PEDIATRIC SLEEP MEDICINE. Arveity Setty, MD Sanford clinic north, Fargo, ND

Transcription

1 PEDIATRIC SLEEP MEDICINE Arveity Setty, MD Sanford clinic north, Fargo, ND

2 EPIDEMIOLOGY OF SLEEP PROBLEMS IN CHILDREN 25 % of children will experience some sleep problems at some time during their childhood Most commonest sleep problem being parasomnia, about 50% Sleep apnea is increasing in western world attributed primarily to obesity and also more identification by primary doctors Prevalence of snoring is about 12 % Prevalence of sleep apnea is about 2 %

3 SLEEP DURATION

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5 TYPES OF SLEEP PROBLEMS(ICSD-3) Insomnia Sleep related breathing disorder - sleep apnea Circadian rhythm disturbances Parasomnia Sleep related movement disorder - hypoventilation syndrome - hypoxemia syndrome Other sleep disorders like sleep related headches, sleep related GERD etc

6 FUNCTION OF SLEEP Restorative/homeostatic Thermoregulation/energy conservation Consolidation of learning and memory Programming of species-specific behaviors Endocrine hormone regulation: Growth hormone, prolactin, LH, TSH Leptin and grehlin Gastric acid secretion Metabolism: Abnormal glucose metabolism Inflammatory mediators:

7 SLEEP DISORDERED BREATHING Primary Snoring (PS) Snoring without obstructive apnea, frequent arousals from sleep, or gas exchange abnormalities. Obstructive Hypoventilation Syndrome (OHS) Persistent partial upper airway obstruction associated with gas exchange abnormalities, rather than discrete, cyclic apneas. Upper Airway Resistance Syndrome (UARS) Increasingly negative intrathoracic pressures during inspiration that lead to arousals and sleep fragmentation, no desaturations. Obstructive sleep apnea (OSA) Disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction. Disrupts normal ventilation. Disrupts normal sleep patterns.

8 SLEEP STUDY IMAGE

9 AAP 2012 RECOMMENDATIONS CAROLE MARCUS PEDIATRICS 2012;130: All children should be screened for snoring 2. PSG should be performed in children with history of snoring and other S/S of OSAS, if PSG is not available then an alternate diagnostic test or referral to specialist must be considered 3. Adenotonsillectomy must be considered as the first line of treatment in patients with adenotonsillar hypertrophy.

10 AAP 2012 RECOMMENDATIONS CAROLE MARCUS PEDIATRICS 2012;130: High risk patients should be managed as inpatients post operatively 5. Patients should be reevaluated post operatively. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy 6. CPAP is recommended in patients who fail adenotonsillectomy or in patients who did not had adenotonsillectomy

11 AAP 2012 RECOMMENDATIONS CAROLE MARCUS PEDIATRICS 2012;130: Weight loss is recommended in addition to other therapy in children with overweight or obesity 8. Intranasal corticosteroids are an option in children with mild OSAS in whom adenotonsillectomy in contraindicated or for mild post operative OSAS

12 SYMPTOMS OF SDB Snoring Pauses in breathing Gasping for air Choking Coughing Restless sleeping Sweating Early morning headaches Excessive day time sleepiness ADHD behavior, executive functions is affected Enuresis, arrhythmias, worsening of cardiac function, etc

13 HIGH RISK PATIENTS Obesity ADHD Craniofacial malformation Cerebral palsy Down s syndrome Cardiopulmonary problems like pulmonary hypertension Asthma Bleeding abnormalities

14 HIGH RISK POPULATIONS AND ARE PREDICTORS OF FAILURE TOO Age more than 7 yrs Obesity with BMI of more than 95 % Presence of asthma Pre-op AHI on overnight polysomnogram of more than 10 events/hr Bhattacharjee R Am J resp 2010

