Helping Our School-Age Children Sleep Better when 23% have sleep problems!

Revisiting the importance of  healthy sleep habits in school-age children.
Common sleep problems and some strategies for resolving them... -JR

Helping Our School-Age Children Sleep Better
By Peri Klass, M.D.

"Everyone knows that getting a baby to sleep through the night can be a big challenge for parents. But sleep problems are common among preschool and school-age children, too. As we ask children to function in school, academically and socially, fatigue can affect their achievement and behavior.

Australian research on sleep problems in children has included work aimed at the “school transition” year in which children adjust to a school schedule. In a study of 4,460 children, 22.6 percent had sleep problems, according to their parents, at that transition age of 6 to 7 years. “We were surprised, we thought it was all baby sleep” that was the problem, said Dr. Harriet Hiscock, a pediatrician who is a senior research fellow at the Murdoch Childrens Research Institute at the Royal Children’s Hospital in Melbourne who was one of the authors of the study.

The most common sleep issues for children around the age of school entry, Dr. Hiscock said, definitely include limit-setting issues — that is, some of them need their parents to make the rules and routines clear. But there are also children with what sleep specialists call “sleep onset association disorder,” in which a child has become habituated to falling asleep only in a certain context, requiring the presence of a parent, or needing to have the TV on, to cite two common examples. Very anxious children are also often problem sleepers. And then there are children beset by nightmares, night terrors and early morning waking.

Many parts of the brain work less well when children are tired. “The prefrontal cortex is very sensitive to sleep deprivation, and it is key to the brain mechanisms which underlie executive function and some of the attention  processes,” she said. “The amygdala is affected by sleep deprivation and is essential for emotional processes.”"

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Childhood sleep disorders could hurt a child's heath

When you think of sleep disorders in children, the first types likely to spring to mind are night terrors, nightmares and sleepwalking. These fall into a class of sleep disorders known as parasomnias.

It is estimated that up to 6.5% of children - particularly those aged 4-12 years - experience night terrors, defined as episodes of intense fear, screaming and flailing during sleep. Approximately 3% of preschool and school-aged children experience nightmares, while up to 15% of children aged 4-12 years sleepwalk.

Perhaps less associated with children and adolescents is insomnia and obstructive sleep apnea. In fact, insomnia, the inability to fall asleep or frequent awakening, is estimated to affect around 25% of children and teenagers. Obstructive sleep apnea - when an individual stops breathing for long periods during sleep - affects around 2-4% of children.

What are the causes and symptoms of childhood sleep disorders?

There are a number of factors that can cause childhood and adolescent sleep disorders.

Just like adults, children and teenagers can experience stress, which can interfere with sleep. Consumption of energy drinks - which contain caffeine - is also known to disrupt sleep, as is use of certain medications, such as antidepressants and corticosteroids.

Children and adolescents are also more likely to develop sleep disorders if they have a family history of such conditions, and poor sleep habits, or poor "sleep hygiene" - such as going to bed at irregular times or attempting to sleep in an inadequate environment - can negatively affect sleep quality.

Increasingly, researchers are pointing to the use of technology as a driver for sleep disorders. Last month,Medical News Today reported on a study published in BMJ Open that found children are 50% more likely to have problems getting to sleep if they spend 4 hours a day or more using media devices.

"In adolescents, with the increase in popularity of technology, many teens are staying up very late communicating with friends on smartphones and tablets. The stimulation and light exposure from these devices are associated with late bedtimes and insomnia," Dr. Neil Kline, a sleep physician and internist at the American Sleep Association, told MNT.

Although often harmless, snoring can be a major indicator for a sleep disorder in children and adolescents. It can be a sign of sleep apnea or disturbed sleep quality.

Other symptoms of sleep disorders to look out for include difficulty getting to sleep, daytime fatigue, poor memory, lack of concentration, reduced attention span, irritability and mood swings, hyperactivity and depression.

"If there is any concern for a sleep problem, such as a child taking longer than 20-30 minutes to fall asleep, not sleeping through the night after about age 1 year, or snoring, it is important to discuss this with the child's pediatrician, health care provider or a sleep doctor," Dr. Shalini Paruthi, a spokesperson for the American Academy of Sleep Medicine (AASM), told us.

