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1University of Medicine and Pharmacy of Tîrgu-Mures, 2Emergency County Hospital of Tîrgu-Mureș Keywords:
Abstract: Introduction: sleep is a behavioural state of perceptual freedom while being unavailable for
the environment, accompanied by characteristic electroencephalographic changes, having the rapidly reversible potential to the state of vigilance (Zepelin, 1987). Short and long-term sleep disorders that are present in childhood may be the cause of many diseases. Aim: the aim of this study was to analyse the international literature and the presentation of the latest information on sleep disorders in children. Material and methods. this study is a compilation of data resulted after the review of the international specialty literature. The used bibliography comprises current studies that have been published recently in international journals. Results: although sleep-related complaints, poor quality and quantity of sleep affect most children, this is still an underdiagnosed problem. Sleep disorders listed previously, under the subtitle classification, can be considered the basis of sleep complaints. The frequency and incidence of each disorder varies according to age. The most common sleep disorder that affects the majority of children of different age groups is the obstructive sleep apnea syndrome. The incidence in school children, without pathological manifestation is of 2-3.5%. Discussion and conclusion. sleep disorders present a complex pathology that can have several causes, both in children and adults. After reviewing the specialty literature, we can say that in case of children, this pathology can be detected early and can be prevented properly. Due to the increased frequency, there is a global need for the creation of laboratories to detect sleep disorders. Cuvinte cheie: tulburări
Rezumat: Introducere: somnul este o stare comportamentală a libertății perceptuale cu indisponibilitate
pentru mediul înconjurător, acompaniat de modificări caracteristice electroencefalografice, având un potențial rapid reversibil spre starea vigilă (Zepelin, 1987). Tulburările de somn prezente în perioada copilăriei pe termen scurt și lung pot determina apariția unor boli cronice. Scopul lucrării: scopul acestui studiu a fost de a parcurge literatura de specialitate internațională și de a prezenta cele mai noi informații referitoare la tulburările de somn la copii. Material și metodă: autorii prezintă în această lucrare, datele obținute în urma parcurgerii literaturii de specialitate internațională. Literatura folosită include studii de actualitate și care au fost publicate în reviste de specialitate în perioada 2008-2012. Rezultate: acuzele legate de somn, calitatea și cantitatea necorespunzătoare de somn afectează majoritatea copiilor și totuși este o problemă subdiagnosticată. Din acest motiv devine din ce în ce mai mult centrul atenției în cadrul pediatrilor și a părinților. La baza acuzelor de somn pot sta tulburările de somn care au fost enumerate la clasificare. Frecvența și incidența fiecăruia se schimbă în funcție de vârstă. Cea mai frecventă tulburare de somn care afectează majoritatea copiilor de diferite categorii de vârstă este sindromul de apnee de somn obstructiv. Incidența la copii de vârstă școlară, fără patologie, este de 2-3,5%. Discuții și concluzii: tulburările de somn reprezintă o patologie complexă care poate avea mai multe cauze atât la copii cât și la adulți. În urma parcurgerii literaturii de specialitate putem spune că în cazul copiilor această patologie poate fi depistată precoce și poate fi prevenită în mod corespunzător. Datorită frecvenței tot mai crescute, se necesită la nivel mondial înființarea unor laboratoare de depistare a tulburărilor de somn. Sleep is a behavioural state of perceptual freedom Short and long term sleep disorders that are present in while being unavailable for the environment, accompanied by childhood may reduce cognitive functions, cause behavioural characteristic electroencephalographic changes, having the rapidly reversible potential to the state of vigilance (Zepelin, cardiovascular risk and the development of diabetes mellitus. 1987). In the Romanian medical dictionary, sleep is defined as a All these possible consequences highlight the fact that periodic and reversible physiological state characterized by the frequency of these sleep abnormalities, risk factors which somatic inactivity, relative and temporary suppression of contribute to the emergence of this condition and treatment consciousness, accompanied by a more or less important possibilities or options for prevention should be evaluated. abolition of sensitivity and the inhibition of vegetative functions. 1Corresponding author: Solyom Reka, Str. Făget, Nr. 2/18, Tîrgu-Mures, România, E-mai, Tel: +40740 833878 Article received on 27.02.2013 and accepted for publication on 02.04.2013 ACTA MEDICA TRANSILVANICA June 2013;2(2):305-308 CLINICAL ASPECTS
