Sleep is essential for physical health and emotional wellbeing. Everyone experiences occasional sleeping problems, but if your child experiences problems sleeping repeatedly, it could indicate an underlying health problem. Sleep disorders are problems associated with sleeping, including difficulty falling or staying asleep through the night, feeling sleepy during the day, or waking up feeling exhausted. Because of lack of sleep you may find it difficult to concentrate and perform activities of daily living. This lack of sleep can lead to depression, mood swings, or other health problems.
According to the International Classification of Sleep Disorders (third edition), there are over 80 different recognized sleep disorders. They are divided into the following 6 categories. Our pediatric sleep medicine providers treat many of the conditions that can be found in each of the categories:
Like narcolepsy, hypersomnolence (also known as idiopathic hypersomnia) is a condition characterized by excessive sleepiness. Patients experience difficulty in waking (either in the morning or at the end of nap periods during the day). Idiopathic simply means 'of unknown cause'. Typically, the diagnosis is made after demonstrating excessive sleepiness on a daytime nap study called an MSLT. Unlike narcolepsy, idiopathic hypersomnia does not have rapid occurrence of dream sleep during daytime napping.
Narcolepsy is a sleep disorder that causes excessive daytime drowsiness and sudden onset of sleep.
Idiopathic hypersomnia is an uncommon disorder causing excessive sleepiness during the day even after a good night's sleep. The need to sleep can arise at inconvenient times like when driving or working, making it potentially dangerous. Other more common disorders must be ruled out before idiopathic hypersomnia diagnosis.
Circadian disorders are a group of sleep disorders where the internal circadian clock is disrupted. Our bodies have a biological clock that can regulate sleep, body temperature, as well as alertness. Sunlight is an important regulator of our biological clock, and when people have significant alterations in their biological clock, a circadian disorder can result. These sleep disorders have a variety of unique treatments, which can include melatonin, light therapy (using a light box), blue light filters, and even chronotherapy.
Delayed sleep phase is a common condition affecting teenagers and young adults, where patients can struggle with falling asleep in the early part of the night. Frequently, this can lead to an irregular sleep schedule where the weekend and weekday hours of restorative sleep vary significantly. As a result, this can lead to frustration and lower sleep efficiency when the body is constantly struggling to maintain a regular sleep schedule and a regular circadian rhythm.
Advanced sleep phase is simply the opposite of delayed sleep phase. This is a condition that typically affects the elderly population. The most common patient complaint is that of unwanted early morning awakenings, which are occurring because the patient may be sleeping too early in the evening and developing a shift to earlier and earlier sleep.
Shift work sleep disorder is a circadian rhythm disorder that leads to a combination of nighttime insomnia and daytime sleepiness. Workers of second and third shift jobs or workers who have excessively long periods of work (such as health care providers or long-distance drivers) can develop this frustrating sleep disorder. A combination of stimulant medications to promote daytime alertness plus sedating/hypnotic medications may be useful in the short-term to increase sleep efficiency. A large 2007 study led by the IARC suggested that long-term shift work is associated with an increased incidence rate of cancer, heart disease, and menstrual irregularities.
Jet-like disorder occurs when patients travel greater than 3 time zones. In general, traveling eastward makes it harder for patients to adjust to the new sleep schedule. Traveling westward makes it easier to adjust to a new sleep schedule. In general, jet-like disorder is treated with a short-term course of hypnotic medications to achieve better sleep.
Insomnia is a type of sleep disorder in which a person has difficulty falling asleep or staying asleep. When a person has difficulty falling asleep, a variety of reasons are explored, which can include medication effects, stress or anxiety, or poor sleep hygiene. When a person has difficulty staying asleep, primary sleep disorders such as obstructive sleep apnea or periodic limb movements of sleep should be assessed and ruled out with a sleep study,
When a person has difficulty falling sleep or staying asleep more than three nights a week for three months or more, this is considered chronic insomnia. The best treatment for chronic insomnia is cognitive behavioral therapy. Patients who combine behavioral strategies with pharmacologic therapy achieve better results than those who employ pharmacologic or behavioral strategies alone..
When the duration of insomnia does not meet criteria for chronic insomnia, this is termed short-term insomnia. Your primary care doctor may prescribe you hypnotic medications for short-term insomnia that is related to travel, stress, pain, or variety of other medical or mental health conditions.
This refers to abnormal behaviors that occur during sleep. Parasomnias include nightmares, night terrors, sleep walking, and sleep talking, head banging, wetting the bed and grinding teeth.
Sleep eating is defined by repeated episodes of binge eating after waking up in the middle of the night. Patients may only be partially awake during these episodes and thus can be completely unaware of these behaviors. An underlying nutritional deficiency should be considered in patients who have excessive and disruptive sleep eating behaviors.
