Significant behavioral consequences Reflection of brain … · 2017. 4. 2. · prescription...

Sleep & Developmental Disabilities:

Lessons for All Children

Lawrence W. Brown, MD

Pediatric Neuropsychiatry Program

Sleep Disorders Center

The Children’s Hospital of Philadelphia

March 28, 2012

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2 Importance of Sleep

Intrinsic scientific interest

Reflection of brain development

Significant behavioral consequences

Relevance to neurological disorders

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3 Sleep - Definition

A reversible behavioral state of perceptual

disengagement from and unresponsiveness

to the environment

Unlike coma, a physiologic, recurrent, and

reversible condition

A complex amalgam of physiological and

behavioral processes

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How do doctors study sleep?

Polysomnography

Multiple Sleep Latency Test

Actigraphy

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5 Polysomnography

Sleep staging (EEG, eye

leads, muscle leads)

Airflow (nasal & oral)

EKG

Chest and abdominal wall

motion

End-tidal CO2

Oxygen saturation

Video

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6 Multiple Sleep Latency Test

Semi-quantitative test of daytime sleepiness

4-5 nap opportunities throughout the day

– Patients asked to try to fall asleep in bed in

darkened room every 2 hrs

– 20 min opportunity to fall asleep; 15 minutes of

recorded sleep

Norms available above 6 yrs old

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Actigraphy

Accelerometer worn on wrist that measures

body movement

Correlates to wakefulness and sleep (including

non-REM vs REM)

Device can be worn for weeks; much more

accurate than sleep diary

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8 Idealized Sleep Histogram

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9 Idealized Sleep Histogram

Note stage 3-4 non-REM sleep

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Idealized Sleep Histogram

Note REM sleep

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11 Normal Sleep in Infants

Term infant - 16-18 hrs sleep

– 3-4 hr cycle throughout day

– Increasing day wakefulness and

night sleep by 1 month

6 month– mean sleep 14.2 hrs

– 6-8 hours of continuous night

sleep most common

6-9 months - increased

nocturnal awakenings

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12 Normal Sleep in Toddlers

Gradual decline in total sleep time

– From mean of 13.9 hrs at 1 yr to 11.4 hrs at 5 yrs

1-2 naps/day totaling 2-4 hrs

– Frequent short naps or long late afternoon nap may

interfere with night sleep

– Most children give up daytime nap by age 3

Sleep problems in 20-40%

“Good sleepers” awaken as often as “poor

sleepers”

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Normal Sleep in Older Children

Decline in total sleep time– From mean of 11.1 hrs at 5 yrs

to 10.2 hrs at 9 yrs

Typical “ideal” sleep/wake schedule– No difficulty in falling asleep

– Least likely to need alarm clock

– Optimal daytime alertness (mean MSLT=19 min)

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14 Normal Sleep in Adolescents

Further decline in total sleep

– From mean of 9.0 hrs at 13 yrs to

7.9 hrs at 16 yrs

Sleep architecture maturation

– 40% decline in SWS; slightly more

stage 2 NREM; stable REM

Increased daytime sleepiness

– Present even if total sleep stable

– Tendency to delayed sleep and

waking

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15 Common Pediatric Sleep Problems

Infant– Poor consolidation of

sleep-wake cycle

– Difficulty settling

Toddler– Behavioral disorders

– Non-REM parasomnias

– Obstructive sleep apnea

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Behavioral Sleep Disorders in Early

Childhood

Sleep-onset associations

Unstructured or inconsistent routine

Highly stimulating bedtime activities

Night fears, anxiety

Acute illness

Activating medications

Neurological disabilities

*Settling problems: 20% of 1-3 yr olds and 10% of 4 yr olds

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17 Graded Approach to Sleep Resistance

Common sense– Consistent sleep schedule

– Regular bedtime routine

– Avoidance of overly stimulating activity

Must first distinguish behavioral sleep disorder from medical conditions such as apnea, reflux

Structured behavioral interventions from graduated extinction (“Ferberizing”) to limiting bedtime hours

Medication only as last resort

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18 Non-REM Parasomnias

Sleep walking, sleep talking, agitated

arousals, sleep terrors

Typically first 1/3 of night (1-4 hrs)

Worse with sleep deprivation, stress

Difficulty in arousing child from event

Little or no recall of event

Must be distinguished from seizures

Family history in 60%

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Treating Non-REM Parasomnias

Reassurance

Environment safeguards

Scheduled awakenings– Only evidenced-based non-drug treatment

– Awaken child 15-30 minutes before expected event

– Effective in 50%

Low dose benzodiazepines– Clonazepam, diazepam

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20 Other Common Pediatric Parasomnias

Rhythmic movement disorder

– Head banging, body rocking

REM sleep disorders (nightmares)

– Most often in last 1/3 of night

– Occur in >50% of 5-7 yr olds

Enuresis

– 15% at 6 yrs with 15% resolution per yr

(which still leaves 2% at 13 yrs)

