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Am Fam Physician. 2022;105(2):168-176

Patient information: See related handout on common sleep disorders in children, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Childhood sleep disorders can disrupt family dynamics and cause cognitive and behavior problems. Early recognition and management can prevent these complications. Behavior subtypes of childhood insomnias affect 10% to 30% of children and result from inconsistent parental limit-setting and improper sleep-onset association. Behavior insomnias are treated using extinction techniques and parent education. Hypnotic medications are not recommended. Obstructive sleep apnea affects 1% to 5% of children. Polysomnography is required to diagnose obstructive sleep apnea; history and physical examination alone are not adequate. Adenotonsillectomy is the first-line treatment for obstructive sleep apnea. Nasal continuous positive airway pressure is the second-line treatment for children who do not respond to surgery or if adenotonsillectomy is contraindicated. Restless legs syndrome can be difficult to recognize and has an association with attention-deficit/hyper-activity disorder. Management of restless legs syndrome includes treatment of iron deficiency, if identified, and removal of triggering factors. Parasomnias affect up to 50% of children and usually resolve spontaneously by adolescence. Management of parasomnias involves parental education, reassurance, safety precautions, and treating comorbid conditions. Delayed sleep phase syndrome is found during adolescence, manifesting as a night owl preference. Treatment of delayed sleep phase syndrome includes sleep hygiene, nighttime melatonin, and morning bright light exposure. Sleep deprivation is of increasing concern, affecting 68% of people in high school.

Sleep is essential for good health and is an important part of child and family life. Sleep supports homeostatic, cognitive, immune, and cardiovascular functions and is fundamental for a child's growth and development. Sleep disruptions can lead to cognitive and emotional challenges and affect family dynamics.1,2 Early recognition and management can prevent these complications. This article provides an overview of common sleep disorders in children.

Clinical recommendation Evidence rating Comments
Behavior interventions are the first-line treatment for healthy children having bedtime resistance or nighttime awakenings.14,18 C Consensus, usual practice, expert opinion, and case series for studies of diagnosis, treatment, prevention, or screening
Home sleep apnea testing and nap or abbreviated polysomnography are not recommended for the diagnosis of obstructive sleep apnea in children.33 C Clinical practice guideline based on inconsistent or limited-quality patient-oriented evidence
Adenotonsillectomy is the first-line treatment for children with obstructive sleep apnea.27 C Clinical guideline based on inconsistent or limited-quality patient-oriented evidence
If restless legs syndrome is suspected in a child, management should include a workup for iron deficiency and avoidance of triggers such as prolonged inactivity, sleep deprivation, and certain medications.49,51,52 C Consensus, usual practice, expert opinion, and a small cohort study
RecommendationSponsoring organization
Do not prescribe medication to treat behavioral childhood insomnia, which usually develops from parent-child interactions and responds to behavior interventions.American Academy of Sleep Medicine

Inadequate sleep and sleep disorders can present differently in children. Adults present with fatigue and daytime sleepiness; however, children may present with behavior problems, including irritability, hyperactivity, and poor school performance. Teenagers may experience increased motor vehicle crashes caused by drowsy driving.3 Although 50% of children may experience sleep problems, only 4% are diagnosed with a formal sleep disorder.4 Children with sleep disorders have at least two more clinic visits for illnesses per year than those without sleep issues.5

Normal Sleep Development

Sleep architecture and patterns change from infancy through adolescence. Understanding normal sleep patterns and progression helps clinicians and caretakers differentiate normal sleep behavior from sleep disorders (Table 169).

AgeTotal sleep time (hours) per 24 hoursAverage number of naps per day
4 to 12 months12 to 16, including naps2 at 12 months of age
1 to 3 years11 to 14, including naps1 at 18 months of age
3 to 5 years10 to 13, including naps50% of children who are 3 years of age do not nap
5 to 12 years9 to 12Daytime naps stop by 5 years of age in 95% of children
13 to 18 years8 to 10Napping in this age group suggests insufficient sleep or a possible sleep disorder

Newborns typically sleep one to four hours at a time and frequently wake for feeding. Circadian rhythm is endogenously generated and cycles over 24 hours. Defined sleep and wake periods are generally seen after two months of age.10 Infants start to develop the ability to sleep through the night by five to six months of age. Infants should be placed on their backs to sleep in a supine position until they reach one year of age to decrease the risk of sudden infant death syndrome. Sleeping in a side position is not safe and is not recommended.11 Prevalence of common childhood sleep disorders differs by age group (Table 26).

