Insomnia and sleep hygiene: Making friends with the monsters under your bed and the voices in

your headJamie Neal, APRN

10/24/14

Objectives Explain the importance of sleep Describe the symptoms of insomnia Identify treatment of insomnia Describe the symptoms of restless leg

syndrome (RLS) Identify treatments for RLS Describe good sleep hygiene techniques

Why is sleep important? Insufficient sleep can

lead to: Mood disturbances

◦ Irritability, emotional lability, depression, anger

Fatigue and daytime lethargy

Cognitive impairment◦ Memory, attention,

concentration, decision making, problem solving

Daytime behavior problems◦ Over activity, impulsivity,

noncompliance Risk taking behaviors Academic problems

◦ Chronic tardiness, falling asleep in class

Use of stimulant meds◦ Other alertness

enhancers like caffeine, nicotine

Sleep Requirements for kids

By Age What they are really getting

Infant 14-15 hrs Toddler 12-14 hrs Preschool 11-13 hr School age 10-11hrs Adolescents 9.5 hrs

Infant 12.7 hrs Toddler 11.7 hrs Preschool 10.3 hrs

School age 9.5 hrs Adolescents 7 hrs

Difficulty with sleep initiation, duration, consolidation or quality that occurs despite adequate time and opportunity for sleep and results in daytime impairment

Acute (adjustment) insomnia-short lived due to life circumstances (identifiable stressor) ◦ i.e.: can’t fall asleep because of a test the next day,

it’s the first day of school Chronic insomnia-at least 3 nights a week for 3

months. ◦ Can be associated with a comorbidity, but not always.

What is insomnia?

Types of Insomnia Behaviorally induced Insufficient sleep Psycho physiologic Paradoxical Medical problems Psychiatric conditions

Relies on inappropriate sleep association Usually presents with frequent night time

awakenings The process of falling asleep is associated

with a specific habit, object, or setting Child becomes unable to fall asleep within a

reasonable time in the absence of these conditions

Examples: extended rocking, parent has to sleep with child or vice versa

Behavioral insomnia- sleep onset-association type

Stalling or refusing to go to bed When parent enforces limits, child falls asleep

quickly Problem arises when parent has trouble setting

and maintaining limits and managing the stalling behavior (inconsistent)

Child’s stalling techniques are based on what they have learned will work

Examples: refusing to put on pajamas, get in bed, saying they are scared, need kisses, etc

Daytime anxiety may trigger night time fears

Behavioral insomnia- limit setting type

◦ Bedtime or middle of the night fears◦ Begin in the preschool years, disappear age 5-6◦ May be provoked by anxiety, stress, traumatic

events◦ Treatments:

Try monster spray Have a pet sleep in the room Security objects Night lights Have the child involved in the solution

Night time fears

◦ Frightening dreams that cause waking, are upsetting and require comfort

◦ Start around age 2◦ Treatment: think happy, pleasant thoughts at

bedtime

Nightmares

Heightened mental arousal and learned sleep-preventing associations

May be associated with emotional reactions Hyper vigilant about sleep Can complain of “racing main” The more the person tries to sleep, the more

irritated they become and the less able one is to fall asleep

People who sleep better when they are not in their own bedroom

May be associated with people who are overanxious about their overall health

Psycho physiologic insomnia

Complaints of severe insomnia that occurs in the face of a normal sleep study or without evidence of an objective sleep disturbance

The severity of the night time complaint is not matched by evidence of pathologic daytime sleepiness ◦ still complain of being tired◦ may not be falling asleep at school, work

No other psychiatric illnesses No suspicion of malingering Overestimate of how long it takes to fall asleep

and underestimate total sleep time

Paradoxical insomnia

Persistent failure to obtain the amount of sleep required to maintain normal levels of alertness and wakefulness

Voluntary but unintentional chronic sleep deprivation

Sleep history of the current sleep patterns reveals disparity between the amount of sleep they are getting and the amount of sleep they need!

