Making Sleep a Priority in Pediatric Primary Care

Sleep is a central part of child development. In the first two years of life, children spend more time asleep than awake. For older children and adolescents, sleep continues to account for approximately 40 percent of a child's day (Mindell & Owens, 2010). Yet for many youth, sleep is highly problematic, with 25-40 percent of children having a sleep issue at some point in their life (Owens, 2005). Common sleep disorders include obstructive sleep apnea, parasomnias, narcolepsy and insomnia. Sleep problems include sleep-related anxiety, deficient sleep and poor sleep hygiene. Some sleep issues may resolve on their own as children grow older. However, for many children and adolescents, untreated sleep problems and sleep disorders persist (Byars, Yolton, Rausch, Lanphear, & Beebe, 2012; Dregan & Armstrong, 2010; Lam, Hiscock, & Wake, 2003), resulting in a chronic issue that severely impacts daytime functioning. Children with comorbid psychiatric, neurodevelopmental, or medical conditions have even more sleep issues than their healthy, typically-developing peers (Konofal, Lecendreux, & Cortese, 2010; Lewandowski, Ward, & Palermo, 2011; Reynolds & Malow, 2011). The relationship between sleep and these types of disorders is quite complex, with disturbed sleep often considered both a symptom and a functional outcome.

Deficient or disrupted sleep in youth has been linked with a number of negative outcomes, including difficulties with concentration and learning, inattention and impulsivity (Beebe, 2011; Gruber, Cassoff, Frenette, Wiebe & Carrier, 2012; Sadeh, Gruber, & Raviv, 2003), poor emotional regulation and increased risk for depression (Gregory & Sadeh, 2011), as well as more accidents and risk taking behaviors (McKnight-Eily et al., 2011; O'Brien & Mindell, 2005; Owens, Fernando, & McGuinn, 2005; Pizza et al., 2010). Recent studies also show that sleep deficiency is related to physical health outcomes, including hypertension, hypercholestemia, insulin resistance and obesity (Flint et al., 2007; Gangwisch et al., 2010; Javaheri, Storfer-Isser, Rosen & Redline, 2008; Javaheri, Storfer-Isser, Rosen & Redline, 2011) . Furthermore, children's sleep issues have a significant impact on parental sleep and daytime functioning, which in turn can impact parent mood, marital quality, family functioning, work performance and general parenting (Boergers, Hart, Owens, Streisand, & Spirito, 2007; Meltzer & Mindell, 2007; Meltzer & Montgomery-Downs, 2011).

Why are pediatric sleep issues under-recognized in primary care?

There are multiple reasons why sleep issues have historically been unrecognized by primary care providers (Erichsen et al., 2012; Meltzer, Johnson, Crosette, Ramos & Mindell, 2010). Training in general sleep medicine, let alone pediatric sleep medicine, is extremely limited for primary care providers. For example, 2 recent studies show that, on average, pediatricians receive less than 4 hours of sleep-related training across medical school and residency (Mindell et al., 2011; Mindell et al., 2013) . This results in primary care providers being unsure about not only what to ask, but also about what to do if a sleep issue is identified (Faruqui, Khubchandani, Price, Bolyard, & Reddy, 2011). Training in sleep for clinical psychologists is also lacking, with only 6 percent of programs in the U.S. and Canada offering formal didactic training in sleep, and most programs reporting that they were ineffective in providing education about sleep, let alone pediatric sleep (Meltzer, Phillips & Mindell, 2009) . Along with a lack of provider training, parents often neglect to raise sleep issues during well-child visits (Blunden et al., 2004; Chervin, Archbold, Panahi, & Pituch, 2001). This may stem from either the need to cover multiple aspects of a child's daytime functioning during a brief well-child visit, or from parents not realizing their child has poor sleep habits that result in deficient or disrupted sleep (Owens & Jones, 2011).

If there is time for only one question related to sleep, providers should ask the parent (and/or child, if age appropriate) if he or she believes the child has a sleep problem. A positive response to this question can be further queried to elucidate concerns related to sleep schedules, sleep duration and/or sleep disorders. If more time is available, providers should learn about children's sleep schedules (what time do they go to bed, what time do they wake up, do they nap, does the sleep schedule change from weekdays to weekends), sleep routines (is there a consistent bedtime routine, who/what is present at bedtime when the child falls asleep), sleep environment (is the bedroom cool, dark, comfortable and technology free), what happens during sleep (snoring, restless sleep, bruxism, enuresis), and daytime consequences of deficient or disrupted sleep (during the day, what do you notice is different about your child following a good/poor night of sleep). The following addresses specific sleep issues in more detail.

