SLEEP APNEA & SLEEP DISORDERS
Spotting Sleep Problems in Special-Needs Children
Small changes at home can help them get essential shuteye
(HealthDay News) -- About 30 percent of children have a sleep disorder, but the rate is even higher in children with special needs, an expert says.
This increased risk in children with special needs is likely related to physical and behavioral differences, as well as side effects from medication, said Dr. Jennifer Accardo, director of the Sleep Disorders Clinic and Lab at the Kennedy Krieger Institute in Baltimore, Md.
Not all children with special needs who have sleep disturbances will be diagnosed with a sleep disorder, but early detection of common signs is the key to improving sleep. Parents know their child's sleep patterns best and can spot sleep issues if they know what to look for.
Signs of sleep problems in school-age children with special needs include: snoring; difficulty falling or staying asleep; sleepwalking, night terrors and other nighttime activities; sleeping too much; and needing parents to be in the room to fall asleep.
"While a good night's sleep is important for all children, it is especially critical for children with special needs," Accardo said in an institute news release. "Parents can make small changes at home to help their child get a better night's sleep and improve their performance in daytime activities, therapies and social interactions."
Accardo offered tips to improve sleep for children with special needs:
Make sleep a priority and develop a bedtime routine.
Keep schedules consistent every day on both weekdays and weekends.
Make the bedroom a restful place and have your child sleep in the same place every night.
Put your child to bed when he or she is sleepy, but not yet fully asleep.
Address anxiety, which is common in children with special needs.
Take note of signs of sleep problems
Sleep disturbances are often due to temporary or chronic medical problems and are seen in as many as 25 to 30 percent of infants and children.
They may range from insufficient sleep, bedtime settling problems and sleepwalking to sleep apnea and narcolepsy.
Sleep disorders in children may lead to daytime moodiness, irritability, lack of focus in class, sleepiness in school, inability to get up in time for school, and significant behavioral and learning problems. Some sleep disorders are serious enough to cause adverse cardiovascular and metabolic effects as well as failure to thrive.
Sleep — or lack of it — is probably the most-discussed aspect of baby care. New parents discover its vital importance those first few weeks and months. The quality and quantity of an infant's sleep affects the well-being of everyone in the household.
And sleep struggles rarely end with a growing child's move from crib to bed. It simply changes form. Instead of cries, it's pleas or refusals. Instead of a feeding at 3:00 AM, it's a nightmare or request for water.
So how do you get your child to bed through the cries, screams, avoidance tactics, and pleas? How should you respond when you're awakened in the middle of the night? And how much sleep is enough for your kids?
How Much Is Enough?
It all depends on a child's age. Charts that list the hours of sleep likely to be required by an infant or a 2-year-old may cause concern when individual differences aren't considered. These numbers are simply averages reported for large groups of kids of particular ages.
There's no magical number of hours required by all kids in a certain age group. Two-year-old Sarah might sleep from 8:00 PM to 8:00 AM, whereas 2-year-old Johnny is just as alert the next day after sleeping from 9:00 PM to 6:00 AM.
Still, sleep is very important to kids' well-being. The link between a lack of sleep and a child's behavior isn't always obvious. When adults are tired, they can be grumpy or have low energy, but kids can become hyper, disagreeable, and have extremes in behavior.
Most kids' sleep requirements fall within a predictable range of hours based on their age, but each child is a unique individual with distinct sleep needs.
During sleep, everyone has brief pauses in their breathing pattern called apneas. Usually this is completely normal.
Sometimes, though, apneas may be prolonged and happen often, making the breathing pattern irregular and abnormal. Abnormal apnea might actually cause decreased oxygen levels in the body and disrupt sleep.
Types of Apnea
The word apnea comes from the Greek word meaning "without wind." Although it's perfectly normal for everyone to experience occasional pauses in breathing, apnea can be a problem when breathing stops frequently or for prolonged periods of time.
There are three types of apnea:
A common type of apnea in children, obstructive apnea is caused by an obstruction of the airway (such as enlarged tonsils and adenoids). This is most likely to happen during sleep because that's when the soft tissue at back of the throat is most relaxed. As many as 1% to 3% of otherwise healthy preschool-age kids have obstructive apnea.
snoring (the most common) followed by pauses or gasping
labored breathing while sleeping
very restless sleep and sleeping in unusual positions
daytime sleepiness or behavioral problems
Because obstructive sleep apnea may disturb sleep patterns, these children may also show continued sleepiness after waking in the morning and tiredness and attention problems throughout the day. Sometimes apnea can affect school performance. One recent study suggests that some kids diagnosed with ADHD actually have attention problems in school because of disrupted sleep patterns caused by obstructive sleep apnea.
