Curbside Consultation in Pediatric Sleep Disorders: 49 Clinical Questions, 1st edition
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Sleep is a crucial and dynamic process that is essential for physical, emotional, social, and cognitive functioning in children and adults alike. While its precise purpose remains unclear, sleep is known to play a role in energy conservation, physical restoration, developmental facilitation, and learning and memory processing. The brain cycles through stages of non-REM (NREM) and REM sleep, with distinct physiological and neural features. During sleep, bodily functions are altered, including changes in body temperature, endocrine function, and other physiological processes. Sleep is not a passive state, but rather an active and well-organized process that is critical for overall health and well-being. Disruptions to sleep can have adverse effects on learning, development, and functioning, and its importance cannot be overstated.
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The regulation of sleep and wakefulness is a complex process that involves the interplay of various brain structures and neurotransmitter systems. The sleep-wake cycle is regulated by two main processes: the intrinsic sleep drive, which is responsible for promoting sleep, and the circadian timing system, which regulates the timing of sleep and wakefulness. The intrinsic sleep drive is influenced by the duration and quality of previous sleep periods and the duration of current wakefulness, while the circadian timing system is regulated by the suprachiasmatic nuclei in the hypothalamus and is influenced by external factors such as light, meal times, and exercise. Neurotransmitters like adenosine, GABA, acetylcholine, dopamine, histamine, hypocretin/orexin, norepinephrine, and serotonin play important roles in promoting sleep and wakefulness. The pons is responsible for generating REM sleep through complex neural interactions. Sleep disorders can occur when there is a mismatch between the circadian timing system and the sleep needs of an individual or when there is an external stressor, and can manifest as conditions such as narcolepsy, delayed sleep phase syndrome, and obstructive sleep apnea syndrome.
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Sleep stages have distinct characteristics, including EEG, electrooculographic, and electromyographic features, which remain constant throughout an individual's lifetime. Sleep stages evolve with development, and their characteristics define sleep quality and quantity. In infancy, sleep is classified as active, quiet, or indeterminate, with rapid sleep-to-wake transitions and persistence of wakeful behaviors. As children mature, sleep patterns evolve to resemble those of adults, with full EEG differentiation of slow wave and non-REM sleep occurring by late school age. Non-REM sleep is divided into three stages, with Stage III being the deepest stage, characterized by low-voltage mixed-frequency EEG activity, slow eye movements, and low chin muscle tone. Arousal during this stage can lead to confusion, disorientation, and parasomnias. The sleep cycle typically consists of 5-6 cycles of NREM and REM sleep, with REM sleep serving to consolidate recent experiences into long-term memory and being an evolutionary adaptation to protect against danger. Disruptions during any sleep stage can lead to specific sleep disorders.
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During sleep, particularly in children, ventilation is compromised due to reduced chemosensitivity, increased upper airway resistance, and decreased diaphragmatic tone. This leads to irregular breathing, apneas, and increased work of breathing. Children's chest wall is more compliant, causing paradoxical inward motion during respiration, especially during sleep. Sleep affects breathing in children, with hypotonia of intercostal muscles during non-rapid eye movement (NREM) sleep and atonia during rapid eye movement (REM) sleep. As a result, alveolar ventilation falls during sleep, leading to increased transcutaneous pCO2 in children and decreased pO2 in both children and adults. Additionally, hypoxic and hypercapnic ventilatory responses are reduced during NREM and REM sleep, and arousal responses are reduced, with children having a higher arousal threshold than adults. Central apneas are common in infants and children, especially during REM sleep, and are considered significant if they last more than 20 seconds, are associated with desaturation, bradycardia, or arousal, or are obstructive. Children with underlying cardiorespiratory disorders are at risk for severe ventilation compromise during sleep, particularly REM sleep, due to reduced chemo-responsiveness, muscle hypotonia/atonia, and decreased arousal responses.
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The circadian timing system regulates our bodily rhythms, consisting of a biological clock, input pathways, and output pathways. The suprachiasmatic nuclei in the anterior hypothalamus, regulated by circadian clock genes and influenced by environmental cues, serve as the site of the biological clock. Light, physical activity, and melatonin play crucial roles in entraining the circadian clock to synchronize with the 24-hour social environment. Melatonin secretion peaks between 3 a.m. and 5 a.m. and decreases during the day due to light suppression. Exposure to blue light in the evening can delay circadian rhythms, while exposure in the second half of the night or early morning can advance them. Circadian rhythms affect various bodily functions and are essential for maintaining a healthy sleep-wake cycle. However, circadian rhythm sleep disorders, such as delayed sleep phase syndrome and advanced sleep phase syndrome, can disrupt functioning due to misalignment between an individual's sleep pattern and the social norm.
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Apneas are classified into three types: central, obstructive, and mixed. Central apnea occurs when there is a cessation of airflow despite the absence of respiratory effort, often caused by a temporary failure of the ponto-medullary pacemaker. Obstructive apnea, on the other hand, is caused by a physical obstruction of the airway, resulting in a significant reduction in measured airflow despite continued respiratory effort. Mixed apnea combines central and obstructive apnea, with a central apnea followed by an obstructive event. These types of apnea can be caused by various factors, including anatomical abnormalities, sleep disorders, and certain medical conditions. If left untreated, apnea can have severe consequences, particularly in children, including behavioral disorders, poor school performance, and cardiac failure. Diagnosis is typically made through polysomnography, and treatment is crucial to prevent these negative outcomes.
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Parasomnias are unwanted physical events or experiences that occur during sleep, characterized by a mix of sleep and wakefulness. There are three main types: disorders of arousal from non-rapid eye movement (NREM) sleep, parasomnias associated with rapid eye movement (REM) sleep, and other parasomnias. Examples of parasomnias include confusional arousals, sleepwalking, and night terrors. Treatment typically involves ensuring a safe environment, except for sleepwalking, which requires measures to prevent self-injury. Nightmares are common in children, while REM-associated parasomnias occur more frequently in adults and the elderly, with a higher risk of self-injury. Other parasomnias include enuresis, sleep-related eating disorder, and exploding head syndrome. Rhythmic movements are common in infants and toddlers, and can resolve on their own. Scheduled awakenings may help manage parasomnias, and referral to a sleep specialist is recommended if concerns arise about daytime mood, behavioral disturbances, safety, or seizure disorder.
