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Medical disorders resulting in problem sleeplessness in children

Medical disorders resulting in problem sleeplessness in children
Author:
Stephen H Sheldon, DO, FAAP
Section Editor:
Ronald D Chervin, MD, MS
Deputy Editor:
April F Eichler, MD, MPH
Literature review current through: Dec 2022. | This topic last updated: Apr 08, 2022.

INTRODUCTION — Problems with sleep onset and maintenance are common complaints presenting to the child health care practitioner. A sleepless child affects the entire family, and symptoms of problem sleeplessness are often identified in several members of the same family. Sleeplessness may cause a child to have problems with daytime performance, behavior, or mood, regardless of the underlying cause of the sleeplessness.

Problem sleeplessness in children (pediatric insomnia) is a symptom of a heterogeneous group of disorders that include but are not limited to conditioned, behavioral, social/environmental, circadian rhythm, and medical causes. The causes and clinical presentation of sleeplessness in children are quite different from those in adults, and the approach to diagnosis and management is correspondingly different.

Little substantive literature exists exploring the association between medical conditions and sleeplessness in childhood. This topic review describes medical conditions that may be associated with sleeplessness in children. The general assessment of sleep disorders in children and the diagnosis and management of behavioral sleep problems are discussed in separate topic reviews. (See "Assessment of sleep disorders in children" and "Behavioral sleep problems in children".)

OTITIS MEDIA — Otitis media is common in children. Acute otitis media is typically characterized by ear pain, with or without associated fever, and rarely goes unrecognized. However, chronic middle ear disease may go unnoticed; serous or secretory otitis media associated with persistent middle ear effusions can present with disrupted nocturnal sleep, with few other symptoms.

Acute otitis — Children with acute suppurative otitis media typically present with fever, otalgia, changes in appetite, and vomiting and may appear acutely ill. Prolonged or repeated arousals and wakings often occur and may be associated with daytime sleepiness and a decrease in daytime activity levels. Physical examination reveals loss of normal tympanic membrane landmarks, erythema, or bulging of the tympanic membrane. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

Sleep disruption caused by acute otitis media should improve promptly with effective treatment of the infection. However, on occasion, a child will have persistent sleep disruption after recovering from acute otitis media, either because of a persistent effusion or because the wakings triggered a behavioral type of sleep problem. As an example, a parent or caregiver's response to the child's wakings may inadvertently reinforce the behavior. (See "Acute otitis media in children: Treatment", section on 'Response to antibiotics or observation' and "Behavioral sleep problems in children", section on 'Behavioral insomnia of childhood'.)

Chronic otitis — In contrast, chronic secretory or serous otitis media can be associated with few symptoms. Conductive hearing loss may be present, but this might be clinically unrecognized. The physical examination reveals a retracted tympanic membrane with limited mobility, and air/fluid levels may be visualized behind the tympanic membrane. Sleep may be disrupted by ear discomfort. This discomfort might not be notable during daytime waking hours but can become problematic during the nocturnal sleep period.

Treatment options for chronic otitis media include watchful waiting, tympanotomy tube placement, a short course of antibiotic therapy, surgical placement of tympanostomy tubes, and adenotonsillectomy. Antihistamines and corticosteroids are not recommended. Indeed, antihistamines can have the paradoxical effect of causing or worsening the sleep disruption [1]. (See "Otitis media with effusion (serous otitis media) in children: Management", section on 'Approach to management'.)

ALLERGIC RHINITIS — Difficulty initiating and maintaining sleep may occur in patients with seasonal allergic rhinitis or chronic allergic rhinitis. Allergic rhinitis affects up to 40 percent of children in the United States. Symptoms include sneezing, rhinorrhea, nasal congestion, pruritus, itching of the eyes and nose, insomnia, and daytime fatigue. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)

Intranasal glucocorticoid sprays (eg, fluticasone propionate, fluticasone furoate, mometasone furoate, or budesonide) have minimal systemic side effects and are the drugs of choice in the treatment of allergic rhinitis in children older than three years [2]. Antihistamines have been shown to be effective in decreasing symptoms and can induce sleepiness but can also result in problem sleeplessness [3]. (See "Pharmacotherapy of allergic rhinitis" and 'Medication-induced sleep disturbance' below.)

