SLEEP
I WEAKEN ALL PEOPLE FOR HOURS EACH DAY.
I SHOW YOU STRANGE VISIONS WHILE YOU ARE AWAY.
I TAKE YOU BY NIGHT, BY DAY TAKE YOU BACK,
NONE SUFFER TO HAVE ME, BUT DO FROM MY LACK.
“TO SLEEP, PERCHANCE TO
DREAM”
SLEEP IN CHILDREN WITH LIFE-LIMITING
CONDITIONS
MAHATMA GHANDHI
“EACH NIGHT, WHEN I GO TO SLEEP, I
DIE.
AND THE NEXT MORNING, WHEN I
WAKE UP,
I AM REBORN.”
I WEAKEN ALL PEOPLE FOR HOURS EACH DAY.
I SHOW YOU STRANGE VISIONS WHILE YOU
ARE AWAY.
I TAKE YOU BY NIGHT, BY DAY TAKE YOU
BACK,
NONE SUFFER TO HAVE ME, BUT DO FROM MY
LACK.
FUNCTION OF SLEEP
EXACT FUNCTION UNKNOWN
• IMPAIRED FUNCTION WITHOUT
MANY THEORIES
• CONFLICTING EVIDENCE (ALL)
1.
2.
3.
4.
5.
6.
RESTORATION
EVOLUTIONARY & ADAPTIVE
ENERGY CONSERVATION
LEARNING
UNLEARNING
OTHERS
1.
2.
3.
4.
5.
SOMATIC & CNS FUNCTION
ENVIRONMENT MODIFIES
ONLY 8 TO 10% ↓ IN BMR!
DIFFERENT ROLES FOR NREM & REM
SLEEP
SYSTEM TO “SCRUB AWAY” NEURAL
WASTE DURING SLEEP
VIGNETTE 1
• 5 YR OLD BOY WITH SMA 2
• ADMITTED WITH RESPIRATORY
INSUFFICIENCY 2O TO PNEUMONIA
• 4 DAY PICU ADMISSION; JUST AVOIDED
VENTILATION
• 12 DAY WARD ADMISSION; IV
ANTIBIOTICS, CHEST PHYSIO
• DISCHARGE AT ~ 90% PRE-MORBID
RESPIRATORY FUNCTION
• HOME VISIT 5 DAYS AFTER DISCHARGE
• RESPIRATORY REVIEW GOOD
• EVERYONE TIRED & FATIGUED FROM LACK OF
SLEEP
WHY?
VIGNETTE 2
• 15 ½ YR OLD GIRL EARLY RELAPSE OF AML AFTER BMT
• ELECTS NO FURTHER THERAPY AS STRUGGLED WITH CHEMOTHERAPY & BMT WAS
“HORRENDOUS”
• HOME VISIT IDENTIFIES PAIN & FATIGUE
• SLEEPING POORLY
• MEDICATION
• PARACETAMOL 1GM QID & CODEINE 30MG (OCCASIONAL)
SLEEP-WAKE CYCLE
TWO-PROCESS MODEL
• CIRCADIAN RHYTHM (PROCESS C)
• CIRCADIAN DRIVE FOR AROUSAL
• REGULATION OF INTERNAL PROCESSES & LEVELS OF
ALERTNESS
• SLEEP-WAKE HOMEOSTASIS (PROCESS S)
• ACCUMULATION OF SLEEP-INDUCING SUBSTANCES IN
BRAIN GENERATES HOMEOSTATIC SLEEP DRIVE
• BOTH PROCESSES INFLUENCED BY GENETICS
• OVERALL INFLUENCE FROM EXTERNAL FACTORS
http://www.howsleepworks.com
CIRCADIAN RHYTHM
