If you’ve ever heard the phrase “sleep like a baby,” you may be wondering where this came from. After all, for many parents, sleep challenges in children begin at birth and continue right through the teen years. While many times, these issues are nothing more than an annoyance, occasionally, a child has a true sleep disorder or condition.

In honor of Better Sleep Month, let’s take some time to review sleep disturbances in children and ways parents can help a child get a good night’s sleep.

Sleep Apnea

Pediatric sleep apnea is a very common condition. A child’s primary care physician is most commonly the one who suspects and diagnoses it. By definition, obstructive sleep apnea is a disorder of breathing during sleep, and it’s characterized by either partial or complete collapse of the upper airway. This, ultimately, leads to disruption of normal breathing during sleep, so the exchange of oxygen and carbon dioxide becomes abnormal. Most importantly, it disrupts a child’s normal sleep patterns.

In WakeMed ENT – Head & Neck Surgery, we use the term sleep disordered breathing, which is the clinical diagnosis. This becomes obstructive sleep apnea when the disordered sleep is accompanied by an abnormal sleep study.

Children Most Susceptible to Sleep Apnea

Commonly, in the ear, nose & throat world, we see children for obstructive sleep apnea because they have enlarged tonsils and adenoids since these children are more likely to contract sleep apnea. Enlarged tonsils or adenoids can make the airways narrower, causing children to snore and stop breathing for short periods of time while sleeping. Along with children who have enlarged tonsils, susceptibility for sleep apnea is common in children who are obese, or who have Down syndrome, craniofacial abnormalities or neuromuscular disorders.

Signs and Symptoms of Pediatric Sleep Apnea

Some signs and symptoms that hint towards obstructive sleep apnea and sleep disordered breathing include loud, nightly snoring with pauses in their breathing. Pausing may present to a parent as silence. Other parents will come into clinic saying their children wake themselves up gasping for air during sleep. Other times, no obvious sleep symptoms are evidenced per se. It may instead present as a child waking up frequently at night or having restless sleep.

It can be difficult to diagnose when there are no obvious sleep disturbances, but in these cases, symptoms may manifest during the day. Children with sleep apnea may complain that they’re tired when they wake up in the mornings, or they may fall asleep at undesirable times. Teachers may tell parents that their child is falling asleep quite a bit during the day.

Alternatively, hyperactivity or attention difficulties may arise due to sleep disturbances.

Treatment for Pediatric Sleep Apnea

In a child with diagnosed obstructive sleep apnea, who also has enlarged tonsils and adenoids, the gold standard of treatment is a tonsillectomy and adenoidectomy. Frequently, that can make obstructive sleep apnea go away completely.

The thought of removing tonsils and adenoids may be upsetting to some parents, yet there is no reason for concern. We only remove tonsils and adenoids when medically necessary to help a patient with obstructive sleep apnea or, even, recurrent throat infections. What’s more, tonsils are lymphoid tissue that live in the mouth and, along with many centers throughout the body, help create white blood cells to fight infections. The tonsils play a contributing role, but they aren’t missed when they’re gone. The body continues to function normally.

After removal, there is a pretty significant recovery period. A child may feel poorly and miss school for one to two weeks. Risks of the surgery include short-term pain, bleeding and dehydration — though these risks are very low. We recommend drinking plenty of fluids and consuming a soft diet for about 10 to 14 days post-surgery. That said, following those two weeks, they bounce back quickly — since children are very resilient. Children with obstructive sleep apnea who have their tonsils removed usually experience significantly improved sleep by the time we see them again in clinic.

Sometimes cases may be so severe that obstructive sleep apnea does not resolve after surgery. In these instances, it becomes more of a multidisciplinary approach for us, including working with pulmonologists, sleep medicine doctors and primary care providers to manage a child with residual obstructive sleep apnea.

Other Pediatric Sleep Disturbances

Insomnia

Insomnia is a very common sleep disorder in children. It is characterized by difficulty falling asleep, staying asleep or a combination of the two. Up to 30% of children have insomnia or struggle with insomnia at some point in their childhood.

Interestingly, there’s a significant behavioral component to insomnia, so children with behavioral insomnia generally have a learned inability to fall asleep. A child may resist sleep, take a long time falling asleep or wake up frequently throughout the night. Prevention of insomnia is actually the best available treatment. It’s important for us, as physicians, to discuss normal sleep patterns and set sleep boundaries with parents.

• Set nap times and bedtime routines are helpful in prevention.
• Letting a child cry it out is a tale as old as time, and it works.
• Putting children to bed in a dark room also helps.

Delayed Phase Sleep Syndrome

Delaying sleep can be a normal component of sleep for teenagers. We, as humans, have tiny, little clocks in our brains that, essentially, control our sleep cycles. These clocks use cues in our environment, such as the stress hormone — cortisol, body temperature, light and the sleep hormone — melatonin to help us wake up and go to sleep. In delayed phase sleep syndrome, adolescents and teens find that their sleep and wake times are delayed by at least two hours often due to these changes.

