A child not sleeping through the night, or not receiving adequate rest, is an unreported and often undiscussed topic between health care providers and parents. Many studies suggest that the lack of sleep, or interruption of sleep, may have numerous adverse effects on the well-being of a child. The lack of sleep may adversely influence the immune system and neurobehavioral changes. A majority of researchers in the field strongly encourage more research in this vastly misunderstood subject.
The subject of sleep disturbance and its ramifications is complex; this article addresses just a few areas that may be of interest to the family chiropractor.
Sleep may be interrupted for numerous reasons: sleep resistance, chemicals, television viewing habits, obesity, snoring and even text messaging are among the reasons for lack of a good night's sleep. Sleep is considered a restorative process that is important for the proper functioning of the immune system. There appears to be a link between severe sleep disorder in depressed and alcoholic subjects, and a decline in natural and cellular immunity and its association with changes in the cytokine network. When experimentally induced partial-night sleep deprivation was replicated, the result was a pattern of change within the immune system similar to that seen with depressive and alcoholic patients.1
A study from O'Brien, et al., revealed an association between primary snoring (PS) and neurobehavioral deficits in children.2 Although both study groups (snoring versus non-snoring) were in the normal range, the study revealed that children with PS performed worse on measures related to attention, social problems, and anxious/depressive symptoms. This was also true for overall cognitive abilities, and certain language and visuospatial functions were significantly lower for the PS group than the control subjects.
Another study, by Chervin, et al., suggests a possible correlation of inattention, hyperactivity, and symptoms of sleep-disordered breathing (SDB). The authors concluded that inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness, and in young boys, snoring and other symptoms of SDB. If daytime behavior is influenced by SDB and sleepiness, this may suggest a significant public health impact.3
For the adolescent population, increased consumption of caffeine beverages has been shown to have a detectable pharmacologic effect - it may cause disrupted sleep or counteract the daytime effect of interrupted sleep.4 Further complication for teenagers is the correlation that depressive symptoms (seen more with females) and cigarette smoking are linked with sleep difficulties.5
Is text messaging spoiling your teenager's sleep? One study of 2,500 teenagers from Belgium revealed, in preliminary findings, that mobile telephones could be having an impact on the quality of sleep of adolescents. Text messaging interrupted the sleep of one out of four 13-year-olds.6
Not to be left out is the potential link between television viewing habits and sleep disturbance. One study revealed that various TV viewing habits were associated with significant sleep disturbance, including increased daily television viewing and increased television viewing at bedtime; more so if the television set were in the child's bedroom. The areas of sleep disturbance that were affected were bedtime resistance, sleep onset delay, anxiety around sleep time, and shortened sleep duration.7
Other health-related issues that may interfere with quality of sleep for children include obstructive sleep apnea (OSA), which might be seen with the obese child, or upper airways resistance syndrome. Many of these disorders go undetected or treated.
The one thing that appears to be a consistent theme in the field of sleep and sleeping disorders is that most pediatricians do not address this health issue. Lack of history-taking is in part to blame: Quality and length of sleep, interruption of sleep, etc., should be assessed. This might be partially related to the minimal amount of instruction that is provided on this subject in medical and residency programs. One national survey discovered that the average instruction on sleep and sleeping disorders is 4.8 hours for pediatricians.8
So, what is a normal and necessary length of sleep for children? For a 6-month-old baby, it is 14.25 hours; for a 2-year-old, 13 hours; for a 5-year-old, 11 hours; for an 8-year-old, 10.25 hours; for a 12-year-old, 9.25 hours, and for an 18-year-old, 8.25 hours. Advising parents that both quantity and quality are equally important for children is key.
How can you make a difference in your family practice? First, pay attention to the patterns of sleeping habits in your child patients. Ask parents periodically about the length of time their child is sleeping, and about other potential disruptors of sleep: Does your child snore or watch television prior to bed, etc.? These are a few questions that might help assess your child patient and provide general advice or referral to parents.
References
- Irwin M. Effects of sleep and sleep loss on immunity and cytokines. Brain, Behavior, and Immunity 2002;16:503-513.
- O'Brien, et al. Neurobehavioral implications of habitual snoring in children. Pediatrics 2004;114:44-49.
- Chervin R, et al. Inattention, hyperactivity, and symptoms of sleep-disordered breathing. Pediatrics March 2002;109:449-456.
- Pollak C, Bright D. Caffeine consumption and weekly sleep patterns in US seventh-, eighth-, and ninth-graders Pediatrics January 2003;111:42-46.
- Pattern C, et al. Depressive symptoms and cigarette smoking predict development and persistence of sleep problems in US adolescents. Pediatrics 2000;106:e23.
- Text messaging is spoiling teenagers' sleep. BMJ, Sept. 13, 2003;327:582 (doi:10.1136/bmj.327.7415.582-c).
- Owens J, et al. Television-viewing habits and sleep disturbance in school children. Pediatrics 1999;104:27.
- Mindell JA, et al. Pediatricians and sleep disorders: training and practice. AAP 1994;94:194-200.
Claudia Anrig, DC
Clovis, California
