SLEEP DISORDERS IN CHILDREN
AND ADOLESCENTS
Rebecca Cho, M.D.
O B J E C T I V E S
Review of sleep architecture and physiology through life stages
Exploration of pediatric sleep disorders and comorbidities
Potential consequences of sleep disruption in development
Behavioral and pharmacological treatment options
Normal Sleep Architecture
• NREM
– Stage 1
•
•
•
•
Transition stage where sleep usually begins, can be easily aroused
Alpha waves, rhythmic = relaxed wakefulness
≈ 1-7 min
 in HR and respirations, eyes move slowly under eyelids
– Stage 2
• Deeper sleep, more difficult to arouse
• ≈ 10-15 min initial cycle, longer with progressive cycles (45-55% total
sleep)
• Sleep spindles and K-complexes  memory consolidation, tranquil sleep
• Further  in HR and respirations, no eye movement
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research;
Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006.
Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Normal Sleep Architecture
- Stages 3 and 4 (slow wave)
o Deepest sleep, highest arousal threshold, may be disoriented if
awakened
o Stage 3 ≈ few min; stage 4 ≈ 20-40 min
o No significant distinguishing pattern in shift from stage 3 to 4
o Primarily delta waves = high voltage slow waves
o Slowest rates of breathing and HR
• REM
- Rapid eye movement
- Atonia, muscle paralysis  safe expression of dreams
- Desynchronous low-voltage mixed frequency waves + mix of wave
patterns seen in other sleep stages and wake state
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and
Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006.
Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Normal Sleep Architecture
• Stage 1 → Stage 2 → Stage 3 → Stage 4 → REM = one cycle
-
Cycle repeats through the night
NREM ≈ 75-80%, REM ≈ 20-25% of total sleep
First cycle ≈ 70-100 min; later cycles longer at 90-120 min
Stage 2 progressively dominates NREM and REM intervals get longer
with subsequent cycles, while slow wave sleep largely disappears
• Differences in sleep architecture through the ages
- Sleep becomes less efficient w/ age
- Newborns
o Sleep up to 16-18 hrs/day in broken segments lasting 2-4 hrs
o No distinct stages, circadian rhythm not fully developed
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research;
Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006.
Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Normal Sleep Architecture
- By 2-3 mos
o Circadian rhythm, NREM, REM develops
o Progressive consolidation of sleep,  naps, less total sleep required (1415 hrs)
o Dreams more apparent by 12 mos, content tends to be more vague
- Children
o Total sleep further  to 11-12 hrs by 3-5 y/o, most napping stops also
o Slow wave tends to dominate sleep cycle (w/ associated GH release)
o May start having more vivid dreams, nightmares, content related to
waking thoughts/fears/desires
- Adolescents
o Need avg 8-10 hrs/night
o  in slow wave sleep w/ onset of puberty and into adulthood
o Frequent shifts in circadian rhythm due to social/environmental factors
and potential biological/hormonal Δs
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors.
Washington (DC): National Academies Press (US); 2006.
Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Physiological Δs in Sleep
Physiological Process
NREM
REM
Brain activity
 from wakefulness
 in motor and sensory areas;
otherwise similar to NREM
Heart rate
 from wakefulness
 and varies
Blood pressure
 from wakefulness
 up to 30 % and varies
Sympathetic nerve activity
 from wakefulness
 significantly from wakefulness
Muscle tone
Similar to wakefulness
Absent
Blood flow to brain
 from wakefulness
 from NREM, depending on brain
region
Respiration
 from wakefulness
 and varies from NREM, but may
show brief stoppages; cough
suppressed
Airway resistance
 from wakefulness
 and varies from wakefulness
Body temperature
Regulated at lower set point than
wakefulness;; shivering initiated at
lower set point than wakefulness
Not regulated; no shivering or
sweating; temp drifts towards that
of local environment
Sexual arousal
Occurs infrequently
> than NREM
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR,
Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006.
Why Do We Sleep??