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Newborns sleep polyphasic, with multiple sleep periods throughout the day, while infants gradually transition to monophasic sleep with one main sleep period at night. Environmental factors influence infant sleep patterns, and total sleep time decreases with age. The proportion of REM to NREM sleep and the length of the sleep cycle change with age, with infants having a 50:50 ratio and adults having a 20:80 ratio. As children develop, they go through various stages, including nocturnal sleep consolidation, cessation of daytime napping, and the emergence of endogenous circadian sleep phase preference. Sleep architecture matures in the first six months of life, and behavioral sleep disorders can occur during childhood due to rapid changes in sleep architecture and timing.
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Apnea of prematurity is a common condition characterized by the cessation of breathing in preterm infants, typically accompanied by bradycardia and/or oxyhemoglobin desaturation. It can occur in infants less than 32 weeks of gestation and can last until 44 weeks of corrected gestational age. Apnea of prematurity is classified into central, obstructive, and mixed categories and is caused by the immaturity of the brainstem respiratory control system. Symptoms include cyanosis, bradycardia, and limpness, and the condition can be treated with airway management and caffeine therapy. Caffeine treatment has been found to be safe and effective, and airway management techniques include supplemental oxygen, continuous positive airway pressure, and endotracheal intubation and mechanical ventilation. In terms of differential diagnoses, apnea of prematurity can be distinguished from other conditions such as bacterial infection, central nervous system abnormalities, airway obstruction, anemia, metabolic disorders, and drug effects. The long-term effects of apnea of prematurity are difficult to differentiate from the independent effects of prematurity or other comorbidities, but it may lead to brain injury due to associated bradycardia and oxygen desaturation. There is no causal relationship between apnea of prematurity and sudden infant death syndrome (SIDS), and risk factors for SIDS include non-supine sleep position, sleeping on a soft surface, and maternal smoking during pregnancy.
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Sudden Infant Death Syndrome (SIDS) is a sudden and unexpected death of an infant under one year old with no explanation, affecting approximately 0.5-0.6 deaths per 1,000 live births in the US. The causes of SIDS are unknown, but it is a multifactorial problem. Risk factors include premature birth, low birth weight, multiple birth, male sex, age between 1-4 months, and ethnicity. Research focuses on central nervous system mechanisms, genes, and arousal responses to sleep, and the triple-risk model highlights the combination of an unfavorable environment, physiological stress, and a vulnerable infant as a challenge leading to SIDS. Modifiable risk factors include prenatal care, maternal health, supine sleep, pacifier use, breastfeeding, and immunization. Clinically, it is recommended to place infants on their backs to sleep, have wakeful periods of supervised "tummy time," and maintain a smoke-free zone around infants and children. A safe sleep surface and avoiding co-sleeping are also essential. Public health impact is affected by socioeconomic factors like prematurity, intrauterine growth retardation, and multiple birth, as well as maternal well-being. Additionally, SIDS is an uncommon occurrence with racial disparities in the US.
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The American Academy of Pediatrics (AAP) has issued recommendations to reduce sudden infant death syndrome (SIDS) rates, which have led to a 50% reduction in SIDS rates. SIDS is a cause assigned to infant deaths that cannot be explained after a thorough investigation. The AAP recommends that infants sleep supine and avoid soft objects, loose bedding, and overheating. The triple-risk model suggests that SIDS is caused by vulnerable infants being exposed to exogenous stressors during periods of critical development. The prevention of SUID, particularly sleep-related deaths and accidental suffocation and strangulation in bed (ASSB), can eliminate preventable infant deaths. The AAP emphasizes the importance of a safe sleep environment, including avoiding tobacco exposure, alcohol and illicit drug use, and ensuring regular prenatal care and breastfeeding. Additionally, co-sleeping or bed-sharing has not been shown to offer any protective benefits against SIDS and has been linked to SUID/ASSB, increasing an infant's risk of death from SIDS and other sleep-related causes.
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Apparent Life-Threatening Events (ALTEs) occur in approximately 1% of pediatric emergency room visits and 2% of inpatient admissions, with a mortality rate ranging from 0% to 0.6%. ALTE is more common in premature infants and young infants, and affects males and females equally. The evaluation of an infant with an ALTE includes a detailed history, physical examination, and consideration of child abuse as a potential cause. The differential diagnosis is broad, including gastrointestinal, respiratory, neurologic, cardiac, metabolic, and miscellaneous causes. A stepwise approach is recommended, considering the history, physical examination, and clinical course. The workup for an ALTE typically involves directed studies based on the history and physical examination, followed by second-line studies such as complete blood count, electrolyte levels, blood glucose, and tests for pertussis and respiratory syncytial virus. Other studies may include urinalysis, urine culture, and neuroimaging. The management of an ALTE typically involves a period of observation, monitoring of vital signs, and infant cardiopulmonary resuscitation training for parents and caregivers. Home monitoring may be appropriate in certain cases, but has not been shown to improve outcomes in general populations of infants with ALTE.
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The American Academy of Pediatrics (AAP) does not recommend home cardiorespiratory monitors for preventing Sudden Infant Death Syndrome (SIDS) in healthy term infants or siblings of SIDS victims. However, they suggest individualized consideration of home monitoring for infants who experience an Apparent Life-Threatening Event (ALTE) to establish a diagnosis. The AAP emphasizes that home monitoring has not been shown to be effective in preventing SIDS. Instead, they recommend a safe infant sleeping environment to reduce the risk of SIDS, and individualized consideration of home cardiorespiratory monitoring for infants who experience ALTE, with event recorders, age-appropriate settings, and close follow-up and family support.
