Assessment of sleep disorders in children

INTRODUCTION — A growing body of evidence suggests that sleep disorders may interfere with physical, cognitive, emotional, and social development. In addition, children with neurodevelopmental problems, learning differences, or behavior problems may be at heightened risk for sleep problems compared with the general pediatric population [1-5]. Children with sleep disorders may present with different symptoms than do adults, and, within the pediatric age group, the clinical manifestations of sleep problems may vary by age and developmental level.

This topic review will discuss the approach to taking a structured sleep history, provide an overview of specific sleep problems that may present during childhood, and explain indications for further diagnostic testing. Specific sleep disorders are discussed in more detail in other topic reviews:

●(See "Behavioral sleep problems in children".)

●(See "Evaluation of suspected obstructive sleep apnea in children".)

●(See "Parasomnias of childhood, including sleepwalking".)

●(See "Sleep-related movement disorders in childhood".)

SLEEP REQUIREMENTS

●Recommended targets – The sleep requirement for children and teenagers is age-dependent and has a wide range, especially in infants. For optimal health, daytime functioning and development, the following sleep times are recommended on a regular basis [6-8]:

•Infants 4 to 12 months – 12 to 16 hours (including naps)

•Toddlers 1 to 2 years – 11 to 14 hours (including naps)

•3- to 5-year-old children – 10 to 13 hours (including naps)

•6- to 12-year-old children – 9 to 12 hours

•Teens 13 to 18 years – 8 to 10 hours

These targets are incorporated into a bedtime calculator [9]. These consensus recommendations were made by the American Academy of Sleep Medicine, endorsed by the American Academy of Pediatrics, and are very similar to those of the National Sleep Foundation (figure 1).

Infants 0 to 3 months of age generally sleep 14 to 17 hours daily (including naps); there are no recommendations for this age group because of the wide range of variation in sleep duration and patterns.

●Anticipatory guidance – Routine counseling to parents, caregivers, and children about age-appropriate targets for nighttime sleep and daytime napping can help them recognize a chronic sleep deficit and its consequences. A child with insufficient sleep may not appear sleepy to parents/caregivers or clinicians. Instead, the child may exhibit attentional difficulties due to unsuspected sleepiness, hyperactivity secondary to efforts to stay awake, or aggressive and disruptive behavior that reflects inability of a sleep-deprived frontal cortex to regulate emotion normally. (See "Cognitive and behavioral consequences of sleep disorders in children".)

Strategies to improve sleep habits in children are outlined in the tables (table 1A-B) and discussed in more detail in a separate topic review. (See "Behavioral sleep problems in children".)

CHIEF SLEEP COMPLAINT AND SLEEP HISTORY

Routine screening for sleep problems — Clinicians should incorporate questions about sleep into routine health assessment for children of all ages. Parents may not volunteer information about their child's sleep or may not appreciate the potential relationship between sleep problems and daytime behavior.

Sleep problems usually present 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.

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 (table 2) [10]:

●B – Bedtime issues

●E – Excessive daytime sleepiness

●A – Awakenings during the night

●R – Regularity and duration of sleep

●S – Sleep-disordered breathing (or Snoring)

This type of screen can help identify patients who should be evaluated with a more detailed sleep history as described below.

Chief sleep complaint — The history begins with asking the parent/caregiver 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

●Snoring or other breathing problems during sleep

●Abnormal movements or behaviors before or during sleep

The sleep history should always assess for difficulties in each of these areas. However, the main focus of the history depends on the nature of the chief complaint. The main diagnostic considerations in each of these categories are outlined below. (See 'Initial classification of the sleep problem' below.)

Additional sleep history — Once the chief sleep complaint is identified, the history can focus on details that distinguish among disorders in that category. The history should include:

●Sleep-wake schedule

●Duration and frequency of the problem, temporal profile of onset (abrupt, gradual, intermittent), and degree of variability from night to night

●Interventions or strategies that have been tried, including any medications used for sleep (either over-the-counter, prescription or herbal medications)

●Daytime symptoms that may be related to insufficient or disrupted sleep, including sleepiness, hyperactivity, inattentiveness, or irritability

In contrast with adults, children with obstructive sleep apnea (OSA) may present with daytime attentional or behavioral problems rather than overt sleepiness [3,12]. Even within the pediatric age group, the clinical manifestations of sleep problems may vary by age and developmental level. For example, a school-aged child with excessive sleepiness may exhibit motor overactivity, inattentiveness, irritability, or oppositional behavior rather than overt sleepiness [13,14].

