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Pediatric Sleep Medicine:
A brief overview from A to Zzzzzz….
Introduction:
Sleep related upper airway problems are common in pediatrics
Behavioral sleep problems are also common Underlying medical and anatomic problems
increase the risk for and severity of these conditions
Involved testing, incomplete understanding and a general lack of “evidence” further complicates the diagnosis and management of pediatric sleep disorders
Why We Sleep Is Unknown, But A Good Night Sleep is Important:
Emotionally Cognitively Behaviorally Performance Family dynamics Influence on health
The Biology of Sleep:
Circadian System:– Circadian rhythms exist in
all living things» Sleep-wake cycle is one of
many examples– Circadian clock is located
in the suprachiasmatic nucleus (SCN)
» SCN neurons generate and maintain an oscillating rhythm via “clock” genes and their products
The Biology of Sleep:
The human Circadian rhythm is slightly longer than 24 hours and must be set or entrained to match our daily schedules
Light, physical activity and melatonin are the most potent “entrainers” (zeitgebers):– These can work to favor or
oppose sleep In general, when the rhythm is
out of synch with scheduling demands, Circadian Rhythm Sleep Disorders are present
The Biology of Sleep:
The Homeostatic System:– “Process S” (Sleep drive) is dependent upon the
duration and quality of prior sleep and waking:» The longer you have been awake, the greater the drive to sleep
and vice versa– After the main sleep period, the “homeostat” has been
re-set and the drive to sleep is low– If there is an abnormality of sleep or if sleep is
restricted, then Process S (the drive to sleep) will remain strong and the individual will be sleepy at inappropriate times
The Biology of Sleep:
Ideally the Circadian rhythm and Homeostatic drive are synchronized and the sleep-wake cycle is smooth and regular
In general:– “Circadian rhythm sleep disorders” occur when the
circadian rhythm is desynchronized from the demands of everyday life
– “Homeostatic or intrinsic sleep disorders” result from problems with sleep quality, quantity or regulation
Pediatric Sleep:What is normal?
Respiration during sleep:– Quiet and subtle
Sleep environment:– Infancy:
» Back-to-Sleep» Safe crib» No co-sleeping» Rooming in for 6-months» No smoking
– Childhood:» Quiet and comfortable» No stimulation» No electronics
General Sleep Hygiene:
Establish routine:– Consistent bedtime and
wake up time– Consistent meals and naps– Bedtime ritual:
» Transitional objects as age-appropriate
– Increase exercise:» Not after dinner though…
– Wind down period:» Quiet activity» Soft light
– Sleep charts if needed
Sleep Hygiene:Is there any hope?
A large study (n=565) of pre-school children evaluating the use of healthy media on sleep quality and problems:– Risk factors for poor sleep include:
» High levels of media use» Bedtime use of media» Frightening or violent media content
– In this cohort problems with sleep latency were most commonly reported
– Substitution of pro-social and educational media in a randomized study:
» Resulted in fewer sleep problems over an 18-month follow up period
Garrison et al. Pediatrics 2012;130:492-499
Sleep Hygiene:Is there any hope?
A small pilot study in adolescents aged 10-18 years:– F.E.R.R.E.T. intervention:
» Food» Emotions» Routine» Restrict» Environment» Timing
– Short term improvements in sleep hygiene and other outcomes:» Sleep hygiene scores» Sleepiness scores» BMI z-scores
Tan et al. BMC Pediatrics 2012, 12:189
Theme Rule 1 Rule 2 Rule 3
Food No food or drink 30 minutes before bed
Avoid food and caffeine 3 hours before bed
No alcohol or smoking 3 hours before bed
Emotions Set a time for thinking and planning each day
Wind down and relax 30 minutes before bed
Try not to worry, think or plan while in bed
Routine Wake up and go to sleep same time each day
Turn lights on when you wake, Dim lights before bed
Keep the same sleep routine each day
Restrict No electronics 30 minutes before bed
No exercise 3 hours before bed
Bed is for sleeping only
Environment Comfortable bed clothes and bed
Light, temperature and noise
Keep clocks faced away from bed
Timing Sleep for the recommended amount of time
Remember 30 minutes and 3 hours
Try to stick to the rules
Tan et al. BMC Pediatrics 2012, 12:189
Pediatric Sleep:What is normal?
