Approach

There is often more than one cause of the child's sleep disturbances. Without taking a careful history to identify them, finding a solution to the child's sleep disturbances can be elusive. Although children with cerebral palsy and developmental delay may have sleep disorders, management is complex and requires specialist input. Management of these patients will not be covered in this topic.

Obstructive sleep apnoea (OSA)

Adenotonsillectomy is considered first-line treatment in children with OSA and adenotonsillar hypertrophy.[30][34][60]​​[88]​​​[89][90]​​ This is generally curative in 79% to 92% of children, although some studies have demonstrated complete resolution of obstruction in smaller numbers, especially in obese children.[91][92][93]​​ One large multicentred trial has demonstrated improvement in behaviour and quality of life in children with OSA undergoing adenotonsillectomy relative to controls.[94] One small randomised controlled trial in otherwise healthy children, between 2 and 4 years of age, with mild to moderate OSA showed significant improvement in quality of life following adenotonsillectomy for those with moderate disease, but no major difference between those treated and those not treated with mild disease. This suggests watchful waiting is a recommended strategy in children with mild disease, but further studies are needed.[95]

Adenotonsillectomy for OSA improved most quality-of-life and symptom severity measurements in children aged approximately 5 to 10 years, but resulted in clinically significant weight gain even in children overweight at baseline.[94][96][97][98] When mild residual disease persists after adenotonsillectomy, the use of montelukast and/or intranasal budesonide has been demonstrated to improve or resolve the obstruction.[34]​[99]​​​​

The US Food and Drug Administration has strengthened its warnings for montelukast about the risk of serious behaviour and mood-related changes.[100]

In children younger than 24 months, there is sometimes reluctance to proceed with adenotonsillectomy because of concern about bleeding and other postoperative complications.[101] In these patients continuous positive airway pressure (CPAP) is initiated, as for those with persistent OSA after adenotonsillectomy, or in instances when surgery is not feasible.[34]​[102][103]​​​​​ Successfully using CPAP requires patience, a multidisciplinary approach, and close follow-up to achieve good compliance and adherence. Behavioural interventions to improve adherence with CPAP, long a mainstay of paediatric sleep medicine, are increasingly being recognised as useful in adult sleep medicine.[104] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

In children who are not treated with surgery, intranasal budesonide and montelukast may be used as additional treatments for mild OSA, and OSA worsened by allergy. However, a 2020 systematic review of anti-inflammatory medications for OSA in non-surgically treated children found insufficient evidence in support of intranasal corticosteroids, and only short-term beneficial effects of treatment with montelukast.[105]

If underlying craniofacial structural abnormalities are present, craniofacial, maxillary, and/or mandibular surgeries are sometimes indicated.[34]​ Surgery may also be indicated if a patient cannot tolerate CPAP.[106][107] Orthodontic interventions such as maxillary expansion have been demonstrated to treat OSA effectively.[108]

Addressing and treating other underlying issues that may be contributing to the OSA is important as well. This includes treating chronic allergic rhinitis, gastro-oesophageal reflux, or obesity; avoiding environmental tobacco smoke or exacerbating medications; and avoiding certain sleep positions if the OSA is only present while maintaining them.

Chronic insomnia disorder

Behavioural interventions should be the mainstay of treatment for chronic insomnia disorder in children.[9][109][110][111]

To facilitate the success of these behavioural interventions, parents should be educated on general positive sleep habits. These include implementing a consistent bedtime routine, ensuring a regular sleep schedule for both night-time sleep and daytime naps, and making sure that the child is in bed for an age-appropriate amount of time. All of these methods have been shown to be effective.[63] If the child has multiple carers, it is also extremely important that they agree upon the approach to be taken; conflicting messages often result in the child not understanding what is expected of them, which leads to unsuccessful behavioural modification.[5][9]​​​

The American Thoracic Society outlines a number of treatments that can be used for sleep-onset difficulties: extinction (e.g., putting the child to bed awake, closing the door, and leaving him/her to cry him/herself to sleep); modified extinction (e.g., putting the child to bed awake, leaving the room, and returning to check in on him/her at set intervals, giving the child the message that he/she needs to go to sleep while reassuring the child that he/she has not been abandoned); extinction with parental presence (e.g., where the child is put to bed awake and the parent sits in a chair in the bedroom with his/her back to the child without actually going over to the child to soothe him/her to sleep); faded bedtime with positive bedtime routines (e.g., in which the child is put to bed later than usual while being given positive bedtime routines); scheduled awakenings (e.g., in which the child is awakened at fixed intervals to pre-empt his/her own patterns of awakening).[9]​ Though all are generally found to be effective, there is insufficient evidence to recommend one intervention over another. Parental acceptance of the modified extinction or extinction with parental presence method tends to be higher than the unmodified extinction method.[63]​ All interventions are associated with a reduction in tantrums.[112] 

