Transcript THE HIGH RISK INDIVIDUAL WITH ASTHMA:

Pediatric Sleep Medicine:
A brief overview from A to
Zzzzzz….
Introduction:
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Sleep related upper airway problems are common
in pediatrics
Behavioral sleep problems are also common
Underlying medical and anatomic problems
increase the risk for and severity of these
conditions
Involved testing, incomplete understanding and a
general lack of “evidence” further complicates the
diagnosis and management of pediatric sleep
disorders
Why We Sleep Is Unknown, But A
Good Night Sleep is Important:
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Emotionally
Cognitively
Behaviorally
Performance
Family dynamics
Influence on health
The Biology of Sleep:
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Circadian System:
– Circadian rhythms exist in
all living things
» Sleep-wake cycle is one of
many examples
– Circadian clock is located
in the suprachiasmatic
nucleus (SCN)
» SCN neurons generate and
maintain an oscillating
rhythm via “clock” genes
and their products
The Biology of Sleep:
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The human Circadian rhythm is
slightly longer than 24 hours
and must be set or entrained to
match our daily schedules
Light, physical activity and
melatonin are the most potent
“entrainers” (zeitgebers):
– These can work to favor or
oppose sleep
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In general, when the rhythm is
out of synch with scheduling
demands, Circadian Rhythm
Sleep Disorders are present
The Biology of Sleep:
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The Homeostatic System:
– “Process S” (Sleep drive) is dependent upon the
duration and quality of prior sleep and waking:
» The longer you have been awake, the greater the drive to sleep
and vice versa
– After the main sleep period, the “homeostat” has been
re-set and the drive to sleep is low
– If there is an abnormality of sleep or if sleep is
restricted, then Process S (the drive to sleep) will
remain strong and the individual will be sleepy at
inappropriate times
The Biology of Sleep:
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Ideally the Circadian rhythm and Homeostatic
drive are synchronized and the sleep-wake cycle is
smooth and regular
In general:
– “Circadian rhythm sleep disorders” occur when the
circadian rhythm is desynchronized from the demands
of everyday life
– “Homeostatic or intrinsic sleep disorders” result from
problems with sleep quality, quantity or regulation
Pediatric Sleep:
What is normal?
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Respiration during sleep:
– Quiet and subtle
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Sleep environment:
– Infancy:
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Back-to-Sleep
Safe crib
No co-sleeping
Rooming in for 6-months
No smoking
– Childhood:
» Quiet and comfortable
» No stimulation
» No electronics
General Sleep Hygiene:
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Establish routine:
– Consistent bedtime and
wake up time
– Consistent meals and naps
– Bedtime ritual:
» Transitional objects as
age-appropriate
– Increase exercise:
» Not after dinner though…
– Wind down period:
» Quiet activity
» Soft light
– Sleep charts if needed
Sleep Hygiene:
Is there any hope?
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A large study (n=565) of pre-school children evaluating
the use of healthy media on sleep quality and problems:
– Risk factors for poor sleep include:
» High levels of media use
» Bedtime use of media
» Frightening or violent media content
– In this cohort problems with sleep latency were most commonly
reported
– Substitution of pro-social and educational media in a randomized
study:
» Resulted in fewer sleep problems over an 18-month follow up period
Garrison et al. Pediatrics 2012;130:492-499
Sleep Hygiene:
Is there any hope?
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A small pilot study in adolescents aged 10-18 years:
– F.E.R.R.E.T. intervention:
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Food
Emotions
Routine
Restrict
Environment
Timing
– Short term improvements in sleep hygiene and other outcomes:
» Sleep hygiene scores
» Sleepiness scores
» BMI z-scores
Tan et al. BMC Pediatrics 2012, 12:189
Theme
Rule 1
Rule 2
Rule 3
Food
No food or drink
30 minutes before
bed
Avoid food and
caffeine 3 hours
before bed
No alcohol or
smoking 3 hours
before bed
Emotions
Set a time for
thinking and
planning each day
Wind down and
relax 30 minutes
before bed
Try not to worry,
think or plan while
in bed
Routine
Wake up and go to
sleep same time
each day
Turn lights on
when you wake,
Dim lights before
bed
Keep the same
sleep routine each
day
Restrict
No electronics 30 No exercise 3
minutes before bed hours before bed
Bed is for sleeping
only
Environment
Comfortable bed
clothes and bed
Light, temperature
and noise
Keep clocks faced
away from bed
Timing
Sleep for the
recommended
amount of time
Remember 30
minutes and 3
hours
Try to stick to the
rules
Tan et al. BMC Pediatrics 2012, 12:189
Pediatric Sleep:
What is normal?