Sufficient Sleep Duration

The most common sleep issue in pediatrics is simply that youth are not getting enough sleep. National surveys show that across development, children and adolescents are obtaining less sleep than recommended (National Sleep Foundation, 2004; National Sleep Foundation, 2006). While late bedtimes and early wake times are the obvious factors that create deficient sleep, the reasons for these sleep schedules are more complex, including school start times, homework, extra-curricular activities and technology in the bedroom.

Parents commonly ask, “How much sleep does my child need?” Recommended ranges of sleep duration at different developmental stages are commonly seen in parenting books or online (for example, the National Sleep Foundation). However, while most children will fall within these ranges, it may be normal for a child to need more or less sleep than other children his/her age. Parents can tell if their child is not getting enough sleep if he/she: 

(1) is extremely difficult to wake in the morning (although they may not be pleasant first thing in the morning, children should be up and moving within 15 minutes of being awakened) 

(2) sleeps 2 or more hours longer on weekends or during vacations than on school nights 

(3) falls asleep in school, on most short car rides or at other inappropriate times/places, and/or 

(4) has notable changes to daytime mood or behavior (i.e., increased hyperactivity in younger children, increased irritability and decreased concentration in older children/adolescents). It is also noteworthy that some children may exhibit signs of deficient sleep even when they have ample sleep opportunities. If this is the case, providers should be concerned about the quality of a child's sleep, including possible sleep disruptors such as sleep disordered breathing or restlessness/movement during sleep.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is one of the most common physiological sleep disorders in children, impacting 1-6 percent of youth. The peak age for this disorder is between 2 and 6 years, and is primarily caused by enlarged tonsils and adenoids, causing the child to snore and have periods with cessation of breathing (apneas). In adolescents, obesity has become the primary cause of OSA, similar to adults. With the rise in pediatric obesity, OSA among youth has also increased (Gozal & Kheirandish-Gozal, 2012; Kang, Lee, Weng, & Hsu, 2012). Because of the significant consequences that OSA has on the developing brain, the American Academy of Pediatrics has recommended that all children be screened for symptoms of sleep disordered breathing, most notably snoring (Marcus et al., 2012). Children who snore loudly and regularly should be further screened for symptoms of OSA, referred for further evaluation by a sleep specialist and/or have an overnight polysomnography completed (Marcus et al., 2012).

Restless Legs Syndrome

In pediatrics, restless legs syndrome (RLS) presents as discomfort in the legs at bedtime or during the night that is alleviated by movement or rubbing. A good question to ask is whether anything is bothering the child at bedtime, such as their head, stomach or legs. Some children give vivid descriptions of RLS symptoms (e.g., ants crawling in my legs, firecrackers in my knees), while others simply state that their legs bother them at night. For most children, low ferritin is the primary cause for this discomfort. Although within the normal range, ferritin below 50 ng/mL has been associated with RLS, as well as restlessness, repetitive movements, kicking, and twitching during sleep (Durmer & Quraishi, 2011; Mohri et al., 2012) .

Bedtime Problems and Night Wakings

For young children (0 to 5 years), bedtime problems and night wakings are the primary culprit for poor quality or deficient sleep. In primary care, providers can find out more about these issues with questions about a child's bedtime routine (is it consistent, who is involved, how/where does it end), how and where the child falls asleep (alone, with a parent present, in the child's room, in the parents' room), and how the parents respond to night wakings (sometimes soothe child, other times bring the child to the parents' bed). Parents need to know that night time arousals are normal, and that all children wake multiple times per night. However, the circumstances that are present at bedtime (e.g., bottle, pacifier) need to also be present for these normal night wakings. Positive sleep onset associations can be created by the child (e.g., thumb sucking), whereas negative sleep onset associations require parental involvement (e.g., rocking the child to sleep). Empirically supported treatments for bedtime problems and night wakings in young children have been well-established (Mindell et al., 2006), and have become the standard of practice for pediatric sleep (Morgenthaler et al., 2006b). For a “nuts and bolts” on how to address bedtime problems and night wakings in clinical practice, I refer readers to a 2010 article published in Behavioral Sleep Medicine (Meltzer, 2010).

