Southeast Houston Sleep Medicine

PEDIATRIC SLEEP DISORDERS

Sleep patterns change gradually from infancy into old age. Newborn
infants do not pass through four sleep stages like adults. They have
only two types of sleep - active sleep and non-active sleep. Active
sleep is the precursor of rapid eye movement (REM) sleep in adults.
The brainwaves are small and fast, and the infant often kicks or moves.

Inactive sleep is comparable to non-REM sleep of adults. It is marked by large and slow brainwaves, decreased movement, and very little spontaneous activity. The newborn infant alternates between active sleep and non-active sleep in 30-60 minute intervals. These intervals fluctuate throughout the day. A newborn can sleep up to 18 hours within a 24-hour period at random times of the day and night. Infants do not consolidate their sleep in the nighttime hours like older children and adults do.

As infants develop, they gradually begin sleeping more at night and less during the day. Although a 6-month-old sleeps less than a newborn, they still sleep more than an adult. Six month olds spend a larger percentage of their sleep time in slow wave sleep (deep sleep) than adults do. Scientists have linked slow wave sleep with the secretion of growth hormone, a hormone secreted by the pituitary gland that promotes the growth of bone and soft tissue in children. Higher concentrations of slow wave sleep persists throughout childhood and into early adulthood. Once a person reaches full maturity, the percentage of time spent in slow wave sleep decreases to 0-20% of the night.

SLEEP TERRORS

Sleep terrors describe an involuntary response in children around 3-4 years of age. They become agitated and upset for a brief period. Sleep terrors usually occur during the first third of the night. Despite the best efforts of their parents, children experiencing sleep terrors are inconsolable. Their eyes are often dilated and they show signs of anxiety, such as sweating and trembling. Despite these outward signs of agitation, children experiencing sleep terrors cannot remember any nightmares or terrifying experiences. In the vast majority of cases, children have no recollection of sleep terrors at all. Children outgrow sleep terrors, and there are no permanent or long lasting effects.

NIGHTMARES

Nightmares are distinguishable from sleep terrors in that children will remember a scary or upsetting dream when awakened, and parents are able to console them. Nightmares and dreams tend to occur during REM sleep in the last third of the night, as opposed to sleep terrors which usually happen in the first third of the night.

ENURESIS

Enuresis is a name that doctors use to describe bedwetting. Enuresis is normal until around age 7 or 8. If it continues as the child matures, parents should consider consulting with a urologist or a sleep specialist. Enuresis can usually be managed with behavioral techniques. Parents should encourage children to avoid drinking before they go to bed. An alarm clock can be set to wake the child up once or twice during the night, cuing them to go to the bathroom and urinate. If these intermittent awakens keep the bladder from becoming full and distended, the frequency of bedwetting will decrease.

NOCTURNAL SEIZURES

Some forms of seizures occur more frequently when people are asleep. A nocturnal seizure usually appears as a repetitive rhythmic movement. The movement can be isolated to one or two body parts such as an arm or leg, or the seizure can be generalized and cause shaking and trembling throughout the entire body. This more severe form, called a grand mal seizure, can often cause loss of bladder or bowel control. If a child experiences a grand mal seizure during sleep, they will be confused and disoriented afterwards. If parents notice seizure activity, they should consult with a pediatrician or a neurologist. These children will require brain scans, electroencephalograms, and possibly medication.

DELAYED PHASE SHIFT DISORDER IN ADOLESCENCE

Although adolescents require less sleep than children before puberty, they still need more sleep than adults. The “internal clock” in most teenagers is longer than twenty-four hours, so they tend to stay up later at night and sleep later in the morning. Although this is a normal part of adolescence, it sometimes causes problems because teens must adapt to the schedule of society. School usually starts at 7 or 8 a.m., and high school students need to be awake and ready early in the morning.

Delayed phase sleep syndrome is usually treated with behavioral modification. By using an alarm clock and forcing the adolescent to get up at 6 or 7 in the morning, he or she will be more tired at night and will go to sleep earlier. It is important that they maintain the same sleep-wake schedule on weekends and not sleep into the early afternoon on weekends. This disruption in their schedule will aggravate the problem. In the rare cases when behavioral modification alone does not correct the problem, sleep specialists will use mild medications such as melatonin, a hormone secreted naturally by the pineal gland, Ramelteon, or Klonopin to help adolescents fall asleep at an appropriate hour.


OBSTRUCTIVE SLEEP APNEA IN CHILDREN

Obstructive sleep apnea in children generally does not cause the classic symptoms of snoring, cessation of breathing and daytime sleepiness found in adults. Although children can have upper airway obstruction and intermittent cessation of breathing like adults, their oxygen levels tend to remain within the normal range, because their respiratory systems adapt well to stressful events. They rarely complain of daytime sleepiness. More commonly, they will appear inattentive and agitated during the day. For this reason, obstructive sleep apnea in children can easily be confused with attention deficit disorder.

It requires an insightful pediatrician to detect sleep apnea in a child. The pediatrician would have to inquire as to the child’s sleeping habits, snoring and daytime behavior. By ordering a sleep study and  providing the correct diagnosis, a pediatrician can do a great service for a child with sleep apnea, because the decreased attention span and hyperactivity associated with sleep apnea is easy to correct.  In most cases, a tonsillectomy will cure the problem, but if surgery alone does not correct the problem, continuous positive airway pressure will usually work. These treatments avoid the use of potentially addictive medicines like Adderall or Ritalin.

SLEEPWALKING

Sleepwalking is not uncommon in children up until age 13 or 14. It occurs during slow wave sleep (deep sleep) when children are most difficult to arouse. Children do not dream while sleepwalking and if awakened, they will be confused and disoriented.

Sleepwalking in itself is not dangerous and does not cause any permanent brain damage. However, it is very important to make sure that children do not accidentally harm themselves. Furniture should be rearranged and sharp objects should be removed to lessen the chances of injury. If the sleepwalking becomes severe enough, it can often be controlled using a small dose of medications such as Klonopin or Ativan.