Typical sleep requirements throughout childhood:
Age group
Infants
Toddlers
Preschoolers
School-aged
Adolescents
Age
3 to 12 months
1 to 3 years
3 to 5 years
6 to 12 years
12 to 18 years
Sleep need
14-15 hours
12-14 hours
11-13 hours
10-11 hours
8.5-9.5 hours
Meltzer and Mindell Psychiatr Clin N Am (2006) 1059-1076
Pediatric Sleep:
What is normal?
Typical patterns of daytime sleep throughout childhood:
Age group
1 week
1 month
3 months
6 months
9 months
12 months
18 months
2-3 years
Daytime Sleep
8 hours
7 hours
5-6 hours
3-4 hours
2.5-3.5 hours
2-3 hours
2 hours
1-2 hours
Most children eliminate regular daytime naps between the age of 3-5 years
How much sleep are American
children and adolescents getting?
Age Group
Recommendation
Infants (3-11 mo)
Toddlers (12-35 mo)
Preschoolers (3-6 yr)
School age (1st-5th grade)
Adolescents (6th-12th grade)
14-15 h
12-14 h
11-13 h
10-11 h
9.25 h
Study Finding
12.7 h
11.7 h
10.3 h
9.5 h
7h
From the “Sleep in America Polls” 2004 & 2006
Adolescents Living the 24/7
Lifestyle:
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Real world assessment of adolescent (n=100, aged 12-18
years) technology and caffeine use:
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66% had television in bedroom
30% had a computer in the bedroom
90% had a cell phone
79% had an MP-3 player
85% with caffeine intake
Self-reported activities after 9PM:
– Watching TV
– Text messaging
“On average, adolescents engaged in 4 technology activities
after 9M”
Calamaro et al. Pediatrics 2009;e1005-e1010
Adolescents Living the 24/7
Lifestyle:
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Multi-tasking was associated with worse sleep and daytime
consequences:
– 20.6% of the cohort obtained 8-10 hours of sleep per night
– 33% of the cohort reported falling to sleep at school
– More multi-taking was associated with lower sleep times and
higher caffeine intake
» Television in bedroom did not correlate with sleep time
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Caffeine intake:
– Timing was skewed to impair sleep:
» 6-8AM
» 3-5PM
» 6-8PM
18.7%
25.3%
21.3%
Calamaro et al. Pediatrics 2009;e1005-e1010
Pediatric Sleep Disorders:
A working list
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Normal sleep:
– Developmental evolution throughout childhood
– Usually defined by satisfied parents!
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Behavioral sleep disorders:
– Developmental evolution throughout childhood
– Overlap syndrome with influence of cultural and societal norms
– Usually defined by dissatisfied/frustrated parents!
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Parasomnias or Transitional Disorders:
– Developmental evolution throughout childhood
– Usually defined by frightened parents!
Pediatric Sleep Disorders:
A working list
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Breathing disorders during sleep:
– Broad spectrum of clinical syndromes and presentations
– A number of common manifestations
– Parents may be unaware of concerning symptoms!
