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Sleep-Wake Disorders of Childhood

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Sleep-Wake Disorders of Childhood Review Article Address correspondence to Dr Suresh Kotagal, Department of Neurology and Sleep-Wake Disorders the Center for Sleep Medicine, 200 1st St SW, Mayo Clinic, Rochester, MN 55905, of Childhood [email protected]. Relationship Disclosure: Suresh Kotagal, MD, FAAN Dr Kotagal has received personal compensation as chair of the data safety monitoring board for INC ABSTRACT Research, Inc and receives royalties from UpToDate, Inc. Purpose of Review: Sleep-wake disorders occur in 10% to 28% of children and differ Unlabeled Use of somewhat in pathophysiology and management from sleep-wake disorders in adults. Products/Investigational This article discusses the diagnosis and management of key childhood sleep disorders. Use Disclosure: Recent Findings: The role of sleep in memory consolidation and in the facilitation of Dr Kotagal reports no disclosure. learning has been increasingly recognized, even at the toddler stage. Cataplexy, a key * 2017 American Academy feature of narcolepsy type 1, may be subtle in childhood and characterized by transient of Neurology. muscle weakness isolated to the face. Children with obstructive sleep apnea and restless legs syndrome display prominent neurobehavioral symptoms such as daytime inattentiveness and hyperactivity, so it is important to elicit a sleep history when these symptoms are encountered. Systemic iron deficiency occurs in about two-thirds of children with restless legs syndrome and is easily treatable. Parasomnias arising out of nonYrapid eye movement (REM) sleep, such as confusional arousals and sleepwalking, may be difficult to distinguish from nocturnal seizures, and, in many cases, video-EEG polysomnography is required to differentiate between causes. Summary: Clinicians should routinely integrate the assessment of sleep-wake function into their practices of neurology and child neurology because of the opportunity to improve the quality of life of their patients. Continuum (Minneap Minn) 2017;23(4):1132–1150. INTRODUCTION adolescence. This article highlights Pediatric sleep-wake disorders are key issues of pediatric sleep medicine very common. A prospective study that are relevant to both child and followed 359 mother-child pairs from adult neurologists. the birth of the child until 36 months of age and administered surveys about SLEEP ONTOGENY the child’s sleep at 6, 12, 24, and Developmental aspects of sleep regu- 36 months of age; the findings showed lation help us understand the patho- that the prevalence of sleep disorders physiologic aspects of childhood sleep at each assessment point was 10%.1 disorders. The overall quantity of Another large study found that 28% sleep over a 24-hour period and the of children aged 11 to 15 years had temporal organization of various sleep sleep disturbances such as insomnia, stages evolves continuously from in- snoring, or parasomnias.2 Childhood fancy through adolescence. Wakeful- sleep-wake disorders can contribute ness can be differentiated from sleep significantly to behavioral dysregula- by 27 to 28 weeks postconceptional tion and impairment of cognition and age in the preterm infant on the basis learning and differ from sleep prob- of clinical observation and EEG pat- lems in adults because of the continu- terns. At this age, about 80% of total ous neurodevelopmental changes that sleep time is active (rapid eye move- are evolving from infancy through ment [REM]) sleep, characterized by an 1132 ContinuumJournal.com August 2017 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINTS irregular respiratory pattern, intermit- ory formation is that 15-month-old h The overall quantity of tent electromyographic activity, and toddlers assimilate new linguistic infor- sleep over a 24-hour low-voltage mixed-frequency EEG activ- mation better if allowed to take a nap period and the temporal ity. By full term (40 weeks post- within 4 hours of presentation of the organization of various conceptional age), active (REM) sleep stimulus, as compared to continued sleep stages evolves decreases to about 50% of the total wakefulness without an ensuing nap.5 continuously from sleep time, with a corresponding in- infancy through crease in the proportion of quiet (non- Shifts in Temporal Organization adolescence. REM) sleep. Sleep spindles and K of Sleep Architecture and Time h Children experience complexes, which reflect maturation of of Sleep Onset large amounts of the N3 thalamocortical activity, appear by 2 to Prior to the age of 3 months, infants sleep stage, which is 3 months of age in full-term infants. By transition from wakefulness directly linked to the release of 4 to 6 months of age after term, non- into REM