Sleep Disorders in Children After Developing COVID-19

Educational Objectives

The goal of this program is to improve diagnosis and treatment of sleep disorders in the pediatric population after COVID-19 infection. After hearing and assimilating this program, the clinician will be better able to:

1. Assess the role of various contributing factors in delayed sleep phase syndrome.
2. Use actigraphy to assess sleep patterns.
3. Optimize use of cognitive behavioral therapy for insomnia.

Summary

Long COVID: defined by the US Centers for Disease Control and Prevention (CDC) as signs, symptoms, and conditions (relapsing or remitting) that continue or develop after initial COVID-19 infection, occurring ≈4 weeks after initial infection; World Health Organization (WHO) requires ≥3 mo of symptoms starting from COVID-19 onset, persisting for ≥2 mo after initial diagnosis, without an alternate diagnosis; unlike adults, pediatric criteria for long COVID require a positive SARS-CoV-2 test and 1 persistent physical symptom for ≥12 wk after initial testing; because it is not a single condition, patients’ experiences vary

Symptoms of long COVID: mirror symptoms that can naturally occur without COVID-19 infection; circadian rhythm disruption occurred in individuals who experienced changes in, eg, exposure to natural light, eating, social interactions, sleep and wake times during the pandemic; insomnia from circadian rhythm disruption led to, eg, depression, anxiety, which were exacerbated by staying home during the pandemic; depression and anxiety can also contribute to insomnia and fatigue; additionally, decreased physical activity during the pandemic may have contributed to obesity and sleep apnea, which can mimic symptoms of long COVID

Delayed sleep phase syndrome (DSPS): characterized by a significant delay in the time a person goes to sleep relative to their social requirements, lasting for ≥3 mo; patients typically experience better sleep quality and functioning when allowed to adhere to their natural sleep schedule; treatment involves melatonin and bright light therapy; it affects 7% to 16% of individuals and often runs in families; treatment depends on the patient's motivation to change; contributing factors include natural circadian delay, bedtime autonomy, school schedules, medical conditions requiring lengthy treatment (eg, cystic fibrosis), and school start times; screening — consider comorbid conditions, eg, primary insomnia, school-related stressors, social issues, and psychiatric disorders; children with DSPS are twice as likely to experience anxiety, depression, and suicidal thoughts; consider overscheduling, an abnormal home bedroom environment, substance use or abuse, medical disorders (eg, narcolepsy), or sleep disorders

Sleep state misperception: can be caused by sleep apnea; individuals perceive difficulty falling asleep, but the actual issue is fragmented sleep, with individuals waking frequently from light sleep

Assessment of DSPS: can be challenging; sleep diary — noninvasive but requires commitment from both the patient and parents for 1 to 2 wk; patients must document sleep and wake times, quality of sleep, caffeine intake, and any issues encountered; compliance can be an issue, and some patients fill it out retrospectively, diminishing its accuracy; actigraphy — measures movements using oscillometry, similar to Fitbits or Apple Watches; actigraphs also have sensors to detect changes in light exposure, eg, closing blinds, using a cellphone or watching television before sleep (it detects different types of light); it provides detailed data on sleep patterns and circadian rhythms; actigraphs are noninvasive but costly and not typically reimbursed; consumer-grade devices, eg, Fitbits and Apple Watches offer reliable data on sleep and wake times, although data on the depth of sleep may not be as reliable

Treatment of DSPS: good sleep hygiene includes a consistent bedtime routine and sleep schedule; low-dose melatonin (0.25 mg) taken 4 hr before bedtime encourages earlier release of naturally produced melatonin, helping readjust the sleep-wake cycle; bright light exposure (≈10,000 lux for 30-90 min) can create sleepiness earlier in the evening; light boxes or exposure to natural sunlight immediately on waking in the morning are recommended; avoid bright light in the afternoon and evening, and consider blue light–blocking glasses and apps; discourage afternoon naps

Insomnia: primary insomnia refers to difficulty falling asleep, staying asleep, or waking up too early despite having the opportunity to sleep; it leads to daytime impairment; it must occur ≥3 times/wk for ≥3 mo; psychophysiologic insomnia is the most common type of primary insomnia; involves heightened arousal and learned associations that prevent sleep onset and cause daytime impairment; predisposing factors include anxiety, depression, and chronic pain; precipitating factors are stressors; perpetuating factors include maladaptive thoughts, caffeine use, and poor sleep habits; ≤30% of children and ≤66% of adolescents experience symptoms, with 9% to 23% having an official insomnia disorder; the severity of insomnia correlates with daytime functioning; insufficient sleep in teenagers is associated with neurocognitive dysfunction, decreased neurobehavioral functioning, mood disorder and suicidal ideation, obesity, insulin resistance, decreased high-school graduation rates, and increased car-accident risk

Assessment: the gold standard is the interview; there are validated surveys available, but there is no formal structured assessment; sleep studies are not first-line diagnostic tools unless there is persistent insomnia after intervention or symptoms suggestive of sleep apnea; interview — determine the problem; assess the medical history, eg, reflux or medication use, developmental history, and psychiatric history; understand the patient's sleep-related beliefs and goals

Treatment: behavioral interventions are typically first-line therapy; medications are second-line therapy; cognitive behavioral therapy for insomnia (CBTI) is the primary behavioral intervention for sleep initiation and maintenance; typically consists of 6 to 8 sessions and targets perpetuating factors contributing to insomnia; CBTI is effective across various patient populations, including those with depression, anxiety, Parkinson disease, undergoing chemotherapy for cancer, and adolescents; 70% to 80% of participants experience improvement in sleep; CBTI includes sleep education (ie, sleep is a learned behavior that requires training) and sleep restriction (restricting time in bed to match actual sleep time, gradually adjusting bedtime earlier); it is important to participate in a structured CBTI program to avoid exacerbating insomnia

