Daniel Erichsen, MD, FAAP 10/25/2011

Pediatric Sleep ClinicThe function(s) of sleepConsequences of sleep loss

Obstructive sleep apneaDivision of Peds Sleep

What’s going on?

Thursday AM sessionPatients

2 – 26 y▪ Sleep-disordered breathing▪ Insomnia▪ Hypersomnia▪ Restless legs ▪ Parasomnias

+ Facesheet Plz

Pediatric Sleep ClinicThe function(s) of sleepConsequences of sleep loss

OSA Insufficient sleep

Born Sävsjö 1600

1620s Captain Dutch West India Company New Netherlands

Jonas Bronck Navigates up East River in De Brant Van

Troyen (The fire of Troy) Purchases land north of Harlem River▪ South of 150th st

South of 150th Jonas Bronk’s land

South of 150th Jonas Bronck’s land -> Bronck’s land

South of 150th Jonas Bronck’s land -> Bronck’s land -> Broncksland

South of 150th Jonas Bronck’s land -> Bronck’s land -> Broncksland -> Bronx

1/3 of your life

Eating Energy supply

Talking Communication

Sex Reproduction

Sleep ???

Sleep No food gathering No reproduction Easy pray

Why do we sleep?How important is sleep?

Important functions conserved How conserved is sleep? How important is sleep?

Lungs Max 7 minutes submerged

Lives in water Emerges 4-6 weeks/year

Land Synchronized slow EEG activity entire

brain and eyes closed night. Asynchronized fast EEG activity entire

brain and eyes open day.

Sea Right hemisphere synchronized slow

activity with left eye closed. Left hemisphere asynchronized fast

activity with right eye open.

All species studied have sleep or sleep equivalent Fish Insects Bacteria

Complete sleep deprivation Hyperphagia Hyperthermia Autonomic dysregulation Loss of fur Death

90 practice tasks-> 8 hr break -> 300 testing tasks Group 1 – Awake 11 am -> 7 pm Group 2 – Awake 11 pm -> 7 am Group 3 – Sleep 11 pm -> 7 am

Outcome % subjects gained “insight”

None gained “insight” after first 90 tasks

% gained “insight” after 300 test tasks

Consolidation of declarative memory

1 hr learning session -> 12 hr break -> 1 hr testing session Group 1 – Slept 3 hrs Group 2 – Slept 8 hrs Group 3 – Awake daytime Group 4 – Awake nighttime

Outcome Improvement in speed of correct answer Decrease in milliseconds

Results

Consolidation of procedural memory

Slow wave, “deep”, sleep Consolidation of declarative memory

REM sleep Consolidation of procedural memory

Memory consolidation

Single neuron recordingZebra Finch

Record singing

New song

Memory consolidation may occur 2nd to reactivation of neural pathways in sleep

Memory consolidation

Corresponding 15% reduction overall metabolism

Corresponding 15% reduction overall metabolism Is energy conservation a function of

sleep?

Vulnerable species Squirrels Mouse birds Humming birds

Vulnerable species Squirrels Mouse birds Humming birds

▪ Several degrees sleep drop

Further decrease in unfavorable conditions Willow Tit Parid species

Memory consolidationEnergy conservation

Is it more dangerous to be asleep or awake?

Meddis 1975Nocturnal animals

Large eyes Large pupils Tapetum Heightened hearing/smell

How minimize risk for diurnal animal (human) being preyed upon by nocturnal predator (python)?

How minimize risk for diurnal animal (human) being preyed upon by nocturnal predator (python)? 8 hour blackout

Memory consolidationEnergy conservationDecreased predation risk

Input of data daytime -> Storing as new synapses or

strengthening of synapses -> increased space and energy demand

of brain

Input of data daytime -> Storing as new synapses or

strengthening of synapses -> increased space and energy demand

of brain If not interrupted▪ -> exhaustion of energy/space▪ No capacity for new memory

Brain taken “off line” during sleep Synapses eliminated Selective weakening/strengthening

synapses

Memory consolidationSynaptic maintenanceEnergy conservationDecreased predation riskMetabolic functions

Memory consolidationSynaptic maintenanceEnergy conservationDecreased predation riskMetabolic functions

Sleep loss may have several consequences

Affects 2-4 % of childrenRelated to

Tonsillar/adenoidal hypertrophy Obesity

Pathophysiology Repetitive complete (apnea) or partial

(hypopnea) upper airway obstructions during sleep resulting in arousals and/or desaturations.

AHI Apneas + Hypopneas per hour of sleep▪ <2 normal▪ 2-5 mild OSA▪ 5-15 moderate OSA▪ >15 severe OSA

Symptoms Respiratory▪ Snoring▪ Choking▪ Apneas

Symptoms Neurocognitive▪ Sleepiness▪ Inattentiveness ▪ Poor academic performance

Symptoms Hormonal▪ Nocturia▪ Obesity?

History Focus on nighttime respiratory

symptoms and daytime neurocognitive impairment

Work up In lab, attended polysomnogram gold

standard

Treatment T&A▪ Medical treatment for mild or residual OSA ▪ Positive airway pressure therapy▪ Mandibular advancement device▪ Maxillary expanders▪ Weight loss

8 y.o boy Snoring Choking in sleep

8 y.o boy AHI 6.5 Recommended T&A

Snoring -> Upper airways resistance syndrome -> Hypopneas -> Obstructive apneas (OSA)

Snoring -> Upper airways resistance syndrome -> Hypopneas -> Obstructive apneas (OSA)

Snoring in itself has health implications

Compared to non snoring children Snoring children perform worse on

measures of:▪ Attention span▪ Social problems▪ Overall cognitive abilities▪ Visuospatial functions

O’brien et al. Pediatrics 2004 Guilleminault. Eur. J. Pediatrics 1982 Kennedy. Ped. Pulm 2004

Neurocognitive effects Snoring at age 2 to 6 is associated with

worse academic performance at age 13 to 14.▪ Gozal. Pediatrics 2001

297 1st grader with lowest 10th grade percentile surveyed for OSA

All underwent sleep study

Prevalence 54 (18%) had OSA▪ 24 elected to have T&A▪ 30 elected not to have T&A

66 had primary snoring 177 had normal breathing

Grades 1 year later compared OSA and T&A group OSA no T&A group Primary snoring Normal controls

Associated with Increased risk of cardiovascular events Strong association with Diabetes Mellitus

II Increased risk of MVH Endothelial dysfunction (peds) Autonomic dysregulation (peds)

How well do we comply with guidelines?

Chart review study St. Barnabas Hospital Adult Outpatient service

n=1049 Snoring Respiratory symptoms in sleep Insomnia symptoms

Results

Results

Results

Results

Chart review study St. Barnabas Hospital Pediatric Outpatient service

n=1026 Detected snoring Specific screening for snoring

Results

Results

Results

Fluid shifts during sleep Neck engorgement / decrease calf

diameter? Role in pediatric OSA

24 hour hunger profile Circadian variation in hunger scale Obese vs nonobese Change in hunger scale with caloric

intake

Smartphone app Monitor leg movements in sleep Screening Treatment efficacy