Sleep Tips for the Primary Care Provider Glenna Winnie, MD, D, ABSM Director Pediatric and Adolescent Sleep Center

Overview

Normal sleep Strategies to prevent sleep disorders Signs and symptoms of sleep disorders Discuss things to do or not to do when

dealing with sleep disorders

Definition of Sleep

A state of decreased responsiveness to outside and inside stimuli

An active process – brain and other organs are restored: “brain flush”

Must be safe to sleep By age 2, a child has spent

about 9500 hours sleeping versus 8000 hours awake

The Stages of Sleep

Stage N1 (transition to sleep): lasts about 5 minutes, slow eye movements, easily awakened

Stage N2 (light sleep): first stage of true sleep , lasts 10 – 25 minutes, eye movement stops, heart rate slows, body temperature decreases

Stage N3 (deep sleep): difficult to awaken, slow large coordinated brain waves, blood directed away from brain and toward muscles

The Stages of Sleep

REM Sleep (dreaming sleep): vivid dreams, rapid eye movements, irregular breathing, heart rate and blood pressure, muscles paralyzed except diaphragm and eyes

Sleep Tip #1: Care About Sleep Sleep problems are a frequent

parental complaint Sleep affects every aspect of a child’s

development (physical, emotional, cognitive, social)

Sleep problems exacerbate virtually all psychiatric, developmental and psychosocial problems of childhood

Why Should Providers Care about Sleep?

Adequate sleep is necessary for a child to function optimally

Sleep problems are common and chronic in children and adolescents (20-30%)

Pediatric sleep disorders are treatable Sleep problems are preventable

Sleep Tip #2: Know How Much Sleep is Needed

NSF, AASM

Prevention of Sleep Disorders

Sleep Tip #3: Comfortable Safe Sleep Environment Keep noise down Use white noise, all night: fan or air purifier,

soft music, sound machine, white noise like static on radio (set between stations)

Temperature around 65 to 68 degrees Make sure the bed is comfortable! Decrease allergens in bedroom Treat snoring family members

Sleep Tip #4: Children Need a Regular Sleep Schedule

Set a regular bedtime Have a regular nap schedule through pre-

school or kindergarten age Wake up at the same time every day Don’t sleep in late – take a short nap if

sleep was short Generally avoid naps – if needed, limit to 30

minutes

Bedtime Routine

Everyone should have a bedtime routine!!!

Have a routine that is 15 – 30 minutes long, always the same, moving towards bed and lights out

Reserve the bedroom for sleeping

Sleep Tip #5: Back to Sleep, Down to Sleep Longstanding recommendation for “back to

sleep” associated with decline in SIDS By 3-4 months of age, put child down before

child falls asleep - helps develop appropriate sleep onset associations

New AAP room sharing recommendations: 6 months and up to 12 months (evidence supports 3 months)

Sleep Tip #6: Regulate the Sleep-Wake Cycle with Light

Sleep-wake cycle and body rhythms are controlled by the circadian clock

The clock has a slightly greater than 24 hour cycle

Melatonin helps regulate the circadian clock Melatonin production and the clock are most

powerfully regulated by light Other factors that regulate the clock are

exercise and eating

Regulate the Sleep-Wake Cycle Increase light exposure during the day

– Spend time outside in daylight – Let light into home and workspace – No sunglasses in the morning – Use a light therapy box if needed

Regulate the Sleep-Wake Cycle Decrease light exposure at night No visual electronics for at least one hour

before bedtime – Get the TV out of the bedroom – No reading from a backlit device

i.e. iPad, phone, computer (can use an eReader that needs external light)

Low–wattage bulbs for night reading Dark bedroom Use low nightlight, yellow or red, or

flashlight for getting up at night

Sleep Tip #6: Exercise Improves Sleep Exercise 30 minutes daily Exercise in late afternoon Avoid vigorous exercise within 3 hours of

bedtime Exercise about 5 hours before bed is best to

help with sleep onset Exercise improves sleep quality, decreases

obstructive sleep apnea

Signs and Symptoms of Sleep Disorders

Sleep Tip #7: Daytime Sleepiness Is Not Normal Overt sleepiness in children and adolescents

is abnormal Insufficient sleep is most common cause Consider other medical disorders Consider medical and behavioral sleep

disorders: OSA, PLMD, narcolepsy, DSPS, behavioral insomnia of childhood, others

Sleep Tip #8: Sleep Deprivation Has Many Effects Fatigue Moodiness, irritability, less ability to cope with

stress, difficulty making decisions Decreased creativity and problem-solving skills Concentration and memory problems Impaired motor skills and increased reaction time,

increased risk of accidents Weight gain Reduced immunity, increased infections Increased risk of diabetes, heart disease

Signs & Symptoms of Sleep Deprivation/Disruption Needs an alarm clock/parent to

wake up Hard to get out of bed in the

morning Gets sleepy in school, lectures, warm rooms Gets drowsy after meals or when driving Needs to nap (after kindergarten) Falls asleep watching TV or relaxing Needs to sleep in on weekends Falls asleep within 5 minutes after going to bed

