Behavioral Sleep Problems

Educational Objectives

The goal of this program is to improve the management of behavioral insomnia in children. After hearing and assimilating this program, the clinician will be better able to:

1. List the number of hours of sleep required by children of different ages.

2. Differentiate between the 2 subtypes of behavioral insomnia in children.

3. Use appropriate management techniques for the
2 subtypes of behavioral insomnia in typically
developing children.

4. Provide families with recommendations on
sleep training techniques.

5. Advise parents about the use of melatonin in children.

Summary

Focus of lecture: typically developing children (ie, not those with autism or attention-deficit/hyperactivity disorder [ADHD]); insomnia in adolescents similar to adult disease

Importance of sleep in children: sleep primary activity of brain during early development; by 2 yr of age, ≈13 mo spent asleep (≈10,000 hr); sleep important for brain development; large amount of sleep required before 2 yr of age; children aged 2 to 5 yr spend equivalent amounts of time asleep and awake; assess amount of sleep at well-child visits; school-aged child spends ≈40% of day asleep; adults spend ≈33% of time asleep; lack of sleep (difficulty falling asleep or sleeping through night) source of significant family frustration; parents may refrain from reporting difficulties, and may seek information online or from family members, which may be conflicting or confusing; parents may medicate children inappropriately (eg, multiple nights of diphenhydramine [Benadryl], frequent use of melatonin)

Tools available to parents: over-the-counter sleep aids — many formulations created and marketed for children (eg, melatonin, lemon balm extract, valerian root); adults can experience rebound insomnia with regular use of valerian; products not regulated by Food and Drug Administration (FDA) and ingredients often unknown; sleep training — books and literature available to support wide range of practices and views, from Ferber method to “cosleeping”; parents received mixed, confusing messages while evaluating apparently good data; sleep coaching and consultation — performed in person or over telephone; expensive

Normal sleep in infants: newborns — 16 to 20 hr each day, broken into blocks of 3 to 4 hr, followed by 1 to 2 hr awake; normal circadian rhythm not established until ≈6 mo of age; nocturnal sleep equivalent to sleep during day; sleeping cues highly linked to feeding and hunger; breastfed babies wake more frequently (breast milk more quickly digested); remind parents about sleep safety (place infant supine, without extra bedding, pillows, or objects around face, in normal-temperature environment); milestones — by 8 to 12 wk of age, sleep begins to consolidate overnight (not necessarily sleeping through night); by 2 to 3 mo of age, electroencephalography shows more mature pattern of sleep (initial non–rapid eye movement [REM] sleep, with more REM sleep [active sleep] during second half of night); infants, unlike adults, may directly enter into REM sleep and do not exhibit normal cycling through sleep stages; infants experience many awakenings during night (prolonged periods likely related to feeding); intervention (eg, feeding, holding) not always necessary; by 8 to 12 wk, infants start to self-soothe and settle to sleep

Advice for parents: instead of allowing infant to fall asleep while feeding or being held, place drowsy infant in crib (child may fuss briefly); when normal arousals occur, infant able to return to sleep independently; present sleep and self-soothing to parents as developmental skills; reframe parental question about sleeping through night as “when will baby stop needing parental intervention to fall back asleep” (individuals of all ages awaken multiple times throughout night); age at which this occurs variable; at 6 mo of age, ≈50% do not require overnight intervention (ensure infant developing and growing normally, ie, feeding not required); at 12 mo of age, ≈90% of infants with normal development and weight gain do not require intervention

Normal sleep in toddlers and preschoolers: toddlers — 12 to 14 hr required; by 18 mo of age, most children require only one nap per day; normally developing child has separation anxiety that can lead to anxiety about bedtime and nighttime fears; consistent bedtime routines and transitional objects important; transition to toddler bed when child climbing out of crib; preschoolers — 11 to 12 hr required; cessation of napping depends on environment, amount of overnight sleep, and individual sleep needs; most children stop napping between 3 and 5 yr of age; children exhibit increased independence, limit testing, imagination, and fantasy thinking (eg, fear of monster under bed); children also increasingly able to appreciate delayed gratification (has bearing on use of positive reinforcement [eg, sticker chart]); children in structured school environment may begin to exhibit daytime behavior problems related to poor sleep