Insufficient sleep syndrome

Restless leg syndrome Central apnea Pain-low back pain, chronic pain GI issues such as reflux Arthritis Endocrine issues such as hyperthyroidism Neurological conditions such as Parkinson’s

Medical causes of insomnia

Bipolar disorder Depression

◦ Insomnia can be a symptom of depression, especially middle of the night waking

◦ Increased risk of severe insomnia in the face of major depressive disorder

Anxiety◦ Tension◦ Ruminating about past events◦ Worrying about future events◦ Feeling overwhelmed◦ Feeling over stimulated

Psychiatric causes of insomnia

Restless Legs Syndrome (RLS)

A sensory disorder characterized by an uncomfortable sensation in extremities accompanied by an urge to move the extremities while awake

Sensations relieved by movement (walking, rubbing, stretching, shaking, rocking)

Legs and arms can be affectedEpisodes occur or are exacerbated by

episodes of rest (sometimes with exercise)Worse in the evening

Sensory RLS Symptoms in Children Ants, spiders, bugs crawling on legs “Lightening in my legs” Squeezing, tingling, itching, aching, or

hurting “My legs feel wiggly” “My legs want to run” “My legs won’t stay still” “Lava running down my legs”

Mechanism of Iron in RLS/PLMD

Low brain iron stores leads to disrupted dopamine synthesis in the CNS= reduction of dopamine availability within critical regions of the brain= development of RLS/PLMD

Risk Factors for RLS

Genetic link, especially first degree relative Sleep deprivation Medical Conditions: iron deficiency anemia,

end stage renal disease, hypothyroidism, DM

Pregnancy Medications: antihistamines,

antidepressants, antipsychotics, antiemetic Caffeine and alcohol may increase RLS

symptoms

Treatment: Iron Supplementation

First line treatment in children with ferritin levels less than 50 ng/mL

Goal is to increase peripheral iron levels and to increase iron stores

Ferritin acts as a marker for the stored iron levels in the body

Goal for iron treatment is a ferritin between 50-70 ng/mL

Dose for oral iron : 3-6 mg/kg/day for 3 or 6 months Iron is continued for 3 month intervals and iron and

ferritin levels are assessed along with clinical improvement (improved RLS sensations, less difficultly with sleep onset, maintenance)

Iron Supplementation Sounds easy, right?

Oral iron is poorly absorbed Compliance with medications for many months

is difficult Liquid iron tastes bad! (We have them take it

with orange or apple juice) Calcium, magnesium, zinc all bind with iron and

decrease absorption Anti reflux medications decrease iron absorption Side effects: most common is constipation Iron toxicity a risk of acute iron overdose

Iron is not the same as lead!

Other RLS treatment Dopamine agonists

◦ Act like dopamine◦ Pramipexole (Mirapex)◦ Ropinirole (Requip)◦ First line treatment for adults (not FDA approved

for kids) Anticonvulsants

◦ Gabapentin (off –label) Alpha 2 agonists

◦ Clonidine (short term use only)

Dim lights 1 hours before bed Room darkening shades and curtains Colors and decorations that are relaxing Room temp between 60 and 67 degrees Comfortable mattresses, pillows and sheets Reduced noise with white noise or fan Keep the TV off while asleep Relaxing scents like lavender

National sleep foundation

Sleep-Friendly environment

Sleep hygiene reality… Watching television is the most popular activity

(76%) for adolescents in the hour before bedtime◦ surfing the internet/instant-messaging (44%)◦ talking on the phone (40%)

Nearly all adolescents (97%) have at least one electronic item in their bedroom.◦ 6th graders=2 items, 12th graders=4

Adolescents with four or more items are 2x likely to fall asleep in school and while doing homework.

• National Sleep Foundation 2006, 2011 Sleep in America Poll.

27% of parents of teens who leave electronic device ON rate their teen’s sleep as excellent

53% of parents of teens who leave devices OFF rate their teen’s sleep as excellent

17% of parents said that their child read or sent electronic communications after initially going to bed

On school nights, teens who leave their TV or iPod on get 1 hour less sleep than those who don’t

On school nights, teens who leave their phone on get 2 hours less sleep than those who don’t

National Sleep Foundation

Electronics and sleep

Kids using electronics as a sleep aid to relax at night have later weekday bedtimes fewer hours of sleep per week and report more daytime sleepiness

Teens with a TV in their bedroom have later bedtimes, more trouble falling asleep and shorter total sleep times

Texting and emailing after bedtime, even once per week, increases self-reported daytime sleepiness among teens

National Sleep Foundation

More bad news about electronics and sleep

Treatment of insomnias

Improve the sleep hygiene!◦ Regular bedtime routine and bedtime◦ 1 hr of sunlight exposure early in the day◦ Regular physical activity◦ Dim lights in the evening◦ No stimulating activities (TV, video/computer

games) for at least 1 hr prior to bedtime◦ No caffeine or chocolate, ◦ Bath time earlier?◦ Relaxing activity when first getting in bed?

