Whatever Gets You Through The Night: All About Sleep Disorders by Dr. JJ Levenstein (MD, FAAP)

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Imagine being a 4th year medical student, with a new baby screaming and wailing incessantly at night. Fast forward to the pediatrician’s office the next day. Conclusion: nothing is wrong. Night after night of mad screaming every three hours. Then it stops. And picks up again months later. Fast forward two years when your child is verbal and screaming and crying as if he is going down on a crashing plane. Imagine the horror of not being able to console him or wake him. Then it clicks. My child has night terrors. Holy shit! He is not possessed. I am not a bad mother (but rather a mother with a tainted history of sleep walking and a legendary history of brushing my teeth with my underwear at age five). So that history behind me, here’s how to possibly sort out those rough nights, with perfect days (as your little ones don’t remember shit, but we remember everything). Here come the hard facts or as I call them, the “Parasomnia Stories." How common are sleep disorders in children?

Sleep disorders, or parasomnias, occur in an estimated 35-45% of children aged 2-18 years.  The most common disorders brought to us in practice include nightmares, night terrors & sleepwalking/sleeptalking.

Sleep is divided into 2 distinct states - REM (rapid eye movement) or “light sleep” and non-REM “deep sleep.” These states alternate every 90-100 minutes through the night.

REM is more of a “wakeful pattern” and constitutes about 25% of the night.

  • Only 90-120 minutes total –
    • 4-5 periods all night
    • gradually lengthen as the night goes on
    • newborns spend about 80% of time in REM
    • aids processing of creativity
    • if REM-deprived, higher risk of depression

Non-REM is present 75% of the night

  • SWS (slow wave sleep) is part of non-REM…also known as “deep sleep”
    • Young children typically enter this phase of deep sleep within 15 minutes of going to bed (thus making it easy to move them)
    • During SWS, growth hormone is made
    • The phase in which the brain recovers from daytime activities
    • Memory processing takes place

NIGHTMARES – occur during REM sleep (the “wakeful” state)

Nightmares are common in younger kids- 30% regularly, but 75% of kids experience a nightmare, at least once. They are defined as recurrent episodes of awakening from sleep with recall of intensely disturbing dream content (typically involve fear, anxiety, anger, sadness, disgust or other negative emotions).

  • Usually occur in the second half of the night when REM states start to lengthen
  • Frightening for the child and the family
  • Prevalence declines in school age and adolescence due to progressive maturing of the brain
  • EYES ARE TYPICALLY CLOSED:  On waking, child is: Alert, easy to arouse; Able to recall the dream in detail;If pre-verbal, able to fall asleep quickly after comforting from parent or caregiver; Able to recall the event the next morning
  • Can impair daily function due to loss of sleep

WHAT TO DO IF YOUR CHILD HAS NIGHTMARES

  • Identify triggers, if any: Child getting “second hand news” – young children frightened by overheard conversations, violence, or misinterpreting news
  • Reduction and editing of media
  • Sleep hygiene – good naps and good bedtime
  • Wake your child if distressed – should be responsive, alert and easily consoled; talk briefly about his/her nightmare, let them disclose content and reassure just a nightmare and then tuck back to sleep

NIGHT TERRORS

  • Also known as sleep terrors
  • Affects 1-6% kids
  • Defined as episodes of extreme panic and confusion associated with vocalization, movement, and autonomic discharge (dilate pupils, gooseflesh, panic, excessive movement, agitation) – eyes are open, child appears awake but is NON-RESPONSIVE to comforting
  • Occur during non-REM sleep (deep sleep) – thus difficult to arouse and console
  • Occur in first third of the night – when non-REM sleep is in greater proportion
  • Child has NO recall of dream or nightmare the next day
  • On waking, child is: Confused, disoriented

WHAT TO DO IF YOUR CHILD HAS NIGHT TERRORS

PREVENTION: Look at triggers:  lots of new activities (onset of school, camp, lots of social events), loss of naps, illness, medications, disruption of usual routine are typical