• Exact role of sleep or why we alternate btwn NREM and REM
are unclear, but overwhelming evidence that lack of sleep or
disrupted sleep architecture leads to negative outcomes
• A lot of interest in research; some hypotheses have arisen
• REM
- Appears to be involved in memory consolidation; learning seems to
intensify/ REM
- Hippocampal neuronal activation in REM mirrors pattern of wake
state
-  NE and 5HT  post-synaptic depolarization and long-term
potentiation  may aid in temporary hippocampal memory storage,
cognitive functioning, synaptic plasticity
• NREM
- Also appears to be associated w/ learning and memory; learning
seems to intensify slow waves during NREM
- May play role in differentiating/organizing important synapses from
those that are underutilized, facilitate protein synthesis
Poe, Gina R., Walsh, Christine M., Bjorness, Theresa E. Cognitive Neuroscience of Sleep. Prog Brain Res. 2010; 185:1-19.
Pediatric Sleep Disorders
Obstructive sleep apnea
Sleep-related movement disorders
Parasomnias
Narcolepsy
Circadian rhythm disorders
Behavioral insomnia of childhood
Psychiatric causes
Medical causes
Obstructive Sleep Apnea
SYMPTOMS
ETIOLOGY
RISK FACTORS
Snoring
Adenotonsillar
hypertrophy
(most common)
Allergies
Apneic episodes
Diaphoresis
Enuresis
Waking up feeling
unrested
Daytime somnolence
Morning HAs
Cognitive dysfunction
Obesity
Craniofacial
dysmorphology
(e.g., Downs)
Neuromuscular d/o
(e.g., CP)
Sinus problems
AA ethnicity
FHx of OSA
Obstructive Sleep Apnea
• Has been associated w/ ADHD: proposed that intermittent
hypoxia + fragmented sleep  prefrontal dysfunction
• Dx: polysomnography + pulse ox
• Tx:
-
Wt loss
Adenotonsillectomy if indicated
Nasal CPAP
Leukotriene receptor antagonists (montelukast)
Intranasal corticosteroids (fluticasone spray)
External nasal dilator strips
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan 15; 63(2): 277-28
Sleep-related Movement Disorders
Rhythmic movement disorder
Periodic limb movement disorder in sleep
Restless leg syndrome
Relationship between ADHD and PLMS/RLS
Rhythmic Movement Disorder
• AKA Jactatio Capitis Nocturna
• Repetitive, stereotyped movements, involvement of large
muscle groups
- Head banging
o
o
o
o
 stress
Lying in prone/supine position
Most common in 1st yr
Boys > girls
- Head rolling
o More common, progressively declines w/ age
- Body rocking
o Child is usually on hands and knees rocking anterior  posterior
o More associated w/ pleasurable activities (e.g., listening to music)
- Hypothesized to be mechanism of self-stimulation/self-soothing
(mimicking cradling/rocking by parents)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Rhythmic Movement Disorder
• Most commonly seen in infants and children < 5 y/o
• Usually occurs when child is sleeping; occ stage 1 or 2 sleep
•  prevalence in MR (esp older individuals)
• Dx: Thorough clinical eval + video polysomnography to r/o
other causes (e.g., seizures)
• Tx:
- Supportive; spontaneous resolution w/ age in most cases
- If movements  risk for injuries (esp head banging)  provide safe
environment (e.g., padding, protective helmets)
- Metronome near bed
- Allowing child to engage in rocking before bedtime (e.g., rocking on
chair or rocking horse)
- If severe, may trial low-dose benzo such as clonazepam
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Periodic Limb Movements in Sleep (PLMS)
• Involuntary brief jerking movements in 20-40 sec intervals
• Lower > upper extremities
• In children movements may be less apparent; instead may
present as:
-
Growing pains
Leg discomfort
Disrupted sleep
Difficulties initiating/maintaining sleep
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Periodic Limb Movements in Sleep (PLMS)
•  rate of parasomnias
• Dx: Video polysomnography to r/o seizures/OSA, detailed hx
• Tx options:
-
Fe supplementation (if low iron levels)
Dopaminergic agents (e.g., ropinirole, pramipexole)
Clonazepam (limited data)
Bupropion (shown to be effective for adult PLMS)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Restless Leg Syndrome (RLS)
• Frequently co-occurs w/ PLMS
• May p/w nonspecific “growing pains” or leg discomfort
• Criteria include:
-
Urge to move legs (may also involve upper ext)
Urge begins/worsens when sitting/lying/inactive
Urge partially or totally relieved upon movement of legs
Urge only occurs in evening/night or more severe than during
daytime
• Sleep onset or maintenance difficulties frequent; anxieties
r/t discomfort may interfere w/ ability to achieve restful
sleep
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Restless Leg Syndrome (RLS)
• Tx:
- Behavioral interventions including strict sleep hygiene and reg
