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Sleep deprivation in children: 2.0

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22 August 2014 • Nursing Management www.nursingmanagement.com

A growing public health concern

www.nursingmanagement.com Nursing Management • August 2014 23

W e live in a sleep-deprived society: The CDC states insufficient

sleep is a public health epidemic for both adults and children.1

Lack of restorative sleep can compromise the physical and

emotional health of children and interfere with normal growth

and development.2-4 This article focuses on sleep-deprived children

between ages 5 and 18 and discusses the causes, long-term effects on

health, signs and symptoms, relevant assessment tools, and appropriate

interventions to manage the problem.

In general, children need more sleep than the 7 to 9 hours recom-

mended for adults.5 Children ages 5 to 10 need 10 to 11 hours of sleep;

those ages 10 to 17 require 8.5 to 9.25 hours.5 Children are getting

enough rest if they can fall asleep within 15 to 30 minutes after going to

bed, wake up easily at the correct time, and are awake and alert all day

without napping.6 The American Academy of Pediatrics estimates that

10% of children in the United States have a sleep issue. The percentage

rises to 50% to 75% in children with mental health and neurologic/

developmental disorders.7

Obvious signs of sleep deprivation in children are excessive daytime

sleepiness, dark circles under the eyes, inattention, and frequent

school tardiness and absenteeism.8 Difficulty getting up in the morn-

ing, irritability, hyperactivity, depression, impatience, mood

swings, impulse control issues, and aggressive behavior are more

subtle indications.9,10

By Lois Gerber, MPH, BSN, RN

Staff development special] ] ] ]

Sleep deprivation in children

24 August 2014 • Nursing Management www.nursingmanagement.com

Untreated sleep disorders can

become chronic, lead to under-

achievement at school or work,

and cause accidents, depression,

interpersonal conflicts, and predis-

position to or exacerbation of

health problems such as obesity

and diabetes.4 Evidence suggests

inadequate sleep results in

increased snacking and carbohy-

drate consumption.8 Research

also indicates that rested children

contract fewer infections because

restorative sleep strengthens the

immune system.11 Inadequate sleep

is a contributing factor in the death

of adolescents, especially from

motor vehicle accidents.12

Physical causes of

sleep deprivation

The source of childhood sleep

problems can be physical (related

either to sleep apnea or chronic

illness) or behavioral (related to

stress, anxiety, or mood disorders).

Often a combination of physical

and behavioral issues leads to sleep

deprivation, and/or a cause-and-

effect relationship exists between

sleep deprivation and its causes.2,13

A sleep-related breathing

disorder called sleep-disordered

breathing (SDB) is an abnormal

respiratory pattern caused by

upper airway obstruction occur-

ring during sleep. It includes

apneas, hypopneas, respiratory

effort-related arousals, and

hypoventilation.14

Signs and symptoms of SBD

include mouth breathing, snoring,

and sleep apnea. It peaks in chil-

dren ages 2 to 6. Poorly controlled

asthma, a high body mass index,

and restless legs syndrome can be

factors.15,16

Obstructive sleep apnea (OSA),

the major physical cause of chronic

sleep deprivation, is characterized

by episodic partial or complete

upper airway obstruction, usually

from enlarged tonsils and/or ade-

noids. OSA affects 2% to 5% of

infants, children, and teens.15

A recent study reports children

with SDB are 40% to 100% more

likely to develop neurobehavioral

problems by age 7, three times more

likely to have school grades of C or

lower, and seven times more likely

to have parent-reported learning

problems.10,17 The most significant

behavior change is hyperactivity.

Studies correlate childhood SDB

with obesity, metabolic syndrome,

and the risk of future heart disease,

hypertension, and cancer.2,11

Low socioeconomic status

increases the risk of SDB, partially

because of environmental concerns

and the high obesity rate in children

living in poverty.11,18,19 Many poor

children eat less fresh food and

have fewer opportunities for out-

door play and involvement in

sports programs.18,20 They’re more

likely to be exposed to air pollutants

and other environmental toxins that

can increase the body’s inflamma-

tory response and cause prolifera-

tion of the lymphadenoid tissue.

Research correlates habitual snoring

with SDB and associates it with

lower socioeconomic status, severe

respiratory problems, and adeno-

tonsillar hypertrophy.19,21,22 Black

children are twice as likely to expe-

rience SDB as White children.8

Sleep problems in children can

also be related to chronic disease.

