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Fall 2014 Meeting
October 3-4, 2014
Overview of Pediatric Sleep Medicine
Jason Coles MD
Spectrum Medical Group
Helen DeVos Children’s Hospital
Conflict of Interest Disclosures for Speakers
X
1. I do not have any relationships with any entities producing, marketing, re-selling, or
distributing health care goods or services consumed by, or used on, patients, OR
2. I have the following relationships with entities producing, marketing, re-selling, or
distributing health care goods or services consumed by, or used on, patients:
Type of Potential Conflict
Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following
objective references are provided as support for this lecture:
1.
2.
3.
Objectives
• At the conclusion of this course, attendees should
be able to…
• Understand normal sleep development and patterns in
childhood
• Understand common pediatric sleep disorders
• Understand important differences between children and
adults regarding conducting, scoring and interpreting
sleep studies
• Understand strategies to make a sleep study experience
child-friendly, and to optimize study quality
Development of Sleep
• Sleep and wake can first be determined in fetus
around 28 weeks gestation
• 32-36 weeks gestation
• Active (REM) and Quiet (non-REM) sleep can be distinguished
• Quite Sleep (non-REM) characterized first by trace alternant EEG
pattern
• Pattern persists until about 4 weeks after birth
• Develops into High Voltage Slow (HVS) activity “more mature” pattern of
Quiet Sleep in infants
Trace alternant EEG pattern
Alternating 3-8 second patterns of high amplitude slow waves
and low amplitude mixed frequency activity
Sleep in the child: normal and abnormal. AACP board review presentation, Lee Brooks MD
Infant Sleep Stages
• Sleep scored as Active (REM), Quite (NREM) or Indeterminate
• Scored based on multiple variables
Active (REM)
Quite (NREM)
Behavior
Smiles, grimaces, limb movements
Rare movement
EEG
Low voltage, mixed frequency
Trace alternant; high voltage
slow waves
EMG tone
Low
High
Respirations
Irregular
Regular
Eye Movements
Present, rapid
Absent
Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sleep and arousal in infants
and children. J Clin Sleep Med 2007; 3:201-40
Infant Sleep
• Spindles develop 2-3 months
• K-complexes and Slow Wave activity 4-6 months
• N1, N2, N3, REM can be scored once these EEG patterns
distinguished  “Pediatric” study rather than “infant”
• Nearly 50% of sleep is REM at birth
• Gradually decreases until age 3-4 when it stabilizes at 25% (same as adults)
• N3 sleep gradually decreases throughout lifetime
Changes to sleep architecture
• Higher density of N3 and fewer
awakenings likely account for
increased parasomnias in children
• Sleep Cycles
• 50-60 min at birth
• 75 min at 2 years
• 90 min at 6 years
Mindell and Owens. A Clinical Guide to Pediatric Sleep 2010
Normal Patterns
• Newborns (0-2 months)
•
•
•
•
Average 13-14.5 hours sleep, with wide variability
No established Circadian pattern
Sleep periods separated by 1-2 hours of wake
Breast fed babies sleep for shorter periods
• Infants (2-12 months)
• Circadian patterns start to form
• 9-10 hours at night plus 3-4 hours of naps = 12-13 hours overall
• By 1 year, number of naps decrease to 1-2/day
Normal Patterns
• Toddlers (1-3 years)
• Average 9.5-10.5 hours at night plus 2-3 hours in naps = 11-13 hours overall
• By 18 months down to 1 nap per day
• Nearly half stop napping by age 3
• Preschool (3-5 years)
• 9-10 hours of sleep at night
• Only 15% of 5 year olds still take a nap
Normal Patterns
• School age (6-12 years)
• Average 9-10 hours of sleep
• Adolescents (12-18 years)
•
•
•
•
9-9.25 hours recommended
But, average is only 7-7.5 hours at night
2-hour sleep debt accumulates per night across the school week
Most parents think their teens are getting enough sleep
Common Pediatric Sleep Disorders
• Insomnia
• Problems going to bed
• Night wakings
• Delayed sleep phase
• Obstructive sleep apnea