  • simplify life- cancel some activities, restore a more restful mellow routine
  • insure that young children nap
  • no media before bedtime and don’t let kids stay up late
  • keep a diary of awakenings, typically they’ll be about the same time each night
    • once that is known, actually wake your child gently about 30 minutes before the anticipated terror, tuck back to sleep
    • do this for 7-10 nights; this approach often aborts the cycle

Listen in: Make sure no obstructive sleep apnea symptoms – irregular snoring, thrashing – this may require medical intervention

Provide: Safe sleep environment to prevent harm 

IF YOUR CHILD IS IN A TERROR:

  • Empty bladder before bedtime, and during the terror quietly walk child to the toilet to see if he/she can void
  • DON’T attempt to wake your child
  • KEEP LIGHTS AND STIMULATION to a minimum
  • DON’T PANIC – as some terrors are terrifying to parents
  • Wrap child in your arms or in a blanket, rock and shush until their body tone relaxes, then get them back in bed.
  • A new device called  Lully, when placed under the mattress and paired with its app, can help parents by providing a gentle stimulus around the time of a night terror, and pull a child out of the unhealthy phase of sleep that leads to a terror. www.lullysleep.com

SLEEPWALKING & SLEEPTALKING

  • Occurs in 1-15% of the general population
  • most prevalent in children – usually disappears by adolescence – peaks 4-8 years, again at 11-12 years, then dissipates

Defined as recurrent episodes of incomplete awakening from sleep, usually without the terrifying feeling of the night terror.

  • Occurs typically in the first 1/3 of the night – slow wave non-REM, deep sleep
  • Rises from bed and walks about and can perform activities that are usually performed in full consciousness – sitting up in bed, cooking, driving, cleaning, and even violent gestures
  • May see lipsmacking, pulling at clothing or chewing are observed
  • Eyes open but blank, staring face, relative unresponsiveness to efforts at communication
  • little or no memory of event
  • lasts 30 seconds to 30 minutes
  • can be inherited – runs in families and identical twins - 45% chance in child if one parent affected, 60% if 2 parents with history
  • Triggers: sleep deprivation, fever, excessive tiredness, medications, stress
  • More often seen in children with enuresis (bedwetting), restless leg syndrome and sleep disordered breathing (obstructive sleep apnea)

What to do:

  • provide safe sleep environment – lock doors and windows, dangerous objects put away
  • avoid sleep deprivation – regular bedtime and regular naps
  • divided opinion on whether to wake – most advise guide sleepwalker back to bed
  • tend to illness, stress
  • keep a diary of sleep walking/talking, typically they’ll be about the same time each night
  • once that is known, actually wake your child gently about 30 minutes before the anticipated event, tuck back to sleep
  • do this for 7-10 nights – may take more repetitions than night terrors
  • this approach often aborts the cycle
  • LISTEN IN: if irregular snoring, thrashing, see your doctor to evaluate for obstructive symptoms

JJ3BIO: Dr. JJ Levenstein has spent the last 30 years caring for children. She received her undergraduate degree from UC Berkeley, graduated summa cum laude with a second undergraduate degree from Duke University, and completed training as a Physician Assistant with a specialty in Pediatrics at Norwalk Hospital/Yale University. After serving as a Pediatric PA for 5 years, she was accepted at the Keck School of Medicine at USC and completed her internship and residency at Children's Hospital of Los Angeles. There she was acknowledged as the outstanding pediatric intern, and was also recognized as one of the top three graduating residents in her class. While in private practice, she was voted one of the Best Doctors in America® 2004 through her retirement in 2012 and recognized as one of the top pediatricians in her community.

Dr. JJ continues as a fellow of the American Academy of Pediatrics and continues to be committed to promoting infant and child health by serving as an educational and media speaker and is also a regular contributor to several parenting websites. Since 2013 she has appeared as a regular medical expert on Hallmark Channel’s Home & Family television show, and leads the Food Allergy Awareness Committee for the National Peanut Board.