Phenotypes of Chronic Insomnia in Early Childhood Proposed to Improve Identification

A recent review suggests that children might be affected by specific types of insomnia and that their treatment should be more suitable to their classified insomnia phenotype.

Oliviero Bruni, MD, associate professor at the University of Rome

Oliviero Bruni, MD

In a recent literature review study, 3 phenotypes of chronic insomnia in early childhood were identified, including insomnia with motor restlessness; insomnia characterized without difficulties in falling asleep but with long-lasting early morning awakenings; and insomnia with multiple night awakenings and difficulties falling asleep.1 The authors noted that these categorizations of the sleep disorder provide a new guide for a better understanding of the pathophysiology as they each may have different implications for treatment and prevention interventions.

The review evaluated multiple studies on pediatric insomnia, although the translation of the findings from the research in practice settings is still unclear as there is a lack of standard definitions for treatments,2 and the review does not specify drug treatment nor provide clear evidence for the frequency and duration of such treatment.3

There was a limited amount of data on older children and adolescents' treatments for insomnia,4 along with sparse assessments available on the severity of insomnia in infants and children. Despite the limited information on efficacy and safety data, a worldwide trend was observed with the increased use of medication even though no specific drug had been approved yet for pediatric insomnia.5

Lead author Oliviero Bruni, MD, associate professor at the University of Rome, and colleagues wrote, “We are aware that this kind of classification might lead a clinician to choose an untested medical intervention prior to attempting behavioral interventions that have clinical efficacy, but this is not our intention nor our recommendation. This report is simply an attempt to classify chronic insomnia of early childhood from a clinical point of view and to underline different pathophysiological mechanisms that might be sensitive to pharmacological therapy, for an eventual integration with the first-line behavioral treatment.”1

Previous studies have been biased on the pharmacological treatment of pediatric insomnia, Bruni and colleagues note, because of a lack of correct identification for the type of chronic insomnia. Based on the review, clinicians have prescribed the same treatment to individuals who experience sleep disturbances as a one-size-fits all approach, yet this method might not work for the different types of insomnia. Hence, as patients’ sleeping problems vary, so do their medications and their characteristics since treatment should be more suitable to the patient based on their presentations of insomnia.

Bruni et al wrote, “It should be noted that the use of most all of the drugs for insomnia in childhood is off-label because they have no specific indication for this condition. Optimizing the medication management of insomnia requires that the clinician selects an agent which has characteristics making it most likely to effectively and safely address the sleep difficulty experienced by that specific individual. Carrying out this process requires awareness of the ways that insomnia may differ between individuals and how to match the medication characteristics to the nature of an individual sleep complaint.”1

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According to the analysis of the review, pharmacological treatment should be chosen based on the individual’s symptoms and treatment goals, the response to past treatment, the presence of any comorbid conditions and contraindications, any concurrent medication interactions, and any potential adverse effects. Another factor to be considered by clinicians when looking into treatment options is if the patient has a history within their family with insomnia, linking genetic traits.

“It is important to take into account that the phenotypical expression of symptoms of sleep disorders might change during development and therefore the sleep diagnosis based on ICDS-3 diagnostic criteria could also change as new symptoms manifest. These changes in diagnosis as symptoms develop are particularly important to consider in the pediatric population,” Bruni et al noted. “We suggest that the early identification of the predisposition to a specific type of insomnia might help starting the appropriate treatment (either behavioral and/or pharmacological, or both) and preventing the chronicity of insomnia, or even the development of future sleep disorders.”1

Future research is needed to test the classification of the different phenotypes of chronic insomnia such as performing an evaluation on the efficacy of treatments between the categories. More investigations should be conducted on the different phenotypes of insomnia that analyze the comorbidities that are specifically associated with the condition as they could prevent long-term negative consequences. Longitudinal studies are also needed on these different insomnia types to evaluate them in the different stages of life such as during late childhood, adolescence, and adulthood.

REFERENCES
1. Bruni O, DelRosso LM, Mogavero MP, Angriman M, Ferri R. Chronic insomnia of early childhood: Phenotypes and pathophysiology. Neurosci Biobehav Rev. 2022;137:104653. doi:10.1016/j.neubiorev.2022.104653
2. Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A; American Academy of Sleep Medicine. Behavioral treatment of bedtime problems and night wakings in infants and young children [published correction appears in Sleep. 2006;29(11):1380]. Sleep. 2006;29(10):1263-1276.
3. Owens JA, Babcock D, Blumer J, et al. The use of pharmacotherapy in the treatment of pediatric insomnia in primary care: rational approaches. A consensus meeting summary. J Clin Sleep Med. 2005;1(1):49-59.
4. Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia [published correction appears in J Pediatr Psychol. 2015 Mar;40(2):262-5]. J Pediatr Psychol. 2014;39(8):932-948. doi:10.1093/jpepsy/jsu041
5. Heussler H, Chan P, Price AM, Waters K, Davey MJ, Hiscock H. Pharmacological and non-pharmacological management of sleep disturbance in children: an Australian Paediatric Research Network survey. Sleep Med. 2013;14(2):189-194. doi:10.1016/j.sleep.2012.09.023
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