SLEEP DISORDERS Kenneth C. Sassower, MD Division of Sleep Medicine; Department of Neurology Massachusetts General Hospital for Children
Distinctive Features of Pediatric Sleep Daytime sleepiness uncommon Attentional and behavioral disturbances common Parasomnias common Psychophysiologic insomnia nonexistent Sleepiness vs fatigue
Sleepiness Drowsiness that interferes with daytime activity Irresistible daytime naps Increased sleep requirements Combination of all of the above
Fatigue Tiredness, exhaustion Not necessarily sleepy Lack of energy Lack of motivation Loss of exercise capacity Loss of endurance May co-exist with sleepiness in same pt
Fatigue: Causes Circadian rhythm sleep disorder Neuromuscular and mitochondrial disorder Anemia, infection Cardiac or chronic lung disease Rheumatologic or endocrinologic disease Psychiatric Physical de-conditioning
Evaluation Define chief sleep symptom: Insomnia Excessive daytime sleepiness Disturbed behavior during sleep
Sleepiness: Diagnostic Tools Subjective scales (Epworth, Stanford) Sleep diary Performance tests (Wilkinson Auditory Vigilance test) Neurophysiologic tests (Multiple Sleep Latency Test, Maintenance of Wakefulness Test, Overnight Sleep Study)
Attentional Deficit Disorder and Sleep Sleep deprivation may exacerbate ADHD symptoms May need to search for occult sleep apnea and periodic limb movements Hyperactivity of restless legs may mimic ADHD behaviors Effect of stimulants on sleep unclear
Attention Deficit Disorder and Sleep - II }Bi-directional relationship }ADD behaviors impact sleep Bedtime resistance Sleep-onset insomnia Night awakenings/motor restlessness Insufficient sleep Stimulant therapy }Sleep disturbances affect ADD symptoms Sleep apnea, Periodic limb movement disorder, Restless legs syndrome
Autism and Sleep }Mostly derived from parental surveys, few overnight sleep studies }Prevalence of sleep disorders: 44-83% (vs typically developing children 11-33%) }Insomnia: Co-existent sleep disorder (sleep apnea, periodic limb movement disorder), neurologic/systemic conditions (epilepsy, reflux disease), psychiatric disorders, medications, behavioral factors, enhanced sensitivity to ambient stimuli }Nocturnal events: Non-REM arousals, REM behavior disorder, sleep-related epilepsies
Sleepiness: Differential Diagnoses Inadequate sleep hygiene Delayed sleep phase syndrome Insufficient sleep syndrome Limit-setting sleep disorder Sleep-onset association disorder Intrinsic sleep disorders
Extrinsic Sleep Issues or Sleep Disorders Inadequate Sleep Hygiene Delayed Sleep Phase Syndrome Limit-Setting Sleep Disorder Sleep-Onset Association Disorder Insufficient Sleep Syndrome
Inadequate Sleep Hygiene: Common Complaints Trouble falling asleep Difficulty staying asleep Increased early morning awakenings Not enough sleep Nonrestorative, unrefreshing sleep Unpredictable sleep Unable to sleep when work schedule permits Needs sleeping pills to fall asleep
Inadequate Sleep Hygiene: Common Associations Consuming alcohol or caffeine Tobacco use Varying the time of going to sleep/waking up Excessive time in bed Excessive napping or dozing Developing hypnotic drug dependency and tolerance
Inadequate Sleep Hygiene: Medications That Cause Insomnia Brochodilators Decongestants Stimulants (caffeine, appetite suppressants) Diuretics Activating antidepressants Corticosteroids Alcohol
Inadequate Sleep Hygiene: Conservative Treatment Guidelines Consistent times of sleep onset/offset Avoid daytime naps Eliminate late-afternoon caffeine use Avoid evening alcohol use Reduce or eliminate tobacco use Avoid evening exercise Keep bedroom dark, quiet and cool Avoid excessive light from laptop computers, I-pads, I-phones Use bedroom only for sleep
Delayed Sleep Phase Syndrome Sleep phase occurs later than desired Difficulty in initiating sleep, waking up Most common in young adults Problem exacerbated on weekends Propensity for jobs that do not require regular hours Mood disorders common
