The Stanford Center for Sleep Sciences and Medicine

Pediatric Disorders

Dr. Rafael Pelayo discusses stress management and other health-related issues that come with starting or returning to school

Sleep disorders in children and adolescents are common; even infants may have sleep disorders. Studies have shown that poor sleep quality and/or quantity in children are associated with a host of problems, including academic, behavioral, developmental and social difficulties, weight abnormalities, and other health problems. Not only do pediatric sleep problems affect child health, but they can impact family dynamics and parental or sibling sleep. Children may suffer from problems falling or staying asleep; physiological problems such as obstructive sleep apnea abnormal or disruptive behaviors during sleep such as sleepwalking or other parasomnias symptoms that occur near sleep onset such as restless legs syndrome, and daytime symptoms such as excessive sleepiness, cataplexy and others. While adults may suffer from the same problems, the etiology, presentation, and associated findings in children may be very different than those seen in adults. In addition, developmental aspects of childhood play an important role in pediatric sleep, such as in the cases of early childhood insomnias and adolescent sleep phase delay. Finally, a sizeable list of medical disorders can contribute to sleep disorders.

Sleep Disorders Present in Children

Learn more about Diagnosing and Treating Pediatric Sleep Disorders

Arousal Disorders in Children

Description of Arousals Disorders

Arousal disorders are common in children. Arousal does not mean that the child wakes-up. The “arousal” is a partial arousal usually from “deep” sleep also called “slow wave sleep”. Most commonly the child transitions from deep sleep to a mixture of very light sleep and/or partial wakefulness. This stage shift will commonly lead to a confusional state or a “confusional arousal”. During such an episode, the child presents features suggestive of being simultaneously awake and asleep. On one hand, the child may appear to be alert by crying very loudly, moving, or even running. However, the child simultaneously appears to be disoriented, and confused. They can be relatively unresponsive to solicitations from parents as well as from other environmental challenges. There is usually little or no recall of the arousal or any event that may had occurred during the episode the next morning or even 10 to 30 minutes later if the child is to awaken completely.

Various behaviors can occur during sleep ranging from simple to complex activities. Simple behaviors would include mumbling during sleep or sitting up in bed then falling right back asleep. However, more elaborate behaviors are also possible, for example crying loudly in distress, inconsolable and ignoring the reassurance of the parents, seemingly “very far away.” The child may even exhibit aggressive behavior against parents that want to reassure the child and trying to escape an embrace. Finally, very complex behaviors such as sleep walking are possible. The child may quietly walk around the bedroom or rush around in highly agitated state hitting the furniture. The complex behaviors may seems goal oriented or they may be poorly directed. For example, a child may go into a closet looking for the bedroom door, or may go into a closet and urinate before returning to bed.

Usually only one episode occurs during the night and often it is within the first 2 hours of falling asleep However, there are always exceptions to this rule. There may be periods where a child has several episodes during a single night and then go several weeks without a single episode.

Possible Triggers for Episodes

It seems that a small disruption of sleep due to another cause, such as a health problem or travel, may elicit behaviors associated with confusional arousals. It was shown that fever, abrupt sleep loss, migraine, irregular sleep-wake schedules can be more associated with these events. It was also shown that another sleep disorder such as sleep-disordered-breathing and to a lesser extent restless legs syndrome or nocturnal asthma may be seen in association with the confusional behaviors.

One hypothesis is that the other health problem (fever, sleep-disordered-breathing as an example) already disturbs sleep, particularly when the child is trying to go to deep sleep. The health problem brings the child very abruptly from the deep sleep to a near awakening. It has also been hypothesized that stress or anxiety could be an added trigger. In older teenagers, alcohol intake and sleep deprivation must also be taken into consideration.

Common Arousal Disorders

The most common confusional behavior syndromes are sleep terrors and sleep walking. When these behaviors are chronic they must be investigated. An epidemiological survey performed on school children in the Tucson (AZ) area found that in this group of children seen outside of a clinic setting, the most common association (though not the only one) with chronic sleepwalking was sleep-disordered-breathing. Other studies have shown that treatment of the associated sleep disorder can positively reduce or eliminate the confusional behaviors. Treating an abnormal sleep-wake schedule and/or reducing stressful conditions has also been associated with the resolution of associated health problems.

The notion that chronic abnormal behavior during sleep has been associated with other sleep disorders, such as sleep-disordered-breathing, is the justification for recommending nocturnal polysomnography when a child presents such a chronic syndrome.

Seizure Disorders

A question often raised is: Does my child have a seizure disorder? The presentation of nocturnal seizure with abnormal behavior during sleep is rare: it has been shown that 98% of the time no seizure disorder is present. Most commonly the clinical presentation is different and a clinical interview will allow the physician to dissociate the two problems. In the difficult cases, a polysomnographic evaluation performed with a seizure montage will help confirm the diagnosis.

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Diagnosing and Treating Pediatric Sleep Disorders

Diagnosing Pediatric Sleep Disorders

The procedure for diagnosing sleep disorders in children is very similar to diagnosing sleep problems in adults. If you suspect your child has a sleep disorder, you should schedule an appointment for an evaluation.

Before your appointment, you will be asked to fill out a comprehensive pediatric sleep and health questionnaire. At your appointment, Stanford Sleep Medicine Center physicians will perform a thorough history and physical exam in order to evaluate your child’s symptoms fully. Information about home, school, and your child’s sleep environment, recent changes in routine or social stressors, school performance, previous sleep history and testing, and other medical conditions are all important. These factors – including the quality of the parents’ sleep – are important to assess. To further help with the diagnosis, the child may be asked to stay overnight for a sleep study at the Stanford Sleep Medicine Center. In some cases, blood tests may be ordered. The child and/or parents may be asked to keep a sleep diary as well.

Treating Pediatric Sleep Disorders

The Stanford Sleep Medicine Center was the first clinic to treat sleep disorders in children. We quickly realized that treating pediatric sleep disorders starts with setting expectations regarding normal pediatric sleep. Behavior modification plans may address some sleep issues. In addition to board-certified pediatric and adult sleep physicians with expertise in pediatric sleep disorders, the Stanford Sleep Clinic has team of behavioral psychologists certified in the treatment of sleep disorders who have expertise in working with children and their families. Using scheduled awakenings, positive reinforcement, and other techniques may be helpful in some cases of sleep disorders. In other cases, your doctor may recommend medications or supplements to treat a specific sleep disorder or underlying condition. Finally, in some cases, evaluation for specific interventions by a specialist in allergy, Ear, Nose and Throat (ENT) surgery, orthodontics, or other specialties may be recommended. In the case of obstructive sleep apnea, continuous positive airway pressure may be recommended.

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MyHealth Proxy Access for Parents

Did you know that you can now sign up for MyHealth Proxy access? If you’re the parent or guardian of a minor patient at Stanford Hospital & Clinics, you now have a range of convenient options at your fingertips -24-7- to help you better manage your child’s health care.

Parents and guardians of children up to 12 years of age can:

  • View upcoming appointments
  • View test results
  • View health history including immunizations, allergies, medications and more
  • Send messages to your child's Stanford clinic

Parents and guardians of children age 12-17 can:

  • View immunization records
  • Send messages to your child's Stanford clinic

To get started, visit our FAQ and download a MyHealth Proxy Access form. To participate, your child must be a patient at Stanford Hospital & Clinics. Ask your doctor's office to help you get started today.

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