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Sleep disorders in cerebral palsy

The study by Jacquier and Newman is a valuable reminder of the challenges faced by carers managing the sleep of young people with cerebral palsy and other motor disabilities. Sleep problems in this population begin at a young age, tend to persist, and can be detrimental to the physical and mental health of young people and their caregivers. This particular study focuses on the prevalence and determinants of co-sleeping using questionnaires for cases and unmatched controls. Co-sleeping is a difficult outcome to define, and is not necessarily a ‘bad thing’, being the preferred sleeping arrangement for many cultures around the world. In this study, although no causality can be determined, co-sleeping was associated with improved sleep in the young people and worse sleep for their carers. While the study goes on to explore medical factors that might explain increased rates of co-sleeping, it is also likely that in some cases sleep association difficulties have arisen and have never been adequately addressed. There is a tendency to overlook basic sleep association disorders when faced with a child requiring overnight postural changes and tube feeding, for example. However, it is nearly always possible to time such interventions to still allow the child to learn appropriate sleep associations and ‘self-soothe’. In this group of families, who are often exhausted and at their wits’ end, it is important to emphasize that such behavioural interventions are as powerful as any sleep medications, without the risk of adverse affects. Well-timed support either in the form of more frequent initial face-toface or telephone follow-up can boost therapeutic success. Sleep can be disrupted in almost every conceivable manner in this group of young people, for whom a combination of intrinsic and extrinsic factors often come together in a perfect storm to disturb sleep rhythms and fragment sleep throughout the night. Intrinsic factors include neurological factors, of which the presence of nocturnal seizures is the most important. The mechanisms are complex and probably include sleep fragmentation secondary to seizures, anticonvulsants compromising sleep and daytime alertness, and alteration in caregivers’ approach to sleep associations. The degree of intellectual disability, and frequent presence of comorbid autism or attention-deficit–hyperactivity disorder, predict poor sleep in this group of young children, just as in those with no motor impairment. Brainstem dysfunction and intrinsic sleep rhythm disorders are often seen, with visual impairments affecting circadian rhythms and worsening sleep. Sleep-related breathing problems are common and underestimated; they include obstructive events secondary to abnormal upper airway tone and central events secondary to poor brainstem control, aspiration, and gastro-oesophageal reflux. Sleep-related breathing disorder questionnaires have particularly poor sensitivity and are no substitute for standardized objective overnight sleep studies. Unsurprisingly, studies indicate that sleep disorders are positively associated with level of motor functioning using Gross Motor Function Classification System. The more severe grades are likely to experience pain from muscle spasms, hip dislocations, and inability to alter sleeping positions. This is a particularly vicious circle whereby poor sleep also affects pain perception thresholds. Extrinsic factors include caregiver variables around employment, single parents, and co-sleeping. This group of young children are frequently prescribed many medications, including anticonvulsants and medications to reduce muscle tone. These can all, singly or in combination, alter sleep maintenance, increase risk of sleep-related breathing difficulties and reduce levels of daytime alertness. With this background knowledge it is now time to conduct well-designed randomized controlled studies that will