Sleep in Medically Compromised Children
By Warren, Sharon
This article reviews the literature on pediatric sleep with a focus on children with chronic medical conditions. Children and adolescents with chronic medical conditions can display abnormal patterns of sleep, including frequent arousals, increased wake time, and reduction of stage 4 sleep. Poor sleep quality can contribute to problems with school attendance and performance, ability to concentrate, and neurocognitive function.1 Additionally, sleep disturbances can be associated with more depressive symptoms and reduced social and emotional functioning.2
Sleep can be disturbed in medically compromised children for a
number of reasons. Pain, whether from injury, from a chronic condition, or from hospital care procedures, can disrupt sleep. For hospitalized patients, light levels and noise volumes can be very different from typical sleeping conditions.3 Procedures, diagnostic testing, and monitoring activities also frequently occur during nocturnal hours. In addition, medications can change both the onset and the architecture of sleep. Medications are typically administered to hospitalized patients for sleep promotion, anesthesia for procedures, depression, seizure, and anxiety. Additionally, certain commonly prescribed pharmacologie agents for chronic conditions can further alter sleeping patterns. Considerations for specific conditions are described below.
ASTHMA
Although asthma-related sleep disturbances have been reported in approximately 80% of adult patients with asthma, pediatric studies have been more limited. However, research indicates that one third of asthmatic children report at least one awakening per night.1
A number of nocturnal physiological changes could contribute to the exacerbation of asthma during sleep; e.g., a decrease in lung volume, increase in intrapulmonary blood volume, reduced muco- ciliary clearance, and nocturnal gastroesophageal reflux (GER).1 Questionnaire-based studies have shown that asthmatic children rate themselves as significantly more tired in the morning compared with normal controls.4
Some nocturnal symptoms can be prevented by using sustained release or long-acting medications. Reduction of allergens in the sleeping environment (e.g., , use of hypoallergenic bedding materials and mattress and pillow covers, elimination of dust-mite collectors such as rugs and stuffed toys, addition of air- filtration systems) may be particularly helpful in children with reactive airway disease related to environmental allergies.
BURN INJURIES
Over half of patients recovering from burn injuries report sleep disturbances.5 Pediatric burn victims can experience nocturnal disturbances such as arousals with nightmares, bed-wetting, sleep- walking, or daytime abnormalities such as age-inappropriate need for naps. Factors that can negatively impact sleep in burn patients include pain, anxiety, depression, pruritus, medications, treatment setting, and upper airway obstruction.
A questionnaire-based study by Boeve et al. on burn victims indicated that while quantity of sleep did not change after burn injury, sleep quality diminished dramatically.6 Polysomnography studies on sleep architecture in burn patients indicate changes such as increased stage 1 and stage 2 sleep, increased arousals, and decreased REM sleep and sleep in stages 3 and 4, also referred to as slow-wave sleep. This is especially troubling in pediatric patients, because peak growth hormone (GH) secretion occurs during the first period of slow wave sleep. There is a positive correlation between the reduction of GH release and the reduction of slow-wave sleep. Diminished GH secretion can have negative effects on wound healing, appetite and weight gain.5
Commonly prescribed medications to treat sleep disorders in burn victims include anti-depressants, hormone replacement therapy, and hypnotics such as benzodiazepines, nonbenzodiazepines, or benzodiazepine receptor agonists, as well as non-prescription medications such as melatonin.5 However, there are no medications approved by the Food and Drug Administration for use in childhood insomnia. Balancing treatment of pain and pharmacologic effects on sleep can also be difficult for patients on certain medications. Increasing pain medication dosage can cause negative side effects such as daytime drowsiness, while other medications, such as opiod analgesics, can be disruptive to sleep.6
JUVENILE RHEUMATOID ARTHRITIS (JRA)
JRA, a condition characterized by episodic exacerbations and remissions, affects approximately 300,000 children in the United States.7 Studies on adult patients with RA have indicated that up to 60% suffer sleep disturbances as a result of arthritis pain.8 In pediatric populations, research has suggested that pain is positively correlated with sleep disturbances, and that children with this condition report greater sleep anxiety and more awakenings per hour and daytime sleepiness than normal controls.2 Similar to burn victims, the timing and levels of GH secretion are a areas of concern for JRA patients, because these children tend to spend less time in slow-wave sleep.7
Benzodiazepines and barbiturates are commonly prescribed to treat insomnia. However, research indicates that sedative-hypnotics increase stage 2 sleep, but decrease sleep stages 1,3,4 and REM sleep. Certain studies have shown that arthritic patients who were prescribed sedative-hypnotics reported increased pain levels and greater disability at night than patients who were not sedated.8 However, research on adult populations has indicated that low-dose amitryptilline or triazolam can improve sleep quality and factors such as pain and morning stiffness.9 For pediatric patients, there are a number of treatment options depending on the severity of the condition. Although ibuprofen and other nonsteroidal anti- inflammatory agents are used as first line of managing JRA, ibuprofen is known to delay deeper stages of sleep. Certain disease modifying anti-rheumatic drugs such as methotrexate and sulfasalazine, can irritate the gastrointestinal system, which in turn can disrupt sleep.7
CHRONIC PAIN
Chronic pain can encompass a number of medical conditions. Comorbid primary sleep disorders such as sleep apnea, restless legs syndrome, and periodic limb movement have been reported in patients affected by chronic pain. Fibromyalgia, which is characterized by widespread musculoskeletal pain and other somatic complaints, is one example of a chronic pain condition. Not only can it interfere with a patient’s ability to function, but the illness can have negative effects on nocturnal sleep patterns. The relationship between fibromyalgia and alterations in sleep architecture has been explored in a number of studies which have concluded that these patients frequently display a characteristic EEG pattern, alpha-delta sleep, which is hypothesized to represent an intrusion of wakefulness rhythms into slow wave sleep. Researchers have suggested this is a measure of sleep fragmentation and that the amount of alpha intrusion corresponds to amount of psychological distress and pain caused by the condition.8 Eimited studies have shown that medications such as zolpidem can be effective in reducing sleep onset latency and increasing total sleep time in fibromyalgia patients. While serotonin selective reuptake inhibitors (SSRIs) are commonly used to treat patients with chronic pain conditions, these medications have been reported to cause insomnia in certain individuals.8
While there is a need for more research on the relationships between sleep and chronic pain, especially within pdiatrie populations, logistical difficulties complicate objective research. One of the most difficult obstacles to overcome in chronic pain patient recruitment is that researchers generally require participants to avoid taking CNS-active medications for two weeks prior to a polysomnographic sleep study. This can be a severe limitation for individuals treated for chronic pain conditions.
