Microsoft PowerPoint - L65-cielo-sleepdisorderschildren-narrated-fmr20f-09052020Christopher Cielo, DO, MS Assistant Professor of Pediatrics University of Pennsylvania Attending Physician Division of Pulmonary & Sleep Medicine Children’s Hospital of Philadelphia
I have no disclosures and will not be discussing the use of anything off-label.
Objectives
• Explain presentations of common pediatric sleep disorders at different ages
• Recognize when to refer a child to a sleep specialist
Outline
• Insomnia (trouble falling and staying asleep) • Parasomnias (doing things during sleep) • Hypersomnias (excessive sleepiness) • Sleep-disordered breathing
Recommended sleep duration
Sleep duration by self-report in children
Iglowstein I, et al. Pediatrics 2003;111(2): 302-307.
Outline
• Insomnia (trouble falling and staying asleep) • Parasomnias (doing things during sleep) • Hypersomnias (excessive sleepiness) • Sleep-disordered breathing
Case 1: “Sleeps like a baby”
A 14-month old girl with a lifelong history of night time wakings every three hours. • Nursed since birth • Developing, growing normally • Child nurses to fall asleep at
bedtime (8PM), mother puts into crib asleep
• Takes almost nothing with overnight feeds but still wakes up every 3 hours
Case 1: Behavioral insomnia of childhood
• Highly prevalent in young children • Child is dependent on specific stimulation,
object, or setting to initiate/return to sleep • Infant: bottle, nursing, being held/rocked • toddler: pacifier, blankie, parent in bed
• Without the association, sleep onset is delayed
• Number of arousals is usually normal
Mindell JA, et al. Sleep 2006;29(10): 1263-76.
Insomnia • Can be difficulty initiating or
maintaining sleep • Can be due to medication,
medical/psych condition, poor sleep hygiene, medication
• Short-term insomnia (<3 mos) • Usually triggered by an acute
event, usually self-resolving • Chronic insomnia (>3 mos)
Multiple types of insomnia • Younger children: Behavioral
insomnia of childhood • Older children/adults:
Psychophysiological insomnia • Circadian rhythm disorders
Insomnia: treatment • Improved sleep hygiene
• Bed only for sleep • Consistent schedule • No screens at bedtime • Child falls asleep independently
• Chronotherapy • AM light/PM melatonin • Cognitive behavioral therapy • Sleep restriction
• When to refer • Medication issues • Children with developmental
delays
Case 2: Screaming child
4 year old boy has been waking up screaming at 11 PM several times a week for the past six months • Gets more upset when parents try to hug
him • In the morning, doesn’t remember waking
up overnight
• NREM-related parasomnia • Most common in toddlers/school-age children • Sleep deprivation and situational stress are potent risk
factors in healthy children • Reported in 1-6.5% of children, 25% of children have
at least 1 • as many as 2.2% in people 15-65 y/o
Parasomnias • Undesirable physical events or experiences
that occur during sleep or arousal • Abnormal complex movements or behaviors,
perceptions, or dreams • Have adverse effects on health or psychosocial
effects • May result from dissociation between sleep and
wake • Can involve basic drive states (feeding, sex,
aggression) • Co-occurrence of parasomnias is common • Significant genetic association
Parasomnias by age
• Nightmares • Sleep-related enuresis
hallucinations • Exploding head
syndrome • Sleep-related eating
disorders • Confusional arousals
Parasomnia treatment • Generally reassurance • Focus on preventing harm • Calmly put child back to bed • Scheduled awakenings may help if
consistent time • Promote healthy sleep
routine/environment
Case #3: Sleepy teen
15 year old boy becoming increasingly sleepy over past year • Falling asleep in school despite
getting 10 hours of sleep overnight • Grades have slipped, cannot get
through homework or after-school activities
• Reports losing balance or jaw going limp when joking around with friends
Case 3 diagnosis: Narcolepsy • Disruption of sleep/wake • Reduction in hypocretin-producing
neurons in the lateral hypothalamus • Rare: 0.02 to 0.18% of population • Typically presents 10-25 years old • No cure. Treatment includes
• Excessive sleepiness: wake- promoting agent + adequate sleep/naps
• Catplexy/other symptoms: sodium oxybate or SSRIs/TCAs
Thannickal TC, et al. Neuron 2000;27: 469-474.
• Symptoms develop over several years: • Sleepiness usually first – becomes
irrepressible • Disrupted sleep • Hypnogogic hallucinations • sleep paralysis • May have cataplexy (type 1) or not
(narcolepsy type 2)
• Medical disorder • CNS: Brain tumor/TBI/ infection/encephalopathy • Hypothyroidism
• Sleep disorders
• Insufficient sleep “syndrome”
• Detailed history • Sleep diary • Epworth Sleepiness Scale • Actigraphy • Multiple Sleep Latency Test
Hypersomnia: treatment
When to refer: • Concern for narcolepsy • Significant sleepiness without other
explanation • Sleep medication issues
Case 4: “Snores like an old man”
Parents of 4-year-old boy report snoring at routine well-child visit • Worse over past six months • Harder to get out of bed in morning • Sleep seems more restless • Wakes up coughing sometimes • Preschool concerned “he may have
ADHD”
• Disorder of breathing during sleep that causes:
• Prolonged partial upper airway obstruction and/or
• Intermittent complete obstruction • Gas exchange and sleep patterns
• In children: • Prevalence of snoring: 3-12% • Prevalence of OSA: 1.2-5.8%
• Structural and neuromotor contributors
OSAS: History & physical exam
History • Snoring/gasping/choking, observed
apnea • Restless sleep, frequent awakenings • Hyperactivity in younger children • Sleepiness in older children Exam • Obesity or failure to thrive • Tonsillar hypertrophy • Adenoid facies • Micro/retrognathia • Midface hypoplasia • unremarkable
OSAS evalution: polysomnography
OSAS: treatment Surgery • Adenotonsillectomy: first
line treatment if appropriate • Craniofacial surgery in select
populations • Tracheostomy: last resort Non-surgical • CPAP • Steroid nasal spray • Weight loss • Positional therapy • Watchful waiting
Marcus CL, et al. NEJM 2013; 368(25): 2366-76.
OSAS: when to refer
• Medically complex high-risk children should be referred for formal evaluation
• Medically complex/severe OSAS/refractory patients should be referred for treatment
• Evaluation could include • Polysomnography • Specialty surgical treatment or CPAP
Summary
treatment of more serious conditions. Resources may vary by region.
Thank you!