Childhood insomnia

GENERAL ASPECTS

Insomnia is a very frequent pathology in pediatric age (30% in children under 5 years of age) that causes a serious cognitive, emotional and learning repercussion together with an important medical comorbidity and affectation of the quality of life of the child and the family.

Sleeping through the night: needs 3 requirements: i. A continuous period of sleep. ii. Nighttime sleep schedule coinciding with the rest of the family. iii. Ability to go back to sleep autonomously after physiological awakenings.

The American Academy of Sleep Medicine defines childhood insomnia as “Sustained difficulty, despite the opportunity for sleep and as a function of age, in initiating or maintaining sleep ‘ or its quality that results in functional disturbance in the child‘ and/or family.� Taking more than 30 minutes to fall asleep and/or awakenings of more than 20 minutes duration may result in clinically significant distress and impairment in social, family, academic or other areas.

FACTORS

Conditioning factors: different factors are involved in insomnia:

1. Circadian factor: melatonin and light. The onset of nocturnal melatonin secretion under dim-light conditions (dim-light-melatonin-onset [DLMO]) precedes sleep onset by approximately 2 h. Children forced to fall asleep at a time excessively close to or far from their DLMO have longer sleep latencies˜ and greater resistance to bedtime.
2. Homeostatic factor: late naps. The greater the number of previous waking hours, the easier it is to fall asleep.
3. Environmental factors: light, sound and temperature. Exposure to light during the night, coupled with low exposure to light during the morning, favors it. The percentage of melatonin secretion suppression in the presence of light before bedtime in children ˜ reaches 88%.
4. Educational factor: healthy lifestyle habits. The sleep routine shows a direct dose-response relationship between sleep habits and perception of problems.
5. Neuroendocrine factor: cortisol. Sleep deficit favors elevated evening cortisol levels.

DIAGNOSTIC CRITERIA

Diagnostic criteria according to the American Academy of Sleep Medicine:

Criteria A-F must be met

A- The patient reports, or the patient’s parent/caregiver observes, one or more of the following: 1. Difficulty initiating sleep

1. Difficulty in maintaining sleep
2. Waking up earlier than desired
3. Resistance to going to bed at an appropriate bedtime
4. Difficulty sleeping without parental/caregiver intervention

B- The patient refers to, or the patient’s parent/caregiver observes, one or more of the following related to difficulty sleeping through the night:

1. Fatigue/discomfort
2. Disturbance of attention, concentration or memory
3. Alteration of social, family, work or academic performance.
4. Mood disturbance/irritability 5. Daytime sleepiness
5. Behavioral problems (e.g. hyperactivity, impulsivity, aggressiveness)
6. Decrease in motivation, energy, initiative
7. Predisposition for errors/accidents 9. Preoccupation or dissatisfaction with sleep˜ 10.

C- Sleep/wakefulness complaints cannot be explained simply by inadequate opportunity for sleep (i.e., allocation of sufficient time for sleep) or inadequate circumstances (i.e., environment is safe, quiet, and comfortable) for sleep

D- Sleep disturbance˜ and associated daytime symptoms occur at least 3 times per week.

E- Sleep disturbance˜ and associated daytime symptoms have been present for at least 3 months.

F- Sleep/wakefulness difficulty ˜ is not best explained by another sleep disorder˜

CLINICAL MANIFESTATIONS

There is dissatisfaction with the quantity or quality of sleep referred to as reluctance to go to bed, frequent awakenings and/or difficulty falling asleep independently. The clinical impact is due to sleep loss and includes both nocturnal and diurnal disturbances:

1. Nocturnal: sleep latency greater than 30 minutes, intrasleep wakefulness greater than 60 minutes, more than 3 nocturnal awakenings or awakenings of more than 20 minutes (requiring caregiver attention).
2. Diurnal: drowsiness, attention and memory difficulties, mood changes, behavioral problems (hyperactivity, impulsivity) and poorer school performance. It can also affect the cardiovascular, immune and metabolic systems, with an increased risk of obesity and impaired growth. In addition, childhood insomnia affects the quality of family life.

