Pediatric Sleep Disorders

Marwa Elhady
lecturer of pediatrics
Al-Azhar univerisity
2015
Objectives

• Understand normal sleep in children

• Review common pediatric sleep disorders
• Discuss proper treatment options for
childhood sleep disorders
The Sleep Cycle
 The Sleep Cycle
• Each sleep cycle 90 – 120 minutes
• First REM period is shortest
• Most NREM deep sleep occurs early
• Most REM occurs late
Children’s Sleep Differs
from Adults

• More frequent REM

• Earlier REM
• More Total Hours of Sleep
• Sleep disorders common in pediatrics than
adults
 Total daily sleep by age
REM & NREM Sleep by Age

18
16
14
Total Hrs Sleep

12
10
8
6
4
2
0
1-3 3-5 6-23 2-3 3-5 5 - 9 10-13 14-18 19-30
M M M Y Y Y Y Y Y

During childhood sleep accounts for 40% of the day

At birth, REM ≈ 50% of total sleep, ↓ to 25% in adult
 prevalence ≈25% - 43%of children ages 1-5
years
 interfere with daily patient and family
functioning.
 sleep problems cause significant emotional,
behavioral, and cognitive dysfunction.
 common among children with
neurodevelopmental, medical and
psychiatric disorders.
Lehmkuhl et al.,2008
Owens, 2011
Sleep disorders divided into 3 categories:
1- Dyssomnias (# duration, timing of sleep)
 Primary Insomnia
 Primary Hypersomnia
 Breathing-Related Sleep Disorder
 Narcolepsy
 Circadian Rhythm Sleep Disorder
2- Parasomnias (abnormal events during sleep)
 Nightmare
 Night Terrors
 Sleep walking
3- Medical psychiatric disorders
APA, 2013
 The clinical evaluation involves:
obtaining a careful medical history
assess for medical cause of sleep disturbance
Current sleep patterns, including sleep duration,
sleep-wake schedule, sleep habits, Nocturnal
symptoms

 Polysomnogram (PSG) record: EEG, EMG, EOG,

Vital Signs and Other Physiologic Parameters
Owens, 2011
 Difficult initiate or maintain sleep or early
morning awake with difficult return to sleep
 Occur 3 nights/week, for at least 3 months,
despite sufficient time for sleep.
 Not due to the effects of a substance
 Not explained by mental/medical illness
 Prevalence 1 – 6 % in pediatrics but higher in
children with chronic med/psych conditions

Czeisler et al., 201

Insomnia is subdivided into:
1. Sleep onset insomnia: difficulty falling asleep.
2. Sleep maintenance insomnia: frequent or
sustained awakenings.
3. Sleep offset insomnia: early morning
awakenings
4. Non-restorative sleep: persistent sleepiness
despite adequate sleep duration

Czeisler et al., 201

 Treatment of insomnia
• Mainly treated with behavioral interventions
• Media removal from bedroom
• Avoid caffeine
• Consistent bedtime routine and positive
reinforcement from parents/caregivers
• Correct the underlying med/psycho factors
Owens, 2011
 prolonged sleep episodes, excessive sleepiness
 prolonged sleep > 9 h/day that is not refreshing
 Difficulty being fully awake after abrupt
awakening
 The complaint is present for at least 6 months.
 Not due to med/psycho disorder
 Common in in late adolescence.
American Academy of Sleep Medicine, 2001
 Obstructive Sleep Apnea (1 – 4 %)
Results in blood oxygen desaturations
 Upper Airway Resistance Syndrome
Similar to OSA but not result in desaturations
 Primary Snoring (7 – 12%)
regular snoring without changes in sleep
architecture, alveolar ventilation or oxygenation

APA, 2013
• Periodic apneas due to sleep-related airway
obstruction
- ↓ patency (obstruction and/or ↓diameter)
- ↑ collapsibility (↓ pharyngeal muscle tone)
-↓ drive to breath (↓ central ventilatory drive)

•Not all snorers have OSA

Bradley and Floras,2009

Sequelae of OSA
• Disrupt ventilation and sleep patterns
• intermittent hypoxia and multiple arousals cause
significant metabolic, CVS, neurocog/behavioral
and academic morbidity
• Daytime Sleepiness, Enuresis as short-term squeal
• Pulmonary hypertension and right heart failure,
FFT as long term sequel
Treatment of Sleep Apnea
• Weight loss
• Positional (sleep on one side or prone)
• CPAP prevents obstruction by soft-tissue and
keeps airway open
• Surgical intervention (e.g., tonsiloadenectomy)
• Avoid sedatives (which prevent reawakening to
breath)
 uncontrollable excessive daytime sleep attacks
interfere with normal daily functioning
 Person goes directly into REM sleep
 Common in adolescence & early adulthood
 Genetic defect in hypothalamic orexin/hypocretin
neurotransmitter
 prevalence is 3-16/10,000

