Pediatric Sleep

Question 1

What characterizes T sleep in an infant

Answer 1

T has features of NREM sleep such as closed eyes, regular respiration, and absence of rapid eye movements.
It also contains features of REM sleep with low baseline chin EMG, transient muscle activity, and low-voltage mixed frequency EEG
At least three NREM and two REM or Vice versa

Question 2

What characterizes wake in an infant

Answer 2

Eyes open open intermittently or scanning movements

vocalization or feeding

sustained chin EMG tone with burst of muscle activity plus irregular respirations

low-voltage irregular or mixed voltage EEG

Question 3

What characterizes Infant NREM

Answer 3

Eyes closed No Eye movements
Chin tone in chin EMG
Regular respiration
Trace alternant high-voltage slow or sleep spindles
Few body movements

Question 4

Describe Infant REM

Answer 4

Low chin EMG

Eyes closed at least one movement

Irregular respiration

Sucking, twitches, or brief head movements

Question 5

what are Pediatric rules for obstructive apnea

Answer 5

Greater than 90% drop in thermal sensor for minimum of two breaths duration

presence of respiratory effort during the event

Question 6

Pediatric central apnea

Answer 6

Greater than 90% drop in on nasal thermal sensor absence of respiratory effort during event last 20 seconds or shorter minimum of two breaths duration but is associated with either arousal, greater than or equal to 3% desaturation

Four instance less than one year decrease in heart rate to West and 50 bpm for at least five seconds or 60 bpm for 15 seconds

Question 7

What are the criteria for pediatric hypopnea

Answer 7

30% drop in nasal pressure transducer signal

3% desaturation arousal minimum of two breaths duration

Question 8

What are the criteria far Obstructive hypopnea In pediatrics

Answer 8

Snoring increased flattening of nasal transducer chest abdomen paradox

Question 9

What are the criteria for Central hypopnea in pediatrics

Answer 9

Meets none of criteria for obstructive hypopnea

Question 10

Pediatric hypoventilation

Answer 10

PCO2>50mm Hg for 25% of total sleep time or >55 for 10 min or elevation in PCO2 > 50 for 10min

Question 11

What gives end tidal CO2 Triangular wave peaks

Answer 11

Nasal obstruction, mouth breathing, supplemental oxygen, and moisture in the tubing

Question 12

What is Hypnagogic Hypersynchrony

Answer 12

Rhythmic, diffuse, bilateral, high amplitude rhythm with a frequency of 3 to 4.5 Hz

Question 13

What Frequency is the posterior dominant rhythm at various ages

Answer 13

At three months 3.5 Hz
at six months six hertz
at 36 months 8 hertz
nine years nine hertz, adult 8 to 13 hertz

Question 14

What is the timing of Trace discontinue vs trace alternant

Answer 14

36 weeks vs 46 weeks

Question 15

When can all stages of sleep be seen in infant sleep

Answer 15

EEG waveforms that allow non-REM sleep to be divided into stages N1 N2, and N3 identifiable by 5 to 6 months of life.

Question 16

Describe what sleep stage produces periodic breathing in infants

Answer 16

Periodic breathing occurs in REM sleep in infants because certain factors that predispose infants to respiratory instability

low functional residual capacity

neuronal instability, sleep stage, and low apnea threshold.

Question 17

Define pediatric central apnea

Answer 17

According to pediatric respiratory scoring rules, a central apnea is scored when there’s a drop in the flow signal by 90% of baseline on the thermal sensor and the event lasts greater than 20 seconds or duration of two breaths and is associated with either an arousal or arterial desaturation greater than 3% or in infants less than a year a decrease in heart rate to less than 50 bpm for at least five seconds or 60 bpm for at least 15 seconds

Question 18

How do you Prevent crib death

Answer 18

Lay the infant in a supine position

Use a firm mattress cover it with a film sheet

Placed it in a bassinet in the parents bedroom

Breast-feed

Offer a pacifier at bedtime and nap times

Stay up-to-date with immunization

Supervised the week tummy time

Don’t smoke

Don’t use commercially available devices they claim to prevent SIDS

Question 19

When does pulse oximetry Become inaccurate

Answer 19

Below 80% however, motion low perfusion abnormal hemoglobin dark skin pigmentation synthetic nails and nail polish can make it more inaccurate

Question 20

When do infant sleep spindles occur

Answer 20

Sleep spindles occur by age 3 months.

Question 21

When do infant k complexes emerge

Answer 21

K complexes and slow waves by six months.

Question 22

When do infant slow waves emerge

Answer 22

slow waves emerge by six months.

