Introduction to Sleep Health

The Biology of Sleep

There are four stages of sleep (3 stages of NREM sleep and REM sleep)

1 Transition from Wakefulness to Sleep (Non Rapid Eye Movement (NREM))

• Intensive sleepiness
• Sometimes hypnogogic hallucinations and/or brief involuntary muscle contractions
• EEG pattern transitions to shorter frequency theta waves

2 Initiation of True Sleep (NREM)

• EEG pattern with changes including sleep spindles and K-complexes
• Average adults spend about 50% of the night in this stage

3 Deep Slow Wave Sleep (NREM)

• EEG pattern shows delta waves (low frequency, high amplitude)
• Least responsive to external stimuli
• Considered "deep sleep"
• Most parasomnias (bed wetting, sleep walking, night terrors) occur during this phase
• Decreases in frequency after childhood

4 REM Sleep

• EEG pattern shows bursts of rapid eye movements
• High brain metabolic rate
• Variable heart rate
• Active suppression of peripheral muscle tone
• Desynchronized cortical activty
• Dreaming, including nightmares, occurs during this phase

The average time to go through all stages of sleep is defined as one sleep cycle. The usual sleep cycle for children and adults is 90-110 minutes.

Sleep architecture changes over the lifespan.

• REM peaks in infancy with 50% of sleep in REM and declines to 30% in teen/adulthood.
• N3 sleep peaks in childhood and declines over the lifespan.
• Increase in N1 and N2 as one ages.

The first REM phase occurs 70-90 minutes after falling asleep. The majority of NREM sleep in adults occurs during the beginning of the sleep period, with more REM sleep towards the end. The purpose of NREM sleep is for rest and restoration with low brain activity.

Complex interactions of circadian rhythms, sleep/wake homeostasis, ultradian rhythms, neurophysiology of sleep, and biological rhythms regulate sleep.

• Circadian rhythms are cyclic biologic changes, which occur with a regular interval, usually 24 hours. The suprachiasmatic nucleus in the ventral hypothalamus drives this process. External environmental cues such as light and daily routines influence circadian rhythms.
• Sleep/wake homeostasis is the biological drive to maintain a balance between sleep and wakefulness. It is influenced by accumulation of sleep-promoting substances called somnogens, which accumulate during wakeful periods and are dissipated during sleep.
• Ultraradian rhythms or sleep cycles are generally organized into 2 main types: REM and NREM.

Newborn (NBN) sleep is different from adult sleep. During the first 6 months of life, infant sleep transitions from periods of Active (similar to REM), to Indeterminate or Non-Active sleep (similar to NREM).

• NBN-6 months of age-enter the sleep cycle through Active sleep then transition to Non-Active sleep.
• Infant sleep cycles last about 45-60 minutes
• More time is spent in Active sleep reflecting the rapid growth and development that is occurring in the brain. Newborns spend 50% of sleep time in REM sleep. Time spent in REM sleep decreases to 25-30% by 1 year of age. Sleep periods are consolidated over the first 5 years of life with increased overnight sleep and decreased napping.

Quality and recommended quantity of sleep contribute to:

• Positive learning outcomes in children.
• Better overall health.
• Development of better interpersonal relationships.
• Better approaches to problem solving.

Lack of good quality and/or quantity of sleep may contribute to:

• Lack of interest in learning and concentration.
• Development of chronic health issues.
• Dysfunctional interpersonal relationships.
• Behavioral problems.

Recommendations for Hours of Sleep Based on Age

Age	American Academy of Sleep medicine (AASM) Sleep hours/24 hour period
0-3 months	N/A
4-12 months	12-16
1-2 years	11-14
3-5 years	10-13
6-12 years	9-12
13-18 years	8-10

American Academy of Sleep Medicine. Paruthi, S, et al. JCEM. 2016; 12(6): 785-786.

Safe Sleep/Sleep Hygiene

In evaluating and educating on safe sleep practices, family values, beliefs, and culture should be considered. Across cultures you may find variations in where infants and children sleep, expected hours of sleep in a 24 hour period, co-sleeping, what type of surface they sleep on, use of pacifiers and other cultural expectations. It is important to explore these areas with families/patients.

Infant Safe Sleep/Sleep Hygiene

The American Academy of Pediatrics (AAP) updated its recommendations for a safe infant sleeping environment in 2016. Highlighted below are some of the recommendations.

