Pediatric Sleep Disorders

Sleep disorders in children and adolescents are common; even infants may have sleep disorders. Studies have shown that poor sleep quality and/or quantity in children are associated with a host of problems, including academic, behavioral, developmental and social difficulties, weight abnormalities, and other health problems. Not only do pediatric sleep problems affect child health, but they can impact family dynamics and parental or sibling sleep. 

Children may suffer from problems falling or staying asleep, sleep deprivation; physiological problems such as obstructive sleep apnea abnormal or disruptive behaviors during sleep such as sleepwalking or other parasomnias symptoms that occur near sleep onset such as restless legs syndrome, and daytime symptoms such as excessive sleepiness, cataplexy and others. While adults may suffer from the same problems, the etiology, presentation, and associated findings in children may be very different than those seen in adults. In addition, developmental aspects of childhood play an important role in pediatric sleep, such as in the cases of early childhood insomnias and adolescent delayed sleep phase syndrome. National Sleep Solutions in Columbus, GA can help you in the diagnosis and treatment of your child.

National Sleep Solutions was the first clinic to treat sleep disorders in children. We quickly realized that treating pediatric sleep disorders starts with setting expectations regarding normal pediatric sleep. Behavior modification plans may address some sleep issues. In addition to board-certified pediatric and adult sleep physicians with expertise in pediatric sleep disorders, National Sleep Solutions has team of behavioral psychologists certified in the treatment of sleep disorders who have expertise in working with children and their families. Using scheduled awakenings, positive reinforcement, and other techniques may be helpful in some cases of sleep disorders. In other cases, your doctor may recommend medications or supplements to treat a specific sleep disorder or underlying condition. Finally, in some cases, evaluation for specific interventions by a specialist in allergy, Ear, Nose and Throat (ENT) surgery, orthodontics, or other specialties may be recommended. In the case of obstructive sleep apnea, continuous positive airway pressure may be recommended.

Arousal disorders are common in children. Arousal does not mean that the child wakes-up. The “arousal” is a partial arousal usually from “deep” sleep also called “slow wave sleep”. Most commonly the child transitions from deep sleep to a mixture of very light sleep and/or partial wakefulness. 

This stage shift will commonly lead to a confusional state or a “confusional arousal”. During such an episode, the child presents features suggestive of being simultaneously awake and asleep. On one hand, the child may appear to be alert by crying very loudly, moving, or even running. However, the child simultaneously appears to be disoriented, and confused. They can be relatively unresponsive to solicitations from parents as well as from other environmental challenges. There is usually little or no recall of the arousal or any event that may had occurred during the episode the next morning or even 10 to 30 minutes later if the child is to awaken completely. 

Various behaviors can occur during sleep ranging from simple to complex activities. Simple behaviors would include mumbling during sleep or sitting up in bed then falling right back asleep. However, more elaborate behaviors are also possible, for example crying loudly in distress, inconsolable and ignoring the reassurance of the parents, seemingly “very far away.” The child may even exhibit aggressive behavior against parents that want to reassure the child and trying to escape an embrace. 

Finally, very complex behaviors such as sleep walking are possible. The child may quietly walk around the bedroom or rush around in highly agitated state hitting the furniture. The complex behaviors may seems goal oriented or they may be poorly directed. For example, a child may go into a closet looking for the bedroom door, or may go into a closet and urinate before returning to bed.Usually only one episode occurs during the night and often it is within the first 2 hours of falling asleep However, there are always exceptions to this rule. There may be periods where a child has several episodes during a single night and then go several weeks without a single episode.

