Download The Rectum and You

Daniel Erichsen, MD, FAAP 10/25/2011
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Pediatric Sleep Clinic
The function(s) of sleep
Consequences of sleep loss
 Obstructive sleep apnea
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Division of Peds Sleep
 What’s going on?
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Thursday AM session
Patients
 2 – 26 y
▪ Sleep-disordered breathing
▪ Insomnia
▪ Hypersomnia
▪ Restless legs
▪ Parasomnias
+ Facesheet Plz
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Pediatric Sleep Clinic
The function(s) of sleep
Consequences of sleep loss
 OSA
 Insufficient sleep
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Born
 Sävsjö 1600
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1620s
 Captain Dutch West India Company
 New Netherlands
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Jonas Bronck
 Navigates up East River in De Brant Van Troyen
(The fire of Troy)
 Purchases land north of Harlem River
▪ South of 150th st
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South of 150th
 Jonas Bronk’s land
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South of 150th
 Jonas Bronck’s land
 -> Bronck’s land
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South of 150th
 Jonas Bronck’s land
 -> Bronck’s land
 -> Broncksland
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South of 150th
 Jonas Bronck’s land
 -> Bronck’s land
 -> Broncksland
 -> Bronx
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1/3 of your life
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Eating
 Energy supply
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Talking
 Communication
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Sex
 Reproduction
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Sleep
 ???
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Sleep
 No food gathering
 No reproduction
 Easy pray
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Why do we sleep?
How important is sleep?
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Important functions conserved
 How conserved is sleep?
 How important is sleep?
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Lungs
 Max 7 minutes submerged
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Lives in water
 Emerges 4-6 weeks/year
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Land
 Synchronized slow EEG activity entire brain and
eyes closed night.
 Asynchronized fast EEG activity entire brain and
eyes open day.
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Sea
 Right hemisphere synchronized slow activity with
left eye closed.
 Left hemisphere asynchronized fast activity with
right eye open.
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All species studied have sleep or sleep
equivalent
 Fish
 Insects
 Bacteria
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Complete sleep deprivation
 Hyperphagia
 Hyperthermia
 Autonomic dysregulation
 Loss of fur
 Death
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90 practice tasks-> 8 hr break -> 300 testing
tasks
 Group 1 – Awake 11 am -> 7 pm
 Group 2 – Awake 11 pm -> 7 am
 Group 3 – Sleep 11 pm -> 7 am
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Outcome
 % subjects gained “insight”
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None gained “insight” after first 90 tasks
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% gained “insight” after 300 test tasks
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Consolidation of declarative memory
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1 hr learning session -> 12 hr break -> 1 hr
testing session
 Group 1 – Slept 3 hrs
 Group 2 – Slept 8 hrs
 Group 3 – Awake daytime
 Group 4 – Awake nighttime
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Outcome
 Improvement in speed of correct answer
 Decrease in milliseconds
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Results
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Consolidation of procedural memory
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Slow wave, “deep”, sleep
 Consolidation of declarative memory
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REM sleep
 Consolidation of procedural memory
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Memory consolidation
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Single neuron recording
Zebra Finch
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Record singing
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New song
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Memory consolidation may occur 2nd to
reactivation of neural pathways in sleep
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Memory consolidation
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Corresponding 15% reduction overall
metabolism
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Corresponding 15% reduction overall
metabolism
 Is energy conservation a function of sleep?
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Vulnerable species
 Squirrels
 Mouse birds
 Humming birds
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Vulnerable species
 Squirrels
 Mouse birds
 Humming birds
▪ Several degrees sleep drop
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Further decrease in unfavorable conditions
 Willow Tit
 Parid species
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Memory consolidation
Energy conservation
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Is it more dangerous to be asleep or awake?
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Meddis 1975
Nocturnal animals
 Large eyes
 Large pupils
 Tapetum
 Heightened hearing/smell
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How minimize risk for diurnal animal (human)
being preyed upon by nocturnal predator
(python)?
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How minimize risk for diurnal animal (human)
being preyed upon by nocturnal predator
(python)?
