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Goals of this Presentation. Learn how to prepare for a successful pediatric sleep study Learn what to look for and how to respond during the study Learn about pediatric sleep disorders and their treatments. Children:. Not just short adults. - PowerPoint PPT Presentation
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Goals of this Presentation
1. Learn how to prepare for a successful pediatric sleep study
2. Learn what to look for and how to respond during the study
3. Learn about pediatric sleep disorders and their treatments
3
Children:
Not just short adults
4
Pediatric Polysomnography Requires Patience and
Preparation • Polysomnographic procedures may be fear
provoking to children• Children require more time to set up for a
polysomnogram than do adults• Crying and removing electrodes may
extend set up time past the child’s usual bedtime, resulting in an overtired child
5
A Family Centered Care Approach
• Parents are the experts on their child and a constant in their child’s life
• Procedures should be conducted to create the least amount of trauma for the child
• The test environment should be inviting and child-friendly
• Psychological preparation of the child and parent are fundamental to the procedure
• Coping-skill development enhances a child’s sense of mastery and control over a potentially stressful experience
Zaremba et al, JCSM, 2005
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Important “Mind-Set” Changes by the Polysomnography Staff
FROM TO
needs of the staff needs of the child, parent
“Good Guy – Bad Guy”parent, child and tech on
the same team
a child lying downperforming the
procedure with the child sitting
Zaremba et al, JCSM, 2005
7
Preparing the Family for a Polysomnogram
• Provide detailed information about the test• Schedule testing for the child’s usual
bedtime• Communications: Confirmation letter sent
with:– Logistics of reaching the center– What to bring (food, transitional objects)– No caffeine, no naps, no hair oils
• Answer questions as they come up
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What the Parent Should Know
• No acute or very recent medical issues– Parents should call to cancel if child is ill
• Recommend shampoo night before– Avoid scalp oils– Avoid new braids
• Avoid caffeinated beverages• Comfortable, loose two piece pajamas• Bring a favorite book, video• Bring usual medications
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Creating a Calm Environment
• Take time to establish rapport• Explore the child’s past experiences and
coping strategies• Create a good first impression
– Have books or toys on the bed– Cover set up supplies, equipment if possible
• Use a calm and soothing tone of voice
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Child and Family Preparation
• On the study night…– Allow the child to explore room and sensors– Define each person’s job– Develop a plan for coping– Maintain patience, flexibility, positive
attitude– Lavish the child with praise
• Focusing on the desired behavior
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Engaging the Parent
• Make the parent part of the team• Encourage the parent to interact in a
reassuring way with the child• Respond positively to parents
questions and concerns• Provide parents with explanations of
the procedures
12
Optimizing the Environmentfor Sleep and Safety
• Quiet – away from doors, overhead paging• Dark – shades over windows• Can you see, hear, communicate with child?
– Call button, two-way communication for calibrations– Need for infrared lighting
• Safety– Outlet plugs, no sharp corners, bed rails up– Hypoallergenic, latex free supplies, no sharp corners
• Access: emergency equipment, personnel
13
Ground Rules for Bedroom Electronics
• No active phones or pagers in sleep room– Arrange local phone access for parent
• Cell phones must be muted– No calls in the room after lights out
• Plan video or TV to end before lights out– Avoid electronic games immediately before
bed
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Explanations• Short, objective and concrete explanations
are appropriate for younger children• Children may regress when upset
– May need to aim explanations at a developmental level less than child’s age
• Be honest and careful in your word choice• Sarcasm and teasing may be
misinterpreted and should be avoided
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Tips for Improving Cooperation
• Younger children may want to sit in their parent’s lap during set-up