Sleep disorders commonly occurring in childhood vigilance.(20) These phenomena occur at awakening, partial signal an evolutionary stage and can be considered awakening or changing sleep phases and are generally physiological. Thus, nightmares, sudden awakenings, nocturnal manifestations of the central nervous system activation enuresis and sleep disorders due to separation anxiety can occur. (especially by muscular activity or changes of the vegetative If these phenomena become constant or occur because of pathological changes, the consequences of these sleep disorders are more frequent and vary according to age. In young children, 1. Waking disorders: they have in common abnormal the most common signs are hyperactivity, behavioural disorders awakening and they begin during deep sleep, with slow waves. and in older children, the symptoms are predominantly similar They can present the following manifestations: to those experienced in adulthood, increased drowsiness during Confused awakenings: appear in the first the day. In the long term, cardiovascular diseases, emotional, period of the night and are characterized by confusion behavioural or cognitive disorders can also appear. during and after waking up from sleep. In addition to these, The aim of this study was a review of the international the following symptoms may also appear: disorientation in literature and the presentation of the latest information on sleep time and space, slow speech, slow thinking, delayed responses to commands or questions, memory loss or This study is a compilation of data resulted after the behavioural disturbances, which last for a few minutes to review of the international specialty literature. The used bibliography comprises current studies that have been published Pavor nocturnus: are episodes of sudden awakening accompanied by sensations of terror and panic, Classification of sleep disorders
shouting, crying, body movements, tachycardia, tachypnea, The first official classification, also recognized sweating. Usually, it occurs during the first third of sleep internationally, was described in 1979 by the Association of and can last for a couple of minutes. Remembering the Sleep Disorders Centres, (ASDC).(13) They distinguished 67 diagnoses classified in four large groups, but these diagnoses Sleepwalking: is an altered state of were based mainly on clinical symptoms, which is why many consciousness when the phenomena of sleep and wakefulness are combined. It is characterized by In 1986, the American Psychiatric Association involuntary movements and walking in the state of deep distinguishes for the first time in the Manual for diagnosis and sleep. During this episode, facial expression is not present, mental disorders statistics (DSM III) dyssomnia, or disorders of the eyes are fixed and awakening is difficult, without the initiating or maintaining sleep from parasomnia, which are behavioural disorders during sleep. DSM IV classifies primary 2. Disorders of the transition period between the state sleep disorders (dyssomnia, parasomnia), sleep disorders of being asleep and awake: e.g. myoclonus when falling asleep, associated with other mental disorders (resulting from a diagnosed mental illness) and sleep disorders due to some 3. Parasomnia associated with REM sleep: it usually occurs during the REM phase (Rapid Eye Movements) of sleep. Nowadays, the most widely used and accepted Behavioural disorders: it is characterized by an international classification is the one released by the American intermittent loss of REM phase atonia and the occurrence of developed motor activities (hitting, International classification (1997) (2,16): jumping, running) associated with the dreaming Dyssomnia: are primary disorders of initiating or
maintaining sleep or excessive drowsiness, which is Recurrent isolated sleep paralysis: consists of a characterized by a quantitative, qualitative disorder or disturbed period of inability to perform voluntary rhythm of sleep.(1) It is assumed that these disturbances appear movements, which may occur during falling because of an impairment of the central nervous system (segment responsible for sleep). This section includes: primary Nightmares: they are experiences of dreams insomnia, primary hypersomnia, narcolepsy, sleep disorders overloaded with fear, which lead to sudden correlated with breathing, sleep-wake rhythm disorders.(15) The awakening with alertness and quick orientation. term “primary” implies that sleep disorder appears to be Remembrance is detailed and vivid and dreams independent of any other known somatic or mental condition. According to causes, we can distinguish 3 subgroups: 4. Other parasomnias are: e.g. nocturnal enuresis, Intrinsic causes: e.g. obstructive apnea, central bruxism, catathrenia, hallucinations, feeding disorders. apnea, restless leg syndrome or Wittmaack-Ekbom Sleep disorders due to a medical condition:
syndrome or nocturnal myoclonus, (PLMD = Psychiatric diseases: e.g. anxiety disorders, mood Periodic Limb Movement Disorder) involuntary movements of the upper and lower limbs during Neurological diseases: e.g. sleep-dependent epilepsy, sleep (during non-REM stages), narcolepsy, primary headache, Parkinson's disease, Huntington's disease, Other diseases: endocrine (hyper-, hypothyroidism, insufficient sleep quantity, difficulties with falling hypo- or hyperadrenocorticism), viral or bacterial asleep due to some improper habits, feeding at infections (hypersomnia in case of viral encephalitis), lung disease (chronic bronchitis), musculoskeletal Circadian rhythm disorders: e.g. changing time diseases (rheumatoid arthritis, fibromyalgia). Sleep disorders induced by the consumption of certain Parasomnia: an essential abnormal event occurring
substances like: alcohol, amphetamines and related either during sleep or on the verge of vigilance and sleep. It stimulants, caffeine, cocaine, opioids, sedatives, focuses on disturbances and not on its effects on sleep and hypnotics, anxiolytics and others (adrenergic agonists CLINICAL ASPECTS
and antagonists of dopamine, acetylcholine and Although sleep-related complaints, poor quality and serotonin, antihistamines, corticosteroids). quantity of sleep affect most children, this is still an Sleep disorders that are not investigated so far: e.g.
