Parents should be given information on normal sleep and sleep behaviour in children, and parents and children should be told that parasomnias, or special sleep disorders, are harmless.
Sleeping problems and sleep disorders are common: one in ten, or even as many as one in four children and adolescents have them at some stage.
Disorders of sleep rhythm in infants should be identified early at the child health clinic and parents should be instructed how to correct such disorders. These disorders, like most sleep problems in children and adolescents, are non-organic and can be treated in primary health care.
Circadian rhythm disorders, parasomnias (in children, most often non-rapid eye movement sleep arousal disorders) and insomnia are the most common sleep disorders.
Organic sleep disorders requiring treatment (for example apnoea and narcolepsy) and other episodes during sleep (epileptic seizures) require hospital investigations.
Particularly in adolescents, daytime tiredness and difficulties falling asleep may be caused by depression or anxiety and, as has been shown, increasingly often by the use of social media immediately before going to bed.
The most common neuropsychiatric disorders (ADHD ADHD, autism spectrum disorders Autism Spectrum Disorder, Tourette's syndrome Tic Disorders in Childhood) are very often associated with sleep disorders, the management of which may significantly contribute to a positive response to neuropsychiatric treatment, and vice versa. For example, ADHD is associated with restless legs syndrome and also with delayed sleep phase and insomnia.
According to the International Classification of Sleep Disorders (ICSD http://aasm.org/clinical-resources/international-classification-sleep-disorders/), sleep disorders are grouped into 6 major categories: circadian rhythm sleep-wake disorders, parasomnias, or special sleep disorders, sleep-related breathing disorders, insomnia disorders, central disorders of hypersomnolence and sleep-related movement disorders.
Normal sleep in children and adolescents
The need for sleep in children varies widely and decreases with advancing age from up to 20 hours sleep in an infant aged less than one month to an average of nine hours in a teenager. The decrease in the need for sleep is most rapid during the first 12 months of life.
Daytime naps are a fundamental part of daily total sleep in infancy. The naps become gradually shorter with age. At the age of a few months, infants usually nap two or three times per day. Naps are usually taken until the age of four or five years.
The longest uninterrupted period of sleep is usually two to four hours during the first weeks of life. At its shortest it can be no more than half of this. From the age of six weeks, the continuous uninterrupted period of sleep increases to 6 h and mostly occurs during night-time.
Sleeping through the night has been defined as sleeping from midnight to 5 a.m. for at least four weeks. Sleep periods of newborns are distributed evenly through the day and night. From the age of three months, children sleep most of their 14-15-hour sleep at night.
From infancy, good sleep associations, i.e. environmental factors associated with falling asleep that support sleep (such as breast-feeding, feeding, and other established evening routines) contribute to developing good sleeping habits and preventing sleeping problems.
Abnormal sleep associations (such as riding in a car, lengthy hushing) may help the child but burden the family for instance by making them tired.
The quality of interaction between child and parent may need to be assessed to investigate sleeping problems (for instance, unstable attachment, symptoms of separation anxiety or phobias).
At the same time, the possibility of somatic symptoms or diseases (such as gastro-oesophageal reflux, allergies) should be assessed.
Puberty-related changes in hormone secretion affect sleep.
As a part of normal development, the secretion of melatonin, the hormone of darkness, becomes delayed. Sleep becomes lighter, different stages of sleep get shorter and the total sleeping time decreases, which may lead to increased daytime tiredness.
Furthermore, social pressure encourages staying up late; therefore it is particularly important in puberty to pay attention to sufficient night's sleep so that the adolescent does not develop a sleep deficit. Because of the risk of numerous harmful health effects associated with staying up late, this applies particularly to adolescents who are “evening persons” Such effects include attention problems, symptoms of conduct disorder and affective symptoms, which may also be associated with insufficient physical exercise.
Energy drinks affect sleep negatively in children and adolescents due to their caffeine contents, for example; therefore, these drinks are not suitable for them. In addition to caffeine, they often contain other stimulating compounds, such as guarana, taurine or glucuronolactone, which are also believed to have stimulating effects.
Children and adolescents cannot sleep according to their circadian rhythm due to factors such as their parents' work, daycare, school and other studying.