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Infants commonly experience sleep problems, with 10-30% of children over six months old experiencing bedtime issues and frequent night wakings. Newborns spend approximately 16 hours a day sleeping, with frequent disruptions due to feeding. By four to seven months, babies may sleep for seven to eight hours at night and take two to three naps. While many babies sleep through the night by six months, 25-50% of children over six months still experience nighttime wakings. Sleep problems in infants can be related to colic, developmental changes, and separation anxiety, as well as environmental and medical factors. Behavioral sleep disorders are common in infants, and can be treated through techniques such as unmodified extinction, graduated extinction, and scheduled awakenings. Establishing a consistent routine and creating a sleep environment that is safe, comfortable, and consistent can help foster sleep and reduce dependence on sleep associations.
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Nightmares are a type of parasomnia that occur during the second half of the night, typically in the early morning hours, and are characterized by vivid, disturbing dreams that trigger a full awakening from REM sleep. Children's nightmares are most common in the age range of 3-6, with boys and girls equally affected, but women being more likely to experience nightmares in adulthood. Nightmares can persist into adulthood, and genetic factors play a significant role in determining their frequency and severity. They can be triggered by childhood trauma, posttraumatic stress disorder, and watching violence on television before bedtime. Nightmares are typically benign and can be managed through reassurance, rescripting, relaxation techniques, medical therapy, desensitization, and avoidance of exacerbating factors.
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Night terrors, also known as sleep terrors, are a type of parasomnia that occurs when a child transitions from slow-wave sleep to wakefulness abnormally. This phenomenon typically affects children between 2 and 10 years of age, with a peak in early school ages, and has a prevalence of 3-4%. The episodes are characterized by sudden and intense agitation, autonomic surge, and pupillary dilatation, and the child remains asleep and unaware of the event. Night terrors can be managed by reassuring parents, avoiding secondary gain, and scheduled awakening, with medical management rarely necessary except in extreme cases. Research suggests that genetic predisposition, sleep deprivation, illnesses, and certain medications can contribute to the development of night terrors. The condition is more common in children whose parents or siblings have night terrors, and first-degree relatives have a 10-fold increase in incidence. Establishing a safe sleeping environment and treating any underlying conditions, such as gastroesophageal reflux, can help alleviate symptoms. The International Classification of Sleep Disorders, pediatric parasomnias, and other relevant articles provide valuable information for understanding and managing night terrors.
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Behavioral sleep problems are common in young children, affecting the entire household. There are two subtypes of behavioral insomnia of childhood: sleep onset association and limit-setting subtypes. Sleep onset association subtype is characterized by frequent night awakenings and a need for certain conditions to fall asleep, while limit-setting subtype is characterized by bedtime resistance, refusal, and stalling. Mixed type combines elements of both subtypes. Understanding these subtypes can help families address behavioral sleep problems and promote healthy sleep habits. Children's sleep problems often stem from their learning that certain behaviors elicit a response from caregivers, leading to delayed bedtime or allowed engagement in preferred activities. Treatment includes establishing sleep hygiene, promoting self-soothing, and behavioral techniques such as extinction, graduated extinction, bedtime fading, and limit setting. Consistent reinforcement is crucial. Untreated behavioral insomnia can lead to increased irritability, temper tantrums, and behavior difficulties, as well as sleep deprivation for the entire family. Sleep specialists and behavior management professionals can provide helpful suggestions, and caregivers can refer to suggested readings for resources and information.
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Establishing a consistent sleep routine and environment is crucial for children's health, and pediatricians play a vital role in assessing sleep and providing guidance on healthy sleep development. Sleep difficulties are common in young children, affecting 20-30% of infants, toddlers, and preschoolers, and are related to sleep onset, resistance, and night awakenings. To prevent and manage sleep problems, pediatricians can recommend evidence-based strategies such as establishing a consistent sleep schedule, creating a comfortable sleep environment, and avoiding sleep associations with caregivers or locations. Additionally, behavioral reinforcement and relaxation techniques, such as deep breathing and positive coping statements, can help children develop good sleep habits and overcome nighttime fears. By addressing sleep issues at each well-child visit and exploring them when other health and behavioral concerns arise, pediatricians can provide comprehensive care and support for children's overall health and well-being.
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Adolescents experience distinct sleep patterns, characterized by longer sleep periods on weekends and shorter sleep periods on weeknights, with delayed sleep onset compared to children and adults. Sleep disorders such as pediatric insomnia and Delayed Sleep Phase Disorder (DSPD) are common among adolescents, and can be caused by various factors including mental health concerns, lifestyle issues, and sleep hygiene issues. Effective treatment plans for sleep disorders involve a combination of behavioral, pharmacological, and referral-based approaches, and may include problem-solving with patients and family members, establishing bedtime routines, and restructuring home activities.
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Adolescents (12-25 years) require consistent and sufficient sleep, which is essential for optimal cognition, emotion, and performance. Unfortunately, they often get less sleep than recommended, leading to excessive sleepiness, increased risk of injury and death, and negative impacts on daytime functioning, academics, and mental health. Puberty brings changes in sleep patterns, leading to a delay in sleep-wake cycling and circadian timing systems. As a result, adolescents need at least 7.5-9 hours of sleep, with individual variability and a preference for sleeping in later hours. Establishing healthy sleep routines, such as sleeping 8-10 hours each night, avoiding caffeine and stimulants late in the day, and exposing oneself to bright light in the morning, is crucial for improving adolescent sleep. Additionally, schools are changing their schedules to accommodate adolescents' sleep needs and behaviors, including later start times and later high school schedules, which research suggests can improve learning outcomes.
