Assessment of Sleep Disorders in Children

26/4/2014 Assessment of sleep disorders in children
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Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Authors
Merrill S Wise, MD
Daniel G Glaze, MD
Section Editor
Ronald D Chervin, MD, MS
Deputy Editor
Alison G Hoppin, MD
Assessment of sleep disorders in children
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2014. | This topic last updated: Mar 28, 2014.
INTRODUCTION Identification of sleep problems in children is important because a growing body of evidence
suggests a link between sleep disorders and physical, cognitive, emotional, and social development. Children with
neurodevelopmental problems, learning differences, or behavior problems may be at heightened risk for sleep
problems compared with the general pediatric population [1-4].
Pediatricians, pediatric subspecialists, and other healthcare practitioners are in an ideal position to identify sleep
problems and disorders in children. Parents may not volunteer information about their child's sleep, or they may not
appreciate the potential relationship between sleep problems and daytime behavior. For these reasons, clinicians
should incorporate questions about sleep into routine health assessment for children of all ages. Sleep problems
present most commonly in the outpatient setting, but the hospitalized child may develop sleep problems during an
acute illness, or chronic sleep disorders may come to medical attention during hospitalization.
This topic review will discuss the approach to taking a structured sleep history, describe specific sleep problems
that may present during childhood, and explain indications for further diagnostic testing. The underlying physiology
of sleep in children, and evaluation and management of some common sleep disorders are discussed in more detail
separately. (See "Sleep physiology in children" and "Behavioral sleep problems in children" and "Evaluation of
suspected obstructive sleep apnea in children" and "Sleepwalking and other parasomnias in children".)
PEDIATRIC SLEEP MEDICINE Pediatric sleep medicine is a multidisciplinary field that includes clinicians in
general pediatrics as well as subspecialists in child neurology, psychiatry, psychology, otolaryngology, pulmonary
medicine, and development.
Although sleep disorders may be phenomenologically similar between adults and children, several important
differences exist [5]. The presentation, natural history, and response to treatment may differ considerably between
adults and children. As an example, obstructive sleep apnea syndrome is well recognized in adults and children.
However, in contrast to adults, most pediatric patients are not obese, boys and girls are equally affected, and some
children present with daytime attentional or behavioral problems rather than overt sleepiness [4,6].
Even within the pediatric age group, the clinical manifestations of sleep problems may vary by age and
developmental level. For example, sleepiness in the school aged child may be subtle and variable in comparison to
adult manifestations. The child with excessive sleepiness may exhibit motor overactivity, inattentiveness, irritability,
or oppositional behavior [7,8]. Sleep problems such as difficulty initiating or maintaining sleep (insomnia) may co-
exist with anxiety or depression in the adolescent, and may worsen certain medical or psychiatric problems.
Sleep and sleep disorders in children are strongly influenced by cultural factors, parental expectations, and parental
responses. When responding to a preschool child with stalling behavior at bedtime, inexperienced parents may
inadvertently promote the behavior, while more experienced parents quickly establish a consistent response that
extinguishes the unwanted behavior. (See 'Behavioral contributors' below and "Behavioral sleep problems in
children".)

Classification of sleep disorders The International Classification of Sleep Disorders (ICSD) [9] provides a
diagnostic and coding manual for recognized sleep disorders. The classification provides a systematic review of the
essential features, diagnostic criteria, prevalence, predisposing factors, pathology, complications, and
polysomnographic findings associated with each recognized sleep disorder. The classification scheme is
summarized in a separate topic review (see "Classification of sleep disorders"). The ICSD third edition (ICSD-3)
includes separate entries for pediatric sleep disorders where children and adults differ most in presentation,
diagnosis, evaluation, or treatment. In particular, pediatric obstructive sleep apnea is described separately, and
chronic insomnia is described as having subtypes that include Behavioral Insomnia of Childhood (BIC, sleep onset
association type and limit-setting type). (See "Behavioral sleep problems in children", section on 'Definitions'.)
The American Academy of Sleep Medicine (AASM) and Sleep Research Society (SRS) are active professional
organizations dedicated to the advancement of sleep medicine and related research. The AASM web site
(www.aasmnet.org) and SRS web site (www.sleepresearchsociety.org) provide information on professional
standards, education and training, accreditation, publications, research opportunities, and patient resources.