Assessment of the possibility of sleeping problems and disorders is complicated by factors associated with the development of independence in adolescence; parents do not necessarily know about adolescents' sleeping habits or any sleeping problems. Further uncertainty is caused by not knowing whether adolescents understand their sleeping habits or any sleeping problems due to, for example, using social media late at night.
All in all, sleep in children, adolescents and young adults and any associated abnormalities should be assessed depending on age and developmental age, particularly if the child/adolescent has developmental delay or psychiatric problems.
Disorders of sleep-wake rhythm
Disorders of sleep-wake rhythm represent deviation from the daily rhythm that prevails in the environment or that is usual at that developmental stage.
The most common sleep disorders in infants and toddlers
Sleep association disorders
Difficulty falling asleep
Interrupted sleep
Waking up too early
Irregular sleep-wake rhythm
A child who wakes up two to four times per night during more than one week or who sleeps most of his/her sleeping hours during daytime is considered to have a sleep problem.
Sleep association disorders and increased expression of what the child wants along with normal development may delay falling asleep in numerous ways.
In infants and toddlers, difficulty falling asleep, waking up at night and/or too early in the morning may burden the parents and any siblings inappropriately.
Seasonal sleep disorder may occur even in children and especially in adolescents.
An adolescent may have delayed sleep-phase syndrome (DSPS), i.e. he/she falls asleep and wakes up too late in relation to the requirements placed by the environment. This is due to the peak melatonin secretion becoming delayed. Consequently, falling asleep is delayed. Other causes may include increased late social demands in adolescence.
A delayed sleep phase may also be associated with psychiatric disorders and, if prolonged, it may be a cause of such a psychiatric disorder.
An advanced sleep phase normally causes no problems.
A completely irregular sleep-wake rhythm is also possible.
Jet lag and, in some adolescents, night work may cause sleep-wake rhythm problems.
Chronic lack of synchrony between intrinsic clocks and external factors affecting the sleep rhythm is considered a health risk.
Parasomnias
Parasomnias, or special sleep disorders, are disturbances of arousal, partial arousal or transitions between sleep stages.
Body rocking and head banging start from the age of six months. No treatment is needed if the infant´s mental development is normal. These children do not usually have any neurological or psychological problems. Repeated jerks or twitches in an infant may be signs of rare infantile spasm syndrome requiring urgent treatment.
Tooth grinding means noisy biting or rubbing of the teeth against each other. This may damage the dental enamel. However, if the child repeatedly bites his/her tongue at night, this may be due to epilepsy Epilepsy in Children. Repeated tooth grinding may also be a symptom of sleep-disordered breathing, which should be borne in mind and the child referred for further investigations. In severe cases, the need for a biteplate should be considered in specialized care.
Night terrors like other non-rapid eye movement (non-REM) parasomnias, usually start one to two hours after falling asleep. The child may sit up in bed with an appearance of fear and may sweat, vocalize or scream. The pulse is quick. The duration of the episode ranges from a few to about 20 minutes. No treatment is needed and there is no reason to wake the child up during the episode. Waking up in association with paroxysmal symptoms in the early morning, particularly, may sometimes be due to epilepsy (see Epilepsy in Children).
Sleepwalking lasts from a few minutes to as long as half an hour. The sleepwalker should be taken back to his/her bed. The surroundings of a sleepwalker should be safe, to minimize the risk of an accident. This also applies to night terrors if they are associated with sleepwalking.
Sleep drunkenness is a confusional state in association with being woken up that may include aggressive behaviour.
Sleep talking is seen during various stages of sleep. No treatment is needed. Sleep talking should be distinguished from nocturnal epileptic seizures, which are usually associated with other kinds of vocalization.
Snoring is also classified as a parasomnia. In most instances, snoring is benign. If snoring is associated with pauses in breathing, excessive daytime tiredness or behavioural or learning disorders, it necessitates further investigations. It should be borne in mind that snoring that is considered benign may be connected to the metabolic syndrome, especially if an overweight child concomitantly has sleep apnoea.
Nightmares are associated with dreaming. The child seems to be fearful, as in night terrors. Yet in most cases, the child remembers his/her nightmares. It is advisable to wake the child up and important to provide parental reassurance. A calm evening routine helps to prevent nightmares. Recurrent, similar and severely anxiety-provoking nightmares may be associated with depression, for instance, and may require further assessment if sleep hygiene and psychoeducation prove insufficient. As opposed to nightmares occurring in the small hours, posttraumatic nightmares often occur before midnight. They require psychiatric assessment.
