Evidence based pediatrics - part 9 pdf

There is level obvi-I evidence that adult patients with RA develop fewer bone erosions over a 2-year period, if treated with prednisolone 7.5 mg daily as compared with placebo.126A recen

Sulfasalazine: sulfasalazine is widely used as a DMARD in the treatment of adult RA.There is now level I evidence (from a small RCT) that sulfasalazine is more effective thanplacebo in the treatment of JA.119About half those children taking sulfasalazine (in this study,the patients had polyarticular and oligoarticular JA) showed a response in a number ofimportant disease features, compared with about 25 percent in the placebo group However,sulfasalazine was associated with frequent side effects Sulfasalazine gets a grade B recom-mendation as a DMARD for JA.

Gold: intramuscular gold was once commonly used in the treatment of childhoodarthritis It is associated, however, with a high toxicity rate Because of the availability of moreeffective and safer alternatives (for example, methotrexate), gold is now rarely used in chil-dren There is level I evidence that the oral preparation of gold (auranofin) has no effect intreating JA.120Therefore, intramuscular gold gets a grade C recommendation, while oral goldgets a grade E recommendation

Hydroxychloroquine: there is level I evidence that suggests that the response of childrenwith JA to hydroxychloroquine is unlikely to be clinically important.121Hydroxychloroquine,however, has recently been widely used in combination with other DMARDs in the therapy

of adult RA There may be an as yet undefined role for hydroxychloroquine as part of bination therapy for JA Hydroxychloroquine gets a grade D recommendation as monother-apy and a grade C recommendation as part of combination therapy

com-Azathioprine: azathioprine is a potentially cytotoxic agent that is rarely used in JA.There is level I evidence from a small study of 32 subjects with severe JA that the toxicity

of azathioprine outweighs its benefit Therefore, azathioprine gets a grade D dation.122

recommen-Cyclosporine: because there is still a sizeable minority of children with JA who do notrespond to methotrexate, many other agents that can potentially relieve inflammation havebeen tried Cyclosporine is an effective agent used in the treatment of adult RA There is onlylevel III evidence, however, in children, which suggests that cyclosporine may have a role in

JA.123–125Cyclosporine, therefore gets a grade C recommendation

Corticosteroids: appropriate doses of corticoteroids result in an undoubted and ous clinical response (ie, reduction of pain, stiffness, and often signs of inflammation) inthe short term However, a high likelihood of serious side effects has prompted mostrheumatologists to limit the use of corticosteroids in the treatment of JA as much as pos-sible It remains unclear whether corticosteroids have any long-term benefit There is level

obvi-I evidence that adult patients with RA develop fewer bone erosions over a 2-year period,

if treated with prednisolone (7.5 mg daily) as compared with placebo.126A recent analysis showed that the short-to medium-term effects of prednisone were the same as, orbetter than, other active therapies for the control of symptoms.127It seems reasonable togive a grade B recommendation for the short-term use of low doses of oral corticosteroids

meta-as bridging therapy in those patients with severe arthritis who require DMARDs, most ofwhich take several months to achieve a reasonable clinical effect Oral corticosteroids may

be used to control symptoms while waiting for a DMARD to work Corticosteroids get agrade C recommendation for longer-term use

Oral Tolerance: oral tolerance with chicken cartilage has recently generated a lot of est in the treatment of inflammatory arthritis This is due to an exciting early report (levelI) of a study in adults with RA.128Oral tolerance is based on the proposal that small, frequentexposures to the cartilage antigen can reduce an arthritic patient’s immune response to theirown cartilage Oral tolerance has a theoretical advantage over other antiarthritic therapies;chicken cartilage is a natural substance with no known adverse effects

inter-A subsequent study of oral tolerance (level I), again in adult Rinter-A, failed to confirm astrong effect.129There is only level III evidence suggesting some effect in children with arthri-tis.130Therefore, oral tolerance gets a grade C recommendation