• ANY BIOLOGICAL PROCESS DISPLAYING ENDOGENOUS & ENTRAINED OSCILLATION OF ~24 HRS
• ENTRAINED MEANS ADJUSTS TO LOCAL ENVIRONMENT FROM EXTERNAL CUES
• CUES INCLUDE LIGHT, TEMPERATURE & REDOX CYCLES
• CIRCADIAN CLOCK PRESENT IN PLANTS, ANIMALS, FUNGI & CYANOBACTERIA
• CLASSIC MEASURES:
• MELATONIN SECRETION
• CORE BODY TEMPERATURE MINIMUM
• PLASMA CORTISOL
PROCESS C – THE “CLOCK”
• CLOCK CENTRED IN HYPOTHALAMUS AT SCN
(SURACHIASMATIC NUCLEUS)
• MAIN MECHANISM TO CONTROL TIMING OF SLEEP
• COORDINATED WITH DAY-NIGHT/LIGHT-DARK CYCLE ~
24HRS
• INDEPENDENT OF PREVIOUS SLEEP OR WAKEFULNESS
• REGULATES SLEEP PATTERNS, FEEDING PATTERNS, CORE
BODY TEMPERATURE, BRAIN WAVE ACTIVITY, CELL
REGENERATION, HORMONE PRODUCTION & OTHER
BIOLOGICAL ACTIVITIES
• ALONE NOT SUFFICIENT TO CAUSE & REGULATE
SLEEP
PROCESS S – THE “SWITCH”
HOMEOSTATIC DRIVE FOR SLEEP AT VLPO
(VENTROLATERAL PREOPTIC NUCLEUS)
• INTERNAL BIOCHEMICAL SYSTEM TO COUNTERBALANCE
CIRCADIAN ELEMENT
• GENERATES PRESSURE TO SLEEP & REGULATES SLEEP INTENSITY
• INTUITIVE REMINDER FOR NEED TO SLEEP
•
LONGER BEEN AWAKE – STRONGER DESIRE & NEED FOR SLEEP
•
•
MORE LIKELY TO FALL ASLEEP
LONGER BEEN ASLEEP – MORE PRESSURE FOR SLEEP TO DISSOLVE
•
MORE LIKELY TO WAKE
• INFLUENCED BY LAST SLEEP & WAKEFULNESS (QUALITY &
DURATION)
THE “CLOCK” (SCN)
• RECEIVES INFORMATION FROM RETINA ON
LENGTH OF DAY & NIGHT (ILLUMINATION)
THE “SWITCH” (VLPO)
• “SWITCH” BETWEEN WAKEFULNESS & SLEEP
• INTERPRETS & PASSES ON TO PINEAL GLAND
• PROMOTES SLEEP BY INHIBITING ACTIVITY IN
AROUSAL AREAS
• PINEAL SECRETES MELATONIN IN RESPONSE
TO ↓ LIGHT
• WHEN AWAKE – AROUSAL AREAS INHIBIT
VLPO & STIMULATE CEREBRAL CORTEX
SLEEP GATE & AWAKENING
• MELATONIN PRODUCTION OPENS “SLEEP GATE”
• IN EVENING ↑ PRODUCTION CAUSES
DROWSINESS & HELPS LOWER BODY
TEMPERATURE
• BY EARLY MORNING BACK TO NORMAL,
NEGLIGIBLE LEVELS
• NEAR END OF NIGHT ↑ CORTISOL PRODUCTION
TO BE READY FOR STRESS OF DAY
• PEAKS AS SPIKE 20-30 MIN AFTER WAKING =
CORTISOL AWAKENING RESPONSE
MELATONIN
• CONVERTED FROM SEROTONIN IN PINEAL