ATOPIC DERMATITIS — Atopic dermatitis (eczema) is a common cause of sleeplessness in children [4]. It affects between 5 and 20 percent of children and causes sleep disruption in up to 60 percent of affected children [5]. Sleep disruption is caused by itching or by the medications such as antihistamines or corticosteroids that are used to treat the dermatitis.

Children with atopic dermatitis have been shown to have increased limb movements during sleep and increased wake after sleep onset [6]. Even in children with mild atopic dermatitis, limb movements during sleep can exceed greater than 15 events per hour of sleep, resulting in sleep fragmentation.

The diagnosis and treatment of atopic dermatitis are discussed in separate topic reviews. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis" and "Treatment of atopic dermatitis (eczema)".)

ASTHMA — For patients with asthma, complaints of difficulty initiating and/or maintaining sleep may be indications that the asthma is not well controlled [7]. Sleep complaints in patients with asthma may be caused by uncontrolled nocturnal symptoms, medications, or continued exposure to environmental allergens. Nocturnal coughing and sleep-related changes in ventilation may also disrupt sleep, resulting in sleeplessness as a primary complaint. (See "Nocturnal asthma".)

Comorbidity of obstructive sleep-disordered breathing (pediatric obstructive sleep apnea [OSA]) in patients with asthma is common. Pediatric OSA may impact the severity of asthma. Global Initiative Guidelines stress the importance of evaluating patients with asthma for OSA [8]. There may be considerable improvement of asthma symptoms and severity after OSA is successfully treated [7]. (See "Evaluation of suspected obstructive sleep apnea in children" and "Management of obstructive sleep apnea in children".)

NEUROLOGIC AND NEURODEVELOPMENTAL DISORDERS — Children with neurologic impairment may exhibit problem sleeplessness, including difficulty initiating sleep, difficulty staying asleep, or both. Disordered sleep-wake schedules and circadian rhythm disorders may also occur. In some cases, the sleep disturbances in these children are caused or exacerbated by the medications used to treat the underlying neurologic condition.

Disorders in which sleep disturbance is particularly common include:

Static encephalopathy, cortical and non-cortical blindness, and hearing impairment mediated by cranial nerve VIII.

Neurodevelopmental disorders, especially autism spectrum disorders, and Rett, Angelman, Williams, and Smith-Magenis syndromes [9,10].

Seizure disorders, which may also present with sleeplessness, sleepiness, or both.

Cerebral palsy – Sleep disorders are present among 20 to 45 percent of children with cerebral palsy and include difficulty in initiating and maintaining sleep, sleep-wake transitions, and sleep-related breathing disorders [11,12]. Children with epilepsy or severe visual impairment are particularly at risk.

Clinical presentation and diagnosis — Sleep problems in children with neurologic disorders may be due to a variety of underlying causes, including the neurologic condition itself, medications used to treat that condition, or non-neurologic factors. Therefore, assessment of the child's sleep problem must include a comprehensive evaluation, and the sleep disturbance should not be prematurely attributed to the neurologic condition itself. As examples, children with static encephalopathy and contractures may present with a difficulty initiating and maintaining sleep that is usually attributable to discomfort and a need for repositioning than to the primary underlying neurologic abnormality. Children with spastic quadriplegia and other forms of static encephalopathy may have obstructive sleep apnea (OSA) or gastroesophageal reflux that fragments sleep.

Assessment of a sleep disorder in a child with a neurologic condition resembles the approach taken in healthy children. Completion of a comprehensive sleep log is frequently helpful in evaluation of the sleep-wake cycle. The sleep log may help to identify a behavioral cause, instead of or in addition to a sleep disorder that arises from dysfunction of the neurologic mechanisms responsible for maintenance of sleep-wake cycles, sleep onset, or sleep maintenance. Medications used for management of the principal neurologic condition may also impair sleep. (See 'Medication-induced sleep disturbance' below and "Assessment of sleep disorders in children", section on 'Chief sleep complaint and sleep history'.)

If a pharmacologic or behavioral cause of the sleep disorder is not identified, nocturnal polysomnography may be useful. Polysomnography is the gold standard for diagnosis of OSA and sleep-related movement disorders. For children with known or suspected seizure disorders, expanded polysomnographic electrode arrays can be used to assess for sleep-related seizure activity not apparent during wakefulness. (See "Evaluation of suspected obstructive sleep apnea in children".)

Management — Management of sleeplessness in a child with neurologic dysfunction is dependent upon the underlying cause. Factors that may influence sleep and the sleep-wake cycle, other than the neurologic disorder, should be considered first.

