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Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S63
0021-7557/02/78-Supl.1/S63
Jornal de Pediatria
Copyright © 2002 by Sociedade Brasileira de Pediatria
REVIEW ARTICLE
Sleep disorders
Magda Lahorgue Nunes*
Abstract
Objective: the aim of this article is to review and update the knowledge about sleep disorders in
childhood.
Sources: normal sleep ontogenesis and therapeutics for the most prevalent sleep disorders were
reviewed. The text was based on classical articles and books and on Medline (publications from 2000 and
2001) using the key words sleep disorders and childhood. the article was structured on descriptive topics
containing definition of the sleep disorder, age, clinical presentation and therapeutics.
Summary of the findings: sleep disorders are frequent concerns referred in pediatrics outpatient
clinics, and a correct diagnosis is the main goal to establish therapeutic procedures.
Conclusions: in the majority of cases clinical history is sufficient to establish diagnosis and assuring
parents of the benign evolution of the symptoms the better treatment.
J Pediatr (Rio J) 2002; 78 (Supl.1): S63-S72: sleep disorders, childhood, sudden infant death
syndrome, apnea.
Introduction
Sleep disorders are very common among pediatric
patients. However, in most cases, they can be diagnosed
through a good anamnesis, showing parents the disorders
are benign and allowing for appropriate treatment.1-3 Most
sleep disorders affect both adults and children, but their
manifestation is different. Possibly, only colics and the
infant sudden infant death syndrome (SIDS) are exclusive
childhood sleep disorders;2 other disorders can occur at any
age, although some are more predominant during childhood.
This article aims at showing the normal aspects of sleep
ontogeny since, in some cases, we can establish treatment if
we know the normal sleep patterns. In addition, the article
reviews therapeutic management of the most prevalent
childhood sleep disorders.
Normal sleep pattern from the neonatal period to
adolescence
Circadian rhythms are already established in the perinatal
period. Newborns have their sleep pattern within the ultradian
rhythm (<24hours), therefore, sleep acquires a circadian
rhythm only after the neonatal period (equivalent to 24
hours).
* Associate Professor of Neurology, Pontifícia Universidade Católica do
Rio Grande do Sul (PUCRS) School of Medicine.
S63
S64 Jornal de Pediatria - Vol. 78, Supl.1, 2002
Sleep disorders - Nunes ML
At birth, newborns have periods of 3-4 hours of
continuous sleep, alternated with approximately one waking
hour. This rhythm is continuous during night and day. In the
neonatal period, the alternation between sleep stages lasts
50-60 minutes, the cycle starts with REM and, the more
premature the newborn is, the longer the REM stage. In the
first month of life, the adaptation of the sleep-wake cycle to
the night-day cycle begins. At the end of the first month of
life, nighttime sleep periods are longer.
afternoon), which do not exceed two hours. At the age of
three, usually only the afternoon nap is necessary. At this
age, infants have the adult REM sleep pattern, which should
be at most 25% of the total sleep time.
Important structural changes in sleep architecture occur
during the third month of life, sleep begins with the NREM
stage, and up to the sixth month of life, 90% of infants will
have already undergone such change. At this age, the
longest uninterrupted sleep period does not usually exceed
200 minutes.
In adolescence, there is a reduction in nighttime sleep
pattern (on average 7 hours of sleep), but there is a difference
between sleep hours on schooldays and weekends. The
increase in the total sleep time on weekends reflects a
compensation for reduced hours of sleep during schooldays.
After the age of five, nighttime sleep should be already
consolidated and there are no longer daytime sleep periods.
Between five and ten years, there is a gradual reduction of
total sleep time, and the adult sleep pattern is reached (± 8
hours).
The average sleep in 24 hours, the percentage between
REM/NREM sleep and the establishment of consistent
nighttime sleep and daytime wakefulness patterns are
associated with growth and are shown in Table 1.3-7
In the sixth month of life, the longest period of
uninterrupted sleep does not exceed six hours. The night is
split into two continuous sleep periods, alternated with one
waking period. During the day, wakefulness begins to
consolidate, but it is already interrupted by daytime sleep.
Sleep disorders
Between the ninth and tenth months, infants sleep on
average 9-10 hours during the night and 2-3 hours during
the day, including two naps.
