Pediatric Sleep Disorders and Sleep Hygiene Overview
Pediatric Sleep
Disorders And
Sleep hygeine
BY DR SHAMAITA GUPTA
O
b
j
ect
i
ve
s
Understand
normal
sleep
in
children
Review
common
pediatric
sleep
disorders
Discuss proper treatment
options for
childhood sleep
disorders
Sleep Cycle
Duration of sleep cycle
The sleep cycle
•
Each sleep
cycle
90 – 120
minutes
•
First
REM
period is
shortest
•
Most NREM deep sleep
occurs
early
•
Most REM
occurs
late
Sleep Regulation
Regulated by the combined action of two processes.
The homeostatic process(
Process S
) - Rise of sleep pressure during
wakefulness and its dissipation during sleep due to accumulation of
adenosine and other sleep promoting
somnogens
during prolonged
wakefulness
The second process refers to circadian oscillations
(Process C
)
, which
superimpose a nearly 24-h pattern on the sleep-wake cycle: by
actively promoting wakefulness during the biological day and sleep
during the biological night,i.e., during phases of melatonin secretion
by the pineal gland. This rhythm is triggered and adjusted to the
external light-dark cycle by external inputs like light(called
zeitgebers
) to the brain’s main circadian pacemaker, the
suprachiasmatic nuclei (SCN)
of the anterior hypothalamus.
The changing trends of sleep
patterns
Newborn - up to 18 hours
1–12 months - 14–18 hours
1–3 years -12–15 hours
3–5 years - 11–13 hours
5–12 years - 9–11 hours
Adolescents - 9-10 hours
The REM sleep time decreases from birth(50%) to early childhood to
adulthood(25-30%)
Irregularities of sleep patterns start in early childhood depending on
school night and non school night bed times
Pediatric sleep disorders
prevalence ≈25% - 43%of children ages
1-5
years
i
n
t
er
f
e
r
e
w
it
h
da
i
l
y
p
a
ti
e
n
t
an
d
f
a
m
ily
functioning.
s
l
ee
p
p
r
o
b
l
e
m
s
cau
se
s
i
g
n
i
f
i
can
t
e
m
o
tio
na
l,
behavioral, and cognitive
dysfunction.
c
o
mm
o
n
a
m
o
ng
children
w
i
th
m
ed
i
c
al,
neurodevelopmental and
psychiatric
disorders
Most common causes of sleep abnormality:
Inadequate duration
(insufficient quantity)
Difficulty in initiating
Difficulty in maintaining sleep
Disrupted or fragmented sleep
(poor quality)
Less common causes of sleep abnormality
Inappropriate timing of sleep
Cicardian rhythm disturbances
Excessive day time sleepiness
DSM-V classification
1-
Dyssomnias (# duration, timing
of
sleep)
Primary Insomnia
Primary
Hypersomnia
Breathing-Related
Sleep
Disorder
Narcolepsy
Circadian Rhythm Sleep
Disorder
2-
Parasomnias
(abnormal events during
sleep)
Nightmare
Night
Terrors
Sleep
walking
3- Medical and Psychiatric disorders
The clinical evaluation involves: obtaining
a
careful
medical
history
assess
for
medical cause
of
sleep disturbance
Current
sleep patterns,
including sleep duration,
sleep-wake
schedule, sleep habits, Nocturnal
symptoms
Polysomnogram
(PSG)
record:EEG, EMG, EOG,
Vital
Signs
and
Other
Physiologic
Parameters
Insomnia
Difficult initiate
or maintain
sleep
or
early
morning
awake
with
difficult
return to
sleep
Occur
3
nights/week,
for
at
least
3
months,
despite sufficient
time
for
sleep.
Not due
to the
effects
of a
substance
Not
explained
by mental/medical
illness
Prevalence
1 – 6 %
in
pediatrics
but higher
in
children
with chronic
med/psych
conditions
Treatment of Insomnia
•
Mainly treated
with behavioral
interventions
•
Media
removal
from
bedroom
•
Avoid
caffeine
•
Consistent bedtime
routine
and
positive
reinforcement
from
parents/caregivers
•
Correct
the underlying med/psycho
factors
Beavioral therapy(graduated
extinction)
More commonly in infants and toddlers the problem stems from learning to fall
asleep only under certain conditions that require the parent to intervene For
example, child must be rocked or fed to fall asleep Child does not learn to self-
soothe during normal brief arousals between sleep cycles
In pre-school age and older children, the problem is active resistance to bedtime
rather than prolonged wakings during the night
Systematic ignoring or “extinction” (Unmodified version is known as “crying it
out”) has been documented to be a highly successful treatment, but difficult for
parents to adhere to . Alternative is to do this more gradually, with longer periods
between checking on child. Keep contact brief and avoid picking child up
Contd..
