_disorders in children and adolescents aacap 睡眠障碍的儿童和青少年 课件

Sleep Disorders in Children and Adolescents Deepti Shenoi MD Objectives To gain an understanding of normal basic sleep physiology and pathology in children and adolescents To learn developmentally appropriate behavioral techniques for improving sleep To obtain an understanding of options in pharmacotherapy for pediatric insomnia I would also like you to think of iatrogenic causes for sleep difficulties. Or how we can make things worse. Stages of Sleep General Sleep Stages Typical sleep need for children and adolescents by developmental stage Age group Years Total sleep need Infants 3 to 12 months 14 to 15 hours Toddlers 1 to 3 years 12 to 14 hours Preschoolers 3 to 5 years 11 to 13 hours School-aged 6 to 12 years 10 to 11 hours Adolescents 12 to 18 years 8.5 to 9.5 hours Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Sleep Time During Development Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84 Newborns (0-3 months) Sleep 10-18 hours per day Many short sleep periods, with no differentiation between day and night. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Tips for newborns and infants (up to 6mo) Nighttime awakenings for changing and feeding should be quick and quiet Place baby in the crib before falling asleep (when drowsy) Avoid feeding the baby to sleep Simple bedtime routinesoothing activities in the same order every night GOAL: Babies to fall asleep by themselves and learn to soothe themselves and go back to sleep if they wake up in the middle of the night Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28. Toddlers (12 mo-3 yrs) and Preschoolers (3-5 yrs) Maintain a daily sleep schedule with regular naptimes and bedtime Establish a consistent bedtime routine. Bedroom should be quiet, comfortable, and dark Have the child fall asleep independently. Set limits that are consistent and enforced. Encourage use of a security object, such as a blanket or stuffed animal. Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28. School-Aged Children(6-12 yrs) Same bedtime and wake-up on weekdays and weekends A 20- to 30-minute bedtime routine that is the same every night. No caffeine No TV in the bedroom The child should spend time outside every day and get daily exercise Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals Acad of Medicine. 2008; 37:722-28. Adolescents (12-18 years) Need 9-9.25 hours of sleep per night but studies show that most get 7 hours/night Onset of puberty hormonal changes and shift in melatonin 2 hour shift in circadian rhythm phase (later sleep onset and morning wake time) Some experience a physiological need for a short sleep period in early afternoon Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 What to ask in a sleep evaluation?- Sleep History Bedtime: Evening activities, bedtime routines Night-time: Latency to sleep onset, behaviors during the night, # and duration of awakenings Daytime: Daytime sleepiness, naps, caffeine intake, psychological, social and family functioning What to ask in a sleep evaluation?- Sleep Hygiene Consistent and appropriate sleep-wake schedule Similar schedule on weekdays and weekends Consistent bedtime routine that involves same 3-4 activities every night No technology in the bedroom BEARS screen (for kids 2- 18y.o.) Bedtime problems Excessive daytime sleepiness Awakenings during the night Regularity of evening sleep time and morning awakenings Sleep related breathing problems or snoring Common Disorders Behavioral Insomnia of Childhood Insufficient or Inadequate sleep Delayed Sleep Phase Syndrome Sleep Disordered Breathing Disorders of Arousal Movement disorders Behavioral Insomnia of Childhood Manifests most commonly as bedtime resistance and/or frequent night wakings and occurs in approximately 10% to 30% of infants and toddlers Sleep-onset Association Type Limit-setting type Combined Type Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Insufficient or Inadequate Sleep Sleep deprivation can have a cumulative effect being late or missing school, falling asleep during school, fatigue, illness, and irritability Poll reports that 28% of high school students report falling asleep in school at least once a week Insufficient sleep can be fatal for adolescents who fall asleep while driving. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Insufficient or Inadequate Sleep Signs that children or adolescents are not getting enough sleep include: (1) needing to be awakened for school or day care in the morning, (2) sleeping 2 hours more on weekends and vacations compared with weekdays, (3) falling asleep in school or at other inappropriate times, (4) behavior and mood differing on days after getting more sleep Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Delayed Sleep Phase Syndrome The persons sleep-wake cycle is delayed by 2 or more hours “Night Owls” Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Delayed Sleep Phase Syndrome Delayed Sleep Phase Syndrome-Treatment Sleep hygiene Shifting the internal clock Phase Advancement: When the difference between the actual and desired bedtime is less than 3 hours. Every night or two, go to sleep 15 minutes earlier. Phase