The treatment of limit-setting behaviours also requires education as to the nature of the problem, and, depending upon the age of the child, active involvement of the child in modifying the sleep-related behaviour. With younger children who refuse to stay in bed, the use of a gate at either the child’s or parent’s bedroom door can be highly effective in establishing boundaries without causing additional distress (e.g., anxiety caused by closing the bedroom door).[113]​ With older children, delineating the desired outcome and devising a graded reward system to give positive reinforcement for following through works well.[65]​ If there is a significant component of separation anxiety that has resulted in the parent having to sleep in the same bedroom as the child (or the child in the parent's bed or bedroom), implementing a modified extinction protocol for this, similar to what might be applied for sleep-onset difficulties, can be effective. For example, the parent might initially sleep on a mattress on the floor of the child's bedroom for the entire night, followed by the parent leaving the bedroom once the child has fallen asleep, followed by the parent beginning to leave the bedroom for short intervals as the child is falling asleep that gradually lengthen until the child no longer requires the parent's presence.

Melatonin is not a treatment for chronic insomnia disorder, except in very specific circumstances. Although it is available in many countries without prescription, the effectiveness and long-term effects of its use in children are largely unknown.[114]​ Melatonin has been used to induce sleep in children with ADHD and autistic spectrum disorder with good results, although the optimal dosage is still unclear, and determining it is made difficult by the fact that it is not a regulated substance and can vary widely between manufacturers.[112]​[115]​​[116][117][118][119]​​​​​ Initiation and dosing should be done in consultation with a specialist.[120]​ Behavioural interventions should be used first in otherwise healthy children.[111] Melatonin may give a small added benefit.[112]

Delayed sleep-wake phase disorder (DSWPD)

Treating DSWPD involves keeping to a regular schedule, both weekdays and weekends, during the school year and while on holidays, with special emphasis on the wake-up time. Exposure to bright light in the mornings needs to be encouraged, as well as reinforcement of the notion that the wake-up time denotes the hour at which the patient gets out of bed, not at which he/she enters into 2 hours of drifting in and out of sleep while continuing to lie in bed. Education about proper sleep hygiene, sleep drives, and the effects of caffeine and certain medications is important. Reduction of exposure to bright light at least 2 hours prior to bedtime is important.

Sleep hygiene involves elimination of caffeine consumption in the 8 hours prior to sleep; minimising bright light exposure in the 2 hours prior to bedtime; removal of electronic media from the bedroom, including televisions, video games, computers, and mobile phones, and avoidance of falling asleep wearing headphones; removal of pets from the bedroom; keeping the bedroom dark, quiet, and at an ambient temperature.

In instances where the circadian phase shift is extreme, using chronotherapy to further delay the bedtime by 3-hour increments around the clock until it is brought back to the desired hour can be very effective. Chronotherapy entails postponing bedtime by 3-hour increments, in order to bring the circadian clock back in synch with the external clock. It is often used with people with significant DSWPD, in whom it is easier to resynchronise by staying up later and later rather than trying to go to sleep earlier and earlier. It is also important to keep in mind that if there is a large circadian phase shift, exposure to bright light in the morning may in fact only serve to further delay the circadian sleep-onset time.

Using melatonin adjunctively has been shown effective to advance circadian phase.[121][122] Melatonin has been used to induce sleep in children with ADHD and autistic spectrum disorder with good results.[112]​[118]​[119]​​​[123]​​​​ The optimal dosage is still unclear, and determination is made difficult by the fact that it is not a regulated substance and can vary widely between manufacturers.[116][117] The behavioural, schedule, and sleep hygiene issues should be addressed first. It should be made clear that these are really what will make a difference, and that the problem will not be solved just by taking a pill. There are no formal criteria for starting melatonin. Initiation and dosing should be supervised by a specialist.[120]

Narcolepsy

The child should take frequent scheduled naps. Various drugs are approved to treat narcolepsy in children, including stimulants (e.g., methylphenidate, dexamfetamine, modafinil, armodafinil), as well as other drugs, including sodium oxybate (and other oxybate salts), pitolisant, and solriamfetol.[124][125][126][127]​​​ Fluoxetine, venlafaxine, and clomipramine have been used with some success.[128]​ These agents should be prescribed under specialist use only. See Narcolepsy.

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