Naps Naps may help to improve:

◦ Alertness◦ Performance◦ Memory recall

◦ Short nap(under 45 minutes) Only if no sleep onset/ maintenance problems

Ficca et.al., Sleep Medicine Reviews, 2010Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006

Light and Sleep

Exposure to light before sleep can inhibit production of melatonin◦Decrease/avoid light at night◦Increase exposure during the day

Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006

Bonnefond et al., Industrial Health, 2004

Melatonin Sleep Time Tea Natural supplements Marley’s Mellow Mood Lazy Cakes

Sleep aids

Secreted by pineal gland Tryptophan → 5HTP → serotonin → melatonin Natural melatonin levels rise at night about

1-2 hours prior to bedtime Give melatonin 1-2 hours prior to bedtime Adult doses range from 0.3mg to 10mg NSF warns against using in patients with

immune system disorders, cancers, taking corticosteroids or immune suppressants

Melatonin

Not regulated by FDA Considered dietary supplement Works best in children with

◦ Circadian rhythm disorders ◦ Mid-line brain defects such as agenesis of the

corpus callosum ◦ Blindness ◦ ADHD◦ Autism

Melatonin and kids

Marley’s Mellow Mood

Lazy cake relaxation brownies

Healthy sleep tips Stick to the same

bedtime and wake time, even on the weekends

Have a relaxing bedtime ritual

Avoid naps, especially in the afternoons

Exercise daily Adjust your sleep

environment

Sleep on a comfy bed Use bright light to help

manage your circadian rhythm

Avoid alcohol, cigarettes and heavy meals in the evening

Give yourself some wind down time

Go to another room and do something relaxing until you are tired

Scaring your child to sleep i.e.: the bogeyman

Talking negatively about ghosts Letting kids watch scary movies, TV shows Discussing vampires, werewolves and

zombies Letting kids play scary video games

Things that won’t help

Goya 1797 Que Viene el Coco (Here comes the bogeyman)

The boogeyman – German/English An imaginary creature used to scare

children into behaving well Aka “If you don’t go to bed right now, the

boogeyman is going to get you” There is a similar creature in many

cultures and countries Usually male He has a sack to carry naughty children

away

Resources for Parents Guide to Your Child’s Sleep.

◦ George J. Cohen, M.D., F.A.A.P. Take Charge of Your Child’s Sleep.

◦ Judy Owens, M.D., and Jodi Mindell, Ph.D. Sleeping Through the Night.

◦ Jodi Mindell, Ph.D.

References American Academy of Pediatrics Section on Pediatric

Pulmonology. 2011. Pediatric Pulmonology. American Academy of Pediatrics.

American Academy of Sleep Medicine. 2005. The international classification of sleep disorders. 2nd edition. American Academy of sleep medicine.

Mindell, J.A & Owens, J.A. 2003. A clinical guide to pediatric sleep: diagnosis and management. 2nd edition. Wolters Kluwer.

Sheldon, S.H., Ferber, R., Kryger, M.H. 2005. Principles and practice of pediatric sleep medicine. Elsevier Inc.

Panitch, H.B. 2005. Pediatric Pulmonology The Requisites in Pediatrics. Elsevier Inc.

Eggermont S., & Van den Bulck J. 2006. Nodding off or switching off? The use of popular media as a sleep aid in secondary-school children. Journal of Paediatrics Child Health. Vol 42 (7-8) pp 428-433b

Shochat, T., Flint-Bretler O., &Tzischinsky O. 2010. Sleep patterns, electronic media exposure and daytime sleep-related behaviours among Israeli adolescents. Acta Paediatrics Vol 99 (9) pp 1220-1223

Pelayo, R., & Dubik, M. 2008. Pediatric Sleep Pharmacology. Semin Pediatr Neuro. 15: 79-90.

Picchietti, D., Allen, R.P., Walters, A.S., Davidson, J.E.Myers, A., et al. 2007. Pediatrics. Restless legs syndrome: Prevalence and impact in children and adolescents the pediatric REST study. 120; 253-266

References

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