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Sleep Disorders in Children
Perhaps the most common pediatric sleep problem in contemporary American society is insufficient sleep because of lifestyle and electronic media. Click on the Table of Contents below for an area that interests you, or scroll to read the entire article.
Dysomnias are a broad classification of sleeping disorders that make it difficult to get to sleep or stay asleep.
Sleep Apnea
Sleep apnea occurs when your child regularly stops breathing for 2 breath cycles or longer during sleep. It can be mild, moderate, or severe, depending on the number of times in an hour that the breathing stops (apnea) or becomes very shallow (hypopnea). For children, 1.5 apneas or hypopneas per hour are abnormal.
There are three types of sleep apnea: obstructive sleep apnea, central sleep apnea, and mixed sleep apnea, although obstructive sleep apnea, also called OSA, is by far the most common in children.
What causes Obstructive Sleep Apnea?
A blockage or narrowing of the airways in the nose, mouth, or throat generally causes obstructive sleep apnea (OSA). This usually occurs when the throat muscles and tongue relax during sleep and partially block the airway. In children, sleep apnea is often caused by excess tonsillar tissue. Even if the tonsils do not appear large, they may be too large for the small airway.
During the day when the child is awake and standing up, this may not cause problems. However, when the child lies down at night, the tonsils and other relaxed tissues in the throat can press down on the airway, narrowing it and causing sleep apnea.
Obesity is also a risk factor for sleep apnea in children, as are allergies, asthma, gastric reflux, and bone deformities of the face or jaw.
What are the symptoms of Sleep Apnea?
Children who have sleep apnea almost always snore or have heavy, labored breathing. Studies report that 10-20% of school-age children snore. It is impossible to distinguish simple snoring from sleep apnea without a sleep study. Other symptoms may include breathing during sleep that seems too shallow or quiet because children have a tendency to hypo ventilate and restless sleep during which your child wakes up often. Your child may bend his/her neck while sleeping or have trouble with bed-wetting. All of these symptoms may be caused by sleep apnea.
The hallmark symptoms are behavior and learning problems that result from chronic, unrecognized sleep deprivation. It is rare for a school age child to be sleepy in the daytime. If your child acts sleepy, it is likely that the child has serious sleep deprivation. However, most children with sleep apnea usually do not appear to be very sleepy during the day (which is a key symptom in adults). In fact, often they act "hyperactive" with difficulties focusing or following directions, and usually there are mood disturbances. Sometimes the only symptom is poor academic performance. The only symptom of sleep apnea in some children may be that they do not grow as quickly as they should for their age.
Should I worry about Sleep Apnea?
Yes, it seriously disrupts the quality of sleep and there is a growing awareness of the vital role sleep plays in children's growth and development. Also, when your child stops breathing or breathes very shallowly during sleep, it may result in less oxygen (and more carbon dioxide) in his/her blood. Over time, this lack of oxygen can lead to serious health problems and learning difficulties. If a children have untreated sleep apnea, they are more likely to get high blood pressure (hypertension), high blood pressure in the lungs (pulmonary hypertension), and heart failure (in very severe cases).
If children have sleep apnea, they often have difficulty concentrating, paying attention and remembering what has been learned. Children can be misdiagnosed with a learning disorder or with ADHD when the problem is really an underlying sleep disorder. Because of the mood disturbances caused by chronic sleep deprivation, children with sleep apnea can be misdiagnosed with depression or other psychiatric illnesses.
How is Sleep Apnea diagnosed?
A sleep specialist will examine your child and ask you and your child questions about his/her snoring and sleep behavior. If your doctor thinks your child may have sleep apnea, he or she may suggest a sleep study. The American Academy of Sleep Medicine recommends an overnight sleep study if there is any suspicion of sleep apnea because studies have shown that doctors cannot predict from the size of the tonsils which child has sleep apnea. Sleep studies find out how often your child stops breathing or has shallow breathing and how much oxygen and carbon dioxide are in his/her blood during sleep. The treatment is often a tonsillectomy which results in a cure in 80-90% of cases.
Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the day. These sudden sleep attacks may occur during any type of activity at any time of day.
Narcolepsy usually begins between the ages of 15 and 25, but it can become apparent at any age. In many cases, narcolepsy is undiagnosed and, therefore, untreated. It is often misdiagnosed as a psychiatric disorder. Patients can go for years without the proper diagnosis or treatment.
What causes Narcolepsy?
The cause of narcolepsy is not known; however, it results in a loss of neurons in the brain that produce a chemical called hypocretin also known as orexin. In addition, researchers have discovered abnormalities in various parts of the brain involved in regulating sleep which seem to contribute to symptom development.
What are the symptoms of Narcolepsy?
Symptoms of narcolepsy include:
Excessive daytime sleepiness (EDS) In general, EDS interferes with normal activities on a daily basis, whether or not a person with narcolepsy has sufficient sleep at night. People with EDS report mental cloudiness, a lack of energy and concentration, memory lapses, a depressed mood, and/or extreme exhaustion.
