Posted by: Indonesian Children | September 13, 2009

Sleep Disorder Treatment and Management

Self-Care at Home

These sleep hygiene measures are important for all parasomnias:

  • Go to bed at the same time each night.
  • Use the bed only for sleeping and intimacy.
  • Avoid napping.
  • Avoid stress, fatigue, and sleep deprivation.
  • Avoid vigorous activity prior to bedtime, though a brief period of aerobic activity 4 hours before bedtime may be helpful.
  • Avoid cigarettes, alcohol, and excessive caffeine.

In general, when a person has been diagnosed with sleepwalking, the following precautions need to be taken:

  • Remove potentially dangerous items.
  • Have the person sleep in a bedroom on the ground floor if possible.
  • Lock the doors and windows.
  • Cover glass windows with heavy drapes.
  • Place an alarm or bell on the bedroom door.

Medical Care

This section primarily reviews cognitive-behavioral treatments (CBT) effective in treating a broad range of childhood behavioral sleep problems. Treatment modalities can be adapted easily to the youth’s developmental level. Furthermore, consider the role of sleep hygiene in all sleep problems. The effectiveness of CBT for childhood sleep disorders has been well demonstrated in controlled studies and clinical case reports. Specific interventions for sleep problems have gained the status of established evidence-based interventions. The issues that received the most attention pertain to settling problems and night awakenings in infants and toddlers. These topics have been extensively studied, with an impressive volume of well-controlled and informative clinical studies. Clinical research of all other sleep problems and in other age ranges is still very limited.

Pharmacologic treatments of sleep disorders lack adequate and significant empirical data. Given the lack of data supporting pharmacological treatment, initially use behavioral and cognitive strategies in most cases. Because of the paucity of adequate empirical studies, pharmacotherapy data are limited to treatment in select sleep disorders.

  • Limit-setting problems, bedtime resistance, and frequent nightly awakenings represent common problems encountered in pediatric practice. Cognitive-behavioral techniques use relatively straightforward and safe strategies for enhancing overall parenting effectiveness as well as ameliorating the aforementioned problems.
    • Extinction technique: This technique involves the parents putting their child to bed at a designated time and ignoring the child’s or infant’s protests until an established time the next morning.
    • Graduated extinction: Many parents may experience or perceive pure extinction as overly taxing or cruel; therefore, a graduated extinction technique may be used. This may include progressive time delays in responding to bedtime protests or refusals (ie, a checking technique), or it may include comforting the child for increasingly shorter intervals when checking on the child.
    • Positive routine-stimulus control techniques: This technique involves developing a consistent, pleasurable, and calming nighttime routine, with pleasurable activities being halted if the child protests or throws a tantrum. The child is then put to bed.
    • Scheduled awakenings: Parents awaken the child approximately 15 minutes prior to the child’s typical nightly awakening times. The scheduled awakenings gradually are stopped or weaned.
       
  • Nocturnal enuresis: History and physical examination usually are sufficient to rule out urological abnormality. Routine dipstick urinalysis, growth/height trajectory, and blood pressure are used to exclude other medical causes of enuresis. Children younger than 6 years should be managed with child and family reassurance that the enuresis is developmentally normal.
    • Alarm clock method: An alarm is set before the most probable time of the event based on the trend of enuretic episodes. The alarm may be set for a predetermined time, such as 2-3 hours after usual onset of enuresis. Children eventually avoid wetting themselves before the alarm is triggered, unlike the bell and pad method. Longer treatment duration results in a higher success rate.
    • Parent education: Parents need to know that sleep hygiene practices serve as prevention of enuresis. Fluid restriction, bedtime voiding, and parent awakening later are components of sleep hygiene (see Patient Education). The earlier the child begins practicing sleep hygiene, the better. Individual families may require creative combinations of the aforementioned interventions.
    • Desmopressin and nocturnal enuresis: Desmopressin reduces nocturnal urine production, has better short-term results than the alarm method, is effective in 50-85% of individuals, and generally is well tolerated. Recidivism after discontinuation can present a problem.
    • Imipramine and nocturnal enuresis: Imipramine is effective, but concern exists for potentially serious adverse effects. Imipramine dosing is 25-100 mg depending on the age and size of the patient. Risks involved in imipramine use often outweigh the benefits for the relatively benign problem. The use of imipramine requires ECG at baseline, with titration and dose increases and periodic monitoring. The clinician should monitor blood pressure and pulse rate and review cardiovascular system issues at each visit.
       
