Sleep Disorders in Children

Sleep Disorders in Children

Summary

Sleep disorders are conditions that prevent children from getting a full night of rest on a regular basis. Many children experience some problems associated with sleep. Many of these issues are normal and may not be classified as a sleep disorder.

According to the National Institutes of Health, more than 100 disorders of sleeping and waking have been identified. These include dyssomnias (disturbances in the amount, timing or quality of sleep) and parasomnias (disorders that involve abnormal behavioral or physiological events during sleep). Some of the most common sleep disorders and problems that affect children include insomnia, sleep apnea, nightmares and night terrors, sleepwalking and bedwetting.

Children who have sleep disorders may have difficulty going to bed and falling asleep, and may frequently awaken during the night. Their sleep patterns may be erratic in terms of regularity and sleep duration and they often may be drowsy during daytime hours. These symptoms may lead to difficulties in a child’s mental and physical development. Children with sleep disorders are also more likely to be moody and to engage in undesirable behavior.

Children require less sleep as they develop. Infants sleep from 16 to 20 hours a day, in four- or five-hour intervals. Because babies sleep in short spurts, naps are very important. At 6 months of age, children require two naps a day instead of three. At 12 to 15 months, they only require one nap daily. By the time they reach age 3 or 4, children usually do not nap and need an average of 10 to 12 hours of sleep at night. By the teenage years, they are sleeping about nine hours per night.

Poor sleep habits are often the cause of a child’s sleep problems. In other cases, emotional difficulties are at the root of a child’s sleep issues. Parents are urged to seek medical attention if their newborn or infant is noticeably fussy over long periods of time. Children should also see a physician if they have breathing problems or noisy breathing, snore loudly, awake at night on a regular basis or have difficulty falling asleep or maintaining sleep.

To diagnose a sleep disorder, a  physician will perform a complete physical examination and compile a thorough medical history of the child. Other diagnostic methods that may be used include neurological examinations and referral to sleep centers for expert analysis.

Treatment of sleep disorders varies depending on the cause of the disorder. Parents can take many steps to help facilitate their child’s efforts to sleep soundly. Some of these vary depending on the child’s age.

About child sleep disorders

Sleep disorders are any problems that prevent children from getting a full night of rest. In some cases, a child may have trouble falling asleep in the first place. In other cases, a child may have trouble remaining asleep, or may fall asleep at inappropriate times. Other disorders impact children’s sleep in various ways.

Sleep is an essential part of good health in all people. Most adults have a regular sleeping and waking cycle known as a circadian rhythm. It takes between three and six months before a child develops this cycle, which is partially responsible for the erratic sleep schedules of newborns.

During sleep, people alternate between non-rapid eye movement (NREM) and rapid eye movement (REM), the more mentally active stage of sleep when dreaming occurs. A baby’s sleep cycle is about 50 minutes, with about 50 percent spent in NREM and 50 percent in REM sleep. At 6 months of age, REM comprises about 30 percent of sleep. When children are between 2 and 4 years of age, their sleep cycle runs about every 90 minutes.

In addition, children require more sleep than adults. Up to the age of 2, most children are asleep more often than they are awake, and a person spends about 40 percent of overall childhood years sleeping.

Sleep disorders occur when children experience a regular interruption of their sleep schedules. According to the National Sleep Foundation, most children experience some sort of sleep disturbance. Some of these disturbances may be as simple as resistance to bedtime or to sleeping alone. Other cases are severe enough to qualify as sleep disorders.

Children with sleep disorders may be less alert and may display poor memory and performance skills, and delayed reaction times. As a result, sleep disorders can lead to difficulties in a child’s mental and physical development. They are also more likely to be moody and to engage in undesirable behavior. In addition, sleep disturbances and disorders tend to affect the family as a whole, with caregivers frequently unable to get enough sleep themselves. Lack of sleep, for any reason, can impact quality of life, relationships, careers and even safety.

Children who experience the occasional sleep disturbance usually do not require treatment. However, parents may want to consult with a physician if their child experiences episodes of sleep disturbances that occur several times a week or several times a night. Although this is often deemed a normal and temporary phase, it sometimes may indicate a more significant problem that requires medical care. This is particularly true if the disorder interferes with a child’s day-to-day behavior.

Comorbid sleep disturbances (in which there is an identifiable or apparent underlying cause of sleep problems) are far more common than primary sleep disorders. In most cases, this type of sleep disorder is temporary, but it can also cause significant distress to the child and parents. Colicky infants often sleep poorly, as do toddlers who are beginning to exhibit more autonomy and separation anxiety. This is a condition known as a disorder of initiating and maintaining sleep (DIMS).

In addition, it appears that sleep disorders in children may be associated with the development of other major health problems including obesity, diabetes and depression.

