Fall 2014 Meeting October 3-4, 2014 Overview of Pediatric Sleep Medicine Jason Coles MD Spectrum Medical Group Helen DeVos Children s Hospital
Conflict of Interest Disclosures for Speakers X 1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients: Type of Potential Conflict Details of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other 1. 2. 3. 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
Objectives At the conclusion of this course, attendees should be able to Understand normal sleep development and patterns in childhood Understand common pediatric sleep disorders Understand important differences between children and adults regarding conducting, scoring and interpreting sleep studies Understand strategies to make a sleep study experience child-friendly, and to optimize study quality
Development of Sleep Sleep and wake can first be determined in fetus around 28 weeks gestation 32-36 weeks gestation Active (REM) and Quiet (non-rem) sleep can be distinguished Quite Sleep (non-rem) characterized first by trace alternant EEG pattern Pattern persists until about 4 weeks after birth Develops into High Voltage Slow (HVS) activity more mature pattern of Quiet Sleep in infants
Trace alternant EEG pattern Alternating 3-8 second patterns of high amplitude slow waves and low amplitude mixed frequency activity Sleep in the child: normal and abnormal. AACP board review presentation, Lee Brooks MD
Infant Sleep Stages Sleep scored as Active (REM), Quite (NREM) or Indeterminate Scored based on multiple variables Active (REM) Quite (NREM) Behavior Smiles, grimaces, limb movements Rare movement EEG Low voltage, mixed frequency Trace alternant; high voltage slow waves EMG tone Low High Respirations Irregular Regular Eye Movements Present, rapid Absent Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sleep and arousal in infants and children. J Clin Sleep Med 2007; 3:201-40
Infant Sleep Spindles develop 2-3 months K-complexes and Slow Wave activity 4-6 months N1, N2, N3, REM can be scored once these EEG patterns distinguished Pediatric study rather than infant Nearly 50% of sleep is REM at birth Gradually decreases until age 3-4 when it stabilizes at 25% (same as adults) N3 sleep gradually decreases throughout lifetime
Changes to sleep architecture Higher density of N3 and fewer awakenings likely account for increased parasomnias in children Sleep Cycles 50-60 min at birth 75 min at 2 years 90 min at 6 years Mindell and Owens. A Clinical Guide to Pediatric Sleep 2010
Normal Patterns Newborns (0-2 months) Average 13-14.5 hours sleep, with wide variability No established Circadian pattern Sleep periods separated by 1-2 hours of wake Breast fed babies sleep for shorter periods Infants (2-12 months) Circadian patterns start to form 9-10 hours at night plus 3-4 hours of naps = 12-13 hours overall By 1 year, number of naps decrease to 1-2/day
Normal Patterns Toddlers (1-3 years) Average 9.5-10.5 hours at night plus 2-3 hours in naps = 11-13 hours overall By 18 months down to 1 nap per day Nearly half stop napping by age 3 Preschool (3-5 years) 9-10 hours of sleep at night Only 15% of 5 year olds still take a nap
Normal Patterns School age (6-12 years) Average 9-10 hours of sleep Adolescents (12-18 years) 9-9.25 hours recommended But, average is only 7-7.5 hours at night 2-hour sleep debt accumulates per night across the school week Most parents think their teens are getting enough sleep
Common Pediatric Sleep Disorders Insomnia Problems going to bed Night wakings Delayed sleep phase Obstructive sleep apnea Restless legs syndrome (Willis-Ekbom Disease) and Periodic limb movement disorder Parasomnias
Insomnia
Behavioral Pediatric Insomnia: Night wakings Sleep onset association disorder How we fall asleep is learned Physical parental presence can become part of the ritual Normal awakenings occur multiple times a night Child doesn t know how to fall back asleep without his parents, so seeks them out by any means necessary Multiple awakenings per night, waking parents each time
Sleep Onset Association Disorder Treatment Behavioral interventions Educate parents Replace physical parental presence with new sleep onset associations that will be present when child wakes at night Parents leave room before child falls asleep If child cries, frequent checks and reassurance, but with increasing intervals If child comes out of room, take right back and tuck back in without unnecessary conversation, arguing, etc Child not allowed to sleep with parents
Behavioral Insomnia: Problems going to bed Limit Setting Sleep Disorder Child is physiologically able to fall asleep, but doesn t stay in bed long enough Refusals Stalling Repeated demands Create any reason (and many reasons) to stay up Parents intermittently or eventually give in, reinforcing behavior Child gains attention and special time from parents (even if arguing)
