World Sleep Day 2024 - recognising sleep disorders

The 15 March is World Sleep Day. Sleep is important for optimal physical, cognitive, emotional and social development. Whilst an adolescent requires eight to 10 hours of sleep every night, a five year old child requires 10 to 13 hours. Children with insufficient sleep may present with hyperactivity in an attempt to stay awake, reduced concentration and difficulties regulating emotions due to a sleep deprived brain. Behavioural sleep problems are common and include bedtime resistance, delayed sleep initiation or night-time awakenings. Transient sleep disturbance may occur in response to a stressful life event and is usually self-limiting. Sleep difficulties are more common in children with depression, anxiety, autism and ADHD.  

To be considered a disorder, the symptoms should be present more than half of the week, persists for more than three months and result in significant impairment of function in the child or family. The BEARS screening tool may be used as part of a sleep diary:

• Bedtime problems – difficulties going to bed or falling asleep, the sleep environment, pre-sleep activities, parental response to the problem
• Excessive daytime sleepiness
• Awakenings during the night
• Regularity and duration of sleep
• Sleep-disordered breathing, snoring or abnormal movements

The majority of sleep difficulties in children can be successfully managed with behavioural interventions. Good sleep hygiene practices are key and include:

• A set bedtime routine which involves quiet time the hour before bed and avoids high-energy and stimulating activities such as television and computer games
• A set bedtime and wake-up time that is approximately the same on school and non-school nights
• Avoiding caffeine products such as chocolate but ensuring your child is not hungry
• Encouraging daily exercise with exposure to natural sunlight
• Keeping the bedroom at a comfortable temperature, quiet and dark although a low-level light may be acceptable if they are frightened
• Keeping televisions, computers and smartphones out of the bedroom
• Not using the bedroom for time-out or punishment but maintaining it as a place associated with relaxation
• Appropriate parental response to sleep difficulties. A consistent approach that anticipates a temporary escalation in the child’s protests is important to help extinguish rather than reinforce the behaviour. This includes avoiding negative sleep onset associations such as needing to be present for the child to fall asleep and excessive attention such as allowing routine switching of beds during night-time awakenings. Systematic ignoring; gradual extinction through weaning dependence on a behaviour; and positive reinforcement such as sticker charts or returning only to the child’s bedroom when they are engaged in an appropriate behaviour can be helpful approaches

Medication may be considered if behavioural interventions have not been effective. Melatonin is a synthetic form of a hormone produced in the brain that helps regulate the sleep-wake (circadian) cycle. It is well tolerated with no known significant long-term adverse effects and is particularly effective in children with difficulties with sleep initiation rather than with sleep maintenance.

Some medications can adversely affect sleep such as methylphenidate, antihistamines and antidepressants. There are also a number of rarer but important to consider organic sleep disorders. Night terrors involve the child waking up suddenly looking petrified and screaming for up to 20 minutes – although it will not be possible to calm the child down you should stay with them until they fall back asleep. Most children outgrow sleep walking but until then they should be kept in a safe environment and gently guided back to bed. Nocturnal epilepsy (seizures) may present with limb shaking, tongue biting and urinary incontinence. Obstructive sleep apnoea with loud snoring, pauses in breathing and gasping is more common in children with excess weight. A restless leg whilst sleeping maybe associated with low iron levels. Children with narcolepsy have symptoms of significant sleepiness including falling asleep during activities (including conversations) during the daytime.

World Sleep Day thus provides an opportunity for us all to reflect upon and optimise our sleep hygiene practices which are essential for optimal health and wellbeing.

Dr Jay Halbert is a senior Consultant Paediatrician based at the Spire Tunbridge Wells Hospital, award winning global expert in child heath, and expert advisor to the WHO, RCPCH, NHS England, CQC and NICE.