physical activity
- If Fe levels low (<50ng/dL) may consider supplementation (2mg/kg)
w/ goal of ing > 50ng/dL + vit C to aid in absorption of Fe
- Pharmacological options only approvde for adults; includes benzos,
clonidine, gabapentin, dopaminergic agents (need to monitor closely
for sedation)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Relationship Between ADHD & PLMS/RLS
• Significant comorbidity
• Possible hypotheses:
- May be r/t impairment in DA pathway:  Fe   effectiveness of
tyrosine hydroxylase   DA production
- Insufficient sleep in children (disrupted sleep commonly seen in
those w/ PLMS & RLS) may manifest as hyperactivity, distractibility,
inattention, impulsivity, cognitive impairments
- ADHD-like sx may be diurnal manifestations of PLMS/RLS during
daytime (difficulties staying seated or remaining inactive for
extended periods of time and needing to move to decrease
discomfort/urge)
• Fe supplementation has been shown to improve both PLMS
& RLS sx at nighttime and some research showing improved
ADHD-like sx during daytime
Walters, Arthur S., Silvestri, Rosalia, Zucconi, Marco, Chandrashekariah, Ranju, Konofal, Eric. Review of the Possible Relationship and Hypothetical Links
Between Attention Deficit Hyperactivity Disorder (ADHD) and the Simple Sleep-Related Movement Disorders, Parasomnias, Hypersomnias, and Circadian
Rhythm Disorders. J Clin Sleep Med. 2008 Dec 15; 4(6): 591-600.
Parasomnias
• Largely seen in children  Condition appears to
spontaneous resolve w/ age, hypothesized to be 2/2 CNS
immaturity
• Generally benign, though may be more impairing esp in
older children if interfering w/ social functioning (e.g.,
sleepovers)
• NREM parasomnias:
- AKA arousal disorders, result from sudden awakening from deep
slow wave sleep, causing confusion and retrograde amnesia
- Generally do not tend to respond to external stimuli
- May be autonomic/motor hyperactivity (e.g., repetitive movements
during sleep)
- Often +FHx
- Ex. sleepwalking, night terrors
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Parasomnias
• REM parasomnias
- No associated confusion, recall may be intact
- Ex. nightmares, REM behavior d/o (more commonly seen in older
adults), recurrent intermittent sleep paralysis
• Should r/o underlying seizures esp if duration is very short,
+repetitive/stereotypic movements, inconsistent pattern in
episodes
• Most common in children:
-
Sleepwalking
Night terrors
Nightmares
Nighttime enuresis
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Sleepwalking (Somnambulism)
• Pathogenesis unknown
• Involves complex motor movements and cognitive
functioning (e.g., ambulation, driving)
• Most frequently seen in pubescent children (peak
prevalance 12 y/o) but can carry on to adulthood
• First third of sleep
• Triggered by psychological or physiological stress (e.g., sleep
deprivation)
•  rates in those w/ comorbid OSA, Tourette’s, migraines
• Uncommonly violent/aggressive behaviors, but may become
combative and agitated if attempted to be restrained during
episode
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Sleepwalking (Somnambulism)
• Tx:
- Supportive, focus on ensuring child does not injure self during
episode
- Limit interference
- Scheduled sleep awakenings
- Psychotherapy (esp if episodes r/t stress)
- Relaxation techniques
- Pharmacotherapy:
o Benzos
o Antidepressants (only case studies, some
may worsen condition 2/2 impairment in
REM sleep)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Night Terrors (Pavor Nocturnus)
• First third of deep slow wave sleep
• Sx include:
-
•
•
•
•
•
•
Loud screaming and/or crying
Difficult to console
 autonomic activity (e.g., tachycardia, tachypnea, sweating)
Intense feelings of panic/anxiety during episode
Lasts ≈ 15-30 min
Little to no recall of event
May co-occur w/ sleepwalking
Peak prevalence 3-7 y/o
Frequent +FHx
May be triggered by fatigue, stress
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Night Terrors (Pavor Nocturnus)
• Two categories which differ in course of illness and tx
approach
• Type A
- Common
- Benign, self-limiting
- No tx required, parent reassurance
• Type B
-
Much less common
Frequently r/t trauma
Tends to be persistent throughout life
Resistant to tx
Tx options include low dose benzos (diazepam 2-5mg), impramine
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Nightmares
• Common in both children and adults, but most common in
children 3-6 y/o; persistence beyond this may warrant
further exploration for underlying trauma, anxiety, mood
disorder
• Must distinguish from night terrors
• Recall intact, not associated w/ confusion
• Second half of sleep in REM
