Clinical Evaluation of Sleep Disorders in Children: Clinical Evaluation of Sleep Disorders in Children History of Sleep Problem: Presenting complaint Related sleep complaints Related am / daytime behavior Bedtime routine, sleeping environment Sleep habits,sleep patterns and duration Frequency and character of night wakings Family’s response to sleep problems, previous rx Previous sleep patterns Family history of sleep problems


Clinical Evaluation of Sleep Disorders in Children: Clinical Evaluation of Sleep Disorders in Children Past and current medical history Social history / stressors Developmental / school history Sleep diagnostic tools: Sleep Diaries: 2 week baseline Home videotaping: paroxysmal arousals Polysomnography: OSAS, PLMD, EDS, parasomnias MSLT: EDS Actigraphy


Sleep History: “BEARS”: Sleep History: “BEARS” Bedtime Excessive daytime sleepiness Awakenings: night waking early morning waking Regularity and duration of sleep Snoring


Insomnia: Insomnia It is a term applied to people who have a complaint of unrefreshing sleep, difficulty initiating or maintaining sleep. Also defined as less than 5.5hrs of sleep/24hrs Most patients with insomnia have daytime effects of the disturbed nighttime sleep such as fatigue, tiredness, irritability or inability to concentrate.


Introduction: Introduction Insomnia is a presenting complaint in several disorders, though it can be the primary problem. Primary insomnia is defined insomnia not secondary to any other cause. 3 types of primary insomnia; Persistent psychophysiological insomnia Childhood onset insomnia Insomnia without objective findings Insomnia can be divided into transient (several days), short term (1-3 weeks and long term (>3 weeks)


Slide7: The presentation of insomnia or pediatric sleeplessness varies according to the age of the patient. There is a wide gulf between acceptable sleep characteristics in infants as compared to teenagers.


Slide8: Newborns: 16-20hrs/24hr period(2-4 hrs separated by 1-2 hr awake periods 1-2 years: 13-16hrs/24hrs. 2-3 hour daytime nap 3-5 years: 13hrs decreasing to 11hrs by 5 years of age. Most children stop napping by 5 years of age. 6-12 years: 8-11 hours at night. No naps Adolescence: 8.5-9.25hrs with delayed sleep onset.


Slide9: In newborns frequent nocturnal arousals is commonest problem In toddlers sleep resistance with night time fears being common In age 3-5 sleep delay is common In age 6-12 night time fears, anxiety around sleep, nightmares are common In adolescence phase delay is common


Slide10: Infants and children learn to fall asleep at the beginning of the night under specific conditions. To fall back to sleep after normal awakenings that occur throughout the night, the same conditions must exist. Teaching a child to sleep independently at the beginning of the night is usually sufficient to correct sleep maintenance problems.


Slide11: An overtired infant or young child does not transition to sleep or sleep as well as a child who is not tired Finding the optimal bedtime can be difficult because it varies by age from child to child


Types of Insomnia: Types of Insomnia Primary or psychophysiologic insomnia Sleep onset association disorder Limit setting sleep disorder Insufficient sleep syndrome Inadequate sleep hygiene Conditions mimicking insomnia: Delayed sleep phase syndrome Sleep state misperception PEDIATRIC SLEEP LECTURE SERIES


Behavioral or Psychophysiological: Behavioral or Psychophysiological Adjustment sleep disorder Psychophysiological insomnia Inadequate sleep hygiene Limit setting sleep disorder Sleep onset association disorder Nocturnal eating syndrome


Sleep Onset Association Disorder: Sleep Onset Association Disorder Defined as impairment in sleep onset as a result of the absence of certain objects or circumstances. The absence of that factor will lead to difficulty initiating and maintaining sleep


ICSD* Classification: ICSD* Classification The patient has a complaint of insomnia Complaint is temporally associated with the absence of certain conditions The disorder is present for at least 3 weeks With the particular association present, sleep is normal in onset, duration and quality Sleep study demonstrates normal timing, duration and quality of sleep when association is present and prolonged sleep latency and frequency or duration of awakenings when association is absent No significant underlyng mental or medical disorder to account for complaint Symptoms do not meet criteria for any other sleep disorder causing difficulty initiating sleep *INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS (ICSD)


Sleep Onset Association Disorder: Sleep Onset Association Disorder Behavior is usually set between 6 months and 3 years. Usually occurs at greater than 3 months as the patient enters a developmental stage characterized by greater attachment to parents, fear of strangers and realization of threatening circumstances.


Slide17: Crying spells may persist for 2-3 hours and place significant burden on parents resulting in shorter sleep duration and poor quality sleep in the child. Treatment involves gradual withdrawal of the object and maintenance of good sleep hygiene.