GLAND
• REGULATES CYCLE BY INHIBITING CIRCADIAN
ALERTING SYSTEM IN SCN
• NEGATIVE FEEDBACK ON SCN REGULATES OWN
PRODUCTION
• PRODUCTION INHIBITED BY LIGHT; STIMULATED
BY DARK
• INTERNAL REPRESENTATION OF EXTERNAL LIGHT
CONDITIONS
• PEAKS AT NIGHT & EBBS DURING DAY
• PRESENCE PROVIDES INFORMATION ABOUT
NIGHT LENGTH
OTHER NEUROTRANSMITTERS
• MANY DIFFERENT NEUROTRANSMITTERS DRIVE WAKEFULNESS & SLEEP
• NONE INDIVIDUALLY NECESSARY BUT ALL APPEAR TO CONTRIBUTE
SLEEP ARCHITECTURE
NON-RAPID EYE MOVEMENT SLEEP (NREM)
• STATE OF DEEP, USUALLY DREAMLESS, SLEEP
• OCCURS REGULARLY DURING A NORMAL PERIOD OF SLEEP
• 4 STAGES
•
EACH ASSOCIATED WITH DISTINCT BRAIN ACTIVITY &
PHYSIOLOGY
RAPID EYE MOVEMENT SLEEP (REM)
• INTERVENING PERIODS
• DREAM SLEEP
NREM – STAGE 1
• TRANSITIONAL ROLE
• DURATION 1 TO 7 MIN (1ST CYCLE)
• CONSTITUTES 2-5% TOTAL SLEEP
• SLEEP EASILY INTERRUPTED BY NOISE
• EEG TRANSITIONS FROM WAKEFULNESS
(RHYTHMIC Α & Β-WAVES) TO LOW-VOLTAGE,
MIXED-FREQUENCY Θ-WAVES
• Α-WAVES ASSOCIATED WITH WAKEFUL RELAXATION
NREM – STAGE 2
• DURATION 10 TO 25 MIN (1ST CYCLE)
• LENGTHENS WITH SUCCESSIVE CYCLES
• CONSTITUTES 45-55% TOTAL SLEEP
• REQUIRES MORE INTENSE STIMULI TO AWAKEN
• EEG SHOWS RELATIVELY LOW-VOLTAGE, MIXEDFREQUENCY ACTIVITY
• CHARACTERISED BY SLEEP SPINDLES & K-COMPLEXES
• SPINDLES MAY BE MEMORY CONSOLIDATION
•
INDIVIDUALS WHO LEARN NEW TASK HAVE HIGHER
DENSITY THAN CONTROL
NREM – STAGE 3 & 4
SLOW-WAVE SLEEP
• MOSTLY DURING FIRST 1/3RD OF NIGHT
• AROUSAL THRESHOLD IS HIGHEST
• EEG – ↑ HIGH-VOLTAGE, SLOW-WAVE ACTIVITY
STAGE 3
STAGE 4
DURATION – FEW MINS
CYCLE)
– 20 TO 40 MIN (1ST
CONSTITUTES – 3-8% SLEEP
– 10-15% SLEEP
SLEEP ARCHITECTURE
RAPID EYE MOVEMENT SLEEP (REM)
• SLEEP ASSOCIATED WITH DREAMING
• DESYNCHRONIZED BRAIN WAVE ACTIVITY, MUSCLE
ATONIA & BURSTS OF RAPID EYE MOVEMENTS
• DURATION 1 TO 5 MIN (1ST CYCLE)
• BECOMES LONGER AS SLEEP PROGRESSES
• CONSTITUTES 20-25% OF SLEEP
• EEG TRANSITIONS TO STAGE 1 & AWAKE
ACTIVITY
I SLEPT LIKE A BABY!
