Pediatric Sleep Disorders Treatment & Management

This section primarily reviews cognitive-behavioral treatments (CBT) effective in treating a broad range of childhood behavioral sleep problems. Treatment modalities can be adapted easily to the youth's developmental level. Furthermore, consider the role of sleep hygiene in all sleep problems. The effectiveness of CBT for childhood sleep disorders has been well demonstrated in controlled studies and clinical case reports. Specific interventions for sleep problems have gained the status of established evidence-based interventions. The issues that received the most attention pertain to settling problems and night awakenings in infants and toddlers. These topics have been extensively studied, with an impressive volume of well-controlled and informative clinical studies. Clinical research of all other sleep problems and in other age ranges is still very limited.

Family dynamics should be explored and redressed, as sleep patterns of parents and their adolescent children reveal similarities; strained and reciprocal parent-child interactions indicate that a mother’s poor sleep may directly affect parenting style. Accordingly, the adolescents’ psychological functioning and sleep are also affected.

Pharmacologic treatments of sleep disorders lack adequate and significant empirical data. Given the lack of data supporting pharmacological treatment, initially use behavioral and cognitive strategies in most cases. Because of the paucity of adequate empirical studies, pharmacotherapy data are limited to treatment in select sleep disorders.

• Limit-setting problems, bedtime resistance, and frequent nightly awakenings represent common problems encountered in pediatric practice. Cognitive-behavioral techniques use relatively straightforward and safe strategies for enhancing overall parenting effectiveness as well as ameliorating the aforementioned problems.

  • Extinction technique: This technique involves the parents putting their child to bed at a designated time and ignoring the child's or infant's protests until an established time the next morning.
  • Graduated extinction: Many parents may experience or perceive pure extinction as overly taxing or cruel; therefore, a graduated extinction technique may be used. This may include progressive time delays in responding to bedtime protests or refusals (ie, a checking technique), or it may include comforting the child for increasingly shorter intervals when checking on the child.
  • Positive routine-stimulus control techniques: This technique involves developing a consistent, pleasurable, and calming nighttime routine, with pleasurable activities being halted if the child protests or throws a tantrum. The child is then put to bed.
  • Scheduled awakenings: Parents awaken the child approximately 15 minutes prior to the child's typical nightly awakening times. The scheduled awakenings gradually are stopped or weaned.
• Nocturnal enuresis: History and physical examination usually are sufficient to rule out urological abnormality. Routine dipstick urinalysis, growth/height trajectory, and blood pressure are used to exclude other medical causes of enuresis. Children younger than 6 years should be managed with child and family reassurance that the enuresis is developmentally normal.

  • Alarm clock method: An alarm is set before the most probable time of the event based on the trend of enuretic episodes. The alarm may be set for a predetermined time, such as 2-3 hours after usual onset of enuresis. Children eventually avoid wetting themselves before the alarm is triggered, unlike the bell and pad method. Longer treatment duration results in a higher success rate.
  • Parent education: Parents need to know that sleep hygiene practices serve as prevention of enuresis. Fluid restriction, bedtime voiding, and parent awakening later are components of sleep hygiene (see Patient Education). The earlier the child begins practicing sleep hygiene, the better. Individual families may require creative combinations of the aforementioned interventions.
  • Desmopressin and nocturnal enuresis: Desmopressin reduces nocturnal urine production, has better short-term results than the alarm method, is effective in 50-85% of individuals, and generally is well tolerated. Recidivism after discontinuation can present a problem.
  • Imipramine and nocturnal enuresis: Imipramine is effective, but concern exists for potentially serious adverse effects. Imipramine dosing is 25-100 mg depending on the age and size of the patient. Risks involved in imipramine use often outweigh the benefits for the relatively benign problem. The use of imipramine requires ECG at baseline, with titration and dose increases and periodic monitoring. The clinician should monitor blood pressure and pulse rate and review cardiovascular system issues at each visit.
• Sleep-related fears and anxiety: Treatment for sleep-related fears and anxiety include relaxation training, guided imagery, positive self-talk, positive reinforcement for increasingly successful efforts, systematic desensitization, and gradual exposure to child-determined hierarchy of sleep-related fears or anxiety. The child progresses from envisioning less threatening fears to conquering in vivo actual feared objects or situations. Exposure-response prevention is combined with relaxation techniques and positive reinforcement for treatment gains.
• OSAS: Adenotonsillectomy is the primary treatment modality in children with OSAS. Positive airway pressure is needed in cases of continued postsurgical symptomatology. Continuous positive airway pressure (CPAP), variable pressure devices (eg, bilevel positive airway pressure [BiPAP]), and on-demand pressure when airflow is impeded (D-PAP) may be needed. Weight loss can be helpful for obese patients.
• PLMS: Focus cognitive and behavioral therapy on alleviating stress and promoting relaxation. Dopaminergic therapy may be necessary; however, only limited data on dopaminergic therapy in youths are available. Pergolide (withdrawn from US market March 29, 2007) is effective in treating ADHD or Tourette syndrome and comorbid sleep disorder. Caffeine restriction can be helpful. Low-dose Depakote has been shown to be effective in a small case series of adults.
• RLS: Focus cognitive and behavioral therapy on alleviating stress and promoting relaxation. Dopaminergic therapy may be necessary; however, limited data exist for treatment in youths. Pergolide (withdrawn from US market March 29, 2007) has been found to be effective in treating ADHD or Tourette syndrome and comorbid sleep disorder. Caffeine restriction may be helpful. Low-dose Depakote has been shown to be effective in small case series of adults.
• Insomnia in ADHD: A study by Blumer et al found that zolpidem failed to improve insomnia in children and adolescents with ADHD. The hypnotic efficacy of zolpidem was compared with that of placebo in children aged 6-17 years who experienced insomnia associated with ADHD. Patients were randomized to receive either zolpidem (dose of 0.25 mg/kg/d, not exceeding 10 mg/d) or placebo. After 4 weeks of treatment, baseline-adjusted mean change in latency to persistent sleep did not differ significantly between the zolpidem and placebo groups.^[2]
• Circadian rhythm disorders

  • Light therapy resets suprachiasmatic nuclei.
  • Melatonin acts directly upon suprachiasmatic nuclei. The effect of light on phase shifts is opposite. Phase delay requires morning dosing of melatonin. Advanced sleep phase syndrome requires evening dosing.
  • In manipulating the internal sleep-wake clock, gradually delaying sleep onset resynchronizes the internal clock. Delay sleep onset by 15-minute increments each night until desired sleep time is established.

Adenotonsillectomy may be indicated for OSAS.

Depending upon patient presentation, the following consultations may be necessary:

• Pulmonologist
• Developmental medicine specialist
• Neurologist
• Child psychologist, child psychiatrist, or developmental-behavioral pediatrician
• Sleep specialists (Multiple disciplines may have expertise, and the child may benefit from interdisciplinary evaluation and treatment planning.)
• Otolaryngologist
• Substance abuse evaluation

Weight loss is recommended for patients with obesity and OSAS.