The Young and the Restless: A Pediatrician's Guide to Managing Sleep
Publish date: Mar 1, 2009
By:  Kathleen H. Armstrong, PhD, NCSP, William C. Kohler, MD, Carol M. Lilly, MD
Source: Contemporary Pediatrics

Desperate and weary, a mother brings her 3-year-old son to the pediatrician's office for help. The child has never slept through the night; upon awakening in the middle of the night, he calls out for his parents and wanders through the house. Consequently, his parents intervene by taking him into their bed, where everyone's sleep is compromised.

During the day, the patient is described as fussy and irritable. His mother is worn down by three years of sleep deprivation, while his father has resorted to sleeping on the couch rather than face never-ending sleepless nights and exhausting days. He is also becoming increasingly withdrawn from his wife and son. How do you begin to help this family?
 
Sleep problems in early childhood are a frequent concern presented to pediatricians. Up to 20% to 30% of all children experience sleep problems sometime during childhood, with bedtime resistance and nighttime awakenings ranked as the second most commonly reported behavioral problem in pediatric offices.1 Of even greater concern is the accumulating evidence linking children's sleep problems with health problems, emotional/behavioral disturbances, as well as academic delays.2-4 Yet, despite all these factors, less than 2% of children are being screened and managed for sleep problems in primary care settings.5

Well-child visits offer the perfect opportunity to screen for sleep problems at the earliest stages of life, to educate parents about sleep hygiene, and to make referrals when needed to the appropriate specialist. What follows is a review of developmental issues related to sleep and sleep problems, sleep screening tools, sleep hygiene, and therapeutic options6,7 that pediatricians can enlist to help their restless patients and their beleaguered parents.

If you or your child has similar problems, you can do a SCREENING NOW for the Six Most Common Sleep Disorders and get Information on the Five Most Common Parasomnias!

Sleep development and disruptions 
By 6 to 9 months of age, most infants have a well-established pattern of nocturnal sleep and are able to sleep through the night, averaging fourteen to fifteen cumulative hours of sleep in a 24-hour period. (It's good to be young.) This amount decreases to 11 to 14 hours for toddlers and preschool-aged children. School-age children require 10 to 11 hours of sleep daily, which decreases to about eight to nine hours as adults.8
Another normal developmental change noted in sleep is the amount of time spent in the rapid eye movement, or REM, stage. Newborns spend about half of their total sleep time in REM, gradually decreasing to about one-fifth of total sleep time for children and adults. The exact mechanism served by REM sleep remains unclear; however, it is thought to impact memory and learning. In addition, various biological processes appear to be modulated by sleep, including the immune system and secretion of growth hormones.9,10

Childhood sleep problems typically arise from disruptions in either the quantity or quality of sleep. Disruptions in the quantity of sleep result from difficulty falling asleep, and/or maintaining sleep, and are thought to be based upon faulty learning during the development of the sleep routine. Disruptions in the quality of sleep result from frequent, brief, and repetitive arousals such as those caused by obstructive sleep apnea (OSA) secondary to adenotonsillar hypertrophy, or anatomical abnormalities.11 In either case, children with inadequate sleep may show poor attention, decreased memory, along with increased impulsivity, emotional lability, and aggression.
Risk factors for the development of sleep disruptions include medical conditions (craniofacial disorders, chronic lung disease, failure to thrive, obesity, etc.), acute illnesses (such as otitis media), and medications (stimulants, bronchodilators, or anticonvulsants). Children with developmental disabilities are also at increased risk for sleep disorders. Children with attention-deficit hyperactivity disorder (ADHD) have twice the risk of sleep-related problems compared to children without ADHD. And 85% of children with autism spectrum disorder (ASD) exhibit sleep-related problems.12,13 Adolescents present special risk for sleep disruptions, in part due to biological maturation and changes related to sleep/wake cycle, irregular sleep patterns, and often earlier starting times of high schools, precluding later waking times.1

Common pediatric sleep disorders 
While there are multiple classification models for sleep disorders, the most common sleep disorders seen in children and adolescents include behavior insomnia disorder of childhood (sleep onset association disorder and limit-setting disorder), delayed sleep phase syndrome, parasomnias (nightmares, sleep terrors, and sleep walking), OSA, narcolepsy, periodic limb movement disorder, and restless leg syndrome.

