Most families think of nighttime as a period of respite from daily activities of their children, a chance to reconnect with their spouse, relax and unwind. However, for families who are dealing with sleep issues in their children, nighttime is often one of the most difficult and challenging times of their day. Children who have difficulties falling asleep, staying asleep or disorders that disrupt the quality/quantity of their sleep end up with families who are also tired and miserable. Thus, promoting healthy sleep habits and effectively treating sleep disorders in children is often one of the best ways to improve a family’s overall quality of life.
Effects of Sleep Disorders in Children
With the advent of physiological procedures for evaluating sleep, we have gained a better understanding of the role of sleep in children. While children suffer from several of the same issues that effect adults (sleep apnea, restless legs, circadian rhythm disorders and insomnia), the causes and treatments of these conditions in children are often quite different. In addition, the daytime effects of disordered sleep in children are quite different from adults. For example, sleep disordered breathing such as apnea and chronic snoring lead to daytime fatigue in adults at rates of over 80%. However, in children, these same conditions lead to behavioral problems (45%), ADHD-like symptoms (50%) and mild learning difficulties (35%). In fact, reported daytime fatigue occurs only about 11% of the time in children.
Common Sleep Disorders in Children
There are several common sleep problems in children. These include onset and maintenance insomnia, sleep disordered breathing, movement disorders, bedwetting, and night terrors. While this list is by no means exhaustive, it does highlight the common problems parents report to pediatricians and health care professionals.
Insomnia is generally characterized as primary (in isolation) or secondary (due to another medical or mental health condition) and as onset (inability to get to sleep) or maintenance (inability to stay asleep). My general belief is that children can fall asleep anywhere and anytime the need strikes. So, when families are reporting insomnia, my first concern is to rule out any systemic problems in the family that may interfere with bedtime routines and sleep habits or secondary factors such as anxiety/fear, side effects of medication (i.e. stimulants for ADHD, allergy and asthma medications). After evaluating and addressing other contributing factors, I try to determine if the child has a shift in their phase of sleep (i.e. adolescents who stay up late and then sleep in the next morning) or pressure for sleep (i.e. the child appears exhausted at night but can’t get to sleep). These are treated with a variety of interventions and frequently do not require pharmaceutical interventions.
Sleep Disordered Breathing
Sleep disordered breathing involves the total or partial cessation of breathing in sleep. It is frequently the result of either obstruction of the airway or a problem in the brain signal to the body to breath in a normal pace/fashion. In adults this can often result from even mild weight gain or a softening of the upper palate. However, in children, enlarged tonsils or adenoids are common causes for sleep disordered breathing. Since these conditions fragment sleep, the children awaken unrested and daytime behavioral problems and learning issues are common. Thus. it is critical that sleep is evaluated in all children referred for ADHD and LD. Removal of the tonsils and/or adenoids is a common and minimally invasive procedure. Adults are often placed on Continuous Positive Airway Pressure (CPAP), though this is considerably less common in children.
Bedwetting, Sleepwalking and Night Terrors
Parasomnias such as bedwetting, sleepwalking and night terrors (child begins screaming or crying but still appears to be asleep and difficult to arouse) represent common and less pathological conditions of sleep. However, their presence can be quite disruptive to families. Most are treated with behavioral interventions and run in families. In some cases medications are used to aid in the treatment of bedwetting, though often these are of limited or short-term benefits. In most cases (99%) there is no contributing medical cause; however, there is considerable debate as to whether bedwetting represents a difficulty in the development of the mechanism that shift the child from deep to REM sleep or an immaturity of the central nervous system. Medications may also be useful in the treatment of sleepwalking; but the major issue appears to be the amount of environmental risk (falling down stairs, leaving the house, etc.). These will be treated with environmental changes such as gates or door locks immediately to ensure the safety of the child regardless of what interventions are used to treat the sleepwalking itself.
Most sleep disorders in children can be treated effectively with the proper intervention. Only a trained professional can determine whether your child’s issues are related to a primary sleep disorder or secondary to a general medical or mental health condition. Once the root causes have been determined, an individualized plan for the family can be developed.