Sleep Disorders in Children and Adolescents

1
Sleep Disorders in Children and Adolescents

• Deepti Shenoi MD

2
Objectives

• To gain an understanding of normal basic sleep
  physiology and pathology in children and
  adolescents
• To learn developmentally appropriate behavioral
  techniques for improving sleep
• To obtain an understanding of options in
  pharmacotherapy for pediatric insomnia
• I would also like you to think of iatrogenic
  causes for sleep difficulties. Or how we can
  make things worse.

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Stages of Sleep
4
General Sleep Stages
5
Typical sleep need for children and adolescents
by developmental stage
Age group Years Total sleep need Infants
3 to 12 months 14 to 15 hours Toddlers 1 to
3 years 12 to 14 hours Preschoolers 3 to 5
years 11 to 13 hours School-aged 6 to 12
years 10 to 11 hours Adolescents 12 to 18
years 8.5 to 9.5 hours
Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
6
Sleep Time During Development
Thiedke, CC. Sleep Disorders and Sleep Problems
in Children. Am Fam Physician 200163277-84
7
Newborns (0-3 months)

• Sleep 10-18 hours per day
• Many short sleep periods, with no differentiation
  between day and night.

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
8
Tips for newborns and infants (up to 6mo)

• Nighttime awakenings for changing and feeding
  should be quick and quiet
• Place baby in the crib before falling asleep
  (when drowsy)
• Avoid feeding the baby to sleep
• Simple bedtime routinesoothing activities in the
  same order every night
• GOAL Babies to fall asleep by themselves and
  learn to soothe themselves and go back to sleep
  if they wake up in the middle of the night

Mindell JA, Meltzer LJ. Behavioural Sleep
Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008 37722-28.
9
Toddlers (12 mo-3 yrs) and Preschoolers (3-5
yrs)

• Maintain a daily sleep schedule with regular
  naptimes and bedtime
• Establish a consistent bedtime routine.
• Bedroom should be quiet, comfortable, and dark
• Have the child fall asleep independently.
• Set limits that are consistent and enforced.
• Encourage use of a security object, such as a
  blanket or stuffed animal.

Mindell JA, Meltzer LJ. Behavioural Sleep
Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008 37722-28.
10
School-Aged Children(6-12 yrs)

• Same bedtime and wake-up on weekdays and weekends
• A 20- to 30-minute bedtime routine that is the
  same every night.
• No caffeine
• No TV in the bedroom
• The child should spend time outside every day and
  get daily exercise

Mindell JA, Meltzer LJ. Behavioural Sleep
Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008 37722-28.
11
Adolescents (12-18 years)

• Need 9-9.25 hours of sleep per night but studies
  show that most get 7 hours/night
• Onset of puberty ?hormonal changes and shift in
  melatonin ? 2 hour shift in circadian rhythm
  phase (later sleep onset and morning wake time)
• Some experience a physiological need for a short
  sleep period in early afternoon

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
12
What to ask in a sleep evaluation?-- Sleep History

• Bedtime Evening activities, bedtime routines
• Night-time Latency to sleep onset, behaviors
  during the night, and duration of awakenings
• Daytime Daytime sleepiness, naps, caffeine
  intake, psychological, social and family
  functioning

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What to ask in a sleep evaluation?-- Sleep Hygiene

• Consistent and appropriate sleep-wake schedule
• Similar schedule on weekdays and weekends
• Consistent bedtime routine that involves same 3-4
  activities every night
• No technology in the bedroom

14
BEARS screen (for kids 2-18y.o.)

• Bedtime problems
• Excessive daytime sleepiness
• Awakenings during the night
• Regularity of evening sleep time and morning
  awakenings
• Sleep related breathing problems or snoring

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Common Disorders

• Behavioral Insomnia of Childhood
• Insufficient or Inadequate sleep
• Delayed Sleep Phase Syndrome
• Sleep Disordered Breathing
• Disorders of Arousal
• Movement disorders

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Behavioral Insomnia of Childhood

• Manifests most commonly as bedtime resistance
  and/or frequent night wakings and occurs in
  approximately 10 to 30 of infants and toddlers
• Sleep-onset Association Type
• Limit-setting type
• Combined Type

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
17
Insufficient or Inadequate Sleep

• Sleep deprivation can have a cumulative effect ?
  being late or missing school, falling asleep
  during school, fatigue, illness, and irritability
• Poll reports that 28 of high school students
  report falling asleep in school at least once a
  week
• Insufficient sleep can be fatal for adolescents
  who fall asleep while driving.

