypotonia in infants with 37 weeks gestational age. Infant apnea has been used to define infants in whom no specific cause was identified for the diagnosis of ALTE, that is, those infants with idiopathic ALTE.8 In the twelfth month, nighttime sleep should be consolidated, but 1-2 daytime naps are maintained. Between the ages of 2 and 3, children have long periods of nighttime sleep (±10 hours), and one or two daytime naps (in the middle of the morning and at the beginning of the Table 1 - Total sleep time according to age Age Total sleep time/24 hours REM/NREM sleep % Daytime sleep Nightime sleep Preterm NB 22 80/20 Yes sleep cycle does not depend on night/day Full-term NB 16.5 60/40 Yes sleep cycle does not depend on night/day 1 month 15.5 50/50 Yes sleep cycle begins to relate to night/day 3 months 15 50/50 Yes sleep cycle is more related to night/day 6 months 14.2 40/60 Yes. Daytime wakefulness begins to consolidate two long periods with one interruption 12 months 13.7 30/70 Yes, 2 naps nightime sleep consolidation 2 years 13 30/70 Yes, 1-2 naps nightime sleep consolidation 5 years 11 25/75 No only 10 years 9.7 25/75 No only Adolescence 8.5 25/75 No only Modified according to references 3,4,5,6 and 7. Sleep disorders - Nunes ML ALTE is an episode that frightens any observer, since it is characterized by a combination of signs: apnea (central or occasionally obstructive), change in skin color (usually cyanosis or paleness, occasionally plectoral), change in muscle tone (important hypotonia), shock or choking. So, an observer would think the child is dying. Initially, these episodes were called near miss sudden infant death syndrome (near miss - SIDS), now this term is outdated, since it implies a direct relation with SIDS which, most times, is not the case. The term ALTE refers to a complaint and can not be regarded as a diagnosis. Infants with this type of episode should be carefully investigated so that its etiology can be determined. There are multiple causes of ALTE (gastroesophageal reflux, seizures, cardiac arrhythmia), and the etiology can be determined in most 50% of the cases. Literature data show that, although the patients who develop SIDS never had previous episodes of ALTE, most deaths caused by ALTE seem to be associated with SIDS, especially in idiopathic cases.8 In an observational descriptive study with 56 patients who suffered from ALTE, at Hospital São Lucas (HSLPUCRS), we observed that 92% of the patients had an episode of ALTE in the first 30 days of life. The incidence of symptomatic ALTE in the study population was high (71%), and the most prevalent causes included gastroesophageal reflux, followed by neurological disorders. No case of SIDS was registered during follow-up, although four children had recurrent episodes of ALTE.9 The treatment of patients with recent episodes of ALTE consists of hospitalization, since these patients have to be carefully observed and their cardiorespiratory function needs to be monitored. In hospital, recurrent episodes, physical and laboratory evidence of hypoxemia or hypoventilation as well as the cause of ALTE should be investigated. Minimal investigation should include hemogram, so that anemia and infectious processes can be ruled out, and serum bicarbonate, in order to rule out metabolic acidosis. Additional work-up is necessary when the anamnesis and/or physical examination determines so.8 The treatment of a patient with ALTE is based on a specific treatment, that is, treatment of the etiology of ALTE; and nonspecific treatment, which consists in monitoring cardiorespiratory function at home. Home treatment is recommended for the cases in which the episode of ALTE is severe, and requires intense stimulation and resuscitation maneuvers. In less severe cases, the indication of home treatment is controversial, and should be analyzed on a case-by-case basis. Usually, when previous family history of SIDS is present, or when the episodes of ALTE are recurrent, cardiorespiratory monitoring is recommended. The use of methylxanthines (theophylline) as respiratory stimulant is controversial as to its efficacy after the neonatal period.8 Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S65 Sudden infant death syndrome SIDS is the sudden, unexpected death of infants which, despite extensive investigation, including clinical history, complete necropsy and death site inspection, still goes unexplained.10 SIDS is considered the major cause of infant death in industrialized countries. Maternal and perinatal risk factors are well established in literature and, today, the etiology of this process is believed to be related to the immaturity of the wake mechanism, associated with environmental factors, (prone position during sleep) and with age of risk (between two and three months of life). Smoking during pregnancy and exposure of infants to tobacco have also been considered risk factors. 