Discover insights into children's sleep disorders on Meri Sehat. Learn to recognize signs and explore effective solutions for better sleep.

Sleep Disorders In Children

A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

Overview

<a href="https://merisehat.pk/article/are-you-sleeping-on-your-sleep-cycle">Sleep</a> disorders in children occur when children and adolescents have trouble falling asleep or staying asleep at night. 
&nbsp;

According to the American Psychiatric Association, sleep disorders or sleep-wake disorders are conditions that affect:

<ul>
	<li>The sleep timing </li>
	<li>The quality of sleep</li>
	<li>The duration of sleep </li>
</ul>

The duration of sleep is determined by age and varies from person to person. Younger kids have the longest sleep duration, and as they grow, they require less sleep. Lack of sleep can lead to a drop in performance at multiple levels, including social relationships, learning, and extracurricular activities.

According to a study, around 50% of kids experience some form of sleep disorder, with nightmares being the most common type of sleep disorder, followed by <a href="merisehat.pk/disease/sleepwalking">sleepwalking</a><a href="#accordion">[1]</a>. Even though sleep is frequently discussed during pediatric visits, nearly 4% of these children are formally diagnosed with a sleep disorder. 
&nbsp;

Some facts about the prevalence of sleep disorders in children<a href="#accordion">[2][5]</a>:

<ul>
	<li>Insomnia &ndash; One of the most common sleep disorders and affects 20-30% of children.</li>
	<li>Behavioral Insomnia &ndash; Mostly occurs in children up to 5 years old, is considered only when symptoms occur persistently and frequently and also interfere with their normal functioning.</li>
	<li>Obstructive Sleep Apnea &ndash; Occurs in 1-5% of children, with onset usually between 2 and 8 years of age, co-occurring with peak tonsil growth. Also, it&rsquo;s more common among ethnic minorities. A major reason why diagnosis is complicated is that around 17% of the affected individuals are habitual snorers. </li>
	<li>Central Apnea &ndash; Fairly common in premature infants as their respiratory center is not fully developed<a href="#accordion">[3]</a>.</li>
	<li>Parasomnias - Common in childhood, affecting nearly 50% of children. Sleep talking, sleepwalking, sleep terrors, and confusional arousals occur during the first half of the night, while nightmares are more common during the second half of the night[4]. Parasomnias often have overlapping nocturnal seizures.</li>
</ul>

Nearly 5% of children present with signs of sleepwalking, which is significant compared to only 1.5% of adults. Similarly, nearly 15% of children aged 7 years complain of bedwetting, compared to 0.5-1% of adults<a href="#accordion">[2]</a>. 
&nbsp;

The onset of nightmares is usually between 3 and 6 years of age, but they&rsquo;re mostly prevalent and more severe in nature during late adolescence and early adulthood.

<ul>
	<li>Restless Leg Syndrome &ndash; It begins in the tweens or twenties, affecting 2-7.2% of the population. Children with ADHD often have this condition.</li>
	<li>Hypersomnolence &ndash; It is diagnosed in 5-10% of individuals visiting sleep disorder clinics. It commonly presents in the late teens or early 20s.</li>
	<li>Narcolepsy &ndash; The condition may present in childhood, adolescence, or young adulthood, with episodes occurring at least 3 times a week for at least 3 months. The condition is rare and affects around 0.02-0.04% of the general population.</li>
	<li>Circadian Rhythm Sleep-Wake Disorders &ndash; More than 7% of adolescents experience delayed sleep phase type, which means they stay up late and get up late. </li>
	<li>Behavioral Insomnia &ndash; It is fairly common in childhood, with an estimated prevalence of 10-30% of behavioral insomnia<a href="#accordion">[1</a><a href="#">]</a>.</li>
	<li>Bruxism &ndash; It is common in young children, with nearly 10% of cases being reported among the youth<a href="#accordion">[6]</a>. It may be associated with some mental and medical disorders, including ADHD, night terrors, and sleep apnea.</li>
</ul>

&nbsp;

