Management of Paediatric Chronic Insomnia in Primary Care

Abstract

Behavioural insomnia, a form of chronic insomnia, is highly prevalent in children. Persisting sleep problems can have multiple impacts on the child and family. Behavioural/sleep hygiene interventions are effective management strategies, and primary care provides the potential for early management and prevention. This thesis explores the management of chronic insomnia in children within primary care. A systematic review explored the evidence-base for primary care practitioners’ (PCP) knowledge, beliefs/attitudes, and practice. A systematic narrative synthesis of 26 studies found that PCPs are aware of the impacts of chronic insomnia, perceive management to be within their role, and endorse behavioural management strategies, but have varied knowledge and confidence for management. However, the methodological quality of the studies varied, and they were from limited primary care settings and countries (usually UK health visitors or US paediatricians). Higher quality UK research for both GPs and health visitors was lacking. A qualitative study analysed posts in online discussion forums to explore parental concerns about children’s sleep problems, awareness of management resources, and perception of management within primary care. Results from 93 discussion threads across two forums suggested that: parents have multiple and varied concerns relating to their children’s sleep; that parents often turn to one another online for emotional and practical support; and use resources online, non-PCPs (such as private sleep consultants) and books. It is uncertain how many of these resources are evidence-based. Parents posted about primary care less frequently but had mixed experiences of and attitudes towards health visitors, and limited experiences with GPs. A mixed-methods study (surveys and qualitative interviews) of UK practicing PCPs was conducted to explore their knowledge, training, beliefs and practice for insomnia management in children up to the age of five. Survey findings (n=355, mainly GPs) suggested that PCPs perceive negative impacts of chronic insomnia on children and their families and believe that it should be addressed in healthcare. However, insomnia is infrequently discussed in consultations, PCPs have varied knowledge and confidence regarding management, and limited training and knowledge of resources. Interview findings (n=21) echoed the survey findings, providing greater depth and insight. Health visitors had greater training opportunities and were perceived to be more suited to in-depth management, whereas the general practitioner’s role was perceived as excluding the presence of other conditions, brief advice and signposting to health visitors and other resources. GPs were interested in undertaking brief training. Further health visitor research and support, Increased discussions of insomnia in primary care consultations, improved access to GP training, and greater awareness of available resources has the potential to improve paediatric chronic insomnia management in primary care.