11,12 Available information about SIDS is scarce in Brazil. There are only two studies carried out in the state of Rio Grande do Sul, where mortality rates of 6.3% and 4% were observed in Porto Alegre and in Pelotas,13,14 respectively, during the first year of life. The risk factors for SIDS in our country are intrinsically related to maternal factors, such as mothers aged less than 20 years and smoking. Prone position during sleep does not seem to be a relevant factor, since most infants usually sleep in a lateral decubitus position.15,16 The best treatment for SIDS is to prevent risk factors. Smoking during pregnancy and indoors should be avoided in the presence of infants younger than one year, perinatal care should be improved, and family planning should be implemented. On top of that, parents should not allow infants to sleep in prone position and should not keep them overly warm during sleep by using a lot of blankets or dressing them in thick layers of clothing, since this would not allow infants to move freely or would end up covering their heads and hindering their breathing. Insomnia Difficulty in falling asleep or maintaining sleep has different characteristics during the developmental stage, and can affect healthy infants or be secondary to several diseases, which will be discussed further ahead. Parents usually overreact when their children suffer from insomnia or difficulty in falling asleep by always emphasizing they had the worst night ever; however, they do not take other nights into consideration. For the sake of diagnosis, it is of paramount importance that the childs routine during the last 24 hours, including all activities or interventions made by the parents or baby-sitter, be investigated. Pediatricians should be careful not to overestimate the complaints made by the parents in order to avoid unnecessary exams or medication.1,17 The most common causes of insomnia in children are shown in Table 2, according to their order of occurrence and age group.1,3,17 Medical problems: these problems usually cause acute insomnia, but for a time period that is limited to the disease. S66 Jornal de Pediatria - Vol. 78, Supl.1, 2002 Sleep disorders - Nunes ML Table 2 - Causes of insomnia according to age Age group Causes Infant Sleep-onset association disorders 2-3 years Excessive intake of food and fluids at nightime Cows milk allergy Chronic or acute diseases Preschool and school-age children Lack of limits Fear, nightmares Chronic and acute diseases Adolescents Anxiety Family and school pressure Emotional disorders (anorexia, schizophrenia, manic disorder) Chronic and acute disease Modified according to reference 17 Physical problems include respiratory diseases, fever, otitis, trauma, teething, milk allergy, gastroesophageal reflux, among others. Fear and anxiety: infants can suffer from separation anxiety after the tenth month of life; the infant can present with different levels of stress when taken away from the mother, which could cause difficulty in falling asleep. Children between two and three years usually present with fear. The fear of being alone can be associated with movies or stories, arguments between father and mother or any other frightening experience, or at a lower frequency, with a problem of psychosocial deterioration of the child.17,18 In adolescents and pre-adolescents, depression and anxiety are among the most common causes of insomnia.19 Habits and associations: sleep has a cyclical pattern during the night, alternating between NREM and REM stages. Short periods of partial or total wakefulness can occur and are considered normal; in this case, the child often goes back to sleeping spontaneously. Some children who usually need different sleep-inducing stimuli, such as being rocked, being tapped on the back, and lying in parents lap, require the same stimuli when going through the normal waking periods, that is, they require parents involvement.20 A recent study that compared the sleep quality of school children and preschool children who sleep alone or with their parents revealed that the latter group had a greater number of wakings during the night.21 Eating during the night: after the sixth month of life, except in cases of premature newborns, infants do not have to be fed during the night anymore. If