A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems

286 Pages·2015·6.21 MB·English

by  Jodi A. Mindell, Judith A. Owens

Dedication
To Scott and Caelie, who are the center of my universe
J A M
To Thad, Evan, and Grace for their ongoing love and patience; and to my colleagues at Children's National
Medical Center, for their support and friendship
J A O
Preface to the Third Edition
Sleep profoundly impacts virtually every aspect of a child's physical and mental health, daily functioning, and
well-being. Thus, it is not surprising that insufficient, disrupted, poor-quality, and, at times, elusive sleep
constitutes one of the most common complaints raised by parents to pediatric and family medicine practitioners,
as well as to child mental health providers. Approximately 25% of children overall experience some type of sleep
problem, ranging from difficulty falling asleep and nightwakings to more serious primary sleep disorders, such as
sleep apnea or narcolepsy; more than one-third of elementary school-aged children and 40% of adolescents
have significant sleep complaints. Although many sleep problems in infants and children are transient and self-
limited, the common wisdom that children “grow out of” sleep problems is not necessarily accurate, and a host of
intrinsic and extrinsic risk factors ranging from demographic variables such as age, gender, and race/ethnicity to
the presence of chronic medical, neurodevelopmental, and psychiatric comorbidities to important ancillary issues
such as difficult temperament, maternal depression, and family stress may predispose a given child to develop a
more chronic sleep disturbance.
Furthermore, there are few pediatric health issues that have a more significant impact on health and well-being
than childhood sleep disorders. Sleep affects every aspect of a child's physical, emotional, cognitive, and social
development, and the consequences of sleep disorders in children range from significant cognitive, mood and
behavioral concerns, academic failure, health and safety issues (e.g., obesity, hypertension, type 2 diabetes),
and an increased risk of accidental injuries and car crashes. Sleep problems in children also have a major impact
on the family, often resulting in significant caregiver stress, fatigue, mood disturbances, and a decreased level of
effective parenting. In addition, the coexistence of sleep problems exacerbates virtually every medical,
psychiatric, developmental, and psychosocial problem in childhood. Given that sleep disorders are highly
treatable with effective medical and behavioral interventions, sleep disorders in children and adolescents are
particularly important for the primary care healthcare provider to recognize and diagnose.
Sleep also represents an important health education issue. Not only are sleep problems treatable, but many are
preventable. Thus, the pediatric health encounter provides an ideal opportunity to educate parents about normal
sleep in children and to introduce strategies to prevent sleep problems from either developing in the first place
(primary prevention) or becoming chronic when problems already exist (secondary prevention). Primary care
providers are in the optimal position to identify sleep concerns because of their regular access to children and
families during well-child encounters, especially prior to school entry, and because of the inherently
biopsychosocial orientation of primary care practice. However, while pediatric providers have become more
vigilant in monitoring and providing education about virtually every aspect of children's health and well-being,
survey studies suggest that sleep issues in both primary care and mental health clinical settings are commonly
inadequately addressed. Unfortunately, given the expanding number of competing demands for increasingly
smaller amounts of time and the information overload that the average busy pediatric practitioner faces on a daily
basis, sleep issues in clinical practice may not always receive the attention that they deserve.
The purpose of this updated and expanded edition of A Clinical Guide to Pediatric Sleep: Diagnosis and
Management of Sleep Problems in Children and Adolescents, therefore, is threefold:
1. To provide the practitioner with an appreciation for the pervasive effect that sleep problems have on children's
and families' lives and the multiple ways in which they impact clinical pediatric practice.
P.viii
2. To synthesize new state-of-the-art information about the etiology, clinical assessment tools, and management
of specific sleep disorders in children and adolescents in a format that provides a comprehensive and
accessible resource for practitioners.
3. To provide the basic knowledge and practical tools with which pediatric healthcare providers can recognize,
evaluate, and treat sleep issues in children and adolescents in primary care, as well as mental health settings.
Other features of the third edition of A Clinical Guide to Pediatric Sleep include updated diagnostic criteria
(International Classification of Sleep Disorders, 3rd edition—ICSD-3, 2014; Diagnostic and Statistical Manual
of Mental Disorders, 5th edition—DSM-5, 2013), inclusion of revised and new practice guidelines from the
American Academy of Sleep Medicine and the American Academy of Pediatrics, and updated and new clinical
screening and parent handouts for each age group.
A Clinical Guide to Pediatric Sleep is divided into four sections, with extensive appendices of handouts for
healthcare practitioners to give parents, now available online: Please see inside cover of your book for online
access information.
