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Downloaded from http://ep.bmj.com/ on August 17, 2017 - Published by group.bmj.com BEST PRACTICE Fifteen-minute consultation on problems in the healthy child: sleep Jessica R Turnbull, Michael Farquhar 2 1Sunshine House Children andABSTRACT Young People’s Development Case study Centre, Guy’s and St Thomas’Sleep-related issues are common reasons children NHS Foundation Trust, present to health professionals. Many factors can Community Children’s Services,versely affect sleep quality, and there are manA severely obese 15-year-old patient pre- London, UK associations of inadequate sleep, including 2Department of Children’s Sleep sented with enuresis, which resolved after Medicine, Evelina London behavioural problems, obesity and accidental treatment of her obstructive sleep apnoea; Children’s Hospital, Guy’s and Sty. We review the current evidence, and direct questioning about snoring allowed Thomas’ NHS Foundation Trust,uggest practical management strategies to identification of the underlying issue. She London, UK promote better sleep, and hopefully, better was delighted that through non-invasive Correspondence to functioning for child and family alike. ventilation her enuresis was ‘treated’. Dr Jessica R Turnbull, Sunshine House Children and Young People’s Development Centre,INTRODUCTION Guy’s and St Thomas’ NHS Sleep is a vital function of life that we RANGE OF NORMALITY Foundation Trust, Community cannot survive without; it is therefore Parents may overestimate or underesti- Children’s Services, 27 Peckunsurprising that sleep-related presenta- mate the degree to which their child’s Road, London SE5 8UH, UK; tions to healthcare professionals are sleep is disturbed.5 As objective monitor- Jessica.turnbull@gstt.nhs.uk 1 common. Sleep-related issues are inter- ing is not always practical, it is important Received 4 February 2016 esting, in that they may be a primary we acknowledge that we are managing Revised 21 March 2016 reason for seeking medical advice, but parents’ experience of their child’s sleep Accepted 22 March 2016 Published Online First may also prove to be the underlying as well as objectively identified problems. 25 April 2016 cause of other presenting problems. So what is ‘normal’ when it comes to Additionally, many common health pro- sleep patterns; when should health pro- blems impact on sleep quality, including fessionals be concerned, and when can asthma, cough, gastro-oesophageal reflux, parents be reassured? constipation, eczema, anxiety and seizures. My child just doesn’t sleep enough Poor sleep quality in children has been Sleep duration alters significantly over associated with hyperactivity, externalis- the life span, with average daily sleep ing behaviours, poor academic progress, duration ranging from 10–17 h at symptoms of depression, daytime somno- 6 mo6ths of age to 8–11 h at 11 years of lence, bed-wetting, obesity and accidental age. If children are otherwise develop- injury.–4 It is sometimes only by asking mentally and physically well, they may be specifically that sleep issues are identified getting enough sleep for them; however and appropriate management interven- potential adverse consequences of sleep tions suggested. deprivation should be considered before Behavioural sleep problems are reassurance is given. common in otherwise well children, causing exhausted parents to seek My child just can’t fall asleep answers as to why their child ‘cannot There is a range of time taken to fall sleep’—‘is something wrong?’ and ‘what asleep (sleep onset latency), which can be done?’ By the time parents reach a averages 19 min for 0–2-year-olds, and health professional, they will have sought 17 min for 3–12-year-olds. 7 The level of advice from family, friends, and the inter- tolerance parents may have for the time To cite: Turnbull JR, net. As health professionals, we must take their child takes to fall asleep will differ, Farquhar M. Arch Dis Child parents’ concerns seriously, and be in a and the tactics children employ to main- Educ Pract Ed 2016;101: position to answer their questions use- tain their parents’ attention during this 175–180. fully (box 1). time will also differ (‘I need a drink’, ‘I Turnbull JR, Farquhar M. Arch Dis Child Educ Pract Ed 2016;101:175–180. doi:10.1136/archdischild-2015-309883 Downloaded from http://ep.bmj.com/ on August 17, 2017 - Published by group.bmj.com Best practice taking precedence; sleep issues must therefore be dir- Box 1 Targeted sleep history ectly enquired about in order for resolution to occur. The first three questions provide a quick screen; if con- BEING ALERT TO CERTAIN CONDITIONS AND cerns are apparent more specific history can be gathered: THOSE FEATURES RAISING