Sleep onset association disorder
Sleep onset association disorder (SOAD) is thought to result from the conditions under which children learn to fall asleep, and their inability to self soothe during brief arousals. For example, a baby girl who learns to fall asleep while feeding learns to associate her mother's touch, smell, and feeding with sleep, and thus is unable to fall asleep without her mother's presence. Once the baby falls asleep, she awakens during periods of light sleep and is unable to soothe herself back to sleep, and cries out for her mother. The mother responds by cuddling and/or feeding her baby until she falls back asleep. As a result, the baby develops a sleep routine in which she is unable to fall asleep without her mother, and both baby and mother risk insufficient sleep. 

Limit-setting disorder (LSD) (newly referred to as Behavioral Insomnia of Childhood or BIC) refers to when parents or caretakers inadvertently reinforce their child's unwillingness to go to sleep or stay in bed through inconsistent reinforcement of the bedtime rules and routines. For example, the child's behavior escalates when a parent attempts to put her to bed, and the parent gives in, rather than following through, thus reinforcing the child's misbehavior. Both SOAD and LSD/BIC are best managed by a process developed by Dr. Richard Ferber,15 which combines sleep hygiene principles with behavioral management.
Following what is now referred to as the Ferber method, parents gradually teach their baby to sleep by first instituting a relaxing bedtime routine, which includes the use of a transitional object or lovey (a blanket or other object to substitute for a caregiver), wind down activities, slowly eliminating nighttime feedings, and gradually increasing their response time to baby's cries. This method is also referred to as graduated extinction, and is highly effective only if parents are consistent. This means that parents must be able to tolerate listening to their baby's cries or child's demands.
Prior to implementation, parents should be forewarned by their pediatrician about the "extinction burst" phenomena. The extinction burst is a temporary escalation of the crying or other behaviors that commonly occur during the initial stages of behavioral interventions, and may result in parents giving up and returning to old habits. The pediatrician's guidance and encouragement will help the parents succeed.

If your child may have problems with Limit-Setting Disorder (LSD) or Behavioral Insomnia of Childhood (BIC), you can SCREEN YOUR CHILD NOW for BIC and 5 Other Common Pediatric Sleep Disorders and get Information How to Correct Them!

Delayed sleep phase syndrome
Delayed sleep phase syndrome (DSPS) refers to a sleep disorder most commonly diagnosed in older children and adolescents. DSPS is learned through a combination of inconsistent bedtime routines and poor limit setting by caregivers. When sleep onset is delayed, the circadian phase of sleep becomes set at a later hour. Poor sleep habits are reinforced when the child resists going to bed, and the parent does not deal with the child's behavior. The child subsequently becomes more oppositional and unwilling to follow the bedtime routine.
Developing and sticking with a consistent bedtime routine, making environmental modifications to support sleep, and motivating the child's cooperation through positive reinforcement is the most successful treatment for these bedtime problems. Younger children may respond to a sticker chart and daytime rewards, while older children may respond to progressive relaxation to help them wind down to sleep.16,17

In the case of older children and adolescents, lifestyle choices such as media, friends, school, or sports may result in irregular bedtimes and missed sleep. Staying up late on weekend nights and sleeping in the following day exacerbates the situation. Sleep hygiene is the first course of intervention, and should include consistent waking and sleeping times, diet and exercise modifications, limitation of media, and use of relaxing, calm activities prior to bed.
Chronotherapy is a behavioral technique utilized by sleep specialists to readjust the sleep-wake cycle through the progressive delay of bedtime by three-hour increments each day, pushing bedtime later until the desired bedtime is reached. Although effective, this intervention is difficult for children attending school, as they will sleep during the day until they reach the desired bedtime. Bright light therapy is also an effective intervention that may help teenagers struggling with DSPS. Bright light exposure early in the morning (a light box at 10,000 lux for 30 minutes), and avoiding light as much as possible in the evening, is considered a first-line therapy.

If you or your older child or adolescent may have problems with Periodic Limb Movement Disorder (PLMD), you can do an ON-LINE SCREENING NOW for PLMD and 5 Other Common Sleep Disorders and get Information How to Correct Them!

