Abstract
Introduction
Sleep disorders may affect 20-30% of young children, and include excessive daytime sleepiness, problems getting to sleep (dysomnias), or undesirable phenomena during sleep (parasomnias), such as sleep terrors, and sleepwalking. Children with physical or learning disabilities are at increased risk of sleep disorders.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for dysomnias in children? What are the effects of treatments for parasomnias in children? We searched: Medline, Embase, The Cochrane Library and other important databases up to September 2006 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antihistamines, behavioural therapy plus benzodiazepines, or plus chloral and derivates, exercise, extinction and graduated extinction, light therapy, melatonin, safety/protective interventions for parasomnias, scheduled waking (for parasomnias), sleep hygiene, and sleep restriction.
Key Points
Sleep disorders may affect 20-30% of young children, and include excessive daytime sleepiness, problems getting to sleep (dysomnias), or undesirable phenomena during sleep (parasomnias), such as sleep terrors, and sleepwalking.
Children with physical or learning disabilities are at increased risk of sleep disorders. Other risk factors include the child being the first born, having a difficult temperament or having had colic, and increased maternal responsiveness.
There is a paucity of evidence about effective treatments for sleep disorders in children, especially parasomnias, but behavioural interventions may be the best first-line approach.
Extinction and graduated extinction interventions improve settling and reduce night wakes compared with placebo in healthy children, and in children with learning disabilities.
Graduated extinction may be less distressing for parents, and therefore may have better compliance.
Sleep hygiene interventions may reduce bedtime tantrums in healthy children compared with placebo, with similar effectiveness to graduated extinction.
Sleep hygiene plus graduated extinction may reduce bedtime tantrums in children with physical or learning disabilities.
We don't know whether combining behavioural therapy with benzodiazepines or with chloral improves sleep or parasomnias.
Melatonin may improve sleep onset and sleep time compared with placebo in healthy children, but we don't know if it is beneficial in children with disabilities, if it improves parasomnias, or what its long-term effects might be.
We don't know whether antihistamines, exercise, light therapy, or sleep restriction improve dysomnias or parasomnias in children.
We don't know whether safety or protective interventions, scheduled waking, extinction, or sleep hygiene are effective in children with parasomnias.
About this condition
Definition
The International Classification of Sleep Disorders-2 (ICSD-2) defines more than 80 sleep disorders, many of which apply to children — although often in different ways — as much as to adults. Sleep problems can be divided into two broad areas: too much sleep (dysomnias), or too little sleep (parasomnias). Dysomnias are disorders that produce either excessive daytime sleepiness, or difficulty initiating or maintaining sleep. They can be intrinsic, extrinsic, or circadian rhythm sleep disorders. Dysomnias include: primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorders, and circadian rhythm sleep disorder. Parasomnias are undesirable phenomena that occur predominantly during sleep. They are caused by inappropriately-timed activation of physiological systems. Parasomnias include: nightmare disorder, sleep terror disorder, and sleepwalking disorder. Children with physical or learning disabilities: Sleep problems tend to be greater in prevalence and severity in this population. For example, pain is related to sleep disturbance, and attention paid to helping the child sleep better is likely to improve recovery. Across a range of physical problems, there are reports in the literature of sleep disturbance associated with them. In most cases, research is limited and the mechanisms are unclear. Children with visual impairment are prone to circadian rhythm problems: their light perception is poor, and the primary cue for sleep onset is lost. Many medications are known to cause sleep problems — such as severe drowsiness with many antiepileptic drugs. Learning disabilities vary considerably in the range of conditions covered by this global term. However, some conditions such as Smith-Magenis, Prader-Willi, and Williams syndrome have sleep disturbance as cardinal features. Others, such as Down's syndrome and mucopolysaccharidoses, are associated with sleep-related breathing problems. Treatment for these groups of children needs to be tailored to their particular problems, and may be problematic for anatomical and neurological reasons. Nevertheless, in large part, these sleep problems should be regarded as treatable, and careful investigation of these problems is required.