NEWBORN (FIRST FEW WEEKS)
• DISTINCTIVE ARCHITECTURE
IMMATURE CIRCADIAN RHYTHMS
• TIMING EVENLY DISTRIBUTED ACROSS DAY & NIGHT
• DEVELOP IN FIRST 3 MONTHS
• NO REGULAR RHYTHM OR CONCENTRATION OF
SLEEP/WAKE
• 3 TYPES OF SLEEP
•
QUIET SLEEP (≈ NREM)
•
ACTIVE SLEEP (≈ REM)
•
INDETERMINATE SLEEP
• ONSET OCCURS THROUGH REM (NOT NREM)
• EACH SLEEP EPISODE CONSISTS OF ONLY 1 OR 2 CYCLES
•
1 MO – 24-HR CORE BODY TEMPERATURE CYCLE
•
2 MO – PROGRESSION OF NOCTURNAL SLEEPING
•
3 MO – CYCLING OF MELATONIN & CORTISOL HORMONES
SLEEP CYCLES ALSO CHANGE BECAUSE OF GREATER
RESPONSIVENESS TO SOCIAL CUES SUCH AS BREASTFEEDING & BEDTIME ROUTINES
MEANS YOU WAKE UP CRYING EVERY 3 OR 4 HRS
NEEDING TO POOP, PEE (THEN CHANGE) & EAT!
I SLEPT LIKE A BABY!
INFANTS & CHILDREN
3 MONTHS
YOUNG CHILDREN
• SLEEP ONSET NOW BEGINS WITH NREM
• DEVELOP SLEEP PHASE PREFERENCE BY TIME
ENTER SCHOOL
• ↓ REM & SHIFTS TO LATER PART OF CYCLE
• TOTAL SLEEP CYCLE TYPICALLY 50 MIN
6 MONTHS
• USUAL MUSCLE PARALYSIS OF REM REPLACES
NEWBORN “ACTIVE SLEEP”
• “NIGHT OWL” VS. “MORNING LARK”
• HOW, WITH WHOM & WHERE SLEEP PREFERENCE
• ↓ DAYTIME NAPPING
• INTRODUCTION OF SCHOOL ROUTINE
OLDER CHILDREN & ADOLESCENTS
OLDER CHILDREN
ADOLESCENTS
• MORE LIKELY TO
• COMPLEX, BIDIRECTIONAL RELATIONSHIP B/W
PUBERTAL DEVELOPMENT & SLEEP
• EXPERIENCE CHALLENGES IN INITIATING &
MAINTAINING SLEEP
• HAVE NIGHTMARES; USUALLY DISRUPTS SLEEP
• HAVE LONGER REM SLEEP LATENCIES THAN
ADOLESCENTS
• ↑ % TIME IN SWS (STAGES 3 & 4)
• MEASURE BY PUBERTAL STAGE RATHER THAN AGE
• HORMONAL CHANGES PLAY A ROLE
• FEW OBTAIN REQUIRED 9 TO 10 HRS EACH
NIGHT
ARCHITECTURE WITH AGE
• DAILY RHYTHM BEGINS ~ 4 MO
• INFANTS & CHILDREN > % REM
• CHANGES WITH INCREASING AGE
• ↓ TOTAL TIME
• ↑ TIME IN STAGE 2
• ↓ SWS & SLEEP LATENCY
• ↓ REM SLEEP FROM ~ 50% TO 20-25%
• DURATION REMAINS CONSTANT IF BEDTIME FIXED
SLEEP DURATION
• AVERAGE SLEEP TIME VARIES CONSIDERABLE WITH AGE
• RECOMMENDATIONS FOR HEALTHY CHILDREN
• NEWBORN – 16 TO 18 HRS PER DAY IN CYCLES OF 3 TO 4 HRS (DAY & NIGHT)
• 6 MONTHS – CAN SLEEP FOR > 6 HRS AT NIGHT WITHOUT A FEED
• 18 MONTHS – PATTERNS MATURE TO OVERNIGHT SLEEP & ONE DAYTIME NAP
• SCHOOL AGE – CONSOLIDATES INTO A SINGLE NIGHT SLEEP OF 11 TO 12 HRS
