Does your child seem fatigued during the day or have difficulty falling or staying asleep? Does your child struggle with school work or have difficulty concentrating? Does your child have emotional outbursts or seem inattentive or hyperactive? These signs may be symptomatic of bad habits surrounding bed time (poor sleep hygiene) or a more serious sleep disturbance, such as obstructive sleep apnea.
As human beings, we spend nearly one-third of our lives sleeping. Getting a good night’s sleep has been proven to be crucial for physical and emotional health. Yet, we learn so little about the health benefits of sleep and proper sleep hygiene in our formal education, unlike the other basic cornerstones of health, including nutrition, exercise, and sex. From a physical health standpoint, sleep is involved in healing of heart and blood vessels, keeping a balance between hormones that tell us when we’re hungry, releasing hormones that allow us to grow and develop normally, as well as maintaining a robust immune system to fight infections. Sleeping well is also associated with improved attention, learning, memory, and regulation of emotions. Conversely, sleep deprivation is linked to increased risk of heart disease, high blood pressure, obesity, diabetes, stroke, inattention, learning problems, depression, anxiety, increased infections, and accidents. If sleep deprivation is associated with such severe consequences, how do we ensure a good night’s sleep for us and our children?
A child with poor sleep hygiene can appear very sleepy, have trouble concentrating, be forgetful, or behave in a hyperactive or impulsive manner. It is crucial that you help create a calm, consistent bedtime routine for your child. Ask yourself if the following apply to your child:
If your child meets one or more of these criteria, then sleep hygiene is an area upon which to improve. Correcting sleep hygiene is imperative BEFORE considering other sleep disorders, such as obstructive sleep apnea, narcolepsy, insomnia, or restless legs syndrome. Please adhere to the following guidelines for sleep hygiene:
According to a consensus statement by the American Academy of Sleep Medicine, the recommended amount of sleep for infants and children for optimal health is as follows:
Maintaining Consistency Is Key
It is very important to acclimate your child to a consistent bedtime and wake time as much as possible. This can be more challenging in infants and young children whose nap and feeding schedules are erratic, but it is important still to set clear boundaries. Children that necessitate a particular condition in order to fall asleep, such as a parent in the bed or evening snack, need to be trained to fall asleep on their own. Rather than lying in bed with your child, try sitting in a chair next to the bed. Reassure your child that you are there as they are falling asleep but do not get back into bed with him or her. Eliminate distracting factors (e.g. electronics, siblings sleeping in the same room, toys) that may be keeping your child from obtaining the optimum number of hours of sleep.
Obstructive sleep apnea can present similarly to poor sleep hygiene with symptoms such as daytime sleepiness, inattention, forgetfulness, and hyperactivity/impulsivity in small children.
Obstructive sleep apnea occurs in 1-5 percent of otherwise healthy children and can be higher in certain conditions, such as Downs Syndrome, children with craniofacial abnormalities, and neuromuscular disorders such as the muscular dystrophies. It can occur at any age, but is most common between 2-6 years of age. Untreated sleep apnea can result in severe health consequences, including high blood pressure, pulmonary hypertension (high blood pressures in the lungs), arrhythmias, heart failure, stroke, diabetes, fatty liver disease, and more. Children with sleep apnea may also have difficulty gaining weight and growing.
When we sleep, the muscles in our airway relax. Sleep apnea occurs when there is complete or partial obstruction or blockage of the airway, leading to arousal and fragmented sleep. Fragmented sleep is not restorative and thus, causes the child to be very sleepy the next day. The most common causes of sleep apnea in children include large tonsils and adenoids (adenotonsillar hypertrophy) and obesity. Size of tonsils/adenoids does not always correlate with symptoms as even “small” tonsils can cause obstruction in the airway during sleep and arousals. Obesity and neck circumference are strong risk factors for sleep apnea, and this risk increases during adolescence.
Frequent snoring (more than three days/week), especially if loud.
If any of the preceding apply to your child, you should immediately seek a more thorough evaluation from your child’s primary care pediatrician or sleep specialist. Obstructive sleep apnea can lead to the previously mentioned serious health consequences, many of which cannot be reversed. Early identification of sleep apnea is extremely important to prevent your child from developing these health problems, which can significantly shorten his or her life span.
If your child’s symptoms are concerning for sleep apnea, your pediatrician may order a sleep study or polysomnogram. You would stay overnight with your child in a sleep laboratory. While your child is sleeping, a sleep technician will monitor various parameters, such as oxygen level, respiratory effort, heart rhythm, and brain electrical activity. The sleep study will determine with high accuracy whether your child has sleep apnea. Conversely, your pediatrician may refer your child to a sleep specialist or ear, nose, and throat physician for further evaluation. Your child may require surgery to remove his or her tonsils/adenoids. Allergies can also cause significant nasal congestion that triggers awakenings.
The Bottom Line
Daytime sleepiness, learning difficulties, inattention, forgetfulness, and hyperactivity are different manifestations of poor sleep quality in children. These may stem from poor sleep hygiene or more rarely from a serious sleep disorder, such as obstructive sleep apnea. Pay close attention to the signs and symptoms in this article and how they relate to your child. Bring any of your concerns to your child’s primary care physician. You may be referred to a sleep specialist or ear, nose, throat physician for further evaluation. Regardless of the underlying cause, sleep hygiene problems and organic sleep disorders, such as obstructive sleep apnea, both benefit from early detection to prevent long-term, irreversible health problems.
Authors: Cheryl Tierney, MD, MPH and Grace Wang, MD
Penn State Hershey Children’s Hospital
© 2021 American Sleep Association.