Delay: When the difference is greater than 3 hours, delay sleep by 2-3 hours on successive nights Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Sleep-Disordered Breathing Can range from primary snoring to obstructive sleep apnea syndrome (OSAS) and is related to signifi cant cognitive and behavioral sequelae, including learning, attention, concentration, hyperactivity, and aggressive behavior Incidence of habitual snoring has been re- ported at 3% to 12% of the general pediatric population, with OSAS seen in 1% to 3% of children Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Narcolepsy Chronic neurologic disorder that involves excessive daytime sleepiness cataplexy (sudden loss of muscle control in response to strong emotional stimuli) hypnagogic hallucinations (vivid dreams at sleep onset) sleep paralysis autonomic behavior in which you continue to funtion, talk, clean but then have no recollection of performing task . Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Narcolepsy Work up Polysomnography (PSG) Typically fall asleep rapidly with early REM Multiple sleep latency test (MSLT) Test subjects are given opportunities to sleep every two hours during the normal awake time and monitored to see how quickly they fall asleep and reach various stages of the sleep cycle. May provide clear evidence of narcolepsy, but in children, results are not always conclusive, and repeat studies may be necessary for a fi nal diagnosis Narcolepsy Individualized based upon symptoms. Treatment includes education, sleep hygiene, and pharmacologic interventions Daytime Sleepiness: Sleep scheduling is essential, with a consistent bedtime, wake time, and good sleep hygiene Children and adolescents who have narcolepsy may benefi t from a scheduled daily nap in the early afternoon. Stimulants are commonly used to treat daytime sedation including provigil Atomoxetine has also been used. Cataplexy: Cholinergic pathway mediated medications with anticholinergic properties are used to treat cataplexy, including clomipramine and imipramine Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Disorders of Arousal Referred as partial arousal parasomnias and include: confusional arousals, sleep terrors, sleep talking, and sleepwalking During an event, although children are asleep, they may appear awake (eyes open), talk, or seem frightened or confused (eg, screaming in the case of sleep terrors) Typical parasomnias resolve spontaneously with children rapidly returning to a deep sleep Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Disorders of Arousal Common feature: retrograde amnesia Strong genetic component to partial arousal parasomnias, with a family history typically reported Partial arousals are more likely to be triggered by insufficient sleep, a disruption to the sleep environment or sleep schedule, stress, illness, or certain medications (eg, chloral hydrate or lithium) Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Sleep Terrors vs Nightmares Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84 Disorders of Arousal Treatment: providing families with information about creating a safe sleep environment (eg, preventing windows from opening or putting alarms or bells on doors to alert if a sleep walker is up), education about the events, and how to interact with children appropriately during an event As some children may develop a fear of going to sleep and a prolonged sleep onset in turn increases the likelihood of an event occurring, parents should be encouraged to not discuss these events in the morning with the child or other children in the home Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Restless Leg Syndrome and Periodic Limb Movement Disorder RLS manifests as uncomfortable sensations in the legs that worsen in the evening and with long periods of inactivity (eg, long car ride or movie) Sensations often are described as creepy-crawly or tingling feelings, most commonly in the legs, which can be alleviated temporarily with movement. PLMS are brief repetitive movements or jerks, lasting on average 2 seconds and occurring every 5 to 90 seconds during stages 1 and 2 of sleep PLMD occurs when PLMS are associated with frequent, but brief, arousals from sleep Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Restless Leg Syndrome and Periodic Limb Movement Disorder Pharmacologic treatment for RLS and PLMD in children and adolescents may include benzodiazepine and dopaminergic medication Some children who have RLS or PLMD have low iron/ferritin and many of these children and adolescents respond favorably to iron therapy At this time, there are no FDA-approved medications available to treat RLS and PLMD in children. Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Sleep-Related Rhythmic Movement Disorders Include head banging and body rocking and are considered to be a sleep-wake transition disorder, occurring as children attempt to fall asleep at bedtime, naptime, or after a normal nighttime arousal common in infants (60% of 9 month olds), the behaviors tend to resolve spontaneously with development (only 8% of 4 year olds demonstrate these behaviors), but they can continue into adolescence and adulthood Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 Sleep-Related Rhythmic Movement Disorders Events typically last 5 to 15 minutes, but prolonged events can go for several hours Important to ensure safety In cases that result in injury, or when the behavior may be highly disruptive to others for a short duration (eg, family vacation or overnight sleepover), benzodiazepines may be indicated. Evaluation is recommended for severe cases or cases persisting past age 3 Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4): 1059-76 “Optimizing” Treatment of Sleep Problems Identification of the suspected causes of disrupted sleep Involvement of the family by explaining the disorder and teaching them developmentally appropriate principles of sleep-wake organization Use of behavioral treatments such as contracts to target specific behaviors that need to be changed Anders, TF, Eiben LA. Pediatric Sleep Disorders: A Review of the Past 10 Years. J Am Acad Child Adolesc Psychiatry. 1997;36:9-20. Pharmocotherapy of Pediatric Insomnia: General Guidelines Reminder: In almost all cases, medication is neither the first treatment of choice, nor the sole treatment for children Medication should be used in combination with non- pharmacological strategies as these have been shown to have long-lasting effects Treatment selection - best match between clinical circumstances and individual properties of medications Medications should be closely monitored for emerging side effects Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: General Guidelines Presence of both medically and behaviorally- based sleep disorders must be assessed Medications should be used in caution in situations where there may be potential drug- drug interactions Non-prescription and over-the-counter medication use should be assessed Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia Antihistamines: Prescription (hydroxyzine) and OTC (diphenhydramine) Bind to H1 receptors in the CNS Rapidly absorbed Side effects: daytime drowsiness, cholinergic effects, paradoxical excitation Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: Melatonin Melatonin: hormone secreted by pineal gland in response to decreased light, mediated through suprachiasmatic nucleus; mechanism of commercially available melatonin is to supplement endogenous pineal hormone Clinical uses for melatonin are principally in normal children with acute or chronic circadian rhythm disturbances and in children with special needs (blindness, Rett syndrome) Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: Melatonin Plasma levels peak within 1 hour of administration Generally safe but potential side effects include suppression of hypothalamic-gonadal axis (i.e. could trigger precocious puberty upon discontinuation Not regulated by FDA Reported doses: 1 mg in infants, 2.5-3 mg in older children, 5 mg in adolescents Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: Herbal Preparations Valerian Root, St. Johns Wort, and Humulus lupulus - some evidence of efficacy in adult and/or pediatric studies Lemon balm, chamomile, and passion flower - limited to no evidence Kava kava, Tryptophan - assoc. with significant safety concerns (e.g. hepatotoxicity and eosinophilic myalgia syndrome, respectively) Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: Benzodiazepines Hypnotic effect mediated at GABA Type A receptors in the brain They shorten sleep- onset latency, increase total sleep time, and improve non-REM sleep maintenance; most disrupt slow-wave sleep. Use of longer- acting BZDs may lead to morning hangover, daytime sleepiness, and compromised daytime functioning. Anterograde amnesia and disinhibition may also occur. Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: Benzodiazepines Risk for habituation or addiction with these medications, as well as withdrawal phenomena Used for short-term or transient insomnia or in clinical situations in which their other properties (e.g., anxiolytic) are advantageous BZDs are occasionally used to treat intractable partial arousal parasomnias (e.g., sleep terrors) in children because of their slow-wave sleep suppressant effects. Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: Melatonin Receptor Agonist Ramelteon (Rozerem): a synthetic melatonin receptor agonist, acting selectively at the MT1 and MT2 receptors Approved for use in sleep initiation insomnia, and shows moderate efficacy in reducing sleep-onset latency (in adults) Two single pediatric case reports have reported efficacy in autistic children Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: -Agonist Clonidine: central 2-agonist that decreases adrenergic tone one of the most widely used medications for insomnia in pediatric and child psychiatry practice, particularly in children with sleep- onset delay and ADHD safety and efficacy in children with ADHD and sleep problems is limited to descriptive studies Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107. Pharmocotherapy of Pediatric Insomnia: -Agonist Clonidine is rapidly absorbed with onset of action within 1 hour and peak effects in 2-4 hours Tolerance often develops necessitating increase in dose Discontinuation may lead to rebound