Restless legs syndrome (RLS) and the periodic limb movement disorder (PLMD; see Restless Legs and Akathisia) may be associated with parasomnias. They are more common in children and adolescents than was previously known.
Restless legs are often associated with ADHD, depression and anxiety.
Diagnosing RLS in children is difficult because they cannot describe the symptoms as adults do, i.e. as uncomfortable leg symptoms that are relieved by moving of the legs.
RLS disturbing the quality of life, as well as other repeated or disturbing motor symptoms associated with sleep should be treated in a unit specialized in sleep disorders.
A child with a sleep disorder and with one or both parents with RLS very likely has the same disorder. The hereditary form may be manifested as early as in infancy.
Respiratory pauses during sleep (apnoeas) are quite significant sleep disorders in children.
Special attention should be paid to the possibility of sleep apnoea in overweight children and adolescents, because overweight may negatively affect the function of the upper respiratory tract. Treating overweight may correct the apnoea symptoms. In adults, weight loss of as little as 5% may eliminate at least mild sleep apnoea. In obese young adults (below 25 years) weight loss is evidently equally effective in treating sleep apnoea.
Obstructive sleep apnoea (OSAS) is the most common form of apnoea. In most cases, airway obstruction in children is caused by enlargement of the adenoids or the tonsils. Physical obstruction combined with decreased muscle tone during sleep prevents free airflow.
Symptoms may include excessive daytime tiredness, sleeplessness, morning headaches, hyperactivity and learning difficulties.
Removal of the pharyngeal and/or palatine tonsils often relieves the symptoms conclusively, although there is scant evidence of its efficacy. The size of the adenoids does not always correlate with the severity of apnoea.
In doubtful cases, the diagnosis of apnoea and the outcome of its treatment should be documented by whole-night polysomnography.
Identification and appropriate treatment of malocclusion may also reduce the occurrence of sleep apnoea even if there are other risk factors, such as overweight, structural facial anomalies (such as micrognathia, or having a small lower jaw), nasal stuffiness or a narrow pharynx.
Brief central apnoeas are common in small infants. Both central and obstructive apnoeas lasting more than 15 seconds require further investigations also because they can precede sudden infant death syndrome.
Insomnia
Insomnia manifests as recurring difficulty falling asleep, waking up repeatedly during the night, too early awakening, poor quality night-time sleep, or a combination of these.
The International Classification of Sleep Disorders definition of insomnia includes daytime consequences, such as tiredness, drowsiness, impaired attention and learning ability and behavioural symptoms.
Transient insomnia in most cases results from various identifiable stress factors. They may be associated with demands related to school or studying or to exceptionally high subjective demands causing anxiety and thus disturbing sleep without representing an anxiety disorder fulfilling psychiatric diagnostic criteria. Its duration is usually short, less than a month. Transient insomnia soon subsides when the stress factor is resolved.
It becomes more common in adolescence.
It is associated with daytime tiredness.
Insomnia in adolescents is often associated with psychiatric or developmental neuropsychiatric symptoms or disorders and vice versa. It may also be the first symptom of a psychiatric disease and a risk factor that predisposes to substance abuse.
Long-term insomnia is also a risk factor for depression and vice versa.
Somatic diseases and their pharmacotherapy may cause insomnia. Encouraged by their parents, even children and adolescents increasingly use natural and herbal remedies, and these products may also cause insomnia.
Insomnia may be due to use of social media before going to bed. Both content stimulating the mind and the blue light from the devices affect melatonin secretion.
Abuse of alcohol and drugs as potential aetiologies of insomnia should be borne in mind with adolescent patients.
Insomnia disorder is defined as prolonged sleeping difficulty, if it occurs at least 3 times a week for at least 3 months and it impairs everyday life and it is not explained by a medical cause.
Prevention of insomnia and abnormal daytime tiredness is most successfully achieved by following general recommendations concerning maintenance of good health. Increasing excercise has beneficial effect on sleep in many children and adolescents, even if they would not perceive themselves to have sleeping difficulties.
