Pediatric Sleep Review

Sleep affects every aspect of a child’s development and is considered a time of healing, processing of information and renewal for the mind and body. Sleep difficulties are experienced by approximately 25-30% of all children/adolescents at one point. Insomnia, insufficient sleep, (IS) sleep disordered breathing, (SDB) nightmares, periodic limb movement disorder (PLMD), parasomnias, nightmares, excessive daytime sleepiness and narcolepsy are common sleep disorders. IS has been identified as a risk factor for obesity in all ages; and IS in adolescents is a risk factor regardless of physical activity. IS among school-aged children is associated with an increased risk of poor academic performance, focus difficulties, hyperactivity and depression (Yland, Guan, Emanuele & Hale, 2015). Furthermore, IS in adolescents can encourage high-risk behaviors such as substance abuse, suicide behaviors and drowsiness while driving.A shift towards poorer sleep in adolescents over the past decade has coincided with a sharp increase in the availability and use of electronic devices such as smart phones, video game consoles, computers, and tablets along with television (Hysing et al., 2015). Along with entertainment, electronic devices play an ever-increasing part in the social lives of adolescents. Educational institutions also play a part of encouraging electronic use for coursework often making it difficult for parents to monitor whether their child is using their electronic devices for homework versus entertainment. The timing of electronic use before bed is also significant because blue light emitted from screens suppresses the endogenous melatonin throughout the night. A recent study, examining technology related behaviors, found electronics (gaming) and online social media in the hour before bedtime were risk factors for shorter and poorer sleep, whereas time with family was protective of sleep duration (Harbard, Allen, Trinder & Bei, 2015). Making sure that children do not substitute electronic gaming for physical activity including outdoor play is vital. Insomnia can be short term or long term. Prolonged insomnia can be caused by stress, depression, generalized anxiety, pain and medical problems such as SDB. Bedtime resistance and dependency upon parents to initiate sleep are considered insomnia with behavioral causes as the root cause. Children with neurological disorders such as Autism Spectrum Disorder and ADHD have the highest rates of sleep problems of all children with mental challenges and, like normally developing children, behavioral insomnia is the most common complaint. Sleep difficulties among children with ADHD are thought to be related to shared neurobiological pathways involving areas of the cortex responsible for regulation and arousal, the medication effects of stimulants used and the presence of comorbid mental health disorders (Tsai et al., 2016). SDB and PLMD are also a common cause of sleep difficulties in this group. Establishing healthy sleep hygiene begins early. Clinical experience suggests that between 3 and 4 months of age may be an ideal time to begin sleep training with infants. Placing infants into their crib drowsy but still awake allows them to initiate sleep independently in their own environment and enables them to return to sleep independently throughout the night. This strategy has been found to be the most important recommendation for parents in multiple studies. Nursing or bottle-feeding a baby to sleep after the newborn period is also not recommended as the infant may learn to associate being fed with returning to sleep. Medications are not generally recommended as a first-line therapy for children with sleep problems. Behavioral therapy and establishing good sleep hygiene with a consistent sleep routine are the mainstays for any child with difficulties sleeping and need to be incorporated even if medication is used.

Parasomnias
Sleep walking and night terrors are parasomnias which occur during NREM sleep, specifically NREM 3 or Delta sleep. Parasomnias commonly occur between 4 to 8 years of age, are often familial. NREM 3 sleep is such a deep state of sleep that when children experience an arousal during this time, their body is awake but the brain sleeps through the event. Children typically have amnesia since they are sleeping during the event. Most episodes are brief, but waking up the child can prolong the episodes. Causes include SDB, PLMD, sleep deprivation, stress, fever, being overheated at night, or a full bladder. Identification and treatment of primary sleep disorders such as PLM’s and OSA often results in the resolution of parasomnias. Nightmares typically occur during the last portion of night, whereas night terrors occur mostly in the first part of the night. Occasional nightmares are common in childhood and reassurance is generally effective. However, recurrent nightmares can be associated with daytime stressors, and psychological evaluation may be needed.

Nocturnal Enuresis
SDB has been associated with secondary enuresis due to altered arousal response and sleep fragmentation. Resolution of secondary enuresis after medical or surgical treatment for obstructive sleep-disordered breathing is common. Therefore, snoring, parasomnias and restless sleep should be evaluated for all children with enuresis.

PLMD
PLMD is fairly common in children and can cause insomnia, restless sleep and daytime sleepiness. Leg pain is common and some children will complain that spiders or bugs are in their bed. A recent study found the most striking single symptom of PLMD was awakening after 1-3 hours of sleep followed by screaming, crying, kicking, and slapping the legs or by verbally expressing that the legs hurt (Munzer & Felt, 2017). Ferritin levels less than 50 have been associated with PLMD’s in children and supplementation with ferrous sulfate (3 mg/kg/day) has been shown to drastically improve symptoms (Munzer & Felt, 2017). Clonazepam and Gabapentin are sometimes used in treatment if ferritin levels are normal and other organic causes have been ruled out, but this should be initiated by a sleep specialist.

