Screening and responding to a positive pediatric screen for sleep issues

Up to half of the general pediatric population and 80% of children with neurodevelopmental disabilities have some type of sleep problem. True sleep disorders are less common, affecting about 4% of the population, but have a significant impact on child and family well-being. [Carter: 2014] An important cause of sleep disturbance in children, obstructive sleep apnea (OSA), occurs in about 1-4% of the population. [Honaker: 2016] [Ngai: 2022] [Blackmer: 2016] Sleep problems have been linked to behavioral, learning, and developmental issues in children. [Ngai: 2022] Yet, there is a well-documented pattern of underscreening for sleep problems among primary care providers, leading to decreased behavioral interventions and low referral rates for specialty services. [Honaker: 2022] [Carson: 2023] [Honaker: 2019]

When to screen
Per American Academy of Pediatrics (AAP) guidelines, primary care providers should screen for sleep apnea by asking about snoring at every well-child visit. Specifically, children who routinely snore, gasp, or have witnessed pauses in breathing during sleep should be further evaluated for sleep apnea. While there are no evidence-based guidelines to recommend formal screening for sleep problems and non-respiratory sleep disorders, medical home providers should strongly consider addressing these during routine well-child visits.

Immediate interventions
The importance of good sleep hygiene for treating all pediatric sleep problems cannot be overstated. Review these sleep hygiene tips with families while they are waiting to see a sleep specialist.

Medications
Avoid routine use of medications without consulting a sleep specialist.

When to refer
All children who persistently snore and have signs or symptoms of obstructive sleep apnea (OSA), such as persistent snoring, witnessed pauses in breathing, and gasping during sleep, should be referred for polysomnography, otolaryngology, or a sleep specialist for further evaluation. [Marcus: 2012] Consider referral to a pediatric sleep specialist if non-respiratory sleep issues persist despite reinforcement of sleep hygiene practices. See Behavioral Techniques to Improve Sleep.

Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN.
Diagnosis and management of childhood obstructive sleep apnea syndrome.
Pediatrics. 2012;130(3):576-84. PubMed abstract

Morgenthaler TI, Owens J, Alessi C, Boehlecke B, Brown TM, Coleman J Jr, Friedman L, Kapur VK, Lee-Chiong T, Pancer J, Swick TJ.
Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children.
Sleep. 2006;29(10):1277-81. PubMed abstract

Given that sleep and hygiene counseling can be time-consuming, and there are relatively few pediatric sleep specialists, pediatric clinicians may avoid asking about sleep concerns. However, helping with sleep can be very meaningful for families. The American Academy of Pediatrics advises screening all children for snoring; other providers with expertise in sleep medicine recommend routinely screening all children for sleep problems. [Honaker: 2016] [Marcus: 2012]

If this is not possible, consider screening for sleep problems in children with:

Because this list could go on, our recommendation is to provide routine surveillance and consider using a sleep screening tool with all children during well-child visits. Also see Medical Conditions Affecting Sleep in Children.

Using a sleep screener may help clinicians find a potential problem to discuss with families, including bedtime problems, night awakenings, inadequate sleep quality or duration, snoring or apnea, periodic limb movements, restless leg syndrome, parasomnias, nocturnal seizures, daytime sleepiness, and narcolepsy. Some practices found that adding a sleep screen to the electronic record for well-child visits significantly increased the identification of sleep problems. [Honaker: 2018] [Honaker: 2016]

Examples of free pediatric sleep screens:

• The BEARS Sleep Screening Tool ( 197 KB) is divided into 5 sleep domains (B=Bedtime Issues, E=Excessive Daytime Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep, S=Snoring) and helps clinicians evaluate potential sleep problems in children 2-18 years old.
• The Children’s Sleep Habit Questionnaire (CSHQ) ( 78 KB) is a parent-reported screening survey with 22 questions designed to assess behavioral and medically based sleep problems in children ages 4-10 years. This questionnaire is frequently used in research.

Acknowledging the significant impact of a child’s sleep problems on the entire family and providing guidance and resources tailored to the situation is important. See Sleep Tips for Adolescents (Medical Home Portal) ( 193 KB) and Sleep Tips for Children (Medical Home Portal) ( 189 KB). Additional clinical resources on the Medical Home Portal discuss the diagnosis and management of sleep problems and provide patient education to share with families. See Sleep Issues for a list of related topics. For positive screens related to sleep apnea or sleep disorders, see the services and referrals list below.

Pediatric Otolaryngology (ENT) (see NM providers [11])
For uncomplicated, suspected obstructive sleep apnea, refer to pediatric otolaryngology (ENT) for consideration of tonsillectomy and/or adenoidectomy. [Marcus: 2012]

Sleep Study/Polysomnography (see NM providers [2])
For obtaining a polysomnography (recommended for complex patients before consideration of tonsil or adenoid removal). Consider referral to a Pediatric Sleep Specialist for other suspected sleep disorders such as periodic limb movement disorder, restless leg syndrome, unusual behavior during sleep, insomnia, excessive daytime sleepiness, or narcolepsy.

Psychiatry/Medication Management (see NM providers [3])
For difficult-to-manage behavioral sleep problems or consultation on pharmacological management of sleep problems, consider referral to a Pediatric Psychiatrist.