Shaken Baby Syndrome

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Amniotic fluid problems

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Choosing a pre-school

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Newborn reflexes

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Mastitis

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Colic

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Antenatal Classes

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Strap-in-the-Future

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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Sleep problems and sleep disorders in children

What are sleep disorders in children?

Parents often report that their children have problems involving sleep. In order to understand these common childhood sleeping problems and sometimes more serious sleep disorders, one needs to bear in mind that there are wide variations in what is normal sleep for children (see our article on normal sleeping patterns in children). At all ages, there are considerable individual variations in a child’s sleeping patterns. Patterns of sleep also change with development. For example, the average newborn sleeps for 16 hours per day, with their sleep being equally distributed between day and night; while the typical 10 year old, sleeps for approximately 8 hours primarily at night.  The sequencing, or the patterns in which the various stages of sleep occur (REM/NREM), also change in accordance with the different developmental levels. To illustrate, during the first year of life active REM sleep decreases from about 8 hours to about half this amount.

During the first year of life, parents most frequently complain that their child does not sleep through the night. The second year, seems to be characterized by a reluctance to go to sleep and nightmares. 3-5 year olds, present with a variety of problems including; difficulty in initiating sleep, nighttime awakenings, and nightmares. Even adolescents, complain of insomnia and not getting enough sleep.

What are the most common sleep disorders in children?

Sleep disorders are generally classified into 2 main categories: dyssomnias, or difficulties in initiating and maintaining sleep or of excessive sleepiness; and parasomnias, or disorders of arousal, partial arousal, or sleep-stage transitions.

Parasomnias

Parasomnias refer to a wide variety of behaviours that occur during arousals from REM sleep or partial arousals from NREM sleep. They are generally infrequent and mild, but if they occur often enough or are severe enough, they may warrant medical attention. Parasomnias include nightmares, night terrors, sleepwalking, confusional arousal and sleep talking. They arise because a child is in a mixed state of being both asleep and awake. The child is sufficiently awake to act out complex behaviours, but asleep enough not to be aware of or remember them. Parasomnias tend to run in families and are not necessarily indicative of psychiatric or psychological problems. Disorders of arousal may be worse if your child is overtired, has a fever or is taking certain medications.

Nightmares

It is common and normal for young children to have bad dreams or vivid nighttime events that cause them to experience feelings of fear, terror and anxiety.  Although preschoolers are gaining a greater understanding of the world, they are not always able to make sense of it completely and may go to sleep with unresolved questions. They are also getting more in touch with their feelings and know what it means to be afraid or know that something is not quiet right. These feelings tend to come out at night. Children may find it difficult to explain their dreams and have problems returning to sleep after a nightmare. Animals, especially wolves and bears, strange, bad or odd-looking people, fires and deep water are common themes of childhood dreams. If your child is having a nightmare but remains asleep, do not wake them. Stay nearby until the dream appears to be over and they are sleeping peacefully. Only if your child wakes up, should you hold them in your arms and console them. Using a night light or security object is often helpful.

Night terrors, also known as sleep terrors or pavor nocturnus

Night terrors tend to occur early in the night and can be very alarming. Parents report feeling quiet anguished when they find their child in bed, apparently awake, terrified, and possibly thrashing about and screaming. Children who experience night terrors may be angry or desperately upset at the time, but don’t remember anything in the morning. As a parent, there is no point trying to reassure your child because they are beyond reason. Don’t scold or leave them, as this will only make the terror worse. All you can do is stay close and wait for the terror to pass. Children tend to outgrow sleep terrors as their central nervous systems develop. Night terrors occur most frequently in children between 3 and 8, and are more common when a child is experiencing some sort of stress. Children with sleep terrors will often talk in their sleep or sleepwalk.

Sleep talking

Sleep talking is a sleep-wake transition disorder. Sleep talking occurs when your child talks, laughs or cries out in their sleep and has no memory of the incident the next day. Talking can be brief and involve simple sounds, or it can involve long speeches by the sleeper. Sleep talking can be perpetuated by external factors such as fever or emotional stress, or they may occur in the context of other sleep disorders.