Cataplexy This symptom consists of a sudden loss of muscle tone that leads to feelings of weakness and a loss of voluntary muscle control. It can cause symptoms ranging from slurred speech to total body collapse depending on the muscles involved and is often triggered by intense emotion, for example surprise, laughter or anger.
Hallucinations Usually, these delusional experiences are vivid and frequently they are frightening. The content is primarily visual, but any of the other senses can be involved.
Sleep paralysis This symptom involves the temporary inability to move or speak while falling asleep or waking up. These episodes are generally brief, lasting a few seconds to several minutes. After episodes end, people rapidly recover their full capacity to move and speak.
Disturbed, fragmented sleep Sleep is repeatedly interrupted by brief awakenings although often patients are not aware of this.
How is it treated?
There are medications that can be quite effective and can help people with narcolepsy lead normal lives. 1. Daytime stimulants: the new gold standard is modafanil (Provigil) which is a wake promoting agent that is not the same as traditional amphetamines and is much gentler while still being quite effective. 2. Nightime hypnotic: sodium oxybate (Xyrem) It is a powerful, but short-acting sleeping agent that is used to help consolidate sleep.
Limit-Setting Problems
Limit-setting problems usually begin after the age of two. It occurs when your child refuses to go to bed, stalls, or makes it hard for you to leave the bedside. Limit-setting problems can occur at bedtime, nap time, or when your child wakes up during the night.
Parents need to assert that they are the ones who decide when it is time for bed. They should enforce this time even if the child disagrees or seems active and alert. Children can get very creative when they want to stay up later.
They may ask for one more hug, a tissue, a drink of water, another story, to have the light turned off or on, or to "tell you something important." It can be hard to know what is real and what is simply a delay tactic.
You need to be firm and consistent when you respond to the delays. Giving in to them will only encourage the behavior. Parents need to give their children well-defined limits.
These are some tips to help your child sleep better:
Follow a consistent bedtime routine. Set aside 10 to 30 minutes to get your child ready to go to sleep each night.
Interact with your child at bedtime. Don't let the TV, computer or video games take your place.
Keep your children from TV programs, movies, and video games that are not right for their age.
Try to avoid allowing your child to use any electronic media for 1 hour before bedtime.
Do not let your child fall asleep while being held, rocked, fed a bottle, or while nursing.
At bedtime, do not allow your child to have foods or drinks that contain caffeine. This includes chocolate and sodas. Try not to give him or her any medicine that has a stimulant at bedtime. This includes cough medicines and decongestants.
A child who gets enough sleep and sleeps well is more likely to be cheerful during the day. The better the child sleeps, the happier the entire family will be. Most sleep problems in children are not a result of bad parenting. These problems also do not mean that there is something seriously wrong with your child.
If your child has an ongoing sleep problem, then you should talk to your child's doctor or to a sleep specialist.
Insomnia and Sleep Onset Association Disorder
Although adults often think that children "sleep like a baby," studies suggest that many youngsters do suffer from insomnia. In one survey of children in pediatricians' waiting rooms, more than 40% were reported by their parents to experience some form of insomnia: unrefreshing sleep, difficulty falling asleep, trouble staying asleep, or early morning awakenings.
Sometimes even sooner than a child can talk and walk independently, poor sleep habits and certain interactions with parents can get in the way of falling asleep.
Changing bedtime behaviors by creating a bedtime routine and setting limits sometimes helps children with insomnia. Most sleep experts agree it is important to allow children to fall asleep on their own. Children can become used to your presence in the room at bedtime and expect it even if they wake during the night. This can lead to Sleep Onset Association Disorder where they must have a certain person, object or activity or they cannot fall asleep. This is seen in toddlers and preschoolers where insomnia is seen in school-age children and teenagers.
Restless Legs Syndrome (RLS)
"Growing pains", "tingling", "creepy crawlies": no matter how it is described, the strange feelings in a child's legs can keep him/her up at night. Uncomfortable feelings in the legs may be a symptom of Restless Legs Syndrome (RLS). This disorder creates discomfort and can compel the sufferer to move her legs, even while trying to fall asleep.
Children with symptoms of RLS at least a few times a week sleep an hour less (8.9 hours vs. 9.9 hours) and are twice as likely to wake up during the night (40% versus 21%) as children with no RLS symptoms, according to NSF's 2004 Sleep in America poll.
Though the cause of restless legs syndrome is unknown, it may run in the family or be due to iron deficiency. Treatment in children is not well established, but deserves discussion with a pediatrician and sleep specialist.
Sleep disorders characterized by arousal, partial arousal, or sleep stage transitions. They are marked by abnormal behaviors during sleep.
Nightmares are vivid nocturnal events that can cause feelings of fear, terror, and/or anxiety. Usually, the person having a nightmare is abruptly awakened from REM sleep and is able to describe detailed dream content. Usually, the person having a nightmare has difficulty returning to sleep. Nightmares can be caused by many factors including illness, anxiety, the loss of a loved one, or negative reactions to a medication. Call your doctor if your child has nightmares more often than once a week or if nightmares prevent him/her from getting a good night's sleep for a prolonged period of time.
