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Pediatric Primary Care Exam 2 > Sleep > Flashcards

Sleep Flashcards

1
Q

Recommended hours of sleep for newborn, infants, toddler, pre-school, school age, and teenager

A

Newborn: 14-17

Infants: 12-15

Toddler: 11-14

Preschooler: 10-13

School age: 9-11

Teen: 8-10

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2
Q

Spotlight system for eliminating co-sleeping (4)

A
  1. Can either be a commercially bought tool that displays a red light until a timer turns on the green light, or it can simply by an image of a red light that can be manually swapped with an image of green light.
  2. The stoplight gets placed next to the child’s bed and is red when the child must remain in bed, and green when the child is allowed to get out of bed.
  3. System helps the child know when it is appropriate to be in bed
    * Promotes self-soothing, and full nights of sleep for the family.
  4. Can help keep the child in the bed; red light helps kid know they need to stay in bed that night
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3
Q

Assessing sleep in primary care setting (4)

A
  1. Obtain a detailed an accurate history followed by a comprehensive physical exam
2. What to screen for?
A. Developmental Delays
B. Cognitive Function
C. Co-sleeping
D. TV before bed? Video games? Cell phone use?
*Do not use these before bed!!
E. Life stressors
  1. Involve family members in clinical interview
  2. Know your patient’s culture and the acceptable sleep norms they have
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4
Q

BEARS Assessment for Sleep Problems

A 
B is for Bedtime Problems
E is for Excessive Daytime Sleepiness
A is for Awakenings During the Night
R is for Regularity and Duration of sleep 
S is for Snoring
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5
Q

Common Challenges in Regulating sleep for newborns (4)

A

Birth-2 months old

  1. Day/night reversal
  2. Sleeping environment
  3. Sleeping surface
  4. Sleeping position
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6
Q

Common Challenges in Regulating sleep for infants (2)

A

2-12 months old

  1. Sleep regulation
  2. Sleep consolidation
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7
Q

Common Challenges in Regulating sleep for toddlers (3)

A

1-3 years old

  1. Transition from crib to bed
  2. Bedtime routines
  3. Transitional objects

*Common challenges include - what surface they are sleeping on (ex: toddler transition from crib to bed; child may climb out of crib at 15-18 months and that is an indication that the side rails should go down)

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8
Q

Common Challenges in Regulating sleep for preschoolers

A

3-5 years old

  1. Co-sleeping and parent presence
  2. Sleep schedules
  3. Second wind or “forbidden zone”
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9
Q

Common Challenges in Regulating sleep for school-aged children

A

6-12 years old

  1. Non-school night vs. school night
  2. Later bedtimes
  3. Increased caffeine intake
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10
Q

Behavioral Insomnia of Childhood (what it is, 3 types)

A

A cluster of insomnia disorders related to falling asleep and waking up

Types:

  1. Sleep onset
  2. Limit setting
  3. Combined
    * All 3 types include the primary difficulties of falling asleep independently and frequent night waking
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11
Q

Sleep Onset Behavioral Insomnia (3)

A
  1. Associated with negative sleep associations.
  2. Child that needs to be rocked to sleep, to watch television or the presence of a parent to fall asleep.
  3. Rely on the presence of something to help them sleep
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12
Q

Limit Setting Behavioral Insomnia (3)

A
  1. Child who refuses to go to bed or make repeated request to delay bedtime.
  2. Limit setting is more attention-seeking behavior to prolong going to sleep
  3. Due to negative association with going to sleep if relying on something to go to sleep (ex: rocking to sleep, etc); need to set limits
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13
Q

Diagnosing Behavioral Insomnia (4)

A
  1. Done through a thorough and detailed history
  2. Nature and duration of the complaint
  3. Previous attempts to fix the problem
  4. Keeping a sleep journal of when and for how long the child sleeps
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14
Q

Behavioral Insomnia Treatments (2)

A
  1. First line: sleep hygiene
  2. Followed by 1 or more of the following
    - Extinction (no caffiene)
    - Positive routines (happy bed time stories, no scary TV etc)
    - Bedtime fading (bring regular schedule back up slowly)
    - Schedules awakenings
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15
Q

Parasomnias (what it is and 3 most common in childhood)

A

A category of sleep disorders that involve abnormal/unnatural movements, behaviors, emotions, perceptions and dreams that occur while falling asleep or sleeping.

  1. Confusional arousals
  2. Sleep Terrors
  3. Sleep walking
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16
Q

Clinical Presentation of Confusional Arousals (4)

A
  1. Sits up
  2. Very distressed
  3. Cry out for help and difficult to console them
  4. Not usually flushed or sweating.
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17
Q

Confusional Arousals Info (5)

A
  1. Must eliminate seizures if there are abnormal movements
  2. Even if the child looks awake, he’s probably not and needs to be woken up
  3. Difficult to console child with confusional arousal
  4. Seizures must be ruled out & EEG must be checked
  5. Usually not flushed or sweating
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18
Q

Sleep Terrors (4)

A
  1. Waking up abruptly
  2. Screaming,
  3. Agitation accompanied by flushing, diaphoresis and tachycardia
  4. Usually start around 1-2 years old
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19
Q

Sleep Walking

A

Mild to severe from walking or crawling peacefully to running or jumping out of windows etc.

