Children and Sleep Apnea
Sleep disorders are a group of conditions that affect the ability to sleep well on a regular basis. Most people occasionally experience sleeping problems due to stress, hectic schedules, and other outside influences.
There are differences between adult sleep apnea and pediatric sleep apnea. Adults usually have daytime sleepiness, children are more likely to have behavioral problems. The underlying cause in adults is often obesity, while in children the most common underlying condition is enlargement of the adenoids and tonsils. However, obesity also plays a role in children. Other underlying factors can be craniofacial anomalies and neuromuscular disorders.
Pediatric sleep disorders increasingly interfere with daily patient and family functioning. Interest in and treatment of sleep disturbances in youth continues to grow, but research lags. One survey indicated that pediatricians were more likely to prescribe antidepressant medications for insomnia than psychiatrists. Further investigation is needed to develop fact-based diagnosis and the treatment of pediatric sleep disorders.
The consequences of untreated sleep problems may include significant emotional, behavioral, and cognitive dysfunction. The magnitude of these events is inversely proportional to the child’s overall ability to adapt and develop in spite of the sleep disturbance. Sleep regulation remains a critical part of health for youths. Elevated rates of sleep problems exist among children and adolescents with neurodevelopmental, nonpsychiatric medical conditions and psychiatric disorders.
Factors such as increased societal demands, academic pressures, family-related stressors (e.g., parental discord), and onset of puberty heighten the risk of sleep problems in adolescents.
Early diagnosis and treatment are important to prevent complications that can impact children’s growth, cognitive development and behavior.
Pediatric sleep disorders require careful and extended evaluations that includes interviewing the parents, child, teachers, as well as assigning and reviewing sleep diaries. Parents should be encouraged to record children’s sleep-wake habits using sleep diaries over a 24-hour period for at least two continuous weeks prior to initial visit. This can be useful to support the reported sleep-related complaints as well as guide routine history taking. Sleep diaries also assist in detecting day-to-day variability in sleep patterns that can often be missed during routine history and physical exams.
Current evidence indicates that chronically disrupted sleep in children and adolescents can lead to problems in cognitive functioning, such as attention, learning, and memory. Behavioral interventions, especially in young children, have been shown to produce clinically significant improvements. This is of particular importance given the relative lack of data regarding use of pharmacological interventions for sleep difficulties in children.
Graphic diaries appear to be more helpful in understanding sleep-wake cycles in pediatric patients rather than descriptive data. An example of a graphic sleep diary can be found at the sleep education website endorsed by the American Academy of Sleep Medicine (AASM) and is available for free download at its Web site. A simple acronym like BEARS (4), which stands for bedtime resistance/sleep onset delay; excessive daytime sleepiness; awakenings at night; regularity, patterns, and duration of sleep; and snoring and other symptoms, can be useful during initial screening of a child’s sleep difficulties.
Self-report sleep questionnaires, such as the School Sleep Habits Survey and Children’s Sleep Habits Questionnaire (CSHQ) are useful to screen for more specific sleep disorders in target populations, such as adolescents and school-aged children(6) The Sleep Disturbance Scale for Children (SDSC) is a useful 26-item parent questionnaire that was developed for children and adolescents to screen for primary sleep disorders such as obstructive sleep apnea.
Obtaining a detailed and accurate history followed by a physical exam, including screening for developmental delays and cognitive dysfunction, appears to be a cornerstone for diagnosing pediatric sleep complaints. It is equally important to involve family members in the clinical interview to understand the potential causes of sleep disturbances because children and adolescents often do not recognize events that can disturb sleep. For example, they are usually not aware of snoring or leg movements that occur during sleep. Patients are unaware if they get deep and restful sleep. They may be sleeping but not getting “good” sleep.
The physical exam may provide clues to treatable medical causes. Diagnostic tests are available but difficult to access in some communities. Many sleep problems in children can be improved with instruction on sleep hygiene and the importance of sleep to health and behavior. Medical causes of sleep problems are rare but often benefit from treatment and therefore warrant attention during any evaluation.
At one time, elementary school children went to bed easily and woke up early, naturally without alarms. Now their sleep is disrupted by TV, computer games, texting, and other digital distractions. Sleep deprivation is often the primary cause now of inattention, school failure, poor peer relations, and obesity. Medical causes of sleep problems are often overlooked in children because of their difficulty in reporting symptoms.