Parasomnias
Parasomnias (eg, sleepwalking, sleep terrors, and nightmares) are quite common in young children, and are thought to result from neurological immaturity. Sleep walking and sleep terrors are most likely to occur during the first third of the night, during slow wave sleep. In contrast, nightmares occur more commonly during the last third of the night, when REM stage sleep is most prominent. Children may become agitated if awakened during sleep terrors, and generally do not recall any details. Nightmares, on the other hand, may waken children, who then recount vivid details.
There appears to be a genetic predisposition to sleepwalking and sleep terrors.18 If night wakening is prolonged as a result of parasomnias, daytime sleepiness may result. Treatments for parasomnias include reassuring parents, helping children to maintain a consistent bedtime routine, and taking safety precautions in the case of sleep walking.18 In adults and children, hypnosis has been documented as an effective therapy for sleep walking.19

If your child may have problems with Parasomnias such as Bed-Wetting, Sleep-Walking, Sleep-Talking, Teeth Grinding or Sleep/Night Terrors, you can SCREEN YOUR CHILD NOW and get Information and interventions from leading pediatric sleep specialists!

Obstructive sleep apnea
Obstructive sleep apnea (OSA) is relatively common among children, with a prevalence of approximately 3%.20 OSA peaks from ages 3 to 7 years, when adenoid and tonsil tissues are greatest in relationship to airway size. The condition peaks again in early adolescence. Children with large tonsils or adenoids, craniofacial abnormalities, genetic syndromes such as trisomy 21, morbid obesity, or neurological disorders are at increased risk for OSA and should be screened regularly.
OSA is characterized by prolonged upper airway obstruction and intermittent complete obstruction that disrupts normal ventilation during sleep and interrupts normal sleep patterns.21 If left untreated, OSA can lead to impaired daytime functioning, as well as more serious complications involving neurological function, developmental delay, heart failure, growth problems, and death.22 Increasing evidence links OSA to behaviors associated with ADHD (attention, conduct, and hyperactivity), and decreased academic performance.23
OSA should be considered by the pediatrician when parents report habitual snoring or restless sleep, in cases of obesity, and for children with disabilities including some genetic disorders (ie, trisomy 21), craniofacial abnormalities, achondroplasia or neuromuscular disorders. The diagnosis of OSA must be confirmed by a sleep specialist, using an overnight polysomnogram. The most common treatment option is adenotonsillectomy. Overweight and obese children may derive less benefit from the surgical procedure, thus lifestyle changes and a continuous positive air pressure (CPAP) machine may be their best options.
Other treatments may include the use of dental appliances, position training to sleep on the side instead of the back, and surgery for those with craniofacial disorders. Surgery is often the first line of treatment for a child with craniofacial disorders. In cases of severe upper airway obstruction in both waking and sleeping states, a tracheostomy may be necessary.24

If you or your child/teen may have some of the symptoms of Obstructive Sleep Apnea, you can do an ON-LINE SCREENING NOW and get Information and recommendations from leading sleep specialists, as well as a website with a list of sleep specialists in your area of the USA!

Narcolepsy
Narcolepsy is a neurological disorder associated with excessive daytime sleepiness (EDS), cataplexy, sleep paralysis, hypnagogic hallucinations, and early onset of REM sleep. This condition first becomes evident during adolescence or young adulthood, and peaks between the ages of 15 to 25.25
Cataplexy is a sudden decrease in muscle tone triggered by emotions such as anger, laughter, or surprise. Milder symptoms of cataplexy may include slurred speech, head nod, buckling of the knees or weakness of the arms. More severe attacks may result in a complete body collapse, with a fall to the ground.

Sleep paralysis is the temporary inability to talk or move when waking up or falling asleep, while being fully aware of one's surroundings. The duration of these episodes may be from seconds to minutes. Breathing is maintained, although some patients report that they feel they cannot breathe. Hypnagogic hallucinations are vivid visual and auditory disturbances that occur while falling asleep.
The Epworth Sleepiness Scale (or the Sleep Disorders Inventory for Students for children under 19 years old) may be used to screen for EDS.26 Narcolepsy is diagnosed from history, polysomnography, and a multiple sleep latency test (MSLT). Sleep specialists may prescribe stimulants to treat EDS, and antidepressants or sodium oxybate (Xyrem) to treat cataplexy; however, practitioners should be mindful that sleep medications are not FDA approved for children.