Owens, 2011
Symptoms associated with
narcolepsy
Cataplexy (pathognomonic for narcolepsy)
Abrupt bilateral partial or complete loss of m. tone.
triggered by intense positive emotion (e.g., laught)
last for seconds to minutes with complete recovery

Hallucinations (visual, auditory, tactile)

occur during transitions bet. sleep and wakefulness
At sleep onset → hypnogogic
At sleep offset → hypnopompic

Sleep paralysis: inability to move or speak for sec-

min at sleep onset or offset; accompanies hallucination
Owens, 2011
DD Potential causes of EDS:
Extrinsic: 2ry to insufficient/fragmented sleep
Intrinsic: CNS disorder with ↑ need for sleep.

Treatment include:
Education, good sleep hygiene, behavioral
changes (eg. Scheduled naps).
Medications as:
• psychostimulants and modafinil to control EDS.
• TAD and SSRI to control REM-associated
phenomena, such as cataplexy

Owens, 2011
Circadian Rhythm Sleep Disorder caused by
mismatch between sleep-wake schedule
required by a person’s environment and
his/her circadian sleep-wake pattern (e.g.,
shift work).
 It is a circadian rhythm disorder
 significant, persistent, intractable phase shift in sleep
wake schedule (later sleep onset and wake time)
 Patients has inability to get to sleep until the early
morning, but little difficulty sleeping once asleep
 Interfere with school, work and lifestyle demands.
 Common in adolescents and young adults (7-16%)

Owens, 2011
 Treatment
Treatment is primarily behavioral
• Shifting the sleep-wake schedule to an earlier time
• Maintaining the new schedule.
→ Gradual shifting bedtime/wake time earlier by 15-
30 min increments
→ Exposure to light in morning and avoidance of
evening light exposure

Oral melatonin supplementation in the afternoon or

early evening is effective in advancing the sleep phase.
 Uncomfortable sensations in the LL accompanied by
irresistible urge to move legs →Disturbs sleep
 Severe leg pain is main symptom, missed as
‘growing pains’.
 partially relieved by movement (walking, stretching,
rubbing) but only as long as the motion continues.
 Diagnosis of RLS is a clinical.
 Prevalence in children is 1-6 %
Khatwa and Kothare, 2010
 periodic, repetitive, brief (0.5-10 sec) highly
stereotyped limb jerks (rhythmic extension of big
toe and dorsiflexion at ankle).
 occurring at 20 to 40 sec intervals.
 occur mainly during sleep → Disrupts sleep
 Prevalence in children is 8-12%
 Diagnosis of PLMs requires overnight
polysomnography to document the characteristic
limb movements with anterior tibialis EMG leads.
Owens, 2011
Treatment according to:
severity (intensity, frequency, periodicity)
degree of sleep disturbance
daytime sequelae

•an index (PLMs per hr) < 5 → no treatment

•index > 5 → promote good sleep hygiene
→ iron supplements if ferritin <50

•Medications that ↑ dopamine in CNS are effective in

adults but limited data in children.
 repetitive, stereotyped, rhythmic movements involve
large muscle groups.
 include head banging, body rocking, head rolling
 common in the 1st yr of life and disappear by age 4 yr
 occur with the transition at sleep at bedtime.
 It is a means of soothing themselves to sleep
 significant injury is rare
 not indicate neurological or psychological problem.
 reassurance to the family
Owens, 2011
• Episodic nocturnal behaviors involve cognitive
disorientation and autonomic and skeletal
muscle disturbance.
 10%
20%
30%
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70%
80%

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 Enuresis

Sleep Terrors

Bruxism

Sleepwalking

0% 5% 10% 15% 20% 25% 30%

• Sleep disorder characterized by high arousal and
appearance of being terrified
• ≈ 2/3 of all kids experience them
• Common in preschoolers ages 3-6 y
• Occur during REM sleep
• Child believes them to be real.