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Neurological disorders:
– Less common in general
– Children with special healthcare needs can be very
challenging
Components of a Pediatric Sleep Evaluation:
“BEARS”
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Mnemonic for:
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Bedtime
Excessive Daytime Sleepiness
Awakenings
Regularity
Snoring
Based on the four most common symptoms of
pediatric sleep disorders:
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Difficulty with sleep onset
Problems that disrupt sleep
Inability to awaken from sleep at the desired time
Daytime sleepiness
Rosen, GM: “Case-Based Analysis of Sleep Problems in Children” in Principles and Practice
of Pediatric Sleep Medicine
Common Non-Respiratory Sleep
Problems: A working list
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Sleep talking
Bruxism
Night terrors
Rhythmic movements
Behavioral insomnia of childhood
Confusional arousals
Sleepwalking
Nightmares
Insomnia
Delayed Sleep Phase
Restless Leg Syndrome
Narcolepsy
Adapted from: Moore, M et al.: CHEST 2006; 1252-1262
Age Distribution of Common NonRespiratory Sleep Problems:
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Infant & Toddler (1-2 yrs):
– Behavioral Insomnia of Childhood
– Rhythmic Movements
Preschool (3-5 yrs):
– Behavioral Insomnia of Childhood
– Rhythmic Movements
– Sleep Terrors
School age (6-12 yrs):
– Insufficient Sleep
– Bedtime Resistance
– Sleep-Walking
Adolescence (13-18 yrs)
Adapted from: Moore, M et al.: CHEST 2006; 1252-1262
– Insufficient Sleep
– Delayed Sleep Phase
– Narcolepsy
Unique Aspects of Pediatric Sleep in
Otherwise Healthy Infants and Children:
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Another working list:
– Delayed Settling
– Trained Night Feeder
– Trained Night Awakening
– Developmental Night Awakening
– Prolonged Routines
– Curtain Calls
– Bedtime Fears
– Parasomnias
Management of these “problems” is facilitated by a good
understanding of normal childhood development and
confident supportive parenting skills
Night Terrors:
Parent is terrified
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Slow Wave Sleep:
– Usually in the first or
second cycle of sleep
– Incidence ~5%, may be
familial
– Rare before 18-24 mo
– Can cluster
– Self resolve by 8-10 yrs
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Child is asleep:
– Sympathetic output:
» Sweating, thrashing,
screaming
– Child has no memory of the
event
Night Terrors:
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Management:
– Reassure parents:
» No need to awaken child
» Safety
» Avoid secondary gain
– Phase shift:
» Afternoon nap to decrease
Stage 3 sleep
» Awaken 1 hour into sleep
– I do not favor medications:
» Benzodiazepines
Nightmares:
Child is terrified
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Occur during REM
periods:
– Latter part of the night
– Most common in
preschoolers:
» Learning about the “hard
knocks” of life
» Stress and other
disruptions to routine
– Child awakens and should
remember dream:
» Child is frightened
Nightmares:
Child is terrified
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Simple management:
– Reassurance
– Bedtime ritual and security
object to prepare for good
dreams
– Brief intervention in child’s
room
– Avoid secondary gain
– I do not favor medications
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Complex management:
– Counseling
– Prazosin
– Relaxation
Select features of Nightmares and
Night Terrors:
Night Terrors:
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Sudden onset
Autonomic nervous system
activity
Behavioral manifestations
of fear
Difficulty arousing the child
Confusion upon awakening
Amnesia of the episode
Dangerous behaviors
Nightmares:
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Recurrent episodes
Recall of a disturbing dream
Various emotions, but none
will be good
Full awakening and alerting
Recall is good
Delayed return to sleep
Episodes occur in the latter
half of the sleep period
Adapted from: ICSD 2nd ed: Diagnostic and Coding Manual. AASM; 2005
Behavioral Insomnia of Childhood:
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Behavioral Insomnia of Childhood:
– Bedtime resistance
– Frequent night time awakenings
– 10-30% of infants and toddlers
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Sleep-onset association type:
– Certain conditions must be met to facilitate sleep
– Positive associations:
Self comfort
– Negative associations:
External stimuli
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Limit setting type:
– Bedtime stalling or refusal
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Combined type
Behavioral Insomnia of Childhood:
Sleep-onset association type:
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Falling asleep is an extended
process
Falling asleep requires special
conditions
When conditions are not met,
sleep latency is prolonged and
sleep is disrupted
Nighttime awakenings require
caregiver intervention
Limit-setting type:
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Difficulty with sleep initiation and
maintenance
Stalling and refusal to go to bed or
return to bed after nighttime
awakening
Caregiver cannot set limits to
establish sleep hygeine
Adapted from: ICSD 2nd ed: Diagnostic and Coding Manual. AASM; 2005
Behavioral Insomnia of Childhood:
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General treatment principles:
– Not particularly evidence-based
– Sleep hygiene:
» Bedtime routine
» Learn self-soothing
– Extinction/Graduated extinction:
» Ignore the behavior until it is extinguished:
 Extinction burst
– Learning about limits:
» Parenting skills
» Bedtime fading
Prolonged Routines and Curtain Calls:
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May be a phase shift or limit setting issue:
– Manage limits and increase daytime attention in general
– Involve child in the plan
– Parents need to “be strong:”
» No escalation: Lead quietly back to bed
– Reward positive behaviors:
» Extra story the next night
» Other systems
– Physical barriers if needed:
» Gates, locks
» Parent sits outside door
Insufficient Sleep:
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Sleep deprivation:
– De-emphasis of sleep due to other commitments
– Cumulative sleep debt results in:
» Fatigue, mood changes, illness