Incidence/ Prevalence
Sleep problems, primarily settling problems and frequent night wakings, are experienced by about 20-30% of children aged 1-5 years, but cultural differences would seem to play at least some role. These sleep disturbances often persist in later childhood: 40-80% of children displaying sleep problems when aged 15-48 months were found to have persistent sleep disorders 2-3 years later. In toddlers, settling and night waking problems are dominant, with rates about 20-25%. A second peak in sleep problems occurs in adolescence, where sleep-timing problems including delayed sleep phase syndrome occur. Such children have difficulty getting off to sleep, and then problems getting up in the morning for school. Across the age range, sleep-related breathing problems occur at rates about 2%. Narcolepsy is thought to occur with a prevalence of 4-6/10,000 in the USA in adults, with the onset of symptoms tending to occur in the second decade. Children with physical or learning disabilities: Prevalence of sleep disorders tends to be even greater in children with physical or learning disabilities: about 86% of children aged up to 6 years, 81% of children aged 6-11 years, and 77% of children aged 12-16 years with physical or learning disabilities suffer from severe sleep problems. We found no separate data for dysomnias and parasomnias.
Aetiology/ Risk factors
Evidence of the aetiology of sleep disorders in children is generally limited; however, the proportion of rapid eye movement (REM — active sleep) is greater in infants than in adults. REM is frequently associated with awakenings, and infants with a sleep disorder often need assistance to resume sleep after such arousals. Factors related to sleep disorders are: having had colic, the child being the first born, and the child having a difficult temperament (e.g. low sensory threshold, negative mood, decreased adaptability). Other factors have been suggested, such as being born prematurely and low birth weight; however, evidence of such associations is contradictory. These factors may influence the onset of a sleep disorder, but the factors influencing the maintenance of a sleep problem are likely to be different. Increased maternal responsiveness is associated with the maintenance of sleep disorders in children.
Prognosis
Children with excessive daytime sleepiness or night waking are likely to suffer from impaired daytime functioning without treatment, and their parents are likely to have increased stress. In addition to these effects, children with parasomnias are at serious risk of accidental injuries. Between 40% to 80% of children aged 15-48 months displaying sleep problems had persistent sleep problems 2-3 years later. Children with physical or learning disabilities: Children with learning disabilities and sleep disorders are more likely to have greater challenging behaviour than those without sleep problems. This naturally affects the quality of life of the parents, frequently resulting in maternal stress, mothers displaying less affection for their children, and marital discord. For children with epilepsy, sleep disorders may exacerbate their condition: a persistent lack of sleep has been associated with an increased frequency of seizures.
Aims of intervention
To improve parental and child satisfaction with sleep; to prevent daytime sleepiness; and improve functional and cognitive ability during the daytime, with minimal adverse effects.
Outcomes
All sleep problems: Adverse effects of treatments; effects on parents (notably parental sleep); quality of life of child (including RAND-GHRI); quality of life of parent; Sleep Behavior Questionnaire. Insomnia: Sleep duration; night wakings (frequency and duration); sleep latency; bedtime tantrums (number and frequency); settling; Composite Sleep Disturbance Score; Compostive Sleep Index Score. Timing problems: Sleep onset time; sleep offset time; sleep duration.
Methods
BMJ Clinical Evidence search and appraisal September 2006. The following databases were used to identify studies for this review: Medline 1966 to September 2006, Embase 1980 to September 2006, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2006, Issue 3. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and National Institute for Health and Clinical Excellence (NICE). Abstracts of the studies retrieved were assessed independently by two information specialists using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language, blinded for pharmaceutical interventions, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded unless blinding was impossible. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the review as required. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).
Table.