Also Known as Ferber Method
The child is allowed to cry for sometime before intervention is done by the parents
The time of intervention is gradually increased.
The child is taught to calm itself and fall asleep on its on
Sometimes a visit for a few minutes and a small pat on the bag is given
Slowly the crying time slowly decreases and the baby falls off to sleep on its own
by 3-4days of extinction
However this method is criticised to be emotionally exhausting for both parents
and the child.
Hypersomnolence disorders
prolonged sleep episodes,
excessive
sleepiness
prolonged sleep
> 9
h/day
that
is not
refreshing
Difficulty
being
fully
awake after
abrupt
awakening
The
complaint is present
for
at
least
6
months.
Not due
to
med/psycho
disorder
Common
in in late
adolescence.
Sleep disordered breathing
Obstructive Sleep Apnea (1
– 4
%)
Results in blood oxygen desaturations
Upper Airway
Resistance
Syndrome
Similar
to
OSA
but not result
in
desaturations
Primary Snoring
(7
–
12%)
regular snoring without
changes in
sleep architecture, alveolar ventilation
or
oxygenation
Obstructive sleep apnea
Periodic
apneas due
to sleep-related airway
obstruction
↓
patency
(obstruction
and/or
↓diameter)
↑
collapsibility
(↓
pharyngeal muscle
tone)
↓
drive to
breath
(↓
central ventilatory
drive)
Not
all
snorers have
OSA
Sequelae of OSA
Disrupt ventilation
and
sleep
patterns
intermittent
hypoxia and
multiple
arousals cause
significant metabolic,
CVS,
neurocog/behavioral
and academic
morbidity
Daytime
Sleepiness,
Enuresis
as short-term
squeal
Pulmonary
hypertension and right
heart failure,
FFT as long
term
sequel
Treatment of Sleep Apnoea
Weight
loss
Positional (sleep
on one
side
or
prone)
CPAP prevents
obstruction
by
soft-tissue
and keeps
airway
open
Surgical
intervention
(e.g.,
tonsiloadenectomy)
Avoid
sedatives (which
prevent reawakening
to
breath)
Narcolepsy
uncontrollable excessive daytime sleep attacks interfere with normal
daily
functioning
Person
goes
directly
into
REM
sleep
Common
in
adolescence
& early
adulthood
Genetic defect in
hypothalamic
orexin/hypocretin neurotransmitter
prevalence is
3-16/10,000
Symptoms
associated
with
narcolepsy
Narcolepsy symptoms
Cataplexy
(pathognomonic
for
narcolepsy)
Abrupt
bilateral partial
or
complete
loss of m.
tone.
triggered
by intense positive
emotion
(e.g.,
laught)
last
for
seconds
to
minutes
with
complete
recovery
Hallucinations
(visual, auditory,
tactile)
occur
during transitions bet. sleep
and
wakefulness
At
sleep onset
→
hypnogogic
At
sleep
offset
→
hypnopompic
S
le
e
p
para
l
ys
i
s
:
i
nab
ili
t
y
t
o
m
ove
o
r
sp
e
a
k
f
or
s
e
c-
min at
sleep onset
or
offset;
accompanies
hallucination
Contd..
DD
Potential
causes of EDS:
Extrinsic:
Secondary
to insufficient/fragmented
sleep
Intrinsic:
CNS
disorder
with
↑ need
for
sleep.
Treatment
include:
Education,
good
sleep
hygiene, behavioral changes (eg. Scheduled naps).
Medications
as:
psychostimulants
and
modafinil to control EDS.
TAD
and
SSRI
to
control REM-associated phenomena, such as
cataplexy
Cicardian rhythm disorder
Circadian Rhythm Sleep Disorder caused by
mismatch
between sleep-wake schedule
required
by
a person’s environment and
his/her
circadian
sleep-wake
pattern.