Types and differences of child sleep disorders

According to the National Institutes of Health, more than 100 disorders of sleeping and waking have been identified. They may fall into one of several categories.

Dyssomnias are disturbances in the amount, timing or quality of sleep resulting in excessive daytime sleepiness. Some common dyssomnias that affect children include:

  • Insomnia. Condition of inadequate or poor sleep that may include difficulty falling asleep, waking up frequently during the night with difficulty falling back asleep, waking up too early in the morning or nonrestful sleep.
  • Sleep apnea. Sleep disorder that causes breathing to become shallow or stop while sleeping. Each pause in breath usually lasts 10 to 20 seconds. Pauses can occur 20 to 30 times in an hour. Sleep apnea in children is associated with daytime drowsiness, poor academic performance and hyperactivity. Obstructive sleep apnea syndrome (OSAS) involves snoring associated with gasping or pauses in breathing. Between 1 and 3 percent of children have this disorder, according to the National Sleep Foundation(NSF). Childhood obesity raises the risk of having sleep apnea.
  • Restless legs syndrome (RLS). Sleep disorder characterized by unpleasant sensations in the legs that are described as creeping, crawling, tingling, pulling or painful. RLS can result from changes in bedtime routine, increased amounts of iron in the body and use of certain medications.
  • Narcolepsy. Chronic sleep disorder characterized by excessive and overwhelming daytime sleepiness and short “sleep attacks,” even after adequate nighttime sleep. About 250,000 Americans have narcolepsy, according to the National Center on Sleep Disorders Research. Its cause is unknown. Narcolepsy may begin as early as age 10 and is most likely to be noticed in puberty.
  • Periodic limb movement disorder (nocturnal myoclonus). Characterized by periodic episodes of repetitive jerking and kicking during sleep.

Parasomnias are disorders that involve abnormal behavioral or physiological events during sleep. They involve partial arousal or interference with sleep stage transition. Some common examples of parasomnias that affect children include:

  • Arousal disorders. Disorders that involve partial arousal, such as sleepwalking and night terrors, which are characterized by sudden arousal from sleep and increased pulse and breathing rate. Night terrors occur when a child wakes up screaming at night and appears confused. Although children in the midst of a night terror appear to be awake, they typically cannot communicate. Night terrors often strike between the ages of 4 and 12 and tend to affect boys more often than girls. Sleepwalking is another arousal disorder. It involves walking around for between five and 20 minutes while in a state of sleep, usually within two hours of falling asleep. Although children in this state appear to be awake, they are actually sleeping and in danger of hurting themselves. Sleepwalking usually begins between the ages of 6 and 12 and affects more boys than girls. Up to 40 percent of children sleepwalk, according to the NSF.
  • Sleep-wake transition disorders. Disorders that interfere with sleep stage transition. Sleeptalking – in which a child talks, laughs or cries during sleep – is one example. In most cases, the child does not remember the behavior the next day. Sleeptalking typically does not require treatment.
  • Nightmares. These are frightening dreams that occur during rapid eye movement (REM) sleep and are associated with increased pulse and rate of breathing, profuse sweating and arousal. Many children have occasional nightmares. Although scary, they are relatively minor and infrequent disruptions in sleep. However, about 3 to 5 percent of preschool and school-aged children may experience chronic nightmares, according to the NSF. These dreams cause significant interference with a child’s ability to sleep and feel rested.
  • Teeth-grinding (bruxism). This occurs in children who clench and grind their teeth during sleep. Over time, this can wear down the teeth or cause jaw pain. Mouthguards or splints are often used to treat this condition.
  • Bedwetting. Bedwetting is a symptom that occurs when a person cannot control bladder function, usually during sleep. It is also known as enuresis, and affects 15 percent of children – especially boys – after the age of 3, according to the American Academy of Child and Adolescent Psychiatry. Occasional bedwetting is a normal part of childhood. However, other factors – including stress – can cause bedwetting. In such cases, it may require treatment.

Some sleep abnormalities may not rise to the level of a sleep disorder. For example, snoring is the result of a partial blockage of the airway that triggers a vibration in the back of the throat. Between 10 and 12 percent of children snore regularly, according to the NSF. This is often caused by nasal congestion or an enlarged adenoid or tonsils, but may be associated with a sleep disorder such as sleep apnea. In other cases, children may resist sleep or develop poor sleep habits. They may be reluctant to go to bed or may insist that a parent stay with them. This is often caused by normal developmental issues, such as separation anxiety. These types of disturbances are considered secondary, as opposed to primary (e.g., sleep apnea). Sleeping disorders are not just limited to younger children. In some cases, pre-adolescents and adolescents may begin to sleep poorly as stresses build in their academic and social lives. Difficulty falling asleep, fewer hours of sleep and daytime drowsiness are all characteristic of sleep disorders in children of this age group.