Sleep Terrors/Night Terrors
Children who are experiencing a night terror or sleep terror seem to awaken abruptly in a terrified state. They appear to be awake, but are confused and unable to communicate. They do not respond to voices and are difficult to fully awaken. Night terrors last about 15 minutes, after which time children usually lie down and appear to fall back asleep. Children who have sleep terrors usually don't remember the events the next morning. Night terrors are similar to nightmares, but differ in that night terrors usually occur during deep sleep, in the first half of the night rather than during REM. Also, the patients are not easily awakened and they don't remember the incident.
Children experiencing sleep terrors may pose dangers to themselves or others because of limb movements. Night terrors are fairly common in children and occur in approximately 5% of them, mostly between the ages of three to five. Children with sleep terrors will often also talk in their sleep or sleepwalk. This sleep disorder, which may run in families, also can occur in adults. Strong emotional tension and/or the use of alcohol can increase the incidence of night terrors among adults. Stress can also trigger night terrors in children, as can illness, but one of the most common causes is inadequate sleep.
Sleepwalking occurs when a person appears to be awake and moving around but is actually asleep. They have no memory of their actions. Sleepwalking most often occurs during deep non-REM sleep (stage 3) early in the night. This disorder is most commonly seen in children aged eight to twelve; however, sleepwalking can occur among younger children and adults.
Sleepwalking appears to run in families. Contrary to what many people believe, it is not dangerous to wake a person who is sleepwalking. The sleepwalker simply may be confused or disoriented for a short time upon awakening. Although waking a sleepwalker is not dangerous, sleepwalking itself can be dangerous because the person is unaware of his or her surroundings and can bump into objects or fall down. They can fall out of windows or leave the house. There are many "accidents" and "suicides" that may have been instances of sleepwalking. In most children, it tends to stop as they enter the teen years.
Confusional Arousals
Confusional arousals usually occur when a person is awakened from a deep sleep during the first part of the night. This disorder, which also is known as excessive sleep inertia or sleep drunkenness, involves an exaggerated slowness upon awakening. Children experiencing confusional arousals react slowly to commands and may have trouble understanding questions that they are asked. In addition, people with confusional arousal often have problems with short-term memory and have no memory of doing these things the following day.
Sleep Talking
Sleep talking is a sleep-wake transition disorder. Although it usually is harmless, sleep talking can be disturbing to sleep partners or family members who witness it. Talk that occurs during sleep can be brief and involve simple sounds, or it can involve long speeches by the sleeper. A person who talks during sleep typically has no recollection of the actions. Sleep talking can be caused by external factors including fever, emotional stress or other sleep disorders.
Sleep Enuresis (Bedwetting)
In this condition, the affected child is unable to maintain urinary control when asleep. There are two kinds of enuresis: primary and secondary. In primary enuresis, a child has been unable to have urinary control from infancy onward. Primary bedwetting appears to run in families. Children are more likely to have it if their parents or siblings had it as children. In secondary enuresis, children have a relapse after previously having been able to have urinary control. Enuresis can be caused by medical conditions (including diabetes, urinary tract infection, or sleep apnea). Some treatments for bedwetting include behavior modification, alarm devices, and medications. Of course, if there is another underlying sleep disorder, such as sleep apnea, that should be treated first and will often solve the bed wetting problem.
Rhythmic Movement Disorders
Rhythmic movement disorder occurs mostly in children who are one year old or younger. A child may lie flat, lift the head or upper body, and then forcefully hit his or her head on the pillow. Rhythmic movement disorder, which also has been called "head banging," also can involve movements such as rocking on hands and knees. The disorder usually occurs just before the child falls asleep. It is thought to be a form of self-soothing. It can be very upsetting for parents to watch, but it is not thought to be associated with psychiatric problems.
Nocturnal Seizures
People who experience nocturnal seizures may find it difficult to wake up or to stay awake. Although unaware of having had a seizure while asleep, they may arise with a headache, have temper tantrums, or other destructive behavior throughout the day.
Nocturnal seizures and their mechanisms are poorly understood. The majority of people with nocturnal seizures have idiopathic epilepsy and there is evidence that sleep enhances epileptic discharges in the EEG, though their daytime recordings may appear to be normal. For many people with epilepsy, seizures occur exclusively during sleep. Researchers (Young et al) estimate 10% of people with epilepsy display seizures exclusively during sleep. Thus, this is a common phenomenon.
Primary sleep disorders such as parasomnias or sleep apnea can mimic, trigger or be caused by seizures. Most nocturnal seizure disorders are attributed to temporal or frontal lobe foci. Nocturnal seizures may present at any time, but the peak age of onset is adolescence. Any nocturnal movement disorder and any tendency to perform bizarre or stereotyped movements in sleep should be evaluated with a fully monitored and video-taped overnight sleep study with a full seizure EEG montage.
If your child is experiencing symptoms or you have other concerns about your child's sleep health, call Northshore Sleep Medicine at 847.674.3600 for a consultation.
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