When sleep problems are medical

Before any behavioural approach to infant sleep, there is a short list of medical causes worth excluding, because none of them respond to routines.

Obstructive sleep apnoea

The most important and most commonly missed.

In children it is usually caused by enlarged tonsils and adenoids, and it affects a meaningful proportion of preschool children.

The signs are not sleepiness, as in adults, but: habitual snoring, mouth breathing, pauses or struggling to breathe during sleep, restless sleep and unusual sleeping positions with the neck extended, sweating, bedwetting, and daytime behaviour problems, hyperactivity or inattention.

Risk is higher in children with obesity, with Down syndrome, with craniofacial differences and with neuromuscular conditions.

Untreated it is associated with growth, behavioural and cardiovascular consequences.

Adenotonsillectomy is highly effective in most children, and it is the reason a snoring child should be assessed rather than sleep-trained.

Iron deficiency

Common in toddlers and associated with restless sleep and with restless legs.

Risk factors: prematurity, low birth weight, high cow's milk intake, low intake of iron-rich foods, and a restricted diet.

Restless legs syndrome occurs in children and is frequently misdiagnosed as growing pains or behavioural resistance to bedtime.

Features: an urge to move the legs, worse in the evening and at rest, relieved by movement.

Iron studies including ferritin are worth checking, and treatment of deficiency frequently improves sleep substantially.

Reflux and allergy

Where discomfort drives waking.

Reflux with distress causes waking, arching and difficulty lying flat, and is discussed elsewhere on this site — with the important caveat that sleeping a baby on an incline or on their front is not an appropriate management and conflicts with safe sleep guidance.

Cow's milk protein allergy can present with disturbed sleep alongside gut, skin and feeding symptoms.

Eczema causes itching that is worse at night, and treating it properly with emollients and appropriate topical steroids frequently transforms sleep for both child and parent.

Ear problems

Acute otitis media causes pain that is worse lying flat, producing sudden onset of night waking in a previously settled child.

Recurrent ear infections and glue ear also disturb sleep.

Which is why a sudden change in a good sleeper should prompt consideration of illness before anything else.

Neurodevelopmental conditions

Where sleep problems are more common and frequently more persistent.

Children with autism, ADHD and various genetic and neurological conditions have substantially higher rates of sleep difficulty.

Melatonin has a specific evidence base in some of these populations and is prescribed by specialists rather than being appropriate as a general remedy.

Behavioural approaches still help and generally need adapting.

And referral to a specialist sleep service is appropriate rather than persisting with generic advice.

Other causes worth considering

Briefly.

Pain of any kind, including dental.

Urinary tract infection, which is easily missed in young children.

Constipation.

Medication effects, including some asthma medications and decongestants.

Thyroid disorders.

And, in an older child, anxiety, which is a common and treatable cause of bedtime resistance and night waking.

What to bring to an appointment

What makes the consultation useful.

A sleep diary over one to two weeks: bedtimes, settling time, wakings, duration, naps, and what happened.

A video of any unusual breathing or movement during sleep, which is enormously more informative than a description.

The pattern over time: when it started, what changed around then.

Growth records.

Daytime behaviour, appetite and mood.

And a clear question, since sleep problems in a busy appointment can otherwise be deflected with general advice.

The practical order

A reasonable sequence.

Exclude the medical causes above, particularly if there is snoring, pain, sudden change, poor growth or daytime symptoms.

Check the basics: timing, environment, routine, daytime sleep and feeding.

Then consider a behavioural approach if wanted and appropriate for the age.

And return for reassessment if nothing works, since persistent unexplained sleep difficulty in a child is a legitimate reason for further investigation rather than for accepting it.

General information only, not medical advice. Consult a clinician about persistent sleep problems, and seek assessment if your child snores habitually or has pauses in breathing.