Potential causes of sleep disorders in children

Poor sleep habits are often the cause of a child’s sleep problems. Children who nap excessively during daytime hours, go to bed too early or spend too much time awake in bed may experience sleep problems. Erratic sleep schedules can also hamper a child’s efforts to maintain regular patterns of sleep.

In other cases, emotional difficulties are at the root of a child’s sleep issues. Some psychiatric conditions, such as anxiety disorders and depression can result in insomnia or hypersomnia (excessive sleepiness). Some children may feel anxious about going to bed or falling asleep, or they may have normal feelings of separation anxiety. Resisting bedtime may also be a sign of autonomy, as toddlers and children test their boundaries. Bedtime often becomes a test of wills between parents and their children.

Other causes of sleep disorders in children may include:

  • Food and drink. Foods and beverages that contain caffeine, such as soft drinks and chocolate, can cause difficulties in falling asleep.
  • Medications. Many medications can interfere with sleep. For instance, insomnia is a common side effect of psychostimulant drugs (e.g., methylphenidate) used in the treatment of attention deficit hyperactivity disorder (ADHD).
  • Medical conditions. Many medical conditions, such as asthma, can interfere with sleep. Research also shows that sleep disorders are common in children with excess body weight.
  • Life stresses. Family turmoil or the death of a parent or other loved one can disrupt sleep patterns. Lesser day-to-day stresses (e.g., moving or school changes) can also trigger nightmares, night terrors and other sleep disorders.
  • Lifestyle habits. Certain activities, such as watching television or spending excessive time on the computer at night before going to bed, may keep a child from getting the necessary sleep.
  • Sometimes no cause for a disturbance or disorder can be found.

Signs and symptoms of child sleep disorders

The signs and symptoms vary among individual sleep disorders. Children may have difficulty going to bed and falling asleep, and may frequently awaken during the night. Their sleep patterns may be erratic in terms of regularity and sleep duration. Although many adults and children with sleep disorders experience daytime drowsiness, children are more likely to have daytime hyperactivity associated with sleep disorders. Many children with sleep disorders also display characteristic symptoms such as loud snoring.

Some common signs and symptoms of dyssomnias include difficulty falling asleep and excessive daytime drowsiness. Some signs and symptoms of parasomnias include abnormal behaviors that occur during sleep, such as walking, head-banging and head-rolling. Signs and symptoms of sleep disorders that are caused by medical or psychiatric conditions vary and may include difficulty falling asleep or irritability.

ConditionSymptoms
InsomniaDifficulty falling asleep

Difficulty staying asleep

Waking up feeling tired, even after a full night’s sleep
Sleep apneaBreathing that stops during sleep

Choking or gasping during sleep

Loud snoring
NarcolepsyCataplexy (sudden episodes of loss of muscle function)

Sleep paralysis (temporary inability to talk or move when falling asleep or waking up)

Hypnagogic hallucinations (vivid, often frightening dream-like experiences)
NightmaresAbrupt awakening from sleep, usually later in the sleep period

Memory of a frightening dream

Little confusion or disorientation upon waking
Night terrorsAbrupt awakening from sleep, usually earlier in the sleep period

No memory of episode

Confusion or disorientation upon waking

Diagnosis methods for child sleep disorders

Parents may not always realize that a child’s symptoms are related to a sleep disorder. They are urged to bring their newborn or infant to a pediatrician if the child is noticeably fussy over long periods of time. Children should also see a physician if they have breathing problems or noisy breathing, snore loudly, wake at night on a regular basis or have difficulty falling asleep and/or maintaining sleep.

When visiting a physician, a physical examination will be performed to determine if there is a medical cause for the problem. A medical history, which may include the patient’s current medications and a psychiatric history, will also be taken. Patients may be given a neurological examination if a neurological cause is suspected.

Parents may be asked questions regarding their child’s sleep patterns and symptoms experienced during waking hours. A sleep diary detailing the child’s sleep times and patterns may help discussions with a physician or sleep specialist.Sleep disorders can sometimes be diagnosed by identifying medications, medical or neurological conditions, psychiatric disorders or other factors that may be causing sleep problems. In other cases, children may be referred to a sleep center where sleep patterns are analyzed in depth (e.g., a sleep study) by health professionals who specialize in sleep disorders.

Treatment/prevention of child sleep disorders

Parents can take many steps to help facilitate their child’s efforts to sleep soundly. For example, scheduling the same bedtime every night and keeping a consistent nighttime routine can help encourage sleep in children who have insomnia. Use of a night-light or providing a child with an object of security – such as a favorite stuffed animal – can reduce the likelihood of nightmares. Night terrors can be reduced by increasing the time a child sleeps. If a child sleepwalks, parents should make sure they are in a secure environment, with no bunk beds and staircases blocked.

