The McMaster at night Pediatric Curriculum Sleep difficulties in early childhood Bhargava S. Diagnosis and management of common sleep problems in children. Pediatrics in Review. 2011;32(3):91 99.
Objectives By the end of the session, learners will: Recognize normal sleep pa9erns for infants and children Use a differen<al diagnosis- based approach to list the elements of a sleep history and physical exam Develop a management approach to behavioural insomnia of childhood
Background Sleep problems are common concerns for parents of young children Insufficient sleep can manifest as changes in mood, behaviour, memory and a9en<on The normal amount of sleep per day varies by age (see next slide) While behavioural insomnia is a common cause of sleep difficul<es, medical causes of sleep disturbances should be considered in all pa<ents
Appropriate dura<on of sleep by age Age Newborn Infants and toddlers Preschool (2-5 years) School aged (6-12 years) Adolescents (13 years and over) Average sleep in 24 hour period (hours) 16-20 13-15 11-12 10-11 8-9
Medical causes of sleep problems in young children Neuro: nocturnal seizures, restless leg syndrome HEENT: obstruc<ve sleep apnea Resp: asthma/chronic cough Cardiac: CHF/dyspnea (PND, orthopnea) GI: GERD GU: polyuria/nocturia MSK: limb or joint pain Psychiatric: anxiety, substance use/medica<ons
The case You are seeing a 2 year old girl in your out- pa<ent clinic for sleep difficul<es. Her parents report that she has had difficul<es with her sleep over the past 6 months and they are wondering what to do.
History What would you ask?
History Onset of symptoms, progression Associated symptoms (pain, cough, nocturia, snoring, etc.) Strategies that have been tried, what has worked so far? Loca<on: Where does the pa<ent sleep? Do they have their own room or do they share? How close is their parents or caregivers room? (would they be able to hearing snoring or seizures if they occurred?) Impact of symptoms on the pa<ent and family? Known medical condi<ons and medica<on?
BEARS screening tool Ques6on Toddler/Preschool (2-5 years) and School Age (6-12 years) Bed<me problems Excessive day<me sleepiness Awakenings during the night Regularity and dura<on of sleep Snoring Difficul<es going to bed, prolonged bed<me rou<ne, sleep latency >1 hr, symptoms preven<ng sleep (pain, restless legs, cough, fears/worries, etc) Napping, falling asleep in inappropriate places (school, bus, etc). In children, day<me fa<gue may manifest as hyperac6vity and inaben6on! Cause of awakenings (pain, cough, urina<on, seizures, etc), dura<on and frequency of awakenings. Is there a consistent rou<ne used throughout the week? How many hours of sleep do they get per night? Does it vary on weekdays vs weekends? Does the pa<ent snore or have apneas?
Physical exam What would you look for?
Physical exam Growth parameters: Signs of failure to thrive? Vital signs: Hypertension? Desatura<ons? Neuro: Increased tone, abnormal reflexes? HEENT: Shape of jaw (micrognathia), tonsillar hypertrophy, rhinosinusi<s (nasal turbinate edema, sinus pain)? Resp: Signs of chronic respiratory disease (clubbing), wheezing or crackles? Cardiac: Murmurs, displaced PMI, hepatomegaly or pedal edema? GU: Hydra<on status? MSK: Joint or limb swelling or erythema?
Differential Diagnosis Neuro: nocturnal seizures, restless leg syndrome HEENT: obstruc<ve sleep apnea Resp: asthma/chronic cough Cardiac: CHF/dyspnea (PND, orthopnea) GI: GERD GU: polyuria/nocturia MSK: limb or joint pain Psychiatric: anxiety, substance use/medica<ons Developmental: behavioural insomnia of childhood
Approach to behavioural insomnia of childhood Once medical causes of sleep problems have the ruled out through a history and physical exam, the most likely cause of sleep problems is behavioural insomnia There are two types of behavioural insomnia: Sleep- onset associa<on Limit- sekng
Behavioural insomnia of childhood Sleep onset associa<on type Falling asleep is an extended process Sleep onset is delayed or sleep is disrupted Falling asleep requires special condi<ons that are problema<c or demanding (ex: being rocked to sleep, sucking a bo9le) Nigh<me awakenings require caregiver interven<on
Behavioural insomnia of childhood Limit- sekng type The child stalls or refuses to return to bed following an awakening Difficulty ini<a<ng or maintaining sleep Caregiver demonstrates insufficient limit sekng to establish appropriate sleep behaviour
Management: behavioural insomnia Consistency: Same bed<me rou<ne each night Same bed<me on weekdays and weekends Establish rules and expecta<ons for bed<me Posi<ve reinforcement for following rou<ne and staying in bed Put the child to bed drowsy but awake to allow them to fall asleep in their bed and promote self- soothing. Op<mize the sleep environment: quiet, dark and cool, use bedroom only for sleeping, no screens (TV, computers, cell phones).
Test Your Knowledge You are assessing an 8 year old boy for fatigue and poor attention. His mother asks how many hours of sleep he needs in a 24 hour period. What do you tell her? A. 7 8 hours B. 10 11 hours C. 14 15 hours D. 18 19 hours
The Answer At 8 years of age, a child would require on average 10 11 hours of sleep in a 24 hour period. B
Summary Sleep problems are a common concern in young children Medical causes of sleep problems should be ruled out with a differential diagnosis-based history and physical exam Behavioural insomnia of childhood is managed with consistent routines and good sleep hygiene
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