Sleep Problems

Key Points

• Many sleep problems can be prevented with good sleep hygiene.

• For obstructive sleep apnea syndrome, criteria to order a sleep study in the evaluation of a child are similar to criteria for adults, but interpretation of the results requires special pediatric expertise.

• The most common cause of obstructive sleep apnea in children is adenotonsillar hypertrophy, and the treatment of choice is surgery.

Normal sleep has a well-characterized pattern of rapid eye movement (REM) and non-REM sleep that changes with age. Non-REM sleep is further categorized into stages 1, 2, 3, and 4, on the basis of electroencephalographs (EEG) characteristics, with the deepest non-REM sleep occurring in stages 3 and 4. A normal nighttime sleep cycle is about every 90 minutes, with multiple brief arousals and quick returns to sleep without memory of having awakened. Deep non-REM sleep predominates in the first several hours of sleep, and REM is most prominent in the last few hours. Children have substantial periods of very deep sleep that lessen with age. There is a gradual decrease in the amount of REM sleep and a significant decrease in deep non-REM sleep, especially in adolescence.

Children and adolescents in American society sleep less than those in other societies and less than children in the past (Dahl, 1998). Because of the wide variations in normal sleep patterns and development, the physician should avoid rigid expectations in counseling parents, but the following are some useful guidelines. A typical infant is able to sleep 6 to 8 hours through the night by age 2 months and 10 to 12 hours by age 6 months. The child usually no longer requires a morning nap by about 1 year of age and outgrows the afternoon nap around age 3. The total daily sleep requirement decreases with age, from 16 V2 hours at 1 week of age to 14 hours by age 1 year, 13 hours by age 2 years, 12 hours by age 3 years, 11 hours by age 5, and 10 hours by age 9 years (Blum and Carey, 1996).

An important aspect of preventing sleep problems is guidance regarding good sleep hygiene (Box 24-1). Sleep hygiene refers to the conditions that are most conducive to healthy, restorative sleep. Some children are reassured by a low-wattage night-light, but more light than that may disturb sleep. Parents of newborns should be counseled to put their infant to sleep supine rather than prone, unless

Box 24-1 Good Sleep Hygiene

Environment

Dark Quiet Cool

Schedule

Regular morning waking time Consistent nap length Regular bedtime

Activities

No frightening TV or stories

No vigorous physical activities in the hour before bedtime Consistent bedtime routine Consistent soothing methods Child put into bed awake

From Blum NJ, Carey WB. Sleep problems among infants and young children. Pediatr Rev 1996;17:87-92.

there is a specific medical indication to the contrary. This results from the association of the prone sleeping position with sudden infant death syndrome (SIDS) in young infants (Guntheroth and Spiers, 1992) (SOR: A). Many children rest better with a "transitional object," a favorite blanket or toy. However, parents should avoid putting the child to bed with a bottle left in the mouth because it may lead to severe dental caries. Finally, the child should be put to bed awake, so that the child develops self-soothing skills to initiate sleep and resume sleep after nighttime disruptions.

About 20% to 30% of children and adolescents have sleep problems that are a serious concern to them and their families (Dahl, 1998). Problems with sleep initiation and nighttime awakenings are most common during infancy. Parasomnias and obstructive sleep apnea syndrome are most common in the 3- to 8-year-old group. Sleep deprivation, delayed sleep-phase syndrome, and narcolepsy are important considerations in the adolescent age group (Carskadon and Roth, 2000).

Besides sleep problems being common, family physicians need to be alert to these conditions because they have such a negative impact on many aspects of physical, mental, and social well-being. Sleep problems early in life are predictive of many later behavioral and emotional problems (Dahl, 1998). Children with frequent nighttime awakenings are at increased risk for physical abuse, perhaps because parents of these children show increased levels of fatigue, irritability, and depression.

The assessment and management of sleep problems in general should include consideration of potential sleep interrupters as primary causes or as exacerbators. One important category of interrupters is conditions that cause pain or itching (e.g., juvenile rheumatoid arthritis, migraine, atopic dermatitis). Another category is problems that lead to respiratory symptoms, including nocturnal asthma, gastroesophageal reflux (GERD), and obstructive sleep apnea.

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