European Journal of Pediatrics (2018) 177:641–648

https://doi.org/10.1007/s00431-018-3116-z

REVIEW

Sleep disorders during childhood: a practical review

D. Ophoff 1 & M. A. Slaats 1,2 & A. Boudewyns 3 & I. Glazemakers 4 & K. Van Hoorenbeeck 1,2 & S. L. Verhulst 1,2

Received: 31 October 2017 / Revised: 6 February 2018 / Accepted: 9 February 2018 / Published online: 3 March 2018
# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Sleep disorders are a common problem during childhood. The consequences are variable, and sleep disorders can influence
medical, psychological and developmental aspects of the growing child. It is important to recognize sleep disorders and to treat
them correctly. We discuss common sleep disorders during childhood using the 3rd edition of the International Classification of
Sleep Disorders. We analyze the different sleep disorders from a clinical approach and provide an overview of adequate treatment
options.
Conlusion: This review discusses common sleep disorders during childhood using the 3rd edition of the International
Classification of Sleep Disorders. We analyze the different sleep disorders from a clinical approach and provide an overview
of adequate treatment options.

What is known:
• Sleep disorders are a common problem during childhood.
• The consequences are variable, and sleep disorders can influence medical, psychological, and developmental aspects of the growing child.
What is new:
• Pediatricians should routinely screen for sleep and sleep disorders.
• It is important to recognize sleep disorders and to treat them correctly.

Keywords Sleep disorders . Childhood . Insomnia . Clinical characteristics . Treatment

Abbreviations PLMD periodic limb movement disorder

DSWPD delayed sleep wake phase disorder REM rapid-eye movements
EEG electroencephalographic RLS restless leg syndrome
ICSD international classification of sleep disorders SOREMP sleep-onset rapid eye movement period
MSLT multiple sleep latency test
NREM non-rapid-eye movements
OSA obstructive sleep apnea
Introduction
D. Ophoff and M. A. Slaats contributed equally to this work.
Sleep is defined as a readily reversible suspension of sensori-
Communicated by Mario Bianchetti motor interactions with the environment, usually associated
with recumbence and immobility. Sleeping is an essential pro-
* S. L. Verhulst cess that gives us the opportunity to absorb emotions and
Stijn.verhulst@uza.be
impressions we experienced during the day, to recover from
1
Department of Pediatrics, Antwerp University Hospital, Wilrijkstraat physical activities and to gain new energy [1]. Sleep is essen-
10, 2650 Edegem, Belgium tial for children’s learning, memory processes, school perfor-
2
Lab of Experimental Medicine and Pediatrics, University of mance, and general well-being. Sleeping is a more complex
Antwerp, Edegem, Belgium and active process than previously thought, with several phys-
3
Department of Otorhinolaryngology Head and Neck Surgery, iological processes involved.
Antwerp University Hospital, Edegem, Belgium The consequences of sleep problems can vary from day-
4
Department of Youth Mental Health, Collaborative Antwerp time sleepiness to headaches, behavioral problems, poor
Psychiatric Research Institute, University of Antwerp, school results, and more. The reported prevalence of sleep
Antwerp, Belgium problems in children is at least 25% [2].
642
In this review, we will briefly discuss the normal sleep
development and needs in children, and we will provide an
overview of sleep disorders, based on the 3rd edition of the
International Classification of Sleep Disorders [ICSD-3] [3].
Each sleep disorder will be presented with a clinical case, its
specific characteristics, and possible treatment.
Sleep development and sleep needs
Sleep architecture consists of two stages: non-rapid eye move-
ment sleep (NREM) and rapid eye movement sleep (REM).
These stages are defined by polysomnographic features of
electroencephalographic (EEG) patterns, eye movements,
and muscle tone. NREM sleep is divided into three stages
from stage 1, the lightest sleep, to stage 3, also called deep
sleep. Deep sleep occurs mostly in the first part of the night.
The amount of deep sleep increases in the first year of life and
becomes maximal during childhood. It will decrease during
adolescence since adults require less deep sleep than children.
REM sleep is characterized by a strong fall in peripheral mus-
cle tone and increased cerebral activity. It is in this phase of
our sleep that we experience most of our dreams. Infants
younger than 4 months enter sleep through REM. After the
age of 3 months, the first REM sleep period occurs between
70 and 100 min after sleep onset and lasts approximately
5 min. REM and NREM sleep progresses cyclically, and every
cycle lasts 50 min during infancy (0–1 years old) and between
90 and 110 min in children and adults [4].
Sleep structure develops and changes according
to age
Neonates do not make any differentiation between day and
night-time [5, 6]. It is difficult to give guidelines about the
amount of sleep necessary for a neonate since there is a wide
range of normal variability. A sleep cycle lasts for 40 to
50 min, and they have only three sleep stages: active sleep
(REM), quiet sleep (NREM), and indeterminate sleep. During
active sleep, infants can express limb movements, sucking
movements, and grimaces, and it is in this stage that they will
fall asleep. When infants grow older, sleep time declines to
approximatively 14 h a day for a baby, and they will experi-
ence a day/night differentiation from the age of 1 month.
