Sleeping Disorders

Advisor:
dr. Nenden Nursyamsyi A, SpA

LEVITA SAVITRY / 1620221211

SMF Ilmu Kesehatan Anak RSUD Prof. Margono Soekarjo

Fakultas Kedokteran UPN Veteran Jakarta
2018
 Introduction

• Sleep is an important need in life, as

important as the nutritional needs of
children. The sleep needs in children will
decrease as their age increasement.
• If the amount of time needed to sleep is
not sufficient, there will be sleep
disturbance.
• Overall sleep disorders may occur in 20%
-30% of children
• In 2006, reported the incidence of sleep
problems in children under 3 years old in
five cities in Indonesia was 44.2%.
 NORMAL SLEEP IN CHILDREN

• Based on EEG, EMG and electro-oculography patterns,

stages of sleep can be identified.
• One cycle of sleep determined to non-rapid eye
movement (NREM) and rapid eye movement (REM).

Source: National Sleep Foundation, 2015

 NREM
• NREM is also called short-wave sleep
phase
• When the NREM phase, there will be
some decreasements with the number of
physiological functions of the body, all
metabolic processes including vital signs
and muscle work.
• NREM has 4 stages.
 NREM STAGE I
• The stage with the most shallow level of
sleep
• Stage I ends in a few minutes
• Easy to be woken up by the sensory
stimulation such as sounds
 NREM STAGE II
• Waking up is still relatively easy
• Stage ends in 10-20 minutes
• Relaxation progress occurs
 NREM STAGE III
• The early stage of deep sleep
• Its difficult to be woken up and rarely
moved
• Muscles in a state of maximum relaxation
• Vital signs are decreasing but still in
regular condition
• This stage ends in 15-30 minutes
 NREM STAGE IV
• It is the deepest stage of sleep
• Very difficult to be woken up
 REM Sleep
• The NREM phase is followed by a REM phase every
90 minutes and lasts for 5-30 minutes
• Characteristics of REM phases:
– Dreams seem to be alive and dreams in this
phase can be remembered because in the REM
phase the memory consolidation occurs
– It usually begins in 90 minutes after starting to
sleep
– There is a decreasement in skeletal muscle tone
– Very difficult to be woken up
EEG
 STAGE EEG EMG EOG

NREM Stage I Low amplitude, Slight decrease in Slow eye

mixed frequency, tonic muscle movements
theta rythm activity

NREM Stage II Low voltage Further decrease No eye

activity with sleep in muscle activity movements
spindles and K-
complexes

NREM Stage III High amplitude, Low tonic activity No eye

slow waves movements

REM Sleep Low voltage, saw- Muscle atonia Rapid eye

tooth waves, movements
predominant theta
activity
 WAKE & SLEEP CYCLE
• Each cycle normally lasts for 1.5 hours
and usually occurs 4-5 cycles over 7-8
hours of sleep
• The cycle starts from NREM phase and
continues into REM phase
 SLEEP DISORDERS
• Set of conditions that characterized:
By an interruption in the amount, quality, or
timing of sleep
• Sleep disorders in children:
Inadequate sleep duration according to
child’s age, poor sleep quality, inappropriate
sleep period related to the circadian rhythm
disturbance and primary sleep disturbance
 ETIOLOGY
• Any factor which could disturb ascending
reticular activating system (ARAS):
– Environmental factors
– Chronic illness
– Habits and behaviors
• There is some evidence showing that essential
fatty acids may modulate sleep. Fagioli from Italy
studied eight children who were fed on total
parenteral nutrition without essential lipids and
seven other children who received a daily
supplement of essential lipids in their parenteral
nutrition. Slow-wave sleep was significantly
decreased in the group of children who did not
receive fatty acids as compared to those who did
• Key evidence of the role of poor nutrition in sleep is
drawn from subjects with primary anorexia nervosa.
Anorexic patients suffer from interrupted sleep and early
morning waking, weight management problems and
usually encounter severe weight loss associated with
carbohydrate starvation. It could be probable that, the
disturbed sleep and semi starvation state is partially be
due to the neurotic psychosomatic response to their
emotional difficulties.
• In a systematic study of sixty patients with anorexia
nervosa, Crisp et al., reported that sleep disturbance
together with other manifestations of increased arousal
such as diffuse restlessness, tended to be a feature of
more severe cases. They did not find sleep disturbance
relationships to factors such as age, duration of illness,
feeding pattern or type of diet. It was concluded that the
sleep disturbance was directly related to malnutrition,
and it was suggested that nutritional factors may play a
significant role in the genesis of sleep disturbance.
 DYSOMNIA

SLEEP
DIS.