Delayed sleep phase syndrome
It
is a
circadian rhythm
disorder
significant, persistent, intractable phase shift
in
sleep
wake
schedule (later sleep
onset
and
wake
time)
Patients
has
inability
to get to
sleep until
the
early morning,
but little
difficulty
sleeping
once
asleep
Interfere
with
school,
work
and
lifestyle
demands.
Common in
adolescents
and
young adults
(7-16%)
Treatment
Treatment
is
primarily
behavioral
•
Shifting
the
sleep-wake
schedule
to an
earlier
time
•
Maintaining the
new
schedule.
→
Gradual shifting
bedtime/wake
time
earlier by
15- 30 min
increments
→
Exposure
to light in
morning and avoidance
of
evening
light
exposure
Oral
melatonin
supplementation
in the
afternoon
or
early evening
is
effective
in
advancing
the
sleep
phase.
Sleep related movement disorder
Restless leg syndrome
:
Uncomfortable sensations
in
the LL accompanied by
irresistible
urge
to
move
legs →Disturbs
sleep→ Often mistaken as growing pains.
Relieved only by movement only to recur on stopping movement
Periodic limb movement disorder
:
periodic, repetitive,
brief
(0.5-10
sec) highly
stereotyped
limb
jerks
(rhythmic extension
of
big
toe and
dorsiflexion
at
ankle)
→
Disrupts
sleep
.
Prevalence
in
children
is
8-12%.
Diagnosis
of
PLMs requires overnight
polysomnography . Treated according to severity (intensity,
frequency,
periodicity(<5/hour or more)) ,
degree
of
sleep
disturbance
,
daytime
sequelae.
Sleep related rhythmic movements:
repetitive,
stereotyped,
rhythmic
movements
involve
large muscle
groups. Like head banging, body rocking etc. may be seen in
transition while going off to sleep. Treatment is reassurance to parents.
Pediatric parasomnias
Episodic nocturnal
behaviors
involve
cognitive disorientation and autonomic
and
skeletal
muscle
disturbance.
Prevalence of parasomnias in
pediatric age group
80
%
70
%
60
%
50
%
40
%
30
%
20
%
10
%
0
%
Any sleep sleep night RLS nocturnal bruxism
walking talking terror enuresis
Persistence of childhood
parasomnias into adulthood
E
nu
r
e
s
i
s
Sleep
Terrors
B
r
u
x
i
s
m
Sleepwalking
0 5 10 15 20 25 35
Nightmare
•
Sleep disorder
characterized
by high
arousal
and appearance
of
being
terrified
•
≈ 2/3 of all
kids experience
them
•
Common in
preschoolers ages
3-6
y
•
Occur during
REM
sleep
•
Child believes them
to
be
real.
Night terror
repeated
abrupt
awakenings
from sleep
characterized
by intense fear, panicky screams,
autonomic
symptoms (tachycardia, rapid breathing,
sweating),
absence
of
detailed dream
recall, amnesia
for
the episode,
and
relative unresponsiveness
to
attempts
to
comfort the
person.
Lasts
~ 10 min
then returns
to
undisturbed
sleep
During Stage 3-4
of
NREM
sleep
(1st
third
of
night)
Prevalence
is
3–6.5% in
children.
can occur
at any
age.
Common in
male
resolves
spontaneously
Nocturnal administration
of
benzodiazepines
has
been
reported
to
be
beneficial
Bruxism
involuntary, forceful grinding
of
teeth during
sleep
Up
to
88% of
children;
20 % of
adults
Any
stage of
sleep
May result
in damage to the
teeth
Periodicity
of 20 to 30
seconds.
May
represent
symptom different
disorders
Patient
is
usually
unaware
of the
problem
In severe cases,
rubber
tooth
guard
is
necessary.
Stress management
or
biofeedback.
Sleep talking
Begins
during school
age
During
NREM and REM
sleep
No
treatment
just
reassurance
Night wakening
One or
more
waking
from midnight
to
5 am
for
at
least
four
of seven
nights per
week
for at least four consecutive
weeks
Sleep walking
More
than
just
walking
around…
Simple
Behaviors
and
Complex
Behaviors
While
sleepwalking,
patient has
a
blank staring face,
relatively
unresponsive
to
others
.
confused
or
disoriented
on
being
aroused.
Complete
amnesia
Occur
during
Stage
3-4 Sleep;
1
st
third
of
night.
Begins
in
ages
4-8
yrs
.