Infants may fall asleep more easily after being fed or rocked prior to bedtime. However, it is important not to overdo this technique, because it can make it more difficult for children to break away from this pattern as they grow a little older. In fact, some experts recommend that parents avoid falling into this trap by either ignoring their child’s cries altogether, or delaying their response to the child’s cries for increasingly longer periods of time. Although this can be emotionally difficult for the parents, it often accomplishes the goal of teaching children to return to sleep on their own.

Other tips for parents vary according to a child’s age. For example, sleeping tips for newborns (ages 1 to 2 months) include:

  • Learn a baby’s sleeping patterns and watch for signs that indicate sleepiness
  • Place drowsy babies in a crib before they fall asleep
  • Lay babies on their backs with the head clear of blankets and other soft items
  • Promote nighttime sleep in the baby

Tips for infants (3 months to 1 year) include:

  • Keep a consistent bedtime schedule and routine that is enjoyable for the child
  • Establish an environment conducive to sleep
  • Encourage the baby to fall asleep independently

Tips for toddlers (1 to 3 years) include:

  • Maintain an established bedtime schedule and routine
  • Keep sleep environment stable throughout the night and from night to night
  • Set clearly communicated, consistent and enforced limits on a child’s night routine
  • Encourage the child to have a security object such as a stuffed animal

Tips for preschoolers (4 to 5 years) include:

  • Maintain a consistent sleep schedule
  • Keep a relaxing bedtime routine that ends in the child’s room
  • Child’s room should be cool and quiet, and not have a television

Tips for school-aged children (6 to 12 years) include:

  • Teach children about healthy sleeping habits
  • Emphasize the need for a regular sleep routine and schedule
  • Monitor the amount of time a child spends watching television or using the computer before bedtime
  • Encourage the child to avoid caffeine

Parents are also encouraged to keep their children from consuming too many foods and beverages with caffeine, such as chocolate and soft drinks. Other tips include:

  • Make sure children avoid eating or drinking too close to bedtime. This can interrupt sleep.
  • Encourage a child to maintain a healthy body weight. Many cases of sleep apnea (slowed or stopped breathing during sleep) occur among overweight children. Weight loss can alleviate or eliminate the symptoms.
  • Exercise. Exercising regularly often helps children sleep, although exercising too soon before bedtime can cause difficulties falling asleep.
  • Find the right temperature for sleeping. Extreme temperatures can disrupt a child’s sleep.
  • Get proper light exposure. Too little exposure to sunlight during the day can cause sleep problems at night. Bedrooms should be kept dark so light does not interfere with sleep.
  • Control noise. Environmental noise can be minimized with ear plugs, rugs, heavy curtains or drapes or double-pane windows.
  • Get a proper mattress. Mattress quality can impact sleep quality.
  • Maintain consistent sleep and wake times and encourage children to get into bed only when tired.

Children who have less serious, secondary sleep disturbances often can improve their sleep time by learning to self-soothe. This technique encourages children to use self-comforting measures to relax themselves when they wake in the middle of the night. Studies have shown that high percentages of children are able to regularly return to sleep once they have mastered this technique. Putting infants to bed when they are drowsy but not yet asleep appears to encourage these children to become successful “self-soothers.”  

In some cases, medical intervention may be needed to treat sleep disorders in children. Some pediatricians have used medications such as antihistamines for children with trouble sleeping. However, long-term use of medications for insomnia in children is not recommended and there is limited information on the use of adult sleep medications for children. Other conditions such as attention deficit hyperactivity disorder or mental retardation may require other medications that can help a child’s sleep disorder.

Many children who have frequent throat infections such as tonsillitis may have troubled breathing and sleeping due to enlarged tonsils. Removal of the tonsils (tonsillectomy) can help this problem.

Research shows that exercise can often alleviate sleep problems in overweight children.

Questions for your doctor

Preparing questions in advance can help parents and children to have more meaningful discussions with a physician regarding the child’s conditions. Parents may wish to ask their doctor the following questions regarding child sleep disorders:

  1. My child sometimes has trouble falling asleep. Is this normal or does he/she have a sleep disorder?
  2. What type of sleep disorder do you suspect my child has?
  3. How will you diagnose my child’s sleep disorder?
  4. What is causing my child’s sleep disorder?
  5. How likely is it that my child will simply outgrow the sleep disorder?
  6. What are the possible health and developmental consequences of my child’s sleep disorder?
  7. Should I consult a sleep center to determine the cause of my child’s sleep disorder?
  8. How should my child’s sleep disorder be treated?
  9. Are the medications used to treat sleep disorders safe for children?
  10. How can I help my child to sleep better?
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