Around the age of 3 months, a diurnal pattern is established
with a longer period of sleep at night, shorter naps during the
day, and a few hours of wakefulness before the nocturnal sleep
period. By the age of 9 months, 70 to 80% of babies will sleep
through the night. They still require two naps of 2 to 4 h a day.
The four sleep stages will develop, and from the age of
6 months, we can define sleep stages as in adults.
An estimated 25 to 50% of 6- to 12-month-olds and 30% of
1-year-olds have problematic nightwakings with an inability
Eur J Pediatr (2018) 177:641–648
of self-soothing at sleep onset and during night waking.
Common sleep disorders in infants are nightwakings, bedtime
problems, and sleep-related rhythmic movements such as
head banging, body rocking, and body rolling.
Toddlers require approximately 12 h of sleep with one nap
during the day; the nap will disappear between 3 and 5 years
of age. The amount of REM-sleep decreases, and the amount
of deep sleep increases.
In toddlers, sleep problems are very common, occurring in
25–30% of individuals. Common sleep disorders include bed-
time problems, nightwakings, and sleep-related rhythmic
movements such as head banging, body rocking, and body
rolling. These sleep disorders in toddlers may persist into pre-
school years.
In pre-school children from 3 to 5 years of age, the preva-
lence of difficulties falling asleep and nightwakings is 15 to
30%. Common sleep disorders are nighttime fears and night-
mares, bedtime problems, nightwakings, obstructive sleep ap-
nea, and sleep-disordered breathing and disorders of arousal
such as sleepwalking and sleep terrors.
During primary school, children require approximately
11 h of sleep, which will decrease to 8–10 h of sleep for
adolescents, even if this amount is often not met. The amount
of deep sleep will first still increase but begins to decrease
during teenage years.
In school-aged children from 6 to 12 years of age, the prev-
alence of sleep problems is about 37%, with 15–25% experienc-
ing bedtime resistance, 10% experiencing sleep-onset delay and
anxiety, and 10% experiencing daytime sleepiness. Common
sleep disorders are sleepwalking and sleep terrors, bruxism,
sleep enuresis, obstructive sleep apnea (OSA), insufficient sleep
syndrome, unhealthy sleep habits, restless leg syndrome (RLS),
and periodic limb movement disorder (PLMD).
The prevalence of sleep problems in adolescents is at least
20%. Common sleep disorders in this group are insufficient
sleep syndrome, unhealthy sleep habits, insomnia, delayed
sleep-wake phase disorders, OSA, RLS, PLMD, and narco-
lepsy [5, 6].
Table 1 shows the average sleep requirements according to
age [7]. Every child has unique sleep needs, which makes it
difficult to give clear advice about how much sleep a child
requires and at what time he should go to bed. A child that gets
up easily and spontaneously in the morning has probably slept
enough. Therefore, it is important to recognize end-of-the-day
behaviors because they could indicate chronic insufficient
sleep. Sleep loss can also impact daytime functioning, includ-
ing daytime behavioral problems (hyperactivity, aggressive
behavior, and impulsivity). It may cause fatigue and daytime
lethargy, headaches, mood disturbance (such as irritability,
emotional lability, depression, and anger), cognitive impair-
ment (problems with memory, attention, concentration, deci-
sion making, and problem solving), and the use of stimulants
such as caffeine and nicotine in adolescents.
Eur J Pediatr (2018) 177:641–648
Table 1 The average
sleep needs according to 4–12 months 12 to 16 h a day
age [6]
1–2 years 11 to 14 h a day
3–5 years 10 to 13 h a day
6–12 years 9 to 12 h a day
13–18 years 8 to 10 h a day
Classification of sleep disorders
ICSDs are used to describe the most frequent sleep disorders
in children. The ICSD-3 identifies seven major categories:
insomnia, sleep-related breathing disorders, central disorders
of hypersomnolence, circadian rhythm sleep-wake disorders,
parasomnias, sleep-related movement disorders, and other
sleep disorders [3, 8].
We refer to a recent European Respiratory Society Task
Force [11] for the diagnosis and management of obstructive
sleep disordered breathing (SDB) in childhood and to the
ICSD-3 for the other categories. In this article, we will only
discuss insomnia, central disorders of hypersomnolence, cir-
cadian rhythm sleep-wake disorders, parasomnias, and sleep-
related movement disorders.
Insomnia
Case
The parents of Lisa, a 2.5-year-old girl, consulted their pedi-
atrician because she has problems falling asleep, leading to a
low energy level during the day. During the previous 6 months,
going to bed has become more and more difficult, and now she
can only fall asleep when mum or dad lie next to her holding
her hand. Even when she wakes up at night, she cannot get
back to sleep without one of them next to her. The parents tried
to avoid it, but they end up lying next to her so that she finally
falls asleep. It is getting so bad that some nights, one of them
has to sleep with her in bed or no one would be able to sleep
with her crying all night long.