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
18
Insufficient or Inadequate Sleep

• Signs that children or adolescents are not
  getting enough sleep include
• (1) needing to be awakened for school or day care
  in the morning,
• (2) sleeping 2 hours more on weekends and
  vacations compared with weekdays,
• (3) falling asleep in school or at other
  inappropriate times,
• (4) behavior and mood differing on days after
  getting more sleep

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
19
Delayed Sleep Phase Syndrome

• The persons sleep-wake cycle is delayed by 2 or
  more hours
• Night Owls

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
20
Delayed Sleep Phase Syndrome
21
Delayed Sleep Phase Syndrome-Treatment

• Sleep hygiene
• Shifting the internal clock
• Phase Advancement When the difference between
  the actual and desired bedtime is less than 3
  hours. Every night or two, go to sleep 15 minutes
  earlier.
• Phase Delay When the difference is greater than
  3 hours, delay sleep by 2-3 hours on successive
  nights

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
22
Sleep-Disordered Breathing

• Can range from primary snoring to obstructive
  sleep apnea syndrome (OSAS) and is related to
  signi?cant cognitive and behavioral sequelae,
  including learning, attention, concentration,
  hyperactivity, and aggressive behavior
• Incidence of habitual snoring has been re-
  ported at 3 to 12 of the general pediatric
  population, with OSAS seen in 1 to 3 of children

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
23
Narcolepsy

• Chronic neurologic disorder that involves
  excessive daytime sleepiness
• cataplexy (sudden loss of muscle control in
  response to strong emotional stimuli)
• hypnagogic hallucinations (vivid dreams at sleep
  onset)
• sleep paralysis
• autonomic behavior in which you continue to
  funtion, talk, clean but then have no
  recollection of performing task
• .

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
24
Narcolepsy Work up

• Polysomnography (PSG)
• Typically fall asleep rapidly with early REM
• Multiple sleep latency test (MSLT)
• Test subjects are given opportunities to sleep
  every two hours during the normal awake time and
  monitored to see how quickly they fall asleep and
  reach various stages of the sleep cycle.
• May provide clear evidence of narcolepsy, but in
  children, results are not always conclusive, and
  repeat studies may be necessary for a ?nal
  diagnosis

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Narcolepsy

• Individualized based upon symptoms.
• Treatment includes education, sleep hygiene, and
  pharmacologic interventions
• Daytime Sleepiness
• Sleep scheduling is essential, with a consistent
  bedtime, wake time, and good sleep hygiene
• Children and adolescents who have narcolepsy may
  bene?t from a scheduled daily nap in the early
  afternoon.
• Stimulants are commonly used to treat daytime
  sedation including provigil
• Atomoxetine has also been used.
• Cataplexy Cholinergic pathway mediated
• medications with anticholinergic properties are
  used to treat cataplexy, including clomipramine
  and imipramine

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
26
Disorders of Arousal

• Referred as partial arousal parasomnias and
  include confusional arousals, sleep terrors,
  sleep talking, and sleepwalking
• During an event, although children are asleep,
  they may appear awake (eyes open), talk, or seem
  frightened or confused (eg, screaming in the case
  of sleep terrors)
• Typical parasomnias resolve spontaneously with
  children rapidly returning to a deep sleep

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
27
Disorders of Arousal

• Common feature retrograde amnesia
• Strong genetic component to partial arousal
  parasomnias, with a family history typically
  reported
• Partial arousals are more likely to be triggered
  by insufficient sleep, a disruption to the sleep
  environment or sleep schedule, stress, illness,
  or certain medications (eg, chloral hydrate or
  lithium)

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
28
Sleep Terrors vs Nightmares
Thiedke, CC. Sleep Disorders and Sleep Problems
in Children. Am Fam Physician 200163277-84
29
Disorders of Arousal

• Treatment providing families with information
  about creating a safe sleep environment (eg,
  preventing windows from opening or putting alarms
  or bells on doors to alert if a sleep walker is
  up), education about the events, and how to
  interact with children appropriately during an
  event
• As some children may develop a fear of going to
  sleep and a prolonged sleep onset in turn
  increases the likelihood of an event occurring,
  parents should be encouraged to not discuss these
  events in the morning with the child or other
  children in the home

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
30
Restless Leg Syndrome and Periodic Limb Movement
Disorder

