Management of childhood insomnia

The parents must help the child to fall asleep on their own, eg setting a bedtime routine that allows the child cues to the approaching bedtime. Number of calls for glasses of milk should be limited in advance.

Assessment of the presenting sleep pattern may reveal features that are readily treatable:

• the parents may have unreasonable expectations about the sleeping patterns of a young child
• the child may be having too much sleep during the daytime and perhaps the parents should consider getting the child into a playgroup (note that a brief early afternoon nap can improve the quality of night-time sleep)
• the child may have erratic bedtimes and so has not developed a bedtime routine
• the sleep cycle may have been displaced eg a parent has let the child sleep until late in the morning and therefore the child does not get tired until late in the evening

If none of the above are features of the delayed settling then options include:

• behavioural interventions
  • 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 (1)
  • a systematic review noted (2):
    • five interventions with behavioural methods for establishing consistent routines or controlled crying showed modest short-term effects
    • and concluded that "..Some support for short-term effects of behavioural treatment strategies was found, but more studies are needed to establish evidence.."
  • use of unmodified extinction or graduated extinction
    • a review (3) suggests there are two general approaches to addressing behavioral insomnia in young children
      • first is unmodified extinction, which involves placing the child in the intended sleep location (eg, their crib in their bedroom) and leaving the room. Any subsequent protest behaviors (eg, crying) is ignored until morning
        • "..although this approach has been shown to be highly effective in research studies, it is often unacceptable to parents and compliance tends to be low.."
      • second approach, often more feasible for parents, involves a graduated extinction approach, which employs a variety of techniques in which parents are instructed to ignore bedtime crying and tantrums for specified periods of time
      • although many caregivers understandably express concern that letting their child cry for a prolonged amount of time will result in psychological harm, there is little published evidence to suggest that behavioral sleep interventions have a negative impact on children’s social-emotional development or the parent-child relationship (3,4)
        
        
  • NHS advice, however, does not advocate the use of unmodified or graduated extinction (5)
    • if your child will not go to sleep without you
      • this technique can help toddlers (over 12 months) or older children get used to going to sleep without you in the room.
      • it can also be used whenever your child wakes in the middle of the night
      • be prepared for your child to take a long time to settle when you first start
      • you can use strokes or pats instead of kisses if your child sleeps in a cot and you cannot reach them to give them a kiss.
        
        • Follow a regular calming bedtime routine.
        • Put your child to bed when they're drowsy but awake, then kiss them goodnight.
        • Promise to go back in a few moments to give them another kiss.
        • Return almost immediately to give a kiss.
        • Take a few steps to the door, then return immediately to give a kiss.
        • Promise to return in a few moments to give them another kiss.
        • Put something away or do something in the room then give them a kiss.
        • As long as the child stays in bed, keep returning to give more kisses.
        • Do something outside their room and return to give kisses.
        • If the child gets out of bed, say: "Back into bed and I'll give you a kiss".
        • Keep going back often to give kisses until they're asleep.
        • Repeat every time your child wakes during the night
      • more sleep tips for under-5s
        • Make sure you have a calming, predictable bedtime routine that happens at the same time and includes the same things every night.
        • If your child complains that they're hungry at night, try giving them a bowl of cereal and milk before bed (make sure you brush their teeth afterwards).
        • If your child is afraid of the dark, consider using a nightlight or leaving a landing light on.
        • Do not let your child look at laptops, tablets or phones in the 30 to 60 minutes before bed – the light from screens can interfere with sleep.
        • If your child wakes up during the night, be as boring as possible – leave lights off, avoid eye contact and do not talk to them more than necessary.
        • Avoid long naps in the afternoon.
          
          
• pharmacological management
  • melatonin improves sleep in children with ASDs (1)
  • melatonin administration can be used to advance sleep onset to normal values in children with ADHD who are not on stimulant medication (1)
    
    
  • with respect to short-term use of sedatative antihistamines in childhood insomnia (1)
  • 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 (6)
  • 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. 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
2. Reuter A et al.A systematic review of prevention and treatment of infant behavioural sleep problems. Acta Paediatr. 2020 Sep;109(9):1717-1732. doi: 10.1111/apa.15182. Epub 2020 Feb 6.
3. Owens JA. Insomnia in Infants and Young Children.Pediatr Ann. 2017;46(9):e321-e326.
4. Sadeh A, Mindell JA, Owens J. Why care about sleep of infants and their parents? Sleep Med Rev. 2011;15(5):335-337. doi: 10.1016/j. smrv.2011.03.001
5. https://www.nhs.uk/conditions/pregnancy-and-baby/sleep-problems-in-children/(Accessed 24/11/2020)
6. 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.