Typical sleep requirements throughout childhood:
Age group Age Sleep needInfants 3 to 12 months 14-15 hoursToddlers 1 to 3 years 12-14 hoursPreschoolers 3 to 5 years 11-13 hoursSchool-aged 6 to 12 years 10-11 hoursAdolescents 12 to 18 years 8.5-9.5 hours
Meltzer and Mindell Psychiatr Clin N Am (2006) 1059-1076
Pediatric Sleep:What is normal?
Typical patterns of daytime sleep throughout childhood:
Age group Daytime Sleep
1 week 8 hours
1 month 7 hours
3 months 5-6 hours
6 months 3-4 hours
9 months 2.5-3.5 hours
12 months 2-3 hours
18 months 2 hours
2-3 years 1-2 hours
Most children eliminate regular daytime naps between the age of 3-5 years
How much sleep are American children and adolescents getting?
Age Group Recommendation Study Finding
Infants (3-11 mo) 14-15 h 12.7 h
Toddlers (12-35 mo) 12-14 h 11.7 h
Preschoolers (3-6 yr) 11-13 h 10.3 h
School age (1st-5th grade) 10-11 h 9.5 h
Adolescents (6th-12th grade) 9.25 h 7 h
From the “Sleep in America Polls” 2004 & 2006
Adolescents Living the 24/7 Lifestyle:
Real world assessment of adolescent (n=100, aged 12-18 years) technology and caffeine use:– 66% had television in bedroom– 30% had a computer in the bedroom– 90% had a cell phone– 79% had an MP-3 player– 85% with caffeine intake
Self-reported activities after 9PM:– Watching TV– Text messaging
“On average, adolescents engaged in 4 technology activities after 9M”
Calamaro et al. Pediatrics 2009;e1005-e1010
Adolescents Living the 24/7 Lifestyle:
Multi-tasking was associated with worse sleep and daytime consequences:– 20.6% of the cohort obtained 8-10 hours of sleep per night– 33% of the cohort reported falling to sleep at school– More multi-taking was associated with lower sleep times and
higher caffeine intake» Television in bedroom did not correlate with sleep time
Caffeine intake:– Timing was skewed to impair sleep:
» 6-8AM 18.7%» 3-5PM 25.3%» 6-8PM 21.3%
Calamaro et al. Pediatrics 2009;e1005-e1010
Pediatric Sleep Disorders:A working list
Normal sleep:– Developmental evolution throughout childhood– Usually defined by satisfied parents!
Behavioral sleep disorders:– Developmental evolution throughout childhood– Overlap syndrome with influence of cultural and societal norms– Usually defined by dissatisfied/frustrated parents!
Parasomnias or Transitional Disorders:– Developmental evolution throughout childhood– Usually defined by frightened parents!
Pediatric Sleep Disorders:A working list
Breathing disorders during sleep:– Broad spectrum of clinical syndromes and
presentations– A number of common manifestations– Parents may be unaware of concerning symptoms!