CONCERN FOR Does your child have any difficulty getting to sleep or POSSIBLE ALTERNATIVE DIAGNOSES While much of the time we can be reassuring about staying asleep? Does your child do anything unusual in the night? sleep patterns and how they may change (and hope- fully improve) over time with appropriate advice, Is your child unusually sleepy in the daytime? there are certain conditions and concerning features (tables 1 and 2) that should be recognised and consid- When is bedtime? What do you do in the hour leading up to bedtime? ered, including the need for further investigation and How long does your child take to fall asleep after ‘lights intervention where appropriate. out’? Where does your child fall asleep? TRICKY QUESTIONS Does anybody need to be with the child while he/she is Is it OK to let my child cry themselves to sleep? falling asleep? Controlled-crying or sleep-training are widely used, and useful, techniques. In a recent review, 49 of 52 Does your child sleep through, once asleep? Does your child snore, have you noticed pauses in breath- (94%) published studies of sleep behavioural interven- ing when asleep? tions showed clinically significant improvements in settling and night waking problems in infants and chil- Is your child restless in sleep? 8 What time does your child wake in the morning? dren. The most extreme of such techniques is ‘extinc- Is your child tired in the daytime? Does he/she fall asleep tion’—leaving children to cry until they stop. during activities? ‘Graduated extinction’ involves attending to children at increasing time intervals and providing reassurance. What effect is this having on your family? ‘Camping out’ is where parents gradually remove themselves from the room. need a wee’, ‘just one more story’, ‘I don’t like that Under the age of 6 months these interventions are shadow’). Limit setting is important, although if sleep not recommended, however for older 91fants these onset is significantly delayed (beyond 30–45 min) have been shown to be effective. They can be wel- further evaluation and intervention is warranted. comed by parents exasperated by sleep deprivation due to the ‘quick fix’ they may provide. The other The child wakes up all night side of this debate is that infants left to cry can have Night wakenings are a normal part of the sleep cycle increased cortisol levels suggesting activation of the (figure 1); many children rouse and fall asleep again stress-axis, and that close sleep-proximity (same room) without conscious realisation up to four to five times to parents is associated with reduced infant-crying at a night, and without disturbing their parents. Night night, therefore this may be a more favourable solu- wakenings form a vital function during early infancy tion.1 However, for many families these remain for feeding. As this need declines over the 1st year, useful techniques; a 5-year follow-up study found no the habit of night-time feeding also needs to fall away. adverse effects on psychosocial functioning or rela- Children need to learn to settle by themselves if they tionships, concluding there were no significant long- wake; it is often the response to night-wakening that lasting effects of behavioural sleep interventions for is important, rather than the wakening itself. 12 infants. Sleep problems affect up to 25% of typically devel- At later ages techniques to improve children’s sleep- oping school-aged children, and up to 80% of children confidence are recommended. A balanced approach with neurodevelopmental disorders, ihowever parents based on ensuring the infant/child feels secure, safe 1 do not always seek advice, possibly due to ‘normalis- and confident in their sleep environment is usually ing’ the sleep disturbance, or with other priorities appropriate. Is it OK to let my child sleep in my bed? Co-sleeping is common practice in many cultures, but The exploration of sleep difficulties within neurodevelopmentalis less common in Westernised societies, partly related disorders is beyond the scope of this article, however in basicto cultural expectations that children sleep in their the range of what is ‘normal’ for sleep pattern within this group is very extensive,with some children with autism and other own rooms/beds, and partly due to the association neurodevelopmental disorders, particularly Smith–Magenis with sudden infant death syndrome. syndrome, seemingly needing very little sleep. Basic principles oA recent analysis of two case-control studies 13 management continue to apply, with emphasis on sleep routines and identifying contributors to sleep disturbance to minimise disruption factors associated with significantly raised risk from treatable causes. of SIDS were: 176 Turnbull JR, Farquhar M. Arch