sleep. After this age, how- growth hormone and REM sleep becomes further differenti- ever, children tend to shift from wake- the consolidation of ated into N1, N2, and N3 sleep stages, fulness into non-REM sleep, with REM explicit memories. which have progressively lighter to sleep occurring 90 to 140 minutes h During transition from deeper arousal thresholds, respectively. after initial sleep onset. Elementary prepuberty to puberty, Sleep stage N3 is characterized by schoolYage children usually become a shift occurs, and melatonin is released at generalized slow-wave activity in the sleepy around 8:00 PM to 8:30 PM. a later time, with a 0.5 Hz to 4 Hz range on EEG. N3 During the transition from prepuberty corresponding delay in (slow-wave) sleep occurs predomi- to puberty, a shift occurs, and melato- sleep-onset time to nantly in the first third of the night. nin is released at a later time, with a 10:30 PM or 11:00 PM. Children experience large amounts of corresponding delay in the sleep- N3 sleep, which is linked to the onset time to 10:30 PM or 11:00 PM, release of growth hormone and the which also correspondingly leads to a consolidation of explicit memories. later shift in the morning wake-up REM sleep decreases progressively time. Also, melatonin secretion de- from the newborn period through clines with advancing Tanner stage ages 3 to 4 years so that by the age during sexual development,6 more so of 3 years, it constitutes only about in boys than girls. When juxtaposed 20% to 25% of total sleep. with early high school start times of The role of sleep in child develop- around 7:30 AM, it is easy to under- ment is underscored by the fact that stand why most teenagers are chron- short-term memories stored in the ically sleep deprived. hippocampus become consolidated into long-term memories in the neo- How Much Sleep Do Children cortex during the N3 sleep stage, at Need? which time a replay of short-term Expert consensus opinions exist regard- memory events occurs. At the electro- ing the amount of sleep children need, physiologic level, this correlates with but there are insufficient recommenda- hippocampal field potential oscilla- tions based on hard data. The widely tions of approximately 180 Hz, which cited opinion of the National Sleep are termed ripples.3,4 Sleep spindles, Foundation,7 shown in Table 11-1, volleys of thalamocortical impulses, provides an approximation of the opti- also play a role in sleep-dependent mum amount of sleep needed. More learning. Both spindles and ripples recently, a panel of experts convened are, in turn, modulated by cortical by the American Academy of Sleep slow waves of approximately 1 Hz. An Medicine also came to approximately example of the role sleep has in mem- the same conclusions concerning Continuum (Minneap Minn) 2017;23(4):1132–1150 ContinuumJournal.com 1133 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Childhood Sleep-Wake Disorders KEY POINT h approximate sleep-onset time, sensa- Inadequate sleep TABLE 11-1 Approximate Sleep hygiene has become the Requirements at tion of discomfort in the extremities foremost etiology for Various Agesa (restless legs syndrome [RLS]), intru- daytime sleepiness sive thoughts or worries (anxiety), ha- in adolescents. Hours bitual snoring, periods of observed Age of Sleep apnea and restless sleep (obstructive Newborns, 12Y18 hours sleep apnea [OSA]), unusual nighttime 0Y2 months events such as sleepwalking or confu- Infants, 14Y15 hours sion (parasomnias), daytime sleepiness 3Y11 months (hypersomnia disorders), mood distur- Toddlers, 12Y14 hours bances, and medications. 12Y36 months The sleep-related examination should Preschoolers, 11Y13 hours include assessment for height, weight, 3Y5 years body mass index, presence of craniofa- School-age 10Y11 hours cial anomalies, tonsillar hypertrophy and Y children, 5 10 years whether the oral airway is crowded, ex- Teenagers, 8Y9.25 hours amination of the anterior nasal passages, Y 10 17 years andauscultationoftheheartandlungs. a Data from National Sleep Foundation.7 nationalsleepfoundation.org/article/sleep. EXCESSIVE DAYTIME SLEEPINESS hours of sleep needed. This was based Excessive daytime sleepiness in child- upon a review of 864 published articles hood is a frequently overlooked, addressing childhood sleep duration. although common and disabling, symp- Sleeping the recommended hours was tom. The prevalence of excessive day- associated with improved health out- time sleepiness in childhood has been comes, including better attention, be- established based on questionnaire havior, learning, memory, emotional studies. Worldwide, the prevalence of regulation, quality of life, and physical excessive daytime sleepiness in child- and mental health.8 hood and adolescence is estimated at Sleep needs
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