Evaluating Sleep and Sleep Disorders in the Pediatric Primary Care Setting

Sleep is a vital physiologic function. Asking parents about their children’s sleep should be part of every routine physical examination. Evaluating infants requires an understanding of changes in sleep associated with developmental stage. Problems with sleep associations may begin in late infancy and become a major issue for toddlers. Good sleep is crucial for success in learning for all children. Daytime behaviors in children may be symptoms of nighttime problems. Adolescents are often chronically sleep-deprived. Educating parents and their children about the importance of sleep is an important intervention that over time can help children lead happier, more productive lives.

Every physician faces the same challenges every day. Why has the patient come to the office? Is there a problem that can be managed by the physician? At what point should a referral be made? Sleep is no different. Almost all childhood issues, from normal development to disease, have a sleep component: separation fears, colic, fever, otitis media, gastroenteritis, and school anxiety, just to name a few. When the child does not sleep well, the parents do not either. But according to the 2004 Sleep in America Poll from the National Sleep Foundation, 52% of physicians do not ask about a child’s sleep habits. When parents were asked in that same poll about their children’s sleep, 69% said their children experience one or more sleep problems at least a few nights a week. Clearly, there is a disconnect here that must be addressed.

Sleep is so basic a function that for a long time it seemed almost unworthy of much attention. In the last 60 years or so, however, sleep has been shown to be so much more. Research in the field has exploded, and now there are subspecialties within medicine to address the new knowledge.

This article highlights the day-to-day experiences of the general pediatrician as an educator and a guidance counselor, not the sleep specialist, in evaluating the sleep of children. There is much pediatricians can do to help families through these hard times. As pediatricians educate themselves about sleep, they can pass that knowledge on to families and help them anticipate the next developmental change, understand sleep disruption in the presence of illness or psychological stress, and provide tools to help everyone in the family sleep better. Pediatricians, almost by definition, are educators. The mission of pediatricians has always been to help parents navigate the changes inherent in their children as they grow, to educate them and to provide guidance for what to expect with each developmental stage. Being awake and alert is key to being able to function at a peak level. Evaluating sleep and educating patients and parents about good sleep habits are the first steps to reaching that goal ( Table 1 ).

Table 1

Normal sleep amounts

Age	Total Sleep	Average Total Sleep (h)
Newborn (0–2 mo)	10–19 h	13.0–14.5
Infants (2–12 mo)	9–10 h at night + 3–4 h of nap	12–13
Toddlers (1–3 y)	9.5–10.5 h at night + 2–3 h of nap	11–13
Preschool (3–5 y)	9–10 h	9–10
School age (6–12 y)	9–10 h	9–10
Adolescents (13–18 y)	9–9.5 h needed (most get 7.0–7.5 h)	9.25 needed

Data from Mindell JA, Owens J. Sleep in infancy, childhood, and adolescence. In: A clinical guide to pediatric sleep: diagnosis and management of sleep problems, 2nd edition. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 12–29.

Evaluating infants

Changes in sleep patterns are virtually characteristic of infant developmental stages. The newborn wakes every 2 to 4 hours, whereas a 1-year-old child generally sleeps a consolidated night of 10 hours plus takes two 1- to 2-hour naps. Therefore, in evaluating the sleep of infants, the age and developmental stage are key.

Parents of newborns often do not know what to expect, and they themselves are often so sleep deprived that they do not remember one day to the next. These parents usually know that the baby needs to feed every 2 to 4 hours and wakes to do so. But these parents are often concerned that the baby seems to sleep during the day and be awake at night, just the opposite of the parents’ daily rhythm. It is as though as the pregnant mother moves through the day the fetus is calm; at night when the mother is quiet, the fetus is more active. This pattern does not change immediately at the time of birth; newborn sleep patterns take 2 to 3 weeks to change. Waking the baby at 2- to 3-hour intervals during the day helps, as well as exposure to light during the daytime and quiet darkness at night.

Asking about the sleeping arrangement for infants is important. It is now well accepted that infants should be placed on their backs for sleep to reduce the risk of sudden infant death syndrome. Once babies are able to roll from back to front, at about 5 to 6 months of age, their nighttime position is less crucial. Many newborns sleep in the same room as their parents and sometime in the same bed. This arrangement makes nighttime nursing easier for parents during the first few months when babies wake to feed. However, once the baby is able to consolidate sleep for 6 to 8 hours, cosleeping becomes more of a choice than a necessity. Many families choose cosleeping for cultural or sentimental reasons. There is evidence that cosleeping increases the number of arousals for both the parents and the child, so this is an important issue to discuss if parents come in with concerns about frequent nighttime awakenings. Once parents are educated about the physiologic processes of sleep, they can make an informed decision about wanting to continue.