• PREPUBESCENT TO 16 YRS – DURATION SLOWLY ↓ FROM 10 TO 8 HRS
• INDIVIDUAL CHILDREN & ADOLESCENTS MAY BENEFIT FROM LONGER
• ENQUIRE ABOUT DAY TIME FUNCTIONING AS PART OF ASSESSMENT
GALLAND. SYSTEMATIC REVIEW. SLEEP MED REV 2012;16
SLEEP PROBLEMS IN HEALTHY CHILDREN
• AFFECT 30 TO 40% OF INFANTS & CHILDREN BEFORE SCHOOL AGE
• EFFECTS ON CHILD HEALTH
• POOR GROWTH
• ADVERSE BEHAVIOURAL & LEARNING OUTCOMES
• ADVERSE PHYSICAL HEALTH OUTCOMES
• EFFECTS FOR THE CHILD & FAMILY
• WORSENED MENTAL HEALTH
• ↓ QUALITY OF LIFE
SLEEP DISORDERS
DYSSOMNIAS
PARASOMNIAS
• PRIMARY DISORDER OF SLEEP INITIATION OR
MAINTENANCE OR EXCESSIVE SLEEPINESS WHICH
DISTURBS SLEEP AMOUNT, QUALITY, OR TIMING
• UNDESIRABLE MOTOR, AUTONOMIC OR
EXPERIENTIAL PHENOMENA OCCURRING
EXCLUSIVELY OR PREDOMINANTLY DURING SLEEP
WATERS. MJA 2013;199 SUPPL
DYSSOMNIAS
INTRINSIC
EXTRINSIC
• IDIOPATHIC HYPERSOMNIA
• ALCOHOL-DEPENDENT SLEEP DISORDER
• NARCOLEPSY
• FOOD ALLERGY INSOMNIA
• PERIODIC LIMB MOVEMENT DISORDER
• BEHAVIOURAL SLEEP DISORDERS INCL.
INADEQUATE SLEEP ROUTINE
• RESTLESS LEGS SYNDROME
• SLEEP APNOEA
• SLEEP STATE MISPERCEPTION
• COMMON IN CHILDHOOD
SLEEP & RESPIRATORY DISORDERS
• SNORING & OSA COMMON
• AFFECTS 3 TO 15% OF HEALTHY CHILDREN
• PEAK PREVALENCE IN PRESCHOOL YEARS
•
LYMPHOID TISSUE LARGEST IN UPPER AIRWAY RELATIVE TO SIZE OF FACIAL SKELETON
• CERTAIN MEDICAL DISORDERS ↑ RISK FOR OSA
• CONGENITAL ABNORMALITIES AFFECTING CRANIOFACIAL OR THORACIC GROWTH
• NEUROMUSCULAR DISEASES
•
↑ INCIDENCE OSA IN FIRST DECADE
• CONGENITAL CARDIOTHORACIC ABNORMALITIES OR RESTRICTIVE LUNG DISORDERS
• NEURODEVELOPMENTAL CONDITIONS SUCH AS CEREBRAL PALSY
•
PREDISPOSE TO NOCTURNAL RESPIRATORY FAILURE
Delayed sleep phase
Advanced sleep phase
Non-24 hr sleep-wake disorder
Irregular sleep-wake disorder
Shift work disorders
Jet lag disorders
CIRCADIAN RHYTHM DISORDERS
CHRONIC ALTERATIONS, DISRUPTIONS, OR MISALIGNMENT
OF CIRCADIAN CLOCK IN RELATION TO
ENVIRONMENTAL CUES & LIGHT-DARK CYCLE
PARASOMNIAS
NREM-RELATED
•
NIGHT TERRORS, HYPNOGOGIC IMAGERY (LUCID DREAM), SLEEP WALKING
REM-RELATED
•
DREAMS, NIGHTMARES, SLEEP PARALYSIS
SLEEP STATE INDEPENDENT
•
BRUXISM, SLEEP TALKING, RHYTHMIC MOVEMENT DISORDER
VIGNETTE 1
• 5 YR OLD BOY WITH SMA 2
• 2 WEEK INTENSIVE HOSPITAL STAY
WHAT NEXT?
