Pediatric Neurology Quick Talks

Sleep DisordersMichael Babcock

Summer 2013

Scenario

-4 yo boy

-screaming at night

-lasts 30 minutes

-occurs about 2 hours after going to bed

-inconsolable during crying, then falls back asleep

-no bed wetting

-no limb shaking

-eyes closed

-no sedation in the AM

Sleep Screen – BEARS

• B – Bedtime issues

• E – Excessive daytime sleepiness (can exhibit as motor over-activity, inattentiveness, irritability, oppositional defiance)

• A – night Awakenings

• R – Regularity and duration

• S – Snoring

• If concerns

– Movements

– Meds

Insomnia

• Onset or Maintenance?

• Usually behavioral

• Psychosocial

• Anxiety (separation)

• Depression

• Medical problems – chronic pain, GERD, breathing problems, medications

Insomnia

• Sleep onset Association– Prolonged night awakenings

– Child has learned to fall asleep with Associations requiring parents – feeding, rocking, reading; can't self-soothe.

– Tx – break connection; put child to be while drowsy but not asleep.

• Limit-setting subtype– Older children

– Active resistance to bedtime

– Verbal protests and repeated demands

– Can manifest as fearful behavior (crying, clinging)

– Usually due to caregiver inconsistency with bedtime rules

– Can have medical underlying causes – asthma, medications, sleep disorder – RLS, anxiety.

– Tx – caregiver enforces rules

Restless Leg Syndrome

• An urge to move legs, usually accompanied by unpleasant sensation in legs

• These symptoms:

– Begin or worsen during rest/inactivity

– Relieved by movement

– Occur exclusively or predominantly in evening

– Not solely accounted for as symptoms of another medical/behavioral condition

• Hx – children may have difficulty explaining this unpleasant feeling – pain should not be only feeling.

• Differential – Periodic leg movement disorder – actual leg movements during sleep without sensation – this can be due to other sleep disorders.

• Work-up – iron studies

• Tx – iron supplementation; off label use of gabapentin, benzo's, clonidine, dopamine agonist used less often in children.

Excessive daytime sleepiness

• A sleepy child may not appear sleepy – can be inattentive, hyperactive (trying to stay awake), aggressive, disruptive (sleep-deprived frontal cortex can't regulate emotion)

• Insufficient sleep – insomnia

• Inadequate sleep hygiene

• Medication side-effects

• Periodic limb movement disorder

• Idiopathic hypersomnia

• endocrine/metabolic problems

• Narcolepsy

• OSA

Narcolepsy

• Narcolepsy

– Excessive daytime sleepiness

– Sleep paralysis

– Hypnagogic hallucinations

– Cataplexy

• Sudden loss of tone

• Precipitated by emotion (laughing, anger)

• REM creep

– Dx – polysomnography, MSLT

Obstructive Sleep Apnea

• Excessive daytime sleepiness

• Symptoms – Snoring, with apneic pauses

• But also

– Daytime nasal obstruction

– Mouth breathing

– Trouble eating/meat refusal

– Behavior problems

– Bed-wetting

– Restless sleep

– Sweaty sleep (needs fan on)

– AM headache

– Poor seizure control

• Who has OSA

– 2-3 % of normal development children have OSA

– 10% of normal children will be habitual snorers – don't have OSA

– 50% of children with Down's

– ~50% in obese children

• Why is it bad

– Hypertension, CHF, stroke, diabetes, difficulty losing weight.

Parasomnias

• Disorders of Non-REM arousal

– Sleep walking

– Sleep terrors

– Confusional arousals

• REM sleep disorders

– Nightmares

– Sleep paralysis

– REM sleep behavior disorder

• Narcolepsy

• SSRI

• neurodevelopmental

• Sleep-related movement disorders

– Rhythmic movement

• infants/toddlers

• Start at sleep onset

• Head rolling/head banging/body rocking

– Bruxism

– RLS/PLMD

• Hypnic starts

– Brief jerks occurring with falling asleep/awakening

– May have sensation of falling

Non-REM arousal parasomnias

• Usually during first 1/3 of night

• Usually only one event/night

• Increased arousals cause increased problems

– OSA, RLS, GERD.

• Triggered by sleep deprivation, fever.

• Toddler and school-aged kids.

• Usually resolve with time

– sleep-walking most likely to persist.

• Not tired the next day

• No stereotypic motor movements

• Last 5-30 minutes

• Differential – nocturnal seizures

– Anytime during night, more often in transition periods

– Last 30 seconds – 5 minutes

– Multiple events nightly

– Daytime seizures

– Daytime irritability/lethargy

– Older age of onset.

• Differential – panic attack, GERD.

• Dx -home videos, polysomnography or overnight EEG.

• Tx – low dose benzo.

References

-Uptodate articles – pediatric sleep, NREM sleep disorders, parasomnias, narcolepsy, RLS