Normal sleep in school-aged children: 10 to 12 hr required; demands begin to increase and conflict (eg, sports, homework, electronics, early school start time); children may need catch-up sleep on weekends; child may exhibit circadian preference, with trouble falling asleep at desired time, wanting to sleep later in morning, and sleeping in on weekends (ask about parents’ preference [familial tendencies]); unlike adults with sleep deficit, children typically able to stay awake but may be irritable, impulsive, and hyperactive; when assessing for ADHD, ensure adequate quality and quantity of sleep

Adolescent sleep: total sleep needs slightly higher than in adults (8-10 hr); melatonin increases in evening with exposure to dim light; this increase delayed during puberty by ≈2 hr; consequently, almost all teenagers exhibit “night owl” tendency despite early school start times; pattern of restricted overnight sleep, sleep debt, napping in afternoon (exacerbating delayed sleep phase) develops, with catch-up sleep on weekends; competing demands include social media, school, and electronics; delayed high school start times found to decrease rates of automobile accidents and differences in learning

Behavioral insomnia (BI): occasional insomnia normal; pathologic BI defined as difficulty falling asleep, staying asleep, sleeping until desired age-appropriate time, or requiring intervention by parent or caregiver; occurs ≥3 days/wk for ≥3 mo; daytime functioning affected; not explained by insufficient time for sleep or other medical condition; occurs in ≤30% of children; usually does not require polysomnography for diagnosis; in typically developing children, usually does not require medical therapy (including melatonin); parents require consistent and practical advice, with concrete recommendations for expectations and management; evaluation — address any sleep-related medical conditions (eg, obstructive sleep apnea, uncontrolled eczema or asthma, nocturnal coughing); based on age of child and symptoms, determine category of BI, as recommendations and management differ

Sleep-onset associations BI: typically seen at <12 mo of age; falling asleep extended process requiring special conditions (eg, bottle, nursing, rocking, presence of parent near crib); associations highly demanding and not readily available in middle of night; if infant used to being held or rocked at beginning of night or 2 to 3 times during night, self-soothing mechanisms never develop; in absence of special conditions, sleep onset delayed and nighttime awakenings require caregiver intervention; rather than falling back asleep after partial arousal, child becomes agitated (with elevated heart rate), fully awake, and crying, leading to prolonged awakening

Recommendations: establish routine — at ≈2 mo of age, before behavior becomes problematic, have parents put infant in crib while drowsy but awake; use developmentally appropriate strategies and transitional objects; child must receive consistent message; ensure overnight feeding not medically necessary (eg, preterm infant); if behavior already problematic, move last nursing session earlier and out of infant’s room; feed before sleep drive sets in to keep infant awake; place in crib when drowsy; take level of parental anxiety and tolerance into account when recommending number of minutes to allow fussing or crying; after time elapses (use timer), parent may enter room, reassure child verbally, and pat on back; choice of method — method (eg, extinction, graduated extinction) not important (prescribe method parents can tolerate); provide written copy of plan to both parents; most parents seeking help do not tolerate extinction method; extend interval of check-ins each day; advise that intervention may take 2 wk (schedule for time when consistency possible); “extinction burst” often occurs during first 2 to 3 days (extended period of crying; behavior worsens before improving); follow up in 2 to 3 wk; parental log of sleep time provides visual record of improvement

Limit-setting BI: often more challenging to manage than sleep-onset associations BI; child has difficulty initiating or maintaining sleep, refusing to go to bed at appropriate time or to return to sleep after normal nocturnal awakenings; caregiver demonstrates inappropriate or insufficient limit setting to establish appropriate routine; sometimes, other behavioral concerns related to limit setting; often seen in toddlers and preschool-aged children (overlap possible with sleep-onset associations); children have frequent “curtain calls,” inventing reasons to leave bed (eg, hug, glass of water) for extended period of time; too much time in bed exacerbates problem (eg, parents set bedtime for 7:00 PM, child wakens at 6:30 AM and takes 1-2 hr nap); child may have anxiety about being alone or exaggerated nighttime fears; child may be using normal nighttime fears as way of stalling bedtime rather than having true anxiety

