Ask the Pediatrician: How Does Sleep Affect My Child’s Health?

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Ask the Pediatrician: How Does Sleep Affect My Child’s Health?

February 1, 2013, 08:41AM

sleeping childKids who are poor sleepers may be at risk for a variety of ailments including decreased ability to concentrate and retain information; decreased mood; increased risk of illness; overweight and obesity; and overall poorer health. Community surveys suggest that 25 to 50 percent of preschoolers and up to 40 percent of teenagers experience sleep-related problems. In my own practice, I can recall many exhausted parents wondering when their children would start to spend the night in their own bed. I also met with several teenagers who were dragged to the doctor's office due to a parent's concern of excessive sleepiness, only to learn that the teens were understandably sleep-deprived, routinely going to be bed at 1 or 2 in the morning, often on school nights.

Sleep Needs
Given the potentially harmful consequences of poor sleep, it is not surprising that many parents worry that their children do not get enough sleep. In fact, a 2012 article published by the American Academy of Pediatrics that traced the historical trend in kids' sleep recommendations, indicated that for the past 100 years parents and pediatricians have been concerned that kids do get enough sleep. The researchers found that regardless of how much sleep children have gotten over the years, actual sleep turns out to consistently be about 37 minutes less than recommended sleep. The authors concluded that "no matter how much sleep children are getting, it has always been assumed that they need more."

Then, just six months later another study conducted by doctoral candidate Jessica Williams of UCLA found that the parents' reports of their children's sleep duration were consistent with sleep recommendations. This study received a great deal of media attention and further confused the issue—do children get enough sleep or not?

It turns out that the research aiming to understand how much sleep that children actually need (and how close they are to attaining it) is limited and inconclusive. While recommendations exist for how much sleep kids should get (see Box 1), they are generally based on expert opinion and consensus and not solid scientific support. It seems that sleep needs vary considerably among individual children. For parents concerned about their children's sleep patterns, Oskar Jenni may have said it best in an editorial accompanying Williams' study: "If the child does not demonstrate signs of sleepiness in the course of the day, wakes up spontaneously in the morning, and shows age-appropriate behavior during the daytime, then no further actions are required in clinical practice."

Identifying Sleep Problems
For children whose parents are concerned about their sleep patterns, pediatricians often use a tool known as the BEARS Screening (Box 2) to understand what type of sleep problem a child may suffer from and how best to manage it. The screening tool assesses if a child has difficulty in any of five domains of sleep: bedtime problems, excessive daytime sleepiness, awakening during the night, regularity and duration of sleep, and snoring. If a parent and child complete the screening tool and it indicates that a child has sleep difficulties in one or more of the domains, the family may consider implementing some of the strategies highlighted in Box 1 and discussing the concerns with the child's pediatrician.

Most Common Sleeping Problems in Childhood and Adolescence
One of the most common childhood sleep problems is "behavioral insomnia" characterized by either an extended process of getting a child to go to sleep or frequent nighttime awakenings in which a child demands caregiver intervention.

Another common sleep problem is referred to as "delayed sleep phase syndrome." This occurs when a child has difficulty falling asleep and subsequent extreme difficulty waking in the morning. The child compensates for the shortened nighttime sleep with afternoon naps or extended sleeping on the weekend. These behaviors further disrupt the child"s circadian rhythm, making normal sleep patterns even more difficult. This abnormal sleep pattern is associated with depression, anxiety, school refusal and school phobia.

Some children suffer from night terrors, which are arousals from deep sleep accompanied by expression of intense fear and disorientation that the child does not remember upon wakening in the morning. Night terrors are most common in four to 12 year olds. Other children experience frequent nightmares characterized by disturbing dreams that usually awaken the child from sleep and make it difficult to fall back to sleep. Nightmares tend to be most profound for children between the ages of three and five. Nightmares are associated with sleep deprivation, depression, some medications and anxiety disorders. A sizeable number of children will suffer from sleepwalking at least once. This is when the child wakes from sleep and walks around the home behaving dazed or agitated. It occurs most commonly between the ages of four and eight.

For many children, sleep is disrupted due to a sleep-related breathing disorder such as obstructive sleep apnea (OSA). OSA is characterized by snoring and periods of a stop in breathing during sleep due to a blockage of the airway. OSA is associated with enlarged adenoids and tonsils, as well as with obesity. OSA is most common in young children aged two to six and adolescents. While snoring may be a sign of OSA, it also can occur for unrelated reasons, but these scenarios are impossible to differentiate without a sleep study in which a child's sleep patterns are closely monitored with specialized equipment in a controlled setting. Parents who are concerned that their child has OSA should seek evaluation from a pediatrician, because untreated OSA can lead to serious health problems.

