Insomnia in children

Behavioral sleep problems are the most common sleep problems in childhood within the general population (1)

• between 15% and 30% of 2- to 5-year-old children experience regular difficulties falling asleep (i.e., bedtime problems) or sleeping through the night (i.e., night waking)
• these problems occur in 11% to 15% of school-age children (6-12 years)
• children with conditions that involve behavior problems and difficulty with self-regulation, notably attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD), present with behavioral sleep problems more frequently than children within the general population, particularly daytime sleepiness (ADHD) and shorter overall sleep duration, reflecting difficulty settling to sleep, night waking, and early morning waking (ASD)

Other possible causes of childhood sleep disturbance include:

• depression
• nightmares
  • child wakes terrified; remembers the dream
  • age 8-10 years
• night terrrors
  • child half-wakes terrified; still dreaming; cannot remember the dream on waking in the morning
• sleep walking
  • very rare condition
  • occurs generally between 11-14 years of age
  • child wakes half-awake and calm; child had no memory of the event on waking the following morning
• childhood illness

Recommended amount of sleep for a child:

• American Academy of Sleep Medicine Consensus Recommendations for Amount of Sleep for Pediatric Populations (2)
  • Infants* age 4-12 months should sleep 12-16 hours per 24 hours (including naps) on a regular basis to promote optimal health
  • Children age 1-2 years should sleep 11-14 hours per 24 hours (including naps) on a regular basis to promote optimal health
  • Children age 3-5 years should sleep 10-13 hours per 24 hours (including naps) on a regular basis to promote optimal health
• * Recommendations for infants younger than age 4 months are not included due to the wide range of normal variation in duration and patterns of sleep, and insufficient evidence for associations with health outcomes

Definition of childhood insomnia:

• the International Classification of Sleep Disorders (ICSD), third edition, outlines clinical characteristics associated with childhood insomnia under the diagnostic category of chronic insomnia disorder, defined as occurring at least 3 times per week and present for at least 3 months (3)

Causes of interrupted sleep include:

• children resist going to bed for a variety of reasons:
  • because they wish to engage in other preferred activities, because they do not feel tired, because they have nighttime fears that make them frightened of going to sleep alone, etc.
  • Bedtime resistance involves active oppositional behavior on the part of the child and in turn may lead to shorter sleep duration.
• Night waking problems occur when children wake at night and do not fall back to sleep promptly and independently
  • many young children experience transient waking periods through the night, but quickly return to sleep on their own, without intervention from parents
  • when children wake frequently and/or for an extended period of time and require parental assistance (e.g., parental presence, soothing activities) to return to sleep, night wakings become problematic

Principles of management of childhood insomnia (4):

• appropriate sleep hygiene measures and more specific techniques of extinction, or graduated extinction, are all more effective than placebo at improving sleep and reducing the number of weekly night wakes in otherwise healthy children who regularly wake up in the night
  
  
• behavioural strategies should be tried first in children with disturbed sleep
• melatonin improves sleep in children with ASDs
• melatonin administration can be used to advance sleep onset to normal values in children with ADHD who are not on stimulant medication

Notes with respect to short-term use of sedatative antihistamines in childhood insomnia (4)

• sedative side effects of antihistamines may speed up behavioural programmes over short periods but seem not to work without behavioural interventions
• in a placebo-controlled double-blind trial in infants aged 6–27 months with the use of trimeprazine tartrate
  • authors concluded that it is not recommended as a pharmacological treatment for infant sleep disturbance unless as an adjunct to a behavioural therapy program (5)
• clinically the short term use of an H1 blocker for transient or extreme insomnia is frequently employed: however, tolerance can develop quickly and some children can experience dramatic and paradoxical over-arousal

Reference:

1. Turnbull K et a. Behavioral Sleep Problems and their Potential Impact on Developing Executive Function in Children.Sleep. 2013 Jul 1; 36(7): 1077–1084.
2. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy hildren: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549-1561.
3. The International Classification of Sleep Disorders. 3rd ed. Westchester, IL: American Academy of Sleep Medicine; 2014.
4. Wilson S et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. Journal of Psychopharmacology 2019, Vol. 33(8) 923– 947
5. France KG, Blampied NM and Wilkinson P .A multiple-baseline, double-blind evaluation of the effects of trimeprazine tartrate on infant sleep disturbance. Exp Clin Psychopharmacol 1999; 7: 502–513.