PEDIATRIC SLEEP CASES

Transcription

1 PEDIATRIC SLEEP CASES Carolyn D Ambrosio, MD, MS, FAASM Director, Harvard-Brigham and Women s Hospital Pulmonary and Critical Care Fellowship Harvard Medical School Boston, MA

2 CONFLICT OF INTEREST Nothing to Disclose

3 FIRST CASE 10 yr old girl who presented with snoring Obese BMI > 90 th percentile Snoring, some fatigue Difficult to wake up in the morning Achondroplasia 3+ tonsils

4 PSG FINDINGS A. OSA B. CSA C. Hypoventilation D. Seizure E. Normal

5 Katz et al, Sleep Apnea, NHLBI, 2008

6 OBSTRUCTIVE HYPOVENTILATION Partial obstruction ( see PTAF) No discrete obstructive events No desaturation Elevated CO2 throughout the study Paradoxical motion of thorax and abdomen

7 SECOND CASE 12 yr old boy Has scoliosis requiring back brace Some arousals from sleep Parents concerned that he doesn t breath well when he is sleeping. Minimal snoring No medications

8 SECOND CASE CONTINUED What do you expect to see on PSG?

9 PSG FINDINGS A. OSA B. Delayed sleep phase syndrome C. frequent spontaneous arousals D. hypoxemia E. hypoventilation F. Normal

10 REM-RELATED HYPOXIA Ventilation Muscle Tone Irreg Breathing Airway Resistance Smith et al, NEJM 1987; 316: Obesity Parenchymal lung Disease Scoliosis Respiratory Muscle Weakness

11 CASE 3 2 week old term infant Mother worried the baby has irregular breathing No prenatal issues, normal birth Mother describes breathing as really fast sometimes then nothing

12 PSG FINDINGS A. Normal new mother syndrome B. OSA C. CSA D. Periodic breathing E. hypoventilation

13 Term 2 week-old Irregular Breathing 120 secs 15 minutes of periodic breathing during 7 hour study

14 PERIODIC BREATHING Defined as 3 or more episodes of apnea, lasting longer than 3 sec, separated by,<20 seconds of breathing increased in preterm, increased temp, hypoxia, sleep deprivation, supine position.

15 PERIODIC BREATHING: Epidemiology Present in % of 1 week-old Term Infants 95% Upper Limits Term 5 10% at 1 month 2% at 3 months with Prematurity but not SIDS, HIE Preterm 15 20% at 1 month 5 10% at 3 months Pathophysiology Apneic CO2 threshold is 1 torr below Eupneic CO2 Khan et al, JAP: 2005; 98:1171- Consequences?

16 4 WEEK-OLD INFANT 37 weeks gestation Dural venous thrombosis 24% periodic breathing Normal baseline O2 Between 92 96% for 21% of the night EtCO2 (peak 55 torr) Many respiratory arousals Recommend canulla O2

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18 Periodic Breathing: Influence of Oxygen Apnea Index Periodic Breathing RA Oxygen RA Oxygen Subjects: GA 30 weeks, PCA 38 weeks Simakajornboon et al, Peds 2002; 110:884-

19 CASE FOUR 8 year old girl brought in for insomnia Parents say she cannot fall asleep until midnight Very hard to wake up on school days. Wakes up around 8 am on weekends Sleepy in school, falls asleep in car ride to and from school most days

20 CASE FOUR CONTINUED What else do you want to know?

21 CASE FOUR CONTINUED Goes to bed at random times Has ipad in bed with her watching videos to help fall asleep Often sleeps in parents bed No medications No caffeine

22 PREVALENCE OF SLEEP DISORDERS IN CHILDREN Sleeplessness/Insomnia Young: behaviorally-based insomnia 25% Teens: 10% (1/2 with co-morbid Ψ diagnosis) Insufficient sleep: 10%, higher in teens Circadian: delayed sleep phase, 7% teens. Parasomnias NREM: Night terrors: 2-3%, sleep walking: 5%; REM Behavioral Disorder case reports, SSRI or SNRI risk factor Rhythmic movement disorders Bruxism: 14%, head banging, body rocking (3-15%) Restless legs syndrome: 0.5 (severe); 2% mild-mod Obstructive sleep apnea: 2% (habitual snoring 10%) Hypersomnolence: narcolepsy: 0.5%

23 SLEEP DISORDERS RUN IN FAMILIES OSA 2-4x risk, + family hx Narcolepsy 2%, 40x if + 1 st deg Parasomnia up to 80% Restless legs syndrome Insomnia Life style/bad sleep habits Circadian rhythm disorders Enuresis

24 OVERVIEW OF COMMON SLEEP PROBLEMS BY AGE Young Infant Toddler Pre-School School-Age Teen SIDS Sleep/wake problems usually self-limited Night Wakings Difficulty Settling Rhythmic Movements* OSA Night Wakings Bedtime Resistance Sleep Terrors* Rhythmic Movements* Bedtime Fears* Nightmares* OSA Insufficient Sleep Bedtime Resistance Night Wakings Confusional Arousals Sleep Walking* OSA Enuresis Bruxism Insufficient Sleep Inadequate hygiene Insomnia Delayed Sleep Phase Narcolepsy OSA Sleep Walking* *Can be normal If snoring+enuresis, think OSA Discuss with dentist Slide by Dr. Carol Rosen.

25 PEDIATRIC SLEEP DISORDERS BY TIME OF NIGHT Behavioral Insomnia Rhythmic movement disturbance Restless legs syndrome Behavioral Insomnia Awake Stage 1 REM Stage 2 Stage 3/4 Delta Sleep Sleep Terrors Sleep Walking Confusional Arousals Nightmares OSA worse in REM 21:00 22:00 23:00 24:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 Clock Time Slide by Dr. Carol Rosen

26 PARTIAL AROUSAL PARASOMNIAS Partial arousals from deep NREM Confusional arousals night terrors (3%) Sleep walking agitated sleep walking 15-40% at least once; 3-4% weekly-monthly Any age 6 mo-100 y/o; often familial Can last minutes Often improves with more, better sleep Generally not dangerous* * Injury indication for further evaluation/management

27 NIGHT TERRORS VS. NIGHTMARES Deep NREM sleep REM sleep 1st third of night Last half of night Child confused or agitated Child alert; describes content Difficult to reassure Comforted by parent Intense arousal 2-10 min Difficulty going back to sleep Abrupt return to sleep Recall the following day No recall in the morning

28 RHYTHMIC MOVEMENT DISTURBANCE Repetitive movements Head banging or head rolling Body rocking Before sleep, light sleep, or even awake Age: 9 mos-4 yr; common (66%8%) Boys > Girls PSG or treatment rarely indicated Problem RMD - neurodevelopmental issues?

29 Children (%) PREVALENCE OF ENURESIS Begin evaluation Age (years) Boys > Girls Snoring + Enuresis, Think OSA!

30 Nighttime Sleep (hr) NORMAL SLEEP DURATION VARIES WITH AGE Age (yr) 2% Mean 98% Iglowstein, I et al. Pediatrics 2003;111:

31 TAKE HOME MESSAGES In children, non-respiratory sleep problems are more common than SDB ~ 25% of pediatric SDB referrals will have a non-respiratory sleep problem SDB referrals often medical co-morbidities AHI Daytime sleepiness is much less common in pediatric OSA compared to OSA in adults Insufficient sleep and bad sleep habits are rampant in US families and that is what we mostly see in practice.