Insomnia Insomnia

Insomnia in Children and Adolescents 55
The intervention in cases like Amanda’s involves identifying the predisposing
factors, explaining normal infant sleep physiology, and helping parents to
do what they can. Amanda might be diagnosed with vulnerable child syndrome
(1). Amanda’s history of prematurity caused her parents to perceive
her as being vulnerable. With the best intentions, Amanda’s parents became
overly responsive to her normal arousals.
It is helpful to explain to parents that all children have brief arousals several
times a night. Although these arousals are spontaneous, return to sleep can be
hindered if parents intervene. Furthermore, Amanda’s parents were gently
reminded that at 2 years of age, Amanda was no longer at risk for Sudden
Infant Death Syndrome.
The solution in cases like Amanda’s is to gradually and gently decrease the
amount of parental intervention. Additionally, in Amanda’s case, the bedtime
routine was changed. She was offered a cup of milk 1 hour before sleep onset.
She was put to bed drowsy but still awake. When she cried out in the middle
of the night, a parent would come to her bedside but would avoid picking her
up, rocking her, turning on the light, talking to her, or providing things she
could not get for herself such as the bottle. After several weeks of disciplined
restraint by her parents, Amanda’s behaviors during the night resolved.
Limit-setting sleep disorder is seen in children whose parents provide little or
inconsistent bedtime routines. It is commonly seen in 2- to 6-year-olds. Bedtime
struggles intensify with the child evading bedtime by stalling, whining, requesting
snacks, and so on. This disorder ultimately leads to prolonged sleep-onset latency.
Resolution occurs when parents communicate first with each other about a consistent
bedtime practice and then implement this reliably with the child.
Differential diagnosis of the sleepless infant involves circadian issues, organic
disorders, and parental stresses. Many children presenting with sleep-onset difficulties
have a circadian rhythm that does not fit parental expectations. For example,
a toddler with a biologically driven sleep-onset time of 9:30 PM is not going to adapt
to a 7:30 PM bedtime no matter what behavioral modification tool is brought to bear.
Using a sleep log (see Fig. 1) helps one to determine the child’s intrinsic circadian
rhythm.
There are several organic conditions seen in infants and toddlers that may interfere
with initiating or maintaining sleep. Among the most common are reflux, milkprotein
intolerance, and asthma. Reflux should be considered in infants who awaken
fully and have difficulty returning to sleep (16). Milk-protein intolerance can manifest
as insomnia in infants. These children have elevated Immunoglobulin E levels
and positive radioallergosorbent testing (16). One study of infants averaging 4
months old with milk-protein intolerance identified frequent arousals (8–22 per
night) and short sleep cycles that resolved when milk protein was eliminated from
the diet (17).