Ultimately, sleep problems in childhood are common, but also preventable with the age-appropriate strategies outlined in Box 1. Parents who have concerns about their child's sleep patterns should discuss these concerns with their pediatrician.


References

Bhargava, S. (2011). Diagnosis and management of common sleep problems in children. Pediatrics in Review, 32, 3, 9199.

Jenni, O.G. (2012). How much sleep is “normal” in children and adolescents?[published online November 26, 2102]. Archives of Pediatric and Adolescent Medicine, Doi:10.1001/jamampediatrics.2013.429.

Matricciani, L. et al. (2012). Never enough sleep: A brief history of sleep recommendations for children. Pediatrics, 129, 3, 548-556.

National Sleep Foundation (sleepfoundation.org)

Williams, J.A., Zimmerman F.J. and Bell J.F (2012). Norms and trends of sleep time among US children and adolescents [published online November 26, 2012]. Archives of Pediatric and Adolescent Medicine, Doi: 10.1001/jamapediatrics.2013.423

Sleep Recommendations for Children

Age

Sleep Recommendation

Signs of Insufficient Sleep

Tips for Better Sleep

Newborn (0-2 months)

12 to 18 hours (in 1-3 hour bouts)

Crying
Rubbing eyes
Gestures

*Put baby to sleep when drowsy but awake
*Put baby back to sleep in crib without any other items (safest way to sleep)
*Encourage nighttime sleep

Infant (3-12 months)

14 to 15 hours, including about 2 naps per day of 30 min to 2 hours

Fussing
Rubbing eyes
Yawning

*Put child to sleep drowsy but awake (to encourage self-soothing)
*Develop plan for addressing nighttime awakenings

Toddlers (1-2 years) and Preschool (3-5years)

12 to 14 (toddlers) and 11-13 (preschool) hours total, including one nap per day of 1-3 hours for many kids

Tantrum and irritability

*Establish regular sleep schedule and bedtime routine
*Establish clear bedtime rules and routines
* Bedroom dark, cool, quiet
*Avoid stimulating TV shows and movies before bedtime

School-age Children (6-10 years)

10-11 hours, no nap

Hyperactive, poor impulse control, poor attention

*Forbid caffeine
*Do not allow TVs or other “screens” in bedroom
*Avoid scary movies or stimulating shows before bedtime
*Follow bedtime routines

Adolescents (10-17 years)

8.5-9.5 hours

Excessive daytime sleepiness

*Avoid caffeine in evening
*Decrease bright light exposure in evening
*Avoid naps
*Remove TV and other “screens” (including cell phones) from room
*Follow a consistent “bedtime”

Sleep recommendations from http://www.cdc.gov/features/sleep/ and the National Sleep Foundation


BEARS SCREENING TOOL

 

Toddler/Preschool
 (2 to 5 years)

School Age
 (6 to 12 years)

Adolescent
(13 to 18 years)

Bedtime Problems

Does your child have any problems going to bed or falling asleep?

Does your child have any problems at bedtime?
Do you (child) have any problems going to bed?

Do you have any problems falling asleep at bedtime?

Excessive Daytime Sleepiness

Is your child sleepy during the day?

Does your child have difficulty waking, seem sleepy during the day, or take a nap?
Do you (child) feel tired a lot?

Do you feel sleepy a lot during the day, in school, or while driving?

Awakenings During the Night

Does your child wake up a lot at night?

Does your child wake up a lot at night?
Do you (child) wake up a lot at night and have trouble falling back asleep?

Do you wake up a lot at night and have trouble falling back asleep?

Regularity and Duration of Sleep

Does your child have a regular bedtime and wake time?

What time does your child go to bed and get up on weekdays/weekends?
Do you think your child gets enough sleep?

What time do you go to bed on school days/weekends?
How much sleep do you usually get?

Snoring

Does your child snore a lot or have difficulty breathing at night?

Does your child have loud or nightly snoring or difficulty breathing at night?

Does your child snore loudly or nightly?

Source: Reprinted in Bhargava, S. (2011). Diagnosis and management of common sleep problems in children. Pediatrics in Review, 32, 3, 91-99, with permission from Mindell, J.A. and Owens, J.A. (2009). A Clinical Guide to Pediatric Sleep, Diagnosis and Management of Sleep Problems. Philadelphia, Pa.: Lippincott Williams & Wilkins.

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