Insomnia is defined as difficulty initiating sleep, difficulty
maintaining sleep, or waking up early with the inability to
return to sleep. In practice, this means that children have dif-
ficulty falling asleep (without a parent’s intervention), wake
up frequently at night, and cannot return to sleep (often with-
out a parent’s attention) or wake up earlier than usual.
Additionally, there are often daytime consequences such as
sleepiness, limitations to daytime activities, or behavioral
problems for either the patient or the parents [9, 10].
Childhood insomnia can be divided into three distinct groups:
behavioral insomnia, psychophysiological insomnia, and tran-
sient sleep disturbances (see Table 2). The most important
insomnia during childhood is behavioral insomnia, which is
divided into sleep-onset association disorder and limit-setting
643
Table 2 Types of childhood insomnia
Behavioral insomnia of childhood
Related to sleep-onset associations
Related to inadequate limit-setting by parents
Psychophysiological [conditioned] insomnia
Transient sleep disturbances
disorder. Psychophysiological or conditioned insomnia occurs
primarily in older children and adolescents.
Childhood insomnia is very common, with an estimated
prevalence of 25 to 40% in children aged 4–10 years old.
Bedtime resistance is a problem in 15% of these children,
and almost 11% have psychophysiological insomnia [11].
The prevalence of insomnia in adolescents is estimated to be
11% [12]. Children with neurodevelopmental, chronic medi-
cal, or psychiatric disorders are at a higher risk for sleep dis-
turbances leading to insomnia [13] and often require an
adapted (behavioral) treatment approach.
Children with sleep-onset association disorder can only fall
asleep under certain conditions. This can be a certain object or
circumstance that usually requires the presence or intervention
of the parents. When the child wakes up at night, he will not be
able to get back to sleep without those same conditions being
present. This disorder usually disappears around the age of 3
to 4 years old [14].
Limit-setting insomnia is very common in preschool- and
school-aged children. It is characterized by the parent’s diffi-
culty in setting rules and limits for bedtime and having their
children follow these rules. Children will protest and show
resistance in such a prolonged way that it can result in inade-
quate and insufficient sleep [14].
Psychophysiological insomnia is characterized by anxiety
about falling or staying asleep due to an excessive physiolog-
ical or emotional arousal related to sleep and the sleep envi-
ronment. Children with this condition have difficulty falling
asleep, sleeping through the night, or waking up early in the
morning. Affected children often have dysfunctional sleep
cognitions such as thinking they will never be able to fall
asleep. Even during daytime, they are already thinking about
how they will fall asleep at night. Other risk factors associated
with insomnia are the excessive use of caffeine or the abuse of
alcohol, marihuana, and other drugs [15].
Transient sleep disturbances occur in children with a pre-
viously normal sleep pattern in times of a stressful event such
as moving or traveling. It is usually self-limiting but can be-
come chronic if the parents respond in a way that reinforces
their inappropriate sleep habits.
Behavioral insomnia is treated through adequate sleep hy-
giene and behavioral therapy with the gradual extinction of
parental involvement and teaching children to self-sooth. The
focus in younger children is mainly on changing parental
644
behavior. It is essential to involve parents in the management
of this disorder because they are the ones who should establish
the rules and limits and maintain them.
In older children with conditioned insomnia, education of
the child about the principles of healthy sleep habits and the
use of relaxation techniques can be very helpful in addition to
behavioral therapy [16].
Pharmacological therapy for the treatment of insomnia is
not a first-line treatment option and should only be considered
in combination with behavioral therapy. Melatonin is an ef-
fective, safe, and well-tolerated agent, particularly in cases of
sleep-initiation insomnia caused by circadian factors. Several
placebo-controlled studies of melatonin in adults and children
(in some studies, as young as 3 years of age) showed that
melatonin administered at bedtime reduces sleep-onset laten-
cy time and increases total sleep time [17].
Central disorders of hypersomnolence
Case
Sophie, a 6-year-old girl, was referred because of excessive
daytime sleepiness; her teacher found her asleep in class, and
she also falls asleep watching television. Her parents initially
attributed these daytime symptoms to her poor sleep.
However, in the last few weeks, she has had sufficient sleep.
Sometimes she wakes up in the night and has the feeling she
cannot move anymore. She has needed a nap during the day
for 1 h for a month. There are no hypnagogic hallucinations
present.
Hypersomnolence, or excessive daytime sleepiness that is
not attributable to another sleep disorder (e.g., circadian
rhythm disorders or sleep deprivation), is the primary com-
plaint in the central disorders of hypersomnolence. It is de-
fined as Bdaily episodes of an irrepressible need to sleep or
daytime lapses into sleep.^ Multiple sleep latency tests
(MSLTs) are necessary to objectify sleepiness and should only
be performed immediately after a PSG because they must be
followed by sufficient nocturnal sleep [of at least 6 h], and
other sleep disorders must be excluded. The test consists of
four or five 20-min nap opportunities at 2-h intervals across
the day. The latency until sleep onset is measured for each nap
opportunity, and sleep recordings are analyzed to detect sleep
stage transitions (based on standard EEG, EOG, and EMG
criteria) and the presence or absence of REM sleep during
each nap (known as sleep-onset rapid eye movement periods,
or SOREMPs when REM latency is less than 10 min). A mean
sleep latency of less than 8 min is generally considered to be
consistent with objective evidence of excessive daytime sleep-
iness [18]. Narcolepsy is one of the central disorders of hyper-
somnolence and is characterized by an abnormal sleep latency
of less than 8 min with evidence of minimal 2 SOREMP.