  • Sleep-related fears and anxiety: Treatment for sleep-related fears and anxiety include relaxation training, guided imagery, positive self-talk, positive reinforcement for increasingly successful efforts, systematic desensitization, and gradual exposure to child-determined hierarchy of sleep-related fears or anxiety. The child progresses from envisioning less threatening fears to conquering in vivo actual feared objects or situations. Exposure-response prevention is combined with relaxation techniques and positive reinforcement for treatment gains.
  • OSAS: Adenotonsillectomy is the primary treatment modality in children with OSAS. Positive airway pressure is needed in cases of continued postsurgical symptomatology. Continuous positive airway pressure (CPAP), variable pressure devices (eg, bilevel positive airway pressure [BiPAP]), and on-demand pressure when airflow is impeded (D-PAP) may be needed. Weight loss can be helpful for obese patients.
  • PLMS: Focus cognitive and behavioral therapy on alleviating stress and promoting relaxation. Dopaminergic therapy may be necessary; however, only limited data on dopaminergic therapy in youths are available. Pergolide (withdrawn from US market March 29, 2007) is effective in treating ADHD or Tourette syndrome and comorbid sleep disorder. Caffeine restriction can be helpful. Low-dose Depakote has been shown to be effective in a small case series of adults.
  • RLS: Focus cognitive and behavioral therapy on alleviating stress and promoting relaxation. Dopaminergic therapy may be necessary; however, limited data exist for treatment in youths. Pergolide (withdrawn from US market March 29, 2007) has been found to be effective in treating ADHD or Tourette syndrome and comorbid sleep disorder. Caffeine restriction may be helpful. Low-dose Depakote has been shown to be effective in small case series of adults.
  • Circadian rhythm disorders
    • Light therapy resets suprachiasmatic nuclei.
    • Melatonin acts directly upon suprachiasmatic nuclei. The effect of light on phase shifts is opposite. Phase delay requires morning dosing of melatonin. Advanced sleep phase syndrome requires evening dosing.
    • In manipulating the internal sleep-wake clock, gradually delaying sleep onset resynchronizes the internal clock. Delay sleep onset by 15-minute increments each night until desired sleep time is established.

 

Surgical Care

Adenotonsillectomy may be indicated for OSAS.

 

Medical Treatment

The treatment of parasomnias is aimed at lessening the frequency and/or intensity of the events.

Sleepwalking and sleep terror disorder 

In children, sleepwalking and sleep terrors usually do not need to be treated. However, risk factors should be identified and minimized. 

In adults, especially in cases involving sleep-related injury, drugs may be required and can be lifesaving. Benzodiazepines, which are used for insomnia situations where an individual awakens after falling asleep, such as estazolam (ProSom), have been found to be safe and remarkably effective in adults with sleepwalking and sleep terrors.

REM sleep behavior disorder 

Treatment for REM sleep behavior disorder is initiated with clonazepam (Klonopin) at 0.5-1.5 mg taken at bedtime. Clonazepam is remarkably effective in controlling both the behavioral and the dream-disordered components of REM sleep behavior disorder. This drug has been shown to be beneficial in the long term. Drug discontinuation often results in prompt relapse.

Tricyclic antidepressants are occasionally used in the treatment of REM sleep behavior disorder. Imipramine has been used, but the effects are unpredictable. 

Several reports of levodopa/carbidopa, gabapentin, pramipexole, and clonidine have been published, but the benefit of these drugs has not been systemically evaluated.

Restless legs syndrome and periodic limb movement disorder 

Restless legs syndrome and periodic limb movement disorder are treated with 3 classes of medications. Treatment guidelines are as follows:

