Assessment and Management of Sleep Disorders in Children

Sponsored by CME LLC for 1.5 Category 1 credits.
Original release date 10/06. Approved for CME credit through September 2007.

Educational Objectives

After reading this article, you will be familiar with:

• The phenomenology of sleep disorders in children and adolescents

• Diagnostic studies in the evaluation of pediatric sleep disorders

• Treatments for pediatric sleep disorders

Who will benefit from reading this article?

Psychiatrists, pediatricians, primary care physicians, neurologists, nurse practitioners, psychiatric nurses, and other mental health care professionals. Continuing medical education credit is available for most specialties. To determine whether this article meets the CE requirements for your specialty, please contact your state licensing board.

Dr Ivanenko is a board certified specialist in psychiatry, child and adolescent psychiatry, and sleep medicine. She is an assistant professor of psychiatry and behavioral neurosciences at the Loyola University Stritch School of Medicine in Maywood, Ill; in addition, she is director of pediatric sleep medicine of the Chicago Sleep Group at the Sleep Disorders Center at Alexian Brothers Medical Center in Elk Grove Village, Ill, and the Sleep Center at Central DuPage Hospital in Winfield, Ill.

Dr Massie is a licensed psychologist and is board certified in sleep medicine and behavioral sleep medicine. He is clinical director of the Chicago Sleep Group at the Sleep Disorders Center at Alexian Brothers Medical Center in Elk Grove Village, Ill, and the Sleep Center at Central DuPage Hospital in Winfield, Ill.

The authors report that they have no conflicts of interest regarding the subject matter of this article.

Sleep disorders are highly prevalent across the life spans of many persons. Epidemiologic studies comprising infants, children, and adolescents indicate a high rate of reported sleep problems. Most of these studies refer to problematic or disrupted sleep with frequent nocturnal awakenings, delayed sleep onset, and restless sleep; the studies also include behaviors associated with sleep, such as sleepwalking, sleeptalking, snoring, witnessed apneas with gasping for air, excessive daytime sleep, and daytime sleepiness. Many of the studies used parental reports or self-reports but some studies used more objective measurements, including actigraphy or polysomnography (PSG).^1-3

About 25% of children experience some type of sleep-related problem during their development. A recent large study of children in a community sample found sleep problems in 20% of children aged 5 years and in 6% of those aged 11 years.¹ Other studies of school-aged children showed the prevalence of sleep problems to be as high as 37% and 50%.^2,3 The high rates of sleep complaints that have been reported by adolescents include problems with sleep initiation, maintenance, and excessive sleepiness due to chronic sleep loss. Recent survey data from a random sample of 1014 adolescents revealed a 10.7% lifetime prevalence of insomnia with a median age of onset at 11 years; 52.8% of those with insomnia also had another psychiatric disorder.⁴

More frequent sleep problems were seen in children with chronic medical, neurodevelopmental, or psychiatric disorders. Sleep problems were reported in 30% to 80% of children with mental retardation and in 50% to 70% of children with pervasive developmental disorder and autism.^5,6 Up to 75% of children with psychiatric disorders such as major depression, anxiety disorders, attention-deficit/ hyperactivity disorder (ADHD), or posttraumatic stress disorder have reported symptoms of insomnia, bedtime resistance, bedtime refusal, nocturnal fears, and nightmares.⁷

PHENOMENOLOGY OF SLEEP DISORDERS

Sleep disorders are very common and are often underrecognized and underreported in children. If left untreated, these disorders can cause serious developmental and physiologic problems.

Behavioral sleep disorders

Behavioral sleep disorders are most commonly observed in infants, toddlers, and preschoolers. The International Classification of Diseases, 9th revision, Clinical Modification⁸ defines 2 subtypes of pediatric behavioral insomnia: (1) limit-setting, and (2) sleep-onset association. Limit-setting sleep disorder refers to parental difficulties in establishing behavioral limits and enforcing bedtimes, which commonly result in stalling by the child and refusal to go to bed. Nocturnal wakings are typically related to inappropriate sleep-onset associations such as rocking, feeding, and parental presence. Once children wake up at night they are unable to go back to sleep without recreating the same sleep association. Behavioral insomnia results in delayed sleep onset, fragmented nocturnal sleep, insufficient sleep, and daytime sleepiness.

Parasomnias

Parasomnias are much more frequently seen in the pediatric population and usually represent the normal neurophysiology of sleep development. These phenomena are partial CNS arousals that are characterized by autonomic and motor activity. They almost always occur in slow-wave sleep and may include sleepwalking, sleeptalking, night terrors, confusional arousals, and nocturnal enuresis. Para- somnias are strongly associated with genetics and usually present in many family members. They appear around the second year of life and continue in preschool-aged or school-aged children. Most parasomnias resolve by adolescence. Although they represent a rather benign developmental condition, they can be associated with severe sleep disruption and may cause significant family distress. Parasomnias are much more prevalent in children with psychiatric or neurologic disorders and can be exacerbated or induced by psychopharmacologic agents.