Sleep walking

Sleepwalking is experienced by 40% of children and usually occurs between the ages of 3 and 7. Sleepwalkers appear to be awake and are moving around but are actually asleep, and do not have any recollection of their actions. Sleep walking most commonly occurs 1-2 hours after sleep onset (NREM sleep) and tends to last for 5-20 minutes. Since sleep deprivation often contributes to sleepwalking, moving bedtime earlier might be helpful. In most children, sleepwalking tends to stop as they enter their teens.

Confusional arousal

Some children wake up, look a bit confused, maybe cry a bit, then drift right back to sleep. These episodes are known as confusional arousals and are generally nothing to worry about. They usually occur when your child is awakened from a deep sleep during the first part of the night. This disorder involves an exaggerated slowness upon awakening and your child is unlikely to remember doing these things the next day. Confusional arousals are also known as excessive sleep inertia or sleep drunkenness, and tend to last for about 30 minutes. 

Rhythmic movement disorders

Rhythmic movement disorder, more commonly known as “head banging”, tends to occur in children of 1 year of age or younger. Children with this disorder may lie flat, lift their head or upper body, and then forcefully hit their head on the pillow. Head banging usually occurs just before a child falls asleep and may also involve movements such as rocking on the hands and knees.

Dyssomnias

A dyssomnia is any disturbance or difficulty related to sleep; including problems initiating or maintaining sleep, as evinced in insomnia, or disorders leading to excessive daytime sleepiness, including obstructive sleep apnea or insufficient sleep syndrome.

Behavioural insomnia of childhood (BIC)

If your child complains of an inability to fall asleep, remain asleep, and/or early morning awakenings, they may be suffering from insomnia. Short-term, insomnia may be due to stress, pain or a medical or psychiatric condition. If the underlying cause is not addressed, good sleep practices are not employed and a consistent sleep schedule is not adhered to, insomnia may become a long-term problem.

Nocturnal enuresis

See our medical A-Z article for further information on enuresis.

Snoring

10-12% of normal children habitually snore. Snoring occurs when there is a blockage in the airway that causes a noise due to the vibration of the back of the throat. Snoring may be a result of nasal congestion or enlarged adenoids or tonsils that block the airway. Other problems associated with snoring include otitis media, halitosis, sore throats, frequent upper respiratory infections and mouth breathing.

Obstructive Sleep Apnea Syndrome (OSAS)

Your child may be suffering from obstructive sleep apnea if they experience frequent, loud snoring that is punctuated by sporadic pauses, choking or gasping, and breathing difficulties. This condition is characterized by pauses in breathing during sleep due to blocked air passages, that in turn results in repeated arousals from sleep. These micro-awakenings, affect the quality of sleep and leave the sleeper feeling tired even after sleeping for a significant amount of time. Obstructive sleep apnea is most commonly found in children between 2-6 years of age, but can occur at any age. It is frequently caused by enlarged tonsils or adenoids, and being overweight. Other children, who are at high risk, include those who have a small jaw, craniofacial syndromes, muscle weakness or Down syndrome. Sleep apnea has been associated with hyperactivity, academic difficulties and daytime sleepiness.

Insufficient sleep syndrome

Insufficient sleep syndrome is characterized by a child’s inability to get an adequate amount of sleep in order to maintain appropriate daytime wakefulness. This is punctuated by other behaviours indicative of sleep loss in a child, such as attention and concentration problems, irritability and hyperactivity. Besides the use of age-based norms as a guideline for a child’s sleep requirements, parents can establish if their child is getting sufficient sleep by asking 3 pertinent questions. My child is getting enough sleep if he or she can: 1) fall asleep easily at night (within 20 minutes), 2) wakes up easily, at his/her usual waking time, and 3) does not require daytime naps, unless it is age appropriate.