Primary sleep disorders, such as obstructive sleep apnea (OSA) and restless legs syndrome (RLS), in children have been shown to be associated with excessive daytime sleepiness, impaired attentional capacity and memory, behavioral issues, and attention deficit hyperactivity disorder (ADHD).
Pediatric OSA is a sleep disorder in which a child’s breathing is completely or partially blocked, often repeatedly during sleep. This is caused by narrowing or blockage of the upper airway during sleep. These breathing disturbances often result in brief arousals from sleep, which can interfere with obtaining good quality sleep. Therefore, screening for daytime impairments are important in children suspected of having obstructive sleep apnea (OSA)
While bedtime difficulties and frequent night time awakenings are seen during infancy and early childhood, sleep difficulties due to insufficient sleep hygiene or circadian rhythm disorders tend to be more prominent in adolescence. Sleep problems in children and adolescents can complicate other underlying medical condition, such as obesity and asthma, and psychological problems, such as depression, anxiety, and substance abuse.
Does Your Child Have A Sleep Disorder?
The chances that your toddler will have a sleep problem go up if he’s a boy, if this is your first child, or if your child is prone to ear infections, among other reasons. Parents are often more anxious about attending to firstborn children and tend to let bedtime routines and rules slide. Boys are more vulnerable to many problems (including hyperactivity and other disorders) that can interfere with sleep.
Calculating body mass index (BMI) after obtaining height and weight variables and measuring waist circumference is important since higher BMI and larger waist circumference are independent risk factors in predicting severity of sleep-disordered breathing, especially in older children who are overweight or obese.
Obtaining blood pressure measurement is equally important. A physical exam can be focused (e.g., examination of upper airway and nasal passages in a healthy, developmentally appropriate child with parental complaints of snoring and excessive daytime sleepiness) or comprehensive (e.g., in children with neuromuscular disorders and chronic illnesses). Physical exam can be aided further by lateral neck x-rays (if suspected OSA) and lab work, such as serum iron and ferritin levels (if sleep-related limb movements are suspected).
Overnight polysomnography (PSG) has been recommended as a “gold standard” for the diagnosis of sleep-related breathing disorders (SRBD), such as obstructive sleep apnea (OSA), in children and adolescents. Polysomnography, however, is not useful for diagnosing behavioral sleep disorders, such as behavioral insomnia unless the presence of an underlying sleep disorder (e.g., SRBD) is suspected. Diagnostic tests such as multiple sleep latency test (MSLT) can be useful to explore presence of sleep disorders (e.g., narcolepsy) that can predispose children and adolescents to excessive daytime sleepiness after a non-eventful PSG is performed.
Teenagers with chronic sleep deprivation appear to be increasingly involved in motor vehicle accidents compared to other age groups making assessment of sleepiness an important public health and safety issue. In this regard, the maintenance of wakefulness test (MWT) may be a useful diagnostic tool to determine if the adolescent’s inability to remain awake poses a significant personal and public safety problem (14). The MWT measures an individual’s ability to remain awake in quiet, comfortable, and dark surroundings. Using an instrument called an actigraph (that may be worn as a wrist-watch) may help obtain sleep-wake measurements. The American Academy of Sleep Medicine (AASM) says that data obtained from a combination of sleep diaries and actigraphy tend to correlate well together (3).
To diagnose pediatric sleep apnea, the doctor will review your child’s symptoms and medical history and conduct a physical exam. He or she might order several tests to diagnose the condition.
Tests might include:
Oximetry. If doctors strongly suspect obstructive sleep apnea, and a full polysomnogram isn’t needed or available, an overnight recording of oxygen levels might help screen for sleep apnea, Oximetry can be done at home. However, it sometimes fails to give the diagnosis, in which case your child will still need to have a polysomnogram.
Polysomnogram (PSG). Doctors evaluate your child’s condition during an overnight sleep study. This test uses sensors applied to the body to record brain wave activity, breathing patterns, snoring, oxygen levels, heart rate and muscle activity while your child sleeps.
Electrocardiogram. In an electrocardiogram, sensor patches with wires attached (electrodes) measure the electrical impulses given off by your child’s heart. Doctors may use this test to determine if your child has an underlying heart condition.
