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Sleep physiology in children

Sleep physiology in children
Literature review current through: Jan 2024.
This topic last updated: Jul 17, 2023.

INTRODUCTION — Sleep is an active, dynamic physiologic process that has a critical impact on many aspects of health, daytime function, and development. During the first few years of life, a number of important developmental changes occur, leading to the expected adult sleep-wake pattern [1-3].

This topic review will describe normal sleep-wake patterns in infancy and childhood. This will provide background for an evaluative approach to sleep problems in children, which is discussed in a separate topic review. (See "Assessment of sleep disorders in children".)

Sleep stages and architecture in adults are discussed in detail separately. (See "Stages and architecture of normal sleep".)

SLEEP STATES — Two distinct sleep states have been identified based on specific physiologic variables: rapid eye movement (REM) sleep and nonrapid eye movement (NREM) sleep. Standardized methods have been developed with regard to scoring sleep states in infants, children, and adults [4].

REM sleep is a physiologically distinct state, characterized by an activated pattern on electroencephalogram (EEG; similar in some respects to wakefulness), associated with marked decrease in muscle tone and episodic bursts of REM. Most dreaming occurs during REM sleep [5,6].

NREM sleep is subdivided into three discrete stages based primarily on the EEG. The stages range from N1 (the lightest and often initial stage of sleep) to N3 (deep NREM sleep with a high arousal threshold); N3 corresponds to what was previously scored as stages 3 and 4.

REM sleep was first characterized in 1953 [7]. In 1966, Roffwarg and colleagues sparked interest in the developmental aspects of sleep when they reported that newborns spend significantly more time in REM sleep as compared with older individuals [1]. These investigators postulated that activation of key portions of the central and autonomic nervous system during REM sleep contributed to functional maturation. This hypothesis helped explain a number of differences in the sleep of infants compared with adults, as described below. Availability of all-night polysomnography in children has allowed more precise characterization of sleep architecture and has improved our understanding of the pathophysiology of many sleep disorders in children.

MATURATION OF SLEEP ARCHITECTURE — Sleep-wake patterns become more diurnal and sleep times gradually decrease from infancy through adolescence, as shown in the figure (figure 1). Sleep time of children in a given age group varies by as much as two hours. In addition, sleep patterns and behaviors have changed over time, such that sleep duration in equivalent age groups has declined, presumably reflecting sociocultural changes [8]. Sleep times for children in the United States tend to be shorter than those in Europe and Australian series, especially on weekdays [9,10]. In a survey of adolescents in the United States, more than 60 percent reported sleeping less than seven hours on weekday nights, substantially less than the 8 to 10 hours recommended for this age group by the American Academy of Sleep Medicine (table 1) [11].

Infants — Sleep in the healthy, full-term newborn is distinguished from that of older individuals by [1,3]:

Longer sleep duration (16 to 18 hours per 24 hours)

Rapid eye movement (REM) sleep occurring at sleep onset

Increased proportion of REM sleep

REM-nonrapid eye movement (NREM) cycle much shorter in duration as compared with older individuals

With maturation of the child's central nervous system, predictable changes occur, including gradual decrease in total sleep time and the proportion of REM sleep, progressive lengthening of the REM-NREM cycle, and shift to the adult pattern of sleep onset via NREM sleep.

Children and adolescents — In normal older children and adolescents, sleep is characterized by:

Onset via NREM sleep

NREM sleep occupying approximately 75 percent of total sleep time

REM and NREM sleep alternating throughout the night with a period of 90 to 100 minutes, and a progressive lengthening of the duration of REM sleep periods in the final one-third of the night

Sleep in adolescents is further characterized by [9,12]:

Decrease in slow-wave sleep beginning in puberty and continuing into adulthood

Physiologic shift in sleep onset to a later time

Increasing irregularity of sleep-wake patterns (primarily discrepancy between weeknights and weekend sleep patterns)

Decrease in average sleep duration despite relatively stable sleep requirement of approximately nine hours

A more detailed discussion of sleep stages and sleep architecture in adults is presented elsewhere. (See "Stages and architecture of normal sleep".)

