Disrupted Sleep: Assessment and Treatment in Children and Adolescents

Although sleep problems occur frequently in the pediatric population, with rates between 25%–40%, they too often go unrecognized and untreated (Sheldon S, Ferber R, Kryger M., Principles and Practice of Pediatric Sleep Medicine. Philadelphia, PA: Elsevier; 2005). In his Q&A interview in this issue, Dr. Rafael Pelayo nicely addresses how common sleep disorders are in children and adolescents; he also reviews some of the signs and symptoms you should look for. In this article, I describe in more detail some of the more common sleep disorders of childhood.

As Dr. Pelayo emphasizes, the cornerstone for diagnosing pediatric sleep disorders is obtaining a detailed and accurate history followed by a comprehensive physical exam that includes screening for developmental delays and cognitive dysfunction. This approach should be developmentally focused and problem driven, starting with, “Is this child waking up refreshed?” If the answer is no, you should follow- up by asking about the variables noted in the table “Assessing Sleep Problems in Young Patients” on page 4 of this issue.

Sleep-disordered breathing

Sleep-disordered breathing in children ranges from primary snoring to obstructive hypoventilation to obstructive sleep apnea syndrome (OSAS). The condition can be subtle or overt. Your clinical suspicion should be high in any child with behavioral problems who wakes up unrefreshed. Any cessation of airflow at the nose and/or mouth causes disrupted sleep, transient hypoxemia (low levels of blood oxygen), and hypercapnia (high levels of CO2). The prevalence of OSAS is between 4% and 11% (Marcus CL, Am J Respir Crit Care Med 2001;164(1):16–30), and it becomes gradually more common from the ages of 2 through 8 years old, coinciding with the increased prevalence of enlarged tonsils.

As is true in adults, symptoms of OSAS in children include frequent loud snoring, observed breathing pauses, restless sleep, nighttime sweating, and choking/gasping/snorting during sleep. Almost all children with OSAS snore, but not all children who snore have OSAS. Children with sleep apnea may sleep in positions that help open the airway (hyperextending the neck or sleeping upright). Daytime symptoms of OSAS include mouth breathing and dry mouth due to enlarged adenoids, chronic nasal congestion, hypo-nasal speech, difficulty swallowing related to enlarged tonsils, morning headaches, frequent episodes of otitis media, and sinusitis. Children can also exhibit mood changes (depression/anxiety), increased somatic complaints, social withdrawal, aggression, impulsivity, hyperactivity, and other ADHD-like symptoms such as inattention, poor concentration, and distractibility.

As a psychiatrist, your main job is to identify the possibility that a sleep disorder exists in your patient, and then refer to a sleep specialist (Pediatrics 2002;109(4):704–712). Specialists will often start with an overnight polysomnogram, the gold standard test for diagnosing OSAS. Treatments range from tonsillectomy/adenoidectomy to nasal continuous positive airway pressure. For milder cases, specialists may prescribe drugs such as montelukast (trade name Singulair, often used for asthma) and intranasal corticosteroids such as fluticasone spray.

Insomnia

Pediatric insomnia is defined as difficulty with sleep initiation, duration, or quality that occurs despite ageappropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family (American Academy of Sleep Medicine. The international classification of sleep disorders: Diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005).

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