APPROACH TO THE SLEEP HISTORY A thorough sleep and medical history, guided by an understanding of
normal sleep physiology, provides the foundation for diagnosis and management of sleep problems. Reviewing a
child's sleep history may be time-consuming. However, this investment of time is greatly appreciated by parents,
and the process often provides valuable information not available through any other means. A variety of checklists
and questionnaires are available and may supplement the history. As an example, BEARS is a screening acronym
that prompts a clinician to inquire about five sleep areas (B=Bedtime Issues, E=Excessive daytime sleepiness,
A=Night awakenings, R=Regularity and duration of sleep, S=Sleep disordered breathing [or Snoring]) [10]. This
type of screen can help identify patients who should be evaluated with a more detailed sleep history. There is no
substitute for a thorough sleep and medical history by a knowledgeable clinician.
The sleep history is most contributory when it is structured, detailed, and systematic. The clinician should evaluate
the sleep/wake schedule, difficulties initiating or maintaining sleep, abnormal movements or behavior during sleep,
and daytime accompaniments (eg, sleepiness, inattentiveness, or irritability). The history should include details
about the duration and frequency of the problem, temporal profile of onset (abrupt, gradual, intermittent), and degree
of variability from night to night. The clinician should note what interventions or strategies have been tried and
whether medications have been used.
Because parents are generally asleep during the night, they may struggle to provide a full history. They may
witness only portions of nighttime events, and they may have limited ability to provide a history due to inexperience,
anxiety, or lack of sophistication. More experienced or organized parents often generate diaries or logs of sleep
problems, and the widespread availability of home video cameras has increased the opportunity for physicians to
visualize episodes of abnormal movement or behavior.
Completion of a sleep log during the two weeks prior to evaluation may provide important information regarding the
sleep/wake pattern and nocturnal events. The log should include bed time, time of sleep onset, awakenings, rise
time, nocturnal events, feeding pattern, naps, perceived quality of sleep, degree of alertness or sleepiness during
the day, and observations regarding nocturnal events and medical or psychological stressors. The childs sleep
patterns can then be compared to typical sleep patterns for his or her age group (figure 1), although it should be
recognized that the average sleep time of children in a given age group varies by as much as two hours. (See
"Sleep physiology in children", section on 'Maturation of sleep architecture'.)
Chief sleep complaint The history begins with asking the parent or child to identity the chief complaint related
to sleep. Despite the many ways children may experience sleep problems, most complaints can be distilled into
one (or more) of four categories [11]:
Difficulty initiating or maintaining sleep
Excessive daytime sleepiness
The sleep history should always assess for difficulties in each of these areas. However, the emphasis of the history
depends on the nature of the chief complaint, as detailed below.
Concomitant medical problems Evaluation of the child with sleep problems should also include a thorough
medical review with attention to possible neurodevelopmental or medical problems. Chronic conditions such as
reactive airways disease, gastroesophageal reflux, congenital heart disease, arthritis, and other causes of chronic
pain may predispose the child to sleep problems. Neurological disorders such as cerebral palsy, mental
retardation, autism and related disorders, blindness, and conditions with poor oropharyngeal function are
associated with elevated risk for sleep disorders [1]. Both behavioral sleep problems and obstructive sleep apnea
(OSA) are associated with attention deficit hyperactivity disorder (ADHD) and other special educational needs [12].
In the case of OSA, the sleep disorder probably causes some of the inattentive, hyperactive, or disruptive daytime
behavior and the educational problems. In other cases, such as ADHD, the behavioral sleep problems appear to be
a consequence of the underlying psychiatric disorder, or of medications used to improve daytime behavior.
Medication history The medication history is important because sleep physiology is affected by many of the
medications used in pediatrics.
Medications with sedating effects can cause daytime sleepiness. These include certain anti-histamines, anti-
depressants (especially the tricyclic compounds), benzodiazepines and anti-seizure medications (especially
barbiturates and topiramate), and alpha-adrenergic agonists (eg, clonidine) [13-16].
The selective serotonergic reuptake inhibitors (SSRIs) decrease the quantity of REM sleep and prolong the latency
to REM sleep [17]. Following abrupt withdrawal of the SSRIs, rebound REM sleep or other REM phenomena may
occur.