Children and teenagers are not getting enough sleep

According to recently updated recommendations from the National Sleep Foundation (NSF), the number of hours sleep children and adolescents need is as follows:

Over the past 20 years, the number of hours teenagers sleep each night has fallen.

• Newborns (0-3 months): 14-17 hours a day
• Infants (4-11 months): 12-15 hours
• Toddlers (1-2 years): 11-14 hours
• Preschoolers (3-5 years): 10-13 hours
• School-age (6-13 years): 9-11 hours
• Teenagers (14-17 years): 8-10 hours.

However, it seems many children and teenagers are failing to meet sleep recommendations.

A 2014 poll from the NSF, which asked parents to estimate how much sleep their child gets on a school night, found that children aged 6-10 are only getting around 8.9 hours sleep a night, while 13-14-year-olds are only getting around 7.7 hours sleep each night.

More recently, MNT reported on a study published in the journal Pediatrics revealing that the number of hours teenagers sleep each night has declined over the past 20 years.

The study, which involved more than 270,000 adolescents, found that 72% of 15-year-olds were getting at least 7 hours or sleep each night in 1991, but this fell to only 63% in 2012.

"Declines in self-reported adolescent sleep across the last 20 years are concerning and suggest that there is potentially a significant public health concern that warrants health education and literacy approaches," said lead study author Dr. Katherine W. Keyes, of Columbia University's Mailman School of Public Health.

But why is lack of sleep among children and adolescents a public health concern?

Sleep deprivation linked to obesity, diabetes and heart problems

Sleep deprivation can cause a number of health problems for children and adolescents, both in childhood and adulthood.

In 2011, a study published in The BMJ claimed that children who do not get enough sleep are at significantly higher risk of becoming overweight, compared with children who get sufficient sleep.

Another study published in The Journal of Pediatrics in December 2014 reported a similar finding, associating severe lack of sleep and sleep-disordered breathing in early childhood with increased risk of obesity.

The researchers found that children with the shortest sleep time at the ages of 5 and 6 years were at 60-100% increased risk of obesity by the age of 15, compared with children with sufficient sleep times.

"If impaired sleep in childhood is conclusively shown to cause future obesity, it may be vital for parents and physicians to identify sleep problems early, so that corrective action can be taken and obesity prevented," commented lead study author Prof. Karen Bonuck, from the Albert Einstein College of Medicine of Yeshiva University in New York, NY.

In March last year, another study published in the same journal found that overweight adolescents who do not get enough sleep may be at increased risk of diabetes, heart disease and stroke.

Past studies have also associated sleep apnea in children with delayed growth and heart failure.

Lack of sleep 'makes it nearly impossible for children to reach their full potential'

It is widely accepted that sleep is important for learning and memory. In June 2014, MNT reported on a study that suggested as such. It found that sleep after learning boosts growth of connections between brain cells, helping them to communicate with each other.

A more recent study found that sleep is particularly important for infants' learning skills. Published in theProceedings of the National Academy of Sciences, the researchers revealed that infants aged 6-12 months who had at least one 30 minute nap within 4 hours of learning a new skill were much more likely to demonstrate the skills they learned once they awoke.

With findings such as these, it is no wonder that lack of sleep and poor sleep quality has been associated with poor learning and educational attainment among children and adolescents.

A 2013 study conducted by researchers from Boston College in the UK found that sleep deprivation was a major contributor to poor grades in numerous countries. While taking literacy tests, 76% of American 9-10-years-olds were identified as sleep-deprived, and these students were found to have poorer results.

"I think we underestimate the impact of sleep. Our data show that across countries internationally, on average, children who have more sleep achieve higher in maths, science and reading. That is exactly what our data show," study co-author Chad Minnich told BBC News.

Dr. Paruthi believes sufficient sleep is crucial for a child's overall health and development. She told MNT:

"Sleep disorders in children and teens can hinder them in school, in social situations, in development and nearly every other aspect of their lives, with the negative impact potentially extending into adulthood. Without healthy sleep, it will be nearly impossible for children to reach their full potential."

