Sleep Problems in Children
Sleep problems in children are common with up to 30% of children under 3 years at some stage having a sleep problem. Those problems can be classified into two broad groups. Problems ininitiating or getting to sleep and problems in maintaining sleep with frequent night awakenings and disruption.
The most common factors causing these problems are behavioural, parasomnias and medical conditions. However to understand these problems, a knowledge of normal sleep patterns is essential as often normality is misinterpreted as abnormalities. Sleep is not a uniform state but cycles between stages of light and deep sleep. These stages change from infancy to adult as does the arousability from one sleep state to the other. To sort out whether the parent's concerns or expectations are realistic, a clinician needs to take a full 24 hour history involving sleep environment, bed time routine, sleep pattern, arousals, snoring, details of morning awakening, daytime function including naps, family and psychological history and whether different care givers in different settings are involved.
Behavioural problems in infants and toddlers are common and present as problems in initiating and maintaining sleep. Inappropriate sleep Associations, excessive night time feeding and inappropriate parental response are the major factors causing them. All of these can be diagnosed on a careful history and a sleep diary. Infants and children have to learn to initiate sleep on their own and continuing parental contact for the child to initiate sleep is the commonest inappropriate sleep association. Once understood, strategies can be started to give the child confidence to initiate sleep on their own. Until this is corrected, management of night awakenings is difficult. In toddlers, other factors that need to be addressed are the lack of limit setting by the parents or failing to address fears and anxieties of the child.
In children, sleep is often disrupted by parasomnias which. Include sleep talking, sleep walking, bed rocking, night terrors and confusional arousals. These occur from deep sleep with the child not fully awake and in the morning they have no memory of the event. There is generally a family history of similar events and their frequency and severity can be increased if the child is sleep deprived. Management involves explanation, reassurance and how to handle the event including safety issues if needed.
Many medical conditions can interrupt sleep including skin irritation, gastric acid reflux, and sleep disordered breathing. Clinical history and physical examination will generally give the diagnosis. In children sleep disordered breathing is now recognised as an important cause of daytime problems in the older child and poor weight gain in infants. Noisy breathing is the clue, as persistent snoring with periods of silence followed by gasping and breakthrough breaths suggests obstructive sleep apnoea. However, accurate diagnosis of obstructive sleep apnoea and its severity is dependent on an overnight sleep study. This must be done in an accredited children's sleep laboratory with personnel trained in handling children to get optimal information. With obstructive sleep apnoea in children, if proven (unlike the adult), tonsillectomy and adenoidectomy is the method of choice with good results.
Although obstructive sleep apnoea has only come of age as a diagnosis in children since the mid 70s, like many new discoveries, this entity was well known in the last century as highlighted by an article in the British Medical Journal in 1889 on 'Some Causes of Backwardness and Stupidity in Children'. In conclusion, sleep problems in children are common. Most can be sorted out by taking a careful history and examination, and instigating a management plan tailored to the family's needs. However children with sleep disturbed breathing will generally need an overnight sleep study to confirm and diagnose its severity before surgery is considered.
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