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In the United States, most adolescents are not getting enough sleep, with six out of ten teenagers sleeping fewer than eight hours a night and feeling unrefreshed several days a week. This sleep deprivation can lead to serious consequences, including accidents while driving, reduced academic performance, mood disorders, and substance use. Chronic sleep deprivation can accumulate over time and is linked to an increased risk of obesity, particularly in the context of the current epidemic among adolescents. Factors contributing to sleep deprivation include demanding schedules, electronic device use before bedtime, and changes in the body's circadian rhythm during adolescence. Parents and caregivers can play a crucial role in establishing healthy sleep habits by creating a bedroom environment free from electronic devices, leading by example, and prioritizing adequate sleep as a family.
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Teenagers are at a higher risk of fatal car crashes, with the highest risk between the ages of 15-19, due to factors such as drowsiness, poor sleep hygiene, and high-risk behaviors. Driver error, including drowsiness, is the leading cause of motor vehicle crashes in teenagers. Chronic sleep deprivation, common among teens, increases the risk of clinically significant drowsiness, impairing judgment, mood, behavior, learning, and driving performance. Pulling over for a 10-15 minute nap is the most effective strategy to prevent drowsy driving, followed by caffeine. Teenagers are more prone to drowsy driving due to their inexperience, lack of sleep, and high-risk behaviors, and are more likely to engage in risky behaviors such as not wearing seatbelts, talking or texting on their phones, and driving under the influence. Poor sleep quality is a risk factor for motor vehicle crashes among adolescents, and teenagers who drive frequently, drive while sleepy, drive at night, have poor sleep quality, or use stimulants and tobacco are more likely to be involved in motor vehicle crashes.
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Narcolepsy is a rare, chronic disorder characterized by excessive daytime sleepiness, sudden sleep attacks, and other sleep-related symptoms. It can affect adults and children, with a prevalence rate of 0.02% to 1.8% in the United States. Children are typically diagnosed after puberty, and the disorder can have a negative impact on school performance and extracurricular activities. The pathophysiology of narcolepsy involves impaired sleep-wake transitions and a deficiency of the neurotransmitter orexin/hypocretin. Symptoms include excessive daytime sleepiness, sleep attacks, cataplexy, sleep paralysis, hypnagogic hallucinations, and disrupted nighttime sleep. Diagnosis in children is challenging and requires a comprehensive evaluation, including a complete history, physical examination, overnight polysomnogram, and multiple sleep latency test. Treatment typically involves education, behavioral changes, stimulants, and REM suppressants, and sodium oxybate can be used in adolescents. With proper treatment and management, most children with narcolepsy can lead normal and productive lives, but close follow-up is necessary as symptoms may change and medication doses may need to be adjusted.
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Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) are common in childhood, affecting approximately 2% of children. RLS is characterized by an uncontrollable urge to move the limb, which is relieved by movement or stretching, while PLMD is a periodic movement disorder that causes sleep disruption and daytime dysfunction. Both conditions may have a shared pathogenesis and are often primary in children, with secondary causes being rare. Symptoms may vary and may relent or resolve spontaneously, and young children may present with symptoms of leg discomfort, sleepiness, and hyperactivity. Diagnosis of RLS relies on patient report, while PLMD is diagnosed using the Periodic Limb Movement Index (PLMI). Treatment options include measuring serum ferritin, iron supplementation, and medications like dopaminergic agents, gabapentin, and benzodiazepines, as well as lifestyle changes like delaying sleep, exercise, stretching, and spine cooling. Untreated RLS and PLMD can cause sleep disruption and long-term effects, and increased PLMI can be a marker for other sleep disorders and influence disease expression and outcome.
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Sleep plays a crucial role in epilepsy, as both sleep deprivation and sleep disorders can trigger seizures in children and adults with epilepsy. Nocturnal seizures are common, often manifesting as sleep disruption, restlessness, bedwetting, and morning headaches. Antiepileptic drugs can alter sleep architecture, causing daytime somnolence and impaired vigilance. It is essential to distinguish between seizures and sleep-related phenomena, such as benign sleep myoclonus, periodic limb movements of sleep, and nocturnal dyskinesias, which may mimic seizures. A comprehensive approach to diagnosis and treatment involves a sleep-deprived EEG, provoking maneuvers, and overnight or multiple night monitoring. Addressing sleep disorders, such as sleep breathing disorders or sleep movement disorders, is crucial to optimize developmental outcome and reduce seizure frequency.
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Sleep disorders are a common issue in pediatric neurological patients, often unrelated to the underlying condition. Children with neurological impairments may experience various sleep problems, including insomnia, sleep-wake cycle disturbance, sleep-disordered breathing, and narcolepsy. Risk factors for sleep issues include chronic pulmonary disease, reflux, pain, and psychological disorders. Certain conditions, such as delayed sleep phase syndrome, insomnia, and sleep-disordered breathing, are more prevalent in specific patient groups, such as teenagers and those with cognitive challenges or autism. Sleep disruption can lead to daytime behaviors like hyperactivity, aggression, and rebelliousness. Treatment approaches for sleep problems in neurologically impaired children are similar to those for normal children, but may require careful consideration of unique factors, such as desensitization for continuous positive airway pressure and stimulant use in certain subgroups.
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Obstructive Sleep Apnea Syndrome (OSAS) is a sleep-related breathing disorder characterized by partial or complete upper airway obstruction, disrupting normal ventilation and sleep patterns. The condition affects 1-5% of children, with common comorbidities including adenotonsillar hypertrophy and obesity. Untreated OSAS can lead to cognitive development, growth, and cardiovascular health impairment, while treatment can improve school performance, attention capacity, behavior, and quality of life. Surgical and medical treatment options are available, including adenotonsillectomy, partial tonsillectomy, weight loss, and continuous positive airway pressure (CPAP). However, CPAP use can be challenging in young children due to mask fit issues and adherence concerns, and close monitoring is necessary to avoid complications. Healthcare providers should recognize the signs and symptoms of OSAS, warranting further evaluation, objective testing, and tailored treatment.
