Pediatric Sleep Flashcards
What characterizes T sleep in an infant
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
What characterizes wake in an infant
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
What characterizes Infant NREM
Eyes closed No Eye movements Chin tone in chin EMG Regular respiration Trace alternant high-voltage slow or sleep spindles Few body movements
Describe Infant REM
Low chin EMG
Eyes closed at least one movement
Irregular respiration
Sucking, twitches, or brief head movements
what are Pediatric rules for obstructive apnea
Greater than 90% drop in thermal sensor for minimum of two breaths duration
presence of respiratory effort during the event
Pediatric central apnea
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
What are the criteria for pediatric hypopnea
30% drop in nasal pressure transducer signal
3% desaturation arousal minimum of two breaths duration
What are the criteria far Obstructive hypopnea In pediatrics
Snoring increased flattening of nasal transducer chest abdomen paradox
What are the criteria for Central hypopnea in pediatrics
Meets none of criteria for obstructive hypopnea
Pediatric hypoventilation
PCO2>50mm Hg for 25% of total sleep time or >55 for 10 min or elevation in PCO2 > 50 for 10min
What gives end tidal CO2 Triangular wave peaks
Nasal obstruction, mouth breathing, supplemental oxygen, and moisture in the tubing
What is Hypnagogic Hypersynchrony
Rhythmic, diffuse, bilateral, high amplitude rhythm with a frequency of 3 to 4.5 Hz
What Frequency is the posterior dominant rhythm at various ages
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
What is the timing of Trace discontinue vs trace alternant
36 weeks vs 46 weeks
When can all stages of sleep be seen in infant sleep
EEG waveforms that allow non-REM sleep to be divided into stages N1 N2, and N3 identifiable by 5 to 6 months of life.
Describe what sleep stage produces periodic breathing in infants
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.
Define pediatric central apnea
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
How do you Prevent crib death
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
When does pulse oximetry Become inaccurate
Below 80% however, motion low perfusion abnormal hemoglobin dark skin pigmentation synthetic nails and nail polish can make it more inaccurate
When do infant sleep spindles occur
Sleep spindles occur by age 3 months.
When do infant k complexes emerge
K complexes and slow waves by six months.
When do infant slow waves emerge
slow waves emerge by six months.
Slow wave activity in children is frequently high amplitude 100 to 400 Microvolts.
What is risk of SIDS
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
What is the best marker of drowsiness in an infant 0 to 2 months of age
Sustained closure of the eyes is the best marker of drowsiness and in the infant 0 to 2 months of age
What is the best marker of the wake in infants 0 to 2 months of age
Eyes open is the best marker for wake in an infant
When does stage T occur
in the transition from wake to REM
What are infant sleep problems
SIDS
Self-limiting sleep wake problems.
What are toddler sleep problems 1 to 2 years old
Night wakings
Difficulty settling
Rhythmic movements
Obstructive sleep apnea
What are preschool 3 to 5 year problems
Night wakings
Bedtime resistance
Sleep terrors
Rhythmic movements
Bedtime fears
Nightmares
Obstructive sleep apnea
What are school-age sleep problems
Insufficient sleep
Bedtime resistance
Night wakings
Confusional arousals
Sleepwalking
Obstructive sleep apnea
Enuresis
Bruxism
Narcolepsy
Insomnia and anxiety
What is the effectiveness of adenotonsillectomy in sleep apnea
80% effective but watchful waiting may be an option and CPAP is second in line.
What are the findings of CHAT
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
What are risk factors for pediatric obstructive sleep apnea
Asthma
nasal allergies
sickle cell
African-American
Prematurity
Prior tonsillectomy
Positive family History
Environmental
What is the severity rating for sleep apnea in children
2 to 5 is mild; 5 to 10 is Moderate; over 10 is severe
What childhood conditions are Comorbid for obstructive sleep apnea
Downs
Prader Willi
Achrondoplasia
Morbid obesity
Pierre Robyn
Cerebral palsy
Sickle cell disease
Spina bifida
Chiari 1
Hunter’s
Craniosynostosis
Pierre Robin Anomaly
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
What type of respiratory problems occur with Spina Bifida, Chiari II malformation, VP shunt, and spinal cord defect
- Respiratory control abnormalities
- Apnea, bradypnea, hypoventilation
- Absent O2, CO2 responses
- OSA 2º vocal cord paresis
- Breath-holding spells
- Restrictive lung disease
What sleep problems occur with Achondroplasia and Other Forms of Dwarfism
- 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%)
Central Sleep Apnea (CSA) in Childhood
- 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
What are the characteristics of Congenital Central Hypoventilation Syndrome
- 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
What is ROHHAD (in ICSD-3): Late Onset Central hypoventilation
• 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
What is Rett Syndrome
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
What is normal breathing in healthy full-term infants.
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
What kind of issues occur in preterm Infants
• 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
Defined.Periodic Breathing In children
• 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
Describe Sudden Infant Death Syndrome (SIDS)
• 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
Define Sleep Hypoventilation In childhood
≥ 25% total sleep time ≥ 50 mmHg by
EtCO2 or tcCO2
What are the usual Genetic Disorders with Awake Hyperventilation with Apnea
• Rett’s • Joubert’s • Angelman’s • Pitt-Hopkins • Mitochondrial disorder – Dilated cardiomyopathy with ataxia
Described Joubert’s and Breath Holding
• 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
How is Infant periodic breathing defined
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