• Restless legs syndrome (Willis-Ekbom Disease) and Periodic limb
movement disorder
• Parasomnias
Insomnia
Behavioral Pediatric Insomnia: Night
wakings
Sleep onset association
disorder
• How we fall asleep is learned
• Physical parental presence can become part of the
ritual
• Normal awakenings occur multiple times a night
• Child doesn’t know how to fall back asleep without
his parents, so seeks them out by any means
necessary
• Multiple awakenings per night, waking parents each
time
Sleep Onset Association Disorder
•Treatment – Behavioral interventions
• Educate parents
• Replace physical parental presence with new sleep onset associations that
will be present when child wakes at night
• Parents leave room before child falls asleep
• If child cries, frequent checks and reassurance, but with increasing
intervals
• If child comes out of room, take right back and tuck back in without
unnecessary conversation, arguing, etc
• Child not allowed to sleep with parents
Behavioral Insomnia:
Problems going to bed
Limit Setting Sleep Disorder
• Child is physiologically able to fall asleep, but doesn’t stay in bed
long enough
• Refusals
• Stalling
• Repeated demands
• Create any reason (and many reasons) to stay up
• Parents intermittently or eventually give in, reinforcing behavior
• Child gains attention and special time from parents (even if arguing)
Limit Setting Sleep Disorder
• Comes out of room repeatedly because child can’t fall asleep because
•
•
•
•
•
Thirsty
Hungry
Afraid of dark, monsters, being alone
Stomach hurts
Not tired, etc…
• Treatment: Behavioral Interventions
• Set clear, 100% predictable, 100% consistent limits
• Bed time is strictly enforced, following an enforced wind down period
beginning predictably 1-2 hours before bed
• Do not give in to protests or requests after bed time
• Decide who is going to win
Delayed Sleep Phase Syndrome
• Sleep physiology is completely normal, but timing of sleep cycle is
misaligned with school/daytime responsibilities
• Not ready or able to fall asleep early at night
• Body not ready to wake up for school
• most sleepy during first part of the day
• Total sleep becomes inadequate, causing cumulative sleep
deprivation; trying to catch up on weekends
• If allowed to get enough total sleep, feels normal
• Runs in families
• Develops in adolescence
• most adolescents will have at least a mild shift in circadian rhythm
Delayed Sleep Phase Syndrome
• Treatment
• Education
• Properly timed melatonin in the evenings
• Bright light exposure in the mornings
• Consistent schedule 7 days a week
Obstructive Sleep Apnea
Obstructive Sleep Apnea
• Epidemiology
• 8% children snore frequently, according to parents
• “Always” snoring 1.5-6%
• 1-4% school age children have OSA based on PSG
• Peak age 2-8 years
• Corresponds to the peak of lymphoid hyperplasia, and
adenotonsillar hypertrophy
• Boys and girls equal until adolescence, when boys
outnumber girls (similar to adult patterns)
• More frequent in African-American and Asian children
OSA Risk Factors
• Enlarged tonsils and/or adenoids
• Allergies
• Facial abnormalities
• Small chin
• Narrow hard palate
• Cleft palate repair
• Down syndrome
• Obesity
• Neuro-Muscular disorders
OSA – Night Symptoms
• Snoring most common complaint
• With or without snorting, choking, gasping, or
witnessed pauses in breathing
• Restless sleep (tossing and turning)
• Sleeping in strange positions (extending neck to
open airway)
• Sweats
• Bed wetting
OSA – Daytime Symptoms
• Daytime sleepiness not present in most kids (less than 10%)
• Behavioral problems
• Inattention
• Hyperactivity
• Irritability
• Decreased school performance
• Morning headaches
OSA – Medical Consequences
• Hypertension
• Pulmonary hypertension
• Failure to thrive (slow growth)
• Heart failure
Diagnosis of OSA
• Clinical history cannot predict presence or absence of
childhood OSA
• Severe OSA can be present even with soft snoring and
minimal symptoms
• Physical examination is often normal
• Degree of tonsillar hypertrophy does not correlate with
