It is important to identify the sleep disorder underlying the problem, rather than treat symptomatically, as the choice of treatment depends on the cause of the problem. There are three basic types of sleep problem:

• Not sleeping enough (sleeplessness or insomnia).
• Sleeping too much (excessive sleepiness or hypersomnia).
• Episodic disturbances of behaviour related to sleep (parasomnias), e.g. night terrors, sleep-talking, sleepwalking. Nocturnal enuresis is regarded by researchers as a parasomnia but enuretic children are not more difficult to waken than children without enuresis.¹

Epidemiology

• Children's sleep problems are very common. At some stage about 40% of children have a sleep problem considered to be significant by their parents.²
• Children with a chronic physical illness (e.g. asthma), psychiatric disorder (e.g. attention deficit hyperactivity disorder) or with a learning disability are particularly prone to problems with sleep.

Assessment

Sleep disorders are often not recognised by general practitioners.³ It is important to establish:

• The nature and development of the sleep problem.
• Whether the child's sleep environment and activities have any adverse affect on the child's sleep pattern. Assess the typical day and night routine, including evening activities leading up to bedtime, getting to sleep, disturbances during sleep, getting up and level of alertness and activities during the day. A sleep diary kept over about a two-week period can be very useful.

Serial neonatal and infant electroencephalographic (EEG)/polysomnographic (PSG) studies are currently used as a research tool but may one day help in the diagnosis of sleep disorder, particularly where it is secondary to an underlying condition such as neurodevelopmental disorder.⁴

Sleeplessness in infants and toddlers

• This is the most common form of sleep problem. ⁵
• The management is dependent on the cause and is often straightforward if the underlying cause can be identified. The most effective way to prevent these problems is to introduce consistent routines in the first few months of life.⁶
• Children should be encouraged from a very early age to fall asleep in their own bed without a parent being present. Although brief waking in the night can be normal at any age, it creates a problem if the child cannot go back to sleep without its parents. Children who are with their parents when they first go to sleep at night are much more likely to insist on them being present again when they wake during the night.⁷
• Modification of the parental behaviour at the time the child is put to bed may be helpful.⁸ One study found that parental interventions which encouraged independence and self-soothing were associated with extended and more consolidated sleep compared to more active interactions.⁹
• Pharmacological treatment may only produce short-term benefits but may be of benefit in a small number of children with sleep problems.^10,11 Medication may also have a detrimental effect on sleep apnoea. It is recognised that severe sleep disorders may require medication as well as behavioural treatment but the evidence base for the use of pharmacological agents in children is weak and is often extrapolated from adult trials.¹²
• The BNF for Children (BNFC) lists chloral hydrate, sedative antihistamines and melatonin under its Hypnotics section.¹³ Chloral hydrate has not been shown to be effective in children's sleep disorders. Sedating antihistamines may cause hangover symptoms during the day and withdrawal sleeplessness. Melatonin has been widely used but has been implicated in causing seizures and there is no clear guidance on the required dosage.¹⁴ The BNFC recommended that it be prescribed in primary care only as part of a shared-care arrangement with a specialist. Consensus evidence-based guidelines are urgently needed.¹⁵
• Behavioural methods to improve parents' handling of bedtime and night-waking problems are very effective. Gradually changing children's need for their parents' presence at bedtime or during the night is usually effective if used consistently and with conviction.¹⁴ Behavioural methods may be of value.¹⁰ These include:
  • Positive routines - a regular bedtime with 20 minute winding down time. Move bedtime back 5 minutes per night until reasonable time .
  • Extinction - on hearing child cry, go in and check child not unwell or needs nappy change. Don't pick up child or feed. Leave.
• The advice and support of a health visitor or, in the occasional severe or complex situation, a psychologist, is very important for any plan of management to be successful. Educational booklets and sleep programmes may also be helpful.

Excessive sleepiness

• Excessive sleepiness is more common in adolescence and adult life but may also be seen in younger children. It may be caused by a variety of problems, e.g. medication, sleep-disordered breathing associated with upper respiratory tract obstruction. It may be interpreted as laziness or boredom. It must be differentiated from fatigue or exhaustion.
• At an early age, instead of sleepiness reducing the child's activity levels, it may cause overactive and disruptive behaviour.
• Management includes identifying and correcting any cause when possible, and behavioural methods to improve the normal sleep routine.

