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Paediatric Sleep Medicine Clinical Network

Introduction

Sleep network

Radio report: Does your child have a sleep disorder?

“Up to 5 percent of children are estimated to be suffering from breathing sleep disorders preventing them getting a good night's rest. Paediatric sleep disorders are thought to affect 15,000 children in Auckland alone, but there are no firm figures, and no national plan to
tackle the problem. Acting Health Correspondent Gareth Thomas reports.”

This is a radio NZ Morning report featuring Drs Liz Edwards, Alex Bartle and Angela Campbell, who are members of the Paediatric Sleep Medicine Clinical Network. Tune in here: https://www.rnz.co.nz/national/programmes/morningreport/audio/201761210/does-your-child-have-a-sleep-disorder

Purpose

The purpose of the New Zealand Paediatric Sleep Medicine Clinical Network is to establish a multi-disciplinary network that will support New Zealand health care professionals working across community, primary, secondary and tertiary services to deliver an equitable, high quality, cost effective and integrated sleep medicine service for children, young people and their families/whanau.

The New Zealand Paediatric Sleep Medicine Clinical Network will provide clinical leadership in the development and maintenance of the nation-wide clinical service for children and young people up to 15 and when appropriate, 18 years of age, aiming to meet basic international benchmark standards.

Over the last 15-20 years there has been increased recognition of the importance of sleep for children's health. Sleep problems and disorders are common. It is estimated that 1 in 4 children and young people have a problem with sleep that warrants a doctor's attention. There are over 60 different diagnosable paediatric sleep disorders ranging from behavioural or non-respiratory conditions (e.g. night terrors or parasomnias) to respiratory disorders of sleep, the commonest being obstructuctive sleep apnoea.

Guidelines and articles

Sleep Disordered Breathing (SDB)

The New Zealand Guidelines for the Assessment of Sleep-Disordered Breathing in Childhood 2014 was produced by the National Paediatric Sleep Medicine Clinical Network as an evidence-based summary for the assessment of children with sleep disordered breathing. It aims to address the following clinical management issues for paediatric health care professionals in New Zealand:

  1. How should general practitioners and paediatricians approach the investigation of a child who snores?

  2. Which children should be referred from around New Zealand to a sleep disorders centre for further evaluation?

  3. What treatments are available for disorders of breathing during sleep in childhood and what are the known benefits of these treatments?

Full guideline: a pdf copy of the full guideline: New Zealand Guidelines for the Assessment of Sleep Disordered Breathing in Childhood 2014 can be downloaded here: https://media.starship.org.nz/guideline-for-the-assessment-of-sleep-disordered-breathing-in-childhood/Final_PSNZ_SDB_guideline_2015_plus_Exc_sum.pdf

Summary: This link provides a summary of the New Zealand Guidelines for the Assessment of Sleep-Disordered Breathing in Childhood 2014. This guideline is intended for GPs and paediatricians involved in the care of children and young people 2 years and older: https://www.starship.org.nz/guidelines/sleep-and-sleep-disordered-breathing-in-children

NZ Regional Clinical Pathways

Access to regional clinical pathways are available through the Goodfellow Unit at this link: https://www.goodfellowunit.org/clinical-pathways and the Health Navigator website at this link: https://www.healthnavigator.org.nz/clinicians/r/regional-pathways/
These supply links to the clinical pathways within each main region of New Zealand. Pathways are localised for each region and access is limited to health providers. If you do not know the login details, you will need to contact your DHB or PHO for more information.