Sign and Symptoms

According to the American Academy of Sleep Medicine (AASM), the recommended sleep duration for each age group for optimal health, daytime functioning, and development is<a href="#accordion">[7]</a>:

<ul>
	<li>Infants (4-12 months) &ndash; 12-16 hours, including naps</li>
	<li>Toddlers (1-2 years) &ndash; 11-14 hours, including naps</li>
	<li>Children (3-5 years) &ndash; 10-13 hours, including naps</li>
	<li>Children (6-12 years) &ndash; 9-12 hours</li>
	<li>Teens (13-18 years) &ndash; 8-10 hours 
	&nbsp;</li>
</ul>

Generally, a child with sleep disorders will complain of:

<ul>
	<li>Trouble sleeping regularly</li>
	<li>Daytime sleepiness or feeling tired during the day despite sleeping for at least 7 hours the night before</li>
	<li>Difficulty performing routine daytime activities (e.g., poor problem-solving skills, poor concentration, and poor memory)</li>
	<li>Mood shifts and trouble controlling emotions</li>
	<li>Weak immune system and overall poor health 
	&nbsp;</li>
</ul>

This can translate into:

<ul>
	<li>Calls for another book, drink, or numerous trips to the loo for a long time during the night</li>
	<li>Sleeping for only 90 minutes at a time, even during the night</li>
	<li>Loud snores</li>
	<li>Itchy legs at night</li>
	<li>Moody, irritable, or overly emotional during the day</li>
	<li>Disruptive behavior during the day</li>
	<li>Not performing at their usual level at school</li>
	<li>Often, they &ldquo;crash&rdquo; earlier than supposed regular bedtime</li>
	<li>Trouble waking up for the day</li>
	<li>Space out during conversations</li>
	<li>Falling asleep during car rides 
	&nbsp;</li>
</ul>

<ol>
	<li>
	<h5>Insomnia In Children </h5>
	</li>
</ol>

Can be categorized into:

<ul>
	<li>Episodic &ndash; An episode lasts 1-3 months</li>
	<li>Persistent &ndash; Symptoms occur for at least 3 months </li>
	<li>Recurrent &ndash; 2 or more episodes in a year&nbsp;</li>
	<li>Behavioral insomnia, including sleep-onset association and limit-setting </li>
	<li>Conditioned insomnia </li>
	<li>Transient sleep disturbance 
	&nbsp;</li>
</ul>

<ol start="2">
	<li>
	<h5>Night Terrors (Sleep Terrors) In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Episodes of flailing, kicking covers off
	</li>
	<li>Abruptly waking from sleep, usually while screaming in distress</li>
	<li>Intense fear during sleep and associated physical signs (e.g., sweating, rapid breathing, and accelerated heart rate)</li>
	<li>Doesn&rsquo;t remember much of the dream</li>
	<li>Sweating upright in bed</li>
	<li>Sleepwalking 
	&nbsp;</li>
</ul>

<ol start="3">
	<li>
	<h5>Sleepwalking (Somnambulism) In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Open eyes, but with a glassy appearance
	</li>
	<li>Blank, staring face and generally unresponsive to others</li>
	<li>Getting out and moving around the house</li>
	<li>Sitting up in bed</li>
	<li>Talking</li>
	<li>Repetitive movements, like rubbing eyes or fumbling with clothing 
	&nbsp;</li>
</ul>

<ol start="4">
	<li>
	<h5>Confusional Arousals In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Confusion
	</li>
	<li>Automatic behaviors that appear purposeful but lack meaningful interaction with the environment</li>
	<li>Amnesia</li>
	<li>Difficulty awakening</li>
	<li>Rapid return to full sleep after the event 
	&nbsp;</li>
</ul>

<ol start="5">
	<li>
	<h5>Nightmares In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Frightened by lengthy, distressing, and well-remembered dreams, usually involving efforts to avoid danger 
	&nbsp;
	</li>
</ul>

<ol start="6">
	<li>
	<h5>Bedwetting In Children </h5>
	</li>
</ol>

<ul>
	<li>
	Struggle with bladder control at night
	</li>
</ul>

Note: It&rsquo;s considered a sleep disorder if the child is older than 5 years and has episodes at least twice a week. Bedwetting at 7 years of age or older can be a sign of sexual abuse. Consult a doctor if bedwetting is accompanied by:

