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Screening for Sleep Problems

Introduction

Sleep problems are common in pediatric populations. Approximately 20-30% of children have pediatric insomnia, a majority of teens have inadequate sleep, and 1-6% of children have obstructive sleep apnea. [Honaker: 2016] [Marcus: 2012] Up to 80% of children with neurodevelopmental disabilities have sleep problems. [Blackmer: 2016] However, prevalence rates are difficult to calculate with certainty because many pediatric providers do not routinely screen for sleep problems or record a diagnosis of sleep-related problems in the medical record. [Kido: 2015]

Which Patients to Screen

Given that counseling on sleep hygiene can be time-consuming and there are relatively few pediatric sleep specialists, many pediatric clinicians may avoid asking about sleep concerns. However, helping with sleep can be very meaningful for families. The American Academy of Pediatrics advises screening all children for snoring, and other providers with expertise in this area recommend routinely screening all children for sleep problems. [Honaker: 2016] [Marcus: 2012] If this is not possible, consider screening for sleep problems in children with:
Neurodevelopmental disabilities History of trauma or abuse
Obesity Asthma or chronic lung disease
Behavior problems Gastroesophageal reflux disease
Genetic disorders Chronic pain
Neuromuscular disorders or hypotonia Nighttime tube feeding
Airway or craniofacial malformations Nighttime respiratory equipment use
Crowded living conditions Seizure disorders
School or academic problems Persistent nocturnal enuresis
Exposure to second-hand smoke or other drugs Growth problems
Unsafe home/neighborhood settings Premature infants
Insecure housing and/or food supply Polypharmacy or medication side effects
Poor nutrition Sickle cell disease
Because this list could go on, our recommendation is to provide routine surveillance and consider using a sleep screening tool with all children during well-child visits.

Sleep Screeners

Using a sleep screener may help clinicians find a potential problem to discuss with families including bedtime problems, night awakenings, inadequate sleep quality or duration, snoring or apnea, periodic limb movements, restless leg syndrome, parasomnias, nocturnal seizures, daytime sleepiness, and narcolepsy. Some practices found that adding a sleep screen to the electronic record for well-child visits significantly increased identification of sleep problems. [Kido: 2015]
Available pediatric screens are numerous. Some examples are:
  • The BEARS Sleep Screening Tool (PDF Document 197 KB) is divided into 5 sleep domains (B=Bedtime Issues, E=Excessive Daytime Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep, S=Snoring) and helps clinicians evaluate potential sleep problems in children 2-18 years old.
  • The Children’s Sleep Habit Questionnaire (CSHQ) (PDF Document 78 KB) is a parent-reported screening survey designed to assess behavioral and medically based sleep problems in children ages 4-10 years. This questionnaire is frequently used in research.

What to Do with a Positive Screen

Additional resources on the Medical Home Portal discuss diagnosis and management of sleep problems and provide patient education to share with families.

Referral Information

For uncomplicated, suspected obstructive sleep apnea, refer to pediatric otolaryngology (ENT) for consideration of tonsillectomy and/or adenoidectomy. [Marcus: 2012]
For obtaining a polysomnography (recommended for complex patients prior to consideration of tonsil or adenoid removal) or for consultation for diagnosis or treatment options of suspected sleep disorders, such as sleep apnea/hypopnea, periodic limb movement disorder, restless leg syndrome, or epilepsy, refer to a Pediatric Sleep Medicine specialist (often a pulmonologist with additional training).
For difficult-to-manage behavioral sleep problems or consultation on pharmacological management of sleep problems, consider referral to a Pediatric Psychiatrist.

Resources

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Psychiatrist, Child-18 (MD)

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Authors & Reviewers

Initial publication: February 2019; last update/revision: February 2019
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP

Page Bibliography

Blackmer AB, Feinstein JA.
Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review.
Pharmacotherapy. 2016;36(1):84-98. PubMed abstract

Honaker SM, Meltzer LJ.
Sleep in pediatric primary care: A review of the literature.
Sleep Med Rev. 2016;25:31-9. PubMed abstract
This review summarizes studies examining the prevalence of sleep problems in primary care settings as well as current practices in screening, diagnosis, and management, including behavioral recommendations and medications.

Kido J, Nishi N, Sakaguchi M, Matsumoto T.
Most cases of cow's milk allergy are able to ingest a partially hydrolyzed formula.
Ann Allergy Asthma Immunol. 2015;115(4):330-331.e2. PubMed abstract

Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN.
Diagnosis and management of childhood obstructive sleep apnea syndrome.
Pediatrics. 2012;130(3):576-84. PubMed abstract
Practice guideline focusing on uncomplicated childhood OSAS, (OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child); American Academy of Pediatrics.