breastfeeding is maintained, waking episodes occur with increased frequency, since this process becomes a transition between wakefulness and sleep. In addition, hunger will be associated with nighttime. Limits: a lack of limits occurs after the infant has motor skills to get out of the cradle by himself/herself and parents neglect controlling the nighttime activities of their children. The causes of lack of limits are often associated with inability to establish limits, feeling of guilt, psychological problems, alcoholism, maternal depression, and family stress. The lack of limits can also be associated with problems presented by the child, such as occasional rewards. Problems with bedtime: the diagnosis of insomnia related to problems with establishing a bedtime involves knowing the normal sleep/wakefulness patterns. A frequent problem is concerned with an early bedtime, that is, the child has to go to bed at a time when he/she is not sleepy. This keeps the child awake while lying in bed since, according to his/her internal rhythm, it is too early to sleep. Insomnia can be treated in several ways, which associated, have excellent complementary effects. The first stage consists in diagnosing the cause of insomnia by means of anamnesis and physical examination. In necessary cases, complementary exams can be performed. The second stage consists of the direct treatment or elimination of the cause of insomnia. The third stage is concerned with sleep hygiene, while the fourth and fifth ones are usually associated and involve a behavioral approach and drug treatment.22 To diagnose the cause of insomnia, the history of sleeprelated problems, which includes position during sleep, pre-sleep rituals, sleep-inducing stimuli, and the sleep/ wakefulness pattern within 24 hours, should be analyzed. Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S67 Sleep disorders - Nunes ML After that, data on sleep disorder itself should be collected, in order to characterize its onset and its possible associations, as well as the environment where the child sleeps. The current psychosocial profile of the family and the family history of sleep disorders should be investigated. Traditional anamnesis and a thorough physical examination should be performed to identify health problems that could be triggering the sleep disorder. In the cases involving fear and anxiety, the major objective is to identify the cause and solve it, until the child can sleep alone again. Postponing bedtime to a later time at which the child is sleepy can solve the problem. In the cases in which parents involvement is necessary, the child has to be trained to sleep in his/her cradle by using his/her transition objects until parental intervention is no longer necessary. When insomnia is related to the habit of eating during the night, the solution is to gradually reduce the supply of food at this time until the child drops the habit. Sleep hygiene refers to the establishment and maintenance of appropriate conditions to a healthy and effective sleep. This process should be implemented in the first months of life, as recommended by pediatricians, and can prevent the development of sleep disorders. Good sleep hygiene is associated with three important aspects: environment, bedtime, and pre-sleep activities. The environment should be dim, silent and have a pleasant temperature (overheating should be avoided). Bedtime and waking time should be consistent and regular. Daytime naps should be adequate for age and always regular and consistent. The routine prior to sleeping should be consistent (example: shower, dinner, tooth-brushing, changing into pajamas, going to the bathroom, soft music or pleasant stories). The way through which the child is put to sleep should be consistent also. In this case, the use of transition objects, such as toys, dolls, favorite diaper, pacifier, among others, should be consistent. Demanding physical activities, TV programs or stories that might be frightening should be avoided before bedtime. Parents should take the child to bed before bedtime while the child is still awake.3 The behavioral approach to childhood insomnia has been widely discussed, and several studies on this issue have been published in the last few years.22-26 After the second year of life, it is possible to establish a reward system with the child, which seems to be quite effective. However, the use and effectiveness of this technique for infants and children up to the age of two is still controversial. The behavioral approach is based on the comprehension of the sleep disorder involving the