Infant apnea - apparent life-threatening events (ALTE)
Infant apnea consists of an unknown respiratory arrest
during 20 or more seconds, or sometimes less than that,
associated with bradycardia, cyanosis, paleness and
hypotonia in infants with 37 weeks gestational age. Infant
apnea has been used to define infants in whom no specific
cause was identified for the diagnosis of ALTE, that is,
those infants with idiopathic ALTE.8
In the twelfth month, nighttime sleep should be
consolidated, but 1-2 daytime naps are maintained.
Between the ages of 2 and 3, children have long periods
of nighttime sleep (±10 hours), and one or two daytime naps
(in the middle of the morning and at the beginning of the
Table 1 - Total sleep time according to age
Age
Total sleep
time/24 hours
REM/NREM
sleep %
Daytime sleep
Nightime sleep
Preterm NB
22
80/20
Yes
sleep cycle does not depend on night/day
Full-term NB
16.5
60/40
Yes
sleep cycle does not depend on night/day
1 month
15.5
50/50
Yes
sleep cycle begins to relate to night/day
3 months
15
50/50
Yes
sleep cycle is more related to night/day
6 months
14.2
40/60
Yes. Daytime
wakefulness begins
to consolidate
two long periods with one interruption
12 months
13.7
30/70
Yes, 2 naps
nightime sleep consolidation
2 years
13
30/70
Yes, 1-2 naps
nightime sleep consolidation
5 years
11
25/75
No
only
10 years
9.7
25/75
No
only
Adolescence
8.5
25/75
No
only
Modified according to references 3,4,5,6 and 7.
Sleep disorders - Nunes ML
ALTE is an episode that frightens any observer, since it
is characterized by a combination of signs: apnea (central or
occasionally obstructive), change in skin color (usually
cyanosis or paleness, occasionally plectoral), change in
muscle tone (important hypotonia), shock or choking. So,
an observer would think the child is dying. Initially, these
episodes were called near miss sudden infant death syndrome
(near miss - SIDS), now this term is outdated, since it
implies a direct relation with SIDS which, most times, is not
the case. The term ALTE refers to a complaint and can not
be regarded as a diagnosis. Infants with this type of episode
should be carefully investigated so that its etiology can be
determined. There are multiple causes of ALTE
(gastroesophageal reflux, seizures, cardiac arrhythmia),
and the etiology can be determined in most 50% of the
cases. Literature data show that, although the patients who
develop SIDS never had previous episodes of ALTE, most
deaths caused by ALTE seem to be associated with SIDS,
especially in idiopathic cases.8
In an observational descriptive study with 56 patients
who suffered from ALTE, at Hospital São Lucas (HSLPUCRS), we observed that 92% of the patients had an
episode of ALTE in the first 30 days of life. The incidence
of symptomatic ALTE in the study population was high
(71%), and the most prevalent causes included
gastroesophageal reflux, followed by neurological disorders.
No case of SIDS was registered during follow-up, although
four children had recurrent episodes of ALTE.9
The treatment of patients with recent episodes of ALTE
consists of hospitalization, since these patients have to be
carefully observed and their cardiorespiratory function
needs to be monitored. In hospital, recurrent episodes,
physical and laboratory evidence of hypoxemia or
hypoventilation as well as the cause of ALTE should be
investigated. Minimal investigation should include
hemogram, so that anemia and infectious processes can
be ruled out, and serum bicarbonate, in order to rule out
metabolic acidosis. Additional work-up is necessary
when the anamnesis and/or physical examination
determines so.8
The treatment of a patient with ALTE is based on a
specific treatment, that is, treatment of the etiology of
ALTE; and nonspecific treatment, which consists in
monitoring cardiorespiratory function at home. Home
treatment is recommended for the cases in which the episode
of ALTE is severe, and requires intense stimulation and
resuscitation maneuvers. In less severe cases, the indication
of home treatment is controversial, and should be analyzed
on a case-by-case basis. Usually, when previous family
history of SIDS is present, or when the episodes of ALTE
are recurrent, cardiorespiratory monitoring is recommended.
The use of methylxanthines (theophylline) as respiratory
stimulant is controversial as to its efficacy after the neonatal
period.8
Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S65
Sudden infant death syndrome
SIDS is the sudden, unexpected death of infants which,
despite extensive investigation, including clinical history,
complete necropsy and death site inspection, still goes
unexplained.10 SIDS is considered the major cause of infant
death in industrialized countries. Maternal and perinatal
risk factors are well established in literature and, today, the
etiology of this process is believed to be related to the
immaturity of the wake mechanism, associated with
environmental factors, (prone position during sleep) and
with age of risk (between two and three months of life).