Eur J Pediatr (2018) 177:641–648
However, the second criterion is not always present in chil-
dren with narcolepsy, certainly not at the onset of the disorder.
There are two types of narcolepsy:
Type 1 includes patients with cataplexy and hypocretin-1
deficiency, which is measured in cerebrospinal fluid.
Cataplexy is a condition characterized by transient weakness
or paralysis of somatic musculature triggered by an emotional
stimulus or physical exertion. Type 2 patients have daily pe-
riods of an irrepressible need to sleep or daytime lapses for at
least 3 months, a positive MSLT for narcolepsy but the ab-
sence of cataplexy, normal hypocretin-1 levels, and no other
explanation for hypersomnolence.
Narcolepsy is mostly a sporadic disorder, but familial pre-
disposition has been recognized. Associations between narco-
lepsy and HLA DQA1 0102 and HLA DQB1 0602 have been
demonstrated in several studies. Most patients will show pos-
itivity for this HLA allele; however, it is also found in 20% of
healthy individuals [19]. The diagnosis is made by a detailed
clinical history and a complete physical examination, includ-
ing neurological assessment in combination with a
polysomnography followed by MSLTs. Lumbar puncture
can be utilized to measure hypocretin-1 levels. Hypersomnia
due to medication or substance abuse should always be
excluded.
The estimated prevalence of narcolepsy is 30 in 100,000
patients. The first symptoms usually appear during adoles-
cence, between 15 and 30 years of age, but some cases in
toddlers have been described. Narcolepsy is found equally in
females and males. The prevalence is known to vary between
nationalities and ethnicities, with the highest prevalence in
Japan [20].
Children with narcolepsy present with four main symp-
toms: excessive sleepiness, cataplexy, sleep paralysis, and
hypnagogic hallucinations. Other symptoms of narcolepsy
are disrupted or fragmented sleep and metabolic, endocrino-
logical, psychiatric, and psychosocial issues.
Excessive sleepiness with an impact on daily life activities
is the most important presenting symptom in patients.
Cataplexy is the second most common symptom of narcolep-
sy and is present in 80% of patients. It is defined as a sudden-
onset loss of skeletal muscle tone with maintained conscious-
ness and can vary in severity from only buccofacial cataplexy
to whole-body cataplexy. It can last for some seconds to sev-
eral minutes and is associated with a strong emotion.
Hypnagogic hallucinations are a third symptom of narco-
lepsy. They are generated when REM-sleep occurs just before
sleep onset or just before awakening. They are mostly visual
hallucinations and can occur together with sleep paralysis.
Sleep paralysis is reported as an inability to move for a few
minutes and occurs typically on awakening from sleep.
Type 1 narcolepsy in childhood is also associated with
overweight and obesity due to hypocretin deficiency
impairing satiety [21].
Eur J Pediatr (2018) 177:641–648
Behavioral therapy is necessary to implement strategies for
managing the daytime sleepiness. This includes sleep hygiene
counseling with scheduled naps during the day. It is important
to integrate the entire family and school in the therapy. Weight
management and the management of associated disorders
should always be included. Medical therapy for narcolepsy
includes stimulating drugs such as methylphenidate,
modafinil, amphetamines, or sodium oxybate. Specifically,
for cataplexy tricyclic antidepressants, selective serotonin or
noradrenalin re-uptake inhibitors (fluoxetine, venlafaxine) can
be prescribed, although they are rarely used in children, and
this requires a referral of these children to a specialized sleep
center [22].
Other central disorders of hypersomnolence are idiopathic
hypersomnia, hypersomnia due to a medical or psychiatric
disorder or due to a medication or substance and insufficient
sleep disorder. We refer to the ICSD-3 for more information
about those disorders.
Circadian rhythm sleep-wake disorders
Case
Alex is a 15-year-old boy who goes to bed around 22h30 but
lies awake for 2 or more hours in bed before falling asleep.
When he is finally sleeping, he has a good night of sleep
without waking up. In the morning, he is still sleeping when
the alarm goes off, and his mom usually has to push him to get
him up. At school, he often complains about a headache and
sleepiness, and his teacher believes that he has concentration
difficulties. During the weekend he’s allowed to stay up until
midnight and then he falls asleep within thirty minutes but he
sleeps until noon.
Delayed sleep-wake phase disorder (DSWPD) is the
most frequent sleeping disorder during adolescence. It in-
volves a habitual and persistent phase shift of more than
2 h in the sleep-wake schedule that conflicts with the indi-
vidual’s normal school, work, and/or lifestyle demands.
