Sleep problems

3.13 Sleep problems





The physiology and function of sleep


Sleep is defined as ‘a natural and periodic state of rest during which consciousness of the world is suspended’. This is brought about by complex interactions between the reticular activating system and the diffuse set of neuronal centres that facilitate different aspects of sleep. The most important factor appears to be the desynchronization with the cortical centres that are related to consciousness. Sleep has been further differentiated with the help of electroencephalography (EEG) and the current convention for staging of sleep is EEG based. In infancy it is differentiated as active and quiet sleep, and as the development progresses characteristic features are noted and the sleep is broadly divided as rapid eye movement (REM) and non-rapid eye movement (NREM) sleep. The usual pattern is to cycle through these stages throughout the night and to arouse (often at stage changes) a number of times during the night. This structure is often referred to as sleep architecture. The total amount of sleep from birth to adolescence is shown in Figures 3.13.1 and 3.13.2.




Although sleep has been studied extensively over the past few decades, the exact function of sleep has not been fully discerned. However, there is a reasonable amount of information available to attribute the following functions to sleep:





Behavioural aspects of children’s sleep


Unlike adults, infants and young children do not often present with problems in their sleep. The parents present their problem. It is important to evaluate the symptoms properly and assess whether there is a sleep disorder present or just a variation of the normal. The treatment, if any, should be for the child primarily and not necessarily to fulfil parental desire. Age-specific common non-respiratory sleep problems are shown in Table 3.13.1.



Common problems encountered are those of difficulties with sleep initiation, sleep maintenance and circadian scheduling problems. Sleep initiation problems often are related to not being able to self-settle and are common in children with attention-deficit/hyperactivity disorder (ADHD) or autistic spectrum disorders, as well as in some typically developing children. They can also relate to poor routines, limit-setting problems and anxiety issues inherent in the child. It is important, as with adult insomnia, to address what is going on at this time and predisposing factors that may contribute to the difficulty settling. A sleep initiation problem will often lead to a circadian shift and thus to difficulties in getting up in the morning. Practical issues need to be addressed and can be done so with:



Children will generally need to learn how to self-settle. Methods such as controlled crying work but are often difficult for tired parents to implement. Often, focusing on the sleep initiation and utilizing a camping-out technique are more acceptable to parents.




Sleep phenomena or parasomnias in children


Parasomnias are undesirable motor, autonomic or experiential phenomena that occur exclusively or predominantly during the sleep state. Parasomnias have sleep state-related features and most of them are benign. The majority of these decrease in frequency as the child gets older. Some of them exhibit familial links and may change with time. The predominant management issue is safety. Parents should be alerted if a child is sleepwalking; this can usually be managed by bells or alarms placed on a child’s doors or windows. Night terrors can be particularly alarming for some, but the child usually remains unaware of the problem – unlike nightmares, where a child will awaken after a bad dream and have good recall of the dream. Night terrors usually occur earlier in the night and, like most parasomnias, can become worse if the child is woken. They are often also worse if a child is tired; hence many children present with night terrors as they begin to give up their daytime sleep.


Table 3.13.2 gives a simplified summary of parasomnias with prevalence rates from a large population study.




image Clinical example


James is a 5-year-old boy who presents with a story of frequent night waking with screaming. He has trouble getting off to sleep and has been very tired, often falling asleep on the drive home from school, but when it comes to time for bed he won’t sleep unless his mother lies down with him. He will then wake frequently during the night with two types of episode – one usually before his parents go to bed and others later in the night. The first ones are the worst, where he is so upset he cannot be comforted. In the later ones during the night, James wakes crying and comes to get a parent but then won’t go back to bed unless they are with him.


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Aug 4, 2016 | Posted by in PEDIATRICS | Comments Off on Sleep problems

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