 8 hour blackout
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Memory consolidation
Energy conservation
Decreased predation risk
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Input of data daytime
 -> Storing as new synapses or strengthening of
synapses
 -> increased space and energy demand of brain
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Input of data daytime
 -> Storing as new synapses or strengthening of
synapses
 -> increased space and energy demand of brain
 If not interrupted
▪ -> exhaustion of energy/space
▪ No capacity for new memory
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Brain taken “off line” during sleep
 Synapses eliminated
 Selective weakening/strengthening synapses
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Memory consolidation
Synaptic maintenance
Energy conservation
Decreased predation risk
Metabolic functions
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Memory consolidation
Synaptic maintenance
Energy conservation
Decreased predation risk
Metabolic functions
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Sleep loss may have several consequences
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Affects 2-4 % of children
Related to
 Tonsillar/adenoidal hypertrophy
 Obesity
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Pathophysiology
 Repetitive complete (apnea) or partial (hypopnea)
upper airway obstructions during sleep resulting
in arousals and/or desaturations.
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AHI
 Apneas + Hypopneas per hour of sleep
▪ <2 normal
▪ 2-5 mild OSA
▪ 5-15 moderate OSA
▪ >15 severe OSA
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Symptoms
 Respiratory
▪ Snoring
▪ Choking
▪ Apneas
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Symptoms
 Neurocognitive
▪ Sleepiness
▪ Inattentiveness
▪ Poor academic performance
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Symptoms
 Hormonal
▪ Nocturia
▪ Obesity?
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History
 Focus on nighttime respiratory symptoms and
daytime neurocognitive impairment
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Work up
 In lab, attended polysomnogram gold standard
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Treatment
 T&A
▪ Medical treatment for mild or residual OSA
▪ Positive airway pressure therapy
▪ Mandibular advancement device
▪ Maxillary expanders
▪ Weight loss
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8 y.o boy
 Snoring
 Choking in sleep
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8 y.o boy
 AHI 6.5
 Recommended T&A
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Snoring -> Upper airways resistance
syndrome -> Hypopneas -> Obstructive
apneas (OSA)
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Snoring -> Upper airways resistance
syndrome -> Hypopneas -> Obstructive
apneas (OSA)
Snoring in itself has health implications
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Compared to non snoring children
 Snoring children perform worse on measures of:
▪ Attention span
▪ Social problems
▪ Overall cognitive abilities
▪ Visuospatial functions
 O’brien et al. Pediatrics 2004
 Guilleminault. Eur. J. Pediatrics 1982
 Kennedy. Ped. Pulm 2004
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Neurocognitive effects
 Snoring at age 2 to 6 is associated with worse
academic performance at age 13 to 14.
▪ Gozal. Pediatrics 2001
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297 1st grader with lowest 10th grade
percentile surveyed for OSA
All underwent sleep study
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Prevalence
 54 (18%) had OSA
▪ 24 elected to have T&A
▪ 30 elected not to have T&A
 66 had primary snoring
 177 had normal breathing
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Grades 1 year later compared
 OSA and T&A group
 OSA no T&A group
 Primary snoring
 Normal controls
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Associated with
 Increased risk of cardiovascular events
 Strong association with Diabetes Mellitus II
 Increased risk of MVH
 Endothelial dysfunction (peds)
 Autonomic dysregulation (peds)
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How well do we comply with guidelines?
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Chart review study St. Barnabas Hospital
Adult Outpatient service
n=1049
 Snoring
 Respiratory symptoms in sleep
 Insomnia symptoms
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Results
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Results
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Results
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Results
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Chart review study St. Barnabas Hospital
Pediatric Outpatient service
n=1026
 Detected snoring
 Specific screening for snoring
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Results
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Results
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Results
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Fluid shifts during sleep
 Neck engorgement / decrease calf diameter?
 Role in pediatric OSA
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24 hour hunger profile
 Circadian variation in hunger scale
 Obese vs nonobese
 Change in hunger scale with caloric intake
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Smartphone app
 Monitor leg movements in sleep
 Screening
 Treatment efficacy