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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
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.