Insomnia

Priya Prashad, MD

Introduction/Etiology/Epidemiology

•By 3–6 months of age, an infant’s circadian rhythms have matured to the point where the infant may begin to sleep through the night.

•During the first 6 months of infancy, parents should begin to establish healthy sleep habits to prevent later sleep problems.

•One of the main sleep problems to arise during the developmental period of 6 months to 2 years is difficulty with self-soothing.

•Bedtime problems and frequent night awakenings are highly prevalent in young children, occurring in 20%–30% of infants, toddlers, and preschoolers.

•Chronic insomnia is defined as difficulty initiating and maintaining sleep, waking up earlier than desired, resisting going to bed on an appropriate schedule, or having difficulty sleeping without parent or caregiver intervention ≥3 times a week for ≥3 months.

Pathophysiology

Behavioral Insomnia of Childhood

The classic description of behavioral insomnia of childhood includes 3 types:

•Sleep-onset association type: Children become dependent on specific sleep-onset associations (eg, rocking, feeding, parental presence) to fall asleep at bedtime and to return to sleep. For older children, sleep onset may be associated with watching television or the use of other electronics.

•Limit-setting type: Children refuse to go to bed and/or make repeated requests or attempts to delay bedtime (eg, asking to use the bathroom or to read one more story). Parents demonstrate difficulties in adequately enforcing bedtime limits.

•Combined type: This occurs when a child has a negative association with sleep, coupled with resistance or refusal to go to bed, due to a lack of limit-setting by caretakers.

Psychophysiological Insomnia

•For older children and adolescents, problems with initiating and maintaining sleep are typically described by the term psychophysiological insomnia from the adult literature.

•The individual’s heightened anxiety makes falling asleep more challenging, which in turn makes sleep a more negative experience and may lead to a vicious cycle.

Delayed Sleep Phase Syndrome