Slow wave activity in children is frequently high amplitude 100 to 400 Microvolts.

Question 23

What is risk of SIDS

Answer 23

SIDS occurs at 40 per 100,000 live births. 
It occurs in the winter months. 
It occurs at high altitude’s. 
80% occurs during night time sleep. 
It occurs in four months of age. 
It is more common in males. 
Pacifier use reduces SIDS

Question 24

What is the best marker of drowsiness in an infant 0 to 2 months of age

Answer 24

Sustained closure of the eyes is the best marker of drowsiness and in the infant 0 to 2 months of age

Question 25

What is the best marker of the wake in infants 0 to 2 months of age

Answer 25

Eyes open is the best marker for wake in an infant

Question 26

When does stage T occur

Answer 26

in the transition from wake to REM

Question 27

What are infant sleep problems

Answer 27

SIDS | Self-limiting sleep wake problems.

Question 28

What are toddler sleep problems 1 to 2 years old

Answer 28

Night wakings Difficulty settling Rhythmic movements Obstructive sleep apnea

Question 29

What are preschool 3 to 5 year problems

Answer 29

Night wakings Bedtime resistance Sleep terrors Rhythmic movements Bedtime fears Nightmares Obstructive sleep apnea

Question 30

What are school-age sleep problems

Answer 30

Insufficient sleep Bedtime resistance Night wakings Confusional arousals Sleepwalking Obstructive sleep apnea Enuresis Bruxism Narcolepsy Insomnia and anxiety

Question 31

What is the effectiveness of adenotonsillectomy in sleep apnea

Answer 31

80% effective but watchful waiting may be an option and CPAP is second in line.

Question 32

What are the findings of CHAT

Answer 32

No significant difference in measured executive function Global behaviors improved Quality of life improved Obstructive sleep apnea symptoms including snoring and sleeping this improve. Normalization of the PSG in a larger proportion of cases

Question 33

What are risk factors for pediatric obstructive sleep apnea

Answer 33

Asthma nasal allergies sickle cell African-American Prematurity Prior tonsillectomy Positive family History Environmental

Question 34

What is the severity rating for sleep apnea in children

Answer 34

2 to 5 is mild; 5 to 10 is Moderate; over 10 is severe

Question 35

What childhood conditions are Comorbid for obstructive sleep apnea

Answer 35

Downs Prader Willi Achrondoplasia Morbid obesity Pierre Robyn Cerebral palsy Sickle cell disease Spina bifida Chiari 1 Hunter’s Craniosynostosis

Question 36

Pierre Robin Anomaly

Answer 36

Micrognathia, glossoptosis UAO  cleft palate May have other cardiac, pulmonary or GI abnormalities High risk for OSA and feeding difficulties Can be part of many genetic syndromes Requires craniofacial, dental , other ENT procedures Distraction osteogenesis has replaced tracheostomy in infancy

Question 37

What type of respiratory problems occur with Spina Bifida, Chiari II malformation, VP shunt, and spinal cord defect

Answer 37

* Respiratory control abnormalities * Apnea, bradypnea, hypoventilation * Absent O2, CO2 responses * OSA 2º vocal cord paresis * Breath-holding spells * Restrictive lung disease

Question 38

What sleep problems occur with Achondroplasia and Other Forms of Dwarfism

Answer 38

* SDB risk factors for both OSA (32%) and central apnea (60%) * Midface hypoplasia, short cranial base, * Brainstem compression @ foramen magnum (35%) * Pulmonary restriction (90%); nocturnal hypoxemia (44%)

Question 39

Central Sleep Apnea (CSA) in Childhood

Answer 39

* CSA in early infancy: part of immaturity of respiratory control * desaturations with altered mechanics, immature reflexes * Short (< 20 sec) central pauses post sigh, post mvt, transition to sleep or in REM are common in children (usually < 5/hr) * Outside of infancy (or altitude), CSA  hypoventilation is unusual requires further evaluation! * a/w other disorders: neurodevelopment, metabolic, genetic * If otherwise normal, r/o hindbrain malformation, eg Chiari I, tumor

Question 40

What are the characteristics of Congenital Central Hypoventilation Syndrome

Answer 40

* Rare genetic disorder of autonomic dysregulation and control of breathing * Profound hypoventilation; NREM > REM > ± Wake; ↓ CO2 response, ↓O2 response * Normal respiratory rate, ↓ tidal volume rather than central apnea * Hirschsprung’s ~20%, neural crest tumors ~6%, other ANS dysfunction * PHOX2B, disease-defining gene, must test patient, parent * Autosomal dominant, heterozygote, 90% de novo * 90% from polyalanine repeat expansion, 10% other * PHOX2B genotype informs CCHS phenotype; more repeats = more severe * If PHOX2B is negative, look for another disease * Treatment: invasive, non-invasive ventilation and diaphragmatic pacing