Smoking during pregnancy and exposure of infants to
tobacco have also been considered risk factors. 11,12
Available information about SIDS is scarce in Brazil. There
are only two studies carried out in the state of Rio Grande
do Sul, where mortality rates of 6.3% and 4% were observed
in Porto Alegre and in Pelotas,13,14 respectively, during the
first year of life. The risk factors for SIDS in our country are
intrinsically related to maternal factors, such as mothers
aged less than 20 years and smoking. Prone position during
sleep does not seem to be a relevant factor, since most
infants usually sleep in a lateral decubitus position.15,16
The best treatment for SIDS is to prevent risk factors.
Smoking during pregnancy and indoors should be avoided
in the presence of infants younger than one year, perinatal
care should be improved, and family planning should be
implemented. On top of that, parents should not allow
infants to sleep in prone position and should not keep them
overly warm during sleep by using a lot of blankets or
dressing them in thick layers of clothing, since this would
not allow infants to move freely or would end up covering
their heads and hindering their breathing.
Insomnia
Difficulty in falling asleep or maintaining sleep has
different characteristics during the developmental stage,
and can affect healthy infants or be secondary to several
diseases, which will be discussed further ahead.
Parents usually overreact when their children suffer
from insomnia or difficulty in falling asleep by always
emphasizing they had the worst night ever; however, they
do not take other nights into consideration. For the sake of
diagnosis, it is of paramount importance that the child’s
routine during the last 24 hours, including all activities or
interventions made by the parents or baby-sitter, be
investigated. Pediatricians should be careful not to
overestimate the complaints made by the parents in order to
avoid unnecessary exams or medication.1,17
The most common causes of insomnia in children are
shown in Table 2, according to their order of occurrence and
age group.1,3,17
Medical problems: these problems usually cause acute
insomnia, but for a time period that is limited to the disease.
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Sleep disorders - Nunes ML
Table 2 - Causes of insomnia according to age
Age group
Causes
Infant
Sleep-onset association disorders
2-3 years
Excessive intake of food and fluids at nightime
Cow’s milk allergy
Chronic or acute diseases
Preschool and school-age children
Lack of limits
Fear, nightmares
Chronic and acute diseases
Adolescents
Anxiety
Family and school pressure
Emotional disorders (anorexia, schizophrenia, manic disorder)
Chronic and acute disease
Modified according to reference 17
Physical problems include respiratory diseases, fever, otitis,
trauma, teething, milk allergy, gastroesophageal reflux,
among others.
Fear and anxiety: infants can suffer from separation
anxiety after the tenth month of life; the infant can present
with different levels of stress when taken away from the
mother, which could cause difficulty in falling asleep.
Children between two and three years usually present with
fear. The fear of being alone can be associated with movies
or stories, arguments between father and mother or any
other frightening experience, or at a lower frequency, with
a problem of psychosocial deterioration of the child.17,18 In
adolescents and pre-adolescents, depression and anxiety
are among the most common causes of insomnia.19
Habits and associations: sleep has a cyclical pattern
during the night, alternating between NREM and REM
stages. Short periods of partial or total wakefulness can
occur and are considered normal; in this case, the child
often goes back to sleeping spontaneously. Some children
who usually need different sleep-inducing stimuli, such as
being rocked, being tapped on the back, and lying in
parent’s lap, require the same stimuli when going through
the normal waking periods, that is, they require parent’s
involvement.20 A recent study that compared the sleep
quality of school children and preschool children who sleep
alone or with their parents revealed that the latter group had
a greater number of wakings during the night.21
Eating during the night: after the sixth month of life,
except in cases of premature newborns, infants do not have
to be fed during the night anymore. If breastfeeding is
maintained, waking episodes occur with increased frequency,
since this process becomes a transition between wakefulness
and sleep. In addition, hunger will be associated with
nighttime.
Limits: a lack of limits occurs after the infant has motor
skills to get out of the cradle by himself/herself and parents
neglect controlling the nighttime activities of their children.
The causes of lack of limits are often associated with
inability to establish limits, feeling of guilt, psychological
problems, alcoholism, maternal depression, and family
stress. The lack of limits can also be associated with
problems presented by the child, such as occasional rewards.