Often, insomnia is the result of inappropriate association or inadequate boundaries:

— Insomnia due to inappropriate associations with sleep: Result of dependence on specific stimulation with specific objects or settings to initiate sleep or return to sleep after awakening. Falling asleep is associated with a form of stimulation (rocking), object (bottle) or environment (lighted room, parents in the room or falling asleep in the parents’ bed). Its absence conditions the difficulties and its restoration facilitates sleep. It manifests as frequent awakenings during the night, night fears or anxiety to sleep alone. It is considered a disorder if: 1) the associations are very problematic and demanding; 2) there are daytime consequences and 3) it frequently requires parental/caregiver intervention.

— Insomnia due to absence of limits: Refusal to go to bed reinforced by inappropriate use of limits. May produce nighttime awakenings, depending on parent/caregiver response during the night.

— Insomnia due to inadequate sleep hygiene. Child or parent/caregiver engages in activities incompatible with good quality sleep and normal daytime alertness. For example, late daytime naps, irregular schedule, stimulating substances, exciting and disturbing mental, emotional or physical activities close to bedtime, inadequate sleep environment (noise, light stimulation, TV, computer, etc.).

— Psychophysiological insomnia. Older children and adolescents may present with sleep disturbances resulting from hypervigilance and/or associations from previous experiences. They have an exaggerated preoccupation with sleep, fear of sleeping or not being able to sleep, fear of elements in their bedroom or memories of previous negative experiences. These children sleep better outside their environment.

DIAGNOSIS

Fundamentally clinical, through information obtained from parents/caregivers and the child.

– Clinical history and physical examination:

To assess organic causes and globally evaluate the child and family, with analysis of the sleep pattern and wakefulness during 24 h, schedules and amount of sleep, sleep events, environmental conditions, education, family context, etc.

– Agenda or sleep diary:

Graphic representation of the sleep-wake rhythm for at least 15 days. It is advisable to collect the information with free sleep schedule to objectify the “ideal” sleep pattern.

– Scales and questionnaires: Different questionnaires perform a general sleep screening, some of them validated in Spanish. These include the Brief Infant Sleep Questionnaire (BISQ), BEARS, Sleep Disturbance Scale for Children (SDSC).

– Polysomnography (PSG) and actigraphy:

These tests are complementary explorations and never substitutes to the clinical history. PSG is indicated when there is a clear clinical suspicion of sleep disordered breathing (apneas), atypical parasomnias, periodic leg movements, nocturnal epilepsy or hypersomnias. Actigraphy monitors body movements and evaluates the sleep-wake rhythm in the patient’s natural environment over several days.

TREATMENT

Although pharmacology has been widely used, behavioral therapy (strategies that help to promote appropriate behaviors) has greater acceptance and more permanent effects. A progressive approach to insomnia is advised:

– Sleep hygiene:

Establish stable pre-sleep routines with regular bedtime and wake-up times. Do not punish the child to go to sleep, to bed or to his/her room. Encourage physical activity, avoiding it late in the day. Avoid screens during the hour before sleep. Adequate temperature. Quiet environment. Do not eat half an hour before the onset of sleep, do not drink stimulating and exciting beverages after noon. Carbohydrates and foods rich in tryptophan promote sleep.

– Psychological treatment: intervention on the whole family, analyzing family behaviors and expectations.

– Cognitive-behavioral treatment:

Scientific evidence indicates that it is the most effective and most widely used in insomnia treatment programs, with different strategies.

– Pharmacological treatment:

There is little scientific evidence of its medium and long-term efficacy and safety, although it is recommended to follow certain general rules:

1. The use of nutritional supplements (immediate and extended release melatonin, tryptophan, iron) and drugs (antihistamines, others) should be considered.
2. Its use should be as short as possible and at the lowest effective dose.
3. The product used is chosen according to the characteristics of the insomnia, the patient’s type and environment.
4. The timing of administration is important.
5. Close monitoring of side effects, especially during withdrawal.
6. May aggravate other coexisting sleep problems (apneas).
7. Caution for possible interactions with other drugs.
8. If these are not effective, referral to specialized units should be made:

Regarding the use of phytotherapy products, their use is based on tradition, with little scientific evidence. Parents should be aware of the lack of studies demonstrating the efficacy and safety of these substances in children and adolescents, as well as the lack of knowledge of dosage, susceptibility and potential contaminants.