It seems that a small disruption of sleep due to another cause, such as a health problem or travel, may elicit behaviors associated with confusional arousals. It was shown that fever, abrupt sleep loss, migraine, irregular sleep-wake schedules can be more associated with these events. It was also shown that another sleep disorder such as sleep-disordered-breathing and to a lesser extent restless legs syndrome or nocturnal asthma may be seen in association with the confusional behaviors.One hypothesis is that the other health problem (fever, sleep-disordered-breathing as an example) already disturbs sleep, particularly when the child is trying to go to deep sleep. The health problem brings the child very abruptly from the deep sleep to a near awakening. It has also been hypothesized that stress or anxiety could be an added trigger. In older teenagers, alcohol intake and sleep deprivation must also be taken into consideration.

The most common confusional behavior syndromes are sleep terrors and sleep walking. When these behaviors are chronic they must be investigated. An epidemiological survey performed on school children in the Tucson (AZ) area found that in this group of children seen outside of a clinic setting, the most common association (though not the only one) with chronic sleepwalking was sleep-disordered-breathing. Other studies have shown that treatment of the associated sleep disorder can positively reduce or eliminate the confusional behaviors. Treating an abnormal sleep-wake schedule and/or reducing stressful conditions has also been associated with the resolution of associated health problems.The notion that chronic abnormal behavior during sleep has been associated with other sleep disorders, such as sleep-disordered-breathing, is the justification for recommending nocturnal polysomnography when a child presents such a chronic syndrome.

A question often raised is: Does my child have a seizure disorder? The presentation of nocturnal seizure with abnormal behavior during sleep is rare: it has been shown that 98% of the time no seizure disorder is present. Most commonly the clinical presentation is different and a clinical interview will allow the physician to dissociate the two problems. In the difficult cases, a polysomnographic evaluation performed with a seizure montage will help confirm the diagnosis.

When a person's airway becomes partially blocked, the restriction prevents some of the air that was inhaled from getting into the lungs. The "extra" air gets redirected into the mouth, creating a negative pressure which vibrates the soft tissue of the palate and creates snoring.

Snoring indicates that there is some resistance to the normal path of air from the outside to the lungs, and snoring is associated with disrupted sleep, daytime fatigue and sleepiness, and decreases in oxygen levels in the body. Snoring can also be extremely disruptive to the sleep of the bed partner and can stress interpersonal relationships of couples.

In addition to disturbed sleep patterns and sleep deprivation, other serious health problems may result. Snoring may also be a symptom of other medical conditions such as obstructive sleep apnea (OSA). Not everybody who snores has OSA, and not everybody who has OSA has snoring.It is estimated that 45 percent of all adults snore occasionally, and 25 percent habitually snore. Snoring is more common in males and people who are overweight.  

Snoring may be caused by many factors, including:

• Poor muscle tone
• Excessively bulky throat tissue
• Long soft palate
• Long uvula
• Stuffed or blocked nasal passages
• Deformities of the nose 
• Deformities of the nasal septum

Mild or occasional snoring may be helped by:

• A healthy lifestyle that includes exercise and proper diet
• Losing weight
• Avoiding tranquilizers, sleeping pills, and antihistamines before bedtime
• Avoiding alcohol at least four hours before bedtime
• Avoiding heavy meals at least three hours before bedtime
• Establishing regular sleeping patterns
• Sleeping on your side
• Tilting the head of the bed up about 4 inches

Heavy or chronic snoring may require medical care.

Obstructive sleep apnea occurs when the airway completely or partially collapses repeatedly throughout the night. During sleep, the soft tissues in the throat relax. For someone with OSA (obstructive sleep apnea), these tissues can block the upper airway enough to disrupt sleep related breathing.When the airway is blocked, the oxygen levels in the body drop causing the person to wake up long enough to begin breathing normally again. These awakenings are often very brief, sometimes only a few seconds, and this is the reason that the affected individual is often not aware that they have these awakenings during sleep. This pattern repeats during the night, and someone with severe sleep apnea may wake up hundreds of times each night. Even though the awakenings are usually very short, they fragment and interrupt the sleep cycle. This sleep fragmentation can cause significant levels of daytime fatigue and sleepiness, which is a common symptom of sleep apnea.

