Z Z Z Z Pediatric Sleep Disorders Craig

Z Z Z Z. . . Pediatric Sleep Disorders Craig T. Nakamura, M. D. 1

People who say they sleep like a baby usually don't have one. -- Leo J. Burke 2

TODAY’S OBJECTIVES: -- background -- obstructive sleep apnea -- sonambulism (sleep walking) -- night terrors -- sleep hygiene -- prevent everyone from falling asleep 3

Animal Sleep Times Brown Bat 20 hours / day Tiger 16 hours / day Ferret 14. 5 hours / day Platypus 14 hours / day Cat 12 hours / day Dog 10. 5 hours / day Pig 8 hours / day Cow 4 hours / day Giraffe 2 hours / day Infant 16 hours / day Adult 8 hours / day Elderly 5. 5 hours / day Peds Pulmonologist 4 hours / day 4

Average Sleep Times By Age AGE: 1 week 1 month 3 months 6 months 9 months 12 months 18 months 2 years 3 years 4 years 5 years 7 years 9 years 10 years 13 years 16 years 18 years Night Sleep (hours): 8. 25 8. 5 9. 5 10. 5 11. 0 11. 25 11. 0 10. 75 10. 25 10. 0 9. 75 9. 25 8. 25 Day Sleep (hours): 8. 25 7. 0 5. 5 3. 75 3. 0 2. 5 2. 0 1. 5 1. 0 5

Fatigue by State TOP TEN: 1. West Virginia 2. Tennessee 3. Kentucky 4. Oklahoma 5. Florida 6. Missouri 7. Georgia 8. Alabama 9. Mississippi 10. Louisiana Courtesy of the Perelman School of Medicine at the University of Pennsylvania 6

Sleep Disturbance by State Courtesy of the Perelman School of Medicine at the University of Pennsylvania 7

“Paying the Mortgage” • Insufficient sleep debt (eventually must be “repaid”) • affects immunity • also nervous system • important for cycling of growth hormone • In adults, ↑ rate of automobile accidents by 3 x 8

Sleep in Children 9

Sleep Induced Changes Sleep impairs ventilation in all children (sick or healthy): -- normal -- underlying respiratory illness -- CNS disease -- obstructive sleep apnea 10

Sleep Disorders in Children • If diagnosed and treated early, morbidity can be avoided • Therefore, important to recognize signs of sleep-disordered breathing: a) primary care providers b) teachers c) parents d) local postman 11

Sleep Stages 12

Sleep Stages 5 phases of sleep stages 1, 2, 3, 4, REM sleep 50% stage 2 20% REM sleep 30% the other 3 stages progresion from stages 1 to REM ~ 90 to 110 min / total cycle then cycle starts again 13

Stage 1 Sleep light sleep drift in and out eyes move very slowly muscle activity slows when awaken, recall fragmented visual images sense of falling muscle contractions 14

Stage 2 Sleep eye movements stop brain waves become slower occasional bursts called sleep spindles 15

Stages 3 & 4 (Deep) Sleep no eye or muscle movements when awakened, groggy, disoriented bedwetting, night terrors, sleep walking Stage 3: extremely slow (delta) brain waves with smaller faster waves Stage 4: delta waves 16

REM Sleep rapid, irregular breathing eyes jerk rapidly limb muscles temporarily paralyzed heart rate & BP ↑ bizarre / illogical dreams first cycle 70 to 90 minutes penile erections HEH. HE SAID, ERECTION. 17

Obstructive Sleep Apnea 18

Apnea: Greek word meaning “want of breath” 19

Obstructive Sleep Apnea Syndrome (OSAS) First described in 1965 Disorder of breathing during sleep characterized by prolonged partial and / or intermittent complete upper airway obstruction that disrupts normal ventilation and patterns during sleep. 20

Obstructive Sleep Apnea • adults: cessation for > 10 seconds • children: cessation for 2 ½ missed breaths • with apneas, oxygen levels ↓, carbon dioxide levels ↑ • also causes arousals and fragmented sleep 21

Obstructive Sleep Apnea • prevalence ~ 2% • affects millions • M = F • more common with family history of OSAS • ↑ in African Americans • ↑ in children with chronic respiratory tract infections 22

Obstructive Sleep Apnea • ↑ in children 2 - 6 years of age • same age of adenoidal & tonsillar hypertrophy • continues through adolescence (especially with craniofacial anomalies, neurologic disorders, obesity) 23

Obstructive Sleep Apnea • due to upper airway collapse • can be due to: – anatomic factors – abnormal neuromuscular tone – both • worse in REM sleep 24

OSAS: etiologic factors • obesity • craniofacial disorders esp. mid-face hypoplasia • micrognathia ie. Pierre-Robin • other -- Crouzon synd -- Down synd -- Duchenne’s MD -- Arnold Chiari malf -- hypothyroidism -- sickle cell anemia -- mucopolysaccharidosis -- Aperts synd -- Achondroplasia -- cerebral palsy -- Prader-Willi synd -- choanal stenosis 25

Obstructive Sleep Apnea: History • predominant symptoms -- snoring -- labored breathing -- daytime somnolence -- difficulty in school • important to ask about snoring, snorting, noisy breathing (gasping, grunting) • note: parents frequently don’t volunteer this information 26

Other Historical Findings: • labored breathing, retractions, paradoxical chest wall motion • observed apneas • restless sleep • diaphoresis • enuresis • cyanosis • unusual positions seated or neck hyper-extension • daytime neurobehavioral abnormalities ADHD or sleepiness • morning headaches from hypercapnia 27

