Helping my 4 year old

sleeplessmommy wrote:He asks me every morning if he wore it all night.

He has no memory of taking it off. That is why I feel badly about the rewards. I feel it isn't for lack of effort on his part, you know what I mean?

I hear you.

I was worried about medicating his ADHD symptoms with a stimulant if he can't sleep as it is... His neurologist feels he is too young and wants to wait until we can try to get the OSA more under control.

If you and childcare providers can manage his symptoms behaviorally without stimulants, I agree about deferring. I'm not saying this because I think you will have a problem with him sleeping (actually, believe it or not, some kids with ADHD fall asleep easier with a tiny evening dose of stimulants, plus there's melatonin and other agents, if need be). I am saying this because I think you will have a much tougher time telling whether CPAP or RME are helping his symptoms if his symptoms are masked by stimulants (and because I always think ADHD should be managed behaviorally rather than with a combination of behavioral therapy and medication when possible...but not until the point that the kid is having significant academic or social impairments...then it's time to do something.)

Janknitz wrote:

How can you tell when he is in REM sleep?

My understanding is that REM sleep occurs 2-3 hours in, which is what it looks like here.

No, adults enter REM sleep about 70 - 90 minutes after falling asleep.

For Children, from the MedScape website: http://www.medscape.com/viewarticle/471909_7

As the child matures, the sleep cycle and REM sleep continue to approach adult distribution. Overall cycle length remains stable at approximately 60 minutes at age 3 years and gradually extends to the adult level of 90 minutes by age 5 years. Children in this age range have six to eight sleep cycles per nighttime sleep period (Sheldon, 2002). The first REM sleep period usually begins 60 minutes after sleep onset. As the child gets older, the initial REM period will shorten while later REM periods lengthen. The first third of the night is dominated by NREM stage 3 and 4 sleep, whereas REM sleep occurs predominately in the latter half of the night (Sheldon, 2002) (see Figure 2). Children in this age range spend 20% to 25% of their total daily sleep in REM sleep and 75% to 80% in NREM sleep, which approximates adult proportions (Roffwarg et al., 1966).

Sludge wrote:

sleeplessmommy wrote:The pediatric forums I have found are not very active.

If the only software you have is Sleepyhead, can you post a screenshot of Overview, only Session Time and Usage selected, date range last 2 months?
?

Here is his overview. Actually, looking at this, he has gotten some good nights. Maybe more than it feels like. Still, it is very inconsistent. Add to that a couple of upper respiratory infections when he couldn't breathe through his nose, so I didn't force the issue. Any other ideas I should look into?

ReadyforRest wrote:

Janknitz wrote:

How can you tell when he is in REM sleep?

My understanding is that REM sleep occurs 2-3 hours in, which is what it looks like here.

No, adults enter REM sleep about 70 - 90 minutes after falling asleep.

For Children, from the MedScape website: http://www.medscape.com/viewarticle/471909_7

As the child matures, the sleep cycle and REM sleep continue to approach adult distribution. Overall cycle length remains stable at approximately 60 minutes at age 3 years and gradually extends to the adult level of 90 minutes by age 5 years. Children in this age range have six to eight sleep cycles per nighttime sleep period (Sheldon, 2002). The first REM sleep period usually begins 60 minutes after sleep onset. As the child gets older, the initial REM period will shorten while later REM periods lengthen. The first third of the night is dominated by NREM stage 3 and 4 sleep, whereas REM sleep occurs predominately in the latter half of the night (Sheldon, 2002) (see Figure 2). Children in this age range spend 20% to 25% of their total daily sleep in REM sleep and 75% to 80% in NREM sleep, which approximates adult proportions (Roffwarg et al., 1966).

Actually, the AASM Pediatric Task Force used several studies of REM Latency in the 132 - 145.5 minute range to help define "normal".

sleeplessmommy wrote:

Sludge wrote:

sleeplessmommy wrote:The pediatric forums I have found are not very active.

If the only software you have is Sleepyhead, can you post a screenshot of Overview, only Session Time and Usage selected, date range last 2 months?
?

Here is his overview. Actually, looking at this, he has gotten some good nights. Maybe more than it feels like. Still, it is very inconsistent. Add to that a couple of upper respiratory infections when he couldn't breathe through his nose, so I didn't force the issue. Any other ideas I should look into?

OK, so if we want to fix a child's sleep debt, we sleep of sufficient quantity and quality. If we use a value of 12 hours for a 4 year old, and assume that CPAP is necessary to achieve quality sleep, then we have to fill the red box with blue bars:

The NPSG reports are woefully inadequate. It is not indicated if CPAP 5.0 cmH20 is ideal pressure, only that events are "decreased". They should have the ability to generate a far more complete report.

Sludge wrote:The NPSG reports are woefully inadequate. It is not indicated if CPAP 5.0 cmH20 is ideal pressure, only that events are "decreased". They should have the ability to generate a far more complete report.

Does this Pediatric Sleep specialist have access to the complete report and/or the raw data? It would seem that if there were residual events, they should have been give a pressure challenge, and if not, then why not. That would be a great question at the F/U visit.