Children diagnosed with painful

chronic illnesses, such as rheuma-

toid arthritis, sickle cell disease,

or gastroesophageal reflux, and

those with neurologic and psychi-

atric illnesses, are more likely to

have sleep problems not related

to sleep apnea.13 Fifty percent to

seventy-five percent of children

with neurologic and/or develop-

mental problems experience sleep

disruption.7

Behavioral and psychiatric factors

Children may become sleep deprived

due to emotional factors such as

stress, anxiety, and mood disorders.23

Children with a diagnosis of

attention-deficit hyperactivity disorder

(ADHD), an autism spectrum disor-

der, or substance abuse may have

impaired sleep cycles.2 Children

who’ve experienced severe trauma,

including physical and sexual abuse,

may suffer from posttraumatic stress

disorder (PTSD), which puts them

at risk for serious sleep problems

such as sleep enuresis, sleepwalk-

ing, nightmares, and night terrors.2

Nocturnal enuresis (recurrent involuntary nighttime voiding in

children over age 5) can disturb a

child’s sleep. Its cause, which can

Untreated sleep disorders can become chronic and lead to

underachievement, depression, and predisposition to or

exacerbation of health problems.

www.nursingmanagement.com Nursing Management • August 2014 25

be either physical (due to renal/

urologic abnormality or bladder

overactivity) or behavioral, needs to

be determined and treated.24 Some

children have a genetic predisposi-

tion to nocturnal (sleep) enuresis.25

Children who’ve never established

urinary continence are considered

to have primary enuresis. Second-

ary enuresis (bedwetting that

occurs after an established 6-month

period of dryness) is usually related

to stress, anxiety, or an undiag-

nosed medical condition.2

Enuresis is treated with behav-

ioral interventions such as enuresis

alarms (activated when a sensor

placed in undergarments or on a

bed pad detects moisture), bladder

training, giving rewards for dryness,

and limiting evening fluids.26 The

most commonly prescribed medica-

tion to treat enuresis is the antidi-

uretic hormone desmopressin.2,25

Sleepwalking usually begins between ages 6 and 12 and affects

more boys than girls.23 It occurs

more frequently and is more intense

in chronically sleep-deprived kids.2

Nightmares, which affect more girls than boys, are common in

childhood and occur later in the

night during light or rapid eye

movement (REM) sleep. Although

the child may be scared or upset,

the dream is usually remembered

and the child can be comforted.6

Night terrors are anxiety provok- ing to parents because the child

appears to be awake but may be

screaming uncontrollably. The

child is confused and disoriented,

unaware of the parent’s presence,

and not easily comforted. The child

may wake up or go back to sleep

quickly and have no memory of the

night terror in the morning. Night

terrors usually occur within 4 hours

of bedtime during deep non-REM

sleep and are more common in

boys.2,6

Behavioral signs of a child’s sleep

problems can also include frequent

awakenings during the night, talk-

ing during sleep, bruxism (teeth

grinding), and jaw clenching.23

Cultural effects on sleep

Insufficient sleep has become

increasingly common among

adolescents.12 The onset of puberty,

circadian rhythm disturbance (a

delayed sleep phase syndrome),

and a physiologic shift in sleep

onset to later times of the night

can disrupt teens’ sleep. Social

researchers believe that adolescent

sleep is also impacted by parents,

peers, and school relationships.27

Teens may have difficulty falling

asleep at their desired bedtime

and not wake spontaneously at

the correct time in the morning.2

Young people who consume

energy drinks may have trouble

falling asleep because of the

drinks’ high-stimulant content.28

Many children in the United

States have busy afterschool sched-

ules, fitting in sports, school

events, and other activities with

heavy homework expectations.

Academic stressors, family discord,

depression, and low self-esteem

can add to the sleep deprivation

problem. Parents who work long

hours may not enforce regular

bedtimes or set consistent bedtime

rules.2,29

The pressure to keep up with

peers while getting enough sleep

is even more intense in teens with

afterschool jobs, who may use the

weekends to catch up on their rest.

Nearly 70% of high-school students

don’t get the recommended hours

of sleep on school nights.29

Both students and teachers corre-

late lack of sleep with poorer school

performance and lower grades.29

Reducing sleep time by just 1 hour

can measurably impair children’s

cognitive processing and increase

their health risk behaviors related to

drugs, alcohol, cigarettes, and sex.30-32

Late evening use of electronics

can also negatively impact chil-

dren’s sleep.7 Evidence is growing

that violent video games and other

electronic activities put the body

in a stressful state by inducing the

fight-or-flight response, which

increases BP and heart rate.33 The

high level of visual and cognitive

stimulation from Internet surfing,

texting, and late evening TV watch-

ing also stresses the brain and body.

On average, children and adoles-

cents spend over 7 hours a day

engaged in a media activity.34 More

than 50% of teens in one study

reported texting or talking on cell

phones after bedtime.12 Too much

Behavioral signs of a child’s sleep problems may include frequent awakenings during the night, talking during sleep, teeth grinding, and jaw clenching.