The timing is problematic; there normally are no problems
with the quality of sleep. Studies suggest that DSWPD
affects 7 to 16% of adolescents. In sleep clinics, it has been
observed in approximately 10% of cases. Young men are
more likely to have an evening preference. The onset is
typically during adolescence [23].
Patients typically present with a history of lying awake in
bed for several hours before they finally fall asleep. They will
sleep through the night but have trouble waking up. The
resulting sleep deprivation leads to sleepiness, petulance,
headache, and concentration problems. Differential diagnosis
should be made with insomnia, RLS, school avoidance or
refusal, psychiatric disorders including depression, anxiety
disorders, or abuse.
645
The goal of the therapy is to reset the sleep-wake cycle
to normal. This can be achieved by some simple life rules
such as no daytime naps, regular bedtimes and wake times
during the week and weekends, no caffeine or other stim-
ulating drinks or food in the evening, no computer or TV in
the bedroom, and more light exposure in the morning. If
this fails, chronotherapy is indicated, where bedtime is
gradually delayed until the desired hour of falling asleep
is reached [24]. Melatonin can sometimes help to reset the
sleep-wake cycle by decreasing sleep onset latency and
increasing total sleep time. However, it will not decrease
night awakenings. Melatonin is in this case most effective
when administered 3 to 5 h before bedtime [25, 26].
Parasomnias
Case
The parents of Adam, a 4-year-old, consulted their pediatri-
cian because they are really worried about their son. Almost
every night, he wakes up screaming loudly. When the parents
arrive in his room, he looks anxious with big eyes, he is sweat-
ing, and they feel that his heart is beating very fast. When they
talk to him, he does not really respond but remains agitated.
When asking him in the morning what happened, he cannot
remember anything.
Parasomnias are sleep phenomena characterized by abnor-
mal behavior or physiological events that occur during sleep
or during the transition from sleeping to awakening. In gener-
al, the sleep quality remains unaffected, but this episodic com-
plex behavior can lead to significant worry for parents.
Parasomnias are divided into NREM-related, REM-related,
and other parasomnias. For a complete overview of all
parasomnias, we refer to the ICSD-3 [3]. Sleepwalking,
sleep-talking, and sleep terrors are NREM-related
parasomnias that occur during deep sleep, that is, mostly dur-
ing the first third of the night.
Nightmares are disturbing dreams that bring up negative
emotions and will usually awaken the dreamer. Since they
occur during REM-sleep, nightmares will occur more during
the second part of the night.
The prevalence of sleepwalking in the overall population is
estimated to be between 1 and 15%. The prevalence is 17% in
children and 4% in adults. Peak incidence occurs between the
ages of 8 and 12 years old [27]. Approximately 3% of all
children experience sleep terrors, which will mostly disap-
pear without intervention. The age of onset is usually be-
tween 3 and 10 years of age [28]. The prevalence of chil-
dren who report at least one nightmare in their lifetime is
approximately 75%. The overall prevalence of at least one
parasomnia event by the age of 13 years has been reported
to be as high as 78% [29].
646
Sleepwalking can vary from mild episodes, in which the
child sits up and crawls around the bed, to more agitated
episodes with running around throughout the house.
Sleepwalkers typically have a poor memory of sleepwalking
episodes.
Sleep terrors are another NREM-related parasomnia and
are characterized by a sudden arousal accompanied by auto-
nomic and behavioral manifestations of intense fear. They can
also show tachycardia, sweating, and mydriasis. The child is
not responsive, is agitated, and will not remember what hap-
pened in the morning.
Nightmares are dreams that seem vivid and real and are
associated with negative emotions such as fear, but not so
intense as with sleep terrors. Once awakened, full alertness
returns immediately, and the child will often remember his
nightmare in contrast to sleep terrors. Differential diagnosis
should be made with sleep terrors and posttraumatic stress
syndrome. A polysomnography can be indicated since night-
mares and parasomnias can be related to OSA.
It is important to explain to parents that parasomnia is a
neurodevelopmental phenomenon; it is not indicative of an
underlying psychological issue and will not result in psy-
chological harm. There is no real treatment for
sleepwalking or sleep terrors. Preventive measures must
be taken so the patient cannot hurt himself, and the parents
must be reassured that it will usually disappear with time.
Healthy sleep habits are important because insufficient
sleep is the primary contributor: adequate sleep and the
discipline to maintain a regular sleep-wake schedule are
necessary, and adolescents should avoid caffeine [it can
increase sleep disruption]. It is important to explain the
response during an event: they must avoid awakening the
child because this can cause agitation and prolong the
event. Parents can guide the child back to bed.