• RLS manifests as uncomfortable sensations in the
  legs that worsen in the evening and with long
  periods of inactivity (eg, long car ride or
  movie)
• Sensations often are described as creepy-crawly
  or tingling feelings, most commonly in the legs,
  which can be alleviated temporarily with
  movement.
• PLMS are brief repetitive movements or jerks,
  lasting on average 2 seconds and occurring every
  5 to 90 seconds during stages 1 and 2 of sleep
• PLMD occurs when PLMS are associated with
  frequent, but brief, arousals from sleep

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
31
Restless Leg Syndrome and Periodic Limb Movement
Disorder

• Pharmacologic treatment for RLS and PLMD in
  children and adolescents may include
  benzodiazepine and dopaminergic medication
• Some children who have RLS or PLMD have low
  iron/ferritin and many of these children and
  adolescents respond favorably to iron therapy
• At this time, there are no FDA-approved
  medications available to treat RLS and PLMD in
  children.

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
32
Sleep-Related Rhythmic Movement Disorders

• Include head banging and body rocking and are
  considered to be a sleep-wake transition
  disorder, occurring as children attempt to fall
  asleep at bedtime, naptime, or after a normal
  nighttime arousal
• common in infants (60 of 9 month olds), the
  behaviors tend to resolve spontaneously with
  development (only 8 of 4 year olds demonstrate
  these behaviors), but they can continue into
  adolescence and adulthood

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
33
Sleep-Related Rhythmic Movement Disorders

• Events typically last 5 to 15 minutes, but
  prolonged events can go for several hours
• Important to ensure safety
• In cases that result in injury, or when the
  behavior may be highly disruptive to others for a
  short duration (eg, family vacation or overnight
  sleepover), benzodiazepines may be indicated.
• Evaluation is recommended for severe cases or
  cases persisting past age 3

Meltzer LJ. Sleep and Sleep Disorders in
Children and Adolescents. Psychiatr Clin North Am
2006 29(4) 1059-76
34
Optimizing Treatment of Sleep Problems

• Identification of the suspected causes of
  disrupted sleep
• Involvement of the family by explaining the
  disorder and teaching them developmentally
  appropriate principles of sleep-wake organization
• Use of behavioral treatments such as contracts to
  target specific behaviors that need to be changed

Anders, TF, Eiben LA. Pediatric Sleep Disorders
A Review of the Past 10 Years. J Am Acad Child
Adolesc Psychiatry. 1997369-20.
35
Pharmocotherapy of Pediatric Insomnia General
Guidelines

• Reminder In almost all cases, medication is
  neither the first treatment of choice, nor the
  sole treatment for children
• Medication should be used in combination with
  non-pharmacological strategies as these have been
  shown to have long-lasting effects
• Treatment selection - best match between clinical
  circumstances and individual properties of
  medications
• Medications should be closely monitored for
  emerging side effects

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
36
Pharmocotherapy of Pediatric Insomnia General
Guidelines

• Presence of both medically and behaviorally-based
  sleep disorders must be assessed
• Medications should be used in caution in
  situations where there may be potential drug-drug
  interactions
• Non-prescription and over-the-counter medication
  use should be assessed

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
37
Pharmocotherapy of Pediatric Insomnia

• Antihistamines Prescription (hydroxyzine) and
  OTC (diphenhydramine)
• Bind to H1 receptors in the CNS
• Rapidly absorbed
• Side effects daytime drowsiness, cholinergic
  effects, paradoxical excitation

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
38
Pharmocotherapy of Pediatric Insomnia Melatonin

• Melatonin hormone secreted by pineal gland in
  response to decreased light, mediated through
  suprachiasmatic nucleus mechanism of
  commercially available melatonin is to supplement
  endogenous pineal hormone
• Clinical uses for melatonin are principally in
  normal children with acute or chronic circadian
  rhythm disturbances and in children with special
  needs (blindness, Rett syndrome)

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
39
Pharmocotherapy of Pediatric Insomnia Melatonin

• Plasma levels peak within 1 hour of
  administration
• Generally safe but potential side effects include
  suppression of hypothalamic-gonadal axis (i.e.
  could trigger precocious puberty upon
  discontinuation
• Not regulated by FDA
• Reported doses 1 mg in infants, 2.5-3 mg in
  older children, 5 mg in adolescents

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
40
Pharmocotherapy of Pediatric Insomnia Herbal
Preparations

• Valerian Root, St. Johns Wort, and Humulus
  lupulus - some evidence of efficacy in adult
  and/or pediatric studies
• Lemon balm, chamomile, and passion flower -
  limited to no evidence
• Kava kava, Tryptophan - assoc. with significant
  safety concerns (e.g. hepatotoxicity and
  eosinophilic myalgia syndrome, respectively)

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
41
Pharmocotherapy of Pediatric Insomnia
Benzodiazepines

• Hypnotic effect mediated at GABA Type A receptors
  in the brain
• They shorten sleep- onset latency, increase total
  sleep time, and improve non-REM sleep
  maintenance most disrupt slow-wave sleep.
• Use of longer- acting BZDs may lead to morning
  hangover, daytime sleepiness, and compromised
  daytime functioning. Anterograde amnesia and
  disinhibition may also occur.