Uveitis Screening

Children with JA are at risk of developing potentially sight-limiting uveitis For many childrenwith JA, this is the most worrisome aspect of their disease The reason for concern is that theuveitis of JA is often asymptomatic and unrecognized until permanent damage has been done.Uveitis associated with JA is often easily treated; therefore, it makes sense to screen for the devel-opment of uveitis and treat it before damage occurs Children with the oligoarticular-onset sub-type, especially those with a positive ANA test, seem to be at the highest risk for uveitis.Children with JA can present with uveitis as late as 10 years after the onset of arthritis.131The American Academy of Pediatrics (AAP) has published guidelines for the frequency

of ophthalmologic examinations for children with JA (level III).132These guidelines rize children as being at high risk, medium risk, or low risk High-risk children are to bescreened every 3 to 4 months, medium risk children every 6 months, and low risk childrenevery 12 months

catego-The AAP guidelines define high-risk children as those with oligoarticular or ular onset, who are ANA positive, and have disease onset before the age of 7 years Four yearsafter the onset of arthritis, these patients are at medium risk, and 7 years after onset they are

polyartic-at low risk

The guidelines define medium-risk children as those with oligoarticular- or ular-onset disease, who are ANA negative, or have the onset of their disease after age 7 years.Four years after the onset of arthritis these children become low risk

polyartic-Children with systemic-onset arthritis are all considered to be in the low-risk category.Although these guidelines have not been formally evaluated, the seriousness of the prob-lem leads to a grade A recommendation

Transition.

As children with JA grow into adulthood, they face special challenges Children with arthritismay need special preparation to be able to work and adapt to a more independent life Manychildren with JA have developed a special, long-term realtionship with their medical careproviders As they approach adulthood, these patients need to move from a more paternalisticpediatric health-care system to an adult-oriented health-care system where they have to fendfor themselves Many models of transition care have been put forward, but there is little or noresearch to guide decisions on choosing the best model We have only testimonial evidence(level III) to support the different programs.133,134While it is clear that there is a need for tran-sitional services, any particular model can get only a grade C recommendation

Approach to Treatment of Juvenile Arthritis

Oligoarticular-onset JA. It is initially important, when a child presents with ticular joint inflammation, to carefully make a positive diagnosis of JA In those children(about half the children with oligoarticular JA) who present with a single swollen joint, it isespecially important to rule out other causes of monoarthritis (such as tuberculosis, hemo-philia in a boy, septic arthritis, or cancer) Children with JA should initially receive a 6-weektrial of an NSAID and usually a referral to a physiotherapist If the signs and symptoms ofinflammation continue or if contractures develop, then a referral to a pediatric rheumatol-ogist or to an adult rheumatologist experienced in dealing with children should be consid-ered for joint injections and follow-up care These children are usually at the highest risk foruveitis and should be screened as above The prognosis in this subtype of JA is good, andfamilies will need educational support

oligoar-Polyarticular and systemic-onset JA. Children with these more severe forms of tis should be referred to a comprehensive care clinic so that they can receive the multidisci-plinary therapies listed above These children should have uveitis screening, as appropriate.Children with chronic arthritis affecting several joints are highly likely to need transition carewhen they become adolescents

low (about 2 or 3 percent) frequency of coronary lesions A single-day infusion is more costeffective than a 4-day treatment as it is associated with a shorter hospital stay.139Therefore,treatment of KD in the acute phase (the first 10 days of illness) with 2 g/kg of intravenousimmunoglobulin (IVIG) as a single infusion gets a grade A recommendation.

The traditional treatment of KD is to combine acetylsalycylic acid (ASA) in high doses(80 to 100 mg/kg/day divided into four doses) with IVIG When the fever has resolved for

24 to 48 hours, the dose of ASA is reduced to 3 to 5 mg/kg/day to achieve an antiplateleteffect Low-dose ASA is continued until the subacute phase resolves, usually by 6 weeks (Thesubacute stage is marked by resolution of fever, elevated acute-phase reactants, high plateletcount, and peeling of the skin of the digits.) However, in a meta-analysis reviewing studies

of both high- and low-dose ASA there was no difference in coronary outcomes as long ashigh-dose IVIG was used.140Therefore, high-dose ASA initially and switching to low dose after