Neurological disorders:– Less common in general– Children with special healthcare needs can be very
challenging
Components of a Pediatric Sleep Evaluation:“BEARS”
Mnemonic for:» Bedtime» Excessive Daytime Sleepiness» Awakenings» Regularity» Snoring
Based on the four most common symptoms of pediatric sleep disorders:
» Difficulty with sleep onset» Problems that disrupt sleep» Inability to awaken from sleep at the desired time» Daytime sleepiness
Rosen, GM: “Case-Based Analysis of Sleep Problems in Children” in Principles and Practice of Pediatric Sleep Medicine
Common Non-Respiratory Sleep Problems: A working list
Sleep talking Bruxism Night terrors Rhythmic movements Behavioral insomnia of childhood Confusional arousals Sleepwalking Nightmares Insomnia Delayed Sleep Phase Restless Leg Syndrome Narcolepsy
Adapted from: Moore, M et al.: CHEST 2006; 1252-1262
Age Distribution of Common Non-Respiratory Sleep Problems:
Infant & Toddler (1-2 yrs):– Behavioral Insomnia of Childhood – Rhythmic Movements
Preschool (3-5 yrs):– Behavioral Insomnia of Childhood – Rhythmic Movements– Sleep Terrors
School age (6-12 yrs):– Insufficient Sleep– Bedtime Resistance– Sleep-Walking
Adolescence (13-18 yrs)– Insufficient Sleep– Delayed Sleep Phase– Narcolepsy
Adapted from: Moore, M et al.: CHEST 2006; 1252-1262
Unique Aspects of Pediatric Sleep in Otherwise Healthy Infants and Children:
Another working list:– Delayed Settling– Trained Night Feeder– Trained Night Awakening– Developmental Night Awakening– Prolonged Routines– Curtain Calls– Bedtime Fears– Parasomnias
Management of these “problems” is facilitated by a good understanding of normal childhood development and
confident supportive parenting skills
Night Terrors:Parent is terrified
Slow Wave Sleep:– Usually in the first or
second cycle of sleep– Incidence ~5%, may be
familial– Rare before 18-24 mo– Can cluster – Self resolve by 8-10 yrs
Child is asleep:– Sympathetic output:
» Sweating, thrashing, screaming
– Child has no memory of the event
Night Terrors:
Management:– Reassure parents:
» No need to awaken child» Safety» Avoid secondary gain
– Phase shift:» Afternoon nap to decrease
Stage 3 sleep» Awaken 1 hour into sleep
– I do not favor medications:» Benzodiazepines
Nightmares:Child is terrified
Occur during REM periods:– Latter part of the night– Most common in
preschoolers:» Learning about the “hard
knocks” of life » Stress and other
disruptions to routine– Child awakens and should
remember dream:» Child is frightened
Nightmares:Child is terrified
Simple management:– Reassurance– Bedtime ritual and security
object to prepare for good dreams
– Brief intervention in child’s room
– Avoid secondary gain– I do not favor medications
Complex management:– Counseling– Prazosin– Relaxation
Select features of Nightmares and Night Terrors:
Night Terrors: Sudden onset Autonomic nervous system
activity Behavioral manifestations
of fear Difficulty arousing the child Confusion upon awakening Amnesia of the episode Dangerous behaviors
Nightmares: Recurrent episodes Recall of a disturbing dream Various emotions, but none
will be good Full awakening and alerting Recall is good Delayed return to sleep Episodes occur in the latter
half of the sleep period
Adapted from: ICSD 2nd ed: Diagnostic and Coding Manual. AASM; 2005
Behavioral Insomnia of Childhood:
Behavioral Insomnia of Childhood:– Bedtime resistance– Frequent night time awakenings– 10-30% of infants and toddlers
Sleep-onset association type:– Certain conditions must be met to facilitate sleep– Positive associations: Self comfort– Negative associations: External stimuli
Limit setting type:– Bedtime stalling or refusal
Combined type
Behavioral Insomnia of Childhood:Sleep-onset association type: Falling asleep is an extended
process Falling asleep requires special
conditions When conditions are not met,
sleep latency is prolonged and sleep is disrupted
Nighttime awakenings require caregiver intervention
Limit-setting type: Difficulty with sleep initiation
and maintenance Stalling and refusal to go to bed
or return to bed after nighttime awakening
Caregiver cannot set limits to establish sleep hygeine
Adapted from: ICSD 2nd ed: Diagnostic and Coding Manual. AASM; 2005
Behavioral Insomnia of Childhood:
General treatment principles:– Not particularly evidence-based– Sleep hygiene:
» Bedtime routine» Learn self-soothing
– Extinction/Graduated extinction:» Ignore the behavior until it is extinguished:
Extinction burst
– Learning about limits:» Parenting skills» Bedtime fading
Prolonged Routines and Curtain Calls:
May be a phase shift or limit setting issue:– Manage limits and increase daytime attention in
general– Involve child in the plan– Parents need to “be strong:”
» No escalation: Lead quietly back to bed– Reward positive behaviors:
» Extra story the next night» Other systems
– Physical barriers if needed:» Gates, locks» Parent sits outside door
Insufficient Sleep:
Sleep deprivation:– De-emphasis of sleep due to other commitments– Cumulative sleep debt results in:
