Sleep plays a fundamental role in child growth. Quality sleep is extremely important in the physiological, cognitive and emotional development of children and parents must have a strong understanding of the sleep requirements necessary for their children at various stages in their lives in order to support their child get as much quality sleep as possible.
Sleep duration varies on different stages of a childhood: 14 to 17 h in newborns, drops to 11–14 h between the first and second years of life and subsequently decreases to 10–13, 9–11, and 8–10 among preschoolers, school-aged children, and adolescents, respectively (1).In the early stages of life sleeping time reduces due to the decreased time of the daytime nap, which completely disappears at the age of 5.
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Although sleeping hygiene generally develops without complications in 70%-80% of children, 20%-30% of them still face sleep abnormalities. Sleep disorders are prevalent in the paediatric age range with higher prevalence among the children with neuropsychiatrist comorbidities (2). Certain sleep disorders can have similar causes. Genetic predispositions, obesity, breathing disorders and other health-related issues can all lead a child to sleep complications.
Obstructive Sleep Apnea
About 1-2% of children face Obstructive Sleep Apnea (OSA) (3), which is most likely caused by enlarged tonsils or other breath defects, obesity, etc. OSA occurs when the tissues in the throat block the passage of air during sleep, which leads a child to frequent, momentary lapses in breathing that can significantly disturb nightly sleep. Other common symptoms include unusual sleeping positions (e.g., hyperextended neck, seated with open mouth), sleep-related paradoxical breathing, nighttime diaphoresis or enuresis, morning headaches, and excessive daytime sleepiness.
Adenotonsillectomy is the primary treatment for OSA in children, if it is determined that the cause is enlarged tonsils or adenoids, however the treatment options strongly depend on the severity of the disease. It may include continuous positive airway pressure (CPAP) therapy or to use a mouthguard during the night.
Restless Leg Syndrome
Restless legs syndrome, also known as Willis-Ekbom disease, is a movement disorder that can meaningfully disturb sleeping processes. It affects not only sleep quality but child behaviour and life quality in general. The main symptom is a pain-free but overwhelming urge to move one’s legs, which often increases at night time when the person is at rest.
Though in certain cases Restless leg is caused by a genetic predisposition, it can be caused by late stage kidney diseases and/or iron deficiency as well, so it is highly recommended to consult with a medical professional for diagnoses. Only after a proper diagnosis can it be treated by medication.
Insomnia
Insomnia is one of the most common sleep disorders in children. Usually medical professionals highlight three different types: behavioural and conditioned insomnia and transient sleep disturbances.
Behavioural insomnia is prevalent in childrens up to 5 years of age and is associated with frequent nighttime walking, resistance to sleep or taking a long time to fall asleep.
Conditioned insomnia is common for the school age or adolescentes. It occurs when anxiety and or fear related to bedtime prevent a child from falling asleep or staying asleep.
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Transient sleep disturbances are temporary disruptions in a child's normal sleeping routine caused by stressful events, travelling or other short-term bouts.
Though it is the most “classic” and prevalent type of sleeping disorder, insomnia can become a real struggle for the whole family. However, there are several different methods that can treat insomnia without medication. Typically the first line treatment can be found in changing behaviour and setting a consistent bedtime routine. This can help avoid further complications for both child and parent.
Parasomnias
Parasomnias represent a dissociation between wakefulness and sleep and REM (rapid eye movement) and non-REM sleep, with superposition of the characteristics of one state onto the other, resulting in undesirable behavioural phenomena (4).Parasomnias are classified as non-REM (confusional arousal, sleepwalking and night terrors) and REM sleep-related (nightmares, nocturnal enuresis) parasomnias.
Most parasomnias, such as sleepwalking, sleep talking, confusional arousals and sleep terrors, occur in the first half of the sleep period during slow wave sleep and children typically have no memory of the event. In contrast, nightmares typically occur in the last half of the sleep period during rapid eye movement sleep, with children able to remember the event. It is important to note that the symptoms and timing of nocturnal seizures can overlap with parasomnias.
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Parasomnias usually dissolve spontaneously by the time of adolescence. However, it is inevitable to take some safety measures such as using motion alarms, closing doors and windows around the house, pacing the mattress on the floor, etc. If a child shows atypical, harmful or violent behaviour or is resistant towards the conservative methods of treatment, need further evaluation and medical help.
Delayed Sleep Phase Disorder
This disorder is characterised by a delay in the time of sleep onset, usually by more than 2 hours in relation to the time desired by the individual needed to fulfil social commitments (5). This may cause the children and adolescents to have difficulties getting up in the morning as well as daytime sleepiness, which may also strongly affect school and life performance. Several factors may be involved in pathogenesis, from social pressure (exacerbated by access to electronic media at bedtime) to issues of homeostatic development and circadian rhythm associated with puberty, which may be evaluated through anamnesis or objective methods, such as actigraphy.
The disorder is diagnosed using patient history and documentation of sleep and wake times on a sleep diary or log. Parental concerns usually focus on late bedtimes (2 a.m. or later), sleeping in, difficulty awakening, and school tardiness.
Tips to help overcome sleep disorders
Parents can use several approaches to support their child overcoming the complications regarding bedtime and sleep.
You can improve your baby’s sleep hygiene which means generating collective habits and routines that can help sleep quality. Consistent bedtime routine promotes healthy sleep and other positive outcomes such as language development and family bonding. Other supporting components of improving sleep hygiene are daily exercises, reducing caffeine and limiting gadgets using time.
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It is also important to reduce stress. Most children and youth who experience mental issues are more likely to suffer from sleep disorders. Even in case they do not have any diagnosed mental issues, they experience an increased amount of pressure while communicating with the surrounding world on a daily basis. It is important to identify stressing factors and try to reduce them to set the child/teenager free of anxiety and fear, build their emotional intelligence in a way to be more resistant towards stressful environments.
Child’s sleeping environment also plays a key role in quality sleep. A place for sleep should help promote relaxation around bedtime. It is good to paint children’s rooms in neutral, calming colours if possible. Avoid harsh lights and maximise the natural light sources which can be muted by curtains or other means before the child goes to bed. Keep the room clutter free and avoid too many toys or other things causing extra excitement. Baby bedding is also an important part while trying to treat some of the sleep disorders. If a child has some sleep problems, moves and frequently rolls during bedtime then using a floor bed can significantly boost safety. Stress and anxiety can be reduced by using proper bedding like a high quality mattress, weighted blanket, etc.
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When to ask for a doctor help
Most of the children experience two or three nights of poor sleep and occasional disturbances, however if it grows to be chronic and the baby faces continuous problems, it is inevitable to discuss the symptoms with a paediatrician and get medical professional help. Depending on their symptoms and medical history, their doctor may recommend an overnight sleep study at a sleep clinic or additional evaluation by a sleep medicine specialist.
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1. Camila dos Santos El Halal, Magda Lahorgue Nunes - Sleep Disorders in Childhood, 2018.
2. Maski K, Owens JA. Insomnia, parasomnias, and narcolepsy in children: clinical features, diagnosis, and management. Lancet Neurol, 2016.
3. National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 2019.
4. Kotagal S. Parasomnias in childhood. Sleep Med Rev. 2009.
5. Camila dos Santos El Halal, Magda Lahorgue Nunes - Sleep Disorders in Childhood, 2018.
