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Sleep Disorders in Childhood

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Sleep Disorders in Childhood Submitted on: 11/22/2017 Approved on: 07/30/2018 REVIEW ARTICLE Sleep disorders in childhood Camila dos Santos El Halal1, Magda Lahorgue Nunes2 Keywords: Abstract Sleep, Objective: the aim of this article is to describe the main sleep disturbances in the paediatric age group, as well as the Sleep Disorders, diagnostic criteria and management for the paediatrician.Methods: a non-systematic review of the current literature was Child. made, based on the most recent international classification.Results: sleep disturbances are common in the paediatric age group, and can lead to a series of behavioural, social, and cognitive diurnal consequences. A sleep-directed interview is essential for suspicion and, frequently, sufficient for the diagnosis. The management is dependent on the diagnosis, as well as the severity of symptoms. Conclusion: the paediatrician plays an important role in the detection of sleep disturbances. Awareness of such conditions is essential for diagnosis and early management. 1 Mestre em Medicina – Área de Concentração Neurociências – Neurologista Pediátrica – Hospital Criança Conceição, Grupo Hospitalar Conceição Programa da Pós-Graduação em Medicina e Ciências da Saúde, Área de Concentração em Neurociências, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). 2 Professora Titular de Neurologia da Escola de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) – Vice-Diretora do Instituto do Cérebro do Rio Grande do Sul. Endereço para correspondência: Magda Lahorgue Nunes INSCER - INSTITUTO DO CÉREBRO DO RIO GRANDE DO SUL - PUCRS. Avenida Ipiranga, 6690, prédio 63, Jardim Botânico CEP 90610.000 - Porto Alegre, RS, Brazil. E-mail: [email protected] Residência Pediátrica 2018;8(supl 1):86-92 DOI: 10.25060/residpediatr-2018.v8s1-14 86 INTRODUCTION Table 1. Classification of Sleep Disorders according to the International Clas- sification of Sleep Disorders (ICSD)* Sleep plays a fundamental role in child growth and de- 1. Insomnia velopment; sleep patterns can be observed in fetuses starting 2. Sleep-Related Breathing Disorders 1 from around 26 weeks. During the first year of life, marked 3. Centrally Originating Hypersomnias changes occur in sleep characteristics, which mature over the 4. Circadian Rhythm Sleep and Wakefulness Disorders course of childhood.2 Newborns demonstrate an ultradian sleep pattern, with frequent awakenings more associated with 5. Parasomnias hunger and discomfort than the time of day, whereas 1-year- 6. Sleep-Related Respiratory Disorders old infants already have a well-established circadian cycle.3 7. Other Sleep Disorders Sleep duration over 24 h, which varies from 14 to 17 h *Adapted from Sateia MJ.6 in newborns, drops to 11–14 h between the first and second years of life and subsequently decreases to 10–13, 9–11, and sleep, or difficulty initiating sleep without intervention by 8–10 among preschoolers, school-aged children, and adoles- parents or caregivers in an environment conducive to sleep cents, respectively.4 During the first years of life, reduction (without the use of television, smartphones, or tablets at 13 in total sleep mainly occurs due to decreasing daytime sleep bedtime). Diagnosis requires daytime consequences of the periods. In this way, approximately half of the sleep period of difficulty described in the form of drowsiness or fatigue and a 1-month-old infant is distributed during the day, whereas a changes in performance at school or at work, in intellectual 12-month-old infant will have 1 or 2 episodes of daytime sleep capacity, or in mood or behavior. These consequences may be lasting around 1.5 h. By 5 years of age, the need for daytime described for the child as well as the main caregiver. Insomnia sleep disappears, with the morning nap eliminated first.5 is defined as chronic if present at least 3 days per week for at 9,13 As the circadian rhythm is established, the number of least 3 months. nighttime awakenings gradually decreases over the first year The most prevalent causes of insomnia vary according of life. Therefore, whereas a 1-month-old infant wakens 2 or 3 to age range and are described in Table 2. times per night, a 12-month-old infant usually does not wake While the main causes among infants are reflux, exces- up more than 2 times per night.6 However, brief awakenings sive ingestion of liquids, and inappropriate associations for that follow the sleep cycle (90–120 min) continue to occur, the onset of sleep, among adolescents, physiological delay of with the child normally falling back to sleep without external sleep phase, psychiatric comorbidities, and family pressure 7 intervention.7 are significant. Sleep disorders are prevalent in the pediatric age range8 Sleep