Sleep problems occur in 20% to 30% of children at some pointduring childhood. Behavioral sleep disorders are common andfound across all age groups but are most prevalent from infancythrough preschool age. Bedtime resistance occurs in 10% to15% of toddlers, and 15% to 30% of preschool-aged children have difficulties achieving and/or maintaining sleep. Althoughgenerally benign, parasomnias occur commonly in young children, including sleep walking (15% to 40%) and sleep terrors(1% to 6%). OSA is reported in 1% to 4% of children. Circadianrhythm disorders occur in 7% to 16% of adolescents.
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Sleep disorders may manifest in a variety of ways and often go unrecognized. Some children present with daytime behavioral problems, including inattentiveness, hyperactivity, or irritability rather than overt sleepiness. Screening for sleep disorders is recommended as part of primary care. Clinicians should inquire about bedtime problems, excessive daytime sleepiness, wakenings during the night, regularity and duration of sleep, and presence of snoring and sleep-disordered breathing.
The assessment of sleep complaints begins with a detailed history of sleep habits, including bedtime, sleep-onset, and wake times. A detailed description of the sleep environment can result in a dynamic understanding of the challenges to and resources for achieving normal sleep. The recommended history includes the type of bed, who shares it, the ambient light, noise, temperature, and the bedtime routine. Household structure, routines, and cultural practices may be important and influence the timing and ease of sleep (e.g., parental work patterns, evening activities, number of household members). Dietary practices influence sleep, including timing of meals and caffeine intake. A detailed history assessing for symptoms of OSA (gasps, snorting noises, breathing pauses, and so on) should be obtained in all children who snore regularly. New-onset sleep disorders may be associated with a psychological trauma. When the history does not reveal the cause of the sleep disorder, a sleep diary can be helpful.
A complete physical examination is important to rule outmedical causes of sleep disturbance, such as conditions thatcause pain, neurologic conditions that could be associated withseizure disorder, and other central nervous system disorders.Children with genetic syndromes associated with developmental delay may have sleep disorders. Similarly children with attention-deficit/hyperactivity disorder and fetal alcohol syndromeare at higher risk for sleep disorders than other children. Carefulattention to the upper airway and pulmonary examination mayreveal enlarged tonsils or adenoids or other signs of obstruction.
A polysomnogram is used to detect OSA, excessive limb movements, and seizure disorder. This consists of an all-night observation and recording performed in a sleep laboratory. Polysomnography is not indicated in children with primary insomnia (difficulty initiating or maintaining sleep), circadian rhythm disorders, uncomplicated parasomnias, or behaviorally based sleep problems.
Behavioral insomnia of childhood is divided into two subtypes: Sleep-onset association subtype manifests as frequent orprolonged nighttime wakenings that occur in infants or youngchildren. During periods of normal brief arousal with each sleepcycle, the child awakens under conditions different from thoseexperienced as they fell asleep. Thus they are unable to return tosleep independently. Limit-setting subtype is most common in preschool-aged and older children and is characterized by bedtime resistance or refusal that stems from a caregiver’s unwillingness or inability to enforce bedtime rules and expectations.Nighttime fears are also common causes of bedtime refusal.