Sleep logs, questionnaires, and video recordings — Parents or caregivers may struggle to provide a full history, as they may witness only portions of nighttime events. Useful tools include:

●Sleep log – Completion of a sleep log (sleep diary) during the two weeks prior to evaluation may provide important information regarding the sleep-wake pattern and nocturnal events (form 1). The log should include:

•Bed time and rise time

•Time of sleep onset and awakenings

•Other nocturnal events

•Perceived quality of sleep

•Naps

•Eating/feeding pattern

•Degree of alertness or sleepiness during the day

•Observations regarding nocturnal events and medical or psychological stressors

The child's sleep patterns can then be compared with 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'.)

●Questionnaires – Several different questionnaires have been developed to assess sleep-related symptoms in children, including the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder (PSQ-SRBD) scale and the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD) (form 2). These questionnaires can be completed by parents and/or children. These tools are discussed in greater detail separately. (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Questionnaires'.)

●Home video recording – For children with a history of abnormal movements or behaviors during sleep, a home video recording of one or more episodes (eg, using a smartphone or video camera) can allow the clinician to make a preliminary diagnosis and identify children who may require additional evaluation with polysomnography. (See 'Polysomnography' below.)

ADDITIONAL MEDICAL HISTORY

Concomitant medical problems — Evaluation of the child with sleep problems should also include a thorough review of the medical history, with a focus on possible neurodevelopmental or medical problems that may be associated with sleep disorders. These include:

●Chronic conditions that may disrupt sleep, such as reactive airways disease, gastroesophageal reflux, congenital heart disease, arthritis, and other causes of chronic pain. (See "Medical disorders resulting in problem sleeplessness in children".)

●Altered craniofacial anatomy or reduced oropharyngeal function, which predispose to obstructive sleep apnea (OSA). (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Other'.)

●Neurologic disorders such as cerebral palsy, intellectual disability, autism spectrum disorder and related disorders, and blindness, which are associated with neurobehavioral and circadian sleep disruption [15].

●Attention deficit hyperactivity disorder (ADHD), in which the association with sleep disorders is probably bidirectional:

•ADHD-associated behavioral problems and stimulant medications tend to cause sleep disruption. (See "Medical disorders resulting in problem sleeplessness in children", section on 'Attention deficit hyperactivity disorder'.)

•Conversely, some types of sleep disorders, such as OSA and restless legs syndrome (RLS), may cause behavioral symptoms that meet diagnostic criteria for ADHD, including inattention, hyperactivity, impulsivity, and irritability. In many cases, the behavioral symptoms improve or resolve if the sleep disorder is effectively treated. (See "Cognitive and behavioral consequences of sleep disorders in children".)

●Anxiety or depression, which may cause or exacerbate sleep problems such as difficulty initiating or maintaining sleep (insomnia). (See 'Other contributors' below.)

Medications, caffeine and alcohol — A wide variety of medications can cause sleep disruption (table 3). Medications with adverse effects on sleep that are commonly encountered in pediatrics include:

●Stimulant medications (eg, for ADHD). (See "Sleep in children and adolescents with attention deficit hyperactivity disorder", section on 'Effects of ADHD medications on sleep'.)

●Sedating medications – Medications with sedating effects include certain antihistamines, antidepressants (especially the tricyclic compounds), benzodiazepines, and antiseizure medications (especially barbiturates and topiramate), and alpha-adrenergic agonists (eg, clonidine) [16,17].

●Selective serotonin reuptake inhibitors (SSRIs) – SSRIs may increase awakenings, and abrupt withdrawal may worsen insomnia.

●Other substances – Caffeine-containing beverages (eg, colas, coffee, and tea) tend to delay sleep onset and cause insomnia. Alcohol tends to shorten latency to sleep but also may cause insomnia later in the night.

(See "Medical disorders resulting in problem sleeplessness in children", section on 'Medication-induced sleep disturbance'.)

PHYSICAL EXAMINATION — The physical examination is directed towards identification of causes of sleep disorders, or sequelae associated with sleep pathology.

●General physical examination:

•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. Persistent mouth breathing or noisy breathing may suggest nasal obstruction.

•Growth – Excessive weight gain and obesity are associated with an increased risk for obstructive sleep apnea (OSA). Failure to thrive also may be a consequence of OSA, or of an underlying chronic medical disorder. (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Examination'.)

•Dysmorphic features – Several syndromes or anomalies are associated with OSA:

-Down syndrome or Prader-Willi syndrome (see "Down syndrome: Clinical features and diagnosis" and "Prader-Willi syndrome: Management")

-Craniofacial anomalies, such as macrocephaly, microcephaly, micrognathia, or Pierre Robin syndrome (see "Syndromes with craniofacial abnormalities")

•Clubbing, cyanosis, or edema may suggest heart failure. Lung examination may suggest chronic lung disease or reactive airways disease.

●Oropharynx/airway examination:

•Oropharyngeal features associated with OSA include tonsillar or adenoidal hypertrophy, abnormally small upper airway, mandibular hypoplasia, micrognathia, retrognathia, high-arched hard palate, dependent soft palate, overjet, overbite, adenoidal facies (elongated face, mouth breathing (figure 2)). (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Examination'.)

