Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach

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true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S26" "paginaFinal" => "S35" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Magda Lahorgue Nunes, Oliviero Bruni" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Magda Lahorgue" "apellidos" => "Nunes" "email" => array:1 [ 0 => "nunes@pucrs.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Oliviero" "apellidos" => "Bruni" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Social Development and Psychology, Universidade La Sapienza, Rome, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Insônia na infância e adolescência: aspectos clínicos, diagnóstico e abordagem terapêutica" ] ] "textoCompleto" => "IntroductionSleep disorders (SD) are a frequent complaint in routine medical appointments and increasingly, the pediatrician must be able to adequately establish their diagnosis and management, thus avoiding referral to specialist consultations, as well as unnecessary and excessive examinations/interventions.SD mostly present as the primary entity, but may also be associated with several organic diseases (e.g., asthma, obesity, neuromuscular diseases, gastroesophageal reflux disease, epilepsy, attention disorder, autism spectrum disorder) or psychiatric comorbidities (anxiety, depression, bullying).Clinical presentation is variable and multiple. During the first years of life, the most frequent complaints are difficulty falling asleep and/or frequent nocturnal awakenings, followed by parasomnias (confusional arousals) and sleep-disordered breathing (obstructive apnea-hypopnea syndrome). From preschool age onwards, disorders related to inadequate sleep hygiene occur and, in adolescence, the disorders are related to circadian issues (delayed sleep phase) or excessive movement during sleep (restless leg syndrome [RLS]).This review will assess a frequent SD, i.e., insomnia, which may present in different clinical forms during childhood, with varied management. The clinical features, diagnosis, comorbidities, and treatments will be assessed, aiming to give the pediatrician an overview of the problem and to provide tools for its diagnosis and management.Sleep characteristics and classification of SDRecommendations about sleep duration in children and adolescents vary according to the source used. Recently, the National Sleep Foundation published a consensus based on an expert panel, stating the ideal number of sleeping hours for every age group and a variability range that contains the acceptable number of sleeping hours (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0215">1</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Nocturnal awakenings occur frequently in childhood and its distribution varies with age. In the first six months of life, they are concentrated in one to two evening peaks; after the sixth month, they follow a distribution that accompanies the sleep cycle (which lasts 90–120min) and occur more commonly in the REM stage. In these cases, it is common that the child goes back to sleep spontaneously.<a class="elsevierStyleCrossRef" href="#bib0220">2</a>The classification of SD is proposed by the American Academy of Sleep Medicine and the Chronic Insomnia Definition-ICSD-3, which is the updated version of ICSD-2, was published in 2005. This classification review maintained the basic principles of the previous one, identifying seven major SD categories: insomnia, sleep-disordered breathing, central hypersomnia, circadian rhythm disorders, movement disorders during sleep, parasomnias, and others.<a class="elsevierStyleCrossRef" href="#bib0220">2</a> There was a standardization of diagnostic criteria for adults and children, maintaining the recognition of specific age-dependent situations. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the prevalence of different SD in childhood, according to the American Academy of Sleep Medicine.<a class="elsevierStyleCrossRef" href="#bib0225">3</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Insomnia definitionInsomnia can be defined as difficulty initiating sleep (considered in children as the difficulty to fall asleep without a caregiver's intervention); maintaining sleep (frequent awakenings during the night and difficulty returning to sleep without a caregiver's intervention); or waking up earlier than the usual schedule with inability to return to sleep. Insomnia can cause distress and social, professional, educational-academic, or behavioral impairment.<a class="elsevierStyleCrossRef" href="#bib0220">2</a>Insomnia prevalenceSD that manifest with difficulty falling asleep and/or difficulty maintaining sleep (due to nocturnal awakenings) affect approximately 30% of children. The increase in prevalence, which has been observed in recent years, is closely related to social habits in the family, as there is often a difference between the child's natural sleep-alertness rhythm and social requirements. This disorder, when chronic, can result in deleterious effects on cognitive development, mood regulation, attention, behavior and quality of life, not only of the child but the entire family, resulting in parents’ sleep deprivation, with consequences for their work activities.<a class="elsevierStyleCrossRefs" href="#bib0230">4,5</a>Data on the prevalence of insomnia vary with age. In the first two years, the rates are high, around 30%, and after the third year of life the prevalence remains stable at around 15%. It is worth mentioning that, as insomnia definition and diagnosis vary widely among the available studies, this fact directly influences the data on prevalence.<a class="elsevierStyleCrossRefs" href="#bib0230">4,5</a>In a population-based study conducted in Pennsylvania, it was demonstrated that one out of five children or pre-adolescents have insomnia symptoms; the highest prevalence (approximately 30%) is observed in girls aged 11–12 years, which appears to be more related to hormonal changes than to anxiety/depression.<a class="elsevierStyleCrossRef" href="#bib0240">6</a>Another large population-based study was carried out in China, using two data collection stages, with a five-year interval between them. An increase in insomnia prevalence from 4.2% to 6.6% and incidence from 6.2% to 14.9% was demonstrated. The initial cases were associated with health issues (laryngopharyngitis) and lifestyle (caffeine intake, smoking), whereas the new cases were associated with parents’ low educational level, alcohol intake, and mental illness.<a class="elsevierStyleCrossRef" href="#bib0245">7</a>A population-based study conducted in Norway with adolescents showed that, on weekdays, the average number of sleep hours was 6h 25m, leading to a deficit of approximately 2h; most subjects (65%) showed long latency to sleep onset (>30min). The prevalence of insomnia in this population was 23.8% according to the DSM-IV criteria, 18.5% using the DSM-V, and 13.6% when quantitative criteria were used.<a class="elsevierStyleCrossRef" href="#bib0250">8</a>Types of insomnia according to age rangeIn children, insomnia has clearly defined behavioral characteristics and can be defined as two main types, sleep-onset association disorder (SOAD) and limit-setting SD.<a class="elsevierStyleCrossRef" href="#bib0255">9</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)SOADIn this condition, the infant learns to sleep under a specific condition (object, circumstance), which usually requires intervention/presence of parents. After a nocturnal physiological awakening, he/she needs the same intervention to resume sleeping. Although the number of awakenings is normal for their age group, the problem occurs due to the inability to return to sleep alone, which prolongs the alertness period. Diagnosis is based on the history of long latency to sleep onset, requiring specific and pre-determined conditions, as well as the need for caregiver intervention during the nocturnal awakenings. By definition, two or three awakenings/night, lasting between 5 and 10min or longer, occur five times a week.This type of insomnia tends to disappear at approximately 3–4 years of age. Polysomnography is normal if the associations are present to facilitate sleep onset. The differential diagnosis with other types of insomnia is made through the rapid sleep onset in the presence of the initial conditions. The therapeutic approach is through the gradual extinction of the association stimulus.<a class="elsevierStyleCrossRefs" href="#bib0220">2,5</a></li><li class="elsevierStyleListItem" id="lsti0010">2)Limit-setting SDIt is typical in preschool and school-age children, characterized by the parents’ difficulty in setting limits and rules for bedtime or having them followed. As a result, the child refuses to sleep or stay asleep all night. Excuses for not going to sleep are a common occurrence (hunger, thirst, “one more story…”), with parents usually giving in. Total sleep time may be reduced by 1–2h, with approximately three to five awakenings that result in the child leaving the bed or calling the parents. Polysomnography is normal, as once the child sleeps, sleep architecture is adequate. For the differential diagnosis, it is important to analyze the parents’ relationship and attitude with the child.Management essentially involves parents, who should establish the limits/rules and maintain them firmly, and utilize behavioral techniques. It is acceptable to use sleep-inducing antihistamines or benzodiazepines for a limited period of time, while behavioral techniques are consolidated.<a class="elsevierStyleCrossRefs" href="#bib0220">2,5</a>Some children may experience a combination of the two types of behavioral insomnia.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>Studies have shown that sleep plays a crucial role in the healthy development of adolescents. However, changes in sleep patterns are very common in adolescence, due to biological and environmental factors such as late bedtime, inadequate sleep hygiene, and sleep restriction and fragmentation. Insomnia in this age group is associated with a poor prognosis in terms of mental health, school performance, and risk behavior.<a class="elsevierStyleCrossRef" href="#bib0220">2</a></li></ul>In adolescence, insomnia may be related to inadequate sleep hygiene and delayed sleep phase, or it can have a psychophysiological origin.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1)Insomnia due to inadequate sleep hygiene:During adolescence, insomnia has characteristics related to changes in social habits (tendency to sleep later) and sleep hygiene problems. The following habits are considered to be inadequate sleep hygiene: sleeping after 11pm and waking up after 8am; irregular sleep schedule between weekdays and the weekend; use of stimulating substances or drugs (licit and illicit); excess caffeine in the late afternoon or at night; and/or use of electronic devices in the bedroom before going to bed (TV, computer, mobile). Social and family pressures, hormonal changes, and the need for belonging to a group also influence sleep quality.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>Insomnia due to poor sleep hygiene leads to an increase in sleep latency and reduction in total sleep time. As a consequence, it results in excessive daytime sleepiness and/or hyperactivity, academic and relationship problems, and sleep-wake cycle inversion.<a class="elsevierStyleCrossRefs" href="#bib0265">11,12</a> It is important to make the differential diagnosis with psychiatric disorders such as depression and schizophrenia, noting that insomnia may be the initial symptom of these morbidities. Therapeutic management consists in following an adequate sleep hygiene routine, behavioral therapy and, in selected cases, the use of melatonin.<a class="elsevierStyleCrossRef" href="#bib0235">5</a></li><li class="elsevierStyleListItem" id="lsti0020">2)Delayed sleep phase insomnia:It is defined as the delay in the sleep schedule that leads to a late awakening. This is a circadian rhythm disorder that occurs in adolescents due to hormonal changes, with a shift in the nocturnal sleep time as a function of the endogenous pacemaker. It is a common cause of insomnia and can occur at other ages, in addition to adolescence.Conflicts occur because the bedtime does not match the sleep schedule; the adolescent refuses to go to sleep and has trouble waking up in the following morning. It results in symptoms of sleep deprivation, hyperactivity, aggression, and even learning disabilities, due to excessive daytime sleepiness. After they manage to fall sleep, sleep is tranquil, with adequate structure and duration (if they do not have to be awakened in the morning). The attempt to compensate for sleepiness with naps during the day or unlimited sleep time on weekends leads to more nocturnal delayed sleep phase.Optimal management consists in readjusting sleep onset time. The use of low-dose melatonin (1mg) in the late afternoon was shown to be effective in correcting delayed sleep phase in a double-blinded study conducted with an adolescent population.<a class="elsevierStyleCrossRef" href="#bib0275">13</a> The association between delayed sleep phase as a cause of insomnia in adolescents has been extensively assessed in the literature. In population-based study, carried out in Norway, including 10,220 adolescents aged 16–18 years, delayed sleep phase was observed in 3.3% of the population; over half of these adolescents (54% girls and 57% boys) also met the criteria for insomnia. Additionally, the delayed sleep phase diagnosis resulted in a three-fold increased risk for school absenteeism in males and 1.8-fold in females.<a class="elsevierStyleCrossRef" href="#bib0280">14</a></li><li class="elsevierStyleListItem" id="lsti0025">3)Psychophysiological insomnia:Characterized by a combination of previously experienced associations and hypervigilance. The complaint consists of an exaggerated preoccupation with sleep, getting to sleep, and the adverse effects of “not sleeping” on the following day. This type of situation occurs through a combination of risk factors (genetic vulnerability, psychiatric comorbidities), triggering factors (stress), and other factors (poor sleep hygiene, caffeine intake, etc.).