15 SLEEP APNEA IN SPECIAL POPULATION Downs syndrome: AAP recommends for sleep evaluation at 4 years of age Neurological problems: due to low tone Syndromes affecting face like micrognathia, depressed malar prominence

16 PATHOPHYSIOLOGY OF SLEEP APNEA Site of obstruction Nose Soft palate Tonsils Adenoids Base of tongue Posterior pharyngeal wall Larynx

17 MANAGEMENT OF SLEEP APNEA

18 MEDICAL MANAGEMENT MARCUS CL ET.AL PEDIATRICS 2012 Intranasal corticosteroids

19 Do systemic steroids work??? Laryngoscope 1997 Al-Ghamdi et. Al,

20 Pediatric adenoid hypertrophy and response to intranasal beclomethasone. - 8 week double blind crossover trial yrs old. Demain JG et al Pediatrics 1995

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22 Efficacy of intranasal momentasone in children with snoring due to adenoidal hypertrophy. 16 week prospective study yrs Sleep disturbances Physical symptoms Excessive daytime sleepiness Day time problems Caregiver concerns An Int J 2014 Gupta v et al, Clin Rhinol

23 INTRANASAL STEROIDS AND LTRA Intranasal steroids and mometasone for 16 weeks 16 weeks observational study yrs 2014 Abraham AA et al, Int J Sci Stud

24 LTRA. Monteleukast alone has been used in children with OSA. Double blind placebo controlled study. Goldbart AD et al pediatrics 2012

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26 WEIGHT MANAGEMENT Tuomilehto H et al, Sleep Med Rev 2013

27 N = 72 Tuomilehto H et al, Sleep Med Rev 2013

28 POSITIVE AIRWAY PRESSURE THERAPY

29 NOVEL THOUGHTS: SMOKING AJRCCM 2004

30 N = 2,187 J Peds 2013

31 HFNC 2013

32 NASAL EPAP

33 SPEECH THERAPY Sleep Breath 2014

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35 ORAL APPLIANCES Mandibular Advancement Devices Moves the tongue forward Decreases soft tissue prolapse Cost, longevity, dental changes Accepted for mild to moderate OSA in adults

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37 RAPID MAXILLARY EXPANSION 31 children and mean age of 8.7 years Pirelli P Sleep 2004

38 POSITIONAL THERAPY Children less likely candidate Works for those whose sleep apnea is worse in supine position at least for 10 percent of the sleep study Long term practicality has not been studied

39 CHAT (CHILDHOOD ADENOTONSILLECTOMY TRIAL) STUDY

40 Primary outcome: NEPSY: attention and executive function did not show statistical significance in children with watchful waiting vs early adenoidectomy Secondary outcome: normalization of the AHI, improvement in the Conner s score for restlessness and emotional lability, improved quality of life. Did not show any significant difference in Black children and obese children

41 SPONTANEOUS RESOLUTION Predictors were Low AHI Low scores on PSQ and snoring score Low waist circumference

42 DO NOTHING N = 194 Chest 2015

43 BEYOND ADENOTONSILLECTOMY Lingual tonsillectomy Supraglottoplasty Turbinectomy

44 CASE #1: HISTORY AND PHYSICAL 5 y/o male Soft snoring Apnea Restless sleep ADHD Bed wetting BMI % =90% small turbinates Tonsils 4+ FTP = 2 Nl occlusion No high arch palate

45 CASE #2: HISTORY AND PHYSICAL 7 y/o male Down Syndrome Soft snoring Apnea Restless sleep Sleeps folded over Sleepiness Recurrent sinusitis BMI % =98% No turbinates Tonsils 1+ FTP = 2 No occlusion No high arch palate

46 PARASOMNIA ICSD 3 Parasomnias are undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep

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48 EPIDEMIOLOGY Generally begins around school age Regular sleep walking reported in around 17 % of children aged 5-17 yrs Sleep terrors associated with children less than 7 yrs and reported to be around 4 % Confusional arousals reported in up to 50 % of childrens aged 5-13 years Klackenberg et al, cirignotta et al, moore M et al.

