Circadian Rhythm Sleep Disorders

Chapter 104


Circadian Rhythm Sleep Disorders

Deborah M. Brooks, MD, and Lee J. Brooks, MD, FAAP


Circadian rhythm basics

Circadian rhythms are the body’s (typically) 24-hour clock, controlled by the suprachiasmatic nucleus (SCN) in the brain.

The circadian clock is regulated or “set” primarily by visual cues of light from the eyes to the SCN (see Figure 104-1). This keeps the clock synchronized to the 24-hour day. Other time cues (zeitgebers) also influence the clock’s timing—for example, meal, social, and exercise schedules.


Figure 104-1. The suprachiasmatic nucleus is the body’s “master clock” that uses light and other zeitgebers to control all of the body’s clocks.

The SCN regulates release of melatonin by the pineal gland. Melatonin is the main sleep hormone. It is secreted about 2 hours before natural sleep time, and levels are highest in the middle of the night.

Circadian rhythm sleep disorders (CRSDs)

CRSDs are a timing problem with wake and sleep—either a problem with the internal body clock or a mismatch between the internal clock and the environment.

Symptoms include trouble falling asleep, trouble staying asleep, waking up too early, or poor quality of sleep—functioning must be impaired for it to be considered a disorder.

Common to these disorders is inflexibility: Even when physically tired or sleep deprived, sufferers cannot make up for lost sleep outside of their endogenous sleep times.

Types of CRSDs include

Advanced sleep phase

Delayed sleep phase

Jet lag

Shift work

Irregular sleep phase

Non–24-hour sleep-wake rhythm disorder

Advanced Sleep Phase


Sleep and wake times are habitually early when compared with conventional times, such as in “morning people” or “larks.”

This is more common in older adults.


Possibly a shortened circadian rhythm


Extreme sleepiness in the late afternoon or early evening

Involuntary early-morning awakening

Delayed Sleep Phase


Sleep and wake times are habitually later than conventional times, such as in “evening people” or “owls” (Figure 104-2).

Earlier wake-up times can lead to daytime sleepiness and impaired work and school performance.


Figure 104-2. Normal sleep phase and variations.

It is more common among adolescents and young adults, with a reported prevalence of 7%–16%.

Forty percent of affected individuals have a positive family history.


An etiologic origin is possibly an exaggerated reaction to the normal shift in the internal clock that is seen in adolescents after puberty.

Because of the delay in falling asleep and yet still needing to get up at the required time for work or school, children or adolescents often experience excessive daytime drowsiness as a result of not getting enough sleep (this is most evident on weekdays). The delayed rhythm is coupled with a delay in the cycle of the night hormone melatonin, which lingers in the morning and makes it harder to wake up.


The patient awakens late.

Inability to fall asleep at the desired time usually manifests as insomnia complaints. It may be exacerbated by the social pressures teenagers feel to stay up late (eg, to do homework or to use the Internet or a cell phone).

Inability to wake up at the desired time and excessive daytime sleepiness are usually the most common complaint because it is more readily evident to parents than the nighttime insomnia.

Jet Lag


Jet lag occurs when long travel by airplane quickly puts a person in another time zone and the person must sleep and wake at times that are misaligned with his or her body clock.

The body clock is slightly longer than 24 hours. This makes it easier to travel westward than eastward because it is easier to delay sleep than to advance sleep.

Jet lag affects all age groups.


Disturbed sleep

Decreased alertness and impaired daytime function

Occasionally, gastrointestinal distress and general malaise

Depressed mood, irritability, and anxiety

Shift Work


This occurs when a person’s work hours are scheduled during the normal sleep period.

It is not common in children.

The primary etiologic origin is the opposition of required sleep and wake times to one’s endogenous circadian rhythm of sleep and waking.


Sleepiness during the work shift

Difficulty sleeping while others are awake

Shortened sleep duration by 1–4 hours

Irregular Sleep Phase


This is characterized by lack of a clearly defined circadian rhythm of sleep and waking.

It is commonly associated with developmental disorders in children and in adults with neurodegenerative diseases and brain tumors or traumatic brain injury.


The etiologic origin is likely central degeneration of SCN neurons.

Decreased exposure to or input of external synchronizing agents (zeitgebers), such as light and activity, results in a weakened central circadian rhythm.


Sleep is fragmented into a series of at least 3 naps that occur throughout a 24-hour period.

Total sleep time is usually normal for the patient’s age.

Non–24-Hour Sleep-Wake Disorder


This disorder is characterized by fluctuating periods of insomnia and/or excessive sleepiness that occur because the intrinsic circadian pacemaker is not entrained to a 24-hour light-dark cycle.

Most individuals with this disorder are totally blind, and the failure to entrain circadian rhythms is related to the lack of light input to the SCN.

Occasionally, the disorder is associated with mental retardation or dementia.