24 to 48 hours of being afebrile, as an adjunctive therapy gets a grade B recommendation.Because of the potential morbidity of the coronary lesions, patients should be seen inthe acute phase by a pediatric cardiologist or by a cardiologist experienced with children for

an echocardiographic evaluation and for follow-up

Henoch-Schönlein Purpura

Corticosteroids

Henoch-Schönlein purpura is a self-limited disease in the vast majority of cases Supportivetherapy is all that is usually required Corticosteroids have traditionally been consideredeffective for reducing the symptoms of arthritis and gastrointestinal pain in HSP, but highlevel evidence is lacking There is level II-3 evidence that prednisone, 1 to 2 mg/kg/day mayshorten the duration of abdominal pain to a certain extent, but by 72 hours, there is no dif-ference in pain between children treated or untreated with corticosteroids.141

More recently, investigators have examined the effects of corticosteroids in preventingthe development of delayed nephropathy (which may account for more than half the cases

of HSP nephritis) Two studies have reached opposite conclusions One American study(level II-2) found that exactly the same number of children treated with prednisone devel-oped nephritis as those who were not treated.142Conversely, an Italian study (level II-1), inwhich children who did not have nephritis at presentation were treated with 2 weeks ofprednisone (1 mg/kg/day) or with nothing, found that the untreated group developednephritis more often than those who were treated.143In fact, nobody in the treated groupdeveloped nephritis The number needed to treat to prevent one case of nephritis in thissecond study was about 9 None of the nephritis cases had persistent disease, and nonedeveloped serious renal failure; the clinical significance of this reported treatment effect isquestionable

Until better evidence is available, the use of corticosteroids in HSP gets a grade C ommendation

rec-Other Treatments

Factor XIII replacement was investigated in one small Japanese study (level I) after the vation was made that (1) factor XIII is decreased in the plasma of patients with active HSP,and (2) that the level of factor XIII is inversely proportional to the severity of the disease.144The investigators found a more rapid resolution of joint, gastrointestinal, and renal findings

obser-in the factor XIII group This study has not been replicated; therefore, at this poobser-int, factorXIII treatment must get a grade C recommendation

Another small study (level II-1) was done recently, comparing ranitidine (5 mg/kg) withplacebo in children with HSP and gastrointestinal bleeding.145Gastrointestinal bleeding wasdiagnosed by abdominal pain and occult blood in the stools This study found that signs and

Table 19–1 Summary of Treatments for Musculoskeletal Disorders

purpura

SLE = systemic lupus erythematosus; JDM = juvenile dermatomyositis; TENS = transcutaneous electrical nerve stimulation; NSAIDs = nonsteroidal anti-inflammatory drugs; IVIG = intravenous immunoglobulin

symptoms resolved about 2 days earlier in the treated group Until this study is repeated in

a proper RCT, ranitidine should get a grade C recommendation

CONCLUSION

The pediatric rheumatic illnesses include a spectrum of illnesses ranging from the commonand benign pain syndromes to the relatively rare but serious autoimmune diseases Althoughmuch of our data came from adult studies, it is clear that we have many successful treatments

to offer our patients A summary of the therapies for various musculoskeletal disorders inchildren is provided in Table 19–1

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121 Brewer EJ, Giannini EH, Kuzmina N, Alekseev L Penicillamine and hydroxychloroquine in the treatment of severe juvenile rheumatoid arthritis Results of the U.S.A.-U.S.S.R double-blind placebo-controlled trial N Engl J Med 1986;314(20):1269–76.

122 Kvien TK, Hoyerall HM, Sandstad B Azathioprine versus placebo in patients with juvenile toid arthritis: a single center double-blind comparative study J Rheumatol 1986;13:118–23.

rheuma-123 Pistoia V, Buoncompagni A, Scribanis R, et al Cyclosporin A in the treatment of juvenile chronic arthritis and childhood polymyositis-dermatomyositis Results of a preliminary study Clin Exp Rheumatol 1993;11:203–8.

124 Ostensen M, Hoyaeraal HM, Kass E Tolerance of cyclosporine A in children with refractory nile rheumatoid arthritis J Rheumatol 1988;15:1536–8.

juve-125 Reiff A, Rawlings DJ, Shaham B, et al Preliminary evidence for cyclosporin A as an alternative in the treatment of recalcitrant juvenile rheumatoid arthritis and juvenile dermatomyositis J Rheumatol 1997;24:2436–43.

