Pediatric Insomnia

Introduction & Background Scenario Activities Resources & Clinical Tools CME Certification for Module

The majority of providers in US and Canada will suggest/prescribe off-label sleep medications for insomnia in their practices

Insomnia has three components:
predisposing, precipitating, and perpetuating

Nearly

1/3
of children and adolescents will suffer from insomnia at some point in childhood

By the end of this module, you will be able to:

Categorize the various kinds of insomnia across the developmental spectrum.
Identify the contributing factors of insomnia.
Help families to identify and overcome barriers to treatment of insomnia.
Compose the basics of an insomnia treatment plan, including a threshold for further referral.
Recognize key features of insomnia in specific conditions.

Insomnia is a disorder of sleep initiation and/or sleep maintenance. This may include difficulties with sleep duration, consolidation, and quality. Issues may be short-term or chronic. These difficulties subjectively cause significant impairment in daytime function for the child and/or family. The manifestations of insomnia and its related daytime impairments vary by individual temperament, family dynamic, developmental and chronologic age, and cultural settings. Importantly, the presentation may be quite different than insomnia in adults. In all children, the presence of co-morbid medical or psychiatric conditions may contribute to the development or worsening of insomnia.

Insomnia develops when the child has a predisposition to insomnia (e.g., temperament, development, genetics, co-morbid condition), a precipitating event (e.g., an acute illness or stressor), and then experiences perpetuating factors (e.g., poor sleep hygiene, lack of accountability).

Overall, treatment of insomnia involves reframing sleep as a daily success instead of a daily failure. The impact of repeated failure for both the child and family continually shape miscognitions and maladaptive behaviors towards sleep, which are further reinforced by broader social behaviors that minimize the importance of sleep for the entire family.

In Younger Children, including infants, toddlers, and early school-aged children

Insomnia frequently presents with bedtime resistance or frequent night wakings greater than that's expected for age.
Often related to inadequate limit setting by caregivers or inappropriate sleep-onset associations.
May significantly disrupt the child's family and caregiver daytime function.
Previously, these disorders were grouped as Behavioral Insomnia of Childhood.

In Children and Adolescents

In older children, short term insomnia is often related to an environmental stressor. However in these older children and adolescents, excessive worry about sleep and consequences of not sleeping prevail in those with chronic insomnia. Chronic insomnia is accompanied by physiologic hyperarousal and cognitive hypervigilance. Function is impaired during the day. Previously, this was known as “conditioned”, “primary”, or “psychophysiologic” insomnia.

Types of Insomnia	Typical age-range
Bedtime resistance Frequent night wakings	Infant (0-2)
Bedtime resistance Frequent night wakings	Preschool (2-5)
Bedtime resistance Frequent night wakings Chronic insomnia	School Age (6-12)
Chronic insomnia	Teenager (13-18)

Medicine	Diagnosis of co-morbid conditions (e.g., eczema, asthma, arthritis, diabetes). Creation of plan with family
Nursing	Guidance on implementing the plan of care within the family’s daily routines Communication with school nurse to review of child stressors in school or impact within the classroom
Nutrition	Review of meal/snack times and content of food Caffeine Overall healthy weight goals Guidance for iron-rich foods in those with low ferritin levels
Pharmacy	Review of medications, supplements taken which might affect sleep
Respiratory Therapy	Optimization of co-morbid asthma or other pulmonary conditions requiring airway clearance/interventions during nighttime hours.
Social Work and Mental Health	Assess larger community influences such as supportive housing, adequate social support for entire family
Family Perspective and Leadership	Link to other families who have successfully managed childhood insomnia