Parents should not assume children will 'grow out' of sleep disorders

It is possible that as a child or teenager gets older, symptoms of their sleep disorder may ease. This is most likely for parasomnias, such as sleepwalking and night terrors.

But in some cases, sleep disorders can persist well into adulthood. "For example, children who have sleep apnea are more likely to develop sleep apnea as adults," noted Dr. Kline.

As such, sleep physicians say parents should not ignore signs of sleep disorders in children with the assumption they will "grow out" of them.

"Parents should never assume that their child will grow out of a sleep disorder," Dr. Paruthi told us. "Parents should talk to their child's doctor about how their child sleeps and discuss any potential sleep problems. It is important for a doctor to monitor sleep problems during childhood, identify any underlying causes and prescribe appropriate treatment when necessary."

Depending on what form of sleep disorder a child has, there are a number of treatments available. Doctors may recommend a melatonin supplement, for example. Melatonin is a natural hormone made by the body that helps regulate sleep.

Cognitive behavioral therapy may also be useful, in which psychological approaches - rather than medication - are used to improve a child's sleep time and quality.

Tips to improve a child's sleep

But while there are a number of therapies that can help treat symptoms of sleep disorders, there are many things the NSF say parents can do to improve the likelihood of their child getting a good night's sleep:

The NSF say parents should ensure their child is sleeping in an adequate environment; if it is too noisy, too cold or too hot, this can disrupt sleep.

• Make sleep a primary health priority in your family
• Talk to your child about the importance of sleep for their health and well-being
• Set regular bedtimes for yourself and your children and stick to them
• Be aware of how your child is using media devices in the bedroom and set boundaries for use before bedtime
• Ensure you and your child are educated on how light from media devices may impair sleep
• Rather than watching TV, playing video games or browsing the Internet before bedtime, encourage your child to read a book or listen to music
• Ensure your child is sleeping in an adequate environment; if it is too noisy, too cold or too hot, this can disrupt sleep
• Talk to your child's teacher to find out about their alertness during the school day, and ask them to inform you if they fall asleep in lessons.

To find out more about how to improve your child's sleep, visit the NSF website. Our Knowledge Center articles provide more general information on specific sleep disorders, including obstructive sleep apneaand insomnia.

Sleep deprivation and obesity in children

This article explains that sleep deprived children are more likely to be obese than children who get enough sleep.

Tired and hungry. There is a reason why these two conditions seem to go together so easily.

A “well established” link in medical research suggests young children and infants who do not get enough sleep are likely to develop obesity —and a host of devastating related health conditions — before they enter their teen years.

And by then, reversing the obesity is almost impossible, health experts say.

A study published in May in the journal “Pediatrics” hypothesizes that children sleeping less in early childhood developed obesity by age 7.

But the findings — from researchers at Massachusetts General Hospital for Children — are hardly shocking, say local physicians.

While studies such as this are likely to be confirmed by additional research in the years ahead, the other non-controversial conclusion is that obese children who suffer from obstructive sleep apnea also experience a variety of health issues, according to Dr. Ignacio Tapia, a pediatric pulmonologist and sleep medicine specialist at the Sleep Center in The Children’s Hospital of Philadelphia.

Tapia notes that youngsters of normal weight who experience deep sleep and REM or rapid eye movement sleep find sleep restorative, resulting in benefit for everything from brain activity to hormone secretions.

But the obese often cannot attain deep sleep because of the apnea, a condition characterized by brief, numerous involuntary breathing pauses that prevent people from reaching restorative levels of slumber.

When children do not get the sleep they need, they are at risk for health, performance and difficulties in school; researchers find that sleep deficiencies in children can be misdiagnosed as attention-deficit or behavior disorders.

Young patients with sleep apnea can be treated effectively with surgery to remove their tonsils and adnoids but for obese children, such a procedure may not resolve the issue. Further treatment can involve wearing cumbersome masks that help regulate breathing.