Sleep disorder (prevalence)Clinical featuresDiagnostic criteriaTreatment options
Childhood insomnias (behavior subtypes; 10% to 30%)Sleep-onset association: children have trouble falling asleep without relying on a person or activity such as rocking or other environmental cue, which results in a significant delay or absence of sleep onset without caregiver involvement
Limit-setting: parent or caregiver does not establish sleep routines, or limits are not consistently followed
Mixed: problems with associations and limit-setting
Diagnosis is clinical
Sleep-wake disturbances characterized by difficulties in initiating or maintaining sleep occurring at least 3 times per week for at least 3 months
Behavior interventions (Table 3)
Hypnotic medications are not recommended
Obstructive sleep apnea (1% to 5%, peaks between 2 and 8 years)Recurrent episodes of partial or complete upper airway obstruction associated with arousals, awakenings, or oxygen desaturations (Table 5)
Obesity and tobacco smoke exposure are risk factors
Polysomnography
Home sleep apnea testing is not recommended
Adenotonsillectomy
Nasal continuous positive airway pressure for second-line treatment
Restless legs syndrome (2% to 4%; more common in adolescents)Unpleasant sensations in the legs that cause difficulty in initiating and maintaining sleep; daytime symptoms can happen with extended periods of inactivity or sitting
About one-fourth of patients with restless legs syndrome have attention-deficit/hyperactivity disorder symptoms, and up to one-third with attention-deficit/hyperactivity disorder have restless legs syndrome
Diagnosis is clinical and requires the following: (1) urge to move legs because of unpleasant or uncomfortable sensations, (2) sensations begin or worsen with rest or inactivity, lying down, or sitting, (3) temporary partial or complete relief with movement such as stretching or walking, (4) occurs mostly in the evening or night, (5) symptoms cause sleep disturbance or impairment of daytime functioning, and (6) symptoms need to be described in the child's wordsIron therapy of 3 mg per kg per day if ferritin levels < 50 ng per mL (50 mcg per L)
Screen for and address triggers if identified as cause or contributing factor (e.g., prolonged inactivity, sleep deprivation, diphenhydramine [Benadryl], selective serotonin reuptake inhibitors, metoclopramide [Reglan], caffeine, nicotine, alcohol)
Parasomnias (up to 50%)During sleep-wake transitions, activities appear purposeful or automatic, but the child has no meaningful interaction with the environment; child is difficult to arouse, appears confused, may quickly go back to sleep, and may have amnesia about the episode
Repetitive stereotypic behaviors and posturing indicate need for investigation for nocturnal seizures
Diagnosis is clinical
Polysomnography is indicated if: (1) the description is not typical or there has been an injury, (2) there is concern about nocturnal seizures or rapid eye movement sleep behavior disorder, or (3) there is concern for precipitating factors such as obstructive sleep apnea or periodic limb movement disorder (clustered neurologically mediated leg movements that disturb sleep)
Self-limiting; most resolve spontaneously by adolescence
Education and reassurance; address sleep hygiene and stress; treat comorbid conditions such as gastroesophageal reflux, obstructive sleep apnea, and restless legs syndrome; take safety precautions
Refer for violent behavior or injury, or when there is no response to conservative treatment
Delayed sleep phase syndrome (7% to 16%)Sleep-onset and wake-up times are delayedDiagnosis is clinical with a sleep diary for 7 to 14 days showing sleep period delayed by more than 2 hours for at least 3 monthsSleep-wake schedules with patient's input
Avoid exposure to bright and blue light (e.g., electronic devices) before bedtime
Melatonin (0.3 to 5 mg) given about 1.5 to 6.5 hours before bedtime
Bright-light therapy in the first 1 to 2 hours after awakening

Childhood Insomnia

Insomnias of childhood are sleep or wake disturbances characterized by difficulties in initiating or maintaining sleep, ultimately leading to chronic sleeplessness. Diagnostic criteria specify that disturbances occur at least three times per week for at least three months.12

Bedtime problems are common in young children, with an estimated prevalence of 10% to 30%.13 Parental concerns involve the child's and their own sleeplessness. Behavior insomnias are no longer considered distinct from chronic insomnia but continue being used for diagnosis and treatment because they develop from improper sleep training by parents or caregivers.12

Sleep-onset association insomnia occurs when the child is unable to fall asleep without certain conditions or actions by the parent or caregiver.12 For example, when a child is first put to bed, a parent or caregiver must sing to the child or rock the child for sleep onset. The same action must be repeated every time the child wakes up during the night for them to return to sleep. This approach is not to be confused with bedtime preparatory routines. In limit-setting insomnia, the child stalls or resists going to bed at the designated bedtime.12 For example, the child may demand to spend time watching television past their bedtime, usually because of a parent or caregiver's inadequate implementation of a bedtime schedule. When making a diagnosis of limit-setting insomnia, other causes of bedtime resistance such as underlying fears (e.g., nightmares, being in the dark, sleeping alone) and anxiety need to be considered. Most children with behavior insomnias have features of the sleep-onset association and limit-setting types (i.e., a mixed type). The diagnosis of insomnia is clinical. Polysomnography is not needed unless other sleep disorders are suspected.

Behavior interventions are the first-line treatment for bedtime problems and nighttime awakenings caused by behavior insomnias in healthy infants and children1418 (Table 31417). Extinction techniques are designed to promote self-soothing behaviors to fall asleep. Infants learn to self-soothe when placed awake in the crib.19 Parental education about age-appropriate sleep times and healthy sleep habits (i.e., sleep hygiene) is important (Table 418,20). Following a consistent bedtime routine of calming transition activities such as taking a bath, changing into pajamas, and reading is effective.21 Television and electronic media are best avoided. 22,23 Hypnotic medications are not recommended for the treatment of behavior insomnias.16 Children who do not respond to simple behavior interventions or have complex problems (e.g., medical, psychiatric, developmental) should be referred to a sleep specialist.16,18

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