Sleep disorders in children Dr Scott Burgess PhD FRACP Paediatric Respiratory and Sleep Physician

Outline / Learning objectives: Be able to describe the Pathophysiology Symptoms Possible consequences Investigation (including role of sleep studies) and Management of OSA in children Gain and understanding of common non-respiratory sleep problems in children, in particular Sleep onset associations disorder in young children Sleep phase disorder in teenagers Questions?

Why worry about sleep problems? Common – up to 30% of children are reported to have sleep problem Important – can impact on... Behaviour Development Growth Medical well-being Adverse impact on parental mental health Treatable – GPs have a crucial role to play.

Obstructive sleep apnoea OSA is characterised by: recurrent episodes of partial or complete upper airway obstruction during sleep disruption of normal gas exchange (intermittent hypoxaemia or hypercapnoea) sleep fragmentation.

Obstructive sleep disordered breathing Primary snoring Increased upper airways resistance Mild OSA Moderate OSA Severe OSA

Frequency of SDB Snoring is a frequent symptom in children Approximately ¼ of children snore intermittently Habitual snoring (loud snoring reported to occur three of more times per week) reported by 10% parents OSA affects approximately 2-3% of children.

Pathophysiology OSA is associated with narrowing or collapse of the upper airway during inspiration. Typically at the level of the soft palate and adenoids (Isono, Shimada et al. 1998).

Predisposing factors (1) Sleep state: REM sleep is associated with loss of pharyngeal muscle tone and a change in breathing Adenotonsillar hypertrophy: growth of adenoids and tonsils relative to the airway, 2-8 years Shape, size and collapsibility of the airway: individual variation in the size and collapsibility of the airway, heritable factor Exposure to cigarette smoke and recurrent viral URTIs Puberty: following puberty males developing longer upper airway, males > females post puberty.

Predisposing factors (2) Arousal threshold and breathing control: mechanoreceptors in the upper airway stimulated by increased respiratory effort cause arousal during apnoea. Blunted in children with OSA Medical conditions and syndromes may be associated with decreased airway tone and calibre (eg Down syndrome, Prader Willi, craniofacial abnormalities for example Pierre Robin) Medications and alcohol can reduce airway tone and respiratory drive Obesity is associated with increased adipose tissue in the neck, decreased lung volumes and diaphragm excursion when supine Obesity may even blunt respiratory drive normally stimulated by hormones such as Leptin.

Symptoms of OSA Snoring Snorting Laboured breathing / paradoxical chest wall movement Witnessed apnoeas Sweating Restless sleep Mouth breathing Sleeping with neck extended or other usual postures Hyperactivity, behavioural and cognitive problems Sleepiness.

Neurobehavioural consequences There is evidence that children with OSA have more behavioural problems than controls Poor attention Concentration Hyperactivity Aggressive behavioural Moodiness Poorer academic performance Reduced scores on psychometric testing (IQ) in school aged children.

Cardiovascular complications Episodes of obstruction are associated with autonomic activation Some, but not all studies, have reported an increase in systolic blood pressure Pulmonary hypertension and right ventricular strain is a risk factor in severe OSA Weak risk factor for metabolic syndrome and cardiovascular disease Combination of OSA and morbid obesity is an increasing concern in relatively young children.

OSA Diagnosis Both history and examination do not accurately predict sleep study findings: Illicit the history of above symptoms Video recording of snoring and apnoea Examination for nasal disease and increased tonsils Consider in obese children and those with strong family history Remember OSA in children with disorders of tone or upper airway.

Remember the nose...

What is a sleep study?

Treatment of OSA Medical treatment of nasal disease: Nasal steroid +/- Singulair Weight loss Cigarette smoke exposure Improve behavioural sleep problems ENT surgery: T’s and A’s, or other surgery CPAP – second line Other: Bi-level (CPAP > 15cm, mixed disease) Maxillary expansion Tracheostomy.

Non-respiratory Sleep problems Inadequate sleep Behavioural insomnia of childhood Nightmares / bad dreams / night time fears Parasomnias (night terrors, sleep walking) Sleep phase syndromes Psychophysiological insomnia Narcolepsy Restless legs syndrome.

How much sleep do children need. Iglowstein. Pediatrics. 2003 How much sleep do children need? Iglowstein. Pediatrics. 2003. p302 Lot of individual variation, below are averages Age (years) Total Sleep % having day nap 0.5 14.2 100 1 13.9 1.5 13.6 2 13.2 96 3 12.5 87 4 11.8 50 5 11.4 35 6 11 8 7 10.6 10.4 9 10.1   10 9.9 9.6 12 9.3 13 14 8.7

Behavioural problems: Is it a problem to them?

Most common behavioural problems Sleep onset association (SOA) Refers to a requirement by the infant or child for certain things to be happening as they go off to sleep Interferes with their ability to independently go to sleep Includes: being fed or patted to sleep, parent being present Parents commonly complain that their child wakes more frequently during night Normal children wake multiple times overnight But can put self back to sleep SOA – child cries until association is repeated Limit setting type: Thus typically involves difficulties getting the child to go to bed and curtain calls.

Routines and sleep hygiene Set a bedtime that will allow adequate sleep duration Consistent routines Should be clear to child when bedtime is coming up Consistent from night to night and between carers Environment: having TV in the child’s room and iPADs have been associated with increased difficulties falling asleep and less sleep time per night Avoid caffeine containing drinks (USA 18% of preschoolers and 28% of younger school aged children drink at least one caffeinated beverage per day) Quiet activity before bed eg looking at picture book or reading.

Sleep association Graduated withdrawal (controlled crying) vs extinction Need to have a plan Need to agree on a plan Need to be consistent Start at beginning of night Repeat during night and day naps Monitor progress Should see progress over days Adjuncts: Melatonin 1-2 mg 30 minutes before bed.

Delayed sleep phase disorder Second most common sleep disorder in adolescents (following inadequate sleep) 5–10% of adolescents Persistent delay of at least 2 h beyond the desired bedtime, resulting in disruptions to the adolescent’s functioning Trouble falling asleep (not anxious or worrying) but once asleep sleeps well and has trouble waking in time for school Melatonin (Circadin) 2mg 45 minutes before bed and natural light at ideal wake up time Need to be consistent If extreme may need to move back slowly.

Resources Triple P (Positive parenting program) Parenting and Family Support Centre, UQ, Ph 3365 7290 Child Health Nurses and Early intervention service Ellen Barron Centre – public inpatient unit (PCH) North West Private Hospital – Brisbane Nurture Centre Q-CLASS (www.qclass.com.au) Suresh and Scott Beth Shirley – GP with interest in infant sleep / settling Fiona Hudson – Psychologist with interest in sleep Wesley sleep studies – short waiting list and covered by private insurance.

Questions?