17% in
children
(4% of
adults)
sleep-walking
most
likely
to persist
it is
important
to
institute safety precautions (use
of gates,
locking
doors and
windows,
and
bedroom
door
alarms).
No
treatment
is
established, but
may
respond
to
benzodiazepines
or
sedating antidepressants
at
bedtime.
Non REM confusional arousal
parasomnia
Usually during first
1/3 of
night
Usually
only one
event/night
Common in
Toddler
and
school-aged
kids.
prevalence rates
15% in
children ages
3-13
yr.
co-occur
with sleepwalking
and
sleep
terrors
Usually resolve
with
time
Not tired the next
day
No stereotypic
motor
movements
Last
5-30
minutes
Treatment of Parasomnias
parent education
and
reassurance
good
sleep
hygiene
avoidance
of
exacerbating factors such
as
sleep deprivation
and
caffeine.
Scheduled awakenings,
parent
wake
the
child
15
to
30 min
before
the time of
first
parasomnia
episode.
Pharmacotherapy
is
rarely necessary, include
benzodiazepines
and
tricyclic
antidepressants.
Sleep hygiene for toddlers
Make sure the baby is not hungry when you put him to bed.
Feed the baby right before bedtime so he or she is not hungry when put to bed.
Place the child in bed when he is sleepy but not yet asleep. Make sure your child is still awake when he is put
down for naps and at bedtime.
Placing the baby in bed while he is still awake lets him learn to fall asleep on his own.
P
lace the child on his back when putting him to bed, up to one year of age .
Have a nighttime routine and a regular sleep schedule.
Set a bedtime for te child. Be sure to stick with the time selected by putting the baby to bed at the same time every
night.
Start a nighttime routine that includes feeding, bath, bedtime story, etc.
Do not let the child nap for too long or too late in the day. Try to limit naps to no more than 3 hours. Also, make
sure the child is awake from the
afternoon nap by 4 pm. Children who sleep later than 4 pm may not be ready to
go back to sleep when it is their bedtime.
Do not put the child in bed with a bottle or cup. Sleeping with milk or juice in the mouth can lead to cavities and
tooth decay.
Sleep hygiene for children
•
Have a set bedtime and bedtime routine
•
Bedtime
and
wake-up
time should be the
same time
on school & non-school
nights.
•
No
more
than 1hour difference
from
one day to another.
•
Make
the hour before
sleep
quiet
time.
•
Avoid high-energy
activities
before
bed.
Contd…
•
D
o
n
'
t
put the child
to
be
d
hu
n
gr
y,
bu
t
avo
i
d
H
e
a
v
y
meals.
•
spend
time
outside
every day and
involve in
regular
exercise.
•
Keep bedroom quiet and dark
with
comfortable
temperature
•
Don't use bedroom
for
punishment
•
Naps should
be
short (no > 1hr) and scheduled
in the
early
to
midafternoon.
•
Keep TV out of
child's
bedroom.
•
Use
bed for sleeping
only.
Don't
study,
read,
watch TV
on
bed.
•
Relaxing,
calm, enjoyable
activities help
you
to get to
sleep.
Sleep hygiene for adolescents
Budgeting eight hours of sleep into your daily schedule and keeping that same
schedule on both weekdays and weekends.
Creating a consistent pre-bed routine to help with
relaxation and falling asleep
fast
.
Avoiding
caffeine
and energy drinks, especially in the afternoon and evening.
Putting away electronic devices for at least a half-hour before bed and keeping
them on silent mode to avoid checking them during the night.
Contd..
Setting up your bed with a supportive
mattress
and
pillows
.
Keeping your bedroom
cool
, dark, and quiet.
Smoking and alcohol disturbs sleep
Use bed only for sleep
Regular exercise
Regular meals before going off to sleep.
Avoid catch up sleep in weekends.
Do not use sleeping pills
The End
Understanding normal sleep patterns in children, common pediatric sleep disorders, and treatment options. Exploring the sleep cycle, duration of sleep cycles, sleep regulation, changing trends in sleep patterns, and prevalence of pediatric sleep disorders impacting daily functioning.