Behavioral management — If a conditioned or behavioral problem is suspected, behavioral interventions, improvements in sleep hygiene, and cognitive-behavioral therapy should be pursued and are often effective [13,14]. In comparison with healthy children, neurologically impaired children may require a more gradual introduction of behavioral interventions. The sleep-wake schedule should be addressed, especially in children with special sensory disorders such as blindness. Treatment of sleep-schedule abnormalities can result in rapid improvement of sleep patterns and often can improve daytime function. (See "Behavioral sleep problems in children", section on 'Young children with behavioral insomnia'.)

If medications are thought to contribute to the sleeplessness, the timing and dose of medication might be modified. Alternatively, the clinician can consider substituting an alternative medication that is less likely to cause sleep disruption.

Even if the underlying neurologic abnormality appears to cause the sleeplessness, the clinician and caretakers should still evaluate and optimize sleep hygiene [15]. If improvement of sleeplessness occurs with mild medications, such as diphenhydramine, the child will most often show similar improvement without the use of drugs.

A meta-analysis of nine randomized trials in 690 children with neurologic and neurodevelopmental disorders found moderate quality evidence that behavioral sleep interventions improve sleep outcomes, including self-reported sleep disturbances and sleep patterns as measured by actigraphy, compared with a control condition [14].

Pharmacotherapy — Hypnotic or sedative medication is occasionally required for children with neurologic and neurodevelopmental disorders who do not respond to sleep hygiene and other behavioral measures. If pharmacotherapy is used, nonpharmacologic strategies should also be used concurrently, including behavioral management and parental education. Treatment goals should be realistic and should be discussed before embarking on a trial of pharmacotherapy.

Selection of the appropriate medication depends on the specific sleep complaint, potential side effects, and interaction with concomitant medications [16]. Drugs used for problems with sleep initiation should generally have quick onset and a short duration of action, whereas those used for problems with sleep maintenance require longer duration of action. However, the duration should not be so long that daytime sedation occurs. Ideally, there should be limited tolerance, few drug-drug interactions, and limited rebound sleeplessness.

Once medication is instituted, daytime function and sleep symptoms should be monitored to assess for efficacy and potential side effects. Periodic withdrawal of medication is also suggested. Once the symptoms of sleeplessness are controlled, it may be possible to discontinue the medication without exacerbation of symptoms [17]. Although medication is typically recommended only for short-term use, prolonged use may be appropriate in some children with neurologic disability, if the benefits outweigh the risks.

There is limited evidence on which to base decisions about pharmacotherapy for problem sleeplessness in children. None of these drugs are approved by the US Food and Drug Administration for this use in children; this is therefore an "off label" use. In our practice, we generally use one or more of the following strategies for patients who do not respond to sleep hygiene and other behavioral measures:

Iron — If the patient appears to have frequent movements during sleep, or a family history of restless legs syndrome or periodic limb movement disorder of sleep, we first attempt supplemental iron therapy and/or measure serum iron and ferritin to assess for iron deficiency. This is because restless legs syndrome is associated with iron deficiency in children [18]. (See "Restless legs syndrome and periodic limb movement disorder in children" and "Iron deficiency in infants and children <12 years: Treatment".)

Melatonin — Melatonin is a second choice if iron therapy is not successful, if the history suggests circadian phase delay, or if an alternative to more mainstream hypnotics is desired. We typically provide a prescription for 1 mg of melatonin to be taken approximately 90 minutes prior to bedtime on an empty stomach. Liquid preparations and sublingual drops usually should be avoided due to the presence of alcohol (melatonin is not water-soluble). We recommend nothing to eat 30 minutes prior to the dosing or 30 minutes following the dosing. The melatonin may be crushed and mixed with a small amount of applesauce or given with a small amount of apple or orange juice; this acidic medium can help with dissolution of the filler. Considerations about melatonin for children are summarized in the table (table 1), and details are discussed separately. (See "Pharmacotherapy for insomnia in children and adolescents: A rational approach", section on 'Melatonin'.)

