Improving sleep in children

Normally, articles like this don't impress me. At least the ones written to help adults sleep. But this one for kids is packed full of great advice to help kids sleep better. It's not as applicable for infants...more for toddlers and older children / adolescents.

Living with children may mean less sleep for women

This article discusses research presented at a the annual meeting of the American Academy of Neurology - I didn't attend this meeting. The article surveyed men and women about sleep duration and level of daytime tiredness. Researchers looked at age, race, education, marital status, number of children in the household, income, body mass index, exercise, employment, and snoring as possible factors linked to sleep deprivation. Results showed that living with children was associated with more sleep deprivation in women, but not with men. Also living with children resulted in women feeling more tired in the daytime. One thing not stated was how old the children are in these households. I would imagine that sleep deprivation and daytime tiredness would increase with younger children.

American Academy of Pediatrics Updates

Recently, the American Academy of Pediatrics released updated guidelines on two important issues related sleep. The first update concerned sudden infant death syndrome (SIDS). Here is a link to the guidelines.

The second update concerned media use in children and adolescents. The recommendations discuss sleep and other aspects of how media affects children. For younger children, here is the link. For older children and adolescents, here is the link.

Bedtime routines and children's sleep

In my practice, I recommend that all parents follow a regular bedtime routine with their younger children. Research has shown that a consistent bedtime routine is linked to better sleep in kids. However, there are no studies that have looked at whether a bedtime routine works better if done every night or just once a week. This study did just that. It involved a questionnaire of over 10,000 moms who had children up to 5 years old. Results showed that less than half of all families had a consistent bedtime routine every night. In those families with a consistent bedtime routine, the children had earlier bedtimes, shorter time to fall asleep, fewer number and duration of awakenings, and more total sleep per 24 hours. Also, there was a linear relationship between number of nights per week of bedtime routine and sleep outcomes - meaning that the more times per week there was a bedtime routine, the better the sleep outcomes. Perceived sleep problems also went up as the number of bedtime routine nights per week went down. Finally, there was a relationship between daytime behaviors (including hyperactivity, attention deficit, and difficult behaviors) and consistent bedtime routine. Again, the relationship was such that a more frequent bedtime routine meant less problematic daytime behaviors.

The authors conclude that pediatricians could easily recommend a consistent bedtime routine to all of their patients. Pediatricians could explain that a bedtime routine is a set of the same activities done in the same order on a nightly basis prior to turning the lights out. For example, brushing teeth, putting on pajamas, and then reading a story before turning out the lights.

Adenotonsillectomy and asthma in children

Some research studies have demonstrated an association between obstructive sleep apnea (OSA) and asthma. It's not clear why they are linked - it could be that both involve inflammation. OSA is also associated with obesity, which is linked to asthma. The most common treatment for OSA in children is the surgical removal of adenoids and tonsils, referred to as an adenotonsillectomy (AT). This study looked at historical medical and pharmacy records of children with asthma who did and did not have AT. The data in this study was from quite a large database, and the children who had AT were matched with those without AT.

The results showed that asthma flare-ups were worse in children the year prior to AT. However, after AT, asthma flare-ups declined significantly, to levels similar to the kids with asthma who did not receive AT. A similar decrease was seen in asthma medication refills in those children who underwent AT.

The study authors conclude that the presence of OSA can worsen asthma control in children, and that treatment of the OSA with AT may reduce asthma flare-ups. The authors appropriately caution that prospective studies will be needed to establish a causal relationship.

Weight gain after tonsil removal for obstructive sleep apnea

Children with obstructive sleep apnea (OSA) can have reduced growth rates. The primary treatment of OSA in children is removing the tonsils adenoids, referred to as an adenotonsillectomy. After this procedure, studies have shown an increase in weight. However, some kids that are overweight before adenotonsillectomy put on even more weight after the surgery.

This study looked at two groups of children, ages 5-10 years old, who had OSA. One group got adenotonsillectomy and the other group received no treatment - just watchful waiting. Sleep studies and height / weight measurements were repeated 7 months later. Results showed that body weight and body mass index (BMI) increased in both groups of patients. This may be because the sleep apnea severity improved in both groups. It's unclear why that happened, especially with the weight gain. I would think that would make the sleep apnea severity worse in the untreated group.

What was remarkable about the study, however, was that after adjusting for baseline weight and other variables, the weight gain experienced by those that had the adenotonsillectomy was significantly greater than the group that received no treatment. In those children who were already overweight at the start of the study, 52% became obese after adenotonsillectomy vs 21% in the group that did not receive treatment. The researchers proposed several mechanisms for weight gain after adenotonsillectomy: increased calories consumed, unhealthy food choices, decreased energy burned due to reduced work of breathing, improvement in blood oxygen levels, and increased growth hormone secretion.

The authors recommend monitoring weight, nutritional counseling, and encouragement of physical activity after adenotonsillectomy for OSA in children.