Stimulant medications, such as dextroamphetamine and methylphenidate, prolong latency to sleep [17]. Exposure
to caffeine also may affect sleep latency and continuity; the child and caregiver should be asked about
consumption of caffeine-containing beverages (eg, colas, coffee, and tea).
Ethanol shortens latency to sleep and decreases the quantity of REM sleep in the first one-half of the sleep period.
DIFFICULTY INITIATING OR MAINTAINING SLEEP A useful way to gather history on a child with difficulty
initiating sleep is to review the child's pattern of activity, hour by hour, from the point of arrival home from school or
daycare.
Behavioral contributors Sleeplessness, or more specifically difficulty initiating or maintaining sleep (insomnia),
in children often has behavioral roots. The problem can be clarified by evaluating the sleep schedule, sleeping
environment, and bedtime routines. When problems are identified, the provider can advise the parent on how to
modify the routine to improve sleep habits. (See "Behavioral sleep problems in children".)
Snoring or other breathing problems during sleep
Abnormal movements or behaviors during sleep
Pre-sleep activities The clinician should record specific times of activities, including periods of exercise or
competitive sports, homework times, dinner time, and whether television viewing or computer game playing
occurs. One study suggests that sedentary activity during the day is associated with increased sleep latency
(ie, more difficulty falling asleep), whereas physical activity reduces sleep latency [18]. The effects of
sedentary activities or sports also depend on the timing of the activities, and vary among individual children.
Bedtime routine The clinician should discuss the bedtime routine, including the consistency with which
parents adhere to schedules, how stalling is addressed, and where the child falls asleep. Other important
features are the circumstances present when the child falls asleep, whether one or both parents are present
as the child falls asleep, and whether stimulating activities are readily available in the sleep environment (such
as television sets or computers in the bedroom). The presence of other siblings in the bedroom, or other
disruptive environmental circumstances (eg, a loud or unsafe neighborhood) should be noted.

Other contributors
EXCESSIVE DAYTIME SLEEPINESS For evaluation of the child with excessive daytime sleepiness, the history
is directed at identification of potential causes. If parents are not aware of age-appropriate norms for nighttime sleep
and daytime napping, they may fail to recognize poor sleep hygiene or chronic sleepiness in their child.
Furthermore, a sleepy child may not appear sleepy to parents or clinicians. Instead, these observers may notice
attentional difficulties due to unsuspected sleepiness, hyperactivity secondary to the child's efforts to stay awake,
or aggressive and disruptive behavior that reflects inability of a sleep-deprived frontal cortex to regulate emotion
normally.
Differential diagnosis Insufficient sleep is the leading cause of daytime sleepiness in children and teenagers.
The sleep requirement for children and teenagers is age dependent and can show a rather wide range, especially in
infants. For optimal daytime functioning and development, the Centers for Disease Control (CDC) recommends the
following sleep times: infants 6 to12 months 14 hours; 5 year old children 11 to 12 hours; 10 year old children 10
hours; adolescents 9 hours. (figure 1). Other common causes of sleepiness include inadequate sleep hygiene
(which contributes to insufficient sleep time), and medication side effects.
Obstructive sleep apnea is also a common cause for daytime sleepiness or associated behavioral problems;
complaints of excessive snoring or abnormal breathing during sleep are usually, but not always present. Less
common but important causes of daytime sleepiness include periodic limb movement disorder, narcolepsy,
idiopathic hypersomnia, and a variety of toxic, endocrine, and metabolic problems. (See 'Obstructive sleep apnea'
below and 'Periodic limb movement disorder and restless leg syndrome' below.)
Response to nighttime awakenings When children experience nighttime awakenings, the parents' response
can promote or extinguish the behavior. As an example, excessive parental attention in response to nighttime
awakenings (including routinely allowing the child to switch beds) may perpetuate the problem. The clinician
should assess whether the parents' response to nighttime awakenings is likely to reinforce the behavior, and
should offer advice on how to reverse this pattern. For some infants and toddlers, habitual nighttime feedings
may disrupt sleep and are often unnecessary. Clinicians should inquire about nighttime feedings and offer
guidance on eliminating these when appropriate.
Psychosocial history Psychosocial dysfunction may cause or present as a sleeping problem. Conversely,
children's sleeping problems can contribute to household and marital stress. The clinician should probe the
psychosocial history, including the presence of marital discord, use of alcohol or drugs by those in the home,
and the possibility of child abuse. In some cases, it may be necessary to interview the child alone to get a
reliable history.