• Tx:
- Reassurance for parents
- CBT (e.g., progressive muscle
relaxation, dream scripting)
- Pharmacotx for trauma-related
nightmares (e.g., prazosin,
clonidine)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Nocturnal Enuresis
• DSM V: Repeated involuntary bedwetting while sleeping ≥
2x/wk for 3 consecutive mos or cause significant
distress/impairment in child
• Toilet training complete by 4-5 y/o for most children
• Occurs proportionally throughout diff sleep stages
• Not associated w/ sleep disruption or arousal
• Two categories
- Primary enuresis
o
o
o
o
o
No h/o consistent dryness through night > 1-2 wks
Strong +FHx
M>F
Neurodev delay
Probable delayed bladder control maturation,
 bladder irritation,  primary detrusor muscle
contraction
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Nocturnal Enuresis
- Secondary enuresis
o Wetting episodes occur after sustained period (6-12 mos) of complete
dryness
o Majority of causes medical or psychological
o Potential medical causes:
a.
b.
c.
d.
e.
f.
Constipation
DMI
UTIs
Seizures
Hyperthyroidism
Medication side effects
(antipsychotics)
o Potential psychological causes
a. Death in the family
b. Abuse/trauma
c. Severe bullying
- Sleep apnea proposed to be possible cause of both primary and
secondary nocturnal enuresis; studies show adenotonsillectomy 
significantly  or relieves enuretic episodes
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Nocturnal Enuresis
• Extensive medical eval beyond PE and UA not necessary
unless H&P c/w underlying medical d/o
• Tx
- Behavioral modification first line tx:
o
o
o
o
o
o
Limit fluid intake in the evening
Bedwetting alarm
Bladder stretching exercises
Positive reinforcement through awards
Responsibility training
Visual sequencing
- Pharmacological agents:
o DDAVP
o Oxybutynin
o TCAs if refractory
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Circadian Rhythm Disorders
• Delayed sleep phase syndrome
-
Sleep schedule lags behind environmentally expected sleep schedule
May be 2/2 genetics or habit
Teens > children
Tx: Systematc sleep deprivation
Motivational phase delay: When child has difficulties falling asleep
and waking up 2/2 distress r/t daytime event (most commonly
school); not due to physiological dyssynchrony of circadian rhythm,
must target underlying issue causing distress
• Phase advance
- Sleep schedule is earlier than environmentally expected sleep
schedule
- Less common than sleep delay
- Tx: Progressively delay sleep time by 30-60 min at a time, shift
activities later in the day (e.g., dinner time), until schedule adjusts
- Tends to be easier to achieve due to 25-hr cycle of circadian rhythm
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Circadian Rhythm Disorders
• Irreg sleep/wake patterns w/o consistent phase delay or
phase advance
- Caused by irreg schedules and lack of consistent structure at home
- Tx focuses on helping parents develop structure in the home
• Some children may have shorter sleep cycles; these children
generally do not have difficulties falling asleep or waking up
in the AM
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Behavioral Insomnias of Childhood
• Sleep-onset association disorder
- Child has difficulties falling asleep independently
- Relies on external interventions/circumstances; examples:
o
o
o
o
o
o
Rocking
TV
Being w/ parent
Being held
Sleeping in parents’ bed
Having bottle
- Esp prevalent for infants who then associate falling asleep w/
parental support; then when waking up mid sleep has difficulties
going back to sleep on his/her own
- Tx
o Awakenings shortly before predicted time the child will awake and
progressively  interval btwn awakenings
o Remove the external cues, allow child to learn to sleep on their own
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Behavioral Insomnias of Childhood
• Limit-setting disorder
- Child repeatedly refuses to go to sleep at bedtime and parent allows
them to stay up later
- Allows excessive/dev inappropriate napping
• Combined type = Sleep onset association disorder + limit
setting disorder
• Feeding-related disorder
- Child must be fed when awakening from sleep in order to fall back
asleep
- Causes further disruptions in sleep r/t discomfort from bladder
distention, diaper soiling
• Poor sleep hygiene
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Psychiatric Causes
• Depression/mood disorders  sleep issues
- Early morning awakenings, incr sleep latency, interruptions/arousals,
 need for sleep, changes in sleep architecture
- Tx underlying condition in addition to relaxation techniques, positive
reinforcement strategies, limit setting, consistent bedtime