Owens, 2011
 repeated abrupt awakenings from sleep characterized
by intense fear, panicky screams, autonomic
symptoms (tachycardia, rapid breathing, sweating),
absence of detailed dream recall, amnesia for the
episode, and relative unresponsiveness to attempts to
comfort the person.
 Lasts ~ 10 min then returns to undisturbed sleep.
 During Stage 3-4 of NREM sleep (1st third of night)
 Prevalence is 3–6.5% in children.
 can occur at any age.
 Common in male
 resolves spontaneously
 Nocturnal administration of benzodiazepines has
been reported to be beneficial
 Nightmares Night Terrors
Age 3 - 6 yrs 4 - 8 yrs
Sleep Stage REM NREM (3/4)
Time of Night Late Early
State on waking Upset / Scared Disoriented
Response to Unaware of
parents
Consolable
Parents
Return to Sleep Difficult Easy / Rapid
Memory of Event occasional None
 involuntary, forceful grinding of teeth during sleep
 Up to 88% of children; 20 % of adults
 Any stage of sleep
 May result in damage to the teeth
 Periodicity of 20 to 30 seconds.
 May represent symptom different disorders
 Patient is usually unaware of the problem
 In severe cases, rubber tooth guard is necessary.
Stress management or biofeedback.
 Begins during school age
 During NREM and REM sleep
 No treatment just reassurance
One or more waking from midnight to 5 am
for at least four of seven nights per week for
at least four consecutive weeks
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
All Infants Breastfed 1-2 Yr 4-5 Yr
Infants Olds Olds

Owens, 2011
 More than just walking around…
Simple Behaviors
Complex Behaviors
 While sleepwalking, patient has a blank staring
face, relatively unresponsive to others
 confused or disoriented on being aroused.
 Complete amnesia
 Occur during Stage 3-4 Sleep; 1st third of night.
 Begins in ages 4-8 yrs
 17% in children (4% of adults)
 sleep-walking most likely to persist
 it is important to institute safety precautions (use
of gates, locking doors and windows, and bedroom
door alarms).
 No treatment is established, but may respond to
benzodiazepines or sedating antidepressants at
bedtime.
 During NREM sleep
 May be restricted to Stage 3-4
 Common in Males with Family History
 prevalence is 30% at age 4 y
10% at age 6 y
5% at age 10 y
3% at age 12 y
1% at age 15 y.
Owens, 2011
 Usually during first 1/3 of night
 Usually only one event/night
 Common in Toddler and school-aged kids.
 prevalence rates 15% in children ages 3-13 yr.
 co-occur with sleepwalking and sleep terrors
 Usually resolve with time
 Not tired the next day
 No stereotypic motor movements
 Last 5-30 minutes
Stores, 2009
 parent education and reassurance
 good sleep hygiene
 avoidance of exacerbating factors such as sleep
deprivation and caffeine.
 Scheduled awakenings, parent wake the child 15 to
30 min before the time of first parasomnia episode.
 Pharmacotherapy is rarely necessary, include
benzodiazepines and tricyclic antidepressants.

Stores, 2009
• Have a set bedtime and bedtime routine
• Bedtime and wake-up time should be the
same time on school & non-school nights.
• No more than 1hour difference from one
day to another.
• Make the hour before sleep quiet time.
• Avoid high-energy activities before bed.

Owens, 2011
• Don't go to bed hungry, but avoid Heavy
meals.
• Avoid caffeine products before bedtime.
• spend time outside every day and involve
in regular exercise.
• Keep bedroom quiet and dark with
comfortable temperature
• Don't use bedroom for punishment.

Owens, 2011
• Naps should be short (no > 1hr) and
scheduled in the early to midafternoon.
• Keep TV out of child's bedroom.
• Use bed for sleeping only. Don't study,
read, watch TV on bed.
• Relaxing, calm, enjoyable activities help
you to get to sleep.
• Smoking disturbs sleep.
• Don't use sleeping pills

Owens, 2011
 Foods
Foods That
That Helps
Helps You
You Sleep
Sleep Better
Better

tryptophan in it convert to serotonin & melatonin which induces sleep, Ca, Mg helps
m. relaxation

Kale Oat salmon & tuna

Cherries rich source source of sleep inducing agents (K, Ca, rich in Vit. B6 for
of melatonin Mg, Vit.B6) melatonin production
 All Sleep
Phenomenon could
be a Seizure…
 Nocturnal seizures
 Anything that is recurrent, stereotyped, and
inappropriate may be manifestation of a seizure
 Some forms of epilepsy occur more commonly
during sleep than during wakefulness
 Most often confused with sleep terrors,
 More common in the first 2 hours of sleep, or
around 4-6 am.
 More common in kids than adults.
REFERENCES

• Gerd Lehmkuhl, Alfred Wiater, Alexander Mitschke, Leonie

Fricke-Oerkermann (2008): Sleep Disorders in Children
Beginning School: Their Causes and Effects. Dtsch Arztebl Int;
105(47): 809–14
• Judith A. Owens (2011): sleep disorders in Nelson text book of
pediatrics. Chapter17.
• Bradley TD, Floras JS: Obstructive sleep apnoea and its
cardiovascular consequences. Lancet 2009; 373:82-90.
• Khatwa U, Kothare SV: Restless legs syndrome and periodic
limb movements disorder in the pediatric population. Curr
Opin Pulm Med 2010; 16:559-567.
• Stores G: Aspects of parasomnias in children and adolescence.
Arch Dis Child 2009; 94:63-69.