•Absent gag reflex, poor movement of the soft palate, or swallowing problems suggest bulbar dysfunction, which is associated with OSA.

●Neurologic examination:

•Evaluate for signs of neuromuscular disease, including scoliosis and weakness. Children with neuromuscular disease are at risk for both OSA (due to oropharyngeal dysfunction) and sleep-related hypoventilation (due to respiratory muscle weakness). (See "Etiology and evaluation of the child with weakness".)

•Assess developmental milestones and cognitive function.

INITIAL CLASSIFICATION OF THE SLEEP PROBLEM

Difficulty initiating or maintaining sleep — For children with difficulty initiating sleep, a detailed history helps to identify behavioral contributors and possible underlying sleep disorders or other psychosocial or medical precipitants.

Behavioral contributors — Sleeplessness, or more specifically difficulty initiating or maintaining sleep (insomnia) often has behavioral roots, especially in young children. 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/caregiver on how to modify the routine to improve sleep habits. (See "Behavioral sleep problems in children".)

●Pre-sleep activities – Review the child's pattern of activity, hour by hour, from the point of arrival home from school or daycare until bedtime. Record specific types and times of activities, including:

•Periods of exercise, competitive sports and sedentary activity – One study suggests that physical activity reduces sleep latency, while sedentary activity during the day is associated with increased sleep latency (ie, more difficulty falling asleep) [18]. The effects of sedentary activities or sports also depend on the timing of the activities and vary between individual children. In young children, the associations between physical activity and sleep duration are inconsistent across studies and may vary by age group [19].

•Other afterschool activities – Including typical times for homework and dinner.

•Viewing of television or playing electronic games in the evening – Use of electronic devices and social media are important contributors to delayed sleep onset, whereas spending time with family may be protective [20]. In a study of more than 300 Swiss adolescents, screen time during the evening was negatively correlated with sleep duration, while off-screen activity was not [21]. In a subset of 183 participants who agreed to avoid screen time after 9 PM, sleep duration increased by 17 minutes and daytime vigilance improved. A meta-analysis of studies in children <5 years of age found an inverse association between total daily screen time and sleep duration [19].

●Bedtime routine – Discuss the bedtime routine, including the consistency with which parents or caregivers adhere to schedules, how they respond if the child stalls or resists bedtime, and where the child falls asleep.

Patterns that are often associated with delayed sleep onset include:

•Stimulating activities readily available in the sleep environment (such as television sets, laptop computers or tablets, cell phones, or video games in the bedroom).

•Presence of a parent/caregiver as the child falls asleep.

•Siblings or other children in the bedroom, or other disruptive environmental circumstances (eg, a loud or unsafe neighborhood).

•Increased attention from the parent/caregiver in response to a child's stalling behavior at bedtime, which inadvertently promotes the behavior. To avoid this, the parent/caregiver can establish a consistent response that extinguishes the unwanted behavior. (See "Behavioral sleep problems in children", section on 'Bedtime routines'.)

●Response to nighttime awakenings – When children experience nighttime awakenings, the parent/caregiver's 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 healthy toddlers and older infants, habitual nighttime feedings may disrupt sleep and are unnecessary. Clinicians should inquire about nighttime feedings and offer guidance on eliminating these when appropriate. (See "Behavioral sleep problems in children", section on 'Young children with behavioral insomnia'.)

Specific sleep disorders — Specific sleep disorders may be responsible for the insomnia in some cases and warrant specific treatment [22].

●Delayed sleep-wake phase disorder, which is a common cause of difficulty initiating sleep in adolescents and is characterized by a shift (delay) in sleep and wake time relative to the patient's desired or required sleep schedule. (See "Delayed sleep-wake phase disorder".)

●Restless legs syndrome (RLS), which usually can be distinguished by questioning about the circadian (worst in evening) urge to move the legs, which is the primary symptom of this movement disorder. (See "Restless legs syndrome and periodic limb movement disorder in children".)

●Nightmares, which may occur in any child but are more frequent in those with anxiety or posttraumatic stress disorder. (See "Parasomnias of childhood, including sleepwalking", section on 'Nightmare disorders'.)

Other contributors — The following problems contribute to insomnia in some children. In such cases, the insomnia is unlikely to respond to behavioral therapy alone until these issues are addressed.

●Psychosocial dysfunction – 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 household members, and any indications 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 phobias in children and adolescents".)

The prevalence of depression is approximately 2 percent among school-aged children and rises sharply during adolescence. In addition to insomnia, symptoms 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 "Pediatric unipolar depression: Epidemiology, clinical features, assessment, 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 feedings) that are given during the night. Some medications, including stimulants used for attention deficit hyperactivity disorder (ADHD), may affect sleep latency and continuity. (See 'Additional medical history' above.)

