1. A Good Night’s Sleep is Important
A Good Night’s Sleep is Important ! Overcoming Sleep Problems in Children
William Wooten, III, MD
Pediatric Pulmonology and
Sleep Medicine
Brody School of Medicine, ECU

2. Sleep in Children Questions to be Answered…
What constitutes normal sleep in children?
What are features of sleep-disordered breathing in children?
Referral and treatment for sleep problems – who, where, and what?

3. What is Sleep Anyway?
“A naturally recurring state characterized by altered consciousness with relatively inhibited sensory and motor activity.”

4. When does sleep begin? Human sleep begins during embryonic development
Cycles of brain activity at weeks gestation
REM sleep develops around weeks

5. Newborn Sleep Changes Rapidly
ACTIVE SLEEP (REM)
QUIET SLEEP (NON-REM)

6. Question
Parents of a 2 month old boy complain that he is not yet sleeping through the night from midnight to 5 am.
What is the correct response?

7. Question
Parents of a 2 month old boy complain that he is not yet sleeping through the night from midnight to 5 am.
What is the correct response?
Reassurance - Most babies “sleep through the night” by 6-9 months of age.

8. Question
Parents of a 2 month old boy complain that he is not yet sleeping through the night from midnight to 5 am.
What is the correct response?
Reassurance - Most babies “sleep through the night” by 6-9 months of age.
Sleep through the night defined as 5 hours of uninterrupted sleep

9. Newborn Sleep Sleep/wake cycle every 4 hours
Sleep onset REM (like narcolepsy) until 6 months and indeterminate sleep on EEG
Sleep/wake cycle every 4 hours
80% of time spent sleeping
Circadian rhythm matures around 3-6 months of life

10. Circadian rhythmicity develops around 3-4 months of age
3-4 hr autonomous rhythm
3 months
4 months
Circadian rhythmicity develops around 3-4 months of age
Synchronized sleep pattern

11. “Sleeping Through the Night” Sleep Training Methods
Parent resources: “sleep training”
Solve Your Child’s Sleep Problems (Ferber)
Healthy Sleep Habits, Healthy Child (Weissbluth)
On Becoming Babywise (Ezzo and Bucknam)

12. Ferber method “Progressive waiting” method
Teach baby to soothe himself when physically ready (at least 3-5 months)
Put baby in bed awake, leave for gradually longer periods of time
Allows infant to develop sleep associations
Placing baby in crib awake helps form good sleep associations

13. Weissbluth method “Extinction” method
Parents watch for sleep cues (ie yawn, rubbing eyes)
Soothe before putting in bed
Extinction: “cry it out” indefinitely, up to an hour for naps
Earlier bedtime if sleep issues (to prevent “over-tired” child)

14. Babywise method
Feed infant on a strict 3-4 hour schedule from birth regardless of demand
Baby should sleep through night from 8-12 weeks
AAP issued a statement that this method is dangerous and should not be followed

16. Recommended Sleep Times: National Sleep Foundation 2015
Newborns (0-3 months): hours each day (previously it was 12-18)
Infants (4-11 months): hours (previously it was )
Toddlers (1-2 years): hours (previously it was 12-14)
Preschoolers (3-5): hours (previously it was 11-13)
School age children (6-13): hours (previously it was )
Teenagers (14-17): hours (previously it was )
Younger adults (18-25): 7-9 hours (new age category)
Adults (26-64): 7-9 hours (no change)
Older adults (65+): Sleep range is 7-8 hours (new age category)

17. Naps – what is normal? 3 naps by age… 3 months
1 nap by age… months
0 naps by age… 4-5 years

18. Infant Sleep Problems
Parents of a 15 month old girl report that she awakens multiple times at night. With awakenings, mother picks her up, rocks her, and feeds her from a bottle until she falls asleep.
What is the diagnosis?

19. Infant Sleep Problems
Parents of a 15 month old girl report that she awakens multiple times at night. With awakenings, mother picks her up, rocks her, and feeds her from a bottle until she falls asleep.
What is the diagnosis?
Diagnosis: Behavioral Insomnia of Childhood: Sleep Association Disorder

20. Behavioral Insomnia of Childhood
Sleep association disorder
6-36 months
Delayed sleep onset and awakenings
Sleep onset becomes related to external cues
Parent rocking child to sleep, drinking from a bottle
Sleep will not occur without cues

21. Behavioral Insomnia of Childhood
Limit setting sleep disorder
>18 months
Delayed bedtime; otherwise normal sleep
Parents unable to control behaviors around bedtime or awakenings
Usually inadvertently reinforce bad behaviors
Inconsistent limit-setting

