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    Human sleep and growth.2 ppt Human sleep and growth.2 ppt Presentation Transcript

    • 04/12/13 22:51
    • Human Sleep and !Gr owth Dr. Ahmed Elshebiny , MD Lecturer of Internal Medicine Faculty of Medicine, Menoufyia University ,Former Clinical Research Fellow Joslin Diabetes Center, Harvard University04/12/13 22:51
    • Sleep for growth Sleep04/12/13 is no less important than food for growth22:51
    • Key message Sleep pattern differs by age Sleep and hormones are interrelated GH is secreted preferentially in the SW sleep Sleep disorders can retard growth Treatment of sleep disorders can lead to catch – up Bidirectional inter-relation between somatotropic system and sleep GH, GHRH , prolactin & somatostatin promote sleep04/12/1322:51
    • Growth Growth Intra-uterine Postnatal Growth Growth Infantile Childhood Pubertal Phase Phase Phase Gonadal steroids Nutrition GH and GH04/12/13 (Sam & Meeran Lecture notes Endocrinology& Diabetes, 2009)22:51
    • Rate of Growth04/12/1322:51
    • Growth failureCauses Some are constitutional, some are genetic, nutritional, psychological, are due to chronic illnesses, and some are the result of hormonal disorders or may be idiopathic. Many primary care physicians do not include sleep OSA as a cause of Growth retardation Bonuck, et al, International Journal of Pediatric Otorhinolaryngology (2005)04/12/1322:51
    • Prevalence of Growth failure Among children under 2 years of age, a population-based screening program in England identified 3% with GF (Wright et al BMJ, 1998) In US children aged 24—71months who are < 5th percentile range between ( 2.7- 5.2 %) ( Third report on nutrition monitoring in US, 1995)04/12/1322:51
    • What happened to our sleep ?04/12/1322:51
    • Sleep is an active process Sleep is not merely the absence of waking. On the contrary, it is a state during which specialized physiological activities occur in the brain and throughout the body. It is an active process in which metabolism, tissue restoration, memory consolidation, and general homeostatic balance is maintained04/12/1322:51
    • 04/12/1322:51
    • Frequency of Night – WakingNewborns – 100%Six-month-olds – 20-30%Up to four years: one in three continues to awaken duringthe night and require intervention by a parent to return to.sleep 04/12/13 22:51
    • ?Sleep Center Recently VLPO of hypothalamus Sleep active neurons GABA inhibition to arousal systems ( Gaus et al, Neuroscience , 2002)04/12/1322:51
    • Sleep disorders in Children 25 % of children experience some type of sleep disturbance Instead of appearing sleepy, the overtired child may appear overactive & inattentive. Wake up America, A National Sleep Alert January, 199304/12/1322:51
    • Prevalence of Insomnia by age group04/12/1322:51
    • 04/12/13 22:51
    • GH secretion during sleep Growth hormone (GH) is preferentially secreted during slow-wave sleep . In normal adult men , sleep onset GH pulse represents 60-70% of the total daily secretion of the hormone There is a quantitative correlation between the amount of GH secretion during sleep and the duration of SW sleep04/12/1322:51
    • GH secretion during sleep04/12/1322:51
    • GH secretion during sleep deprivation and daytime sleep04/12/13 Van Cauter et al, 200022:51
    • Effect of interrupted sleep on GH secretory pattern04/12/13 (Y. TAKAHASHI, et al)22:51
    • SW sleep and nocturnal GH patterns through adult life04/12/13 Cauter et al, 1998 , American Academy of Sleep Medicine Van22:51
    • Bidirectional Interactions between GH &sleepGHRH SW sleep GHGhrelin REM sleep Somatostatin04/12/1322:51
    • Sleep & Feeding problems co-exist Problematic sleep and feeding behaviors tend to coexist in early childhood. Increased awareness of this coexistence may improve outcome. (Pediatrics 2011;127:e615-e621 )04/12/1322:51