• Back to sleep for every sleep.
• Use a firm sleep surface.
• Breastfeeding is recommended.
• Room-sharing with the infant on a separate sleep surface is recommended.
• Keep soft objects and loose bedding away from the infant’s sleep area.
• Consider offering a pacifier at naptime and bedtime.
• Avoid smoke exposure during pregnancy and after birth.
• Avoid alcohol and illicit drug use during pregnancy and after birth.
• Avoid overheating.
• Continue the “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant deaths, including SIDS, suffocation, and other unintentional deaths. Pediatricians and other primary care providers should actively participate in this campaign.
• Avoid the use of commercial devices that are inconsistent with safe sleep recommendations.
• Supervised, awake tummy time is recommended to facilitate muscular development and to minimize development of positional plagiocephaly.

Sudden Unexpected Infant Death and Sudden Infant Death Syndrome

Sudden unexpected infant death (SUID) describes any sudden and unexpected death that occurs during an observed or unobserved sleep period, whether explained or unexplained. After case investigation, SUID can be attributed to several medical conditions that were unknown before the death or unintentional or nonaccidental trauma.

Sudden Infant Death Syndrome (SIDS) is a subcategory of SUID. SIDS is the death of infants before their first birthday the cause of which cannot be explained after a thorough case investigation, including a scene investigation, autopsy, and review of the clinical history.

FAST FACTS

• In 2015, there were about 3,700 SUID cases in the United States.
• In 2015, there were about 1,600 deaths due to SIDS, 1,200 deaths due to unknown causes, and about 900 deaths due to accidental suffocation and strangulation in bed.
• In addition to the above recommendations for safe sleep, the AAP does not recommend the use of home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS.

Infants, Children and Adolescents Safe Sleep/Sleep Hygiene

As children grow they have different sleep requirements which must be taken into consideration when counseling families on safe sleep practices and evaluating for sleep problems. The AAP, via its Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, has recommendations for safe sleep and sleep hygiene practices for older infants, children, and adolescents.

Approximately 9 months:

• Continue infant safe sleep recommendations.
• Put baby on back while they sleep even though they may be turning over.
• Start a bedtime routine (singing, reading, warm bath).
• If baby continues to wake during the night, check in on the baby, sooth, and put the baby back to sleep.
• When baby begins to stand, lower crib to lowest level.

1-2 year olds

• Bedtime should be the same time every day.
• Continue safe sleeping environment.
• Continue soothing bedtime routine.
• Favorite toy may be used.
• Night-lights may be helpful.
• Put in crib awake to help establish routine.
• If using “time-outs” for discipline, do not use the child’s bedroom/sleeping area for this purpose.

2-5 year olds

• Make sure their sleeping area is safe and comfortable.
• Sleeping area should not be used for discipline.
• Child should have a daily routine established which may include nap time.
• Bedtime routine should be continued.
• TV and electronic interactions should be discontinued early in the evening to encourage quality sleep.
• Children should not have a TV or electronic devices in their bedroom/sleeping area.
• Make sure physical activity is part of the daily routine.

Middle childhood (5-10 year olds)

• Daily routines should be well established and include physical exercise.
• Number and duration of naps decreases, and may be eliminated.
• Maintain safe and comfortable sleeping area.
• Continue bedtime routine, however, this may change and the child should be given safe age appropriate choices in this routine.

Adolescence (11-21 year olds)

• Maintain safe, healthy routines that are age appropriate throughout the day.
• Maintain a safe, healthy place for sleeping and this place should be used only for sleeping (no homework, reading, electronic devices).
• No TV in bedroom.
• Remove all electronic devices from bedroom including cell phones before teen goes to bed.

It is a normal part of development during puberty for adolescents to go through a sleep phase delay. This causes a shift in circadian rhythm resulting in a shift of the internal clock by 2 hours. This results in teens wanting to have a later bedtime and wake time.

Screening

At each well child visit the practitioner should inquire about the sleeping habits of the patient. There are several pediatric validated screening tools to evaluate for sleep problems in an office setting. Additionally if there are concerns about sleep, suggesting the parent /child keep a sleep diary may be helpful.