Other issues related to the evaluation of infant sleep are often brought up by parents, such as questions of normal versus abnormal sleep behavior. Most of these problems are easily identified as normal after a discussion of normal infant sleep. The twitching and eye rolling seen in newborn infants is typical of active sleep and is easily distinguished from seizure activity. The inability at times to wake young infants is likely related to the depth of sleep they experience in quiet sleep. Of course, further questioning to rule out serious illness must be done, that is, if there is fever, vomiting, general lethargy, or other system involvement.

One of the symptoms of the condition known as colic is sleep disruption. The other main symptoms are fussiness and crying. Colic is a poorly understood phenomenon even today. Whether the origin is feeding intolerance and abdominal pain, immaturity of the nervous system, or irritability, the lack of sleep experienced by the family unit as a result of a colicky baby is perhaps the most significant issue. In this case, evaluation of the sleep of the parents is as important as the sleep of the infant. Interventions to help the parents, such as trading off baby care, enlisting a grandparent or other adult, or other options, give them some respite. Sleep-deprived parents may make poor decisions and exhibit labile emotions toward the baby and each other. In fact, in about 10% of families with infants, the baby’s sleep habits cause significant stress on family relationships.

Older infants, ages 6 to 12 months, have sleep issues related to their emerging brain development. These infants begin to see patterns in their experiences and come to expect a particular outcome after a particular behavior. At this time, sleep associations begin to become important. Parents may ask about the frequent nighttime awakenings of their baby. Certainly medical illness must be ruled out, for example, pain from otitis media or gastroesophageal reflux, upper airway congestion, and itching from eczema. Once it is clear that there is no medical reason for the wakening, the possibility of a trained nighttime feeder, who expects to be fed whenever awake, or a baby with separation fears may become more evident.

At this stage of development, the older infant, it is often helpful to discuss good sleep habits with parents. Sleep habits are learned behaviors; a baby who is successful at calling a parent to the bedside may become a signaler, whereas the baby that can comfort itself may become a self-soother.

Sleep problems in infancy typically do not require referral to a sleep specialist. Some cases of sleep disruption in the young infant are caused by medical concerns, and treating the underlying illness improves sleep. Those babies with specific medical problems may need referral to a medical specialist. As the infant gets a bit older, behavioral issues and parenting style are often the cause of poor sleep. At this point, discussions between the pediatrician and the parents are often all that is needed. Parents who are overwhelmed by taking care of an infant, or a mother with postpartum depression, may themselves require referrals to counselors, but the main intervention at this time is education of the parents about normal sleep processes, guidance about what to expect with each developmental phase, and ways to develop good sleep habits (eg, set bedtimes, establishment of a bedtime routine).

Evaluating toddlers

The toddler years, ages 1 to 4 years, are a time of explosive development. The brain has enlarged almost 40%, and the child transitions from a preverbal, barely independently walking infant to a verbal, willful, socially interactive individual. Along with these major changes in physical and emotional development, the sleep/wake cycle matures as well. At this time, toddlers generally sleep 10 to 11 hours at night and move from 2 naps a day at age 1 year to none at age 4 years. Evaluating sleep in children of this age group means looking at behavior. Significant chronic medical problems have likely been identified by now and their effect on sleep reduced or at least understood.

Most appointments to the pediatrician at this time are not made because of a sleep complaint. Usually, sleep problems are secondary to an acute illness, resulting from pain, fever, illness, or stimulating medications, such as albuterol. When the medical issue has been resolved, sleep returns to normal, unless behavioral issues have intervened and the child has realized a secondary gain from waking at night.

Asking about sleep should be a part of every routine physical examination. This opportunity allows parents to bring up and discuss issues that they might otherwise think are normal, are embarrassed to talk about, or have just given up on solving. Questions to explore include

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When does the child go to bed?
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Is there a bedtime routine? What is it?
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Who puts the child to bed?
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Where does the child sleep, alone or with a sibling or parent?
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What happens when the parent leaves?
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Does the child wake during the night? What happens then?
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What time does the child wake in the morning?
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Does the child take a nap?
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What is the child’s daytime functioning like?
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How much sleep does the parent get? How is the parent functioning during the day?