• FAMILY STRUGGLING AT HOME
• POOR SLEEP
ASSESSMENT
• THOROUGH HISTORY & EXAMINATION
• BEARS – SCREENING TOOL
• B = BEDTIME (SETTLING) PROBLEMS
• E = EXCESSIVE DAYTIME SLEEPINESS
• A = NIGHT AWAKENINGS
• R = REGULARITY AND DURATION OF SLEEP
• S = SNORING
• PARENTS DEFINE PRESENCE OF SLEEP PROBLEMS
• EVALUATION OF PARENTAL EXPECTATIONS (MAY NOT BE VALID)
VIGNETTE 1
Behaviour
• USUAL SLEEP PATTERN
• AFTER DINNER HAS BATH & READIES FOR BED
• STORY FOR 15 TO 20 MIN
• SINCE HOSPITALISATION
• DISRUPTIVE BEHAVIOUR AT DINNER; BATTLE TO GET
HIM READY FOR BED
• NO STORY & PUT TO BED AT USUAL TIME
• BED NO LATER THAN 6:30PM
• NOT SETTLING UNTIL 8PM
• ASLEEP WITHIN 15 MIN
• WAKING FREQUENTLY DURING NIGHT; FIRST
WAKING AT 10PM
• SLEEPS THROUGH; WAKING 7AM EVERYDAY
• WAKES REFRESHED
• FATIGUED BY 1PM & HAS NAP FOR ~2 HR
• OFTEN ENDS UP IN PARENTAL BED AFTER WHICH
SLEEPS THROUGH
• UNREFRESHED & FATIGUED ON BEING WOKEN 9AM
• SLEEPING X2 DURING DAY; X1 OF 3 TO 4 HRS
EFFECT OF BEING IN HOSPITAL
• ADMISSION OF PREVIOUSLY HEALTHY
CHILDREN CAN RESULT IN 25 TO 50% LOSS
OF SLEEP TIME
• ENVIRONMENT DEPENDENT; WARD VS. ICU
• CAN PERSIST OF UP TO 7 WEEKS
• CHILDREN WITH LLC
• 52% WITH POOR SLEEP
HERBERT A. SLEEP BIOLOG RHYTHMS 2006;6 (SUPPL 1)
PHYSICAL FACTORS
•
UNDERLYING CONDITION
•
PAIN & OTHER SYMPTOMS
•
PROCEDURES
ENVIRONMENTAL FACTORS
•
NURSING INTERRUPTIONS
•
TOILETING NEEDS
•
NOISE & LIGHT – WARD, OTHER PATIENTS, ALARMS
PSYCHOSOCIAL FACTORS
•
LOSS OF ROUTINE
•
LACK OF CONTROL, ANXIETY, FEAR
•
SEPARATION FROM FAMILY
Canadian Paediatric Society
VIGNETTE 2
• 15 YR OLD GIRL WITH RELAPSED
AML AFTER BMT
• HOME VISIT IDENTIFIES
• BONE PAIN
• FATIGUE
• SLEEP DISRUPTION
• SLEEP DISRUPTION
NO ROUTINE PRIOR TO BED
ISOLATING SELF TO ROOM
EXCESSIVE SCREEN TIME; MAINLY IN BED
SLEEP INITIATION ERRATIC; AVERAGE 2 AM
WAKING HOURLY FOR 30 MIN UNTIL 6AM;
50% TIME PAIN
• FROM 6 AM TO 10 AM SLEEPS
• NO MORE THAN 3 HRS DURING DAY
WITHOUT SLEEPING
•
•
•
•
•
PAIN & SLEEP
BED TIME IMPACT
SLEEP TIME SYMPTOMS
• DELAY IN SLEEP ONSET
•
LOWER SLEEP EFFICIENCY (<90%)