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20
Q

Clinical Presentation of Night Terrors/Sleep Terrors (8)

A
  1. Mimic partial complex seizures
  2. Occur in 6% of children
  3. Peak incidence in preschool and early school aged child
  4. Episode generally occurs within two hours of falling asleep
  5. Child’s eye open, sits up, glazed look and does not respond to parent
  6. Lasts about ten minutes and child falls back to sleep
  7. No recollection of the episode
  8. Rapid partial arousal from a slow deep sleep
21
Q

Diagnosing Parasomnias (3)

A
  1. EEG normal
  2. History
    - Rare but can continue into adolescence
    - Sleep deprivation makes them worse
  3. If persists despite adequate sleep schedule, a sleep study is indicated to rule out obstructive sleep apnea
22
Q

Treatment of Mild Parasomnias

A

Mild parasomnias occur 1-2 times per month and there is no treatment necessary, but provide parent education

23
Q

Severe Parasomnias

A
  1. Become associated with daytime mood or behavioral disturbances, when the safety of the child is a concern, a sleep study should be considered.
  2. If the symptoms occur at the same time every night, scheduled awakenings are a behavior technique that can be used.
  3. Use behavioral management over drugs when at all possible
24
Q

Benign Neonatal Sleep Myoclonus (6)

A
  1. Sudden brief jerks as the child falls asleep
  2. Begin in neonatal period and occur as the child is in quiet phase of sleep
  3. The jerking movement start in one extremity and move to another extremity—upper tend to be involved more than lower extremity
  4. Jerks occur every few seconds for several seconds
  5. Can last up to 12 hours
  6. This is not epilepsy
    * *Little babies/toddlers can have benign jerking as they are falling asleep; this is very common in neonatal and early infancy and can persist through toddlerhood; tends to be upper extremities
25
Q

Obstructive Sleep Apnea Syndrome

A

Disorder of breathing sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns

26
Q

Info About Obstructive Sleep Apnea Syndrome (5)

A
  1. Daytime sleepiness uncommon in young children
  2. Gold standard today is a sleep study; this is because sleep histories are usually inaccurate and apneas get over or underestimated
  3. Neurodevelopmental problems during the day, may be behaviorally difficult
  4. Will have big tonsils and have big adenoids
    * Adenotonsillar hypertrophy — when both are enlarged
    * Adnoidal hypertrophy can’t be diagnosed by child opening mouth and saying “aah”; order a sleep study if there is a history of of child waking up and gasping
  5. Children with Turner’s Syndrome (ex: of craniofacial anomalies) have risk for sleep apnea and should get a regular sleep study (down syndrome is another example)
27
Q

OSAS Risk Factors

A
  1. Adenotonsillar hypertrophy
  2. Obesity
  3. Craniofacial anomalies
  4. Neuromuscular disorders
28
Q

AAP Guidelines for OSAS (11)

A
  1. Clinicians should inquire about snoring

History

  1. Frequent snoring more than or equal to 3 times per week
  2. Labored breathing during sleep
  3. Gasps, snorting noises observed apnea
  4. Sleep enuresis *secondary enuresis
  5. Sleep in seated position or with neck hyperextended
  6. Cyanosis
  7. AM headache; May wake up with morning headache due to high CO2 level
  8. Daytime sleepiness
  9. ADHD/hyperactivity/learning problem
  10. Prefer to sleep seated rather than laying down
29
Q

Nocturnal Symptoms of OSAS (6)

A
  1. Snoring
  2. Paradoxical chest-abdominal motion
  3. Retractions
  4. Observed apnea
  5. Observed difficulty breathing during sleep
  6. Cyanosis during sleep or disturbed sleep
30
Q

Daytime Symptoms of OSAS (3)

A
  1. Nasal obstruction with mouth breathing
  2. Excessive daytime somnolence.
  3. Severe symptoms
    - Associated cor pulmonale
    - Developmental delay
    - Failure to thrive
31
Q

OSAS Physical Exam (7)

A
  1. Under or over weight
  2. Tonsillar hypertrophy
  3. Adenoidal facies
  4. Micrognathia/retrognathia
  5. High arched palate
  6. Failure to thrive
  7. Hypertension
32
Q

OSAS Predisposing Factors (8)

A
  1. Anything that reduces the caliber, increases collapsibility or interferes with neural control of the nasopharyngeal airway:
  2. Obesity
  3. Down Syndrome
  4. Craniofacial Syndromes
  5. Achondroplasia
  6. Mucopolysaccharide storage disease
  7. Neurologic disorders
  8. Abnormal build up of mucoid polysaccharides in adenoids and tonsils due to lack of enzyme causing sleep apnea due to tonsillar and adenoid hypertrophy; trouble with airway after surgery is done is a risk
33
Q

OSAS Associated Features (7)