Problems with bedtime: the diagnosis of insomnia related
to problems with establishing a bedtime involves knowing
the normal sleep/wakefulness patterns. A frequent problem
is concerned with an early bedtime, that is, the child has to
go to bed at a time when he/she is not sleepy. This keeps the
child awake while lying in bed since, according to his/her
internal rhythm, it is too early to sleep.
Insomnia can be treated in several ways, which
associated, have excellent complementary effects. The first
stage consists in diagnosing the cause of insomnia by means
of anamnesis and physical examination. In necessary cases,
complementary exams can be performed. The second stage
consists of the direct treatment or elimination of the cause
of insomnia. The third stage is concerned with sleep hygiene,
while the fourth and fifth ones are usually associated and
involve a behavioral approach and drug treatment.22
To diagnose the cause of insomnia, the history of sleeprelated problems, which includes position during sleep,
pre-sleep rituals, sleep-inducing stimuli, and the sleep/
wakefulness pattern within 24 hours, should be analyzed.
Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S67
Sleep disorders - Nunes ML
After that, data on sleep disorder itself should be collected,
in order to characterize its onset and its possible associations,
as well as the environment where the child sleeps. The
current psychosocial profile of the family and the family
history of sleep disorders should be investigated. Traditional
anamnesis and a thorough physical examination should be
performed to identify health problems that could be triggering
the sleep disorder.
In the cases involving fear and anxiety, the major
objective is to identify the cause and solve it, until the child
can sleep alone again. Postponing bedtime to a later time at
which the child is sleepy can solve the problem.
In the cases in which parent’s involvement is necessary,
the child has to be trained to sleep in his/her cradle by using
his/her transition objects until parental intervention is no
longer necessary.
When insomnia is related to the habit of eating during
the night, the solution is to gradually reduce the supply of
food at this time until the child drops the habit.
Sleep hygiene refers to the establishment and
maintenance of appropriate conditions to a healthy and
effective sleep. This process should be implemented in the
first months of life, as recommended by pediatricians, and
can prevent the development of sleep disorders. Good sleep
hygiene is associated with three important aspects:
environment, bedtime, and pre-sleep activities. The
environment should be dim, silent and have a pleasant
temperature (overheating should be avoided). Bedtime and
waking time should be consistent and regular. Daytime naps
should be adequate for age and always regular and consistent.
The routine prior to sleeping should be consistent (example:
shower, dinner, tooth-brushing, changing into pajamas,
going to the bathroom, soft music or pleasant stories). The
way through which the child is put to sleep should be
consistent also. In this case, the use of transition objects,
such as toys, dolls, favorite diaper, pacifier, among others,
should be consistent. Demanding physical activities, TV
programs or stories that might be frightening should be
avoided before bedtime. Parents should take the child to
bed before bedtime while the child is still awake.3
The behavioral approach to childhood insomnia has
been widely discussed, and several studies on this issue
have been published in the last few years.22-26 After the
second year of life, it is possible to establish a reward
system with the child, which seems to be quite effective.
However, the use and effectiveness of this technique for
infants and children up to the age of two is still controversial.
The behavioral approach is based on the comprehension of
the sleep disorder involving the diagnosis of the family and
the child.22 The most widely used behavioral techniques,
their indications and disadvantages are shown in Table
3.22,26 The establishment of positive routines should be
implemented approximately 20 minutes before bedtime.
These routines can be followed by parents, and time can be
gradually reduced until an ideal time is reached; after these
Table 3 - Behavioral approaches to insomnia
Technique
Advantages
Disadvantages
Application
Contraindication
Positive routines and
systematic ignoring
Quite effective
and fast technique
Parents’ resistance
and lack of adherence
Only with motivated
parents
If previous
interventions failed
Minimal checking
associated with systematic
ignoring /modified extinction
Parents feel confident.
Despite the crying,
they know everything
is ok with the child
Parents’ presence may
trigger intense crying
Recommended for
If previous
parents that feel
interventions failed
the necessity of
checking on the child
Parents’ presence associated
with systematic ignoring
Less crying,
more confident
parents
It’s difficult for parents
not to interact
during crying
Flexible parents,
separation anxiety
If parents can’t
avoid interacting
Systematic ignoring
or graduated extinction
The technique is
gradual, but parents
feel more confident
Long adherence
and organization
Anxious parents,
organized parents,
healthy children
Children with
health problems
Scheduled wakings
Gradual technique
Adherence
It requires highly
organized parents
–
Modified according to references 22 and 26.
