Overview of Pediatric Sleep Medicine

Jason Coles MD Spectrum Medical Group

Helen DeVos Children’s Hospital

Fall 2014 Meeting

October 3-4, 2014

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

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:

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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

Sleep in the child: normal and abnormal. AACP board review presentation, Lee Brooks MD

Alternating 3-8 second patterns of high amplitude slow waves and low amplitude mixed frequency activity

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 1st 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 3rd 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

Adults Children

Obstructive Apnea

10 seconds with

respiratory effort

2 missed breaths

with respiratory

effort

Central Apnea

10 seconds with no

respiratory effort

20 seconds or 2

missed breaths with

arousal or ≥ 3%

desaturation

Hypopnea

10 seconds ≥ 30%

drop in nasal

pressure with

arousal or ≥ 3% desat

2 breaths ≥ 30% drop

in nasal pressure

with arousal or ≥ 3%

desat

HypoventilationPCO2 > 55 mmHg for

≥ 10 minutes

PCO2 > 50 mmHg for

> 25% TST

Periodic BreathingCheyne-Stokes

breathing pattern

≥ 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