SLEEP DISORDERS IN

CHILDREN
DR. SUBRATA NASKAR, MD
CONSULTANT PSYCHIATRIST
• SLEEP IS A NATURALLY OCCURING STATE CHARACTERISED BY
REDUCED OR ABSENT CONSCIOUSNESS,RELATIVELY SUSPENDED
SENSORY ACTIVITIES AND INACTIVITY OF MOST VOLUNTARY
MUSCLES.
• SLEEP DISORDERS ARE COMMON IN CHILDHOOD AND ADOLESCENCE
AND ARE ASSOCIATED WITH NEUROCOGNITIVE AND PSYCHOSOCIAL
IMPAIRMENTS AS WELL AS AN INCREASE IN CAREGIVER BURDEN. 

• CURRENT EVIDENCE INDICATES THAT CHRONICALLY DISRUPTED SLEEP

IN CHILDREN AND ADOLESCENTS CAN LEAD TO PROBLEMS IN
COGNITIVE FUNCTIONING, SUCH AS ATTENTION, LEARNING, AND
MEMORY. 
OBJECTIVE TODAY
• 1. UNDERSTAND NORMAL SLEEP IN CHILDREN

• 2. REVIEW COMMON PEDIATRIC SLEEP DISORDERS

• 3. DISCUSS TREATMENT OPTIONS

What is “enough” sleep in children?
• “THE AMOUNT OF SLEEP THAT A CHILD NEEDS TO FEEL WELL
RESTED.”

• PARENTS ARE GOOD AT RECOGNIZING WHEN THEIR CHILD IS

“OVERTIRED” (WHINY, CRANKY, MOODY, “HYPER”) IN ASSOCIATION
WITH AN ACUTE SLEEP LOSS LIKE A MISSED NAP OR LATE BEDTIME.
Total sleep duration

6 Months 16 Years
14±2 HOURS

8±1 HOURS
• Consolidation of nocturnal sleep occurs
during the first 12 months after birth, with
a decreasing trend of daytime sleep.

• Daytime napping typically disappears after

age 5 years in monophasic sleep cultures.
• During sleep, an ultradian rhythm determines the timing and duration
of sleep states.

• The ultradian rhythm refers to the alternation of two distinct types of

sleep, ie, nonrapid eye movement (NREM) and rapid eye movement
(REM) sleep throughout the sleep period.
• NREM sleep has been categorized into four distinct stages according
to electroencephalographic changes.

• The stages represent gradations in depth of sleep and difficulty of

arousal
• stage 1 - the lightest
• stage 4 - the deepest.
• The differentiation of NREM sleep into four distinct stages is
completed by 6 months of age.
• The distinguishing electroencephalographic characteristics of the
NREM stages are:

• Stage I or drowsiness, mixed frequency (theta, alpha, and delta), isolated

vertex sharp transients, slow rolling eye movements
• Stage II, prominent sleep spindles and K complexes
• Stage III, delta slowing constitutes 20%–50% of a 30 second epoch
• Stage IV, delta slowing constitutes 50% or more of a 30 second epoch.
• When first drifting off, the child enters stage 1 NREM sleep, which is
characterized by reduced body movements and responsiveness.

• This stage comprises approximately 2%–5% of total sleep, with the

majority occurring at the beginning of the sleep period.
• Stage 2 sleep then follows, and is considered the onset of true sleep.

• It is characterized by decreased eye movements, reduced muscle

tone, and deceleration of respiration and heart rate.

• The child may move freely and reposition in bed.

• About one half of the total sleep time is spent in stage 2, with the
majority occurring in the middle of the night. 
• The third and fourth stages are nearly identical and are together called
delta, deep, or slow-wave sleep.

• These stages are characterized by a relaxed body position, slow and

rhythmic breathing, and a decreased heart rate.

• Arousal is difficult and if awakened, the child will appear confused and
disoriented.

• Constitute approximately 20% of total sleep time

• REM sleep is characterized by bursts of rapid eye movements

• EEG activity similar to that of the awake state, muscle paralysis, and vividly
remembered dreams. 

• The muscle paralysis in the presence of intense brain activity has led to the
synonymous term “paradoxical sleep,” whereby the paralysis protects the
child from physically acting out the action in dreams.
 Highest in Infancy

REM Sleep 55% 20-25%

5 Years of Age
DIFFERENCE WITH ADULTS
• Infants younger than 6 months spend 50% of their sleep time in REM
sleep, compared with 20% in adults. 

• In infants, sleep starts with an initial active REM stage, in contrast

with adults, who do not commonly enter REM sleep until 90 minutes
into the sleep cycle. 

• Until 6 months of age, sleep cannot be subdivided into the four

electroencephalographic stages seen in the mature sleep pattern.
SLEEP DISORDERS IN CHILDREN
• Prevalence –
• The overall prevalence of a variety of parent-reported sleep problems
have been estimated to range from 25% to 50% in preschool-aged
samples to 37% in a community sample of 4–10 year-olds.