<ul>
	<li>Cloudy or pink bloodstains </li>
	<li>Pain or burning sensation while urinating</li>
	<li>Swelling of ankles or feet</li>
	<li>Wetting the pants during the day 
	&nbsp;</li>
</ul>

<ol start="7">
	<li>
	<h5>Restless Leg Syndrome In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Creepy-crawly, burning, or tingly sensation in legs when trying to sleep
	</li>
	<li>Asking to massage or rub legs to help fall asleep</li>
	<li>Frequently awaken the individual from sleep</li>
</ul>

Note: Symptoms of restless legs syndrome partially or completely improve with stretching or walking. The urge to move the legs begins or worsens during periods of inactivity or rest. It either occurs only in the evening or at night, or it becomes worse in the evening or at night compared to during the day. 
&nbsp;

<ol start="8">
	<li>
	<h5>Sleep Apnea (Obstructive And Central) In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Nightly snoring that may be followed by long, silent pauses
	</li>
	<li>Repeated episodes of airway obstruction during sleep causing snorting/gasping, snoring, or breathing pauses</li>
	<li>Open-mouth breathing</li>
	<li>Restless or fragmented sleep</li>
	<li>Sweating during sleep</li>
	<li>Unusual sleep positions, like hyperextended neck </li>
	<li>Morning headaches</li>
	<li>Depressed mood</li>
	<li>Decreased attention</li>
	<li>Poor concentration</li>
	<li>Behavioral issues</li>
	<li>Nighttime bedwetting 
	&nbsp;</li>
</ul>

<ol start="9">
	<li>
	<h5>Non-Rapid Eye Movement (NREM) Sleep Arousal Disorders In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Episodes of incomplete awakening from sleep, usually during the first third of a major sleep episode
	</li>
	<li>Accompanied by sleep terrors or sleepwalking (repeatedly rising from bed and walking around during sleep) 
	&nbsp;</li>
</ul>

<ol start="10">
	<li>
	<h5>Hypersomnolence Disorder In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Sleep inertia or difficulty being fully awake after waking up abruptly
	</li>
	<li>Recurring periods of sleep within the same day, like unintentional naps during lectures</li>
	<li>Sleeping for more than 9 hours a day and not feeling rested</li>
</ul>

Note: Episodes of extreme sleepiness happen at least 3 times a week for at least 3 months 
&nbsp;

<ol start="11">
	<li>
	<h5>Narcolepsy</h5>
	</li>
</ol>

<ul>
	<li>
	Poor sleep
	</li>
	<li>
	Periods of irrepressible need to sleep 
	</li>
	<li>Cataplexy or brief and sudden loss of muscle tone 
	&nbsp;</li>
</ul>

<ol start="12">
	<li>
	<h5>Circadian Rhythm Sleep-Wake Disorders</h5>
	</li>
</ol>

<ul>
	<li>
	Extreme sleepiness during the day 
	</li>
	<li>Habitual sleep-wake times are delayed by at least 2 hours compared to socially-acceptable times 
	&nbsp;</li>
</ul>

<ol start="13">
	<li>
	<h5>Sleep Bruxism</h5>
	</li>
</ol>

<ul>
	<li>
	Clenching or grinding teeth during sleep, loud enough to wake up sleep partner
	</li>
	<li>Sleep disruption 
	&nbsp;</li>
</ul>

Causes

These can be categorized according to the type of sleep disorder in children:

<ol>
	<li>
	<h5>Insomnia</h5>
	</li>
</ol>

<ul>
	<li>
	Unhealthy daytime habits, like eating too much sugary food
	</li>
	<li>
	Poor sleep routines, like watching TV right before bed or drinking energy drinks that contain caffeine 
	</li>
	<li>
	Stress triggered by issues at home or at school (e.g., bullying, the arrival of a new baby, change in sleeping arrangements that require them to share their bedroom)
	</li>
	<li>
	Side effects of medications like antidepressants or drugs to treat ADHD
	</li>
	<li>
	Medical issues, including another sleep disorder (e.g., sleep apnea), allergic reactions (e.g., stuffy nose)
	</li>
	<li>
	Spending too much time in bed
	</li>
	<li>
	Absence of certain conditions, like being rocked to sleep, leading to unwillingness or inability to fall asleep or return to sleep 
	</li>
	<li>Failure on the part of parents to set appropriate limits</li>
</ul>