<a class="elsevierStyleCrossRef" href="#bib0235">5</a></li></ul>Clinical characteristicsAmong the factors that predispose to insomnia are: birth order (more prevalent in the first-born and/or only child), genetic factors (positive family history); temperament (mood variability); presence of maternal psychopathology or depression; caregivers’ behavior during the nocturnal awakenings (the tendency to make the child fall asleep while holding him/her on one's lap or pick up the infant in one's arms immediately after the nocturnal awakening tends to make insomnia a chronic condition); night feeding (nocturnal awakenings are more common in infants who are breastfed between 6 and 12 months and persist longer in children who continue to be breastfed after 12 months); and co-sleeping (frequently associated with insomnia).<a class="elsevierStyleCrossRef" href="#bib0220">2</a>Different causes of insomnia or its precipitating factors are directly related to the child's neuropsychological development stage and/or typical characteristics of adolescence, as detailed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. The division by age group is an instructive presentation; however, overlaps between different age groups can occur. It should be noted that an irregular and erratic sleep routine can also lead to insomnia at all ages, as well as acute and/or chronic systemic diseases. Although scarcely discussed in childhood, the genetically determined characteristic of short sleep duration (an individual who sleeps well, but has a total duration of sleep below the average expected for age and level of development) can occur, and these cases have normal sleep quality (organization).<a class="elsevierStyleCrossRef" href="#bib0285">15</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Clinical investigationClinical history is extremely important for the diagnosis of insomnia, in which the falling asleep routine, as well as sleep and wake characteristics should be investigated. The impact of sleep disturbance on the child's life and family structure should be evaluated. The physical examination also helps to exclude possible causes of secondary insomnia.<a class="elsevierStyleCrossRefs" href="#bib0220">2,5,16</a>Early detection of SD is essential for the proper management to be established and for prognosis to be favorable. During the routine pediatric consultation, a tool that can assist in the screening is the Bedtime routines, Excessive daytime sleepiness, Awakenings during night, Regularity and duration of sleep, Sleep-disordered breathing; (BEARS) algorithm, consisting of five easy-to-apply questions that have good power to detect sleep alterations.<a class="elsevierStyleCrossRef" href="#bib0295">17</a><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the trigger questions for adequate sleep assessment.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Another option that can help assess the dimension of insomnia is the use of sleep journals. These allow for the assessment of the circadian rhythm and time (amount of sleep). Some questions may be directed to assess sleep habits and routine. The journal should cover the 24-h period, and contain information related to a mean period of two weeks.Additionally, validated questionnaires that assess sleep quality are also quite useful and should be used in association with interviews and the sleep journal.For children aged between 0 and 3 years, the Brief Infant Sleep Questionnaire, created by Sadeh et al. and validated in Brazilian Portuguese should be used.<a class="elsevierStyleCrossRefs" href="#bib0300">18,19</a> For children older than 3 years, the Sleep Disturbance Scale for Children, proposed by Bruni et al. and also validated in Brazilian Portuguese, should be used.<a class="elsevierStyleCrossRefs" href="#bib0310">20,21</a> The Brazilian Portuguese version of this scale is available in the digital version of this article (Appendix 1).Actigraphy is also a simple way to evaluate the sleep-wake rhythm. This device is shaped like a wristwatch and monitors body movements. The obtained signals can be analyzed through software and correlated with the child's condition, and can be used at any age.<a class="elsevierStyleCrossRef" href="#bib0320">22</a>Polysomnography (PSG) is the gold standard exam for sleep evaluation. It consists in recording the electroencephalogram (EEG) with other physiological variables (eye movements, submental electromyogram, respiratory channels, ECG, oxygen saturation, leg movements, position sensor, snore sensor). It allows for a complete analysis of sleep architecture, respiratory events, and body movements. It assists in the assessment of sleep organization, time asleep, sleep latency, and in the differential diagnosis between epileptic and non-epileptic motor events.<a class="elsevierStyleCrossRef" href="#bib0325">23</a>Comorbidities<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">1)DepressionPsychiatric disorders are usually associated with sleep problems such as hypersomnia, fatigue, irregular sleep-wake pattern, and nightmares, among others. Children with major depression have a high prevalence of insomnia (around 75%), and 30% have severe insomnia. The use of psychotropic medications can also negatively affect sleep. Conversely, there is new evidence suggesting that childhood insomnia itself is a risk factor for the development of psychiatric disorders in adolescence and adulthood.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>A population-based study conducted with Norwegian adolescents showed that depression leads to significant sleep time reduction, as well as longer latency to sleep onset and more episodes of nocturnal awakenings in both genders. Adolescents with insomnia had a four to five times higher risk of depression than those who sleep well. Sleep deprivation (sleeping fewer than 6h/night) results in an eight-fold higher risk of depression.<a class="elsevierStyleCrossRef" href="#bib0330">24</a></li><li class="elsevierStyleListItem" id="lsti0035">2)Attention-deficit disorder/hyperactivity disorder (ADHD)It is estimated that around 25–50% of children with ADHD have sleep disorders. Miano et al. suggest different patterns, including hyperarousal, latency delay, association with respiratory disorders, RLS, and epilepsy.<a class="elsevierStyleCrossRef" href="#bib0335">25</a> Children with the combined subtype of ADHD tend to have more sleep problems. Strategies related to better sleep hygiene and positive sleep routines are effective in these children. In selected cases, it may be necessary to use drugs to treat the insomnia, such as alpha agonists (clonidine), non-benzodiazepine sleep-inducers (zolpidem), or melatonin.<a class="elsevierStyleCrossRef" href="#bib0340">26</a></li><li class="elsevierStyleListItem" id="lsti0040">3)Autism spectrum disorder (ASD)ASD consists of neurodevelopmental disturbances (pervasive diseases, Asperger's) characterized by significant social interaction and communication (language) impairment. SDs are common in this population and have severe effects on the affected child's and family's quality of life. Sleep restriction has been associated with increased frequency of stereotypies and worse severity scores. The complaint of insomnia characterized by long latency to sleep onset, resistance to sleep, reduced sleep efficiency, and nocturnal awakenings are of great concern to parents. In younger children, there is also increased prevalence of behavioral insomnia (SOAD and limit-setting SD).<a class="elsevierStyleCrossRef" href="#bib0345">27</a></li><li class="elsevierStyleListItem" id="lsti0045">4)EpilepsyPatients with epilepsy have several changes in macro and micro sleep architecture, such as increased latency to sleep onset, reduced sleep efficiency, reduced REM sleep, and sleep fragmentation (especially those who have nocturnal seizures or refractory epilepsy). Complaints of excessive daytime sleepiness and poor sleep quality are also frequent.<a class="elsevierStyleCrossRefs" href="#bib0350">28–30</a></li><li class="elsevierStyleListItem" id="lsti0050">5)Tourette syndromePatients with Tourette syndrome frequently have sleep and attention disorders. Insomnia is the most frequent SD and is usually associated with behavioral disorder during sleep.<a class="elsevierStyleCrossRef" href="#bib0365">31</a></li></ul>Therapeutic approachThe treatment of insomnia starts with a detailed assessment of its causes and triggers. Parents should be educated about sleep hygiene and adequate sleep routines by the pediatrician during routine visits. Some of these recommendations are listed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Strategies for the treatment of primary insomnia involve sleep hygiene routines, behavioral techniques, and/or pharmacological treatment.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055">1)Sleep hygiene routinesParents’ education regarding what is adequate sleep hygiene is the start of the treatment, noting that these procedures start during the day. Diet is an important factor, and high intake of caffeine (chocolate, teas, soft drinks) should be avoided during the day and especially at night. Another daytime aspect is physical activity, which, when moderate, has a beneficial effect on sleep. At least 3h before the child's established bedtime, he/she should be involved in relaxing activities; overstimulation should be avoided. Activities involving electronic media (TV, computer, tablet, and mobile phone) should also be restricted and avoided at least 1h before bedtime. The bedroom environment is also a sleep hygiene factor. It should be well ventilated, quiet and dark, at an adequate temperature, and have a comfortable bed. It is advisable not to use the bedroom for punishments (“time-outs”) applied during the day to prevent negative associations with the place of sleep.<a class="elsevierStyleCrossRef" href="#bib0340">26</a>Positive routines can also help the child learn appropriate sleep behaviors and reduce stress. In addition to defining bedtime, consistent routines (activities that help prepare for sleep) should be established and repeated every night. As an example, let the child know that is almost time to go to bed, brush the teeth, perform other hygiene routines, put on pajamas, read a story or spend some time with the parents, turn off the lights. It is important to make sure that the time set for these routines is sufficient, so that they can be conducted calmly, without harming (reducing) total sleep time.<a class="elsevierStyleCrossRef" href="#bib0340">26</a>In brief, adequate sleep hygiene consists of (1) regular/consistent bedtime that is appropriate for the age group; (2) avoiding high caffeine consumption; (3) welcoming nocturnal atmosphere; (4) bedtime routines; and 5) consistent and regular wake-up time, regardless of what occurred during the night (to maintain internal clock synchronization).<a class="elsevierStyleCrossRef" href="#bib0295">17</a></li><li class="elsevierStyleListItem" id="lsti0060">2)Behavioral therapyThe main objective of the behavioral approach is to eliminate the negative associations that lead to insomnia. It is possible to start this type of therapy after six months of life. Several studies have demonstrated the effectiveness of this approach in most cases, with clear benefits to the child's daytime routine, as well as to that of the family.<a class="elsevierStyleCrossRefs" href="#bib0370">32,33</a>There are several behavioral techniques that have been developed or adapted for the management of children with behavioral insomnia. These techniques have proven efficacy and safety and are widely used, especially in Anglo-Saxon countries. The technique should be decided by the pediatrician together with the parents, so that they can define the most appropriate one according to the child's age and the parents’ circumstances regarding treatment adherence.<a class="elsevierStyleCrossRef" href="#bib0380">34</a>The following briefly describes the most often used techniques.<a class="elsevierStyleCrossRefs" href="#bib0220">2,16,17,34</a>Extinction: consists in putting the child to sleep safely and ignoring the nocturnal behavior (crying, tantrums, calling the parents) until the following morning. This procedure can also be performed with a parent in the bedroom, who will not interact until the predetermined time.Gradual extinction: consists in putting the child to sleep safely and ignore the nocturnal behavior (crying, tantrums, calling the parents) for periods of time that increase during the night (starting with 5min and gradually increasing the waiting time by 5min each time). The purpose of this technique is to encourage the child to learn to self-comfort and return to sleep alone.Positive routines: consists of developing a series of activities/calm routines that the child enjoys to prepare for bedtime, trying to disconnect the act of going to bed from a stressful routine. It is also possible to establish rewards to be given on the next day for those who manage to stay in bed until the next morning without going to the parents’ room or calling them.Planned bedtime: consists of removing the child from bed if he/she cannot fall asleep within the pre-established time interval (15–30min) and letting him/her perform some calming activity to get sleepy; the parents should delay bedtime, so that the child goes to bed when feeling sleepy. After establishing the time when the child goes to sleep spontaneously, put the child to bed 15–30min earlier every day, until the appropriate time is achieved.Programmed awakening: consists of waking up the child at night, between 15 and 30min before the usual time of spontaneous awakening, and after that, increasing the interval between episodes.Cognitive restructuring: consists of using cognitive-behavioral techniques, in which the patient is taught to control his/her negative thoughts about sleep and bedtime. For instance, instead of thinking “I won’t sleep tonight”, the child should think “tonight I will relax and rest in my bed.”Relaxation techniques: consists of meditation, muscle relaxation, taking deep breaths, visualizing positive images.Sleep restriction: consists of restricting the time in bed, so that the child will only lie in bed when he/she is almost asleep; it helps to disconnect the idea of staying in bed without feeling sleepy and helps to consolidate the connection between bed and sleep.Stimulus control: consists of avoiding performing activities that are not sleep-inducing when the child/adolescent is already in bed (TV, social media, worries, etc.).Gradual extinction and extinction techniques, which have been used for several decades, still generate discussion and debate, and parents have difficulty adhering to them, especially in Latin culture countries. Controlled studies have shown that the use of behavioral interventions in children with insomnia not only improves their daily functions (sense of well-being and less crying), but also the mood, sleep, and parental marital satisfaction.