In addition to all this, so-called paradoxical insomnia should be kept in mind, meaning an experience of insomnia even if objective measurement shows normal duration of sleep.
Paradoxical insomnia may even require psychiatric assessment to exclude posttraumatic stress disorder and anxiety disorder.
Excessive daytime tiredness
Excessive daytime tiredness means difficulty keeping awake or tendency to fall asleep while awake.
In infants, the total amount of daily sleep is usually sufficient. Excessive daytime tiredness is rare, because an infant usually falls asleep when he/she is sufficiently tired. An infant should be alert when awake.
Of the causes of excessive daytime tiredness, obstructive sleep apnoea is the most important. Narcolepsy is rare and may manifest as early as school age, in the form of restlessness and hyperactivity before the appearance of tiredness, involuntary falling asleep, cataplexy and other additional symptoms. Exceptional daytime tiredness may be present in depressed adolescents, but tiredness in the morning or during the daytime may also be caused by narcolepsy that requires treatment. Narcolepsy Narcolepsy and other Hypersomnias of Central Origin usually starts at the age of 15-20 years. The diagnosis is often delayed by many years.
The COVID-19 vaccine is, due to its structure, not associated with the development of narcolepsy.
In adolescents, too few hours of sleep during the night may cause significant daytime tiredness, usually because of going to bed too late. Daytime tiredness correlates with the adolescent's age and the experienced stress. Excessive use of social media in the evening may be associated with daytime tiredness.
Daytime tiredness may be due to the delayed sleep-phase syndrome.
In addition, there are several sleep disorders causing daytime tiredness, such as delayed sleep phase and other circadian rhythm sleep-wake disorders, restless legs, periodic limb movements and sleep apnoea.
When assessing abnormal daytime tiredness in adolescents, the possibility of nocturnal exposure to social media, alcohol and drug use must also be kept in mind.
Neurological and somatic disorders may affect falling asleep and various sleep phases. Abnormal tiredness associated with such disorders should first lead to consulting an outpatient clinic treating the disorder.
Particular attention should be paid to the association between sleep and driving health in young people.
The functional ability required for driving may vary greatly due to late use of social media, for instance.
A short night's sleep, staying awake for a long time (more than 20 h), use of sedative medication and driving in the small hours, in particular, affect driving ability.
For example, timing of ADHD medication: Is the effect sufficient to maintain alertness when driving at night?
Driving health is essentially affected by sleep apnoea, for instance.
Young people experience increased anxiety and tiredness. They often confuse tiredness and fatigue or use these synonymously. Fatigue means an experience of deficient mental and/or physical coping affecting the person's functional ability. This could be expressed briefly so that when a person is tired, sleep will have a refreshing effect, but fatigue cannot be eliminated by sleeping.
When suspecting chronic fatigue syndrome in a child or adolescent, investigations, treatment and rehabilitation should be carried out according to local guidelines after careful history taking in a specialized care hospital.
Examination of the child or adolescent
First, the examiner should find out what parents and the adolescent mean by a sleep disorder.
Depending on the developmental stage of the child or adolescent, his/her views on the quality of sleep and any sleep problems and their causes should also be discussed with him/her alone.
In addition to health and sickness records, a detailed sleep history including an assessment of the amount of sleep and sleep need of a child as well as an assessment of the circadian rhythm and the character of the sleep difficulty should be obtained. Environmental factors affecting the sleep by supporting or disturbing it, as well as the role of any long-term or new-onset diseases, should also be assessed.
The child's alertness and functional ability during daytime, and onset and factors associated with any daytime tiredness should be examined.
A concise account on the sleeping habits and any sleep disturbances of the parents provides further information on any inherited sleep characteristics and even negative effects of the parents' sleeping habits on the child's or adolescent's sleep.
How the parents raise their child, and their own sleeping problems (such as severe tiredness) may lead to inconsistent upbringing affecting the child's or adolescent's sleep.
In disturbed sleep of recent onset, remember to check the eardrums.
A video recording of the symptoms will help to distinguish parasomnias from epilepsy, for instance, based on factors such as the timing of symptoms during sleep, their type and duration.