SDB
Children with SDB can manifest along a continuum from simple snoring and upper airway resistance to obstructive sleep apnea (OSA). OSA is characterized by upper airway obstruction, abnormal respiratory patterns, and fragmented sleep and can result in various physical, mental, and cognitive problems. Symptoms may include mood and behavioral problems, failure to thrive, ADHD, and/or daytime sleepiness and pulmonary hypertension in severe cases. OSA has been shown to be a contributing factor to the pathogenesis of obesity by inducing leptin resistance and increasing ghrelin levels which Leptin is a key hormonal regulator of appetite and metabolism; it promotes a sense of fullness leading to reduced food intake. Ghrelin is a hormone secreted in the gut that increases appetite, which can potentiate cravings of high calorie comfort foods. generally causes insufficient sleep, compounding this metabolic insult (Falbe, et al., 2015). Even snoring alone had effects on neurocognitive functioning leading to learning difficulties. Signs of SDB can include snoring, gasping, apneas, increased work of breathing with paradoxical respirations, neck hyperextension, night sweating, tachycardia, restless and and disrupted sleep. Risk factors include tonsillar or adenoid hypertrophy, obesity, craniofacial abnormalities, gastroesophageal reflux, neuromuscular disorders, and untreated allergic rhinitis. Children with neuromuscular disorders might not snore and should be evaluated with other criteria, specifically increased work of breathing, tachycardia, nocturnal sweating, and daytime symptoms.
Surgical and Medical Treatment of Sleep Disordered Breathing. Adenotonsillectomy (TA) is considered a first line treatment for OSA (Roberts et al., 2016). The American Academy of Sleep Medicine and the American Academy of Pediatrics recommend a polysomnogram (PSG) to confirm and characterize obstructive sleep apnea syndrome (OSAS) before Adenotonsillectomy (Rosen et al., 2015). However, the American Academy of Otolaryngology-Head and Neck Surgery recommends a PSG for children with certain complex medical conditions or when there is lack of agreement between tonsil size and reported severity of OSAS symptoms. The PSG allows the surgery team to understand the severity of the OSA so that perioperative and postoperative complications can be anticipated. Nonsurgical options include positive airway pressure (PAP), nasal steroids, and leukotriene receptor antagonists (Montelukast), normal saline rinses, rapid maxillary expansion, oral appliances, and weight loss (Rosen et al., 2015). PAP therapy stents open the larynx to allow ventilation and is typically used without oxygen. Nasal steroids and Montelukast can be effective in mild to moderate OSA by reducing the lymphoid tissue, especially the adenoid.

Central Sleep Apnea
Central sleep apnea (CSA) refers to absences of airflow that are related to failure of the ventilator control system to stimulate a breath (American Academy of Sleep Medicine, 2015). Unlike OSA, CSA is not associated with a snore or gasp and is common in children intermittently, especially following a sigh. When CSA occurs frequently or results in oxygen desaturations, it is considered pathologic. CSA is more common in premature infants or those with neurological conditions, such as cerebral palsy, brainstem lesions, or Chiari malformations. CSA can also be induced by narcotic use. Oxygen and/or BIPAP therapy are treatments for CSA

Narcolepsy
Narcolepsy is a disorder characterized by excessive daytime sleepiness, fragmented nocturnal sleep, and frequently REM sleep intrusion during awake times. Cataplexy is a form of REM sleep intrusion and is characterized by a brief sudden loss of skeletal muscle tone, which is typically brought on by laughter but can also be stimulated by other strong emotions. Neck, facial, and knee weakness are common and individuals retain consciousness during cataplexy events, which can help differentiate it from seizures. Not all people with narcolepsy have cataplexy. Excessive sleepiness, which is typically the first symptom to manifest, may present years before the cataplexy (American Academy of Sleep Medicine, 2015). Other manifestations of narcolepsy include sleep onset paralysis, (inability to move any muscles (except respiratory muscles) when falling asleep or waking up) and hypnogogic hallucinations (vivid dream-like visual, tactile or auditory hallucinations that occur as the patient is falling asleep). Narcolepsy with cataplexy is caused by a deficiency of hypothalamic hypocretin which is and this can be measured in the cerebral spinal fluid. The HLA-DQB1*06:02 allele gene has been identified in most patients with narcolepsy. Diagnosing Narcolepsy is complex and a referral to a sleep specialist is warranted. Medication management is the core therapy for narcolepsy with cataplexy.

Summary
Pediatric sleep disorders are challenging and can impact growth, behavior, development and social interactions inside and outside of the home environment. Early recognition of pediatric sleep disorders, appropriate treatment and referral to a pediatric sleep specialist are critical steps in improving sleep hygiene for the family unit.

About the author:

Susan Hines, RN, BSN, MSN, CPNP began her career in pediatric medicine in 1994 as a BSN and specialized in pediatric critical care medicine at The Medical College of Georgia. She became a pediatric nurse practitioner in 2003 from University Of Colorado School Of Nursing. She has enjoyed a diverse and rewarding career as a pediatric nurse practitioner (PNP) at CHCO, specializing in Urgent care, Neurosurgery, Neurology, Newborn nursery, Hospitalist and Pulmonary sleep medicine. She currently practices as a PNP for the Breathing Institute (BI) at CHCO, primarily treating Sleep Disordered Breathing (SDB), Asthma, Narcolepsy and Insomnia. Susan is also developing protocols for several sleep laboratories in the Denver Metro area and educating internal and external providers and ancillary staff.  She moved to Colorado in 1998 after completing a travel nurse job at Children’s Hospital Colorado after falling in love with Colorado and is actively raising two wonderful yet busy teenagers in Golden, CO.

Susan Hines, RN, BSN, MSN, CPNP | Pediatric Nurse Practitioner | The Breathing Institute-Sleep 13123 East 16th Avenue, Box 395 | Aurora, CO 80045 | Phone: 720-777-8437 | Fax: 720-777-7284

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