The Paediatric Sleep Medicine Clinical Network has been involved in the development of the Canterbury Community HealthPathways: Snoring and Sleep Apnoea in Children and Sleep Problems in Children. Further information for this pathway can be found below:

Canterbury Community HealthPathways: Snoring and Sleep Apnoea in Children and Sleep Problems in Children

HealthPathways offers clinicians locally agreed information to make decisions, together with patients, at the point of care. The Canterbury HealthPathways suite includes Community HealthPathways, which provide general practice teams with information to consistently assess and manage medical conditions, as well as the criteria for requesting health services in the Canterbury DHB. Written for general practice teams, Community HealthPathways is also useful to all other health professionals.
A link to a pathway on ‘Snoring and Sleep Apnoea in Children’ can be found under the ‘Child and Youth Health’ section; ‘Respiratory -Child’:
https://canterburydraft.communityhealthpathways.org/index.htm?441470.htm
https://canterburyclassicdraft.communityhealthpathways.org/index.htm?441470.htm?stayonsite=1
A link to the pathway on ‘Sleep Problems in Children’ can be found under the ‘Child and Your Health’ section; ‘Behaviour and Development – Child’: https://canterburydraft.communityhealthpathways.org/469263.htm

Obstructive Sleep Apnoea

Obstructive sleep apnoea syndrome (OSA) is a relatively common and potentially serious medical condition in children causing sleep disruption and abnormal physiology. A guideline in regard to OSA can be found here: https://www.starship.org.nz/guidelines/obstructive-sleep-apnoea/

Oximetry

A guideline intended to assist clinicians with the performance, reporting and interpretation of paediatric overnight pulse oximetry studies can be found here: https://www.starship.org.nz/guidelines/oximetry/

Sleep and Sleep Disordered Breathing in Cystic Fibrosis.

Chronic respiratory disease such as cystic fibrosis can be associated with sleep disturbance due to problems such as cough, wheeze, nasal obstruction or side effects of medication. A guideline in relation to this can be found here: https://www.starship.org.nz/guidelines/sleep-and-sleep-disordered-breathing-in-cystic-fibrosis

Melatonin

Melatonin is increasingly being used to facilitate sleep in the paediatric population. This article reviews the indications for melatonin in children, and the evidence of benefits and of safety for melatonin use by children presenting with difficulty falling asleep or maintaining sleep.

Tools and questionnaires

BEARS mnemonic

The BEARS mnemonic can be used as a guide for history taking. Parents should be asked about snoring or noisy breathing in particular. https://www.starship.org.nz/guidelines/sleep-and-sleep-disordered-breathing-in-children/ (page 48) Chamness JA. Taking a pediatric sleep history. Pediatr Ann 2008; 37:502-508.

BEARS

 

Paediatric OSA screening questionnaire

If symptoms of snoring or noisy breathing are noted, a paediatric OSA screening questionnaire should be completed https://media.starship.org.nz/osas-screening-questionnaire/osas_screening_questionnaire.pdf This questionnaire is based on the Chervin Paediatric Sleep Questionnaire.

For the linked questionnaire add up the "Yes" scores for the 22 items. A score greater than 7 with no missing items, or a percentage value of 0.33, has a 78% sensitivity and a 72% specificity for detecting polysomnograph (PSG) diagnosed OSA (AHI >5).

Paediatric Sleep Questionnaire (PSQ)

Access to an electronic version of the PSQ will be available through the Whanau Pakari project - an electronic link to the PSQ will be uploaded when available.

Guidance for the assessment and management of children with sleep disordered breathing

For further guidance for the assessment and management of children with sleep disordered breathing see NZCYCN guideline on sleep disordered breathing, including a suggested pathway (Appendix 3). This is also outlined and summarised in the OSA guidelines on the Starship website: https://www.starship.org.nz/guidelines/obstructive-sleep-apnoea/

Pictures of Tonsil size

The size of the tonsils is graded on a scale from one to four. Four is the largest size. The tongue should be rested comfortably in the mouth for best judgment of the tonsil. Palatine tonsils are graded based on how much the airway is obstructed due to the tonsil protruding from either side of the oropharynx.

Brodsky grading scale: The Brodsky grading scale is comprised of the following 5 grades:

  • Grade 0: Tonsils are absent or have been removed. Tonsils are within the tonsillar fossa.

  • Grade 1: Tonsils are barely visible. This is the normal tonsil size. It indicates that the tonsil extends to the pillars. Tonsils are just outside of the tonsillar fossa and occupy ≤25% of the oropharyngeal width.