<a class="elsevierStyleCrossRef" href="#bib0380">34</a>More recent studies support and confirm these findings, demonstrating that, at school age, children with insomnia who received behavioral intervention had better performance at social skills when compared to children who did not receive it.<a class="elsevierStyleCrossRef" href="#bib0385">35</a> Additionally, another study also reported improvements in maternal sleep and mood.<a class="elsevierStyleCrossRef" href="#bib0390">36</a>During the literature review for the preparation of this article, the authors did not retrieve any studies that associated the use of behavioral interventions in children with insomnia to deleterious effects on mental health or on the emotional connection with parents. On the contrary, several studies that consistently demonstrated the benefits of this intervention were retrieved.<a class="elsevierStyleCrossRefs" href="#bib0395">37,38</a> It is also important to mention two studies in which children who received early behavioral interventions for insomnia were reassessed at the follow-up and the authors did not detect any changes in emotional function or internalizing and externalizing behaviors.<a class="elsevierStyleCrossRefs" href="#bib0395">37,39</a></li><li class="elsevierStyleListItem" id="lsti0065">3)Pharmacological therapyPharmacological therapy indication in childhood insomnia should occur when the parents cannot adapt to behavioral therapies due to objective difficulties or when the therapy does not show adequate results. The indication must be made before the problem becomes chronic, and must be conducted in association with behavioral therapy and for a limited period of time. It is important to emphasize that there are no drugs for insomnia approved for use in children with such an indication, which already limits this strategy.<a class="elsevierStyleCrossRefs" href="#bib0220">2,17</a> Indications are empirical, based more on clinical experience than on evidence. In most children, sleep problems can be solved using a sleep hygiene approach and behavioral techniques; however, if there is drug indication, it is recommended to follow these guidelines when choosing it:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070">a)The medication should act on the target symptom (pain, anxiety);</li><li class="elsevierStyleListItem" id="lsti0075">b)Primary SDs (e.g., apnea, RLS) should be treated before insomnia medication is indicated;</li><li class="elsevierStyleListItem" id="lsti0080">c)The choice of medication must be appropriate for the age and neurodevelopmental level, always weighing the benefits against the side effects.</li></ul></li></ul>3.1) Antihistaminic agents:They are the most frequently prescribed drugs for insomnia therapy at the level of primary care (e.g., hydroxyzine, diphenhydramine, promethazine). They assist in the acute phase, leading to a decrease in latency and awakenings, and must be used in combination with a behavioral intervention program. Daytime sedation, dizziness, or paradoxical hyperactivity can occur as side effects.<a class="elsevierStyleCrossRef" href="#bib0410">40</a>3.2) Alpha-agonists (clonidine)They are used for the treatment of insomnia in children due to their sedative effect. Their duration of action is 3–h and the half-life is 12–6h. They should be administered at bedtime, orally. Hypotension and weight loss have been described as side effects. Rapid withdrawal can lead to unwanted symptoms, such as shortness of breath, high blood pressure, and tachycardia.<a class="elsevierStyleCrossRef" href="#bib0340">26</a>3.3) MelatoninIt is a hormone (N-acetyl-5-methoxytryptamine) synthesized by the pineal gland, whose secretion is controlled by the suprachiasmatic nucleus of the hypothalamus, with a peak between 2 and 4am. It reduces latency to sleep onset and number of awakenings, as well as improving mood and daytime behavior. Its efficacy in children with ADHD and ASD has been reported in several studies. The recommended dose is 0.5–3mg in children and 3–5mg in adolescents. At the usual doses, the side effects are irrelevant. The medication does not interfere with antiepileptic drug action, endogenous melatonin production, or pubertal development, and does not cause addiction.<a class="elsevierStyleCrossRef" href="#bib0415">41</a>3.4) L5-hydroxytryptophanIt is a serotonin precursor. It has shown to be effective in episodes of certain types of parasomnia, such as night terrors, at a dose of 1–2mg/kg/day at bedtime. It appears to have a sleep stabilizing function, being effective in some patients. It can be used as an alternative treatment, as it has practically no side effects.<a class="elsevierStyleCrossRef" href="#bib0410">40</a>3.5) IronThe association between reduced iron levels and motor activity during sleep has been widely discussed in recent years. Iron deficiency in the substantia nigra can reduce dopaminergic function, as this element has a modulatory function. Iron-deficiency anemia may be associated with nocturnal motor hyperactivity, with reduced sleep time and increase in the number of awakenings. As this hyperactivity can be a precursor of RLS, oral iron replacement is indicated when ferritin levels are low.<a class="elsevierStyleCrossRef" href="#bib0420">42</a>3.6) BenzodiazepinesThese are the most often prescribed psychotropic drugs for children with neurological and/or psychiatric problems. They reduce the latency to sleep onset and improve sleep efficiency. Side effects may occur and vary from daytime sedation, changes in behavior, paradoxical hyperactivity, and memory deficits. They are contraindicated in suspected sleep-disordered breathing.<a class="elsevierStyleCrossRef" href="#bib0415">41</a>3.7) Tricyclic antidepressantsImipramine at a dose of 0.5mg/kg/day at bedtime appears to have some efficacy in insomnia; however, it is not widely used due to the risk of severe side effects.<a class="elsevierStyleCrossRef" href="#bib0415">41</a>3.8) Non-benzodiazepine sleep inducers (imidazopyridine)Their use in children younger than 12 years is contraindicated. Zolpidem and zaleplon are the most often used; as they have few side effects, they can be administered in children aged 12 years and older at a dose of 5–0mg at bedtime.<a class="elsevierStyleCrossRef" href="#bib0415">41</a><a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> summarizes drug indications for insomnia according to the nocturnal complaint.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>In conclusion, insomnia complaints in children and adolescents should be taken into account and properly investigated by the pediatrician, considering its association with several comorbidities, which must also be diagnosed. The main causes of insomnia and its triggers vary according to the age and level of development. The therapeutic approach should include sleep hygiene measures, behavioral techniques, and, in individual cases, pharmacological treatment.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres583846" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Data synthesis" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec600037" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres583845" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fonte dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec600036" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Sleep characteristics and classification of SD" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Insomnia definition" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Insomnia prevalence" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Types of insomnia according to age range" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical characteristics" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical investigation" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Comorbidities" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Therapeutic approach" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-07" "fechaAceptado" => "2015-06-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec600037" "palabras" => array:4 [ 0 => "Insomnia" 1 => "Sleep disorders" 2 => "Childhood" 3 => "Adolescence" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec600036" "palabras" => array:4 [ 0 => "Insônia" 1 => "Distúrbios do sono" 2 => "Infância" 3 => "Adolescência" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo review the clinical characteristics, comorbidities, and management of insomnia in childhood and adolescence. SourcesThis was a non-systematic literature review carried out in the PubMed database, from where articles published in the last five years were selected, using the key word “insomnia” and the pediatric age group filter. Additionally, the study also included articles and classic textbooks of the literature on the subject. Data synthesisDuring childhood, there is a predominance of behavioral insomnia as a form of sleep-onset association disorder (SOAD) and/or limit-setting sleep disorder. Adolescent insomnia is more associated with sleep hygiene problems and delayed sleep phase. Psychiatric (anxiety, depression) or neurodevelopmental disorders (attention deficit disorder, autism, epilepsy) frequently occur in association with or as a comorbidity of insomnia. ConclusionsInsomnia complaints in children and adolescents should be taken into account and appropriately investigated by the pediatrician, considering the association with several comorbidities, which must also be diagnosed. The main causes of insomnia and triggering factors vary according to age and development level. The therapeutic approach must include sleep hygiene and behavioral techniques and, in individual cases, pharmacological treatment." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Data synthesis" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivosRevisar as características clinicas, as comorbidades e o manejo da insônia na infância e adolescência. Fonte dos dadosRevisão não sistemática da literatura realizada na base dados PubMed,onde foram selecionados artigos publicados nos últimos 5 anos, selecionados com o uso da palavra chave insônia e o filtro faixa etária pediátrica. Adicionalmente foram também incluídos artigos e livros texto clássicos da literatura sobre o tema. Síntese dos dadosNa infância existe predomínio da insônia comportamental na forma de distúrbio de início do sono por associações inadequadas e/ou distúrbio pela falta de estabelecimento de limites. Na adolescência a insônia está mais associada a problemas de higiene do sono e atraso de fase. Transtornos psiquiátricos (ansiedade, depressão) ou do neurodesenvolvimento (Transtorno do déficit de atenção, autismo, epilepsias) ocorrem com frequência em associação ou como comorbidade do quadro de insônia. ConclusõesA queixa de insônia nas crianças e adolescentes deve ser valorizada e adequadamente investigada pelo Pediatra, levando em consideração a associação com diversas comorbidades, que também devem ser diagnosticas. As causas principais de insônia e fatores desencadeantes variam de acordo com a idade e nível de desenvolvimento. A abordagem terapêutica deve incluir medidas de higiene do sono e técnicas comportamentais, e em casos individualizados tratamento farmacológico." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fonte dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Nunes ML, Bruni O. Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach. J Pediatr (Rio J). 2015;91:S26–35." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0060" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age range \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ideal hours of sleep \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acceptable hours of sleep (maximum and minimum) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Newborns (0–3 months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14–17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18–19 and 11–13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infants (4–12 months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16–18 and 10–11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Toddlers (1–2 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11–14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–16 and 9–10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preschoolers (3–5 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10–13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 and 8–9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">School-aged children (6–13 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9–11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 and 7–8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adolescents (14–17 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 and 7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Young adults (18–25 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–11 and 6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adults (26–64 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 and 6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elderly (>65 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7–8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 and 5–6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952492.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Recommendations of the National Sleep Foundation in 2015, based on an expert panel." ] ] ] "descripcion" => array:1 [ "en" => "Sleep duration.