Portal de Periódicos da CAPES

Sleep Disorders

2001; American Academy of Pediatrics; Volume: 22; Issue: 10 Linguagem: Inglês

10.1542/pir.22-10-327

1529-7233

Barbara J. Howard, Joyce Wong,

Sleep and Wakefulness Research

Objectives After completing this article, readers should be able to: Sleep problems are very common during childhood, occurring in 20% to 30% of children. They are often a clue to underlying emotional, interactional, or family problems that deserve attention and may be the aspect of the child’s functioning that the family is most open to addressing. Sleep problems can be a source of stress and sleeplessness for parents and behavioral or learning difficulties for the child, but families may not be aware that the clinician can help. Sleep disturbances generally are resolved easily by the primary care physician in fewer than 3 weeks by using behavioral interventions, but they can persist for more than 3 years if left untreated.Sleep problems almost always can be diagnosed and treated based solely on a careful history. An algorithm of questions for sorting out sleep problems forms the structure for this article. In addition, the clinician may want to ask some “trigger” questions to determine related family/environmental factors: “At what age did the problem begin?” “What else was happening at that time?” “How much of a problem is this?” “What factors are associated with it worsening or getting better?” “Who are the family members most affected by the problem?”“What have others told you about this sleep problem?”Family sleep practices and the family’s cultural expectations for independent sleeping will affect treatment planning.As a general guide: The following questions can help the clinician sort out sleep complaints and guide management.For any sleep difficulty be sure to ask: Sleep disturbances can be divided into: 1) difficulty falling asleep (dyssomnias and protodyssomnias), 2)difficulties with arousals once asleep (parasomnias),and 3) excessive sleepiness. Difficulty falling asleep and night wakings frequently occur concomitantly.Difficulty falling asleep is very common in young children and is the most frequent sleep complaint(27%) of parents of school-age children. Its etiology differs by age. It is usually a problem of sleep routines for infants, limit-setting with or without circadian rhythm problems in older children,and circadian problems created by lifestyle in adolescents. It includes the dyssomnias (difficulty falling asleep) and protodyssomnias (the less severe problems of falling asleep of young children that do not qualify as dyssomnias).Waking at night occurs in more than 80% of children and, of course, infants who still need to feed at night. Night waking is only problematic when the child cannot return to sleep on his or her own. As many as 20% of 2-year-olds, 14% of 3-year-olds, and 6.5% of 5- to 12-year-olds have problematic night wakings.Sleepiness usually is due to inadequate sleep, which is most common when older children and adolescents control their own sleep schedules. Sleepiness from obstructive sleep apnea or narcolepsy is also more common in older children.How old was he or she when this problem started?There is a predictable age-related development of sleep patterns. By 6 to 7 months gestational age, rapid eye movement (REM) sleep can be discerned via fetal ultrasonography. Nonrapid eye movement (NREM) sleep develops around 7 to 8 months gestational age. At birth, infants have a basic pattern of quiet and active sleep states that alternate every 2 to 6 hours. The total amount of sleep at birth ranges from 11 to 23 hours, with an average of 16.5 hours and cycles lasting 50 to 60 minutes. Paralleling changes in neurophysiologic reorganization, the random distribution of sleep and wake periods gradually changes to cluster sleep and waking in longer periods but without any significant change in total sleep. The timing of sleep and waking is determined by environmental influences,the so-called zietgebers, the most powerful of which is light exposure. Feeding and social interaction also affect sleep-wake cycles and need to be coordinated in any interventions.By 3 months of age, stages III and IV sleep can be seen on electroencephalography (EEG), sleep begins with NREM, and babies begin the more mature pattern of sleeping for longer periods at night, with the possibility of sleeping through the night. By 4 months of age, quiet sleep comprises more of total sleep than active sleep, and most babies can sleep for long periods unless they have learned to do otherwise. From 8 to 10 months to age 4 years,children respond to fears and awareness of separation by waking. The child reaches an adult pattern of sleep by 3 years of age, with cycles lasting 70 to 100 minutes, NREM occurring more in the first part of the night (accounting for early night disorders of arousal), and REM occurring more toward the end of sleep (accounting for nightmares later in the night).During each sleep cycle, the child progresses