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Objectives

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Objectives

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  1. Objectives • Outline normal developmental changes in sleep from infancy through adolescence • Describe the causes of daytime sleepiness affecting children • Outline the clinical evaluation of daytime sleepiness in children and adolescents

  2. Young Children Sleep A Lot • By age 2y, average child has spent 9500 h (approx. 13 months) asleep vs 8000 h awake • Between 2-5 y, time asleep = time awake • In school-age children, sleep occupies 40% of the 24 h day • Sleep is the primary activity of the brain during early development

  3. Appropriate Duration of Sleep by Age

  4. Reality

  5. Sleep Dysfunction In Children Insufficient Sleep Sleep deprivation Fragmented Sleep Sleep disruption Excessive Daytime Sleepiness Primary Disorders of EDS

  6. Sleep in Newborns • 3 sleep states in term newborns: active, quiet and indeterminate; enter sleep thru active (REM) • Total sleep time: 16-20 hours/day with equal amounts day and night • Sleep episodes 3-4 hours/1-2 hours awake; breast fed-more frequent wakings

  7. Sleep in Infants • Critical sleep reorganization at 8-12 weeks; establish diurnal cycle • Develop NREM sleep by 6 months; decreased REM • At 6 months: TST is 13-14 hours; sleep episodes 6-8 hours • 70-80% sleep through the night at 9 months

  8. Sleep in Toddlers • Total sleep time – 12-14 hours • Most give up second nap at 1 year • Developmental issues: separation anxiety→nightime fears, mastery of independent skills→power struggles • Sleep problems common-20-40% • Importance of bedtime routines, transitional objects

  9. Sleep in Pre-Schoolers • TST-11-12 hours/day • Many give up regular daytime nap by age 4-5 years • Signaled night wakings occur frequently; role of parental reinforcement • Sleep problems may become chronic

  10. Sleep in School Age Children • Total sleep time 9-11 hours • 10-11 hours in 6-7 y.o. ↓9.5 hours in adoles. • Stable sleep pattern night to night • Low level of daytime sleepiness • Rare naps • Some have prolonged sleep latency • Increasing pressure from schedule • Earlier wake times, later bedtime from school work/activities

  11. Sleep Changes in Adolescence • Delayed sleep onset • Circadian: relative phase delay at puberty • Environmental factors-music, computer, work • Advanced wake times (sleep offset) • Earlier school start time • Decreased sleep/wake regularity • Different weekday/weekend schedule

  12. Sleep Changes in Adolescence • Decreased daytime alertness • ↑ sleep pressure, ↓ circadian output • Less parental “protection” of TST • Leads to insufficient sleep • Most need 9-9.5 hours • Average high school student sleeps only 7 1/4 hours

  13. Causes of EDS-Insufficient Sleep • Common problem in 24/7 society • More fun activities at night • Electronic babysitter, electronics in bedroom • Family stresses • Daycare, work schedules • Adolescents “escape” parental controls

  14. Insufficient Sleep Evaluation • Question child and caregivers • Signs/symptoms of sleepiness • Sleeping, irritable, behavioral/focus issues • Weekdays and weekends? • Duration/quality of sleep-day and night • What time in bed, what time asleep • Sleep diary can be very informative! • Rise time-hard to get up? • Weekday vs weekend schedule

  15. Insufficient Sleep Evaluation • Bedtime routine • Stimulating activities? • Activities during the night • Once down do they stay down? • Fun activities during the night • Child who won’t sleep or never sleeps • Limit setting disorder • Sleep onset association disorder • Anxiety issues

  16. Sleep Onset Association Disorder • Child learns to fall asleep under certain conditions which are usually present at bedtime (parent in room, rocking); no problems settling when conditions met • Child continues to require conditions during normal nighttime arousals in order to fall back to sleep • Absence of those conditions results in prolonged night wakings

  17. Limit Setting Sleep Disorder • Parents unable to set consistent bedtime rules→bedtime struggles, bedtime refusal, protests, requests, excuses • Results in prolong sleep onset latency; most common in 2-6 year olds

  18. Behavioral Sleep Disorders: Management Preventative education for parents SOAD-child needs to learn to fall asleep in reproducible conditions LSSD-family needs help with setting limits and consequences Problems will wax and wane and re-training is necessary

  19. Disrupted Nocturnal Sleep • Environmental issues • Sleep location-bed-who’s?, couch, variable? • Electronics, temperature, light, food • What to do? • Importance of bedtime routine • Regular sleep location-quiet, dark • No electronics-TV, phone, games • No food • No reason to be up!