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Presentation Transcript
Pediatric Sleep Disorders And Sleep hygeine BY DR SHAMAITA GUPTA
Objectives Understand normal sleep in children Review common pediatric sleep disorders Discuss proper treatment options for childhood sleep disorders
The sleep cycle Each sleep cycle 90 120 minutes First REM period is shortest Most NREM deep sleep occurs early Most REM occurs late
Sleep Regulation Regulated by the combined action of two processes. The homeostatic process( Process S) - Rise of sleep pressure during wakefulness and its dissipation during sleep due to accumulation of adenosine and other sleep promoting somnogens during prolonged wakefulness The second process refers to circadian oscillations(Process C), which superimpose a nearly 24-h pattern on the sleep-wake cycle: by actively promoting wakefulness during the biological day and sleep during the biological night,i.e., during phases of melatonin secretion by the pineal gland. This rhythm is triggered and adjusted to the external light-dark cycle by external inputs like light(called zeitgebers) to the brain s main circadian pacemaker, the suprachiasmatic nuclei (SCN) of the anterior hypothalamus.
The changing trends of sleep patterns Newborn - up to 18 hours 1 12 months - 14 18 hours 1 3 years -12 15 hours 3 5 years - 11 13 hours 5 12 years - 9 11 hours Adolescents - 9-10 hours The REM sleep time decreases from birth(50%) to early childhood to adulthood(25-30%) Irregularities of sleep patterns start in early childhood depending on school night and non school night bed times
Pediatric sleep disorders prevalence 25% - 43%of children ages 1-5 years interferewith daily patient and family functioning. sleep problems cause significant emotional, behavioral, and cognitive dysfunction. common among children with medical, neurodevelopmental and psychiatric disorders
Most common causes of sleep abnormality: Inadequate duration(insufficient quantity) Difficulty in initiating Difficulty in maintaining sleep Disrupted or fragmented sleep(poor quality) Less common causes of sleep abnormality Inappropriate timing of sleep Cicardian rhythm disturbances Excessive day time sleepiness
DSM-V classification 1- Dyssomnias (# duration, timing of sleep) Primary Insomnia Primary Hypersomnia Breathing-Related Sleep Disorder Narcolepsy Circadian Rhythm Sleep Disorder 2- Parasomnias (abnormal events during sleep) Nightmare NightTerrors Sleep walking 3- Medical and Psychiatric disorders
The clinical evaluation involves: obtaining a careful medical history assess for medical cause of sleep disturbance Current sleep patterns, including sleep duration, sleep-wake schedule, sleep habits, Nocturnal symptoms Polysomnogram (PSG) record:EEG, EMG, EOG, Vital Signs and Other Physiologic Parameters
Insomnia Difficult initiate or maintain sleep or early morning awake with difficult return to sleep Occur 3 nights/week, for at least 3 months, despite sufficient time for sleep. Not due to the effects of a substance Not explained by mental/medical illness Prevalence 1 6 % in pediatrics but higher in children with chronic med/psych conditions
Treatment of Insomnia Mainly treated with behavioral interventions Media removal from bedroom Avoid caffeine Consistent bedtime routine and positive reinforcement from parents/caregivers Correct the underlying med/psycho factors
Beavioral therapy(graduated extinction) More commonly in infants and toddlers the problem stems from learning to fall asleep only under certain conditions that require the parent to intervene For example, child must be rocked or fed to fall asleep Child does not learn to self- soothe during normal brief arousals between sleep cycles In pre-school age and older children, the problem is active resistance to bedtime rather than prolonged wakings during the night Systematic ignoring or extinction (Unmodified version is known as crying it out ) has been documented to be a highly successful treatment, but difficult for parents to adhere to . Alternative is to do this more gradually, with longer periods between checking on child. Keep contact brief and avoid picking child up
Contd.. Also Known as Ferber Method The child is allowed to cry for sometime before intervention is done by the parents The time of intervention is gradually increased. The child is taught to calm itself and fall asleep on its on Sometimes a visit for a few minutes and a small pat on the bag is given Slowly the crying time slowly decreases and the baby falls off to sleep on its own by 3-4days of extinction However this method is criticised to be emotionally exhausting for both parents and the child.
Hypersomnolence disorders prolonged sleep episodes, excessive sleepiness prolonged sleep > 9 h/day that is not refreshing Difficulty being fully awake after abrupt awakening The complaint is present for at least 6 months. Not due to med/psycho disorder Common in in late adolescence.