diagnosis of the family and the child.22 The most widely used behavioral techniques, their indications and disadvantages are shown in Table 3.22,26 The establishment of positive routines should be implemented approximately 20 minutes before bedtime. These routines can be followed by parents, and time can be gradually reduced until an ideal time is reached; after these Table 3 - Behavioral approaches to insomnia Technique Advantages Disadvantages Application Contraindication Positive routines and systematic ignoring Quite effective and fast technique Parents resistance and lack of adherence Only with motivated parents If previous interventions failed Minimal checking associated with systematic ignoring /modified extinction Parents feel confident. Despite the crying, they know everything is ok with the child Parents presence may trigger intense crying Recommended for If previous parents that feel interventions failed the necessity of checking on the child Parents presence associated with systematic ignoring Less crying, more confident parents Its difficult for parents not to interact during crying Flexible parents, separation anxiety If parents cant avoid interacting Systematic ignoring or graduated extinction The technique is gradual, but parents feel more confident Long adherence and organization Anxious parents, organized parents, healthy children Children with health problems Scheduled wakings Gradual technique Adherence It requires highly organized parents Modified according to references 22 and 26. S68 Jornal de Pediatria - Vol. 78, Supl.1, 2002 Sleep disorders - Nunes ML routines, the child must sleep in his/her bed. In the gradual approach, parents ignore when the child wakes up and cries during previously determined time periods, whose interval should increase every week. At the end of the waiting period, parents go into the room, ease the child down and put him/her back to bed, leaving the room as soon as possible. In the systematic approach, parents enter the room when the child begins to cry, check whether if everything is ok, change diapers if necessary, do not take the child out of the bed, and leave the room, disregarding continuous crying. A variation of this technique is when one of the parents stays in the room, but does not interact with the child. The modified approach consists in ignoring cry/waking for 20 minutes, entering the room to check if there is any problem, not interacting with the child and leaving, taking more or less 20 minutes before returning to the room. Programmed waking consists in waking up the child before the usual waking hour, checking whether he/she is ok, and letting him/her go back to sleeping spontaneously. The treatment of childhood insomnia with drugs is limited. It should always be used in combination with some behavioral techniques. The drugs of choice are antihistamines and, in more severe cases, chloral hydrate 10% at a dose of 0.4-0.5 ml/kg. The medications must be used temporarily as coadjuvants in the first three weeks of treatment.17,22 In a recent study, melatonin at 5mg/day was efficient in reducing insomnia symptoms in children aged between six and twelve years.26 associated with urinary incontinence, such as diabetes, urinary tract infection and generalized seizures.28,29 Although the etiology of enuresis is not clearly defined, it is believed that it occurs due to an association of factors involving failure to release vasopressin during sleep, bladder instability and inability to wake up secondary to bladder fullness.30 The treatment of enuresis is based on drugs and on the development of continence. The use of imipramine is recommended at 25-75 mg every night; initially, it has quick results, but after it is discontinued, there is a high recurrence rate. Antidiuretics, such as intranasal desmopressin at 20-40 mg at bedtime, are another alternative. The development of continence shows better results than drug treatment in the long run, since it develops the ability to control urinary urge. Drug-free treatments consist in using alarm monitors, doing exercises to interrupt the urinary flow, and waking up before enuresis occurs. It is essential that the child be rewarded for his/her dry days, and that the child participate directly. Parasomnias Parasomnias are disorders characterized by undesirable motor, autonomic or experiential phenomena that occur during sleep.31-33 Parasomnias can be categorized according to the sleep state of origin as non-rapid eye movement and rapid-eye movement. The former occurs during the first third of the night in NREM sleep (see characteristics in Table 