presence of OSA
• Parental perception varies widely
• Sleep study is needed
OSA Treatments
• Adenotonsillectomy – Recommended 1st line treatment
by American Academy of Pediatrics
• Large study* in 2010 demonstrated complete resolution of
OSA in only 27% of kids, though most were improved
• High AHI, older age, obesity and asthma predict failure
• Rapid maxillary expansion (orthodontic)
• Medical management of allergies and GERD
• CPAP/BiPAP
• Craniofacial surgery
• Tracheostomy
*Bhattacharjee et al. Adenotonsillectomy Outcomes in Treatment of Obstructive Sleep
Apnea in Children. Am J Crit Care Med 2010; 182: 676-683
Central Sleep Apnea
• Usually periodic breathing
• Can be a sign of structural brain abnormalities
• Arnold Chiari malformation
• If significant, MRI brain is recommended
• Treatment protocols for central apnea are not defined
• Treat OSA if present (start with T&A)
• Neurosurgical consultation for Chiari malformation
• Oxygen
• CPAP
• BiPAP ASV/APAPs
12 year old with brain stem tumor
Trial of BiPAP with backup rate 12
Trial of BiPAP ASV
Restless Legs and PLMs
Restless Legs and Periodic Limb Movements
• Restless legs syndrome
• Clinical diagnosis
• Uncomfortable sensations in the legs accompanied by urge to move
them
• Often described as “growing pains”
• Worse at night or when inactive (car rides)
• Periodic Limb Movement Disorder
• Identified PLMs on polysomnography
• Brief (0.5-10 seconds) repetitive limb movements, not in association
with OSA
• For children, >5 per hour required
• AND associated with sleep or daytime symptoms
Periodic Limb Movements
RLS and PLMD
• 70-90% of adults with RLS also have PLMs (not studied in kids)
• Share underlying abnormalities in the brain’s dopamine system
• Thought to be under-recognized generally
Pediatric RLS
• Present in 1-6% of kids
• Equal rates in boys and girls (unlike adults)
• Possibly life long and severe
• Risk factors
•
•
•
•
•
•
Family history
Sleep deprivation or poor sleep hygiene
Caffeine
Antihistamines
Antidepressants
Iron deficiency (ferritin < 50 ng/ml)
• Present in 75% of kids with RLS
Pediatric PLMs
• Same link with iron deficiency and antidepressants
• 50% of kids with PLMs also have OSA on sleep study
• Treatment of OSA resolves the PLMs in 50% of these kids
Treatments for RLS/PLMD
• Replace iron if ferritin is low
• Stop or reduce antidepressants
• Avoid caffeine
• Good sleep hygiene
• Treat OSA if present
• Exercise, stretching, massage
• Medications only approved for adults
Parasomnias
Parasomnias
• Episodic disorders in sleep
• Not resulting in complaint of excessive sleepiness or insomnia
• Arousal disorders
• REM related disorders
• Sleep-wake transition disorders
Arousal Disorders
• “Partial” arousal from deep non-REM sleep
• Occurs typically first third of the night
• Difficult to wake up
• No recall of event
• Worsened by
• Sleep deprivation
• Sleep fragmentation (sleep apnea, caffeine)
• Psychological factors – Anxiety, stress, change
Arousal Disorders
• Somnambulism
•
•
•
•
40% of kids at least once
5% frequently
Outgrown usually by age 15
Dangerous
• Sleep Terrors
•
•
•
•
Abrupt onset
Blood curdling scream or cry
Confusion, agitation, tachycardia
Not associated with dream
• Confusional arousals
Arousal Disorders
• Treatment
• Reassurance
• Insure safety!!
• Locks, door alarms, gates
• Good sleep hygiene
• Minimize triggers (sleep apnea)
• Medications (benzodiazepines)
REM Associated Disorders
• Nightmares
• Last 3rd of night
• Remembers dream, able to fully awaken
• REM Behavioral Disorder
• Sleep paralysis
Sleep-Wake Transition Disorders
• Rhythmic Movement Disorders
• Head banging, Body rocking as way to self-sooth and transition to sleep
• 2/3 of normal children
• Usually ends by age 4
• Hypnic Jerks
• Occurs with transition to N1
• 60-70% or normal people
• Somniloquy – very common
Pediatric Polysomnography
• Must be ‘child oriented.’ Ergonomically pediatric.
• Techs must be experienced, motivated to work with children, and
very patient!