    • Sleep deprivation & appetite Total sleep deprivation in humans has been associated with hyperphagia Leptin & ghrelin – hormones associated the central regulation of food intake Van Cauter E et al 200404/12/1322:51
    • Sleep and intra-uterine growth In a study of pregnant women in Sri Lanka , sleeping for less than or equal to 8 h during 2nd or 3rd or both trimesters is a risk factor for small for gestational age baby. (Abeysena, et al., Australian & New Zealand Journal of Obstetrics & Gynaecology. 49(4):382-7, 2009 )04/12/1322:51
    • 04/12/13 22:51
    • SDB in children Sleep disordered breathing is relatively common in children While the exact prevalence of SDB in children is unknown, snoring may occur in 3—12%, while OSA may occur in 1—10% Bonuck, et al, International Journal of Pediatric Otorhinolaryngology (2005)04/12/1322:51
    • Sleep disordered breathing and Growth failure SDB, secondary to adenotonsillar hypertrophy increases the risk of growth failure in children. Just 20% of pediatricians screen for SDB OSA peaks at 2—6 years of age, because of the relative adenotonsillar hypertrophy found at this timeBonuck, et al, International Journal of Pediatric Otorhinolaryngology (2006)04/12/1322:51
    • Potential pathways for the effect ofOSA Increased energy expenditure Nocturnal hypoxemia Metabolic alkalosis Impaired growth hormone secretion Feeding problems04/12/1322:51
    • 04/12/1322:51
    • Effect of Adenotonsillectomy on growth Studies found that otherwise healthy children experiencing GF show significant catch up following T&A( Tonsillectomy and adenoidectomy). The American Academy of Pediatrics identifies GF as a serious complication of untreated obstructive apneaBonuck, et al, International Journal of Pediatric Otorhinolaryngology (2005)04/12/1322:51
    • 04/12/1322:51
    • Sleep disturbance, cortisol and growth hormones Sleep disturbance has a stimulatory effect on the HPA axis and a suppressive effect on the GH axis. There is an observed hypocortisolism in idiopathic hypersomnia and HPA axis relative activation in chronic insomnia. Vogontzas et al., Clin Endocrinol (Oxf). 1999 Aug;51(2):205-15.04/12/1322:51
    • Bidirectional Interactions between GH &sleepGHRH SW sleep GHGhrelin REM sleep Somatostatin04/12/1322:51
    • Central effects of GH High density of GH binding sites has been demonstrated in pituitary, hypothalamus and hippocampus. The binding sites are also abundant in choroid plexus (Lai et al., 1991)04/12/1322:51
    • GH deficiency and sleep GHD is associated with impaired sleep quality (Bjo¨rk et al., 1989). The analysis of sleep microstructure by means of CAP (cyclic alternating pattern) , in children with GHD, showed a reduction of transient EEG amplitude oscillations. Verrillo et al., Neuroendocrinology. 2011 Apr 5. (online)04/12/1322:51
    • Effects of GH, GHRH , Prolactin, and somatostatin on sleep GH, PRL & Somatostatin possess REM sleep-promoting activity. (Danguir J. Brain Res 367, 26-30 -1986) GHRH by itself promotes non-REM sleep. Krueger JM and ObaÂl Jr F. FASEB J 7, 645-652 (1993).04/12/1322:51
    • Potential for novel therapeutic approaches Pharmacological approaches that stimulate SW sleep may act as GH secretagogues e.g oral GHB ( investigational drug for narcolepsy) and ritanserin( 5HT2 antagonist) Aging effects on GH and SW sleep? Improvements of lifestyle indices in GH deficient adults after treatment with GH may be related to improvement of sleep quality04/12/1322:51
    • Take home message1. Normal sleep is important to the survival, growth and development of children.2. Primary care physicians, parents, and even teachers, to some extent, should be aware of sleep disorders that effect children.3. Appropriate diagnosis and management of these disorders can significantly improve the lives of children and their families.04/12/1322:51
    • 04/12/1322:51
    • 04/12/13 22:51