126 Kirwan JR The effect of glucocorticoids on joint destruction in rheumatoid arthritis N Engl J Med 1995;333:142–6.

127 Saag KG, Criswell LA, Sems KM, et al Low-dose corticosteroids in rheumatoid arthritis tis Rheum 1996;39(11):1818–25.

Arthri-128 Trentham DE, Dynesius-Trentham RA, Orav EJ, et al Effects of oral administration of type II lagen on rheumatoid arthritis Science 1993;261:1727–30.

col-129 Sieper J, Kary S, Sorensen H, et al Oral type II collagen treatment in early rheumatoid arthritis Arthritis Rheum 1996;39(1):41–51.

130 Barnett ML, Combitchi D, Trentham DE A pilot trial of oral type II collagen in the treatment of juvenile rheumatoid arthritis Arthritis Rheum 1996;39(4):623–8.

131 Akduman L, Kaplan HJ, Tychsen L Prevalence of uveitis in an outpatient juvenile arthritis clinic: onset of uveitis more than a decade after onset of arthritis J Pediatr Ophthalmol Strabismus 1997;34:101–6.

132 Anonymous Guidelines for ophthalmologic examinations in children with juvenile rheumatoid arthritis Pediatrics 1993;92(2):295–6.

133 White PH, Shear ES Transition/job readiness for adolescents with juvenile arthritis and other chronic illness J Rheumatol 1992;19(Suppl 33):23–7.

134 Chamberlain MA, Rooney CM Young adults with arthritis: meeting their transitional needs Br

137 Newburger JW, Takahashi M, Beiser AS, et al A single intravenous infusion of gamma globulin

as compared with four infusions in the treatment of acute Kawasaki syndrome N Engl J Med 1991;324:1633–9.

138 Newburger JW, Takahashi M, Burns JC, et al The treatment of Kawasaki syndrome with venous gamma globulin N Engl J Med 1986;315:341–7.

intra-139 Klassen TP, Rowe PC, Gafni A Economic evaluation of intravenous immune globulin therapy for Kawasaki syndrome J Pediatr 1993;122:538–42.

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in Kawasaki disease: a meta-analysis of the efficacy of aspirin and immunoglobulin treatment Pediatrics 1995;96(6):1057–61.

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pre-144 Fukui H, Kamitsuji H, Nagao T, et al Clinical evaluation of a pasteurized factor XIII concentrate administration in Henoch-Schonlein purpura Japanese Pediatric Group Thrombosis Res 1989;56(6):667–75.

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vas-CHAPTER 20

Common Sleep Problems in Children

Darcy L Fehlings, MD, MSc, FRCPCGolda Milo-Manson, MD, MHSc, FRCPC

O

Sleep problems in children and adolescents are common and are frequently brought to theattention of the primary care physician Sleep problems can be divided into two general cat-egories: insomnias (defined in this chapter to mean difficulty falling or staying asleep) andparasomnias (disorders of sleep arousal associated with behaviors that intrude on sleep) Thischapter discusses the clinical features and management of common pediatric sleep problems

A critical review of the evidence supporting the management techniques is presented andthe quality of this evidence discussed

INSOMNIAS

Frequent Night Awakenings

Frequent night awakenings (NA) is one of the most common sleep problems, particularly inyoung children aged 6 months to 4 years The reported prevalence rates vary according tothe definition of NA from 10 percent (defined as a child who wakes up at least two times pernight) to 30 percent (defined as a child who wakes up at least three times per week).1–7 There

is evidence that sleep problems persist over time Zuckerman and colleagues8found in a gitudinal study that 41 percent of children who had a night awakening problem at

lon-8 months still had a sleep problem at 3 years of age These children were also more likely tohave behavioral problems during the day, particularly tantrums An NA pattern also affectsparents whose own sleep becomes disrupted

Several factors have been associated with frequent night awakenings These haveincluded a difficult temperament,5perinatal difficulties,1,5neurodevelopmental problems,9maternal depression, and family stress.7,8,5Parental responses, such as night-time feeding andcosleeping, have been considered potential risk factors.7,10From the child’s perspective, theseresponses can be very soothing and can reinforce and maintain the NA