The use of melatonin is based primarily on expert opinion, but clinical evidence is accumulating to support its safety and efficacy in some populations of children with neurologic and neurodevelopmental disorders. This was shown in a meta-analysis of melatonin in children with neurologic disabilities, autism spectrum disorder, or attention deficit hyperactivity disorder (ADHD; total of 541 children in 13 trials) [19]. In the pooled analysis, melatonin improved total sleep time (mean difference compared with placebo [MD] 48.26 minutes, 95% CI 36.78-59.71) and sleep onset latency (MD -28.97 minutes, 95% CI -39.8 to -18.1) but did not change the frequency of nocturnal awakenings. There were no medication-related serious adverse effects.

Special considerations for selected groups of patients:

Autism spectrum disorders – The meta-analysis included a subgroup with autism spectrum disorder (110 children, four trials) [19]. Melatonin significantly improved total sleep time (MD 61.3 minutes, 95% CI 50.5-72.1) and sleep onset latency (MD -35.3 minutes, 95% CI -45.7 to -25.0). Further details of sleep problems in this population are discussed in a separate topic review. (See "Autism spectrum disorder in children and adolescents: Pharmacologic interventions", section on 'Sleep disturbance'.)

ADHD – The meta-analysis included a subgroup with ADHD (72 children, two trials) [19]. Melatonin modestly improved sleep onset latency (MD -17.7 minutes, 95% CI -27.3 to -8.1). Further details of sleep problems in this population are discussed in a separate topic review. (See "Sleep in children and adolescents with attention deficit hyperactivity disorder", section on 'Management of sleep problems in ADHD'.)

Epilepsy – Although early reports raised the possibility that melatonin might increase seizures in children with epilepsy, subsequent reports do not support this concern and some suggest that melatonin may even reduce seizure activity [20,21].

Smith-Magenis syndrome – In patients with Smith-Magenis syndrome, there appears to be an inversion of melatonin secretion. Administration of melatonin in the morning may be helpful, although the mechanism for this paradoxical effect is unclear. Additionally, treatment may include daytime administration of acebutolol, an adrenergic antagonist that blocks melatonin secretion, combined with nocturnal melatonin administration. This might increase nocturnal melatonin concentration, improve nocturnal sleep, and aid in correcting the timing of sleep. Behavior may also be improved [22-24]. (See "Microdeletion syndromes (chromosomes 12 to 22)", section on '17p11.2 deletion syndrome (Smith-Magenis syndrome)'.)

Tasimelteon, an oral melatonin receptor agonist, is an option that was approved by the US Food and Drug Administration (FDA) in 2020. In a small randomized cross-over trial of 25 patients with Smith-Magenis syndrome (age ≥3 years), nightly tasimelteon modestly improved subjective sleep quality compared with placebo [25]. In the clinical trial, although improvement in the amount of sleep obtained on the 50 percent of nights with least sleep favored tasimelteon, the difference compared with placebo was not statistically significant. With the small sample size, there is uncertainty about the clinical effects in children with Smith-Magenis syndrome, and care should be taken. The most common side effects from tasimelteon are headache, increased alanine aminotransferase, and nightmares. Co-administration with strong CYP1A2 inhibitors such as fluvoxamine should be avoided.

Other drugs — Other drugs that are sometimes useful in the management of sleep problems in children with neurodevelopmental disabilities include:

Gabapentin or other anticonvulsant drugs – May be appropriate for children with concomitant seizure disorders and/or disorders of arousal

Nonbenzodiazepine receptor agonists (eg, zolpidem or eszopiclone) – Limited data on efficacy or safety in children, but may be appropriate for older adolescents

Benzodiazepines (eg, lorazepam) or antihistamines (eg, diphenhydramine) – Primarily for children with a specific short-term need for pharmacotherapy

Antidepressants (eg, tricyclic antidepressants or atypical antidepressants) – Primarily for insomnia in the presence of comorbid mood issues

We generally avoid clonidine or chloral hydrate for sleep in children, including those with neurodevelopmental disabilities, due to adverse effects. Clonidine is sometimes used for treatment of ADHD as an adjunct or alternative to stimulants and may have a beneficial effect on sleep in that population. (See "Sleep in children and adolescents with attention deficit hyperactivity disorder", section on 'Adjustment of ADHD medications'.)

Selection among these drugs should be based on the clinician's judgment of the best match between the clinical circumstances (eg, type of sleep problem, patient characteristics, expected duration of therapy), the individual properties of currently available drugs (eg, onset of action, safety, and tolerability), and any comorbid disorders (eg, ADHD, anxiety, or depression). For children with neurodevelopmental disabilities, the child's baseline level of function also influences choice of treatment. Details about each of these drugs are discussed in a separate topic review. (See "Pharmacotherapy for insomnia in children and adolescents: A rational approach".)