from light sleep stage I to deeper sleep stage II, then arouses through stages III and IV (slow wave sleep)and has a variable period of REM or dreaming sleep. This increase in dreaming plus cognitive awareness of life stresses makes nightmares and bedtime fears and manipulations more common among preschoolers. After stages III and IV of the sleep cycle, there is often a behaviorally inapparent arousal. When this arousal is disordered or results in awakening from which the child cannot return to sleep independently,it becomes an arousal problem. Because NREM III and IV are more predominant in the preschool and school-age child, arousal problems are more frequent in this group. School-age children test autonomy issues at bedtime and may have stresses from school and peers that make falling asleep more difficult. Slow wave sleep is increased during adolescence along with a slight increase in sleep requirement but a decrease in time in bed in accord with their social life. Sleep debt, therefore, is a common reason for the daytime sleepiness of adolescents.Has this problem been constantly present or does it come and go?Children who have behaviorally reinforced bedtime problems often go to sleep without difficulty with other adults who set clearer limits. Determining this directs treatment and often clarifies the source of the problem to parents. Stress can elicit sleep difficulties at any age. Parents may not have associated stress with the child’s problem,sometimes because they are experiencing the same stress, are tense, are not spending as much time with the child, or have let routines deteriorate. Some sleep disorders are episodic, such as disorders of arousal, which occur in clusters regardless of management.What is your bedtime routine and how does your child respond to it? (Circumstances of bedtime)Obtaining a detailed description of the bedtime routine and how the child acts is essential to understanding and solving any kind of sleep problem.Is bedtime the same time every night?New parents may not realize the power of establishing a regular bedtime and routines to settle their child. This is particularly important for temperamentally irregular infants who do not fall asleep naturally at the same time each night. Establishing a moderately regular schedule for night sleeping and naps also affords the parents some predictability for their days.Because the natural circadian cycle (repeated pattern of daily sleep and wakefulness) is approximately 25 hours, some individuals are vulnerable to shifting day-night cycles over time. This is especially likely when families do not adhere to routines by the clock but allow the child to set his or her own schedule. Children whose clocks are easily shifted need to be kept on the same sleep and nap schedule 7 days per week. Variable bedtimes also may reflect parents’ inability to set limits or a chaotic household.Where does your child sleep?Almost all infants who sleep with parents have sleep associations. As long as the parent stays in the bed, the infant sleeps well, but the adult arising may arouse the infant. Parents who plan to cosleep only for a limited time need an exit plan, such as ending this practice at 6 months of age, before the infant will protest excessively. Overlying deaths of infants have been associated largely with intoxicated, obese, or extremely deep sleeping parents. Safety of bedding should be assured for infants who are not in cribs to avoid suffocation. Specifically, infants never should sleep on a water bed, on soft bedding or with the head covered, or where they may fall through a space large enough to trap their heads, such as between a bed and the wall or on a sofa with moveable cushions. All infants should sleep on their backs in the first 6 months of life to reduce the risk of sudden infant death syndrome.Cosleeping is not associated with any other problems except for disturbed sleep for the adults and is the norm for most cultures. Some studies actually report improved sleep for mothers who cosleep. However, some families may resort to cosleeping as a result of an inability to enforce bedtime, anxiety over separation from the child, guilt over lack of quality daytime interactions, a sense of vulnerability of the child, a desire for the child to remain dependent, or a desire to avoid the spouse. These factors can benefit from intervention.School-age children who demand to cosleep often have significant emotional problems, such as separation anxiety disorder or other excessively dependent behaviors that require counseling. Situations where parents insist on cosleeping should be evaluated for the emotional issues noted for preschool cosleeping plus the possibility of sexual misuse.How much time is there between the last feeding and bedtime?Some parents have unrealistic ideas about feedings and put their young infant in bed when hungry.How long after being put to bed is your child asleep?Humans evolved to sleep in groups for survival because REM sleep leaves them defenseless