» Fatigue, mood changes, illness» School tardiness» Falling asleep in school
– Sleepy driver accidents or fatalities Clinical clues:
– Needing to be awakened for school– Sleeping 2 hours or more on weekends and vacations– Falling asleep at inappropriate times– Behavior and mood differ after getting adequate sleep
Delayed Sleep Phase Syndrome:
Circadian rhythm disorder with delayed sleep-wake times:– 2 or more hours– Interfering with daily schedules activities (school)– Most common in adolescents
Night owl syndrome:– Inability to fall asleep at “normal” time
» Bedtimes of 0200-0300– Sleep onset/efficiency and quality are normal at this shifted time– Treatment is difficult:
» Chronotherapy—phase advancement or phase delay» Melatonin to advance the circadian clock» Light therapy
The Spectrum of Pediatric Sleep Disordered Breathing:
Central Sleep Apnea Syndromes:– May or may not be developmental– CNS Disorders
Hypoventilation Syndromes:– Congenital Central Hypoventilation Syndrome– Neuromuscular
Respiratory Dysrhythmia Syndromes:– May be developmental– CNS Disorders
Awake respiration may or may not be normal Laboratory studies may actually be helpful
The Spectrum of Pediatric Sleep Disordered Breathing:
Airway Obstructive Syndromes A number of conditions which are possibly
interrelated:– Primary snoring– Upper airway resistance syndrome– Obstructive sleep apnea syndrome
All three are manifest by snoring Respiration during wakefulness usually normal Routine laboratory studies not generally helpful
Primary Snoring:
Defined as snoring in the absence of apnea, gas exchange abnormalities or arousals
Snoring is a common “symptom:”– Up to 10% of children snore regularly– The majority have Primary Snoring
Consequences of Primary Snoring are unclear:– No evidence of progression to OSA…– Some developmental consequences are proposed– No treatment is currently recommended
“He snores just like his father!”Maybe that is not so cute…
A large cohort study (n=249 parent-child pairs) evaluated snoring in preschool children:– Parental report of loud snoring more than twice weekly
that was absent (no snoring), transient (snoring at age 2 but not age 3) or persistent (snoring at both ages):» Non-snorers: 68% » Transient snorers: 23%» Persistent snorers: 9%
Beebe et al.: Pediatrics 2012;130:382-389
“He snores just like his father!”Maybe that is not so cute…
Risk factors for snoring:– Higher BMI– Pre and post natal tobacco smoke exposure– African American race– Lower parental education and family income– Absent or shorter duration of breast feeding
Persistent snoring was associated with adverse behavioral and developmental outcomes:– Behavioral:
» Hyperactivity» Depression» Attention
Beebe et al.: Pediatrics 2012;130:382-389
Upper Airway Resistance Syndrome:
Defined as a syndrome of snoring and prolonged partial upper airway obstruction:– Repetitive episodes of increased work of breathing that
leads to arousal:» Diagnosed by polysomnogram with evidence of increased
work of breathing (paradoxical breathing) and arousal
– Apnea, hypopnea and gas exchange abnormality are generally absent
– Treatment options are the same as those for obstructive sleep apnea syndrome
Obstructive Sleep Apnea Syndrome:
A syndrome occurring during sleep characterized by:– Obstructive apnea– Partial upper airway
obstruction – Hypoventilation– Hypoxemia
Incidence thought to be 1-3% of all children:– Up to 40% of specialty
referred patients with snoring
Obstructive apnea with desaturation
Obstructive Sleep Apnea:
Imbalance of forces:– Airway opening and
closing pressures– An imbalance between
these forces balance due to anatomic or neuromuscular factors results in inappropriate airway closure
– Retropalatal– Retroglossal
Katz, ES: Proc Am Thorac Soc Vol 5, 2008
Approaching the Patient with Possible Sleep Disordered Breathing:
Sleep & Developmental History Co-existing conditions Physical Examination:
– Growth parameters– Upper airway anatomy and
patency– Heart sounds– Chest wall configuration– Awake gas exchange
Potential testing:– Chest and airway/neck films– ECG – Blood tests are usually normal– Specialized testing
Rating tonsil hypertrophy
Adenotonsillar Hypertrophy:
Most common “cause” of OSA in children
Most prevalent in young school age children:– Related to normal lymphoid
hyperplasia ages 2-6 years– Tonsil and adenoid size
related to severity but not presence of OSA
Most common reason for referral to our lab
Diagnosis of Obstructive Sleep Apnea Syndrome:
Literature supports the benefits of early diagnosis and treatment
Obstructive sleep apnea cannot be diagnosed based upon history and physical exam alone:– Sleep history should be obtained– Screen for symptoms of OSA– Physical examination features
Polysomnography is the “gold standard:”– Expensive, but cost-effective when used correctly
Symptoms of Pediatric Obstructive Sleep Apnea Syndrome:
Nocturnal:– Symptoms correlate with severity:
» Snoring» Labored breathing» Sweating» Restless sleep» Unusual sleep position» Enuresis
Normal breathing during sleep in a child should be a subtle finding!
