Sleep Problems in Pediatric Patients with Trisomy 21 (Down Syndrome): What Parents Need to Know

Sleep is essential for every child’s growth and development, but for children with Trisomy 21 (Down syndrome), getting quality rest can be especially challenging. Parents and caregivers often notice signs of poor sleep, such as having difficulty falling asleep or staying asleep, daytime sleepiness, restlessness, or behavioral concerns. These difficulties may stem from a range of sleep disorders that are more common in this population.

This article explores why sleep problems occur more frequently in children with Down syndrome, how to recognize sleep problems, and what families can do to support better sleep health.

Why are children with Down syndrome more prone to sleep disorders?

Children with Down syndrome have certain anatomical and physiological features that make sleep more difficult, particularly when it comes to breathing during sleep. These include:

• Low muscle tone (hypotonia) that affects the muscles that keep the airway open
• Enlarged tonsils and adenoids that cause narrowing of the upper airway
• Obesity or being overweight which can further compromise airway (patency)
• Craniofacial features that narrow the upper airway (e.g., midface hypoplasia, macroglossia)
• Neurodevelopmental differences that can impact circadian rhythm and sleep regulation
• Comorbid medical conditions, such as hypothyroidism, gastroesophageal reflux disease (GERD), or obesity, which also disrupt sleep

These factors contribute to a high risk of sleep-disordered breathing, especially obstructive sleep apnea (OSA), which is one of the most common sleep issues in this population. OSA causes a child to briefly stop breathing while sleeping.

Common sleep disorders in children with Down syndrome

1. Obstructive Sleep Apnea (OSA)

• Prevalence: Studies estimate that 30% to 80% of children with Down syndrome have OSA.
• Symptoms:
  • Loud snoring
  • Pauses in breathing
  • Restless sleep
  • Mouth breathing
  • Daytime irritability or fatigue
• Diagnosis: A polysomnography (sleep study) is the gold standard for diagnosis.
• Treatment: These may include medications, adenotonsillectomy, continuous positive airway pressure (CPAP) therapy, weight management, or referrals to Ear, Nose and Throat (ENT) and sleep specialists.

2. Chronic insomnia or behavioral sleep difficulties

Some children may have trouble falling or staying asleep, even in the absence of OSA. Causes may include:

• Anxiety
• Poor sleep habits or bedtime resistance
• Sensory sensitivities

Why is chronic insomnia more common in Down syndrome? 

Several factors contribute to chronic insomnia:

• Neurodevelopmental differences affecting circadian rhythm and arousal regulation
• Anxiety, sensory processing difficulties, or autism spectrum disorder, which may co-occur
• Communication limitations make it harder for children to express distress or discomfort
• Disrupted sleep due to OSA, GERD, or pain
• Inconsistent bedtime routines or behavioral insomnia of childhood

Consequences of chronic insomnia

Chronic insomnia can have significant negative effects, including:

• Behavioral problems (irritability, hyperactivity, aggression)
• Worsening of cognitive and learning delays
• Increased caregiver stress
• Exacerbation of comorbid conditions like ADHD or autism
• Poor growth or immune function due to insufficient restorative sleep

3. Restless sleep and movement disorders

• Restless legs syndrome (RLS) or periodic limb movement disorder (PLMD) can occur.
• Iron deficiency is more common in Down syndrome and may contribute.
• Movement during sleep can lead to disrupted, nonrestorative rest.
• RLS or PLMD may mimic ADHD tendencies as a result of disrupted, nonrestorative sleep. 

4. Parasomnias (such as sleep terrors, sleepwalking, and confusional arousals)

• Parasomnias are more common in children with Down syndrome due to underlying sleep fragmentation, obstructive sleep apnea, and atypical neurodevelopment.
• These events can further impair sleep quality, exacerbate daytime behavioral and cognitive challenges, and may overlap with other sleep disturbances common in Down syndrome.
• They typically get better with improving the total amount of sleep and avoiding sleep deprivation. However, if persistent, then further evaluation is recommended. 

How can parents recognize a sleep problem?

Parents are usually the first to notice the signs of poor sleep. They should watch for:

• Loud or irregular snoring
• Gasps, choking, or pauses in breathing
• Frequent awakenings
• Night sweats (a sign of labored breathing)
• Bedwetting beyond the expected age
• Behavioral issues like hyperactivity or inattention that often mimic ADHD
• Sleeping in abnormal positions or frequently changing positions in sleep
• Falling asleep during the day

Even subtle signs can indicate significant sleep disruption, especially if they are new or worsening.

What should parents do if they suspect a sleep disorder?

1. Talk to your pediatrician

• Share detailed observations of your child’s sleep.
• Ask if a referral to a sleep specialist or ENT is appropriate.

2. Get a sleep study

• The American Academy of Pediatrics recommends a sleep study by age 4 for all children with Down syndrome — even if no symptoms are present.

3. Establish healthy sleep habits

• Regular bedtime and wake-up time
• Calming bedtime routine
• Screen-free time before bed
• Avoiding caffeine or large meals before sleep
• Regular daily exercise
• Ensuring adequate amounts of sleep for age 

4. Consider therapies

Depending on the severity of OSA, therapies may vary based on your child’s needs. These may include: 

• Medications such as antihistamines, intranasal steroids
• Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) for OSA
• Occupational therapy for sensory-related sleep resistance
• Sleep psychologist for behavioral interventions related to sleep

Why is identifying sleep problems in Trisomy 21 challenging?

• Communication barriers: Children with Down syndrome may have limited ability to describe sleep difficulties or nighttime symptoms.
• Symptom overlap: Behavioral issues, inattention, and daytime sleepiness may be attributed to developmental delays rather than underlying sleep disorders.
• High comorbidity: Coexisting conditions (e.g., congenital heart disease, hypotonia, and gastroesophageal reflux) can mask or complicate recognition of sleep problems.
• Under-recognition by caregivers/clinicians: Parents and providers may normalize snoring, restlessness, or frequent awakenings as expected features of Down syndrome, thus delaying evaluation.

Texas Children’s expertise with sleep problems in children with Down syndrome

Managing sleep problems in children with Trisomy 21 often requires a multidisciplinary and collaborative approach. At Texas Children’s, our patients with Trisomy 21 who have sleep problems receive expert care at our Down Syndrome Clinic, Sleep Center (which sees a large Down syndrome population), and our Multidisciplinary Obstructive Sleep Apnea (MOSA) Clinic. 

• Multidisciplinary expertise: Texas Children’s Hospital offers dedicated pediatric sleep and pulmonary specialists alongside ENT physicians, ensuring thorough evaluation of both medical and airway-related contributors to sleep problems.
• Behavioral and psychological support: Access to sleep psychologists provides evidence-based strategies for managing insomnia, parasomnias, and adherence to therapies like CPAP.
• Holistic care approach: Dietitians are part of the team to address obesity, nutrition, and weight-related factors that can worsen sleep-disordered breathing.
• Comprehensive, coordinated care: Families benefit from an integrated evaluation that brings together multiple specialties in one setting, streamlining diagnosis and individualized treatment.

When sleep improves, so often does mood, cognition, attention, and quality of life — not just for the child, but also for the entire family.

Final thoughts

Sleep disorders are common but treatable in children with Trisomy 21. Awareness is the first step toward better rest and better health. If your child is struggling with sleep, trust your instincts and seek support early.

Well-rested kids thrive — and every child deserves the chance to wake up feeling their best. 

Resources

• National Down Syndrome Society (NDSS)
• American Academy of Pediatrics (AAP)
• Sleep Education by the American Academy of Sleep Medicine
• Family Voices offers support for families of children with special health care needs.