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Am Fam Physician. 2000;61(9):2805-2806

The most common sleep disorders in children, night waking and difficulty initiating sleep, are believed to affect about 20 percent of children one to three years of age and about 10 percent of children four and five years of age. These disorders cause significant distress and adverse effects in children and their families, but treatment remains controversial. Many families and health care professionals oppose the use of sedatives in young children. Conversely, behavioral-based treatments may be impractical or unacceptable to families. Ramchandani and colleagues reviewed the literature regarding the efficacy of treatments of sleep disorders in young children.

MEDLINE, current abstracts and references were reviewed to identify relevant studies. The authors also contacted drug companies and content experts to review unpublished work or studies not identified by conventional searches. Inclusion criteria consisted of randomized controlled studies of young children with a sleep disorder that was recognized as a problem by the parents. Of the 44 studies located, nine met inclusion criteria for quality and appropriateness to the topic. Four of the studies concerned behavioral treatment, four concerned drug therapy treatments and one concerned an educational approach.

There were four behavioral approaches: positive routines, extinction, scheduled wakings and a customized sleep program. Of these, scheduled wakings reduced night wakenings. Parents were instructed to awaken their child 15 to 60 minutes before the expected time of wakening and to resettle them to sleep. The extinction technique appeared to be as effective as scheduled wakenings, but some parents found extinction unacceptable. The extinction technique required parents to ignore their child for 20-minute periods, after which time they could check that the child was not ill but could not interact with the child in any way. Behavioral techniques appeared to provide effective results for at least six weeks, but studies varied in duration and intensity of follow-up. Other behavioral techniques failed to show convincing evidence of efficacy in clinical trials.

The drug trials used trimeprazine and niaprazine and showed short-term effectiveness, but results for long-term follow-up were mixed. Approximately one third of the children were withdrawn from the studies. Use of an educational booklet alone did not result in any improvement.

The authors conclude that drug therapy provides effective short-term treatment in some children, but that specific behavioral interventions are more likely to provide effective short- and long-term management if acceptable to families.

editor's note: The number of children who were withdrawn from the drug intervention studies indicates the importance of treating sleep problems in a family context. In practice, the complaint of a sleep disturbance in a child commonly indicates issues in the family. Physicians can quickly find themselves triangulated in arguments over child rearing, or they may recognize that the child is not the primary patient. Sleeping arrangements, appropriate sleeping patterns and bedtime rituals are highly dependent on culture. The waking and extinction techniques reflect an expectation that the child sleeps in his or her own room and that a period of excessive crying can be tolerated. In some families, this may not be technically possible because of crowded living arrangements and the consequences of disturbing neighbors. For others, it may be too distressing or culturally unacceptable to allow a child to cry even for 20 minutes without seeking to comfort the child.—a.d.w.

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