Sleep Tip #9: Hyperactive Behavior Is More Common

In children, excessive sleepiness more often manifests as increased activity, problems with focus and attention, and mood and behavior problems than as overt sleepiness

Excessive sleepiness is more likely to present as overt sleepiness in adolescents, although they too may show only mood and behavior problems

Sleep Tip #10: Delayed Sleep Phase is Common in Teens

Delayed sleep phase circadian rhythm disorder is a shift of the sleep phase to a later period that conflicts with academic and work schedules and social norms, and is associated with daytime sleepiness

Delayed Sleep Phase

Affects ~7% of adolescents Sleep in the morning to early afternoon,

cannot get up for school, feel best in evening or late at night, cannot fall asleep at normal bedtime

Usually presents as insomnia or excessive daytime sleepiness

Sleep quality itself is normal Is treatable with chronotherapy

Sleep Tip #11: Restless Sleep Is Not Normal Children (and adults) should sleep quietly, shift

position occasionally during sleep Frequent motor activity before or during sleep

is abnormal Any cause for discomfort can cause restless

sleep Restlessness during sleep may be due to OSA,

PLMD, narcolepsy, and before sleep to RLS

Sleep Tip #12: Snoring is Often a Sign of OSA 2-4% of children and teens have OSA Snoring, gasping, snorts, respiratory

pauses, paradoxical breathing Tossing and turning, restless sleep, hanging

out of bed, unusual sleep positions Hyperactivity, mood or behavior problems,

excessive sleepiness, depression Secondary or prolonged enuresis Headaches

Things Not To Do, and Things To Do

Sleep Tip #13: Avoid Drug Use for Sleep Disorders

Pediatricians often recommend medications for chronic sleep problems

Medication use is ineffective for long term treatment of sleep disorders in children

Melatonin does have an established role for sleep onset / circadian problems, but is not effective for wakings

Better to evaluate and treat underlying disorders, or refer for sleep medicine consult

Sleep Tip #14: No School Excusal Due to Sleepiness

Inability to get up to attend school indicates a significant disorder, which may be a behavioral, psychiatric, medical, or sleep disorder, or a combination

Identification and treatment of that disorder is important

School excusal (except when acute medical disorder present) can impede treatment

Sleep Tip #15: Follow AAP Clinical Practice Guidelines All children and adolescents should be screened

for snoring as part of routine health maintenance visits

Polysomnography should be performed if there is snoring and signs/symptoms of OSA – The presence of OSA cannot be determined from

history and physical alone – Polysomnogram determines severity of

OSA, allows risk stratification for surgery – Other disorders may be present, most often PLMD

Marcus et al. Pediatrics 2012;130(3):576-584

AAP Clinical Practice Guidelines for OSA Adenotonsillectomy is the primary

treatment for OSA Postoperatively, high-risk patients

should be monitored as inpatients

Marcus et al. Pediatrics 2012;130(3):576-584

Sleep Tip #16: Screen for Sleep Disorders with BEARS

Behavior or Bedtime problems Excessive daytime sleepiness Awakenings and Apnea Restless sleep and Regular sleep

schedule Snoring

Minimum Screening

Ask about snoring (per AAP) Ask if child moves a lot during sleep Look at tonsils

Sleep Tip #17: When to Order Polysomnography If you feel comfortable explaining

results to parents and: – When there are symptoms of OSA – Possible PLMD, especially in children with

behavior problems or ADHD

– Tracheostomy before decannulation – Evidence of SDB in child with ALTE

Sleep Tip #18: Sleep Study is Sometimes Not Indicated

Trouble falling asleep Diagnosis or routine eval of seizures Seizures without sleep disorder Uncomplicated parasomnias Most ALTEs Oxygen adjustment in lung disease Ventilator adjustment in outpatient

sleep lab

Sleep Tip #19: You Can Refer for Sleep Consult If you are concerned about OSA or PLMD but

are not comfortable doing eval or ordering and explaining sleep study results: – Persistent daytime sleepiness or fatigue – Frequent awakenings, early morning awakenings – Non-refreshing sleep, can’t get up in am – Loud snoring, especially with pauses – Restless sleep, lots of movement during sleep – Morning headaches or

severe headaches – Secondary enuresis

After T&A with persistent symptoms

#19: When to Refer for Sleep Medicine Consult Any child with sleep problems not responsive

to simple interventions Excessive sleepiness in any child who does not

have severe obstructive sleep apnea Trouble with falling asleep, staying asleep,

frequent or prolonged awakenings, early morning awakenings

Leg discomfort or crawling sensations at night Restless sleep

Summary

Normal sleep Strategies to prevent sleep disorders Signs and symptoms of sleep disorders Discussed things not to do or to do when

dealing with sleep disorders in children

You can have a positive long term impact on your patients and their families by addressing the child’s sleep problems!

Thank you for your attention! Questions? Glenna Winnie, MD, D, ABSM 2730-D Prosperity Avenue, Fairfax 703-226-2290 205 E Hirst Road, Suite 303, Purcellville 540-751-1955 gwinnie@fnapc.com