Scheduled awakening is a behavioral technique that is most
likely to be successful in situations in which episodes occur on
a nightly basis. The parent wakes the child 15 to 30 min prior
to the time that the first episode typically occurred during the
past 2–4 weeks. Pharmacologic treatment may be indicated in
cases of frequent or severe episodes with a high risk of injury
or violent behavior; however, this is rarely indicated in chil-
dren. The primary agents are suppressants of slow-wave sleep
such as benzodiazepines (diazepam, 1–2 mg for 3–6 months
before bedtime or intermittent in clusters of days/weeks) and
tricyclic antidepressants (in case of nonresponse to benzodi-
azepines) [6]. An alternative medical treatment for sleep ter-
rors is the use of L-5-hydroxytryptophan that has proven his
efficacy in certain studies [30].
The best treatment for nightmares is reassurance of the
child that it was only a bad dream. When nightmares become
problematic and recurrent, further evaluation to assess anxiety
and an underlying cause is indicated. Treatment is based on
behavioral therapy [31].
Eur J Pediatr (2018) 177:641–648
Sleep-related movement disorders
Case
Case 1: Martha, a 10-year-old girl, resists going to bed
every evening. She says that she has an annoying, electric
feeling in her legs and starts shaking her legs when lying
in bed. This makes it difficult for her to fall asleep and
sometimes the feeling also wakes her up during the night.
Case 2: The parents of Jim, a 7-year-old boy, noticed that
his legs move vigorously when he’s sleeping. He always
seems to have disturbed sleep. He just started primary
school but has difficulty concentrating in the classroom.
Sleep-related movement disorders are characterized by
simple, often stereotypical movements that occur during
sleep, contrary to the complex movements of parasomnias.
There are several types of sleep-related movement disorders
such as head banging, body rocking, head rolling, bruxism,
RLS, and PLMD.
Head banging, body rocking, or head rolling are sleep-
related rhythmic movements and are common in young chil-
dren (59%). Body rocking is the most common (43%), follow-
ed by head rolling (24%) and head banging (22%).
The onset is typically prior to 1 year of age, with body
rocking starting at an earlier age than head banging.
– Body rocking begins at approximately 6 months of age
and presents without head banging. Only the body is
rocking back and forward.
– Head banging starts at approximately 9 months of age and
can occur by lifting the head to bang down into the pillow,
rocking on hands and knees, or sitting upright and
banging.
– Head rolling involves side-to-side movements of the head
and starts at the age of 10 months. Body rolling is less
common.
These body movements can occur at sleep onset, following
normal nighttime arousals, and while sleeping. Sleep is not
really disrupted, and significant injury is rare. These behaviors
occur in normally developing children, and in most cases, there
is no association with an underlying neurologic or psycholog-
ical problem. The parents should be instructed about safety and
behavioral management. The most important aspect is reassur-
ance that this is a normal, common, benign, and self-limited
phenomenon. Most children will outgrow the condition by the
age of 2 or 3 years. The prevalence is 33% in children 18 months
old and only 5% by 5 years of age [6].
Bruxism is defined as nonfunctional repetitive grinding or
clenching of teeth during sleep. It can lead to dental erosion,
jaw and/or facial pain, and tissue damage over time. It typi-
cally occurs during stages 1 and 2 of NREM sleep and
Eur J Pediatr (2018) 177:641–648
infrequently during REM sleep. Prolonged breastfeeding, de-
creased nighttime sleep, dental trauma, stress, light and noise
in the bedroom, reflux, and a history of cerebral palsy are risk
factors for bruxism. Thereby, it persists in adults in two-thirds
of cases. Treatment could be focused on stress management
techniques. Sometimes, there is need for pain relief with med-
ication or dental appliances. Pharmacotherapy with REM-
suppression is rarely indicated in children [6].
Restless leg syndrome (RLS) is a well-known diagnosis in
adults and probably underestimated in children since many
adult patients report symptoms that started before the age of
20 years. RLS can be mistaken in children with attention-
deficit hyperactivity disorder (ADHD) since symptoms can
be similar [32].
The diagnostic criteria for RLS in adolescents are as fol-
lows: the urge to move legs starting or worsening when sitting
or lying down. This urge to move declines or disappears when
getting up and worsens or exists only in the evening or at
night. In children, the same diagnostic criteria are used with
the addition of a description of the unpleasant feeling in their
legs in the child’s own words. This syndrome may lead to
sleep avoidance, difficulty falling asleep, and waking up at
night. Polysomnography may show a periodic limb move-
ment index of more than 5 per hour (which is also necessary
in the diagnosis of PLMD). RLS is associated with a higher
risk for depression and anxiety [33].
PLMD is diagnosed in children when polysomnography
shows a periodic limb movement index of more than 5 per
hour, associated with a clinically disturbed sleep or functional
impairment and no other underlying sleep disorders such as
RLS. The major difference between PLMD and RLS is that
PLMD is a disorder of limb movements (without sensory
symptoms) while RLS there is a sensory symptomatology.
