- Chronic Insomnia Disorder, is a newer umbrella term that now includes what was previously called Behavioral Insomnia of Childhood and its two subtypes (Sleep Onset Association Type, and Limit Setting Type). It affects up to 50% of infants <1 year of age at some point during their first year of life. Symptoms need to be present for at least 3 nights a week and greater than 3 months duration.
- For children, Chronic Insomnia is defined in part by an inability to establish/maintain sleep, despite the presence of adequate opportunity and circumstance, without parental intervention. Importantly, there must also be evidence of daytime dysfunction related to this impaired sleep, which varies in presentation across age groups.
- For further information on infant sleep, please refer to the Normal Sleep module.
- Infants who have insufficient sleep may consequently lack focus and the ability to self soothe enough for sleep onset, worsening a vicious cycle of insufficient sleep and difficulty with sleep onset.
Ahmed's Story
Ahmed is a 9 month old who presents to his health care provider for a routine 9 month visit. He was generally healthy until 6 months of age, at which point he had several back to back ear infections and respiratory infections, coincident to starting daycare when mom returned to work.
At this visit, Ahmed’s health care provider notices that Ahmed’s mom looks particularly fatigued. Ahmed’s mom states that Ahmed has not been sleeping well, stating that Ahmed will not fall asleep in his crib and will only sleep if held. He seems to awaken frequently throughout the night.
She says he will only go back to sleep if Mom nurses him and rocks him back to sleep. Mom states that she is desperate to have him sleeping through the night.
Expert Insights
BEARS Screening for Pediatric Insomnia
BEARS is not valid for patients under 2 years, but the questions raised serve as a useful template to others. As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of pediatric sleep histories that was obtained from Ahmed and his mother.
Bedtime Problems
Ahmed’s mom states that he cannot fall asleep without nursing or being held.
When parents place him in his crib awake and drowsy, which is what they have read to do, he just screams, and does not seem to stop for what they deem ‘a very long time’ though they have never actually timed this period.
Expert Insights
- Ahmed has a sleep onset association disorder, in which he requires parental presence and nursing in order to fall asleep. He has learned to fall asleep only in these circumstances.
- Families often undergo significant stress when this occurs, with heightened parental anxiety which then escalates their sensitivity to the infant’s distress and often leads to strife between parents.
Excessive Daytime Sleepiness
Ahmed’s mom states that he also does not nap well at daycare, though he does fall asleep quickly in the carseat on the way home from daycare.
Expert Insights
- Remember that Excessive Daytime Sleepiness in younger children frequently does not present with only overt sleepiness during the day, but rather with more subtle findings such as irritability, fussiness, mood lability, poor behavior, etc.
- Difficulty napping in children with Insomnia may result from being overtired and an inability to focus enough on self-soothing for sleep onset, as well as sleep onset associations that carry over from nighttime sleep at home to daytime sleep in a different environment.
Awakenings
Ahmed’s mom states that he will awaken every 1-2 hours throughout the night, with the exception of the first part of the night when he will sleep solidly for 3 hours once he falls asleep.
Expert Insights
- Timing of awakenings at night can help distinguish between pathologic and physiologic awakenings, both of which may manifest with difficulty falling back asleep unassisted. Awakenings that occur every 90-120 minutes are likely physiologic arousals between ultradian sleep cycles, with the first uninterrupted portion of sleep being delta sleep. Children who alert caregivers during those arousals when they cannot fall back asleep then become behaviorally more aroused when they cannot be rapidly soothed back into sleep, typically with their needed associations. Children who are able to self-soothe will arouse during those same sleep stage transitions, but be able to fall back asleep quickly and independently, not signaling an acute need for parental presence. Those who cannot self-soothe at the beginning of the night usually cannot self-soothe after nocturnal arousals.
Regularity & Duration
Ahmed’s mom states that these sleep problems occur nightly. Ahmed has rarely slept through the night and definitely not since he was 6 months old.
Ahmed’s mom states he awakens at least 4 times a night, mostly between midnight and 6AM. Awakenings last anywhere from a few minutes to close to an hour.
Expert Insights
- The frequency and duration of awakenings helps to seal a diagnosis of chronic insomnia, which requires episodes 3 nights a week for at least 3 months.
- The chronicity of these issues also suggest that Ahmed has developed long standing sleep onset associations that became more pronounced after a combination of repeated illnesses and mom returning to work. In addition, a resurgence of night wakings is common between 9-12 months of age when children are able to physically accomplish much more during those transient physiologic awakenings (e.g., able to crawl, pull to stand) contributing to heightened arousal during those times.
Sleep-Disordered Breathing / Snoring
Ahmed’s mom states that Ahmed does not snore. He has had isolated nights of congested nasal breathing during colds and ear infections, but not persistently.
Expert Insights
- Determining the difference between obstructive sleep apnea and habitual (or even occasional) snoring is difficult by parent report alone. Lack of witnessed apneic episodes or gasping unfortunately does not rule out more significant sleep disordered breathing.
- The role of infant obstructive sleep apnea on later childhood development and behavior is only beginning to be explored, but early studies suggest that the presence of snoring or OSA in early infancy may be associated with later childhood difficulties with behavior and cognitive performance.
Ahmed's Evaluation & Diagnosis
What evaluation & diagnostic protocol should Dr. Matthews use to diagnose Ahmed's nighttime awakenings?
Check all that apply:
The evaluation protocol strategies we recommend for Ahmed's case are:
- Further determine child’s sleep history.
- Perform a physical examination.
- Complete a sleep diary.