Treatment for obstructive apnea involves keeping the throat open to aid air flow, such as with adenotonsillectomy (surgical removal of the tonsils and adenoids) or continuous positive airway pressure (CPAP), which is delivered by having the child wear a nose mask while sleeping.
Central apnea occurs when the part of the brain that controls breathing doesn't properly maintain the breathing process. In very premature infants, it's seen fairly commonly because the respiratory center in the brain is immature.
Mixed apnea is a combination of central and obstructive apnea and is seen particularly in infants or young children who have abnormal control of breathing. Mixed apnea may occur when a child is awake or asleep.
Conditions Associated With Apnea
Apnea can be seen in connection with:
Apparent Life-Threatening Events (ALTEs)
An ALTE itself is not a sleep disorder — it's a serious event with a combination of apnea and change in color, change in muscle tone, choking, or gagging. Call 911 immediately if your child shows the signs of an ALTE.
ALTEs, especially in young infants, often are associated with medical conditions that require treatment; these include gastroesophageal reflux disease (GERD), infections, or neurological problems or cardiac disorders.
ALTEs are frightening to see, but can be uncomplicated and may not happen again. However, any child who has one should be seen by a doctor for evaluation immediately.
Apnea of Prematurity (AOP)
AOP can occur in infants who are born prematurely (before 34 weeks of pregnancy). Because the brain or respiratory system may be immature or underdeveloped, the baby may not be able to regulate his or her own breathing normally. AOP can be obstructive, central, or mixed.
Treatment for AOP can involve the following:
keeping the infant's head and neck straight (premature babies should always be placed on their backs to sleep to help keep the airways clear)
medications to stimulate the respiratory system
continuous positive airway pressure (CPAP) — to keep the airway open with the help of forced air through a nose mask
Premature infants with AOP are followed closely in the hospital. If AOP doesn't resolve before discharge from the hospital, the baby might be sent home on an apnea monitor and parents and other caregivers will be taught CPR. The family will work closely with the child's doctor to have a treatment plan in place.
Apnea of Infancy (AOI)
Apnea of infancy occurs in children younger than 1 year old who were born after a full-term pregnancy. Following a complete medical evaluation, if a cause of apnea isn't found, it's often called apnea of infancy.
AOI usually goes away on its own, but if it doesn't cause any significant problems (such as low blood oxygen), it may be considered part of the child's normal breathing pattern.
Infants with AOI can be watched at home with the help of a special monitor prescribed by a sleep specialist. This monitor records chest movements and heart rate and can relay the readings to a hospital apnea program or save them for future examination by a doctor. Parents and caregivers will be taught CPR before the baby is sent home.
If You Think Your Child Has Apnea
If you suspect that your child has apnea, call your doctor. If you suspect that your child is experiencing an ALTE, call 911 immediately.
Although prolonged pauses in breathing can be serious, after a doctor does a complete evaluation and makes a diagnosis, most cases of apnea can be treated or managed with surgery, medications, monitoring devices, or sleep centers. Many cases of apnea go away on their own.
Babies (up to 6 Months)
There is no sleep formula for newborns because their internal clocks aren't fully developed yet. They generally sleep or drowse for 16 to 20 hours a day, divided about equally between night and day.
Newborns should be awakened every 3 to 4 hours until their weight gain is established, which typically happens within the first couple of weeks. After that, it's OK if a baby sleeps for longer periods of time. But don't get your slumber hopes up just yet — most infants won't snooze for extended periods of time because they get hungry.
After the first couple of weeks, infants may sleep for as long as 4 or 5 hours — this is about how long their small bellies can go between feedings. If babies do sleep a good stretch at night, they may want to nurse or get the bottle more frequently during the day.
Just when parents feel that sleeping through the night seems like a far-off dream, their baby's sleep time usually begins to shift toward night. At 3 months, a baby averages about 13 hours of sleep in a 24 hour period (4-5 hours of sleep during the day broken into several naps and 8-9 hours at night, usually with an interruption or two). About 90% of babies this age sleep through the night, meaning 5 to 6 hours in a row.
But it's important to recognize that babies aren't always awake when they sound like they are; they can cry and make all sorts of other noises during light sleep. Even if they do wake up in the night, they may only be awake for a few minutes before falling asleep again on their own.
If a baby under 6 months old continues to cry, it's time to respond. Your baby may be genuinely uncomfortable: hungry, wet, cold, or even sick. But routine nighttime awakenings for changing and feeding should be as quick and quiet as possible. Don't provide any unnecessary stimulation, such as talking, playing, or turning on the lights. Encourage the idea that nighttime is for sleeping. You have to teach this because your baby doesn't care what time it is as long as his or her needs are met.