Insomnia

By definition, insomnia is difficulty initiating and maintaining sleep. For older children and adolescents, insomnia may be primarily caused by anxiety. However, for some youth insomnia has no comorbid medical or psychiatric component. For these patients, a referral to a specialist who is trained in cognitive-behavioral therapy for insomnia (CBT-I) is warranted. Although there is little empirical evidence demonstrating the effectiveness of CBT-I in children and adolescents, there is an abundance of research with adults demonstrating its effectiveness (Edinger & Means, 2005; Morgenthaler et al., 2006a; Siebern & Manber, 2011) .

Personally, I have found that motivated adolescents respond well to CBT-I treatment recommendations, including stimulus control and sleep restriction. For stimulus control, patients are instructed to use the bed only for sleep, and to only sleep in bed (not on the couch or other location). If patients have difficulties initiating sleep after about 15-20 minutes, they should get out of bed and engage in a quiet, boring activity in dim light until they feel sleepy again. This process should be repeated until they fall asleep quickly and easily, and may also be applied to prolonged night awakenings. Sleep restriction limits the amount of time the patient is in bed to increase sleep efficiency (sleep duration/time in bed x 100, expressed as a percent). So for a patient who is typically sleeping only 7 hours, they should have a set wake time every day, with a bedtime 7.5 hours earlier (allowing for 30 minutes to fall asleep).

Delayed Sleep Phase

In adolescents, the circadian rhythm shifts about 2 hours later, making early sleep onset difficult for most teens (Carskadon, 2011; Crowley, Acebo, & Carskadon, 2007). However, there is also a group of adolescents who experience a circadian rhythm sleep disorder, delayed sleep phase type. Delayed sleep phase primarily presents as difficulty waking in time for school. Patients with a delayed sleep phase will have difficulties initiating sleep prior to 3:00 or 4:00 a.m. However, if they go to bed at this late hour, they will fall asleep quickly and have no difficulties with sleep continuity (unless they have to wake early for school). The primary differential between insomnia and delayed sleep phase is that a youth with insomnia will have difficulties falling asleep no matter what time they go to bed, whereas a youth with a delayed sleep phase, as mentioned, will fall asleep quickly and easily with a delayed bedtime. For some adolescents, inquiring about when they feel they are most alert also helps to identify delayed sleep phase (i.e., if you were able to choose what time you took the SATs or big exams so that you are the most alert when would that be?). Patients with delayed sleep phase will typically respond that they are most alert in the late afternoon and early evening. Treatment for delayed sleep phase is challenging and requires a highly motivated adolescent. There are a couple of excellent review articles that describe treatment approaches for delayed sleep phase in detail (Wyatt, 2004; Wyatt, 2011) .

Along with the articles and books cited above, I highly recommend “A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems” (Mindell & Owens, 2010). This book was co-authored by a pediatric psychologist (Jodi Mindell) and a developmental and behavioral pediatrician (Judith Owens), and provides a comprehensive overview of all pediatric sleep issues and disorders. In addition, they include patient handouts that cover normal sleep, as well as common pediatric sleep disorders.

Finally, it is notable that the American Psychological Association recently voted to recognize “Sleep Psychology” as a specialty. The field of behavioral sleep medicine (BSM) is growing, and there is a need for additional providers. The Society of Behavioral Sleep Medicine has more information about the practice of BSM, as well as where to find BSM certified providers and how to obtain additional training in BSM (www.behavioralsleep.org).

In pediatric primary care it is time to “Make sleep a priority!” By learning more about pediatric sleep disorders, how to identify common sleep problems, as well as tips for good sleep health, primary care providers will be well positioned to help children and their families obtain optimal sleep.

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Lisa J. Meltzer, PhD, CBSM is an associate professor of Pediatrics at National Jewish Health and an assistant professor of Family Medicine at the University of Colorado School of Medicine. She received her PhD in Clinical and Health Psychology from the University of Florida, and completed her clinical internship and post-doctoral fellowship at the Children's Hospital of Philadelphia. She was selected as a Pickwick Postdoctoral Fellow in Sleep Research by the National Sleep Foundation, studying sleep patterns in parents of children with chronic illnesses. Meltzer is board certified in Behavioral Sleep Medicine by the American Academy of Sleep Medicine, and directs the Pediatric Behavioral Sleep Clinic at National Jewish Health. Her research focuses on sleep in children with chronic illnesses and their parents, the impact of deficient sleep on health outcomes in adolescents with asthma, as well as the development and validation of objective and subjective measures of pediatric sleep.