During sleep, signs and symptoms of pediatric sleep apnea might include:
- Bed wetting
- Sleep terrors
- Restless sleep
- Snorting, coughing or choking
- Pauses in breathing
- Mouth breathing
Infants and young children with obstructive sleep apnea (OSA) don’t always snore. They might just have disturbed sleep.
During the day, children with OSA might:
- Have poor weight gain
- Be hyperactive
- Have behavioral problems
- Have difficulty paying attention
- Have learning problems
- Perform poorly in school
Besides obesity, other risk factors for pediatric sleep apnea include having:
- Down syndrome
- History of low birth weight
- Abnormalities in the skull or face
- Neuromuscular disease
- Sickle cell disease
- Cerebral palsy
- Family history of obstructive sleep apnea
Pediatric obstructive sleep apnea can have serious complications, including:
- Failure to grow
- Heart problems
Your doctor will work with you to find the most appropriate treatment for your child’s sleep apnea. Treatment might include:
Removal of the tonsils and adenoids. Your doctor might refer your child to a pediatric ear, nose and throat specialist to discuss removing the tonsils and adenoids. An adenotonsillectomy (ad-uh-no-ton-sil-EK-tuh-me) might improve obstructive sleep apnea by opening the airway. Other forms of upper airway surgery might be recommended, based on the child’s condition.
Medications. Topical nasal steroids might ease sleep apnea symptoms for some children with mild OSA.
For kids with allergies, Singulair might help relieve symptoms when used alone, or with nasal steroids.
Positive airway pressure therapy. In continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP), small machines gently blow air through a tube and mask attached to your child’s nose, or nose and mouth. The machine sends air pressure into the back of your child’s throat to keep your child’s airway open (air splint). Doctors often treat pediatric OSA with positive airway pressure therapy.
Proper fitting of the mask and refitting as the child grows can help the child tolerate the mask over the face.
Oral appliances. Oral appliances, such as dental devices or mouthpieces, move your child’s bottom jaw and tongue forward to keep your child’s upper airway open. Only some children benefit from such devices
Lifestyle and Home Remedies
Avoid airway irritants and allergens. All children, but especially those with pediatric OSA, should avoid tobacco smoke or other indoor allergens or pollutants, as they can cause airway irritation and congestion.
Weight loss. Doctors may recommend that your child lose weight if he or she is obese. Your doctor can provide you and your child with diet and nutrition information, or refer your child to other specialists with expertise in managing obesity.
Preparing For Your Appointment
You’ll likely start by seeing your child’s primary care provider (PCP). Or, you might be referred immediately to an ear, nose and throat (ENT) specialist or a sleep medicine specialist.
Here’s some information to help you get ready for your appointment.
What you can do
Make a list of:
- Your child’s symptoms, including any that seem unrelated to the reason for your appointment.
- All medications, vitamins or other supplements your child takes, including the doses.
- Sleep and Diet Diary recording all sleep and food intake.
Questions to ask your doctor
- For pediatric obstructive sleep apnea, some basic questions to ask your doctor include:
- What tests are needed? Is this condition likely temporary or chronic?
- What’s the best course of action?
- What are the alternatives to the primary approach you’re suggesting?
- Should I take my child to a specialist?
- Are there brochures or other printed material I can have?
- What websites do you recommend?
Don’t hesitate to ask other questions.
What to Expect From Your Doctor
Your doctor is likely to ask you questions, such as:
- Does your child snore? What else have you observed about your child’s sleep?
- Does your child have problems paying attention?
- Does your child have learning difficulties?
- Do you have a family history of obstructive sleep apnea (OSA)?
- Does your child have excessive daytime sleepiness?
Some Common Sleep Disorders in Children and Adolescents
SRBD. Sleep-Related Breathing Disorders includes habitual snoring at its least severe form and obstructive sleep apnea (OSA) at its most severe form. In children and adolescents, concern for symptoms (e. g., snoring) suggestive of underlying SRBD, such as obstructive sleep apnea (OSA), needs further examination of possible symptoms including witnessed pauses in breathing, chronic morning headaches, dry mouth/throat, night-time bed wetting, early morning thirst, feelings of grogginess or fatigue upon awakening, history of chronic ear infections, recent weight gain, and chronic mouth breathing.
The association between SRBD and ADHD is well documented (12). The association of SRBD with low academic performance, behavioral disorders, learning difficulties has been shown in these studies. Treatment has shown improvement in ADHD following the treatment of SRBD, providing additional evidence into this “bidirectional” relationship.