22. Behavioral Insomnia: Tips for Parents
Focus on bedtime routine
Be consistent and predictable
Good: Play with toys, read books, take bath
Bad: TV, electronics, snacking after dinner
Maintain regular bedtime (not too late)

23. Behavioral Insomnia: Tips for Parents
Focus on environment
Keep things quiet
Dim lights
Maintain a restful sleeping space
Avoid games or activities in bed
Remove distractions

24. Behavioral Insomnia: Tips for Parents
Establish sleep associations
Toy/object to crib with child, not available during the day
Don’t become a sleep association… try to be “boring” or “robot” parent after bedtime

25. Behavioral Insomnia: Tips for Parents
Remember to reward good behavior !

26. Get Rid of Bad Sleep Associations!
No bottles in the crib !
… Can lead to cavities, GERD, aspiration

27. Get Rid of Bad Sleep Associations!

28. Remember to think about Caffeine…

29. Question
Parents of a 3 year old girl are concerned about awakenings at night when she sits up, mumbles a few words and then goes back to sleep. This has been happening almost every night for the past few months and she does not seem to remember the events.
What would be appropriate to do next?

30. Question
Parents of a 3 year old girl are concerned about awakenings at night when she sits up, mumbles a few words and then goes back to sleep. This has been happening almost every night for the past few months and she does not seem to remember the events.
What would be appropriate to do next?
Ask about symptoms of sleep disorders,

31. Question
Parents of a 3 year old girl are concerned about awakenings at night when she sits up, mumbles a few words and then goes back to sleep. This has been happening almost every night for the past few months and she does not seem to remember the events.
What would be appropriate to do next?
Ask about symptoms of sleep disorders,
Ensure safety of sleep environment,

32. Question
Parents of a 3 year old girl are concerned about awakenings at night when she sits up, mumbles a few words and then goes back to sleep. This has been happening almost every night for the past few months and she does not seem to remember the events.
What would be appropriate to do next?
Ask about symptoms of sleep disorders
Ensure safety of sleep environment
…then, Reassurance

33. Parasomnias – Normal or Not?
Parasomnias are usually normal in children
If frequent, may indicate condition causing arousal
OSA
Restless legs syndrome
Seizures can be confused with parasomnia

34. Parasomnias Parasomnias: Disorders of Arousal Non-REM parasomnias
Confusional arousals
Night terrors
Sleepwalking
Sleep-related eating disorder
REM parasomnias
Nightmares
REM behavior disorder

35. Disorders of Arousal Occur in NREM ,usually deep sleep (early night)
Patient remains asleep during / following arousal
No recollection of event
Classic types:
Confusional arousals
Night terrors
Sleepwalking

36. REM parasomnias Nightmares REM behavior disorder Occur during REM
Usually occur LATE at night (early morning)
Recollection of dream
REM behavior disorder
Absence of normal REM atonia
Large movements and/or complex behaviors
“Acting out dreams” with recollection of dream when awakened
Associated with neurodevelopmental disorders and medications

37. Nightmares or Night Terrors?
Most often occurs late night/ early morning hours (REM sleep)
Awakenings from sleep with frightening dreams
Child responds to being consoled
Night terrors
Usually occurs in the early night (non-REM)
Awakenings from sleep with crying, screaming
Child does not respond to being consoled
Will not remember in the morning

38. Nightmares and Fears: Tips
Read happy books at bedtime, avoid scary videos
Bedtime ritual – should be quiet, comforting
Physical reassurance is helpful
Child sleeping in your bed
May work temporarily
Often becomes a habit
Be careful about “monster hunts” and “monster sprays”

39. Question
Parents of a 5 year old girl complain of heavy snoring every night. Parents have witnessed respiratory pauses during sleep. Tonsils are enlarged. She has symptoms of ADHD and is on stimulant medications.
What is the suspected diagnosis?

40. Question
Parents of a 5 year old girl complain of heavy snoring every night. Parents have witnessed respiratory pauses during sleep. Tonsils are enlarged. She has symptoms of ADHD and is on stimulant medications.
What is the suspected diagnosis?
Obstructive sleep apnea…
What next?

41. Overview of SDB - Questions
What is sleep disordered breathing??
Why is it important (and different) in children?
What common conditions are associated with sleep disordered breathing during childhood?
How to reconcile different evaluation/treatment guidelines for OSA in children (AASM, AAP, AAOHNSF)?
What are new and emerging treatments for sleep apnea in children?

