Insomnia

Key Features

Essentials of Diagnosis

• Children younger than 12 years:

  • Difficulty initiating or maintaining sleep that is viewed as a problem by the child or caregiver

  • May be characterized by its severity, chronicity, frequency, and associated impairment in daytime function in the child or family

  • May be due to a primary sleep disorder or occur in association with other sleep, medical, or psychiatric disorders

• Adolescents—difficulty initiating or maintaining sleep, or early morning awakening, or nonrestorative sleep, or a combination of these problems

Clinical Findings

• Insomnia includes difficulty initiating sleep and nighttime awakenings

• Can result in daytime fatigue for both the parents and the child, parental discord about management, and family disruption

• Common in children with complex medical conditions and neurologic, developmental, and psychiatric disorders

Diagnosis

• A complete medical and psychosocial history should be obtained and a physical examination performed

• A detailed sleep history and diary should be completed, and both parents should contribute

• Assessment for allergies, lateral neck films, and polysomnography may be indicated to complete the evaluation

• It is important to consider disorders such as gastroesophageal reflux, which may cause discomfort or pain when recumbent

• Dental pain or eczema may cause nighttime awakening

• It also is important to make sure that any medications that the child is taking do not interfere with sleep

Treatment

• Good sleep hygiene includes discontinuing any activities that are stimulating in the hour before bedtime

• Exposure to light and physical activity during the day are helpful and it is important to ask about caffeine ingestion.

• There is little evidence regarding pharmacologic management of sleep disorders in children

  • While the role for melatonin in children with typical development is unclear, there is mounting evidence that it can be effective in children with visual impairments, developmental disabilities, and autism spectrum disorders

  • Medications such as clonidine are often used for sleep disorders, but there are little data to support its use