Daniel Erichsen, MD, FAAP 10/25/2011. Pediatric Sleep Clinic The function(s) of sleep ...
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Transcript of Daniel Erichsen, MD, FAAP 10/25/2011. Pediatric Sleep Clinic The function(s) of sleep ...
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Daniel Erichsen, MD, FAAP 10/25/2011
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Pediatric Sleep ClinicThe function(s) of sleepConsequences of sleep loss
Obstructive sleep apneaDivision of Peds Sleep
What’s going on?
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Thursday AM sessionPatients
2 – 26 y▪ Sleep-disordered breathing▪ Insomnia▪ Hypersomnia▪ Restless legs ▪ Parasomnias
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+ Facesheet Plz
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Pediatric Sleep ClinicThe function(s) of sleepConsequences of sleep loss
OSA Insufficient sleep
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Born Sävsjö 1600
1620s Captain Dutch West India Company New Netherlands
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Jonas Bronck Navigates up East River in De Brant Van
Troyen (The fire of Troy) Purchases land north of Harlem River▪ South of 150th st
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South of 150th Jonas Bronk’s land
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South of 150th Jonas Bronck’s land -> Bronck’s land
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South of 150th Jonas Bronck’s land -> Bronck’s land -> Broncksland
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South of 150th Jonas Bronck’s land -> Bronck’s land -> Broncksland -> Bronx
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1/3 of your life
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Eating Energy supply
Talking Communication
Sex Reproduction
Sleep ???
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Sleep No food gathering No reproduction Easy pray
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Why do we sleep?How important is sleep?
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Important functions conserved How conserved is sleep? How important is sleep?
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Lungs Max 7 minutes submerged
Lives in water Emerges 4-6 weeks/year
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Land Synchronized slow EEG activity entire
brain and eyes closed night. Asynchronized fast EEG activity entire
brain and eyes open day.
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Sea Right hemisphere synchronized slow
activity with left eye closed. Left hemisphere asynchronized fast
activity with right eye open.
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All species studied have sleep or sleep equivalent Fish Insects Bacteria
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Complete sleep deprivation Hyperphagia Hyperthermia Autonomic dysregulation Loss of fur Death
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90 practice tasks-> 8 hr break -> 300 testing tasks Group 1 – Awake 11 am -> 7 pm Group 2 – Awake 11 pm -> 7 am Group 3 – Sleep 11 pm -> 7 am
Outcome % subjects gained “insight”
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None gained “insight” after first 90 tasks
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% gained “insight” after 300 test tasks
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Consolidation of declarative memory
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1 hr learning session -> 12 hr break -> 1 hr testing session Group 1 – Slept 3 hrs Group 2 – Slept 8 hrs Group 3 – Awake daytime Group 4 – Awake nighttime
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Outcome Improvement in speed of correct answer Decrease in milliseconds
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Results
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Consolidation of procedural memory
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Slow wave, “deep”, sleep Consolidation of declarative memory
REM sleep Consolidation of procedural memory
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Memory consolidation
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Single neuron recordingZebra Finch
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Record singing
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New song
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Memory consolidation may occur 2nd to reactivation of neural pathways in sleep
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Memory consolidation
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Corresponding 15% reduction overall metabolism
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Corresponding 15% reduction overall metabolism Is energy conservation a function of
sleep?
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Vulnerable species Squirrels Mouse birds Humming birds
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Vulnerable species Squirrels Mouse birds Humming birds
▪ Several degrees sleep drop
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Further decrease in unfavorable conditions Willow Tit Parid species
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Memory consolidationEnergy conservation
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Is it more dangerous to be asleep or awake?
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Meddis 1975Nocturnal animals
Large eyes Large pupils Tapetum Heightened hearing/smell
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How minimize risk for diurnal animal (human) being preyed upon by nocturnal predator (python)?
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How minimize risk for diurnal animal (human) being preyed upon by nocturnal predator (python)? 8 hour blackout
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Memory consolidationEnergy conservationDecreased predation risk
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Input of data daytime -> Storing as new synapses or
strengthening of synapses -> increased space and energy demand
of brain
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Input of data daytime -> Storing as new synapses or
strengthening of synapses -> increased space and energy demand
of brain If not interrupted▪ -> exhaustion of energy/space▪ No capacity for new memory
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Brain taken “off line” during sleep Synapses eliminated Selective weakening/strengthening
synapses
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Memory consolidationSynaptic maintenanceEnergy conservationDecreased predation riskMetabolic functions
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Memory consolidationSynaptic maintenanceEnergy conservationDecreased predation riskMetabolic functions
Sleep loss may have several consequences
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Affects 2-4 % of childrenRelated to
Tonsillar/adenoidal hypertrophy Obesity
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Pathophysiology Repetitive complete (apnea) or partial
(hypopnea) upper airway obstructions during sleep resulting in arousals and/or desaturations.
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AHI Apneas + Hypopneas per hour of sleep▪ <2 normal▪ 2-5 mild OSA▪ 5-15 moderate OSA▪ >15 severe OSA
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Symptoms Respiratory▪ Snoring▪ Choking▪ Apneas
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Symptoms Neurocognitive▪ Sleepiness▪ Inattentiveness ▪ Poor academic performance
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Symptoms Hormonal▪ Nocturia▪ Obesity?
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History Focus on nighttime respiratory
symptoms and daytime neurocognitive impairment
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Work up In lab, attended polysomnogram gold
standard
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Treatment T&A▪ Medical treatment for mild or residual OSA ▪ Positive airway pressure therapy▪ Mandibular advancement device▪ Maxillary expanders▪ Weight loss
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8 y.o boy Snoring Choking in sleep
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8 y.o boy AHI 6.5 Recommended T&A
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Snoring -> Upper airways resistance syndrome -> Hypopneas -> Obstructive apneas (OSA)
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Snoring -> Upper airways resistance syndrome -> Hypopneas -> Obstructive apneas (OSA)
Snoring in itself has health implications
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Compared to non snoring children Snoring children perform worse on
measures of:▪ Attention span▪ Social problems▪ Overall cognitive abilities▪ Visuospatial functions
O’brien et al. Pediatrics 2004 Guilleminault. Eur. J. Pediatrics 1982 Kennedy. Ped. Pulm 2004
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Neurocognitive effects Snoring at age 2 to 6 is associated with
worse academic performance at age 13 to 14.▪ Gozal. Pediatrics 2001
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297 1st grader with lowest 10th grade percentile surveyed for OSA
All underwent sleep study
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Prevalence 54 (18%) had OSA▪ 24 elected to have T&A▪ 30 elected not to have T&A
66 had primary snoring 177 had normal breathing
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Grades 1 year later compared OSA and T&A group OSA no T&A group Primary snoring Normal controls
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Associated with Increased risk of cardiovascular events Strong association with Diabetes Mellitus
II Increased risk of MVH Endothelial dysfunction (peds) Autonomic dysregulation (peds)
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How well do we comply with guidelines?
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Chart review study St. Barnabas Hospital Adult Outpatient service
n=1049 Snoring Respiratory symptoms in sleep Insomnia symptoms
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Results
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Results
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Results
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Results
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Chart review study St. Barnabas Hospital Pediatric Outpatient service
n=1026 Detected snoring Specific screening for snoring
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Results
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Results
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Results
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Fluid shifts during sleep Neck engorgement / decrease calf
diameter? Role in pediatric OSA
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24 hour hunger profile Circadian variation in hunger scale Obese vs nonobese Change in hunger scale with caloric
intake
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Smartphone app Monitor leg movements in sleep Screening Treatment efficacy