Post on 07-May-2015
Sleep & Sleep Issues in the Pediatric Population
Kids Sleep A lot
• Sleep is a common discussion point among parents and doctors
Many Issues from birth to adolescence….
• SIDS
• Co-sleeping
• Night-wakenings
• Bed-wetting
• Nightmares
• Sleepwalking & Sleeptalking
• Timing of High School start times…
Sleep Physiology
Wakefulness REM
Indeterminate NREM
Wakefulness
Stage 1 NREM• Waves
Stage 2 NREM• Sleep Spindles• K-Complexes
Stage 3 NREM• 20-50 % Waves
Stage 4 NREM• > 50 % Waves
Stage REM Alpha Waves
Conjugate Eye Movements
Sleep Stages Overnight
NREM is more common in the first part of sleep. REM is more common in the latter half of sleep
Children’s Sleep Architecture Differs from Adults
• More REM• Earlier REM• More frequent REM • More Total Hours of Sleep
REM & NREM Sleep by Age
02468
1012141618
1 - 3M
3 - 5M
6-23M
2 - 3Y
3 - 5Y
5 - 9Y
10-13Y
14-18Y
19-30Y
Tot
al H
rs S
leep
Total Daily Sleep by Age
02468
1012141618
1 - 3M
3 - 5M
6-23M
2 - 3Y
3 - 5Y
5 - 9Y
10-13Y
14-18Y
19-30Y
Tot
al H
rs S
leep
Sleep in Preemies• “Indeterminate Sleep”
– Neither REM nor NREM
– Characterized by “Delta Brushes” and temporal spikes
– Predominant pattern at 34 wks
– Disappears by 3 months of age
• As gestational age increases…– maximum EEG sleep activity switches from temporal to frontal– Indeterminate Sleep decreases– Synchrony between the 2 hemispheres increases
• The preemie’s sleep legacy is easier arousal later on…
Normal Infant Sleep Patterns
• 18 hours a day, 50% REM, at birth
• Infants start sleep with REM
• Most sleep through night by 3 months– 25 % still have not by 6 months of age
• Naps– Usually 2 / day until 1st Birthday– 2nd nap usually given up by age 3
Night Wakenings
0%5%
10%15%20%25%30%35%40%45%50%
All Infants BreastfedInfants
1-2 YrOlds
4-5 YrOlds
Promotion of Good Sleep Habits starts early
** Beware of bastardizations of Ferberizing **
SIDS• Death of an infant under the age of 1 during sleep
– 90% under the age of 6 months– Usually during winter months
• No known cause but many theories– Poor respiratory response to CO2– Poor blood pressure control– Inability to remove obstructions to breathing
• Known associations– Sleeping on tummy– Smokers in the house– Not being breastfed
School-Age Sleep Issues
• Bedtime Struggles– Associated with TV viewing behaviors
• Parasomnias
Parasomnias
• Impressive Phenomena• Positive Family History• Usually Deep NREM Sleep (Stages 3/4)• Common in childhood, decrease with age
– Persistence into adulthood NOT a sign of psychopathology
• Can be induced or precipitated by fever, sleep deprivation, and certain medications
Prevalence of Parasomnias in Childhood
0%10%20%30%40%50%60%70%80%
Persists
PersistsPersists
Parasomnias Go Together
Sleepwalking Sleeptalking
Night Terrors Bruxism
Nightmares
• Extremely common– 2/3 of all kids experience them
• Preschoolers ages 3-6
• REM
• Child believes them to be real.
Night Terrors
• 5 % of pre-schoolers.• Starts between ages 4-12 and resolves
spontaneously• Increased FHx of enuresis / sleepwalking in 1st
degree relatives• During Stage 3-4 during 1st third of night.• Sits upright, stares, appears frightened, screams,
cries, autonomic arousal, unresponsiveness– Lasts ~ 10 minutes then child returns to undisturbed
sleep. No recall.
Night Terrors
• Not associated with psych problems in childhood; although in adults, associated with PTSD, panic disorders
• If disruptive or occur daily, can try Benzo qhs.
• Sometimes can be manifestation of seizures
Nightmares Night Terrors
Age 3 - 6 yrs 4 - 8 yrs
Sleep Stage REM NREM (3/4)
Time of Night Late Early
State on waking Upset / Scared Disoriented
Response to parents Consolable
Unaware of Parents
Return to Sleep Difficult Easy / Rapid
Memory of Event Vivid None
Sleep Bruxism
• Up to 88% of children; 20 % of adults
• Any stage of sleep
• May result in damage to the
• Periodicity of 20 to 30 seconds.
• Malocclusion plays no role in bruxism
Sleeptalking
• Begins during school age
• NREM and REM sleep
• No treatment
Sleepwalking
• More than just walking around…– Simple Behaviors– Complex Behaviors
• Begins in ages 4-8 yrs and resolves spontaneously by adolescence.
• 10 % of children (2.5 % of adults)• Positive Family History • Stage 3-4 Sleep; 1st third of night.
Nocturnal Enuresis
• NREM sleep• May be restricted to Stage 3-4• Increased bladder pressures during deep
sleep• Males with Family History• 15% of 5 year olds• 10% cure per year, with 3-5% of
adolescents
Treatment Of Nocturnal Enuresis
• Behavioral Modification• Less drinks• Double Voids @ night• Timed Nighttime voids
• Alarm Systems
Sleep Motor Phenomena• Hypnic Jerks• Body Rocking• Restless Legs Syndrome
– “Periodic Limb Movement Disorder”– Parathesias and desire to move the legs– Stage 1-2 NREM Sleep– More common in children than recognized
• 40% start in childhood
“Restless Legs Syndrome”
– “Periodic Limb Movement Disorder”
– Stage 1-2 NREM Sleep– More common in children than recognized
• 40% start in childhood
– Secondary Causes• Anemia, Pregnancy, Uremia, Neuropathy
Periodic Limb Movement Disorder
Persistence of Childhood Parasomniasinto Adolescence
0% 5% 10% 15% 20% 25% 30%
Sleepwalking
Bruxism
Sleep Terrors
Enuresis
Adolescent Sleep
• Public Safety
• Extracurriculars
• School Start times
Nocturnal Emissions
• Nocturnal penile erections throughout all life stages– Occurs in utero
• Oigarche @ 13 yrs, 2 months
• Sexual dream causes ejaculation– How common?
Delayed Sleep Phase Syndrome
• Excessive Daytime Sleepiness or typically as the sum of its complications
• Patients complain of inability to get to sleep until the early morning hours, but little difficulty sleeping once asleep
Melatonin
Narcolepsy
• Begins in adolescence
• Triad of SymptomsDaytime Sleep Attacks
Cataplexy
HypnagognicHallucinations
• Sleep Study Findings–Normal total sleep time –REM @ onset of sleep–Decreased latency
• Highest HLA-disease linkage in medicine
Narcolepsy Somnogram
Obstructive Sleep Apnea
• Periodic apneas due to sleep-related airway obstruction– Large adenoids– Obesity– Not all snorers have OSA
• Daytime Sleepiness in the short-term
• Pulmonary hypertension and right heart failure in the long term
All Sleep Phenomenon can be a Seizure…
• Anything that is recurrent, stereotyped, and inappropriate may be the manifestation of a seizure
• Most often confused with sleep terrors,• More common in the first 2 hours of sleep,
or around 4-6 am. • More common in kids than adults.