Sleep-onset association disorder in infancy usually can beprevented by parental understanding of infant sleep physiology, developmentally appropriate expectations, and planningthe infant sleep environment to coincide with family needs.It is recommended that infants be put in bed drowsy, but stillawake, after they have had a diaper change, food, and comfort. Some toleration of infant crying is required for the infantto achieve self-regulation of sleep. A safe sleep environmentis essential. It is important for parents to understand that it isnormal for their infant to wake frequently for the first 6 weeksbefore settling into a routine of waking every 3 to 4 hoursfor feeding. Infants typically do not sleep through the nightbefore 6 months of age, and some do not sleep through thenight before 12 to 18 months of age. Even though co-sleeping(mother and infant sleeping together) is common, it is notrecommended because of increased risk of SIDS. Proactivelyconsidering the desirability of bed sharing allows parents tobe in control rather than ceding control to the young child.
Behavioral interventions comprise the mainstay of treatmentfor behavioral sleep disorders. In addition to meticulous attention to sleep hygiene and bedtime practices, difficulty fallingasleep and bedtime resistance in young children are treated byspecific behavioral strategies. Systematic ignoring consists of not responding to a child’s demands for parental attention at bedtime. Unmodified extinction (“cry it out”) involves putting thechild to bed and then ignoring the child’s demands until thenext morning. Graduated extinction involves waiting successively longer periods of time before briefly checking on the child.Both methods are effective in decreasing bedtime resistance andenabling young children to fall asleep independently. Positivereinforcement strategies can also be used in preschool-aged and older children. These include rewards (e.g., stickers) for meeting a bedtime goal (e.g., staying in bed). Rewards should beprovided immediately (first thing in the morning) to increaseeffectiveness and better link the reward with the positive behavior. Children with nighttime fears can benefit from behavioraltherapy aimed at reinforcing feelings of safety.
Infrequent or nonintrusive parasomnias do not need treatment beyond education and reassurance. Ensuring a safe environment is important. Sleep terrors are best managed by minimal intervention, because conversation with the child is impossible during the episode. Anticipatory brief awakening of the child shortly before the typical occurrence of a parasomnia may be effective in aborting the event. Children with frequent or prolonged parasomnias may need a sleep study to evaluate for possible coexisting sleep disorders or nocturnal seizures. Medications that suppress slow-wave sleep may be indicated in severe cases.
Circadian rhythm disorders are also treated by ensuring sleephygiene practices and gradual resetting of the biologic clock.Bedtime fading involves allowing the child to go to bed at thetime he or she naturally feels tired, then gradually advancingthe bedtime forward over the course of several weeks.
Rarely children with insomnia are treated pharmacologically. Melatonin (dose, 2.5 to 10 mg) has soporific properties useful in treating delayed sleep phase syndrome. It has been used successfully in both children with normal development and those with developmental delays. Melatonin is available without prescription in stores that sell dietary supplements. The α-agonist clonidine acts preferentially on presynaptic α2 neurons to inhibit noradrenergic activity. Somnolence is a side effect of clonidine, which can be put to use in cases of refractory sleep difficulties; this is an off-label use in children. Clonidine is usually started with a dose of 0.05 mg at bedtime and increased to 0.1 mg if needed. There are data on treating children as young as 4 years old with clonidine. Weaning offclonidine is recommended at the end of treatment.
The most obvious and serious complication associated with childhood sleep disorders is impairment of cognitive ability and emotional regulation. This impairment puts children at risk for school failure, family difficulties, and social problems. It is likely that sleep-deprived children are at increased risk for acute illness and psychiatric disorders.