  • Grade 2: the tonsillar tissue is not beyond the tonsillar pillars. This is also normal tonsil size. Tonsils occupy 26-50% of the oropharyngeal width.

  • Grade 3: The tonsils are enlarged. Can be seen with infection. It indicates that tonsils extend beyond the pillars but stop short of the midline. Tonsils occupy 51-75% of oropharyngeal width.

  • Grade 4: Tonsils extend to the midline and are almost touching each other. Seen with significant infection. Tonsils occupy >75% of oropharyngeal width.

Video of child with OSA

 

Oximetry Learning Tool

This educational tool would be most useful for paediatric trainees and paediatricians, as well as other paediatric health professionals. The course is password protected. The instructions on how to access it are as follows:

  • If you are not a member of Goodfellow Unit you must first register (this takes 2 minutes):

    1. To register, go to this link

    2. Click ‘Register’ (green button) in top right hand corner of screen

    3. Enter details and click ‘Create New Account’ at bottom right

  • If you are a member log into the Goodfellow Unit website

  1. Once logged on, look for your name in top right-hand corner of screen

  2. Just below your name click on ‘View my Learning Record’

  3. You will now see a screen headed ‘Manage my Account’

  4. Click on the Tab labelled ‘Courses’

  5. Enter the code Oxi06 and hit ‘Submit’

  6. The course Paediatric overnight oximetry will now be visible; click on course and begin.

Information for clinicians and families

Kidshealth

The KidsHealth website has been created by a partnership between the Paediatric Society of New Zealand (PSNZ) and the Starship Foundation, supported and funded by the Ministry of Health. The aim of this website is to provide New Zealand parents, caregivers, family and whānau with accurate and reliable information about their children's health. Visit https://www.kidshealth.org.nz to see a range of information developed for parents and caregivers. These are the main links on the Kidshealth website about sleep and there are many relevant factsheets within each link:

This link https://www.kidshealth.org.nz/tags/sleeping-sound leads to information about:
- Normal sleep
- Sleep problems
- Tools for Managing Sleep Problems

This link https://www.kidshealth.org.nz/tags/sleep leads to information about:
- Problems getting to sleep
- Night Terrors
- Restless Legs syndrome
- Sleep and breathing problems in Neuromuscular conditions
- Bedtime resistance
- Nightmares
- Sleep and anxiety
- Positional head flattening in babies
- Delayed sleep
- Night waking problems
- Sleep Associations
- Polysomnography (Sleep Study)
- Insomnia
- Snoring or noisy breathing in children
- Overnight oximetry

Example of Rapid Eye Movement (REM) sleep in an infant (video)

Often parents can misinterpret an infant in REM sleep for being awake or waking up and can possibly disturb an infant’s sleep. Here is an example of REM sleep, which may be helpful to show families, so they can distinguish REM sleep: https://www.youtube.com/watch?v=AZ6I9N7t7Vc

Ministry of Health

The Ministry of Health https://www.health.govt.nz/ has also produced information and factsheets about sleep. These include:

Health Navigator NZ

The Health Navigator website https://www.healthnavigator.org.nz provides a place for New Zealanders to find reliable and trustworthy health information and self-care resources. It is a non-profit community initiative combining the efforts of a wide range of partner and supporter organisations, and is overseen by the Health Navigator Charitable Trust. Some links with sleep related information for families from this website include:

Raising Children

Raising Children Media Ltd https://www.raisingchildren.org.nz/ is a media company set up to support parents by providing them with quality video content on subjects they'll find helpful. This is supported by the New Zealand Government. For example:

Sleep/Wake Research Centre Moe Tika/Moe Pai

The Sleep/Wake Research Centre, Massey University have developed a series of COVID19 resources regarding sleep. Each information sheet is also available as a downloadable PDF. https://www.sleepwake.ac.nz/what-we-do/covid-19-resources/

These include (each information sheet is also available as a downloadable PDF):

Conferences and educational opportunities

Upcoming events can be found on the Australasian Sleep Association (ASA) website at this link: https://asa.associationonline.com.au/conferences/events and the World Sleep Society at this link: https://worldsleepsociety.org/membership/societymembership/meetings/

2021: Please check websites as some conferences have been cancelled or postponed due to COVID-19.