Excessive daytime sleepiness — For evaluation of the child with excessive daytime sleepiness, the history is directed at identification of potential causes. Sleepiness should be differentiated from chronic fatigue, which often involves somatic complaints, such as weakness or easy fatigability, malaise, nonrestorative sleep patterns, and depression or other emotional disturbances. (See "Fibromyalgia in children and adolescents: Clinical manifestations and diagnosis".)

Excessive sleepiness is of particular concern in older adolescents because of the known association between drowsy driving and accidents. Driving while drowsy can have the same consequences as driving while under the influence of drugs or alcohol including reduced attentiveness, delayed reaction times, and impaired decision-making. Young men between 16 and 24 years of age are most at risk for having an accident while driving drowsy [23]. (See "Drowsy driving: Risks, evaluation, and management", section on 'High-risk populations'.)

Insufficient sleep — Insufficient sleep is the leading cause of daytime sleepiness in children and teenagers [24,25]. Insufficient sleep is common [26], and often is a consequence of poor sleep hygiene (which contributes to insufficient sleep time), failure of the parents or older children to prioritize sleep, and/or medication side effects.

Recommended sleep times by age are outlined in the figure (figure 1). However, sleep needs vary substantially between individuals. Sufficient sleep for any given individual can be defined as that amount which, when obtained on a regular basis, allows optimal daytime alertness and (importantly for children) behavioral and emotional regulation. By this definition, any individual may still have insufficient sleep even if the number of hours obtained falls within the limits suggested in the table.

In some cases, the primary care clinician may provide counseling to improve sleep hygiene (table 1A-B). For children with suspected emotional triggers, further evaluation and referral to a mental health specialist is appropriate. If this is not successful, then referral to a specialist in sleep medicine may be helpful, especially for children with neurologic or developmental disorders. (See "Behavioral sleep problems in children".)

Delayed sleep-wake phase disorder — Delayed sleep-wake phase disorder involves a circadian rhythm disturbance characterized by a shift in sleep and wake time relative to the patient's desired or required sleep schedule. It is particularly common among adolescents and young adults, and results in complaints of difficulty waking in the morning and difficulty initiating sleep at the targeted time. (See "Delayed sleep-wake phase disorder".)

Narcolepsy — Children with narcolepsy often experience severe sleepiness, including falling asleep during meal times and conversation, sports events, or social activities. The disorder is most often diagnosed during adolescence, but is increasingly recognized in younger children. Academic failure is common. Unique features that may or may not be present initially are cataplexy (sudden bilateral loss of tone, often precipitated by a sudden emotion such as laughter), sleep paralysis, or hypnagogic hallucinations (vivid, dreamlike imagery at sleep onset) [14,27-30]. 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 (PSG), and multiple sleep latency test (MSLT). (See 'Multiple sleep latency test' below.)

Children with symptoms suggesting narcolepsy (eg, severe daytime sleepiness, with or without cataplexy, sleep paralysis, or hypnagogic hallucinations) should be referred to a sleep medicine clinician for further evaluation. Narcolepsy is discussed in detail separately. (See 'Multiple sleep latency test' below and "Clinical features and diagnosis of narcolepsy in children".)

Other causes — The following disorders sometimes present with daytime sleepiness as a chief complaint, but usually can be distinguished by their other clinical features:

●Obstructive sleep apnea (OSA) – OSA is also a common cause for daytime sleepiness or associated behavioral problems. The sleepiness is often less obvious in children compared with adults with OSA. Complaints of excessive snoring or abnormal breathing during sleep are usually, but not always, present. (See 'Obstructive sleep apnea' below.)

●Periodic limb movement disorder (PLMD) – PLMD is characterized by periodic episodes of repetitive limb movements during sleep. It may present with daytime sleepiness. Periodic limb movements and arousals that occur with them can also be associated with transient increases in blood pressure. Affected children also may complain of symptoms of restless legs syndrome (RLS), which is a closely associated disorder. (See 'Periodic or rhythmic movements' below.)

●Underlying medical conditions – Many medical conditions may be associated with excessive daytime sleepiness, diminished alertness, fatigue, or related complaints that can be challenging to distinguish. Such conditions include:

•Any chronic disease – eg, including anemia, cardiac disease, malignancy, or metabolic problems

•Acquired central nervous system disorders

-After traumatic brain injury (concussion) or in association with meningitis, encephalitis, or certain toxic exposures (eg, carbon monoxide and heavy metals).

-Increased intracranial pressure, due to hydrocephalus or mass lesions in the region of the third ventricle or posterior hypothalamus [13]. Headaches, diplopia, or papilledema may be present. Further evaluation with neuroimaging is indicated for children with suspected mass lesions. (See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis".)

