Pediatric Sleep

A Pediatric Sleep Specialist has special advanced training in disorders of sleep and wakefulness in youngsters through the age of adolescence. Children are not "little adults". Our medical staff is certified by the American Board of Pediatrics. If your physician suggests that your child see a sleep specialist, be assured that your child will receive the best possible care from our team of specialists.

Sleep Disorders

  • Sleep Studies
  • Actigraphy
  • Complex Sleep Apnea Management

The most common kind of sleep apnea is called Obstructive Sleep Apnea Syndrome. It is characterized by repetitive episodes of upper airway obstruction that occur during sleep, usually associated with a reduction in blood oxygen saturation. (Adapted from stanford.edu)

  • Excessive daytime sleepiness.
  • Frequent episodes of obstructed breathing during sleep.

Associated features may include:

  • snoring
  • nocturnal snorting, gasping, choking (may wake self up)
  • restless sleep
  • heavy irregular breathing
  • excessive perspiring/sweating during sleep
  • bedwetting
  • bad dreams (nightmares)
  • night terrors
  • sleeps with mouth open, causing a dry mouth upon awakening
  • chest retraction during sleep in young children (chest pulls in)
  • sleeps in strange positions
  • confusion upon awakening
  • morning headaches
  • unrefreshing sleep
  • excessive daytime sleepiness
  • may develop high blood pressure
  • may be overweight or underweight
  • learning problems
  • excessive irritability
  • change in personality
  • depression
  • difficulty concentrating
  • Developmental problems
  • failure to thrive or grow
  • frequent upper respiratory infections
  • hyperactive behavior

It is a potentially life-threatening condition that requires immediate medical attention.

The risks of undiagnosed Obstructive Sleep Apnea in children with sleep apnea include learning problems, developmental problems, behavior problems, and in some cases, failure to grow, heart problems and high blood pressure. In addition, Obstructive Sleep Apnea causes daytime sleepiness that can result in personality changes, lost productivity in school, and interpersonal relationship problems. A child with sleep apnea may lag behind in many areas of development. The child may become frustrated and depressed. The severity of the symptoms may be mild, moderate, or severe.

A sleep test, called polysomnography (PSG) is usually done to diagnose sleep apnea. An overnight polysomnography test involves monitoring brain waves, muscle tension, eye movement, respiration, oxygen level in the blood, and audio monitoring (for snoring, gasping, etc.). The test is painless. More information on the test is explained in the sections below.

In children, simply removing the tonsils or adenoids may take care of the problem. Sleep Apnea in children, where removing the tonsils or adenoids does not take care of the problem, is usually treated with a C-PAP (continous positive airway pressure) or Bi-Level positive airway pressure. C-PAP is a machine that blows air into your nose via a nose mask, keeping the airway open and unobstructed. Bi-Level has an inspiratory pressure that is higher than the expiratory pressure. The sleep doctor will "prescribe" the pressure and a home healthcare company will set it up and provide training in its use and maintenance.

When your child needs a machine, it can be quite intimidating. A C-PAP machine requires some care and a period of adjustment, but the benefits of C-PAP therapy are worth the inconvenience. C-PAP is NOT a ventilator. It merely keeps the airway open so your child can breathe easily. It is not a complicated machine. You do not have to worry about 24-hour nursing care or your child being in intensive care, unless there are more complicated problems. A one-night stay in a sleep clinic to monitor the child's breathing is generally all that is required. Here are some tips if your child comes home on a machine. A C-PAP machine may be "prescribed" for your child. A home healthcare company that contracts with your insurance will provide the machine and show you how it works and how to clean and maintain it.

Some children have facial deformities that may cause the sleep apnea. It simply may be that their jaw is smaller than it should be or they could have a smaller opening at the back of the throat. Some children have enlarged tonsils, a large tongue, or some other tissues partially blocking the airway. Fixing a deviated septum may help to open the nasal passages. Removing the tonsils and adenoids or polyps may help also. Children are much more likely to have their tonsils and adenoids removed to solve the problem. There are other treatments that your doctor may consider, including orthodontics and surgery.

It is important to instill healthy sleeping habits in your child. Some studies suggest sleep plays a role in brain development. A tired child may have developmental or behavioral problems. Your child's sleep problems not only affects him or her, but can also be a source of stress and concern for the entire family.

For this reason, it is important to make sure that your child gets enough sleep and sleeps well.

