Medical sleep disorders as common causes of the sleepless child
Behavioral sleep disorders as common causes of the sleepless child
Restless legs syndrome
Sleep-onset association disorder
Circadian rhythm disorder—delayed-sleep phase
Limit-setting sleep disorder
Mood disorders (anxiety, depression)
Inadequate sleep hygiene
Obstructive sleep apnea syndrome
Excessive time in bed
Table 14.2
Common causes of sleep-onset insomnia and sleep maintenance insomnia
Common causes of sleep-onset insomnia | Common causes of sleep maintenance insomnia |
|---|---|
Restless legs syndrome | Obstructive sleep apnea |
Circadian rhythm disorder—delayed-sleep phase | Parasomnias—nightmares |
Limit-setting sleep disorder | Sleep-onset association disorder |
Excessive time in bed | Excessive time in bed |
Inadequate sleep hygiene | |
Mood disorders |
Normal Sleep Duration
Additionally, it is important caregivers and clinicians are aware of normal sleep duration expectations. Newborns and infants <12 months of age will sleep a majority of the day, around 14–18 h in a 24-h period, usually as brief 1–3-h intervals. Toddlers, 1 year of age to about 5 years of age, will sleep around 11–14 h in a 24-h period including nap time. Children from age 5 years to early teenagers need approximately 10-h sleep per night. Children ages 14–16 years should get 9.25 h per night, and teens 17–18 years need at least 8.25 h per night.
Another normal developmental factor of infant sleep is the ability to self-soothe and thus “sleep through the night.” The majority of newborns will cry after awakening, needing attention to help settle; however, by the time they reach 1 year of age, approximately 70 % have learned to self-soothe and fall back asleep despite 1–2 awakenings in a night [3]. Up to eight (brief 1–5 min) awakenings may be considered normal, commonly occurring during the regular cycles of non-rapid eye movement (NREM) and REM sleep. “Sleeping through the night” is defined as 5–6 consecutive hours of sleep and can typically be achieved by most children weighing approximately 14 lb and approximately 6 months of age.
Chronic Insomnia
The International Classification of Sleep Disorders-3 (ICSD-3) defines insomnia as “a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment” that persists for longer than a 3-month period [2]. Key symptoms or concerns described by the caregiver are difficulty placing the child to bed, typically met with some form of resistance, night awakenings, and possibly the insistence of the child to not sleep independently without a caregiver or other relative. These concerns then progress into daytime consequences, such as fatigue/tiredness during the day, lack of focus, poor cognition, or younger children that may show a paradoxical hyperactivity (due to the use of motor activity to stay alert despite their sleepiness), often misdiagnosed as attention-deficit hyperactivity disorder (ADHD). Medical comorbidities include depressed mood and anxiety. Poor sleep, in addition to daytime impairment, has also been linked with increased risk taking and substance abuse [2].
The child’s medical, surgical, and mental health histories all can play a significant role in sleep. Clarification of medications and supplements used may also share insight on sleep quality [2]. Family history particularly looking for obstructive sleep apnea syndrome (OSA), restless legs syndrome (RLS), depression, or anxiety can all hold significance for children presenting with a complaint of insomnia. Additionally, understanding a child’s social history can explain stressors, household dynamics, and sleeping environment which can affect sleep [4].
A thorough physical exam is important. Most often the child with insomnia will have a normal physical exam. However, the exam may suggest other etiologies of poor sleep, such as signs suggestive of OSAS or other medical conditions which may affect sleep, such as a tired or fatigued appearance, crowded nasal or oral airway, or obesity.
Evaluation or testing for insomnia begins with reports from caregivers and teachers. Additional diagnostic tools include sleep diaries and actigraphy. Actigraphy provides an objective measurement of movement; lack of movement can help distinguish periods of rest (presumed sleep) and active periods of wake. Blood work may reveal specific causes of insomnia such as hyperthyroidism or assist with the treatment plan, such as when low ferritin levels (<50) are found in association with RLS [5]. In the evaluation of insomnia, a polysomnogram is not usually required to identify the etiology; however, a polysomnogram should be ordered in cases of suspected concurrent medical sleep disorders such as OSA.
Treatment often begins with sleep hygiene improvement, and cognitive behavioral therapy for insomnia (CBT-I) delivered by a specially trained behavioral sleep specialist (physician or psychologist). Treatment may also include short-term or, less frequently, long-term hypnotic medications. Treatment of comorbid disorders such as anxiety or depression may be needed for full resolution of sleepless symptoms. The next several paragraphs describe subtypes of insomnia that are included in the ICSD-3.