Section I addresses basic sleep issues in pediatric practice, including an overview of sleep regulation and core
features of sleep physiology relevant to clinical practice. This section also presents information on
developmental aspects of sleep, including normal sleep parameters and commonly experienced sleep problems
for each age group, as well as updated data regarding epidemiology of pediatric sleep disorders. Finally, basic
approaches to evaluation of sleep problems, including the use and interpretation of sleep diagnostic tools, as
well as a new chapter on polysomnography, are presented.
Section II provides extensively updated, comprehensive information on the etiology, evaluation, treatment,
management, and prognosis for each of the most common pediatric sleep disorders. Section II also contains
symptom-based algorithms based on the three most common presentations of sleep problems in the clinical
setting (i.e., difficulty falling asleep, nightwakings, and daytime sleepiness). Since there are multiple sleep
problems that can account for each of these presenting symptoms, the algorithms enable the healthcare provider
to evaluate sleep complaints in a stepwise fashion with the goal of developing the most appropriate treatment
plan.
Section III discusses sleep pharmacology, including sedatives and hypnotics in children and medication effects
on sleep. New hypnotics, use of over-the-counter medications in pediatrics, especially melatonin, and misuse of
stimulants (e.g., medications such as methylphenidate, caffeine) to manage fatigue in the adolescent population
are also covered.
Section IV presents updated and expanded information on sleep problems in special populations, including
children with neurodevelopmental disorders and pediatric patients with a comorbid medical or psychiatric
problem.
Furthermore, an updated national listing of clinical resources and other informational resources (e.g.,
foundations, Internet sites) is included. Finally, the updated online Appendices (see inside cover of your book
for online information) provide comprehensive resources for pediatric providers, including an expanded list of
intake and screening questionnaires, as well as parent education handouts for each age group and each sleep
disorder. All parent education handouts are now provided in English and Spanish.
Our goal is to make it possible for all children and families to get the quantity and quality of sleep they need and
to identify and treat disorders that may impact and thus compromise sleep, in order to optimize the health and
well-being of children and adolescents. It is our hope is that this book will provide primary care and mental health
providers with a state-of-the-art, comprehensive, accessible, and user-friendly resource on pediatric sleep to
help us move closer to achieving that goal.
Acknowledgments
No project of this magnitude is ever developed without the enthusiasm and support of others. We would like to
extend our thanks to the many individuals who supported this work with their advice and feedback, to the
clinicians with whom we have had the privilege of working, and to the families who shared their experiences (and
sleepless nights!) to help further our knowledge of pediatric sleep.
We would also like to acknowledge the incredible work of the nonprofit organization Sleeping Children Around
the World, whose mission is to provide children in the poorest nations around the globe with the comfort of a
good night's sleep, as well as other nonprofits whose goals are to support sleep for youths and their families,
including Beds for Kids (Philadelphia, PA) and SweetDreamzz (Detroit, MI).
Finally, our deepest appreciation to those who have supported this project: particularly Jamie Elfrank,
Acquisitions Editor of Lippincott Williams & Wilkins, and Ashley Fischer, Product Development Editor, who
shepherded this book through the publishing process. We are also grateful to our many colleagues in sleep
medicine, past, present, and future, who continue to inspire and educate us.
And, most importantly, to our families, for their unwavering support, enthusiasm, good humor, and endless
patience.
Authors
Jodi A. Mindell PhD
Professor of Psychology
Director, Graduate Program in Psychology
Saint Joseph's University
Associate Director, Sleep Center
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Judith A. Owens MD, MPH
Associate Professor of Pediatrics
Harvard Medical School
Director of Sleep Medicine
Boston Children's Hospital
Boston, Massachusetts
1
Sleep 101
Sleep is the primary activity of the brain during early development. It is estimated that by the age of 2 years the
average child has spent about 9,500 hours (or a total of 13 months) sleeping, in contrast to 8,000 hours for all
waking activities combined. Between the ages of 2 and 5 years, children spend equal amounts of time awake
and asleep. And throughout childhood and adolescence, sleep continues to account for about 40% of a child's
average day.
The organization and regulation of sleep and wakefulness are complex, highly active physiologic processes that
involve the interaction of multiple central nervous system components. A detailed description of the
neuroanatomy and neurophysiology of sleep, which may be found in a number of excellent reviews (see
Suggested Readings), is beyond the scope of this book. However, some understanding of the function of sleep,
the impact of insufficient sleep, the basic structure or architecture of sleep, and familiarity with the basic neural
mechanisms that regulate sleep and wakefulness is necessary in order for the primary care practitioner to fully
appreciate the causes and effects of both sleep disturbances and insufficient sleep in children and adolescents.
