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 for diagnosis and treatment information.

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 and Anxiety Disorders for management information.

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. See Pain in Children with Special Health Care Needs.

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.

Because depression can lead to increased somnolence or decreased sleeping, consider depression in the differential diagnosis for a change in sleep patterns. See Depression.

Sleep behavior issues are common in children with FASDs and may include any combination of:

• Increased bedtime resistance
• Greater sleep anxiety
• Delayed sleep onset
• Increased incidence of parasomnias (e.g., nightmares and enuresis)
• Shorter overall sleep duration (waking earlier than necessary or desired by the family)
• Frequent nighttime awakenings
• Difficulty returning to sleep after nighttime awakenings, which frequently resulted in problematic and sometimes unsafe behaviors such as climbing on furniture, accessing dangerous household items (e.g., knives), or excessive eating.

These sleep problems are thought to be related to sensory processing disorders frequently seen in FASD. The number and severity of problematic sleep-related symptoms were highly correlated with scores indicating pathology on the Sensory Profile, a caregiver report of sensory reactions displayed by a child to given inputs and their behavioral and emotional responses to such. [Wengel: 2011] The brainstem reticular formation, important in sensory processing, must be down-regulated in order to facilitate the induction of sleep. This down-regulation causes the brain to “filter out” irrelevant or nonthreatening stimuli in order to maintain sleep, while maintaining the capability for arousal in case a threatening or noxious stimulus is perceived. It is posited that in children with FASD, their inability to ignore irrelevant stimuli and down-regulate may be at least partially responsible for their difficulties with both delayed sleep onset and with nighttime awakenings. In addition, abnormalities in the hypothalamic-pituitary axis resulting from in-utero alcohol exposure are thought to contribute to the sleep difficulties and associated hypervigilance often seen in children with FASD. Animal models have also demonstrated increased nighttime wakefulness and decreased sleep hours overall in those exposed prenatally to alcohol.
Children with FASDs have a distinctive sensory processing profile that is most often characterized by a predilection for sensation-seeking, but poor registration (e.g., understanding) of what is actually occurring around them. [Jirikowic: 2008] These children tend to have a high neurological threshold and feel under-stimulated; hence, the seeking of additional sensation appeals to them. Additionally, children with FASD are more likely to fall into the clinically concerning range on both long- and short-form Sensory Profile tests in the domains of tactile sensitivity, auditory filtering, and movement sensitivity. Low scores (indicative of more significant pathology) on the short sensory profile were predictive of more significant behavioral problems, as measured by the Child Behavior Checklist. Thus, sensory processing problems tend to correlate both with poorer sleep at night and more disruptive behavior during the day. [Franklin: 2008] As such, children with FASD will likely benefit from early consultation of Occupational Therapy in order to target sensory processing impairment that appear to lead to secondary disability via behavioral and sleep problems.

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.

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.

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.

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.

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.