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Sleep disorders - Nunes ML
routines, the child must sleep in his/her bed. In the gradual
approach, parents ignore when the child wakes up and cries
during previously determined time periods, whose interval
should increase every week. At the end of the waiting
period, parents go into the room, ease the child down and
put him/her back to bed, leaving the room as soon as
possible. In the systematic approach, parents enter the room
when the child begins to cry, check whether if everything is
ok, change diapers if necessary, do not take the child out of
the bed, and leave the room, disregarding continuous crying.
A variation of this technique is when one of the parents stays
in the room, but does not interact with the child. The
modified approach consists in ignoring cry/waking for 20
minutes, entering the room to check if there is any problem,
not interacting with the child and leaving, taking more or
less 20 minutes before returning to the room. Programmed
waking consists in waking up the child before the usual
waking hour, checking whether he/she is ok, and letting
him/her go back to sleeping spontaneously.
The treatment of childhood insomnia with drugs is
limited. It should always be used in combination with some
behavioral techniques. The drugs of choice are
antihistamines and, in more severe cases, chloral hydrate
10% at a dose of 0.4-0.5 ml/kg. The medications must be
used temporarily as coadjuvants in the first three weeks of
treatment.17,22 In a recent study, melatonin at 5mg/day was
efficient in reducing insomnia symptoms in children aged
between six and twelve years.26
associated with urinary incontinence, such as diabetes,
urinary tract infection and generalized seizures.28,29
Although the etiology of enuresis is not clearly defined, it is
believed that it occurs due to an association of factors
involving failure to release vasopressin during sleep, bladder
instability and inability to wake up secondary to bladder
fullness.30 The treatment of enuresis is based on drugs and
on the development of continence. The use of imipramine
is recommended at 25-75 mg every night; initially, it has
quick results, but after it is discontinued, there is a high
recurrence rate. Antidiuretics, such as intranasal
desmopressin at 20-40 mg at bedtime, are another alternative.
The development of continence shows better results than
drug treatment in the long run, since it develops the ability
to control urinary urge. Drug-free treatments consist in
using alarm monitors, doing exercises to interrupt the
urinary flow, and waking up before enuresis occurs. It is
essential that the child be rewarded for his/her dry days, and
that the child participate directly.
Parasomnias
Parasomnias are disorders characterized by undesirable
motor, autonomic or experiential phenomena that occur
during sleep.31-33
Parasomnias can be categorized according to the sleep
state of origin as non-rapid eye movement and rapid-eye
movement. The former occurs during the first third of the
night in NREM sleep (see characteristics in Table 4).
Nocturnal enuresis
Nocturnal enuresis is the most prevalent and persistent
sleep disorder in childhood. The diagnosis of enuresis is
based on the following criteria: chronological age >5 years,
and mental age >4 years; two or more events of urinary
incontinence in one month between the ages of five and six
years, or more events after six years; absence of diseases
Sleep-walking episodes range from quiet walking (most
common) to restlessness (associated with restless walking,
unintelligible speech and aggressive behavior in the presence
of constraint). Although sleep-walking is not usually
dangerous, the child might get into hazardous situations,
such as going outdoors, and climbing up windows or
balconies.
Table 4 - Clinical characteristics of parasomnias with waking reaction
Characteristics
Sleep-walking
Confusional arousal
Night terror
Time of night
First 1/3
First 1/3
First 1/3
Duration (minutes)
1-10
5-40
1-5
Restlessness
None or mild
Moderate
Severe
Autonomic signs
None or mild
Moderate
Severe
1-5%
Incidence
40%
5-40%
Age
School-age child, pre-adolescent
infant, preschool and school-age child
Adolescent
Amnesia
Yes
Yes
Yes
Waking threshold
High
High
High
+ family Hx
Frequent
Frequent
Frequent
Modified according to references 31 and 32.
Sleep disorders - Nunes ML
Confusional arousal can affect infants, preschool children
and school-age children. The episodes often last between
five and 15 minutes and are characterized by crying,
screaming, motor restlessness and confusion, which
gradually worsen until they cease spontaneously. The
situation gets worse when someone tries to comfort the
child; in addition, it not possible to arouse him/her.
Night terror usually affects older children and
adolescents. It often begins abruptly with crying, screaming,
eyes wide open, tachycardia, mydriasis, and sweating. The
child looks frightened and can jump out of the bed and run
aimlessly. The episodes last for no more than one minute,
but the child is at great risk of getting hurt by bumping into
pieces of furniture and windows.