Another variable that is widely accepted as a potential risk factor for an NA problem isthe presence of nonadaptive sleep associations Sleep associations have been well described

by Ferber and represent the regular bedtime environment or conditions that are present asthe child falls asleep.11Nonadaptive sleep associations are defined as bedtime conditions thatthe child cannot recreate by himself, for example, falling asleep while feeding (Table 20–1).Ferber theorized that children with nonadaptive sleep associations would have difficultyfalling asleep alone after an NA They would not settle to bed until the sleep associations wererecreated by the caregiver Research supports nonadaptive sleep associations as a risk factorfor NA Keener12found that children who were put to bed asleep and therefore, by defini-tion, had nonadaptive sleep associations had more night awakenings than children put to bedawake Adair and colleagues13reported that 9-month-old infants whose parents were presentwhen the child fell asleep were significantly more likely to wake at night than infants whoseparents were not present A study evaluating the risk of sleep problems in infants dischargedfrom neonatal intensive care units did not identify perinatal difficulties as a risk factor.Instead, they found that children whose parents stayed with them until they were asleep weremore likely to wake at night

Difficulty Settling to Bed

Difficulty settling to bed is also a very common sleep problem It often starts in thepreschool-age child and by elementary school age (5 to 12 years) becomes the most fre-quently reported sleep problem with a prevalence rate of 27 percent.14It often correlates withthe time that the child moves from a crib to a bed and therefore is not as easily contained.Developmentally, it corresponds to the time that the child is exerting his/her independencefrom the primary caregiver

Delayed Sleep Phase Syndrome

Delayed sleep phase syndrome (DSPS) refers to a shifting of the biologic sleep clock forward.The child/adolescent falls asleep late and wakes up late in the morning The human sleepclock, without external cueing, runs on an average 25-hour cycle Therefore, it is easy to shiftthe bedtime later each night and then sleep in during the morning The syndrome can often

be associated with difficulty settling to bed in the preschooler but becomes even more lent in the adolescent This occurs for a combination of reasons: increased autonomy of theadolescent over bedtime routines, social and school demands in the evening, and anincreased sleep requirement once the youth has entered puberty Factors such as excessivecaffeine, alcohol, or drug intake also need to be considered In the adolescent, DSPS can beassociated with daytime sleepiness and poor school performance

preva-EVIDENCED-BASEDMANAGEMENT FORPEDIATRICINSOMNIAS

There are two basic modalities for the management of NA, difficulty settling, and delayedsleep phase syndrome These include behavioral management and the use of medications

Description of Behavioral Management Techniques

Techniques for Night Awakenings

The four basic principles for treating night awakenings are:

1 Identifying nonadaptive sleep associations and guiding the parents in training the child

to fall asleep alone under conditions that the child can recreate himself or herself,

2 Identifying and removing any night-time positive reinforcers (enjoyable things pening to the child during the NA),

hap-3 Keeping morning awakening time consistent, and

4 Rewarding good sleep behavior

At the beginning of treatment, the parents should be encouraged to list the nonadaptivesleep associations that are present and the positive reinforcers of the NA This list can then

be addressed gradually over 2 to 3 weeks The parents should be encouraged to keep a sleepdiary to monitor the child’s sleep progress There are many different approaches and varia-tions of techniques Practical examples of techniques that the authors have used over manyyears in a pediatric sleep disorders clinic are outlined below

Table 20–1 Examples of Nonadaptive Sleep Associations

Falling asleep while feeding (breastfeeding or bottle feeding)

Falling asleep while being held by a parent

Falling asleep outside the bedroom and being brought into the bedroom asleep

Falling asleep with a pacifier that the child cannot put back in his/her mouth

Structured Bedtime Routine. Parents should be encouraged to structure a bedtime tine and keep it the same each night Four to seven activities should be chosen and done withthe child in the same order each night The bedtime routine ideally should last approximately

rou-20 minutes The structure and familiarity of the routine will help to make the child feel moresecure about going to bed It also sets limits about what is allowed at bedtime

Teaching a child in a crib to fall asleep alone. This technique is well described inFerber’s book “Solve Your Child’s Sleep Problems” and is an excellent reference book forparents.11After the structured bedtime routine is completed, the child should be put intothe crib awake The parent then leaves the room but is allowed to intermittently come backand reassure the “crying” child The parent is instructed to stay in the room for 1 minuteand to wait longer between checks The parent should also increase the time betweenchecks each subsequent night The parent can use this routine to respond to the child dur-ing the NA to decrease the amount of parental presence, which can act as a positive rein-forcer for the NA