STRATEGIES FOR ADDRESSING SLEEP PROBLEMS
Practitioner awareness of primary and secondary sleep disorders can facilitate early screening and prevent symptoms such as mood changes and daytime sleepiness from being attributed to a child’s underlying chronic condition.10 Pain management can be an effective alternative to medication for facilitating sleep in children with chronic medical conditions. Relaxation techniques, such as hypnosis and biofeedback, can be an effective pain management strategy. Practitioners can also encourage strategies such as cognitive behavior therapy, maintenance of a regular sleep schedule, and parent education.
CONCLUSION
Children spend at least a third of their time sleeping, so disruptions in sleep duration and architecture can impair functioning and behavior. 9 The expense of objective sleep methodologies such as overnight polysomnography, and the difficulty of recruiting adequate numbers of participants, have contributed to the prevalence of research studies supported only by parental- report or subjective data for topics relating to sleep in medically compromised children. The limited objective studies on chronic medical conditions and their relation to juvenile sleep points toward the need for more research on pediatric populations using newer methodologies such as actigraphy (a portable, wristwatch-like device that measures and stores body movement data over days to weeks that may be used to estimate sleepwake patt\erns). In addition, larger sample sizes in previously conducted research would better allow physicians and scientists to interpret results and understand the complexities of chronic conditions. Finally, more extensive research is needed on alternatives to pharmacologic treatments to mitigate sleep disruption. Relaxation, cognitive- behavioral intervention, exercise, and phototherapy all have the potential to be effective treatments for certain juvenile patient populations. The institution of sleep hygiene principles (e.g., , regular sleep-wake pattern, bedtime routine, avoidance of stimulants such as caffeine), and behavior modification techniques, including well-established insomnia strategies such as stimulus control and sleep restriction, also has the potential to alleviate sleep symptoms associated with certain conditions.
REFERENCES
1. Bandla H, Splaingard M. Sleep problems in children with common medical disorders. Pediatr Clin North Am 2004;51:203-27.
2. Palermo TM, Kiska R. Subjecrive sleep disturbances in adolescents with chronic pain: Relationship to daily functioning and quality of life. J Pain 2005: 6:201-7.
3. Tamburri LM, DiBrienza R, et al. Nocturnal care interactions with patients in critical care units. Am J Crit Care 2004; 13:102- 12.
4. Sadeh A, Horowitz I, et al. Sleep and pulmonary function in children with well-controlled, stable asthma. Sleep 1998;21:379-83.
5. Jaffe SE, Patterson DR, Treating sleep problems in patients with burn injuries, J Burn Care Rehabil 2004;25:294-305.
6. Boeve SA, Aaron LA, et al. Sleep disturbance after burn injury. J Bum Care Rehabil 2002;23:32-8.
7. Labyak SE, Bourguignon C, et al. Sleep quality in children with juvenile rheumatoid arthritis. Mist Nurs Pract 2003:17:193- 200.
8. Menefee LA, Cohen MJMC, et al. Sleep disturbance and nonmalignant chronic pain. Pain Med 2000;1:156-72.
9. Bloom B, Owens J, et al. Sleep and its relationship to pain, dysfunction, and disease activity in juvenile rheumatoid arthritis. J Rheumatol 2002; 29:169-73.
10. Mindel, J, Owens J. Sleep and Medical Disorders. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems in Children and Adolescents. Lippincott Williams & Wilkins. 2003;191- 204.
Sharon Warren, Brown ’05, is a Research Associate with The Advisory Board Company.
CORRESPONDENCE:
Sharon Warren
The Advisory Board Company
2445 M Street, NW
Washington DC, 20037
phone: (202) 266-5584
email: sharon.warren05@gmail.com
Copyright Rhode Island Medical Society Mar 2006