Inadequate sleep hygiene

Inadequate sleep hygiene refers to habits and activities that enhance wakefulness and interrupt the sleep period, which can lead to a decrease in both the quality and quantity of sleep, as well as excessive daytime sleepiness. Inappropriate and possibly detrimental sleep habits include; engaging in stimulating activities before bedtime, the use of bed for non-sleep related activities (playing or watching TV), and routinely consuming caffeine near to bedtime. Sleep may also be disturbed by inconsistent sleep and wake times with or without inappropriate napping.

Signs of sleep problems in children:

•    Snoring
•    Breathing pauses during sleep
•    Problems sleeping through the night
•    Difficulty staying awake during the day
•    Unexplained decrease in daytime performance
•    Unusual events during sleep

Diagnosis:

Sleep disorders are generally diagnosed by pediatricians, educators, psychologists or sleep specialists. Because young children in particular do not have the language or awareness to express their sleep problems, parents need to monitor their children’s sleeping habits if they suspect a sleep disorder. Keeping a sleeping journal can help you do this. Useful information to document includes; when your child goes to bed and wakes up, how many times they wake up during the night, their pre-bedtime routine, what they ate or drank before bed, if they have a problem with daytime sleepiness and if this occurs at specific times. In some cases, your doctor may suggest that an overnight or series of sleep studies be performed. These are generally done in a hospital or sleep centre. While sleeping, your child’s brainwaves, breathing patterns and sleep habits are monitored and possibly video taped.

Treatment:

Each sleep disorder is handled differently.

In most cases, children tend to outgrow parasomnias and they rarely indicate the presence of an underlying medical or psychiatric problem. The number of disruptive events usually decreases as children get older and no treatment is required, although they may persist into adulthood.

Practically, simple measures can be taken to ensure your child’s safety. For example; clearing the bedroom of obstructions, securing windows, or sleeping on the first floor. In severe cases, treatment may involve the use of prescription drugs or behaviour modification techniques.

As far as dyssomnias are concerned, there is often more than one cause of a child’s sleep disturbances. Interventions include; treating any contributory underlying issues, such as chronic allergic rhinitis, obesity, gastro-esophageal reflux, etc.; removing environmental hindrances to sleep, such as tobacco smoke, excessive temperatures or exacerbating medications; providing the child with coping mechanisms to deal with emotional stressors; behavioural modification techniques, such as the use of graded reward systems to reinforce positive outcomes; educating parent and child about the importance of sleep hygiene issues; and the use of medication, such as melatonin, under the supervision of a specialist if behavioural, schedule and sleep hygiene issues have already been addressed and are ineffective.

How to help your child:

•    Establish a predictable sleep and bedtime routine. Ensure that your child goes to bed at the same time every night and that their waking time does not differ by more then 1-1/5 hours, from weekdays to weekends.
•    Provide your child with cues that it is time for bed, for example when the news ends on television or after you have read them a story.
•    Ensure that your child feels safe and relaxed. Give them a warm bath or gentle massage and read them a story.
•    Avoid giving your child any caffeinated drinks at least 6 hours before bedtime.
•    Make sure that the temperature in your child’ bedroom is comfortable and that the room is dark.
•    Make sure the noise level in the house is low.
•    Avoid giving your child large meals close to bedtime.
•    Keep after dinner play relaxing. Too much activity too close to bedtime may keep your child awake.
•    Avoid stimuli such as the television, radio or music playing while your child is going to sleep.
•    If your infant or child appears tired, put them to bed. Avoid allowing them to fall asleep in another room or in your arms.

Stoppard, M. (2005). Family Health Guide: The essential home reference for a lifetime of good health. Dorling Kindersley: Great Britain.
Wicks-Nelson, R. & Israel, A.C. (2000). Behaviour Disorders of Childhood. Prentice Hall: New Jersey.
http://www.sleepforkids.org
http://www.webmd.com
http://www.medscape.com
http://www.online.epocrates.com
http://www.livestrong.com