against predators. Thus, to fall asleep alone, they must feel safe, mostly conveyed by a reassuring bedtime routine and by the parents’ own attitude of comfort. Many infants normally take 10 to 20 minutes of fussing to fall asleep alone. The fussing should be recognized as such by the parents. Chronic crying for more than 20 minutes raises concern about hunger, pain, an excessively early bedtime, or parental inability to provide reassurance.Taking longer than 30 minutes to be put to bed is considered a prolonged routine. This can be seen as a problem of falling asleep even if the parent is complicit in not setting limits because of enjoying the time with the child, feeling guilty after being away all day, being anxious, or avoiding being alone with the spouse. The child may plead charmingly for one more story, game, or glass of water or be tearful. Toddlers and preschool children no longer sleeping in a crib may come out of their rooms after being put to bed, thus prolonging the routine. These “curtain calls” easily are reinforced unintentionally by the parental attention needed to return the child to bed, even if this is done with obvious displeasure. Some children pretend to be fearful at bedtime to gain extra time,although their affect exposes the act. In addition,be sure that a phase shift problem is not the cause of the prolonged routine. In this case, the child is truly not tired at bedtime and will struggle against being put in bed where he or she would be bored or lonely for a long time.Prolonged routines can be prevented through reasonable daily routines and assuring adequate“special” individual time with each parent every day. This reduces child and parent urgency about being together as well as parental guilt. The bedtime routine should be limited to a defined set of activities or length and ended on time. The parent then may notify the child that he or she will not respond to further requests or to“only one more” and must adhere to this. A “one more time” ticket may be offered to provide concrete evidence of parental availability. Parents should be warned not to respond to the excuses that likely will ensue after the last“good night.” Having the parent promise to “check” the child in 5 minutes also can be reassuring.Curtain calls, in addition to the previously noted strategies, require that the parent lead the child back to bed without any talking as many times as necessary. Children succeeding in staying in bed without calling out may be rewarded (eg, with two stories at the next bedtime or a reward in the morning). If they come out or call out, they only receive one story. An alternative is for the parent to inform the child that the door will be closed and the light shut off if the child comes out or calls out. If the child does either, the adult carries out the consequence for a few seconds before opening the door to give the child a second chance. Toddlers who come out may need their doorway gated if they are not mature enough to respond to these other measures. One parent may be better able to set these limits than the other without showing emotion.A child who protests the parent leaving the room can be weaned progressively of this need by having the parent sit silently in the room as the child falls asleep and moving 1 ft closer to the door each night until he or she is out of the room. Feigned fears should be minimized verbally with a brief response or turned into a joke. Real fears at bedtime are discussed later in this article. Some children are noncompliant at bedtime as part of a general noncompliance. Parents may need coaching on limit-setting or referral if discipline is a major problem. Parents who prolong routines to avoid each other may need marital counseling. Domestic discord or violence should be considered as a potential reason for children avoiding bedtime because they worry about how the parents will get along when they are not present to distract them or they can hear their parents fighting.Children older than 3 years of age may resist falling asleep even when tired because of fears. Preschoolers often go through a stage of fearfulness at bedtime. Children older than age 6 may have worries from the day that keep them awake. Children who have asthma or sleep apnea may fear falling asleep because of the associated shortness of breath, even if they are unaware of it.Preschool and early school-age children are most susceptible to fears at bedtime because of their active fantasies yet limited abilities to distinguish reality. Exposure to violent or frightening media or video games can be a major contributing factor and should be eliminated. Fears also may be generated by the child’s daily stresses, such as problems with child care or after-school settings, aggressive peers, learning problems, pressure for the young child to be toilet-trained, problems separating from parents,corporal punishment, witnessing or hearing about violence, moves, sibling birth, or experiencing a loss. Stresses should be reduced