Case scenario

Ken is a 3-year-old boy, and his parents are regular customers. His mother, Kerry, comes in one day asking for advice. She says that after being put to bed, Ken will keep coming to the parents’ room to ask for a final cuddle. This can last up to 2 hours each night and is becoming increasingly frustrating for the parents, who are already exhausted from a full day at work. Ken eventually settles around 10 pm. He seems otherwise healthy, though a bit tired in the mornings, as he wakes up at 6.30 am every day.

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Introduction

Sleep is now recognised as a meta-regulatory process that helps maintain a range of physiological, neuronal and cellular processes that are essential for human health.¹

Sleep is both a physiological process and a behaviour, and is defined as a state in which one is perceptually disengaged from and non-responsive to the environment.²

Healthy sleep requires a range of complex physiological processes to be aligned with the body’s circadian clock and matched to social and environmental contexts.² In children, sleep is particularly important from a developmental viewpoint, as it can impact mood, coping ability, vocabulary acquisition, learning and memory.^1,2 Sleep also has important effects on growth, especially in early infancy.² Poor sleep in children can therefore have a profound impact on both physical and mental development.^3,4 Indeed, poor sleep in early childhood has been associated with dysregulated immunological function leading to conditions such as allergic rhinitis,⁴ as well as mental health issues such as anxiety, depression and emotional dysregulation.^5,6 As with adults, poor sleep quality is emerging as a potential risk factor for future cardiometabolic disease in children, including obesity, diabetes and hypertension.⁷

An important focus in children’s sleep for parents/carers should be to embed healthy sleep routines (sleep hygiene) in childhood. Sleep-related habits are learnt behaviours, and childhood patterns impact sleep health habits over a person’s lifetime.⁸

Contemporary evidence has been reviewed by experts to develop a consensus for recommended sleep durations in children and adolescents^9,10

• Infants younger than 1 year of age

• • • 0–3 months: 14–17 hours, including naps
    • 4–11 months: 12–16 hours, including naps

• Toddlers (aged 1–2 years) 

• • • 11–14 hours, including naps
    • consistent sleep and wake-up times

• Preschool children (aged 3–5 years)

• • • 10–13 hours, which might include a nap
    • Consistent sleep and wake-up times

• Children 5–13 years 
  • • 9–11 hours of uninterrupted sleep every night

• Adolescents 14–17 years
  • • 8–10 hours of uninterrupted sleep every night.

Australian data, however, indicates that children and adolescents often do not meet these recommended sleep durations, particularly as school and social activities start to become prominent in their lives.¹⁰ In teenagers, there is also sometimes a natural shift of the body clock towards more delayed phases, leading to later sleep and wake-up times (delayed sleep phase syndrome).¹¹ Screen time, schoolwork and social pressures compound the matter, leading to sleep deprivation in this group, often resulting in what is referred to as ‘yo-yo sleeping’, where short sleep occurs during schooldays with catch-up on the weekend.^11,12

Sleep disorders in children

Sleep disorders in children and adolescents may be classified as either behavioural or medical.¹³ Estimates indicate that 14–31% of Australian children have a sleep-related problem between infancy and adolescence.¹³ Behavioural sleep disorders are the most common sleep disorder in children.^13,14 Sleep-related breathing disorders (sleep apnoea) affect up to 5% of children.^15-17 Similarly, restless legs syndrome may impact 2–4% of children.¹³

Behavioural sleep problems

Insomnia may be considered as difficulty falling asleep, maintaining sleep and staying asleep.¹³ As with adults, the evidence supports behavioural treatments for these insomnia types as first-line treatment. Many of these behavioural treatments can be administered by parents/carers successfully (see Table 1).