GRADE evaluation of interventions for sleep disorders in children
| Important outcomes | Sleep onset, duration and quality of sleep, bedtime tantrums, quality of life in both child and carer, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for dysomnias in children? | |||||||||
| 2 (94) | Sleep duration | Extinction and graduated extinction v placebo (in otherwise healthy children) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and poor follow-up |
| 1 (45) | Sleep duration | Sleep programme v behavioural booklet advice (in otherwise healthy children) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and poor follow-up |
| 1 (36) | Bedtime tantrums | Graduated extinction v placebo (in otherwise healthy children) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and poor follow-up |
| 1 (36) | Bedtime tantrums | Sleep hygiene v graduated extinction (in otherwise healthy children) | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data and incomplete reporting of results |
| 1 (66) | Sleep duration | Graduated extinction plus sleep hygiene v placebo (in children with physical or learning disabilites) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and poor follow-up |
| 3 (90) | Sleep duration | Extinction and graduated extinction v placebo (in children with physical or learning disabilites) | 4 | –3 | –1 | –2 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting, and poor follow-up. Consistency point deducted for conflicting results. Directness point deducted range of disabilities included |
| 1 (36) | Bedtime tantrums | Sleep hygiene v placebo | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and poor follow-up |
| 2 (102) | Sleep duration | Melatonin v placebo (in otherwise healthy children) | 4 | –3 | –1 | –2 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and poor follow-up. Consistency point deducted for conflicting results. Directness points deducted for uncertainty of measurement of outcome and population differences |
| 2 (62) | Sleep improvement | Melatonin v placebo (in children with epilepsy) | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data and poor follow-up. Consistency point deducted for conflicting results. Directness point deducted for uncertainty about doses |
| 1 (23) | Sleep improvement | Melatonin v placebo (in children with ADHD) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, poor follow-up, and uncertainty about methodology |
| What are the effects of treatments for parasomnias in children? | |||||||||
| 2 (62) | Reduction of parasomnia | Melatonin v placebo (in children with epilepsy) | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data and poor follow-up. Consistency point deducted for conflicting results. Directness point deducted for broad inclusion criteria |
Type of evidence: 4 = RCT; 2 = Observational; 1 = Non-analytical/expert opinion. Consistency: similarity of results across studies. Directness: generalisability of population or outcomes. Effect size: based on relative risk or odds ratio.
Glossary
- Actigraphy
An actigraph is a motion sensing device. It can be worn on the wrist overnight to provide data when a person falls asleep owing to change in the person's motion.
- Circadian rhythm
The cycle of sleep and wake across the 24 hour day.
- Dysomnias
are disorders that produce either excessive daytime sleepiness or difficulty initiating or maintaining sleep. They can be intrinsic, extrinsic, or circadian rhythm sleep disorders.
- Extinction
involves the removal of the positive reinforcement for the child's resistance to go to bed and awakenings by ignoring demands for attention. The child is placed in its bed and ignored pending sleep onset.
- Graded extinction
follows the same principle as extinction, but involves the gradual withdrawal of parental attention. It may be recommended that parents respond to the child's cries at lengthening intervals to teach the child to soothe itself to sleep. For example, parents may initially respond to cries after 2 minutes, then on the next occasion after 4 minutes and so on to a maximum of 20 minutes. Alternatively, parents may gradually increase the physical distance between themselves and the child. For example, the parent may start off sitting next to the child's bed, then on the second night move 30 cm away and so on until the parent is outside the child's room.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Parasomnias
are undesirable phenomena (physical or behavioural events) that occur predominantly during sleep. They can include nightmares, sleep terror disorder, and sleepwalking.
- Scheduled waking
is based on the rationale that by systematically waking the child before they usually awake the likelihood of spontaneous awakenings is reduced. The frequency of the scheduled wakes is gradually reduced and eventually discontinued.
- Sleep hygiene
, also referred to as positive routines, is an umbrella term for several modifications to the environment, and to behaviour that parents would perform in order to prepare their child for sleep in a more effective way. Examples include: removing caffeine from the child's diet, a short regular routine leading up to bed, ensuring the bedroom environment is conducive to sleep (dark, quiet, comfortable, no extreme temperatures), and avoiding boisterous play immediately before bedtime.
- Sleep latency
is the time between going to bed and going to sleep.
- Sleep restriction
is intended to increase the sleep efficiency of the child (the ratio of total sleep time to time spent in bed). The child is only allowed in bed when sleeping and the time allowed in bed is gradually increased. This increases the association of being asleep and being in bed.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Insomnia in the elderly
Nocturnal enuresis
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Paul Montgomery, University of Oxford, Oxford, UK.
Danielle Dunne, Queen Mary, University of London, London, UK.