» School tardiness
» Falling asleep in school
– Sleepy driver accidents or fatalities
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Clinical clues:
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Needing to be awakened for school
Sleeping 2 hours or more on weekends and vacations
Falling asleep at inappropriate times
Behavior and mood differ after getting adequate sleep
Delayed Sleep Phase Syndrome:
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Circadian rhythm disorder with delayed sleep-wake times:
– 2 or more hours
– Interfering with daily schedules activities (school)
– Most common in adolescents
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Night owl syndrome:
– Inability to fall asleep at “normal” time
» Bedtimes of 0200-0300
– Sleep onset/efficiency and quality are normal at this shifted time
– Treatment is difficult:
» Chronotherapy—phase advancement or phase delay
» Melatonin to advance the circadian clock
» Light therapy
The Spectrum of Pediatric Sleep
Disordered Breathing:
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Central Sleep Apnea Syndromes:
– May or may not be developmental
– CNS Disorders
Hypoventilation Syndromes:
– Congenital Central Hypoventilation Syndrome
– Neuromuscular
Respiratory Dysrhythmia Syndromes:
– May be developmental
– CNS Disorders
Awake respiration may or may not be normal
Laboratory studies may actually be helpful
The Spectrum of Pediatric Sleep
Disordered Breathing:
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Airway Obstructive Syndromes
A number of conditions which are possibly
interrelated:
– Primary snoring
– Upper airway resistance syndrome
– Obstructive sleep apnea syndrome
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All three are manifest by snoring
Respiration during wakefulness usually normal
Routine laboratory studies not generally helpful
Primary Snoring:
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Defined as snoring in the absence of apnea, gas
exchange abnormalities or arousals
Snoring is a common “symptom:”
– Up to 10% of children snore regularly
– The majority have Primary Snoring
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Consequences of Primary Snoring are unclear:
– No evidence of progression to OSA…
– Some developmental consequences are proposed
– No treatment is currently recommended
“He snores just like his father!”
Maybe that is not so cute…
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A large cohort study (n=249 parent-child pairs)
evaluated snoring in preschool children:
– Parental report of loud snoring more than twice weekly
that was absent (no snoring), transient (snoring at age 2
but not age 3) or persistent (snoring at both ages):
» Non-snorers:
68%
» Transient snorers:
23%
» Persistent snorers:
9%
Beebe et al.: Pediatrics 2012;130:382-389
“He snores just like his father!”
Maybe that is not so cute…
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Risk factors for snoring:
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Higher BMI
Pre and post natal tobacco smoke exposure
African American race
Lower parental education and family income
Absent or shorter duration of breast feeding
Persistent snoring was associated with adverse behavioral
and developmental outcomes:
– Behavioral:
» Hyperactivity
» Depression
» Attention
Beebe et al.: Pediatrics 2012;130:382-389
Upper Airway Resistance Syndrome:
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Defined as a syndrome of snoring and prolonged
partial upper airway obstruction:
– Repetitive episodes of increased work of breathing that
leads to arousal:
» Diagnosed by polysomnogram with evidence of increased
work of breathing (paradoxical breathing) and arousal
– Apnea, hypopnea and gas exchange abnormality are
generally absent
– Treatment options are the same as those for obstructive
sleep apnea syndrome
Obstructive Sleep Apnea Syndrome:
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A syndrome occurring during
sleep characterized by:
– Obstructive apnea
– Partial upper airway
obstruction
– Hypoventilation
– Hypoxemia
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Incidence thought to be 1-3% of
all children:
– Up to 40% of specialty
referred patients with snoring
Obstructive apnea with desaturation
Obstructive Sleep Apnea:
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Imbalance of forces:
– Airway opening and
closing pressures
– An imbalance between
these forces balance
due to anatomic or
neuromuscular factors
results in inappropriate
airway closure
– Retropalatal
– Retroglossal
Katz, ES: Proc Am Thorac Soc Vol 5, 2008
Approaching the Patient with Possible
Sleep Disordered Breathing:
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Sleep & Developmental History
Co-existing conditions
Physical Examination:
– Growth parameters
– Upper airway anatomy and
patency
– Heart sounds
– Chest wall configuration
– Awake gas exchange
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Potential testing:
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Chest and airway/neck films
ECG
Blood tests are usually normal
Specialized testing
Rating tonsil hypertrophy
Adenotonsillar Hypertrophy:
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Most common “cause” of
OSA in children
Most prevalent in young
school age children:
– Related to normal lymphoid
hyperplasia ages 2-6 years
– Tonsil and adenoid size
related to severity but not
presence of OSA
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Most common reason for
referral to our lab
Diagnosis of Obstructive Sleep Apnea
Syndrome:
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Literature supports the benefits of early diagnosis
and treatment
Obstructive sleep apnea cannot be diagnosed
based upon history and physical exam alone:
– Sleep history should be obtained
– Screen for symptoms of OSA
– Physical examination features
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Polysomnography is the “gold standard:”
– Expensive, but cost-effective when used correctly
Symptoms of Pediatric Obstructive Sleep
Apnea Syndrome:
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Nocturnal:
– Symptoms correlate with severity:
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Snoring
Labored breathing
Sweating
Restless sleep
Unusual sleep position
Enuresis
Normal breathing during sleep in a child should
be a subtle finding!