42. What is SDB ?
Sleep-disordered breathing Nonspecific, umbrella term encompassing spectrum of respiratory alterations during sleep
Often refers to airway obstruction during sleep
Primary snoring (PS)
Upper airway resistance syndrome (UARS)
Obstructive sleep apnea syndrome (OSAS)
Also encompasses sleep related hypoventilation syndromes and central sleep apnea

43. Spectrum of SDB in Children
Obstructive sleep apnea syndrome (OSAS) – Obstructive events, arousals and gas-exchange abnormalities (O2, CO2)
Upper airway resistance syndrome (UARS) – Flow limitation, arousals, criteria not met for hypopneas
Primary snoring - snoring NOT associated with gas exchange abnormalities or arousals.

44. OSA in Children is Important
Obstructive sleep apnea (OSA): Repeated events of partial or complete upper airway obstruction during sleep. Diagnosed by polysomnography (PSG).
Upper airway obstruction causes disruption of ventilation and/or sleep structure (sleep fragmentation)
Implications for developing nervous system: neurobehavioral and cognitive problems (ADHD, learning problems)

45. Pediatric OSA: Research Topic
“Pediatric Obstructive Sleep Apnea”
on PubMed per year

46. “Adenoid facies”

47. 2 Peaks of OSA prevalence
Peak 1: Adenotonsillar hypertrophy (3-6 yr)
Peak 2: Obesity (adolescents) 3 6 9 12 15 18

48. Symptoms of SDB in Children
NIGHT symptoms
Snoring, apnea, restlessness, night sweats
Awakenings may precipitate disorders of arousal (night terrors, confusional arousals, sleepwalking)
Nocturnal enuresis –
Children who snore and wet the bed are more likely to have moderate to severe sleep apnea than those who stay dry at night (Pediatric Research 2014)

49. Symptoms of SDB in Children
DAYTIME symptoms
Neurocognitive impairment (poor school performance)
Behavior problems (aggression, irritability)
Cardiovascular morbidity
Changes in appetite, weight

50. Exam: SDB in children “Adenoid facies”
High-arched palate
Narrow nasal passages
Short upper lip
Crowded, prominent teeth
Small maxilla
Mouth breathing leads to molding of facial bones
“Adenoid facies”

51. Exam: Modified Mallampati
Sitting position, tongue extended
Measures relationship of
soft palate to tongue
Scoring
Class I: Soft palate, uvula, fauces, pillars visible.
Class II: Soft palate, uvula, fauces visible.
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible.

52. Exam: Tonsils Tonsillar pillars Scoring Grade 0: Tonsils absent
Grade 1: hidden behind pillars
Grade 2: Extend to pillars
Grade 3: Visible beyond pillars
Grade 4: Enlarged to midline
“kissing” tonsils
Tonsillar
pillars

53. Exam: Tongue
Scalloping
Macroglossia
Ankyloglossia

54. Retrognathia / Micrognathia

55. Retrognathia / Micrognathia
Seen in genetic / craniofacial conditions:
Pierre Robin
Treacher Collins
Marfan’s
Smith-Lemli Opitz

56. Retrognathia / Micrognathia
Retrognathia: Posterior displacement of chin (gnathion) compared to the bridge of nose (nasion) Micrognathia: Mandible is smaller size than normal (mandibular hypoplasia)

57. Exam: Overbite and Overjet
Overjet = Horizontal
Overbite = Vertical

58. Exam: High Arched Palate
Normal
Mild
Moderate
Severe

59. Treatment of OSA Surgery CPAP Orthodontics Weight loss
Adenoidectomy and/or tonsillectomy
Nasal turbinate reduction
CPAP
Effective in overweight children or if surgery impossible
May affect facial bone structure until age 11 yr
Orthodontics
Rapid maxillary expansion – especially before years of age
Weight loss
Should always be encouraged if overweight / obese
Anti-inflammatory drugs
Nasal corticosteroids
Leukotriene antagonists (Singulair)

60. Treatment of OSA: Orthodontics
Rapid maxillary palatal expansion
Children have temporary gap between front teeth
Usually 3 weeks to fully expand

61. Treatment of OSA: CPAP

62. PSG: Measuring Sleep Apnea

63. PSG – obstructive events

64. PSG – results (AHI) Mild : AHI 1-5 (adult 5-15)
Apnea-hypopnea index (AHI)
Number of events per hour of total sleep time.
OSA severity (pediatric vs adult)
Mild : AHI (adult 5-15)
Moderate : AHI (adult 15-30)
Severe : AHI >10 (adult >30)