Slide18: Parental education Behavioral modification techniques including extinction, scheduled awakenings, appropriate non pharmacologic sleep/relaxation aids


Limit Setting Sleep Disorder: Limit Setting Sleep Disorder Delayed sleep onset resulting from inadequate enforcement of bedtime by the caregivers. Once patient is asleep, rest of sleep is normal It leads to inadequate sleep at night, with resultant irritability, fatigue , inattentiveness, reduced school performance and and tension in interfamily relationships.


ICSD* Classification: ICSD* Classification The patient has difficulty in initiating sleep The patient stalls or refuses to go to bed at an appropriate time Once sleep period is initiated, sleep is of normal quality quality and duration Sleep study demonstrates normal timing, quality and duration of the sleep period No significant underlyng mental or medical disorder to account for complaint Symptoms do not meet criteria for any other sleep disorder causing difficulty initiating sleep


Limit Setting Sleep Disorder: Limit Setting Sleep Disorder Typically, the parents do not enforce sleep time and when attempted the child will attempt to engage parents a variety of ways including: making requests for things, tantrums, complaining of fears. Parents give in to child and habit becomes formed over time.


Treatment: Treatment Parental education Instituting and adhering to and enforcing appropriate bedtimes and wake times. Behavioral modification may be necessary A regular routine before sleep also helps.


Slide23: If problems persist and are refractory to parental attempts to modify behavior, then etiological or moderating factors should be considered: Child temperament and psychopathology Parental psychopathology Inconsistent limit setting Irregular bedtime activities History of feeding or health problems.


Adjustment Sleep Disorder: Adjustment Sleep Disorder This results from an acute emotional stress that can be related to conflict or loss, etc. Usually lasts days and not more than 3 weeks Features include prolonged sleep latency, frequent awakenings or early morning arousals.


Adjustment Sleep Disorder: Adjustment Sleep Disorder Treatment is essential to avoid development of chronic psychophysiological insomnia. Consider psychological intervention early Reassurance and control of stressor is important Patients may be treated with hypnotic/sedatives and should be encouraged to maintain good sleep hygiene


Psychophysiological Insomnia: Psychophysiological Insomnia In this condition, the patient dwells on things and issues that prevent the patient from being able to go to sleep. Example is focusing on the next days work etc. it is also referred to as learned insomnia. Not common between 6-12 years of age. Occurs in adolescence


Treatment: Treatment Education and reassurance Improved sleep hygiene Cognitive –behavioral treatment: Relaxation training Stimulus control Sleep restriction Cognitive therapy


Stimulus Control: Stimulus Control This is considered the first line and most validated behavioral therapy for chronic insomnia. Designed to decondition presleep arousal and reassociate the bed/bedroom environment with rapid well consolidated sleep Typical instructions include: Maintain fixed wake time 7 days a week Avoid any behavior in bed/bedroom outside of sleep and sexual activity Sleep only in bedroom Leave the bedroom when awake for approximately 15-20 minutes Return only when sleepy.


Sleep Restriction: Sleep Restriction Limits patient time in bed to average total sleep time. Instructions: Establish a fixed wake time Limit subjects total time in bed to an amount that averages total sleep time Increase sleep time by 15 mins if sleep efficiency is greater than 85%


Relaxation Training: Relaxation Training Progressive muscle relaxation Diaphragmatic breathing Autogenic training


Pharmacologic Management : Pharmacologic Management See attached list


SLEEP DISORDER BREATHING: SLEEP DISORDER BREATHING The term sleep disordered breathing is a wide term that refers to various breathing abnormalities in Sleep, ranging from primary snoring to obstructive sleep apnea syndrome. In addition, it includes conditions such as respiratory events related to arousals and central sleep apnea syndrome. Associated with these condition can be sleep fragmentation. PEDIATRIC SLEEP LECTURE SERIES


Sleep Disordered Breathing: Sleep Disordered Breathing Types: Primary snoring Respiratory events related to arousals Obstructive sleep apnea syndrome Central sleep apnea syndrome Central alveolar hypoventilation syndrome PEDIATRIC SLEEP LECTURE SERIES


Primary Snoring: Primary Snoring Definition: Snoring during sleep without associated apnea, hypoventilation, hypoxemia or hypercarbia. No associated sleep disturbance and no daytime symptoms other than those related to adenotonsillar enlargement. PEDIATRIC SLEEP LECTURE SERIES


