Early diagnosis and treatment are important to prevent complications that can impact children’s growth, cognitive development and behavior.
Pediatric sleep disorders require careful and extended evaluations that includes interviewing the parents, child, teachers, as well as assigning and reviewing sleep diaries. Parents should be encouraged to record children’s sleep-wake habits using sleep diaries over a 24-hour period for at least two continuous weeks prior to initial visit. This can be useful to support the reported sleep-related complaints as well as guide routine history taking. Sleep diaries also assist in detecting day-to-day variability in sleep patterns that can often be missed during routine history and physical exams.
Current evidence indicates that chronically disrupted sleep in children and adolescents can lead to problems in cognitive functioning, such as attention, learning, and memory. Behavioral interventions, especially in young children, have been shown to produce clinically significant improvements. This is of particular importance given the relative lack of data regarding use of pharmacological interventions for sleep difficulties in children.
Graphic diaries appear to be more helpful in understanding sleep-wake cycles in pediatric patients rather than descriptive data. An example of a graphic sleep diary can be found at the sleep education website endorsed by the American Academy of Sleep Medicine (AASM) and is available for free download at its Web site. A simple acronym like BEARS (4), which stands for bedtime resistance/sleep onset delay; excessive daytime sleepiness; awakenings at night; regularity, patterns, and duration of sleep; and snoring and other symptoms, can be useful during initial screening of a child’s sleep difficulties.
Self-report sleep questionnaires, such as the School Sleep Habits Survey and Children’s Sleep Habits Questionnaire (CSHQ) are useful to screen for more specific sleep disorders in target populations, such as adolescents and school-aged children(6) The Sleep Disturbance Scale for Children (SDSC) is a useful 26-item parent questionnaire that was developed for children and adolescents to screen for primary sleep disorders such as obstructive sleep apnea.
Obtaining a detailed and accurate history followed by a physical exam, including screening for developmental delays and cognitive dysfunction, appears to be a cornerstone for diagnosing pediatric sleep complaints. It is equally important to involve family members in the clinical interview to understand the potential causes of sleep disturbances because children and adolescents often do not recognize events that can disturb sleep. For example, they are usually not aware of snoring or leg movements that occur during sleep. Patients are unaware if they get deep and restful sleep. They may be sleeping but not getting “good” sleep.
The physical exam may provide clues to treatable medical causes. Diagnostic tests are available but difficult to access in some communities. Many sleep problems in children can be improved with instruction on sleep hygiene and the importance of sleep to health and behavior. Medical causes of sleep problems are rare but often benefit from treatment and therefore warrant attention during any evaluation.
At one time, elementary school children went to bed easily and woke up early, naturally without alarms. Now their sleep is disrupted by TV, computer games, texting, and other digital distractions. Sleep deprivation is often the primary cause now of inattention, school failure, poor peer relations, and obesity. Medical causes of sleep problems are often overlooked in children because of their difficulty in reporting symptoms.
Primary sleep disorders, such as obstructive sleep apnea (OSA) and restless legs syndrome (RLS), in children have been shown to be associated with excessive daytime sleepiness, impaired attentional capacity and memory, behavioral issues, and attention deficit hyperactivity disorder (ADHD).
Pediatric OSA is a sleep disorder in which a child’s breathing is completely or partially blocked, often repeatedly during sleep. This is caused by narrowing or blockage of the upper airway during sleep. These breathing disturbances often result in brief arousals from sleep, which can interfere with obtaining good quality sleep. Therefore, screening for daytime impairments are important in children suspected of having obstructive sleep apnea (OSA)
While bedtime difficulties and frequent night time awakenings are seen during infancy and early childhood, sleep difficulties due to insufficient sleep hygiene or circadian rhythm disorders tend to be more prominent in adolescence. Sleep problems in children and adolescents can complicate other underlying medical condition, such as obesity and asthma, and psychological problems, such as depression, anxiety, and substance abuse.
