Sleep Problems in Children

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, sleep walking. Nocturnal enuresis is regarded by researchers as a parasomnia but enuretic children are not more difficult to waken than children without enuresis.¹

• 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 learning disability are particularly prone to problems with sleep.

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.

• This is the most common form of sleep problem.
• 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.⁴
• 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.⁵
• Pharmacological treatment may only produce short term benefits but may be of benefit in a small number of children with sleep problems.^6,7 Sedating antihistamines may cause hangover symptoms during the day and withdrawal sleeplessness. Chloral hydrate has not been shown to be effective in children's sleep disorders. Melatonin has been widely used but has been implicated in causing seizures and there is no clear guidance on the required dosage.⁸ Medication may also have a detrimental effect on sleep apnoea.
• 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 are usually effective if used consistently and with conviction.⁸ Behavioural methods include positive and planned pre-bed routines, graduated extinction, scheduled wakes, extinction or systematic ignoring, modified extinction, educational booklets and sleep programmes.⁶
• The advice and support of a health visitor or, in the occasional severe or complex situation, a psychologist is very important important for any plan of management to be successful.

• 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.

• There are many types of parasomnia. They may be a primary sleep phenomena or related to a physical or psychiatric disorder.
• Most resolve spontaneously with time and so explanation and reassurance is often appropriate.
• Measures to avoid accidental injury may be necessary, especially in the case of sleep walking.
• 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.

• Sleep problems may lead to daytime problems such as poor memory and concentration, irritability, behaviour problems, aggression, emotional distress, depression and increased accident rates.
• It is claimed that teenagers need 9 hours sleep each night and suffer emotional problems and learning difficulties if they got less than this recommended amount of sleep.
• There may also be adverse effects on school performance, immune function and even growth.
• There may also be adverse effects on the family such as parental ill-health, reduced affection for the child, marital discord and adverse effect on the parent's work ability.