References
- 1.American Academy of Sleep Medicine. International classification of sleep disorders: diagnostic and coding manual. Westchester, IL: American Academy of Sleep Medicine, 2005. [Google Scholar]
- 2.Quine L. Sleep problems in children with mental handicap. J Ment Defic Res 1991;35:269–290. [DOI] [PubMed] [Google Scholar]
- 3.Pahl J, Quine L. Families with mentally handicapped children: a study of stress and of service response. Report to the South East Thames Regional Health Authority, University of Kent at Canterbury, 1984. [Google Scholar]
- 4.Mindell JA. Sleep disorders in children. Health Psychol 1993:12;151–162. [DOI] [PubMed] [Google Scholar]
- 5.Tynjala J, Kannas L, Valimaa R. How young Europeans sleep. Health Educ Res 1993:8;69–80. [DOI] [PubMed] [Google Scholar]
- 6.Dollinger SJ. On the varieties of childhood sleep disturbance. J Clin Child Psychol 1982;11:107–115. [Google Scholar]
- 7.Jenkins S, Bax M, Hart H. Behaviour problems in preschool children. J Child Psychol Psychiatry 1980;21:5–17. [DOI] [PubMed] [Google Scholar]
- 8.Salzarulo P, Chevalier A. Sleep problems in children and their relationships with early disturbances of the waking-sleeping rhythms. Sleep 1983;6:47–51. [DOI] [PubMed] [Google Scholar]
- 9.Kataria S, Swanson MS, Trevathon GE. Persistence of sleep disturbances in preschool children. J Pediatr 1987;110:642–646. [DOI] [PubMed] [Google Scholar]
- 10.Richman N, Graham J. A behaviour screening questionnaire for use with three year old children. J Child Psychol Psychiatry 1971;12:5–33. [DOI] [PubMed] [Google Scholar]
- 11.Carroll JL, McColley SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 1995;108:610–618. [DOI] [PubMed] [Google Scholar]
- 12.Stores G. Recognition and management of narcolepsy. Arch Dis Child 1999;81:519–524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Quine L. Severity of sleep problems in children with severe learning difficulties: description and correlates. J Community Appl Soc Psychol 1992;2:247–268. [Google Scholar]
- 14.France KG, Blampied NM. Infant sleep disturbance: description of a problem behaviour process. Sleep Med Rev 1999;3:265–280. [Google Scholar]
- 15.Weissbluth M, Davis AT, Poncher J. Night waking in 4- to 8-month-old-infants. J Pediat 1984;104:477–480. [DOI] [PubMed] [Google Scholar]
- 16.Richman N. A community survey of characteristics of one-to-two-year-olds with sleep disruptions. J Am Acad Child Psych 1981;20:281–291. [DOI] [PubMed] [Google Scholar]
- 17.Jimmerson KR. Maternal, environmental, and tempermental characteristics of toddlers with and toddlers without sleep problems. J Pediatr Health Care 1991;5:71–77. [DOI] [PubMed] [Google Scholar]
- 18.Ungerer JA, Sigman M, Beckwith L, et al. Sleep behavior of preterm children at three years of age. Dev Med Child Neurol 1983;25:297–304. [DOI] [PubMed] [Google Scholar]
- 19.Wiggs L, Stores G. Severe sleep disturbance and daytime challenging behaviour in children with severe learning disabilities. J Intellect Disabil Res 1996;40:518–528. [DOI] [PubMed] [Google Scholar]
- 20.Durand VM and Mindell JA. Behavioral treatment of multiple childhood sleep disorders. Effects on child and family. Behav Modif 1990;14:37–49. [DOI] [PubMed] [Google Scholar]
- 21.Rajna P, Veres J. Correlation between night sleep duration and seizure frequency in temporal lobe epilepsy. Epilepsia 1993;34:574–579. [DOI] [PubMed] [Google Scholar]
- 22.Seymour FW, Brock P, During M, et al. Reducing sleep disruptions in young children: evaluation of therapist-guided and written information approaches: a brief report. J Child Psychol Psychiatry 1989;30:913–918. [DOI] [PubMed] [Google Scholar]
- 23.Adams LA, Rickert VI. Reducing bedtime tantrums: comparison between positive routines and graduated extinction. Pediatrics 1989;84:756–759. [PubMed] [Google Scholar]