• ANXIETY, RUMINATION
•
LONGER TIME IN S1; LESS IN SWS
• INTENSE FATIGUE & MORE INTENSE PAIN
•
NUMEROUS SLEEP STAGE SHIFTS (SWS TO S2 OR S1)
•
FRAGMENTATION OF SLEEP CONTINUITY
WAKE TIME IMPACT
• UNREFRESHING SLEEP SENSATION, FATIGUE, HEADACHE…
• SLEEPINESS
• ANXIETY & ANGER AT NOT COMPLETING DAY
•
MISSED SCHOOL, POOR CONCENTRATION, TIME WITH FRIENDS
•
↑ MICROAROUSALS, AWAKENINGS, RESPIRATORY EVENTS (APNOEA)
•
↑ PARASOMINAS – NIGHTMARES, PERIODIC LEG MOVEMENTS
•
PHYSIOLOGIC CHANGES – SWEATING, HEART PALPITATIONS & ABSENT
↓ IN HR VARIABILITY (CARDIAC SYMPATHETIC OVER ACTIVITY)
•
Α-WAVE INTRUSIONS IN SWS
•
WAKE TIME IN SLEEP WITH PAIN
LAVIGNE 2005
VIGNETTE 2
• 15 YR OLD GIRL WITH RELAPSED
AML AFTER BMT
• SLEEP DISRUPTION
• NO BED ROUTINE CONTINUES
• STILL STAYING IN ROOM
• HOME VISIT IDENTIFIES
• BONE PAIN – WELL MANAGED
• FATIGUE – CONTINUES
• SLEEP DISRUPTION – CONTINUES
• ON MOBILE, LAPTOP; MAINLY IN BED
• SLEEP INITIATION IMPROVED; NOW 12AM
• WAKING X3 EACH NIGHT FOR 60 MIN
• RISING AT 10 AM
• X2 NAPS OF 1 TO 2 HRS DURING DAY
Canadian Paediatric Society
SLEEP IN CPC
• 3RD GROUP OF SLEEP DISORDERS ARE THOSE ASSOCIATED WITH MEDICAL CONDITIONS
• DIRECTLY FROM PHYSICAL EFFECTS OF CONDITION OR ITS MANAGEMENT
• INDIRECTLY FROM EMOTIONAL IMPACT I.E. ANXIETY, DEPRESSION
• HIGH PREVALENCE (50 TO 80%) IN NEUROLOGICAL & OTHER COMPLEX ILLNESSES
• LARGE IMPACT ON CAREGIVERS
• MARKEDLY IMPAIRED HEALTH-RELATED QOL IN MOST DOMAINS OF SF-36
• IMPAIRED SLEEP QUALITY IN > 50%
• ↑ FATIGUE, SOMATIC COMPLAINTS, DEPRESSION & OTHER PSYCHIATRIC DISORDERS
TIETZE A. DEV MED CHILD NEUROL 2014;56
MEASURES
WWW.DEUTSCHES-KINDERSCHMERZZENTRUM.DE
SNAKE
•
SCHLAFFRAGEBOGEN FÜR KINDER MIT NEUROLOGISCHEN UND
ANDEREN KOMPLEXEN ERKRANKUNGEN
•
SLEEP QUESTIONNAIRE FOR CHILDREN WITH SEVERE
PSYCHOMOTOR IMPAIRMENTS
• 16 QUESTIONS TO LOOK AT 6 COMPONENTS OF SLEEP
5.
SLEEP QUALITY
6.
SYMPTOMS AND CONSEQUENCES OF SLEEP DISORDERS
•
DISTURBANCES GOING TO SLEEP
1.
SLEEP CONDITIONS
•
2.
SLEEP ONSET LATENCY
DISTURBANCES REMAINING ASLEEP
•
3.
LENGTH OF SLEEP
AROUSAL DISORDERS
4.
