Features

Waking up to the child sleep crisis

08 February 2019

As sleep issues in children increase and parents struggle to access specialist sleep services, how can CPs best support families? Journalist Georgina Wintersgill reports.

Sleep time iStock

Sleep well? If you’re a parent, possibly not, as sleep problems among children are on the rise. NHS Digital reveals that, in England, hospital admissions with a primary diagnosis of sleep disorder among under-17s rose substantially from 6520 in 2012-13 to 9429 in 2017-18 (Marsh, 2018). Meanwhile, the number of under-18s in England prescribed the hormone melatonin in an attempt to improve their sleep rose by 25% between 2015-16 and 2017-18, when it peaked at 117,085 (Marsh and Greenfield, 2018).

 

A growing issue

So why are sleep problems rising? In England, most of the admissions with a primary diagnosis of sleep disorder among under-17s (8274 in 2017-18) are for obstructive sleep apnoea (OSA) (Marsh, 2018). A serious disorder that occurs when breathing is interrupted at night, OSA is thought to be linked to increasing childhood obesity rates, as extra weight around the neck and upper airway makes it harder to breathe when muscle tone falls during sleep.

Other primary sleep conditions, such as narcolepsy, an autoimmune condition that causes excessive daytime sleepiness, also appear to be increasing. Dr Don Urquhart, consultant in paediatric respiratory and sleep medicine at the Royal Hospital for Sick Children in Edinburgh, and co-chair of the British Paediatric Sleep Association, says: ‘Some of the increase is about better recognition of the condition – although average time from onset to diagnosis is several years. Concerns about sleep breathing problems, or excessive daytime sleepiness in the absence of a sleep hygiene problem, should prompt referral for assessment.’

Poor sleep may be related to sleep hygiene – routines and behaviours that lead to good sleep quality. Many aspects of modern life, including lack of routine, screen use and the popularity of caffeinated products such as energy drinks may have increased sleep hygiene issues.

Vicki Dawson, CEO and founder of The Children’s Sleep Charity, says: ‘Part of the problem may be connected to the busyness of family life. Both parents may be out working, and they don’t do a great bedtime routine because they’re coming home to cook dinner and trying to get the child to bed, but they also want to spend time with the child.

‘Part of the problem is probably about screen use. Screens are much more accessible to children these days and are being used in the hour before bedtime. Light-emitting devices suppress melatonin production, which makes it harder for children to fall asleep.’


Six healthy sleep habits

Vicki Dawson, CEO and founder of The Children’s Sleep Charity, suggests six simple steps to a better night’s sleep for children:

  • Set a regular wake-up time as well as a regular bedtime, even at weekends
  • Make the bedroom a calm, non-stimulating environment
  • Plan calming activities for the hour before bedtime
  • Ban screen time in the hour before bed
  • Limit sugar, particularly from lunchtime onwards
  • Avoid caffeine and energy drinks

The sleep-loss impact

‘Sleep really does hold the key to a lot of issues in our overall health,’ says Dr Urquhart. ‘During sleep, we consolidate memories to facilitate learning. During slow-wave [deep] sleep, we produce growth hormone. Thus sleep deprivation or reduced sleep quality may have deleterious effects on growth and learning. It’s known that fragmented sleep may impact on learning and behaviour, with attention and concentration often affected. An overtired child may present as “hyperactive” or “naughty” rather than drowsy.’

‘We see parents who can’t go to work because they’re so affected by sleep deprivation, families who’ve lost work then had to move house because they can’t pay the mortgage’

It’s well known that obesity can cause sleep problems such as OSA, but new research at the University of Warwick has found that sleep problems can also cause obesity: children and adolescents who regularly sleep less than others of the same age are more likely to become overweight or obese (Miller et al, 2018).

And sleep deprivation doesn’t have an impact only on the child. It also affects parents’ sleep and wellbeing, and the consequences can be catastrophic. Vicki says: ‘We see families where relationships have broken down. We see families where parents can’t go to work because they’re so affected by sleep deprivation, families who’ve lost work then had to move house because they can’t pay the mortgage.’