Recommendations: encourage parent to engage in concrete discussion rather than using, eg, “monster spray” (eg, “I know it’s dark but there are no monsters”); consistent approach especially important in this age group and this subtype of BI; use age-appropriate positive reinforcement; match child’s physiologic sleep needs with time in bed (including nap time); ask about naps at daycare (child often does well with consistent routine and timing); bedtime fading — delaying bedtime until closer to typical sleep time; if bedtime 7:30 PM and child typically delays for 90 min, delay bedtime until 9:00 PM to increase physiologic sleep drive and reduce anxiety about bedtime; once sleep-onset latency ≈15 min, gradually move bedtime earlier by 5 to 10 min daily (may not match original bedtime); “hall pass” — can be traded for, eg, trip to bathroom; gives child some control but represents last time out of bed; immediate reward for good behavior important (eg, sticker on chart in morning; offering prize at end of week for 5 nights of good sleep ineffectual for very young children); other advice — avoid intermittent reinforcement; follow up for troubleshooting and review of sleep logs

Real-world challenges to sleep training: conflicting parenting styles (eg, one more stern, one with lower tolerance for crying) lead to inconsistencies in reinforcement; write down recommendations as prescription and discuss with both parents; children may have multiple caregivers with different approaches; home environment (eg, presence of siblings, sharing room with parents)

Long-term effects of sleep training: none; Gradisar et al (2016) — enrolled infants with difficulty sleeping; 6 of 67 mothers screened positive for depression; 43 infants randomized to graduated extinction, bedtime fading, or control (educational pamphlet about sleep); infants and mothers followed over 12 mo; used parental report and actigraphy to assess 4 measures of sleep (sleep-onset latency, wake after sleep onset, number of awakenings, and total sleep time); statistically significant improvement exhibited in all 4 measures with either method of sleep training; total sleep time best in graduated extinction group; no statistically significant difference seen in morning cortisol level; afternoon cortisol slightly decreased in infants graduated extinction group; maternal stress reduced in both training groups; no differences in maternal mood; at 12 mo, infant emotional scores (related to behavioral problems) showed no difference; no differences seen in parent-child attachment scores; Price et al (2012) — no differences at 5 yr in multiple measures of child-parent emotional health (positive or negative); practitioners can confidently give advice on improving infant sleep habits to improve short-term outcomes (eg, maternal stress, depression) without long-term effects on child or relationship with parent

Melatonin: parents often give to children without consulting clinician; naturally occurring neurohormone; bright light (from, eg, television, smartphone) can inhibit production as retinohypothalamic tract inhibited by light or other environmental factors; normally, signal to suprachiasmatic nucleus (circadian pacemaker) causes surge of melatonin that peaks at sleep onset and decreases in morning; safety in children — short-term use “probably safe,” but data limited; melatonin has anti-inflammatory (antioxidative) effects; studies in preterm infants given high doses show no significant effects (≤10 mg/kg per dose for 10 doses); several studies in children with neurodevelopmental disorders (most using doses of 0.5-10 mg) show no serious adverse effects with short-term use; reported adverse effects same as in adults (headache [especially with high doses], grogginess, nausea, daytime sleepiness); some animal studies show effect on seasonal reproduction and decrease in function of hypothalamic-pituitary-gonadal axis; study of ≈30 adolescents over 2 to 3 yr showed no change in pubertal development; more studies needed to establish safety of use in children; potential candidates — reasonable data support use in children with autism (may lack normal peak in melatonin); fewer data available for children with ADHD; those with special neurologic conditions (especially blindness) may benefit

Dose: FDA regulates as dietary supplement, not as medication (less stringent); in Europe and Australia, available only by prescription; study of ≈50 brands — found high variability in amount of melatonin, often not matching amount listed on label; serotonin present in >25%; lower doses (0.5 mg, 1 mg) had highest variability; chewable and liquid formulations had higher variability than tablets and capsules; valerian root and hops present in some; mean variability in 1-mg tablet ≈100%, with highest variability in chewable form (1-2 mg in tablet); between lots of same brand, highest level of variability ≈500% (eg, 2-mg chewable tablet could contain 10 mg)

