Sleep in Children and Teens: Medical Aspects Dr. Hazen Gandy, M.D., FRCP (C) Psychiatrist Hub Specialist, Project ECHO Ontario Child and Youth Mental Health Tuesday, November 27, 2018
Faculty and/or presenter disclosure Presenters: Hazen Gandy, Project ECHO Ontario CYMH Relationships with commercial interests: none Disclosure of commercial support: not applicable Conflict of interest: none for this session Mitigating potential biases: none
Learning Objectives At the end of this presentation, participants will be able to: Identify three psychiatric diagnoses that can cause sleep problems. Identify two sleep promoting medications and describe when to use them and for what age group.
Q1. What are the recommended range of hours per night of sleep that teens should be getting? a) 12-16 hrs/night b) 11-14 hrs/night c) 10-13 hrs/night d) 9-12 hrs/night e) 8-10 hrs/night Q2. Most teens are getting how much sleep according to a 2015 study in New Jersey, USA? a) 4-5 hrs/night b) 5-6 hrs/night c) 6-7 hrs/night d) 7-8 hrs/night e) 8-9 hrs/night
Case: He s constantly complains of feeling tired. He is always irritable, cranky and argumentative! 12-yo Henrique Always oppositional, irritable and easily frustrated with parents. He is a very restless sleeper seems to wake up a lot throughout the night. Mom reports he often snores loudly. His BMI is 32
Sleep Physiology 101
Sleep Guidelines from the American Academy of Sleep Medicine
Most teens are NOT getting enough sleep Study of 3,000 teens in Edison school district, New Jersey, showed that 70% of teens are not getting enough sleep (i.e. getting 5-6 hrs/night as opposed to the recommended 8-9 hrs/night) due to late night texting or cell phone use 20-25% are awakened in the middle of the night by texts Polos, 2015
Assessment
Sleep Concerns? Consider the BEARS Scale B)edtime problems E)xcessive daytime sleepiness A)wakening during the night R)egularity and duration of sleep S)noring Questions for Parent / Child Problems going to bed? Falling asleep? Fatigue during the daytime? Falling asleep during the day? Needing naps? Wake up at night? What is the bedtime? Wakeup time? Are these times regular? Snore at night? Owens & Dalzell, Sleep Med, 2005 Owens & Dalzell, Sleep Med, 2005 http://keltymentalhealth.ca/sites/default/files/kelty_proftoolkit_m5_bearssleepscreening.pdf
For More Detailed Information, Consider a Sleep Diary
Diagnosis / Differential Diagnosis
Main Sleep Disorders (ICSD-3) Rank Category Prevalence 1 Insomnia 20-30% from pre-2014 data (perhaps even higher nowadays!) 2 Parasomnias 25% 3 Circadian rhythm disorders such as delayed sleep phase syndrome (e.g. DSPS) 4 Sleep-disordered breathing (e.g. sleep apnea) 5 Sleep-related movement disorders (e.g. restless legs, periodic limb movement disorder) 7% 2-3% 1-2% 6 Hypersomnia 0.01-0.2% International Classification of Sleep Disorders-3, 2014; American Academy of Sleep Medicine, 2014
Insomnia in Childhood Definition Difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age-appropriate time and opportunity for sleep, which results in daytime functional impairment. Presents usually as bedtime refusal or resistance, delayed sleep onset, and/or prolonged night-time waking that requires parental intervention.
DDx Insomnia in Children / Adolescents Injury or physical trauma Teething Nightmares and bad reams afraid of sleeping Difficulty breathing nasal blockage, sinusitis, hay fever, asthma, etc. Infections, e.g. common cold Itchy skin Stimulants in the diet / environment, e.g. caffeine, nicotine Excessive intake of high glycemic index (GI) foods, e.g. causing sugar high Substance use Psychiatric Disorders Technology overuse
Parasomnia Undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep. Examples: Night terrors Sleep walking (somnambulism) Confusional arousals
Circadian Rhythm Disorder Delayed sleep phase syndrome (DSPS): Common cause of insomnia in adolescents (Pelayo, 2008) Teenager falls asleep later than the socially expected 9-10 PM, falling asleep later such as 12 AM or later, has normal sleep, but as a result doesn t wake up at the expected 6-7 AM for school. Management / Treatment: Adjust the circadian rhythm such as: Phototherapy at the desired wake up time. Melatonin 0.3-0.5 mg given 5-6 hrs before desired bedtime. Accommodate to the DSPS School boards that accommodate to delayed sleep phase by having later start times, e.g. 9-10 AM, have noted that students are happier and do better at school.
