Sleep disturbance

Pre-referral guidelines for primary care providers

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice points

Management

Referral pathways

Sleep disturbance is extremely common, ranging from settling difficulties in infants through to adolescent sleep patterns with prolonged sleep latency. It is important to address sleep disturbance in children given the correlation with poor behaviour, impact on school performance, etc.

Up to 30-45% of infants will have difficulty settling to sleep and/or night waking, which has been associated with higher rates of post-natal depression, poorer maternal physical functioning and a significant cost to the health service budget. Infant irritability often co-exists with sleep difficulties.

Dyssomnias (problems getting to sleep) and parasomnias (problems during sleep) are common, often poorly understood and frequently misdiagnosed occurrences.

Diagnosis

Sleep disturbance is diagnosed via a thorough history focusing on the following points:

  • bed time, routine and setting
  • use of technology prior to or whilst falling asleep (melatonin suppression)
  • night wakings, when they occur and how the family ‘settles’ the child again
  • behaviour during night wakings, whether these are remembered in the morning
  • obstructive symptoms: persistent snoring, obstructive epidoes, daytime somnolence, mouth breathing
  • time of morning waking, how easily they wake (school vs. weekend)
  • daytime naps

A sleep diary for 1-2 weeks can be invaluable in the assessment of sleep difficulties (download sleep diary for children or infants here).

Normal sleep - it is important to understand normal sleep patterns at different ages:

  • infants having 20-40 minute sleep cycles with no deep sleep (phases 3-4) until 4-6 months and have a lot of movements during sleep.
  • children, adolescents & adults have closer to 90-120 sleep cycles and are immobile in REM sleep, but can move freely in deep sleep
  • total sleep time varies widely (Arch Dis Child 2014; 99: 119-125)

Dyssomnias to consider:

  • Sleep onset association disorder (esp. infants & preschoolers): Wakes throughout the night due to difficulty self-soothing with semi-wakefulness overnight; often triggered by not being put into bed prior to sleep.
  • Delayed sleep phase syndrome (esp. adolescents): Delay in natural circadian rhythm; gives a permanently ‘jet-lagged’ feeling with poor morning waking.
  • Limit setting sleep disorder (esp. preschoolers): Child continually makes excuses or fails to stay in bed; due largely to poor limit setting by parents.
  • Inadequate sleep hygiene: Failure of healthy sleep patterns (see Management below).
  • Obstructive sleep apnoea
  • Restless leg syndrome: Unpleasant sensation in legs leading to a strong desire to get up and move around at night or in the evening, better in the morning; often accompanied by ‘periodic limb movement disorder’ during the night; can be diagnosed with sleep studies.

Parasomnias to consider:

  • Confusional arousals: Occur within 3 hours of sleep; last 2-10 minutes; characterized by mumbling, grimaces, disorientation; child remains asleep throughout; no morning recollection.
  • Sleep walking/talking: Seen in 1-15% children, begins 4-8 years old and can last into adulthood; arousal is difficult (and not recommended); morning recollection rare, largely benign.
  • Night terrors: Seen in 1-6% children; from 18 months old and stop at 6-7 years old; occurs in first half of the night; characterised by sudden arousal from deep sleep with screaming, dilated pupils, tachycardia; appear awake but are not; no morning recall, largely benign.
  • Nightmares: Seen in 25-50% children, especially 3-6 years old; more during 2nd half of the night in REM sleep; become fully awake with good recall; recurrent themes may indicate stress.
  • Rhythmic movement disorder: Occur in those less than 2 years old; characterized by large muscle group movements (e.g. head banging, rocking); transient and self-limiting.

Practice points

  • Assessing sleep relies on a thorough history (above) and can generally be tackled using simple behavioural measures (below).
  • Remember that sleep difficulties can adversely impact on, or even present as, behavioural difficulties, learning difficulties and the like. They can challenge the whole family dynamic.
  • Consider possible mood disorders impacting on sleep, such as anxiety and depression.
  • Infant sleep difficulties are common and often co-occur with infant irritability.
  • Always consider parental post-natal depression with significant infant sleep difficulties.

Management

Assessment

  • Most sleep disturbances are diagnosed on history (above) and do not require investigations.
  • Sleep diary for 1-2 weeks can be invaluable (download sleep diary for children or infants).
  • Sleep studies
    • Rarely required for diagnosis of dyssomnias and parasomnias
    • Can only be done in Melbourne, often with extremely long waiting lists (Monash Hospital or Royal Children’s Hospital)
    • Ballarat Health Services can organise downloadable oximetry, which is an informal and less precise form of a sleep study – requires paediatric referral prior.
  • Iron studies
    • Checking iron studies when children have significant rhythmic movement disorder may be of benefit given the association between the two

Management

  • Healthy sleep patterns are essentially to achieving normal sleep:
    • Fall asleep in familiar surroundings (and not being held to sleep)
    • Consistent night time routines (similar time, routines to get ready to sleep, no parent present when falling asleep)
    • Promote positive interactions at bed time (firm but loving, one on one time)
    • Good sleep environment (mostly dark, minimise noise, not too warm)
    • Use bedrooms for sleep and relaxing (avoid them being play areas or for punishment)
    • Avoid stimulation prior to bed (caffeine, chocolate, active play/exercise, TV and other screens)
    • Infant sleep and settling:
      • Explain normal sleep patterns, cycles and regulation
      • Consider tired signs (e.g. jerking, frowning, grizzling, crying)
      • Consider SIDS guidelines for infants.
      • Infant sleep problems are often closely related to infant irritability.
      • Consider post-natal depression in the setting of infant sleep difficulties.
  • Dyssomnias can often be effectively managed with a few simple strategies:
    • Emphasis on healthy sleep patterns (above)
    • Controlled comforting
    • Camping out
    • Reinforcement of settling techniques 2-3 weeks later ('extinction burst')
  • Parasmonias:
    • Parental reassurance as most parasomnias are benign and often self-limiting.
    • Focus on healthy sleep patterns (above).
    • Scheduled waking 30 mins prior to parasomnia consistently over 2-3 weeks (for night terrors, sleep walking/talking, rhythmic movement disorder).
    • Reassurance for child and 'suggestion' ("Let's go back to bed") for most parasomnias
    • Avoid waking the child as this can cause extreme agitation/confusion.
  • Medication
    • Although not generally required, some medications can be of use in sleep disturbances outside the infant age group, when employed in conjunction with healthy sleep patterns (above).
      • melatonin: exogenous hormone to mimic endogenous melatonin, improves sleep latency, minimal effect on total sleep time or night wakings (not listed on the PBS).
      • antihistamines (Phenergan, Vallergan): short term use to reset sleep patterns.
      • other: clonidine (alpha-2-agonist), mirtazipine (tricyclic), risperidone (atypical antipsychotic).
      • benzodiapezines: rarely indicated in children.

Referral pathways