Ideally, your baby should be placed in the crib before falling asleep. And it's not too early to establish a simple bedtime routine. Any soothing activities, performed consistently and in the same order each night, can make up the routine. Your baby will associate these with sleeping, and they'll help him or her wind down.
The goal is for babies to fall asleep independently, and to learn to soothe themselves and go back to sleep if they should wake up in the middle of the night.
6 to 12 Months
At 6 months, an infant may nap about 3 hours during the day and sleep about 9 to 11 hours at night. At this age, you can begin to change your response to an infant who awakens and cries during the night.
Parents can give babies a little more time to settle down on their own and go back to sleep. If they don't, comfort them without picking them up (talk softly, rub their backs), then leave — unless they appear to be sick. Sick babies need to be picked up and cared for. If your baby doesn't seem sick and continues to cry, you can wait a little longer, then repeat the short crib-side visit.
Between 6 and 12 months, separation anxiety, a normal developmental phase, comes into play. But the rules for nighttime awakenings are the same through a baby's first birthday: Try not to pick up your baby, turn on the lights, sing, talk, play, or feed your child. All of these activities do not allow your baby to learn to fall asleep on his or her own and encourage repeat awakenings.
From ages 1 to 3, most toddlers sleep about 10 to 13 hours. Separation anxiety, or just the desire to be up with mom and dad (and not miss anything), can motivate a child to stay awake. So can simple toddler-style contrariness.
Parents sometimes make the mistake of thinking that keeping a child up will make him or her sleepier for bedtime. In fact, though, kids can have a harder time sleeping if they're overtired. Set regular bedtimes and naptimes. Though most toddlers take naps during the day, you don't have to force your child to nap. But it's important to schedule some quiet time, even if your child chooses not to sleep.
Establishing a bedtime routine helps kids relax and get ready for sleep. For a toddler, the routine may be from 15 to 30 minutes long and include calming activities such as reading a story, bathing, and listening to soft music.
Whatever the nightly ritual is, your toddler will probably insist that it be the same every night. Just don't allow rituals to become too long or too complicated. Whenever possible, allow your toddler to make bedtime choices within the routine: which pajamas to wear, which stuffed animal to take to bed, what music to play. This gives your little one a sense of control over the routine.
But even the best sleepers give parents an occasional wake-up call. Teething can awaken a toddler and so can dreams. Active dreaming begins at this age, and for very young children, dreams can be pretty alarming. Nightmares are particularly frightening to a toddler, who can't distinguish imagination from reality. (So carefully select what TV programs, if any, your toddler sees before bedtime.)
Comfort and hold your child at these times. Let your toddler talk about the dream if he or she wants to, and stay until your child is calm. Then encourage your child to go back to sleep as soon as possible.
Preschoolers sleep about 10 to 12 hours per night. A preschool child who gets adequate rest at night may no longer need a daytime nap. Instead, a quiet time may be substituted.
Most nursery schools and kindergartens have quiet periods when the kids lie on mats or just rest. As kids give up their naps, bedtimes may come earlier than during the toddler years.
School-Age Children and Preteens
School-age kids need 10 to 12 hours of sleep a night. Bedtime difficulties can arise at this age for a variety of reasons. Homework, sports and after-school activities, TVs, computers, and video games, as well as hectic family schedules might contribute to kids not getting enough sleep.
Lack of sleep can cause irritable or hyper types of behavior and may make it difficult for kids to pay attention in school. It is important to have a consistent bedtime, especially on school nights. Be sure to leave enough time before bed to allow your child to unwind before lights out.
Adolescents need about 8½ to 9½ hours of sleep per night, but many don't get it. Because of early school start times on top of schedules packed with school, homework, friends, and activities, they're typically chronically sleep deprived.
And sleep deprivation adds up over time, so an hour less per night is like a full night without sleep by the end of the week. Among other things, an insufficient amount of sleep can lead to:
decreased short-term memory
delayed response time
These can cause bad tempers, problems in school, stimulant use, and driving accidents (more than half of "asleep-at-the-wheel" car accidents are caused by teens).
Teens also experience a change in their sleep patterns — their bodies want to stay up late and wake up later, which often leads to them trying to catch up on sleep during the weekend. This sleep schedule irregularity can actually aggravate the problems and make getting to sleep at a reasonable hour during the week even harder.
Ideally, a teen should try to go to bed at the same time every night and wake up at the same time every morning, allowing for at least 8 to 9 hours of sleep.
No matter what your child's age, establish a bedtime routine that encourages good sleep habits. These tips can help kids ease into a good night's sleep:
Include a winding-down period in the routine.
Stick to a bedtime, alerting your child both half an hour and 10 minutes beforehand.
Encourage older kids and teens to set and maintain a bedtime that allows for the full hours of sleep needed at their age.
Reviewed by: Mary L. Gavin, MD
Date reviewed: January 2011