ATTENTION DEFICIT HYPERACTIVITY DISORDER — Sleep disturbances have been reported in as many as 70 percent of children with attention deficit hyperactivity disorder (ADHD), depending upon the definitions of sleep problems used [26,27]. Common complaints are of bedtime resistance and sleep-onset difficulties, night awakenings, morning awakenings, and daytime sleepiness [28]. Important contributors to these problems include behavioral issues (distractions and poor sleep hygiene) and side effects of stimulant therapy. Assessment and management of these issues are discussed in separate topic reviews. (See "Behavioral sleep problems in children" and "Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents", section on 'Amphetamines' and "Sleep in children and adolescents with attention deficit hyperactivity disorder".)

Conversely, disrupted or inadequate sleep may result in tiredness and daytime behavioral difficulties with focused attention, learning, and impulse regulation, which may mimic or exacerbate ADHD symptoms. Therefore, children with ADHD should be assessed for the possibility of obstructive sleep apnea or other primary sleep disorders. (See "Assessment of sleep disorders in children".)

MEDICATION-INDUCED SLEEP DISTURBANCE — A wide variety of medications can cause sleep disruption (table 2), including some that are intended to treat the sleep problem. Although sedative-hypnotic drugs are often initiated as a treatment for sleep problems, they rarely solve the sleep problem in the long term; indeed, chronic use of these drugs frequently exacerbates the sleep problem. If improvement is noted when these medications are first tried, it is often due to its effects on sleep hygiene, and attention to appropriate sleep hygiene would have resulted in resolution of symptoms. (See "The effects of medications on sleep quality and sleep architecture".)

Medications that are commonly prescribed to treat sleep problems in children may paradoxically contribute to sleep disturbance. These include antihistamines and major sedatives (eg, chloral hydrate and phenobarbital, which may cause paradoxical hyperactivity). Benzodiazepines such as diazepam and lorazepam are not generally useful for the management of sleep problems, because of the development of tolerance, as well as abuse potential. However, the anxiolytic effects of benzodiazepines tend to persist, so some patients are able to use them for this purpose without undesirable sedation. Each of these classes of medications may result in residual daytime sleepiness and adversely affect daytime performance. (See 'Pharmacotherapy' above and "Generalized anxiety disorder in adults: Management", section on 'Benzodiazepines'.)

Seemingly innocuous medications prescribed for acute or chronic illness may also be responsible for sleeplessness. Orally administered bronchodilators (eg, albuterol or theophylline) often cause sleep disruption through direct or indirect stimulation of the central nervous system. Inhaled bronchodilators are less likely to disrupt sleep because they tend to have a short duration of action. Antibiotics, especially liquid preparations, have been associated with difficulty initiating and maintaining sleep [17]. The vehicle rather than the antibiotic itself may be responsible for the sleep disruption. Over-the-counter medications, especially combination drugs, may also be implicated.

Several classes of drugs, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors, may precipitate or exacerbate nighttime movement disorders in adults (eg, bruxism or restless legs syndrome).

Consumption of or withdrawal from caffeine, alcohol, and nicotine are associated with acute and sometimes chronic insomnia. The possibility of overt or covert use of these substances should be considered in children and adolescents with problem sleeplessness that is otherwise unexplained. (See "Risk factors, comorbidities, and consequences of insomnia in adults", section on 'Medication and substances'.)

Clinical presentation and diagnosis — Medication history should be taken, including use of over-the-counter medications and herbal preparations. If the child is taking any medications, it is important to determine their doses and timing of administration. Although most medications do not result in marked or stereotypical patterns of sleep disruptions, nocturnal settling difficulties and nighttime waking problems may occur.

Hypnotics, sedatives, and neuroleptics can cause significant changes in sleep architecture. Depending on the medication, total sleep time may be decreased or the sleep-wake cycles may be shifted. For patients who are taking these medications, recording sleep patterns in a sleep diary for a period of two weeks is often helpful in documenting circadian sleep-wake rhythms. In addition, nocturnal polysomnography may be useful.

Treatment — If possible, the suspected offending medication should be discontinued. If this is not possible, modification of timing of administration or dose may be attempted. Switching to a similar medication or the same medication prepared differently may be successful (eg, changing from orally administered bronchodilators to inhaled preparations).