• Distractions are often useful (stickers, bubbles, toys, favorite video)
• Medical play may reduce anxiety (put the electrodes on a doll)
• Older children can help by holding electrodes or sensors
16
Positions for Comfort
Zaremba et al, JCSM, 2005
17Courtesy of Dr. Carol Rosen
Pediatric Polysomnography
Tech Observer Video Camera
SaO2
Leg EMG (2)
Microphone
EKG
Chin EMG (2)
EEG EOG
Nasal EtCO2
Records behaviorDocuments arousals, parasomnias, abnormal sleeping position, and attends to any technical problem
Respiratory Effort
Nasal Oral Airflow
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During the Night
• Children need more frequent adjustment of sensors during the night than adults
• Nearly all studies of children require that the sensors be replaced at some point during the night
• Technologists should warn the patient and the parent that they will be entering the room during the night
19
Documentation • Due to the prevalence of parasomnias,
children’s studies need frequent documentation
• Children may have significant sleep disorders without dramatic polysomnographic findings
• Recordings may be ambiguous at times (i.e., when breathing sensors have been displaced); technologist observations become crucial to interpretation– For example: “discovered nasal pressure
transducer pushed to side of face – restored to proper position”
20
Describe What You See
• Helpful– Sat up abruptly--staring
and mumbling– Patient breathing quietly– Mom moving, wakes
child– Went into room, snoring
from mother, not patient
• Not Helpful– Possible seizure– Can’t hear patient– Patient moving in
bed– Artifact– Sounds from room
21
The Spectrum of Pediatric Sleep Disorders
Prevalent in Children and
Adults
Prevalent in Children Using
Different Criteria Than
in Adults
More Prevalent in
Children Than Adults
Unique to Children by Definition
Delayed sleep phase syndrome
Periodic limb movement disorder
Obstructive sleep apnea
Restless legs syndrome
Narcolepsy
Sleepwalking, sleep talking
Sleep terrors
Nightmares
Behavioral insomnia of childhood
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Estimated Prevalence of Sleep Disorders in Children
• Insufficient sleep – 10% (higher in teens – up to 33%)– Behaviorally based - 25%
• Sleep related breathing disorders - 2%• Narcolepsy – 0.05%• Sleep/wake timing (delayed sleep phase) - 7%
teens• Partial arousals (parasomnias)
– Night terrors 2 - 3% – Sleep walking 5%
• Rhythmic movement disorder 3 -15%• Restless legs syndrome – 2%
23
Who Should Have a Polysomnogram?
• All children should be screened for snoring– Habitual snoring with labored breathing– Witnessed apnea– Restless sleep– Evidence of daytime sleepiness
• And be sent for a polysomnogram if they show physical signs of sleep apnea– Growth abnormalities– Signs of upper airway obstruction– Evidence of pulmonary hypertension
American Academy of Pediatrics, 2002
Guidelines for Investigation of Sleep Related Breathing Disorders in Children
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Prevalence of Sleep Related Breathing Disorders in Children• Habitual snoring – 10%
• Sleep disordered breathing – 2%
• Risk factors– African-American heritage– Family history of OSA– History of prematurity– Chronic conditions - cerebral palsy, trisomy 21,
achondroplasia and other genetic syndromes– Obesity (less risky than in adults)– No gender difference in prepubertal children
Rosen et al 2003
25
Many Pediatric Diagnoses Do Not Require a Polysomnogram
Usually requires polysomnography:
• Obstructive Sleep Apnea, Pediatric• Narcolepsy
Usually diagnosed by tests other than polysomnography (i.e., ICU monitoring)
• Primary Sleep Apnea of Infancy(formerly Primary Sleep Apnea of Newborn)
• Congenital Central Hypoventilation Syndrome
May require polysomnography with extended EEG montage:
• Complicated or atypical parasomnia
Usually does not require polysomnography:
• Behavioral Insomnia of Childhood (Sleep Onset Type)
• Behavioral Insomnia of Childhood (Limit-Setting Type)
• Sleepwalking, Night Terrors• Sleep Enuresis• Restless Legs Syndrome• Sleep Related Rhythmic
Movement Disorder
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Evaluating Breathing during Sleep in Children
• Children experience less desaturation with apnea
• Carbon dioxide monitoring is recommended (< 12 years)
• Monitoring behavior, body position, snoring is important
• Additional measures of effort such as esophageal pressure monitoring may be helpful in special cases
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Scoring Rules
• Apnea is recurrent partial or complete airway obstruction despite continued effort– Adult -- respiratory event is 10 seconds or