In older children, issues such as mood disorders and anxiety may require a review with a child psychologist. Medicines to induce sleep are not generally recommended in children experiencing insomnia.¹⁴ Parents/carers may be discomfited in using some of the behavioural techniques, but evidence suggests that they have no impact on the child-parent relationship or child behaviour, and can improve stress in parents long term.^18,19

Use of medicines

Melatonin has been used in children, given its perceived safety, especially in those children with neurodevelopmental disorders who commonly experience sleep problems such as insomnia, and in children with insomnia related to difficulty initiating or maintaining sleep.^22,23 However, melatonin is likely more effective if the sleep issue is of circadian origin (e.g. delayed sleep phase in teenagers); it only has a mild sedative effect, but is an effective circadian pacemaker. For children 2 years and older, a paediatric controlled-release formulation is available in Australia on prescription and indicated for use in the treatment of insomnia in autism spectrum disorders, when sleep hygiene measures are insufficient.²³ Melatonin should only be used for children and adolescents under specialist advice.²⁴

In the past, sedating antihistamines (H1-receptor antagonists) were often used off-label for sedation in children. However, these medicines are no longer commonly used, given the risks associated with use outweigh the benefits. In children <2 years, these medicines should not be used at all for any indication due to the risk of respiratory depression.¹⁴ Caution has also been advised in children <6 years. Use of these medicines may have a sedative effect but can lead to paradoxical excitation and wakefulness; and tolerance to the sedative effect also develops very quickly (3–5 days).¹⁴ Overall, in older children, if these are used, short-term use with specialist medical supervision is advised.

Medical sleep problems

Apnoeas/sleep-related breathing disorders 

Sleep apnoea involves temporary upper airway closure leading to micro periods of no breathing.²⁵ Symptoms noticeable in children will include habitual snoring, gasping, sleeping in odd positions, night sweats, mouth breathing and morning headaches. Children with sleep apnoea may also be visibly tired during the day and unable to concentrate. Risk factors for sleep apnoea include high body weight, narrow facial structures, having neurodevelopmental issues such as Down syndrome, or a cleft palate.²⁴

If such symptoms are perceived, parents should be referred to a doctor (general practitioner followed by sleep specialised paediatrician). As in adults, an overnight polysomnography is the standard method of diagnosing sleep apnoea.²⁴ Treatments tried may include some lifestyle measures (healthy eating and activity levels) and surgery (e.g. to remove tonsils/adenoids). Continuous positive airway pressure (CPAP) may be recommended if the issue is not stemming from tonsil/adenoid-related upper airway obstruction.²⁴ Recent evidence suggests that in children with sleep-related breathing disorders, nasal saline irrigation improves sleep quality,²⁶ and can help avoid tonsillectomies.²⁷

Parasomnias

Parasomnias are common in children aged 2–8 years old. Symptoms may include waking up anxious, crying out in sleep and thrashing or being restless during sleep.^28,29 Some 10–50% of children, for example, may have nightmares, which occur late in the sleep cycle during the rapid eye movement (REM) phase.²⁹ In the case of nightmares, when the child awakens they remember the event and need to be consoled. 

Non-REM parasomnias include night/ sleep terrors, confusional arousals, or sleep-walking and occur in the first third of the night.³⁰ While the actions may appear to be those of a child that is awake, the child is unaware of and unresponsive to the environment and has no memory of the activity when they awake.³¹ If they occur too frequently or impact daytime function, or pose a danger, specialist medical review should be sought.³¹ The diagnosis may involve a clinical interview, videography in the child’s home, and a video polysomnography. Some non-REM parasomnias may be genetic.²⁹

Comforting a child waking up from a vivid dream or waking up anxious is a key role for parents/carers, as is ensuring environmental safety.³¹ If the child is on any medicines, they should be reviewed to ensure they are not associated with triggering parasomnias. Most parasomnias should subside by adolescence.³¹ While treatments such as clonidine and other antidepressants or benzodiazepines (clonazepam) are used off label in adults for these disorders, they are not recommended for children.³¹ In children, L-OH-tryptophan (a precursor of serotonin) and melatonin have been trialled in case studies, but further research is needed to understand their efficacy.³¹ Scheduled awakening (20 minutes before usual episodes, i.e. if there is a regular pattern), hypnosis and psychotherapy are non-pharmacological interventions used in some cases of childhood parasomnias.³¹

Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) may also occur in children. PLMD involves jerky movements of the arms or legs or both with thrashing around when asleep. RLS is a separate disorder but can often co-occur with PLMD.³² The child may describe the symptoms of RLS as an uncomfortable sensation in the limbs, more commonly the legs, which is worse during inactivity and the evening, and is relieved by movement.^30,32 If the above symptoms are troublesome and disrupting sleep, medical review should be recommended. A medical practitioner may undertake serology/complete blood tests. If indicated by these, they may trial iron supplements to treat PLMD and RLS, as altered central nervous system iron levels are implicated in the pathophysiology of these conditions. In adults, if iron is not indicated, other medicines such as gabapentin, clonidine and dopamine agonists (pramipexole, ropinirole, rotigotine) are tried, though these are not approved for use in children for these conditions.^14,32

Narcolepsy

Narcolepsy may be another condition, though much rarer than the above listed conditions (the global paediatric prevalence is 20–50/100,000).³³ This condition manifests as a sudden transition to sleep during the day (narcolepsy), and muscle weakness sometimes catalysed by sudden laughing or other emotions or stressors (cataplexy).³³ Excessive daytime sleepiness, sleep terrors or nightmares are symptoms often associated with narcolepsy.³³

In adults, excessive daytime sleepiness related to narcolepsy is treated with agents such as modafinil, armodafinil, methylphenidate and dexamfetamine. In children, methylphenidate or dexamfetamine are sometimes used off-label for children >6 years, given these medicines have a history of use in children or attention-deficit/hyperactivity disorder (ADHD).²³ Sodium oxybate has been used for the treatment of narcolepsy in children overseas.³⁴ However, this is not available in Australia, except under the Special Access Scheme as a Schedule 8 medicine.³⁵

Knowledge to practice 

Pharmacists are an essential point of advice for parents/carers about sleep issues in children. As for other conditions, when sleep-related paediatric presentations occur, the first step should involve thorough information gathering (see Figure 1), followed by appropriate behavioural management advice and a referral if the child’s symptoms appear to be that of a medical sleep disorder. Complementary medicines have limited evidence in adults or children, and over-the-counter sleep aids should not be used in young children. Where prescribed in older children with a medical sleep problem, medicine counselling should be accompanied by reinforcement about proactive sleep health behaviours (i.e. sleep hygiene principles).

Conclusion

Good-quality sleep in children and adolescents is essential and plays a key role in both physical and mental development. Pharmacists can advise and support parents/carers to implement healthy sleep routines and behavioural interventions where needed, as well as refer on to other health professionals for further advice and management where indicated.

Resources for parents/carers

• Sleep Health Foundation 
• Raising Children 
• Teenagers Sleep: SleepShack
• The Royal Children’s Hospital resource on sleep problems in babies and toddlers
• Queensland Government Resource on healthy sleep in children

Case scenario continued

You feel this is a behavioural insomnia problem of the limit-setting type. You suggest enforcing the 8.30 pm bedtime to allow 10 hours of sleep. After going to the toilet, you suggest placing a drink of water on Ken’s bedside table, providing a final good night kiss/cuddle and then ignoring further calls, unless there appears to be a real issue. You discuss rewarding good behaviours and a bedtime pass system. You explain that for the extinction method to succeed, it is important to not give in to Ken’s protests and calls. You advise Kerry to speak to the GP if these techniques are not effective.

Key points

• Sleep is an essential physiological process for the physical and mental development of children. Poor sleep may stem from unproductive sleep health behaviours or from underlying sleep disorders.
• For most sleep disorders in children, healthy sleep behaviours are recommended, and medicines are not encouraged.
• Behavioural approaches to manage sleep in children should be a key focus of pharmacists’ counselling.
• For symptoms described by parents that may be a likely sleep disorder, parents/carers should be referred for medical review.

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References

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Our author

Bandana Saini (she/her) BPharm, MPharm (Pharmaceutics), MBA (International Business), PhD (Pharmacy) Grad Cert Ed Studies (Higher Edu), GradCert Imple is a registered pharmacist who works at the Sydney Pharmacy School at the University of Sydney. Her therapeutic areas of expertise include sleep disorders, asthma, COPD, pharmacy practice and education.

Our reviewer

Morna Falkland BPharm