49 SLEEP WALKING Confused/dazed appearance and rarely agitation Variable bizarre behavior (complex and consolidated movement, impaired judgement, walking to another room etc) Mumble and bizarre answers Usually last for minutes Concerns with physical harm to self and others on the way always exists

50 CONFUSIONAL AROUSAL Child appears disoriented, unresponsive and has no recall Tends to last few minutes May be triggered by external environmental stimuli (also reported in morning with forced awakenings) Odd behaviors like sit up, trash and agitated

51 SLEEP TERRORS Dramatic, extreme terrorizing activity in NREM sleep Eyes may be open Autonomic response (dilated pupils. Sweating, tachycardia, tachypnea etc) Agitated appearance, screaming Not recalled by the child child might wake up and feel scared after the event but no dream like mentation

52 TRIGGERING FACTORS Sleep deprivation Alcohol, caffeine, drugs Medications Stress, emotional or physical Family history, more common in twins, more common in children of parents who had parasomnia Underlying neurodevelopmental disorders.

53 PARASOMNIA NREM parasomnia Occur in the first 1/3-1/2 of the night but can occur with any sleep transition. Typically benign and diminishes in occurrence with age. NREM Confusional arousals Sleepwalking Sleep terrors Enuresis Bruxism REM: later 1/3 rd of night or early morning. Might need treatment Night mares RBD Sleep paralysis Visual hallucinations

54 PARASOMNIA Influencing Factors Age Sleep deprivation Medications (neuroleptics, sedative hypnotics, and antihistamines). Fever, stress Intrinsic sleep disorder (periodic leg movements, OSA) Genetic predisposition

55 PARASOMNIA: MANAGEMENT Sleep hygiene Safety counseling Alarm on door, gates, locks on windows/doors, keeping room bare, removing sharp objects within reach Informing other caregivers (sleep overs) Scheduled awakening Briefly woken minutes before characteristic event Medications : clonazepam / SSRI Treatment of comorbid conditions: OSA/PLMD* Counseling Avoid waking, redirect to bed due to potential for sleep associations or prolonging event *Guillieminault et al 2003

56 PARASOMNIA MIMIC

57 Epilepsia 2006 Derry CP et al.

58 RLS: ICSD-3 CRITERIA A. An urge to move the legs, usually accompanied by or thought to be caused by uncomfortable and unpleasant sensations in the legs (worsen with rest, relieved by movement, more noticed at night/evening) B. No other medical symptoms or behavioral conditions like leg cramps, positional discomfort, venous stasis etc) C. Symptoms of RLS cause concern or distress D. In children: sibling or parent have definite RLS, sleep disturbance for age, PSG diagnosis of PLMD

59 WHAT IS PLMD Not a clinical diagnosis Periodic limb movements while asleep leading to restless sleeping Pathophysiology is equivalent of RLS Look for serum ferritin. Target ferritin level to 50 and still restless sleeping then refer Needs different medications

60 ADHD AND SLEEP Circadian cycle is pushed to later time with delayed melatonin secretion Prefrontal cortex is affected in both ADHD and in sleep deprivation Numerous studies have demonstrated all most all sleep problems are more common in ADHD compared to control children Most common is RLS and PLMD Watch for sleep problems before diagnosing ADHD and also while on treatment. Once on stimulants they are high risk of insomnia and RLS

61 EXCESSIVE DAY TIME SLEEPINESS Epworth sleepiness scale Narcolepsy with or without cataplexy Idiopathic hypersomnia with or without long sleep time Due to medical condition Due to sedative-hypnotic If no precipitating factors then referral to sleep center

62 INSOMNIA Difficulty in falling asleep or maintaining sleep Number of sleep medications approved for children by FDA : 0 Thus try to address the cause of insomnia and most likely transient stress Rule out some psychiatric problems especially anxiety disorder and depression Rule out drugs Then referral