CHRONIC ILLNESS — Many chronic conditions can contribute to persistent sleep problems. Pain or discomfort from the illness or from treatment regimens may be contributory. As an example, sleep abnormalities are common in children with juvenile idiopathic arthritis and are multidimensional, including nocturnal waking and parasomnias [29]. Disorders such as migraine cephalgia, asthma, diabetes mellitus, gastroesophageal reflux, and seizures have all been associated with sleep disturbances [30-33]. The problem of sleeplessness may be directly caused by the underlying disorder or may be an indirect consequence of therapy, medication, anxieties, or pain.

Clinical presentation and diagnosis — It is often difficult to isolate factors related to the illness that precipitate the sleep problems. In some cases, the cause of the sleep disruption is obvious, as in a child whose sleep is disrupted because of itching associated with chronic eczematous dermatitis. In many other cases, it is unclear whether the sleep disruption is caused by the primary illness, associated symptoms, side effects of medication or therapy, or the family's or child's response to the illness. Therefore, each of these factors must be considered during a thorough evaluation.

Treatment — Treatment is based on management of the underlying chronic disorder, control of associated symptoms, and appropriate attention to sleep hygiene. If parental or patient anxiety about the chronic illness is suspected, appropriate supportive interventions should be recommended. The potential roles of medication or cognitive-behavioral therapy in the setting of sleeplessness due to chronic medical disorders remain largely unstudied.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Insomnia in children".)

SUMMARY AND RECOMMENDATIONS

Overview – A variety of medical problems may contribute to sleep disturbance in children and are often compounded by behavioral problems, inadequate sleep hygiene, or adverse effects of medications. (See 'Introduction' above.)

Otitis media – On occasion, a child will have persistent sleep disruption after recovering from acute otitis media, either because of a persistent effusion or because the wakings triggered a behavioral type of sleep problem. Chronic secretory or serous otitis media may disrupt sleep in children even if minimal clinical symptoms appear during the day. (See 'Otitis media' above.)

Allergic rhinitis – Seasonal allergic rhinitis or chronic allergic rhinitis often impair initiation or maintenance of sleep. Responsible symptoms can include sneezing, rhinorrhea, nasal congestion, pruritus, and itching of the eyes and nose, which can all contribute to insomnia and daytime fatigue. (See 'Allergic rhinitis' above.)

Eczema – Up to 60 percent of children with atopic dermatitis (eczema) have disrupted sleep, which is caused by itching or by medications such as antihistamines or corticosteroids used to treat the dermatitis. (See 'Atopic dermatitis' above.)

Asthma – Difficulty with sleep initiation or maintenance in a child with asthma may warrant evaluation for inadequate nocturnal control of asthma symptoms, influence of medications, exposure to allergens, or obstructive sleep apnea, which is a common comorbidity. Diagnosis and treatment of sleep apnea may improve both sleep symptoms and asthma control. (See 'Asthma' above.)

Neurologic disorders – Children with neurologic disorders are at increased risk for problem sleeplessness. This may be caused by the neurologic condition itself (causing disturbance of sleep-wake cycles), discomfort due to comorbidities, medications used to treat that condition, or conditioned or behavioral factors. (See 'Neurologic and neurodevelopmental disorders' above.)

Behavioral management and efforts to improve sleep hygiene should be included in any management plan. (See 'Behavioral management' above.)

Pharmacotherapy is occasionally required for children with neurologic disorders who do not respond to sleep hygiene and other behavioral measures. If pharmacotherapy is used, nonpharmacologic strategies should also be used concurrently, including behavioral management and parental education. (See 'Pharmacotherapy' above.)

Attention deficit hyperactivity disorder (ADHD) – Children with ADHD often have associated problems with sleep initiation or maintenance. These symptoms are sometimes but not always associated with stimulant therapy. Behavioral issues also may contribute to the problem. (See 'Attention deficit hyperactivity disorder' above and "Sleep in children and adolescents with attention deficit hyperactivity disorder".)

Medication-induced sleep disturbance – A wide variety of medications can cause sleep disruption, including some that are intended to treat the sleep problem (table 2). Although sedative-hypnotic drugs are often prescribed in practice as a treatment for sleeplessness, for most children, these agents are not optimal long-term strategies. Indeed, chronic use of these drugs can exacerbate the sleep problem. (See 'Medication-induced sleep disturbance' above and 'Pharmacotherapy' above.)

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