ObjectivesObjectivesOutline normal developmental

changes in sleep from infancy through adolescence

Describe the causes of daytime sleepiness affecting children

Outline the clinical evaluation of daytime sleepiness in children and adolescents

Young Children Sleep A Young Children Sleep A LotLotBy age 2y, average child has spent

9500 h (approx. 13 months) asleep vs 8000 h awake

Between 2-5 y, time asleep = time awake

In school-age children, sleep occupies 40% of the 24 h day

Sleep is the primary activity of the brain during early development

Appropriate Duration of Sleep Appropriate Duration of Sleep by Ageby Age

RealityReality

Sleep Dysfunction In Sleep Dysfunction In ChildrenChildren

Insufficient SleepSleep deprivation

Fragmented SleepSleep disruption

Excessive Daytime Sleepiness

Primary Disorders of EDS

Sleep in NewbornsSleep in Newborns

3 sleep states in term newborns: active, quiet and indeterminate; enter sleep thru active (REM)

Total sleep time: 16-20 hours/day with equal amounts day and night

Sleep episodes 3-4 hours/1-2 hours awake; breast fed-more frequent wakings

Sleep in InfantsSleep in InfantsCritical sleep reorganization at 8-

12 weeks; establish diurnal cycleDevelop NREM sleep by 6

months; decreased REMAt 6 months: TST is 13-14 hours;

sleep episodes 6-8 hours70-80% sleep through the night at 9 months

Sleep in ToddlersSleep in Toddlers

Total sleep time – 12-14 hoursMost give up second nap at 1 yearDevelopmental issues: separation

anxiety→nightime fears, mastery of independent skills→power struggles

Sleep problems common-20-40%Importance of bedtime routines,

transitional objects

Sleep in Pre-SchoolersSleep in Pre-SchoolersTST-11-12 hours/dayMany give up regular daytime

nap by age 4-5 yearsSignaled night wakings occur

frequently; role of parental reinforcement

Sleep problems may become chronic

Sleep in School Age Sleep in School Age ChildrenChildrenTotal sleep time 9-11 hours

◦10-11 hours in 6-7 y.o. ↓9.5 hours in adoles.

Stable sleep pattern night to nightLow level of daytime sleepiness

◦Rare naps◦Some have prolonged sleep latency

Increasing pressure from schedule◦Earlier wake times, later bedtime

from school work/activities

Sleep Changes in Sleep Changes in AdolescenceAdolescenceDelayed sleep onset

◦Circadian: relative phase delay at puberty

◦Environmental factors-music, computer, work

Advanced wake times (sleep offset)◦Earlier school start time

Decreased sleep/wake regularity◦Different weekday/weekend schedule

Sleep Changes in Sleep Changes in AdolescenceAdolescenceDecreased daytime alertness

◦↑ sleep pressure, ↓ circadian output Less parental “protection” of TSTLeads to insufficient sleep

◦Most need 9-9.5 hours◦Average high school student sleeps

only 7 1/4 hours

Causes of EDS-Insufficient Causes of EDS-Insufficient SleepSleepCommon problem in 24/7 societyMore fun activities at night

◦Electronic babysitter, electronics in bedroom

Family stresses◦Daycare, work schedules

Adolescents “escape” parental controls

Insufficient Sleep Insufficient Sleep EvaluationEvaluationQuestion child and caregivers

◦Signs/symptoms of sleepiness Sleeping, irritable, behavioral/focus issues

◦Weekdays and weekends?Duration/quality of sleep-day and

night◦What time in bed, what time asleep

Sleep diary can be very informative!

◦Rise time-hard to get up?◦Weekday vs weekend schedule

Insufficient Sleep Insufficient Sleep EvaluationEvaluationBedtime routine

◦Stimulating activities?Activities during the night

◦Once down do they stay down?◦Fun activities during the night

Child who won’t sleep or never sleeps◦Limit setting disorder◦Sleep onset association disorder◦Anxiety issues

Sleep Onset Association Sleep Onset Association DisorderDisorderChild learns to fall asleep under

certain conditions which are usually present at bedtime (parent in room, rocking); no problems settling when conditions met

Child continues to require conditions during normal nighttime arousals in order to fall back to sleep

Absence of those conditions results in prolonged night wakings

Limit Setting Sleep Limit Setting Sleep DisorderDisorderParents unable to set consistent

bedtime rules→bedtime struggles, bedtime refusal, protests, requests, excuses

Results in prolong sleep onset latency; most common in 2-6 year olds

Behavioral Sleep Disorders: Behavioral Sleep Disorders: ManagementManagementPreventative education for parentsSOAD-child needs to learn to fall

asleep in reproducible conditionsLSSD-family needs help with setting

limits and consequencesProblems will wax and wane and re-

training is necessary

Disrupted Nocturnal SleepDisrupted Nocturnal SleepEnvironmental issues

◦Sleep location-bed-who’s?, couch, variable?

◦Electronics, temperature, light, foodWhat to do?