Circadian rhythm disorders

Circadian rhythm disorders are disruptions of the internal body rhythms that regulate the sleep-wake cycle. Delayed sleep-phase syndrome is normally associated with changes in the regulation of sleep homeostasis and the circadian clock seen during the pubertal stage of development and results in the delay of sleep phase in relation to dark and light cycles. Because of the necessity of rising early on school days, adolescents with delayed sleep-phase syndrome may become significantly sleep deprived and present with excessive daytime sleepiness that results in academic decline, mood problems, and attentional deficits.

Sleep apnea

Sleep apnea is defined as episodes of complete or partial cessation of the airflow during a respiratory cycle, and it is associated with oxygen desaturations or arousals. Breathing-related sleep disorder in children has been associated with daytime somnolence and symptoms of inattentiveness and hyperactivity.⁹ Obstructive sleep apnea (OSA) has been estimated to affect about 2% of children in the general population¹⁰ with much higher rates found in children with neuromuscular and craniofacial problems; in children with genetic syndromes, the prevalence may be as high as 85%.¹¹ Because OSA in children may increase the risk for serious neurocognitive impairment, it is imperative to recognize and treat this syndrome early to prevent negative consequences.

Narcolepsy

Narcolepsy is a rare chronic neurologic disorder that presents with daytime sleepiness, cataplexy (sudden loss of muscle tone triggered by emotional arousal such as laughter), hypnagogic hallucinations, and sleep paralysis. The prevalence in adults is about 2 to 5 cases per 10,000, and in children it is presumably half that. In children, the classic presentation of narcolepsy with all of the above symptoms is rare. Many pediatric patients present with excessive daytime sleepiness that is often masked by behavioral and emotional symptoms, such as irritability, hyperactivity, inattentiveness, and, in younger children, an increased need for sleep.

Restless legs syndrome and periodic limb movement disorder

Restless legs syndrome (RLS) is a common sensorimotor disorder defined as an urge to move the legs, which is often accompanied by uncomfortable and unpleasant sensations in the legs. Periodic limb movement disorder (PLMD) is characterized by episodes of repetitive stereotypical limb movements. Insomnia or excessive sleepiness is required to establish a diagnosis of PLMD. Several studies have documented the occurrence of RLS and PLMD in children and adolescents.^12-15 Similar to adults, children with RLS manifest their symptoms by moving their legs, fidgeting, running, walking, and stretching; however, because they frequently report symptoms of RLS differently from adults, diagnosing RLS in children is more challenging. As RLS and PLMD have been more extensively studied, the association between these disorders and ADHD in children has become evident: many children with ADHD were found to have RLS/PLMD and vice versa.¹⁶

DIAGNOSTIC TOOLS

Because of the high prevalence of sleep disorders in children, taking a sleep history is the first and most important step in assessing pediatric patients. The best time to do this would be during the child's routine yearly examination or when the parents bring the child for evaluation because of sleep-related complaints or behavioral/emotional problems. A sleep history along with a neurodevelopmental and psychiatric history, in conjunction with a physical examination, are the essential parts of a comprehensive sleep assessment. BEARS (bedtime, excessive daytime sleepiness, awakenings, regularity, and snoring) is an easy-to-remember mnemonic that can be used to help gather the history of symptoms.¹⁷

Several validated questionnaires have been developed to screen for the most common sleep problems in children and adolescents. Chervin and colleagues¹⁸ validated their pediatric sleep questionnaire for evaluation of sleep-disordered breathing, daytime sleepiness, snoring, and behavioral problems (hyperactivity, impulsivity, and inattentiveness) in children aged 2 to 18 years. The Children's Sleep Habits Questionnaire developed by Owens and colleagues³ consists of 8 subscales that reflect the major domains of behavioral and medical sleep disorders and a total score indicating the extent and severity of sleep-related problems. The Sleep Disorders Inventory for Students, introduced more recently, is a validated parent-report screening for children aged 2 through 10 years and for adolescents aged 11 through 18 years.¹⁹

Sleep diaries can provide information on the child's bedtime, sleep onset time, rise time, and number of nocturnal awakenings and are typically kept for a period of 2 weeks. Sleep diaries are usually filled out by parents or caregivers for younger children; adolescents can fill out their own sleep diaries. Because they are based on observations, the diaries lack objective measurements of sleep.

Actigraphy is an activity-based sleep-wakefulness monitoring method that provides continuous objective data of patients' sleep with night-to-night variability. It can detect nocturnal awakenings and unreported circadian sleep disturbances. Actigraphy uses a small device worn on the wrist that counts movements per minute and translates "activity count" into sleep-wakefulness measurements using a specially designed algorithm.

