What are the treatment options for disordered sleep in children?

Treatment Options for Disordered Sleep in Children

Behavioral interventions should be the first-line treatment for most sleep disorders in children, with pharmacological options reserved for specific conditions or when behavioral approaches have failed. 1, 2

Assessment and Classification

Sleep disorders in children typically fall into several categories:

• Behavioral insomnia (bedtime resistance, delayed sleep onset)
• Frequent night wakings
• Sleep-disordered breathing (obstructive sleep apnea)
• Parasomnias (sleepwalking, night terrors)
• Circadian rhythm disorders (delayed sleep phase)
• Restless legs syndrome

First-Line Treatments

Behavioral Interventions

1. Sleep Hygiene Education

   • Consistent bedtime and wake time (even on weekends)
   • Quiet, darkened, and comfortable bedroom environment
   • Regular daytime exercise (preferably morning)
   • Limiting screen time before bed
   • Relaxing bedtime routine 2, 3

2. Behavioral Techniques

   • Stimulus control: Breaking association between bed and wakefulness

     • Going to bed only when sleepy
     • Using bed only for sleep
     • Getting out of bed when unable to sleep 2

   • Extinction techniques: For bedtime resistance

     • Standard extinction (letting child cry until falling asleep)
     • Graduated extinction (checking on child at progressively longer intervals)
     • Positive routines with fading parent presence 1, 4

3. Cognitive Techniques (for older children)

   • Identifying and challenging negative thoughts about sleep
   • Relaxation techniques (deep breathing, progressive muscle relaxation)
   • Visual imagery 2

Condition-Specific Approaches

For Autism Spectrum Disorder (ASD) and Neurodevelopmental Disorders

• Structured visual schedules for bedtime routines
• Environmental modifications (reducing sensory stimulation)
• Wet wrap therapy for children with atopic dermatitis to reduce nighttime itching
• Parent education on avoiding co-sleeping 1, 5

For Obstructive Sleep Apnea

• Adenotonsillectomy is the primary treatment 6
• Evaluation for comorbid conditions that may affect breathing

For Parasomnias

• Safety measures to prevent injury
• Scheduled awakenings (waking child 15-30 minutes before typical episode)
• Parental reassurance (most parasomnias resolve with age) 6

For Delayed Sleep Phase Disorder

• Consistent sleep-wake schedule
• Morning bright light therapy
• Evening light restriction 6

Pharmacological Options

Medications should be considered only when:

1. Behavioral interventions have failed
2. Sleep disturbance is severe and affecting daytime functioning
3. For specific conditions where medication has proven efficacy

Melatonin

• Most evidence exists for supplemental melatonin, particularly for:
  • Children with ASD (1-6 mg, 30-60 minutes before bedtime)
  • Delayed sleep phase disorder
  • Sleep onset insomnia 1, 5

Other Medications (limited evidence in children)

• Low-dose non-benzodiazepine receptor agonists for specific cases
• Sedating antihistamines (short-term use only)
• Alpha-agonists for children with ADHD and sleep problems 2, 7

Implementation Algorithm

1. Start with comprehensive sleep hygiene education and behavioral techniques
2. If no improvement after 2-4 weeks, evaluate for:
   • Medical contributors (pain, reflux, breathing issues)
   • Psychiatric conditions (anxiety, depression)
   • Medication side effects
3. For persistent problems:
   • Consider melatonin for sleep onset issues
   • Refer to pediatric sleep specialist for complex cases
4. Follow up within 2-4 weeks of any intervention

Common Pitfalls to Avoid

• Focusing solely on sleep hygiene without addressing behavioral components
• Using medications before adequate trial of behavioral interventions
• Failing to identify underlying medical conditions contributing to sleep problems
• Inconsistent implementation of behavioral strategies
• Co-prescribing multiple sedating medications, especially in older children 2

Proper treatment of sleep disorders in children is crucial as chronic sleep disruption can lead to significant problems with behavior, mood, attention, and academic performance 6, 4.