Primary Snoring : Primary Snoring ICSD criteria for diagnosis of primary snoring Complaint of snoring by the observer No evidence of daytime symptoms or sleep disruption resulting from snoring Polysomnography demonstrates Snoring often occurring for prolonged periods No associated arousals, disturbed sleep, O2 desaturation, hypercarbia or arrhythmias Normal sleep pattern for age Normal respiratory pattern for age during sleep 4. Does not meet diagnostic criteria for other sleep disorders PEDIATRIC SLEEP LECTURE SERIES


Obstructive Sleep Apnea Syndrome : Obstructive Sleep Apnea Syndrome Definition: Obstructive sleep apnea syndrome is characterized by episodes of partial or complete upper airway obstruction that occur during sleep, usually associated with a reduction in oxyhemoglobin saturation and/or hypercarbia. PEDIATRIC SLEEP LECTURE SERIES


Prevalence: Prevalence The prevalence of obstructive sleep apnea syndrome in children varies according to the Studies, but is generally agreed to be between 2-4% of all children. The incidence of PS is about 7-9% of all children. Sex ratio is 1 in prepubertal children Age of onset: 14 months. PEDIATRIC SLEEP LECTURE SERIES


Slide38: Obstructive apnea: Absence of oronasal airflow in the presence of continued respiratory effort, lasting longer than 2 respiratory cycles. Usually, but not always associated with Hypoxemia Central apnea: Cessation of respiratory effort lasting at least 2 respiratory cycles Obstructive hypopnea: Decreased breathing associated with a 30% or greater reduction in airflow, usually associated with paradoxical breathing and O2 desaturation PEDIATRIC SLEEP LECTURE SERIES


Obstructive Sleep Apnea Syndrome : Obstructive Sleep Apnea Syndrome The presentation of children with obstructive sleep apnea syndrome varies depending on the specialist seeing the patient. Pediatricians: Snoring, obesity, failure to thrive Neurologists: Sleepiness, snoring ENT: Adenotonsillar enlargement Psychiatrist/psychologists: Behavioral problems Pulmonologists: Snoring, difficulty breathing Sleep specialists: All of the above + sleep fragmentation, sleep parasomnias. PEDIATRIC SLEEP LECTURE SERIES


Obstructive Sleep Apnea Syndrome : Obstructive Sleep Apnea Syndrome Nocturnal symptoms: Snoring, paradoxical chest-abdominal motion, retractions, observed apnea, observed difficulty breathing during sleep, cyanosis during sleep or disturbed sleep PEDIATRIC SLEEP LECTURE SERIES


Obstructive Sleep Apnea Syndrome : Obstructive Sleep Apnea Syndrome Daytime symptoms: Nasal obstruction, mouth breathing, and other symptoms of adenotonsillar enlargement, behavior problems, or excessive daytime somnolence. Other severe symptoms include associated cor pulmonale, developmental delay and failure to thrive. PEDIATRIC SLEEP LECTURE SERIES


Associated Features: Associated Features Impaired somatic growth Sudden nocturnal awakenings Gastroesophageal reflux Increased risk of nasopharyngeal aspiration Hypoxemia Hypercarbia Neuropsychiatric disturbances PEDIATRIC SLEEP LECTURE SERIES


Predisposing Factors: Predisposing Factors Anything that reduces the caliber, increases collapsibility or interferes with neural control of the nasopharyngeal airway Obesity Down Syndrome Craniofacial Syndromes Achondroplasia Mucopolysaccharide storage disease Neurologic disorders PEDIATRIC SLEEP LECTURE SERIES


Complications: Complications Growth Cardiovascular Gastrointestinal Pulmonary Behavioral Neurologic Surgical PEDIATRIC SLEEP LECTURE SERIES


Complications: Complications Growth Failure to thrive Short stature Impaired growth hormone release Cardiovascular Cor Pulmonale/Pulmonary hypertension Polycythemia Chronic respiratory acidosis Possible systemic hypertension PEDIATRIC SLEEP LECTURE SERIES


Complications: Complications Gastrointestinal Feeding difficulties Gastroesophageal reflux Pulmonary Chronic aspiration Pulmonary edema (Post operative) Pectus excavatum PEDIATRIC SLEEP LECTURE SERIES


Complications: Complications Behavioral Developmental delay Behavioral problems School problems Neurologic Enuresis Increased intracranial pressure Lethargy/dull effect Hypoxia induced headaches PEDIATRIC SLEEP LECTURE SERIES


Complications: Complications Surgical Post surgical dehydration Post surgical hemorrhage Post operative respiratory compromise Pulmonary edema Death:Intraoperative, Related to right ventricular hypertrophy and dilatation Post operative death PEDIATRIC SLEEP LECTURE SERIES