In both RLS and PLMD, genetic factors, dopamine distur-
bance, and iron deficiency seem to play a role [34]. It can be
helpful to start iron supplements for a child with a limb move-
ment disorder and a ferritin level below 50 ng/ml. General
recommendations about daily physical exercise before bed-
time, stretching, massage, and heat and cold patches can give
relief of symptoms. Caffeine, alcohol, antihistamines, and
cold circumstances should be avoided since they can trigger
RLS. Medical therapy for both disorders includes gabapentin,
clonidine, clonazepam, or dopamine-receptor agonists but
should be started by a specialist since large trials in children
with these disorders are lacking [35, 36].
Conclusion
In this review, a practice-based overview of sleep disorders
during childhood was presented based on the ICSD-3 classi-
fication. Sleep disorders in children are common and can be
difficult to diagnose, so it is important to be aware of them.
647
Good sleep hygiene is essential (see Table 3—useful tips for
good sleep hygiene), and specific behavior therapy has been
proven helpful for several sleep disorders. At times, medical
therapy is necessary, but the risks and benefits must be con-
sidered. Children should be referred to a specialized sleep
center when standard therapy fails or when polysomnography
is indicated.
Table 3 Useful tips for good sleep hygiene
Many people think sleep problems are a normal part of childhood and
education, which is often true. However, in some cases, sleep problems
can have a serious impact on the child and its family. With some simple
advice and rules, we can help parents and children [when old enough]
provide insight into sleep habits and teach them healthy sleep
behaviors.
A good night’s sleep starts at daytime
Maintain a clear daytime schedule
Explain which behaviors are accepted and which are not by positive
reinforcement of the good behavior and ignoring the bad behavior.
Do not punish a child by sending him/her to bed.
A bedroom is only for sleeping, not for playing.
Avoid heavy or stimulating food and drinks before bedtime.
Reward the child when he had a good night.
Preparing for bedtime
Warn the child that it is almost bedtime; indicate when the last activity
starts so he/she can prepare for bedtime.
Try to ease your child down and to have a regular bedtime.
Take your time and do not give your child the impression that you are
working against them.
Parents should provide consistency by working together as a team
Teach the child to fall asleep by themselves and do not stay with
him/her until he/she sleeps.
Bedtime routines
Use the same ritual every day but keep it short.
If reading is part of the bedtime ritual, make clear rules about the
reading time.
Some older children can experience benefits from relaxing exercises.
Environment
A dark, calm and not too warm [approximately 18°] room is the best.
If the child is afraid of the dark, use a dimmed light in the room or keep
the door slightly open to reassure the child.
Remove computers and televisions from the bedroom
Avoid Bblue light^ from screens before going to sleep.
At night
At the beginning, send the parent who can be the firmest to the child.
Use the same strategy as your partner.
Do not react on the first call but do not wait until the child is completely
upset.
Try to stay calm, keep the lights low, and talk softly. Keep the child in
his room and even better in his bed. Do not stay too long with the
child.
Let the child sleep in his own bed.
Do not approach your child if you are feeling angry
648
Authors’ contributions Concept of the manuscript: D.O., M.S. and S.V.;
Acquisition of data: D.O., M.S. and S.V.; Drafting of the manuscript:
D.O., M.S. and S.V.; Critical revision of the manuscript: A.B., I.G. and
K.V.H.; Final manuscript: all authors.
References
1. Bathory E, Tomopoulos S (2017) Sleep regulation, physiology and
development, sleep duration and patterns, and sleep hygiene in
infants, toddlers, and preschool-age children. Curr Probl Pediatr
Adolesc Health Care 47(2):29–42
2. Maski K, Owens JA (2016) Insomnia, parasomnias, and narcolepsy
in children: clinical features, diagnosis, and management. Lancet
Neurol 15(11):1170–1181
3. Darien. (2014) International classification of sleep disorders, 3rd
ed. American Academy of Sleep Medicine
4. Jodi A Mindell. (2003) A clinical guide to pediatric sleep. Owens
JA, editor
5. MacLean JE, Fitzgerald DA, Waters KA (2015) Developmental
changes in sleep and breathing across infancy and childhood.