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
42
Pharmocotherapy of Pediatric Insomnia
Benzodiazepines

• Risk for habituation or addiction with these
  medications, as well as withdrawal phenomena
• Used for short-term or transient insomnia or in
  clinical situations in which their other
  properties (e.g., anxiolytic) are advantageous
• BZDs are occasionally used to treat intractable
  partial arousal parasomnias (e.g., sleep terrors)
  in children because of their slow-wave sleep
  suppressant effects.

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
43
Pharmocotherapy of Pediatric Insomnia Melatonin
Receptor Agonist

• Ramelteon (Rozerem) a synthetic melatonin
  receptor agonist, acting selectively at the MT1
  and MT2 receptors
• Approved for use in sleep initiation insomnia,
  and shows moderate efficacy in reducing
  sleep-onset latency (in adults)
• Two single pediatric case reports have reported
  efficacy in autistic children

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
44
Pharmocotherapy of Pediatric Insomnia ?-Agonist

• Clonidine central ?2-agonist that decreases
  adrenergic tone
• one of the most widely used medications for
  insomnia in pediatric and child psychiatry
  practice, particularly in children with sleep-
  onset delay and ADHD
• safety and efficacy in children with ADHD and
  sleep problems is limited to descriptive studies

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
45
Pharmocotherapy of Pediatric Insomnia ?-Agonist

• Clonidine is rapidly absorbed with onset of
  action within 1 hour and peak effects in 2-4
  hours
• Tolerance often develops necessitating increase
  in dose
• Discontinuation may lead to rebound in REM and
  slow-wave sleep
• Possible side effects include hypotension and
  bradycardia, anticholinergic effects,
  irritability, and dysphoria rebound hypertension
  may occur on abrupt discontinuation
• Avoid in patients with diabetes and Raynaud
  syndrome

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
46
Pharmocotherapy of Pediatric Insomnia Atypical
Antidepressants

• Trazodone one of the most sedating
  antidepressants because it both inhibits binding
  of serotonin and blocks histamine receptors
• Suppressant effects on REM and may increase
  slow-wave sleep
• Morning hangover is a common side effect
• Associated with reports of priapism in the 50- to
  150-mg dose range

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
47
Pharmocotherapy of Pediatric Insomnia Atypical
Antidepressants

• Mirtazepine (Remeron) ?2-adrenergic 5-
  hydroxytryptamine receptor agonist with a high
  degree of sedation
• Shown to decrease sleep- onset latency, increase
  sleep duration, and reduce wake after sleep onset
  in adults with and w/o major depression with
  little effect on REM

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
48
Pharmocotherapy of Pediatric Insomnia

• SSRIs may cause sleep-onset delay and sleep
  disruption (Fluoxetine) and sedation
  (Fluvoxamine, Paroxetine, Citalopram)
• SSRIs suppress REM sleep and often prolong REM
  onset while increasing the number of REMs
• Most increase sleep-onset latency and decrease
  sleep efficiency (time asleep/time in bed)
• Selective serotonin reuptake inhibitors
  frequently are associated with motor restlessness
  and may exacerbate preexisting RLS and periodic
  limb movements

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Pharmocotherapy of Pediatric Insomnia

• Other classes which have reportedly been used
  include mood stabilizers/anticonvulsants (e.g.,
  carbamazepine, valproic acid, topiramate,
  gabapentin), atypical antipsychotics (e.g.
  risperidone, olanzapine, quetiapine), and chloral
  hydrate.
• These meds should be used with caution as there
  are no or limited date on safety and
  tolerability.
• Sedating effects may interfere with daytime
  functioning and learning
• Atypical antipsychotics may cause weight gain and
  worsen Obstructive Sleep Apnea also tend to sup-
  press REM sleep and increase motor restlessness
  during sleep
• Chloral Hydrate and Barbiturates are not
  indication for use in children due to significant
  side effects (inc. hepatotoxcity)

Owens, JA. Pharmocotherapy of Pediatric Insomnia.
J Am Acad Child Adolesc Psychiatry.
20094899-107.
50
The End