  • Anti-parkinsonian drugs, such as levodopa/carbidopa, bromocriptine, ropinirole (Requip), pergolide (Permax), and pramipexole (Mirapex), have been used.
  • Benzodiazepines, especially clonazepam have been effective. Other benzodiazepines used have included diazepamtemazepam, and lorazepam.
  • Opiates, such as codeine, oxycodone, methadone, and propoxyphene, are other drugs that have been used.
  • Dopamine agonists, such as levodopa or pergolide, may be effective, but the effectiveness may not last, and some individuals are unable to tolerate side effects. 
  • Other drugs that have shown effectiveness include clonidine or anticonvulsants, such as carbamazepine, valproate, and gabapentin. 
  • Several studies have reported efficacy of different medications belonging to the aforementioned groups, but comparative studies between various classes of drugs or even individual drugs do not exist. Therefore, persons should receive one drug, and, if no response is noted, they should be placed on another drug of the same class or a different class.
  • A combination of drugs may be required in more severe cases. Some persons who do not respond to benzodiazepines alone, levodopa alone, or a combination of both may be treated with opiates.
  • One should receive the smallest possible dose and should be closely observed for the development of dependency. Experience reveals that the incidence of abuse, tolerance, or addiction to opiates or benzodiazepines in persons with severe restless legs syndrome appears to be insignificant. The disabling condition of severe restless legs syndrome must be treated aggressively.
  • Restless legs syndrome and periodic limb movement disorder are chronic conditions that require long-term drug therapy. Some persons may develop symptoms of restless legs during the daytime, and this may be treated with controlled release of levodopa/carbidopa administered in the evening and morning.
  • Avoidance of certain drugs, such as tricyclic antidepressants, fluoxetine, or lithium, may be helpful because these drugs generally worsen the symptoms of restless legs syndrome and periodic limb movement disorder.
  • A decrease in body iron stores, as indicated by serum ferritin (an iron-protein complex) levels less than 50 mcg/L, should be corrected with iron supplementation. Oral iron is preferred but takes a long time to provide improvement, because gastrointestinal absorption is low. However, replenishment is an effective treatment strategy for iron-deficiency anemia and may also relieve symptoms of restless legs syndrome and periodic limb movement disorder (if present).

Medications

The common classes of drugs used for the treatment of parasomnias are benzodiazepines and anticonvulsants. The general aim of drug treatment is to prevent arousal out of sleep or to suppress REM sleep.

Benzodiazepines 

Benzodiazepines help suppress REM sleep and limit arousal. They include the following drugs:

  • Diazepam (Valium) is most frequently used in children, especially children with night terrors.
  • Alprazolam (Xanax) is the second choice in this category for parasomnias. It has a brief duration of action; therefore, the likelihood of morning effects, such as grogginess, is decreased. However, it has a potential for exacerbating symptoms at lower doses when effects attenuate, owing to possible rebound.
  • Clonazepam (Klonopin) is similar to alprazolam; it is a good alternative option to diazepam.

Anticonvulsants 

Anticonvulsants inhibit arousal. They include the following drugs:

  • Carbamazepine (Tegretol, Carbatrol) is the most commonly used drug for parasomnias.
  • Valproate (Depakene, Depakote) has been reported to be effective in treating parasomnias, in both a once nightly dosage schedule and a standard dosage schedule.
  • Gabapentin (Neurontin) has not been used as frequently as the other 2 anticonvulsants. As with carbamazepine and valproate, no information is available and no consensus has been reached regarding the use of a once nightly dosage versus a standard antiepileptic dosage.

Antiparkinsonian 

Antiparkinsonian drugs are very effective for the treatment of persons with restless legs syndrome and periodic limb movement disorder.

  • Levodopa is the most commonly used drug for the treatment of restless legs syndrome and periodic limb movement disorder. An oral dose of 50-100 mg, controlled-release formulation, is prescribed as initial therapy for restless legs syndrome.
  • For periodic limb movement disorder, a controlled-release preparation of levodopa combined with a decarboxylase inhibitor (carbidopa) at a dose of 50-100 mg is started.
  • A dose increase not to exceed 200 mg may be required to completely suppress restless legs syndrome and periodic limb movement disorder.
  • The major adverse effects of levodopa therapy are (1) rebound of symptoms during the daytime and (2) tardive dyskinesia (difficulty in performing voluntary movements), which is extremely uncommon.
  • Ropinirole (Requip), pergolide (Permax), and pramipexole (Mirapex) cause fewer side effects compared with levodopa and have become first-line drugs in the treatment of restless legs syndrome and periodic limb movement disorder. Pramipexole is started at a lowest dose of one half tablet of 0.25 mg once a day for 5 days and then increased to 0.25 mg per day. The dose may be increased to a maximum of 0.5 mg per day. Ropinirole is started at 0.25 mg at bedtime for individuals with primarily nighttime symptoms. For those with symptoms throughout the day, it may be given 2 times per day. The dose may be gradually increased each week. Average doses are 2.5 mg per day.