Sleep disordered breathing Obstructive Sleep Apnea (1 4%) Results in blood oxygen desaturations Upper Airway Resistance Syndrome Similar to OSA but not result in desaturations Primary Snoring (7 12%) regular snoring without changes in sleep architecture, alveolar ventilation or oxygenation
Obstructive sleep apnea Periodic apneas due to sleep-related airway obstruction patency (obstruction and/or diameter) collapsibility ( pharyngeal muscle tone) drive to breath ( central ventilatory drive) Not all snorers have OSA
Sequelae of OSA Disrupt ventilation and sleep patterns intermittent hypoxia and multiple arousals cause significant metabolic, CVS, neurocog/behavioral and academic morbidity Daytime Sleepiness, Enuresis as short-term squeal Pulmonary hypertension and right heart failure, FFT as long term sequel
Treatment of Sleep Apnoea Weight loss Positional (sleep on one side or prone) CPAP prevents obstruction by soft-tissue and keeps airway open Surgical intervention (e.g., tonsiloadenectomy) Avoid sedatives (which prevent reawakening to breath)
Narcolepsy uncontrollable excessive daytime sleep attacks interfere with normal daily functioning Person goes directly into REM sleep Common in adolescence & early adulthood Genetic defect in hypothalamic orexin/hypocretin neurotransmitter prevalence is 3-16/10,000
Narcolepsy symptoms Cataplexy (pathognomonic for narcolepsy) Abrupt bilateral partial or complete loss of m. tone. triggered by intense positive emotion (e.g., laught) last for seconds to minutes with complete recovery Hallucinations (visual, auditory,tactile) occur during transitions bet. sleep and wakefulness At sleep onset hypnogogic Atsleep offset hypnopompic Sleep paralysis: inability to move or speak for sec- min at sleep onset or offset; accompanies hallucination
Contd.. DD Potential causes of EDS: Extrinsic:Secondary to insufficient/fragmented sleep Intrinsic:CNS disorder with need for sleep. Treatment include: Education, good sleep hygiene, behavioral changes (eg. Scheduled naps). Medications as: psychostimulants and modafinil to control EDS. TAD and SSRI to control REM-associated phenomena, such as cataplexy
Cicardian rhythm disorder Circadian Rhythm Sleep Disorder caused by mismatch between sleep-wake schedule required by a person s environment and his/her circadian sleep-wake pattern.
Delayed sleep phase syndrome It is a circadian rhythmdisorder significant, persistent, intractable phase shift in sleep wake schedule (later sleep onset and waketime) Patients has inability to get to sleep until the early morning, but little difficulty sleeping once asleep Interfere with school, work and lifestyledemands. Common in adolescents and young adults (7-16%)
Treatment Treatment is primarily behavioral Shifting the sleep-wake schedule to an earliertime Maintaining the new schedule. Gradual shifting bedtime/wake time earlier by 15- 30 min increments Exposure to light in morning and avoidance of evening light exposure Oral melatonin supplementation in the afternoon or early evening is effective in advancing the sleepphase.
Sleep related movement disorder Restless leg syndrome: Uncomfortable sensations in the LL accompanied by irresistible urge to move legs Disturbssleep Often mistaken as growing pains. Relieved only by movement only to recur on stopping movement Periodic limb movement disorder: periodic, repetitive, brief (0.5-10 sec) highly stereotyped limb jerks (rhythmic extension of big toe and dorsiflexion at ankle) Disruptssleep. Prevalence in children is 8-12%. Diagnosis of PLMs requires overnight polysomnography . Treated according to severity (intensity, frequency, periodicity(<5/hour or more)) , degree of sleep disturbance, daytime sequelae. Sleep related rhythmic movements: repetitive, stereotyped, rhythmic movements involve large muscle groups. Like head banging, body rocking etc. may be seen in transition while going off to sleep. Treatment is reassurance to parents.
Pediatric parasomnias Episodic nocturnal behaviors involve cognitive disorientation and autonomic and skeletal muscle disturbance.
Prevalence of parasomnias in pediatric age group 80% 70% 60% 50% 40% 30% 20% 10% 0% Any sleep sleep night RLS nocturnal bruxism walking talking terror enuresis
Persistence of childhood parasomnias into adulthood Enuresis SleepTerrors Bruxism Sleepwalking 0 5 10 15 20 25 35
Nightmare Sleep disorder characterized by high arousal and appearance of being terrified 2/3 of all kids experience them Common in preschoolers ages 3-6 y Occur during REM sleep Child believes them to be real.
