“Sleep, Baby, Sleep” – Insights into Pediatric Sleep Medicine with Dr. Alfred Wiater
In the first years of life, most neural networks (Fig. 1) are formed during sleep. This goes hand in hand with considerable learning capacity across all domains, including emotional skills. If sleep is disturbed during this sensitive developmental phase, the basic foundations on which all further development builds are lacking. But that’s not all. If sleep disorders in childhood are not diagnosed and treated in time, they can become chronic and still have significant consequences in adulthood. After all, many sleep disorders in adults originate in childhood and adolescence. If they are treated during this period, many problems can be prevented for those affected.
The complex issue of sleep disorders
Like adults, children’s sleep disorders are closely linked to daytime behavior; however, non-restorative sleep in children more frequently results in restlessness and hyperactivity, while in adults, daytime sleepiness and fatigue are the main issues. You cannot properly evaluate sleep quality without understanding how the person functions during the day. But this is just one part of the broader complexity of sleep disorders.
Another important aspect is that various sleep disorders can affect one another, forming a bidirectional relationship. In the Summer 2025 issue of Inspiration, Dr. Weeß covered “COMISA: The Burdensome Dual Diagnosis,” where OSA and insomnia co-occur and affect one another. A phenomenon that can also relate to sleep disorders and other conditions, and which likewise occurs in pediatric sleep medicine.
Dr. Alfred Wiater, Pediatrician and Sleep Medicine Specialist, Online Pediatric Sleep Medicine Practice, www.kinderschlaf.net
How restless legs syndrome (RLS) and ADHD are related.
A retrospective study of children with restless legs syndrome (RLS) showed that 64% had one or more concurrent psychiatric conditions, especially ADHD. The relationship between RLS and ADHD is complex and bidirectional. The co-occurrence of RLS and ADHD may be due to a dysfunction in the synthesis of the neurotransmitter dopamine.
Since iron is needed as a cofactor for dopamine production in the brain, this indicates that the pathogenesis of both disorders is closely associated with iron deficiency. Particularly because iron therapy may be beneficial for both disorders. This is only effective if the ferritin level, which reflects iron metabolism, is below a specific threshold.
Physical and psychological consequences of sleep disorders.
Ultimately, sleep disorders can also be caused by organic or psychological conditions. For instance, depression may cause trouble falling or staying asleep, resulting in impaired daytime activity characteristic of insomnia. Conversely, insomnia is associated with an increased risk of developing depression.
The interrelationships between sleep and wakefulness, between different sleep disorders, and between sleep disorders and other conditions underlie the complexity of the issue.
Moreover, chronic sleep disorders can lead to physical issues in children as well. These include high blood pressure and cardiac strain as consequences of obstructive sleep apnea. In children, chronic sleep disorders can result in growth issues, since growth hormone is secreted during sleep. Psychologically, sleep disorders can lead not only to depression but also to anxiety.
Increase of obstructive sleep apnea (OSA) in children and adolescents.
Since the COVID-19 lockdown, there has been a marked rise in obstructive sleep apnea among children and adolescents.
The reason cited is that children and adolescents were not physically active enough, spent a lot of time on digital media, and ate unhealthily. The result: Weight gain up to the point of obesity.
Obesity is a risk factor familiar from adults with sleep apnea, yet in children and adolescents, it is just one of several contributing factors.
In this age group, the most frequent cause of obstructive sleep apnea is adenotonsillar hypertrophy – an enlargement of the throat and palatine tonsils. In such cases, the preferred treatment is ENT surgery.
Enlarged tonsils narrow the upper airways in children, leading them to breathe through their mouths instead of their noses. As a result of this breathing behavior, the tongue sits in a middle position instead of resting against the palate, as it does with a closed mouth.
This deprives the facial skeleton, especially the jaw and midface, of an important growth stimulus. Both remain too narrow, the upper jaw protrudes beyond the lower jaw, creating a risk factor for OSA in adulthood – an issue that can be avoided with early diagnosis and intervention.