Parasomnias

• There are many types of parasomnia. They may be primary sleep phenomena or related to a physical or psychiatric disorder.
• Most resolve spontaneously with time and so explanation and reassurance are often appropriate.
• Measures to avoid accidental injury may be necessary, especially in the case of sleepwalking.
• When treatment is required, behavioural treatment methods are preferable and medication is a last resort. Management may also need to include treatment of any underlying physical or psychological disorder.

Complications

• Sleep problems may lead to daytime problems such as poor memory and concentration, irritability, behavioural problems, aggression, emotional distress, depression and increased accident rates.¹⁶
• It is claimed that teenagers need nine hours' sleep each night and suffer emotional problems and learning difficulties if they got less than this recommended amount of sleep.
• There may be adverse effects on school performance, immune function and even growth.
• There may also be effects on the family, such as parental ill-health, reduced affection for the child, marital discord and adverse effect on a parent's work ability.¹⁷

Document references

1. Thiedke C; Sleep Disorders and Sleep Problems in Childhood.; Am Fam Phys 2001 Jan 15;63:277-84; Full Text. Good overview from primary care perspective.
2. Boyle J, Cropley M; Children's sleep: problems and solutions. J Fam Health Care. 2004;14(3):61-3. [abstract]
3. Blunden S, Lushington K, Lorenzen B, et al; Are sleep problems under-recognised in general practice? Arch Dis Child. 2004 Aug;89(8):708-12. [abstract]
4. Scher MS; Ontogeny of EEG-sleep from neonatal through infancy periods. Sleep Med. 2008 Aug;9(6):615-36. Epub 2007 Nov 19. [abstract]
5. Sadeh A, Sivan Y; Clinical practice : Sleep problems during infancy. Eur J Pediatr. 2009 Apr 3. [abstract]
6. Hiscock H, Wake M; Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ. 2002 May 4;324(7345):1062-5. [abstract]
7. Eckerberg B; Treatment of sleep problems in families with young children: effects of treatment on family well-being. Acta Paediatr. 2004 Jan;93(1):126-34. [abstract]
8. Sadeh A, Tikotzky L, Scher A; Parenting and infant sleep. Sleep Med Rev. 2009 Jul 22. [abstract]
9. Sadeh A, Mindell JA, Luedtke K, et al; Sleep and sleep ecology in the first 3 years: a web-based study. J Sleep Res. 2009 Mar;18(1):60-73. Epub 2008 Oct 16. [abstract]
10. Ramchandani P, Wiggs L, Webb V, et al; A systematic review of treatments for settling problems and night waking in young children. BMJ. 2000 Jan 22;320(7229):209-13. [abstract]
11. Stores G; Medication for sleep-wake disorders. Arch Dis Child. 2003 Oct;88(10):899-903. [abstract]
12. Gringras P; When to use drugs to help sleep. Arch Dis Child. 2008 Nov;93(11):976-81. Epub 2008 Aug 1. [abstract]
13. British National Formulary for Children; British Medical Association and Royal Pharmaceutical Society of Great Britain. London.
14. Heussler HS; Common causes of sleep disruption and daytime sleepiness: childhood sleep disorders II. Med J Aust; 2005 May 2;182(9):484-489.
15. Pelayo R, Dubik M; Pediatric sleep pharmacology. Semin Pediatr Neurol. 2008 Jun;15(2):79-90. [abstract]
16. Reid GJ, Hong RY, Wade TJ; The relation between common sleep problems and emotional and behavioral problems among 2- and 3-year-olds in the context of known risk factors for psychopathology. J Sleep Res. 2009 Mar;18(1):49-59. [abstract]
17. Fauroux B, Aubertin G, Clement A; What's new in paediatric sleep in 2007? Paediatr Respir Rev. 2008 Jun;9(2):139-43. Epub 2008 May 12. [abstract]

Internet and further reading

• The Royal College of Psychiatrists; Sleep problems in childhood and adolescence.

Acknowledgements