If you or your child/teen may have some of the symptoms of Narcolepsy, you can do an ON-LINE SCREENING NOW and get Information and recommendations from leading sleep specialists, as well as a website with a list of sleep specialists in your area of the USA!

Periodic limb movements of sleep
Periodic limb movements of sleep (PLMS) and restless leg syndrome (RLS) often occur simultaneously, and have only been recognized fairly recently in children.
PLMS is characterized by periodic, repetitive movements usually in the legs, feet, or toes during sleep, and may be associated with partial arousal or awakening. In contrast, RLS is a sensorimotor disorder characterized by uncomfortable sensations in the lower extremities often described as "snakes in the legs" or "creepy-crawly things in the legs" that are temporarily relieved by movement and occur mainly in the evening or during quiet times.27
RLS is a clinical diagnosis based upon symptoms, and includes history, examination, polysomnography, and actigraphy. With mild RLS cases, exercise, leg massages, and elimination of caffeine may provide relief.27 Serum ferritin levels of below 50 ng/mL have been associated with RLS. At particular risk for RLS are infants and toddlers, female adolescents who are menstruating, and adolescents. Thus, iron supplements may be of benefit for children with low ferritin levels, absorption of which is enhanced when taken with Vitamin C.28 Medications such as D2, D3 agonists, benzodiazepines, and anticonvulsants are used to treat severe symptoms of PLMS and RLS by sleep specialists; however, evidence regarding the long-term effect of these medications is sparse.29 

Periodic limb movement disorder (PLMD) is a movement disorder of sleep with increased PLMS, and daytime symptoms of excessive somnolence or difficulty sleeping at night, which cannot be better explained by another condition. See Table 1 for a summary of sleep disorders, diagnostics, and interventions.

If you or your child or teen may have some of the symptoms of Restless Legs Syndrome or Periodic Limb Movement Disorder, you can do an  ON-LINE SCREENING NOW and get Information and recommendations from leading sleep specialists, as well as a website with a list of sleep specialists in your area of the USA!

ADHD and sleep
Pediatricians are faced with the growing challenge of addressing behavioral disorders, the most common of those affecting school-aged children being ADHD.
According to the DSM-IV TR, ADHD is characterized by a cluster of symptoms including inattention, distractibility, poor impulse control, and in some cases, motor restlessness.30 These symptoms interfere with functioning across multiple settings, including home and school, and are associated with academic underachievement, poor interpersonal skills, and low self esteem. Most often, ADHD is treated with a combination of stimulant medication and behavioral therapy.31

ADHD symptoms may be indistinguishable from those of a sleep disorder. For example, 64% of children with RLS or PLMD are diagnosed with ADHD.32 Similarly, children with OSA have been found to be at increased risk for ADHD and learning problems. Finally, children placed on stimulant medication for ADHD are more likely to report insomnia.33 Therefore, any child suspected to have ADHD should be screened for sleep problems.

How to screen and treat
In our experience, screening for sleep problems successfully identifies sleep as a contributor or consequence of behavioral disorders in 30% to 40% of children evaluated for behavior problems and developmental delays.34 Given the association between ADHD and sleep disorders, all children with ADHD symptoms or significant behavior disturbances should also be screened. Likewise, the importance of screening children who are overweight is critical to prevention/intervention efforts.
A careful medical history will illuminate underlying medical causes such as allergies, medications, and pain, which may be contributing to sleep problems. A review of sleep habits and the bedtime routine, as well as a sleep diary, may be useful in documenting wake-sleep cycles. Sleep screeners offer a quick and reliable method to identify and differentiate sleep disturbances, and help in making treatment decisions. Finally, those children who exhibit symptoms of OSA should be referred to a sleep specialist for evaluation.

Screening tools
The BEARS sleep screening algorithm addresses the most common sleep issues in 2- to 18-year-olds.35 It incorporates five basic sleep domains: 1) Bedtime problems, including difficulty going to bed and falling asleep; 2) Excessive daytime sleepiness, which includes behaviors associated with daytime somnolence in children; 3) Awakenings during the night; 4) Regularity of sleep/wake cycles and average sleep duration; and 5) Snoring. 