Sleep apnea may impair kids behavior and adaptive functioning

Studies have shown that kids with obstructive sleep apnea (OSA) can have behavioral difficulties that affect school and home. Some will present to their pediatrician with symptoms of attention deficit-hyperactivity disorder (ADHD) - but in reality, the cause is underlying OSA. This study in the Journal Sleep looked at how kids with OSA have increased risk of behavior and adaptive functioning difficulties. Adaptive functioning refers to how these kids "negotiate social situations, engage in self-care to meet his or her own needs, and apply skills learned in school."

Researchers studied 263 kids starting at ages 6-11 years old. They had the kids and parents fill out questionnaires about behavior and functioning. They had the kids do home sleep studies. Then 5 years later, they repeated the questionnaires and sleep studies.

The results showed that the highest rate of impairment occurred in those kids diagnosed with OSA, particularly those that had it on both sleep studies (5 years apart). Researchers note, however, that some behaviors, like aggression and conduct problems, were accounted for by sociodemographic variables, rather than the OSA. And kids who had OSA on both sleep studies were 3-7 times more likely to have learning problems and lower grades than in kids who never had OSA.

Kids can sleep right through a fire alarm

Here is a video story about how kids can sleep through a fire alarm. Most parents know that kids sleep deeply. In this video story, the reporter set up an experiment demonstrating that three young boys slept right through the ear-piercing fire alarm in their home. But there is hope - one company is trying to improve the fire alarm but changing the noise it produces - instead of the beeping, it will be the parents voice telling the kids to get up.

TV before bedtime can reduce kids sleep duration

This article discusses research showing that increased TV time before bed can reduce total amount of sleep time in children. The study is based on a survey, so has biases but still points to some commonsense things parents need to remember about their children's bedtime rituals. Limiting screen time, especially around bedtime can help kids sleep better and longer. It's not just the content of the TV program that is the problem, but just the light from the screen itself can suppress melatonin.

Young children with cystic fibrosis at risk for obstructive sleep apnea

This article discusses how young patients with cystic fibrosis, a chronic lung disease, are at increased risk for obstructive sleep apnea.

More sleep helps children in school

Here is an article about how more sleep helps kids - seems obvious but at least here is some scientific evidence. For kids that got more sleep, they were less emotional, better focused, and better behaved. There are some good tips in the article for parents as well - monitor for sleepiness, which should be relatively low at a elementary age if they are getting enough sleep.

Asthma linked to daytime tiredness in children

This article discusses research showing that kids with asthma may be more sleepy during the day. However, the results showed that the asthma does not affect sleep quality, sleep duration, or bedtime. The researchers are not sure why asthma is linked to feeling tired in the daytime. It may be due to increased work of breathing at night, but this may not be reported by parents - just experienced by the child. More research is needed to determine if better control of the asthma results in less daytime tiredness.

Sleep quality and cell phones

This article discusses research about the affects of late night texting on sleep quality. Obviously, getting texts all night will disrupt sleep. But also, the light from the little screen is enough to suppress secretion of melatonin, which can also reduce sleep quality. The article mentioned Dr. Breus, who is an insomnia expert, and he gives some tips on improving sleep in kids with cell phones. Limiting screen time in the evening and certainly at night can help.

Children, Sleep, and the Television

I saw this article in the journal Pediatrics. Researchers surveyed about 600 parents about their preschool children's sleep and sleep problems, their TV viewing habits, and the content of television shows. The more TV that children watched in the evening and the more violent content they watched during the day, the more likely they were to experience sleep problems. It did not matter whether the violent programs were animated or live-action, or whether the kids were watching the shows with their parents.

This makes sense to most people. When I watched the Wizard of Oz with my then five year old daughter, she had nightmares that night - my wife said, "Way to go, sleep doctor daddy!" What is even more interesting about this study is that most of the violent content watched was actually children's programming - but these shows were more appropriate for 7 - 12 year olds, rather than preschool age.

Another interesting point about the study was that about 8% of preschoolers with a bedroom TV were tired during the day, compared with only 1% without a TV in their bedroom.

I am a strong believer that kids, especially young ones, should not have electronic devices in their rooms - they make it hard for kids to fall and stay asleep. Also, do not let your preschool children watch scary television - even if you think they can handle it. Stick with shows that have a PG-Y rating.

Researchers at the University of Louisville have found that a urine test can tell if children who snore have obstructive sleep apnea (OSA) or not. Apparently, there are different concentrations of stress-related proteins the urine of snoring children with OSA, than in snoring children without OSA. The researchers believe that the test is so simple, it could be performed in the home, like a home pregnancy test. It also might eliminate the need for a costly overnight sleep study to determine if children who snore also have OSA.

This study was published in the December 2009 edition of the American Journal of Respiratory and Critical Care Medicine, but I just saw a blurb about it from the University a few months ago. I thought that perhaps more information had come out about this, but a google search only showed the original findings from 2009. I guess we'll have to wait until more studies have been completed.