Anxiety or depression Anxiety (including separation anxiety) and depression are common causes of
insomnia in children. All children have fears at some point in their lives, and these may interfere with sleep. If
the fears are persistent and consistently interfere with functioning (ie, sleep), evaluation for a specific phobia
or generalized anxiety disorder may be warranted (see "Overview of fears and specific phobias in children"). In
addition to insomnia, symptoms of depression include depressed or irritable mood, diminished interest or
pleasure (anhedonia), change in appetite or weight status, psychomotor agitation or retardation (eg, talking or
moving more slowly than is usual for them), fatigue or loss of energy, feelings of worthlessness or guilt,
impaired concentration, or recurrent thoughts of death or suicide. (See "Depression in adolescents:
Epidemiology, clinical manifestations, and diagnosis".)
Concomitant medical problems The clinician should identify chronic medical problems that may influence
sleep, including chronic or recurrent pain, symptoms suggestive of gastroesophageal reflux, breathing
problems during wakefulness or sleep, and the medication history. Such medical problems may disrupt sleep
because of discomfort or because of medical interventions (eg, medications, breathing treatments, or feeds)
that are given during the night. Some medications, including stimulants used for attention deficit disorder, may
affect sleep latency and continuity. (See 'Medication history' above.)

Narcolepsy The child with narcolepsy may experience cataplexy (sudden bilateral loss of tone, often
precipitated by a sudden emotion such as laughter), sleep paralysis, or hypnagogic hallucinations [8,19-21].
Children with narcolepsy often experience severe sleepiness, including falling asleep during meal times and
conversation, sports events, or social activities. Academic failure is common. Cataplexy should be differentiated
from atonic seizures, syncope, vestibular disorders, transient ischemic attacks, and behaviorally based loss of
postural tone.
The diagnostic evaluation for narcolepsy includes a focused history and physical examination, polysomnography
and multiple sleep latency test (MSLT). (See 'Multiple sleep latency test' below.)
Narcolepsy in adults is discussed in detail separately. (See "Clinical features and diagnosis of narcolepsy".)
Underlying medical conditions Children with chronic disease, including anemia, malignancy, or metabolic
problems may exhibit excessive sleepiness. Other sources of hypersomnia include post-traumatic hypersomnia,
recurrent hypersomnia (Kleine-Levin syndrome), menstruation-associated hypersomnia, pregnancy-associated
hypersomnia, and circadian rhythm disorders [22-24]. Acute hypersomnia may occur in association with
meningitis, encephalitis, or certain toxic exposures (eg, carbon monoxide and heavy metals). Sleepiness may
occur in association with increased intracranial pressure due to hydrocephalus or mass lesions in the region of the
third ventricle or posterior hypothalamus [7]. Headaches, diplopia, or papilledema may be present, and further
evaluation with neuroimaging is indicated for children with suspected mass lesions. (See "Classification of sleep
disorders", section on 'Central disorders of hypersomnolence'.)
Sleepiness should be differentiated from chronic fatigue, which often involves somatic complaints, such as
weakness or easy fatigability, malaise, nonrestorative sleep patterns, and emotional disturbances. (See
"Fibromyalgia in children and adolescents: Clinical manifestations and diagnosis".)
SNORING OR BREATHING PROBLEMS Sleep-related breathing disorders may cause snoring and other
sounds while sleeping.
Obstructive sleep apnea Obstructive sleep apnea (OSA) in children typically presents with complaints of
snoring or other sounds, such as snorting or gasping. Daytime behavioral problems can be presenting symptoms,
and excessive daytime sleepiness is often evident on specific questioning. Children whose initial screening reveals
these issues, or those with marked adenotonsillar hypertrophy or obesity, deserve a more detailed clinical
evaluation. (See "Evaluation of suspected obstructive sleep apnea in children" and 'Polysomnography' below.)
In children with upper airway obstruction, snoring may occur more frequently in the supine position. When the
airway obstruction is severe, the snoring often occurs in any sleeping position. However, in contrast to adults with
OSA, children with OSA may not snore, and they may not experience recurrent awakenings or arousals with
episodes of obstruction. Because upper airway obstruction is often worse during REM sleep, episodes of snoring,
gasping, apnea, and sudden arousal during airway obstruction are often observed more frequently in the final one-
third of the night [22]. (See "Sleep physiology in children", section on 'Association of sleep disorders with sleep
states'.)