Obstructive Sleep Apnea Syndrome : Obstructive Sleep Apnea Syndrome ICSD criteria for diagnosis of obstructive sleep apnea syndrome Complaint of noisy or disturbed breathing during sleep and/or inappropriate anytime sleepiness or behavioral problems Episodes of complete or partial airway obstruction during sleep Associated features should include: Snoring Paradoxical chest/abdominal motion and/or retractions Apnea or difficulty breathing observed by caregivers Excessive daytime sleepiness Behavior problems Adenotonsillar hypertrophy Daytime mouth breathing Other features of adenotonsillar hypertrophy Failure to thrive or obesity PEDIATRIC SLEEP LECTURE SERIES


Obstructive Sleep Apnea Syndrome : Obstructive Sleep Apnea Syndrome 4. Sleep polysomnogram with Obstructive hypoventilation and/or One or more obstructive apnea/hour usually with one or more of the following: Arterial oxygen desaturation below 90-92% Arousals from sleep associated with upper airway obstruction A multiple sleep latency test demonstrating an abnormal sleep latency for age 5. Usually associated with other medical conditions 6. Other sleep disorders can be present PEDIATRIC SLEEP LECTURE SERIES


Who needs a sleep study ?: Who needs a sleep study ? “CHILDREN THAT SNORE” Children with suspected obstructive sleep apnea syndrome Children with a history of behavioral, learning or mood issues with a history of poor quality or restless sleep Children with suspected central sleep apnea syndrome


Who needs a sleep study ?: Who needs a sleep study ? Children with excessive daytime sleepiness Progressive muscular disorders such as Duchenne Muscular Dystrophy Obesity: Neck circumference > 17 ½ inches usually associated with obstructive sleep apnea syndrome


Who needs a sleep study ?: Who needs a sleep study ? CHILDREN WHO SNORE Not all children that snore require sleep studies. If snoring is present then ask more sleep related questions If you are considering referring them to ENT then they require a sleep study.


Who needs a sleep study ?: Who needs a sleep study ? CHILDREN WITH ENLARGED TONSILS AND ADENOIDS Not all children with large tonsils or adenoids require sleep studies. Only if you are considering referring them to ENT for possible tonsillectomy and adenoidectomy The exception being patients with recurrent tonsillar infections in which that is an accepted indication for surgery


Who needs a sleep study ?: Who needs a sleep study ? CHILDREN WITH SUSPECTED OBSTRUCTIVE SLEEP APNEA SYNDROME According to the American Academy of Pediatrics, all children with suspected sleep apnea regardless of severity should have a diagnostic sleep polysomnography unless they are at risk of imminent cardiopulmonary decompensation in which case scheduling a sleep study must not interfere with management.


Who needs a sleep study ?: Who needs a sleep study ? Mild: Important to confirm the diagnosis and severity and rule out any co-morbidities Moderate: Important to confirm the diagnosis and severity and rule out any co-morbidities. Also to predict likelihood of continued morbidity post intervention


Who needs a sleep study ?: Who needs a sleep study ? Severe: Important to confirm the diagnosis and severity and rule out any co-morbidities. Predict success rate of surgical intervention Identify patients at risk for life threatening post-op complications and allow for presurgical anticipatory management


Who determines surgical candidates?: Who determines surgical candidates? The perception exists that ENT is the primary service that determines who gets surgery. The reality is that the primary physician determines who gets surgery Why?


Who determines surgical candidates?: Who determines surgical candidates? Primary physician identifies suspected obstructive sleep apnea syndrome ENT does not do diagnostic evaluations to confirm the PCP’s suspicions ENT treats suspected or confirmed obstructive sleep apnea syndrome.


Recommendations for diagnosis Pediatrics:Vol 109:4,pp 704-712 : Recommendations for diagnosis Pediatrics:Vol 109:4,pp 704-712 All children should be screened for snoring Complex high risk patients should be sent to specialists Patients with cardiorespiratory failure can not await elective evaluation Diagnostic evaluation is useful in discriminating between primary snoring and obstructive sleep apnea syndrome, the gold standard being polysomnography PEDIATRIC SLEEP LECTURE SERIES


Recommendations for diagnosis Pediatrics:Vol 109:4,pp 704-712 : Recommendations for diagnosis Pediatrics:Vol 109:4,pp 704-712 Adenotonsillectomy is the first line of treatment for most children, and CPAP is an option for patients who are not candidates for surgery or do not respond to surgery High risk patients should be monitored as in patients post operatively Patients should be reevaluated post operatively to determine whether additional treatment is required PEDIATRIC SLEEP LECTURE SERIES