underdiagnosed problem. This explains why pediatricians and sleep disorders due to menstrual periods. parents become more and more interested in this problem. Sleep The frequency of complaints and sleep disorders in
disorders listed previously, under the subtitle classification can children
be considered the basis of sleep complaints. The frequency and Different forms of sleep disorders affecting 25% of incidence of each disorder varies according to age. children around the world.(22) Temporary physiological symptoms at a certain age also belong to this category such as Table no. 2. Complaints and sleep disorders by age groups
awakenings during the night, nightmares, and the most sever among primary and secondary sleep disorders, the obstructive Newborns, Young Children
infants children
>14 year
sleep apnea syndrome. The pathology of this disorder recently is 0-1 year 1-3 years school age 6-14 years
more and more often investigated. Some studies based on 3-6 years
questioning parents, show a frequency of sleep disorders in Respiratory Sleep
young children (3-5 years of age) at 25-50% and 4 -10 years of sleep
age 37%.(4,14) Based on a study performed in 14,000 disorders newborns The syndrome of obstructive sleep apnea during
schoolchildren regarding their complaints revealed the presence of the disorder in 20% (in 5 year old children) and 6% in 11 year old children.(18) Another study performed in a group of 8 - 10 year old children estimates the presence of symptoms in 43%.(8) Most studies are performed by questioning parents, which Etiology of the CNS
frequently underestimate the importance and severity of present complaints. During a self-evaluation, 12% of the teenagers considered that they have sleep disorders and 40% complained because of some symptoms of sleep disturbances.(9) In the United States, the frequency of children who presented to medical services with sleep disorders was assessed. Based on the acquired data during one year, in 2930 patients of Respiratorym
pediatric cases, 0.05% were diagnosed with sleep disorders and disorders
0.01% were treated for insomnia (24), data showing that sleep disorders actually relatively common in children rarely are diagnosed in health care services, so they are probably underdiagnosed. There are several studies which describe the Etiology
shortening of sleep time in children. In 2004, in the United States, the children under the age of 10 were assessed at the The most common sleep disorder that affects the same time with adults regarding their sleeping habits. The majority of children of different age groups is the obstructive results highlighted sleep insufficiency in each age category. sleep apnea syndrome. The incidence in school-children, Newborns spent 12.7 hours sleeping instead of 14 -15 hours, without pathological manifestation is of 2-3.5%.(5) We can infants 1 - 3 years of age spent 11.7 hours sleeping instead of 12 highlight two peaks of incidence, one is in the age group of 2-8 -14 hours, children 3 - 5 years of age spent 10.4 hours sleeping years old, in whom the most common cause are adenoid instead of 11 -12 hours, and children 5 -10 years of age spent on hypertrophy and tonsillitis. The second peak is identified at the average 9.5 hours sleeping instead of 10 -11.(22) age of adolescence and is correlated with obesity. In young children, there are no differences between genders, but in case Table no. 1. The frequency of sleep disorders according to
of teenagers, there is an increased frequency in boys.(6) the type of evaluation
The assessment of sleep disorders can be performed Parents’
by various methods. The results depend, among others, on the definition of sleep disorder, the surveyed person (child or parent) and age. The number of sleeping hours, however, is a more reliable indicator for detecting complaints. Children with sleep disorders are more often hospitalized (6), present most commonly associated diseases 0.05-0.01%
(19), such as cardiovascular alterations, behavioural problems, poor school results.(3,7,21) These alterations and diseases can be considered as consequences of obstructive sleep apnea Figure no. 1. Average sleeping hours according to USA