Two of these challenges — light and melatonin — are within a teen’s control. Light is an extremely powerful influencer of sleep. So, now more than ever, it’s important to teach teens that avoiding screen time 60 to 90 minutes before bed can do wonders for their sleep hygiene. Melatonin is a natural sleep aid and can be helpful for this group as well.

On a different note, delayed phase sleep syndrome is thought to occur most commonly when adolescents are becoming more social and, therefore, wanting to stay up later and socialize. Since delayed sleep can negatively impact school performance, it’s important to help teens understand the importance of sleep.

Narcolepsy

Narcolepsy and daytime sleepiness have similarities, but they also have important distinguishing characteristics.

In children who have narcolepsy, their condition is identified by hormonal changes in the brain that modify the normal sleep and wake patterns. Children with narcolepsy frequently fall immediately into rapid eye movement (REM) sleep, which is abnormal. This condition can also be associated with symptoms, such as muscle paralysis or cataplexy, where children will lose their ability to move their limbs during sleep.

Daytime drowsiness, on the other hand, most notably causes fatigue. Patients with excessive daytime sleepiness have difficulty staying awake throughout the day and may fall asleep at inappropriate times, but the reasons for this are wide ranging. Children could be fatigued from burning tons of energy, but with this fatigue, children are usually able to stay awake through it.

Some children may be suffering from a lack of sleep at night. It’s important for parents to note what their child’s quality of sleep looks like. Are they getting enough sleep at night? Is their sleep broken up throughout the night? These are important considerations. In many such cases, along with feeling fatigued and even falling asleep during the day, these children may also appear restless or irritable.

If a child is regularly sleepy during the day (nearly every single day, day in and day out), it is important to rule out sleep disorders or other chronic medical conditions. Otherwise, an occasional incident of daytime sleepiness is likely no cause for concern.

Restless Leg Syndrome and Periodic Limb Movement Disorder

A group of sleep disorders are often characterized by repetitive movement. Two of the most common are restless leg syndrome and periodic limb movement disorder.

In restless leg syndrome, patients often feel the urge to move. Children experience a painful or irritating feeling in their extremities. They move their limbs to make themselves feel better. That’s where the repetitive movement comes from, and it is frequently related to nutritional deficiencies, such as iron deficiency anemia. Treatment involves supplying patients with nutritional supplements and helping them make lifestyle changes to eliminate the symptoms.

This differs from periodic limb movement disorder, which is the repetitive movements of arms, legs, feet, etc. In this case, it is important to prevent a child from sleeping near sharp edges, such as a bedside table. Parents should use railing to keep a child contained safely in the bed, if appropriate.

Parasomnia

Parasomnia is an event that occurs most frequently at the time of the sleep and wake transitioning component. It’s an unwanted behavior, to include sleepwalking and sleep talking. Interestingly, children’s actions may seem purposeful during this time, but they actually aren’t meaningfully interacting with their environment at all, so they often don’t know that they’re doing it.

Sleepwalking is an especially interesting phenomenon. It can be as simple as walking around. Other children may do an entire routine, to include getting dressed.

Treatments for Sleepwalking:

• Eliminate risks and hazards in the home for a child who sleepwalks. That’s an essential component of treatment for these children. Moving tripping hazards, installing motion sensor lights and locking doors and windows can be helpful.
• Experts often recommend not waking a child who is sleepwalking. The reason is that patients are simply unaware that they’re doing so. Waking sleepwalking children can be extremely frightening to them because they won’t know where they are. They won’t know who they’re with. They won’t know who’s waking them up. Yet, if caregivers do have to wake someone up, do so as gently as possible. Alternatively, use a gentle voice or a light touch to try to guide a person back to safety or bed.
• Treating underlying causes of sleep disturbances, such as obstructive sleep apnea and restless leg syndrome is important because data shows these can trigger parasomnia.
• Cognitive behavioral therapy is helpful also.
• If other methods don’t work, medications are available.

Sleep talking is, typically, an innocent, genetic anomaly and is no cause for alarm. It only becomes an issue when there’s a room partner, namely a child sharing a bedroom with their sibling and this sibling isn’t able to sleep.

Improving sleep hygiene is key. Having a consistent sleep routine and schedule, limiting caffeine, getting regular physical activity and exposing patients to light during the day are all important. If ongoing sleep talking is bothersome, parents can talk to a medical provider, such as a sleep medicine specialist.

Sleep Terrors and Nightmares

Sleep terrors most often occur in young children ages three to seven. There’s not much known about why children have sleep terrors, but it is thought to be a familial predisposition. Sleep terrors are characterized by sleepers waking up feeling scared or panicked. They don’t recall an event, so they’re just waking up from sleep and a parent is often coming into the room to check on them. It’s important to provide comfort and reassurance to these children because treatment options can be limited.

