Pediatric Sleep

Pediatric Sleep
By: Joseph Anderson, RPSGT, RST, RPFT, CCSH, CRT-NPS

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.

Diagnosis

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.

 

Common Symptoms

Bed wetting
Snoring
Sleep terrors
Restless sleep
Snorting, Coughing or Choking
Pauses in Breathing
Mouth Breathing

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.

Pediatric obstructive sleep apnea can have serious complications, including:

Failure to grow
Heart problems
Death

Treatment

Your doctor will work with you to find the most appropriate treatment for your child's sleep apnea. Treatment might include:

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.

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, 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

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.