Symptoms of Pediatric Obstructive Sleep
Apnea Syndrome:
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Daytime:
– May be absent
– Mouth breathing
– Nasal obstruction
– Hyponasal speech
– Increased attention being given
to neurobehavioral aspects of OSA:
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Attention problems
Learning problems
Behavior problems
Hyperactivity
Mouth breathing in
adenoidal hypertrophy
Complications of Pediatric Obstructive
Sleep Apnea Syndrome:
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Growth related:
– Failure to thrive reported:
» Increased work of
breathing
» Decreased growth
hormone secretion
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Cardiopulmonary:
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Pulmonary hypertension
Cor pulmonale
Systemic hypertension
Right or left ventricular
hypertrophy
Treatment of Pediatric Obstructive Sleep
Apnea Syndrome:
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Healthy children:
– Adenotonsillectomy is
usually curative:
» Post-operative risk factors
well documented
– Mild OSA:
» Intranasal Steroids
» Montelukast
» Antihistamines
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Other items to address:
– Chronic or allergic rhinitis
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Co-morbidities:
– Obesity
– Asthma
Tonsillar hyperplasia and infection
Adenoid size (adenoidal/nasopharyngeal ratio) significantly
decreased with montelukast.
Goldbart A D et al. Pediatrics 2012;130:e575-e580
©2012 by American Academy of Pediatrics
Montelukast treatment resulted in a significant improvement in the
OAI. The pretreatment average of 3.7 ± 1.6 before (pre) dropped to 1.9
± 1.0 after (post) treatment; P < .05.
Goldbart A D et al. Pediatrics 2012;130:e575-e580
©2012 by American Academy of Pediatrics
Treatment of Pediatric Obstructive Sleep
Apnea Syndrome:
– Nasal mask ventilation:
» CPAP/BiPAP®
» Can be implemented
post-operatively if
needed
– Supplemental oxygen:
» Use with caution
– Devices:
» Not well studied
Efficacy and safety unknown…
Recently Updated Clinical Practice
Guideline:
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Clinical practice guideline: Diagnosis and Management of
Childhood Obstructive Sleep Apnea Syndrome:
– www.pediatrics.org/cgi/doi/10.1542/peds2012-1671
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All children should be screened for snoring
PSG should be performed for snoring and symptoms/signs of OSAS
Adenotonsillectomy is recommended as first-line treatment of patients
with ATH
High risk patients should be monitored as inpatients post-operatively
Patients should be re-evaluated post-operatively
CPAP is recommended
Weight loss is recommended
Intranasal corticosteroids are an option in mild OSAS
The diagnosis and management of
pediatric sleep disorders is important!
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A large (~11,000) cohort study evaluated sleep disordered
breathing (SDB) and behavioral sleep problems (BSP) in
children:
– SDB defined by:
» Snoring, Witnessed apnea, Mouth breathing
– BSP defined by:
» Evaluation of sleep behaviors
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“A history of either SDB or BSP in the 1st 5-yrs of life was
associated with the need for SEN at 8 yrs of age. Findings
highlight the need for pediatric sleep disorder screening”
Bonuck et al.: Pediatrics 2012;130:634-642
Some Final Thoughts:
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Sleep disordered breathing
common in pediatrics:
– OSA is just one example
– Many underlying medical
conditions can affect sleep
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Behavioral sleep problems
are also common:
– Treatment can be
challenging
– Sleep hygiene is critical
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Important outcomes
require clarification
Lean CPAP Patient