<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disorder \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insomnia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20–30% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-disordered breathing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypersomnia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01–0.20% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Circadian rhythm disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parasomnias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-related movement disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–2% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952495.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Prevalence of sleep disorders in childhood according to ICSD-3." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age range \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="7" align="left" valign="top">Infants</td><td class="td" title="table-entry " align="left" valign="top">Sleep-onset association disorder (SOAD) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food allergies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastroesophageal reflux \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colic in infants \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excessive nighttime fluid intake \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute otitis media or other infectious diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top">2–3 years</td><td class="td" title="table-entry " align="left" valign="top">SOAD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parental separation anxiety \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged naps or at inappropriate times \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infectious diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Preschoolers and school-aged children</td><td class="td" title="table-entry " align="left" valign="top">Limit-setting sleep disorder \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nightmares \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infectious diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="8" align="left" valign="top">Adolescents</td><td class="td" title="table-entry " align="left" valign="top">Sleep hygiene problems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Delayed sleep phase \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psychiatric comorbidities (anxiety, depression, attention deficit hyperactivity disorder) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family, school pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-disordered breathing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Movement disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infectious diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952493.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Causes and/or triggering factors of insomnia according to the age group." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Source: Modified from Mindell & Owens.<a class="elsevierStyleCrossRef" href="#bib0295">17</a>BEARS, Bedtime routines, Excessive daytime sleepiness, Awakenings during night, Regularity and duration of sleep, Sleep-disordered breathing." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BEARS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2–5 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6–12 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">13–18 years \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bedtime/sleep problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child have any problems going to bed? Falling asleep? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child have any problems at bedtime? Do you have any problems going to bed? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Do you have any problems falling asleep at bedtime? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excessive daytime sleepiness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child seem overly tired or sleepy a lot during the day?Does he/she still take naps? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child have difficulty waking in the morning, seem sleepy during the day, or take naps? Do you feel tired a lot? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Do you feel sleepy a lot during the day? At school? While driving? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Awakenings during the night \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child wake up a lot at night? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? Do you wake up a lot at night? Do you have trouble getting back to sleep? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Do you wake up a lot at night? Have trouble getting back to sleep? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regularity and duration of sleep \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child have a regular bedtime and wake up time? What are they? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">What time does your child go to bed and get up on school days? On weekends? Do you think he/she is getting enough sleep? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-disordered breathing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child snore a lot or have breathing difficulties at night? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child snore a lot or have any breathing difficulties at night? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does your child snore? \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952496.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Questions in the age group 2–5 years are addressed to parents/caregivers; between 6 and 12 years, they are addressed to parents/caregivers and to the child him/herself; between 13 and 18 years, they are addressed to the adolescents, while the last (snoring) is also answered by the partner." ] ] ] "descripcion" => array:1 [ "en" => "BEARS algorithm.<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>" ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall recommendations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Place the baby/child in the crib/bed still awake \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Encourage the practice of sleeping alone without intervention from parents/caregivers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoid making the child sleep while being held, in the stroller, or other place rather than his/her room/bed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use a transitional object to help baby/child fall asleep \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoid bottle-feeding the baby/child to sleep \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Have regular hours for daytime and nighttime activities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Establish consistent sleep preparation routines that exclude activities with the potential to excite the child \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Differentiate daytime from nighttime activities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Establish bedtime and wake up times that are appropriate to the age range and personal characteristics of the child and his/her daytime activities, as well as the nighttime routine of the family \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Teach relaxation techniques that the child can follow on his/her own \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Offer positive reinforcement with awards when the child reaches goals of not waking up at night \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not encourage inappropriate behaviors or the bargaining of bedtime hours \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoid foods/drinks with caffeine at night \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952494.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sleep routine recommendations." ] ] 5 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: Modified from Bruni & Angriman.<a class="elsevierStyleCrossRef" href="#bib0220">2</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptom \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medications \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difficulty in initiating sleep without nocturnal awakenings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Melatonin, antihistaminic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difficulty in initiating sleep with multiple nocturnal awakenings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Antihistaminic, melatonin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple nocturnal awakenings but no difficulty in initiating sleep \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5-Hydroxytryptophan, antihistaminic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Awakens in the middle of the night with difficulty returning to sleep \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5-Hydroxytryptophanantihistaminic in the middle of the night \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Partial awakening with continuous crying \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5-Hydroxytryptophan \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Awakening with intense motor activity (restless leg syndrome) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Iron, gabapentin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Delayed sleep phase and insomnia in adolescents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Melatonin, zolpidem \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952497.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pharmacotherapy of insomnia according to the type of nocturnal symptoms." ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 28725 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The National Sleep Foundation's sleep time duration recommendations: methodology and results summary" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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Insônia na infância e adolescência: aspectos clínicos, diagnóstico e abordagem terapêutica

Magda Lahorgue Nunesa,

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nunes@pucrs.br

Corresponding author.

, Oliviero Brunib

a Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

b Department of Social Development and Psychology, Universidade La Sapienza, Rome, Italy

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sleep disorders &#40;SD&#41; are a frequent complaint in routine medical appointments and increasingly&#44; the pediatrician must be able to adequately establish their diagnosis and management&#44; thus avoiding referral to specialist consultations&#44; as well as unnecessary and excessive examinations&#47;interventions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">SD mostly present as the primary entity&#44; but may also be associated with several organic diseases &#40;e&#46;g&#46;&#44; asthma&#44; obesity&#44; neuromuscular diseases&#44; gastroesophageal reflux disease&#44; epilepsy&#44; attention disorder&#44; autism spectrum disorder&#41; or psychiatric comorbidities &#40;anxiety&#44; depression&#44; bullying&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical presentation is variable and multiple&#46; During the first years of life&#44; the most frequent complaints are difficulty falling asleep and&#47;or frequent nocturnal awakenings&#44; followed by parasomnias &#40;confusional arousals&#41; and sleep-disordered breathing &#40;obstructive apnea-hypopnea syndrome&#41;&#46; From preschool age onwards&#44; disorders related to inadequate sleep hygiene occur and&#44; in adolescence&#44; the disorders are related to circadian issues &#40;delayed sleep phase&#41; or excessive movement during sleep &#40;restless leg syndrome &#91;RLS&#93;&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This review will assess a frequent SD&#44; i&#46;e&#46;&#44; insomnia&#44; which may present in different clinical forms during childhood&#44; with varied management&#46; The clinical features&#44; diagnosis&#44; comorbidities&#44; and treatments will be assessed&#44; aiming to give the pediatrician an overview of the problem and to provide tools for its diagnosis and management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Sleep characteristics and classification of SD</span><p id="par0025" class="elsevierStylePara elsevierViewall">Recommendations about sleep duration in children and adolescents vary according to the source used&#46; Recently&#44; the National Sleep Foundation published a consensus based on an expert panel&#44; stating the ideal number of sleeping hours for every age group and a variability range that contains the acceptable number of sleeping hours &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Nocturnal awakenings occur frequently in childhood and its distribution varies with age&#46; In the first six months of life&#44; they are concentrated in one to two evening peaks&#59; after the sixth month&#44; they follow a distribution that accompanies the sleep cycle &#40;which lasts 90&#8211;120<span class="elsevierStyleHsp" style=""></span>min&#41; and occur more commonly in the REM stage&#46; In these cases&#44; it is common that the child goes back to sleep spontaneously&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The classification of SD is proposed by the American Academy of Sleep Medicine and the Chronic Insomnia Definition-ICSD-3&#44; which is the updated version of ICSD-2&#44; was published in 2005&#46; This classification review maintained the basic principles of the previous one&#44; identifying seven major SD categories&#58; insomnia&#44; sleep-disordered breathing&#44; central hypersomnia&#44; circadian rhythm disorders&#44; movement disorders during sleep&#44; parasomnias&#44; and others&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a> There was a standardization of diagnostic criteria for adults and children&#44; maintaining the recognition of specific age-dependent situations&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the prevalence of different SD in childhood&#44; according to the American Academy of Sleep Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Insomnia definition</span><p id="par0040" class="elsevierStylePara elsevierViewall">Insomnia can be defined as difficulty