Obstructive Sleep Apnea in Children/Adolescents: Modified STOP-Bang Questionnaire 1) S)noring (How often does your child snore loudly?) Y/N 2) T)ired (Is your child sleepy during the daytime?) Y/N 3) O)bserved apnea (Does your child stop breathing during sleep?) Y/N 4) P)ressure - Systolic / diastolic blood pressure greater/equal to 95%ile for height / age Y/N 5) B)MI greater than 95th percentile for age Y/N 6) A)cademic problems (Does your child have learning problems?) Y/N 7) N)eck circumference greater than 95th percentile for age, and male Y/N 8) G)ender Male Y/N Scoring: Low risk = 0-2; Intermediate risk = 3-4; High risk = 5+ (Combs, 2015)
Sleep Related Movement Disorder (SRMD): Restless Legs Single Question Screener by Ferri Restless legs 1-item screener: "When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? If positive, ask further for diagnostic criteria 1. Urge to move the legs, With young children, consider age-appropriate descriptors such as spiders crawling, tickles in your legs 2. That is present at rest. 3. Relieved by movement. 4. Circadian pattern with peak symptoms occurring at night or in the evening. Ferri, 2016
Psychiatric Disorders with Sleep Problems Condition Major depressive disorder Generalized anxiety disorder Separation Anxiety disorder PTSD ADHD Oppositional defiant disorder Autism spectrum disorder; developmental delay Nocturnal enuresis Substance use Comments Mid-cycle awakening (MCA) Early morning awakening (EMA) Difficulty falling asleep Difficulties falling asleep, nightmares Difficulty falling asleep, decreased total sleep time Exacerbated by stimulants Refusal to go to bed Myriad sleep problems; immature sleep architecture; low melatonin production Wake up after urinating in bed Numerous sleep issues
Management/Treatment: Low Blue Light and Medication Strategies
Management/Treatment Options Behavioural: As will be discussed in Dr. Kortstee s presentation next week Sleep hygiene CBT-I)nsomnia Light: Phototherapy (i.e. bright light). Low blue light. Medications Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Blocking blue light Evidence suggests that blue light exposure from screens impairs melatonin production. (van der Lely, 2015). Ways of reducing blue light include: Turning off your devices! Low blue light glasses (i.e. amber/orange colored) Apps such as F.lux that claim to reduce blue light Night mode on devices
Consider Red / Orange (LED) Light Bulbs Researchers at the Ohio State University showed that for sleep / mood (in hamsters) Blue light was the worst. Red light was the best of all lights. Total darkness was the best. Nelson et al.: Nocturnal Light Exposure Impairs Affective Responses in a Wavelength- Dependent Manner, J. Neurosci, 2013, Aug 7 http://www.jneurosci.org/content/33/32
Medications for Sleep: General Principles Most medications for sleep in children/youth are off label No prescription hypnotics approved for those younger than age 18 Few randomized controlled trials Most medications change sleep architecture effects on neuronal growth and synaptogenesis in developing brains unknown Indications When first-line interventions such as behavioural therapy have been unsuccessful. Certain conditions such as narcolepsy, restless legs that respond to medications Medication with short half-life for initial insomnia, i.e. sleep onset problems. Medication with longer half-life for sleep maintenance problems. Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Medications for Sleep: General Principles Side effects SSRIs can exacerbate restless legs; Medications with long half-life can cause daytime sedation. Risk of dependence In adults, de-prescribing guidelines in adults recommend short-term use of sleep medications (i.e. no more than 4-weeks or so in most cases Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14; Moturi, 2010
Medications for Sleep: General Principles Antipsychotics should NOT be routinely used to treat primary insomnia in children, adults, or the elderly Choosing Wisely Canada, 2015
Herbal Supplements Chamomile, lavender, kava kava Evidence Limited-to-no evidence of efficacy (Moturi, 2010) Moturi et al.: Assessment and treatment of common pediatric sleep disorders, 2010 Jun; 7(6): 24-37.