  • Infants (3 to 11 months): 14 to 15 hours
  • Toddlers: 12 to 14 hours
  • Preschoolers: 11 to 13 hours
  • School-age children: 10 to 11 hours
  • Is too much time spent "helping" your child fall asleep?
  • Does your child wake up repeatedly during the night?
  • Does your child snore or has pauses in breathing during sleep?
  • Does your child have behavioral, mood, or school performance problems?
  • Does your child wet the bed?
  • Is your child's sleep problems affecting your own sleep?
  • Does your child have trouble falling or staying asleep?
  • Follow a consistent bedtime routine.
  • Set aside 10-30 minutes to get your child ready to go to sleep each night.
  • Establish a relaxing setting at bedtime.
  • Interact with your child at bedtime.
  • Don't let the TV, computer, or video games take your place.
  • Keep your children from TV programs, movies, and video games that are not right for their age.
  • Do not let your child fall asleep while being held, rocked, fed a bottle, or while nursing.
  • At bedtime, do not allow your child to have foods or drinks that contain caffeine, including chocolate and sodas.
  • Try not to give him or her any medicine that has a stimulant at bedtime, including cough medicines and decongestants.
  • A child who gets enough sleep and sleeps well is more likely to be cheerful during the day. The better the child sleeps, the happier the entire family will be.
  • Most sleep problems in children are not a result of bad parenting. These problems also do not mean that there is something seriously wrong with your child.
  • If your child has an ongoing sleep problem, then you should talk to your child's doctor or to a sleep specialist.

It is a potentially life-threatening condition that requires immediate medical attention. The risks of undiagnosed Obstructive Sleep Apnea include heart attacks, strokes, high blood pressure, irregular heartbeat, and impotence. In addition, obstructive sleep apnea causes daytime sleepiness that can result in accidents and lost productivity.

Doctors estimate that about 20 million Americans have sleep apnea. Men who are over age 40 are more likely to have sleep apnea, but it can affect anyone at any age.

The prevalence in children is around 1-3 percent.

Although snoring is a common symptom in children with Obstructive Sleep Apnea, it is important to remember that between 10-20 percent of normal children snore (primary snoring) on a regular or intermittent basis. In addition to continuous loud snoring, other symptoms of obstructive sleep apnea in children include:

  • mouth breathing
  • enlarged tonsils and adenoids
  • problems sleeping and restless sleep
  • excessive daytime sleepiness
  • daytime cognitive and behavioral problems, such as paying attention, aggressive behavior, and hyperactivity

Common night symptoms include:

  • snoring or snorting during sleep
  • choking or gasping
  • apneas (stopping breathing)
  • restless sleep
  • diaphoresis (sweating)
  • enuresis (bed wetting)
  • sleeping in abnormal positions such as with neck hyperextended

Common daytime symptoms include:

  • inattention or daydreaming
  • hyperactive behavior
  • learning difficulties
  • depression
  • aggressive/oppositional defiant behavior
  • morning headaches
  • tiredness
  • difficulty with morning awakening
  • mood changes and irritability
  • right heart overload/failure (known as cor pulmonale)
  • high blood pressure
  • failure to thrive (in infants)

Risk factors for sleep-disordered breathing include the following:

  • enlarged tonsils and adenoids
  • being overweight (although not all with sleep apnea are overweight)
  • craniofacial characteristics, including mid-facial hypoplasia, retrognathia, micrognathia, high arched palate, choanal atresia
  • cleft palate
  • Down syndrome
  • sickle cell disease
  • spina bifida
  • cerebal palsy
  • neuromuscular conditions associated with hypotonia
  • allergic rhinitis
  • gastroesophageal reflux
  • congenital heart disease
  • asthma
  • family history of sleep-disordered breathing

In adults, untreated sleep apnea can cause high blood pressure and other cardiovascular diseases, memory problems, weight gain, impotence, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and motor vehicle crashes.

In children, untreated sleep apnea can cause failure to thrive, loss of memory and IQ, inattention, hyperactivity, aggressive behavior, and high blood pressure.

When does my child need a sleep study?

When sleep-disordered breathing is suspected, pediatricians should refer the child for a sleep study. The combination of historical information and physical findings have been shown to be poor predictors of obstructive sleep apnea in children. The gold standard for diagnosis remains overnight polysomnography.

A sleep study provides additional information for your physician to risk stratify each child prior to surgery. The more severe and high risk cases require closer monitoring and possible overnight hospitalization. There have been many reported cases of post operative deaths in children undergoing surgery (adenotonsillectomy) who were not properly assessed prior to surgery.

What should you do if you suspect that you or your child may have a sleep disorder?

You should first discuss it with your physician, and if sleep disordered breathing is suspected or a problem beyond implementing healthy sleep habits, you might need to see a sleep specialist. In order to diagnose certain conditions, you or your child might require an overnight polysomnography or sleep study.

What is a sleep study or polysomnography?

Polysomnography is a series of comprehensive tests that are performed on patients while they sleep in order to look for sleep disorders. It usually involves monitoring of the patients airflow through both the nose and mouth, blood pressure, heart rate, blood oxygen level, brain wave patterns, eye movements, and the movements of respiratory and limb muscles movements.

