Sleep Disorders: Evaluation and Prevention
Emma L. Peterson, PhD, and Jocelyn H. Thomas, PhD
Introduction: Typical Sleep in Pediatric Populations
•Children ≥6 months of age experience 4 stages of sleep in a typical night (Figure 96-1).
•All individuals (infants, toddlers, children, teenagers, adults) wake several times throughout the night.
•Self-soothers can return to sleep independently, without their parents.
•Recommended quantity of sleep in a 24-hour cycle is found in Figure 96-2.
Figure 96-1. Stages of sleep.
Figure 96-2. Recommended quantity of sleep in a 24-hour cycle. From Paruthi S, Brooks LJ, D’Ambrosio C, et al. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med. 2016;12:785.
Consequences of Insufficient Sleep
•Poor cognitive development
•Poor mood regulation
•Increased physical aggression, hyperactivity, and impulse control
•Reduced metabolic and immune functioning
Clinical Features of Sleep Disorders
•Excessive daytime sleepiness (EDS) (ie, dozing, falling asleep)
—This is different than general fatigue (ie, feeling tired)
—Several factors contribute to EDS
▪Insufficient sleep (sleep restriction)
▪Fragmented sleep (sleep interruption) may be
~Extrinsic (noise, light, etc)
~Intrinsic (obstructive sleep apnea, periodic limb movement syndrome, etc)
~Narcolepsy, idiopathic hypersomnolence, etc
▪Circadian rhythm disorders
•Additional behavioral or medical symptoms
—Poor concentration in school
Evaluation: Conducting a Sleep Interview
•Caregivers may not recognize some behavioral or medical symptoms as indicators of sleep disorders. However, sleep difficulties may be identified in primary care settings through routine screening questions (see Table 96-1).
•Routine screenings can help to identify the need for a more comprehensive sleep interview.
•A sleep interview is used to obtain additional information and assess the presence of sleep disorders (both behaviorally and biologically based).
•A sleep interview is critical for differential diagnosis.
—Different sleep disorders often manifest with similar symptoms (eg, excessive daytime sleepiness). Yet, the treatment varies, depending on the diagnosis.
—Multiple sleep disturbances may coexist, and the presence of one sleep disorder may exacerbate another.
•Sleep disorders can be secondary to, or exacerbated by, physical and mental conditions; thus, a sleep interview that includes a comprehensive history allows for the evaluation of possible contributing factors to the sleep disturbance.
•Components of a sleep interview are described in Table 96-2.
Prevention and Intervention
•“Sleep hygiene” is a variety of different habits and practices that are intended to promote better-quality sleep.
•Components of sleep hygiene are described in Box 96-1.
•Sleep problems in children are persistent and are unlikely to spontaneously resolve without appropriate intervention.
•Sleep problems in children are likely to affect other areas of functioning (eg, behavioral, academic, psychological).
The “BEARS” sleep screening tool includes bedtime problems, excessive daytime sleepiness, awakenings during the night, regularity and duration of sleep, and sleep-disordered breathing. From Owens JA, Dalzell V. Use of the “BEARS” sleep screening tool in a pediatric residents’ community clinic: a pilot study. Sleep Med. 2005;6:63–69.
|Table 96-2. Components of a Sleep Interview|
Patient and/or parent’s primary concern
Family’s ultimate goal (eg, sleeping independently, sleeping through the night, falling asleep independently)
Presence of set bedtime
Typical sleep schedule during a 24-hour period
|Bedtime routine||Activities, timing, location, and length|
Events occurring and people present at the time the child falls asleep (eg, feeding, rocking, parent in bed, television on, music playing)
Sleep associations will generally need to be repeated during nighttime awakenings, as well
|Bedtime behaviors||Types, intensity, duration, frequency, what typically terminates them|
|Sleep onset||Time and location|
|Sleep environment||Characteristics of the bedroom (eg, location, temperature, light, sound, type of bed, people present)|
|Daytime sleeping||Timing, frequency, duration|
Night awakenings (frequency, number, timing, duration, identifiable triggers)
Behaviors that occur upon waking (eg, calling out for parents, parental response to awakenings)
Presence and nature of episodic nocturnal events (eg, disorders of arousal and nightmares)
Symptoms suggestive of sleep-disordered breathing and periodic limb movement disorder
Time of morning awakening
Daytime fatigue and sleepiness
|Review of medical history||Current and past medical diagnoses, previous surgeries, hospitalizations, and injuries|
|Daytime functioning||Timing of developmental milestones Functioning at school|
|Family medical history||Particularly related to obstructive sleep apnea, narcolepsy, and parasomnias|
|Psychosocial history||Psychological and mental health Social history|
|Physical examination||Often normal|
•Presence of set bedtime and morning wake time
—Bedtime before 9:00 pm for infants and toddlers
•Allows for sufficient quantity of sleep (refer to Figure 96-2)
•Consistent sleep schedule every day (within 1–2 hours if variation exists on the weekends)
•Presence of bedtime routine
•Caregiver supervision of bedtime routine for infants, toddlers, and children
•Consistent order of 3–4 activities each night, slowly moving in the direction of the bedroom
—Feeding should occur early in the routine for infants and toddlers to avoid falling asleep while nursing or drinking from a bottle.