Clinical and Pathophysiological Subtypes of Insomnia
Psychophysiological Insomnia
In this type of insomnia, the child is unable to “turn off his/her brain.” Children, just like adults, can have difficulty with falling asleep due to the inability to stop thinking. They may replay events of the day or incessantly recite a to-do list. Physical exam is usually normal. Evaluation may include a visit with a psychologist for assessment of mental health disorders such as anxiety. A polysomnogram is usually not necessary. Treatment begins with CBT-I performed by a behavioral sleep specialist (physician or psychologist) or with a hypnotic medication if no medical sleep disorder is identified.
Idiopathic Insomnia
Idiopathic insomnia refers to lifelong insomnia. Children may admit to “I’ve never been a good sleeper.” Physical exam is usually normal. A polysomnogram is usually not necessary. Treatment begins with CBT-I performed by a behavioral sleep specialist (physician or psychologist) or with a hypnotic medication if no medical sleep disorder is identified.
Paradoxical Insomnia
Paradoxical insomnia is identified if a child states he/she has not slept at all or has slept only a little each night, when in fact he/she has slept an appropriate duration overnight. Physical exam is usually normal. Evaluation may include actigraphy or polysomnography to better describe sleep duration. Treatment begins with CBT-I performed by a behavioral sleep specialist (physician or psychologist) or with a hypnotic medication if no medical sleep disorder is identified.
Inadequate Sleep Hygiene
Inadequate sleep hygiene may be a cause of insomnia. Sleep hygiene is linked with sleep duration, including naps taken throughout the day, and behaviors associated with the bedtime routine. Therefore, it is important for the clinician to verify the current sleep patterns and schedule [1]. Questions should include bedtime and wake time for weekdays, weekend days, and vacation time. Physical exam is usually normal. No diagnostic tests are needed to make the diagnosis; this diagnosis is by clinical history. Treatment includes creation of a dark, cool, quiet sleep environment for sleep and includes regular routines for bedtime and wake-up time.
Noise and light, either inside or from outside the room, can affect sleep [5]. Screen time should be limited during the day and especially prior to sleep, as the light from mobile type devices has been shown to affect sleep patterns by altering circadian rhythm [4]. Caffeine should be limited, with no intake after 4 PM to prevent stimulant-related awakening [3].
Sleep schedules should follow the same pattern each day and vary by 1 h or less including weekend and vacation days. Naps should occur in a specific time window each day and last no longer than approximately 2 h for most children. Older children and teens should not be napping, as this may cause them to be less sleepy at their regular bedtime. The child should have a daily bedtime routine that should be the same each day and last 15–30 min in duration [4]. An example of this would be after dinner a child may play, complete homework, and then, as bedtime nears, shower, change in pajamas, brush teeth, and finally read and/or say prayers just prior to lights out.
The sleep space is also important. Children, who share a bed, may bump into each other during the night, causing arousals/awakenings; thus, a large enough bed is recommended for siblings who share a bed. If possible, children should have their own sleep space. Additionally, a noisy sibling may be keeping a child up at night; conversely some children prefer to have a sibling also sleeping in the same room.
Often by the time the caregiver brings the child into a clinician’s office for a sleeplessness complaint, they have already tried improving sleep hygiene as these treatment suggestions are readily reviewed through family and friends and found on the Internet. Thus, when treating a child for insomnia, briefly review sleep hygiene and continue evaluating for another cause.
Behavioral Insomnia of Childhood
Behavioral insomnia of childhood is a disorder of two subtypes: limit setting and sleep-onset association. Limit setting may be on the part of the child showing resistance or refusal at bedtime or on the part of the caregiver, due to poor establishment and enforcement of bedtime and wake-up times.
Limit–Setting Disorder. Limit-setting disorder on the part of the child is described as a child who does not get ready for bed or refuses to go to bed [5]. Parents see the child perform “curtain calls,” delay going to their room to sleep, make trips to bathroom, ask for a glass of milk or water, or seek out a parent for another hug. Parents note the child may easily go to bed and fall asleep for other relatives, babysitter, or in other situations such as sitting by the TV or on the couch.
When the history is clear for limit-setting sleep disorder, no further evaluation may be needed unless another sleep disorder, such as RLS or OSAS, is suspected. Physical exam is usually normal. Treatment success is dependent on the caregiver’s ability to establish and enforce bedtimes and wake-up times. Parents needs to be firm, consistent, and persistent with bedtimes and bedtime routine nightly [4] (and morning wake ups daily) for up to 6 weeks. Children may be most upset with this new change in routine during the third through seventh days.
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