Sleep studies are pain free and are able to diagnose sleep apnea, narcolepsy, cataplexy, hallucinations, sleep paralysis, and even what is called parasomnias. Parasomnias are abnormal behaviors or movements during sleep (i.e. sleepwalking, nightmares, bed-wetting). Sleep studies can be used to detect and evaluate seizure disorders, sleep related depression, and panic disorders.

Although tonsillectomy and adenoidectomy (T&A) is a common procedure that is done frequently, it is not without risk for complication. Certain high risk children, such as those less than three years and those who already have serious medical complications of OSAS, such as failure to thrive, pulmonary hypertension, cor pulmonale, and who have underlying congenital or medical conditions, such as genetic diseases and facial deformities, may require close inpatient observation.

Patients with sleep apnea are at an increased risk for anesthesia complications. For this reason, appropriate post-operative monitoring is crucial post-surgery. There is little data on other surgical options (e.g., uvulopalatopharyngoplasty) for OSAS in children. Age-appropriate weight management strategies are necessary for overweight and obese children with OSAS.

Treatment of contributing risk factors, such as asthma and allergies, is also important. While there is little in the literature about CPAP for children, Continuous (or bi-level) Positive Airway Pressure (CPAP) therapy has been shown to be an effective treatment in children and adolescents for whom other treatment options have failed or are inappropriate. To our knowledge, there are no published studies on the use of oral appliances for pediatric patients.

In adults, the mainstay of treatment remains CPAP, which is nasal continous positive airway pressure therapy. This involves the use of a high-pressure blower that delivers constant air flow through a mask that is worn by the patient during sleep. This continous air-flow helps to keep the airway open and prevents from collapsing and causing apnea. Although some patients may find CPAP inconvenient and noisy, patients that are compliant with therapy, often report feeling better rested, less headaches, and improved energy throughout the day. Other treatment options include certain types of surgeries, which are usually effective for mild sleep apnea.

What is Insomnia?

It is a sleep disorder that results in a difficulty to fall and/or stay asleep. People with insomnia have one or more of the following symptoms:

  • dDifficulty falling asleep
  • waking up often during the night and having trouble going back to sleep
  • waking up too early in the morning
  • tired upon waking

Causes of insomnia include:

  • significant life stressors such as a death in the family, moving, or job loss
  • emotional or physical (pain) discomfort
  • environmental factors such as light, noise, and extreme temperatures (hot or cold) that interfere with sleep
  • some medications, for example those used to treat colds, allergies, depression, high blood pressure, and asthma, may interfere with sleep
  • changes in normal sleep schedule, such as jet lag or shift work, for example switching from a day to night shift
  • depression and/or anxiety
  • chronic stress

Mild insomnia can be cured by following good sleep habits. Acute insomnia may not require treatment.

Moderate to severe insomnia requires following good sleep habits and treatment of any underlying medical conditions. Additional treatment may include the use of sleep aids and behavioral modification techniques. Sleep aids should only be prescribed by your doctor. Over the counter sleep aids may have undesirable side effects. Behavioral techniques include relaxation exercise, sleep restriction therapy, and reconditioning.

Many children have behavioral insomnia of childhood. Here are two common causes in children.

1. Sleep-onset association

All of us wake up briefly a number of times during the night. This occurs most often during the stage of sleep when we have most of our dreams. This sleep stage is known as rapid eye movement (REM) sleep. Usually, we are unaware of these awakenings and return to sleep quickly.

Young children may cry when they wake up. Parents naturally may feel that they need to help their child return to sleep. Parents do this by feeding, rocking, holding, or lying down with their child. As a result, many young children become unable to fall asleep on their own.

They depend on their parent's help, instead of learning to comfort themselves. The child learns to connect or associate going to sleep with a person or activity. If this describes your child, then he or she may have a problem with sleep-onset association.

A parent may recognize this problem by saying something like this: "I am exhausted. I have to rock my child to sleep every night and for every nap. If she wakes up during the night, she is unable to fall asleep until I rock her again." This child appears to be connecting the action of falling asleep with being rocked. He/she is unable to fall asleep when that action is missing.

2. Limit-setting problems

Limit-setting problems usually begin after the age of two. It occurs when your child refuses to go to bed, stalls, or makes it hard for you to leave the bedside. Limit-setting problems can occur at bedtime, naptime, or when your child wakes up during the night.

Parents need to assert that they are the ones who decide when it is time for bed. They should enforce this time even if the child disagrees or seems active and alert. Children can get very creative when they want to stay up later.

They may ask for one more hug, a tissue, a drink of water, another story, to have the light turned off or on, or to tell you something important. It can be hard to know what is real and what is simply a delay tactic.

You need to be firm and consistent when you respond to the delays. Giving in to them will only encourage the behavior. Parents need to give their children well-defined limits.

If your child or you has an ongoing sleep problem, then you should talk to your pediatrician or to a sleep specialist.

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