• Can be performed on any child of any age
• Most children tolerate it well
• Parent must accompany child for entire evening
• Interpretation and scoring different from adult criteria
• Children have shorter and fewer events, and higher proportion of
partial obstructions: scoring requires great care
Getting better studies
• Parents are the experts for their child; use them
• Try to adapt to family routines
• Explain everything to parents to keep them involved
• Environment should resemble a child’s room
• Quiet, appropriate room temperature
• Age appropriate toys, pictures, books
• Parental accommodations should be comfortable
• Room child-proofed
• Quality of study directly dependent on the skill of the technologist
• Preferably experienced and enjoys working with kids
• Set up should be fun
• Distraction
• Adequate staffing – liberal use of 1:1 especially for set up
• Document everything!
PSG Interpretation
• Adult criteria do not apply to children
• 80% of kids with clinically significant OSA would be missed
• Cutoffs continue to be debated, but abnormal if…
• AHI>1 (HDVCH uses AHI 1.5 or OAI of 1.0)
• EtCO2 > 45 mmHg for >60% of TST (some researchers suggest this cutoff
should be as low as 10%)
• Pediatric respiratory scoring rules may be used until age 18
• Adult respiratory scoring rules may be used starting at age 13
Pediatric PSG Scoring
• Sleep Stages
• Wakefulness defined by “dominant posterior rhythm”
• gradually increasing in frequency with age until full “alpha rhythm” of 8 Hz first seen at
ages 1-3
• Stages N1, N2, N3, and REM similar rules as adults, can be scored as soon as
K-complexes and Spindles seen (2-6 months)
• N (NREM), REM, and Indeterminate scored if <6 months, and no N2
• Cardiac Events – Heart rates 2 Standard Deviations from the mean,
based on age normative values
Respiratory Monitoring
• Apneas detected by thermal sensor
• Alternate (if not reliable) nasal pressure transducer
• Hypopneas detected by nasal pressure transducer
• Alternate oronasal thermal sensor
• Alveolar hypoventilation detected by either transcutaneous (Tc) or
end-tidal (ET) PCO2
• Crucial to obtain a plateau in the EtCO2 waveform for the signal to be
considered valid
• Transcutaneous PCO2 not always reliable
• Et PCO2 will yield inaccurately low values if
•
•
•
•
Nasal obstruction
Nasal secretions
Obligate mouth breathers
Receiving supplemental oxygen
Scoring Respiratory Events
Adults
Obstructive Apnea
10 seconds with
respiratory effort
Central Apnea
10 seconds with no
respiratory effort
Hypoventilation
10 seconds ≥ 30%
drop in nasal
pressure with
arousal or ≥ 3% desat
PCO2 > 55 mmHg for
≥ 10 minutes
Periodic Breathing
Cheyne-Stokes
breathing pattern
Hypopnea
Children
2 missed breaths
with respiratory
effort
20 seconds or 2
missed breaths with
arousal or ≥ 3%
desaturation
2 breaths ≥ 30% drop
in nasal pressure
with arousal or ≥ 3%
desat
PCO2 > 50 mmHg for
> 25% TST
≥ 3 episodes of CA
lasting >3 seconds,
separated by ≤ 20
seconds or normal
breathing
AASM Manual for the Scoring of
Sleep and Associated Events Version
2.0. 2012
Obstructive Apneas
Hypopneas
Obstructive Hypoventilation
Periodic Breathing
Summary
• Pediatric sleep and sleep disorders can appear very
different from adult patients
• Pediatric sleep studies present special challenges to
perform and interpret
• Treatment of pediatric sleep disorders can
sometimes require more trial and error, and an
appreciation for the child as a member of a family
References
• Berry RB, Brooks R, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL
and Vaughn BV for the American Academy of Sleep Medicine. The
AASM Manual for the Scoring of Sleep and Associated Events: Rules,
Terminology and Technical Specifications, Version 2.0.2.
www.aasmnet.org, Darien, Illinois: American Academy of Sleep
Medicine, 2013
• Mindell J, Owens J. Clinical Guide to Pediatric Sleep: Diagnosis and
Management of Sleep Problems. 2010
• Sheldon S, Ferber R, Kryger M. Principles and Practice of Pediatric
Sleep Medicine, 2005