Psychiatric Times.
No. 11
Assessment and Management of Sleep Disorders in Children
By Anna Ivanenko, MD, PhD and Clifford Massie, PhD |
October 1, 2006
Behavioral interventions for RLS and PLMD include maintenance of a stable sleep-wake schedule; avoiding sleep deprivation; reducing caffeine(Drug information on caffeine) intake; and eliminating tobacco, alcohol(Drug information on alcohol), and stimulating activities close to bedtime. Medical interventions include iron supplementation and pharmacologic treatment. Iron therapy is usually recommended if the child's serum ferritin level is below 35 µg/L. Serum ferritin levels should be monitored every 3 to 4 months and iron therapy should be discontinued when the serum ferritin level rises above 35 to 50 µg/L. Iron supplementation reduces the number of periodic limb movements and improves daytime functioning in children with symptomatic PLMD.30
Dopaminergic medications such as pramipexole(Drug information on pramipexole) and ropinirole(Drug information on ropinirole) are used in adults with RLS, and evidence suggests that these drugs are effective in children as well.14 Ropinirole is FDA-approved for RLS treatment in adults but not in children. The lowest available dose of ropinirole is 0.25 mg and the maximum recommended adult dosage for RLS is 4.0 mg per day.31 Gabapentin(Drug information on gabapentin) is another pharmacologic agent that may be effective in reducing symptoms of RLS in children. While there are no clinical trials to determine the effectiveness of gabapentin for RLS, pediatric epilepsy trials have demonstrated the safety and tolerability of gabapentin.32
Narcolepsy
Treatment options for narcolepsy include pharmacotherapy and behavioral intervention. Children and adolescents with narcolepsy should adhere to good sleep habits. Specifically, children with narcolepsy should obtain adequate nocturnal sleep and maintain a consistent sleep-wake schedule, since alterations to sleep patterns can exacerbate daytime sleepiness. Patients should avoid alcohol and recreational substances, and adolescents need to be cautioned about the perils of driving or operating machinery when sleepy. Planned daytime naps are quite beneficial. Counseling and support groups are helpful for both the patient and the family.
Long-term administration of pharmacologic agents may be required to reduce sleepiness and improve daytime alertness. Longer-acting stimulants, such as modafinil(Drug information on modafinil), administered in the morning can provide all-day benefits. Stimulants with a short duration of action, such as methylphenidate(Drug information on methylphenidate), can be used alone or in combination with modafinil. There are no double-blind placebo-controlled studies in children with narcolepsy.
In a small sample of children, 200 mg to 600 mg of modafinil daily reduced daytime sleepiness without significant side effects.33 Because of its favorable side-effect profile, this medication may be considered as initial medication for the treatment of excessive daytime sleepiness in children with narcolepsy.34 Methylphenidate and dextroamphetamine have been used successfully in treating excessive sleepiness in children with narcolepsy and are well tolerated. Tricyclic antidepressants and SSRIs may be used to treat cataplexy and other symptoms of narcolepsy, such as sleep paralysis and hypnagogic hallucinations.
Snoring and OSA
Snoring and OSA in children are often the result of adenotonsillar hypertrophy, obesity, sinus problems, or craniofacial abnormalities.35 Adenotonsillectomy is often the first treatment.36 PSG is recommended before surgery to assess the severity and nature of the sleep-disordered breathing and should be performed postoperatively to assess treatment efficacy.36 Postsurgical PSG has shown that surgery is curative in about 80% of cases.37 Additionally, children with sinus problems may benefit from inhaled nasal corticosteroids.38
Continuous positive airway pressure (CPAP) is appropriate for children who have either failed to respond to surgical intervention or are not candidates for surgery.
36 Its efficacy and tolerability has been reported in a number of studies.
39,40 The use of CPAP was recently approved by the FDA for children aged 7 years and older who weigh more than 40 pounds. An attended laboratory titration of CPAP should be performed to determine effective treatment. Supplemental oxygen is not recommended for routine use in children with OSA because of the risks of developing hypoventilation.
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Drugs Mentioned in This Article
Clonazepam (Klonopin, Rivotril)
Dextroamphetamine (Dexedrine)
Diazepam (Valium)
Diphenhydramine HCI (Benadryl, others)
Gabapentin (Neurontin)
Lorazepam (Ativan)
Melatonin (Bevitamel)
Methylphenidate (Ritalin LA)
Modafinil (Provigil)
Montelukast (Singulair)
Pramipexole (Mirapex)
Ropinirole (Requip)
Trazodone (Desyrel)
Evidence-based Medicine:
- Kuhn BR, Elliot AJ. Treatment efficacy in behavioral pediatric sleep medicine. J Psychosom Res. 2003;54:587-597.
- Owens JA, Babcock D, Blumer J, et al. The use of pharmacoltherapy in the treatment of pediatric insomnia in primary care: rational approaches. A consensus meeting summary. J Clin Sleep Med. 2005;1:49-59.
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