Teaching a child in a bed how to fall asleep alone. The above method does not work aswell for a child who is in a bed as the child often will follow the parent out of the room Aroutine that works well for this age is the “chair-sitting” routine It was first described byRichman.15The parent starts by sitting in a chair close to the child The chair is moved far-ther away each night until it is out of the room and down the hall The parent is instructednot to talk or interact with the child during this time Children usually tolerate this routinewell without crying; however, an occasional child will not stay in bed The parent should beinstructed to warn the child once, to leave the room and hold the door shut for 1 minute,and then return to the chair This can be repeated, with a gradual increase in the time thedoor is held closed until the child stays in bed quietly Before starting this routine, the planshould be explained to the child For the child over 3 years of age, a sticker and praise can begiven in the morning if they are cooperative Besides teaching the child how to fall asleepalone and creating adaptive sleep associations, the chair-sitting routine can be used to grad-ually decrease parental contact during the NA

Decreasing night-time feeding. Night-time feeding is a common positive reinforcer for

NA and is not required for nutrition in healthy children past the age of 4 months If time feeding is present, it should be eliminated first before other issues are addressed.Changes in feeding should be made gradually over 1 to 2 weeks For the child who is bottlefed, the parents should be instructed to put one ounce less in the bottle each night Theamount in the bottle (or bottles) should be decreased by one ounce each night until the par-ent reaches zero This method works better than watering down the feed, as the parent is notleft trying to eliminate a bottle of water at the end of the routine

night-For breast-fed children the same principle is applied, but in this case, the feeding time

is decreased by 1 to 2 minutes each night The length of time between feeds can also belengthened by half an hour each night

Praising “good” night-time behavior. Parents should be encouraged to praise the child

in the morning for “good” night-time behavior For children in the preschool and early mentary grades, the use of stickers is recommended

ele-Prevention of night awakenings. Parents should be encouraged at the four month baby visit” to put their baby in the crib awake and to establish a structured bedtime routine.Night-time positive reinforcers can be reduced by keeping night-time encounters with thechild boring and brief, eliminating night-time feeding by 6 months of age and changing dia-pers at night-time only if necessary

“well-Techniques for Difficulty Settling

The same techniques described above for night awakenings under structured bedtime tines, teaching the child how to fall asleep alone (chair-sitting routine), and positive rein-

rou-Common Sleep Problems in Children 385

forcement of “good” sleep behavior are also used for difficulty settling Parents should beencouraged to help their child to shift to quiet activities an hour before bedtime.

Techniques for Delayed Sleep Phase Syndrome

Intervention techniques for DSPS involve resetting the circadian clock (chronotherapy) ofthe child/adolescent For children who have moved the bedtime and awakening time forward

2 to 4 hours, the parent should be counseled to move the awakening time in the morningearlier by 15 minutes to half an hour each day until the desired rising time is reached Thiscan be followed in a few days’ time by moving the bedtime earlier Parents should be coun-seled that bedtime and morning rising time need to be consistently reinforced 7 days a week.For the adolescent, often the shift is much greater than 4 hours Bedtime can occur at 4 or 5o‘clock in the morning and rising time in the early afternoon For individuals with this muchshift, it is recommended that the time clock be moved forward (usually by 3 hours eachnight) until the desired bedtime is reached For example, if an adolescent falls asleep at 4 am,

in the next 24-hour period, he should stay up until 7 am and continue to shift the bedtimeforward by 3 hours until the desired bedtime (for example, 11 pm) is reached This resettingneeds to be rigidly maintained 7 days a week, or it becomes easy to slip back into delayingthe bedtime Prior to starting these behavioral interventions, the child/adolescent and fam-ily require education about DSPS and need to be in agreement about the management sug-gestions The clinical features of DSPS and the use of chronotherapy are well outlined byCzeisler16and Thorpy.17