Dis Child Educ Pract Ed 2016;101:175–180. doi:10.1136/archdischild-2015-309883 Downloaded from http://ep.bmj.com/ on August 17, 2017 - Published by group.bmj.com Best practice Figure 1 Typical hypnogram (adapted from Luke Mastin). ▸ co-sleeping with a parent who has consumed alcohol INTERVENTIONS ▸ co-sleeping with a parent who smokes The foundation of good quality sleep is the develop- ▸ co-sleeping on the sofa. ment of good sleep habits and routines (box 2). The There was a trend towards higher OR in premature same routine should be carried out nightly in order infants and this was added as a risk factor. In the for ‘cues’ to sleep to become associated with sleep absence of these risk factors, the OR of SIDS for onset. Studies have found that consistent parental co-sleeping infants was not significantly raised, input, particularly around setting of bedtime rules is however this is not to say the risk for any individual associated with longer average sleep durations. 14 infant is abolished; advice continues to be that the Some children require more input than others; chil- safest sleep position for infants <6 months is to be dren with higher levels of resistance to control were placed on their back, and in their own cot in the same found to have more sleep problems and externalising 15 room as their carers (National Institute for Health and behaviours than those more accepting of control. Care Excellence (NICE) Clinical Guideline 37; Parents in this circumstance may need a higher level Department of Health; NHS choices; Lullaby Trust). of support in carrying through with setting a night- Guidance on co-sleeping differs between countries, time routine, and this should be anticipated from the and will change over time; recent evidence is brought outset to set expectations. 16 together on the Infant Sleep Information Source Physical exertion improves sleep quality; it has (http://www.isisonline.org.uk), a useful resource to been found that just half an hour of high intensity access. physical exertion can be as effective as melatonin for Table 1 Specific sleep conditions Specific sleep condition Considerations Partial arousal parasomnias Ensure safety measures (eg, window and door locks) for sleepwalkers. Warn that (confusional arousals, sleep terrors, sleepwalking): changes in the environment may confuse/be hazardous to children who may be able Occurs between sleep states; accompanied by movement. Usually navigate their way around the ‘known’ environment. occurs at predictable times earlier in the night (generally beforening for families, but does not generally cause harm. Reassurance and midnight). explanation needed. Obstructive sleep apnoea: Further assessment required which may include pulse oximetry, polysomnography Snoring, gasping, pauses in breathing, daytime somnolence. Can/or referral to appropriate specialist (eg, ENT, respiratory paediatrician or sleep be a contributing factor to enuresis. service). Restless legs syndrome: Can be associated with iron deficiency; consider trial of iron treatment if ferritin Compelling feeling to move legs; associated with sensory <50 mg/L. symptoms for example, skin crawling, itching (difficult forOften interpreted as ‘growing pains’. describe). Nocturnal pain and night-time sweating: Common presentations, but potentially worrying therefore warrants evaluation. Waking complaining of pain/ache. Pain that is persistent, or not responsive to simple measures, may indicate pathological Report of significant sweating in sleep. pain such as dental pain or malignancy. Sleep hyperhidrosis may occur as commonly as in 11% of chilcan be associated with obstructive sleep apnoea, atopy and parasomnias. Head-banging/body-rocking: Needs reassurance, generally does not result in injury. Usually a method of self-soothing (cf thumb-sucking); can be associated with moaning. Delayed sleep phase in adolescents: Some degree of circadian shift is physiological and normal in adolescence. Very Significantly delayed sleep onset. disordered sleep patterns (eg, staying awake all night and sleeping in the morning) that are disruptive to everyday functioning warrant referral for specialist assessment. Turnbull JR, Farquhar M. Arch Dis Child Educ Pract Ed 2016;101:175–180. doi:10.1136/archdischild-2015-309883 177 Downloaded from http://ep.bmj.com/ on August 17, 2017 - Published by group.bmj.com Best practice Table 2 Red flags/concerning features Sleep issue Features raising concern Multiple stereotyped night Stereotyped movements. wakings. Multiple episodes in the same night. Predominant occurrence after first third of sleep period. Event starts and stops suddenly. While most unusual episodes during the night are parasomnias, the above features raise the level of concern for