Sleep deprivation in children

26 August 2014 • Nursing Management www.nursingmanagement.com

light in the bedroom, heavy use of

caffeine, late evening meals, family

noise or outdoor noise pollution,

and uncomfortable bedroom tem-

peratures are other deterrents to

restorative sleep.

Assessing for sleep problems

Routine use of brief assessment

tools can lead to early identification

of sleep issues and their underlying

causes. Various screening tools are

available to help clinicians assess

children for sleep deprivation. (See

Screening for sleep deprivation.) A nurse who suspects a child has

sleep problems should obtain a

comprehensive health history and

perform a complete physical assess-

ment. Parents can use a sleep diary

to record the child’s sleep/wake

habits over a 24-hour period for

2 consecutive weeks.2,6,13

Any child who snores, gasps, or

exhibits noisy or difficult breathing

during sleep should be assessed

for OSA.35 An overnight polysom-

nographic evaluation may be

needed.13 If the child is diagnosed

with OSA, treatment options

include positive airway pressure

therapy (continuous positive airway

pressure or bilevel positive airway

pressure) or surgery (often an ade-

notonsillectomy). If obesity is a

contributing factor, the child and

parents should receive dietary coun-

seling and information about the

importance of regular physical

activity.2,13,30

Treatment options

The plan of care for children with

sleep deprivation should include

the entire family. Advise parents to

model healthy sleep habits for their

children. Explore family dynamics

for strain, discord, and dysfunc-

tion.3,36 Consider ethnicity and

cultural values about cosleeping,

daytime napping, night snacking,

watching TV, and the importance

of sleep. Children with chronic night

terrors or those with special needs

(such as PTSD, ADHD, Tourette

disorder, or Prader-Willi syndrome)

should be referred to a sleep spe-

cialist or child psychologist or psy-

chiatrist for ongoing professional

follow-up.2,3,13,30

Children and parents may bene-

fit from techniques and lifestyle

changes to address limit-setting

problems, busy parental work

schedules, and other family stress-

ors. Sleep-related fears and anxiet-

ies may be eased by relaxation

training, guided imagery, and posi-

tive reinforcement.2,3

School nurses, who interact with

both teachers and students, should

discuss sleep hygiene in health

education classes; middle-school

children are particularly receptive

to this material.37 Along with teach-

ing the importance of healthy sleep

practices and the signs and symp-

toms of sleep deprivation, advise

children to:

• Avoid naps late in the day. • Reduce food and drink with high caffeine and sugar content, espe-

cially in the evening.

• Cut down on nonessential after- school activities.

• Create a bedtime routine centered on quiet activities such as reading

or listening to mellow music.

• Avoid high-energy activities 3 hours before bedtime.

• Use the bedroom for sleep only, not for communicating with friends,

watching TV, or eating.

• Make the bedroom cool, dark, and quiet. For specific ways to improve

the sleep environment, visit www.

sleepfoundation.org.13,30,35,38,39

Encourage parental involvement

in children’s sleep hygiene practices.

When speaking with parents, advise

them to:

• Remove TV sets, smartphones and cell phones, video games, and com-

puters from the child’s bedroom

and set curfews on their use.

• Keep sleep and wake-up times consistent, even on weekends for

elementary and middle-school chil-

dren. Teens may benefit from week-

end sleeping in.13,30,35,38,39

Medications should be prescribed

for sleep problems only if behav-

ioral therapy and modifications of

sleep practices are unsuccessful.

When used under the direction of a

healthcare provider, melatonin can

be a safe over-the-counter medica-

tion to induce sleep.6,13 In children

with anxiety or mood disorders,

antidepressants have been used

successfully. Suicide risk must be

carefully assessed, as children and

adolescents may have increased

Advise parents to model healthy sleep habits for their children.

www.nursingmanagement.com Nursing Management • August 2014 27

suicidal tendencies when taking

antidepressants.27 For children with

persistent insomnia whose psychi-

atric problems are under control,

medications with sedative effects,

such as chloral hydrate, gabapentin,

or risperidone may be helpful.

However, they must be used with

caution, if at all.2,13

Educating the community

To increase public awareness of

sleep problems in children, nurses

should advocate for:

• sleep education programs in hos- pitals, health departments, schools,

and work places

• placement of school nurses and pediatric nurse practitioners in

school-based health centers and

wellness clinics

• removal of caffeinated beverages and foods high in sugar from school

meal plans

• evidence-based clinical screening and evaluation tools for sleep

deprivation

• increased school board involve- ment in sleep and other health

issues

• nursing school curricula address- ing sleep deprivation in children.12,15

Sleep tight

Nurses are in a pivotal position to

improve the wellness of children by

routinely identifying and address-

ing sleep deprivation and its impact

on associated health, school, and

family issues. Screening for sleep

problems and developing individu-

alized care plans is a cost-effective

and easy way to improve children’s

health. Sleep habits established in

youth often carry over into adult-

hood, so addressing this issue with

pediatric patients can have lifelong

benefits.5,34 NM

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Screening for sleep deprivation

The following assessment tools for determining sleep deprivation in children can be found online.