as possible and counseling provided when indicated. Sexual issues may result in fears if the child is overstimulated by excessive home nudity, cobathing, or lack of limits on physical intimacy with adults, which should be discontinued. Sexual misuse also can result in bedtime fears, especially if the child was molested in his or her own bed. Some aggressive children have bedtime fears that apparently are in reaction to their own lack of control. Better limits and behavior management during the day tend to resolve the fears. Fears deserve sympathy for the emotion but reassurance that the fear is unwarranted and the adult will keep the child safe. A ritual of the adult “spray for monsters” may be helpful. Having the child help buy a special flashlight to use to check out the room at night provides a sense of mastery. Older children benefit from relaxation exercises (eg, self-hypnosis)accompanied by empowerment stories. Any child may do better with a nightlight as long as it does not interfere with sleep once achieved.School-age children and older children may have trouble falling asleep because of worries or anxiety. It is important to ask directly what they are thinking about while trying to go to sleep. Some stresses may be unknown to the parents yet within their ability to amend. Others may need mental health referral. Certain substances can make it difficult to fall asleep, including caffinated beverages, tobacco, bronchodilators,antidepressants, and stimulants, which need to be asked about and altered. Alcohol withdrawal is another problem that is associated with sleep disorders.Does your child fall asleep in body contact with someone,with a bottle or pacifier, or with the television or radio on?Habits of falling asleep with a person or object may begin as early as the first 2 months of life. These sleep associations make falling asleep independently difficult and may persist for years. The pattern develops when the child habitually falls asleep at the breast or with a bottle or pacifier or simply in body contact with the parent. When placed in the crib asleep, the child reawakens either immediately or later on and cries until the same circumstances are recreated. Repeated arousals may occur every 1.5 to 2 hours at times of lighter sleep or when the pacifier falls out of the child’s mouth.A sleep association also may result in night waking even if there is no difficulty falling asleep initially. The best treatment is to avoid sleep associations by placing the infant in bed awake for naps and at night. The child who already is asleep should be awakened before being placed in bed. This practice should start by the time the child is 2 months old. The infant who has been fed recently in the parent’s arms and fallen asleep should be reawakened. Placing an unwashed shirt that the mother has worn for several days in the crib for the infant to smell has been reported anecdotally as being helpful. If a sleep association already has developed, the parent may have to sit beside the bed or sing to the child as he or she learns to fall asleep independently over several days.Older children may develop a sleep association to radio or television that can delay sleep onset and make return to sleep after night waking difficult. Children will not offer the information that they are falling asleep with electronics on; the clinician must ask.What is the nap routine?Does your child fall asleep for naps in body contact with someone or with someone nearby? Does your child wake up before or after 4 pmwith his or her last nap of the day?Children generally give up the morning nap at about 1 year of age and the afternoon nap at approximately age 4 years. Children older than 4 who still nap may be put down for an unncessary nap or may be falling asleep because of inadequate total sleep at night. In either case, they are not tired at bedtime and, therefore, resist. Adolescents may develop daytime napping, sometimes to avoid homework or family interaction, that effectively shifts their sleep pattern, creating difficulty getting up in the morning. They develop a sleep deficit that is reflected in sleeping in late on weekend mornings. An irregular nap routine or having the child wake up after 4 pm may cause a sleep phase shift or circadian rhythm disturbance because of lack of fatigue at bedtime. Parents may need to investigate the napping being done at child care to solve these problems. Naps for children of all ages must be kept to fewer than 3 hours. New onset of napping can be a sign of illness, depression, or narcolepsy.What is your child’s total sleep time?Total sleep time, including naps, is typically 11.5 to 13 hours for the child between 2 and 4 years of age (Table 6). A 3-year-old child given a 3-hour nap who wakes up at 7 am may not be tired until 10:30 pm! Infants allowed to sleep excessively during the day or to sleep late in the morning are not ready for bed at the time their parents may be. These are considered circadian rhythm disorders or phase shift