The treatment of parasomnias requires parents’
knowledge about basic safety rules. The pediatrician should
assure parents about the benign nature of these events and
reaffirm their self-limitation according to pediatric age.
Occasional psychological stress can increase the frequency
of episodes.34 Parents should be instructed not to restrict
motor function, since this can make episodes last longer.
The child’s bedroom must be as free of furniture and objects
as possible and the windows must remain firmly shut.
Regular sleep and bedtime should be encouraged in order to
avoid sleep deprivation. The use of medication can be
necessary if waking up involves restlessness and if the child
is at risk of getting hurt. The drugs of choice are usually
benzodiazepines, such as clonazepam 0.25 mg at bedtime.
Three to six weeks of treatment are usually enough to avoid
relapses.31,32
Polysomnography is only recommended if there is
suspicion of apnea, gastroesophageal reflux or periodic
limb movement associated with waking episodes. For
differential diagnosis with complex partial crises, sleep
EEG is often enough.
In the group of parasomnias that are not associated with
waking, we have those that occur in REM sleep (sleep
talking, hypnagogic hallucinations, sleep paralysis), and
those that occur both during REM and NREM sleep
(bruxism). Sleep-talking is the most common type of
parasomnia, but its nature is benign and it does not require
any treatment. Bruxism (grinding one’s teeth) has a
prevalence rate between 7 and 88%. When bruxism is too
intense, there can be damage to the teeth and to the
temporomandibular articulation. Treatment ranges from
intraoral devices to orthodontic braces, and can also include
botulinum toxin (for muscle relaxation).33
Primary snoring and obstructive sleep apnea syndrome
(OSAS)
Primary snoring in children is characterized by nighttime
snoring not associated with apnea, hypoxemia or
hypercarbia. Usually, there are no sleep disorders or signs
of daytime sleepiness. On examination, the patient often
presents with hypertrophic tonsils and adenoids. There are
Jornal de Pediatria - Vol. 78, Supl.1 , 2002 S69
several factors involved in the etiology of snoring that
should be investigated (e.g.: narcotics or sedative drugs,
genetic syndromes associated with craniofacial
malformations, hypothyroidism, macroglossia,
micrognathia, obesity). The necessity to treat primary
snoring in children is arguable in cases in which OSAS is
not confirmed.35
Obstructive sleep apnea syndrome consists of total or
partial upper airway obstruction. Snoring, paradoxal
movements between abdomen and thorax, apnea, and
intermittent sleep are night symptoms. Daytime symptoms
include nasal obstruction, open-mouth breathing, irritability,
excessive daytime sleepiness, failure to thrive, reduced
weight gain and, in more severe cases, cor pulmonale and
death. Night polysomnography is the gold standard for the
diagnosis and must be carried out at sleep laboratories
specialized in pediatric treatment. The treatment of OSAS
ranges according to its severity from clinical follow-up,
drug treatment (theophylline), surgery (tracheostomy,
adenotonsillectomy) to continuous positive airway pressure
(CPAP).36-39
Narcolepsy
Narcolepsy is a clinical syndrome, relatively rare in our
country, which is characterized by excessive daytime
sleepiness, daytime intromissions of REM sleep (cataplexy
and sleep paralysis) and hypnagogic hallucinations. It is a
hereditary disorder related to HLA DR2 antigen class II in
chromosome 6. Symptoms usually appear in adolescence or
in adult life, but in some cases, they can be present in
childhood. The diagnosis is established by polysomnography
and multiple sleep latency test. The treatment consists of
stimulants, such as methylphenidate, amphetamines or
tricyclic antidepressants (imipramine). More recently,
modafinil, a drug that induces wakefulness, has been used
for the treatment of narcolepsy. The treatment of cataplexy
is based on clomipramine or fluoxetine. The pediatrician
should remember that this is a chronic disease and that its
treatment is continuous, during the whole life of the
patient.40-41
Sleep and epilepsy
There is a clear influence between sleep/wake cycle and
the occurrence of some types of seizures. Absence seizures
and juvenile myoclonic seizures always occur in the daytime
while the patient is awake. Frontal lobe epileptic seizures,
Landau-Kleffner syndrome and benign rolandic epilepsy
occur during sleep or waking. Sleep deprivation is certainly
a factor that triggers off seizures. On the other hand,
epilepsies can also alter sleep patterns, especially progressive