In addition to somatic examination and a short assessment of mental well-being and functional capacity, of laboratory tests only basic blood count with platelet count is needed to exclude anaemia, even though the iron status may be abnormal even if haemoglobin is normal. Other laboratory investigations are determined by the condition of the patient and by aetiological considerations (e.g. TSH, ferritin).
Increasing overweight among children and adolescents and its association with any sleep apnoea should be kept in mind.
The association of sleeping difficulties with medication to treat any diseases should be examined, as well as any use of stimulants, such as caffeine or energy drinks, used by adolescents, in particular.
If it is possible to use actigraphic registration either within primary care or in the context of a specialized care consultation, it is useful in the investigation of the aetiology of e.g. insomnia, abnormal daily rhythm or abnormal daytime tiredness.
Actigraphic registration usually takes 2 weeks. During registration, a sleep log should also be kept, with the assistance of adults, depending on the patient's age (see below). Data provided by actigraphy is objective compared with the subjective information provided by a sleep log.
There are numerous commercially available devices and apps for monitoring sleep and alertness. However, their diagnostic and therapeutic reliability should be taken with reserve. These have not yet been approved for use in health care and they have not been validated. Nevertheless, by the immediate feedback they provide they can increase people's interest in the importance of sleep and good sleeping habits. Smart devices can even be used to monitor sleep for many years.
Sleep log
If the cause of the sleep problem cannot be found out, the parents should keep a sleep log for two to three weeks. In the sleep log, time to bed, observed or assumed time of falling asleep, nightly awakening and duration of wakefulness, night feeding or eating at night, naps and eating times during the day should be marked as accurately as possible with agreed symbols.
If sufficiently motivated, adolescents may fill in the sleep log by themselves, together with the parents, as necessary.
Adolescents may also record in the sleep log the use of social media particularly before going to bed and after any interruption of the night's sleep.Consumption of soft drinks and energy drinks, as well as coffee and tea, should also be recorded for adolescents.
The parent's and the child's/adolescent's assessments of the quality of sleep should be recorded on a scale of 0-10, for example,
with 10 representing the optimum quality of sleep.
With the history and sleep log it is possible to clarify whether the child has dysfunctional sleep habits, faulty sleep associations (e.g. the child always requires a parent to stay at his/her side or wants to eat before being able to fall asleep) or a serious disorder requiring hospital investigations, or whether the parents have unrealistic expectations about sleep quality. The whole issue may be explained by the wide normal variability of sleep.
Falling asleep too early or too late and waking up too late or too early are revealed by a carefully completed sleep log, as are regular but inappropriate, and completely irregular sleep habits.
A sleep log provides subjective information about sleep.
Treatment
Treating sleep disorders as early as possible may prevent them from becoming chronic.
The infant's sleep routines and associations should be modified. If the child becomes used to company or other entertainment immediately after waking, this may lead to a sleep problem in the whole family.
The best way to prevent sleep disorders in children and adolescents is to follow regular living habits and to prefer bedtime routines that the child finds agreeable and positive.
Sleeping in the same bed as the parents makes it more difficult for the child to transfer to his/her own bed. An infant should not be taught to fall asleep in a brightly lit room, or when held, rocked or fed, or to being fed when waking at night.
The sleep environment should be quiet. Soft sleep toys are recommended from infancy onwards.
Non-pharmacological treatment methods for children and adolescents are similar to those used for adults, with modifications as needed.
If at all possible, arrangements should be made to ensure a sufficient night's sleep for the parents of a child with a sleep disorder.
The best and most gentle method to treat disturbances of the sleep-wake rhythm is a gradual change of sleep rhythm, although the quickest results have been reached by letting the child cry himself or herself asleep. The latter approach may, however, lead to abnormal increase in stress hormone levels. The sleep-wake rhythm may be corrected at home according to an agreed gradual changing of the sleep rhythm (correction by 15 to 30 minutes at a time at an interval of a couple of days, or a correction by 10 minutes every day until the targeted sleep rhythm has been achieved), or at a sleep school.
There are different types of sleep schools. Before a sleep school is started, the child's sleep disorder should be characterized. Deviances in the circadian rhythm can be treated at a sleep school, whereas a sleep school is not suitable for the treatment of sleep difficulties caused by irregular or unfavourable living habits of the family.