Behavioral Therapy Improves Sleep and Psychosocial Quality of Life

At the annual meeting of the Pediatric Academic Societies, researchers presented data from a study of 108 families with children (mean age 5.6 years) that had moderate to severe sleep problems based on a survey of parents. Right off, this should raise a flag as to the conclusions, since these children were not officially diagnosed by a physician.

The intervention was an initial 45 minute private consultation with parents at the school, a 20-minute telephone call 10 days later, and a 30-minute private consulation at the school if needed (the study report does not state how many needed that extra 30-minute consultation). The report does not state specifically what the behavioral interventions were or who did them.

The results showed a 74% improvement in the intervention group vs a 53% improvement in the control group in the parents report of their childrens sleep at 6 months. Also, the children in the intervention group had less bedtime delay and resistance, and less daytime tiredness than the control group. The intervention group also had inmproved social and emotional functioning, but no effect on ADHD symptoms.

The authors conclude that a brief, behavioral intervention had significant benefits in the short to medium term, and that it is possible to deliver such an intervention in the school environment. Of note, over half of the patients in the control group got better on their own. But still, behavioral therapy for children can be beneficial, especially for those parents who find it difficult to set limits - one of the most common causes of insomnia in children.

Bedwetting Children and Sleep Quality at Home

Interesting article in the March edition of the Sleep Journal about bedwetting, which occurs in upto 15% of children and sometimes has no known cause. Parents of children who wet the bed often say that their child sleeps too deeply. But research does not support this when kids with and without bedwetting have sleep studies.

In an attempt to cope with the bedwetting, some parents wake up their child during the night or maneuver them to the potty to prevent accidents in the bed. The authors of this study suggest these awakenings could worsen bed wetting.

They measured the sleep in children with and without bedwetting over five continuous nights at home with a portable sleep monitor (actigraphy). The results showed that kids with bedwetting had more nighttime awakenings and were more tired in the morning. Of all the awakenings, 27% were to prevent bedwetting, 2% were by parent after bedwetting, 20% were by child after bedwetting, and 50% were unrelated to bedwetting.

The authors theorize that if bedwetting kids have more broken up sleep at home, they are more likely to be sleep-deprived. Being more sleep-deprived will make it harder to wake up to empty their bladders. Therefore, reduced sleep quality may play a role in the maintenance of bedwetting.

Sleep duration and obesity in children

There was an article by NPR about a recent study published in the Archives of Pediatric and Adolescent Medicine. The researchers surveyed 2000 children about their sleep duration and measured the children's weight over a five year period.

The researchers concluded that children who slept greater than 10 hours per night were less obese than those that slept less than 10 hours per night. Napping during the daytime did not help, implying that nighttime sleep duration is the more important factor. The effect was most prominent in infants and toddlers. The authors of the study hypothesized that children who do not get enough sleep would be too tired to exercise. Also, certain hormones that control appetite can be affected by sleep duration, but this has only been proven in adults.

The article author at NPR lead off the story by stating that in infants and pre-schoolers, a good and long nights sleep may be just as important as diet and physical activity with regards to obesity! This is highly misleading, in my opinion. It takes the focus off the real problem with childhood obesity, which is their poor diet. If it only were that easy - just get more sleep and your overweight child will be thin again. The problem with this study is that it is dependent on parents' report of sleep duration, which is frought with uncertainty. Also, it could be argued that parents who let their children stay up late probably also let them eat too much junk food. I wish the authors of the study had surveyed caloric intake along with sleep duration in these children.

Don't get me wrong. Sleep is very important to kids' physical, emotional, and cognitive development. And too little sleep could play a small role in weight regulation. But lets focus on the real problem with childhood obesity rather than on these minor issues.

Children and Insomnia

There is a review from Medscape about an article that's coming out in the August edition of Sleep Medicine. The authors performed a nation-wide survey of child and adolescent psychiatrists about their patients with insomnia. Apparently, upto one-third of patients receiving psychiatric care have insomnia. At least one-fourth of those with insomnia receive either prescription or over-the-counter medications for their sleeping difficulty.

However, those surveyed expressed concerns about the side effects and lack of proof that medications for insomnia work. I guess this is why only one-fourth of their patients with insomnia received medications.

It's my opinion that medications are not a good long term strategy for children and adults that struggle with insomnia. Even if these medications have few side effects and are not physically addictive, patients can still develop psychological dependence to the medication. The patients often begin to believe they must have a pill to sleep, instead of using their body's own sleep drive and circadian rhythm to help them sleep.

Treating insomnia in children is very challenging and obviously common. Parents must be educated because the work really falls on their shoulders. The child can not be expected to do it alone. When dealing with adolescents, however, they need to become willing participants in their own insomnia treatment. Non-medication treatments for insomnia often work well in both children and adolescents, and it can be rewarding to see family dynamics improve once the child is sleeping better.