Opiates
 
Opiates, such as codeine, propoxyphene, and dihydromorphone, have been used in persons who have severe restless legs syndrome and who do not benefit from other therapy. One should be closely observed for development of tolerance and dependency 

Medications

The common classes of drugs used for the treatment of parasomnias are benzodiazepines and anticonvulsants. The general aim of drug treatment is to prevent arousal out of sleep or to suppress REM sleep.

Benzodiazepines 

Benzodiazepines help suppress REM sleep and limit arousal. They include the following drugs:

  • Diazepam (Valium) is most frequently used in children, especially children with night terrors.
  • Alprazolam (Xanax) is the second choice in this category for parasomnias. It has a brief duration of action; therefore, the likelihood of morning effects, such as grogginess, is decreased. However, it has a potential for exacerbating symptoms at lower doses when effects attenuate, owing to possible rebound.
  • Clonazepam (Klonopin) is similar to alprazolam; it is a good alternative option to diazepam.

Anticonvulsants 

Anticonvulsants inhibit arousal. They include the following drugs:

  • Carbamazepine (Tegretol, Carbatrol) is the most commonly used drug for parasomnias.
  • Valproate (Depakene, Depakote) has been reported to be effective in treating parasomnias, in both a once nightly dosage schedule and a standard dosage schedule.
  • Gabapentin (Neurontin) has not been used as frequently as the other 2 anticonvulsants. As with carbamazepine and valproate, no information is available and no consensus has been reached regarding the use of a once nightly dosage versus a standard antiepileptic dosage.

Antiparkinsonian 

Antiparkinsonian drugs are very effective for the treatment of persons with restless legs syndrome and periodic limb movement disorder.

  • Levodopa is the most commonly used drug for the treatment of restless legs syndrome and periodic limb movement disorder. An oral dose of 50-100 mg, controlled-release formulation, is prescribed as initial therapy for restless legs syndrome.
  • For periodic limb movement disorder, a controlled-release preparation of levodopa combined with a decarboxylase inhibitor (carbidopa) at a dose of 50-100 mg is started.
  • A dose increase not to exceed 200 mg may be required to completely suppress restless legs syndrome and periodic limb movement disorder.
  • The major adverse effects of levodopa therapy are (1) rebound of symptoms during the daytime and (2) tardive dyskinesia (difficulty in performing voluntary movements), which is extremely uncommon.
  • Ropinirole (Requip), pergolide (Permax), and pramipexole (Mirapex) cause fewer side effects compared with levodopa and have become first-line drugs in the treatment of restless legs syndrome and periodic limb movement disorder. Pramipexole is started at a lowest dose of one half tablet of 0.25 mg once a day for 5 days and then increased to 0.25 mg per day. The dose may be increased to a maximum of 0.5 mg per day. Ropinirole is started at 0.25 mg at bedtime for individuals with primarily nighttime symptoms. For those with symptoms throughout the day, it may be given 2 times per day. The dose may be gradually increased each week. Average doses are 2.5 mg per day.

Opiates
 
Opiates, such as codeine, propoxyphene, and dihydromorphone, have been used in persons who have severe restless legs syndrome and who do not benefit from other therapy. One should be closely observed for development of tolerance and dependency

 

Supported  by

CHILDREN SLEEP CLINIC

Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

https://sleepclinic.wordpress.com/

 

 

 

Clinic and Editor in Chief :

Widodo Judarwanto, pediatrician

email : judarwanto@gmail.com

curriculum vitae

 

 

Copyright © 2009, Children Sleep Clinic  Information Education Network. All rights reserved


Responses

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  2. It is really hard when we do not have enough sleep.

    I am having a hard time focusing on my work when I have only 3 hours to 5 hours of sleep at night. I am so dizzy that it often resulted in head ache.

    I am having a hard time sleeping because I am so fatigued at night that my mind is still so active… that is really scary for me.

    There are times that I need to leave work because of migraines. And it was really devastating because I needed money.

    That is before I realized that I needed to protect my body because I will spend more money if I will abuse myself.

    So I search for insomnia cure so I could be worry-free, and through a wonderful suggestion of a friend, I am now happy and my family is happy because I could balance my time in my family and for my work.

  3. Wow thanks for the info very informative and helpful. Thanks again


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