Medical Conditions Affecting Sleep in Children

Children and youth with special health care needs (CYSHCN), including ADHD, autism spectrum disorder, fetal alcohol syndrome, intellectual disability, traumatic brain injury, and similar conditions, tend to have more sleep problems than typically developing children. This page provides guidance on how to identify and treat medical issues that can contribute to poor sleep.

Symptoms of Sleep Problems

Symptoms suggesting a possible sleep problem:
  • Daytime sleepiness
  • Behavior problems
  • Attention difficulties
  • Mood problems
  • Learning problems
  • Headaches
  • Dry mouth

Medical Causes of Sleep Issues

Asthma and Chronic Cough

Children who frequently cough at night may have asthma. Use adequate controller medications for night-time coughing, and consider pre-treatment with albuterol prior to bedtime. If asthma is exacerbated by allergens present in the home, provide additional education on limiting exposures to allergens and consider allergy medications. See Asthma for diagnosis and treatment information.

Anxiety

Consider anxiety contributing to poor sleep in babies and children who wake frequently, worry excessively, or have difficulty separating from parents. (While it is normal for babies and children to wake 8-10 times during the night, some experience anxiety when this occurs.) Anxious children benefit from relaxation activities, such as deep breathing, progressive muscle relaxation, biofeedback, or guided imagery. In more severe cases, consider a behavioral health referral or anti-anxiety medication, such as a selective serotonin reuptake inhibitor, to reduce the negative impacts of anxiety when going to bed and staying in bed all night. Clonazepam may help with bedtime anxiety, although it can cause agitation in some kids with neurodevelopmental disorders. See Sleep Medications for more details and Anxiety Disorders for management information.

Chronic Pain

Whenever possible, address the underlying issue. Consider a Rheumatology consult, a Pediatric Chronic Pain specialist, and Behavioral Health for coping strategies, and/or acupuncture. When appropriate, work with a palliative care or hospice team to treat pain in patients with end-stage cancer or other life-limiting conditions. See Pain in Children with Special Health Care Needs.

Constipation

Children with infrequent, hard, or bulky stools or an abdominal mass consistent with stool burden may have abdominal pain that wakes a child during the night. See Constipation.

Depression

Because depression can lead to increased somnolence or decreased sleeping, consider depression in the differential diagnosis for a change in sleep patterns. See Depression .

Fetal Alcohol Syndrome

Sleep behavior issues are common in children with FASDs and may include any combination of:
  • Increased bedtime resistance
  • Greater sleep anxiety
  • Delayed sleep onset
  • Increased incidence of parasomnias (e.g., nightmares and enuresis)
  • Shorter overall sleep duration (waking earlier than necessary or desired by the family)
  • Frequent nighttime awakenings
  • Difficulty returning to sleep after nighttime awakenings, which frequently resulted in problematic and sometimes unsafe behaviors such as climbing on furniture, accessing dangerous household items (e.g., knives), or excessive eating.
These sleep problems are thought to be related to sensory processing disorders frequently seen in FASD. The number and severity of problematic sleep-related symptoms were highly correlated with scores indicating pathology on the Sensory Profile, a caregiver report of sensory reactions displayed by a child to given inputs and their behavioral and emotional responses to such. [Wengel: 2011] The brainstem reticular formation, important in sensory processing, must be down-regulated in order to facilitate the induction of sleep. This down-regulation causes the brain to “filter out” irrelevant or nonthreatening stimuli in order to maintain sleep, while maintaining the capability for arousal in case a threatening or noxious stimulus is perceived. It is posited that in children with FASD, their inability to ignore irrelevant stimuli and down-regulate may be at least partially responsible for their difficulties with both delayed sleep onset and with nighttime awakenings. In addition, abnormalities in the hypothalamic-pituitary axis resulting from in-utero alcohol exposure are thought to contribute to the sleep difficulties and associated hypervigilance often seen in children with FASD. Animal models have also demonstrated increased nighttime wakefulness and decreased sleep hours overall in those exposed prenatally to alcohol.

Children with FASDs have a distinctive sensory processing profile that is most often characterized by a predilection for sensation-seeking, but poor registration (e.g., understanding) of what is actually occurring around them. [Jirikowic: 2008] These children tend to have a high neurological threshold and feel under-stimulated; hence, the seeking of additional sensation appeals to them. Additionally, children with FASD are more likely to fall into the clinically concerning range on both long- and short-form Sensory Profile tests in the domains of tactile sensitivity, auditory filtering, and movement sensitivity. Low scores (indicative of more significant pathology) on the short sensory profile were predictive of more significant behavioral problems, as measured by the Child Behavior Checklist. Thus, sensory processing problems tend to correlate both with poorer sleep at night and more disruptive behavior during the day. [Franklin: 2008] As such, children with FASD will likely benefit from early consultation of Occupational Therapy in order to target sensory processing impairment that appear to lead to secondary disability via behavioral and sleep problems.