Nocturnal PSG is the objective gold-standard procedure to study sleep. PSG involves recordings of electroencephalogram, electro-oculogram, electromyogram, airflow, respiratory and abdominal efforts, oxygen saturation, end tidal CO₂ level, and limb muscle activity. It requires that the child spend a night in the sleep laboratory, usually accompanied by a parent. Ambulatory home-based studies have also been conducted in children; however, because of the technical challenges associated with home-based monitoring, it is not routinely used for clinical purposes. PSG is indicated for the diagnosis of sleep-disordered breathing in children. With PSG, the presence and degree of OSA, central apnea, alveolar hypoventilation, snoring, and upper airway resistance syndrome in children can be assessed. PSG is also used to establish the diagnosis of PLMD and to evaluate the possible presence of nocturnal seizures.

The Multiple Sleep Latency Test (MSLT) uses a series of 4 or 5 naps conducted at 2-hour intervals that begin 2 hours after the final morning awakening following nocturnal PSG. The MSLT is used to assess daytime sleepiness. It helps establish a diagnosis of narcolepsy and to objectively quantify sleepiness that is either associated with OSA or idiopathic hypersomnia or is due to chronic sleep loss.

The Maintenance of Wakefulness Test (MWT) is similar to the MSLT but the patient is asked to remain awake while sleep latency is measured. The MWT is rarely used in the pediatric population since it has not been validated in children.

The Epworth Sleepiness Scale provides a means for assessing sleepiness and has been modified recently for use in children and adolescents²⁰; it is a helpful instrument for screening subjective propensity to fall asleep in certain situations and measuring treatment outcome.

TREATING PEDIATRIC SLEEP DISORDERS

Sleep disorders in children manifest in a variety of ways and have different treatment options. An overview of the disorders and their treatment is presented in the Table.

Insomnia

Nonpharmacologic interventions are the first line of therapy for children with sleep disorders. Behavioral interventions include education of parents, sleep hygiene education, extinction, graduated extinction, scheduled awakenings, and positive bedtime routines.^21,22 The management of insomnia in children should include education about normal sleep development, the establishment of appropriate and realistic expectations for the parents and child, and clear treatment goals. School schedule and extracurricular activities should be taken into consideration when establishing the treatment protocol.

It is very important to set and consistently reinforce fixed bedtimes and rise times. Bedtime should be age appropriate with an established routine that provides behavioral cues for transition to sleep. Morning rise time is especially important as a powerful environmental cue for reinforcement of the sleep-wake cycle. Avoidance of excessive fluids at bedtime and caffeinated beverages helps with sleep onset and reduces the likelihood of nocturnal awakenings. The sleeping environment should be controlled to exclude such things as television, video games, and access to a computer. Children should be encouraged to sleep in their own bed on a consistent basis. Establishment of appropriate nap time is very important, since it will affect nocturnal sleep onset and sleep duration time. Long and frequent daytime naps result in a shorter nocturnal sleep period, delayed sleep onset, and nocturnal awakenings.

There are no well-designed controlled studies of sedative/hypnotic use in children and there are no FDA-approved pharmacologic agents for use in pediatric insomnia. Diphenhydramine hydrochloride is the most commonly used agent in children for sleep initiation problems. Dose ranges are 12.5 to 25 mg at bedtime for children aged 2 to 6 years, and 25 to 50 mg or more for children aged 6 to 12 years and older.²³ The use of tricyclic antidepressants for insomnia in children is diminishing in popularity, and there are no established dose recommendations for hypnotics in children. One report suggested that trazodone was associated with a reduction of sleep onset insomnia in children after administration of 25 to 50 mg at bedtime.²⁴ However, there are no systematic data available on the safety and tolerability of trazodone in children with insomnia. Benzodiazepine hypnotics are rarely used in children with the exception of clonazepam, 0.25 to 0.5 mg, which is the drug of choice for treating those with parasomnias.²⁵

The use of melatonin in children may be effective for sleep initiation insomnia caused by circadian factors.^26,27 A double-blind placebo-controlled trial by Smits and colleagues²⁸ in healthy elementary-school children showed that 5 mg of melatonin administered at bedtime reduced sleep-onset latency and increased total sleep time. Melatonin dose recommendations for children of different ages are lacking, as are data on the long-term efficacy and safety in pediatric populations. The recently published Consensus Statement by Mindell and colleagues²⁹ provides a useful summary of the current status of knowledge on pharmacologic treatment of pediatric insomnia.