More random observations:

• If it is decided that more pressure is needed, you can max out the C-Flex and create a "pseudo" BiPAP effect.
• Slow wave sleep usually occurs in the first (and maybe second, in kids) sleep cycle of the night. Each sleep cycle lasts about 90 minutes. Slow wave sleep is very stable, so there are few respiratory events. A more complete NPSG report (with histograms) would confirm this.
• If the aforementioned parasomnia(s) is (are) sleep terrors, they would tend to appear coming out of SWS, so perhaps a strategy might be check/replace CPAP >~2300 (to try to cover as much light REM and REM as possible).
• The 0.0 Sleep Latency is CPAP titration is NOT normal, and a REM Latency of 34.5 minutes is a little short. While these may be due to sleep deprivation, if one adds in the horrid sleep fragmentation, one might want to at least consider narcolepsy (although admittedly rare in young children)(although maybe that's becauses it's not quite florrid)(or nobody really spends the time looking for it).
• Is there any evidence of cataplexy? How about falling asleep during the day?
• I'd try to get the complete report including histograms to find out exactly how many PLMs and where, how many residual events and where, and if pressures >5.0 mmHg were attempted.
• You could ask for the raw data from all studies, if for nothing else, just to see the look on their faces.

I am sure they have access to all of the data you mentioned. It is a hospital-based sleep center and it the lab is the same location as the doctor's office.

There is no cataplexy that I have seen. He only falls asleep during the day if I drive him around at length. He fights sleep.

The 0.0 latency may have been because they were running late and put started the study after he had already fell asleep. They put the mask on him after he had fallen asleep. If I estimate, he was probably asleep for 15-30 minutes before the study technically began.

Could the PLMs come from his night terrors and his thrashing about in his sleep?

Also, the "red bars" (i.e., days without CPAP usage) tend to be times when he falls asleep on my way home from work with him. He does this if he doesn't get a nap and it tends to be around 7pm. I haven't been successful at getting the mask on him once he is already sleeping. He swats it off. Do you think I should wake him up for a little while and then try to get him back on track with the mask? He is extrememly irritable and non-compliant when he is awakened from sleep, so I worry I won't be able to accomplish this and my usual thought is to let him sleep when he is asleep since he is so exhausted. Not sure what is the right thing to do there.

sleeplessmommy wrote:Could the PLMs come from his night terrors and his thrashing about in his sleep?

Absolutely not.

Consequently, if the PLMs WERE scored on that basis, that would be ANOTHER major error. ANY PLMs in a small child are worrisome.

"IMHO" this (these) reports are now completely suspect. Reporting 0.0 Sleep Onset is a blunder. Reporting SOREM is a blunder. Reporting ETCO2 >46 (instead of >50 mmHg) is a blunder. Saying the kid has UARS is a blunder. Reporting PLMs may be a blunder. Inadequate titration may be a blunder.

At this point (and "IMHO") everything becomes suspect. If they're scoring PLMs off artifact it could also be that they're scoring respiratory events off artifact and those results are spurious. I mean, can one safely say, "Well, all those parameters are wrong, but we're going to take the AHI as Gospel"? How does know when a liar is telling the truth?

IIWY (and I'm not) I'd find out EXACTLY what was happening all the way back to Square One (I don't mean to sound skeptical, because I'm not. I'm way beyond cynical).

BTW, and at the risk of generalizing, the effectiveness of any treatment for SRB other than CPAP is ~50% (and that (TTBOMK) includes RPE) so you may need to continue therapy with/after that intervention.

sleeplessmommy wrote:Not sure what is the right thing to do there.

Well, since overall compliance now looks to be about 10%, I'd say just trying just about anything else at this point would be helpful.

BTW2, (and also "IMHO"), reporting TSTs of 431.5 and 439 as Normal would also be a MAJOR blunder in a 4YO, but the Pediatric Task Force noted a number of studies showing in-lab TST at ~470 minutes (although really all over the place) so imagine that technically they might be able to get away with that.

Sludge wrote:BTW2, (and also "IMHO"), reporting TSTs of 431.5 and 439 as Normal would also be a MAJOR blunder in a 4YO, but the Pediatric Task Force noted a number of studies showing in-lab TST at ~470 minutes (although really all over the place) so imagine that technically they might be able to get away with that.

Upon further reflection, since the 470 value is based on FNE, and he's had (at least) 3 NSPG, I'd say they shouldn't get away with that either.

"First Night Effect".

Got a full 8 hours before he ripped it off tonight, but that was with 2 wake ups. Wish I knew why this kid is still waking up so much? Tried getting mask on two nights ago after he had fallen asleep in the car but he wasnt having it no matter what and ended up crying and screaming "just let me sleep."

Forgive me, but this information contains jargon I am unfamiliar with. Ok- so plan of action given the crappy studies should be asking about if the ideal pressure was ascertained and to investigate PLMs (whether they were properly scored and if so, having blood work done)?