●Central disorders of hypersomnolence – In addition to narcolepsy, other central disorders of hypersomnolence include Kleine-Levin syndrome (recurrent hypersomnia, which may be menstrual-related), and idiopathic hypersomnia [31-33]. (See "Classification of sleep disorders", section on 'Central disorders of hypersomnolence'.)

Snoring or breathing problems

Snoring — Snoring is very common, affecting up to 10 to 17 percent of young children in the United States [34,35]. It is estimated that 50 percent of children referred for a PSG will be diagnosed with snoring. Snoring is due to vibration of upper airway tissues during sleep, secondary to upper airway narrowing and sleep-induced pharyngeal hypotonia, and results from increased upper airway resistance. Children who snore ≥3 nights per week should be evaluated by their primary care clinician or specialist to determine the need for a PSG. In addition, persistent comorbidities such as hypertension [36], behavioral disturbances [37], and poor asthma control [38] have been associated with clinically significant snoring in children and their presence suggests that treatment for snoring may be indicated. (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Screening'.)

Obstructive sleep apnea — OSA is particularly common in school-aged children with adenotonsillar hypertrophy, or in children of any age with obesity. It typically presents with complaints of snoring or other sounds, such as snorting or gasping. It is often associated with neurobehavioral symptoms such as inattention, hyperactivity, impulsivity, and irritability. Children whose initial screening reveals any of these symptoms, or those with marked adenotonsillar hypertrophy or obesity, warrant a more detailed clinical evaluation (algorithm 1). (See "Evaluation of suspected obstructive sleep apnea in children".)

Referrals — Children with suspected OSA should be referred to a sleep medicine clinician or an otolaryngologist (ear, nose, and throat specialist) whose practice includes children. Existing literature does not indicate which referral serves best, and local resources and access to care may vary. If PSG is indicated, this usually can be arranged by the sleep clinician or otolaryngologist. Many accredited sleep laboratories will only perform studies after children are seen by a sleep clinician, otolaryngologist, or other clinician experienced with sleep apnea in children. This is because screening for sleep disorders other than OSA, choices for equipment used during sleep studies, interpretation of results, formulation of comprehensive treatment plans, assessment of outcomes, and plans for further interventions when needed are not subjects commonly taught in other types of medical training.

Movements or behaviors during sleep — Abnormal movements or behaviors may be observed in a variety of sleep disorders, including respiratory disturbance, parasomnias, and sleep-related epilepsy (nocturnal seizures) (table 4). Nocturnal events associated with vigorous (high-amplitude) movements may present a 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 or smartphone may provide useful information. In some cases, additional diagnostic evaluation, such as consultation with a neurologist and consideration of electroencephalography (EEG) or prolonged EEG/video monitoring, is necessary.

Simple or single movements — Simple movements during sleep that are common in children include (table 5) [33]:

●Sleep starts (hypnic jerks) – Sleep starts are abrupt, startle-like movements that occur as one is drifting off to sleep. They are very common in all age groups. (See "Sleep-related movement disorders in childhood", section on 'Sleep starts (hypnic jerks)'.)

●Limb jerks associated with OSA – Limb movements may occur during arousals triggered by OSA, but these are not stereotyped; they are not scored as periodic limb movements. OSA usually can be distinguished by snoring, paradoxical abdominal movements, and/or risk factors such as adenotonsillar hypertrophy or obesity, and the diagnosis is confirmed by polysomnography (PSG). (See 'Obstructive sleep apnea' above.)

●Benign sleep myoclonus of infancy – This is characterized by brief myoclonic jerks of the limbs or the trunk during sleep in infants younger than six months of age; the condition is uncommon and benign, but consultation with a neurologist and electroencephalography may be required to differentiate it from myoclonic seizures. (See "Sleep-related movement disorders in childhood", section on 'Benign sleep myoclonus of infancy'.)

These and other simple movements during sleep are discussed separately. (See "Approach to abnormal movements and behaviors during sleep", section on 'Simple or single movements'.)

Periodic or rhythmic movements — Periodic or rhythmic movements during sleep are common in children and include (table 6):

●PLMD – PLMD (nocturnal myoclonus) is characterized by periodic episodes of repetitive and highly stereotypic limb movements during sleep, as documented on PSG, and associated with sleep disturbance or daytime dysfunction [33]. 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. In addition to the movements, affected children have daytime problems, often including diminished attentiveness [2].

There is significant overlap between PLMD and restless legs syndrome (RLS) in both children and adults. RLS is characterized by an urge to move the legs, usually accompanied by uncomfortable or unpleasant sensations in the legs. The symptoms begin or worsen during rest or inactivity, are relieved by movement, and occur exclusively or predominantly in the evening or night. Children with RLS or PLMD 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 and periodic limb movement disorder in children".)

If the child has a suspected PLMD or RLS that disrupts sleep or quality of life, referral to a sleep clinician may be helpful to confirm the diagnosis and initiate treatment. Alternatively, the clinician may choose to recommend avoidance of caffeine and to evaluate for deficiency of iron or ferritin before referring to a specialist.