&nbsp;

<ol start="2">
	<li>
	<h5>Bedtime Fears</h5>
	</li>
</ol>

<ul>
	<li>
	Fear of the dark or fear of going to bed because they can&rsquo;t separate what&rsquo;s imaginary from what&rsquo;s real; e.g., monsters under the bed 
	</li>
	<li>Any issue that the child is facing during the day can manifest as disturbing dreams at night</li>
</ul>

&nbsp;

<ol start="3">
	<li>
	<h5>Parasomnias</h5>
	</li>
</ol>

<ul>
	<li>
	Certain medications or illnesses (e.g., GERD, periodic limb movement disorder, etc.)
	</li>
	<li>
	Lack of sleep or irregular sleep schedule
	</li>
	<li>Changes in the sleep environment</li>
</ul>

&nbsp;

<ol start="4">
	<li>
	<h5>Bedwetting </h5>
	</li>
</ol>

<ul>
	<li>
	Bladder not fully developed to hold urine for the night or increased urine production at night
	</li>
	<li>
	Communication between the bladder and brain is not fully established
	</li>
	<li>
	Changes at home
	</li>
	<li>
	Deep sleeper and can&rsquo;t feel a full bladder while asleep
	</li>
	<li>Constipation </li>
</ul>

&nbsp;

<ol start="5">
	<li>
	<h5>Obstructive Sleep Apnea In Children</h5>
	</li>
</ol>

<ul>
	<li>
	Obstructed airway due to enlarged tonsils and adenoids
	</li>
	<li>
	Obesity 
	</li>
	<li>Craniofacial abnormalities or decreased muscle tone, as seen in Down Syndrome</li>
</ul>

&nbsp;

<ol start="6">
	<li>
	<h5>Restless Leg Syndrome</h5>
	</li>
</ol>

<ul>
	<li>
	Genetics
	</li>
	<li>
	Dopamine dysfunction
	</li>
	<li>
	Iron deficiency 
	</li>
	<li>
	Inadequate or excessive physical activity
	</li>
	<li>Use of nicotine, caffeine, selective serotonin reuptake inhibitors, antihistamines, or tricyclic antidepressants 
	&nbsp;</li>
</ul>

<ol start="7">
	<li>
	<h5>Coexisting Conditions</h5>
	</li>
</ol>

<ul>
	<li>
	Depression and anxiety
	</li>
	<li>
	Chronic health problems, including diabetes and heart disease
	</li>
	<li>Neurological or medical issues, such as Parkinson&rsquo;s disease, osteoarthritis, and congestive heart failure</li>
</ul>

&nbsp;

<ol start="8">
	<li>
	<h5>Narcolepsy</h5>
	</li>
</ol>

<ul>
	<li>
	Strong emotional trigger, like laughing or crying
	</li>
</ul>

&nbsp;

<ol start="9">
	<li>
	<h5>Circadian Rhythm Sleep-Wake Disorders</h5>
	</li>
</ol>

<ul>
	<li>
	Internal factors, like a person&rsquo;s body clock being different from the light-dark cycle
	</li>
	<li>External factors, like jet lag or shift work 
	&nbsp;</li>
</ul>

While sleep disorders are extremely common in young children, they occur more frequently in neurodivergent children, including those with ADHD and autism.

They may present with sleep issues, including insomnia, sleep terrors, sleep paralysis, sleepwalking, narcolepsy, sleep apnea, restless leg syndrome, a flattened melatonin curve, and circadian rhythm sleep disorders.

