Which clinical history findings are characteristic of pediatric sleep disorders related to a general medical condition?

Updated: Oct 09, 2018
  • Author: Sufen Chiu, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
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Answer

A wide variety of medical and psychiatric disorders may result in sleep disruption. The clinician should establish the presence of a general medical condition, but it is not necessary for the diagnosis of sleep-wake disorder in DSM-5. The clinician should consider how, the sleep disturbance is causally related to the medical illness through a physiologic mechanism to help clarify treatment. For example, cluster headaches occur more frequently during the night than in the daytime. Sleep-related headaches usually awaken the patient and fragment sleep. Blind individuals experience cyclic disorders because of the lack of cues that continually reset the internal clock to fit the 24-hour day-night cycle.

In pediatric populations, epilepsies occurring during sleep account for 30% of seizure disorders. Epilepsy appears to fragment sleep and causes impairment in daytime functioning. [13] The sleep disturbances associated with developmental central nervous system (CNS) disorders generally reflect fragmentation with frequent awakenings, difficulty in initiating sleep, and early morning awakenings. 

Kleine-Levin syndrome or periodic hypersomnia comprises a constellation of symptoms that include episodes of excessive somnolence, overeating, and sexual disinhibition; it is 4 times more frequent in boys than in girls. [14] Behavioral disturbances, such as irritability and confusion, are associated with this syndrome, and occasional hallucinations have been reported. Derealization, a dream-like state or experiencing life outside their own bodies, is often present. A significant number of patients have had a complicated birth history and some developmental delay.

Symptoms of Kleine-Levin syndrome typically begin during adolescence, median age of onset is 15 years, either gradually or abruptly. Onset follows a flulike illness or injury with loss of consciousness in half the cases. The course of the syndrome is characterized by remissions and relapses, with relapses occurring at intervals of weeks to months. Symptoms may last from days to weeks. Kleine-Levin syndrome usually resolves spontaneously during late adolescence or early adulthood. The etiology of Kleine-Levin syndrome is unknown. The majority of individuals have slowing of their EEG during an episode. Imaging studies, cerebrospinal fluid analysis, and MLST are usually normal.

Paradoxical hyperactivity in children with attention deficit hyperactivity disorder (ADHD) encourages them to stay awake. Emotional lability may be observed. Children with ADHD tend to have fewer and shorter arousals than adults. They also tend to have obstructive hypopnea (transient reduction of airflow that lasts at least 10 seconds), with relatively few complete apneic (breathing stops for >10 seconds during sleep) events. Children with ADHD have a strong tendency to fall asleep during the day. They have high rates of restless legs syndrome (RLS) and periodic limb movement in sleep (PLMS) and a higher prevalence of OSAS.

Sleep-disordered breathing and PLMS have been frequently found in children with ADHD who have symptoms and complaints of disturbed sleep. Routine assessment of the sleep habits of patients with ADHD is important; consider objective sleep assessment, including polysomnography (PSG).

Approximately 50% of children with Tourette syndrome have sleep disturbances. Nocturnal awakenings and movements increase when tics persist into sleep. Comorbidity exists with obsessive-compulsive signs, traits associated with increased sleep latency, decreased REM sleep, and deceased REM sleep latency. Children and adolescents with this movement disorder are at risk for parasomnias. Patients with Tourette syndrome have a higher incidence of enuresis. Tourette syndrome is associated with prolonged sleep latency. Short and fragmented sleep results in low sleep efficiency.

In Down syndrome or Trisomy 21, airway hypotonia leads to obstructive apnea that is not associated with obesity, age, or congenital heart disease. Central apnea also is common and is associated with significant oxygen desaturation. These individuals are also at greater risk for early hypothyroidism, which contributes to disrupted sleep.

In Prader-Willi syndrome, obesity, hyperphagia, and developmental delay are the most common features. Prader-Willi syndrome develops when a segment of the paternal chromosome 15 is deleted. Obesity can cause obstructive sleep apnea. An increased frequency of apneas, a decreased nadir of oxygen saturation, an increased maximum heart rate, and a blunted respiratory response to hypercapnia during non-REM (NREM) sleep all may occur in patients with Prader-Willi syndrome. Sleep time and slow-wave sleep increase during the day and at night. Upper airway resistance syndrome results in REM fragmentation and extra daytime sleep (EDS).

Individuals with Smith-Magenis syndrome have severe disrupted sleep patterns, which begin early in life. This disorder is caused by the deletion of a small piece of chromosome 17. Neurobehavioral abnormalities also include aggressive and self-injurious behavior. Children may be very sleepy during the day, have trouble falling asleep, and awaken several times each night. These sleep disturbances are correlated with disturbed circadian rhythm in melatonin levels. The chromosome delete results in the absence of the RAI1 protein. This protein appears to control the expression of several genes involved in circadian rhythm. [15]

Menstrual-associated periodic hypersomnia is another cyclic sleep disorder, noted during the first few years after menarche. Attacks generally last 1–2 weeks after ovulation, with sudden resolution occurring at the time of menses. Pregnancy is associated with increased risk for RLS.

Sleep-related gastroesophageal reflux disease (GERD) is characterized by regurgitation of stomach contents into the esophagus during sleep. It is very common in patients using theophylline as a respiratory stimulant for apnea of prematurity or asthma. Theophylline is a prescribed medication related to caffeine. Nighttime exacerbations of childhood asthma are common and may lead to significant sleep disruption.

Children with atopic dermatitis tend to have increased sleep-onset difficulty, night awakenings, and decreased sleep duration as a result of pruritus and medications, such as antihistamines and corticosteroids. Children with chronic illnesses, such as juvenile rheumatoid arthritis (JRA) or sickle cell disease, can experience sleep difficulties. Treatment of the primary disorder does not necessarily improve the sleep issues.


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