Night terror repeated abrupt awakenings from sleep characterized by intense fear, panicky screams, autonomic symptoms (tachycardia, rapid breathing, sweating), absence of detailed dream recall, amnesia for the episode, and relative unresponsiveness to attempts to comfort the person. Lasts ~ 10 min then returns to undisturbed sleep During Stage 3-4 of NREM sleep (1st third of night) Prevalence is 3 6.5% in children. can occur at any age. Common in male resolves spontaneously Nocturnal administration of benzodiazepines has been reported to be beneficial
Bruxism involuntary, forceful grinding of teeth during sleep Up to 88% of children; 20 % of adults Any stage of sleep May result in damage to the teeth Periodicity of 20 to 30 seconds. May represent symptom different disorders Patient is usually unaware of the problem In severe cases, rubber tooth guard is necessary. Stress management or biofeedback.
Sleep talking Begins during school age During NREM and REM sleep No treatment just reassurance Night wakening One or more waking from midnight to 5 am for at least four of seven nights per week for at least four consecutive weeks
Sleep walking More than just walking around Simple Behaviors and Complex Behaviors While sleepwalking, patient has a blank staring face, unresponsive to others. confused or disoriented on being aroused. relatively Complete amnesia Occur during Stage 3-4 Sleep; 1st third of night. Begins in ages 4-8 yrs. 17% in children (4% of adults) sleep-walking most likely to persist it is important to institute safety precautions (use of gates, locking doors and windows, and bedroom door alarms). No treatment is established, but may respond to benzodiazepines or sedating antidepressants at bedtime.
Non REM confusional arousal parasomnia Usually during first 1/3 of night Usually only one event/night Common in Toddler and school-aged kids. prevalence rates 15% in children ages 3-13 yr. co-occur with sleepwalking and sleep terrors Usually resolve with time Not tired the next day No stereotypic motor movements Last 5-30 minutes
Treatment of Parasomnias parent education and reassurance good sleep hygiene avoidance of exacerbating factors such as sleep deprivation and caffeine. Scheduled awakenings, parent wake the child 15 to 30 min before the time of first parasomnia episode. Pharmacotherapy is rarely necessary, include benzodiazepines and tricyclic antidepressants.
Sleep hygiene for toddlers Make sure the baby is not hungry when you put him to bed. Feed the baby right before bedtime so he or she is not hungry when put to bed. Place the child in bed when he is sleepy but not yet asleep. Make sure your child is still awake when he is put down for naps and at bedtime. Placing the baby in bed while he is still awake lets him learn to fall asleep on his own. Place the child on his back when putting him to bed, up to one year of age . Have a nighttime routine and a regular sleep schedule. Set a bedtime for te child. Be sure to stick with the time selected by putting the baby to bed at the same time every night. Start a nighttime routine that includes feeding, bath, bedtime story, etc. Do not let the child nap for too long or too late in the day. Try to limit naps to no more than 3 hours. Also, make sure the child is awake from the afternoon nap by 4 pm. Children who sleep later than 4 pm may not be ready to go back to sleep when it is their bedtime. Do not put the child in bed with a bottle or cup. Sleeping with milk or juice in the mouth can lead to cavities and tooth decay.
Sleep hygiene for children Have a set bedtime and bedtime routine Bedtime and wake-up time should be the same time on school & non-school nights. No more than 1hour difference from one day to another. Make the hour before sleep quiet time. Avoid high-energy activities before bed.
Contd Don't put the child to bed hungry, but avoid Heavy meals. spend time outside every day and involve in regular exercise. Keep bedroom quiet and dark with comfortable temperature Don't use bedroom for punishment Naps should be short (no > 1hr) and scheduled in the early to midafternoon. Keep TV out of child's bedroom. Use bed for sleeping only. Don't study, read, watch TV on bed. Relaxing, calm, enjoyable activities help you to get to sleep.
Sleep hygiene for adolescents Budgeting eight hours of sleep into your daily schedule and keeping that same schedule on both weekdays and weekends. Creating a consistent pre-bed routine to help with relaxation and falling asleep fast. Avoiding caffeine and energy drinks, especially in the afternoon and evening. Putting away electronic devices for at least a half-hour before bed and keeping them on silent mode to avoid checking them during the night.
Contd.. Setting up your bed with a supportive mattress and pillows. Keeping your bedroom cool, dark, and quiet. Smoking and alcohol disturbs sleep Use bed only for sleep Regular exercise Regular meals before going off to sleep. Avoid catch up sleep in weekends. Do not use sleeping pills