Other nighttime symptoms of OSA may include paradoxical chest-abdominal movements, retractions, observed
apneas, restless sleep, excessive sweating, or cyanosis. Nocturnal enuresis occurs more frequently in children
with OSA than in children without OSA, and enuresis may improve in association with treatment of OSA [25,26].
Daytime symptoms may include nasal obstruction, mouth breathing or other signs of adenotonsillar hypertrophy,
poor attentiveness, irritability or other behavior problems, or daytime sleepiness.
Children with severe OSA may sleep in the upright or semi-upright position to maintain upper airway patency.
Severe forms may be associated with failure to thrive, cor pulmonale, or delayed development [21]. Upon
questioning, parents may acknowledge staying awake during the night to monitor whether their child was breathing,
and to stimulate the child to make him or her breathe during sleep [21,27].
ABNORMAL MOVEMENTS OR BEHAVIORS DURING SLEEP Abnormal movements or behaviors may be
observed in a variety of sleep disorders, including respiratory disturbance, parasomnias, and nocturnal seizures.
Nocturnal events associated with high amplitude movements may present a significant risk of injury to the child,
and protective measures may be required.
A thorough history is adequate in most cases for characterization of nocturnal events and establishing a diagnosis.
Recordings of representative clinical events with a home video camera may provide useful information. In some
cases, additional diagnostic evaluation, such as electroencephalography (EEG) or prolonged
EEG/video/polygraphic monitoring is necessary.
Nocturnal seizures Nocturnal seizures may be generalized or partial (focal) in character. Temporal and frontal
lobe seizures are the most common localization-related epilepsies in sleep. Events are highly stereotypic (ie, the
same behavior pattern recurs), and are often brief but frequent during the night. (See "Benign partial epilepsies of
childhood" and "Localization-related (partial) epilepsy: Causes and clinical features".)
Seizures versus parasomnias Differentiation of nocturnal seizures from parasomnias is important since
treatment of the two conditions is different, and because identification of seizures may require additional evaluation
such as neuroimaging [28]. Both parasomnias and nocturnal complex partial seizures may be associated with
altered behavior and responsiveness, and automatisms; attempts to awaken a child during a NREM parasomnia
may precipitate a lengthy period of confusion (ie, partial arousal) reminiscent of a post-ictal state. (See
"Sleepwalking and other parasomnias in children", section on 'Disorders of arousal from non-rapid eye movement
(NREM) sleep'.)
A key differentiating feature involves the time of occurrence in the sleep period. NREM parasomnias (eg, sleep
walking, sleep terrors, and confusional arousals) typically occur in association with deeper stages of NREM sleep
in the first one-third of the night [29,30]. REM sleep phenomena (eg, nightmares, sleep paralysis, and REM sleep
behavior disorder) tend to occur in the final one-third of the night, when REM sleep predominates [31,32]. Nocturnal
seizures may occur during any stage of sleep but are observed most frequently in the transition into non-REM
sleep, or upon arousal from sleep [33]. (See "Sleep physiology in children", section on 'Association of sleep
disorders with sleep states' and "Sleepwalking and other parasomnias in children", section on 'Differential diagnosis
of arousal parasomnias'.)
Periodic limb movement disorder and restless leg syndrome Periodic limb movement disorder (nocturnal
myoclonus) is characterized by periodic episodes of repetitive and highly stereotypic limb movements during sleep
[22]. The movements usually involve extension of the great toe and partial flexion of the ankle, knee, and
sometimes hip. When these movements are associated with repetitive partial arousals or awakenings, sleep is
fragmented. Although this problem was once thought to begin in adulthood, subsequent investigations have
indicated that these movements also occur in children and that an association exists between periodic limb
movements and daytime problems, including diminished attentiveness [3].
There is significant overlap between periodic limb movement disorder and restless leg syndrome in both children
and adults. Children with restless legs syndrome often have depressed serum ferritin levels, indicating reduced iron
stores, and in this case the disorder may improve with iron supplementation. (See "Restless legs syndrome/Willis-
Ekbom disease and periodic limb movement disorder in children" and "Clinical manifestations and diagnosis of
restless legs syndrome in adults".)