65. Primary snoring
Primary snoring: frequent snoring NOT associated with gas exchange abnormalities or frequent arousals.
Cannot be differentiated from OSA without PSG.
Prevalence of habitual snoring (>3x per week) is 10-15% of children (Lumeng et al 2008).
Studies have found clinical consequences in children who snore, even without sleep apnea on PSG…

66. Snoring and Reduced IQ?
IQ scores ~10 points lower in PS compared to controls. Impairments in verbal knowledge and language development (Blunden et al 2000, Bourke et al 2003, Kohler et al 2009)
Lower scores in reading and arithmetic (Bourke et al 2011)
10x risk of daytime sleepiness compared to controls, compared to 5x risk in OSA. (Brockman 2012)

67. Primary snoring – Behavioral effects
Children with PS have cognitive impairment SIMILAR to those with moderate to severe OSA
Children with PS appear to have MORE behavioral problems, inattention and daytime sleepiness than those with mod/severe OSA (Bourke 2011, Jackman 2012, Brockman 2012)

68. Hypoxia-Arousal or another Mechanism ?
Number of desaturations >3% linked to impairments in working memory, attention and IQ
Number of arousals associated with daytime sleepiness, sleep fragmentation
In PS, cognitive and behavioral problems occur without desaturations or arousals
Does PSG have poor sensitivity to detect meaningful EEG or O2 changes? Does PS represent another phenotype or mechanism? More research needed…

69. Cognitive Effects of Snoring ?
Preschool children appear to have equivalent cognitive scores in all SDB severity groups
Neuroplasticity – is there a protective mechanism ?
Is there a cumulative effect ?
Studies have limitations
Variability in PSG and scoring criteria
Disease overlap – OSA, ADHD, asthma
Recruitment bias – who wants a free sleep study?
Few studies in preschool population

70. Where to Refer for SDB?
Guidelines for screening and management for sleep disordered breathing in children
American Academy of Sleep Medicine (AASM) 2011
American Academy of Otolaryngology-HNS (AA-OHNS) 2011
American Academy of Pediatrics (AAP) 2012
Guidelines similar, but with differences

71. AASM Practice Parameters
PSG indicated when clinical assessment suggests OSA
PSG indicated in children being considered for adenotonsillectomy to treat OSA
PSG indicated after treatment of OSAS following AT in mild OSA with residual symptoms and in all with mod/severe OSA, obesity, craniofacial or neurologic disorders
Reasons for PSG prior to AT:
Surgery involves risks of hemorrhage, infection, airway compromise, and should only be done if indicated
Clinical parameters for diagnosis unreliable
Higher risk in certain medical disorders: sickle cell, HIV, coagulopathy, congenital heart disease
Severe OSA with higher risk for airway compromise and other complications
Summary: Preoperative PSG appears to have strong clinical utility but evidence showing clinical benefit of PSG prior to AT is lacking

72. AA-OHNS

73. AA-OHNS Guideline for PSG
PSG indicated in certain children with SDB:
Obesity, Trisomy 21, Craniofacial or Neuromuscular disorders, Sickle cell disease, Mucopolysaccharidosis
Advocate for PSG:
Need for surgery uncertain
Discrepancy between tonsillar size and reported symptoms

74. AA-OHNS Guidelines Surgery considerations
PSG results should be communicated to anesthesiologist prior to induction
Criteria for admission after AT
Any child younger than age 3
Severe OSA (AHI >10/hr and/or O2 nadir <80%)

75. AAP Clinical Practice Guideline

76. AAP Clinical Practice Guideline
All children/adolescents should be screened for snoring
PSG performed in children with snoring and symptoms/signs of OSAS.
If PSG not available, consider alternative diagnostic tests or specialist referral
Adenotonsillectomy recommended treatment in patients with adenotonsillar hypertrophy
High risk patients should be monitored as inpatients postoperatively

77. AAP Clinical Practice Guideline
OSA diagnosed NO
Adenotonsillar hypertrophy
Obesity?
YES NO
YES NO
Clinical judgment
CPAP
Adenotonsillectomy

78. Referral for SDB in Children
Since guidelines differ,
Primary MD has to determine best practice for referral
Primary MD
ENT
Sleep MD
Open communication between providers is always helpful…

79. Referral for SDB in Children
ENT
Sleep MD
Primary MD

80. Guideline consensus…
In children, in-lab standard PSG recommended compared to unattended PSG or oximetry
AT is first line treatment for OSA in children with AT hypertrophy
CPAP is an alternative to AT if surgery is not indicated

81. Success after childhood…