2 Sleep in the Pre-teen Years Pre-school (3 to 5 years) Sleep needs: 11 to 12 hours Naps: Decrease from one a day to none Clinical Issues: Sleep onset and sleep maintenance problems are common Pre-pubertal (6 to 12 years) Sleep needs: 9 to 11 hours Naps: Daytime naps are infrequent Delayed sleep-wake timing – later bed times

3 Age-related Changes of Parent Reported Sleep Times From Iglowstein et al 2003

4 Polysomnographically Determined Age-related Changes of Sleep Time From Coble et al. 1984

5 Sleep Architecture Changes From Quan et al 2003

6 Acebo et al. SLEEP 2005 Age-related Changes in Napping Frequency and Duration

7 Estimated Prevalence of Sleep Disorders in Children Insufficient sleep – 10% (higher in teens – up to 33%) Behaviorally based - 25% Sleep related breathing disorders - 2% Narcolepsy – 0.05% Sleep/wake timing (delayed sleep phase) - 7% teens Parasomnias Nightmares – 10-50% Night terrors 2 - 3% Sleep walking 5% Rhythmic movement disorder 3 -15%

8 Developmental Overview of Common Non-respiratory Sleep Problems Newborn/ Young Infant Older Infant & ToddlerPre-schoolerSchool AgeTeenager Usually normal Developmental Self limited Night wakings Difficulty settling Night terrors Rhythmic movements Bedtime fears Night wakings Bedtime resistance Night terrors Sleep walking Rhythmic movements Bedtime fears Nightmares Insufficient sleep Bedtime resistance Sleep walking Enuresis Bruxism Insufficient sleep Nightmares Delayed sleep phase Narcolepsy

9 Insomnia Complaint of: Difficulty initiating sleep (bedtime resistance) Maintaining sleep (inability to sleep independently) Daytime impairment: Inattention, mood disturbance Problems with memory and concentration Impaired performance (at school in children)

10 Behavioral Insomnia of Childhood Symptoms meet criteria of insomnia Pattern consistent with either: Sleep-onset association type Limit-setting type

11 Behavioral Insomnia of Childhood Evaluation History Precise description of the problem Parent response and interaction with child Typical night, not extremes Careful description of bedtime routines, including naps Evaluate the 24 hour schedule (weekday, weekend, vacation)

12 Behavioral Insomnia of Childhood Sleep-onset Association Type Child begins to associate sleep onset with circumstances that are problematic and demanding of the caregiver Child unable to fall asleep without these associations either at initial sleep onset or during nocturnal awakenings

13 Treatments for Sleep-onset Association Type Education Awakenings during the night are normal Sleep onset associations are learned Sleep onset associations are present at all ages New sleep onset associations can be taught Behavioral treatment Place child in crib/bed awake and leave room If child is upset, return to comfort Do not pick up the child; comfort verbally Stay in room briefly, leave before child sleeps Increase time between responses Same routine for awakenings and naps

14 Treatments for Sleep-onset Association Type Usual response between 3 to 5 nights If symptoms persist, consider: Instructions not followed Co-existing problems Error in diagnosis More time needed Modifying the technique Modified techniques: Eliminate associations in stages Parents present longer Limit physical contact Gradually withdraw

15 Behavioral Insomnia of Childhood Limit-setting Type Refusal to go to bed at an appropriate time or following a nighttime awakening Insufficient or inappropriate limit setting demonstrated by the caregiver

16 “Daddy, I need…” A drink. One more kiss. One more hug. The light on. The light off. To tell you something A band-aid. My mommy. You to cover me up. You to rub my back. A tissue. Some medicine Behavioral Insomnia of Childhood Limit-setting Type: Favorite Delay Tactics “Mommy …” I’m hot. I’m cold. I’m scared. I’m not sleepy. I’m thirsty. My tummy hurts. I hear something. I have to go to the bathroom. Fix my blanket. I need to be tucked in again.

17 Bedtime refusals, stalling and repeated demands May also occur at naptime and nighttime wakings May be straightforward or complex Behavioral Insomnia of Childhood Limit-setting Type

18 Emphasize the importance of limit-setting Teach general limit-setting guidelines (day as well as night) Specific and individualized techniques (gate, progressive door closure) Positive reinforcement (star chart) Treatment of Limit-setting Type

19 Pediatric Obstructive Sleep Apnea

20 Spectrum of conditions determined by relative amount of upper airway obstruction: (CIRCLES DISPLAY INCREASING UPPER AIRWAY OBSTRUCTION) o PS - Primary snoring: NOISY BREATHING o UARS - Upper airway resistance syndrome: NOISY BREATHING + DISTURBED SLEEP oOH - Obstructive hypoventilation: NOISY BREATHING ± DISTURBED SLEEP +  CO2 and/or  SaO2 o OSA - Obstructive sleep apnea: NOISY BREATHING ± DISTURBED SLEEP +  CO2 and/or  SaO2 + ABSENCE OF AIRFLOW Sleep Disordered Breathing

21 OSA Epidemiology Snoring in children: 7% - 10% Habitual snorers 20% Intermittent snorers OSA – 1% to 3% of preschool children Peaks ages two to five years Gender distribution: M:F ratio approximately equal in children Prevalence is higher among African Americans

22 Cross-Section of Oropharynx Tonsillar hypertrophy Micro- or retrognathia Nasal obstruction Large tongue

23 Pathophysiology of OSA Neuromotor tone Cerebral palsy Genetic diseases Structural factors Adenotonsillar hypertrophy Craniofacial abnormality Obesity Other factors Genetic Hormonal ? OSA

