Many teens have inadequate sleep, 20-30% of children have pediatric insomnia, 1-4% have obstructive sleep apnea, and up to 80% of children with neurodevelopmental disabilities have sleep problems. [Honaker: 2016] [Ngai: 2022] [Blackmer: 2016] These 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] [Meltzer: 2014]

When to screen
Primary care providers should discuss sleep issues and consider screening for sleep problems at every well-child visit.

Immediate interventions
Non-pharmacological interventions for behavioral sleep problems can be initiated while families are waiting to see a sleep specialist.

When to refer
All children who persistently snore and have any sign or symptom of obstructive sleep apnea (OSA) should be referred for polysomnography, otolaryngology, or a sleep specialist for further evaluation. [Marcus: 2012]

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 counseling on sleep hygiene 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]

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.
• The Pediatric Sleep Questionnaire 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. A sign-in is required.

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.

Pediatric Otolaryngology (ENT) (see NW providers [1])
For uncomplicated, suspected obstructive sleep apnea, refer to pediatric otolaryngology (ENT) for consideration of tonsillectomy and/or adenoidectomy. [Marcus: 2012]

Sleep Study/Polysomnography (see NW providers [0])
For obtaining a polysomnography (recommended for complex patients prior to consideration of tonsil or adenoid removal) or for consultation for diagnosis or treatment options of suspected sleep disorders, such as sleep apnea/hypopnea, periodic limb movement disorder, restless leg syndrome, or epilepsy, refer to a Pediatric Sleep Medicine specialist (often a pulmonologist with additional training).

Psychiatry/Medication Management (see NW providers [0])
For difficult-to-manage behavioral sleep problems or consultation on pharmacological management of sleep problems, consider referral to a Pediatric Psychiatrist.