Insomnia in Children Care Plan

Patient Instructions/Care Plan Information

If you have any other questions about insomnia or the treatment we discussed today, please let me know. Attached is a detailed care plan that includes more information about insomnia as well as things you can do to help you and your child address this issue. If your child’s sleep problems are not improving with our recommended interventions please see your child’s doctor for further evaluation and management. Thanks for choosing K for Parents! 

What is insomnia?

Insomnia is a sleep problem characterized by difficulty falling or staying asleep.

While most children experience occasional periods of insomnia, prolonged insomnia can lead to behavioral, academic, and even medical problems. 

Insomnia, like other sleep issues, is more common in children with behavioral disturbances, anxiety, depression, ADHD, intellectual disability, and autism. Sleep problems are occasionally the result of medical issues such as anxiety disorders, restless leg syndrome, or obstructive sleep apnea.

Insomnia is categorized into 3 different types (based on their causes):

• Behavioral – where a child cannot fall asleep without the help of the parent. It is more common in younger kids, and seen as behavioral because it’s often associated with inadequate limit-setting and bedtime rules.

• Conditioned – this relates to anxiety about not falling or not staying asleep. It is more common in older children and adolescents, who may be anxious about what might happen if they don’t get enough sleep, which perpetuates the cycle.

• Transient – this refers to temporary episodes of sleep disturbance around a stressful life event, travel, or illness and lasts for a short period of time.

Diagnosis

The fact that a child isn’t sleeping as much as a parent thinks they should, doesn’t mean they have insomnia*. In order to be diagnosed officially with insomnia, sleep problems have to meet 3 criteria:

• It occurs at least 3 nights per week 

• For a time period of 4 weeks (or more) 
• Results in disruption to the child, parent, or family life

To establish a diagnosis, clinicians will want to know things like:

• When the problem started and how often it occurs
• How you respond to the problem
• Pre-sleep activities, bedtime routine, and sleep schedule
• Sleep environment, including the presence of siblings in the room, ambient noise, electronics in the bedroom
• Medication and/or caffeine use
• Daytime napping and or/sleepiness
• Nighttime snoring or frequent movement
• Psychosocial contributors such as stressful or major life events

*Keeping a sleep diary of when your child falls asleep and wakes up, including middle of night wake-ups, can provide useful information to clinicians.

Treatment

Treatment would depend on the nature and cause of your child’s insomnia.

→ For a child with behavioral sleep problems, try the following:

• Wind down an hour before bedtime with light activities like a puzzle or a book. No vigorous activity.
• Follow the same bedtime routine every night (e.g. a bath, pajamas, reading a story). 
• Keep all electronic devices out of the bedroom 
• Keep the room at a cool temperature
• Give your child a sleep association object such as a blanket or stuffed animal

→ For a child who resists sleep time, try the following:

• Either: end bedtime abruptly, and don’t respond to crying or opposition – or: check in at set intervals and gradually increase the time between check-ins.
• If your child is used to going to sleep later than they should, gradually move the bedtime forward 5 minutes per night until the correct time is achieved.
• Offer small, positive reinforcement (like a sticker in the morning) for an attainable goal (like staying in their room the whole night).
• Set clear limits after which no attention will be given. Expect opposition to increase initially before gradually fading.

→ For older children & adolescents, sleep problems are usually anxiety-related or due to circadian rhythm disturbance meaning that the child’s internal clock is a little off. Here are some suggestions:

• Keep a regular sleep schedule which means going to bed and waking up at the same time during the week and weekends. No sleeping in!
• No electronics at least 1 hour before bedtime. This means no cell phone in bed. The blue light disrupts the circadian rhythm causing the child to be more awake.
• They should get out of bed if they can’t fall asleep so maintain the association between their bed and sleep.
• Try relaxation techniques and CBT strategies to reduce anxiety

Medications

There is no medication labeled specifically for insomnia in children. (There are some medications that help with sleep issues indirectly, but these are for children with medical or psychiatric disorders or for extreme cases where behavioral strategies fail for at least 4 weeks.)

In some instances (like when returning from travelling), short term use (1-2 weeks) of melatonin, or a sedating antihistamine such as benadryl (diphenhydramine) can be tried after consulting with a clinician. 

Melatonin (for 1-2 weeks max)

Melatonin is a hormone that your body releases naturally at night readying your body for sleep. Melatonin is a non-prescription medication and can be used for short periods of time as a sleep aid: 

• Comes as pills, liquids, chewables
• Given 30 minutes before bedtime
• Common side effects: increased nighttime urination, morning grogginess

Dosage 

• Starting dose: 0.5-1mg 
• Older children: 2.5-3mg
• Adolescents: up to 5mg

Consult with a clinician beforehand, and do not use it for more than 1-2 weeks as its long term effects are not well understood.

Benadryl (for 1-2 weeks max)

Benadryl is an OTC sedating antihistamine that comes as a liquid or capsule.

Dosage (weight dependent, but generally):

• Smaller children – 12.5mg
• Older children and teens – 25mg

Note: 2^nd generation antihistamines such as Zyrtec or Clsritin are non-sedating and therefore cannot be used as sleep-aids.

Seek in-person care if:

• If your child has a chronic medical or behavioral issue
• Your child is not responding to basic behavioral interventions
• If you’d like to discuss prescription medications
• If you’re child experiences significant daytime sleepiness
• If your child snores or moves a lot at night

Clinicians at K Health can virtually help with:

• General questions about your child’s condition
• Supportive care suggestions and guidelines
• General followup for your child
• Dosages of specific medications

*If your child is a preschooler (3-5 years), they should be getting 10-13 hours of sleep per 24 hours, naps included. Gradeschoolers (6-12yo) need  9-12 hours of sleep, and teens (13-18 years) need about 8-10 hours of sleep.