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Snoring and Obstructive Sleep Apnea Syndrome (OSAS) can occur in children of any age, but are more common in specific populations, including those with adenotonsillar hypertrophy, behavioral problems, and comorbid medical conditions. All children should be screened for snoring and OSAS during routine pediatric care. OSAS is often misdiagnosed as Attention Deficit Hyperactivity Disorder (ADHD) and can present with symptoms such as hyperactivity, behavioral problems, and poor school performance. Adenotonsillar hypertrophy is a common cause of OSAS, and removal can be curative in otherwise healthy children. Risk factors for OSAS include obesity, craniofacial anomalies, neuromuscular weakness, and comorbid medical conditions affecting craniofacial structure or muscle tone. Certain populations, such as children with Down syndrome, Prader-Willi syndrome, and neuromuscular disorders, are at higher risk for OSAS due to their innate characteristics.
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Diagnosing pediatric obstructive sleep apnea syndrome (OSAS) requires a comprehensive approach involving a detailed clinical history, physical examination, and objective diagnostic tools. Polysomnography, also known as nocturnal in-laboratory polysomnography (PSG), is the gold standard for diagnosing OSAS, providing valuable information on the severity of the condition. AHI (apnea-hypopnea index) is used to determine the severity of OSAS, with an abnormal AHI score above 1 indicating the presence of the condition. The Pediatric Obstructive Sleep Apnea Syndrome Severity Scale is used to categorize the severity of OSAS based on AHI scores and the presence of frequent or sustained desaturations below 80%. Additionally, overnight oximetry reports can show clusters of desaturations, indicating obstructive respiratory events, and are used to screen for OSAS. Accurate diagnosis and severity classification are crucial for determining the urgency of intervention and postoperative management.
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Obstructive sleep apnea (OSA) can have significant effects on a child's behavior, physical growth, and overall health, regardless of the severity of the condition. The impact of OSA is not solely determined by the severity of the sleep apnea, but is influenced by factors such as sleep duration, environmental exposures, and genetic susceptibility. Children with OSA may experience cognitive and behavioral problems, including learning difficulties, hyperactivity, and mood changes, even without severe oxygen desaturations. OSA can also lead to structural damage in the brain, disrupt normal sleep patterns, and affect the cardiovascular, metabolic, and immune systems. In addition, OSA can cause spikes in blood pressure, heart rate, and vascular tone, leading to complications such as pulmonary hypertension and cor pulmonale. Children with OSA may also display fatigue, sleepiness, and impaired learning and cognitive performance, which can be subtle and only revealed through formal standardized testing. Confirming a diagnosis of OSA can lead to significant improvement of symptoms in some children, and patients with obesity and behavior problems are at higher risk for complications and should be screened for OSA and undergo a formal sleep study if suspected.
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Obstructive sleep apnea (OSA) in children is often caused by enlarged tonsils and adenoids, and treatment typically begins with surgery, such as adenotonsillectomy, which is the most effective method. However, for those who are not good candidates for surgery or whose surgery did not work, less invasive approaches can be considered. These may include continuous positive airway pressure (CPAP) therapy, medications, weight loss, getting more sleep, oral appliances, and learning to play a wind instrument. The choice of treatment depends on the child's individual needs and circumstances. Oral appliances are typically used less often and are most effective for patients with mild or positional OSA, while dental sleep specialists may hesitate to manipulate the jaw until most of a child's growth is done. Weight loss is also recommended, but can be challenging, especially in children. The close link between obesity, metabolism, and OSA means that using CPAP can improve metabolism and enhance weight loss. If other options are not available, playing a wind instrument like the didgeridoo may be a potential alternative. Untreated OSA can have significant consequences, including irritability, poor school performance, and poor growth, making it essential to identify and eliminate the obstruction through surgery, CPAP, or other treatments.
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Obstructive Sleep Apnea Syndrome (OSAS) is a common disorder in children, affecting approximately 2% of them, causing repeated episodes of airway obstruction during sleep. The disorder can lead to various comorbidities such as failure to thrive, neurocognitive, cardiovascular, metabolic, and inflammatory sequelae. Adenotonsillar hypertrophy is the most common cause of OSAS in children aged 2-8 years, and adenotonsillectomy is the preferred treatment. Positive Airway Pressure (PAP) therapy is used as a second-line therapy in pediatrics, particularly for children with complex sleep apnea, patients not considered candidates for airway surgery, and perioperative management of severe obstructive sleep apnea. PAP therapy applies positive airway pressure to mechanically stent the airway open, reducing work of breathing and improving lung volumes. The therapy is customized for each patient through a process called PAP titration, which is done by an experienced technologist after an attended polysomnography. Common side effects of PAP therapy include nasal congestion, dryness, and irritation, which can be addressed with heated humidification. Other side effects, such as aerophagia/gastroesophageal reflux, mid-facial hypoplasia, and chest discomfort and pneumothorax, can be managed by adjusting the therapy. Compliance and adherence to PAP therapy are significant issues, and factors such as higher baseline apnea-hypopnea indices and greater changes in apnea-hypopnea indices on PAP therapy can affect adherence. Ongoing follow-up is essential for both clinical efficacy and patient adherence.
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Snoring is a common symptom of sleep-disordered breathing in children, affecting approximately 7.5% of children, and is linked to significant morbidity if left untreated. Snoring and obstructive sleep apnea syndrome (OSAS) are associated with various morbidities, including hypertension, endothelial dysfunction, and neurobehavioral deficits. Snoring has also been linked to developmental deficits, such as hyperactivity, depression, and inattention. A comprehensive evaluation of snoring children involves a detailed history and physical exam, including assessment of growth curve, craniofacial anomalies, nasal obstruction, oropharyngeal exam, and thoracic exam. Radiologic assessment, such as lateral neck radiographs, can be useful in evaluating the snoring child, while polysomnography (PSG) is considered the gold standard for diagnosing sleep-disordered breathing in children. Overnight PSG is the most comprehensive tool, but ambulatory PSG is not currently recommended due to conflicting results. Children with suspected OSAS should be referred if they have craniofacial anomalies, genetic syndromes, neurobehavioral deficits, obesity, kissing tonsils, or pectus excavatum, as OSAS is linked to neurobehavioral deficits, and primary snoring has been linked to cognitive impairments in school-age children.