- 24.Ramchandani P, Wiggs L, Webb V, et al. A systematic review of treatments for settling problems and night waking in young children. BMJ 2000;320:209–213. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Reid MJ, Walter AL, O'Leary SG. Treatment of young children's bedtime refusal and nighttime wakings: a comparison of “standard” and graduated ignoring procedures. J Abnorm Child Psychol 1999;27:5–16. [DOI] [PubMed] [Google Scholar]
- 26.Montgomery P, Stores G, Wiggs L. The relative efficacy of two brief treatments for sleep problems in young learning disabled (mentally retarded) children: a randomised controlled trial. Arch Dis Child 2004;89:125–130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Wiggs L, Stores G. Behavioural treatment for sleep problems in children with severe learning disabilities and challenging daytime behaviour: effect on sleep patterns of mother and child. J Sleep Res 1998;7:119–126. [DOI] [PubMed] [Google Scholar]
- 28.Mindell JA. Empirically supported treatments in pediatric psychology: bedtime refusal and night wakings in young children. J Pediatr Psychol 1999;24:465–481. [DOI] [PubMed] [Google Scholar]
- 29.Buscemi N, Vandermeer B, Hooton N, et al. The efficacy and safety of exogenous melatonin for primary sleep disorders: A meta-analysis. J Gen Intern Med 2005;20:1151–1158. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Armour D, Paton C. Melatonin in the treatment of insomnia in children and adolescents. Psychiatr Bull 2004;28:222–224. Search date 2003; primary source Medline. [Google Scholar]
- 31.Smits MG, Nagtegaal EE, van der Heijden J, et al. Melatonin for chronic sleep onset insomnia in children: a randomized placebo-controlled trial. J Child Neurol 2001;16:86–92. [DOI] [PubMed] [Google Scholar]
- 32.Smits MG, van Stel HF, van der Heijden K, et al. Melatonin improves health status and sleep in children with idiopathic chronic sleep-onset insomnia: a randomized placebo-controlled trial. J Am Acad Child Adolesc Psychiatry 2003;42:1286–1293. [DOI] [PubMed] [Google Scholar]
- 33.Brzezinski A, Vangel MG, Wurtman RJ, et al. Effects of exogenous melatonin on sleep: a meta-analysis. Sleep Med Rev 2005;9:41–50. [DOI] [PubMed] [Google Scholar]
- 34.Jan JE, Freeman RD. Melatonin therapy for circadian rhythm sleep disorders in children with multiple disabilities: what have we learned in the past decade? Dev Med Child Neurol 2004;46:776–782. [DOI] [PubMed] [Google Scholar]
- 35.Gupta M, Aneja S, Kohli K. Add-on melatonin improves sleep behaviour in children with epilepsy: randomized, double-blind, placebo-controlled trial. J Child Neurol 2005;20:112–115. [DOI] [PubMed] [Google Scholar]
- 36.Gupta M, Gupta YK, Aneja S, et al. Effects of add-on melatonin on sleep in epileptic children on carbamazepine monotherapy: A randomized placebo controlled trial. Sleep & Biological Rhythms 2004;2:215–219. [Google Scholar]
- 37.Weiss MD, Wasdell MB, Bomben MM, et al. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry 2006;45:512–519. [PubMed] [Google Scholar]
- 38.Arendt J. Safety of melatonin in long-term use. J Biol Rhythms 1997;12:673–681. [DOI] [PubMed] [Google Scholar]
- 39.Weaver DR. Reproductive safety of melatonin: a “wonder drug” to wonder about. J Biol Rhythms 1997;12:682–689. [DOI] [PubMed] [Google Scholar]
- 40.Sheldon SH. Pro-convulsant effects of oral melatonin in neurologically disabled children. Lancet 1998;351:1254. [DOI] [PubMed] [Google Scholar]
- 41.Rickert VI, Johnson CM. Reducing nocturnal awakenings and crying episodes in infants and young children: a comparison between scheduled awakenings and systematic ignoring. Pediatrics 1988;81:203–211. [PubMed] [Google Scholar]
- 42.Lawton C, France KG, Blampied NM. Treatment of infant sleep disturbance by graduated extinction. Child Family Behav Ther 1991;13:39–56. [Google Scholar]
- 43.Minde K, Faucon A, Falkner S. Sleep problems in toddlers: effects of treatment on their daytime behavior. J Am Acad Child Adolesc Psychiatry 1994;33:1114–1121. [DOI] [PubMed] [Google Scholar]