4). Nocturnal enuresis Nocturnal enuresis is the most prevalent and persistent sleep disorder in childhood. The diagnosis of enuresis is based on the following criteria: chronological age >5 years, and mental age >4 years; two or more events of urinary incontinence in one month between the ages of five and six years, or more events after six years; absence of diseases Sleep-walking episodes range from quiet walking (most common) to restlessness (associated with restless walking, unintelligible speech and aggressive behavior in the presence of constraint). Although sleep-walking is not usually dangerous, the child might get into hazardous situations, such as going outdoors, and climbing up windows or balconies. Table 4 - Clinical characteristics of parasomnias with waking reaction Characteristics Sleep-walking Confusional arousal Night terror Time of night First 1/3 First 1/3 First 1/3 Duration (minutes) 1-10 5-40 1-5 Restlessness None or mild Moderate Severe Autonomic signs None or mild Moderate Severe 1-5% Incidence 40% 5-40% Age School-age child, pre-adolescent infant, preschool and school-age child Adolescent Amnesia Yes Yes Yes Waking threshold High High High + family Hx Frequent Frequent Frequent Modified according to references 31 and 32. Sleep disorders - Nunes ML Confusional arousal can affect infants, preschool children and school-age children. The episodes often last between five and 15 minutes and are characterized by crying, screaming, motor restlessness and confusion, which gradually worsen until they cease spontaneously. The situation gets worse when someone tries to comfort the child; in addition, it not possible to arouse him/her. Night terror usually affects older children and adolescents. It often begins abruptly with crying, screaming, eyes wide open, tachycardia, mydriasis, and sweating. The child looks frightened and can jump out of the bed and run aimlessly. The episodes last for no more than one minute, but the child is at great risk of getting hurt by bumping into pieces of furniture and windows. The treatment of parasomnias requires parents knowledge about basic safety rules. The pediatrician should assure parents about the benign nature of these events and reaffirm their self-limitation according to pediatric age. Occasional psychological stress can increase the frequency of episodes.34 Parents should be instructed not to restrict motor function, since this can make episodes last longer. The childs bedroom must be as free of furniture and objects as possible and the windows must remain firmly shut. Regular sleep and bedtime should be encouraged in order to avoid sleep deprivation. The use of medication can be necessary if waking up involves restlessness and if the child is at risk of getting hurt. The drugs of choice are usually benzodiazepines, such as clonazepam 0.25 mg at bedtime. Three to six weeks of treatment are usually enough to avoid relapses.31,32 Polysomnography is only recommended if there is suspicion of apnea, gastroesophageal reflux or periodic limb movement associated with waking episodes. For differential diagnosis with complex partial crises, sleep EEG is often enough. In the group of parasomnias that are not associated with waking, we have those that occur in REM sleep (sleep talking, hypnagogic hallucinations, sleep paralysis), and those that occur both during REM and NREM sleep (bruxism). Sleep-talking is the most common type of parasomnia, but its nature is benign and it does not require any treatment. Bruxism (grinding ones teeth) has a prevalence rate between 7 and 88%. When bruxism is too intense, there can be damage to the teeth and to the temporomandibular articulation. Treatment ranges from intraoral devices to orthodontic braces, and can also include botulinum toxin (for muscle relaxation).33 Primary snoring and obstructive sleep apnea syndrome (OSAS) Primary snoring in children is characterized by nighttime snoring not associated with apnea, hypoxemia or hypercarbia. Usually, there are no sleep disorders or signs of daytime sleepiness. On examination, the patient often presents with hypertrophic tonsils and adenoids. There are Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S69 several factors involved in the etiology of snoring that should be investigated (e.g.: narcotics or sedative drugs, genetic syndromes associated with craniofacial malformations, hypothyroidism, macroglossia, micrognathia, obesity). The necessity to treat primary snoring in children is arguable in cases in which OSAS is not confirmed.35 Obstructive sleep apnea syndrome consists of total or partial upper