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Obstructive Sleep Apnea Syndrome (OSAS) is a common condition affecting individuals of all ages. In children, OSAS affects 1-5% of non-obese and healthy children, 10% of children aged 2-8 years, and is more prevalent in boys than girls. In adults, OSAS affects 6-9% of men and 3-4% of women. Adenotonsillar hypertrophy is the leading cause in children, while obesity is a significant risk factor in both children and adults. Craniofacial anomalies and neuromuscular diseases also increase the risk of developing OSAS. Common symptoms of OSAS include snoring, daytime sleepiness, and attention deficit hyperactivity disorder (ADHD) in adults. Treatment options include surgical removal of the tonsils and adenoids, as well as medical treatment with non-invasive ventilation, oral appliances, anti-inflammatory medications, and weight reduction therapy. For children with obesity, weight management plans prioritize maintaining weight while allowing for height growth over immediate weight reduction. Relevant studies and guidelines have been published to aid in the diagnosis and treatment of pediatric OSAS.
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Sleep patterns are influenced by a combination of genetic, physical, and environmental factors. Certain genetic disorders, such as Duchenne Muscular Dystrophy, Prader-Willi Syndrome, and Congenital Central Hypoventilation Syndrome, can affect sleep quality and increase the risk of sleep-disordered breathing. Treatment options for sleep-disordered breathing include continuous positive airway pressure (CPAP) devices, behavioral modifications, and polysomnography. Specific genetic disorders, such as CCHS, Rett Syndrome, and Trisomy 13, 18, and 21, can cause breathing abnormalities and require unique treatment approaches. For example, children with CCHS may require tracheostomy and mechanical ventilation, while those with Rett Syndrome may benefit from polysomnogram evaluation and behavioral modifications. Trisomy 21 children are at risk of developing sleep apnea, which can be exacerbated by obesity, and may require alternative therapies such as dietary modifications and nocturnal low-flow oxygen.
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Children with facial disorders such as Pierre Robin Sequence, Treacher Collins Syndrome, and Apert Syndrome are at high risk of developing abnormal sleep quality, sleep-disordered breathing, and obstructive sleep apnea syndrome. Facial malformations can disrupt the process of facial formation, leading to upper airway obstruction and sleep-disordered breathing. These disorders often require surgical interventions to correct the disrupted process and augment airway function, and surgical techniques such as glossopexy and jaw extraction surgery can help augment the size of the airway. Additionally, positive pressure support and tracheotomy may be necessary to maintain adequate oxygenation and airway patency. Cleft palate is a common feature in these disorders and can be associated with obstructive sleep apnea, and surgical intervention may be necessary to treat sleep-disordered breathing. Craniosynostosis, a condition involving premature fusion of cranial sutures, can also affect the skull's shape and brain growth, leading to features such as a high forehead, flattened back of the head, and low-set ears. Children with these disorders often require the expertise of craniofacial and sleep medicine specialists, and regular polysomnographic testing is crucial for successful management and frequent discussions of sleep and breathing are necessary.
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Effective sleep is crucial for children's growth and development, and sleep disorders can have significant effects on their health. Children with sleep-disordered breathing (SDB) are at risk for attention deficit disorder, obesity, and other health concerns. SDB is common in children with underlying lung diseases such as cystic fibrosis, bronchopulmonary dysplasia, and neuromuscular diseases. The disorder is characterized by decreased minute ventilation, increased airway resistance, and decreased functional residual capacity during sleep. Children with SDB may experience sleep disturbances, poor quality sleep, and decreased oxygen saturation. Management of SDB involves optimizing and adhering to asthma therapy, considering surgery for tonsillo-adenoidal hypertrophy, and using non-invasive ventilation and supplemental oxygen therapy. The severity of SDB in children with underlying lung diseases can worsen as the disease progresses, highlighting the importance of early diagnosis and management.
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Sleep-disordered breathing (SDB) is a common issue in obese children, and it's essential to identify and treat it to prevent long-term complications. Obesity is a significant risk factor for SDB, and screening is crucial to diagnose and treat it. Children with obesity may experience altered pulmonary function, airway adiposity, and adenotonsillar hypertrophy, which can contribute to SDB. Polysomnography (PSG) is the recommended test to evaluate sleep staging, gas exchange, and respiratory patterns in obese children. The results show that almost half of obese children undergoing PSG will have an abnormal result, often diagnosing obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). Untreated OHS can lead to serious complications, including hypertension, mood disturbances, and cognitive delay. Treatment options include weight loss, adenotonsillectomy, positive airway pressure therapy, and hospitalization. It's essential to screen and treat SDB in obese children to mitigate its negative effects on their health and development.
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Attention Deficit Hyperactivity Disorder (ADHD) is a chronic neurobehavioral disorder that affects a child's ability to focus, control impulses, and manage time. The relationship between ADHD and sleep is complex, with many children with ADHD experiencing sleep difficulties, and vice versa. In fact, 25-50% of children with ADHD have sleep difficulties, including sleep-disordered breathing and periodic limb movements during sleep. Medications used to treat ADHD can impact the sleep cycle, and children with ADHD often struggle with sleep initiation and following bedtime routines due to difficulties calming down and following routine. Sleep quality can impact daytime behavior in individuals with ADHD, and improving sleep quality and increasing sleep duration can improve ADHD symptoms. Diagnosis and treatment of ADHD should consider sleep history, and clinicians should monitor sleep in children taking longer-acting stimulant medications and consider using shorter-acting formulations or non-stimulant medications if sleep initiation difficulties occur.