◦Importance of bedtime routine◦Regular sleep location-quiet, dark◦No electronics-TV, phone, games◦No food◦No reason to be up!

Disrupted Nocturnal SleepDisrupted Nocturnal SleepIssues intrinsic to child

◦OSA-Hx of snoring, gasping or observed apnea Consider sleep study

◦Leg movements-Family history of RLS Ask RLS questions to caregiver/child Treat clinically or consider PSG

◦Parasomnias-clinical history Sleep walking, confusional arousals, night

terrors No sleep study needed usually

Causes of Daytime Causes of Daytime SleepinessSleepinessMedications

◦Many associated with daytime sleepiness

◦Anti-epileptic medications◦Medications to treat muscle spasm◦Psychotropic medications◦Antihistamines

Caffeine-sleep disruption, PLMs

Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessHypersomnia

◦Excessive daytime sleep despite normal nocturnal sleep

Narcolepsy◦EDS – may have co-existing sleep

disordersAbnormal brain regulation of

sleep/wakeDiagnosis of exclusion after ruled out

insufficient sleep or disrupted sleep

Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessNarcolepsy

◦EDS + cataplexy makes diagnosis◦Other symptoms: sleep paralysis,

hypnagogic hallucinations, disrupted nocturnal sleep

Narcolepsy statistics◦Onset in second decade◦Diagnosis may take years to make◦25-50/100,00 in US

Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessHypersomnia

◦Similar issues as in narcolepsy◦Lack other symptoms seen in narcolepsy◦Kleine-Levin, menstrual associated

Diagnosis made by history + PSG/MSLTPSG to look for other sleep disordersMSLT quantifies daytime sleepiness

◦Necessary for diagnosis, to get medications

Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessHistory

◦Amount of daytime sleep◦Where falling asleep- School, bus,

bathroom, meals, clinic?PSG-looking for OSA, PLMs, seizure,

etcMSLT

◦Daytime studied to quantify sleepiness◦5 naps 2 hours apart looking for sleep

and REM

Intrinsic Disorders of Intrinsic Disorders of SleepinessSleepinessTreatmentConsider referral to sleep expert

◦ Determine exact diagnosis, treat other sleep disorders

◦ Arrange appropriate testing◦ Determine appropriate medication regimen

Stimulants, treatment for cataplexyMaximize nocturnal sleepScheduled daytime napsSchedule important tests/activities during

periods of maximal alertness

Circadian Rhythm DisordersCircadian Rhythm Disorders

Child’s internal clock for sleep/wake behavior conflicts with family expectations

Delayed sleep phase◦May be transient (jet lag) or persistent (night

owl)◦Sleep onset and offset delayed, but regular◦Difficulty am waking and daytime sleepiness◦Rx: strict and controlled sleep/wake

schedule, delayed bedtime/gradual phase advance, chronotherapy, bright light therapy, melatonin

Sleep Problems in ADHDSleep Problems in ADHDChildren with ADHD ↑ sleepiness

vs nl◦Hyperactivity adaptive behavior for

EDSMedication role in sleep problems

◦Stimulant side effects-↑sleep latency, nocturnal awakenings, ↓total sleep time

◦“Wearing off” in evening→rebound increase in arousal and hyperactivity

Signs of Sleepiness???Signs of Sleepiness???

Signs of SleepinessSigns of SleepinessSleepy behaviorImpulsivity, hyperactivity,

aggressivenessLabile mood and inattentionNeurocognitive deficits

◦↓creativity, poor abstract thinking◦↓memory, vigilance, attention, motor

skillsSleep problems may mimic ADHD

Sx

Sleep History: ‘BEARS”Sleep History: ‘BEARS”BedtimeExcessive daytime sleepinessAwakenings: night or early

morningRegularity and duration of sleepSnoring

BEARS: BEARS: BBedtimeedtimeWhat happens at sleep onset

◦Difficulty going to bed or falling asleep

◦What happens at bedtime◦What keeps the child from falling

asleep◦Is the child anxious at bedtime

BEARS: BEARS: EExcessive Daytime xcessive Daytime SleepinessSleepinessWhat is the extent of daytime

sleepiness◦Difficulty waking in am◦Does the child act sleepy or seem

overtired◦Behavior when overtired◦Daytime naps◦Any similar history in family

members

BEARS: BEARS: AAwakeningswakeningsCharacterize extent and content

of awakenings◦Does the child have trouble waking

up at night◦What awakens the child◦Behavior when awake at night◦Does the child leave their bed after

awakenings

BEARS: BEARS: RRegularity and egularity and Duration of SleepDuration of SleepCharacterize sleep habits

◦Bedtime and wake time Weekdays vs. weekends

◦Does the child get enough sleep◦How much sleep does the child need

BEARS: BEARS: SSnoringnoring

Screen for OSA◦Does the child snore at night

How loud, how often

◦Does the child gasp, choke or stop breathing

◦Is the child a restless sleeper or sweaty

◦Anyone else at home snoring