Limit Setting Sleep Disorder Comes out of room repeatedly because child can t fall asleep because Thirsty Hungry Afraid of dark, monsters, being alone Stomach hurts Not tired, etc Treatment: Behavioral Interventions Set clear, 100% predictable, 100% consistent limits Bed time is strictly enforced, following an enforced wind down period beginning predictably 1-2 hours before bed Do not give in to protests or requests after bed time Decide who is going to win
Delayed Sleep Phase Syndrome Sleep physiology is completely normal, but timing of sleep cycle is misaligned with school/daytime responsibilities Not ready or able to fall asleep early at night Body not ready to wake up for school most sleepy during first part of the day Total sleep becomes inadequate, causing cumulative sleep deprivation; trying to catch up on weekends If allowed to get enough total sleep, feels normal Runs in families Develops in adolescence most adolescents will have at least a mild shift in circadian rhythm
Delayed Sleep Phase Syndrome Treatment Education Properly timed melatonin in the evenings Bright light exposure in the mornings Consistent schedule 7 days a week
Obstructive Sleep Apnea
Obstructive Sleep Apnea Epidemiology 8% children snore frequently, according to parents Always snoring 1.5-6% 1-4% school age children have OSA based on PSG Peak age 2-8 years Corresponds to the peak of lymphoid hyperplasia, and adenotonsillar hypertrophy Boys and girls equal until adolescence, when boys outnumber girls (similar to adult patterns) More frequent in African-American and Asian children
OSA Risk Factors Enlarged tonsils and/or adenoids Allergies Facial abnormalities Small chin Narrow hard palate Cleft palate repair Down syndrome Obesity Neuro-Muscular disorders
OSA Night Symptoms Snoring most common complaint With or without snorting, choking, gasping, or witnessed pauses in breathing Restless sleep (tossing and turning) Sleeping in strange positions (extending neck to open airway) Sweats Bed wetting
OSA Daytime Symptoms Daytime sleepiness not present in most kids (less than 10%) Behavioral problems Inattention Hyperactivity Irritability Decreased school performance Morning headaches
OSA Medical Consequences Hypertension Pulmonary hypertension Failure to thrive (slow growth) Heart failure
Diagnosis of OSA Clinical history cannot predict presence or absence of childhood OSA Severe OSA can be present even with soft snoring and minimal symptoms Physical examination is often normal Degree of tonsillar hypertrophy does not correlate with presence of OSA Parental perception varies widely Sleep study is needed
OSA Treatments Adenotonsillectomy Recommended 1 st line treatment by American Academy of Pediatrics Large study* in 2010 demonstrated complete resolution of OSA in only 27% of kids, though most were improved High AHI, older age, obesity and asthma predict failure Rapid maxillary expansion (orthodontic) Medical management of allergies and GERD CPAP/BiPAP Craniofacial surgery Tracheostomy *Bhattacharjee et al. Adenotonsillectomy Outcomes in Treatment of Obstructive Sleep Apnea in Children. Am J Crit Care Med 2010; 182: 676-683
Central Sleep Apnea Usually periodic breathing Can be a sign of structural brain abnormalities Arnold Chiari malformation If significant, MRI brain is recommended Treatment protocols for central apnea are not defined Treat OSA if present (start with T&A) Neurosurgical consultation for Chiari malformation Oxygen CPAP BiPAP ASV/APAPs
12 year old with brain stem tumor
Trial of BiPAP with backup rate 12
Trial of BiPAP ASV
Restless Legs and PLMs
Restless Legs and Periodic Limb Movements Restless legs syndrome Clinical diagnosis Uncomfortable sensations in the legs accompanied by urge to move them Often described as growing pains Worse at night or when inactive (car rides) Periodic Limb Movement Disorder Identified PLMs on polysomnography Brief (0.5-10 seconds) repetitive limb movements, not in association with OSA For children, >5 per hour required AND associated with sleep or daytime symptoms
Periodic Limb Movements
RLS and PLMD 70-90% of adults with RLS also have PLMs (not studied in kids) Share underlying abnormalities in the brain s dopamine system Thought to be under-recognized generally
Pediatric RLS Present in 1-6% of kids Equal rates in boys and girls (unlike adults) Possibly life long and severe Risk factors Family history Sleep deprivation or poor sleep hygiene Caffeine Antihistamines Antidepressants Iron deficiency (ferritin < 50 ng/ml) Present in 75% of kids with RLS
Pediatric PLMs Same link with iron deficiency and antidepressants 50% of kids with PLMs also have OSA on sleep study Treatment of OSA resolves the PLMs in 50% of these kids
Treatments for RLS/PLMD Replace iron if ferritin is low Stop or reduce antidepressants Avoid caffeine Good sleep hygiene Treat OSA if present Exercise, stretching, massage Medications only approved for adults
Parasomnias
Parasomnias Episodic disorders in sleep Not resulting in complaint of excessive sleepiness or insomnia Arousal disorders REM related disorders Sleep-wake transition disorders
