360° of Neuroscience Newsletter
Sutter Neuroscience Institute

Sleep Problems in Children
Common Conditions, Evaluation and Management
By Myrza Perez, M.D.

Sleep problems are extremely common in infants, children and adolescents.  A recent poll by the National Sleep Foundation found that two thirds of young children experience at least one sleep problem a few nights per week and greater than half of adolescents reported daytime sleepiness.  Daytime symptoms of insufficient sleep in young children consist of inattention, hyperactivity, learning problems, moodiness, aggressiveness and restlessness.  Classic daytime sleepiness is a symptom more typically reported by adolescents and adults.  Children and adolescents experience the same range of sleep problems as adults however the presentation, evaluation and management are often different. 

Obstructive sleep apnea has been reported in approximately 3% of children, however snoring is seen far more frequently in up to 20% of children.  In addition to snoring, parents may report heavy breathing, noisy breathing, mouth breathing, observed apnea, nocturnal enuresis or restlessness in sleep as presenting symptoms.  Physical exam findings are often normal however findings including adenotonsillar hypertrophy, adenoidal facies, mouth breathing and hyponasal speech suggest a need for further inquiry and evaluation.  Children with Down Syndrome, craniofacial abnormalities and neuromuscular diseases are at increased risk.  An overnight sleep study is necessary to differentiate those with habitual snoring from sleep apnea.  First line treatment in children is adenotonsillectomy.  This is curative in the vast majority of patients.  In the rare instances when surgery is contraindicated, or for those who are not cured by surgery, nocturnal supplemental oxygen or continuous positive airway pressure (CPAP) via nasal mask, are then prescribed. 

Restless Legs Syndrome and Periodic Limb Movement Disorder affect 5 to 10% of adults.  Approximately one third of these adults report their symptoms beginning in childhood, though their prevalence in childhood is unknown.  Parents describe these children as being excessively restless during the day, reporting fidgeting and inability to sit still.  Children and adolescents with Restless Legs Syndrome complain of difficulty falling asleep or staying asleep. This is a clinical diagnosis that requires the child to complain of discomfort in their legs, occurring primarily in the evenings and at night that improves with movement.  Some children will describe a tingly, burning or creepy crawly feeling in their legs and many ask parents to rub or massage their legs at night.  These are frequently mislabeled as “growing pains.” A closely associated condition is Periodic Limb Movement Disorder. It is characterized by rhythmic, stereotypic jerking of the legs during sleep, occurring in clusters and often causing arousals and sleep fragmentation.  Presenting symptoms include difficulty falling and staying asleep, frequent wakening and non-restorative sleep. Children will often state that they want to fall asleep but cannot.  The diagnosis is made by clinical history and finding on an overnight sleep study.  Both disorders are associated with diminished ferritin levels and first line treatment is iron supplementation for ferritin <50 ng/ml.  Other pharmacologic treatments include dopamine agonists, gabapentin and clonidine.

The most common sleep disorder in children and adolescents is insomnia.  In late infancy and early childhood, this is usually classified as behavioral insomnia of childhood.  It is associated with negative sleep onset associations, needing the same conditions that were present from the start of the night such as a parent, a bottle or a pacifier, in order to fall back asleep throughout the night.  In the toddler and early school aged child, a limit setting type is more prevalent whereby the child asks for one more drink or water, hug, story, trip to rest room, etc. all the while further delaying their sleep onset.  In both of these scenarios the parents complain of how involved they must be in order for their child to initiate and maintain sleep.  The treatment of these involves behavior modification for both parent and child.  There is no role for medications in the treatment of these conditions. 

In adolescence, a shifting of the circadian rhythm results in a shift towards later sleep onset time.  This results in chronic sleep deprivation.  Compounding this is increasing use of caffeine as well as the intrusion of technology by way of television, computers and cell phones into the bedroom.  For those with significant impairment, adherence to a strict bedtime routine with a shift in focus to relaxing activity in the hours before bed (improving sleep hygiene), limiting caffeine intake and using bright light in the morning yields better long term results than medications.

Unfortunately pediatric sleep disorders are often under-recognized and under-diagnosed.  Insufficient sleep affects attention and cognition and certainly impacts the family dynamic.  Inquiries about sleep should be part of routine health care visits. 

At Sutter Health, we have pediatric sleep specialists along with monitoring and treatment facilities dedicated to children. The Sutter Sleep Disorders Centers in Sacramento and Roseville offer state-of-the-art diagnostics and overnight testing.