Review of the Evidence Evaluating Behavioral Management

Over the past 10 to 15 years, there have been numerous research studies, many of them domized controlled trials, evaluating the use of behavioral management in the treatment ofthe common pediatric sleep disorders such as night awakenings, difficulty settling, anddelayed sleep phase syndrome Table 20–2 summarizes research involving children who aredeveloping normally, and Table 20–3 reviews research in children with neurodevelopmentaldisorders Where two or more articles are identified evaluating the same behavioral tech-nique, the article with the strongest study design (usually a randomized trial) is summarized

ran-As outlined in Table 20–2, the quality of the evidence is strong with multiple ized controlled trials supporting the use of behavioral management for night awakenings anddifficulty settling, and behavioral management receives an “A” recommendation The use ofchronotherapy for DSPS has not been specifically researched in children/adolescents andreceives a “C” recommendation

random-Although there are not as many randomized controlled trials, there is still good dence (“A” recommendation) to support behavioral management in the treatment of nightawakenings and difficulty settling in children with mental retardation The treatment ofDSPS with chronotherapy has not been extensively evaluated and receives a “C” recom-mendation Behavioral management for other diagnostic conditions (for example, autism,visual impairment, cerebral palsy, acquired brain injury, and attention deficit hyperactiv-ity disorder) have not been well evaluated Further research evidence in these areas isrequired

Common Sleep Problems in Children 387

Common Sleep Problems in Children 389

Common Sleep Problems in Children 391

of tolerance, and an insomnia rebound effect.30The two most commonly used medicationsare chloral hydrate31and melatonin.32–34

Chloral Hydrate

The American Academy of Pediatrics policy recommendations on chloral hydrate31refer toshort-term sedation use only and not sleep disorders specifically A theoretical risk of car-cinogenicity has been found in animal studies; however, it is insufficient to warrant an alter-native selection There are no studies associating carcinogenicity and chloral hydrate inhumans Chloral hydrate is generally given 30 minutes prior to the desired bedtime at 10mg/kg/dose The dosage may need to be gradually increased to 25 mg/kg/dose After 4 weeks

of improved sleep, the child should be weaned from chloral hydrate over three to five nights.For recurrrence of sleep difficulties, the medication can be maintained for an additional 1

to 2 months and then the child weaned There is no research evaluating the efficacy of ral hydrate for sleep disorders in children It therefore receives a “C” recommendation

chlo-Melatonin

Melatonin is a naturally occurring hormone produced by the pineal gland and is felt to berelated to the resetting of a person’s biologic clock Few side effects have been docu-mented.33–35Long-term studies of both the safety and efficacy of melatonin are lacking Mela-tonin is available in fast- and slow-release forms In Canada, melatonin is available under theemergency drug release program through the Health Protection Branch of Canada In theUnited States, melatonin is available as a nonprescription hormone and can be purchasedover the counter in many drug and health food stores The preparation most readily avail-able is the fast-release form Melatonin is given 30 minutes prior to the desired bedtime Thedosage range is 1 to 10 mg A starting dosage for a toddler (less than 25 kg) is 2.5 mg, andschool-age children (greater than 25 kg) is 5 mg If there are no improvements after threenights, the dosage can be increased In our clinical setting, the maximum dosage has been 9

mg Following successful treatment over 2 to 4 months, the child can be weaned from tonin over 1 week If sleep problems return, melatonin can be restarted and then the childweaned again in 1 to 2 months If there is no response after 2 to 3 weeks, it should be dis-continued.35

mela-As outlined in Table 20–4, the level of evidence for the use of melatonin is primarily fromcase series with only one randomized trial supporting its use It therefore receives a “C” rec-ommendation Further randomized controlled trials are required

PARASOMNIAS

Parasomnia is a disorder of sleep arousal associated with behaviors occurring during sleep,such as night terrors and sleepwalking The behaviors are secondary to central nervous sys-tem motor and autonomic arousal.42Parasomnias are divided into two disorders of arousal,determined by their occurrence during either rapid eye movement (REM) or non-REMsleep Night terrors and sleepwalking are both non-REM sleep arousal disorders Nightmaresare REM sleep arousal disorders Parasomnias occur more frequently in males than infemales.42Individuals who have one type of parasomnia have a greater likelihood of having

a second parasomnia A family history of parasomnias is also common in these individuals.42

Night Terrors

Night terrors occur during the transition from non-REM to REM sleep43and generally inthe first 1 to 4 hours of sleep They are considered a normal developmental phenomenon.Night terrors generally begin after 18 months of age The reported prevalence is 6 percentfor healthy children.30 They often occur in clusters and then will disappear for severalmonths before recurring Night terrors in children can be extremely frightening for their