Enlarged tonsils is a common cause of SRBD in children. An exam finding tonsil enlargement is sometimes absent in children with suspected SRBD, but other characteristics such as a nasal septal deviation or high-arched palate can predispose a child to a SRBD. If nasal polyps or other nasal/oral obstruction is suspected, a consultation with an ENT may be needed. It is also important to note that children with disorders such as Down’s syndrome or Prader-Willi syndrome with craniofacial abnormalities, including mid-face hypoplasia, may also have a SRBD.
Other risk factors associated with SRBD include obesity (high BMI, large waist circumference), chronic sinus problems, recurrent wheezing, nasal allergies, or a family history of OSA If a child is suspected of having a SRBD he or she should be referred for an overnight polysomnogram (PSG). A PSG can measure apneas (cessation in airflow with effort) or hypopneas (reduction in airflow) and is used to determine the apnea-hypopnea index (AHI), which is the total number of apneas and hypopneas per hour of sleep. An AHI 5 to 15 is considered mild, 16-29 is considered moderate, 30 or higher is considered severe.
In many circumstances, adenotonsillectomy (AT) is considered the treatment of choice once moderate-to-severe AHI is documented on initial polysomnography. Symptom alleviation in SRBD after AT has been shown to be as high as 83 percent. However, persistent symptoms are seen in patients who are obese or have craniofacial abnormalities. A PSG may be repeated in a few months after AT to reevaluate the severity of persistent SRBD.
Sleep-related movement disorders. Sleep-related movement disorders in children include sleep myoclonus of infancy, rhythmic movement disorder, periodic limb movement disorder (PLMD), and restless legs syndrome (RLS). Sleep myoclonus of infancy is typically associated with clusters of jerks that involve the whole body or limbs and are usually considered to be benign and gradually disappear after six months of age.
In rhythmic movement disorder (RMD), a child exhibits repetitive and stereotyped motor behaviors involving large muscle groups and are mostly sleep related. RMD can also be associated with daytime impairments and/or associated with self-inflicted bodily injuries. Nocturnal seizures may mimic REM sleep behavior disorder. However, these behaviors are more stereotyped. Symptoms in young individuals are usually an indication of narcolepsy or medication-induced REM sleep behavior disorder. Symptoms in young females are more likely to be caused by narcolepsy.
Diagnosis can be made using video PSG and treatment includes ensuring safety of the child during sleep. RMD should gradually resolve by five years of age. Symptoms beyond five years of age can be seen in children with developmental disorders. Treatment with medications such as clonazepam has been shown to be useful in severe cases of RMD.
Periodic limb movements in sleep (PLMS) are brief jerks (movements) during sleep occurring over a period of time and occur more commonly in the legs than the arms. Patients are usually unaware of these symptoms. If sleep disruption due to PLMS is documented on a PSG and PLMS cannot be explained by any other underlying sleep disorder, then such movements may be considered PLMD.
RLS in childhood is diagnosed using the same criteria that is used in adults and is usually supported by other features, such as family history and/or PLMS on polysomnography. Some RLS symptoms include: 1) A “need” to move the legs, 2) the “need” to move begins or worsens when lying down or sitting, 3) the “need” to move is sometimes relieved by movement, and 4) the “need: to move is worse in the evening or night or only occurs at night. Sleep-onset (the length of time it takes to fall asleep) can be a common occurrence in children with underlying RLS.
Behavioral treatment options for RLS and associated sleep disturbances in children and adolescents include enforcing strict routines for bedtime and wake-up time, reducing environmental stimulation prior to/at bedtime (e. g., limiting TV and cell phones), and encouraging daily physical exercise.
Childhood insomnia. Insomnia in children is repeated difficulty falling asleep, the total duration of sleep, or quality of sleep that occurs during appropriate times and opportunity for sleep. Behavioral insomnia of childhood (BIC) is the bedtime refusal or resistance to fall asleep, delayed start of sleep, and/or prolonged night-time waking.
BIC is classified into three categories: 1) limit-setting type, 2) sleep-onset association type, 3) and combined type. In limit-setting type the child delays bedtime by refusing to go to bed and the parent has a hard time setting limits and allows the child to stay up past their “bed-time. ”
In the sleep-onset association type the child may have difficulty falling asleep independently and may associate falling asleep with certain signals or activity such as:
1) Feeding from a bottle, being rocked, or watching television,
2) Going to a certain place like a couch or the parent’s bed,
3) Or the presence of the parent.
