Sleep problems in children and teens


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Having problems getting your child to sleep? Dr. Jared Johnson, a family medicine physician with Via Christi Clinic in Wichita, Kan., presented "Sleep problems in children and teens" at the March Via Christi Women's Connection luncheon.

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  • Sort of in order of affected age groups
  • Before we dig into the medical terms and all the things that can go wrong with sleep, I want to point out that by far the greatest sleep problem out there is quite simple: We don’t get enough!!! Concept of sleep debt
  • 2-3 times the national rate in these minorities
  • Notice that we don’t even consider this a problem before 5 years old
  • Bed wetting is not child’s fault. Deliberate bed wetting usually associated with abuse
  • Keeping a calendar helps to track improvement. If restricting fluids in the evening, be sure to get enough in the rest of the day
  • Initial goals should be simple and involve following instructions (such as remembering to go to the bathroom before bed) rather than staying dry. Eventually work up to goals of staying dry for 7 – 14 consecutive nights
  • Works best if child will wake up to alarm without alarm disturbing the rest of the house. The child being fully awake and cognizant is critical to success
  • May be best used for short term, i.e. sleepovers, camps
  • Could include taking a bath, changing into pajamas, reading stories
  • Even the gradual variation helps child to learn self-soothing skills. Doing this at bedtime only will also carry over to nighttime awakenings
  • Bedtime fading: If child just seems to naturally prefer a later bed time, temporarily put lights out at child’s preferred time and gradually move it earlier over several weeks Positive reinforcement: Discussed earlier
  • Sleepwalking study was done on 2.5 to 6-year-olds. Sometimes treated with low-dose benzodiazepines or (if the sleepwalking occurs at the same time most night) scheduled awakenings just prior to usual time of event
  • Sleep problems in children and teens

    1. 1. Sleep issues in children and teensJared Johnson, MDFamily MedicineVia Christi Clinic3/12/2013
    2. 2. Today’s discussionNormal sleep in children and teensSIDSBed wettingBehavioral sleep problems and insomniaNightmaresSleep walking
    3. 3. Sleep trends in AmericaAverage sleep period in late 1800s wasapproximately 9-11 hoursAverage sleep period today is around 6.5hoursMuch more sleep debt than our ancestors
    4. 4. Why?Electric lightsMore shift workersMore distractions  Busier lifestyles, especially for children  Internet  TV  Video/computer gamingStress
    5. 5. Normal sleep in children and teens Age Hours of sleep needed 0–2 months 12–18 hours 3–11 months 14–15 hours 1–3 years 12–14 hours 3–5 years 11–13 hours 5–10 years 10–11 hours 10–17 years 8.5–9.25 hours Adults 7–9 hours
    6. 6. Sudden Infant Death Syndrome(and other sleep-related infant deaths)Rare: less than one in 1000 birthsStill the leading cause of death from ages 1month to 1 year in the USMore common in black and Native AmericanchildrenSlightly more common in boys
    7. 7. Sleep-related infant deaths“Back to Sleep” introduced in 1992Rate of SIDS was cut in halfRisk factors  Mother < 20 years old  Mother smoked during pregnancy  No prenatal care (or very little)  Premature baby  Baby shares bed  Loose blankets and pillows
    8. 8. Nocturnal bed wettingCommon: occurs in 16% of 5-year-olds,10% of 7-year-olds, 5% of 10-year-oldsOccurs during sleepAdditional symptoms might indicate a morecomplicated problem:  Daytime incontinence  Pain in genitals  Bowel symptoms (i.e. constipation)
    9. 9. Nocturnal bed wettingAlmost always stops on its own if enoughtime is allowedTreatment is unlikely to succeed if child isnot motivatedNever ever punish child for wetting the bed
    10. 10. Nocturnal bed wettingInitial measures:  Calendar of wet and dry nights  Child should go to the bathroom before bed  Avoid caffeine in the evening  Try to take in majority of daily fluids in the morning and afternoon, while restricting fluids in the evening  Avoid diapers and pullups (may use during sleepovers, camps, etc.)
    11. 11. Nocturnal bed wettingMotivational therapy  Reward system (a star chart)  Works best in younger children who do not wet the bed every night  Start easy and work up to tougher goals  Penalties are counterproductive  Generally done for three to six months
    12. 12. Nocturnal bed wettingEnuresis alarms  Most effective treatment  Child must be able to take charge of alarm with only some parental supervision  May be used anywhere from one to six months, generally should be some improvement by three months
    13. 13. Nocturnal bed wettingDesmopressin  Works immediately  Generally safe  High relapse rate after stopping medication
    14. 14. Behavioral sleep problemsMost common sleep issues in childrenMostly seen in children 0–5 years of age,but may persist longerMay involve prolonged night awakenings,bedtime resistance or some combination
    15. 15. Behavioral sleep problemsMore commonly in infants and toddlers theproblem stems from learning to fall asleeponly under certain conditions that require theparent to interveneFor example, child must be rocked or fed tofall asleepChild does not learn to self-soothe duringnormal brief arousals between sleep cycles
    16. 16. Behavioral sleep problemsMore commonly in pre-school age and olderchildren, the problem is active resistance tobedtime rather than prolonged wakingsduring the night
    17. 17. Behavioral sleep problemsInfants and toddlers: 25–50% over 6 monthsold continue to awaken during the night, and10–15% of toddlers resist going to bedPreschool-aged children: 15–30% eitherresist falling asleep or wake in the night, orboth
    18. 18. Behavioral sleep problemsChildren 4 to 10 years old: 25–40% havesleep problemsAdolescents 13 to 16 years old: 11%
    19. 19. Behavioral sleep problemsBedtime routine  Include 3 or 4 soothing activities  Should last 20–45 minutes  Put child to bed drowsy but awake  Coincide bedtime with child’s natural sleep onset time to reinforce circadian clock
    20. 20. Behavioral sleep problemsSystematic ignoring or “extinction”  Unmodified version is known as “crying it out”  Documented to be a highly successful treatment, but difficult for parents to adhere to  Alternative is to do this more gradually, with longer periods between checking on child  Keep contact brief and avoid picking child up
    21. 21. Behavioral sleep problemsBedtime fadingPositive reinforcement
    22. 22. InsomniaCaused by anxiety surrounding fallingasleep or staying asleepMost common sleep problem in adultsInsomnia in adolescents is treated similarlyto adults
    23. 23. InsomniaPrinciples of sleep hygiene in children  Have a set bedtime  Bedtime and wake-up should be about the same on school nights and weekends  Don’t go to bed hungry  Avoid caffeine for several hours before bed
    24. 24. InsomniaPrinciples of sleep hygiene in children  Spend time outside every day and exercise regularly  Keep bedroom quiet and dark  Keep bedroom at a comfortable temperature  Don’t use bedroom for time-out or punishment  NO TV IN BEDROOM!
    25. 25. NightmaresSevere nightmares are associated withanxiety or post-traumatic stress disorderIf severe enough to require intervention,they are usually addressed by psychologistsor therapistsMedications are rarely used and often serveto trigger the nightmares instead
    26. 26. SleepwalkingSeen in 15% of young children in one studyWill often go away after a year or twoSometimes triggered by sleep deprivation,or another sleep disorder such as sleepapnea or restless legsKeep environment safe
    27. 27. Questions?