Periodic limb movements must be differentiated from sleep starts (hypnic jerks), benign neonatal sleep myoclonus,
myoclonic seizures, and the limb jerks associated with sleep apnea [22]. (See "Sleepwalking and other
parasomnias in children", section on 'Hypnic starts' and "Nonepileptic paroxysmal disorders in infancy", section on
'Benign neonatal sleep myoclonus'.)
Rhythmic movement disorder Rhythmic movement disorder consists of stereotyped repetitive movements
involving large muscle groups, usually of the head and neck. The movements often begin immediately prior to sleep
onset and are sustained into light sleep [22]. Examples include repetitive head-banging, head rolling, and body
rocking or rolling. Rhythmic humming or chanting may occur with these movements. This group of movements
occurs typically in the toddler years, and movements often resolve gradually by the school years. The distinctive
character of rhythmic movement disorder allows a clinical diagnosis in most cases, although differentiation from
epileptic seizures may be required in rare cases. (See "Sleepwalking and other parasomnias in children", section
on 'Rhythmic movement disorder' and 'Obstructive sleep apnea' above.)
PHYSICAL EXAMINATION The physical examination is directed towards identification of causes of sleep
disorders, or sequelae associated with sleep pathology.
General observations include the child's level of alertness (including possible fluctuations in degree of alertness)
during the examination. Repetitive yawning, droopy eyelids, blank facial expression, frequent changes in position,
overactivity, and irritability may indicate excessive sleepiness.
The general examination should include assessment for dysmorphic features such as those associated with Down
syndrome, Prader-Willi syndrome, craniofacial anomalies, and microcephaly or macrocephaly. Inspection for signs
of scoliosis and neuromuscular disease should be performed. Developmental milestones should be evaluated.
Evaluation of growth parameters may indicate failure to thrive, evolving obesity, or obesity.
Examination of the oropharynx may reveal evidence of tonsillar or adenoidal hypertrophy, an abnormally small upper
airway, mandibular hypoplasia, retrognathia, or bulbar dysfunction. Bulbar dysfunction can manifest with decreased
or absent gag reflex, poor movement of the soft palate, or swallowing problems. Persistent mouth breathing or noisy
breathing may suggest nasal obstruction. Clubbing, cyanosis, or edema may suggest heart failure. Lung
examination may suggest chronic lung disease or reactive airways disease.
POLYSOMNOGRAPHY Polysomnography (PSG) typically consists of an all-night recording performed in the
sleep laboratory in order to characterize sleep architecture and sleep pathology. A number of physiological
parameters are measured, including sleep stages (characterized using a combination of EEG, eye movements, and
muscle tone), respiratory function (including air flow at the nose and mouth, respiratory movements of the chest and
abdomen, and oximetry), electrocardiogram (EKG), limb movements, a microphone to detect sounds such as
snoring or vocalizations, and video tape to characterize movements or behaviors during sleep [34]. A standardized
scoring manual provides guidelines and criteria for analysis of polysomnography in adults and children [35]. Specific
guidelines are also available for infants [36]. (See "Evaluation of suspected obstructive sleep apnea in children",
section on 'Polysomnography'.)
Laboratory-based polysomnography performed by a sleep technologist is indicated for the following purposes [37]:
Polysomnography also may be indicated for evaluation of [37]:
Polysomnography with an expanded EEG montage may be indicated for evaluation of [37]:
Assessment for a sleep-related breathing disorder (eg, obstructive sleep apnea)
Assessment for narcolepsy (in conjunction with a multiple sleep latency test) (see 'Multiple sleep latency test'
below)
Assessment for periodic limb movement disorder (see "Restless legs syndrome/Willis-Ekbom disease and
periodic limb movement disorder in children")
Titration of continuous positive airway pressure (CPAP)

Patients with neuromuscular disorders and sleep-related symptoms
A parasomnia associated with clinical suspicion for a sleep-related breathing disorder or periodic limb
movement disorder
Children suspected to have restless legs syndrome, when additional supportive data (demonstration of
periodic leg movements) are desired to help confirm the diagnosis
Patients with suspected sleep-related epilepsy when the initial clinical evaluation and standard EEG are
Polysomnography is not routinely indicated for evaluation of difficulty initiating or maintaining sleep (insomnia),
circadian rhythm disorders, uncomplicated parasomnias, chronic lung disease, depression, restless legs
syndrome, bruxism, or behaviorally based sleep problems [37,38].