epileptic encephalopathies, West syndrome and LennoxGastaut syndrome, which can cause a total disruption of
normal sleep stage patterns. In general, patients with epilepsy
have intermittent sleep, increased number of wakings,
S70 Jornal de Pediatria - Vol. 78, Supl.1, 2002
lengthening of NREM sleep stages I and II and reduction of
stages III and IV. When generalized seizures occur during
the night, there is also a tendency towards the reduction of
REM sleep. The control of seizures with antiepileptic drugs
can be effective to improve these aspects. It is advisable that
the patient have a good sleep hygiene and avoid sleep
deprivation.42,43
Sleep disorders in children with neurological and/or
behavioral problems
Sleep disorders can be associated with any type of
acquired or congenital injury of the diencephalon and
nuclei of the brainstem involved in the regulation of the
sleep/wake cycle and REM-NREM cycle.44
Visually impaired children have several sleep disorders,
such as difficulty falling asleep, frequent waking during the
night, daytime weariness, and excessive daytime naps. The
cause of these disorders is related to chronobiological
problems, such as free-running circadian rhythm.44
In some genetic syndromes, there are specific sleep
disorders, such as obstructive apnea (Down’s syndrome)
and excessive daytime sleepiness (Prader-Willi’s
syndrome).44
Children with severe mental retardation often have
several changes in their sleep pattern. Sleep periods are split
into night and day. These children must be treated with a
behavioral and pharmacological approach. The aim of
behavioral treatment is to avoid daytime sleep and encourage
nighttime sleep. Drug treatment can include sedatives (e.g.:
chloral hydrate) or antihistamines. Melatonin at 2-10mg at
bedtime can also be effective.44
Sleep disorders - Nunes ML
In patients with neuromuscular diseases involving
respiratory muscles, the most common sleep disorder is
caused by hypoventilation and nocturnal apneas, which can
result in irritability and daytime sleepiness. The treatment
to improve respiratory pattern during the night includes
correction of scoliosis, weight control, and use of nasal
CPAP.44,47
Sleep disorders in children with respiratory problems
Physiological respiratory abnormalities during sleep do
not cause any kind of problem to children who have healthy
lungs. However, for children with chronic lung diseases and
with limited lung capacity, the effects of sleep on breathing
may result in significant changes in ventilation and in gas
exchange.48
Patients with cystic fibrosis have nocturnal hypoxemia,
which can be associated with cor pulmonale. In addition to
treating the underlying disease, nasal CPAP has been
suggested for more severe cases in order to improve
oxygenation during sleep.48
Asthma is characterized by periods of nocturnal
exacerbation and this is probably due to the normal circadian
variation of pulmonary function (which is better during the
day). However, asthmatic children have a reduction in
NREM sleep stage IV and more frequent waking during the
night. There seems to be a higher death risk in patients
whose asthmatic attacks occur during the night. The
pediatrician should consider both daytime and nighttime
symptoms when defining the treatment. Theophylline should
be included as an option to treat these patients.48,49
In Rett syndrome, an X-linked neurodevelopmental
disorder that is characterized by mental retardation,
microcephaly and pervasive disorders, insomnia is a frequent
complaint.44
Autistic children show sleep disorders characterized by
an immature sleep pattern, changes in sleep architecture
that are incompatible with chronological age, and functional
disorders, such as difficulty falling asleep and early waking.46
In Tourette’s syndrome, a family neurological behavior
disorder characterized by motor and vocal tics, obsessivecompulsive behavior and attention-deficit/hyperactivity
disorder, there is a significant increase in parasomnias
(sleep-walking and night terror). In untreated children,
there are changes in sleep architecture related to reduction
in REM sleep, increase in NREM sleep stages III and IV,
and sleep disruption by waking in the middle of the night.44
Sleep disorders are also reported by parents in attentiondeficit/hyperactivity disorder. Difficulty falling asleep,
restless sleep, and evening waking are the most frequent
symptoms. The chronic use of methylphenidate seems to
increase the total sleep time.44
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Corresponding author:
Dra. Magda Lahorgue Nunes
Serviço de Neurologia do Hospital São Lucas da PUCRS
Av. Ipiranga, 6690/220
CEP 90610-000 – Porto Alegre, RS
Telephone/Fax: +55 (51) 3339.4936
E-mail: [email protected]