problems. Appropriate expectations should be established for total sleep and choices made for how the family fulfills these. Children said to “require very little sleep” compared with others their age are often overtired but not being put to bed because of lack of limit-setting or lack of family structure. Setting a reasonable sleep schedule and enforcing it often results in a more pleasant child sleeping more than the parents ever thought possible. Adolescents actually require more sleep than do younger children due to changes of puberty, but they usually get less because of the many demands on their time.Sometimes there is an early phase shift, usually in infants or toddlers, in which the child falls asleep early in the evening but then awakens early in the morning. Parents should make sure the child is not just waking, feeding, and returning to sleep,which requires weaning from the feeding by 1 oz/d,then ignoring any fussing.Children of any age may have a circadian disorder,which can be differentiated from a prolonged bedtime routine or an oppositional disorder by a lack of resistance to going to bed but an inability to fall asleep. In this case, the child is not tired, usually because of excessive or late day napping. The child who has a phase shift usually is being allowed to sleep late in the morning or the child is difficult to arouse and does not feel rested. Either early or late circadian shifts can be adjusted in about 1 week. In late phase shift situations, bedtime initially should be set at the time the child is tired rather than at the desired bedtime to avoid struggles. Bedtime then is advanced by 10 minutes per night until it is at an acceptable hour. The waking time is adjusted initially or simultaneously and both times held constant 7 days per week. Naps,bedtime, and meals can be shifted simultaneously to a desired schedule that matches the child’s sleep needs.Circadian disorders due to daytime naps and sleeping late in the morning are the most common reasons for difficulty falling asleep for school-age children and adolescents. Treatment is as described previously, except that adolescents may be uncooperative about adjusting bedtime when it serves a social or avoidant purpose.Most children awaken during the night; those who do not settle themselves are considered to have a parasomnia. Timing of the waking, reinforcement provided by parents, and the child’s affect are clues to the cause and solution.When is the first waking? ( 3 hours)Specific sleep disturbances are more likely to occur at certain times of the sleep cycle. For example, sleep-wake transition disorders occur while falling asleep; disorders of arousal, which include sleep terror disorder, sleepwalking disorder, and confusional arousals, occur during stage IV sleep. Because the deepest stage IV sleep is in the first cycles of the night, these disorders are most likely to occur in the first 2 hours of sleep. Nightmares are common parasomnias that occur during REM sleep and, therefore, typically present in the last third of the night when more REM occurs.Sleep association is the most common reason for early night waking (<30 min) in infants.Bruxism (grinding teeth during sleep) occurs in 50%of healthy infants at the time of tooth eruption, but it also occurs in children 10 to 20 years of age due to stress. Bruxism also can be caused by dental malocclusion and neurologic conditions. For persistent nightly bruxism,tooth guards can protect the teeth and reduce potential damage to the temporomandibular joint. Relaxation exercises such as self-hypnosis to relax the body at bedtime also can be helpful for older children.Sleep-wake transition disorders are especially common among preschoolers because they have NREM at the beginning of sleep. Among the sleep-wake transition disorders are rhythmic movement disorders, including head banging, sleep starts(jumping movements of the body), and body rocking. Some rhythmic activity at bedtime occurs in 58% of 9-month-olds, decreasing to 33%at 18 months and 22% at 2 years. Head banging is very common, occurring in 3% to 15%of children, often after an initial history of head rolling that started at 6 months of age. It is typically monotonous, occurring 60 to 80 times per minute for fewer than 15 minutes. Children who have intense temperaments are especially prone to this activity. Head banging also may be due to pathologic conditions, including central nervous system injury,headache, ear pathology, sensory deprivation (eg,visual or hearing impairment), neglect, or abuse. Head banging does not cause brain injury, but it can destroy cribs and walls and upset the family. It often can be reduced by kinesthetic stimulation (eg,rocking, dancing) during the evening and holding the child as part of the bedtime routine. Imipramine or hydroxyzine are effective in reducing head banging,but rarely are they needed. Parents may require reassurance that the child is not autistic or retarded because the occurrence of head banging in these