Causes of disrupted sleep in these children include:

<ul>
	<li>Lack of understanding about night and day</li>
	<li>Food sensitivities or allergies</li>
	<li>Lack of routine</li>
	<li>Hunger</li>
	<li>Less production of melatonin</li>
	<li>Overstimulating room (e.g., noise and light) that may be both distressing and distracting 
	&nbsp;</li>
</ul>

Diagnosis

It&#39;s important to note that children&#39;s sleep patterns can vary widely based on their age, developmental stage, and individual needs. Some sleep disturbances are normal during certain developmental phases. However, persistent and severe sleep problems that impact a child&#39;s daily functioning should be evaluated by a healthcare professional.

Screening and diagnosing sleep disorders in children ensures their overall health, well-being, and proper development. 
&nbsp;

<ul>
	<li>
	<h5>Initial Assessment</h5>
	</li>
</ul>

A healthcare provider, such as a pediatrician or family doctor, conducts an initial assessment by gathering information about the child&#39;s sleep patterns, habits, and any specific concerns raised by the parents or caregivers. This assessment helps determine if further evaluation is necessary.

<ul>
	<li>
	<h5>Medical History</h5>
	</li>
</ul>

The healthcare provider will ask questions about the child&#39;s medical history, including any pre-existing medical conditions, medications, and family history of sleep disorders. Certain medical conditions can contribute to sleep problems, so it&#39;s important to identify any underlying factors.

<ul>
	<li>
	<h5>Questionnaires</h5>
	</li>
</ul>

There are various validated questionnaires designed to assess children&#39;s sleep habits and potential sleep disorders. These questionnaires can provide valuable insights into the child&#39;s sleep quality, duration, and any associated symptoms.

<ul>
	<li>
	<h5>Polysomnography (Sleep Study)</h5>
	</li>
</ul>

If the initial assessment and history suggest a potential sleep disorder, the healthcare provider may recommend polysomnography. This is a comprehensive sleep study conducted in a sleep center or hospital.

It involves monitoring the child&#39;s brain activity, heart rate, eye movements, muscle activity, and other physiological parameters during sleep. Polysomnography can diagnose disorders like sleep apnea, restless legs syndrome, etc.

<ul>
	<li>
	<h5>Actigraphy</h5>
	</li>
</ul>

Actigraphy involves using a small device worn on the child&#39;s wrist to monitor movement and activity patterns. It can provide objective data on the child&#39;s sleep-wake patterns over an extended period and is particularly useful for assessing circadian rhythm disorders. 
&nbsp;

<ul>
</ul>

Treatment

Treatment may involve lifestyle changes, behavioral interventions, medication (if necessary and recommended by a specialist), and addressing any underlying medical conditions.

<ul>
	<li>Lifestyle changes, such as regular exercise, avoiding caffeine, and not using electronic devices before bedtime</li>
	<li>Cognitive-behavioral therapy (CBT), which involves addressing negative thoughts and behaviors associated with sleep</li>
	<li>Adenotonsillectomy, or removal of enlarged tonsils and adenoids, to improve airflow and reduce obstructive sleep apnea</li>
	<li>Continuous positive airway pressure (CPAP) therapy, which is basically a machine that delivers a steady stream of air to keep the airways open during sleep</li>
	<li>Addressing underlying iron deficiency, if present</li>
	<li>Medications, such as stimulants (e.g., modafinil) </li>
	<li>Ensuring a safe sleep environment to prevent injury during episodes 
	&nbsp;</li>
</ul>

Here are some potential complications associated with sleep disorders in children:

<ul>
	<li>Cognitive issues, including impaired memory and problem-solving skills</li>
	<li>Health issues like cardiovascular issues, obesity, and metabolic disturbances</li>
	<li>Social isolation and strained relationships</li>
	<li>Behavioral disorders, such as attention-deficit hyperactivity disorder (ADHD)</li>
	<li>Increased risk of accidents</li>
	<li>Developmental delays</li>
	<li>Impaired immune function</li>
</ul>

&nbsp;

These risk factors can vary depending on the specific type of sleep disorder and the child&#39;s individual circumstances.