Definition of Sleep
Sleep may be defined as a behavioral state characterized by the following:
Reduced motor activity
Decreased interaction with and responsivity to the environment
Specific postures (e.g., lying down, eyes closed)
Easy reversibility
Sleep is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the
environment. It is also true that sleep is a complex amalgam of physiological and behavioral processes.
(Carskadon & Dement, 2011)
FUNCTIONS OF SLEEP
Despite the virtual explosion of knowledge in the past half-century regarding the structure, neuroanatomy, and
neurophysiology of sleep (e.g., the discovery of rapid eye movement [REM] sleep occurred in the 1950s), the
basic function of sleep largely remains a mystery. Most of what we understand about the function of sleep has
evolved from studies that have examined the impact of experimentally induced sleep loss or pathologic sleep
conditions on a host of physiologic and neurobehavioral systems in both animal models and humans. What we
do know is that adequate sleep is a biologic imperative that appears necessary for sustaining life, as well as for
optimal functioning. For example, slow-wave sleep (SWS; also termed “deep sleep,” delta sleep, and stage N3
sleep) appears to be the most “restorative” form of sleep and is relatively preserved in the face of insufficient
total sleep. The increased amount of SWS in children and the high arousal threshold characteristic of SWS may
also be protective in terms of neurodevelopment. REM sleep (see below, Sleep Architecture) appears not only to
be involved in vital cognitive functions, such as the consolidation of memory, but also to be an integral
component in the growth and development of the central nervous system. Recent studies indicate that adequate
amounts of both of these sleep stages are necessary for optimal learning. In addition, the release of growth
P.4
hormone during SWS clearly links sleep to the regulation of somatic growth as well as many other
neuroendocrine functions. Sleep may also functionally reflect a neurobiologic need to limit time in the awake
state, thereby protecting the individual, especially the developing organism, from being bombarded by
information and environmental stimulation that cannot be adequately processed. Finally, studies have clearly
demonstrated that “rest” is not a substitute for sleep and, furthermore, that wakefulness-promoting agents (e.g.,
psychostimulants, caffeine) used to combat sleepiness induced by insufficient sleep do not restore the
physiologic benefits of sleep itself.
Insufficient Sleep
Insufficient sleep is the most common cause of excessive daytime sleepiness. The resulting chronic sleep
loss impacts daytime functioning, including mood disturbances, daytime behavior problems, cognitive
impairment, and increased risk-taking behavior.
INSUFFICIENT SLEEP
A basic principle of sleep physiology relates to the consequences of the failure to meet basic sleep needs,
termed insufficient, inadequate sleep, or “sleep loss.” Many of the early studies conducted examined the effects
of total sleep loss (sleep deprivation) rather than the more “real-world” scenario of partial sleep loss (sleep
restriction). However, more recent studies have demonstrated that partial sleep loss on a chronic basis
accumulates into what is termed a “sleep debt” and produces deficits equivalent to those seen under conditions
of total sleep deprivation. If the sleep debt becomes large enough and is not voluntarily paid back (by obtaining
adequate recovery sleep), the body may respond by overriding voluntary control of wakefulness, resulting in
periods of decreased alertness, dozing off, and napping that is excessive daytime sleepiness. In addition, the
sleep-deprived individual may experience very brief (several seconds) repeated daytime microsleeps of which he
or she may be completely unaware, but which nonetheless may result in significant lapses in attention and
vigilance. There also appears to be a relationship between the amount of sleep restriction and performance, with
decreased performance correlating with decreased sleep. Furthermore, subjective perception of sleepiness and
the degree of associated performance impairment tend to be poorly correlated with actual impairment, commonly
leading individuals to overestimate their ability to function adequately in the face of sleep loss.
What is Sleepiness?
Sleepiness is defined as a state of decreased ability to maintain wakefulness or an increased propensity to
fall asleep; this is in contrast to fatigue, which typically does not include this sleep tendency. Sleepiness,
like hunger or thirst, is a normal biologic need; sleep is to sleepiness as food is to hunger. Furthermore, the
only thing that replaces sleep is sleep (i.e., not “rest”). Excessive sleepiness is a symptom characterized by
difficulty maintaining wakefulness and an increased propensity to fall asleep, even in inappropriate
circumstances and situations, that interferes with activities of daily living.