• More than 40% of adolescents were also reported to have significant

sleep complaints.
International Classification of Sleep
Disorders-Third Edition (2016)
INSOMNIA

SLEEP RELATED BREATHING DISORDERS

CENTRAL DISORDERS OF HYPERSOMNOLENCE

CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS

PARASOMNIAS

SLEEP RELATED MOVEMENT DISORDERS

OTHER SLEEP DISORDERS

INSOMNIA
BEHAVIORAL INSOMNIA OF CHILDHOOD

• Prevalence: 10% to 30%

• TYPES
• Sleep-onset association type
• Limit-setting type
Sleep-onset association type.
• children begin to associate certain conditions with sleep, and
will need these conditions to be present in order to fall asleep.

• POSITIVE SLEEP ASSOCIATION

• NEGATIVE SLEEP ASSOCIATION

• The sleep-onset association type is characterized by the child's

inability or unwillingness to fall asleep or return to sleep in the
absence of specific conditions, such as a parent rocking the
child to sleep
Limit-setting type
• Onset of this sleep disorder usually begins in the toddler years as the
child gains individual mobility and language with which the child can test
his/her limits.

• Manifestations of this disorder include difficulty initiating sleep at the

appropriate time by stalling or refusing to go to bed.

• Children will stall by asking to complete an activity “just one more time”
before going to bed
Primary prevention
• sleep-based anticipatory guidance such as placing the infant to sleep while
drowsy but awake

• eliminating night feedings after 6 months of age

• introducing a transitional object

• establishing a “short and sweet” positive bedtime routine

• and consistent reinforcement of bedtime.

Once the sleep disorder has been established
• Behavioral strategies begin with the enforcement of good sleep
hygiene.
• children respond best to positive reinforcement for appropriate
behaviors.
• MEDICATIONS USUALLY NOT REQUIRED UNLESS THE DISORDER IS
INTRACTABLE
Other disturbances that can present as
insomnia
• Nighttime fears
• These fears are usually developmentally appropriate with pre- schoolers
being frightened of imaginary creatures in the dark while older children
may have a fear of being hurt by a burglar.

• Onset of these fears usually begins around 3 years of age and tends to
disappear by age 6

• resurgence of fears in school-aged girls may occur, particularly in those

who have anxiety issues.
HOW TO TREAT ?
• PARENTAL REASSURANCE OF SAFETY TO THE CHILD
• AVOIDING MULTIMEDIA WITH FRIGHTENING CONNOTATIONS
• GIVING CHILDREN AN OBJECT THAT RELAYS A SENSE OF SAFETY, CAN
HELP.
SLEEP RELATED BREATHING
DISORDERS
• OBSTRUCTIVE SLEEP APNOEA (OSA)

• PREVALENCE – 1-5%
• ONSET BETWEEN 2-8 YEARS
CLINICAL FEATURES
• SNORING
• UNUSUAL SLEEPING POSITION
• NIGHT-TIME ENURESIS
• MORNING HEADACHES
• COGNITIVE PROBLEMS
• DAYTIME SOMNOLENCE
• ENLARGED TONSILS OR ADENOIDS
MANAGEMENT
• POLYSOMNOGRAPHY FOR DIAGNOSIS

• FIRST LINE – ADENOIDECTOMY

• OTHERS -
• CPAP
• NASAL STEROIDS
PARASOMNIAS
MANAGEMENT
MANAGEME
NT
MANAGEME
NT
MANAGEME
NT
MANAGEMENT
MANAGEME
NT
MEDICATIONS

Moturi et al.. (2010). Psychiatry , 7(6), 24–37. 38

MEDICATIONS

Moturi et al.. (2010). Psychiatry , 7(6), 24–37. 39

MEDICATIONS

Moturi et al.. (2010). Psychiatry , 7(6), 24–37. 40

ALWAYS FINISH WITH SLEEP
HYGIENE
SLEEP HYGIENE FOR CHILDREN
• TO HAVE A SET BEDTIME AND BEDTIME ROUTINE

• BEDTIME AND WAKE-UP TIME SHOULD BE THE SAME TIME ON SCHOOL &
NON-SCHOOL NIGHTS.

• NO MORE THAN 1HOUR DIFFERENCE FROM ONE DAY TO ANOTHER.

• TO MAKE THE HOUR BEFORE SLEEP QUIET TIME.

• TO AVOID HIGH-ENERGY ACTIVITIES BEFORE BED.

SLEEP HYGIENE FOR CHILDREN
• NOT TO GO TO BED HUNGRY, BUT AVOID HEAVY MEALS.

• TO AVOID CAFFEINE PRODUCTS BEFORE BEDTIME.

• TO SPEND TIME OUTSIDE EVERY DAY AND INVOLVE IN REGULAR EXERCISE.

• TO KEEP BEDROOM QUIET AND DARK WITH COMFORTABLE TEMPERATURE

• DON'T USE BEDROOM FOR PUNISHMENT.

SLEEP HYGIENE FOR CHILDREN
• NAPS SHOULD BE SHORT (NO MORE THAN 1HR) AND SCHEDULED IN
THE EARLY TO MID AFTERNOON.

• TO KEEP SCREEN OUT OF CHILD'S BEDROOM.

• TO USE BED FOR SLEEPING ONLY. TO AVOID STUDYING, READING, ON

BED.

• BETTER TO AVOID SLEEP MEDICATIONS IF NOT ABSOLUTELY INDICATED

THANK
YOU