A person’s day length is longer than 24 hours. Sleep times get progressively later and later, so the person is eventually sleeping during the day until he or she cycles back to a nighttime bedtime.

Differential Diagnosis

The presence of sleep disorders, including obstructive sleep apnea (OSA), narcolepsy, and restless legs syndrome, among others, needs to be considered.

In addition to comorbid sleep disorders, psychiatric disorders—particularly depression and anxiety—are common in patients with nearly all types of CRSDs and should be considered in the differential diagnosis.

Children and adolescents with a delayed sleep phase may experience depression and other psychiatric problems, including behavioral problems, as a result of daytime drowsiness and missing school. Daytime drowsiness can also lead to lowered academic performance from missed school days or tardiness and inattention. Dependency on caffeine, sedatives, or alcohol may also be seen.

Diagnostic Considerations

The diagnosis of all CRSDs is based on a careful history and review of a sleep diary with actigraphy.

In addition to the typical symptomatology, diagnosis of irregular sleep phase requires a history of a minimum of 3 irregular sleep-wake cycles in a 24-hour cycle, recorded for 14 days in a sleep diary and/or with actigraphy.

Polysomnography (PSG) is not routinely indicated to establish the diagnosis. However, PSG is indicated to assess the presence of other comorbid sleep disorders, such as OSA syndrome and narcolepsy.


All patients and parents should be encouraged to practice sleep hygiene (see Chapter 96, Sleep Disorders: Evaluation and Prevention).

Non–24-hour sleep-wake disorder

This disorder is treated via timed, exogenous melatonin administration. One method is to give the patient 3 mg of melatonin 1 hour before the desired bedtime. Entrainment typically occurs between 3 and 9 weeks. After entrainment, melatonin must be continued at a lower dose (0.5 mg) nightly to prevent relapse.

Tasimelteon, a melatonin receptor agonist, has been approved for use in adults with non–24-hour sleep disorder.

In patients with some remaining sensitivity to light, morning bright-light therapy (2,500 lux for 2 hours daily on awakening) may be effective.

Irregular sleep phase

Bright-light therapy

Exposure to 3,000–5,000 lux of bright light for 2 hours every morning for 4 weeks has been shown to improve daytime alertness, decrease napping, consolidate nighttime sleep, and reduce nocturnal agitation.

Structured social and physical activity (9:00–10:30 pm and 7:00–8:30 pm daily for 2 weeks)

Minimizing noise and light during the scheduled sleep period and addressing issues such as nocturia (or nocturnal polyuria) and enuresis to reduce sleep disturbances at night

Delayed sleep phase

Good sleep habits

Going to bed and waking up at the same times on weekends as on weekdays

Avoiding caffeinated products; avoiding other stimulants and products that can disrupt sleep (eg, alcohol, sleeping pills, nicotine)

Maintaining a cool, quiet, and comfortable bedroom and avoiding activities before bedtime that are stimulating (eg, computer games and television)

Avoidance of light at night

Shifting the bedtime schedule

Advancing the internal clock simply involves moving the bedtime a bit earlier on each night, until the desired bedtime is reached. For example, set the bedtime at midnight on one night, 11:45 pm on the next night, 11:30 pm on the following night, and so on. This is facilitated by concomitantly moving the waking time to allow this transition to occur with more control. These methods are best individualized with the help of a sleep specialist.

Delaying the internal clock involves moving the bedtime sequentially ≥1–3 hours later on successive nights until the desired bedtime is reached. This requires several days free from social activities and may be best attempted during a long school break or vacation period. The rationale behind this strategy is that it is much easier for the body to adjust to a later bedtime than an earlier one. Again, this is best accomplished with advice from a sleep specialist.

Bright-light therapy

Exposing the child to bright light for approximately half an hour in the morning helps to reset the body’s internal clock. Reduced exposure to bright light in the evening also helps.

Taking melatonin about an hour before the desired bedtime may help shift the circadian clock.

Advanced sleep phase

Sleep-wake scheduling

Time light exposure in the evening and avoid light in early morning hours.

Melatonin or hypnotics may be beneficial for sleep maintenance insomnia.

Jet lag


For greatest effectiveness, melatonin should be taken at the target bedtime, optimally starting 3–4 days before departure.

Light therapy

Strategic exposure and avoidance of exposure to light have been used as an effective treatment approach.

Additional treatment options include maintaining home-based sleep hours for brief travel, short-term use of hypnotics for insomnia, and caffeine to alleviate daytime sleepiness.

Resources for Families

What Is Delayed Sleep Phase Disorder? (National Sleep Foundation). disorders

What Are Circadian Rhythm Sleep Disorders? (Circadian Sleep Disorders Network).

Circadian Rhythm Sleep-Wake Disorder Symptoms (PsychCentral).

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Aug 22, 2019 | Posted by in PEDIATRICS | Comments Off on Circadian Rhythm Sleep Disorders

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