Pediatric Neurology Quick Talks Sleep Disorders Michael 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 selfsoothe. – 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