schedules/routines
• Anxiety
- Tx underlying condition in addition to
behavioral/environmental interventions
- At times strict limit setting may worsen
anxieties/fears so parents must show
understanding and compassion for child’s
distress and set limits more gradually in
these cases
• Alcohol/drug abuse
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Psychiatric Causes
• PTSD
- Associated w/ specific parasomnias (e.g., nightmares, night terrors,
enuresis)
- Type 1: Acute specific trauma resulting in hyperautonomic arousal
and insomnia
- Type 2: Chronic trauma associated w/ hypersomnia
- Tx for nightmares should be oriented more behaviorally (e.g., using
dream scripting and trauma-focused CBT) vs meds such as prazosin
given limited studies
• ADHD
- Sleep issues hypothesized to be r/t combo of hypoarousal during day
+ compensatory hyperactivity to combat daytime hypoarousal and
then inability to calm down at bedtime to fall asleep
- Other factors include disruptions in baseline circadian rhythm,
sensory integration difficulties, stimulant rebound effects, comorbid
psychiatric d/o (e.g., anxiety)
- If behavioral interventions ineffective/suboptimal, trial
melatonin/alpha-agonist
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Psychiatric Causes
• 5 factors seen in children w/ sleep issues > than those w/o
-
Family member who has experienced an accident/illness
Unaccustomed absence of mother
Mother w/ depressed mood
Co-sleeping
Maternal ambivalence towards child
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Medical Causes
• Colic
- Prolonged episodes of inconsolable crying, fussiness, and hypertonia
(e.g., fist clenching, writhing/twisting movements, flapping,
grimacing facial expressions)
- Usually dev by 2-3 wks old, resolves by 4 mos
- Hypotheses on etiology
o
o
o
o
o
CNS immaturity
Adaptive purpose of exercising infant lungs
Pain r/t gas
Cow’s milk allergy
Insufficient progesterone levels
- Studies showing potential sleep disturbance (e.g.,  arousals and
shorter duration of sleep), difficult temperament, sensitivities to Δs
in sleep sched in children who have outgrown colic
o Possbily r/t parental overresponsiveness to child’s needs during colic
o Target by educating parents on importance of strict sleep hygiene
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Medical Causes
• Medication side effects
- Sedative/hypnotics: Associated w/ sleepwalking episdes, in
particular non-benzos (e.g., zolpidemn, eszopiclone)
- Sedative/hypnotics and antihistamines may cause residual daytime
sedation
- Antibiotics
- Beta-blockers: Suppress nighttime
melatonin secretion
- Steroids: Cause imbalance in adrenal
glands
- SSRIs: Suppress REM sleep; some may
also incr sleep latency and/or frequency
of awakenings/arousals
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Sleep Hygiene
• Integral part of tx for any sleep d/o
• Some differences depending on age
• Infants:
- Fragmented and irreg sleep pattern c/w nl dev for newborns (up to
3-6 mos old) so parents should limit interference w/ sleep unless
needed (e.g., getting on a plane)
- As infant begins to consolidate sleep at night and responding more
to external cues for sleep, parents should incorporate additional cues
(e.g., waking them up earlier from daytime naps, minimizing
disruptions at night while changing diapers by using low light)
- Begin bedtime routine to help infant experience calm before sleep
and ensure consistent routine in same order on nightly basis
o Bath, PJs
o Reading/humming
o Changing diapers
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Sleep Hygiene
- Assist infant in learning to independently fall asleep in their own bed
and remove parental presence as much as possible
o Study by Anders and Keener showed 50% infants at 2 mos old able to
fall asleep after arousal on their own
o Allow infant to attempt to fall asleep on their own even if crying upon
arousal  If prolonged crying, parents may come to child and make eye
contact to show support but no other interventions, and progressively
increase interval of parental presence w/ subsequent arousals
- By 6 mos need for nighttime feeding no longer present  Start
weaning nighttime feeding over 1-2 wks to avoid feeding-related d/o
- Ensure comfortable environment for sleep
o
o
o
o
Warm blankets
Supine sleep position
Humidifier
Breathe Right strips for nasal congestion
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Sleep Hygiene
• Older children/adolescents
- Parents must reinforce consistent sleep sched, even on wknds
- Bedroom should be reserved for bedtime ritual and sleeping only; no
TVs, games, toys, computers, tablets, phones, etc.