MULTIPLE SLEEP LATENCY TEST The Multiple Sleep Latency Test (MSLT) is an objective, in-laboratory
assessment for excessive daytime sleepiness [39]. This test is based on the concept that the speed with which
one falls asleep is an indication of the severity of sleepiness. The MSLT is also used more specifically to assess for
narcolepsy when the clinical history suggests this diagnosis [37]. (See "Quantifying sleepiness", section on
'Multiple sleep latency test (MSLT)'.)
The MSLT is performed following nocturnal PSG and consists of five nap opportunities at two-hour intervals across
the day. With each nap opportunity the patient is placed in a dimly lit, quiet room in the recumbent position, and
the subject is given instructions to "lie quietly, close your eyes and try to fall asleep." The latency until sleep onset
is measured for each nap opportunity, and the patient is allowed to sleep for 15 minutes after sleep-onset. A
maximum of 20 minutes is permitted for the nap attempt. If no sleep occurs, the sleep latency for that nap is
considered to be 20 minutes when the mean sleep latency is calculated.
The mean sleep latency across all nap opportunities represents a measure of the subject's ability to fall asleep in
an environment conducive to sleep. Adults who are not excessively sleepy fall asleep in 10 to 20 minutes under
these circumstances, whereas mean sleep latency values less than five minutes are considered to indicate
pathological sleepiness [39]. Normative values in children are less well defined than in adults, but normal school-
aged children typically remain awake throughout each 20 minute nap opportunity, or demonstrate a mean sleep
latency in the 15 to 20 minute range.
Individuals with narcolepsy or severe sleep deprivation typically fall asleep in less than five minutes, and sometimes
as quickly as one or two minutes. Individuals with narcolepsy generally experience two or more naps with entry into
REM sleep as a manifestation of an abnormal propensity for REM sleep. However, abnormal entry into REM sleep
may occur in other disorders associated with fragmented nocturnal sleep, such as obstructive sleep apnea, sleep
deprivation, and as a rebound phenomenon after REM suppressing medications are stopped abruptly.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5 to 6 grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the
10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS Sleep disorders in children can impair academic function and daytime
behavior. Clinicians should incorporate questions about sleep into their routine health assessment of children.
inconclusive, to help distinguish the disorder from a parasomnia
Patients with an atypical or potentially injurious parasomnia, to confirm the diagnosis and assess for sleep-
related epilepsy
th th
th th
Basics topics (see "Patient information: Daytime sleepiness (The Basics)" and "Patient information: Night
terrors, confusional arousals, and nightmares in children (The Basics)" and "Patient information: Sleepwalking
in children (The Basics)")
A structured sleep history assesses the sleep/wake schedule, difficulties initiating or maintaining sleep,
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REFERENCES
1. Brown LW, Maistros P, Guilleminault C. Sleep in children with neurological problems. In: Principles and
Practice of Sleep Medicine in the Child, Ferber R, Kryger M (Eds), WB Saunders, Philadelphia 1995. p.135.
2. Okawa M, Sasaki H. Sleep disorders in mentally retarded and brain-impaired children. In: Sleep and its
Disorders in Children, Guilleminault C (Ed), Raven Press, New York 1987. p.269.
3. Picchietti DL, England SJ, Walters AS, et al. Periodic limb movement disorder and restless legs syndrome in
children with attention-deficit hyperactivity disorder. J Child Neurol 1998; 13:588.
4. Chervin RD, Dillon JE, Bassetti C, et al. Symptoms of sleep disorders, inattention, and hyperactivity in
children. Sleep 1997; 20:1185.
5. Ferber R. Introduction: Pediatric sleep disorders medicine. In: Principles and Practice of Sleep Medicine in
the Child, Ferber R, Kryger M (Eds), WB Saunders, Philadelphia 1995. p.1.
abnormal movements or behavior during sleep, and daytime accompaniments (eg, sleepiness,
inattentiveness, or irritability). The history should include details about the duration and frequency of the
problem, temporal profile of onset (abrupt, gradual, intermittent), and degree of variability from night to night.