Sleep hygiene: adopt consistent and calming practices conducive to sleep and avoid activities that induce anxiety or excitement before bedtime; stimulus control focuses on using the bed only for sleep; implement relaxation strategies; cognitive techniques include scheduling worrying thoughts for other times of the day or rescripting thought processes

Obstructive sleep apnea (OSA): causes fatigue and can involve insomnia; it affects 2% to 6% of children, with a bimodal distribution (2-6 yr of age and adolescence); after adolescence, it is more common in boys; SA is characterized by prolonged or intermittent obstruction of the upper airway, causing abnormal gas exchange and disrupted sleep architecture; untreated OSA can result in decreased neurobehavioral functioning, obesity and metabolic changes, systemic and pulmonary hypertension, mood and behavior disorders, and comorbid pulmonary disease; in younger children, OSA is usually caused by anatomic factors, eg, enlarged tonsils and adenoids or obesity, narrowing the airway; assessment of neuromuscular tone is crucial; some individuals have weaker muscle tone in their upper airway during sleep, making them more prone to airway collapse and apnea episodes; during pediatric checkups, ask about snoring and unrefreshing sleep; assess the size of the upper airway, Mallampati score, tongue size (macroglossia), and chin size; these factors can help determine the need for a sleep study

Guidelines: the American Academy of Pediatrics (AAP) recommends that children with frequent snoring (>3 times/wk) and polysomnography (PSG) should be used for sleepiness, restless sleep, labored breathing, nocturnal enuresis, learning or behavioral problems, obesity, or enlarged tonsils; PSG is a comprehensive recording of physiologic signals during sleep; it includes electroencephalography (EEG), airflow, heart rate and rhythm, oxygen and carbon dioxide levels, leg movements, and video monitoring; it is the gold standard for diagnosing OSA; overnight pulse oximetry is recommended for children without access to a sleep laboratory

Treatment: may include tonsil and adenoid removal, continuous positive airway pressure (CPAP), weight management, and addressing associated disorders, eg, allergic rhinitis, reflux, asthma

Chronic fatigue: shares similarities with long COVID; patients have persistent fatigue without an identifiable cause; it may be secondary to infection or an acute inflammatory process; treatment — involves addressing individual symptoms, eg, insomnia depression; research suggests that progressive exercise (gradually increasing activity levels to build endurance) is helpful; however, caution is needed to prevent postexertional malaise, which can exacerbate symptoms; patient education plays a crucial role in helping individuals understand their limits and avoid overexertion

Readings

Behnood SA, Shafran R, Bennett SD, et al. Persistent symptoms following SARS-CoV-2 infection amongst children and young people: A meta-analysis of controlled and uncontrolled studies. J Infect. 2022 Feb;84(2):158-170. doi: 10.1016/j.jinf.2021.11.011; Ceban F, Ling S, Lui LMW, et al. Fatigue and cognitive impairment in Post-COVID-19 Syndrome: A systematic review and meta-analysis. Brain Behav Immun. 2022 Mar;101:93-135. doi: 10.1016/j.bbi.2021.12.020. Epub 2021 Dec 29. PMID: 34973396; PMCID: PMC8715665; Davis HE, McCorkell L, Vogel JM, et al. Author Correction: Long COVID: major findings, mechanisms and recommendations. Nat Rev Microbiol. 2023 Jun;21(6):408. doi: 10.1038/s41579-023-00896-0. Erratum for: Nat Rev Microbiol. 2023 Mar;21(3):133-146. PMID: 37069455; PMCID: PMC10408714; Hicks SD. Comparison of symptom duration between children with SARS-CoV-2 and peers with other viral illnesses during the COVID-19 pandemic. Clin Pediatr (Phila). 2023 Feb 7:99228231152840. doi: 10.1177/00099228231152840; Lopez-Leon S, Wegman-Ostrosky T, Ayuzo del Valle NC, et al. Long-COVID in children and adolescents: A systematic review and meta-analyses. Sci Rep. 2022;12, 9950; Maddux AB, Berbert L, Young CC, et al. Health impairments in children and adolescents after hospitalization for acute COVID-19 or MIS-C. Pediatrics. 2022;150(3):e2022057798; Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84. doi: 10.1542/peds.2012-1671; Merikanto I, Dauvilliers Y, Chung F, et al. Sleep symptoms are essential features of long-COVID - Comparing healthy controls with COVID-19 cases of different severity in the international COVID sleep study (ICOSS-II). J Sleep Res. 2023 Feb;32(1):e13754. doi: 10.1111/jsr.13754; Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, et al. Use of Actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: An American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2018 Jul 15;14(7):1231-1237. doi: 10.5664/jcsm.7230. PMID: 29991437; PMCID: PMC6040807; Typaldos M, Sockrider M. Delayed Sleep Phase Syndrome. Am J Respir Crit Care Med. 2019 Aug 15;200(4):P7-P8. doi: 10.1164/rccm.2004P7. PMID: 31414911.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Ortiz was recorded at the 46th Annual Florida Suncoast Pediatric Conference, held June 8-11, 2023, in Sarasota, FL, and presented by the Johns Hopkins University School of Medicine and Johns Hopkins All Children's Hospital. For information about upcoming CME activities from this presenter, please visit https://www.hopkinsallchildrens.org/Health-Professionals/Conferences-Classes/CME. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

PD701901

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.