longer– Child – “two missed breath” duration
• ETCO2 levels above 50 mm Hg for more than 10% of sleep time may be abnormal
28
Types of Sleep Related Breathing Disorders in
Children • Upper airway resistance syndrome is common
– Repetitive respiratory effort related arousals without discrete apnea or hypopnea
– No changes in oxygen saturation or ETCO2
• Obstructive hypoventilation is common– Upper airway narrowing with gas exchange
abnormalities, but without clear apnea or hypopnea
• Most prominent in REM
29
The Spectrum of Obstructive Sleep Related Breathing Disorders in
ChildrenAPNEAAPNEA
HYPOPNEAHYPOPNEA
RESPIRATORY EFFORT RELATED
AROUSAL
RESPIRATORY EFFORT RELATED
AROUSAL
OBSTRUCTIVE HYPOVENTILATION
OBSTRUCTIVE HYPOVENTILATION
SNORINGSNORING
Degree of Obstruction HIGHLOW
30
Normal Breathing – NREM Sleep
Delta activity, K complexe
s, spindles in EEG
Very regular
breathing
No oxygen desaturatio
n or CO2 elevation
8 y/o with daytime sleepiness
Note time scaleNote time scale
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Normal Breathing –REM Sleep
Rapid eye movemen
ts, low voltage fast EEG pattern
Breathing, heart
rate somewh
at irregular
8 y/o with daytime sleepiness
32
RERA
Arousal (alpha activity
at arrow)
Recurrent episodes
of flattened nasal air pressure
and minimal oxygen
desaturation 10 y/o with restless sleep
33
Apnea and Hypopnea
Hypopnea –
between 30 and 70% air
flow
Apnea – less than 30% air
flow
9 y/o with snoring and gasping at night and poor school performance
34
ICSD-2 Diagnostic Criteria: Obstructive Sleep Apnea,
Pediatric• The caregiver reports snoring, and/or labored or
obstructed breathing, during the child’s sleep. • The caregiver reports observing at least one of the
following:i. Paradoxical inward rib-cage motion during inspiration ii. Movement arousals iii. Diaphoresis iv. Neck hyperextension during sleep v. Excessive daytime sleepiness, hyperactivity, or
aggressive behavior vi. A slow rate of growth vii. Morning headaches viii. Secondary enuresis
35
ICSD-2 Diagnostic Criteria (cont.)
• Polysomnographic recording demonstrates one or more scoreable obstructive respiratory events per hour (i.e., apnea or hypopnea of at least two respiratory cycles in duration)– Note: Very few normative data are available for
hypopneas, and the data that are available have been obtained using a variety of methodologies. These criteria may be modified in the future once more comprehensive data become available.
Obstructive Sleep Apnea, Pediatric
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ICSD-2 Diagnostic Criteria (cont.) • Polysomnographic recording demonstrates either i or
ii. i. At least one of the following is observed:
• a. Frequent arousals from sleep associated with increased respiratory effort
• b. Arterial oxygen desaturation in association with the apneic episodes • c. Hypercapnia during sleep • d. Markedly negative esophageal pressure swings
ii. Periods of hypercapnia, desaturation, or hypercapnia and desaturation during sleep associated with snoring, paradoxical inward rib-cage motion during inspiration, and at least one of the following:
• a. Frequent arousals from sleep • b. Markedly negative esophageal pressure swings
Obstructive Sleep Apnea, Pediatric
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Obstructive Sleep Apnea, Pediatric
• Many children have associated cognitive problems and difficulty at school
• Pediatric obstructive sleep apnea is frequently associated with adenotonsillar hypertrophy
• Adenotonsillectomy is effective in most children
• When applied to pediatric recordings, adult polysomnographic measures alone (i.e., AHI) may underestimate the number of patients who would benefit from adenotonsillectomy
38
CPAP Therapy for Children
• Continuous positive airway pressure is an effective second-line treatment in pediatric patients
• A desensitization program is an extremely important part of treatment
• Successful trials reported in 74% of patients, with 86% of those able to use the therapy long-term
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Primary Sleep Apnea of Infancy
ICSD-2 Diagnostic Criteria• Apnea of Prematurity. Prolonged central respiratory pauses of
20 seconds or more in duration (or shorter-duration events that include obstructive or mixed respiratory patterns and are associated with a significant physiologic compromise, including decrease in heart rate, hypoxemia, clinical symptoms, or need for nursing intervention), are recorded in an infant younger than 37 weeks conceptional age.
