Nonpharmacologic treatments for pediatric sleeplessness

The infant's maturity and sleep state influence the central control of breathing, which is coordinated by complex interactions of the central nervous system with the respiratory muscles. Periodic breathing, apnea of prematurity and sudden infant death syndrome are thought to be caused by abnormalities of respiratory control in the infant. Sleep disordered breathing occurs in infancy, particularly in those with certain congenital anomalies. A common sleep disorder of infancy is behavioral insomnia, which can be managed effectively by a number of behavioral interventions.

Clinical recommendations include putting infants to bed using a consistent bedtime routine at an appropriate hour to promote longer nighttime sleep. Actigraphy was used in this exploratory study to examine how bedtime routines and nighttime sleep onset were associated with nighttime total sleep time (TST) and efficiency from 6 to 24 weeks of age.

Infants (n = 24) wore sleep actigraphs for three, one-week periods at 6, 15, and 24 weeks of age. Nighttime TST, sleep efficiency, sleep onset and offset were quantified. Mothers reported on infant bedtime routines using the Brief Infant Sleep Questionnaire at each age. Multilevel models examined between- and within-person associations.

As infants aged, sleep onset was earlier, and bedtime routines became shorter (p's < 0.05). Infants fell asleep between 7 and 8:00PM on 24% of the nights. Most mothers (70%) reported that they often fed infants to sleep for the night. For every 1 h earlier in infants' usual sleep onset, nighttime TST was 34.4 min longer that night (p < 0.01). Infants with earlier than usual sleep onset had slightly earlier sleep offset the next morning (8.4 min for every 1 h earlier in onset; p = 0.02). Between-person analyses showed similar patterns. Infants with a more consistent bedtime routine and who were not typically fed to sleep at bedtime had longer nighttime TST at 6 weeks, with a trend or no association at later ages.

Infants who fell asleep earlier also slept longer at night. Keeping infants up later in hopes of them sleeping in longer may be counterproductive.

Up to 85% of children with neurodevelopmental disorders have sleep problems, compared with 25% of typically developing children. Children with cerebral palsy (CP)may have risk factors (brain injury, physical disability, and comorbidities) that make them more likely to have sleep problems compared with typically developing children.

To determine prevalence of sleep problems in children with CP.

We conducted a systematic review and meta-analysis to report on the prevalence of sleep problems in children with CP, within subgroups (age, CP phenotype, presence of impairments [auditory, visual, and cognitive], and presence of epilepsy) and compared with control groups of healthy children. We searched eight relevant electronic databases from their respective start dates until September 2018.

23 full-text articles (n=2,908 children with CP) were included in the review. All studies were cross-sectional and examined caregiver-reported sleep measures. The Sleep Disturbance Scale for Children (SDSC) was the most commonly used questionnaire. No study met all Joanna Briggs Institute quality assessment criteria for prevalence studies; selection, coverage, classification, and/or confounding biases were present in all studies. Using a random effects model with a Freeman-Tukey double arcsine transformation, the pooled prevalence was 23.4% (95% confidence interval [CI] 18.8-28.4%; n=9 studies) for an abnormal total score on the SDSC and 26.9% (95% CI 21.5-32.7%; n=9 studies) for disorders of initiation and maintenance of sleep, the most prevalent sleep problem reported. For the studies that reported prevalence for control groups of healthy children (n=4 studies), sleep problems were generally more prevalent in the CP group.

The prevalence of sleep problems in children with CP is high. There is notable variability in the prevalence of sleep problems between subgroups of children with CP. Future studies using questionnaires validated in children with CP and objective measures (such as polysomnography or actigraphy) in well-described, large, broadly recruited samples are recommended.

Children with neurodevelopmental disorders (NDD) are at high risk for sleep problems, especially insomnia. It is currently not known whether behavioural sleep interventions developed for typically developing (TD) children are effective for children with NDD, and if interventions need to be modified for each diagnostic group. The aim of this systematic review was to identify and evaluate commonalities, trends in outcomes, and the methodological quality of parent-delivered behavioural sleep interventions for children with NDD, specifically Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Cerebral Palsy, and Fetal Alcohol Spectrum Disorder. Nine databases were searched. A total of 40 studies met eligibility criteria. The majority of studies were conducted with ASD and ADHD populations. Common sleep problems were evident across the NDD populations. The most frequently reported included bedtime resistance, night-waking, early morning awakening, and co-sleeping. The most common interventions used were implementation of healthy sleep practices, reinforcement, graduated extinction, and faded bedtime. All studies reported at least one behavioural treatment component as effective. Commonalities across NDD populations, as well as the TD population, for both sleep problems reported and behavioural interventions implemented, suggest the feasibility of developing a transdiagnostic behavioural sleep intervention suitable for children with a range of NDD.

Insomnia, which is related to daytime deficits and is a common problem for children with neurodevelopmental disorders (NDDs), is often successfully treated with behavioral strategies. However, there are barriers to accessing these treatments, and there has been little research examining what these interventions need to be usable and effective. The goal of this study was to gain consensus from experts in the field on the key components of an eHealth, parent-implemented, intervention program aimed at improving sleep in children with attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, and fetal alcohol spectrum disorder. This was achieved using the Delphi method, which involves asking participants to respond to open-ended questions about a topic of interest and then, in iterative rounds, to rate the recommendations that were made by the group. In the current study, participants (27 responders in the first round, 21 in the second, and 18 in the third) rated a total of 131 recommendations. Of those 131 recommendations, 52 items had high importance and high consensus and were deemed to be priority items to consider for creating an eHealth, parent-delivered, behaviorally-based intervention for insomnia in children with NDD. Furthermore, 75% (n = 84) of the 112 recommendations from the first round were believed to be applicable across all 4 NDD groups, thus providing evidence of the potential for a transdiagnostic intervention.

Postpartum women have highly disturbed sleep, also known as sleep fragmentation. Fragmentation extends their total sleep period, also disrupting sleep timing. A stable and earlier sleep period among non-postpartum populations is related to better performance, physical health, and mental health. However, sleep timing has not been examined among postpartum women who are also vulnerable to daytime impairment. The study objective was to examine how the timing and regularity of sleep during the early postpartum period are related to daytime functioning across postpartum weeks 2–13. In this field-based study, 71 primiparous women wore an actigraph, a small wrist-worn device that monitors sleep and sleep timing, for the 12-week study period. Mothers self-administered a 5-min psychomotor vigilance test (PVT) each morning to evaluate the number of > 500 ms response lapses. They also completed a Morningness–Eveningness scale at the beginning of the study to identify chronotype. After controlling for maternal age, earlier sleep timing was associated with significantly fewer PVT lapses at postpartum weeks 9,12; a more stable sleep midpoint was associated with significantly fewer PVT lapses at postpartum weeks 2,5–13. Earlier sleep midpoints were related to more stable sleep midpoints at postpartum week 2 and a morning-type chronotype. An earlier sleep midpoint was also associated with a reduced slope of worsening PVT lapses across weeks. Across the first 12 postpartum weeks, women with earlier or more stable sleep periods had less daytime impairment than women with later or more variable sleep midpoints. Postpartum women with earlier sleep midpoints also showed less severe decrements in performance across time, which has been attributed to cumulative impacts of sleep disturbance. These data suggest that the sleep period, in addition to sleep duration and fragmentation, should be more closely examined, particularly among vulnerable women, as it may affect the neurobehavioral performance of new mothers.