24 Risk Factors Adenotonsillar hypertrophy Craniofacial anomalies Down syndrome Obesity Neurologic disorders

25 The degree of tonsillar hypertrophy may not correlate with the presence of OSAS Tonsillar Hypertrophy

26 Clinical Features Nocturnal Symptoms Loud snoring Observed apneic pauses Snorting / gasping / choking Restless sleep Diaphoresis Paradoxical chest wall movement Abnormal sleeping position Secondary enuresis

27 Clinical Features Diurnal Symptoms Daytime somnolence Behavioral / school problems Difficulty awakening in AM Morning headaches Nasal congestion Mouth breathing

28 Courtesy of Dr. Carol Rosen Pediatric Polysomnography Tech Observer Video Camera Sao2 Leg EMG (2) Microphone EKG Chin EMG (2) EEG EOG Nasal EtCO2 Record behavior Documents arousals, parasomnias, abnormal sleeping position, and attends to any technical problem Respiratory Effort Nasal Oral Airflow

29 Consequences of Pediatric OSA Effects on growth Neurocognitive morbidity Cardiovascular consequences

30 Neurocognitive Morbidity Hyperactivity, inattention, aggression Impaired school performance Daytime sleepiness Depression

31 Cardiovascular Consequences Pulmonary Hypertension Cor Pulmonale Systemic Hypertension

32 Cor Pulmonale in OSAS

33 Blood Pressure in OSAS Marcus et al. Am J Respir Crit Care Med 1998

34 Positive Airway Pressure

35 Children on CPAP

36 Special Considerations for CPAP in Children Need wide variety of mask sizes and styles to fit children Compliance may be enhanced by behavioral techniques Empowerment Positive reinforcement Desensitization Role modeling

37 Childhood Parasomnias Undesirable events or experiences occurring: At entry into sleep Within sleep During arousal from sleep

38 Parasomnia Classification Disorders of Arousal (from NREM sleep) Parasomnias Associated with REM Sleep Other Parasomnias

39 Disorders of Arousal Arousals from NREM sleep First half of night, typically short duration Prolonged or multiple episodes may occur Confusion / automatic behavior Difficult to awaken during event Fragmented imagery Rapid return to sleep after event Amnesia of events

40 Confusional Arousals Clinical Characteristics: Occur on arousal from NREM sleep May not recognize parents May cry, yell, or moan Speech often unintelligible, sounds like words Most common words: “No, No!”

41 Sleep Terrors Peak age: 5-7 years Prevalence rate of % Most will later sleepwalk Usual duration in children:- 4 years 50% end by age 8 36% continue into adolescence

42 Sleep Terrors Begin abruptly from NREM sleep Episodes of agitation and apparent terror Heralded by a blood-curdling scream or cry Followed by confusion, agitation and autonomic disturbances Patient difficult to arouse If patient can be awakened, may describe: Vague sense of terror Isolated or fragmented dream imagery

43 Sleepwalking Clinical Characteristics Quiet wandering (injury unlikely) Agitated wandering (injury more likely) Behaviors of variable complexity Inappropriate behaviors Most sleepwalkers have few daytime effects

44 Disorders of Arousal: Treatment Allow episodes to run their course: Interfere only to prevent injury May try to lead the patient calmly to bed Emphasize sleep hygiene Secure the bedroom to prevent injury: Consider ground floor bedrooms Window and door locks, pad bedrails Remove sharp objects or toys on bedroom floor Alarms or barriers at door/stairs Medications may be necessary in severe cases

45 Parasomnias Associated with REM Sleep Nightmares Sleep paralysis REM Sleep Behavior Disorder

46 Nightmares 75% of children experience nightmares % of children have nightmares severe enough to disturb their parents Proportion of children reporting nightmares reaches a peak around ages 6-10 years and decreases thereafter

47 Nightmares Clinical Characteristics: Usually during last half of night Complex dream mentation: – “Good dream gone bad” Emotional reaction more significant than autonomic response Fully alert upon awakening Responsive to comforting

48 Nightmares Precipitating Factors: Anxiety / Stress Personality – association with creativity Post-traumatic stress disorder

49 Nightmares and PTSD When there is a history of significant physical or psychological trauma, recurrent nightmares may occur and are likely a symptom of Posttraumatic Stress Disorder (PTSD)

50 Nightmares of PTSD Trauma-related nightmares are the most consistent problem reported by Posttraumatic disorder (PTSD) patients Nightmares are present in up to 80% of PTSD patients (usually beginning within three months of the trauma)

51 Nightmares Treatment: Explanation and reassurance Sleep hygiene Behavioral therapies

52 Nightmares & Sleep Terrors REM sleep Most common parasomnia 2nd half of night Delayed return to sleep Easily comforted Detailed narrative description of episode Mild autonomic activity Alert upon awakening NREM sleep % prevalence 1st half of night Rapid return to sleep Resists comforting Fragmented recall / amnesia Intense autonomic activity Confusion on waking NightmaresSleep Terrors

53 Pediatric RLS: Prevalence “Night-Walkers” Survey 138 adults with RLS (mean age 60 years) 18% reported symptoms began before age 10 years 25% reported symptoms began before age 20 years Childhood RLS case reports

54 Pediatric RLS: Clinical features Attention sought for “growing pains” These present as: Sleep onset problems Sleep maintenance problems Daytime irritability and attention problems may occur, likely due to sleep deprivation Family history is positive for RLS Iron deficiency may play a role as in adults

55 Pediatric RLS An urge to move legs, caused by discomfort as described in child’s own words Begins or worsens during periods of inactivity Partially or totally relieved by movement Worse in the evening or night Biological parent / sibling with definite RLS Periodic limb movements of 5 or more per hour of sleep on PSG

56 Pediatric RLS: Treatment Strict sleep hygiene is necessary to avoid sleep deprivation Limiting setting often required (day and at bedtime) Treatment of iron deficiency Medications: Clonazepam 0.25 to 1.0 mg qHS