BEARS Sleep Screening

The “BEARS” (Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity and duration of sleep, and Snoring) instrument is divided into five major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children from 2-18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview. If a trigger question is answered with a positive response, further evaluation is indicated.

	Toddler/preschool (2-5 years)	School-aged (6-12 years)	Adolescents (13-18 years)
Bedtime Problems	Does your child have any problems going to bed? Falling asleep?	Does your child have any problems at bedtime? (P) Do you have any problems going to bed? (C)	Do you have any problems falling asleep at bedtime? (C)
Excessive Daytime Sleepiness	Does your child seem overtired or sleepy a lot during the day? Does (s)he still take a nap?	Does your child have difficulty waking in the morning, seem sleepy during the day or take naps? (P) Do you feel tired a lot? (C)	Do you feel sleepy a lot during the day? In school? What driving? (C)
Awakenings during the night	Does your child wake up a lot at night?	Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? (P) Do you wake up a lot at night? Have trouble getting back to sleep? (C)	Do you wake up a lot at night? Have trouble getting back to sleep? (C)
Regularity and duration of sleep	Does your child have a regular bedtime and wake time? What are they?	What time does your child go to bed and get up on school days? Weekends? Do you think (s)he is getting enough sleep? (P)	What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get? (C)
Snoring	Does your child snore a lot or have difficulty breathing at night?	Does your child have loud or nightly snoring or difficulty breathing at night? (P)	Does your teenager snore? (P)

P=Parent answers question, C=Child answers question

Adapted with permission from Mindell JA & Owen JA (2003). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. Philadelphia: Lippincott Williams & Wilkins.

The Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD)

The ESS-CHAD is another screening tool which can be used to assess sleep problems in children. It is evaluates 8 domains using a 0-3 Likert scale describing likelihood of falling asleep during different situations. The questionnaire is copyrighted and a license is required to use it.

A sample questionnaire can be found on the Epworth Sleepiness Scale website.

Sleep Diaries

A sleep diary is an important tool to gain additional information concerning a child’s/adolescent’s sleep patterns. Depending on each situation, you may want to change the format. This is illustrated in the cases throughout the modules.

Here is a sample Sleep Diary

Sleep Testing

In certain situations a formal sleep test, or overnight polysomnogram may be needed. An in lab sleep test monitors EEG waves, respiratory rate, respiratory effort, heart rate, oxygenation, carbon dioxide, and limb movement. The study is monitored by a sleep technician who records observations such as loud snoring, awakenings, unusual body positioning or posturing. The report of all the measurements is reviewed by a sleep doctor.

Sleep studies can be used to evaluate for obstructive sleep apnea, seizures during sleep, ventilation during sleep, parasomnias, limb movement disorders, sleep latency, evaluation of noninvasive ventilation (BiPAP or CPAP), ventilator titration, and titration of oxygen.

Medicine	Medical providers (MD, PA, APNP) should routinely ask about daily health habits including sleep duration, quality, signs and symptoms of sleep disturbance, and sleep hygiene. Obtain additional information about medications that might be interfering with sleep, daily activities and possibly follow up with parent/teen. Explore environmental factors that may affect quality of sleep.
Nursing	Follow up phone calls to determine treatment response from recommended interventions. School nurses should include sleep issues when asked to consult around issues of disruptive behavior, falling asleep in class, obesity or poor academic performance. They should also inquire about the environmental issues that can affect quality sleep
Nutrition	Review of general dietary practices that may impact sleep including caffeine intake, late night or middle of the night eating, nutrient deficiencies, obesity, poor nutrition or over nutrition. Additionally, in children with special health care needs, assessment of overnight G-tube feedings is pertinent to sleep history.
Pharmacy	Determine what medications the patient is taking that may have an impact on routine sleep that can contribute to difficulty falling asleep, vivid dreaming or daytime sleep/wake pattern. Check for potential drug interactions and timing of medication administration.
Respiratory Therapy	Assist with diagnostic testing such as polysomnography (sleep studies) and be involved in the introduction, titration, patient education, and monitoring of therapeutic treatments.
Social Work and Mental Health	Parents/teens may be referred to a Social Worker if other professionals have determined the need for more thorough assessment of family or environmental factors interfering with adequate sleep.
Family Perspective and Leadership	Help determine if the family’s concerns are being appreciated by the entire team and if recommendations are realistic for the family to follow.