●Hypnagogic foot tremor – Hypnagogic foot tremor is a benign rhythmic movement of the feet or toes, occurring around the time of sleep onset with a periodicity of once every one to two seconds. The periodicity and timing near sleep onset distinguish it from periodic limb movements of sleep (table 6). (See "Sleep-related movement disorders in childhood", section on 'Hypnagogic foot tremor and alternating leg muscle activation'.)

●Rhythmic movement disorder – Rhythmic movements of the head, neck, or trunk associated with sleep are likely developmental (physiologic) in infants and young children. They are most common in infants and toddlers, and often resolve spontaneously by five years of age. The term sleep-related rhythmic movement disorder is used if the movements have or are likely to have significant consequences such as self-injury or interference with normal sleep [33].

Typical manifestations are body rocking, head rolling (side to side), or head banging, sometimes accompanied by rhythmic humming or inarticulate chanting. The movements often begin immediately prior to sleep onset and are sustained into light sleep [33]. The distinctive character of rhythmic movements allows a clinical diagnosis in most cases, although in a few cases with atypical features, further investigation may be required to distinguish these from sleep-related epilepsy. (See "Sleep-related movement disorders in childhood", section on 'Rhythmic movement disorder'.)

Complex movements or behaviors — Complex movements during sleep usually are parasomnias and are common in young children. Occasionally, sleep-related epilepsy can present with similar clinical features. These disorders are summarized briefly below and discussed in more detail in the linked topic reviews.

●Parasomnias – Parasomnias are episodic and complex behaviors that intrude into sleep. The most common parasomnias in children are sleepwalking, confusional arousals, and sleep terrors, which occur upon partial arousal from non-rapid eye movement (NREM) sleep [33]. They are benign and most common in young children but occasionally occur in older children or adolescents. Common triggers include sleep deprivation and other sleep disorders, such as OSA.

Parasomnias usually are easily identified by a description or video recording of the behavior and its timing. Rarely, certain types of sleep-related epilepsy can mimic parasomnias, but usually can be distinguished by clinical characteristics, or with nocturnal EEG if needed. Assessment includes gathering clinical history on common triggers such as insufficient sleep, or symptoms of OSA or RLS. (See "Parasomnias of childhood, including sleepwalking".)

●Sleep-related epilepsy – Sleep-related epilepsy (nocturnal seizures) may be generalized or focal (also known as partial or localization-related epilepsy). A generalized tonic clonic seizure arising out of sleep is usually obvious by history and not easy to confuse with a sleep disorder; the seizure involves bilateral tonic clonic movements, often with tongue biting or urinary incontinence, postictal drowsiness and confusion. It may be difficult for parents to provide a full description of nocturnal seizures since they may directly observe only the latter portion of the event rather than the beginning of the event. Assessment may include PSG with expanded EEG montage.

•Benign epilepsy – Benign (childhood) epilepsy with centrotemporal spikes, also known as benign rolandic epilepsy, is one of the more common epilepsy syndromes in childhood. It is an age-dependent focal epilepsy of unknown etiology with a peak incidence in children between seven and nine years of age. (See "Sleep-related epilepsy syndromes", section on 'Self-limited focal epilepsies of childhood'.)

•Juvenile myoclonic epilepsy – Juvenile myoclonic epilepsy typically occurs in otherwise healthy adolescents and is characterized by the triad of myoclonic jerks, generalized tonic-clonic seizures, and absence seizures (also called petit mal). The seizures characteristically occur upon awakening, often in the early morning, or in association with sleep deprivation. (See "Juvenile myoclonic epilepsy".)

•Sleep-related focal epilepsy – Temporal lobe epilepsy and sleep-related hypermotor epilepsy (formerly called nocturnal frontal lobe epilepsy) are relatively rare but distinctive focal epilepsies in sleep. Events are highly stereotypic (ie, the same behavior pattern recurs) and are often brief but clustered or frequent during the night. Occasionally these types of seizures may be difficult to distinguish from arousal (NREM) parasomnias (sleep walking, sleep terrors, and confusional arousals) because both may be associated with altered behavior, responsiveness, and automatisms, and because attempts to awaken a child during a parasomnia may precipitate a lengthy period of confusion (ie, partial arousal) that is reminiscent of a postictal state [39]. (See "Sleep-related epilepsy syndromes", section on 'Sleep-related focal epilepsies'.)

A key feature that differentiates nocturnal epilepsy from parasomnias is the time of occurrence in the sleep period, as outlined in the table (table 7):

•NREM parasomnias typically occur in association with deeper stages of NREM sleep in the first one-third of the night [40].

•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 [41,42].

•Nocturnal seizures may occur during any stage of sleep but are observed most frequently in the transition into NREM sleep or upon arousal from sleep [43].

