pediatric neurology quick talks sleep disorders michael babcock summer 2013
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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
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