Paediatric sleep disorders

By Dr Mandy-Lyn Meyer, Paediatrician at Melomed

Paediatric sleep disorders are important as they affect both the child and the family unit. Sleep deprivation can have a negative impact on scholastic achievement; by causing daytime sleepiness and irritability, it can also contribute to behavioural problems and learning difficulties.

Dyssomnias present with difficulty initiating or maintaining sleep while parasomnias result in disruption of sleep. Common examples of parasomnias include:

• Sleepwalking (Somnambulism)

Occurs in 17% of children. The child will walk in their sleep, with eyes open, but they are difficult to arouse.

• Sleep talking (somniloquy)
• Confusional arousals

This disorder affects up to 17% of kids. The child is ‘sleep drunk’ with inappropriate behaviour or slurred speech, and after the child wakes there is no memory of the event

• Sleep terrors occur in 6.5% of children. The child suddenly cries or screams in their sleep as if experiencing something terrifying, he or she may even walk about. The child is very difficult to arouse at the time and has no memory of the event, once it has passed.
• The last parasomnia is nightmares, affecting up to 50% of young children.

Nightmares usually occur in the second half of the night and there is memory of the event.

Most parasomnias affect otherwise healthy children and commonly improve over the course of adolescence. They are viewed as transient developmental phenomena and general measures, like good sleep hygiene, reassurance, increased total sleep time and scheduled wakenings may help.

Examples of common dyssomnias include:

• Obstructive sleep apnoea (OSA)

A condition in which the upper airway is obstructed and the child wakes up gasping for air or may stop breathing for a period of time (apnoea). The primary cause in children is enlarged tonsils and adenoids, other contributory factors include obesity and airway issues. These children often present with snoring but OSA can also contribute to morning headaches and bed wetting. Daytime sleepiness  may occur, but children more often display symptoms of poor concentration and inattention, depressive symptoms or even behavioural issues. In severe cases, OSA can lead to pulmonary hypertension and right sided heart failure. Treatment involves weight loss where appropriate, adenotonsillectomy and continuous positive airway pressure if other measures fail.

• Behavioural insomnia of childhood (BIC)

Affects up to 30% of children and is a learned inability to fall asleep. One subtype is sleep-onset association type, where the child demonstrates reliance on a sleep aid, for example a parent rocking the child to sleep. In limit-setting type, the child will exhibit defiance around bedtime, asking for one more story or to go to the bathroom etc, to delay sleep. However, most children will exhibit features of both (combined type). BIC prevention is better than cure; this includes structure to feeding times, nap-times and strict bedtime routines. Sleep training techniques are sometimes used to treat this disorder.

• Delayed sleep phase disorder is more common in adolescence, it is characterised by the sleep-wake cycle shifting to later hours. An example is the child who goes to bed regularly at 2am and then struggles to wake for school. Treatment involves good sleep hygiene, setting limits on screen time and, occasionally, melatonin supplementation.

• Restless leg syndrome occurs in 2% of children and although difficult to diagnose is described as an unpleasant sensation in the legs, accompanied by an urge to twitch or thrash when going to bed. Children may present with features similar to ADHD, difficulty sleeping, growing pains and bedtime resistance. Treatment involves sleep hygiene, exercise, avoiding precipitating factors like caffeine, nicotine and drugs like antihistamines and certain antidepressants. Iron deficiency is associated and treating this may help improve symptoms.

Sleep problems are common affecting up to 50% of children. They can have a negative effect on growth and behaviour if ignored. It is important to practice good sleep hygiene, the routine around bedtime, to help prevent these disorders. Examples of sleep hygiene include limiting or eliminating caffeine intake, which is present in tea, coffee and fizzy cooldrinks.

Encouraging physical activity and outside play is helpful, as inactivity during the day may lead to difficulty falling asleep. It is important to create a calm environment (pre-sleep); try to avoid screens and gadgets in the bedroom and other toys which may distract the child from sleep.

Establish a routine sleep schedule that promotes independent sleeping (without a parent), and include winding down activities like a bedtime story or a warm bath before bed. It is advisable to avoid heavy meals late in the evening which may impact on sleep patterns.

Last of all, there is a relationship between sleep disorders and psychiatric and medical disorders. For example a child suffering from depression may also suffer from sleep disturbance, however sleep issues can also aggravate depressive symptoms.

Therefore please consult a medical specialist if you have any concerns about your child and their sleeping patterns.