Point to consider: melatonin may be effective (even as placebo effect) but may send wrong message about using medication rather than behavioral approach

Questions and answers: melatonin — speaker does not recommend prescribing >2 mg; sleep safety — American Academy of Pediatrics discourages bed sharing at <12 mo of age (room sharing acceptable); risk for sudden infant death syndrome (SIDS) decreases after 4 mo of age; in infants >6 mo, room sharing may lead to BI or unsafe behaviors (eg, bed sharing); monitoring sleep — SIDS monitors not approved; speaker discourages use of smartphone apps to observe sleep

Readings

Badin E et al: Insomnia: the sleeping giant of pediatric public health. Curr Psychiatry Rep 2016 May;18(5):47; Baweja R et al: Sleep problems in children. Minerva Pediatr 2013 Oct;65(5):457-72; Bruni O et al: Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol 2015 Mar;19(2):122-33; Carter KA et al: Common sleep disorders in children. Am Fam Physician 2014 Mar 1;89(5):368-77; Danner F et al: Adolescent sleep, school start times, and teen motor vehicle crashes. J Clin Sleep Med 2008 Dec 15;4(6):533-5; Erland LA et al: Melatonin natural health products and supplements: presence of serotonin and significant variability of melatonin content. J Clin Sleep Med 2017 Feb 15;13(2):275-81; Falbe J: Sleep duration, restfulness, and screens in the sleep environment. Pediatrics 2015 Feb;135(2): e367-75. doi: 10.1542/peds.2014-2306; Ferber RA: Behavioral “insomnia” in the child. Psychiatr Clin North Am 1987 Dec;10(4):641-53; Galland BC et al: Normal sleep patterns in infants and children: a systematic review of observational studies. Sleep Med Rev 2012 Jun;16(3):213-22; Gradisar M et al: Behavioral interventions for infant sleep problems: a randomized controlled trial. Pediatrics 2016 Jun;137(6): pii: e20151486. doi: 10.1542/peds.2015-1486; Grigg-Damberger M et al: Treatment strategies for complex behavioral insomnia in children with neurodevelopmental disorders. Curr Opin Pulm Med 2013 Nov;19(6):616-25; Honaker SM et al: Sleep in pediatric primary care: a review of the literature. Sleep Med Rev 2016 Feb;25:31-9; Minges KE et al: Delayed school start times and adolescent sleep: a systematic review of the experimental evidence. Sleep Med Rev 2016 Aug;28:86-95; Nunes ML et al: Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach. J Pediatr (Rio J) 2015 Nov-Dec;91(6 Suppl 1):S26-35; Owens JA et al: Insomnia in infants and young children. Pediatr Ann 2017 Sep 1;46(9): e321-e326. doi: 10.3928/19382359-20170816-02; Owens JA et al: Pediatric insomnia. Pediatr Clin North Am 2011 Jun;58(3):555-69; Price AM et al: Five-year follow-up of harms and benefits of behavioral infant sleep intervention: a randomized trial. Pediatrics 2012 Oct;130(4):643-51; Salti R et al: Age-dependent association of exposure to television screen with children’s urinary melatonin excretion? Neuro Endocrinol Lett 2006 Feb-Apr;27(1-2):73-80.

Disclosures

For this program, members of the faculty and the planning committee reported nothing to disclose.

Acknowledgements

Acknowledgments

Dr. Strang was recorded at Pediatric Perspectives 2018: Issues in Pulmonology, Infectious Diseases, and Newborn Care, presented by the Nemours/Alfred I. duPont Hospital for Children, the CME office of Nemours Children’s Health System, and Christiana Care Health System, and held September 7-9, 2018, in Rehoboth Beach, DE. For information about upcoming CME conferences from the Nemours Children’s Health System, please visit www.pedsuniversity.org. The Audio Digest Foundation thanks Dr. Strang, the Nemours/Alfred I. duPont Hospital for Children and the CME office of Nemours Children’s Health System, and Christiana Care Health System for their cooperation in the production of this program.

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Lecture ID:

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