• Apnea of Infancy. Prolonged central respiratory pauses of 20 seconds or more in duration (or shorter-duration events that include obstructive or mixed respiratory patterns and are associated with bradycardia, cyanosis, pallor, or marked hypotonia), are recorded in an infant with a conceptional age of 37 weeks or older.
(formerly Primary Sleep Apnea of Newborn)
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Primary Sleep Apnea of Infancy
• Should be distinguished from Acute Life Threatening Events (ALTE), an ill-defined disorder based on parental complaints and Sudden Infant Death Syndrome (SIDS), a post-mortem diagnosis
• A polysomnogram is the best way to evaluate breathing during sleep
• Prognosis is excellent with infrequent events– Prognosis guarded when frequent resuscitation is
required and events persist over time
41
Congenital Central Alveolar Hypoventilation Syndrome
ICSD-2 Diagnostic Criteria• The patient exhibits shallow breathing, or cyanosis and
apnea, of perinatal onset during sleep. – Note: In severely affected infants, consequences of hypoxia, including
pulmonary hypertension and cor pulmonale, may also be present.
• Hypoventilation is worse during sleep than during wakefulness.
• The rebreathing ventilatory response to hypoxia and hypercapnia is absent or diminished.
• Polysomnographic monitoring during sleep demonstrates severe hypercapnia and hypoxia, predominantly without apnea.
42
Congenital Central Alveolar Hypoventilation Syndrome
• Present from birth• Requires lifelong treatment
– Mechanical ventilation or pacing– Most patients do not need treatment when awake
• Associated with abnormality of the PHOX2B gene
• Associated with Hirschsprung's disease
43
Narcolepsy in Children• Narcolepsy with cataplexy is rare in children
younger than four years old• Daytime sleepiness frequently presents as
reappearance of napping in a child that has stopped napping
• Sleepiness at school may be manifest by symptoms similar to attention deficit disorder
• Diagnosis may be clinical or supported by findings from overnight polysomnography with multiple sleep latency testing. Alternatively, measurement of levels of hypocretin in cerebrospinal fluid may be appropriate for certain patients.
44
Recognizing Sleepiness in Children
• Sleepy children do not always “act sleepy”– Parent may endorse other terms like seems “overtired”
• Children with insufficient or disrupted sleep can show: – Inattention– Hyperactivity– Behavioral disturbances– Poor school performance
• Persistent, overt sleepiness is uncommon in preadolescent children unless the disorder is severe
45
Pediatric MSLT• Use standard MSLT protocol from AASM
Practice Parameter– Review procedure with child and parent and
answer any questions– It is recommended that parents leave the
testing room during naps– Ask if child needs to go to the bathroom– Put up side rails if necessary– Remind the child, “I will come back in to the
room when the nap test is over.”
46
SOREMP in a Child
Rapid eye
movement
Alpha activity
Nap #1 00:30
Nap #1 lights out
12 y/o referred for excessive daytime
sleepiness and cataplexy symptoms
Reducedtone
47
Nocturnal Sleep Decreases with Age
Ohayon et al SLEEP 2004;27(7):1255-73.
Min
utes
of
slee
p
48Acebo et al. SLEEP 2005; 28(12): 1568-1577.
Napping is Normal in Very Young Children
Age (months)
49
MSLT Latency
0
2
4
6
8
10
12
14
16
18
20
I II III IV V OlderTeens
Tanner Stage
La
ten
cy
(m
in)
Sleep Latency during MSLT Naps Decreases in Adolescents with
Increasing Tanner Stage
Data from Carskadon MA. The second decade. In Guilleminault C, ed, Sleeping and waking disorders: indications and techniques. Menlo Park: Addison Wesley, 1982: 99-125
NOTE: Mean sleep latency is longer in children compared with adults
50
Sleep Latency Increases with Age after Adolescence
From Arand et al, SLEEP 2005;28(1):123-144.