Paediatr Respir Rev 16(4):276–284
6. Iglowstein I, Jenni OG, Molinari L, Largo RH (2003) Sleep dura-
tion from infancy to adolescence: reference values and generational
trends. Pediatrics 111(2):302–307
7. Paruthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd
RM, et al. (2016) Recommended amount of sleep for pediatric
populations: a consensus statement of the American Academy of
sleep medicine. J Clin sleep med 15;12(6):785-6
8. Sateia MJ (2014) International classification of sleep disorders-third
edition: highlights and modifications. Chest 146(5):1387–1394
9. Ohayon MM (2002) Epidemiology of insomnia: what we know and
what we still need to learn. Sleep Med Rev 6(2):97–111
10. Nunes ML, Cavalcante V (2005) Clinical evaluation and treatment
of insomnia in childhood. J Pediatr 81(4):277–286
11. Owens JA, Spirito A, McGuinn M, Nobile C (2000) Sleep habits
and sleep disturbance in elementary school-aged children. J Dev
Behav Pediatr 21(1):27–36
12. Johnson EO, Roth T, Schultz L, Breslau N (2006) Epidemiology of
DSM-IV insomnia in adolescence: lifetime prevalence, chronicity,
and an emergent gender difference. Pediatrics 117(2):e247-e256
13. Owens JA, Mindell JA (2011) Pediatric insomnia. Pediatr Clin N
Am 58(3):555–569
14. Meltzer LJ (2010) Clinical management of behavioral insomnia of
childhood: treatment of bedtime problems and night wakings in
young children. Behav Sleep Med 8(3):172–189
15. Espie CA, Barrie LM, Forgan GS (2012) Comparative investigation
of the psychophysiologic and idiopathic insomnia disorder pheno-
types: psychologic characteristics, patients' perspectives, and impli-
cations for clinical management. Sleep 1;35(3):385–393
16. Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A (2006)
Behavioral treatment of bedtime problems and night wakings in
infants and young children. Sleep 29(10):1263–1276
17. Ferracioli-Oda E, Qawasmi A, Bloch MH (2013) Meta-analysis:
melatonin for the treatment of primary sleep disorders. PLoS One
8(5):e63773
18. Kotagal S, Nichols CD, Grigg-Damberger MM, Marcus CL,
Witmans MB, Kirk VG et al (2012) Non-respiratory indications
Eur J Pediatr (2018) 177:641–648
for polysomnography and related procedures in children: an
evidence-based review. Sleep 1;35(11):1451–1466
19. Singh AK, Mahlios J, Mignot E (2013) Genetic association, sea-
sonal infections and autoimmune basis of narcolepsy. J Autoimmun
43:26–31
20. Dye TJ, Gurbani N, Simakajornboon N. (2016) Epidemiology and
pathophysiology of childhood narcolepsy. Paediatr Respir Rev.
21. Ponziani V, Gennari M, Pizza F, Balsamo A, Bernardi F, Plazzi G
(2016) Growing up with type 1 narcolepsy: its anthropometric and
endocrine features. J Clin Sleep Med 15;12(12):1649–1657
22. Kotagal S. (2017) Treatment of narcolepsy and other organic
hypersomnias in children. Paediatr Respir Rev.
23. Gradisar M, Crowley SJ (2013) Delayed sleep phase disorder in
youth. Curr Opin Psychiatry 26(6):580–585
24. Vetter C, Fischer D, Matera JL, Roenneberg T (2015) Aligning
work and circadian time in shift workers improves sleep and re-
duces circadian disruption. Curr Biol 30;25(7):907–911
25. Bruni O, Alonso-Alconada D, Besag F, Biran V, Braam W, Cortese
S, Moavero R, Parisi P, Smits M, van der Heijden K, Curatolo P
(2015) Current role of melatonin in pediatric neurology: clinical
recommendations. Eur J Paediatr Neurol 19(2):122–133
26. Auger RR, Burgess HJ, Emens JS, Deriy LV, Thomas SM, Sharkey
KM (2015) Clinical practice guideline for the treatment of intrinsic
circadian rhythm sleep-wake disorders: advanced sleep-wake phase
disorder (ASWPD), delayed sleep-wake phase disorder (DSWPD),
Non-24-hour sleep-wake rhythm disorder (N24SWD), and irregu-
lar sleep-wake rhythm disorder (ISWRD). An update for 2015: an
American Academy of sleep medicine clinical practice guideline. J
Clin Sleep Med 15;11(10):1199–1236
27. Carter KA, Hathaway NE, Lettieri CF (2014) Common sleep dis-
orders in children. Am Fam Physician 1;89(5):368–377
28. Kotagal S (2009) Parasomnias in childhood. Sleep Med Rev 13(2):
157–168
29. Laberge L, Tremblay RE, Vitaro F, Montplaisir J (2000)
Development of parasomnias from childhood to early adolescence.
Pediatrics 106(1 Pt 1):67–74
30. Bruni O, Ferri R, Miano S, Verrillo E (2004) L -5-
Hydroxytryptophan treatment of sleep terrors in children. Eur J
Pediatr 163(7):402–407
31. Mason TB, Pack AI (2007) Pediatric parasomnias. Sleep 30(2):
141–151
32. Angriman M, Cortese S, Bruni O (2017) Somatic and neuropsychi-
atric comorbidities in pediatric restless legs syndrome: a systematic
review of the literature. Sleep Med Rev 34:34–45
33. Bloomfield ER, Shatkin JP (2009) Parasomnias and movement
disorders in children and adolescents. Child Adolesc Psychiatr
Clin N Am 18(4):947–965
34. Khatwa U, Kothare SV (2010) Restless legs syndrome and periodic
limb movements disorder in the pediatric population. Curr Opin
Pulm Med 16(6):559–567
35. Rulong G, Dye T, Simakajornboon N. (2017) Pharmacological
Management of Restless Legs Syndrome and Periodic Limb
Movement Disorder in children. Paediatr Drugs
36. Dye TJ, Jain SV, Simakajornboon N (2017) Outcomes of long-term
iron supplementation in pediatric restless legs syndrome/periodic
limb movement disorder (RLS/PLMD). Sleep Med 32:213–219