initiating sleep &#40;considered in children as the difficulty to fall asleep without a caregiver&#39;s intervention&#41;&#59; maintaining sleep &#40;frequent awakenings during the night and difficulty returning to sleep without a caregiver&#39;s intervention&#41;&#59; or waking up earlier than the usual schedule with inability to return to sleep&#46; Insomnia can cause distress and social&#44; professional&#44; educational-academic&#44; or behavioral impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Insomnia prevalence</span><p id="par0045" class="elsevierStylePara elsevierViewall">SD that manifest with difficulty falling asleep and&#47;or difficulty maintaining sleep &#40;due to nocturnal awakenings&#41; affect approximately 30&#37; of children&#46; The increase in prevalence&#44; which has been observed in recent years&#44; is closely related to social habits in the family&#44; as there is often a difference between the child&#39;s natural sleep-alertness rhythm and social requirements&#46; This disorder&#44; when chronic&#44; can result in deleterious effects on cognitive development&#44; mood regulation&#44; attention&#44; behavior and quality of life&#44; not only of the child but the entire family&#44; resulting in parents&#8217; sleep deprivation&#44; with consequences for their work activities&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Data on the prevalence of insomnia vary with age&#46; In the first two years&#44; the rates are high&#44; around 30&#37;&#44; and after the third year of life the prevalence remains stable at around 15&#37;&#46; It is worth mentioning that&#44; as insomnia definition and diagnosis vary widely among the available studies&#44; this fact directly influences the data on prevalence&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In a population-based study conducted in Pennsylvania&#44; it was demonstrated that one out of five children or pre-adolescents have insomnia symptoms&#59; the highest prevalence &#40;approximately 30&#37;&#41; is observed in girls aged 11&#8211;12 years&#44; which appears to be more related to hormonal changes than to anxiety&#47;depression&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Another large population-based study was carried out in China&#44; using two data collection stages&#44; with a five-year interval between them&#46; An increase in insomnia prevalence from 4&#46;2&#37; to 6&#46;6&#37; and incidence from 6&#46;2&#37; to 14&#46;9&#37; was demonstrated&#46; The initial cases were associated with health issues &#40;laryngopharyngitis&#41; and lifestyle &#40;caffeine intake&#44; smoking&#41;&#44; whereas the new cases were associated with parents&#8217; low educational level&#44; alcohol intake&#44; and mental illness&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A population-based study conducted in Norway with adolescents showed that&#44; on weekdays&#44; the average number of sleep hours was 6<span class="elsevierStyleHsp" style=""></span>h 25<span class="elsevierStyleHsp" style=""></span>m&#44; leading to a deficit of approximately 2<span class="elsevierStyleHsp" style=""></span>h&#59; most subjects &#40;65&#37;&#41; showed long latency to sleep onset &#40;&#62;30<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; The prevalence of insomnia in this population was 23&#46;8&#37; according to the DSM-IV criteria&#44; 18&#46;5&#37; using the DSM-V&#44; and 13&#46;6&#37; when quantitative criteria were used&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Types of insomnia according to age range</span><p id="par0070" class="elsevierStylePara elsevierViewall">In children&#44; insomnia has clearly defined behavioral characteristics and can be defined as two main types&#44; sleep-onset association disorder &#40;SOAD&#41; and limit-setting SD&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">SOAD</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this condition&#44; the infant learns to sleep under a specific condition &#40;object&#44; circumstance&#41;&#44; which usually requires intervention&#47;presence of parents&#46; After a nocturnal physiological awakening&#44; he&#47;she needs the same intervention to resume sleeping&#46; Although the number of awakenings is normal for their age group&#44; the problem occurs due to the inability to return to sleep alone&#44; which prolongs the alertness period&#46; Diagnosis is based on the history of long latency to sleep onset&#44; requiring specific and pre-determined conditions&#44; as well as the need for caregiver intervention during the nocturnal awakenings&#46; By definition&#44; two or three awakenings&#47;night&#44; lasting between 5 and 10<span class="elsevierStyleHsp" style=""></span>min or longer&#44; occur five times a week&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">This type of insomnia tends to disappear at approximately 3&#8211;4 years of age&#46; Polysomnography is normal if the associations are present to facilitate sleep onset&#46; The differential diagnosis with other types of insomnia is made through the rapid sleep onset in the presence of the initial conditions&#46; The therapeutic approach is through the gradual extinction of the association stimulus&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Limit-setting SD</p><p id="par0095" class="elsevierStylePara elsevierViewall">It is typical in preschool and school-age children&#44; characterized by the parents&#8217; difficulty in setting limits and rules for bedtime or having them followed&#46; As a result&#44; the child refuses to sleep or stay asleep all night&#46; Excuses for not going to sleep are a common occurrence &#40;hunger&#44; thirst&#44; &#8220;one more story&#8230;&#8221;&#41;&#44; with parents usually giving in&#46; Total sleep time may be reduced by 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h&#44; with approximately three to five awakenings that result in the child leaving the bed or calling the parents&#46; Polysomnography is normal&#44; as once the child sleeps&#44; sleep architecture is adequate&#46; For the differential diagnosis&#44; it is important to analyze the parents&#8217; relationship and attitude with the child&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Management essentially involves parents&#44; who should establish the limits&#47;rules and maintain them firmly&#44; and utilize behavioral techniques&#46; It is acceptable to use sleep-inducing antihistamines or benzodiazepines for a limited period of time&#44; while behavioral techniques are consolidated&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Some children may experience a combination of the two types of behavioral insomnia&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Studies have shown that sleep plays a crucial role in the healthy development of adolescents&#46; However&#44; changes in sleep patterns are very common in adolescence&#44; due to biological and environmental factors such as late bedtime&#44; inadequate sleep hygiene&#44; and sleep restriction and fragmentation&#46; Insomnia in this age group is associated with a poor prognosis in terms of mental health&#44; school performance&#44; and risk behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">In adolescence&#44; insomnia may be related to inadequate sleep hygiene and delayed sleep phase&#44; or it can have a psychophysiological origin&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Insomnia due to inadequate sleep hygiene&#58;</p><p id="par0125" class="elsevierStylePara elsevierViewall">During adolescence&#44; insomnia has characteristics related to changes in social habits &#40;tendency to sleep later&#41; and sleep hygiene problems&#46; The following habits are considered to be inadequate sleep hygiene&#58; sleeping after 11<span class="elsevierStyleHsp" style=""></span>pm and waking up after 8<span class="elsevierStyleHsp" style=""></span>am&#59; irregular sleep schedule between weekdays and the weekend&#59; use of stimulating substances or drugs &#40;licit and illicit&#41;&#59; excess caffeine in the late afternoon or at night&#59; and&#47;or use of electronic devices in the bedroom before going to bed &#40;TV&#44; computer&#44; mobile&#41;&#46; Social and family pressures&#44; hormonal changes&#44; and the need for belonging to a group also influence sleep quality&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Insomnia due to poor sleep hygiene leads to an increase in sleep latency and reduction in total sleep time&#46; As a consequence&#44; it results in excessive daytime sleepiness and&#47;or hyperactivity&#44; academic and relationship problems&#44; and sleep-wake cycle inversion&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;12</span></a> It is important to make the differential diagnosis with psychiatric disorders such as depression and schizophrenia&#44; noting that insomnia may be the initial symptom of these morbidities&#46; Therapeutic management consists in following an adequate sleep hygiene routine&#44; behavioral therapy and&#44; in selected cases&#44; the use of melatonin&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Delayed sleep phase insomnia&#58;</p><p id="par0140" class="elsevierStylePara elsevierViewall">It is defined as the delay in the sleep schedule that leads to a late awakening&#46; This is a circadian rhythm disorder that occurs in adolescents due to hormonal changes&#44; with a shift in the nocturnal sleep time as a function of the endogenous pacemaker&#46; It is a common cause of insomnia and can occur at other ages&#44; in addition to adolescence&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Conflicts occur because the bedtime does not match the sleep schedule&#59; the adolescent refuses to go to sleep and has trouble waking up in the following morning&#46; It results in symptoms of sleep deprivation&#44; hyperactivity&#44; aggression&#44; and even learning disabilities&#44; due to excessive daytime sleepiness&#46; After they manage to fall sleep&#44; sleep is tranquil&#44; with adequate structure and duration &#40;if they do not have to be awakened in the morning&#41;&#46; The attempt to compensate for sleepiness with naps during the day or unlimited sleep time on weekends leads to more nocturnal delayed sleep phase&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Optimal management consists in readjusting sleep onset time&#46; The use of low-dose melatonin &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#41; in the late afternoon was shown to be effective in correcting delayed sleep phase in a double-blinded study conducted with an adolescent population&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a> The association between delayed sleep phase as a cause of insomnia in adolescents has been extensively assessed in the literature&#46; In population-based study&#44; carried out in Norway&#44; including 10&#44;220 adolescents aged 16&#8211;18 years&#44; delayed sleep phase was observed in 3&#46;3&#37; of the population&#59; over half of these adolescents &#40;54&#37; girls and 57&#37; boys&#41; also met the criteria for insomnia&#46; Additionally&#44; the delayed sleep phase diagnosis resulted in a three-fold increased risk for school absenteeism in males and 1&#46;8-fold in females&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Psychophysiological insomnia&#58;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Characterized by a combination of previously experienced associations and hypervigilance&#46; The complaint consists of an exaggerated preoccupation with sleep&#44; getting to sleep&#44; and the adverse effects of &#8220;not sleeping&#8221; on the following day&#46; This type of situation occurs through a combination of risk factors &#40;genetic vulnerability&#44; psychiatric comorbidities&#41;&#44; triggering factors &#40;stress&#41;&#44; and other factors &#40;poor sleep hygiene&#44; caffeine intake&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical characteristics</span><p id="par0165" class="elsevierStylePara elsevierViewall">Among the factors that predispose to insomnia are&#58; birth order &#40;more prevalent in the first-born and&#47;or only child&#41;&#44; genetic factors &#40;positive family history&#41;&#59; temperament &#40;mood variability&#41;&#59; presence of maternal psychopathology or depression&#59; caregivers&#8217; behavior during the nocturnal awakenings &#40;the tendency to make the child fall asleep while holding him&#47;her on one&#39;s lap or pick up the infant in one&#39;s arms immediately after the nocturnal awakening tends to make insomnia a chronic condition&#41;&#59; night feeding &#40;nocturnal awakenings are more common in infants who are breastfed between 6 and 12 months and persist longer in children who continue to be breastfed after 12 months&#41;&#59; and co-sleeping &#40;frequently associated with insomnia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Different causes of insomnia or its precipitating factors are directly related to the child&#39;s neuropsychological development stage and&#47;or typical characteristics of adolescence&#44; as detailed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The division by age group is an instructive presentation&#59; however&#44; overlaps between different age groups can occur&#46; It should be noted that an irregular and erratic sleep routine can also lead to insomnia at all ages&#44; as well as acute and&#47;or chronic systemic diseases&#46; Although scarcely discussed in childhood&#44; the genetically determined characteristic of short sleep duration &#40;an individual who sleeps well&#44; but has a total duration of sleep below the average expected for age and level of development&#41; can occur&#44; and these cases have normal sleep quality &#40;organization&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Clinical investigation</span><p id="par0175" class="elsevierStylePara elsevierViewall">Clinical history is extremely important for the diagnosis of insomnia&#44; in which the falling asleep routine&#44; as well as sleep and wake characteristics should be investigated&#46; The impact of sleep disturbance on the child&#39;s life and family structure should be evaluated&#46; The physical examination also helps to exclude possible causes of secondary