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. Daytime Sleepiness in Children: Impact

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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!

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Signs of Sleepiness???

31. 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

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

33. 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

34. 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

35. 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

36. 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

37. 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