PARAINSOMNIA
 OSA

Primary
Insomnia Dysomnia Narcolepsy

RLS and
periodic limb
movement
disorder
 Primary Insomnia
• Insomnia: difficulty to start or maintaining
of sleep.
• Primary insomnia: insomnia that is not
caused by sleep disorders, medical
problems, or other psychiatric conditions,
but it’s related with pre-bedtime habits,
sleep patterns, and sleep environment.
Obstructive Sleep Apnea (OSA)
• Repeated episodes of partial or total airway
obstruction
• Happens in 1-5% children
• Onset: 2-8 years old
• Etiology: adenotonsilar hypertrophy
• Symptoms: snoring, sleeping with
hyperextension of head, headache, frequent of
daytime sleepiness
• Signs: enlargement of tonsils and adenoid,
paradoxical breath, pectus excavatum
 Narcolepsy
• Neurological disorders characterized by
excessive sleepiness during the day
• Can be accompanied by:
– Cataplexy
– hallucinations
– Sleep paralysis
• 50-70% of narcolepsy patients have cataplexy.
• These symptoms are caused by the sudden
onset of the REM phase in the patient who’s
awake.
Restless Leg Syndrome & Periodic
Limb Movement Disorder
• 2% in children
• Risk factors: anxiety or stress, iron deficiency
• Symptoms:
– feeling uncomfortable in the legs so the child moves
his legs to remove the uncomfortable feeling
– Symptoms appear in the afternoon
– It worsens when rest
– Feels better when moved
• Periodic Limb Movement Disorder:
– Periodic episodes of limb movements during sleep
• Diagnostic of RLS can be enforced if there
is a history of RLS before and at least
there are 2 of 3 criterias which are :
– Sleep disturbance
– RLS history in parents
– Polysomnography shows > 5 periodic
episodes of limb movements during sleep in 1
hour
 Sleep terror

Somnambulisme Parainsomnia Nightmare

Bruxism
 Somnambulism
• “Sleep walking”
• Occurs during the first 1/3 of a night's sleep
• Not known for sure but 80-90% obtained by
genetic factors
• 15% of children experience at least 1 episode of
the sleep walking
• Symptoms: walking during sleep, difficult to be
woken up, eyes open, agitation, get back to
sleep quickly
 Sleep Terror
• Awaken from slow wave sleep and often
accompanied by screaming, weeping, and
agitation.
• 1-6% in children
• Gets better without specific treatment
 Nightmare
• Occurs in the REM sleep phase
• 10-50% at the age of 3-5 years
• Onset at the age of 3-6 years
 NIGHTMARE SLEEP TERROR

REM NREM (Stage III-IV)

Mid and end of sleep 1-2 hours after starting to sleep

The child is in awake condition The child is in sleeping condition

The child remembers well after the The child can not remember anything
episode ends after the episode ends
Children can be invited to communicate Children are difficult to communicate
during episodes
 Bruxism
• The habit of swiping teeth during sleep
• Occurs in approximately 50% of children
• Risk factors: anxiety, stress, allergies, mental
retardation, using stimulant drugs
 DIAGNOSTIC
• Two objective methods for studying sleep are
polysomnography (PSG) and actinography
(ACG)
• PSG is based on EEG recording, while ACG
uses motor activity information
• PSG examinations can provide complete
information on sleep-wake changes, while the
ACG provides estimations of sleep quality
• Other screening methods : SDSC (Sleep
Disturbances Scale for Children)
 TREATMENTS
• Mostly, sleep disorder treatment in
children correlate with behaviour therapy.
• Behavioral therapy or also called non-
pharmacological therapy in the form of
sleep patterns, relaxation therapy,
stimulation settings, and sleep hygiene
settings.
• Sleep hygiene is a daily behavior that can shape
the quality and quantity of a good sleep. Some
of these behaviors include:
– Avoid to sleep in the afternoon which is too late and
the duration is short enough that is not more than 1
hour
– Sleeping with comfortable and calm conditions and
surroundings
– Maintain a stable sleep schedule such as starting
sleep and waking at the same time each day
• According to research adenotonsillectomy is
effective in overcoming Obstructive Sleep Apnea
(OSA). The authors also recommend positive
pressure oxygen therapy if adenotonsillectomy
does not respond well or in patients that is not
indicated for surgery.
 PHARMACOLOGY
Medication Dosage

Chloralhydrate 25-50 mg/kgBB

Niaprazine 1 mg/kgBB

Nitrazepam 5-10 mg

Melatonin 0,3-5 mg

Clonidine 0,05-1 mg

Gabapentin 300-900 mg

Clonazepam 0,25-0,5 mg
• Restless leg syndrome: Some researchers
recommend of giving 50-60 mg of oral iron
tablets and given twice daily.
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