Insufficient sleep in children adolescents
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Insufficient Sleep in Children & Adolescents. Teresa M. Ward, RN, PhD Associate Professor Department of Family & Child Nursing University of Washington. Discuss recent National Sleep Foundation results regarding sleep disturbances in school-age children and adolescents.

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Insufficient Sleep in Children & Adolescents

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Insufficient sleep in children adolescents

Insufficient Sleep in Children & Adolescents

Teresa M. Ward, RN, PhD

Associate Professor

Department of Family & Child Nursing

University of Washington


Objectives

Discuss recent National Sleep Foundation results regarding sleep disturbances in school-age children and adolescents.

Describe the consequence of sleep disturbances and sleep disorders in children, adolescents, and their families.

Describe sleep physiology and sleep patterns.

Describe sleep disorders in school-age children and adolescents.

Integrate sleep screening into routine health assessments.

Objectives


Sleep in the news

Sleep in the News

Insufficient Sleep Is a Public Health Epidemic, CDC

http://www.cdc.gov/features/dssleep/

Seattle petition urges later start times for high schools, middle schools, Seattle Times, Feb 2014

Diagnosing the Wrong Deficit, NYT, April 2013

Teens Short On Sleep Have Higher Car Accident Risk, Study Find, Huffington Post, May 2013

Irregular Bedtimes Lead to Misbehaved Kids, TIME , Oct 2013

Research links later school start times to benefits for teens, StarTribune, March 2014

On Sleep Research, My Children Didn’t Get the Memo, NYT, July 2013

Up all night: Parents and kids are losing sleep to their devices,

Today Health, March 2014


Prevalence of sleep disturbances

Top 5 complaints presented to primary care clinicians:

Infants – up to 40%

Preschool – 25% to 30%

School-age – 15%

Adolescents – 11% to 33%

Prevalence of Sleep Disturbances

Faruqui et al., 2011; Meltzer et al., 2010


National sleep foundation 2014 results

National Sleep Foundation 2014 Results

Estimates of nighttime sleep:

  • Children 6 to 10 years sleep ~ 8.9 hours/night

  • Children 11 to 12 years ~ 8.2 hours/night

  • Adolescents 13 to 14 years ~ 7.7 hours/night

  • Adolescents 15 to 17 years ~ 7.1 hours/night

http://sleepfoundation.org/media-center/press-release/national-sleep-foundation-2014-sleep-america-poll-finds-children-sleep


Children s sleep duration by age group

7 hours or less

8 hours

9 hours or more

80%

69%

70%

56%

60%

50%

42%

34%

40%

29%

29%

30%

23%

20%

10%

8%

10%

0%

6-11 years

12-14years

15-17 years

Age Group

Children’s Sleep Duration by age group

National Sleep Foundation 2014 Results

.


Electronics and sleep

Electronics and Sleep

National Sleep Foundation 2014 Results


Sleep quality by number of electronic devices left on

Never leaves any electronic on

Sometimes leaves ONE electronic device on

Sometimes leaves TWO OR MORE electronic devices on

100%

57%

51%

49%

44%

33%

23%

20%

13%

7%

0%

Excellent

Good

Fair or Poor

Parent's rating of Child's Sleep Quality

Sleep quality by number of electronic devices left on

.


Reasons for difficulty sleeping findings reasons for difficulty sleeping

Reasons for Difficulty SleepingFindings: Reasons for Difficulty Sleeping

National Sleep Foundation 2014 Results

At least once

Never

34%

Evening activities

66%

Children

.

28%

Homework

72%

18%

Temperature

82%

15%

Inside Noise

84%

8%

Outside noise

92%

8%

Light

92%

9%

Pets

91%

0%

80%

90%

100%

10%

70%

20%

60%

40%

30%

50%

41%

Evening activities

Parents

59%

35%

Temperature

65%

28%

Inside Noise

72%

16%

Outside noise

83%

13%

Light

87%

18%

Pets

82%


Insufficient sleep in children adolescents

National Sleep Foundation 2014 Results

Impact of Inadequate Sleep


Consequences of insufficient sleep

Consequences of Insufficient Sleep

  • decrements in neurobehavioral function (attention span, slower reaction time) (Wahlstrom et al., 2014; Vedaa etal., 2012; Lufi, Tzischinsky, & Hadar 2011; Beebe et al., 2010; Carskadon et al., 1981)

  • increased risky behaviors & mental health challenges (depression) (Adrian et al., 2014; McKnight-Eily et al., 2011; Onyper, et al., 2012)

  • increased automobile accidents (Wahlstrom et al., 2014; Vorona et al., 2011; Pizza et al., 2010)

  • increased family stress(Johnson et al., 2009; Lopez-Wagner et al., 2008; Smaldone 2007)

  • increased screen time and electronic devices (Barlett, et al., 2013; Cain, Gradisar, 2010)


Sleep disturbances impact families

Knowledge about a child’s sleep problem alone is NOT enough

Rather, a combination of the child’s sleep habits, family & parental caregiving characteristics, sleep environment and other social contexts are necessary. (Ward et al., 2007; Jenni etal., 2005 )

Children, adolescents & their families vary in their ability to cope and adapt to sleep problems.