Symptoms of Pediatric Obstructive Sleep Apnea Syndrome:
Daytime:– May be absent– Mouth breathing– Nasal obstruction– Hyponasal speech– Increased attention being given
to neurobehavioral aspects of OSA:» Attention problems» Learning problems» Behavior problems» Hyperactivity
Mouth breathing in adenoidal hypertrophy
Complications of Pediatric Obstructive Sleep Apnea Syndrome:
Growth related:– Failure to thrive reported:
» Increased work of breathing
» Decreased growth hormone secretion
Cardiopulmonary:– Pulmonary hypertension– Cor pulmonale– Systemic hypertension– Right or left ventricular
hypertrophy
Treatment of Pediatric Obstructive Sleep Apnea Syndrome:
Healthy children:– Adenotonsillectomy is
usually curative:» Post-operative risk factors
well documented– Mild OSA:
» Intranasal Steroids» Montelukast» Antihistamines
Other items to address:– Chronic or allergic rhinitis
Co-morbidities:– Obesity– Asthma
Tonsillar hyperplasia and infection
Adenoid size (adenoidal/nasopharyngeal ratio) significantly decreased with montelukast.
Goldbart A D et al. Pediatrics 2012;130:e575-e580
©2012 by American Academy of Pediatrics
Montelukast treatment resulted in a significant improvement in the OAI. The pretreatment average of 3.7 ± 1.6 before (pre) dropped to 1.9
± 1.0 after (post) treatment; P < .05.
Goldbart A D et al. Pediatrics 2012;130:e575-e580
©2012 by American Academy of Pediatrics
Treatment of Pediatric Obstructive Sleep Apnea Syndrome:
– Nasal mask ventilation:» CPAP/BiPAP®
» Can be implemented post-operatively if needed
– Supplemental oxygen:» Use with caution
– Devices:» Not well studied
Efficacy and safety unknown…
Recently Updated Clinical Practice Guideline:
Clinical practice guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome:– www.pediatrics.org/cgi/doi/10.1542/peds2012-16711. All children should be screened for snoring
2. PSG should be performed for snoring and symptoms/signs of OSAS
3. Adenotonsillectomy is recommended as first-line treatment of patients with ATH
4. High risk patients should be monitored as inpatients post-operatively
5. Patients should be re-evaluated post-operatively
6. CPAP is recommended
7. Weight loss is recommended
8. Intranasal corticosteroids are an option in mild OSAS
The diagnosis and management of pediatric sleep disorders is important!
A large (~11,000) cohort study evaluated sleep disordered breathing (SDB) and behavioral sleep problems (BSP) in children:– SDB defined by:
» Snoring, Witnessed apnea, Mouth breathing– BSP defined by:
» Evaluation of sleep behaviors “A history of either SDB or BSP in the 1st 5-yrs of life was
associated with the need for SEN at 8 yrs of age. Findings highlight the need for pediatric sleep disorder screening”
Bonuck et al.: Pediatrics 2012;130:634-642
Some Final Thoughts:
Sleep disordered breathing common in pediatrics:– OSA is just one example– Many underlying medical
conditions can affect sleep Behavioral sleep problems
are also common:– Treatment can be
challenging– Sleep hygiene is critical
Important outcomes require clarification
Lean CPAP Patient