Isolated (or “benign”) sleep paralysis can occur with excessive sleep deprivation, anxiety or other mental health conditions, or an untreated obstructive sleep apnea. When sleep paralysis is recurrent, central causes of sleep disturbance such as narcolepsy are suspected. When people report the occurrence of sleep paralysis with excessive sleepiness during the daytime, central disorders of hypersomnolence such as narcolepsy should be ruled out with sleep testing.
Sleepwalking is common in children and is often benign and self-limiting. Sleepwalking can be associated with sleep deprivation, medication use, and obstructive sleep apnea. Population studies show that ~ 40% of children have at least 1 episode of sleepwalking. Although sleepwalking is very common, excessive sleepwalking should alert parents to the possibility of an undiagnosed obstructive sleep apnea condition.
Sleep terrors can be distressing to both children and their parents. When they occur over and over and have the exact same pattern, it is important to rule out frontal lobe seizures with the help of advanced sleep testing with Video EEG and to consult a Sleep Neurologist. Whereas sleep terrors tend to resolve by school age, frontal lobe seizures will continue until the correct diagnosis is made and seizure medications are started.
Sleep disordered breathing or “sleep apnea” occurs when the upper airway closes and airflow to the lung stops for at least 10 seconds. The most common form of sleep apnea is called obstructive sleep apnea with ~2-4% of children suffering from obstructive sleep apnea.
Population studies show that 10-20% of children have at least soft snoring. When kids have snoring and ADHD behaviors (poor attention, hyperactivity, learning difficulties), obstructive sleep apnea should be considered as a potential cause. Kids do not have the same clinical features as adults who are suspected to have sleep apnea. Many kids with sleep apnea are not obese and do not have sleepiness, thus it is critical for the physician to recognize this condition early by obtaining a polysomnogram (sleep study).
The first line treatment for children with obstructive sleep apnea is surgical removal of the tonsils and adenoids and is likely to be curative. Most kids who are diagnosed with OSA will not need CPAP after surgery is performed.
Central sleep apnea is a condition that is more common at higher altitudes. ~25% of people at altitudes above 2500m develop this condition characterized by frequent pauses in breathing, insomnia, and poor sleep quality. At altitudes above 3000m, almost everyone develops this condition. Denver, by comparison sits at just above 1609m. Treatment may include supplemental low flow oxygen or the use of a breathing device such as “CPAP”.
Restless leg syndrome, periodic limb movements of sleep, and other rhythmic movement disorders of sleep can be primary or secondary. When a secondary sleep related movement disorder is suspected, addressing the underlying problem such as excessive caffeine intake, prescription medication side effect, or low iron state is critical. When a primary sleep-related movement disorder is suspected, referral to a sleep clinic for further evaluation is recommended.
Restless leg syndrome (RLS) is a condition in which one experiences an uncontrollable urge to move the legs, usually described as “creepy crawly or worm-like sensation deep within the legs”. It typically happens in the evening when you're sitting or lying down and can lead to significant sleep disruption. Restless legs frequently run in families. The symptoms of restless legs are very difficult to elicit from children. The best description seems to be “growing pains” in the legs that occur exclusively in the nighttime period.
Periodic limb movement disorder is diagnosis that requires both clinical history of excessive leg jerks and sleep testing demonstrating PLMI (periodic limb movement index) > 5/hr. This disorder is uncommon in children but can be much more frequent in the elderly. Periodic limb movements should be distinguished from hypnic jerks, which are isolated leg jerks occur in more than half of the population and is a benign finding.
Sleep disorder treatment can be classified into two main categories: pharmacological treatment and non-pharmacological treatment.
Pharmacological treatment includes any prescription or non-prescription medications to help prevent the onset of the symptoms or treat the developed symptoms. Depending on the type of disorder, treatment could include sedatives (in case the condition is related to insomnia), or stimulants (in case the condition is related to narcolepsy or sleep apnea).
Non-pharmacological sleep treatment refers to those options that do not require the use of prescription or non-prescription drugs. These may include behavioral therapy, medical equipment, surgery, and other options. Surgery may be needed to correct the anatomic abnormalities of the upper airway which can lead to the onset of obstructive sleep apnea. Behavioral treatments for sleep problems may include relaxation training, cognitive therapy, stimulus control (SC), sleep restriction therapy (SRT), and sleep hygiene. Behavioral therapy can be used to treat people with insomnia, parasomnias, bedwetting, and other sleep problems. Another option is the use of different types of medical equipment such as “continuous positive airway pressure” (CPAP) and bilevel — or BiPAP for the treatment of sleep apnea. CPAP is a device that prevents narrowing of the airway during inspiration and expiration by providing a persistent increased pressure. Another similar option is “bilevel” in which the face mask allows for two different alternating pressures: one with inhalation and one with exhalation. Other non-pharmacological treatment options for sleep disorders include mandibular advancement devices, nasal strips, positional therapy, and playing didgeridoo (a wind instrument) to strengthen the upper airway.
Lifestyle changes, such as beginning a regular exercise program, establishing regular sleep patterns, and eliminating or decreasing the use of caffeine may also be helpful.
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