“Remember when your grandparents told you you need to go to sleep to grow?” Tapia asked. “Well, that turned out to be true. Growth is associated with longer sleep. The people who sleep less (for example) may have less insulin secretion which can be related to diabetes and pre-diabetes.”

Since the 1800s, each generation has lived longer than the one that preceded it, said Tapia, also assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Such longevity can be linked to the development of antibiotics and advances in cardiac care.

Now, this generation may be the one that loses ground, because of the epidemic of obesity, which is a complex issue relating to social and cultural issues as well and having income components, physicians say. Those who earn less may not have ready access to healthy foods while eating at fast-food chains has been made increasingly affordable, Tapia said. Portion size also is an issue in this country.

“We are seeing patients who are not a little big but really really big,” he said. “It is not rare to see patients who have doubled their ideal weight. They do not weigh 20 or 30 percent more but 100 percent more’’ than growth charts indicate.

The “Pediatrics” study measured the effect of sleep deficiencies over time, using data from Project Viva, a longitudinal research study of women and children that examines the effects of mothers’ diets and other factors during pregnancy and after birth.

Obesity “definitely spans all ages,” said Dr. Tina Rakitt, a pediatric gastroenterologist at the Unterberg Children’s Hospital at Monmouth Medical Center. But the study published in May “is unique enough to say the obesity and sleep link even exists in young children,” she added. “There are many reasons for that link. People who don’t sleep well tend to eat more and they tend to eat more of the wrong things.”

The battle is lost once children are old enough to select their own snacks or meals, unless they are taught correctly. Physicians say healthy eating must be established when children are infants and must be carried on by the family. Obesity does not exist in a vacuum, the experts said.

“The obesity epidemic is not only an adult problem; it is a adult-pediatric problem,” Rakitt said. “We are seeing more sleep apnea…That is a terrible one. Children are developing fatty liver disease. We are starting to see some kids with serious complications either in their childhood or young adult years.”

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Irregular bedtime can mean behavioral problems in children

Irregular bedtimes in children can lead to sleep deprivation which can harm a child's brain and cause children to have behavioral issues.

Researchers from UCL have found that children with irregular bedtimes are more likely to have behavioral difficulties.

The study, which is published in the journal Pediatrics, found that irregular bedtimes could disrupt natural body rhythms and cause sleep deprivation, undermining brain maturation and the ability to regulate certain behaviours.

Professor Yvonne Kelly (UCL Epidemiology & Public Health), said: "Not having fixed bedtimes, accompanied by a constant sense of flux, induces a state of body and mind akin to jet lag and this matters for healthy development and daily functioning."

"We know that early child development has profound influences on health and wellbeing across the life course. It follows that disruptions to sleep, especially if they occur at key times in development, could have important lifelong impacts on health."

Analysing data from more than 10,000 children in the UK Millennium Cohort Study, the team collected bedtime data at three, five and seven years, as well as incorporating reports from the children's mothers and teachers on behavioral problems.

The study found a clear clinical and statistically significant link between bedtimes and behavior as irregular bedtimes affected children's behavior by disrupting circadian rhythms, leading to sleep deprivation that affects the developing brain.

As children progressed through early childhood without a regular bedtime, their behavioural scores -- which included hyperactivity, conduct problems, problems with peers and emotional difficulties -- worsened. However, children who switched to a more regular bedtime had clear improvements in their behaviour.

Professor Kelly said: "What we've shown is that these effects build up incrementally over childhood, so that children who always had irregular bedtimes were worse off than those children who did have a regular bedtime at one or two of the ages when they were surveyed.

"But our findings suggest the effects are reversible," continued Professor Kelly. "For example, children who change from not having to having regular bedtimes show improvements in their behaviour."

Irregular bedtimes were most common at the age of three, when around one in five children went to bed at varying times. However, by the age of seven, more than half the children went to bed regularly between 7.30 and 8.30 pm. Children whose bedtimes were irregular or who went to bed after 9 pm came from more socially disadvantaged backgrounds, and this was factored into the study findings.