Gastroesophageal Reflux

Chest or upper abdominal pain when lying down or night-time vomiting, cough, or wheeze can suggest GERD. Consider raising the head of the bed, reducing intake for the couple hours before bed, or an empiric trial of reflux medications. See Gastroesophageal Reflux Disease.

Organic Sleep Disorders

Organic sleep disorders such as sleep apnea, restless legs, periodic limb movement disorders, parasomnias, bruxism, and enuresis, can impair sleep. See Screening for Sleep Problems.

Seizures

Abnormal repetitive movements or behaviors during the night can indicate a seizure disorder. Consult a pediatric neurologist to obtain an EEG. Ensure the bed is safe. See Seizures/Epilepsy.

Spasticity

For children with high tone, undertreated spasticity can cause pain and reduce sleep quality. Consult a physical medicine and rehabilitation doctor (physiatrist) for treatment of spasticity; this may include medications such as baclofen, Botox, tizanidine, and others. In collaboration with the specialists, 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] See Cerebral Palsy for more information.

Substance Abuse

Youth who are using various substances may have erratic moods or secretive behaviors. Some may have odors on their breath or clothes, pupillary changes, or skin findings such as track marks from injections that serve as clues to their use. Substance abuse can contribute to poor sleep (e.g., alcohol, marijuana, stimulant abuse). Ensure that all household medications are securely stored. Youth with substance use disorders benefit from brief intervention, referrals, and treatment starting in the medical home. See Substance Use Disorders.

Pearls & Alerts

Nonverbal children with sleep issues
It may take trial and error to rule out conditions that can disturb sleep. The Questionnaire to Help Identify Underlying Medical Conditions in Children with Autism (AAP) (PDF Document 281 KB) is a useful framework to evaluate for possible medical causes of disrupted sleep, even for children without autism.

Role of the Medical Home

In addition to monitoring for and treating underlying conditions impairing sleep, the medical home clinician should:
  • Review sleep behaviors and sleep hygiene. See Behavioral Techniques to Improve Sleep.
  • Ensure that the child has a safe environment at night if unmonitored while awake and discuss respite needs and options with the family. Consider safety gates, door alarms, cabinet, or fridge locks, etc.
  • Be aware that recurrent hospitalizations, surgeries, or illnesses can negatively impact CYSHCN’s sleep patterns. Consider a behavioral health referral and child life consultation during periods of hospitalization.
  • Review patient's medications to identify those that can make it harder to fall asleep (e.g., stimulants) or cause difficulty staying awake during the day (e.g., phenobarbital, clonidine).
    • Be aware that some medications used for sleep have increased potential to cause agitation in children with neurodevelopmental disorders (e.g., gabapentin, clonazepam).
    • Ask about the use of non-prescription medications, supplements, caffeine and energy drinks, and illicit substances that can impact sleep.
If no medical issues are keeping the child awake, then you can reassure parents so they can focus on Behavioral Techniques to Improve Sleep.

Resources

Tools

Screening for Sleep Problems
Links to commonly used screens and clinical information for next steps after a positive screen, including when to refer; Medical Home Portal.

Questionnaire to Help Identify Underlying Medical Conditions in Children with Autism (AAP) (PDF Document 281 KB)
A list of 29 yes/no questions given to parents by clinicians to help evaluate potential medical contributors to sleep issues in children with autism; American Academy of Pediatrics.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Bruni O, Angriman M, Calisti F, Comandini A, Esposito G, Cortese S, Ferri R.
Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities.
J Child Psychol Psychiatry. 2018;59(5):489-508. PubMed abstract

Authors & Reviewers

Initial publication: November 2020
Current Authors and Reviewers:
Reviewer: Jennifer Goldman, MD, MRP, FAAP

Page Bibliography

Franklin L, Deitz J, Jirikowic T, Astley S.
Children with fetal alcohol spectrum disorders: problem behaviors and sensory processing.
Am J Occup Ther. 2008;62(3):265-73. PubMed abstract / Full Text

Jirikowic T, Olson HC, Kartin D.
Sensory processing, school performance, and adaptive behavior of young school-age children with fetal alcohol spectrum disorders.
Phys Occup Ther Pediatr. 2008;28(2):117-36. PubMed abstract

Mathew A, Mathew MC.
Bedtime diazepam enhances well-being in children with spastic cerebral palsy.
Pediatr Rehabil. 2005;8(1):63-6. PubMed abstract

Wengel T, Hanlon-Dearman AC, Fjeldsted B.
Sleep and sensory characteristics in young children with fetal alcohol spectrum disorder.
J Dev Behav Pediatr. 2011;32(5):384-92. PubMed abstract