—Save new stories and books for daytime to avoid excitement and overstimulation .
—Some children may enjoy visual schedules to indicate the order of the bedtime routine .
—Some children may benefit from positive reinforcement (eg, stickers, verbal praise) for completing each step of the routine.
—Make the child’s favorite activity in the routine occur last (eg, cuddling with a caregiver, story time).
—Avoid the use of electronics during the bedtime routine .
•Routine lasting 20–30 minutes (45 minutes if including a bath or shower)
Positive Sleep-Onset Associations
•Sleep-onset associations must be independent of adults (ie, adults are not present at the moment the infant is falling asleep.
—Avoid feeding the child at the end of the routine to prevent the development of an association between sleep and feeding.
—Put the infant in the crib while drowsy but still awake.
—Avoid having the caregiver remain in bed or in the bedroom as the child is falling asleep.
•The presence of a transitional object (eg, a special blanket or stuffed animal) can be soothing at bedtime.
•Avoid any activities other than sleep (eg, homework, talking on the phone) in bed.
•Avoid sleeping in other locations (eg, in front of the TV, on a couch).
•Consider the type of bed .
—It is best to transition infants to a crib at about 3 months of age.
—Crib safety considerations
▪Use a firm, tight-fitting mattress .
▪There should be no missing, loose, broken, or improperly installed screws, brackets, or hardware .
▪The crib slats should be no more than 2⅜ inches apart.
▪No corner posts should be over 1/16 inch high.
▪The headboard and footboard should have no cutouts.
▪Use a crib that was manufactured since 1990 and has been certified to meet national safety standards.
—No pillows should be used for children <2 years of age.
•When possible, individuals should sleep in a room alone—sharing a room with other family members can disrupt sleep.
•Reduce light and noise in the bedroom.
•Make the sleep area an appropriate temperature.
•No electronic devices should be used in the bedroom.
•Avoid use of electronic devices within 1 hour of bedtime.
•Avoid using electronic devices as a sleep aid.
•Limit screen time to <2 hours per day.
Daytime Behavior and Naps
•Increase the exposure to light in the morning upon waking.
•The napping schedule should be predictable.
•Specified times each day (eg, 12:30 pm) or at a fixed interval (eg, every 2 hours)
•Avoid napping past 4:30 pm.
•Naps should occur in same location as nighttime sleeping.
•Consider the length of naps.
▪Reduced sleep inertia (grogginess that lasts 15–30 minutes after a nap)
▪Short-term boost in cognitive functioning (1–3 hours)
▪Increased immediate sleep inertia
▪Longer-term boost in cognitive function
•Avoid caffeine consumption for infants, toddlers, and children.
•If caffeine consumption does occur, avoid caffeine consumption 6–8 hours before bedtime.
Additional Considerations According to Age Group
|Infants and toddlers (0–3 y)|
•By 6 months of age, most babies are physically capable of sleeping through the night without feeding.
|Young and school-aged children (4–12 y)|
•Avoid using staying up as a reward or going to bed early as a punishment—this gives the subtle message that “sleep is bad.”
•Avoid using the bed as a place for time-out.
•Avoid cognitive and emotional stimulation before bedtime.
•For individuals experiencing anxiety or stress around bedtime, a variety of relaxation strategies may be useful, including diaphragmatic breathing, progressive muscle relaxation, and visualizations.
|Adolescents (≥13 y)|
•Avoid using a cell phone as an alarm clock.