SLEEP EFFICIENCY
•
DAYTIME SLEEPINESS
•
DAYTIME BEHAVIOUR DISORDERS
•
RATIO TOTAL SLEEP TIME TO TIME SPENT IN BED
MEASURES
WWW.DEUTSCHES-KINDERSCHMERZZENTRUM.DE
HOST
•
HOLISTIC ASSESSMENT OF SLEEP AND DAILY TROUBLES IN PARENTS
OF CHILDREN WITH SEVERE PSYCHOMOTOR IMPAIRMENTS
• 12 QUESTIONS TO LOOK AT 5 COMPONENTS OF
PARENTAL SLEEP BEHAVIOUR
1.
SLEEP CONDITIONS
2.
SLEEP ONSET LATENCY
3.
LENGTH OF SLEEP
4.
SLEEP EFFICIENCY
•
RATIO TOTAL SLEEP TIME TO TIME SPENT IN BED
5.
EFFECTS OF CHILDREN’S SLEEP DISORDERS ON PARENTS
•
SLEEP DISTURBANCES
•
IMPAIRMENTS OF PHYSICAL/ MENTAL FUNCTIONING
•
IMPAIRMENTS OF SOCIAL FUNCTIONING
•
IMPAIRMENTS OF WORKING ABILITY
RULES OF THUMB
• HISTORY SHOULD ALWAYS INCL. ASKING ABOUT
SLEEP (CHILD & CARERS)
• MOSTLY NEEDS FOCUSSED QUESTIONS
• SLEEP DURATION – TIME FOR SLEEP ONSET TO
MORNING WAKENING
• SLEEP EFFICIENCY – % TIME ASLEEP IN BED
• SLEEP ONSET LATENCY – TIME TO SLEEP; < 30 MIN
• SLEEP MAINTENANCE – NUMBER & DURATION OF
NIGHT AWAKENINGS
• SLEEP DIARIES (SNAKE & HOST) CAN PROVIDE MORE
DETAIL
• POLYSOMNOGRAPHY (SLEEP STUDY) USED FOR
SPECIFIC ANALYSIS
•
SLEEP-DISORDERED BREATHING
•
UPPER AIRWAY OBSTRUCTION
•
CENTRAL SLEEP APNOEA
•
PRE-SURGICAL RISK ASSESSMENT
•
STARTING NON-INVASIVE VENTILATION
•
MONITORING CHILDREN ALREADY ON RESPIRATORY SUPPORT
MEASURES
MANAGEMENT
• INTERDISCIPLINARY APPROACH
• RATIONALISE MEDICATIONS
• IF POSSIBLE, SEDATIVE AGENTS AT NIGHT
• IDENTIFY & MANAGE PHYSICAL &
PSYCHOLOGICAL SYMPTOMS
• MELATONIN – SLEEP INITIATION & REGULATION
• HYPNOSEDATIVES
• BARBITUATES
• BENZODIAZEPINES
• CHLORAL HYDRATE
• OTHER AGENTS
• ANTI-DEPRESSANTS
• REINFORCE SIMPLE SLEEP HYGIENE STRATEGIES
• ANTI-CONVULSANTS
• CONSIDER MEDICATIONS
• ANTI-HISTAMINES
• ANTI-PSYCHOTICS
• ALPHA-2 AGONISTS
MEDICATIONS
ANTI-HISTAMINE AGENTS
ANTI-CHOLINERGIC AGENTS
• CAUSE DROWSINESS & ↑ NON-REM SLEEP
• CAUSE DROWSINESS & ↓ REM SLEEP
• HISTAMINE
• ACETYLCHOLINE
• “MASTER” WAKEFULNESS-PROMOTING NT
• HIGH ACTIVITY DURING WAKEFULNESS
• ↓ ACTIVITY DURING NREM SLEEP
• AT LOWEST LEVELS DURING REM SLEEP
• NT ACTIVITY IN RAS STIMULATES FOREBRAIN &
CEREBRAL CORTEX ENCOURAGING ALERTNESS &
WAKEFULNESS
• ACTIVE DURING REM SLEEP