insomnia&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;5&#44;16</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Early detection of SD is essential for the proper management to be established and for prognosis to be favorable&#46; During the routine pediatric consultation&#44; a tool that can assist in the screening is the Bedtime routines&#44; Excessive daytime sleepiness&#44; Awakenings during night&#44; Regularity and duration of sleep&#44; Sleep-disordered breathing&#59; &#40;BEARS&#41; algorithm&#44; consisting of five easy-to-apply questions that have good power to detect sleep alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the trigger questions for adequate sleep assessment&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Another option that can help assess the dimension of insomnia is the use of sleep journals&#46; These allow for the assessment of the circadian rhythm and time &#40;amount of sleep&#41;&#46; Some questions may be directed to assess sleep habits and routine&#46; The journal should cover the 24-h period&#44; and contain information related to a mean period of two weeks&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Additionally&#44; validated questionnaires that assess sleep quality are also quite useful and should be used in association with interviews and the sleep journal&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">For children aged between 0 and 3 years&#44; the Brief Infant Sleep Questionnaire&#44; created by Sadeh et al&#46; and validated in Brazilian Portuguese should be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;19</span></a> For children older than 3 years&#44; the Sleep Disturbance Scale for Children&#44; proposed by Bruni et al&#46; and also validated in Brazilian Portuguese&#44; should be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">20&#44;21</span></a> The Brazilian Portuguese version of this scale is available in the digital version of this article &#40;Appendix 1&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Actigraphy is also a simple way to evaluate the sleep-wake rhythm&#46; This device is shaped like a wristwatch and monitors body movements&#46; The obtained signals can be analyzed through software and correlated with the child&#39;s condition&#44; and can be used at any age&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Polysomnography &#40;PSG&#41; is the gold standard exam for sleep evaluation&#46; It consists in recording the electroencephalogram &#40;EEG&#41; with other physiological variables &#40;eye movements&#44; submental electromyogram&#44; respiratory channels&#44; ECG&#44; oxygen saturation&#44; leg movements&#44; position sensor&#44; snore sensor&#41;&#46; It allows for a complete analysis of sleep architecture&#44; respiratory events&#44; and body movements&#46; It assists in the assessment of sleep organization&#44; time asleep&#44; sleep latency&#44; and in the differential diagnosis between epileptic and non-epileptic motor events&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Comorbidities</span><p id="par0210" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1&#41;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Depression</p><p id="par0220" class="elsevierStylePara elsevierViewall">Psychiatric disorders are usually associated with sleep problems such as hypersomnia&#44; fatigue&#44; irregular sleep-wake pattern&#44; and nightmares&#44; among others&#46; Children with major depression have a high prevalence of insomnia &#40;around 75&#37;&#41;&#44; and 30&#37; have severe insomnia&#46; The use of psychotropic medications can also negatively affect sleep&#46; Conversely&#44; there is new evidence suggesting that childhood insomnia itself is a risk factor for the development of psychiatric disorders in adolescence and adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">A population-based study conducted with Norwegian adolescents showed that depression leads to significant sleep time reduction&#44; as well as longer latency to sleep onset and more episodes of nocturnal awakenings in both genders&#46; Adolescents with insomnia had a four to five times higher risk of depression than those who sleep well&#46; Sleep deprivation &#40;sleeping fewer than 6<span class="elsevierStyleHsp" style=""></span>h&#47;night&#41; results in an eight-fold higher risk of depression&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2&#41;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Attention-deficit disorder&#47;hyperactivity disorder &#40;ADHD&#41;</p><p id="par0235" class="elsevierStylePara elsevierViewall">It is estimated that around 25&#8211;50&#37; of children with ADHD have sleep disorders&#46; Miano et al&#46; suggest different patterns&#44; including hyperarousal&#44; latency delay&#44; association with respiratory disorders&#44; RLS&#44; and epilepsy&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">25</span></a> Children with the combined subtype of ADHD tend to have more sleep problems&#46; Strategies related to better sleep hygiene and positive sleep routines are effective in these children&#46; In selected cases&#44; it may be necessary to use drugs to treat the insomnia&#44; such as alpha agonists &#40;clonidine&#41;&#44; non-benzodiazepine sleep-inducers &#40;zolpidem&#41;&#44; or melatonin&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3&#41;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Autism spectrum disorder &#40;ASD&#41;</p><p id="par0245" class="elsevierStylePara elsevierViewall">ASD consists of neurodevelopmental disturbances &#40;pervasive diseases&#44; Asperger&#39;s&#41; characterized by significant social interaction and communication &#40;language&#41; impairment&#46; SDs are common in this population and have severe effects on the affected child&#39;s and family&#39;s quality of life&#46; Sleep restriction has been associated with increased frequency of stereotypies and worse severity scores&#46; The complaint of insomnia characterized by long latency to sleep onset&#44; resistance to sleep&#44; reduced sleep efficiency&#44; and nocturnal awakenings are of great concern to parents&#46; In younger children&#44; there is also increased prevalence of behavioral insomnia &#40;SOAD and limit-setting SD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4&#41;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Epilepsy</p><p id="par0255" class="elsevierStylePara elsevierViewall">Patients with epilepsy have several changes in macro and micro sleep architecture&#44; such as increased latency to sleep onset&#44; reduced sleep efficiency&#44; reduced REM sleep&#44; and sleep fragmentation &#40;especially those who have nocturnal seizures or refractory epilepsy&#41;&#46; Complaints of excessive daytime sleepiness and poor sleep quality are also frequent&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">28&#8211;30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">5&#41;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Tourette syndrome</p><p id="par0265" class="elsevierStylePara elsevierViewall">Patients with Tourette syndrome frequently have sleep and attention disorders&#46; Insomnia is the most frequent SD and is usually associated with behavioral disorder during sleep&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a></p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Therapeutic approach</span><p id="par0270" class="elsevierStylePara elsevierViewall">The treatment of insomnia starts with a detailed assessment of its causes and triggers&#46; Parents should be educated about sleep hygiene and adequate sleep routines by the pediatrician during routine visits&#46; Some of these recommendations are listed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">Strategies for the treatment of primary insomnia involve sleep hygiene routines&#44; behavioral techniques&#44; and&#47;or pharmacological treatment&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1&#41;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Sleep hygiene routines</p><p id="par0285" class="elsevierStylePara elsevierViewall">Parents&#8217; education regarding what is adequate sleep hygiene is the start of the treatment&#44; noting that these procedures start during the day&#46; Diet is an important factor&#44; and high intake of caffeine &#40;chocolate&#44; teas&#44; soft drinks&#41; should be avoided during the day and especially at night&#46; Another daytime aspect is physical activity&#44; which&#44; when moderate&#44; has a beneficial effect on sleep&#46; At least 3<span class="elsevierStyleHsp" style=""></span>h before the child&#39;s established bedtime&#44; he&#47;she should be involved in relaxing activities&#59; overstimulation should be avoided&#46; Activities involving electronic media &#40;TV&#44; computer&#44; tablet&#44; and mobile phone&#41; should also be restricted and avoided at least 1<span class="elsevierStyleHsp" style=""></span>h before bedtime&#46; The bedroom environment is also a sleep hygiene factor&#46; It should be well ventilated&#44; quiet and dark&#44; at an adequate temperature&#44; and have a comfortable bed&#46; It is advisable not to use the bedroom for punishments &#40;&#8220;time-outs&#8221;&#41; applied during the day to prevent negative associations with the place of sleep&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Positive routines can also help the child learn appropriate sleep behaviors and reduce stress&#46; In addition to defining bedtime&#44; consistent routines &#40;activities that help prepare for sleep&#41; should be established and repeated every night&#46; As an example&#44; let the child know that is almost time to go to bed&#44; brush the teeth&#44; perform other hygiene routines&#44; put on pajamas&#44; read a story or spend some time with the parents&#44; turn off the lights&#46; It is important to make sure that the time set for these routines is sufficient&#44; so that they can be conducted calmly&#44; without harming &#40;reducing&#41; total sleep time&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">In brief&#44; adequate sleep hygiene consists of &#40;1&#41; regular&#47;consistent bedtime that is appropriate for the age group&#59; &#40;2&#41; avoiding high caffeine consumption&#59; &#40;3&#41; welcoming nocturnal atmosphere&#59; &#40;4&#41; bedtime routines&#59; and 5&#41; consistent and regular wake-up time&#44; regardless of what occurred during the night &#40;to maintain internal clock synchronization&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2&#41;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Behavioral therapy</p><p id="par0305" class="elsevierStylePara elsevierViewall">The main objective of the behavioral approach is to eliminate the negative associations that lead to insomnia&#46; It is possible to start this type of therapy after six months of life&#46; Several studies have demonstrated the effectiveness of this approach in most cases&#44; with clear benefits to the child&#39;s daytime routine&#44; as well as to that of the family&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">32&#44;33</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">There are several behavioral techniques that have been developed or adapted for the management of children with behavioral insomnia&#46; These techniques have proven efficacy and safety and are widely used&#44; especially in Anglo-Saxon countries&#46; The technique should be decided by the pediatrician together with the parents&#44; so that they can define the most appropriate one according to the child&#39;s age and the parents&#8217; circumstances regarding treatment adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">The following briefly describes the most often used techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;16&#44;17&#44;34</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Extinction&#58; consists in putting the child to sleep safely and ignoring the nocturnal behavior &#40;crying&#44; tantrums&#44; calling the parents&#41; until the following morning&#46; This procedure can also be performed with a parent in the bedroom&#44; who will not interact until the predetermined time&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Gradual extinction&#58; consists in putting the child to sleep safely and ignore the nocturnal behavior &#40;crying&#44; tantrums&#44; calling the parents&#41; for periods of time that increase during the night &#40;starting with 5<span class="elsevierStyleHsp" style=""></span>min and gradually increasing the waiting time by 5<span class="elsevierStyleHsp" style=""></span>min each time&#41;&#46; The purpose of this technique is to encourage the child to learn to self-comfort and return to sleep alone&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Positive routines&#58; consists of developing a series of activities&#47;calm routines that the child enjoys to prepare for bedtime&#44; trying to disconnect the act of going to bed from a stressful routine&#46; It is also possible to establish rewards to be given on the next day for those who manage to stay in bed until the next morning without going to the parents&#8217; room or calling them&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Planned bedtime&#58; consists of removing the child from bed if he&#47;she cannot fall asleep within the pre-established time interval &#40;15&#8211;30<span class="elsevierStyleHsp" style=""></span>min&#41; and letting him&#47;her perform some calming activity to get sleepy&#59; the parents should delay bedtime&#44; so that the child goes to bed when feeling sleepy&#46; After establishing the time when the child goes to sleep spontaneously&#44; put the child to bed 15&#8211;30<span class="elsevierStyleHsp" style=""></span>min earlier every day&#44; until the appropriate time is achieved&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Programmed awakening&#58; consists of waking up the child at night&#44; between 15 and 30<span class="elsevierStyleHsp" style=""></span>min before the usual time of spontaneous awakening&#44; and after that&#44; increasing the interval between episodes&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Cognitive restructuring&#58; consists of using cognitive-behavioral techniques&#44; in which the patient is taught to control his&#47;her negative thoughts about sleep and bedtime&#46; For