airway obstruction. Snoring, paradoxal movements between abdomen and thorax, apnea, and intermittent sleep are night symptoms. Daytime symptoms include nasal obstruction, open-mouth breathing, irritability, excessive daytime sleepiness, failure to thrive, reduced weight gain and, in more severe cases, cor pulmonale and death. Night polysomnography is the gold standard for the diagnosis and must be carried out at sleep laboratories specialized in pediatric treatment. The treatment of OSAS ranges according to its severity from clinical follow-up, drug treatment (theophylline), surgery (tracheostomy, adenotonsillectomy) to continuous positive airway pressure (CPAP).36-39 Narcolepsy Narcolepsy is a clinical syndrome, relatively rare in our country, which is characterized by excessive daytime sleepiness, daytime intromissions of REM sleep (cataplexy and sleep paralysis) and hypnagogic hallucinations. It is a hereditary disorder related to HLA DR2 antigen class II in chromosome 6. Symptoms usually appear in adolescence or in adult life, but in some cases, they can be present in childhood. The diagnosis is established by polysomnography and multiple sleep latency test. The treatment consists of stimulants, such as methylphenidate, amphetamines or tricyclic antidepressants (imipramine). More recently, modafinil, a drug that induces wakefulness, has been used for the treatment of narcolepsy. The treatment of cataplexy is based on clomipramine or fluoxetine. The pediatrician should remember that this is a chronic disease and that its treatment is continuous, during the whole life of the patient.40-41 Sleep and epilepsy There is a clear influence between sleep/wake cycle and the occurrence of some types of seizures. Absence seizures and juvenile myoclonic seizures always occur in the daytime while the patient is awake. Frontal lobe epileptic seizures, Landau-Kleffner syndrome and benign rolandic epilepsy occur during sleep or waking. Sleep deprivation is certainly a factor that triggers off seizures. On the other hand, epilepsies can also alter sleep patterns, especially progressive epileptic encephalopathies, West syndrome and LennoxGastaut syndrome, which can cause a total disruption of normal sleep stage patterns. In general, patients with epilepsy have intermittent sleep, increased number of wakings, S70 Jornal de Pediatria - Vol. 78, Supl.1, 2002 lengthening of NREM sleep stages I and II and reduction of stages III and IV. When generalized seizures occur during the night, there is also a tendency towards the reduction of REM sleep. The control of seizures with antiepileptic drugs can be effective to improve these aspects. It is advisable that the patient have a good sleep hygiene and avoid sleep deprivation.42,43 Sleep disorders in children with neurological and/or behavioral problems Sleep disorders can be associated with any type of acquired or congenital injury of the diencephalon and nuclei of the brainstem involved in the regulation of the sleep/wake cycle and REM-NREM cycle.44 Visually impaired children have several sleep disorders, such as difficulty falling asleep, frequent waking during the night, daytime weariness, and excessive daytime naps. The cause of these disorders is related to chronobiological problems, such as free-running circadian rhythm.44 In some genetic syndromes, there are specific sleep disorders, such as obstructive apnea (Downs syndrome) and excessive daytime sleepiness (Prader-Willis syndrome).44 Children with severe mental retardation often have several changes in their sleep pattern. Sleep periods are split into night and day. These children must be treated with a behavioral and pharmacological approach. The aim of behavioral treatment is to avoid daytime sleep and encourage nighttime sleep. Drug treatment can include sedatives (e.g.: chloral hydrate) or antihistamines. Melatonin at 2-10mg at bedtime can also be effective.44 Sleep disorders - Nunes ML In patients with neuromuscular diseases involving respiratory muscles, the most common sleep disorder is caused by hypoventilation and nocturnal apneas, which can result in irritability and daytime sleepiness. The treatment to improve respiratory pattern during the night includes correction of scoliosis, weight control, and use of nasal CPAP.44,47 Sleep disorders in children with respiratory problems Physiological respiratory abnormalities during sleep do not cause any kind of problem to children who have healthy lungs. However, for children with chronic lung diseases and with limited lung capacity, the effects of sleep on breathing may result in significant changes