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64 MELATONIN Mechanism: supplementation affects endogenous pineal hormone - Has both hypnotic (MT1) and chronobiotic (MT2) properties - Pharmacokinetics: plasma levels peak 1 hr - Affects sleep architecture: minimal - Concentration may vary

65 MELATONIN Side effects: hypotension/bradycardia; possible decrease seizure threshold - Long-term side effects unknown - potential suppression hypothalamic-gonadal axis (trigger precocious puberty upon discontinuation) - Increase immune system reactivity Observation: precipitates parasomnia Dosing: - Hypnotic: mg younger, 2.5-3mg older, 5 mg adol;up to 10 mg special needs reported; - Chronobiotic: 0.5 mg 5-7 hours before habitual sleep onset - Timing of dose dependent on DLMO (3-6 hrs prior)?1

66 WHAT PARENTS READ ONLINE Children: Melatonin should not be used in most children. It is POSSIBLY UNSAFE. Because of its effects on other hormones, melatonin might interfere with development during adolescence. Melatonin, according to more than 24 studies, is safe for children and has been used with little to no side effects. Although the use of low doses of melatonin to help children sleep seems to be safe and effective, more research is needed to answer lingering questions.

67 MELATONIN: PEDIATRIC STUDIES Premise: Children with ADHD have a delayed endogenous circadian clock - ADHD patients with sleep onset insomnia vs normal controls have significantly later sleep onset, morning wake time,melatonin onset - Several studies suggest 5 mg bedtime melatonin significantly shortens SOL in children with ADHD1-5 Premise: Studies suggest alterations of melatonin secretion in children with ASD Daytime elevation, lack of or later nighttime elevation, decreased amplitude - Growing evidence melatonin effective in treating sleep-onset and possibly maintenance insomnia in ASD - Dose ranging from 1-6 mg 1-2 Smits et al 2001, 2003; 3-4 Van der Heijden et al 2005, 2007; 5 Weiss 2006; 6 Nir et al 1995; 7 Kulman et al, 2000; 8 Paavonen 2003; 9Jan 2004; 10 Garstang 2006; 11 Giannotti et al, 2006; 12 Andersen 2008; 13 Wasdell 2008; 14 Braam 2009; 15 Wright 2011

68 BEHAVIORAL INSOMNIA OF CHILDOOD Association type: 1. Requires special condition to fall asleep 2. Highly demanding and problematic 3. In the absence of associated condition sleep onset is significantly delayed 4. Night time awakenings requires care giver intervention to return to sleep. Limit setting type: 1. Difficulty in initiating and maintaining sleep 2. Refuses to go to bed at appropriate time or refuses to return to bed following awakening 3. Caregiver demonstrates insufficient or inappropriate limit settings

69 TREATMENT Detailed history is necessary Different approaches - extinction technique - modified extinction: appearing at scheduled interval - bed time fading - excuse me method

70 CIRCADIAN RHYTHM DISTURBANCES Most common is delayed sleep phase, commonly viewed as only insomnia or hypersomnia Adolescents Inherent biological delaying associated with technology usage before bedtime with blue or green light exposure Affects school as they wake up late in the morning Melatonin before bedtime and light exposure in the morning.

71 TECHNOLOGY USE N = 83 Hysing M et al. BMJ Open 2015

72 TECHNOLOGY USE N = 9846 Hysing M et al. BMJ Open 2015

73 TECHNOLOGY USE N = 9846 Hysing M et al. BMJ Open 2015

74 SLEEP HYGIENE Bed time routine Dim light at least 30 minutes before bedtime Avoid blue or green lights. Dark is best Avoid vigorous exercises 2-3 hrs before bedtime Warm baths before bedtime Relaxed clothing Keep temp slightly colder than normal Avoid napping Don to eat to full stomach before bedtime Associate bed to sleep Avoid caffeine, nicotine and alcohol

75 Questions?