Pediatric Sleep Medicine

Educational Objectives

The goal of this program is to improve the management of pediatric sleep disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Compare adenoid tonsillectomy vs watchful waiting in pediatric patients with mild to moderate sleep apnea.
2. Differentiate central sleep apnea from an obstructive event.
3. Optimize diagnosis of narcolepsy in children.

Summary

Obstructive sleep apnea (OSA): has increased exponentially in children; >20% of children experience OSA in certain cultures and parts of the United States; >50% of children who visit clinics have some form of sleep disorder (insomnia is common)

Sleep physiology: infants typically sleep 50% to 75% of the day; circadian rhythm starts ≈6 mo of age; managing circadian rhythm is important for pediatric sleep; electronics, lack of exercise, and indoor confinement disrupt this rhythm, affecting sleep; 12 to 14 hr of sleep is normal in preschool-age children; normal sleep ranges vary for different ages, with teenagers needing 8 hr of sleep; longer duration disrupts sleep and circadian rhythm

Importance of sleep: sleep is the consolidation of memory and learning; without enough rapid eye movement (REM) sleep, learning is affected; sleep disruption can lead to poor school performance, with ≈50% of the bottom 20% of children in a class having some sleep disruption; sleep is restorative, allowing the brain to heal at night; studies show inadequate sleep leads to early Parkinson disease, Alzheimer disease, and other diseases, eg, dementia in adults

Growth hormone secretion: sleep is important for the secretion of growth hormone; inadequate or disrupted sleep can lead to growth failure; hormones, eg, thyrotropin, cortisol, and prolactin, are important for sleep; lack of sleep inhibits the secretion of these hormones, causing abnormal body chemistry

Polysomnography (PSG): includes ≈24 physiologic parameters, which include electroencephalography, stage of sleep, respiratory changes, abdominal changes, pulse oxygen levels, and leg movement; usually ≥6 hr of sleep is required; it is important to choose a pediatric laboratory when referring for a pediatric sleep study because of the challenges of placing wires on a child; 30-sec epochs include examining eye movements, nasal flow, pulse oximetry, electrocardiography (ECG), and chest and abdominal movement; central sleep apnea is associated with decreased airflow and decreased chest and abdominal movement; an obstructive event is associated with decreased airflow but with chest and abdominal movement; many children experience mixed apneas, with a central apnea where their upper airway collapses followed by an obstructive event

Normal sleep cycle: includes stage 1, stage 2, stage 3, and stage 4 (eg, REM sleep) occurring every 90 to 120 min; disruption in these cycles can lead to sleep disruption, sleep fragmentation, inadequate sleep, poor learning, and a lack of growth hormone secretion; REM sleep typically occurs for a prolonged duration in the later part of sleep and is important for learning and memory; inadequate sleep (<8 hr) does not provide enough REM sleep; the first REM sleep cycle is the shortest

Sleep-disordered breathing: 90% of children visit clinics because of sleep-disordered breathing, primarily referred by ear, nose, and throat (ENT) specialists; it represents a continuum from primary snoring to upper airway resistance syndrome, obstructive hypopnea, and obstructive apnea; in snoring, there is no change in oxygenation and ventilation, and there is usually no arousal or sleep disruption; OSA and obstructive hypopneas cause oxygen changes, arousals, and sleep disruption, which interfere with sleep cycles

Snoring: occurs in 10% to 20% of the pediatric population, while OSA occurs in only 1% to 2%; 1 in 10 children who snore are diagnosed with OSA; snoring, hypersomnia during the day, daytime somnolence, and hyperactivity (in young children) are some signs of OSA; attention-deficit/hyperactivity disorder (ADHD) is often associated; treating OSA may improve ADHD; other signs include irritability, poor cognitive function, paradoxical breathing, heavy breathing, night sweating, and morning headaches; there is no sleep fragmentation in primary snoring; some studies show no changes in behavior or cognitive performance; upper airway resistance syndrome involves snoring with arousals and sleep disruption; long-term consequences are unknown

Factors contributing to OSA: include obesity, adenotonsillar hypertrophy, and any syndrome associated with hypotonia, eg, Down syndrome, micrognathia, and macroglossia; children with Pierre Robin syndrome have micrognathia, which obstructs the airway; Mallampati scores of 3 (the top of the uvula is visible) and 4 (the uvula is not visible) increase the risk for OSA by 10-fold

Diagnostic criteria: apnea-hypopnea index (AHI) scores for mild (1-5), moderate (5-10), and severe (>10-15); a positive sleep study requires one event per hour, eg, one hypopnea, or OSA, or both per hour