Professor Kelly said: "As it appears the effects of inconsistent bedtimes are reversible, one way to try and prevent this would be for health care providers to check for sleep disruptions as part of routine health care visits. Given the importance of early childhood development on subsequent health, there may be knock-on effects across the life course. Therefore, there are clear opportunities for interventions aimed at supporting family routines that could have important lifelong impacts."

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Study: Sleep restriction reduces insulin sensitivity in boys

A study shows that short periods of sleep restriction in boys leads to reduced insulin sensitivity which can lead to insulin resistance, weight gain, obesity, and other health issues.

Background:

Short sleep duration has been linked to impaired glucose metabolism in many experimental studies. Moreover, studies have reported indications of an increased metabolic stress following sleep restriction.

Objective:

We aimed to investigate the effects of partial sleep deprivation on markers of glucose metabolism. Additionally, we aimed to investigate if short sleep duration induces a state of endocrine stress.

Design:

A randomized crossover design, with 2 experimental conditions: 3 consecutive nights of short sleep (SS, 4 h/night) and long sleep (LS, 9 h/night) duration.

Subjects and Measurements:

In 21 healthy, normal-weight male adolescents (mean ± SD age: 16.8 ± 1.3 y) we measured pre- and post-prandial glucose, insulin, C-peptide, and glucagon concentrations. Furthermore, we measured fasting cortisol, 24-h catecholamines, and sympathovagal balance.

Results:

Fasting insulin was 59% higher (P = 0.001) in the SS than the LS condition as was both fasting (24%, P < 0.001) and post-prandial (11%, P = 0.018) C-peptide. Pre- and post-prandial glucose and glucagon were unchanged between conditions. The homeostasis model assessment of insulin resistance (HOMA-IR) index was 65% higher (P = 0.002) and the Matsuda index was 28% lower (P = 0.007) in the SS condition compared to the LS condition. The awakening cortisol response and 24-h norepinephrine were not affected by sleep duration, whereas 24-h epinephrine was 24% lower (P = 0.013) in the SS condition. Neither daytime nor 24-h sympathovagal balance differed between sleep conditions. Short wave sleep was preserved in the SS condition.

Conclusion:

Short-term sleep restriction is associated with decreased insulin sensitivity in healthy normal-weight adolescent boys. There were no indications of endocrine stress beyond this.

Citation:

Klingenberg L; Chaput JP; Holmbäck U; Visby T; Jennum P; Nikolic M; Astrup A; Sjödin A. Acute Sleep Restriction Reduces Insulin Sensitivity in Adolescent Boys. SLEEP 2013;36(7):1085-1090.

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Sleep deprivation in children can be misdiagnosed as ADHD

This article discusses how sleep deprivation in children can be mistaken for ADHD.

More children - and adults - than ever are being diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).

Yet many of those may not have the behavioural disorder but could instead be suffering from sleep deprivation, says a leading U.S. doctor. He estimates more than a third of children and a quarter of adults diagnosed with ADHD actually have sleep problems.

Sleep deprivation, especially in children, does not - as might be expected - cause lethargy, but very similar problems to ADHD, including hyperactivity, an inability to focus, aggression and forgetfulness.

The similarity between the symptoms, coupled with many doctors' poor understanding of sleep disorders, is what is causing the confusion in some patients, says Vatsal Thakkar, a clinical assistant professor of psychiatry at the New York University School of Medicine.

'While there is no doubt that many people have ADHD, a substantial proportion of cases are really sleep disorders in disguise,' he says.

ADHD is characterised by problems with attention, concentration and impulsiveness. Around 5 per cent of British children are thought to be affected, with prescriptions for drugs to treat them rising by 70  per cent between 2005 and 2011. 

Prescriptions for Ritalin, the most popular drug for ADHD, have quadrupled in the past decade, with children as young as three taking the powerful medication.

ADHD is most commonly diagnosed between the ages of three and seven and is four times more common in boys than girls. In around half of cases, the disorder continues into adult life.

But now some experts are questioning whether the real problem is poor quality sleep. Numerous studies have shown that many children with ADHD also have breathing problems during sleep such as snoring and apnoea - where breathing becomes slow or interrupted by the muscles and soft tissue in the throat collapsing, causing a blockage - and are more likely to have disrupted delta sleep.