• Children’s Sleep Habit Questionnaire A 35-item questionnaire to identify behaviorally and medically based sleep

problems in school children. http://www.gse.uci.edu/childcare/pdf/questionnaire_interview/Childrens

Sleep Habits Questionnaire.pdf

• Pediatric Sleep Questionnaire and the Pediatric Daytime Sleepiness Scale Appropriate for middle-school children. http://www.mcbg.org/internal/services/Sleep_Center/documents/

SleepPeds.pdf

• School Sleep Habits Survey A 63-item questionnaire that assesses older teens’ sleep/wake habits

and daytime functioning. http://sleepforscience.org/contentmgr/showdetails.php/id/93

• Sleep Disorders Inventory for Students Screens youth for physical causes of sleep deprivation. http://www.sleepdisorderhelp.com

Sleep deprivation in children

28 August 2014 • Nursing Management www.nursingmanagement.com

barriers to interventions. Soc Sci Med. 2013;95:97-105.

19. Billings ME, Auckley D, Benca R, et al. Race and residential socioeconomics as predictors of CPAP adherence. Sleep. 2011;34(12):1653-1658.

20. Levine JA. Poverty and obesity in the U.S. Diabetes. 2011;60(11):2667-2668.

21. Goldbart AD, Mager E, Veling MC, et al. Neurotrophins and tonsillar hypertrophy in children with obstructive sleep apnea. Pediatr Res. 2007;62(4):489-494.

22. Li S, Jin X, Yan C, Wu S, Jiang F, Shen X. Habitual snoring in school-aged children: environmental and biological predictors. Respir Res. 2010;11:144.

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25. Patel V, Golwalkar R, Beniwal S, et al. Elimination disorders: enuresis. Med J DY Patil Univ. 2012;5:14-17.

26. Tu ND, Baskin LS. Management of noctur- nal enuresis in children. UpToDate. http:// www.uptodate.com.

27. Maume DJ. Social ties and adolescent sleep disruption. J Health Soc Behav. 2013;54(4):498-515.

28. Pennington N, Johnson M, Delaney E, Blankenship MB. Energy drinks: a new health hazard for adolescents. J Sch Nurs. 2010;26(5):352-359.

29. Willingham D. Are sleepy students learning? http://www.aft.org/pdfs/americaneducator/ winter1213/willingham.pdf.

30. George NM, Davis JE. Assessing sleep in adolescents through a better understand- ing of sleep physiology. Am J Nurs. 2013; 113(6):26-31.

31. Waters F, Bucks RS. Neuropsychological effects of sleep loss: implication for neuro- psychologists. J Int Neuropsychol Soc. 2011;17(4):571-586.

32. McKnight-Eily LR, Eaton DK, Lowry R, Croft JB, Presley-Cantrell L, Perry GS. Relation- ships between hours of sleep and health- risk behaviors in US adolescent students. Prev Med. 2011;53(4-5):271-273.

33. Garrison MM, Liekweg K, Christakis DA. Media use and child sleep: the impact of content, timing, and environment. Pediat- rics. 2011;128(1):29-35.

34. Rideout VJ, Foehr UG, Roberts DF. Generation M: media in the lives of 8- to 18-year-olds. http://kff.org/other/ event/ generation-m2-media-in-the-lives-of.

35. Cleveland Clinic. Is your teen getting enough sleep? http://health. clevelandclinic.org/2013/01/is-your- teen- getting-enough-sleep.

36. Byars KC, Yeomans-Maldonado G, Noll JG. Parental functioning and pediatric sleep disturbance: an examination of factors associated with parenting stress in children clinically referred for evaluation of insom- nia. Sleep Med. 2011;12(9):898-905.

37. Turner LP. The nurse in the schools. In: Stanhope M, Lancaster J, eds. Public Health Nursing: Population-Centered

Health Care for the Community. 8th ed. Maryland Heights, MO: Mosby; 2011.

38. Cleveland Clinic. Healthy sleep habits for children. http://myclevelandclinic.org/dis- orders/sleep_disorders/hic_healthy_ sleep_habits_for_children.aspx.

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Lois Gerber is guardian ad litem for the state of Florida’s foster children.

This article originally appeared in the April issue of Nursing2014.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

DOI-10.1097/01.NUMA.0000451997.95978.2f

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