A
  1. Impaired somatic growth
  2. Sudden nocturnal awakenings
  3. Gastroesophageal reflux
  4. Increased risk of nasopharyngeal aspiration
  5. 5Hypoxemia
  6. Hypercarbia
  7. Neuropsychiatric disturbances
34
Q

Who needs a sleep study? (6)

A
  1. Children with suspected obstructive sleep apnea syndrome
  2. Children with a history of behavioral, learning or mood issues with a history of poor quality or restless sleep
  3. Children with suspected central sleep apnea syndrome
  4. Children with excessive daytime sleepiness
  5. Progressive muscular disorders such as Duchenne Muscular Dystrophy
  6. Obesity: Neck circumference > 17.5 inches usually associated with obstructive sleep apnea syndrome
35
Q

AAP Guidelines if OSAS is suspected/needs treatment (5)

A
  1. Obtain polysomnogram (Level A) or
  2. Refer patient to sleep specialist or otolaryngologist for more extensive evaluation (Grade D)
3. If there is no polysomnography available, may order alternative tests
– Nocturnal video recording
– Nocturnal oximetry
– Daytime nap polysomnography
– Ambulatory polysomnography (Grade C)
  1. If you can’t get polysynography, refer to ENT
    * First step is to take out tonsils and adenoids
  2. If there is OSAS and clinical exam shows tonsillar hypertrophy and there is not contraindication to surgery
    * Tonsillectomy can be recommended as the first line treatment
    * In obese children, clinical judgment needs to be exercised if there is a varying degree of hypertrophy
36
Q

6 months after tonsillectomy surgery…

A

The child will need another sleep study to ensure that it worked; it may not work particularly in children with Down Syndrome or neuromuscular weakness (will need CPAP most of the time if T and A didn’t work)
*With obesity, if tonsils are small then may need to lose weight before removal of tonsils and adenoids

37
Q

Risks of Patient Undergoing Adenotonsillectomy (8)

A
  1. Pain
  2. Dehydration
  3. Anesthetic complication
  4. Upper airway obstruction during induction
  5. Hemorrhage
  6. Velopharyngeal incompetence
  7. Nasopharygeal stenosis
  8. Death
38
Q

Surgical Complications of Tonsillectomy and Adenotonsillectomy (4)

A
  1. Post surgical dehydration
  2. Post surgical hemorrhage
  3. Post operative respiratory compromise
  4. Pulmonary edema
39
Q

Contraindications for Adenotonsillectomy (6)

A
  1. No tonsils
  2. Very small tonsils/adenoids
  3. Morbid obesity and small tonsils/adenoid
  4. Bleeding disorder refractory to treatment
  5. Submucus cleft
  6. Medical conditions causing unstable patient
40
Q

AAP Guidelines for OSAS Treatment (

A
  1. Weight loss should be recommended in patients with OSAS if the patient is overweight or obese
  2. If a T and A is contraindicated and there is mild OSAS, topical nasal steroid should be used (Grade B)
  3. Reevaluation of all patients after therapy for persistent signs and symptoms
  4. Reevaluation high risk patient after T and A
    - Especially abnormal baseline polysomnogram
    - Obese
    - Remain symptomatic
    - Use objective test (Grade B)
41
Q

Mechanical Therapy for OSAS (what it is and 4 indications for it)

A

Continuous positive airway pressure (CPAP); intraoral appliances

Indications:

  1. Failed tonsillectomy and adenoidectomy
  2. Obesity
  3. Craniofacial abnormalities
  4. Down Syndrome
42
Q

Growth complications of OSAS (3)

A
  1. Failure to thrive
  2. Short stature
  3. Impaired growth hormone release
43
Q

Cardiovascular complications of OSAS (5)

A
  1. Cor Pulmonale/Pulmonary hypertension
  2. Polycythemia
  3. Chronic respiratory acidosis
  4. Possible systemic
  5. Hypertension
44
Q

GI complications of OSAS (2)

A
  1. Feeding difficulties

2. Gastroesophageal reflux

45
Q

Pulmonary complications of OSAS (3)

A
  1. Chronic aspiration
  2. Pulmonary edema (Post operative)
  3. Pectus excavatum
46
Q

Behavioral complications of OSAS (3)

A
  1. Developmental delay
  2. Behavioral problems
  3. School problems
47
Q

Neurological Complications of OSAS (4)

A
  1. Enuresis
  2. Increased intracranial pressure
  3. Lethargy/dull effect
  4. Hypoxia induced headaches

*Anuresis is a big one; as well as headaches every morning (need to consider sleep apnea with these)

48
Q

Summary of sleep problems (4)

A
  1. Sleep complaints are fairly common in the pediatric primary care setting
  2. A comprehensive and detailed history is vital in the identification and treatment of sleep disturbances
  3. In most cases, sleep disturbances are outgrown with behavioral interventions (sleep hygiene)
  4. As PNP’s it is important to always be aware of the possibility of underlying physiological issues resulting in sleep complaints (ie. Sleep obstructive apnea or neurologic disorders)

Pediatric Primary Care Exam 2 (12 decks)

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