 

Postcode lottery

Despite the increase in demand, there are only a few NHS-funded sleep services in the UK. Doncaster and neighbouring Bassetlaw clinical commissioning groups (CCGs) have both commissioned sleep services from The Children’s Sleep Charity. But in many other areas, families are unable to access specialist support, and Vicki says the charity can’t meet demand.

‘It’s a postcode lottery,’ she says. ‘In the vast majority of the country, there is little support available for these families. CPs are having to provide it, but many haven’t accessed sleep training and even if they have, they don’t have the capacity to support a family to change sleep habits, as it’s time-consuming work.’

Ruth Silverman is a qualified nurse, midwife and health visitor, and a former sleep lead for West Sussex. She is now a clinical services manager (child development services) at Sussex Community NHS Foundation Trust. Ruth says: ‘There are issues around accessing training. You might get a little bit in your original training, then after that a lot of it is simply through experience. There are training courses you can go on but they are usually costly and will take you away from clinical workloads.

‘Sleep support works best when you can offer that one-to-one, long-term support and help parents through change. But that becomes very difficult when you’ve got to weigh that up against a family in crisis or a safeguarding issue.

‘When the CP has done their first-tier intervention, if that’s not working and they need more expert support, where do they go from there? In some areas there are specialist sleep services or sleep experts they can turn to. For example, in our area of West Sussex there are specialist health visitors and nurses who have had extra sleep training and can offer further sleep intervention for some families. But it’s often a case of seeing what’s locally available.’

So why is sleep support so hard to get? Vicki believes sleep still isn’t taken seriously as a public health issue. ‘The money goes into things like nutrition and exercise,’ she says, ‘but sleep seems to be the forgotten pillar of health. That’s difficult to comprehend when it’s so vitally important for wellbeing.’


 

Sleep Game Picture
Learning through play

While working as a sleep lead in West Sussex, health visitor Ruth Silverman organised sleep training for professionals working in health and social care. But she found that as demand increased and professionals changed roles or left, the skills were lost and it wasn’t feasible to keep paying for external training or run workshops herself. So she invented The Sleep Game, an interactive board-game training resource.

Sleep game picture
Covering topics including why sleep is important, sleep recommendations, safer sleeping tips, the impact of sleep deprivation, techniques to encourage sleep, and sleep problems for children with additional needs, the game is designed both to educate and to promote discussion.

Ruth says: ‘My aim was for people to learn about sleep, talk about the questions and relate it to a family they’d seen and share their experiences, and our feedback shows that’s exactly what they’re doing. The games have been used in children’s centres, networking meetings for early years practitioners and even universities as a springboard for lectures. I’ve been really surprised by how powerful it’s been.’

Go to sleepgame.co.uk for more information.


 

Ideal provision

Our experts also shared what sleep support they would like to see available for all children in the UK.

Ruth says: ‘If HVs had more support in accessing sleep training they’d feel more confident about supporting all families, although they’d still be balancing all their other priorities. The ideal would be for every area to have a sleep service, so if the HV has done preventative work and first-tier support, but it hasn’t worked and they feel the issue needs specialist intervention, that would be the place to go.’

Vicki says: ‘Our ideal is for every family to be able to receive quality, evidence-based sleep support in their locality. In Doncaster, the CCG commissions a sleep service from us, so we have educated professionals who are able to support families around sleep. Over the last four years, we’ve proven that it’s extremely successful, can reduce the need for medication and is usually cost-saving. You’ve got CCGs prescribing half a million pounds’ worth of melatonin a year for children, whereas our sleep services cost about £250 per child in Doncaster.’

Dr Urquhart agrees that more access to sleep training for health professionals is necessary, but warns that training alone isn’t enough. He says: ‘Access to training is one thing, but it requires post-training support and a mentoring programme for it to work; you need someone to discuss your difficult cases with.’

However, he is optimistic about future provision: ‘There is a move to get sleep on a training agenda within the medical profession. In the last couple of years, there’s been a curriculum overhaul, and all paediatricians in their basic level of training now have a small amount of paediatric sleep exposure that wasn’t there before.’