Sleep Disturbances Impact Families


Sleep in early childhood

Sleep in Early Childhood

  • Primary activity of the brain in early childhood

    (Dahl 1996)

  • By 2 years of age, the average child has spend almost 10,000 hours (nearly 14 months) asleep and approximately 7,500 hours (about 10 months) in all waking activities.

  • By early school age a child has spend more time asleep than in social interactions, exploring the environment, eating or any other single waking activity.(Dahl 1996)


Sleep physiology

Homeostatic and circadian process

- endogenously driven rhythms (approx 24 hours)

- Suprachiasmatic nucleus (SCN) internal biologic clock)

- i.e. sleep-wake rhythms, body temperature, melatonin, prolactin, growth hormone

Sleep Physiology

Jenni & LeBourgeois 2006


Common sleep problems

Common Sleep Problems

BEHAVIORAL

Sleep Onset Association Disorder

(SOAD)

Limit Setting

Delayed Sleep Phase Syndrome

(DSPS)

PARASOMNIAS

- Sleep Terrors/ Night Terrors

- Nightmares

- Sleep Walking

- Sleep Talking

- Sleep Enuresis

MEDICAL

Sleep Disordered Breathing (SDB)

Restless Leg Syndrome (RLS)

Narcolepsy (adolescents)


Delayed sleep phase syndrome

Delayed Sleep Phase Syndrome

Biological shift to later bedtimes and rise times

  • hormonal influence

  • extracurricular activities

    7% of adolescents

Hagenauer et al., 2009; Crowley et al., 2007; Carskadon et al., 1993


Dsps treatment

DSPS Treatment

  • Shift sleep cycle slowly

    • Phase advance 15 min earlier every few days

  • Sleep Hygiene (must change sleep habits!)

  • Relaxation techniques

  • Bright light exposure in morning

  • Parent or guardian support

  • Child motivated


Sleep disordered breathing sdb

Sleep Disordered Breathing (SDB)

  • Sleep Disordered Breathing (SDB) is a serious health concern1 associated with significant adverse health outcomes and high use of health care resources.2

  • Spectrum of SDB:

  • - primary snoring

  • - upper airway resistance syndrome (UARS)

  • - obstructive sleep apnea (OSA)

  • Polysomnography (PSG) gold standard to diagnose SDB

  • *** Not all children who snore have SDB. Likewise not all children with enlarged tonsils and adenoids are diagnosed with SDB

Lumeng JC, Chervin RD. (2008). Proc Am Thorac Soc. ; Halbower AC, Mahone EM. (2006). Sleep Med Rev.


Night time symptoms

Night time Symptoms

Snoring

Observed breathing pauses

Gasping / choking

Sweating

  • Restless sleeper (frequent tossing and turning, kicking)

  • Unusual position (neck hyperextension)

  • Mouth breather

  • Prolonged Bedwetting


Daytime symptoms

Nasal speech

Mouth breathing

Excessive daytime sleepiness

Morning headaches

Daytime Symptoms

  • Hyperactive, difficulty focusing

  • Mood disturbances

  • Failure to Thrive


Sdb risk factors

Family history

Prematurity

Craniofacial development (micrognathia, retrognathia)

Chronic Allergies

SDB Risk Factors

  • Unfavorable oronasal anatomy (turbinate hypertrophy, adenoidal and tonsillar hypertrophy)

  • Failure To Thrive (FTT)

  • Hypotonia

  • Obesity

Urschitz et al., 2007; Arens & Marcus 2004; Marcus 2001


Treatment of sdb

Sleep study (Polysomnography [PSG]

Surgical

- Tonsillectomy & adenoidectomy

Non-Invasive Ventilation

- CPAP/BiPAP

Treatment of SDB


Restless leg syndrome rls

Restless Leg Syndrome (RLS)

Sensorimotor disorder characterized by uncomfortable sensations in the legs with an urge to move the legs