Ideally, children blissfully go to bed in their own crib or bed after a short bedtime routine, say night-night, fall asleep quickly, and wake 11 hours later. However, there are sometimes bumps in this scenario. If a child cannot fall asleep without the aid of a parent, in an environment other than his/her own bed, or wakes frequently, the issue may be that the child simply has not yet learned good sleep behaviors. Once parents understand what they need to teach the child, hopefully they can implement change. The use of a transitional object, such as a blanket or a doll, may be helpful. Bedtime is often the first real parenting challenge parents face. Do they do what is right for the child’s health and development, or do they give in to the child and do what is easy for them and makes the child happy? The pediatrician can gain much insight into family dynamics and parenting style when evaluating this problem. Passive parents are more likely to give in, whereas assertive parents are more likely to insist on the child following the prescribed program and are more willing to stick with it. The child has no motivation to change, that is, the child likes being with parents at night. It is the parents who must impose the change on the child, preferably in a gentle way using positive reinforcement, and they must be willing to deal with some push back.

Parents who themselves are not sleeping well may have less patience dealing with the tantrums and typical behavioral issues of toddlers. About 70% of parents report that their toddler wakes them up at night. Evaluating daytime functioning of the parents, then, is important for overall family dynamics.

It is unusual to make a referral to a sleep specialist during the toddler years. More likely, outside help from counselors and behavior specialists may be warranted, although there are sleep specialists who focus on behavioral issues. Occasionally, a toddler might exhibit enough snoring or apnea to warrant a sleep study or an otolaryngology referral, but most of the problems in children of this age group are behavioral. Some sleep problems, as defined for older children and adults, are actually normal for toddlers, for example, daytime sleepiness and enuresis (toddlers normally take naps and cannot control their urine during the night).

The other caveat for needing a sleep specialist in this age group is for children with disabilities. Developmental disabilities typically become more apparent between the ages of 1 and 4 years. Conditions such as autism, pervasive developmental disorder, and developmental delay can affect a child’s daily rhythm and sleep (see the articles by Dean Beebe; and Reynolds and Marlow elsewhere in this issue for further exploration of this topic). These children are often seen by many specialists who may be able to design treatment plans that also help sleep. However, a pediatric sleep specialist can often give particularly helpful guidance.

The toddler years are a time to develop good sleep habits, proper sleep associations, and a positive attitude toward sleep for everyone in the family. Educating parents about normal sleep processes and behaviors in the developing toddler is essential. There may be times when enough of an issue exists that a separate visit with the pediatrician may be helpful so that both parents might attend, hear the same information, and come up with a plan together for dealing with the sleep of a difficult toddler ( Box 1 ).

Box 1

Infants/babies
- What are the sleeping arrangements? Where? Cosleeping?
- What is the sleep routine? Is there a schedule?
- How do the parents handle nighttime awakenings?
- Are there medical problems? (colic, otitis, reflux, congestion, eczema, and so forth)
- How are the parents sleeping?
Toddlers
- What time does the child go to bed and get up in the morning?
- What is the bedtime routine? (who helps, what does it include, where does it happen)
- Where does the child sleep? Is he/she alone? With a sibling or a parent?
- What happens at separation, when the parent leaves? Is there a transitional object?
- Are there nighttime arousals? What happens then?
- Does the child nap? When? Where?
- How does the child function during the day?
- How are the parents sleeping? How are they doing during the day?
Children
- What time does the child go to bed and get up in the morning?
- What is the bedtime routine?
- What is in the sleep environment? Electronics?
- Are there nighttime arousals? What happens then?
- Does the child snore?
- Is there sleep refusal, separation anxiety, fear of the dark, or fear of strangers?
- Is the child enuretic?
- How does the child function during the day? How does he/she feel?
Teenagers
- Is there a regular bedtime? Wake time? When?
- Is there a presleep routine?
- What is the cause of delay in going to sleep? Homework or socializing?
- Does the teenager nap?
- Are there electronics in the bedroom?
- How does the teenager feel during the day? How is he/she functioning?
- Are there after school activities or commitments?
- Does the teenager complain of fatigue?

Fatigue
Ask about these issues:
- Medical: acute illness, thyroid dysfunction, anemia, Epstein-Barr virus disease, muscle disease, medications, snoring, diabetes, poor nutrition, medications
- Psychological: depression, anxiety, school refusal, drug use, stress
- Sleep related: phase delay, overscheduling, late bedtime, caffeine use, naps, electronics, cataplexy