So, then these circumstances become required signals for the child to initiate or re-initiate sleep. If a child requires certain circumstances to initiate sleep without parent limitations, the diagnosis may be the combined type.
The diagnosis of pediatric insomnia is almost always multifactorial (encompassing data from multiple indicators). Assessment should include screening for presence of developmental disorders; functional impairments at school and home; and any associated burden on the parents. It is also important to screen for presence of OSA or RLS, as these may be possible causes of insomnia.
It is important to consider whether the delay in sleep onset and/or staying asleep are due to inconsistent sleep or napping schedules. For example, parents may have the children napping even though doing so may be outside of a child’s developmental need, in other words “naps might no longer be appropriate. ” Doing so may lead to difficulty regulating the child’s sleep-wake schedule.
The same issues relate to teenagers. A variable sleep schedule, later bedtimes, and early school start times may be associated with inappropriate napping. Adolescents who regularly take long naps will likely take longer to fall asleep at bedtime, further disrupting the sleep-wake cycle.
Behavioral interventions should be the first line of treatment for pediatric insomnia. (Possibly in conjunction with medications). These interventions aim to help initiate/maintain sleep resulting in increased total sleep time and improved sleep quality.
The American Academy of Sleep Medicine (AASM) found that behavioral interventions produce reliable and lasting improvements in bedtime problems both in infants and young children. Sleep problems in children younger than age 5 improved in 94 percent of the 54 studies reviewed, and over 80 percent of children benefited from treatment with most improvements continuing for 3 to 6 months. The key for success is parental consistency in implementing the proper sleep management techniques. Some techniques may need to be tailored for the parent and child when taking into account issues such as room-sharing, parental skills, siblings, and parental stress.
For older children, behavioral strategies such as sleep hygiene education is particularly important. Also muscle relaxation, stimulus control, and cognitive behavioral therapy techniques, such as increasing positive thinking, thought stopping, and journaling “worries” at bedtime, are often recommended.
Parasomnias. Parasomnias are defined as undesirable physical events or experiences that occur while falling asleep, within sleep, or during arousals from sleep. Parasomnias result in disruption of an existing state of sleep. Most parasomnias affect otherwise healthy youths and commonly subside over the course of adolescence. They are classified as either rapid eye-movement (REM) parasomnias or non-REM parasomnias depending on the stages (type) of sleep at the time.
Non-REM parasomnias (also termed arousal disorders) involve simple or complex behaviors as a consequence of arousal from slow-wave sleep (N3, Delta, or deep sleep), usually in the first half of the night. They are associated with confusion and amnesia to an event.
Confusional arousals, night-terrors, and sleep walking (somnambulism) are also considered to be part of non-REM parasomnias. Confusional arousals tend to occur immediately after falling asleep or early in the early morning. This seems to be more common in early childhood and usually resolves itself by the age of 5.
Night terrors are often associated with crying (consoling usually delays recovery from the event) and physical activity related to the night terror. Night terrors occur in the first few hours of sleep. Nightmares involve vivid recall, whereas night terrors generally have amnesia of the event.
Night terrors appear to be generally mild during childhood; however more severe forms may require behavioral interventions such as scheduled awakenings and treatment with medications like clonazepam.
Nightmares are arousals from “dream” sleep (REM stage). Nightmares generally have no associated amnesia or confusion when the child is awakened. Nightmares usually diminish by the age of 6. Repeated occurrences of extended, unpleasant, and well-remembered dreams often occur during the second half of sleep and is defined as a nightmare disorder. When awakened, the individual is rapidly alert and oriented.
In some cases, fear of nightmares may cause some children to be afraid to try and go to sleep because of the association between past nightmares and sleep, this can lead to insomnia. Parental reassurance to the child may be helpful.
Sleep walking can include complex behaviors, such as walking while still sleeping. Chronic sleep deprivation (reduced sleep) has been shown to increase the frequency of sleep-walking it’s important to maintain proper sleep hygiene to help prevent sleep walking. It is also important to know that certain conditions (e. g., Tourette’s syndrome and migraines) may be associated with increased likelihood of sleep walking.