conditions is well known.Waking after 60 to 100 minutes of sleep (ie, at the end of the first sleep cycle) may represent confusional arousals in younger children. They sleep so deeply that the transition from stage IV to REM sleep may result in thrashing and moaning episodes that last 5 to 15 minutes and become progressively stronger. These episodes are difficult to interrupt. When multiple arousals occur, they may extend into the second half of the night, although they generally decrease in intensity. Confusional arousals are most common when the child is overtired, the schedule is altered, or the child is upset or ill. Behaviorally caused awakenings during the night can make disturbing partial arousals more likely earlier in the same night. Management of the behavioral problem waking generally resolves the partial wakings. Older children who experience partial arousals may be responding to internal stresses. Most children who have partial arousals can be helped by adequate sleep and a routine schedule, but intervention should be minimal at the time of the episode to avoid reinforcement or the conveying of a sense of concern. In severe cases, a few weeks of a benzodiazepine such as clonazepam 0.125 to 0.5 mg at bedtime may be needed to interrupt the sequence,although prolonged use results in tolerance. A sleep study to confirm the diagnosis is needed only in these cases.One of the most upsetting sleep problems for parents is sleep terrors, which are disordered arousals from stage III or IV that occur after 60 to 90 minutes of sleep. They are characterized by physiologic arousal,including pallor, sweating, pupil dilation, piloerection,and tachycardia. The child may speak but incoherently,is not responsive to others, and even may thrash violently. Usually the child does not remember anything in the morning. Sleep terrors occur in 3% of children, mostly from 18 months to 6 years of age, and do not reflect mental health problems at these ages,although they may be stress-related. There is often a family history of sleep terrors, enuresis, sleepwalking,or talking in the sleep, which are all disorders of arousal. Fatigue, stress, a full bladder, or loud noises may precipitate sleep terrors. They tend to occur in bouts of up to 20 per night for several weeks, then disappear, only to recur several weeks later. Parents should be reassured about the benign nature of sleep terrors and the tendency to resolve around age 6 to 8 years of age. The bladder should be emptied routinely at bedtime and the environment kept dark and quiet. Awakening the child 30 minutes before the expected episode (generally 1 hour into sleep) each night for about 1 week may interrupt the pattern. A 30- to 60-minute afternoon nap also can reduce stage IV sleep, thereby decreasing episodes. Brief sedation with diazepam can reduce the frequency of episodes, but they may recur when it is weaned or tolerance occurs. Having a parent sleep in the child’s room may be helpful, presumably because it reassures the child and possibly alters sleep stages. Seizures should be considered only in intractable cases or when the onset is in adolescence.About 15% of children sleep walk at some time; 1% to 6% of children have 1 to 4 attacks per week, mostly between ages 4 and 12 years. Sleep walking, like other disorders of arousal, occurs in stage IV, generally 60 to 120 minutes into sleep. During sleep walking, children are uncoordinated, are difficult to arouse, and tend to wander in illogical places, often urinating outside the toilet. Sleep walking, like other disorders of arousal, can be triggered by excessive fatigue, changes in routines, and daily stresses. Chronic sleepwalkers need to be safeguarded carefully to avoid self-injury. Alarms and door or window locks may be necessary. There is amnesia for the event in the morning. Sleepwalking usually can be differentiated from dissociative states or seizures by history or videotapes.In the first month of life, infants may have trouble falling asleep at night because they are getting their longest stretch of sleep during the day, which is known as day-night reversals. A concern about this presents a valuable opportunity to assess parental coping and maternal depression and to help first-time parents understand their important roles in the child’s physiologic regulation. Day-night reversals can be shifted by establishing a general bedtime, keeping the lights off or low, and minimizing handling and interaction during nighttime feedings. In the morning, lights should be bright and social interaction encouraged. A bath may soothe some infants or arouse others. Parents can use this effect to help regulate sleep by shifting its timing. If the infant sleeps more than 3 hours during the day, he or she can be awakened, ideally watching for active sleep and then arousing, which tends to be more effective.Infants not sleeping more than 5 hours after midnight for 4 weeks by 4 months of age are considered to have delayed settling. Typically,70% of 3-month-old