For motivated adolescents, in particular, there are also sleep schools associated with CBT-I.
Sleep problems in adolescents are treated with medication in exceptional cases only.
In addition to an educational working method, i.e. psychoeducation, it is essential to take care of the sleep hygiene. Late use of social media should be avoided, in particular, because of its numerous effects on behaviour and symptoms.
In addition to the aforementioned method, the most effective treatment methods for insomnia in adolescents include sleep-related aspects of cognitive behavioural therapy (CBT-I). These include various relaxation techniques, combined with positive mental images associated with sleep and sleeping environment. Additionally, possible erroneous sleep-related beliefs and behavioural models are changed. Such modes of therapy have the benefit of not having any adverse effects. Seeing a trained sleep nurse with expertise in sleep disorders in adolescents may help significantly.
A young person cannot treat his/her sleep disorder alone. Therefore, it is important to support the parents in keeping the everyday life of the adolescent under control. No studies of high quality are available concerning self-care methods in adolescents, albeit the use of internet-based treatment-programmes will apparently increase in the future.
If the underlying factor behind the sleep problems is excessive stress, attention should be paid to its management.
Fathers are nowadays participating more actively in the management of children's sleep disorders. According to several studies, this appears to enhance and accelerate the achievement of the pursued change. Therefore, fathers should be encouraged to participate in the treatment.
Waking the child/adolescent up as agreed 15-30 minutes before the onset of the symptom can be used to treat sleep walking or night terrors recurring at the same time. The treatment should be continued for about 2-3 weeks.
Delayed sleep phase can be treated by bright light therapy, gradual advancing of the sleep rhythm and cognitive behavioural therapy for the parts suitable for sleep disorders (CBT-I).
Both short- and long-acting melatonin have been used, as a few weeks' courses, to reduce sleep latency. Melatonin has been used particularly in sleep disturbances that are associated with neuropsychiatric disorders.
Although melatonin is not an actual hypnotic drug, its unnecessary long-term use should be avoided due to its suspected characteristics affecting glucose metabolism. On the other hand, our knowledge is still inadequate concerning especially the adverse effects of long-term melatonin therapy for sleeping difficulties and sleep disorders associated with autistic spectrum disorders and intellectual disability.
Melatonin treatment should always involve sleep hygiene and guidance for the parents.
None of the sleep medicines accepted for adult use have accepted indications in the pharmacological treatment of sleep disturbances in children or adolescents. Some country-specific exceptions may apply.
Some drugs concomitantly used for the treatment of a psychiatric or somatic disorder may have positive side effects on some sleep disorders (e.g. sedative antihistamines, sedative anxiolytics or antidepressants).
Treatment with hypnotics, which is less often used in children and adolescents, should be started and initially monitored by a specialist.
Good treatment of sleeping problems and disorders often has positive effects on attention and learning. It may even have positive effects on defiance and symptoms of behavioural disturbances, which may be increased by insomnia and daytime tiredness, for example.
All in all, good sleeping habits in childhood and adolescence and good treatment of sleep disorders will contribute to the most undisturbed sleep possible in adulthood, even though several new sleeping problems and disorders may occur then.
Internet-based therapies for adults and partly adolescents, too, are becoming more common with the positive feedback achieved.
Use of mandibular advancement devices is increasing in the treatment of sleep apnoea in young adults.
Levels of care and indications for consultation
Most sleep disorders are investigated and treated in primary health care.
Initial investigations required and criteria for referral may vary in different health care systems, for example as to which specialized care outpatient clinic patients should be referred to.
For pharmacological treatment of sleep disorders, a specialist in the field should be consulted.
If epilepsy is suspected, examination by a paediatric neurologist or paediatrician and a a sleep-wake EEG are necessary.
Restless legs and the periodic limb movement disorder should be diagnosed and treated in specialized care.
Obstructive sleep apnoea is treated by an ENT specialist.
Central apnoeas should usually be investigated at a tertiary care hospital or appropriately specialized centre.
Narcolepsy should be diagnosed and treated at a tertiary care hospital or appropriately specialized centre.
The severe and rare periodic hypersomnias are investigated and treated in specialized care.
Because of parents' exhaustion it is sometimes necessary to refer the child to a hospital to change the sleep-wake rhythm.
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