(See 'Approach to the sleep history' above.)
Difficulties initiating or maintaining sleep (sleeplessness or insomnia) in children are most often behavioral.
These issues can be identified by evaluating the sleep schedule, sleeping environment, and bedtime routines.
Other causes or contributors include psychosocial stressors, underlying medical problems, and anxiety or
depression. (See 'Difficulty initiating or maintaining sleep' above and "Behavioral sleep problems in children".)
The most common causes of daytime sleepiness include insufficient nocturnal sleep as compared to the
average sleep requirements for the age group (figure 1), inadequate sleep hygiene, and medication side
effects. Less common but important causes include narcolepsy, idiopathic hypersomnia and periodic limb
movement disorder. (See 'Excessive daytime sleepiness' above.)
Obstructive sleep apnea in children typically presents with snoring, other noisy breathing, daytime behavioral
problems, or excessive daytime sleepiness. If these symptoms are present, or if a child has significant
adenotonsillar hypertrophy or obesity, a more detailed clinical evaluation is warranted. (See 'Obstructive sleep
apnea' above and "Evaluation of suspected obstructive sleep apnea in children".)
Abnormal movements or behaviors may be observed in a variety of sleep disorders, including parasomnias and
nocturnal seizures. As compared with nocturnal seizures, NREM parasomnias more typically occur during the
first part of the night, are less likely to have stereotypic behaviors, and are more likely to recur during the
same night. (See 'Abnormal movements or behaviors during sleep' above and 'Nocturnal seizures' above.)
Restless legs syndrome and periodic limb movements in sleep are relatively common in children and are
associated with diminished attentiveness. Children with restless leg syndrome often have depressed serum
ferritin levels, indicating reduced iron stores, and in this case the disorder may improve with iron
supplementation. (See 'Periodic limb movement disorder and restless leg syndrome' above.)
In some children, evaluation with overnight polysomnography may be required to confirm a specific sleep
disorder (eg, obstructive sleep apnea or narcolepsy) or to titrate positive airway pressure. Polysomnography is
not routinely indicated for children with insomnia, circadian rhythm sleep disturbances, uncomplicated
parasomnias, or behavioral sleep problems. (See 'Polysomnography' above.)
The Multiple Sleep Latency Test (MSLT) is an objective, in-laboratory assessment of daytime sleepiness. It is
often used in conjunction with a nocturnal polysomnogram to evaluate patients suspected of having
narcolepsy. (See 'Multiple sleep latency test' above.)

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Topic 6357 Version 14.0
GRAPHICS
Average sleep time for children
Mean sleep time of 493 healthy Swiss children enrolled in the Zurich
Longitudinal Studies, based on parent report. Error bars represent 2
standard deviations (which includes 97 percent of the population).
The dashed red line represents the lower limit of sleep time for each age
group, as recommended by the Centers for Disease Control and Prevention
(CDC).
Data from: Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy
to adolescence: Reference values and generational trends. Pediatrics 2003; 111:302.
Graphic 82604 Version 2.0
Di scl osures: Merrill S Wise, MD Nothing to disclose. Daniel G Glaze, MD Grant/Research Support: Neuren Pharmaceuticals (Rett
syndrome). Ronald D Chervin, MD, MS Grant/Research/Clinical Trial Support: Philips Respironics; Fisher Paykel (sleep apnea).
Consultant/Advisory Boards: Proctor & Gamble; MC3; Zansors (sleep). Patent and Copyright Holder: University of Michigan (diagnosis and
treatment of sleep disorders). Employment: University of Michigan Health System, Sleep Disorders Center (sleep disorders). Other
Financial Interest: Regents of University of Michigan (Pediatric Sleep Questionnaire); American Academy of Sleep Medicine (sleep);
International Pediatric Sleep Association (sleep). Alison G Hoppin, MD Employee of UpToDate, Inc.
Contributor disclosures are reviewed f or conf licts of interest by the editorial group. When f ound, these are addressed by vetting through
a multi-level review process, and through requirements f or ref erences to be provided to support the content. Appropriately ref erenced
content is required of all authors and must conf orm to UpToDate standards of evidence.
Conflict of interest policy
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26/4/2014 Assessment of sleep disorders in children

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Titration of continuous positive airway pressure (CPAP)

26/4/2014 Assessment of sleep disorders in children

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