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21 Apnea: Definition

Apnea: absence of airflow at the nose/mouth

Obstructive apnea: No airflow despite respiratory

effort (due to airway obstruction)

Central apnea: No airflow or respiratory effort

(often due to CNS dysfunction)

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Obstructive Sleep Apnea: Nocturnal Signs

Noisy respirations and loud snoring

Observed apnea, gasping, choking

Restless sleep

Night sweats

Enuresis

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23 Obstructive Sleep Apnea: Daytime Signs

Morning headache, dry mouth

Overactivity

Attention problems

Learning difficulties

Irritability

Aggression

Fatigue

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24 Treating Obstructive Sleep Apnea

Tonsillectomy & Adenoidectomy

Continuous Positive Airway Pressure

Weight loss

Other surgery– Palatal reconstruction

– Craniofacial repair

– Tracheostomy

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Common Pediatric Sleep Problems

Older Child

– Insomnia


– Sleep schedule disorders

– Daytime sleepiness

– Periodic limb movements of sleep

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26 Periodic Limb Movements of Sleep and

Restless Legs Syndrome

PLMS: Brief, repeated jerks of extremities

during sleep every 0.5-5 sec, cycle every 5-90

seconds

Often seen with Restless Legs Syndrome in

adults, but children rarely complain

– Desire to move extremities, usually associated with

discomfort and motor restlessness

– Relief by movement

– Increased in evening and during periods of rest/

inactivity

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27 Evaluating PLMS in Children

Usually presents as insomnia or “growing

pains”

Family history - positive in >70%

Serum ferritin as indication of iron depletion

Consider renal failure, diabetes, thyroid

function studies, B12, folate, EMG/ Nerve

conduction studies

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Treating PLMS and RLS

Avoid drugs that may aggravate symptoms

– Antihistamines, neuroleptics, SSRIs

Iron therapy for low ferritin (<50 mcg/L) or iron

saturation < 16%

Medications

– Dopaminergic agents (pramipexole, ropinirole)

– Other drugs (clonazepam, clonidine, gabapentin)

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29 Common Pediatric Sleep Problems

Adolescent

– Insomnia

– Daytime sleepiness including

inadequate sleep, delayed sleep phase

syndrome, narcolepsy

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30 Insomnia in Adolescents

Inadequate sleep time and poor sleep hygiene

– Late bedtime, irregular sleep schedule, availability

of multiple electronic devices, caffeine

– All compounded by increasing autonomy

Natural tendency toward delayed sleep

– Delayed melatonin release

Consider substance abuse

Primary insomnia and other sleep disorders

are unusual but need to be ruled out

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Treating Adolescent Insomnia

Screen patients for concurrent use of non-

prescription remedies, alcohol, drug, pregnancy

Rule out primary sleep disorders

Emphasize sleep hygiene

– Avoid caffeine, excessive exercise, bright light

Medications for short term use only

– No refills without reassessing target symptoms and

evaluating patient compliance

Choose medication with appropriate duration

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32 Selected Drugs for Pediatric Insomnia

Melatonin 1-10 mg– Sleep promoter taken 30-45 min before bedtime

Clonidine – 0.025-0.3 mg – Short action < 4 hrs

Zolpidem 5-10 mg

– 6-8 hour effect; rare residual drowsiness

Mirtazapine 15-45 mg

Trazadone 25-100 mg

Diphenhydramine 25-50 mg

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33 Selected Drugs for Pediatric Insomnia

Melatonin 1-10 mg– Sleep promoter; taken 30-45 min before bedtime

Clonidine – 0.025-0.3 mg – Short action < 4 hrs

Zolpidem 5-10 mg – 6-8 hour effect; rare residual drowsiness

Mirtazapine 15-45 mg

Trazadone 25-100 mg

Diphenhydramine 25-50 mg– Little evidence for chronic usage, side effects include

paradoxical activation, increased seizures

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Delayed Sleep Phase Syndrome

Inability to sleep at socially

appropriate time

“Night owl”

No objective sleep abnormality

– Can sleep in and awaken refreshed if allowed to

extend time in bed

Consider secondary gain

– Unusual schedule avoids both parental control of

night activities and school attendance

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35 Treating Delayed Sleep Phase

Syndrome in Adolescents

Melatonin 3-10 mg 30-45 min before lights out

Chronotherapy– Gradually advance bedtime by 10-15 min

or delay bedtime by 2-4 hours per night until desired effect achieved

– Importance of strict adherence to schedule once entrained

Light therapy– AM light resets biological clock

Medication as last resort

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36 Sleep and Developmental Disorders

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Sleep and Epilepsy

60% of children with epilepsy have seizures while asleep

Secondarily generalized nocturnal seizures

Benign rolandic epilepsy– Facial twitching, speech arrest, drooling, secondary

generalization

Nocturnal frontal lobe epilepsy– Bizarre clinical manifestations

(thrashing, laughter, agitation, bicycling movements)