Treatment: the primary treatment is removing the adenoids and tonsils; weight loss, especially in older children or adolescents, can decrease OSA; continuous positive airway pressure (CPAP) therapy can help; CPAP machines can be full masks or nasal masks; pediatric-friendly masks are under development; it is challenging to comply with CPAP all night; adherence to CPAP in the first 30 days is important; ensure that a child has the appropriate equipment and mask and that there are no air leaks; the mask depends on the facial structure of the child; petroleum jelly (eg, Nivea, PRZ, Vaseline) around the mask's edge can help seal it, especially if there is an air leak around the eyes; there are objective measurements and visual guidance for airway changes and improved dynamics in sleep studies

CHAT study: Redline et al (2011) compared watchful waiting vs adenoid tonsillectomy (AT) in 500 children aged 5 to 9 yr with mild to moderate apnea and found a difference in behavioral scores but no change in neuropsychological scores in AT vs watchful waiting

Approach: sleep apnea in children typically occurs between ages 3 and 5 yr because of rapid growth (as the airway stretches); at ages 6 to 7 yr, the neck becomes wider, causing resistance to decrease (OSA decreases); prepubertal growth also contributes to the development of OSA in children; children with a small tonsil (Mallampati score class 1/2) need surgery; a repeat sleep study is needed for patients with severe OSA after surgery, as ≈30% have residual OSA after AT

Dyssomnia or primary insomnia: a child becomes used to having somebody next to him to fall asleep (Pavlovian reflex); there is no mild snoring or other signs of OSA; usually, a sleep study is not required; graduated extinction is mainly used, which involves waiting 5 min one night before going into the room, followed by gradually increasing the time; cognitive behavioral therapy for 6 mo is probably not needed

Sleep hygiene: avoid electronics after bedtime, go to bed at the same time every night, and wake up every morning at the same time; parents should avoid electronics in the bedrooms

Other sleep disorders: non-REM parasomnias (eg, sleep-walking and talking, enuresis) happen earlier in the night when there is less REM sleep; very little enuresis is related to OSA; children with enuresis without other signs of OSA do not need a sleep study; sleep terrors are increasing, especially since the pandemic, with more anxiety, occurring in the early part of sleep; sleepwalking is associated with anxiety; confusion arousals occur when children wake up early in the night, usually associated with anxiety; REM parasomnias (eg, sleep paralysis, nightmares) happen during REM sleep; children remember nightmares but do not remember sleep terrors; REM sleep behavior disorder is more important in adults; it occurs when children act out in their dream sleep; this may indicate some other neurologic dysfunction; anxiety disorders are increasing in children; the hypersomnia disorders are not circadian rhythm-related; most teenagers have delayed sleep phase angle disorder (going to bed late and waking up late); during the summer, teenagers experience a delayed phase, waking up at noon, which makes it difficult to return to school

Narcolepsy: can be diagnosed with a multiple sleep latency test (MSLT); rule out OSA with PSG before conducting the MSLT; the MSLT consists of 5 naps of 20 min each; most children with narcolepsy fall asleep quickly and go into REM sleep; a positive MSLT needs ≥2 sudden-onset instances of REM sleep to diagnose narcolepsy

Readings

Andlauer O, Moore H, Jouhier L, et al. Nocturnal rapid eye movement sleep latency for identifying patients with narcolepsy/hypocretin deficiency. JAMA Neurol. 2013;70(7):891–902. doi:10.1001/jamaneurol.2013.1589; Badr MS, Javaheri S. Central sleep apnea: a brief review. Curr Pulmonol Rep. 2019;8:14–21. https://doi.org/10.1007/s13665-019-0221-z; Gozal D, Tan HL, Kheirandish-Gozal L. Treatment of obstructive sleep apnea in children: handling the unknown with precision. J Clin Med. 2020;9(3):888. doi:10.3390/jcm9030888; Khayat A, Bin-Hassan S, Al-Saleh S. Polysomnographic findings in infants with Pierre Robin sequence. Ann Thorac Med. 2017;12(1):25–29. doi:10.4103/1817-1737.197770; Redline S, Amin R, Beebe D, et al. The Childhood Adenotonsillectomy Trial (CHAT): rationale, design, and challenges of a randomized controlled trial evaluating a standard surgical procedure in a pediatric population. Sleep. 2011;34(11):1509–1517. doi:10.5665/sleep.1388; Waterhouse J, Fukuda Y, Morita T. Daily rhythms of the sleep-wake cycle. J Physiol Anthropol. 2012;31:5. doi:10.1186/1880-6805-31-5; Wong SD, Wright KP, Spencer RL, et al. Development of the circadian system in early life: maternal and environmental factors. J Physiol Anthropol. 2022;41:22. doi:10.1186/s40101-022-00294-0.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Livingston was recorded at the 10th Annual Hot Topics in Pediatrics 2024, held July 18-20, 2024, in Lake Buena Vista, FL, and presented by Nemours Children's Health, Office of Continuing Education. For information on upcoming CME activities from this presenter, please visit https://ce.nemours.org. Audio Digest thanks the speakers and Nemours Children's Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

PD704301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.