onset association disorder, one of the types of It is estimated that until adolescence, 20%–30% of children behavioral insomnia, is one of the most prevalent disorders present some sleep abnormality, and this prevalence is higher among infants and preschoolers. In this case, the child re- among children with neuropsychiatric comorbidities.9 On the quires certain external conditions to fall asleep. This inevita- other hand, sleep disorders may also in themselves increase bly requires intervention from parents or caregivers such as the risk that a series of metabolic and behavioral changes may swaddling or breastfeeding the child. In this way, there is a emerge, leading to attention deficits, mood disorders, weight psychological wakening at the end of each sleep cycle when gain, and even neurodevelopmental alterations.10,11 the intervention must be repeated for sleep to resume. When The pediatrician plays a fundamental role in orienting this associated factor is absent, there is a loss of sleep for both sleep habits, as well as in recognizing, suspecting, and manag- the child and caregiver. ing possible disturbances. The objectives of this article are to describe the main sleep disorders in children, with an emphasis Sleep-Related Respiratory Disorders on the most prevalent, and to cite management measures This classification includes pathologies associated with according to the diagnosis. breathing and ventilation abnormalities during sleep; in the latest edition of the ISCD, these comprise obstructive sleep SLEEP DISORDERS apnea (OSA), central apnea syndromes, sleep-related hypoven- tilation, and sleep-related hypoxemia.13 Of these, OSA is the The most recent edition of the International Classifica- most prevalent and relevant for pediatric patients. tion of Sleep Disorders (ICSD-3) divides sleep disorders into OSA is characterized by partial or complete obstruction seven main categories, as described in Table 1.12 of the upper airways, leading to increased respiratory effort, hypoxia, and hypercapnia.14 It affects 1%–5% of the pediatric Insomnia population, with peak incidence between 2 and 8 years, and Insomnia is the most prevalent sleep disorder in the the main cause is adenotonsillar hypertrophy.15-17 Risk factors pediatric age group, affecting up to 30% of children.7 The are male sex, black race, family history of OSA, prematurity, ICSD-3 defines insomnia as difficulty initiating or maintaining obesity, allergic rhinitis, asthma, presence of neurological sleep, waking up earlier than desired, resisting the onset of diseases such as Down syndrome, Prader–Willi syndrome, Residência Pediátrica 2018;8(supl 1):86-92 87 Table 2. Causes of Insomnia According to Age Group* Centrally Originating Hypersomnias Inadequate associations for onset Centrally originating hypersomnias are classified as of sleep narcolepsy type 1 (formerly “with cataplexy”), narcolepsy type Gastrointestinal alterations (gastro- 2 (formerly “without cataplexy”), idiopathic hypersomnia, esophageal reflux, food allergies, Kleine–Levin syndrome, hypersomnia secondary to medical pa- < 2 years infant colic) thology and medication or substance, hypersomnia associated Excessive ingestion of liquids with psychiatric pathology, and insufficient sleep syndrome.13 Acute infectious diseases The common point among these pathologies, according to the Chronic diseases ICSD-3, is daily episodes of the irrepressible need to sleep or 13 Inadequate associations for onset daily sleep episodes. of sleep Narcolepsy is one of the most common causes of ex- Fear or anxiety about separation cessive daytime sleepiness, affecting approximately 1 in every from parents 2000 individuals, and has peak incidence in the second decade 2–3 years 19 Long naps or naps at inappropriate of life. Nevertheless, the period from the onset of symptoms times to the establishment of diagnosis tends to be long, on average Acute infectious diseases up to 15 years, mainly because of lack of knowledge of this 9,20 Chronic diseases diagnosis among physicians. In addition, the symptoms of narcolepsy are commonly confused with other patholo- Lack of establishment of limits gies, leading to erroneous diagnoses of OSA, chronic fatigue Pre-school and school-aged Fear or nightmares syndrome, psychiatric diseases (depression, schizophrenia), children Acute infectious diseases conduct and learning disorders, and epilepsy.21 In addition to Chronic diseases excessive daytime sleepiness, classic symptoms are cataplexy Delayed sleep phase (a REM sleep intrusion phenomenon consisting of sudden loss Sleep hygiene problems of muscle tone without loss of consciousness lasting a few second to a few minutes usually triggered by strong emotions) Psychiatric comorbidities in narcolepsy type 1, sleep paralysis, or hallucinations at the Family and/or school
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