Medications for Insomnia Prescription Benzodiazepines (BZD) Non-BZD Alpha agonists Antidepressants Antipsychotics Melatonin-receptor agonists (used in adults, no data yet for paediatrics) Over the Counter Antihistamines Melatonin Adapted from: Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Antihistamines (Diphenhydramine) Binds to H1 receptor in CNS; rapid absorption, crosses blood brain barrier. Available as OTC Frequently prescribed medication for insomnia in primary care (e.g. hydroxyzine, diphenhydramine, promethazine) Side effects Morning drowsiness Dry mouth Constipation Urinary retention Constipation due to anticholinergic effects Moturi, 2010
Melatonin Synthesized from tryptophan Available OTC in North America; requires prescription in UK Indications Felt to be a more natural option prior to using prescription options For circadian rhythm issues Dosage 3-9 mg as hypnotic given 1 hr earlier 0.3-0.5 mg given 5-6 hrs earlier for circadian rhythm Side effect Hypotension May increase seizure threshold (thus being used in patients with epilepsy) Increases immune reactivity (psychoneuroendocrinologic immune system) Long-term effects on puberty are not well understood ; caution with delayed puberty Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Non-BZD Agents (Zolpidem, Eszopiclone) Binds GABA, high affinity BZD receptor agonist; little effect on sleep architecture Zaleplon, 1-2 hrs half-life Zolpidem, 2-3 hrs half-life Eszopiclone, 6 hrs half life Indications Short-acting for initial insomnia Long-acting for middle insomnia Side effects Daytime drowsiness Headache Dizziness Hallucinations Complex sleep related behaviours Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Alpha Agonists (Clonidine, Guanfacine) Central alpha2 agonist; reduces noradrenergic tone Rapid absorption; onset of action within 1 hour Increases SWS Decreases REM Thus when stopped, it causes REM rebound, i.e. vivid dreams Indication Used in childhood insomnia due to sedative effect Attention deficit hyperactivity disorder (ADHD) Side effects Hypotension Anticholinergic irritability Dysphoria Worsens parasomnias Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Tryptophan Serotonin precursor Indications Certain types of parasomnia such as night terrors Evidence Evidence supporting a sleep moderating effect of L- tryptophan, though controlled trials in samples of insomnia patients, however, are quite limited and their combined findings are mixed at best. (Yurcheshen, 2015) Dosage 1-2 mg /kg/day at bedtime Tryptophan
Selective Serotonin Reuptake Inhibitors Suppress REM sleep. Most reduce slow wave sleep (SSRIs). Increased sleep onset latency / number of awakenings and arousals, leading to an overall decrease in sleep efficiency. Indications Sleep issues with comorbid mood, anxiety disorder Side effects Drowsiness Insomnia Nausea Dizziness Appetite increase Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Tricyclic Antidepressants Most suppress REM sleep. Most sedating (Amitriptyline, Doxepin). Indications Sleep issues with comorbid mood disorder. Side effects Agitation Anxiety Anticholinergic Cardiotoxicity Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Trazodone 5HT, alpha receptor antagonist, blocks histamine. Evidence Widely used, but two trials failed to show effects in adolescents for insomnia. Indications Sleep issues with a comorbid mood disorder. Dosage 25-75 mg QHS Side effects Drowsiness Nausea, vomiting, dizziness, headache Szigethy, E. Assessing and Treating Sleep Disturbances in Pediatric IBD, 13/12/14
Phototherapy Indications Seasonal affective disorder Circadian rhythm disorder Regulating sleep cycle How to use Indirect light not looking directly into the SADs light Dosage for sleep phase delay syndrome (SPDS) (Chesson, 2005) 2000-2500 lux from 6-9 AM; dark sunglasses Dark goggles after 4 PM until dusk Dosage for seasonal depression (Levitan R, 2005) 5000 lux hours per day, e.g. 10,000 lux x 0.5 hr each morning before 8 AM Image Source: Day-Light from Uplift Technologies
When to Refer to Sleep Specialist Indications for sleep specialist When specific sleep disorders are suspected such as Obstructive sleep apnea, Restless legs / Periodic limb movement disorder. When sleep issues persist despite trying various initial interventions. With resistant mental health conditions (e.g. depression), consider the possibility of underlying sleep issues. Image source: Western Ottawa Sleep Centre
Case: He s constantly complains of feeling tired. He is always irritable, cranky and argumentative! Undergo sleep hygiene protocol - no improvement Document wakenings. Look for apneic episodes - positive. Refer for sleep study found to have documented apnea with O2 desaturations. Trial of CPAP with substantial improvement in demeanor and fatigue.
Q1. What are the recommended range of hours per night of sleep that teens should be getting? a) 12-16 hrs/night b) 11-14 hrs/night c) 10-13 hrs/night d) 9-12 hrs/night e) 8-10 hrs/night Q2. Most teens are getting how much sleep according to a 2015 study in New Jersey, USA? a) 4-5 hrs/night b) 5-6 hrs/night c) 6-7 hrs/night d) 7-8 hrs/night e) 8-9 hrs/night
Learning Objectives At the end of this presentation, participants will be able to: Identify three psychiatric diagnosis that can cause sleep problems. Major depression disorder. Anxiety. ADHD. Identify two sleep promoting medications and describe when to use them and for what age group. Melatonin. Antidepressants (with comorbid depression).
Clinical Pearls Paediatric sleep problems are common and can mimic many symptoms of psychiatric disorders. Fixing sleep problems may be a gateway to improving mental and physical health. First step is to identify the problem and determine if sleep specialist needed (not commonly true). First line treatment is behavioural and environmental. Only use medications if true psychiatric disorder or if temporary sleep problem that is causing high dysfunction.
References Pelayo et al.: Pharmacotherapy of Insomnia in Children, Current Sleep Medicine Reports, Mar 2016, 2(1): 38-43. Yurcheshen M et al.: Updates on Nutraceutical Sleep Therapeutics and Investigational Research, Evid Based Complement Alternat Med. 2015; 2015: 105256. Van der Lely et al.: Blue Blocker Glasses as a Countermeasure for Alerting Effects of Evening Light-Emitting Diode Screen Exposure in Male Teenagers, J. Adolescent Health, 56(1), Jan 2015, 113-119 Pelayo et al.: Pediatric Sleep Pharmacology, Seminars in Pediatric Neurology, 2008, 78-90.