possible nocturnal seizures; consider referral for specialist assessment. Also lowered threshold for further assessment in children with atypical development or daytime seizures. Nightmares with specific imagPersistent, severe, disruptive nightmares. Nightmares consisting of concerning imagery—consider potential traumatic events in child’s life. Excessive/unusual daytime Consistent inability to stay awake during the daytime (including during activities child is engaged with) is very unusual sleepiness. beyond the age of normal daytime napping. Consider—narcolepsy, obstructive sleep apnoea. Any sleep issue. In association with significant daytime behavioural change—consider full neurodevelopmental assessment as presenting sleep issue may be part of a wider neurodevelopmental dysfunction. aiding sleep onset in children. 17 Daily outdoor phys- important as these may alter the recommendations ical exertion is more difficult to achieve in today’s given. society, but should be a goal for all children, and The stress hormone cortisol is antagonistic to mela- should be encouraged. tonin, inhibiting sleep to maintain vigilance in times The child’s wider sleep environment, including of perceived danger; 2 enquiry about potential add- sleeping arrangements, bed comfort, temporary itional stressors including exposure to domestic vio- accommodation, shared living-sleeping spaces, are lence, neglect or abuse, may be crucial in understanding the root cause of the sleep problem. Box 2 Encouraging good sleep habits MEDICATION The majority of children will respond to the behav- Physical exertion in the afternoon. ioural management described, however a minority require specialist assessment and possibly medication. Consistent daily bedtime. Last drink 1–1.5 hour(s) before bed (reduce chance of Melatonin is the most frequently prescribed of these. Other medications are available, however assessment nocturia). by a specialist with an interest in sleep may be indi- Avoid stimulating food and drink (eg, sugar/caffeine). cated if these are being considered. A useful review of Wind-down time in the hour before attempting to settle medications for sleep disorders has been published to sleep (calming activities, eg, reading, board games, previously.18 Melatonin is the natural sleep hormone produced calming music). No screens (television, phones, tablets) for at least by the pineal gland, and regulates sleep–wake cycles. Melatonin as a medication is currently unlicensed for 1 hour before bed. use in children in the UK, however is prescribed with No television in bedroom. varying frequency by specialists and appears to be Low light during settling; red coloured light if night light generally well tolerated. is needed (does not interfere with natural melatonin Melatonin has specific uses. It can be effective in production). children in whom natural melatonin production may be disrupted, (eg, some children with ADHD, Having a transitional object (eg, a soft toy) to develop 2 sleep confidence and a healthy sleep association. autism, visual impairment). It does not necessarily significantly increase total sleep duration, with an Working towards child falling asleep by themselves in average increase of only 13 min in a study of chil- their own bed. 19 dren with neurodevelopmental disorders. In this Limit setting on ‘fussing’ after ‘lights out’: ‘I am going to study, although melatonin helped bring sleep onset give you one last kiss then it’s time to sleep’. forward by an average of 45 min, it was also asso- ciated with earlier waking times in some children, Reducing attention given after ‘lights out’ to prevent reinforcing messages of attention (eg, avoid eye contact/ thus not significantly increasing total sleep time for them. The main benefit of melatonin may be in conversation). helping children feel sleepier at sleep onset time, 178 Turnbull JR, Farquhar M. Arch Dis Child Educ Pract Ed 2016;101:175–180. doi:10.1136/archdischild-2015-309883 Downloaded from http://ep.bmj.com/ on August 17, 2017 - Published by group.bmj.com Best practice which in turn gives parents a better chance of Resources making key changes to sleep routine and behaviour which, in the long term, are more likely to result in improved sleep quality. ▸ Contact a Family (http://www.cafamily.org.uk). The action of melatonin in inducing sleep occurs Information leaflet ‘Helping your child’s sleep’. while levels are increasing within the bloodstream; Developed for parents of disabled children, this has once maximal levels are reached it loses efficacy. very relevant sleep information for all families. Baseline blood levels can increase with regular use; if ▸ Royal College of Psychiatrists (http://www.rcpsych.ac. efficacy is lost, stopping medication