OSA Findings • hypertension -- systemic -- pulmonary • failure to thrive • adenoidal facies • nasal obstruction • mouth breathing • hyponasal speech • tongue size • tonsils size • soft palate size and shape 28

Obstructive Sleep Apnea • gold standard nocturnal full, observed polysomnogram (sleep study) • rarely, multiple sleep latency test (MSLT) • other studies much less helpful -- audiotapes -- nocturnal videotaping -- overnight pulse oximetry -- nap sleep study (1 hr) • re-testing after T&A essential (~ 6 week post-op) 29

Obstructive Sleep Apnea • questionaires to 7 th and 8 th graders • 1, 588 questionaires • top 25% [HP] and bottom 25% [LP] • frequent / loud snoring: 5 % HP / 13% LP • Prior tonsillectomy / adenoidectomy: 7 HP / 24 LP (3. 4 odds ratio) • Conclusion: children with lower academic performance ↑ snoring and more likely to require T&A. “A learning debt that may hamper future performance” Gozal D et al. Pediatrics. 2001; 107(6): 1394 -1399. 30

Obstructive Sleep Apnea • 297 first graders in lowest 10 th percentile • sleep studies to assess for sleep-associated gas exchange abnormalities [SAGEA] • SAGEA identified in 54 (18. 1%) • encouraged to Rx • 24 underwent T&A [T&A] • in T&A group, improvement by 0. 5 • no change in non-T&A group & those in top 90 th percentile Gozal D et al. Pediatrics. 1998; 102(3 pt 1): 616 -620. 31

Obstructive Sleep Apnea Conclusion: SAGEA is frequently present in poorly performing 1 st grade students in whom it adversely affects learning performance. The data suggest that a subset. . . could have SAGEA and may benefit from prospective medical evaluation and treatment. Gozal D et al. Pediatrics. 1998; 102(3 pt 1): 616 -620. 32

Obstructive Sleep Apnea • surgical treatment – adenotonsillectomy adenoids can reappear – uvulopalatopharyngoplasty (UP 3) – rarely tracheostomy – occasional recurrence • otherapies – CPAP – Bi. PAP – lifestyle changes (ie. weight loss) 33

Primary Snoring in Children ZZZZZ! 34

Primary Snoring • snore – a noise produced when breathing in (vibrates soft palate and uvula) • snoring without sleep apneas • 20% of normal children snore occasionally • 7 - 10% snore every night • OSAS only ~ 2% of snorers 35

Primary Snoring • differs from primary snoring • OSAS associated w/ complications • primary snoring – 10% of children – not associated with OSA, arousals, or gas exchange abnormalities 36

Primary Snoring • study on 1, 144 3 rd grade school children • snoring shown to be associated with poor academic performance in math and spelling in 3 rd grade school children Urschitz MS et al. Am J Respir Crit Care Med. 2003. 37

Central apneas Sudden infant death syndrome (SIDS) 38

Sleepwalking (somnambulism) 39

Somnambulism • typically pre-pubertal children • highest 11 -12 years old (17%) • can last into adulthood • genotyping • walking or moving during sleep • potential for harm 40

Somnambulism • difficulty arousing • can be triggered by sleep disorder • amnesia following • first 3 rd of sleep episode • slow wave sleep (stages 3 or 4) 41

Somnambulism • get plenty of sleep • develop calming bedtime ritual • remove hazardous materials • ground floor if possible • reduce open windows • occasionally hypnosis • benzodiazepines • Topamax? 42

Night Terrors 43

Night Terrors • sudden arousal from slow wave sleep (stage 3 or 4); 1 st third of p. m. • intense terror cry followed by autonomic changes • tachycardia • partial or total amnesia • can occur nightly 44

Sleep Hygiene 45

Sleep Hygiene – habits / behaviors • stimulants caffeine: coffee, tea, colas, cocoa, chocolate, medications nicotine • exercise -- generally helpful -- avoid within 6 hours of bedtime 46

Sleep Hygiene – habits / behaviors • alcohol slows brain waves initially, but disrupts sleep later (↓ REM sleep) avoid within 4 – 6 hours of bedtime 47

Sleep Hygiene • environment comfortable bed, dark & quiet room mask / earplugs if necessary minimize changes • diet heavy meals before disrupts light snack can help, especially milk and other dairy products (tryptophan) 48

Sleep Hygiene • regular schedule • reduce stress • avoid long daytime naps • reduce stimuli • avoid clock-watching • designate worry time 49

Sleep Hygiene helpful tips: • sleep only when drowsy • if unable to sleep, leave & return when sleepy • maintain regular waking time • limit bedroom activities • avoid / reduce naps – limit to less than 1 hour – no later than 3 p. m. 50

Signs of problems • too much time needed to help child fall asleep • child wakes repeatedly • behavior & mood are affected • parents also lose sleep • parent-child relationship starts to suffer 51

Three common problems • sleep-onset association disorder ie. child requires rocking • night-time eating / drinking disorder ie. frequently awakens for feeds • limit-setting problems ie. refusing to go to bed or stalling children can get pretty creative 52

Sleep Hygiene in Children • bedtime preparation can reduce anxiety • 10 to 30 minutes of “special time” before bed • should not be stimulating – ie. no wrestling or scary stories • don’t extend length of “special time” 53

YAWN FACTS: - unknown cause - possible boredom color test bar pattern 5. 8 yawns / min “MTV-like” video 3. 4 yawns / min -- lasts six seconds -- heart rate ↑ 30% -- 55% yawn within 5 min of seeing someone else -- the blind yawn after hearing someone else -- reading about yawning stimulates yawning -- fetuses yawn -- olympic athletes often yawn before competing 54

THE END 55