Elements of Ahmed's Sleep History
| Sleep History | Case Specific Information | Ahmed's Evaluation Results |
|---|---|---|
Circumstances of sleep onset |
Please describe your bedtime routine at the beginning of the night. |
Ahmed is given a bath, plays with parents for a while, and then is nursed when he appears fussy and tired. He and mom usually fall asleep in rocking chair together. |
Review timing of events at night (bedtime/wake time) |
Please describe what happens after Ahmed first falls asleep through the rest of the night. |
Ahmed’s first awakening occurs after mom wakes up in the chair and tries to put him down in the crib. He will usually awaken and cry. Mom will nurse him again and he will fall asleep shortly, and this time she is usually successful at getting him in his crib. A few hours later though, he will wake up and cry until mom picks him up and nurses him. Sometimes she is able to get him back into the crib where he will sleep another 1-2 hours, but frequently she will fall asleep with him while nursing in the chair. |
Establish sleep routine prior to onset of difficulties |
What was Ahmed’s sleep like before you went back to work? |
He’s always nursed to go to sleep, but he seemed to wake up less and be easier to put in his crib. Mom is just more prone to falling asleep with him because she is so tired from working and not napping herself during the day. |
Parental expectations of sleep |
What do you think would be ideal for Ahmed’s sleep? |
Ahmed’s mom and dad do not agree on approaches to sleep. Dad thinks that they should let Ahmed “cry it out” and is frustrated that Mom is not letting him do so. Mom feels that Ahmed needs her at night and must need something if he cries as much as he does at night. She also says it is difficult for her to return to sleep when she has been listening to him crying for a long time so she leans toward ending the crying as quickly as possible. |
Perform a Physical Exam
| Information to obtain includes: | Case Evaluation Results |
|---|---|
A physical exam should include height, weight and head circumference to assure adequate growth; general developmental assessments; ENT exam; cardiopulmonary exam; neurologic exam for tone and general temperament. |
Ahmed has a completely normal exam for age, with the exception of advanced motor milestones in that he can pull to stand and crawl well. |
Sleep/Other Diary
| Information to obtain includes: | Case Evaluation Results |
|---|---|
Timing, duration, frequency of awakenings and interventions delivered |
Ahmed’s sleep onset time and awakenings are erratic and follow mom’s variable work schedule, though for the most part he sleeps between 9-11PM every night without awakenings. From then, awakenings tend to be every 60-120 minutes, and last anywhere from 5-45 minutes, with nearly each time nursing for return to sleep. Pacifier, rocking, bottled milk, bottled formula, bottled water have all been attempted. Letting him cry has lasted no longer than 15 minutes. |
Options that are Not Recommended
Order Labs/Other Diagnostic Tests
There is no need to order other labs or diagnostic tests.
Sleep Study
A sleep study is not recommended in this case.
Refer to a Specialist
A referral to a specialist is not recommended in this case.
Red Flags
- Any signs of significant parental stress, abuse, or clinically significant parental depression/anxiety.
- Family unable to give a reliable history.
- Child has concerning signs of developmental delays.
- Any history of in utero drug or alcohol exposure.
When evaluating a child for possible parasomnias, consider how other health care providers may also need to be involved.
Expert Insights: Triggers for Chronic Insomnia
- Predisposing factors, such as infant and parent temperament, maternal anxiety/depression, sleeping environment (e.g., co sleeping), breastfeeding
- Precipitating factors, such as acute illness, mother’s return to work, and acquisition of motor ability to crawl/stand during these awakenings, further increasing arousal
- Perpetuating factors, such as ongoing breastfeeding, maternal exhaustion, permissive parenting
Evaluation & Diagnosis
What factors are contributing to Ahmed's nighttime behaviors?
Check all that apply:
- Breastfeeding
- Normal Development
- Maternal stress/guilt
- Acute Illness
All of the above factors are contirubuting to Ahmed's nighttime behaviors.
Ahmed's signs and symptoms are consistent with:
- Chronic insomnia, previously known as behavioral insomnia of childhood, sleep onset association subtype.
Ahmed's Treatment & Referrals
Now it’s time to recommend treatment options for Ahmed's insomnia.
Check all that apply:
The following treatment strategies are recommended for Ahmed's chronic insomnia, previously known as sleep onset association subtype:
- Parental Educaiton
- Behavioral Intervention
- Sleep Hygiene
Treatment Strategies for chronic insomnia in young children varies from family to family
- Development and implementation of a consistent sleep schedule, including napping, with identification of a transition object and a safe, consistent sleep space.
- Elimination of parental presence through extinction, graduated extinction, or bedtime fading.
- Elimination of nighttime feeds.
Interdisciplinary Treatment Components
Ahmed's Results:
Good news! Ahmed’s difficulty sleeping has improved with treatment.
Treatment strategies and results for chronic insomnia:
- Sleep hygiene and routine.
Ahmed’s parents agreed on a routine which included the same three items every night starting at a set time, regardless of if mom was home or not; including a bath, book, and songs. This seemed to calm Ahmed down quite a bit. If mom was home, she nursed him prior to bath. - Graduated extinction, extinction.
Mother and father disagreed on how best to remove mother’s presence at bedtime. Father wanted to do full extinction, but mother wanted to do parental fading. Ultimately, they compromised and agreed to try graduated extinction. However, after the first two nights, during which time Ahmed had an extinction burst, mom realized that going into his room repeatedly was harder on her than anticipated, and thus opted for full extinction. After four days, he was asleep after 20 minutes of fussing at the beginning of the night. Nighttime signaling during awakenings was eliminated. He awoke much better rested, happier, and napped much more reliably at daycare afterwards. - Elimination of nighttime feeds.
Ahmed’s parents identified that they did not just want to eliminate feeds, but rather all nighttime signaling and hence opted for extinction which inherently eliminated feeds.