Sleep Problems

Sleep problems are more common in children with chronic health condtions, although there has been little research into their epidemiology, etiology, and treatment. Issues that may contribute include:

• disrupted sleep cycles;
• limited mobility in bed;
• gastrointestinal or respiratory issues;
• psychosocial issues;
• seizures;
• vulnerable child syndrome;
• pain or discomfort from spasticity;
• medications; and
• recurrent hospitalization.

To determine the best intervention, think of sleep problems in several main categories:
1. Medical Issues Interfering with Sleep (e.g., sleep apnea, gastro esophageal reflux or chronic cough, seizures, pain, discomfort from spasticity)
Think about identifying and treating medical issues that might be contributing to poor sleep. If seizures might be contributing to sleep problems, consider a referral to a pediatric neurologist. If spasticity is a problem, and may be causing discomfort at night, consider a valium trial at bedtime only (starting at low doses and working up as needed) which may decrease spasticity without causing daytime drowsiness. [Mathew: 2005] Also consider trying medications for reflux empirically. Once the provider is able to reassure parents that there are not medical issues keeping their child awake, parents may then be able to deal with behavioral issues.

2. Behavioral Difficulties with Sleep Onset or Maintenance (e.g., sleep associations, parental difficulty setting limits, co-sleeping)
Interventions for this type of sleep problem must focus on parental perceptions and desires. Then the clinician can teach the parents the behavioral and environmental interventions necessary to achieve the parents' desired outcome. Parents may need ongoing support to have success. Medications are not the focus of intervention but may be employed to try and "take the edge" off of the problem while initiating a behavioral program or to get the parents some needed sleep before they embark on the behavioral program. The two major options in behavioral intervention are graduated extinction (the Ferber approach) and bedtime fading. Although physicians are generally more familiar with graduated extinction, for many children with special needs, bedtime fading may be the more useful/manageable approach.

3. Parasomnias (e.g., partial awakenings [sleep walking, sleep talking, night terrors], enuresis, nightmares)
Sleep walking/talking and night terrors are relatively common. For partial awakenings, first line intervention involves teaching the parent what these are and why the parent should leave the child alone. In some cases, gently waking the child 30 minutes before a predictable event on a nightly basis will help to resolve the problem. For nightmares, intervention involves reassurance and minimizing exposure to materials that may create a higher likelihood of frightening dreams. The clinician should also monitor for generalized worries that might suggest an anxiety disorder or a child's response to a stressful environment or life event. Evaluation and treatment for enuresis should proceed like any other typically developing child with the caveat that a neurogenic bladder may be the cause in a child with cerebral palsy.

4. Phase Shifts (e.g., the child who routinely falls asleep at 11 pm and sleeps until 10 am.)
This is a common problem for teens and may be seen in individuals with severe visual impairment. Intervention is somewhat difficult but not impossible. First, educate the parents/patient on good sleep hygiene (e.g., routine bedtime, no caffeinated drinks, exercise early in the day, no TV in the bedroom, limit non--sleep activities in the bed). One approach is to gradually try to move the sleep time earlier, but this may meet with limited success. A more successful approach (but very difficult to do) is to gradually shift the child's sleep onset 1/2 hour later every few nights till you get fully around the clock (only try this over long term school/work holidays). There is limited data to suggest that melatonin might be helpful in some children to treat sleep latency/phase shifts (see below).

5. Organic Sleep Problems (e.g., sleep difficulties in the child with autism, ADHD, head injury)
In some cases the child's organic brain disorder appears to be contributing to the sleep problems. It is important to address any behavioral and medical concerns that may be contributing per above, ensure that the child has a secure/safe environment at night if unmonitored while awake, and discuss respite needs/options with the family. Medications for sleep may be a focus in this group.