Etiology

- Primary RLS: genetic

- Secondary RLS: iron deficiency anemia, pregnancy, ESRD, polyneuropathy

(Pichetti et al., 2013; Walters, Gabelia, & Frauscher 2012; Pichetti & Pichetti 2010)


Insufficient sleep in children adolescents

RLS

Symptoms:

- urge to move the legs that begins or worsens when sitting or lying down

- urge to move legs worse in the evening or at night

- urge to move is partially or totally relived by movement

Diagnosis

  • self report of symptoms & sleep study are necessary

    Treatment

  • check CBC, serum ferritin levels (<50)

  • supplemental iron, or folate, B12


Assessment of sleep disorders

Sleep History

Medical History

Nocturnal Behaviors

Daytime Behavior

- teacher & parent report

Assessment of Sleep Disorders

Owens & Dalzell 2005; Lewanski, Ward, & Palermo 2011


Screening tool bears

Screening Tool: BEARS

Bedtime problems

SCHOOL-AGE (6-12 years)

  • Does your child have any problems at bedtime? (P)

  • Do you have any problems going to bed? (C)

    ADOLESCENT (13-18 years)

  • Do you have problems falling asleep at bedtime?

    Excessive daytime sleepiness

    SCHOOL-AGE (6-12 years)

  • Does your child have difficulty waking in the morning,

  • seem sleepy during the day or take naps? (P)

  • Do you feel tired a lot? (C)

    ADOLESCENT (13-18 years)

  • Do you feel sleepy a lot during the day? in school? while driving? (C)


Bears continued

BEARS continued

Awakenings during the night

SCHOOL-AGE (6-12 years)

  • Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? (P)

  • Do you wake up a lot at night? Have trouble getting back to sleep? (C)

    ADOLESCENT (13-18 years)

  • Do you wake up a lot at night? Have trouble getting back to sleep? (C)

    Regularity and duration of sleep

    SCHOOL-AGE (6-12 years)

  • What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep? (P)

    ADOLESCENT (13-18 years)

  • What time do you usually go to bed on school nights?

  • How much sleep do you usually get? (C) Weekends?


Bears continued1

BEARS continued

Sleep Disordered Breathing

SCHOOL-AGE (6-12 years)

  • Does your child have loud or nightly snoring or any

  • breathing difficulties at night? (P)

    ADOLESCENT (13-18 years)

  • Does your teenager snore loudly or nightly? (P)

Owens & Dalzell, Sleep Medicine, 2005

http://illinoisaap.org/wp-content/uploads/BEARS.-Spruyt-third-of-three.pdf


Diagnosis

Diagnosis

Polysomnography (PSG)

  • overnight sleep study in an accreditedpediatric sleep center

    Multiple Sleep Latency Test (MSLT)

  • completed after a PSG to diagnose narcolepsy

    Actigraphy

  • sleep watch that is worn for several days or weeks to assess sleep patterns

    Radiographs

  • Lateral Neck X-Ray

  • MRI


Polysomnography psg

Polysomnography (PSG)


Insufficient sleep in children adolescents

PSG HOOK-UP


Insufficient sleep in children adolescents

Actigraphy


Sleep hygiene

Sleep Hygiene

  • Consistent & clear bedtime routines and bedtime rules

  • Set clear limits and follow through

  • Do not ask questions (i.e. ready for bed? Rather time for bed)

  • Limit use of technology before bedtime and in the bedroom


When to refer

Seattle Children’s Hospital, Pediatric Sleep Disorders Center, Division of Pulmonary Medicine

Dr. Maida Chen, & Amber McAfee, RN, APRN

Swedish Medical Center, Pediatric Sleep Disorders Center, Division of Pulmonary Medicine

Dr. Preetam Bandla

When to Refer


Resources for families children adolescents

Resources for Families, Children, & Adolescents

National Sleep Foundation (bilingual)

http://www.sleepfoundation.org

www.sleepforkids.org

http://kidshealth.org/teen

http://www.aasmnet.org/spanishbrochures.aspx


Resources for clinicians

Resources for Clinicians

  • Accredited pediatric sleep centers in your area can be found here www.aasmnet.org

    click on patients and public and find a sleep center

    http://sleepfoundation.org/

    www.sleepeducation.com

    http://www.aasmnet.org/practiceparameters.aspx?cid=100


Multidisciplinary team

Primary care provider

Social work

Nurses, Psychologists, Neurologists, Psychiatrists

Child life specialist

Dietician

Behavioral health team

Childcare Teachers/Teachers/educators

Sleep specialist

Sleep lab staff, CPAP coordinator

Multidisciplinary Team


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