Irritable, Unfocused Children Could Have Sleep Disorders

Whether the problem is needing 'one more glass of water' or a temporary fear of the dark, childhood sleep issues are not uncommon. "Nearly two-thirds of children have a sleep problem at least once a week that requires parental intervention," said Lynn A. D'Andrea, MD, Medical College of Wisconsin Associate Professor of Pediatrics.

Dr. D'Andrea is the chief of the Division of Pediatric Pulmonary and Sleep Medicine and director of the Pediatric Sleep Center at Children's Hospital of Wisconsin.

Sleep Disorders Can Cause Behavioral Problems
Although sleep issues are common, there are some signals that parents should be aware might indicate a sleep disorder. "Children can have the same sleep disorders that grown-ups do, but they present differently," said Dr. D'Andrea. While adults who are not getting enough sleep often feel tired during the day, many times children 'act out'.

"What parents say is that they start to see behavioral changes," Dr. D'Andrea said. "The kids have a hard time concentrating or focusing in school. They may get more irritable or grouchy. There's concern that some children might be mistakenly diagnosed as having attention deficit disorder."

As the only board-certified pediatric sleep specialist in Wisconsin, Dr. D'Andrea sees pediatric patients with all types of sleep problems.

Sleep Apnea in Children
Sleep apnea is a common disorder in which breathing becomes labored or even stops temporarily. These pauses in breathing can occur 20 to 30 times or more in an hour. If parents notice loud snoring and the child seems to have to work hard to breathe, sleep apnea could be the problem.

The most common type of sleep apnea is obstructive sleep apnea, often caused by enlarged tonsils - which lie on either side of the upper throat - or adenoids, located behind the nose. The most common treatment for this situation is an adenotonsillectomy - surgical removal of the tonsils and adenoids. Although fewer adenotonsillectomies are being performed for children with chronic strep throat infections than in the past, Dr. D'Andrea said the procedure remains the primary treatment for obstructive sleep apnea in children.

In addition, there are about 200 children who visit the sleep clinic who use a continuous positive airway pressure (CPAP) device to help them sleep. A CPAP machine consists of a mask that fits over the nose or nose and mouth, a hose that attaches the mask to the machine, and the machine itself (about the size of a shoebox), which usually is placed on a bedside table. The CPAP gently blows air into the throat to hold the airway open.

Dr. D'Andrea said that most of the children who go on to require CPAP are overweight. The remainder of the children have a neuromuscular disease, such as muscular dystrophy which contributes to their sleep-disordered breathing.

Other Reasons for Disturbed Sleep
Children can also experience restless legs syndrome. Restless legs syndrome (RLS) is a neurological disorder characterized by unpleasant feelings in the legs and an uncontrollable urge to move them for relief. People who have RLS describe the feelings as burning, creeping, tugging, or like insects crawling inside the legs. The sensations range in severity from uncomfortable to irritating to painful.

"Sometimes parents think their children are just having growing pains, but then it happens every night. Their legs start to hurt, and they get this creepy-crawly feeling," Dr. D'Andrea said. The most common cause of RLS in children is a low iron level.

Nightmares, night terrors and sleepwalking are classified as parasomnias. Often, they are linked to stress. "It becomes concerning if it's frequent or if it persists into adolescence," Dr. D'Andrea said. "We take it for granted that we can go from one sleep stage to the next. Sometimes kids get stuck and then the parasomnia occurs."

Children can also have narcolepsy, a neurological disorder caused by the brain's inability to regulate sleep-wake cycles. People with narcolepsy can suddenly fall asleep - usually for a few seconds to several minutes - at random times.

Narcolepsy might be indicated when a child is overwhelmingly sleepy during the day. "Sometimes people think the children are not getting enough sleep, but they're going to bed at a good time," Dr. D'Andrea said. "In the past, most people with narcolepsy were not diagnosed until they were young adults, but now that we're more aware, the diagnosis happens earlier."

Sleep Study Not Always Needed
A common misconception is that if a child is suspected of having a sleep disorder, a sleep test will always be conducted. Children with obstructive sleep apnea most likely will need a sleep study to confirm the diagnosis and determine the severity, but for most other childhood sleep disorders such as insomnia, restless legs syndrome or parasomnias, no sleep study is required. Instead, diagnosis is made by parental observation and consultation or clinical testing.

Many other sleep disturbances are addressed in the sleep clinic with cognitive behavioral therapy, Dr. D'Andrea said. Cognitive behavioral therapy involves working with patients to modify behaviors and address emotional issues. "Behavioral intervention is like training or exercising. You need to do it every day. There are protocols and programs we set up. It's hard work, but they are all routines the family can do at home."

In addition, children might be given supplemental melatonin, a hormone made naturally by the body in response to darkness and light. Additional melatonin helps some people achieve better sleep.

"We rarely, if ever, prescribe sleeping pills for children," Dr. D'Andrea said. "Most of the time it just involves learning new habits. They learned the bad sleep habits, now they have to learn some good sleep habits."

"We have one of only 20 free-standing pediatric sleep centers in the country," Dr. D'Andrea said. In February 2006, the Sleep Center at Children's Hospital received accreditation from the American Academy of Sleep Medicine, making it the only sleep disorders center in Wisconsin dedicated exclusively to the care of children.

Melissa Rigney Baxter
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.