Sleep and Its Disorders in Children

Timothy F. Hoban, MD

Disclosures

Semin Neurol. 2004;24(3) 

In This Article

Treatment of Sleeplessness in Infants and Younger Children

Treatment of sleeplessness in younger children usually begins with effective bedtime management—a set of interventions focused on establishing a regular sleep schedule, an appropriate sleep environment, and consistent limit-setting for dealing with bedtime struggles:[12]

Bedtime Routine. A regular and well-structured set of prebedtime activities usually helps settle children and promote sleep onset. The routine for many younger children often includes changing, bathing, stories, and being "tucked in." Stimulating activities (e.g., vigorous play, watching cartoons) should be avoided due to their potential alerting effect. Keeping the routine quiet and regular helps young children achieve a quiet, relaxed state more conducive to sleep onset.

Sleep Schedule. Maintaining a consistent bedtime and waking time 7 nights per week is usually helpful in several respects. Eliminating late sleeping and any daytime napping that is inappropriate for age may increase the chance that a child will be tired at the usual bedtime. In addition, regularity of sleep schedule may promote entrainment and stabilization of circadian rhythms as an added impetus for more rapid sleep onset at the regular bedtime.[25]

Sleep Environment. For most children, a quiet environment is more conducive to sleep than a noisy one. Likewise, a dark or dimly lit environment promotes settling and sleep onset better than bright lighting, although use of a night-light is appropriate for children who are afraid of the dark. Finally, it is generally recommended that children be put to sleep without a parent remaining present. This provides the child with an opportunity to learn to fall asleep comfortably and independently and to minimize dependence upon parental presence or intervention as a sleep onset association.

Limit Setting. Children who stall, cry, or leave the room at bedtime in an attempt to stay up later will sometimes repeat this behavior to the point where a parent or caregiver "gives in" and allows the child to stay up. For some children, this pattern of behavior may be repeated nightly to the point of causing consistent delay and disruption of sleep onset. Setting and enforcing appropriate limits on inappropriate bedtime behavior are crucial for the effective treatment of limit-setting sleep disorder.[12] Limits must be enforced consistently by all caregivers, usually for periods of days or weeks, for maladaptive bedtime behaviors to subside. Parents should be made aware that temperamental and agitated behavior often transiently worsen during the first days of treatment before gradual improvement becomes evident, making the initials days of treatment the most difficult.

In cases where bedtime management alone is not sufficient in the treatment of a younger child's sleeplessness, a variety of structured behavioral interventions are available. Although these treatments have been widely utilized, they have received only limited scrutiny in controlled scientific studies, recently reviewed by Ramchandani and colleagues and by Kuhn and Elliott:[22,26]

Extinction (Systematic Ignoring). This technique involves placing a child in bed and ignoring agitation or inappropriate behavior until morning except for legitimate concerns regarding illness or safety of the child. Extinction has been found effective in several large-scale studies and was found by Kuhn and Elliott to represent a well-established intervention.[26]

Graduated Extinction. First described by Douglas and Richman,[27] this technique was popularized by Ferber in his mass-market book, Solve Your Child's Sleep Problems.[13] Using this technique, parents ignore bedtime tantrums or nighttime waking for a specified period of time before being allowed to enter the bedroom and briefly calm the child before exiting. The specified interval for ignoring the child's agitation progressively increases over time, usually over successive nights, and in some versions on successive checks within the same night. Kuhn and Elliott also considered this to be a well-established intervention, validated by several well-controlled studies.[26]

Scheduled Awakenings. For young children with nighttime waking occurring at predictable times during the night, this technique requires that the parent preemptively awaken and then resettle the child 15 to 30 minutes before the usual time of spontaneous awakening. If effective in eliminating the spontaneous awakenings, the scheduled awakenings are gradually spaced out or delayed systematically. Kuhn and Elliott classified scheduled awakening as a probably efficacious intervention for excessive night waking.[26]

Bedtime Fading. This technique initially delays a child's bedtime by ~30 minutes. If rapid sleep onset is not observed, a "response cost procedure" allows the child to be removed from bed and kept awake for 30 to 60 minutes, with the process being repeated as necessary until the child falls asleep rapidly. On subsequent nights, the initial bedtime is set 30 minutes before the time of rapid sleep onset was achieved on the night immediately prior, and the response cost procedure repeated if the child does not fall asleep quickly. The rules are applied on successive nights until the child's sleep onset is "faded" toward a predetermined bedtime goal. Although no randomized, large-group comparison studies have assessed this intervention, Kuhn and Elliott classified this technique as promising and deserving of further study.[26]

Drug treatment of sleeplessness in infants and younger children has received limited scientific study despite seemingly common use of both prescription and nonprescription agents in this population. In one report, one-quarter of firstborn English children had been given sedatives by 18 months of age.[28] In a German survey of pediatricians, psychiatrists, and primary care providers, sleep problems were the most common reason for prescribing medicine to infants up to 1 year of age, accounting for 35% of prescriptions in this age group.[29] Several placebo-controlled trials have suggested short-term efficacy of trimeprazine for treatment of night waking in children aged 12 through 24 months[30] and 12 through 36 months.[31] Use of nonprescription agents such as melatonin and diphenhydramine and prescription agents such as short-acting hypnotic agents has not been the subject of controlled studies in healthy young children. Reports of efficacy using these agents for younger children are largely anecdotal apart from limited experience in the treatment of youngsters with developmental disabilities.[24,32]

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