Parasomnias have been shown to sometimes be preceded by an undiagnosed SRBD, such as OSA. Therefore, presence of a SRBD should be screened for in children who have recurring parasomnias. Treatment usually starts with behavioral management (e. g., scheduled awakenings, sleep hygiene, and avoiding sleep deprivation).
Arousal disorders are sometimes mistakenly grouped under the common entity nightmares. It is important to note this distinction because nightmares are considered to be a REM sleep-related parasomnia and can involve a different management strategy altogether. The distinction can be diagnosed by a PSG.
Other REM parasomnias, such as REM behavior disorder and recurrent intermittent sleep paralysis (RISP), are rare in childhood. Sleep enuresis (wetting the bed while sleeping) belongs to a miscellaneous group of parasomnias (e. g. sleep-related bruxism, sleep-related groaning, sleep talking or somniloquy) that are not related to any specific stage of sleep.
Sleep enuresis is defined as involuntary urination during sleep at least twice per week in children at least 5 years of age. It is usually classified as either primary or secondary. Primary is when the child has never been consistently dry at night. However, if the child has experienced at least six months of dryness during sleep and then begins bedwetting again, the condition is referred to as secondary enuresis.
Secondary enuresis can occur from recent psychological stressors or undiagnosed medical illnesses, such as diabetes, epilepsy, urinary tract infections, hyperthyroidism, and OSA. Restricting evening intake of fluids, limiting caffeine intake, establishing a bedtime toileting schedule, and positive reinforcements with rewards can be beneficial.
Diagnostic evaluation using an overnight polysomnogram is rarely needed to diagnose parasomnias unless initial clinical evaluation is needed for the “type” of parasomnia and if the child is engaging in dangerous sleep behaviors.
Circadian rhythm sleep disorders. Delayed sleep phase syndrome (DSPS) is the most common sleep circadian rhythm disorder seen in adolescents and is characterized by a shift in sleep onset to later times of the night. Children with DSPS have difficulty falling asleep at the scheduled bedtime and unable to wake spontaneously at the desired wake time in the morning. This results in delayed bedtime later that night, delayed sleep-onset, reduced sleep duration, chronic sleep deprivation, and excessive daytime sleepiness (EDS). Most children with DSPS can sleep into late mornings or early afternoon if given the opportunity.
Some teenagers voluntarily delay their bedtime as a means to avoid school (intentional sleep-phase delay), and should be screened for underlying reasons that prompt such behaviors (e. g., exposure to school-related bullying, academic pressures, undiagnosed learning disabilities, or worsening ADHD).
Behavioral interventions, such as maintaining a consistent sleep-wake schedule seven days a week, are the mainstay of treatment.
Hypersomnolence disorders. Hypersomnolence is characterized by recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep. It is the need to sleep despite already obtaining adequate sleep and having at least one of the following symptoms:
Recurrent periods of sleep or naps within the same day A prolonged sleep of more than 9 hours per day that is not refreshing Difficulty being fully awake after abrupt awakening
Children with hypersomnolence disorder tend to fall asleep quickly and have good sleep efficiency (>90%). But even with adequate and successful sleep, they awake with sleep drunkenness and appear confused or combative and naps are not refreshing despite lasting more than 1 hour. The disorder often begins in late adolescence (17-24 years of age).
PSG findings include normal-to-prolonged sleep duration, short sleep onset (< 8 min), normal-to-increased sleep continuity, and normal levels of rapid eye movement (REM) sleep but increased amounts of deep (slow-wave) sleep. During naps REM may be present but may occur in less than 2 times.
Narcolepsy. Pediatric narcolepsy is defined as recurrent periods of an irrepressible need to sleep, lapsing into sleep, or multiple napping that occurs within the same day. In these pediatric patients, excessive daytime sleepiness (EDS) is the most common first symptom. Symptom onset peaks around 15 years of age.
Nocturnal sleep PSG shows REM sleep latency to be less than or equal to 15 minutes or a multiple sleep latency test (MSLT) shows a mean sleep onset of less than or equal to 8 minutes with 2 or more these naps showing a sleep-onset REM periods.
REM and Non-REM sleep mechanisms can be disrupted in youths with narcolepsy. REM-associated sleep phenomena intrude into the awakened state. Sleep attacks (falling sleep), cataplexy (abrupt atony precipitated by strong emotions), and hypnagogic and hypnopompic hallucinations (experienced as dreamlike events immediately before sleep onset or upon awakening) are also characteristic of narcolepsy.
