Sleep disorders in children manifest in a variety of ways and have different treatment options. An overview of the disorders and their treatment is presented in the Table.
Treatment of pediatric sleep disorders
|Disorder||Empiric treatment options|
|Circadian rhythm insomnia||Melatonin|
Clonazepam(Drug information on clonazepam)
Diazepam(Drug information on diazepam)
Lorazepam(Drug information on lorazepam)
Pramipexole(Drug information on pramipexole)
Ropinirole(Drug information on ropinirole)*
Gabapentin(Drug information on gabapentin)
Modafinil(Drug information on modafinil)
Methylphenidate(Drug information on methylphenidate)
|Sleep apnea||Surgical intervention
Inhaled nasal steroids
Montelukast(Drug information on montelukast)
|*FDA-approved for adult use only.|
Nonpharmacologic interventions are the first line of therapy for children with sleep disorders. Behavioral interventions include education of parents, sleep hygiene education, extinction, graduated extinction, scheduled awakenings, and positive bedtime routines.21,22 The management of insomnia in children should include education about normal sleep development, the establishment of appropriate and realistic expectations for the parents and child, and clear treatment goals. School schedule and extracurricular activities should be taken into consideration when establishing the treatment protocol.
It is very important to set and consistently reinforce fixed bedtimes and rise times. Bedtime should be age appropriate with an established routine that provides behavioral cues for transition to sleep. Morning rise time is especially important as a powerful environmental cue for reinforcement of the sleep-wake cycle. Avoidance of excessive fluids at bedtime and caffeinated beverages helps with sleep onset and reduces the likelihood of nocturnal awakenings. The sleeping environment should be controlled to exclude such things as television, video games, and access to a computer. Children should be encouraged to sleep in their own bed on a consistent basis. Establishment of appropriate nap time is very important, since it will affect nocturnal sleep onset and sleep duration time. Long and frequent daytime naps result in a shorter nocturnal sleep period, delayed sleep onset, and nocturnal awakenings.
There are no well-designed controlled studies of sedative/hypnotic use in children and there are no FDA-approved pharmacologic agents for use in pediatric insomnia. Diphenhydramine(Drug information on diphenhydramine) hydrochloride is the most commonly used agent in children for sleep initiation problems. Dose ranges are 12.5 to 25 mg at bedtime for children aged 2 to 6 years, and 25 to 50 mg or more for children aged 6 to 12 years and older.23 The use of tricyclic antidepressants for insomnia in children is diminishing in popularity, and there are no established dose recommendations for hypnotics in children. One report suggested that trazodone was associated with a reduction of sleep onset insomnia in children after administration of 25 to 50 mg at bedtime.24 However, there are no systematic data available on the safety and tolerability of trazodone in children with insomnia. Benzodiazepine hypnotics are rarely used in children with the exception of clonazepam, 0.25 to 0.5 mg, which is the drug of choice for treating those with parasomnias.25
The use of melatonin(Drug information on melatonin) in children may be effective for sleep initiation insomnia caused by circadian factors.26,27 A double-blind placebo-controlled trial by Smits and colleagues28 in healthy elementary-school children showed that 5 mg of melatonin administered at bedtime reduced sleep-onset latency and increased total sleep time. Melatonin dose recommendations for children of different ages are lacking, as are data on the long-term efficacy and safety in pediatric populations. The recently published Consensus Statement by Mindell and colleagues29 provides a useful summary of the current status of knowledge on pharmacologic treatment of pediatric insomnia.Parasomnias
Parasomnias include sleepwalking, sleeptalking, nightmares, night terrors, and REM sleep-behavior disorder. There are no methodologically rigorous, blinded, and controlled studies of parasomnias in children. The behavioral abnormalities in this disorder can be triggered by factors that disrupt sleep. Therefore, strict adherence to sleep hygiene is obligatory. Children should avoid sleep deprivation, stressful situations, and caffeine(Drug information on caffeine) close to bedtime.
Sleepwalking is the most common parasomnia in children. In cases in which self-injury is unlikely and in which parental distress is minimal, education and reassurance of parents should be provided with the emphasis on preventing injury and helping the child return to bed. Removing potentially dangerous objects close to the bedside and on bedside tables, keeping knives and firearms out of the reach of the child, and locking bedroom doors and windows are among the safety precautions that par-ents can take to maximize the safety of the child. For more severe forms of the disorder in which self-injury is imminent, and when behavioral measures have failed, medications such as clonazepam (0.01 mg/kg; usual starting dosage 0.25 mg qhs), diazepam (0.04 to 0.25 mg/kg), and lorazepam (0.05 mg/kg) can be considered.25RLS and PLMD