Delayed Sleep Phase Syndrome: Diagnosis and Treatment Dx: Sleep diary Tx: Chronotherapy Early-evening Melatonin or Melatonin receptor agonists Bright-light exposure in AM (Light box of 2500 lux)
Sleep Log Two-week diary Time the patient begins to try to sleep When the patient ends the night by getting out of bed Sleep (at any time in 24-hour period) Times of caffeine, alcohol, nicotine consumption
Limit-Setting Sleep Disorder Inadequate enforcement of bedtimes by caretaker Difficulty in initiating sleep Stalling or refusing No associated medical condition Normal polysomnography
Sleep-Onset Association Disorder }Difficulty > 3 months }Occurs when not holding, rocking, breastfeeding, etc. }If holding, etc., sleep is otherwise normal }If not holding, increased sleep onset latency and awakenings
Insufficient Sleep Syndrome Most common cause of sleepiness Sleep inertia (confusion, disorientation, and grogginess on awakening) Decreased daytime performance on vigilance tasks, irritability, concentration difficulties, depression, muscle aches Catch-up sleep common: weekends/days off Often do not come to medical attention
Insufficient Sleep Syndrome: Treatment Increase sleep time of one or more hours Strategic use of caffeine or other wake-promoting agents
Common Intrinsic Sleep Disorders
Sleep apnea Periodic limb movements of sleep Restless legs syndrome Narcolepsy Idiopathic CNS hypersomnia Non-REM parasomnia REM parasomnias Intrinsic Sleep Disorders
Intrinsic Sleep Disorders: Sleep Apnea Symptoms: Snoring Respiratory pauses Increased awakenings Excessive sleepiness Diagnosis: Sleep study Management: Sleep on sides Weight loss CPAP/Bi-level Oral dental device ENT surgical approaches
Intrinsic Sleep Disorders: Periodic Limb Movements of Sleep Symptoms: Lower limb twitching movements during 1 st half of night Increased awakenings and excessive sleepiness Diagnosis: Sleep study Management: Dopamine agonists, GABA-ergic meds Low-dose benzodiazepines
Intrinsic Sleep Disorders: Restless Legs Syndrome Symptoms: Restless lower limb sensory complaints during drowsiness or just prior to going to sleep Diagnosis: Clinical history, confirmed by sleep study Management: Same as for PLMS
Intrinsic Sleep Disorders: Narcolepsy Symptoms: Extreme daytime sleepiness and REM sleep-wake dissociative behaviors Diagnosis: Overnight sleep study; Multiple Sleep Latency Test (MSLT) Management: Daytime naps, Modafinil, Armodafinil, Sodium Oxybate, Traditional stimulants
Intrinsic Sleep Disorders: Idiopathic CNS Hypersomnia Symptoms: Extreme daytime sleepiness Markedly increased sleep requirements Nonrestorative sleep Sleep drunkenness Diagnosis: Overnight sleep study, Multiple Sleep Latency Test (MSLT) Management: Similar to narcolepsy
Abnormal Arousal Behaviors } Confusional Arousals } Sleepwalking } Night terrors } Nightmares } REM behavior disorder } Sleep-related epilepsies
Non-REM Arousal Disorder Sleepwalking, Night terrors, Confusional arousals Activated by stress, fever, or relative sleep deprivation Non-REM stage III ( slow-wave ) sleep Monosyllabic utterances
Non-REM Arousal Disorder II Led back to bed peacefully Partial or total amnesia Family history common
Intrinsic Sleep Disorders: Symptoms: Nightmares Sleep paralysis Increased motor agitation (REM Behavior Disorder) Diagnosis: Sleep study; Exclusion of seizure disorder Management: Increased total sleep time Tricyclics (sleep paralysis) Low-dose benzodiazepines (REM Behavior Disorder) REM Parasomnias
Sleep-Related Epilepsies Complex partial seizures May be benign or refractory May have lateralizing features May mimic nightmares or arousal disorders Continuous spike waves during slow sleep
Polysomnography: Common Indications Early-morning awakenings of unspecified cause (either frequent awakenings, or infrequent awakenings with increased wake times) Paroxysmal nocturnal disturbances of unclear etiology Part of hypersomnia evaluation
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