Pediatric Sleep Disorders Treatment & Management

This section primarily reviews forms of cognitive-behavioral therapy (CBT) that are effective in treating a broad range of childhood behavioral sleep problems. Treatment modalities can be adapted easily to the youth’s developmental level and should 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.

Pharmacologic treatments of sleep disorders are not supported by adequate and significant empiric data. Given the lack of supporting data, it is advisable to employ behavioral and cognitive strategies initially in most cases. Because of the paucity of adequate empirical studies, pharmacotherapy data are limited to treatment in select sleep disorders.

Adenotonsillectomy may be indicated for obstructive sleep apnea syndrome (OSAS). Weight loss is recommended for patients with obesity and OSAS.

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. Sleep patterns of parents and their adolescent children reveal similarities ^[12] ; for example, strained and reciprocal parent-child interactions indicate that a mother’s poor sleep may directly affect parenting style. Accordingly, adolescents’ psychological functioning and sleep are also affected.

Limit-setting problems, bedtime resistance, and frequent nightly awakenings represent common problems encountered in pediatric practice. CBT uses relatively straightforward and safe strategies for enhancing overall parenting effectiveness as well as ameliorating the aforementioned problems. Such strategies include the following:

• 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, which may include progressive time delays in responding to bedtime protests or refusals (ie, a checking technique) or may involve comforting for increasingly shorter intervals when checking on the child

• Positive routine-stimulus control technique – 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 before his or her typical nightly awakening times; the scheduled awakenings then are gradually stopped or tapered off

In patients with nocturnal enuresis, the history and physical examination are usually sufficient to rule out a urologic abnormality. If medical causes of enuresis are ruled out, children younger than 6 years should be managed with child and family reassurance that the enuresis is developmentally normal. Older children may benefit from medication to reduce embarassment. Helpful behavioral strategies include the following:

• Alarm clock method – An alarm is set before the most probable time of the event (as suggested by preceding 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 (in contrast with 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

Treatment for sleep-related fears and anxiety includes relaxation training, guided imagery, positive self-talk, positive reinforcement for increasingly successful efforts, systematic desensitization, and gradual exposure to a 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.

In patients with periodic limb movement during sleep (PLMS) or restless legs syndrome (RLS), CBT should focus alleviating stress and promoting relaxation. Pharmacologic therapy may be considered (see below).

In patients with circadian rhythm disorders, light therapy in the morning can help reset the suprachiasmatic nuclei. The individual is exposed immediately upon awakening to 8,000–10,000 lux of bright light for 20 to 30 minutes. ^[20] If a light box is used, it is placed at 18 to 24 inches from the face. Chronic use of a light box can lead to development of cataracts. This is the opposite of the effect of melatonin (see below), which can be used at night to help induce sleep. In manipulating the internal sleep-wake clock, gradually delaying sleep onset resynchronizes the internal clock. Sleep onset should be delayed in 3-hour increments each night until the desired sleep time is established. ^[20]

Pharmacotherapy for insomnia in youth is generally not a permanent intervention. For transient episodes of insomnia, melatonin or antihistamines such as diphenhydramine (Benadryl) have been used clinically with varying degrees of success.

For patients with nocturnal enuresis, desmopressin therapy may be helpful. Individuals with primary enuresis and lack of circadian rhythmicity of plasma arginine vasopressin are more likely to respond to desmopressin therapy. This agent 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 discontinuance can present a problem. Some individuals can experience severe hyponatremia and seizures, which is why the intranasal form of desmopressin has been discontinued. Treatment with desmopressin tablets should be interrupted during episodes of fluid and/or electrolyte imbalance, such as fever, recurrent vomiting or diarrhea, vigorous exercise, or other conditions associated with increased water consumption.

Imipramine therapy has been used historically in the treatment of enuresis; however, it is not a first-line medication, given its potentially serious cardiac adverse effects. This agent (given in a dose of 25-100 mg, depending on the age and size of the patient) may be effective, but there are concerns about potentially serious adverse effects, which often outweigh the benefits in patients with relatively benign problems. Baseline electrocardiography (ECG) is required, with titration and dose increases and periodic monitoring. The clinician should also monitor blood pressure, pulse rate, and review cardiovascular issues at each visit.

For patients with PLMS or RLS, dopaminergic therapy may be necessary; however, only limited data on dopaminergic therapy in youths are available. Pergolide (withdrawn from the US market on March 29, 2007) is effective in treating ADHD or Tourette syndrome and comorbid sleep disorder. Caffeine restriction can be helpful. Low-dose valproic acid has been shown to be effective in a small case series of adults.

A study by Blumer et al found that zolpidem failed to improve insomnia in children and adolescents with ADHD. ^[21] 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 (0.25 mg/kg/day, not exceeding 10 mg/day total) 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.

In patients with circadian rhythm disorders, melatonin may be used. Melatonin acts directly on suprachiasmatic nuclei (the opposite of the effect of light on phase shifts). Phase delay requires morning dosing of melatonin; advanced sleep phase syndrome requires evening dosing (0.5 to 5 mg about 5 to 5.5 hours before bedtime). ^[20]  Ramelteon, a melatonin receptor agonist, is a US Food and Drug Administration (FDA)–approved medication for the treatment of insomnia in adults. A new medication, tasimelteon, has been approved by the FDA for the treatment of non–24-hour disorder in totally blind adults. Tasimelteon is also a melatonin receptor agonist.

Other common pharmacologic interventions include central alpha-2 agonists and antihistamines, even though little data support their use. In one recent survey, one third of pediatricians reported using clonidine for sleep onset, nighttime awakening, early morning awakening problems, and parasomnias. Central alpha-2 agonists may decrease nightmares associated with trauma. ^[22] Antihistamines were the most commonly used medication for treating sleep disorders. ^[23] In a larger study, physicians also commonly prescribed benzodiazepines 15% and antidepressants (trazodone) 6%. ^[24]

Adenotonsillectomy is the primary treatment modality in children with OSAS, however recurrence is common post-surgery. ^[6] Myofunctional therapy in conjuction with orthodontia and craniofacial surgery may be more effective. Tongue and facial muscle exercises improve adult OSAS. Positive airway pressure is needed in cases of continued postoperative symptoms. 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.

Depending on 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

School avoidance may develop and result in truancy, especially in adolescence.

Education about the effects of alcohol and caffeine can improve many issues related to insomnia.

Regular exercise improves sleep. For some individuals, exercise 3 to 6 hours before sleep may be helpful.

Anticipatory guidance at well child appointments by primary care providers is the most important preventative measure against developing common sleep disorders. Good sleep habits are correlated with better behavioral health outcomes. ^[25] To enable clinicians with a busy practice, sleep specialists recommend using the mnemonic “ABCs” of “SLEEPING.”

A ge appropriate B edtimes and waketimes with Consistency

Schedules and routines

Location

Exercise and diet,

no Electronics in the bedroom or before bed

Positivity

Independence when falling asleep

Needs of child met during the day

equal Great sleep.

Regular follow-up is essential to monitor appropriate use of equipment for obstructive sleep apnea, adherence to medications, and for worsening of symptoms or related complications. Cognitive behavioral therapy "refresher" sessions every 3 months to yearly will also help maintain good sleep hygiene strategies.