Arousal Disorders Partial arousal from deep non-rem sleep Occurs typically first third of the night Difficult to wake up No recall of event Worsened by Sleep deprivation Sleep fragmentation (sleep apnea, caffeine) Psychological factors Anxiety, stress, change
Arousal Disorders Somnambulism 40% of kids at least once 5% frequently Outgrown usually by age 15 Dangerous Sleep Terrors Abrupt onset Blood curdling scream or cry Confusion, agitation, tachycardia Not associated with dream Confusional arousals
Arousal Disorders Treatment Reassurance Insure safety!! Locks, door alarms, gates Good sleep hygiene Minimize triggers (sleep apnea) Medications (benzodiazepines)
REM Associated Disorders Nightmares Last 3 rd of night Remembers dream, able to fully awaken REM Behavioral Disorder Sleep paralysis
Sleep-Wake Transition Disorders Rhythmic Movement Disorders Head banging, Body rocking as way to self-sooth and transition to sleep 2/3 of normal children Usually ends by age 4 Hypnic Jerks Occurs with transition to N1 60-70% or normal people Somniloquy very common
Pediatric Polysomnography Must be child oriented. Ergonomically pediatric. Techs must be experienced, motivated to work with children, and very patient! Can be performed on any child of any age Most children tolerate it well Parent must accompany child for entire evening Interpretation and scoring different from adult criteria Children have shorter and fewer events, and higher proportion of partial obstructions: scoring requires great care
Getting better studies Parents are the experts for their child; use them Try to adapt to family routines Explain everything to parents to keep them involved Environment should resemble a child s room Quiet, appropriate room temperature Age appropriate toys, pictures, books Parental accommodations should be comfortable Room child-proofed Quality of study directly dependent on the skill of the technologist Preferably experienced and enjoys working with kids Set up should be fun Distraction Adequate staffing liberal use of 1:1 especially for set up Document everything!
PSG Interpretation Adult criteria do not apply to children 80% of kids with clinically significant OSA would be missed Cutoffs continue to be debated, but abnormal if AHI>1 (HDVCH uses AHI 1.5 or OAI of 1.0) EtCO2 > 45 mmhg for >60% of TST (some researchers suggest this cutoff should be as low as 10%) Pediatric respiratory scoring rules may be used until age 18 Adult respiratory scoring rules may be used starting at age 13
Pediatric PSG Scoring Sleep Stages Wakefulness defined by dominant posterior rhythm gradually increasing in frequency with age until full alpha rhythm of 8 Hz first seen at ages 1-3 Stages N1, N2, N3, and REM similar rules as adults, can be scored as soon as K-complexes and Spindles seen (2-6 months) N (NREM), REM, and Indeterminate scored if <6 months, and no N2 Cardiac Events Heart rates 2 Standard Deviations from the mean, based on age normative values
Respiratory Monitoring Apneas detected by thermal sensor Alternate (if not reliable) nasal pressure transducer Hypopneas detected by nasal pressure transducer Alternate oronasal thermal sensor Alveolar hypoventilation detected by either transcutaneous (Tc) or end-tidal (ET) PCO2 Crucial to obtain a plateau in the EtCO2 waveform for the signal to be considered valid Transcutaneous PCO2 not always reliable Et PCO2 will yield inaccurately low values if Nasal obstruction Nasal secretions Obligate mouth breathers Receiving supplemental oxygen
Scoring Respiratory Events Obstructive Apnea Central Apnea Adults 10 seconds with respiratory effort 10 seconds with no respiratory effort Children 2 missed breaths with respiratory effort 20 seconds or 2 missed breaths with arousal or 3% desaturation Hypopnea Hypoventilation Periodic Breathing 10 seconds 30% drop in nasal pressure with arousal or 3% desat PCO2 > 55 mmhg for 10 minutes Cheyne-Stokes breathing pattern 2 breaths 30% drop in nasal pressure with arousal or 3% desat PCO2 > 50 mmhg for > 25% TST 3 episodes of CA lasting >3 seconds, separated by 20 seconds or normal breathing AASM Manual for the Scoring of Sleep and Associated Events Version 2.0. 2012
Obstructive Apneas
Hypopneas
Obstructive Hypoventilation
Periodic Breathing
Summary Pediatric sleep and sleep disorders can appear very different from adult patients Pediatric sleep studies present special challenges to perform and interpret Treatment of pediatric sleep disorders can sometimes require more trial and error, and an appreciation for the child as a member of a family
References Berry RB, Brooks R, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL and Vaughn BV for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.0.2. www.aasmnet.org, Darien, Illinois: American Academy of Sleep Medicine, 2013 Mindell J, Owens J. Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2010 Sheldon S, Ferber R, Kryger M. Principles and Practice of Pediatric Sleep Medicine, 2005