for 5 days uk) factsheet ‘Sleep problems in childhood and ado- (washout), and reintroducing at a lower dose may lescence; for parents, carers and anyone who works reinstate efficacy. with young people’, covering a range of sleep pro- The sleep environment must also be conducive, with blems in typically developing children. low lighting, calm atmosphere and absence of screens ▸ Lullaby Trust UK (http://www.lullabytrust.org.uk) (blue wavelength light counteracts production of It has a useful leaflet for parents on bed-sharing 20 21 natural melatonin ). It is important this is under- and safety. stood by parents; prescribing of melatonin should be ▸ Raising Children Network (http://www.raisingchildren. part of an overall plan for good sleep habits, with net.au). It has sleep information and advice for differ- appropriate timing of administration of melatonin ent age groups, alongside other useful parenting (usually half an hour before the desired bedtime). tips. In children prescribed any medication for sleep, ▸ Kids Sleep Dr (http://www.kidssleepdr.com) app. regular breaks in administration should be agreed to Freely available through App Store; parents can enter assess the need for ongoing prescription. Any pre- data on child’s sleep, export data by email and scription of medications unlicensed for use in children receive tips on successful sleep. should be supported by a consultant paediatrician (eg, with shared-care agreement) in liaison with the general practitioner. Test your knowledge STRUCTURED MANAGEMENT SUGGESTIONS 1. Waking during the night is a normal part of the sleep ▸ Look out for specific conditions and concerning features cycle. True or false? (tables 1 and 2). ▸ Minimise disruption from treatable causes such as 2. On average children take 5 to 10 minutes to fall asleep. True or false? asthma, nocturnal cough, eczema, gastro-oesophageal 3. Increasing the dose of melatonin would be the best reflux. option if the current dose has stopped working. ▸ Explain the sleep cycle—parents are often not aware that True or false? night wakenings are part of the normal sleep cycle. 4. Head-banging during the night does not usually result ▸ Encourage good sleep habits (box 2). in injury. True or false? ▸ For child falling asleep late at night, gradually bring bedtime forward in small steps so the child continues to 5. Restless sleepers do not need investigation. True or false? associate being in bed with falling asleep. ▸ Gradual removal of parent from room in a stepwise Answers are at the end of the references. manner for a child who needs a parent present to fall asleep; sitting on bed, sitting by bed, facing away from Acknowledgements The authors thank Luke Mastin for bed, sitting away from bed, sitting in doorway, sitting permission to reproduce artwork of figure 1. outside bedroom, being away from bedroom (eg, Contributors JRT drafted the article and compiled tables/boxes. ‘making a cup of tea’). MF provided advice and editing. ▸ Reinforce all achievements with praise and visual Competing interests None declared. rewards such as star-chart; for star-charts to be successfulProvenance and peer review Commissioned; externally peer they must be devised with the child, start with an achiev- reviewed. able step (‘I can fall asleep with Mummy sitting next to my bed’), be consistently applied, be made exciting and motivating for child (by changing reward when needed), REFERENCES and keep up momentum (‘look, you’ve done brilliantly, 1 Blunden S, Lushington K, Lorenzen B. Are sleep problems under-recognised in general practice? Arch Dis Child now we can do the next step’). 2004;89:708–12. ▸ Encourage and support parents in sticking with the 2 Gregory AM, Sadeh A. Sleep, emotional and behavioural routine; it takes a long time to break an undesirable difficulties in children and adolescents. Sleep Med Rev sleep habit. 2012;16:129–36. Turnbull JR, Farquhar M. 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Arch Dis Child Educ Pract Ed 2016;101:175–180. doi:10.1136/archdischild-2015-309883 Downloaded from http://ep.bmj.com/ on August 17, 2017 - Published by group.bmj.com Fifteen-minute consultation on problems in the healthy child: sleep Jessica R Turnbull and Michael Farquhar Arch Dis Child Educ Pract Ed  2016 101: 175-180 originally published online April 25, 2016 doi: 10.1136/archdischild-2015-309883 http://ep.bmj.com/content/101/4/175n be found at: These include: References This article cites 22 articles, 7 of which you can access for free at: http://ep.bmj.com/content/101/4/175#BIBL Email alerting Receive free email alerts when new articles cite this article. Sign up i n the service box at the top right corner of the online article. 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