51
Interpreting Pediatric MSLT Results
• Two or more sleep onset REM periods are necessary to support a diagnosis of narcolepsy
• Age has a complicated and profound impact on MSLT mean sleep latency
• Limited normative data is available• Mean sleep latencies that might be considered
normal for adults are often abnormal for children
• The ICSD-2 states, “The MSLT has not been validated as a diagnostic test in children younger than eight years of age.”
52
Parasomnias
• Children are often referred to the sleep center because of unusual behaviors during the night– Sleepwalking– Sleep terrors– Nightmares– Seizures
53
Abnormal Breathing and EEG Activity in Sleep
9 y/o with known epilepsy and snoring
54
Sleepwalking and Sleep Terrors: Partial Arousal
ParasomniasPartial arousal parasomnias
– Occur during first half of night– Arise from slow wave sleep– Child is not awake
• Sleepwalking– Child moves around room or house– May be quiet or agitated– May engage in purposeful activities, like unlocking
door
• Sleep terrors– Child abruptly sits up screaming– Appears frightened and agitated
55
Night Terrors
• Deep NREM sleep• First third of night• Child confused or
agitated• Difficult to reassure• Intense arousal lasting
2-10 min• Abrupt return to sleep• No recall in the
morning
Nightmares
• REM sleep• Last half of night• Child alert; describes
dream content• Comforted by parent• Difficulty going back to
sleep• Recall the following day
56
Technologist Response to Unusual Behaviors
• Parasomnias can lead to injury– Be sure patient is safe
• Parasomnias sometimes resemble seizures– Seizures (especially frontal lobe) can resemble
parasomnias
• During study describe what you see• Note event on record when it is happening
– Sitting up yelling– Patient mumbling – can’t understand words– Patient’s left arm and leg twitching– Mother trying to comfort, patient keeps yelling “mommy”– Patient trying to get out of bed
57
Confusional Arousal
5 y/o with witnessed apnea and restlessness
58
Restless Legs Syndrome
• The patient reports an urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs.
• The urge to move or the unpleasant sensations – begin or worsen during periods of rest or inactivity (lying or
sitting)– are partially or totally relieved by movement, such as
walking or stretching, at least as long as the activity continues
– are worse, or only occur, in the evening or night
ICSD-2 Diagnosis in Adult Patients
59
Restless Legs Syndrome ICSD-2 Diagnostic Criteria• The child meets all four essential adult criteria for RLS listed above
and relates a description, in his or her own words, that is consistent with leg discomfort.
OR• The child meets all four essential adult criteria for RLS listed above
but does not relate a description in his or her own words that is consistent with leg discomfort.
AND• The child has at least two of the following three findings:
i. A sleep disturbance for age ii. A biological parent or sibling with definite RLS iii. A polysomnographically documented periodic limb movement
index of five or more movements per hour of sleep Note: Criteria for probable and possible childhood RLS have been
developed for research purposes and are included in a National Institutes of Health diagnostic workshop report.
60
Restless Legs Syndrome (RLS) & Periodic Limb Movement Disorder
(PLMD)• Prevalence in children 0.5-2%, familial
link– RLS - “growing pains”– PLMD – leg jerks - what’s normal
• Relationship with hyperactivity?
• Can be associated with:– Iron deficiency/low ferritin– Chronic renal disease
• Diagnostic controversies in adults– Scant data in children– May present as insomnia or sleepiness
61
Criteria for Sleep Related Rhythmic Movement Disorder
ICSD-2 Diagnostic Criteria• The patient exhibits repetitive, stereotyped, and
rhythmic motor behaviors.• The movements involve large muscle groups.• The movements are predominantly sleep related,
occurring near nap or bedtime, or when the individual appears drowsy or asleep.