instance&#44; instead of thinking &#8220;I won&#8217;t sleep tonight&#8221;&#44; the child should think &#8220;tonight I will relax and rest in my bed&#46;&#8221;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Relaxation techniques&#58; consists of meditation&#44; muscle relaxation&#44; taking deep breaths&#44; visualizing positive images&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Sleep restriction&#58; consists of restricting the time in bed&#44; so that the child will only lie in bed when he&#47;she is almost asleep&#59; it helps to disconnect the idea of staying in bed without feeling sleepy and helps to consolidate the connection between bed and sleep&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Stimulus control&#58; consists of avoiding performing activities that are not sleep-inducing when the child&#47;adolescent is already in bed &#40;TV&#44; social media&#44; worries&#44; etc&#46;&#41;&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Gradual extinction and extinction techniques&#44; which have been used for several decades&#44; still generate discussion and debate&#44; and parents have difficulty adhering to them&#44; especially in Latin culture countries&#46; Controlled studies have shown that the use of behavioral interventions in children with insomnia not only improves their daily functions &#40;sense of well-being and less crying&#41;&#44; but also the mood&#44; sleep&#44; and parental marital satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">More recent studies support and confirm these findings&#44; demonstrating that&#44; at school age&#44; children with insomnia who received behavioral intervention had better performance at social skills when compared to children who did not receive it&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">35</span></a> Additionally&#44; another study also reported improvements in maternal sleep and mood&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">36</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">During the literature review for the preparation of this article&#44; the authors did not retrieve any studies that associated the use of behavioral interventions in children with insomnia to deleterious effects on mental health or on the emotional connection with parents&#46; On the contrary&#44; several studies that consistently demonstrated the benefits of this intervention were retrieved&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">37&#44;38</span></a> It is also important to mention two studies in which children who received early behavioral interventions for insomnia were reassessed at the follow-up and the authors did not detect any changes in emotional function or internalizing and externalizing behaviors&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">37&#44;39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3&#41;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Pharmacological therapy</p><p id="par0385" class="elsevierStylePara elsevierViewall">Pharmacological therapy indication in childhood insomnia should occur when the parents cannot adapt to behavioral therapies due to objective difficulties or when the therapy does not show adequate results&#46; The indication must be made before the problem becomes chronic&#44; and must be conducted in association with behavioral therapy and for a limited period of time&#46; It is important to emphasize that there are no drugs for insomnia approved for use in children with such an indication&#44; which already limits this strategy&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;17</span></a> Indications are empirical&#44; based more on clinical experience than on evidence&#46; In most children&#44; sleep problems can be solved using a sleep hygiene approach and behavioral techniques&#59; however&#44; if there is drug indication&#44; it is recommended to follow these guidelines when choosing it&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">a&#41;</span><p id="par0390" class="elsevierStylePara elsevierViewall">The medication should act on the target symptom &#40;pain&#44; anxiety&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">b&#41;</span><p id="par0395" class="elsevierStylePara elsevierViewall">Primary SDs &#40;e&#46;g&#46;&#44; apnea&#44; RLS&#41; should be treated before insomnia medication is indicated&#59;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">c&#41;</span><p id="par0400" class="elsevierStylePara elsevierViewall">The choice of medication must be appropriate for the age and neurodevelopmental level&#44; always weighing the benefits against the side effects&#46;</p></li></ul></p></li></ul></p><p id="par0405" class="elsevierStylePara elsevierViewall">3&#46;1&#41; Antihistaminic agents&#58;</p><p id="par0410" class="elsevierStylePara elsevierViewall">They are the most frequently prescribed drugs for insomnia therapy at the level of primary care &#40;e&#46;g&#46;&#44; hydroxyzine&#44; diphenhydramine&#44; promethazine&#41;&#46; They assist in the acute phase&#44; leading to a decrease in latency and awakenings&#44; and must be used in combination with a behavioral intervention program&#46; Daytime sedation&#44; dizziness&#44; or paradoxical hyperactivity can occur as side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">3&#46;2&#41; Alpha-agonists &#40;clonidine&#41;</p><p id="par0420" class="elsevierStylePara elsevierViewall">They are used for the treatment of insomnia in children due to their sedative effect&#46; Their duration of action is 3&#8211;<span class="elsevierStyleHsp" style=""></span>h and the half-life is 12&#8211;6<span class="elsevierStyleHsp" style=""></span>h&#46; They should be administered at bedtime&#44; orally&#46; Hypotension and weight loss have been described as side effects&#46; Rapid withdrawal can lead to unwanted symptoms&#44; such as shortness of breath&#44; high blood pressure&#44; and tachycardia&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a></p><p id="par0425" class="elsevierStylePara elsevierViewall">3&#46;3&#41; Melatonin</p><p id="par0430" class="elsevierStylePara elsevierViewall">It is a hormone &#40;N-acetyl-5-methoxytryptamine&#41; synthesized by the pineal gland&#44; whose secretion is controlled by the suprachiasmatic nucleus of the hypothalamus&#44; with a peak between 2 and 4<span class="elsevierStyleHsp" style=""></span>am&#46; It reduces latency to sleep onset and number of awakenings&#44; as well as improving mood and daytime behavior&#46; Its efficacy in children with ADHD and ASD has been reported in several studies&#46; The recommended dose is 0&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>mg in children and 3&#8211;5<span class="elsevierStyleHsp" style=""></span>mg in adolescents&#46; At the usual doses&#44; the side effects are irrelevant&#46; The medication does not interfere with antiepileptic drug action&#44; endogenous melatonin production&#44; or pubertal development&#44; and does not cause addiction&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">3&#46;4&#41; L5-hydroxytryptophan</p><p id="par0440" class="elsevierStylePara elsevierViewall">It is a serotonin precursor&#46; It has shown to be effective in episodes of certain types of parasomnia&#44; such as night terrors&#44; at a dose of 1&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day at bedtime&#46; It appears to have a sleep stabilizing function&#44; being effective in some patients&#46; It can be used as an alternative treatment&#44; as it has practically no side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">3&#46;5&#41; Iron</p><p id="par0450" class="elsevierStylePara elsevierViewall">The association between reduced iron levels and motor activity during sleep has been widely discussed in recent years&#46; Iron deficiency in the substantia nigra can reduce dopaminergic function&#44; as this element has a modulatory function&#46; Iron-deficiency anemia may be associated with nocturnal motor hyperactivity&#44; with reduced sleep time and increase in the number of awakenings&#46; As this hyperactivity can be a precursor of RLS&#44; oral iron replacement is indicated when ferritin levels are low&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">3&#46;6&#41; Benzodiazepines</p><p id="par0460" class="elsevierStylePara elsevierViewall">These are the most often prescribed psychotropic drugs for children with neurological and&#47;or psychiatric problems&#46; They reduce the latency to sleep onset and improve sleep efficiency&#46; Side effects may occur and vary from daytime sedation&#44; changes in behavior&#44; paradoxical hyperactivity&#44; and memory deficits&#46; They are contraindicated in suspected sleep-disordered breathing&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a></p><p id="par0465" class="elsevierStylePara elsevierViewall">3&#46;7&#41; Tricyclic antidepressants</p><p id="par0470" class="elsevierStylePara elsevierViewall">Imipramine at a dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day at bedtime appears to have some efficacy in insomnia&#59; however&#44; it is not widely used due to the risk of severe side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a></p><p id="par0475" class="elsevierStylePara elsevierViewall">3&#46;8&#41; Non-benzodiazepine sleep inducers &#40;imidazopyridine&#41;</p><p id="par0480" class="elsevierStylePara elsevierViewall">Their use in children younger than 12 years is contraindicated&#46; Zolpidem and zaleplon are the most often used&#59; as they have few side effects&#44; they can be administered in children aged 12 years and older at a dose of 5&#8211;0<span class="elsevierStyleHsp" style=""></span>mg at bedtime&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a></p><p id="par0485" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> summarizes drug indications for insomnia according to the nocturnal complaint&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0490" class="elsevierStylePara elsevierViewall">In conclusion&#44; insomnia complaints in children and adolescents should be taken into account and properly investigated by the pediatrician&#44; considering its association with several comorbidities&#44; which must also be diagnosed&#46; The main causes of insomnia and its triggers vary according to the age and level of development&#46; The therapeutic approach should include sleep hygiene measures&#44; behavioral techniques&#44; and&#44; in individual cases&#44; pharmacological treatment&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0495" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Sleep characteristics and classification of SD"
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          "titulo" => "Insomnia definition"
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          "titulo" => "Types of insomnia according to age range"
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    "fechaRecibido" => "2015-05-07"
    "fechaAceptado" => "2015-06-09"
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          "clase" => "keyword"
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            0 => "Insomnia"
            1 => "Sleep disorders"
            2 => "Childhood"
            3 => "Adolescence"
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          "palabras" => array:4 [
            0 => "Ins&#244;nia"
            1 => "Dist&#250;rbios do sono"
            2 => "Inf&#226;ncia"
            3 => "Adolesc&#234;ncia"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To review the clinical characteristics&#44; comorbidities&#44; and management of insomnia in childhood and adolescence&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a non-systematic literature review carried out in the PubMed database&#44; from where articles published in the last five years were selected&#44; using the key word &#8220;insomnia&#8221; and the pediatric age group filter&#46; Additionally&#44; the study also included articles and classic textbooks of the literature on the subject&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Data synthesis</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During childhood&#44; there is a predominance of behavioral insomnia as a form of sleep-onset association disorder &#40;SOAD&#41; and&#47;or limit-setting sleep disorder&#46; Adolescent insomnia is more associated with sleep hygiene problems and delayed sleep phase&#46; Psychiatric &#40;anxiety&#44; depression&#41; or neurodevelopmental disorders &#40;attention deficit disorder&#44; autism&#44; epilepsy&#41; frequently occur in association with or as a comorbidity of insomnia&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Insomnia complaints in children and adolescents should be taken into account and appropriately investigated by the pediatrician&#44; considering the association with several comorbidities&#44; which must also be diagnosed&#46; The main causes of insomnia and triggering factors vary according to age and development level&#46; The therapeutic approach must include sleep hygiene and behavioral techniques and&#44; in individual cases&#44; pharmacological treatment&#46;</p></span>"
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            "titulo" => "Objectives"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Revisar as caracter&#237;sticas clinicas&#44; as comorbidades e o manejo da ins&#244;nia na inf&#226;ncia e adolesc&#234;ncia&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fonte dos dados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revis&#227;o n&#227;o sistem&#225;tica da literatura realizada na base dados PubMed&#44;onde foram selecionados artigos publicados nos &#250;ltimos 5 anos&#44; selecionados com o uso da palavra chave ins&#244;nia e o filtro faixa et&#225;ria pedi&#225;trica&#46; Adicionalmente foram tamb&#233;m inclu&#237;dos artigos e livros texto cl&#225;ssicos da literatura sobre o tema&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">S&#237;ntese dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Na inf&#226;ncia existe predom&#237;nio da ins&#244;nia comportamental na forma de dist&#250;rbio de in&#237;cio do sono por associa&#231;&#245;es inadequadas e&#47;ou dist&#250;rbio pela falta de estabelecimento de limites&#46; Na adolesc&#234;ncia a ins&#244;nia est&#225; mais associada a problemas de higiene do sono e atraso de fase&#46; Transtornos psiqui&#225;tricos &#40;ansiedade&#44; depress&#227;o&#41; ou do neurodesenvolvimento &#40;Transtorno do d&#233;ficit de aten&#231;&#227;o&#44; autismo&#44; epilepsias&#41; ocorrem com frequ&#234;ncia em associa&#231;&#227;o ou como comorbidade do quadro de ins&#244;nia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A queixa de ins&#244;nia nas crian&#231;as e adolescentes deve ser valorizada e adequadamente investigada pelo Pediatra&#44; levando em considera&#231;&#227;o a associa&#231;&#227;o com diversas comorbidades&#44; que tamb&#233;m devem ser diagnosticas&#46; As causas principais de ins&#244;nia e fatores desencadeantes variam de acordo com a idade e n&#237;vel de desenvolvimento&#46; A abordagem terap&#234;utica deve incluir medidas de higiene do sono e t&#233;cnicas comportamentais&#44; e em casos individualizados tratamento farmacol&#243;gico&#46;</p></span>"
