Pediatric Neurology Quick Talks Sleep Disorders Michael Babcock
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
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