The pediatrician asks parents about possible problems in each domain, eliciting a yes or no response. If the answer is yes, then the parents are asked to describe the problem. For example, if a parent responded yes to snoring, she would then be asked to describe how often the child snored, and whether apnea accompanied the snoring. See Table 2 for the BEARS sleep screening algorithm.

The Epworth Sleepiness Scale (ESS), a tool developed for use in adults, is often used to determine the level of daytime sleepiness.26 Patients are asked to rate their level of sleepiness, from 0 to 3, in eight separate situations. A cumulative score of 10 or more is considered at-risk, and the patient is advised to think about whether he or she is obtaining adequate sleep, needs to improve sleep hygiene, or may need further evaluation by the sleep specialist.

The Sleep Disorders Inventory for Students (SDIS), available on our web site, is a standardized screening instrument used to identify children at risk for OSA, narcolepsy, periodic limb movement disorder, restless leg syndrome, and delayed sleep phase syndrome, as well as five parasomnias.36 There are two versions of the SDIS; one for children ages 2 to 10 years (SDIS-C), and one for adolescents ages 11 to 18 years (SDIS-A). Parents are asked to rate their child's sleep behaviors on 41 items, which takes about 15 minutes. Both versions are available in English and Spanish. A computerized scoring system takes less than five minutes to complete, and generates a very comprehensive report. We have found this instrument very useful in our clinical practice when determining the need for refer to the sleep specialist.

Pharmaco, surgical, and other treatments
In instances of behaviorally based sleep disturbances, basic principles of sleep hygiene should be attempted first, as there is little research supporting pharmacological treatment of pediatric sleep disorders. Adenotonsillectomy is the most common treatment for children with OSA, while CPAP, weight loss, and dental appliances may also be options. CPAP is a safe and well-tolerated treatment, but requires compliance. Obese children are six times more likely to develop OSA than non-obese children, and are less likely to respond favorably to adenotonsillectomy. Therefore, weight loss programs focused on healthy diets and increased physical activity must be included in any treatment plan.37

Sleep medications most commonly used in children include over-the-counter medications and prescription sleep aides. Over-the-counter products including melatonin, valerian, and antihistamines have very limited evidence supporting efficacy and safety. Bear in mind, however, that parents can buy these products independently.38

Clonidine (Catepres) is commonly used to treat insomnia, and may be used in conjunction with stimulants used to treat ADHD symptoms. Nonbenzodiazepines, such as zolpidem tartrate (Ambien), are less frequently used with children and should only be used by a sleep specialist on a short-term basis. Note that no sleep medications have been FDA approved for use with children. If used, they must be carefully monitored due to adverse side effects.39

Revisiting the young and the restless
A first step in solving sleep problems is to find out more about the child's sleep routine. Pediatricians should use the BEARS algorithm to find out more about a patient's sleep habits, validate whether there are snoring or breathing problems, and help parents develop a sleep plan, if needed.

Taking into account daily activities and time factors, a sleep plan would ask that a family develop a routine that includes ample time to wind down and prepare for sleep. Once tucked into bed, parents would be required to leave their child's room, and ignore his/her attempts to resist the sleep routine, gradually increasing time away before checking on and reassuring the child. Prior to these attempts, the family's pediatrician should prepare the parents for the onset of the extinction burst phenomena. This process takes about two weeks, as long as parents do not give in along the way.

A Parent Guide offers a sample sleep log, which can be helpful in monitoring progress. The guide also contains further suggestions on how parents can improve their child's sleep habits.

For practitioners, both the American Academy of Sleep Medicine ( http://www.aasmnet.org), and the American Academy of Pediatrics ( http://www.aap.org) offer practice guidelines, which may be accessed through their Web sites. The National Sleep Foundation ( http://www.sleepfoundation.org) can provide additional information regarding sleep across the life span.
DR. ARMSTRONG is is the Director of Pediatric Psychology and Associate Professor of Pediatrics in the Department of Pediatrics at University of South Florida, Tampa.
DR. KOHLER is the Director of Pediatric Sleep Services at University Community Hospital, Tampa, and Medical Director of the Florida Sleep Institute.
DR. LILLY is Division Chief and Associate Professor of Pediatrics at the Department of Pediatrics at USF-Tampa.
The authors have nothing to disclose with regard to affiliations with, or financial interest in, any organization that may have an interest in any part of this article.

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