Sleep Problems in Children and Teens

When children or teens with a heart defect have a sleep problem, sometimes they show symptoms that are obviously connected to sleep. For example, they might:

• be tired during the day

• fall asleep during the day

• be awake at night

• complain of problems sleeping

Other times, sleep problems can show up in symptoms that do not seem as clearly related. For example, children with sleep problems may:

• be irritable

• have trouble with attention

• have behavioral problems

• be moody

• have learning problems

Teens who have sleep problems may also have driving problems, including getting into car accidents.

When a child has obstructive sleep apnea, their throat muscles relax and block their throat while they are sleeping. This makes them briefly stop breathing, then start to wake up, and then start breathing again.

Obstructive sleep apnea can cause problems such as:

• not enough deep sleep

• snoring

• moodiness

• trouble concentrating

• mouth breathing

• waking up gasping and choking

• dry mouth and sore throat

• bedwetting

Treatments for obstructive sleep apnea include:

• surgery to remove adenoids and/or tonsils

• wearing a device that widens the lower jaw and pushes it forward

• nasal steroids

• wearing a device that pushes air into the airway and keeps it open (CPAP)

Families should always consult a doctor if they suspect a child has sleep apnea. It can negatively affect a child's health, especially when a child already has a heart defect.

When a child has nightmares, they have scary dreams that wake them up. Almost all children have occasional nightmares, and occasional nightmares are not a cause for concern. Children generally have more nightmares if they are overtired or very stressed. Children with heart defects often have more nightmares after a medical procedure, hospitalization, or other scary experience.

Nightmares can become a problem if they are very frequent. Children who have frequent nightmares may become afraid of sleeping, bedtime, and the dark. Then, they may avoid sleeping, which can lead to more tiredness, which can lead to more nightmares.

In many cases, parents can help kids reduce and manage nightmares with strategies such as:

• playing and relaxing in their bed

• reminding them what is real and what is pretend

• having a consistent and pleasant bedtime routine

• using a nightlight

• using comfort items such as a special blanket or stuffed toy

• prioritizing sleep and having more total sleep time

• using calming strategies before bed such as meditating, singing, or stretching

Children who have ongoing problems with nightmares may need help from a doctor and/or therapist. When children are less anxious overall, they usually have fewer nightmares.

When a child has sleep terrors, they suddenly act very afraid while they are sleeping. They may sit or stand up, open their eyes, cry, scream, and wave their eyes or legs. They are usually very difficult to awaken during an episode.

Unlike nightmares, sleep terrors do not usually wake the child. When a child wakes up later, they usually have no memory of the sleep terror.

In most cases, sleep terrors are not a cause for concern. They can be a problem if they occur frequently, or if they cause the child to be unsafe. For example, some children run around or try to fight while having a sleep terror, which can be dangerous.

Families can usually manage sleep terrors by reassuring the child and keeping the child safe while they wait for the terror to end. Sometimes waking a child several hours after bedtime can help to prevent sleep terrors. Since sleep terrors are more common when a child is overtired, going to bed earlier can also help.

If a child walks or fights during sleep terrors, families should make the sleeping area safe with baby gates, door latches, removing clutter, and containing any sharp or dangerous objects.

Families should consult a doctor if sleep terrors are very frequent, if they lead to dangerous behavior, or if a child is overtired because of sleep terrors.

Children who have behavioral insomnia of childhood have sleep difficulties that do not result from physical causes. Instead, these sleep problems are considered "behavioral." Behavioral insomnia is fairly common among children with heart defects.

There are 3 types of behavioral insomnia:

1. Sleep-onset association: In this type, a child cannot go to sleep without certain conditions that they associate with sleep. For example, a child may require rocking in a chair, listening to a particular song, or sucking milk from a a sippy cup in order to go to sleep. When a child naturally rouses overnight, they require these conditions in order to go back to sleep.

2. Limit-setting: in this type, a child has trouble agreeing to go to bed. They may refuse to comply with bedtime, and deliberately delay going to sleep.

3. Combined: In this type, the child has sleep associations, and also refuses or delays going to bed.

Behavioral insomnia can get better with behavioral treatments. In many cases, treatment is provided by a psychologist or other therapist.

Families can work with a therapist to break unhelpful sleep associations, and to form sleep associations that work well in their family. They can learn behavioral strategies to help children be able and willing to go to bed as expected.

Families can talk to their cardiac neurodevelopmental team, therapist, or pediatrician for help with behavioral insomnia.

Delayed sleep phase usually appears in adolescents or young adults. When a teenager has delayed sleep phase, they have a lot of trouble falling asleep and waking up at the typical times for their culture. It can take them 2 hours or longer to fall asleep on most nights unless they stay up very late.

Delayed sleep phase can be a problem if it affects a teen's ability to get to school or work on time, if it disrupts family life, or if it negatively influences a teen's mood.

Delayed sleep phase can get better when young people practice sleep hygiene, including:

• no screens before bedtime

• low light before bedtime

• regular sleep/wake times and routines

• cool, dark bedroom

• a fan or white noise

• only using the bed for sleep

Families should consult a doctor if delayed sleep phase is causing a teen to not get enough sleep, to miss out on activities, or to feel grumpy or sad.

Children or teens who have restless leg syndrome feel a strong urge to move their legs while they are resting. Their legs may feel uncomfortable but not painful, and the discomfort is reduced when they move.

In most cases restless leg syndrome is not a serious problem. In some cases it can be a problem if it makes it hard for a child to sleep, and results in their being overtired or distressed. Doctors can sometimes treat restless leg syndrome with iron supplements or other medications.

When a child has a heart defect, sleep is central to their wellbeing, and to the wellbeing of their parents and siblings. Sleep disturbances can lead to physical problems, as well as problems with attention, behavior, mood, social skills, and learning.

When a child has developmental concerns, families and providers should always discuss their sleep, and consider if a sleep problem may be part of their profile. In some cases, improving sleep can lead to drastic improvement across many areas of functioning.

This content was reviewed by a psychologist at Boston Children's Hospital.

Families local to Boston can get help for sleep concerns from the Cardiac Neurodevelopmental Program and the Sleep Center. Click below for more information.