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38 Sleep and Epilepsy

Drowsiness and non-REM sleep facilitate

epileptic discharges

Seizures can disrupt sleep; post-ictal lethargy can

disrupt sleep-wake schedule

Drugs can lead to sleepiness or insomnia

Disturbed sleep can lead to cognitive-behavioral

deterioration

Children with epilepsy not immune to inadequate

sleep and/or primary sleep disorders

*Bottom line: better sleep may improve seizure control

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39 Epilepsy and Sleep Apnea

Apnea associated with increased seizures– Almost 1/3 of patients with intractable epilepsy have

sleep apnea

– Treatment of apnea improves seizure control

AEDs causing weight gain (valproate, carbamazepine, gabapentin) may induce or worsen apnea

Sedating AEDs (phenobarbital, clonazepam) produce upper airway relaxation and reduce arousability

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Sleep and Selected Genetic Syndromes

Down syndrome

(obstructive apnea)

– Obesity, mid-facial and

mandibular hypoplasia,

marcoglossia, adeno-

tonsillar enlargement

Smith-Magenis syndrome

(severe insomnia)

– Sleep disorders in >75%

– Abnormal melatonin

production

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41 Sleep and Autism

Severe sleep problems independent of cognitive level

Most sleep disorders are behavioral– Inappropriate sleep associations

– Stereotypies - headbanging, rocking

– Excessive anxiety, rituals

– Communication problems

Must consider nocturnal seizures and epileptic autistic regression

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42 Sleep and ADHD

Frequent settling problems,

restless sleep, night

arousals, early arousals or

difficulty awakening

Primary sleep disorders

rarely cause ADHD, but may

exacerbate symptoms


– PLMS

– Sleep phase disorders

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Sleep and ADHD

Co-morbid conditions may contribute to sleep problems– Depression

– Anxiety disorders

– Migraine

Medication issues– Stimulants may decrease sleep need

– Rebound hyperactivity if stimulants wear off too early

Parenting factors– Child allowed to set own schedule to avoid tantrums

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44 Sleep and Tourette Syndrome

Sleep onset difficulties, restless sleep, early awakening

PSG may show sleep fragmentation or persistence of tics in all sleep stages

Increased incidence of parasomnias and migraine

Sleep abnormalities increased with co-morbid ADHD and anxiety/OCD

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45 Recent Sleep Research in Tourette

Syndrome

80% of unselected university based clinic patients age 7-17 had > 1 sleep related problem – sleep onset insomnia

– poor sleep efficiency

– frequent arousals

– parasomnias

– nightmares

20% had > 4 sleep related problems

Sleep problems linked to reduced quality of life

Anxiety linked to increased problems

Storch et al, 2009

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Back to the Basics: When to Suspect

Underlying Sleep Disorder

Delayed sleep onset

Prolonged or frequent night awakenings

Restless sleep

Snoring, apnea

Decreased total sleep time

ADHD, irritability, aggression

Excessive daytime sleepiness

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47 Summary: Treating Sleep Disorders in

Developmental Disabilities

Always identify and treat underlying medical

condition

– Epilepsy

– Cardiorespiratory problems including apnea,

hypoventilation

– Pain – muscle spasms, contractures

– Medication effects – stimulants, sedatives, AEDs,

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48 Summary: Treating Sleep Disorders in All

Children

Sleep hygiene

– Consistent bedtime and regular sleep routine

– Consistent morning awakening

– Maintain daytime wakefulness

– Allow appropriate naps

Non-pharmacologic treatment

– Chronotherapy

– Light therapy

Sleep-promoting drugs, only if necessary

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Summary: Treating Sleep Disorders in All

Children

Pharmacotherapy

Melatonin 1-10 mg 30-45 min before sleep

Clonidine 0.05-0.3 mg

Mirtazipine 15-45 mg

Trazadone 25-100 mg

Intermittent benzodiazepines acceptable

Avoid diphenhydramine, if possible

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50 Selected References:

Meltzer LJ et al. Sleep and sleep disorders in children and

adolescents. Psychiatric Clinics of North America. 29: 1059-1076, 2006.

Mindell JA et al. Pharmacologic management of insomnia in children and

adolescents: consensus statement. Pediatrics 117: e1223-1232, 2006.

Kotagal S. Parasomnias in childhood. Sleep Medicine Reviews 13: 157-

168. 2009.

Koh S et al. Sleep apnea treatment improves seizure control in children

with neurodevelopmental disorders. Pediatric Neurology 22: 36-39,

2000.

Storch EA et al. Sleep-related problems in youth with Tourette’s

syndrome and chronic tic disorder. Child and Adolescent Mental Health

14: 97-103, 2009

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Significant behavioral consequences Reflection of brain … · 2017. 4. 2. · prescription...

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Transcript of Significant behavioral consequences Reflection of brain … · 2017. 4. 2. · prescription...