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

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1 - 3M

3 - 5M

6-23M

2 - 3Y

3 - 5Y

5 - 9Y

10-13Y

14-18Y

19-30Y

Tot

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rs S

leep

Total Daily Sleep by Age

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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.