Chronic sleep loss impacts daytime functioning and causes excessive daytime sleepiness, which can manifest in
a number of ways in children and adolescents (e.g., dozing off while engaged in activities, hyperactivity,
behavioral problems). Falling asleep at an unintended time, especially in school, is a common manifestation, as
are unplanned naps and planned naps past an age when napping is appropriate. Functional neuroimaging
studies in both adults and children have suggested that chronic sleep loss selectively impacts the following brain
regions: the prefrontal cortex (PFC), which houses complex cognitive or “executive” functions (e.g., time
management, decision making, organization, selective attention, judgment, motivation, monitoring
P.5
and modifying behavior, predicting outcomes); the amygdala, which regulates emotional responses; and the
striatum, which controls reward-related behaviors. For example, in one study in which sleep-restricted volunteers
viewed emotional images, there was an increased response of the “emotional brain” (amygdala) combined with a
weaker connection between the amygdala and the PFC, implying a heightened emotional response with less
emotional control. Studies also suggest that insufficient sleep is linked to changes in reward-related decision
making, and so these individuals tend to take greater risks and are less concerned about the potential negative
consequences of their behavior. In addition, it should be noted that both the PFC and the striatum are
undergoing important structural and functional changes during adolescence, a period during which the risk of
chronic sleep loss is especially high.
Sleep Deprivation/Prolonged Wakefulness Affects the Brain
On a basic neurobiologic level, sleep loss (and its parallel, extended wakefulness) profoundly impacts brain
function:
Neuronal functions
Neuronal “plasticity”: ability of the brain to change structure/function in response to the environment
Downscaling of synapses to compensate for net increase in synapse formation and strength during the
wake state
Gene activation/expression
Neurogenesis
Brain cell protection/repair from stress
Neurotransmitters (e.g., serotonin, dopamine)
Melatonin production/circadian biology
Cellular metabolism, neurogenesis, brain/eye development
Highest susceptibility during critical developmental periods
Increases in stress response and stress hormones
The relationship between sleep and memory has also been actively explored. Both SWS and REM sleep play an
active and important role in regard to memory, particularly memory consolidation (as opposed to encoding of
memories during wakefulness). For example, postlearning reactivation and reorganization of memory
representation occurs during sleep, with potential impact on long-term subsequent memory performance. REM
sleep may be particularly important for emotional memory processing.
These effects on brain function account for many of the observed behavioral and cognitive sequelae of chronic
sleep loss. Insufficient sleep, however, can also manifest in the following manner:
Fatigue and daytime lethargy, including increased somatic complaints (e.g., headaches, muscle aches)
Mood disturbance, including complaints of moodiness, irritability, emotional lability, increased negative
emotions, depression, and anger
Cognitive impairment, including problems with memory, attention, concentration, decision making, and
problem solving
Daytime behavioral disinhibition, including hyperactivity, oppositional, defiant, and aggressive behavior,
impulsivity, and noncompliance
Poor impulse control and increased risk-taking behaviors, especially in adolescents
Academic problems, including chronic tardiness related to insufficient sleep and school failure resulting from
chronic daytime sleepiness
Use of stimulants, and other alertness enhancers such as caffeine and nicotine, to artificially maintain
wakefulness and combat daytime fatigue
P.6
Functions of Sleep: Cognition
Sleep is needed to:
Remember what we learned
Organize our thoughts, predict outcomes and avoid consequences, be goal-directed (“executive
functions”)
React quickly
Work accurately and efficiently
Think abstractly
Be creative
There are multiple causes of insufficient sleep, including that resulting from a primary sleep disorder (e.g.,
insomnia, obstructive sleep apnea); however, the predominant reasons are environmental:
Academic and extracurricular demands can result in delayed bedtimes.
Social activities, such as late-night socializing (including on the Internet), often delay bedtime in older children
and adolescents.
Electronic media use such as television viewing, smartphone use, and playing computer/video games,
particularly if the electronic devices are readily available in the child's bedroom, may take priority over bedtime
in some families.
Part-time employment, especially if over 20 hours per week, is associated with insufficient sleep in teenagers.
Early school start times (particularly before 8:00 a.m.) are a major risk factor for insufficient sleep in middle-
and high-school students and adolescents. Given the need for 8.5 to 9.5 hours of sleep in adolescents,
coupled with a biologically based circadian phase delay occurring in conjunction with puberty, early school
start times do not enable most adolescents to obtain sufficient sleep on school nights.
SLEEP ARCHITECTURE
Basic Sleep Terminology
Sleep architecture: structure/stages of sleep: REM, non-REM (NREM; stages 1-3), wake
Ultradian rhythms: the nocturnal cycle of sleep stages
Circadian rhythms: the 24-hour rhythm of sleep/wakefulness and many physiologic systems (e.g., body
temperature, hormones)
Sleep regulation: determinants of sleepiness and alertness levels
Sleep patterns: a combination of biology, learning, maturation, culture, and environment
The framework or architecture of sleep is based on the recognition of three distinct states: wake, NREM sleep,
and REM sleep (or “dream” sleep). These stages are defined by distinct polysomnographic features of