Sleep issues in children and teens Sleep issues in children and teens

Jared Johnson, MDFamily MedicineVia Christi Clinic

3/12/2013

Today’s discussionToday’s discussion

Normal sleep in children and teens

SIDS

Bed wetting

Behavioral sleep problems and insomnia

Nightmares

Sleep walking

Sleep trends in AmericaSleep trends in America

Average sleep period in late 1800s was approximately 9-11 hours

Average sleep period today is around 6.5 hours

Much more sleep debt than our ancestors

Why?Why?

Electric lights

More shift workers

More distractions Busier lifestyles, especially for children Internet TV Video/computer gaming

Stress

Normal sleep in children and teensNormal sleep in children and teens

Age

0–2 months

3–11 months

1–3 years

3–5 years

5–10 years

10–17 years

Adults

Hours of sleep needed

12–18 hours

14–15 hours

12–14 hours

11–13 hours

10–11 hours

8.5–9.25 hours

7–9 hours

Sudden Infant Death Syndrome Sudden Infant Death Syndrome (and other sleep-related infant deaths)(and other sleep-related infant deaths)

Rare: less than one in 1000 births

Still the leading cause of death from ages 1 month to 1 year in the US

More common in black and Native American children

Slightly more common in boys

Sleep-related infant deathsSleep-related infant deaths

“Back to Sleep” introduced in 1992

Rate of SIDS was cut in half

Risk factors Mother < 20 years old Mother smoked during pregnancy No prenatal care (or very little) Premature baby Baby shares bed Loose blankets and pillows

Nocturnal bed wettingNocturnal bed wetting

Common: occurs in 16% of 5-year-olds, 10% of 7-year-olds, 5% of 10-year-olds

Occurs during sleep

Additional symptoms might indicate a more complicated problem:

Daytime incontinence Pain in genitals Bowel symptoms (i.e. constipation)

Nocturnal bed wettingNocturnal bed wetting

Almost always stops on its own if enough time is allowed

Treatment is unlikely to succeed if child is not motivated

Never ever punish child for wetting the bed

Nocturnal bed wettingNocturnal bed wetting

Initial measures: Calendar of wet and dry nights Child should go to the bathroom before bed Avoid caffeine in the evening Try to take in majority of daily fluids in the

morning and afternoon, while restricting fluids in the evening

Avoid diapers and pullups (may use during sleepovers, camps, etc.)

Nocturnal bed wettingNocturnal bed wetting

Motivational therapy Reward system (a star chart) Works best in younger children who do not

wet the bed every night Start easy and work up to tougher goals Penalties are counterproductive Generally done for three to six months

Nocturnal bed wettingNocturnal bed wetting

Enuresis alarms Most effective treatment Child must be able to take charge of alarm

with only some parental supervision May be used anywhere from one to six

months, generally should be some improvement by three months

Nocturnal bed wettingNocturnal bed wetting

Desmopressin Works immediately Generally safe High relapse rate after stopping medication

Behavioral sleep problemsBehavioral sleep problems

Most common sleep issues in children

Mostly seen in children 0–5 years of age, but may persist longer

May involve prolonged night awakenings, bedtime resistance or some combination

Behavioral sleep problemsBehavioral sleep problems

More commonly in infants and toddlers the problem stems from learning to fall asleep only under certain conditions that require the parent to intervene

For example, child must be rocked or fed to fall asleep

Child does not learn to self-soothe during normal brief arousals between sleep cycles

Behavioral sleep problemsBehavioral sleep problems

More commonly in pre-school age and older children, the problem is active resistance to bedtime rather than prolonged wakings during the night

Behavioral sleep problemsBehavioral sleep problems

Infants and toddlers: 25–50% over 6 months old continue to awaken during the night, and 10–15% of toddlers resist going to bed

Preschool-aged children: 15–30% either resist falling asleep or wake in the night, or both

Behavioral sleep problemsBehavioral sleep problems

Children 4 to 10 years old: 25–40% have sleep problems

Adolescents 13 to 16 years old: 11%

Behavioral sleep problemsBehavioral sleep problems

Bedtime routine Include 3 or 4 soothing activities Should last 20–45 minutes Put child to bed drowsy but awake Coincide bedtime with child’s natural sleep

onset time to reinforce circadian clock

Behavioral sleep problemsBehavioral sleep problems

Systematic ignoring or “extinction” Unmodified version is known as “crying it out” Documented to be a highly successful

treatment, but difficult for parents to adhere to Alternative is to do this more gradually, with

longer periods between checking on child Keep contact brief and avoid picking child up

Behavioral sleep problemsBehavioral sleep problems

Bedtime fading

Positive reinforcement

InsomniaInsomnia

Caused by anxiety surrounding falling asleep or staying asleep

Most common sleep problem in adults

Insomnia in adolescents is treated similarly to adults

InsomniaInsomnia

Principles of sleep hygiene in children Have a set bedtime Bedtime and wake-up should be about the

same on school nights and weekends Don’t go to bed hungry Avoid caffeine for several hours before bed

InsomniaInsomnia

Principles of sleep hygiene in children Spend time outside every day and exercise

regularly Keep bedroom quiet and dark Keep bedroom at a comfortable temperature Don’t use bedroom for time-out or punishment NO TV IN BEDROOM!

NightmaresNightmares

Severe nightmares are associated with anxiety or post-traumatic stress disorder

If severe enough to require intervention, they are usually addressed by psychologists or therapists

Medications are rarely used and often serve to trigger the nightmares instead

SleepwalkingSleepwalking

Seen in 15% of young children in one study

Will often go away after a year or two

Sometimes triggered by sleep deprivation, or another sleep disorder such as sleep apnea or restless legs

Keep environment safe

Questions?Questions?