Medical Conditions Affecting Sleep in Children

Overview

Children and youth with special health care needs (CYSHCN), including ADHD, autism spectrum disorder, fetal alcohol syndrome, intellectual disability, traumatic brain injury, and similar conditions, tend to have more sleep problems than typically developing children. This page provides guidance on how to identify and treat medical issues that can contribute to poor sleep.

Symptoms

Symptoms suggesting a possible sleep problem:
  • Daytime sleepiness
  • Behavior problems
  • Attention difficulties
  • Mood problems
  • Learning problems
  • Headaches
  • Dry mouth

Underlying Causes

Organic sleep disorders, such as sleep apnea, restless legs, periodic limb movement disorders, parasomnias, bruxism, and enuresis, can impair sleep. See Screening for Sleep Problems.
Many other medical conditions can contribute to poor sleep. The primary care clinician should assess for the following. If the child is known to have any of the following, ensure it is treated adequately prior to initiating new treatments.
Anxiety: Consider anxiety contributing to poor sleep in babies and children who wake frequently, worry excessively, or have difficulty separating from parents. (While it is normal for babies and children to wake 8-10 times during the night, some experience anxiety when this occurs.) Anxious children benefit from relaxation activities, such as deep breathing, progressive muscle relaxation, biofeedback, or guided imagery. In more severe cases, consider a behavioral health referral or anti-anxiety medication, such as a selective serotonin reuptake inhibitor, to reduce the negative impacts of anxiety when going to bed and staying in bed all night. Clonazepam may help with bedtime anxiety, although it can cause agitation in some kids with neurodevelopmental disorders. See Sleep Medications for more details.
Asthma and chronic cough: Children who frequently cough at night may have asthma. Use adequate controller medications for night-time coughing, and consider pre-treatment with albuterol prior to bedtime. If asthma is exacerbated by allergens present in the home, provide additional education on limiting exposures to allergens and consider allergy medications. See Asthma.
Constipation: Children with infrequent, hard, or bulky stools or an abdominal mass consistent with stool burden may have abdominal pain that wakes a child during the night. See Constipation.
Depression: Because depression can lead to increased somnolence or decreased sleeping, consider depression in the differential diagnosis for a change in sleep patterns. See Depression .
Gastroesophageal reflux: Chest or upper abdominal pain when lying down or night-time vomiting, cough, or wheeze can suggest GERD. Consider raising the head of the bed, reducing intake for the couple hours before bed, or an empiric trial of reflux medications. See Gastroesophageal Reflux Disease.
Chronic pain: Whenever possible, address the underlying issue. Consider a Rheumatology consult, a Pediatric Chronic Pain specialist, and Behavioral Health for coping strategies, and/or acupuncture. When appropriate, work with a palliative care or hospice team to treat pain in patients with end-stage cancer or other life-limiting conditions.
Seizures: Abnormal repetitive movements or behaviors during the night can indicate a seizure disorder. Consult a pediatric neurologist to obtain an EEG. Ensure the bed is safe. See Seizures/Epilepsy.
Spasticity: For children with high tone, undertreated spasticity can cause pain and reduce sleep quality. Consult a physical medicine and rehabilitation doctor (physiatrist) for treatment of spasticity; this may include medications such as baclofen, Botox, tizanidine, and others. In collaboration with the specialists, consider a valium trial at bedtime only (starting at low doses and working up as needed), which may decrease spasticity without causing daytime drowsiness. [Mathew: 2005] See Cerebral Palsy for more information.
Substance abuse: Youth who are using various substances may have erratic moods or secretive behaviors. Some may have odors on their breath or clothes, pupillary changes, or skin findings such as track marks from injections that serve as clues to their use. Substance abuse can contribute to poor sleep (e.g., alcohol, marijuana, stimulant abuse). Ensure that all household medications are securely stored. Youth with substance use disorders benefit from brief intervention, referrals, and treatment starting in the medical home. See Substance Use Disorders.

Pearls & Alerts

Nonverbal children with sleep issues
It may take trial and error to rule out conditions that can disturb sleep. The Questionnaire to Help Identify Underlying Medical Conditions in Children with Autism (AAP) (PDF Document 281 KB) is a useful framework to evaluate for possible medical causes of disrupted sleep, even for children without autism.

Role of the Medical Home

In addition to monitoring for and treating underlying conditions impairing sleep, the medical home clinician should:
  • Review sleep behaviors and sleep hygiene. See Behavioral Techniques to Improve Sleep.
  • Ensure that the child has a safe environment at night if unmonitored while awake and discuss respite needs and options with the family. Consider safety gates, door alarms, cabinet, or fridge locks, etc.
  • Be aware that recurrent hospitalizations, surgeries, or illnesses can negatively impact CYSHCN’s sleep patterns. Consider a behavioral health referral and child life consultation during periods of hospitalization.
  • Review patient's medications to identify those that can make it harder to fall asleep (e.g., stimulants) or cause difficulty staying awake during the day (e.g., phenobarbital, clonidine).
    • Be aware that some medications used for sleep have increased potential to cause agitation in children with neurodevelopmental disorders (e.g., gabapentin, clonazepam).
    • Ask about the use of non-prescription medications, supplements, caffeine and energy drinks, and illicit substances that can impact sleep.
If no medical issues are keeping the child awake, then you can reassure parents so they can focus on Behavioral Techniques to Improve Sleep.

Resources

Tools

Screening for Sleep Problems
Links to commonly used screens and clinical information for next steps after a positive screen, including when to refer; Medical Home Portal.

Questionnaire to Help Identify Underlying Medical Conditions in Children with Autism (AAP) (PDF Document 281 KB)
A list of 29 yes/no questions given to parents by clinicians to help evaluate potential medical contributors to sleep issues in children with autism; American Academy of Pediatrics.

Services for Patients & Families in Nevada (NV)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Bruni O, Angriman M, Calisti F, Comandini A, Esposito G, Cortese S, Ferri R.
Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities.
J Child Psychol Psychiatry. 2018;59(5):489-508. PubMed abstract

Authors & Reviewers

Initial publication: November 2020
Current Authors and Reviewers:
Reviewer: Jennifer Goldman-Luthy, MD, MRP, FAAP

Page Bibliography

Mathew A, Mathew MC.
Bedtime diazepam enhances well-being in children with spastic cerebral palsy.
Pediatr Rehabil. 2005;8(1):63-6. PubMed abstract