Referrals — Children with typical benign sleep-related movements such as typical parasomnias or rhythmic movements in a toddler often can be addressed by a primary care provider who is familiar with diagnosis and management of these common conditions. Management also includes follow-up to ensure that the problem resolves or remains consistent with a benign condition. Parental education and reassurance are important.

Features that raise the possibility of epilepsy include:

●Movement disorders with late age of onset or complex movements that are atypical for a parasomnia

●Other features strongly suggesting nocturnal seizures, such as generalized tonic-clonic movements, or presence of daytime seizures

Children with these features should be referred to a specialist in pediatric neurology or pediatric sleep medicine, if available. For diagnosis and determining the character of the behaviors (eg, seizures versus nonepileptic events), evaluation with polysomnography with expanded electroencephalography montage or prolonged electroencephalography-video monitoring may be needed.

ANCILLARY TESTS

Polysomnography — Polysomnography (PSG) typically consists of an all-night recording performed in the sleep laboratory to characterize sleep architecture and sleep pathology.

●Indications – Indications for laboratory-based PSG performed by a sleep technologist include [44,45]:

•Assessment for a sleep-related breathing disorder (eg, obstructive sleep apnea [OSA])

•Assessment for narcolepsy (in conjunction with a multiple sleep latency test [MSLT])

•Assessment for periodic limb movement disorder (PLMD)

•Titration of continuous positive airway pressure (CPAP)

PSG also may be indicated for evaluation of [44]:

•Patients with neuromuscular disorders and sleep-related symptoms

•Parasomnia with clinical suspicion for a sleep-related breathing disorder or PLMD

•Selected children with suspected restless legs syndrome (RLS) who require supportive data for the diagnosis

PSG is not routinely indicated for evaluation of difficulty initiating or maintaining sleep (insomnia), circadian rhythm disorders, uncomplicated parasomnias, chronic lung disease, depression, RLS, bruxism, or behaviorally based sleep problems [44,46]. Home sleep apnea tests are not currently recommended for diagnosis of OSA in children, as explained in a position paper from the American Academy of Sleep Medicine [47]. (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Alternatives to polysomnography'.)

●PSG with EEG – PSG with an expanded electroencephalography (EEG montage; typically 16-channels) may be indicated for evaluation of [44]:

•Patients with suspected sleep-related epilepsy when the initial clinical evaluation and standard EEG are 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

●Technique – PSG measures multiple physiologic parameters, including sleep stages (characterized using a combination of electroencephalography [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, limb movements, sounds such as snoring or vocalizations (via microphone), and video recording to characterize movements or behaviors during sleep. (See "Overview of polysomnography in infants and children".)

A standardized scoring manual provides guidelines and criteria for analysis of PSG in adults and children [48]. Specific criteria are also available for infants.

Multiple sleep latency test

●Indications – The multiple sleep latency test (MSLT) is an objective, in-laboratory assessment for excessive daytime sleepiness [49]. Its primary use is for evaluation of suspected narcolepsy when the clinical history suggests this diagnosis [44]. (See "Quantifying sleepiness", section on 'Multiple sleep latency test (MSLT)' and "Clinical features and diagnosis of narcolepsy in children".)

●Technique – The MSLT is performed following nocturnal PSG and consists of five 20-minute nap opportunities at two-hour intervals across the day, while recording EEG and other parameters similar to a PSG. The test is based on the concept that the speed with which one falls asleep is an indication of the severity of sleepiness.

●Interpretation – During the MSLT, a sleep latency time of less than five minutes is markedly abnormal and supports a diagnosis of narcolepsy or severe sleep deprivation. The International Classification of Sleep Disorders, 3^rd edition (ICSD-3), requires a mean sleep latency of less than eight minutes and two or more sleep onset REM periods as part of the diagnostic criteria for narcolepsy [33]. Prepubertal children tend to have a somewhat longer sleep latency on the MSLT compared with adults, such that values of 8 to 15 minutes (rather than less than eight minutes) on the MSLT may suggest pathologic sleepiness [50].

In addition to abnormal sleep latency, patients with narcolepsy tend to enter rapid eye movement (REM) sleep quickly during daytime naps. Abnormal entry into REM sleep also may occur in disorders other than narcolepsy that are associated with fragmented nocturnal sleep, such as OSA, sleep deprivation, and as a rebound phenomenon after REM-suppressing medications are stopped abruptly.

Actigraphy — Actigraphy involves use of a wristwatch-like device to monitor movement at night [51], usually during a 5- to 14-day period. Actigraphy has been validated against PSG and shown to provide a reasonable estimate for patterns of sleep versus wakefulness in children and adults. The advantage of actigraphy over polysomnography is that it captures multiple days of data from the home environment. Actigraphy is typically used by sleep medicine specialists as part of a comprehensive characterization of sleep-wake patterns and to monitor response to interventions. (See "Actigraphy in the evaluation of sleep disorders".)

