Transcript Sleep Disorders

Pediatric Neurology Quick Talks
Sleep Disorders
Michael Babcock
Summer 2013
Scenario
-4 yo boy
-screaming at night
-lasts 30 minutes
-occurs about 2 hours after going to bed
-inconsolable during crying, then falls back asleep
-no bed wetting
-no limb shaking
-eyes closed
-no sedation in the AM
Sleep Screen – BEARS
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B – Bedtime issues
E – Excessive daytime sleepiness
(can exhibit as motor over-activity,
inattentiveness, irritability,
oppositional defiance)
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A – night Awakenings
R – Regularity and duration
S – Snoring
If concerns
– Movements
– Meds
Insomnia
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Onset or Maintenance?
Usually behavioral
Psychosocial
Anxiety (separation)
Depression
Medical problems – chronic pain,
GERD, breathing problems,
medications
Insomnia
• Sleep onset Association
– Prolonged night awakenings
– Child has learned to fall
asleep with Associations
requiring parents – feeding,
rocking, reading; can't selfsoothe.
– Tx – break connection; put
child to be while drowsy but
not asleep.
• Limit-setting subtype
– Older children
– Active resistance to bedtime
– Verbal protests and repeated
demands
– Can manifest as fearful
behavior (crying, clinging)
– Usually due to caregiver
inconsistency with bedtime
rules
– Can have medical underlying
causes – asthma,
medications, sleep disorder –
RLS, anxiety.
– Tx – caregiver enforces rules
Restless Leg Syndrome
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An urge to move legs, usually
accompanied by unpleasant
sensation in legs
These symptoms:
– Begin or worsen during
rest/inactivity
– Relieved by movement
– Occur exclusively or
predominantly in evening
– Not solely accounted for as
symptoms of another
medical/behavioral condition
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Hx – children may have
difficulty explaining this
unpleasant feeling – pain should
not be only feeling.
Differential – Periodic leg
movement disorder – actual leg
movements during sleep without
sensation – this can be due to
other sleep disorders.
Work-up – iron studies
Tx – iron supplementation; off
label use of gabapentin, benzo's,
clonidine, dopamine agonist used
less often in children.
Excessive daytime sleepiness
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A sleepy child may not appear sleepy – can be inattentive,
hyperactive (trying to stay awake), aggressive, disruptive
(sleep-deprived frontal cortex can't regulate emotion)
Insufficient sleep – insomnia
Inadequate sleep hygiene
Medication side-effects
Periodic limb movement disorder
Idiopathic hypersomnia
endocrine/metabolic problems
Narcolepsy
OSA
Narcolepsy
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Narcolepsy
– Excessive daytime sleepiness
– Sleep paralysis
– Hypnagogic hallucinations
– Cataplexy
• Sudden loss of tone
• Precipitated by emotion (laughing, anger)
• REM creep
– Dx – polysomnography, MSLT
Obstructive Sleep Apnea
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Excessive daytime sleepiness
Symptoms – Snoring, with
apneic pauses
But also
– Daytime nasal obstruction
– Mouth breathing
– Trouble eating/meat refusal
– Behavior problems
– Bed-wetting
– Restless sleep
– Sweaty sleep (needs fan on)
– AM headache
– Poor seizure control
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Who has OSA
– 2-3 % of normal
development children have
OSA
– 10% of normal children will
be habitual snorers – don't
have OSA
– 50% of children with Down's
– ~50% in obese children
Why is it bad
– Hypertension, CHF, stroke,
diabetes, difficulty losing
weight.
Parasomnias
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Disorders of Non-REM arousal
– Sleep walking
– Sleep terrors
– Confusional arousals
REM sleep disorders
– Nightmares
– Sleep paralysis
– REM sleep behavior disorder
• Narcolepsy
• SSRI
• neurodevelopmental
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Sleep-related movement disorders
– Rhythmic movement
• infants/toddlers
• Start at sleep onset
• Head rolling/head
banging/body rocking
– Bruxism
– RLS/PLMD
Hypnic starts
– Brief jerks occurring with
falling asleep/awakening
– May have sensation of falling
Non-REM arousal parasomnias
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Usually during first 1/3 of night
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Usually only one event/night
Increased arousals cause increased problems
– OSA, RLS, GERD.
Triggered by sleep deprivation, fever.
Toddler and school-aged kids.
Usually resolve with time
– sleep-walking most likely to persist.
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Not tired the next day
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No stereotypic motor movements
Last 5-30 minutes
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Differential – nocturnal seizures
– Anytime during night, more often
in transition periods
– Last 30 seconds – 5 minutes
– Multiple events nightly
– Daytime seizures
– Daytime irritability/lethargy
– Older age of onset.
Differential – panic attack, GERD.
Dx -home videos, polysomnography
or overnight EEG.
Tx – low dose benzo.
References
-Uptodate articles – pediatric sleep, NREM sleep disorders, parasomnias,
narcolepsy, RLS