Guidelines for Evaluation : Guidelines for Evaluation Provisional diagnosis History/physical Screening tests Brief observation in the clinic Home audiotaping Home videotaping Overnight oximetry Sleep sonography Tests to diagnose Sleep studies. PEDIATRIC SLEEP LECTURE SERIES


Sleep Polysomnography : Sleep Polysomnography Sleep studies in children are best done in a pediatric sleep laboratory Reasons: Qualified sleep technicians Sensitive equipment and different modalities Different scoring modalities Child friendly environment Better data collection PEDIATRIC SLEEP LECTURE SERIES


Sleep Polysomnography : Sleep Polysomnography What is recorded? Electroencephalography(EEG) Electromyography(EMG) Electrooculography(EOG) Electrocardiography(EKG) Snore channel, Flow channel (Thermistor), ETCO2 Respiratory inductance plethysmography Calibrated flow-volume loops/Konno-mead loops Chest and abdominal piezo belts Pulse oximetry CPAP/BiPAP channel PEDIATRIC SLEEP LECTURE SERIES


Sleep Polysomnography : Sleep Polysomnography Analysis Total sleep time, sleep stages, amount of time in each stage. # of arousals, awakenings, REM awakenings, abnormal EEG patterns. Heart rate and rhythm, respiratory rate and pattern, limb movements and arousals related to limb movement (Apnea and apnea/hypopnea index). Oxyhemoglobin saturation, End-Tidal CO2 levels PEDIATRIC SLEEP LECTURE SERIES


Sleep Polysomnography : Sleep Polysomnography Apnea index(# apnea/heart rate ) 92 or 50 torr PEDIATRIC SLEEP LECTURE SERIES


Other Evaluation Techniques: Other Evaluation Techniques Nap studies with sleep deprivation and/or sedation Home audiotaping Home videotaping Observation, physical examination, oximetry Fluoroscopic evaluation Endoscopic evaluation Cephalometric X-rays Sleep sonography Multiple sleep latency test PEDIATRIC SLEEP LECTURE SERIES


Technical ReportPediatrics:Vol 109:4,pp 704-712: Technical Report Pediatrics:Vol 109:4,pp 704-712 Clinical evaluation has unacceptably low SENSITIVITY AND SPECIFICITY for predicting OSAS Nap studies with sleep deprivation and/or sedation Home audiotaping/Home videotaping (Not validated, can not predict sleep architecture or fragmentation,can not differentiate obstructive from central or primary snoring. Can not give accurate indication of seizure activity, end tidal CO2 levels or hypoventilation Pulse oximetry with daytime nap studies. Highly specific but very poor sensitivity. PEDIATRIC SLEEP LECTURE SERIES


Treatment: Treatment There are various modalities for the management of obstructive sleep apnea syndrome. Some of the options include: Doing nothing/close follow up Medical/pharmacologic Surgical: Mechanical therapy PEDIATRIC SLEEP LECTURE SERIES


Treatment: Treatment The commonest and most accepted means of managing childhood obstructive sleep apnea syndrome is tonsillectomy and adenoidectomy. It is preferred to remove both when possible as studies have shown that failure to do so often results in a repeat procedure later. PEDIATRIC SLEEP LECTURE SERIES


Treatment: Treatment Complications: Post operative death Hemorrhage Pain Airway compromise Respiratory distress Dehydration PEDIATRIC SLEEP LECTURE SERIES


Predictor of Post-op Complications: Predictor of Post-op Complications Age less than 3 years old High apnea index(>10) Failure to thrive Craniofacial abnormalities Abnormal EKG or echocardiogram * Awake arterial blood gases, elevated hematocrit or elevated bicarbonate level are not clear indicators PEDIATRIC SLEEP LECTURE SERIES


Treatment: Treatment Other surgical techniques: Uvulopalatopharyngoplasty(UPPP) Tracheostomy Mandibulo-hyoid advancement Partial epiglottectomy Lingual tomsillectomy PEDIATRIC SLEEP LECTURE SERIES


Treatment: Treatment Mechanical therapy: Continuous positive airway pressure (CPAP): Indications: Failed tonsillectomy and adenoidectomy Obesity Craniofacial abnormalities Down Syndrome Intraoral appliances PEDIATRIC SLEEP LECTURE SERIES


Treatment: Treatment Medical therapy: Weight loss Supplemental oxygen Pharmacologic approaches: Nasal vasoconstrictive sprays and decongestants, medroxyprogesterone, acetazolamide, nicotine, tca’s theophylline PEDIATRIC SLEEP LECTURE SERIES


Slide76: Thank You for Attending.