Pediatric Neurology Quick Talks

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Pediatric Neurology Quick Talks

• Sleep Disorders
• Michael Babcock
• Summer 2013

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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

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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

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Insomnia

• Onset or Maintenance?
• Usually behavioral
• Psychosocial
• Anxiety (separation)
• Depression
• Medical problems chronic pain, GERD, breathing
  problems, medications

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Insomnia

• 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

• 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.

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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.

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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

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Narcolepsy

• Narcolepsy
• Excessive daytime sleepiness
• Sleep paralysis
• Hypnagogic hallucinations
• Cataplexy
• Sudden loss of tone
• Precipitated by emotion (laughing, anger)
• REM creep
• Dx polysomnography, MSLT

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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.

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Parasomnias

• 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

• Disorders of Non-REM arousal
• Sleep walking
• Sleep terrors
• Confusional arousals
• REM sleep disorders
• Nightmares
• Sleep paralysis
• REM sleep behavior disorder
• Narcolepsy
• SSRI
• neurodevelopmental

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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.

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References

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