Sleep problems

3.13 Sleep problems



Sadasivam Suresh, Helen Heussler



Introduction


Sleep is a universal phenomenon in the animal kingdom. The role of sleep in human beings has been studied with increasing interest over the last 60 years. This has resulted in increased awareness of sleep medicine as a separate entity. This chapter focuses on some of the aspects of paediatric sleep medicine: the physiology and function of sleep, development and maturity of sleep, parasomnias, behavioural aspects of children’s sleep, the spectrum of paediatric sleep disorders and its role in future morbidity of the individuals.



‘If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process ever made.’


Dr Alan Rechtshaffen, Sleep Research Pioneer



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.


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Fig. 3.13.1 Total sleep time through the ages.


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Fig. 3.13.2 Total sleep time with a rapid eye movement (REM)/non-rapid eye movement (NREM) split.


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:



• Sleep is noted to restore and recuperate the human body to optimal daytime functioning (restoration theory). NREM sleep is thought to function in reparation of body tissue and REM sleep in restoration of brain tissue.


• Sleep is considered important in the process of learning and memory (learning theory). The unlearning theory complements this process by handling the clutter of information and removing non-essential information in an orderly fashion, thereby facilitating enhanced learning.


• Sleep is considered a facet of evolutionary development, and complexity of sleep is attributed to the complex nature of the human physiological system.



Development and maturity of sleep


Similar to many aspects of development, sleep also undergoes changes with age. The physiological aspects that evolve during the early years are maturation of the EEG, development of cardiorespiratory reflexes, establishment of the circadian rhythm and consolidation of sleep architecture. Some 95% of infants cry with a night awakening that requires a parental response. By the age of 1 year, 60–70% of these infants are able to go back to sleep on their own. The ability to self-soothe and return to sleep is the most important aspect for consolidated sleep as awakenings are a normal part of a night sleep, even in adulthood. Self-sleep initiation is a learned phenomenon and is essential for establishment of sleep continuity (‘sleeping through’). Minor arousals will continue to be seen, but will not require external intervention. Sleep maturation is linked to intellectual development in children.



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.



Table 3.13.1 Commonest non-respiratory sleep disorders

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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:



• a stable routine that helps with entrainment (external factors that help keep circadian scheduling in a regular pattern)


• settling procedures/relief of anxiety


• entrainment of circadian schedule with regular and stable wake-up and bedtimes


• comfortable non-stimulatory environment


• removal of technology from the bedroom (e.g. televisions, mobile phones, game equipment).


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.



image Practical point




• Camping out involves a parent sleeping on a mattress or chair in the child’s room until the child is going to sleep in his/her own bed and then gradual removal of the parent from the room.



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.



Table 3.13.2 Parasomnias with population prevalence

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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.



What other information might you like?


Family history is important, as these problems tend to have a familial pattern. Children usually have no daytime nap by the age of 5 years and continuation of daytime napping will have impact on night sleep patterns. The dietary intake of children could have an impact on sleep routine. Habituation of sleep patterns are important and exactly what his mother does at each wake time will have an impact on either exacerbating or reducing the problem.

Related posts:

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  3. Resuscitation
  4. The newborn infant: stabilization and examination

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

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