The 6th Congress of the International Pediatric Sleep Association. 5-6 February 2021. http://www.pedsleep.org/ Virtual/Online

6th International conference by the European Respiratory Society (ERS) and the European Sleep Research Society (ESRS). 16-17 April 2021. Prague. https://esrs.eu/events/sleep-and-breathing-2021/

Thoracic Society of Australia and New Zealand and Society of Respiratory Science Ltd (TSANZSRS) Annual Scientific Meeting. 29th April - 4th May 2021. Melbourne Convention and Exhibition Centre, Melborne, Australia. https://www.thoracic.org.au/events/event/tsanzsrs-annual-scientific-meeting-2020

The 2021 Sleep in Aotearoa ASM will be held on May 10-11 2021, Te Papa, Cable Street, Wellington. It will be both an in-person and virtual event.

A workshop (May 10th 9am-12pm) on Actigraphy (separate registration and limited numbers), will cover some of the technical details of this technology, research applications and clinical cases.

The main meeting (Monday May 10th 1-5pm and Tuesday May 11th 9am – 5pm) will include presentations of submitted abstracts, New Investigator Award, sleep surgery session and a review of code of practice of different sleep health groups.

Registration closes 1st may 2021
Enquiries to: SleepInAotearoa@gmail.com

Registration: https://www.eventbrite.co.nz/e/sleep-in-aotearoa-2021-registration-97888014687

American Thoracic Society (ATS) 2021 International Conference. May 14–19, 2021. Virtual. San Diego, USA. https://conference.thoracic.org/

SLEEP 2021. 10-13 June 2021. Virtual. The 35th annual meeting of the APSS. A joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society. https://www.sleepmeeting.org/

European Respiratory Society (ERS) International Congress. 4-8 September 2021. Barcelona, Spain. https://erscongress.org/

Sleep DownUnder 2021. 32nd Annual Scientific Meeting of the Australasian Sleep Association (ASA) and Australian and New Zealand Sleep Science Association (ANZSSA) and Dental Sleep Medicine 10, 11-13 October 2021, Brisbane Convention and Exhibition Centre, South Brisbane, Queensland, Australia and virtual. https://sleep.org.au/iCore/Events/Event_Display.aspx?EventKey=42b736b5-b1d7-47c8-b7de-7439bc301dc5&iSearchResult=true&WebsiteKey=5f74e3d8-8f71-4cbc-a836-21ba8f81755a and https://sleep.org.au/Public/Events/Dental-Sleep-Medicine-2020/Public/Events/DSM-2020.aspx?hkey=94e81263-83ef-4947-a8eb-a1d228b45c78

15th Congress of the European Society of Pediatric Otorhinolaryngology (ESPO): “Transfers, Bridges and Frontiers in Pediatric Otorhinolaryngology”. 6-9 November 2021. Palais du Pharo, Marseille. https://www.espo-2021.org/

2022

World Sleep 2022. March 11-16, 2022, Rome, Italy. Congress on Sleep Medicine. https://worldsleepcongress.com/

SLEEP 2022. 4-8 June 2022, Charlotte, NC. The annual meeting of the APSS. A joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society. https://www.sleepmeeting.org/about/

2023

SLEEP 2023. 3-7 June 2023, Indianapolis, IN. The annual meeting of the APSS. A joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society. https://www.sleepmeeting.org/about/

2024

SLEEP 2024. 8-12 June 2024, Houston, TX. The annual meeting of the APSS. A joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society. https://www.sleepmeeting.org/about/

For further information on PSNZ / MoH Clinical Network development, please contact Clinical Networks Support Manager, Karyn Sanson, karyn.sanson@paediatrics.org.nz.