Nightmares are brought on often by a negative life event, stressor or underlying anxiety. These visualizations often occur during REM sleep, which is the dream component of sleep, and, therefore, they’re more often remembered by the sleeper. I would recommend that these children talk through their stressors with their family to get support for any underlying anxiety and help alleviate nightmares.

9 Tips on Sleep Hygiene for Children

Many sleep disturbances can be resolved in children by practicing good sleep hygiene.

1. Children should go to sleep and wake up at the same time, including on weekends.
2. For holidays, parents may allow a short change in schedule, but it should not exceed more than one hour.
3. An hour before bed needs to be wind down time. Children should not do high-energy activities, engage in technology or do any other stimulating activity.
4. Children should eat their last meal of the day, preferably a couple of hours before bed. Yet, children should not be sent to bed hungry. If a child is hungry before bed, a light snack can help.
5. Children should not drink caffeinated beverages, including soda, coffee and tea. Chocolate can be enjoyed in light moderation.
6. Children should go outside daily and engage in high-energy activities. Exposure to natural light helps to regulate sleep.
7. The bedroom should be a cool, dark, quiet space. For children who are afraid of the dark, a very soft night light can be used.
8. Children should think of the bedroom as a place of comfort, not anxiety. Avoid using a child’s room for punishment or time-outs.
9. All technology — smartphones, tablets, video game consoles, televisions, computers, laptops, etc. — should be avoided between one to two hours before bed.

Where to Seek Care for Pediatric Sleep Issues

After an initial consult with the pediatric primary care provider, patients with sleep breathing issues should schedule with WakeMed ENT – Head & Neck Surgery. For other sleep concerns, patients may schedule with WakeMed Pediatric Pulmonology & Sleep Medicine.

WakeMed ENT – Head & Neck Surgery is a great resource for both families and primary care doctors because we frequently see children with snoring or even suspected obstructive sleep apnea. We can evaluate the appropriateness of surgery in some children. We may recommend a sleep study if it hasn’t already been done, and in other children, we may just recommend surgery and can provide reassurance and plenty of information on how surgery may benefit the child.

For those wondering when a sleep study is indicated, the American Academy of Otolaryngology and Head Neck Surgery will often recommend sleep studies for children with the following signs or symptoms:

• Sleep issues under the age of two
• Obesity
• Down syndrome
• Craniofacial abnormalities
• Underlying conditions, such as neuromuscular disorders
• Sickle cell disease
• Underlying conditions where tonsillectomy is not certain

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About Kelly Kamp, MD

Dr. Kelly Kamp is a board-certified otolaryngologist with clinical interests in general adult and pediatric otolaryngology with a particular interest in pediatric patients with common ENT related disorders, including allergy, nasal and sinus surgery, hearing loss and endocrine related disorders. Dr. Kamp received her medical degree from Georgetown University School of Medicine and completed her residency in otolaryngology at the University of North Carolina at Chapel Hill in 2022.

Dr. Kamp believes in building a trusting patient-physician relationship. She strives to care for the whole person and treats her patients as if they were one of her own family members. Dr. Kamp enjoys helping her patient’s quality of life substantially improve under her care. Outside of work, she enjoys spending time with family, friends and her dogs, Raleigh and Goose. Dr. Kamp also enjoys weekend trips to the beach and mountains, finding new restaurants in Raleigh, and cheering on the UNC Tar Heels.

About WakeMed ENT – Head & Neck Surgery

WakeMed ENT – Head & Neck Surgery is proud to offer ear, neck, and throat (ENT) services in addition to audiology services for adults and children in Apex, Garner, North Raleigh and Raleigh, North Carolina.

Pediatric ENT Services:

• Adenoids, tonsils, sleep apnea
• Hearing loss, ear infections, ear tubes
• Neck lumps
• Sinusitis and nose bleeds
• Thyroid cancer

About WakeMed Pediatric Primary Care

We are proud to offer exceptional, compassionate pediatric care to families throughout Wake and Johnston counties. WakeMed Children’s wide range of pediatric care includes annual well visits, sick visits and comprehensive pediatric physical exams. Our team of pediatricians in Raleigh and pediatricians in Clayton offers the most comprehensive services for children in Wake and Johnston counties.

About WakeMed Pediatric Pulmonology & Sleep Medicine

At WakeMed Pediatric Pulmonology & Sleep Medicine, we are passionate about the evaluation and treatment of respiratory and sleep problems in infants, children and adolescents. Whether the issue is acute or chronic, common or complex, when taking care of your family, our goal is to have everybody breathing easy and sleeping peacefully.

About WakeMed Sleep Centers

We offer sleep studies for adults and children. Though our pediatric sleep studies are very similar to our adult sleep studies, we boast a family-friend environment and always treat kids like kids. Parents are welcome to remain overnight with their child.

Sources:

Children and Sleep | Sleep Foundation

Clinical Practice Guideline: Tonsillectomy in Children (Update) – American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)

Common Sleep Disorders in Children | AAFP