in ventilation and in gas exchange.48 Patients with cystic fibrosis have nocturnal hypoxemia, which can be associated with cor pulmonale. In addition to treating the underlying disease, nasal CPAP has been suggested for more severe cases in order to improve oxygenation during sleep.48 Asthma is characterized by periods of nocturnal exacerbation and this is probably due to the normal circadian variation of pulmonary function (which is better during the day). However, asthmatic children have a reduction in NREM sleep stage IV and more frequent waking during the night. There seems to be a higher death risk in patients whose asthmatic attacks occur during the night. The pediatrician should consider both daytime and nighttime symptoms when defining the treatment. Theophylline should be included as an option to treat these patients.48,49 In Rett syndrome, an X-linked neurodevelopmental disorder that is characterized by mental retardation, microcephaly and pervasive disorders, insomnia is a frequent complaint.44 Autistic children show sleep disorders characterized by an immature sleep pattern, changes in sleep architecture that are incompatible with chronological age, and functional disorders, such as difficulty falling asleep and early waking.46 In Tourettes syndrome, a family neurological behavior disorder characterized by motor and vocal tics, obsessivecompulsive behavior and attention-deficit/hyperactivity disorder, there is a significant increase in parasomnias (sleep-walking and night terror). In untreated children, there are changes in sleep architecture related to reduction in REM sleep, increase in NREM sleep stages III and IV, and sleep disruption by waking in the middle of the night.44 Sleep disorders are also reported by parents in attentiondeficit/hyperactivity disorder. Difficulty falling asleep, restless sleep, and evening waking are the most frequent symptoms. The chronic use of methylphenidate seems to increase the total sleep time.44 References 1. Stein MA, Mendelsohn J, Obermeyer WH, Amromin J, Benca R. Sleep and behavior in schoolaged children. Pediatrics 2001;107:E60. 2. Ferber R. Childhood sleep disorders. Neurol Clin 1996;14: 493-511. 3. Blum NJ, Carey WB. Sleep problems among infants and young children. Pediatr Rev 1996;17:87-93. 4. Sheldon SH, Spire JP, Levy HB. Pediatric sleep medicine. Philadelphia: WB Saunders; 1992. Sleep disorders - Nunes ML 5. Wolfson AR. Sleeping patterns of children and adolescents, developmental trends, disruption and adaptations. Child Adolesc Psychiatr Clin N Am 1996;5:549-68. 6. Anders TF, Sadeh A, Apparedy V. Normal sleep in neonates and children. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.7-18. 7. Kahn A, Dan B, Groswasser J, Franco P, Sottiaux M. Normal sleep architecture in infants and children. J Clin Neurophysiol 1996;13:184-97. 8. Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol 1992;19:809-38. 9. Nunes ML, Da Costa JC, Ferreira CP, Garcia CC, Marques FC, Spolidoro JV. Patologias associadas e prognóstico de eventos com aparente risco de vida (ALTE). J Pediatr (Rio J) 1999;75:55-8. 10. Williger M, James LS, Catz C. Defining the sudden infant death syndrome: deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol 1991;11:677. 11. Hoffman HJ, Hillman LS. Epidemiology of sudden infant death syndrome: maternal, neonatal and postneonatal risk factors. Clin Perinatol 1992;19:717-37. 12. Glotzbach SF, Ariagno RL, Harper RM. Sleep and the sudden infant death syndrome. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.231-44. 13. Nunes ML, Pinho APS, Aerts D, Sant Anna A, Martins MP, Da Costa JC. Síndrome da morte súbita do lactente: aspectos clínicos de uma doença subdiagnosticada. J Pediatr (Rio J) 2001;77:29-34. 14. Barros FC, Victora CG, Vaughan JP, Teixeira AMB, Ashworth A. Infant mortality in southern Brazil: a population based study of causes of death. Arch Dis Child 1987;62:487-90. 15. Pinho APS. Fatores de risco para síndrome da morte súbita do lactente [dissertação de mestrado]. Porto Alegre: Pontifícia Universidade Católica do Rio Grande do Sul; 2001. 16. Nunes ML, Martins MP, Nelson EAS, Cowan S, Cafferata ML, Da Costa JC. Orientações adotadas nas maternidades dos hospitais-escola do Brasil sobre posição de dormir. Cadernos de Saúde Pública (no prelo). 17. Ferber R. Sleeplessness in children. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.79-89. 18. Goodlin-Jones BL, Anders TF. Relationship disturbances and parent-child therapy: Sleep problems. Child Adolesc Psychiatr Clin N Am 2001;10:487-99. 19. Johnson EO, Chilcoat HD, Breslau N. Trouble sleeping and anxiety/depression in childhood. Pediatr Res 2000;94:93-102. 