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            "titulo" => "Fonte dos dados"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Nunes ML&#44; Bruni O&#46; Insomnia in childhood and adolescence&#58; clinical aspects&#44; diagnosis&#44; and therapeutic approach&#46; J Pediatr &#40;Rio J&#41;&#46; 2015&#59;91&#58;S26&#8211;35&#46;</p>"
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            "apendice" => "<p id="par0505" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0060"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ideal hours of sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acceptable hours of sleep &#40;maximum and minimum&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Newborns &#40;0&#8211;3 months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#8211;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#8211;19 and 11&#8211;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infants &#40;4&#8211;12 months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#8211;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#8211;18 and 10&#8211;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Toddlers &#40;1&#8211;2 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#8211;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#8211;16 and 9&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preschoolers &#40;3&#8211;5 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#8211;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 and 8&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">School-aged children &#40;6&#8211;13 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#8211;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 and 7&#8211;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adolescents &#40;14&#8211;17 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#8211;10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Young adults &#40;18&#8211;25 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;11 and 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adults &#40;26&#8211;64 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 and 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elderly &#40;&#62;65 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#8211;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 and 5&#8211;6&nbsp;\t\t\t\t\t\t\n
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        ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Sleep duration&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insomnia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#8211;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-disordered breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#8211;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypersomnia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&#8211;0&#46;20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Circadian rhythm disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parasomnias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-related movement disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab952495.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Prevalence of sleep disorders in childhood according to ICSD-3&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Infants</td><td class="td" title="table-entry  " align="left" valign="top">Sleep-onset association disorder &#40;SOAD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food allergies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastroesophageal reflux&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colic in infants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excessive nighttime fluid intake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute otitis media or other infectious diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">2&#8211;3 years</td><td class="td" title="table-entry  " align="left" valign="top">SOAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parental separation anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged naps or at inappropriate times&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infectious diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Preschoolers and school-aged children</td><td class="td" title="table-entry  " align="left" valign="top">Limit-setting sleep disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nightmares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infectious diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="8" align="left" valign="top">Adolescents</td><td class="td" title="table-entry  " align="left" valign="top">Sleep hygiene problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Delayed sleep phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psychiatric comorbidities &#40;anxiety&#44; depression&#44; attention deficit hyperactivity disorder&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family&#44; school pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-disordered breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Movement disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infectious diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab952493.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Causes and&#47;or triggering factors of insomnia according to the age group&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Modified from Mindell &#38; Owens&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a></p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">BEARS&#44; Bedtime routines&#44; Excessive daytime sleepiness&#44; Awakenings during night&#44; Regularity and duration of sleep&#44; Sleep-disordered breathing&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BEARS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&#8211;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6&#8211;12 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">13&#8211;18 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bedtime&#47;sleep problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child have any problems going to bed&#63; Falling asleep&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child have any problems at bedtime&#63; Do you have any problems going to bed&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Do you have any problems falling asleep at bedtime&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excessive daytime sleepiness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child seem overly tired or sleepy a lot during the day&#63;Does he&#47;she still take naps&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child have difficulty waking in the morning&#44; seem sleepy during the day&#44; or take naps&#63; Do you feel tired a lot&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Do you feel sleepy a lot during the day&#63; At school&#63; While driving&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Awakenings during the night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child wake up a lot at night&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child seem to wake up a lot at night&#63; Any sleepwalking or nightmares&#63; Do you wake up a lot at night&#63; Do you have trouble getting back to sleep&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Do you wake up a lot at night&#63; Have trouble getting back to sleep&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regularity and duration of sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child have a regular bedtime and wake up time&#63; What are they&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">What time does your child go to bed and get up on school days&#63; On weekends&#63; Do you think he&#47;she is getting enough sleep&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">What time do you usually go to bed on school nights&#63; Weekends&#63; How much sleep do you usually get&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep-disordered breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child snore a lot or have breathing difficulties at night&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child snore a lot or have any breathing difficulties at night&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does your child snore&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab952496.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Questions in the age group 2&#8211;5 years are addressed to parents&#47;caregivers&#59; between 6 and 12 years&#44; they are addressed to parents&#47;caregivers and to the child him&#47;herself&#59; between 13 and 18 years&#44; they are addressed to the adolescents&#44; while the last &#40;snoring&#41; is also answered by the partner&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BEARS algorithm&#46;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Place the baby&#47;child in the crib&#47;bed still awake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Encourage the practice of sleeping alone without intervention from parents&#47;caregivers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoid making the child sleep while being held&#44; in the stroller&#44; or other place rather than his&#47;her room&#47;bed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use a transitional object to help baby&#47;child fall asleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoid bottle-feeding the baby&#47;child to sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Have regular hours for daytime and nighttime activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Establish consistent sleep preparation routines that exclude activities with the potential to excite the child&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Differentiate daytime from nighttime activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Establish bedtime and wake up times that are appropriate to the age range and personal characteristics of the child and his&#47;her daytime activities&#44; as well as the nighttime routine of the family&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Teach relaxation techniques that the child can follow on his&#47;her own&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Offer positive reinforcement with awards when the child reaches goals of not waking up at night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not encourage inappropriate behaviors or the bargaining of bedtime hours&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoid foods&#47;drinks with caffeine at night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab952494.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Sleep routine recommendations&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Modified from Bruni &#38; Angriman&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
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                  <table border="0" frame="\n
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Article information

ISSN: 00217557
Original language: English

DOI:10.1016/j.jped.2015.08.006

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	10	17
2024 October	23	26	49
2024 September	51	44	95
2024 August	53	31	84
2024 July	41	33	74
2024 June	31	16	47
2024 May	25	21	46
2024 April	38	32	70
2024 March	32	20	52
2024 February	31	31	62
2024 January	28	29	57
2023 December	35	28	63
2023 November	71	38	109
2023 October	41	43	84
2023 September	59	39	98
2023 August	57	26	83
2023 July	23	27	50
2023 June	19	11	30
2023 May	26	18	44
2023 April	25	17	42
2023 March	32	25	57
2023 February	29	17	46
2023 January	27	24	51
2022 December	45	38	83
2022 November	43	22	65
2022 October	37	29	66
2022 September	19	30	49
2022 August	30	31	61
2022 July	100	55	155
2022 June	31	30	61
2022 May	33	30	63
2022 April	81	47	128
2022 March	40	48	88
2022 February	56	30	86
2022 January	104	21	125
2021 December	90	22	112
2021 November	25	24	49
2021 October	30	31	61
2021 September	19	13	32
2021 August	20	15	35
2021 July	20	9	29
2021 June	20	11	31
2021 May	21	18	39
2021 April	130	37	167
2021 March	80	25	105
2021 February	35	25	60
2021 January	18	13	31
2020 December	27	13	40
2020 November	33	14	47
2020 October	23	13	36
2020 September	29	19	48
2020 August	14	11	25
2020 July	14	13	27
2020 June	19	8	27
2020 May	19	4	23
2020 April	24	14	38
2020 March	23	2	25
2020 February	18	6	24
2020 January	20	9	29
2019 December	19	4	23
2019 November	15	4	19
2019 October	23	15	38
2019 September	38	8	46
2019 August	19	6	25
2019 July	16	11	27
2019 June	34	18	52
2019 May	10	11	21
2019 April	25	10	35
2019 March	11	8	19
2019 February	12	7	19
2019 January	12	7	19
2018 December	9	17	26
2018 November	16	8	24
2018 October	118	17	135
2018 September	66	16	82
2018 August	3	6	9
2018 July	4	17	21
2018 June	5	9	14
2018 May	5	16	21
2018 April	7	2	9
2018 March	11	2	13
2018 February	2	4	6
2018 January	3	1	4
2017 December	0	2	2
2017 November	5	2	7
2017 October	11	7	18
2017 September	3	2	5
2017 August	4	19	23
2017 July	0	2	2
2017 June	4	6	10
2017 May	2	0	2
2017 April	3	1	4
2017 March	1	6	7
2017 February	2	3	5
2017 January	5	1	6
2016 December	7	6	13
2016 November	8	13	21
2016 October	11	12	23
2016 September	10	3	13
2016 August	5	1	6
2016 July	7	5	12
2016 June	9	8	17
2016 May	24	15	39
2016 April	13	14	27
2016 March	24	9	33
2016 February	12	13	25
2016 January	23	18	41
2015 December	14	6	20
2015 November	26	11	37

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