RESOURCES

●International Classification of Sleep Disorders, 3^rd edition, text revision (ICSD-3-TR) – The ICSD-3 provides a diagnostic and coding manual for recognized sleep disorders [33]. 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 ICSD-3 includes separate entries for pediatric sleep disorders where children and adults differ most in presentation, diagnosis, evaluation, or treatment. The classification scheme is summarized in a separate topic review. (See "Classification of sleep disorders".)

●American Academy of Sleep Medicine – This is a professional organization dedicated to the advancement of sleep medicine and related research. The website (www.aasmnet.org) provides information on professional standards, education and training, accreditation, publications, research opportunities, and patient resources.

●Sleep Research Society – Similarly, the Sleep Research Society provides professional education, training and guidance on sleep and related disorders (www.sleepresearchsociety.org).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Insomnia in children" and "Society guideline links: Sleep-related breathing disorders including obstructive sleep apnea in children" and "Society guideline links: Restless legs syndrome".)

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^th to 6^th 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^th to 12^th 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.)

●Basics topics (see "Patient education: Daytime sleepiness (The Basics)" and "Patient education: Night terrors, confusional arousals, and nightmares in children (The Basics)" and "Patient education: Sleepwalking in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Routine screening – Sleep disorders in children are very common and can impair academic function and daytime behavior. Clinicians should incorporate questions about sleep into their routine health assessment of children (table 2). (See 'Routine screening for sleep problems' above.)

●Detailed sleep history – A structured sleep history assesses the sleep-wake schedule, difficulties initiating or maintaining sleep, presence of snoring, 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 'Chief sleep complaint and sleep history' above.)

Sleep logs, questionnaires, and video recordings can be used to complement the history. (See 'Sleep logs, questionnaires, and video recordings' above.)

Information from the history can be used to classify the concern into one (or more) of the following categories:

•Insomnia – Difficulties initiating or maintaining sleep (sleeplessness or insomnia) often have behavioral origins in young children. These issues can be identified by evaluating the sleep schedule, sleeping environment, and bedtime routines. Other causes or contributors in all age groups include psychosocial stressors, underlying medical problems, and anxiety or depression. Specific sleep disorders that may cause sleep-onset insomnia include restless legs syndrome (RLS) and delayed sleep-wake phase disorder, which is common in adolescents. (See 'Difficulty initiating or maintaining sleep' above and "Behavioral sleep problems in children".)

•Daytime sleepiness – The most common causes of daytime sleepiness include insufficient nocturnal sleep compared with the average sleep requirements for the age group (figure 1), poor sleep hygiene, and medication side effects. Practices to improve sleep hygiene are summarized in the tables (table 1A-B). Less common but important causes include narcolepsy, obstructive sleep apnea (OSA), idiopathic hypersomnia, and periodic limb movement disorder (PLMD). (See 'Excessive daytime sleepiness' above.)

•Snoring or breathing problems – OSA 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 (algorithm 1). (See 'Obstructive sleep apnea' above and "Evaluation of suspected obstructive sleep apnea in children".)

•Movements or behaviors – Abnormal movements or behaviors may be observed in a variety of sleep disorders (table 4), including (see 'Movements or behaviors during sleep' above):

-Rhythmic movements of the head, neck, or trunk associated with sleep are common and likely developmental (physiologic) in infants and young children. They are most common in infants and toddlers and generally resolve spontaneously by five years of age. (See 'Periodic or rhythmic movements' above.)

-RLS and periodic limb movements in sleep are relatively common in children and are associated with diminished attentiveness. Children with RLS often have depressed serum ferritin levels, indicating reduced iron stores, and in this case, the disorder may improve with iron supplementation. (See 'Periodic or rhythmic movements' above.)

-Parasomnias (sleepwalking, confusional arousals, and night terrors) are benign and most common in young children but occasionally occur in older children or adolescents. The differential diagnosis includes nocturnal seizures. Compared with parasomnias, nocturnal seizures are more likely to recur during the same night, have stereotypic behaviors, and occur randomly through the night (rather than in the first one-third of the night) (table 7). (See 'Complex movements or behaviors' above.)

●Ancillary tests – In some children, evaluation with overnight polysomnography (PSG) may be required to confirm a specific sleep disorder (eg, OSA or narcolepsy) or to titrate positive airway pressure therapy. The multiple sleep latency test (MSLT) is an objective, in-laboratory assessment for excessive daytime sleepiness, used primarily to evaluate patients with suspected narcolepsy. PSG is not routinely indicated for children with insomnia, circadian rhythm sleep disturbances, uncomplicated parasomnias, or behavioral sleep problems. (See 'Ancillary tests' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel G Glaze, MD, who contributed to earlier versions of this topic review.