- Child should fall asleep in their own bed and alone
- Avoid excessive physical activity near bedtime, though reg exercise
earlier in the day may promote sleep
- No daytime naps
- Avoid caffeine or other stimulating substances
- Avoid heaving eating or excessive drinking prior to bedtime
- Avoid lying in bed unless sleepy
- Provide cool, dark, quiet room
- Must distinguish resistance to sleep from legitimate anxieties (e.g.,
school) b/c strict limit setting may exacerbate fears/worries; if this is
the case must target underlying issue
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Thiedke, C. Carolyn. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
General Pyschopharmacology
• First-line tx is always behavioral/environmental/sleep
hygiene!!!!
Medication
Alpha-agonists (clonidine,
guanfacine)
Dosing
PO clonidine 0.05mg QHS
(titrated by 0.05mg q5days)
PO guanfacine 0.5mg QHS
(gradual titration by 0.5mg
q5days)
Safety Concerns
Pearls
Cardiovascular risk at higher
doses and overdose
Guanfacine less sedating and
has less anticholinergic/CV
side effects vs clonidine
Guanfacine helpful in
comorbid seizure d/o due to
anticonvulsant effects;
newer longer-acting
formulation can be helpful in
tx of ADHD and help w/ sleep
maintenance
REM suppression may occur,
resulting in REM rebound
upon d/c
Often prescribed to target
sleep onset delay in children
w/ ADHD
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
General Psychopharmacology
Medication
Melatonin and its receptor
agonists (e.g. ramelteon)
Dosing
Clear dosing guidelines for
melatonin unavailable in
children
0.5-3mg/day (administered
2-3 hrs prior to sleep onset)
Safety Concerns
Possible suppression of the
hypothalamic-gonadal axis
(caution in children w/
delayed puberty)
Pearls
Often prescribed to target
sleep onset delay in children
w/ ADHD and dev d/o
More useful for chronobiotic
rather than hypnotic
properties (thus, useful in
circadian rhythm sleep d/o)
Effective doses may be
higher in children w/ dev d/o
(up to 10mg/day)
Ramelteon (melatoninreceptor agonist) has limited
data for use in children
New agents (Agomelatine)
can have potential uses in tx
of comorbid anxiety and
insomnia (due to melatonin
agonist and 5HT antagonist
properties)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
General Psychopharmacology
Medication
Antihistamines
Dosing
Diphenhydramine (0.5mg/kg
up to max dose 25mg/day)
Hydroxyzine (0.5mg/lb)
Safety Concerns
Daytime drowsiness, dry
mouth, urinary retention,
paradoxical hyperactivity,
cardiac toxicity in overdose
Pearls
Sedative effects through H1
receptor blocking properties
Dev of tolerance requiring
escalating doses
Anxiolytic and
anticholinergic properties of
antihistamines can
potentiate substance abuse
in adolescents
Benzodiazepines and
benzodiazepine-receptor
agonists (zaleplon, zolpidem,
eszopiclone)
Ultra-short half-life
(zaleplon, 1-2hrs); short halflife (zolpidem, 2-3hrs);
intermediate to long half-life
(eszopiclone, 6hrs)
Behavioral disinhibition and
agitation w/ aggression and
impulsivity, paradoxical
hyperactivity
Limited use in children 2/2
potential for abuse; none are
approved for use in children
by FDA
Benzodiazepine-receptor
agonsists have been shown
to induce complex sleeprelated behaviors (e.g., sleep
eating and sleep walking);
longer-acting medications
(e.g., eszopiclone) are used
mostly in adults 2/2 lack of
dev of tolerance
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
General Psychopharmacology
Medication
Antidepressants
Dosing
Trazodone at lower doses
(12.5-50mg/day)
TCAs (amitriptyline,
nortriptyline)
Safety Concerns
Priapism w/ trazodone; txemergent anxiety and
agitation; exacerbation of sx
of RLS w/ TCAs; significant
cardiotoxicity in overdose
Pearls
Most TCAs are potent REM
sleep suppressants and
suppress slow wave sleep
Should be used at the lowest
possible doses to avoid
cardiac side effects
