Therapy in Practice – The (Lack Of) Provision Of Sleep Systems For Children

Wherever it is in the country that you practice, it is likely that the funding of sleep systems is very erratic. But why should this be?

Along with Seating, Standing and Walking, Supine postural supports (sleep systems) are a key component of a child’s 24-hour postural management programme but unfortunately, they are given much less recognition, research or reimbursement than the others. A consensus statement back in 2006 (Gericke, 2006) recommended that children with cerebral palsy in GMFCS levels IV and V should begin postural management in lying soon after birth. Sunnyhill Health Centre in Canada went on to develop a useful visual aid for positioning these children, with the focus on symmetry and changes to position for hip health. For supine support, they recommended aiming for hip abduction of between 15⁰-30⁰ in those under two years, and 20⁰ degrees in children above two. Despite these expert reviews, the provision of sleep systems is patchy, and knowledge among both families and therapists on correct usage is low.

To confound matters, a recent systematic review by Humphreys et al. (2019)1 which set out to inform therapists on the evidence base for sleep systems, ‘Sleep positioning systems for children and adults with a neurodisability: A systematic review’,  concluded that due to a lack of research, the evidence supporting their use is still low - What may be beneficial in improving sleep quality and latency (the time to fall asleep) for one child, may be difficult to tolerate for another.  And despite the work of Sunnyhill back in 2014, the difficulty in conducting research in this field has meant that evidence, which conclusively links sleep posture to hip health, has unfortunately not materialised.

As we all know, sleep problems affect the whole family - so what can we, as clinicians, do to move this field forward?

From personal experience, sleep systems, like toilet aids, are often not introduced by therapists out of fear that families are already overburdened. But is this fair? As we move to a family-centred therapeutic approach, families need educated so that they can lead the decision-making process. They need guided on how to introduce new supports slowly, build up tolerance gradually and be consistent until new routines are established. Therapists need support to assist their professional prescribing, confidence to advocate for funding for these essential supports and tools to measure the effectiveness of their interventions.

Thankfully, in an effort to assist therapists in their clinical decision-making, and hopefully contribute to building an evidence base, Ginny Humphreys, Tanya King and Jo Jex, have created an excellent, free resource ‘Clinical Practice Considerations For Postural Support In Lying For Children And Adults With Neurodisability’ available from the PMG website.

This document contains practical information such as:

  • Who is likely to benefit?
  • What are key aims and difficulties when prescribing?
  • What are core outcomes?
  • How to measure them?

It is well worth checking out.With the need for robust evidence, our field tends to move slowly, but I have no doubt that in time, sleep systems will become as common as standing and walking frames in supporting hip health and improving the functional outcomes for children with additional needs.

1. Humphreys G, King T, Jex J, Rogers M, Blake S, Thompson, Coon J, et al. Sleep positioning systems for children and adults with a neurodisability: a systematic review. London, England: SAGE Publications; 2019. p. 5–14.


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