<ul>
	<li>Age</li>
	<li>Genetics</li>
	<li>Underlying medical conditions like asthma, allergies, obesity, and neurological disorders</li>
	<li>Anxiety and depression</li>
	<li>Stress and trauma</li>
	<li>A disruptive sleep environment</li>
	<li>Lifestyle, including excessive screen time, caffeine and diet</li>
	<li>Certain medications, including stimulants and some antihistamines 
	&nbsp;</li>
</ul>

This includes:

<ul>
	<li>
	<h5>Sleep Diary</h5>
	</li>
</ul>

Parents or caregivers are often asked to maintain a sleep diary for a couple of weeks. This diary records the child&#39;s bedtime, wake-up time, nap duration, and any sleep disturbances. This information can help identify patterns and potential issues.

&nbsp;

<ul>
	<li>
	<h5>A Healthy Sleep Environment</h5>
	</li>
</ul>

<ol>
	<li>Maintain a comfortable room temperature and use a supportive mattress and pillows.</li>
	<li>Avoid electronic devices such as smartphones, tablets, and computers at least an hour before bedtime.</li>
	<li>Remove or reduce external noise.</li>
</ol>

&nbsp;

<ul>
	<li>
	<h5>Consistent Sleep Schedule</h5>
	</li>
</ul>

<ol>
	<li>Set a regular bedtime and wake-up time, even on weekends. Consistency helps regulate the body&#39;s internal clock and improve sleep quality.</li>
	<li>Exposure to bright light in the morning to help reset the biological clock.</li>
	<li>Avoid bright light in the evening to promote melatonin production.</li>
	<li>Scheduled daytime naps to manage excessive daytime sleepiness.</li>
	<li>Using positive reinforcement for following bedtime rules.</li>
</ol>

&nbsp;

<ul>
	<li>
	<h5>Creating A Relaxing Bedtime Routine</h5>
	</li>
</ul>

Develop calming pre-sleep rituals such as reading a book, taking a warm bath, or practicing gentle stretching exercises to manage stress or anxiety.

Avoid heavy meals close to bedtime. A light, balanced snack before bed can be helpful, but avoid large meals that could cause discomfort.

&nbsp;

<ul>
	<li>
	<h5>Encourage Physical Activity</h5>
	</li>
</ul>

Regular physical activity during the day can promote better sleep at night. However, avoid intense exercise close to bedtime, as it can be stimulating.

&nbsp;

<ul>
	<li>
	<h5>Set A Positive Sleep Example</h5>
	</li>
</ul>

Demonstrate healthy sleep habits as a parent or caregiver. Children often model their behavior after adults.

Also, as children get older, teach them about the importance of good sleep hygiene. Help them understand how sleep impacts their health, mood, and overall well-being. 
&nbsp;

According to the first long-term cohort study, children with insomnia are more likely to develop an insomnia disorder in early adulthood compared to children who do not have difficulty sleeping.

About 15% of them developed insomnia symptoms in the transition to adolescence and persisted with them into adulthood, while another 21% developed them in young adulthood.

These findings suggest that childhood insomnia symptoms require early intervention, and adolescence is a critical time to address chronic sleep issues<a href="#accordion">[8]</a>.&nbsp; 
&nbsp;

key points

<ul>
	<li>Sleep disorders are common in children, affecting a significant portion of the pediatric population.</li>
	<li>They can have significant effects on a child&#39;s physical, cognitive, and emotional well-being, leading to difficulties in concentration, memory, mood regulation, and overall cognitive development.</li>
	<li>There are several types of sleep disorders that can affect children, including insomnia, sleep apnea, nightmares, restless leg syndrome, and sleepwalking.</li>
	<li>There are several causes of sleep disorders in children, including genetics, environmental factors, medical conditions, medications, and even lifestyle habits such as excessive screen time before bed or irregular sleep schedules.</li>
	<li>An accurate diagnosis of a sleep disorder often involves a comprehensive assessment, including a detailed sleep history, a physical examination, and possibly sleep studies like polysomnography.</li>
	<li>Treatment strategies vary based on the specific sleep disorder and its underlying cause and may include behavioral interventions, surgical interventions, and medications.</li>
</ul>