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Children with chronic medical conditions often struggle with sleep disturbances, which can affect their overall health, quality of life, and caregiver well-being. Various factors such as hospitalizations, pain, stress, medication, and disease processes can impact sleep quantity and quality. Common pediatric conditions like rhinitis and asthma can significantly disrupt sleep, and their treatment can involve targeting nasal congestion and nocturnal symptoms. Chronic pain can also have a major impact on sleep, causing sleep onset and maintenance insomnia, disrupted sleep, and increased wakefulness. Furthermore, caregivers of children with medical conditions often experience significant sleep disruptions, leading to fatigue, irritability, and depressed mood, which can negatively impact the child's adjustment and quality of life. It is essential to consider the impact of illness on sleep for the entire family, including caregivers, and to provide anticipatory guidance to prevent sleep disruptions.
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Pediatric neuropsychiatric disorders such as ADHD, autism, and anxiety/depression can have a significant impact on sleep, leading to insomnia, changes in sleep architecture, and sleep fragmentation. Co-existent sleep disorders can worsen sleep and daytime function. Specific conditions like ADHD, autism, and anxiety/depression can manifest distinct sleep problems, including insomnia, delayed sleep onset, and restless sleep. Treatment options include medical therapies like melatonin and clonidine, as well as behavioral therapies, but the lack of medical evidence makes treating sleep problems in these conditions a challenge. It is essential to carefully screen for sleep-disordered breathing and sleep-related movements to diagnose and treat these conditions. Additionally, underlying anxiety disorders can be alleviated with medication and behavioral therapy, which can also help alleviate sleep-related symptoms.
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Medications can significantly impact sleep and arousal, with varying effects depending on the medication and individual. Certain medications, such as antidepressants, benzodiazepines, and anticonvulsants, can affect sleep architecture, including suppressing REM or slow wave sleep, and cause or worsen periodic limb movements and parasomnias. Caffeine, a commonly used stimulant, can promote arousal and inhibit sleep, and its effects can last for hours after ingestion. Understanding the potential effects of medications on sleep is crucial when prescribing medications, especially for pediatric patients. Practitioners should obtain a full list of medications, supplements, and drugs of abuse, as well as the timing of their use, to effectively evaluate patients with sleep difficulties or excessive sleepiness.
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Insomnia in adolescents is a common and debilitating issue, characterized by persistent difficulty falling asleep or staying asleep, leading to daytime impairment. Females are more likely to experience insomnia than males, and children and adolescents with neurodevelopmental, psychiatric, and medical comorbidities are more prone to chronic insomnia. The diagnosis is typically made through a clinical and sleep history, including questions about sleep onset, sleep maintenance, restfulness, and level of distress or concern about sleep. A frank discussion of sleep hygiene and direct questioning about medications, caffeine, or substance use are also important. While polysomnography is not usually necessary for diagnosis, it may be used if other symptoms of a respiratory or non-respiratory sleep disorder are present. Non-pharmacological strategies, such as behavioral therapy, and pharmacological options, including melatonin and clonidine, have shown some improvement in sleep-related symptoms, but more research is needed.
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Melatonin is a hormone produced by the pineal gland, regulated by the suprachiasmatic nucleus, and influenced by light-dark cycles. It plays a crucial role as a circadian timing signal, signaling the onset of night and adjusting biological activities accordingly. Melatonin is available as a dietary supplement, but its availability and formulation vary, and its effects on pediatric insomnia are limited and inconclusive. In clinical practice, melatonin should be used with caution and only as a second option after sleep hygiene and regularity have been addressed. When used, the lowest effective dose should be used at a logical time, in a dimly lit and quiet setting, to signal the onset of biological night, not as a sedative or hypnotic agent.
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Pediatricians play a crucial role in addressing sleep problems in children, and their consultations typically involve an in-depth history and physical examination to identify the underlying causes of the issue. The pediatrician will ask questions about the child's daily routine, sleep quality, and any chronic pains or medical problems that may be related to the sleep issue. The examination may also involve a physical assessment of the child's breathing, tonsils, and overall physical health. Depending on the suspected diagnosis, the pediatrician may recommend an overnight sleep study to confirm or refute their suspicions and provide an objective measure for treatment decisions. Ideal care involves a pediatric sleep center with experienced technicians and board-certified pediatric sleep physicians.
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Establishing good sleep hygiene is crucial for promoting quality sleep in children, from infancy to adolescence. Caregivers and healthcare providers should prioritize sleep education and encourage parents to establish consistent routines, creating a healthy sleep environment, and setting realistic expectations. For infants and toddlers, this includes regular sleep schedules, bedtime routines, and avoiding changes in sleep environment. For school-age children, maintaining a consistent routine, reducing stimulating activities, and limiting electronics and caffeine are essential. Adolescents should prioritize getting at least 9 hours of sleep, establishing a consistent bedtime and wake time, and limiting electronics and caffeine intake. By promoting good sleep hygiene, parents and caregivers can help children develop healthy sleep habits, leading to improved cognitive development, mood regulation, attention, behavior, and overall quality of life.
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The preparation for a polysomnography (PSG) test involves creating a relaxed and cooperative environment, explaining the process to patients and guardians, and involving them in the process, especially when applying sensors. Pediatric sleep centers should have necessary supplies and amenities, and offer rewards to encourage patient compliance. During the recording process, PSG detects sleep stages using EEG, EOG, and chin EMG channels, categorizing them as Wake, NREM Sleep, and REM Sleep. Respiratory channels record airflow, nasal pressure, ETCO2, and RIP to monitor respiratory events. The scoring of respiratory events includes the detection of apneas, which are classified into four types: central apnea, mixed apnea, hypopnea, and periodic breathing. Hypoventilation is defined as CO2 levels above 50 mm Hg for more than 25% of sleep time.