20. Estivill E. Childhood insomnia due to disorderly habits. Rev Neurol 2000;30:188-91. 21. Hayes MJ, Parker KG, Sallinen B, Davare AA. Bedsharing, temperament, and sleep disturbance in early childhood. Sleep 2001;24:657-62. 22. France KG, Henderson JMT, Hudson SM. Fact, act, and tact: a three stage approach to treating the sleep problems of infants and young children. Child Adolesc Psychiatr Clin N Am 1996; 5:581-99. 23. France KG, Hudson SM. Behavior management of infant sleep disturbance. J Appl Behav Anal 1990;23:91-8. 24. Lawton C, France KG, Blampied NM. Treatment of infant sleep disturbance by graduated extinction. Child Family Behavioral Therapy 1991;13:39-56. Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S71 25. Rickert VI, Johnson CM. Reducing nocturnal awakening and crying episodes infants and young children: a comparison between scheduled awakenings and systematic ignoring. Pediatrics 1988;81:203-12. 26. Ramchandani P, Wigs L, Webb V, Stores G. A systematic review of treatments for settling problems and night-waking in young children. BMJ 2000;320:209-13. 27. Smits MG, Nagtegaal EE, van der Heijden J, Coenen AM, Kerkhof GA. Melatonin for chronic sleep onset insomnia in children: a randomized placebo-controlled trial. J Child Neurol 2001;16:86-92. 28. Friman PC. Nocturnal enuresis in the child. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.107-13. 29. Sheldon SH. Sleep related enuresis. Child Adolesc Psychiatr Clin N Am 1996;5:661-72. 30. Butler RJ, Holland P. The three systems: a conceptual way of understanding nocturnal enuresis. Scand J Urol Nephrol 2000;34:270-7. 31. Rosen G, Ferber R, Mahowald MW. Evaluation of parasomnias in children. Child Adolesc Psychiatr Clin N Am 1996;5:601-16. 32. Rosen G, Mahowald MW, Ferber R. Sleepwalking, confusional arousals, and sleep terrors in the child. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.99-106. 33. Mahowald MW, Thorpy MJ. Nonarousal parasomnias in the child. In: Ferber R, Kryger M, eds. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.115-23. 34. Laberge L, Tremblay RE, Vitaro F, Montplaisir J. Development of parasomnias from childhood to early adolescence. Pediatrics 2000;106:67-74. 35. Carroll JL, Loughlin GM. Primary snoring in children. In: Ferber R, Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders, 1995.p.155-61. 36. Carroll JL, Loughlin GM. Obstructive sleep apnea syndrome in infants and children: clinical features and pathophysiology. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders, 1995. p.163-91. 37. Marcus CL. Obstructive sleep apnea syndrome: differences between children and adults. Sleep 2000;23 Supl 4:140-1. 38. Scholle S, Zwacka G. Arousals and obstructive sleep apnea syndrome in children. Clin Neurophysiol 2001;112:984-91. 39. Marcus CL. Sleep-disordered breathing in children. Curr Opin Pediatr 2000;12:208-12. 40. Brown LW, Biliard M. Narcolepsy, Kleine-Levin syndrome and other causes of sleepiness in children. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.125-34. 41. Guilleminaut C, Pelayo R. Narcolepsy in children: a practical guide to its diagnosis, treatment and follow up. Paediatric Drugs 2000;2:1-9. 42. Méndez M, Radtke RA. Interactions between sleep and epilepsy. J Clin Neurophysiol 2001;18:106-27. 43. Batista BHB, Appel CHC, Nunes ML. Sono e epilepsia. In: Acta Médica da ATM 2001. Porto Alegre: EDIPUCRS; 2001. p.389-99. 44. Brown LH, Maistros P, Guilleminaut C. Sleep in children with neurologic problems. In: Ferber R & Kryger M, editores. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.135-45. 45. Johnson CR. Sleep problems in children with mental retardation and autism. Child Adolesc Psychiatr Clin N Am 1996; 5:673-83. 46. Abril BV, Mendez MG, Sans OC, Valdizan JRU. Sleep in infantile autism. Rev Neurol (Paris) 2001;32:641-4. S72 Jornal de Pediatria - Vol. 78, Supl.1, 2002 47. Kohrman MH, Carney PR. Sleep-related disorders in neurologic disease during childhood. Pediatr Neurol 2000;23:107-13. 48. Loughlin GM, Carrol JL. Sleep and respiratory disease in children. In: Ferber R, Kryger M, eds. Principles and practice of sleep medicine in the child. Philadelphia: WB Saunders; 1995. p.217-30. 49. Miller BD, Strunk RC. Circumstances surrounding the death of children due to ashma. Am J Dis Child 1989;143:1294-9. Sleep disorders - Nunes ML Corresponding author: Dra. Magda Lahorgue Nunes Serviço de Neurologia do Hospital São Lucas da PUCRS Av. Ipiranga, 6690/220 CEP 90610-000 Porto Alegre, RS Telephone/Fax: +55 (51) 3339.4936 E-mail: [email protected]