Accessing appropriate training will give CPs the confidence to tackle some of the more complex issues that might arise, says Ruth. She is a great advocate of preventing problems before they occur. ‘By giving those healthy and safe sleep messages at every contact, you’re getting them embedded into the lifestyle of that growing family.’

 

Sleep Infographic
Further help

Early on, Ruth suggests giving families a list of local support networks and details of specialist charities where they can access support or information.

She says: ‘Every area has the Local Offer and we often signpost to that – it can be useful for non-SEN children too. Children’s and family centres are good places that give loads of information.’

Sleep training will equip CPs with the skills to offer a proper sleep intervention to families in need of support. Ruth says: ‘What I found worked best was doing a proper sleep intervention – finding out what’s going on in the family, then giving them a really good sleep plan and supporting them through that change by phoning up to keep them motivated through the difficult period.’

Vicki seconds the need for support for families struggling with sleep issues. She says: ‘You feel isolated when you’ve got a sleep issue. Just being heard and not judged is really important.’

Dr Urquhart says that simply asking about children’s sleep at every contact is one of the most important things CPs can do for them. ‘Healthy sleep is of key importance to a child’s health and wellbeing,’ he says. ‘Do make sure that you ask about sleep as it could help identify a remediable problem that could be resolved, with far-reaching benefits.’ 


Resources

  • The Children’s Sleep Charity is the only charity registered in England and Wales dedicated to supporting the sleep of all children. It works directly with families in crisis, provides accredited training for professionals, and has a range of leaflets that CPs and families can download. For details, visit thechildrenssleepcharity.org.uk
  • The charity Sleep Scotland offers sleep counselling to families and carers, sleep counsellor training courses, a helpline and a UK-wide education programme, ‘Sound Sleep’, which helps teenagers implement positive sleep habits. For more information, visit sleepscotland.org
  • The British Sleep Society (BSS) is a professional organisation for medical, scientific and healthcare professionals dealing with sleep disorders. It aims to improve public health by promoting education and research into sleep and its disorders. Go to sleepsociety.org.uk

Image credit | iStock

References

Dawson V. (2017) Sleep issues in young people and strategies to support them. See: https://www.nursinginpractice.com/article/sleep-issues-young-people-and-strategies-support-them (accessed 22 January 2019).

Marsh S. (2018) Children’s lack of sleep is ‘hidden health crisis’, experts say. See: https://www.theguardian.com/lifeandstyle/2018/sep/30/childrens-lack-of-sleep-is-hidden-health-crisis-experts-say (accessed 21 January 2019).

Marsh S, Greenfield P. (2018) Rise in melatonin use to help children sleep leads to safety warning. See: https://www.theguardian.com/society/2018/nov/02/rise-in-melatonin-use-to-help-children-sleep-leads-to-safety-warning (accessed 21 January 2019).


Miller MA, Kruisbrink M, Wallace J, Ji C, Cappuccio FP. (2018) Sleep duration and incidence of obesity in infants, children, and adolescents: a systematic review and meta-analysis of prospective studies. Sleep 41(4). See: https://academic.oup.com/sleep/article/41/4/zsy018/4833233 (accessed 21 January 2019).

Quach J, Gold L, Hiscock H, Mensah FK, Lucas N, Nicholson JM, Wake M. (2013) Primary healthcare costs associated with sleep problems up to age 7 years: Australian population-based study. BMJ Open 3: e002419. See: bmjopen.bmj.com/content/3/5/e002419 (accessed 21 January 2019).

Subscription Content

Click To Return To Homepage

Only current Unite/CPHVA members or Community Practitioner subscribers can access the Community Practitioner journals archive. Please provide your name and membership/subscriber number below to verify access:

Name
Membership number

If you are not already a member of CPHVA and wish to join please click here to JOIN TODAY

Membership of Unite gives you:

  • legal and industrial support on all workplace issues 
  • professional guidance on clinical and professional issues 
  • online information, training and support 
  • advice and support for all health professionals and health support workers
  • access to our membership communities 
  • CPHVA contribution rate is the Unite contribution rate plus £1.25 per month 

Join here https://www.unitetheunion.org/join-unite/

If you are not a member of Unite/CPHVA but would like to purchase an annual print or digital access subscription, please click here

Top