  20. Disrupted Nocturnal Sleep • Issues intrinsic to child • OSA-Hx of snoring, gasping or observed apnea • Consider sleep study • Leg movements-Family history of RLS • Ask RLS questions to caregiver/child • Treat clinically or consider PSG • Parasomnias-clinical history • Sleep walking, confusional arousals, night terrors • No sleep study needed usually

  21. Causes of Daytime Sleepiness • Medications • Many associated with daytime sleepiness • Anti-epileptic medications • Medications to treat muscle spasm • Psychotropic medications • Antihistamines • Caffeine-sleep disruption, PLMs

  22. Intrinsic Disorders of Sleepiness • Hypersomnia • Excessive daytime sleep despite normal nocturnal sleep • Narcolepsy • EDS – may have co-existing sleep disorders • Abnormal brain regulation of sleep/wake • Diagnosis of exclusion after ruled out insufficient sleep or disrupted sleep

  23. Intrinsic Disorders of Sleepiness • Narcolepsy • EDS + cataplexy makes diagnosis • Other symptoms: sleep paralysis, hypnagogic hallucinations, disrupted nocturnal sleep • Narcolepsy statistics • Onset in second decade • Diagnosis may take years to make • 25-50/100,00 in US

  24. Intrinsic Disorders of Sleepiness • Hypersomnia • Similar issues as in narcolepsy • Lack other symptoms seen in narcolepsy • Kleine-Levin, menstrual associated • Diagnosis made by history + PSG/MSLT • PSG to look for other sleep disorders • MSLT quantifies daytime sleepiness • Necessary for diagnosis, to get medications

  25. Intrinsic Disorders of Sleepiness • History • Amount of daytime sleep • Where falling asleep- School, bus, bathroom, meals, clinic? • PSG-looking for OSA, PLMs, seizure, etc • MSLT • Daytime studied to quantify sleepiness • 5 naps 2 hours apart looking for sleep and REM

  26. Intrinsic Disorders of Sleepiness • Treatment • Consider referral to sleep expert • Determine exact diagnosis, treat other sleep disorders • Arrange appropriate testing • Determine appropriate medication regimen • Stimulants, treatment for cataplexy • Maximize nocturnal sleep • Scheduled daytime naps • Schedule important tests/activities during periods of maximal alertness

  27. Circadian Rhythm Disorders • Child’s internal clock for sleep/wake behavior conflicts with family expectations • Delayed sleep phase • May be transient (jet lag) or persistent (night owl) • Sleep onset and offset delayed, but regular • Difficulty am waking and daytime sleepiness • Rx: strict and controlled sleep/wake schedule, delayed bedtime/gradual phase advance, chronotherapy, bright light therapy, melatonin

  28. Sleep Problems in ADHD • Children with ADHD ↑ sleepiness vs nl • Hyperactivity adaptive behavior for EDS • Medication role in sleep problems • Stimulant side effects-↑sleep latency, nocturnal awakenings, ↓total sleep time • “Wearing off” in evening→rebound increase in arousal and hyperactivity

  29. Signs of Sleepiness???

  30. Signs of Sleepiness • Sleepy behavior • Impulsivity, hyperactivity, aggressiveness • Labile mood and inattention • Neurocognitive deficits • ↓creativity, poor abstract thinking • ↓memory, vigilance, attention, motor skills • Sleep problems may mimic ADHD Sx

  31. Sleep History: ‘BEARS” • Bedtime • Excessive daytime sleepiness • Awakenings: night or early morning • Regularity and duration of sleep • Snoring

  32. BEARS: Bedtime • What happens at sleep onset • Difficulty going to bed or falling asleep • What happens at bedtime • What keeps the child from falling asleep • Is the child anxious at bedtime

  33. BEARS: Excessive Daytime Sleepiness • What is the extent of daytime sleepiness • Difficulty waking in am • Does the child act sleepy or seem overtired • Behavior when overtired • Daytime naps • Any similar history in family members

  34. BEARS: Awakenings • Characterize extent and content of awakenings • Does the child have trouble waking up at night • What awakens the child • Behavior when awake at night • Does the child leave their bed after awakenings

  35. BEARS: Regularity and Duration of Sleep • Characterize sleep habits • Bedtime and wake time • Weekdays vs. weekends • Does the child get enough sleep • How much sleep does the child need

  36. BEARS: Snoring • Screen for OSA • Does the child snore at night • How loud, how often • Does the child gasp, choke or stop breathing • Is the child a restless sleeper or sweaty • Anyone else at home snoring