• The behaviors result in a significant complaint as manifest by at least one of the following:
i. Interference with normal sleepii. Significant impairment in daytime functioniii. Self-inflicted bodily injury that requires medical
treatment (or would result in injury if preventable measures were not used)
62
Sleep Related Rhythmic Movements
• Repetitive movements– Head banging or head rolling– Body rocking
• Before sleep, light sleep, or even awake• Prevalence of rhythmic movements decreases
with age– At nine months = 59%– At eighteen months = 33%– At five years = 5%
• No gender difference• Polysomnogram or treatment rarely indicated
63
Sleep Enuresis
Primary• The patient is older than
five years of age• The patient exhibits
recurrent involuntary voiding during sleep, occurring at least twice a week.
• The patient has never been consistently dry during sleep.
Secondary • The patient is older than five
years of age• The patient exhibits
recurrent involuntary voiding during sleep, occurring at least twice a week.
• The patient has previously been consistently dry during sleep for at least six months.
ICSD-2 Diagnostic Criteria
64
Prevalence of Enuresis
0.0
10.0
20.0
30.0
40.0
4 5 6 7 8 10 18
Age (years)
Ch
ildre
n (
%)
65
Developmental Overview of Common Non-respiratory Sleep
Problems
Newborn/ Young Infant
Older Infant and
ToddlerPre-
schooler School Age TeenagerUsually normalDevelopmentalSelf limited
Night wakingsDifficulty settlingNight terrors
Night wakingsBedtime resistanceNight terrorsSleep walking
Insufficient sleepBedtime resistanceSleep walking
Insufficient sleepDelayed sleep phaseNarcolepsy
Rhythmic movementsBedtime fears
Rhythmic movementsBedtime fearsNightmares
EnuresisBruxism
66
Behavioral or Life Style Sleep Problems
• Sleep onset association disorder• Limit setting disorder• Poor “sleep hygiene”
• Caffeine• Irregular schedule• TV/computer/cell phone/electronics in bedroom
• Overlap with delayed sleep phase– Perpetuated by weekend sleep-in and late day
naps
• Management – change behaviors
67
Behavioral Insomnia of Childhood (Sleep-onset Type)
ICSD-2 Diagnostic Criteria • Falling asleep is an extended process that requires
special conditions• Sleep-onset associations are highly problematic or
demanding• In the absence of the associated conditions, sleep
onset is significantly delayed or sleep is otherwise disrupted
• Awakenings require caregiver intervention for the child to return to sleep.
68
Sleep Onset TypeTypical Presentations
• Child falls asleep during rocking or patting, needs to be rocked or patted after night waking
• Child falls asleep feeding, needs to be fed to fall asleep
• Child falls asleep with parent singing, reading or lying next to child, but cannot fall sleep alone
• Child falls asleep in car seat, needs to be driven around to fall asleep
69
Behavioral Insomnia of Childhood (Limit-setting Type)
ICSD-2 Diagnostic Criteria• The child has difficulty initiating or maintaining
sleep• The child stalls or refuses to go to bed at an
appropriate time or refuses to return to bed following a nighttime awakening
• The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriate sleeping behavior in the child
70
Limit-setting TypeTypical Presentations
• Child is two years or older• “Stalling” behaviors at bedtime
– Needs a drink or food– Multiple stories– Crying, clinging– Gets out of bed (“curtain calls”)
• Parent’s behavior contributes to problem– Irregular or inappropriate schedules– Inconsistent application of rules– Secondary gain for child
71
Contributing Factors
• Circadian rhythms develop over the first few months of life – infants have frequent awakenings and irregular schedules at birth
• Homeostatic drive to sleep is blunted by frequent napping
• Environmental factors such as warmth, soothing sounds and vestibular stimulation promote sleepiness
• Learned associations serve as triggers for sleep onset
72
Behavioral Insomnia of Childhood:
Treatment Options• Extinction • Graduated extinction (“Ferberizing”)• Positive routines• Faded bedtime with response cost• Scheduled awakenings• Parent education• Medications (efficacy unproven in children)
– Prescription– Over-the-counter