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Sleep Disorders in Children and Adolescents

Essentials

  • Parents are given information on normal sleep and sleep behaviour in children and told that parasomnias are usually harmless.
  • Sleeping problems and sleep disorders are common: every tenth, or even as many as every fourth child or adolescent suffers from 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 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 proven by research, 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 Disorders, 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.

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 no more than half of this. From the age of six weeks, the continuous uninterrupted period of sleep increases to six hours and mostly occurs during night-time.
  • Sleeping through the night has been defined as sleep 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.
  • Puberty-related changes in hormone secretion affect sleep.
    • As a part of normal development, the secretion of melatonin, the hormone of darkness, becomes delayed and sleep becomes lighter, the different stages of sleep get shorter and the total sleeping time is reduced, which leads to increased daytime fatigue.
    • Furthermore, social pressure encourages staying up late; therefore it is particularly important in the puberty to pay attention to sufficient night's sleep so that the adolescent does not develop sleep deficit. This applies particularly to adolescents who are “night persons” because of the risk of numerous harmful health effects associated with this.
    • Energy drinks may affect sleep negatively in children and adolescents due to their caffeine contents; therefore, these drinks are not suitable for them.
    • Children and adolescents cannot sleep according to their circadian rhythm because of their parents' work, daycare, school and other studying.

Disorders of sleep-wake rhythm

  • The most common sleep disorders in infants and toddlers are
    • difficulty in 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 problems.
  • Seasonal sleep disorder may occur even in children and especially in adolescents.
  • An adolescent may have the 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.

Parasomnias

  • Parasomnias 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 in order to refer the child for further investigations in good time.
  • Night terrors (pavor nocturnus) like other 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 attack ranges from a few to 20 minutes. No treatment is needed and there is no reason to wake the child up during the attack. 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 waking 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, 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.
  • The 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.
    • 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 should be differentiated from ”growing pains” Innocent Limb Aches (Growing Pains) in Children which wake the child up.
    • 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 in whom one or both parents suffer from RLS very likely has the same disorder. The hereditary form may be manifested as early as in the infancy.

Apnoeas Anti-Inflammatory Medications for Obstructive Sleep Apnea in Children, Oral Appliances and Functional Orthopaedic Appliances for Obstructive Sleep Apnoea in Children

  • Respiratory pauses during sleep (apnoeas) are significant sleep disorders in children.
  • Special attention should be paid to the possibility of sleep apnoea in overweight children and adolescents, because overweight affects the function of the upper respiratory tract. Treating overweight may correct the apnoea symptoms.
  • Obstructive sleep apnoea (OSAS) is the most common form of apnoea. In most cases, airway obstruction is caused by enlargement of the adenoids or the tonsils. Physical obstruction combined with decreased muscle tone 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 scanty evidence of its efficacy Adenotonsillectomy for Obstructive Sleep Apnoea in Children. The size of the adenoids does not always correlate with the severity of apnoea.
    • In doubtful cases, the apnoea diagnosis and the outcome of its treatment should be established by a whole-night polysomnography.
  • Brief central apnoeas are common in small infants. Both central and obstructive apnoeas lasting more than 15 seconds require detailed 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 fatigue, drowsiness, impaired attention and learning ability and behavioural symptoms.
  • Transient insomnia in most cases results from various identifiable stress factors. Its duration is 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 symptoms 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 carried out 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.

Excessive daytime tiredness

  • 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 at school age, already, as 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.
  • According to current knowledge, 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.
  • When suspecting chronic fatigue syndrome in a child or adolescent, investigations, treatment and rehabilitation should be carried out in a tertiary care hospital.

Examination of the child or adolescent

  • First, the examiner should find out what parents 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 are also 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 possible long-term or new-onset diseases, should also be assessed.
  • A concise account on the sleeping habits and any sleep disturbances of the parents provides further information on any inherited sleep characteristics and any 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 fatigue) 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. Other laboratory investigations are determined by the condition of the patient and by aetiological considerations.
  • An interview with an adolescent patient can be performed using the relevant parts of the information included in the Basic Nordic Sleep Questionnaire (BNSQ, see e.g. http://link.springer.com/chapter/10.1007/978-1-4419-9893-4_6).
  • A sleep log should be used.
  • 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 insomnia.

Sleep log

  • If the cause of the sleep problem is not obvious, 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 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 sleep and after a any interruption of the night's sleep.
  • 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.

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 (a 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.
  • 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.
    • In addition to the aforementioned method, the most effective treatment methods for insomnia in adolescents include sleep-related aspects of cognitive behavioural therapy. 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.
    • 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 is apparently increasing 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.
  • 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.
  • Typically none of the sleep medicines accepted for adult use have accepted indications in the pharmacological treatment of sleep disturbances in children or adolescents.
  • 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 fatigue, for example.

Levels of care and indications for consultation

  • Most sleep disorders are investigated and treated in primary health care.
  • 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 university hospital or appropriately specialized centre.
  • Narcolepsy should be diagnosed and treated at a university 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.
  • For bed-wetting see Enuresis in a Child.