ASSOCIATION OF SLEEP DISORDERS WITH SLEEP STATES — The distinctive physiology of nonrapid eye movement (NREM) sleep, rapid eye movement (REM) sleep, or transitions between sleep and wakefulness can influence the timing and nature of specific sleep disorders.

Nonrapid eye movement sleep — NREM parasomnias are characterized by impaired arousal from deep NREM sleep. Certain features of wakefulness and sleep occur simultaneously. These parasomnias tend to arise during the first one-third of the night, when deep NREM sleep is common [13,14]. Disorders of arousal from NREM sleep include sleep walking, sleep terrors, and confusional arousals. (See "Parasomnias of childhood, including sleepwalking", section on 'Disorders of arousal from non-rapid eye movement sleep'.)

Rapid eye movement sleep — REM sleep phenomena tend to occur in the latter portion of the sleep period, when REM sleep predominates [15,16]. These include nightmares, REM sleep behavior disorder, and sleep paralysis. (See "Parasomnias of childhood, including sleepwalking", section on 'Parasomnias usually associated with rapid eye movement sleep'.)

Other respiratory problems (eg, obstructive sleep apnea) also tend to be more severe during REM sleep, although they may occur at any time during the night. This is because upper airway obstruction is often more severe during REM (when muscle tone is markedly reduced compared with wakefulness) and light NREM sleep [17,18]. (See "Mechanisms and predisposing factors for sleep-related breathing disorders in children", section on 'Changes in respiratory physiology during sleep'.)

Sleep-wake transition disorders — Sleep-wake transition disorders occur during the transition from wakefulness to sleep, from sleep to wakefulness, or, less commonly, during sleep stage transitions [18]. These disorders include rhythmic movement disorder, sleep starts, and sleep talking. (See "Sleep-related movement disorders in childhood", section on 'Rhythmic movement disorder' and "Sleep-related movement disorders in childhood", section on 'Sleep starts (hypnic jerks)'.)

No association — Other parasomnias (eg, sleep bruxism and nocturnal enuresis) may occur during any sleep stage and at any time of the night [18].

SUMMARY

Sleep states – Nonrapid eye movement (NREM) sleep is subdivided into three discrete stages based primarily on the electroencephalogram (EEG). The stages range from N1 (lightest sleep) to N3 (deepest NREM sleep with a high arousal threshold). (See 'Sleep states' above.)

Rapid eye movement (REM) sleep is associated with marked decrease in muscle tone and episodic bursts of REM. Most dreaming occurs during REM sleep. (See 'Sleep states' above.)

Sleep architecture maturation – As compared with older children and adults, newborn infants have longer sleep duration, an increased proportion of REM sleep, and shorter REM-NREM cycles. Sleep-wake patterns become more diurnal and sleep times gradually decrease from infancy through adolescence (figure 1). (See 'Maturation of sleep architecture' above.)

Sleep disorders – The distinctive physiology of NREM sleep, REM sleep, and transitions between sleep and wakefulness can influence the timing and nature of specific sleep disorders.

NREM parasomnias are characterized by impaired arousal from deep NREM sleep and tend to occur in the first one-third of the night. They include sleep walking, sleep terrors, and confusional arousals. (See 'Nonrapid eye movement sleep' above.)

REM sleep phenomena tend to occur in the latter portion of the night, including nightmares, REM sleep behavior disorder, and sleep paralysis. Sleep apnea also tends to be more severe during REM sleep. (See 'Rapid eye movement sleep' above.)

Sleep-wake transition disorders include rhythmic movement disorder, sleep starts, and sleep talking. (See 'Sleep-wake transition disorders' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel G Glaze, MD, who contributed to an earlier version of this topic review.

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