Question 41

What is ROHHAD (in ICSD-3): Late Onset Central hypoventilation

Answer 41

• Rapid onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation • Endocrine dysfunction: ↓thyroid, ROHHAD (in ICSD-3): Late Onset Central Hypoventilation • Rapid onset obesity with hypothalamic dysfunction, hypoventilation,and autonomic dysregulation • Endocrine dysfunction: ↓thyroid, ↓GH, DI, precocious puberty • Autonomic: temp instability, pupillary abnormalities, GI dysmotility • Association with tumors of neural origin • Rapid weight gain with hyperphagia between 3 to 10 y • High incidence of respiratory arrest: 50-60% require ventilation • PHOX2B mutations not seen GH, DI, precocious puberty

Question 42

What is Rett Syndrome

Answer 42

MECP2 gene on X chromosome; 1/10 K females • Developmental regression 6 – 18 months with stereotypic movements, dystonia, seizures, aspiration, scoliosis; high incidence of sudden death • Breathing • Wake: hyperventilation alternating with prolonged apnea; • Sleep: central apneas, insomnia, circadian disturbance

Question 43

What is normal breathing in healthy full-term infants.

Answer 43

Full-term infants: centrals < 20 sec, but OA rare • Healthy term infants 43% had central apnea >20 s; 2% had >30 s • Regular breathing in NREM sleep; irregular breathing in REM sleep • Thoraco-abdominal asynchrony in REM up to age 2-3 y • Desaturation with normal pauses, especially if lung disease

Question 44

What kind of issues occur in preterm Infants

Answer 44

• Apnea of prematurity: 100% if <1000 gm; rare after 36 wk • Last longer with greater immaturity; management caffeine • Associated with periodic breathing • Apnea can “reappear” if triggered by illness or metabolic disturbance • Prolonged apnea and bradycardia in preterm infants typically disappears by 43-44 week post-conceptional age

Question 45

Defined.Periodic Breathing In children

Answer 45

• 3 or more episodes of central apnea last ≥ 3 sec separated by no more than 20 sec of normal breathing; cycle length 16 sec • Commonly seen in preterm infants, rare in childhood • % of sleep time: up to 5% (term) and 10% (preterm < 40 wk PCA) • 1 preterm > term; related to lower lung volumes; faster desaturation rates • Can improve with supplemental O2 in infants with desaturation • Often caused by ventilatory instability where apneic CO2 threshold ~ 1 torr below eupneic CO2 • In older infants and children, can be a sign of CNS pathology

Question 46

Describe Sudden Infant Death Syndrome (SIDS)

Answer 46

• Sudden death of a child < 1 y, unexplained after post mortem and death scene investigation • Prevalence (2013) is 39.7/100,000 – Peak age 4 mo; winter, altitude, 80% nighttime sleep • Modifiable risk factors: position, maternal smoking, bed sharing, soft sleeping surfaces, overheating • Protective factors: supine, breastfeeding, room sharing, pacifier use – Apnea monitors do not reduce risk

Question 47

Define Sleep Hypoventilation In childhood

Answer 47

≥ 25% total sleep time ≥ 50 mmHg by | EtCO2 or tcCO2

Question 48

What are the usual Genetic Disorders with Awake Hyperventilation with Apnea

Answer 48

``` • Rett’s • Joubert’s • Angelman’s • Pitt-Hopkins • Mitochondrial disorder – Dilated cardiomyopathy with ataxia ```

Question 49

Described Joubert’s and Breath Holding

Answer 49

• Rare (1/80,000), heterogeneous, AR disorder – Agenesis of the cerebellar vermis and failure of decussation of the superior cerebellar peduncles and pyramidal tracts – Ataxia, hypotonia, nystagmus, and MR – “molar tooth sign” on MRI • Breathing disturbances: tachypnea followed by prolong central apnea in wake and sleep or other types of periodic breathing also at risk for OSA

Question 50

How is Infant periodic breathing defined

Answer 50

The scoring manual defines periodic breathing as three more episodes of central apnea lasting for at least three seconds each and separated by 20 seconds or less of normal breathing. Periodic breathing in the absence of high altitude is abnormal if it is 5% of total sleep time in full term or 10% in preterm