Narcolepsy triggered by streptococcus infections, H1N1 influenza, and H1N1 vaccinations have been reported. Narcolepsy can be diagnosed even when secondary to infections, trauma, or tumor, such as in Whipple disease.
Breathing-Related Sleep Disorders
The International Classification of Sleep Disorders identifies many types of sleep-related breathing disorders. Among them are Obstructive Sleep Apnea (OSA), Central Sleep Apnea (CSA), and Sleep-Related Hypoventilation. This simplification is to facilitate the recognition of these sleep problems and referral for further evaluation of the child.
Obstructive Sleep Apnea
OSA is sometimes poorly understood. Obesity is now recognized as one of leading risk factors for increasing rates of OSA in both the pediatric and adult populations. Snoring is common in OSA, but some children with OSA have no snoring. Certain medical conditions such as Prader-Willi syndrome or trisomy 21 (Down syndrome) increase the risk for OSA because of midline deformities such as macroglossia, micrognathia, midface hypoplasia.
OSA is confirmed through a PSG study and is defined as at least 5 obstructive apneas or hypopneas per hour (AHI) of sleep. Research criteria used to identify children with OSA is less stringent, setting the threshold of hypopneas at 1 to 5 events per hour.
Central Sleep Apnea
CSA is caused by a variability in respiratory effort that results in repeated episodes of apneas during sleep. Central sleep apnea and obstructive sleep apnea can coexist. Central sleep apnea is defined through a PSG as 5 or more central apneas per hour (AHI) of sleep with air flow and no respiratory effort.
There are several subtypes that can be diagnosed including: idiopathic central sleep apnea and Cheyne-Stokes breathing. Idiopathic (unknown origin) is characterized by variability in respiratory effort without evidence of any airway obstruction.
Cheyne-Stokes is a pattern of periodic crescendo-decrescendo (waxing and waning) variations in tidal volume (air inhaled and exhaled) of at least 5 events (AHI) per hour, accompanied by frequent arousals or awakenings. This type of breathing is often associated with heart failure, stroke, or renal failure.
In sleep-related hypoventilation the PSG shows times of decreased tidal volume (air inhaled and exhaled) associated with increased levels of carbon dioxide measured by a CO2 monitor during the PSG. Individuals with sleep-related hypoventilation may have insomnia, day time sleepiness, and/or headaches when awaking from sleep. This disorder can coexist with OSA and CSA. Some causes of sleep-related hypoventilation include neuromuscular disorders and childhood obesity.
Circadian Sleep Disorders
A circadian clock in our brain (anterior hypothalamus) influences our wakefulness or alertness phases. This circadian clock potentiates the sleep-wake cycle. A free-running human sleep-wake cycle is 25 hours; however, the cycle in the environment we live in results in a 24-hour cycle. This hour difference often shifts to one side of the cycle or the other. There is an increasing prevalence during adolescence, which may related to physiological and behavioral factors.
In pediatrics with circadian sleep disorders these opposite phases may represent a poor ability to compensate resulting in sleep loss and failure to adequately synchronize sleep-wake behaviors. This can make it difficult to adapt to environmental demands, such as school. This is frequently observed in adolescents with delayed sleep phase. The history consists of a delay in the timing of onset of sleep by more than 2 hours
Some children may be hypersensitive to evening light, which delays their sleep onset. Others are hyposensitive to morning light and do not respond to the phase-advancing effects.
Surveys report that 20–25% of youths have some type of a sleep problem. The following are commonly reported in children aged 2–15 years:
Nightmares (30%) are more common in younger youths Sleepwalking with at least more than 1 episode occurs in 25–30% of youths and is most common in children aged 3–10 years Insomnia occurs in 23% of youths Enuresis rates decrease from 8% in children aged 4 years to 4% in children aged 10 years Bruxism is reported in 10% of youths and may occur in people of any age Sleep rocking or head banging is reported in 5% of youths, with head banging being common in infants and in children aged 9 months to 12 years OSA is the most common reason for sleep laboratory referral and affects an estimated 1 to 4% of children Narcolepsy (0.01–0.20%) may be underestimated in children because a classic symptoms is uncommon in this age group; only about 10% of children show all the symptoms: excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis; semi purposeful automatic behavior, disrupted nocturnal sleep, sudden onset of weight gain, and OSA Bedtime resistance in school-aged children has been reported at 15% and is often associated with limit-setting disorder Restless legs syndrome (RLS) affects 2 to 4% of school-aged children and adolescents
The results of a population-based study on schoolchildren in Istanbul found that decreased total sleep duration is more prevalent in boys, older children, and children with higher socioeconomic status; insufficient sleep in these groups may be associated with negative behavioral symptoms and sleep hygiene.