Parasomnias

Parasomnias include sleepwalking, sleeptalking, nightmares, night terrors, and REM sleep-behavior disorder. There are no methodologically rigorous, blinded, and controlled studies of parasomnias in children. The behavioral abnormalities in this disorder can be triggered by factors that disrupt sleep. Therefore, strict adherence to sleep hygiene is obligatory. Children should avoid sleep deprivation, stressful situations, and caffeine close to bedtime.

Sleepwalking is the most common parasomnia in children. In cases in which self-injury is unlikely and in which parental distress is minimal, education and reassurance of parents should be provided with the emphasis on preventing injury and helping the child return to bed. Removing potentially dangerous objects close to the bedside and on bedside tables, keeping knives and firearms out of the reach of the child, and locking bedroom doors and windows are among the safety precautions that par-ents can take to maximize the safety of the child. For more severe forms of the disorder in which self-injury is imminent, and when behavioral measures have failed, medications such as clonazepam (0.01 mg/kg; usual starting dosage 0.25 mg qhs), diazepam (0.04 to 0.25 mg/kg), and lorazepam (0.05 mg/kg) can be considered.²⁵

RLS and PLMD

Behavioral interventions for RLS and PLMD include maintenance of a stable sleep-wake schedule; avoiding sleep deprivation; reducing caffeine intake; and eliminating tobacco, alcohol, and stimulating activities close to bedtime. Medical interventions include iron supplementation and pharmacologic treatment. Iron therapy is usually recommended if the child's serum ferritin level is below 35 µg/L. Serum ferritin levels should be monitored every 3 to 4 months and iron therapy should be discontinued when the serum ferritin level rises above 35 to 50 µg/L. Iron supplementation reduces the number of periodic limb movements and improves daytime functioning in children with symptomatic PLMD.³⁰

Dopaminergic medications such as pramipexole and ropinirole are used in adults with RLS, and evidence suggests that these drugs are effective in children as well.¹⁴ Ropinirole is FDA-approved for RLS treatment in adults but not in children. The lowest available dose of ropinirole is 0.25 mg and the maximum recommended adult dosage for RLS is 4.0 mg per day.³¹ Gabapentin is another pharmacologic agent that may be effective in reducing symptoms of RLS in children. While there are no clinical trials to determine the effectiveness of gabapentin for RLS, pediatric epilepsy trials have demonstrated the safety and tolerability of gabapentin.³²

Narcolepsy

Treatment options for narcolepsy include pharmacotherapy and behavioral intervention. Children and adolescents with narcolepsy should adhere to good sleep habits. Specifically, children with narcolepsy should obtain adequate nocturnal sleep and maintain a consistent sleep-wake schedule, since alterations to sleep patterns can exacerbate daytime sleepiness. Patients should avoid alcohol and recreational substances, and adolescents need to be cautioned about the perils of driving or operating machinery when sleepy. Planned daytime naps are quite beneficial. Counseling and support groups are helpful for both the patient and the family.

Long-term administration of pharmacologic agents may be required to reduce sleepiness and improve daytime alertness. Longer-acting stimulants, such as modafinil, administered in the morning can provide all-day benefits. Stimulants with a short duration of action, such as methylphenidate, can be used alone or in combination with modafinil. There are no double-blind placebo-controlled studies in children with narcolepsy.

In a small sample of children, 200 mg to 600 mg of modafinil daily reduced daytime sleepiness without significant side effects.³³ Because of its favorable side-effect profile, this medication may be considered as initial medication for the treatment of excessive daytime sleepiness in children with narcolepsy.³⁴ Methylphenidate and dextroamphetamine have been used successfully in treating excessive sleepiness in children with narcolepsy and are well tolerated. Tricyclic antidepressants and SSRIs may be used to treat cataplexy and other symptoms of narcolepsy, such as sleep paralysis and hypnagogic hallucinations.

Snoring and OSA

Snoring and OSA in children are often the result of adenotonsillar hypertrophy, obesity, sinus problems, or craniofacial abnormalities.³⁵ Adenotonsillectomy is often the first treatment.³⁶ PSG is recommended before surgery to assess the severity and nature of the sleep-disordered breathing and should be performed postoperatively to assess treatment efficacy.³⁶ Postsurgical PSG has shown that surgery is curative in about 80% of cases.³⁷ Additionally, children with sinus problems may benefit from inhaled nasal corticosteroids.³⁸

Continuous positive airway pressure (CPAP) is appropriate for children who have either failed to respond to surgical intervention or are not candidates for surgery.

³⁶

Its efficacy and tolerability has been reported in a number of studies.

^39,40

The use of CPAP was recently approved by the FDA for children aged 7 years and older who weigh more than 40 pounds. An attended laboratory titration of CPAP should be performed to determine effective treatment. Supplemental oxygen is not recommended for routine use in children with OSA because of the risks of developing hypoventilation.

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