Bruxism associated with OSA.
Now let’s talk about teeth grinding, or bruxism, which frequently accompanies OSA.
During obstructions of the upper airways, the genioglossus muscle is activated, which helps to widen the airways. In OSA, the respiratory signals that trigger the genioglossus muscle also engage the masseter muscles, which function in chewing.
This results in bruxism. The hypothesis has been proposed that activation of the masseter muscle serves to stabilize the lower jaw and allows the genioglossus muscle to keep the upper airways open more efficiently.
In practice, OSA treatment can also alleviate bruxism. Considering that about one in five adolescents in Germany show clear clinical signs of bruxism and that one in 20 already have enamel worn down to the dentin, early OSA treatment could have a positive effect on dental health – at least in children whose teeth grinding is related to OSA.
Finally, there are children and adolescents with facial and jaw anomalies from birth as a cause of OSA. In these cases, orthodontists should be involved in treatment early on, depending on the individual findings, even as early as toddler age.
This can help normalize jaw growth, thereby reducing the risk of OSA in adulthood. CPAP for children with OSA? Yes, but there is rarely an indication for this.
What conclusions can be drawn from this?
Children’s sleep disorders need to be taken seriously, because their effects can extend all the way into adulthood.
Sleep should always be evaluated in the context of daytime behavior and symptoms. In children, issues like difficulty concentrating, attention problems, and hyperactive behavior may indicate a sleep disorder.
Different sleep disorders can appear at the same time and be connected, as illustrated by OSA and bruxism.
Psychological disorders such as depression can both result from and contribute to sleep disorders.
Beyond psychological disorders, sleep disorders in childhood can already contribute to organic conditions, such as cardiovascular disease.
References
(1) Solveig Magnusdottir, Elizabeth A. Hill: Prevalence of obstructive sleep apnea (OSA) among preschool aged children in the general population: A systematic review, Sleep Medicine Reviews, Volume 73, 2024, 101871, ISSN 1087-0792, https://doi.org/10.1016/j.smrv.2023.101871.
(2) Yap A.U., Chua A.P.: Sleep bruxism: Current knowledge and contemporary management. J Conserv Dent, 2016 Sep–Oct;19(5):383-9. doi: 10.4103/0972-0707.190007. PMID: 27656052; PMCID: PMC5026093.
(3) Erdim İ., Kandemir İ., Sapmaz E., Gül A.: Sleep Disorders and Restless Legs Syndrome in Schoolage Pediatric Population. J Turk Sleep Med, 2022 Jun;9(2):165–171. doi:10.4274/jtsm.galenos.2022.33255.
(4) Lourdes M. DelRosso, Maria Paola Mogavero, Argelinda Baroni, Oliviero Bruni, Raffaele Ferri: Restless Legs Syndrome in Children and Adolescents, Child and Adolescent Psychiatric Clinics of North America, Volume 30, Issue 1, 2021, Pages 143–157, ISSN 1056-499 ISBN 9780323791144, doi.org/10.1016/j.chc.2020.08.010.
(5) Migueis D.P., Lopes M.C., Casella E., Soares P.V., Soster L., Spruyt K.: Attention deficit hyperactivity disorder and restless leg syndrome across the lifespan: A systematic review and meta-analysis. Sleep Med Rev, 2023 Jun;69:101770. doi: 10.1016/j.smrv.2023.101770. Epub 2023 Feb 27. PMID: 36924608.
(6) Alan Mark, Zhou Borong.: Association among attention-deficit hyperactivity disorder, restless legs syndrome, and peripheral iron status: a two-sample Mendelian randomization study. Frontiers in Psychiatry Volume 15 – 2024. www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2024.1310259.
(7) Christian Hirsch. Bruxismus im Kindes- und Jugendalter. Quintessenz Zahnmedizin, Februar 2019, p. 186 et seq.