Specific racial risk factors may predispose certain individuals to a sleep disorder. African Americans that have narcolepsy more often have narcolepsy without cataplexy or with atypical cataplexy. They may also be more prone to having advanced sleep phase–type sleep disorder because of having a shorter circadian period than whites. Asian Americans may be at increased risk of OSA despite having low body mass index (BMI).
Sex differences in sleep-wake disorders may be associated with sex roles and/or hormonal changes. Insomnia is more common in females. In assessing narcolepsy, female children and adults may report fatigue instead of sleepiness and also underreport snoring.
During NREM sleep arousal disorders, females are more likely to have eating behaviors. During childhood, sleepwalking occurs more often in females but sleep terrors are more common in males. In contrast, in adulthood, sleepwalking occurs more often in males but the sex ratio for sleep terrors is even. Adult females report having nightmares more often than males.
RLS is more common in females without diagnostic differences. OSA is, in contrast, more common in boys.
Learning difficulties, emotional lability, attention deficits, disruptive behaviors, social and school impairments, family dysfunction, low self-esteem, depression, anxiety, cognitive dysfunction hyperactivity, irritability, and memory impairment represent common comorbidities of sleep disorders in children. OSA may lead to cor pulmonale, pulmonary hypertension, right-side heart failure, growth retardation, and failure to thrive.
The treatment of primary insomnia often is difficult. Associated anxiety is often responsive to psychotherapy. Narcolepsy is a lifelong illness. Cataplexy, hypnagogic hallucinations, and sleep paralysis may diminish in frequency over time.
Tonsillectomy and adenoidectomy relieve symptoms in about 70% of pediatric patients with OSA. Continuous Positive Airway Pressure (CPAP) is indicated for children who partially respond to surgery or in whom surgery is contraindicated. A review of available treatments for OSA in children revealed only a limited evidence to support their use.
The success of therapy for delayed sleep phase syndrome (DSPS) depends to a large extent on the adolescent’s level of motivation. To prevent relapse of DSPS, the new schedule must be rigidly maintained.
Most children with parasomnias outgrow this condition when younger than 10. Approximately 88% of all bed-wetting children outgrow this condition by the time they are 13. The prevalence of enuresis in children older than 13 is 2%, which is similar to the prevalence rate in the adult population.
Because human beings spend a third of their time sleeping, it is essential to emphasize the need for good sleep hygiene to children, adolescents, and their families. Treatment of any behavioral problems generally will not help unless sleep problems are identified and addressed. “Catch-up sleep” is a misconception as more studies demonstrate the long-term effects of sleep deprivation. Sleep hygiene includes the following:
Keeping the room quiet, dark, cool, and comfortable Practicing a simple bedtime ritual that includes voiding Limiting time spent in bed Not eating or drinking heavily for about 3 hours before bedtime Maintaining the bedroom for sleeping only Removing distractions, such as television Avoiding medications Considering the effect of sleep partners (including pets) Maintaining a consistent sleep schedule 7 days a week Avoiding naps Exercising regularly Taking a hot bath or drinking something warm before bedtime
Pediatric sleep problems are a common occurrence and are associated with significant daytime impairments. Pediatric sleep problems might be the primary sleep disorder or a secondary consequence of an underlying medical or psychiatric disorder. They can compromise social, academic, and neurobehavioral functioning.
Over the past decade, there has been a growing body of literature with regard to effective diagnostic methods for identifying pediatric sleep disorders and utilization of evidence-based behavioral approaches coupled with rational pharmacotherapy, when needed. However, there appears to be a rather slow development in awareness regarding childhood sleep difficulties among the general public and us healthcare professionals. This review provides brief yet useful information that can be helpful for those involved in pediatric healthcare, which hopefully will increase awareness regarding developmentally appropriate diagnostic and treatment approaches available for common pediatric sleep problems.
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