2/14/2014
Disclosures
None
Sleep difficulties Jessica Litwin, MD Assistant Clinical Professor of Neurology th 47 Annual Recent Advances in Neurology
Patient History Past History
6 ½ year old girl who “has never been a good sleeper” Medications- multivitamin Difficulties falling asleep and bedtime battles Allergies- NKDA Prolonged nighttime awakenings that can last hours PMH/PSH- eczema, autism spectrum disorder (ASD), anxiety. No surgeries. Immunizations up to date Hard to get up in the morning on school days Birth history- born at 37 weeks gestation, pregnancy Poor behavior, extremely disruptive especially as the day complicated by uncontrolled gestational diabetes. Limited progresses information available- child is adopted Development- global delays- walked at two, child is nonverbal, sensory integration dysfunction Family history- unknown, she is adopted
1 2/14/2014
Sleep History- further details Sleep History- further details
Bedtime routine- bath at 7 pm. Skin cream for eczema, gets in No snoring or respiratory distress pajamas. Brushes teeth, shares books. Can be a restless sleeper Parents try to leave her in her room around 7:45 pm Anxiety escalates through bedtime routine No parasomnia Head banging and restlessness noted at bedtime and with night Head banging at bedtime and with awakenings waking Difficult to awaken on school days It is unclear how many times she wakes up at night, except that there is always a prolonged awakening at about 4 am Sleeps later on weekends and vacations Dad reports that if mom is traveling, there are less bedtime problems, as he lets the child go to bed later
Physical Exam- pertinent findings Question 1
Normocephalic, nondysmorphic, not overweight What test would you order based on this history? 78% Nares are patent, no tonsillar hypertrophy 1. Blood tests Normal CV and pulm exam 2. Diagnostic polysomnogram 3. Nonfocal neuro exam excepting that child is nonverbal, Actigraphy exhibits repetitive behavior, poor eye contact 4. EEG 16% Is anxious during assessment, but can be soothed and 4% 2% redirected by parents
s s t E E G d t e p o l . . . o s t i c B l o n o Actigraphy a g D i
2 2/14/2014
Further details to consider
This child is autistic and has sensory integration dysfunction Sensory challenges tolerating monitoring apparatus Severe anxiety regarding invasive procedures Autism has been associated with decreased melatonin production and an alteration in the timing of melatonin release This child can also have any sleep disorder that can be present in a typically developing child
Question 2 Multifactorial sleep issues
What do you think the diagnosis is? Restlessness and limb movements- 1. Insomnia could be sensory processing 77% 2. self stimulatory such as a sleep onset rhythmic movement disorder Circadian rhythm disorder Anxiety 3. Limb movement disorder limb movement disorder such as restless legs/periodic limb movements 4. Sleep disturbance is secondary to anxiety Behavioral/ developmental component 9% 9% 5% Sleep phase disturbance 5. Rhythmic movement disorder 0% . Parasomnia or nightmare or seizures? i a .. n m . . . v e o I n s o m i a n r h y t m i c m h C i r c a d Sleep disturba... Lim b m ovem ent ... R h y t
3 2/14/2014
Next steps Question 3
What additional tests or evaluations would you Behavioral techniques recommend now? Consistent routines 37% Consistent bedtimes and wake times 1. Blood tests Good morning light 2. EEG 23% 23% Positive reinforcement 3. Diagnostic polysomnogram 16% Referral for medical evaluation 4. Psychiatric evaluation
EG l ...... E e v c p o i c s t i Blood tests h i a t r y c D i a g n o P s
Next steps One month later
Labs Some improvements Iron studies - normal Easier time with bedtimes Ferritin is low at 15 Falling asleep consistently within 20-30 minutes CBC- normal Parents are concerned that child is still restless and seems Thyroid studies- normal to be indicating limb discomfort Start on iron supplement at 3 mg/kg/day Next started on gabapentin 100 mg nightly Start on melatonin supplement Parents note further improvement Weighted blanket, sensory techniques added to bedtime routine Follow up actigraphy is ordered Reinforced behavioral techniques
4 2/14/2014
Follow up
Child was treated with iron for 6 months, and then transitioned to a multivitamin with iron
She continues with behavioral techniques and with melatonin 3 mg nightly as well as gabapentin 100 mg
She is now sleeping 10-11 hours nightly
Daytime behavior is much improved- less anxiety, less repetitive behaviors
Significant improvement in social interactions- more This graph represents C’s sleep during the study. Dates are on the left and time is appropriate play and has begun using words! across the bottom, starting at noon on the left. Shaded sections are the sleep period per sleep diary. Underlined sections in the sleep period are when the watch thought C was asleep, while vertical black lines indicate activity.
Autism spectrum disorder (ASD) Sleep in autism
Not a disease as there is not a unique biologic cause Sleep difficulties, particularly insomnia, occur in 50-80% of children with autism spectrum disorders (ASDs) Behaviorally defined syndrome of early life Often accompanied by child and family distress Defining deficits of ASD Disordered sleep may exacerbate manifestations of autism, Social skills including poor social interactions, repetitive behaviors, affective problems, and inattention and hyperactivity, and Communicative language and imagination seizures Narrowness of focus resulting in rigidity Preoccupations Therefore, it is vital to identify sleep issues in these Repetitive movements and speech vulnerable children
5 2/14/2014
This is the goal!
6