While some types of snoring can be considered benign in adults, snoring or noisy breathing is never normal in children. Obstructive sleep apnea in children is often overlooked in kids because the symptoms are more different in children than they are in adults and they tend to be more subtle. Not all children with OSA snore, and when they are tired they rarely nap, instead they become hyperactive (and may mimic those children with attention deficit-hyperactivity disorder) or develop behavioral problems. 

These behavioral problems may manifest themselves as irritability, lack of concentration, easy distractibility, and acting out which can lead to problems at school. Additionally, many children with obstructive sleep apnea are not overweight, so they don't fit the stereotypical picture of some with sleep apnea.Children with medical conditions impacting the shape of their face, nose and airway or neuromuscular system are at a higher risk of developing sleep apnea. Parents of children with disorders such as Down Syndrome should be aware of the elevated risk and should be evaluated when there has been a change in behavior that may be related to OSA. Common symptoms of obstructive sleep apnea in children may include:

• Snoring
• Daytime cognitive and behavior problems, including problems paying attention, easy distractibility, aggressive behavior and hyperactivity
• Mouth breathing
• Enlarged tonsils and adenoids
• Problems sleeping and restless sleep
• Parasomnias such as sleep walking or night terrors
• Bed wetting
• Failure to thrive (weight loss or poor weight gain)
• Excessive daytime sleepiness

Restless legs syndrome (RLS) and periodic limb movements during sleep (PLMS) should not be confused with each other. Indeed, restless legs syndrome is a neurological disorder with established effects on the quality of life and health. In contrast, periodic leg movements during sleep is a polysomnographic finding of unknown clinical significance. While the majority of RLS patients also have PLMS witnessed during nocturnal polysomnography, many patients with PLMS do not have restless legs syndrome.

RLS is increasingly recognized as an important neurological disorder. It is about twice more common in women versus men and increases with aging. Awareness has come from public education efforts by the RLS Foundation and the realization by the pharmaceutical industry that a significant part of the population is affected by restless legs syndrome (3% severely affected). In spite of these efforts, however, the disorder is often not considered by neurologists, academia and funding agencies as an important condition.

Research in the area of RLS has advanced over the last few years. First, there has been a growing realization that low brain iron metabolism may be a critical pathway in the pathophysiology of RLS. Blood ferritin levels are often lower in RLS patients (typically below 50 µg/L), and iron deficiency seems to be most pronounced when measured in the brain or CSF. Iron deficiency can also produce anemia (low hemoglobin and red blood cell count) and fatigue. If iron deficiency is discovered, it is important to establish its cause.

The cause of RLS also likely involved abnormal Dopamine. Dopamine is an important neurochemical in the brain that is involved in sleep, movements (for example low dopamine is partially responsible for Parkinson's disease), and the control of pleasurable emotions. For this reason some of the treatment used for Parkinson's diseases called Dopaminergic agonist can be effective in the treatment of RLS, although they should be used with caution.

Genetic factors are strong predictors of RLS. First, RLS commonly runs in family, especially when it is severe and start early in life. DNA changes in five genes have been associated with RLS. These genes are MEIS1, BTBD9, MAP2K5/LBXCOR1, and PTPRD. Interestingly, these genes are mostly DNA binding factors and some are highly expressed in the spinal cord. Although unproven, it is likely that polymorphisms at the level of these genes modulate how the spinal cord process sensory inputs and/or regulate spinal cord motor reflexes. This disturbance would also explain the association of RLS with Periodic Leg Movements during sleep (PLMS).

Environmental factors and other medical problems are also associated with RLS. Most notably, RLS is frequently exacerbated or may start during pregnancy. Second, in addition to iron deficiency, RLS can be caused or exacerbated by renal/kidney failure, spinal cord/back painissue, and is likely more frequent in people who have damaged peripheral nerves ending, such as in those with peripheral neuropathy (for example in patients with long term diabetes).

RLS may be associated with other conditions, and has been suggested to predispose to depression and heart disease.