syndrome, because of the impact made on the period of sleep. Sleep disorders present a complex pathology that can have several causes, both in children and adults. After reviewing the specialty literature, we can say that in case of children, this pathology can be detected early and can be prevented properly. Many authors pay more attention to this disease, because sleep disorders can be the precursor to chronic diseases occurring in childhood. In most studies, clinicians diagnose by using the method of interrogation. Recently questionnaires corroborated with polysomnographic examination can give much valuable information that helps explicitly the pediatrician to detect the apparition of this pathology. Due to the increased CLINICAL ASPECTS
frequency, there is a global need for the creation of laboratories 20. Roy H Lubit, MD, PhD Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Acknowledgement
Child Psychiatry, New York University School of This paper is partly supported by the Sectoral Medicine; Sleep Disorders, Medscape, 2012 May 14. Operational Programme Human Resources Development (SOP 21. Salorio CF, White DA, Piccirillo J, Duntley SP, Uhles, ML. HRD), financed from the European Social Fund and by the Learning, memory, and executive control in individuals Romanian Government under the contract number POSDRU with obstructive sleep apnea syndrome. J Clin Exp 22. Sheldon H, et al. Pediatric sleep Medicine. USA, Elsevier; REFERENCES
Allen C. Richert, MD, and Alp Sinan Baran, MD, A 23. Thomas F, Anders MD, Lisa A, Eiben MS. Pediatric Sleep Review of Common Sleep Disorders, NS Spectrums - Disorders: A Review of the Past 10 Years Journal of the American Academy of Child & Adolescent Psychiatry. American Academy of Sleep Medicine, 1997: The International Classification of Sleep Disorders, Revised. 24. Vignan J, et al. Epidemiologic study of sleep quality and troubles in French secondary school adolescents. J Adolesc Archbold KH, Pituch KJ, Panahi P, Chervin RD. Symptoms of sleep disturbances among children at two general pediatric clinics. J Pediatr. 2002;140:97-102. Blader JC, Kopelwicz HS, Abikoff H, Foley C. Sleep problems of elementary school children. A community survey. Arch Pediatr Adolesc Med. 1997;151:473-480. Chang SJ & Chae KY. Obstructive sleep apnea syndrome in children: Epidemiology, pathophysiology, diagnosis and sequelae. Korean J Pediatr. 2010;53:863-871. Goodwin JL, et al. Symptoms Related to Sleep-disordered Breathing in White and Hispanic Children > the Tucson Children’s Assessment of Sleep Apnea Study. Chest. 2003;124:196-203. performance in children. Pediatrics. 1998;102:616-620. Kahn A, et al. Sleep problems in healthy preadolescents. Pediatrics. 1989;84:542-546. Levy D, Gray-Donald K, Leech J, Zvagulis I, Pless IB. Sleep patterns and problems in adolescents. J Adolesc Health Care. 1986;7:386-389. 10. Smith MA, Robinson L, Boose G, Segal R. Sleep Disorders and Sleeping Problems Symptoms, Treatment & Help for Common Sleep Disorders Last updated: January 2013. 11. Moore M, Allison D, Rosen CL. A review of pediatric nonrespiratory sleep disorders. Chest. 2006;130:1252-1262. 12. National Sleep Fundation: Information about Children’s 13. Novák M. Alvás-és ébrenlét zavarok diagnosztikája és terápiája. Budapest, OKKER; 2000. p. 87-92. 14. Owens JA, Spirito A, McGuinn M, Nobile C. Sleep habits and sleep disturbance in elementary school-aged children. J Dev Behav Pediatr. 2000;21:27-36. 15. Panossian LA, Avidan AY. UCLA Department of Neurology, UCLA Medical Centre, Los Angeles, CA 90095-1767, USA. Review of sleep disorders. Med Clin North Am. 2009 Mar;93(2):407-25. 16. Peraita-Adrados R. Advances in sleep disorders, Rev 17. Richert AC, Baran AS. A review of common sleep disorders. CNS Spectr. 2003 Feb;8(2):102-9. 18. Rona RJ, Li L, Gulliford MC, Chinn S. Disturbed sleep: effects of sociocultural factors and illness. Arch Dis Child. 1998;78:20-25. 19. Ronksley PE, et al. Excessive daytime sleepiness is associated with increased health care utilization among patients referred for assessment of OSA. Sleep. 2011;34:363-370.


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