This is the deep, rejuvenating kind which starts about 30 to 50 minutes after we fall asleep. Children need delta sleep for proper growth and development.

One study, published in 2004 in the journal Sleep, looked at 34 children with ADHD. Every one showed a deficit of delta sleep, compared with only a handful of the 32 children in the study who didn't have the disorder.

Meanwhile, a study of more than 11,000 British children published last year found those who suffered breathing problems during sleep in infancy were more likely to have behavioural difficulties later in life.

These children were 20 to 60 per cent more likely to have behavioural problems at the age of four, and 40 to 100 per cent more likely to have such problems at seven.

Tellingly, when sleep problems are resolved, the behavioural problems attributed to ADHD can disappear. A study published in the journal Paediatrics in 2006 found that removing tonsils to improve sleep seems to banish ADHD symptoms. A year after the surgery, half of the children who had previously been diagnosed with ADHD no longer had it.

Professor Thakkar's theory is supported by British sleep experts, who say it is no coincidence that the rise in ADHD diagnoses in the Nineties came at a time when people were getting less sleep.

The latest figures suggest that the number of adults who sleep fewer than seven hours each night has risen from 2 per cent in 1960 to more than 35 per cent in 2011.

According to Dr Neil Stanley, a British sleep expert, children today get at least an hour less sleep than they did 100 years ago. Many ten-year-olds do not get the recommended ten hours a night.

The distraction of 24-hour TV, computer games and mobile phones is a major factor because they not only stimulate the mind but suppress levels of melatonin, a hormone that helps to regulate sleeping and waking cycles.

The light-sensitive cells at the back of the eye are more sensitive to the light emitted by screens - which tricks the body into thinking that it's still daytime, so it disrupts the production of melatonin.

'Ask any parent to describe a sleep-deprived child and the characteristics are not dissimilar to ADHD,' he says. 'Some children do have ADHD, but others are sleep-deprived and we are calling it ADHD.

'Some perfectly normal children who, for whatever reason, are chronically sleep-deprived, are being diagnosed with ADHD by their GPs. Many doctors also  have very little knowledge of  sleep disorders.'

More controversial is his belief that it may also be easier for doctors to tell parents their child has a medical condition rather than that he or she needs more sleep, with the parenting implications that involves.

'For some children it may be a diagnosis of convenience. Yet by misdiagnosing sleep-deprived patients as having ADHD, we are not only doing a disservice to those who really have ADHD but may be treating thousands of patients with poor sleep with medications designed to control or modify daytime behaviour.'

Furthermore, drugs for treating ADHD can have side-effects, including poor appetite, stomach pain and, in rare cases, heart problems, chest pain, liver problems and suicidal thoughts.

Professor Thakkar's interest in the link between ADHD and sleep disorders was prompted by his own experience after being diagnosed with ADHD as an adult.

For nearly a decade he suffered from profound cognitive lethargy and difficulty focusing - he needed a daily nap and spent much of the weekend sleeping.

Initially he was told that the problems were the result of psychological issues. Then, in 2005, he was diagnosed with ADHD.

Not convinced, he underwent a sleep study which showed, at the age of 33, that he had an unusual form of narcolepsy, a neurological disorder which usually causes intermittent, uncontrollable episodes of falling asleep.

'I'd never fallen asleep while eating or talking, but it turned out that just 5 per cent of my sleep was delta sleep. With the proper treatment my cognitive problems came to an end. My daytime focus is remarkably improved.'

Professor Thakkar says there is more going on in our nocturnal lives than we realised.

'However, it is impossible to know how well you sleep unless you undergo tests - that's because sleep is partly biological and partly behavioural,' he says.

'Even if parents and children do all the right things to make sure they get enough sleep, they may be getting too little quality sleep.

'Limiting time on devices, especially in the evenings, is a good first step for children with these types of symptoms.'

If that doesn't work, parents should ensure that their child gets enough sleep for their age (ten to 11 hours for school-age children, seven to eight for adults). 

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