Sedating antidepressants
(e.g., mirtazapine) have
limited data in children; REM
suppression by mirtazapine
appears to be minimal
Herbal supplements
Chamomile, lavender,
tryptophan, kava kava
Necrotizing hepatitis (kava
kava); eosinophilia myalgia
syndrome (tryptophan)
Use of herbal supplements
have limited-to-no evidence
of efficacy
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Evaluation for Sleep Disorders
• Etiology of pediatric sleep d/o usually multifactorial
• Detailed hx most important
• Record sleep diary for ≥ 2 wks (e.g.,
http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf)
• Questionnaires
- Children’s Sleep Habits Questionnaire (CSHQ)
o Vaildated for 4-12 y/o
o 33 items (41 points cut off)
o http://www.education.uci.edu/childcare/pdf/questionnaire_interview/C
hildrens%20Sleep%20Habits%20Questionnaire.pdf
- Adolescent Sleep Hygiene Scale
o
o
o
o
12-18 y/o
28 items (no specific scoring)
Dev for evaluating healthy teens
http://sleep.colorado.edu/sites/default/files/ASHS_website_130303.pdf
Evaluation for Sleep Disorders
• Medical work-up
-
VS including BMI
Focused or comprehensive PE
Labs (e.g., Fe levels)
Polysomnography if suspecting primary sleep d/o
• Evaluation of Sleep Complaints and Pertinent Clinical Hx:
Sleep Complaint
Exploring Pertinent History
✭ Habitual bedtimes (sleep onset/offset on wkdays and wknds/holidays)
✭ Time taken to sleep onset; “desired” bedtime
✭ Duration, frequency, and severity of complaints
Difficulty falling asleep
✭ Inappropriate nap schedules
✭ FHx
✭ Negative associations (fears, worries) w/ distressing sensorimotor sx of restless leg
syndrome, nightmares
✭ Difficulty sleeping through the night (nighttime awakenings, early morning
awakening); activities during the awakenings
Difficulty staying asleep (and/or
multiple nocturnal awakenings) ±
early morning awakenings
✭
✭
✭
✭
Screen for mood and anxiety sx
Screen for primary sleep disorders (sleep apnea)
FHx
Use of alerting substances at bedtime
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Evaluation for Sleep Disorders
Sleep Complaint
Exploring Pertinent History
✭
✭
✭
✭
Total duration of nocturnal sleep
Quality of morning awakenings
Difficulty to stay awake in the classroom, while driving, watching TV, eating meals
Persistent use of stimulants (e.g., nicotine, caffeine) to stay awake
Excessive daytime sleepiness
✭ Exploring other potential sx associated w/ disorders of excessive sleepiness (e.g.,
cataplexy, sleep paralysis, sleep attacks, hallucinations)
✭ Daytime consequences of sleepiness (e.g., poor academic performance, learning
difficulties, impaired concentration, disruptive behaviors, mood sx)
✭ FHx
✭ Medication use (long-acting psychotropic meds w/ “hangover” effects)
✭ Substance use (alcohol and other illicit drugs, OTC meds)
✭ Occupation (odd hrs at employment, shift-work schedules)
✭ Social environment (co-sleeping/sharing bedroom, sleep patterns of parents and
other children, pets in bedroom)
Poor sleep routine and sleep
hygiene due to environment and
psychosocial variables
✭ Housing (light, noise, temp)
✭ Activities at bedtime (computer/telephone, HW completion, TV viewing)
✭ Substance use (alcohol and other illicit drugs, caffeine intake, nicotine use, OTC
meds)
✭ Parental involvement (limit setting, adult supervision)
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-3
Ramifications of Sleep Deprivation
• Neurocognitive
-
Deficits in attention, memory, learning
Hyperactivity/impulsivity (more common in younger children)
Deficits in executive functioning
Daytime sedation
• Psychological
-
Depression/mood lability
Irritability
Oppositionality
Anxiety
Fatigue/weakness
O’Brien, Louise M. The neurocognitive effects of sleep disruption in children and adolescents. Child and Adolescent Clinics of North
America. 2009 Oct; 18(4): 813-823
https://monkeytraps.wordpress.com/2012/05/23/the-dark-insomnia/