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Polysomnography (PSG) is a crucial diagnostic tool for pediatric sleep disorders, serving as the gold standard for diagnosing and managing various conditions. PSG is indicated for both respiratory and non-respiratory indications, including obstructive sleep apnea (OSA), periodic limb movement disorder, restless legs syndrome, and nocturnal epilepsy. Children with symptoms such as snoring, mouth breathing, daytime sleepiness, or behavior changes, as well as those with enlarged tonsils and/or adenoids, nasal congestion, and restless sleep, are candidates for PSG testing. The test is also used to titrate positive airway pressure therapy for OSA and monitor children who have undergone adenotonsillectomy or had severe OSA prior to surgery. In addition, infants with apparent life-threatening events or suspected central apnea or hypoventilation require PSG testing, which measures end-tidal carbon dioxide levels. PSG is essential for diagnosing and managing various pediatric sleep disorders, and its results are sensitive and specific for diagnosing OSA.
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The Multiple Sleep Latency Test (MSLT) is a diagnostic tool used to assess a patient's sleepiness and diagnose narcolepsy. The test involves a series of naps during the day, with the patient instructed to try to sleep or fall asleep during each nap. The patient must have a minimum of 6 hours of sleep during the overnight polysomnogram (PSG) and complete sleep logs before the test. The test consists of 4-5 naps at 2-hour intervals, during which the patient should avoid stimulating substances and strenuous activity. Abnormal results indicate a positive result for narcolepsy, with an average sleep latency of 8 minutes or less and the presence of sleep onset REM periods (SOREMPs) in 2 or more naps.
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Edition: 1st
ISBN: 978-1-63091-294-9
Publisher: Slack
Published: November 14, 2015
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Copyright
Dedication
Acknowledgments
About the Editor
Contributing Authors
Foreword by Carl Gartner, MD
Introduction
Section I The ABCs of Sleep
Question 1 Why Do We Sleep and What Is Happening When Children Sleep?
Question 2 What Are the Nuts and Bolts of Sleep and Its Regulation?
Question 3 What Are the Different Stages of Sleep?
Question 4 What Changes in Breathing Are Associated With Normal Sleep?
Question 5 What Is a Circadian Rhythm?
Question 6 What Are the Different Kinds of Apnea?
Question 7 What Is a Parasomnia?
Question 8 How Does Sleep Change From Infancy to Adulthood?
Section II Unique Aspects of Sleep in Infancy
Question 9 What Is Apnea of Prematurity and How Is It Treated?
Question 10 What Is Sudden Infant Death Syndrome?
Question 11 What Are the Latest Recommendations for Safe Infant Sleep and the Prevention of Sudden Infant Death Syndrome?
Question 12 What Is an Apparent Life-Threatening Event?
Question 13 What, if Anything, Are Apnea Monitors Used for?
Section III Nonrespiratory Sleep Disorders of Infancy and Childhood
Question 14 My Infant Just Won’t Sleep. What Are Some Common Sleep Disorders Unique to Infants?
Question 15 What Are Nightmares?
Question 16 What Are Night Terrors?
Question 17 What Is Behavioral Insomnia of Childhood?
Question 18 What Are Some Pearls or Strategies to Manage or, Even Better, to Prevent Behavioral Sleep Disorders in Young Children?
Section IV Sleep Issues That Are Unique to Adolescents
Question 19 Some of My Teenage Patients Are Staying Up Late and Then Having Difficulty Getting Up for School. Do They Have Insomnia?
Question 20 Some of My Teenage Patients Complain of Being Tired All the Time. When Do I Need to Be Concerned?
Question 21 Is Sleep Deprivation Really That Big of a Problem in Adolescents?
Question 22 How Big of a Problem Is Drowsy Driving in Teen Drivers?
Section V Neurological Sleep Disorders
Question 23 What Is Narcolepsy and Do Children Actually Develop This Condition?
Question 24 What Is Restless Legs Syndrome and Do Children Actually Develop This Condition?
Question 25 Do Seizures Occur During Sleep and How Commonly Does This Occur?
Question 26 What Are Some of the Other More Common Neurological Problems That Can Influence Sleep?
Section VI Pediatric Obstructive Sleep Apnea Syndrome
Question 27 What Is Obstructive Sleep Apnea Syndrome?
Question 28 Which Children Are at Increased Risk for Pediatric Obstructive Sleep Apnea Syndrome?
Question 29 How Is Pediatric Obstructive Sleep Apnea Syndrome Diagnosed?
Question 30 What Are the Nonrespiratory Consequences of Obstructive Sleep Apnea?
Question 31 What Are the Medical and Surgical Treatment Options for Pediatric Obstructive Sleep Apnea Syndrome?
Question 32 Is CPAP Therapy Used in Children?
Question 33 How Do I Best Evaluate the Snoring Child?
Question 34 What Are the Differences Between Pediatric and Adult Obstructive Sleep Apnea Syndrome?
Section VII Sleep and Medical Conditions and Genetic Disorders
Question 35 What Are Some of the More Common Genetic Syndromes That Are Associated With Sleep-Disordered Breathing?
Question 36 What Are Some of the More Common Craniofacial Syndromes That Are Associated With Sleep-Disordered Breathing?
Question 37 What Do I Need to Know About Sleep and Breathing in Children With Underlying Lung Diseases?
Question 38 What Is the Impact of Obesity on Sleep?
Question 39 What Is Known About the Relationship Between Sleep and Attention Deficit Hyperactivity Disorder?
Question 40 What Are Some of the Other Medical Conditions That Can Affect Sleep?
Question 41 What Are the Effects of Neuropsychiatric Disorders on Sleep?
Question 42 What Are the Effects of Medications on Sleep?
Question 43 Are There Any Medical Treatments for Insomnia in Children and Adolescents?
Question 44 What Is Melatonin and Is This an Effective Treatment for Insomnia?
Section VIII Sleep Evaluation and Testing
Question 45 How Do I Screen for Sleep Problems in My Practice?
Question 46 How Can I Promote Sleep Hygiene in My Practice?
Question 47 What Is a Polysomnogram?
Question 48 Which of My Patients Should Have a Polysomnogram?
Question 49 What Other Tests Are Used to Diagnose Sleep Disorders?
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