Sleep Histories: Who Has Time?
A BEAR of a Problem

Keith L. Cavanaugh, MD,
Assistant Professor of Pediatrics, Department of Pulmonary Medicine, University of Colorado Denver School of Medicine
Associate Director, The Children’s Hospital Sleep Center
Diplomat, American Board of Sleep Medicine

Sleep problems are highly prevalent in the pediatric and adolescent primary care setting. The National Sleep Foundation (NSF) reported in 2004 that 69 percent of children under the age of ten experience some type of sleep problem.¹  This fact can present a challenge for primary care providers. This is especially evident when one considers a cross-sectional community survey obtained from pediatricians in 2001 identified a lack of confidence in screening, evaluating and treating sleep problems.²  A lack of confidence is a reflection of the inadequate sleep training that providers receive in medical school. In 1993 a survey of 137 medical schools showed 30 percent of schools had no sleep training and those schools which did averaged only two hours over the course of four years.³   Anecdotally, I oftentimes find that I am the first sleep specialist who has lectured medical students and residents about any sleep topic. 

In this modern era with the World Wide Web, it is not uncommon for families to turn to the Internet for guidance about sleep problems rather than raise their concerns with their provider, who may not have the answer. The 2004 NSF survey found that 3/4 of parents identified some sleep related issue involving their child they would like to change. Unfortunately when parents research the issue, mixed messages found on the Internet and the multitude of self-help sleep books can only further confuse them.⁴    It has been estimated that less than 14 percent of parents will ask their provider about a sleep problem. On the other hand, while providers tend to ask about sleep problems more often in infants and toddlers and less with school aged children, more than half of all parents wish that their providers would ask more questions about their child’s sleep^.1  When parents do present with a child with sleep problems, it is important for a provider to have a broad differential diagnosis in order to appropriately screen, evaluate and treat the problem. There are 70 specific diagnoses within the eight major categories within the International Classification of Sleep Disorders.⁵

Case Study

Here is a case of a young lady which highlights the challenges of addressing a child’s sleep problem. AJ is a 15-year old girl who presented in the Sleep Clinic at The Children’s Hospital last winter. She was accompanied by her mom, who had concerns that AJ had insomnia and daytime sleepiness.

It is not uncommon to have parents use language with which they are familiar to label the sleep problem, such as insomnia. It can bias one’s approach to the issue by defining the problem before one is certain that insomnia truly is the diagnosis. It was important to get a better understanding of exactly what mom meant by “insomnia” and “sleepiness.” Unfortunately in a primary care setting this type of investigation can be laborious. Obtaining a thorough sleep history can be time-consuming, and time can be a luxury during back to back well child visits.

It would take AJ up to three hours to fall asleep at night. While her set bedtime was at 10:30 p.m., she did not feel tired then. Being motivated to fix this problem, she had attempted to improve upon her sleep habits by eliminating caffeine several hours before bedtime. However, she still was not sleepy until the early morning hours. Socially, this was her first year back at a traditional high school after having been home schooled for the past several years. At her new school, she had tremendous trouble staying awake in the morning and was even falling asleep in the bathroom. She was really struggling to keep her grades up. However, during school breaks and over the prior summer, she denied that sleep was a problem. Once asleep, she slept through the night and was always refreshed upon awakening. She has been sleeping in on weekends until past noon and she denied snoring.

When time is limited in clinic, a basic sleep history can give you a general sense of the type of sleep problem you may be facing.

Use the acronym: BEARS

Bedtime Resistance: For any sleep problem with any age group, it is critical to create structure and have a regular routine. Any patient who cannot clearly define a set bedtime is likely to have sleep hygiene issues that need to be addressed. People should sleep when they are tired at night. It is important to explore why a child protests at bedtime.

Excessive Daytime Sleepiness:  “Sleepiness” suggests that in the right daytime environment, one can fall asleep quickly. It is important to distinguish this from “fatigue,” which is often misconstrued as sleepiness. There are screening tools, like the Modified Epworth Sleepiness Scale (Table 1), available for families to complete that can help distinguish between these two.

Awakenings: This can help determine if there is disruption of the quality of sleep one is getting. Knowing the timing of awakenings can help, as certain problems like Gastroesophageal Reflux Disease (GERD) are more common at various times of the night.

Routine: As stressed with “Bedtime,” the body prefers regular structure and routine in order to promote and maintain good sleep. The lack of a routine suggests a disruption in the quantity of sleep.

Snoring: More recent literature has shown that snoring is not as benign as some may think. It can be associated with daytime behavioral problems like Attention Deficit Hyperactivity Disorder (ADHD) or conduct issues.⁶

As for AJ’s case:

Bedtime Resistance? She states that she maintains a structured bedtime, but it’s more important to ask, “Is she tired at bedtime?” The answer to this question can help one distinguish if the issue is insomnia or if there is a Circadian Rhythm Disorder (CRD). This is especially important if one reports, as AJ does, that she is not tired when she is expected to go to bed. Have an increased suspicion of a CRD, if your patient is not tired until at least two hours later than the bedtime they are attempting to keep. Unfortunately, most people do not give a good history of their sleep routines. For this reason, a two-week sleep diary (Figure 2) is critical to determine the true nature of their sleep behaviors.

Does she have Excessive Daytime Sleepiness? Yes and No. During school days, AJ is nonfunctional in the morning hours because she is sleepy. But on weekends and school breaks, she wakes up refreshed in the mid-day and is not sleepy until the next night. Note that she does not nap, which one would expect if she were truly sleepy during the daytime.

Awakenings? No. Once asleep AJ stays asleep until the next day. Again, this makes the likelihood of some type of sleep-related disturbance, such as obstructive sleep apnea less likely, but does not completely rule it out. Not all children with sleep disordered breathing awaken or snore at night, so this needs to remain on the differential diagnosis, if her sleepiness persists.

Routine? She does have a routine, but it is different on school nights and weekends. Sleep specialists can sound like broken records when it comes to stressing the importance of sleep routines. Families and healthcare providers are oftentimes more tuned in to the importance of sleep routines with newborns and infants, but become less inclined to stress this concept with older children, adolescents, and (unfortunately) themselves. We all benefit from good sleep routines.

Snoring? No, AJ doesn’t snore. If she did, a formal sleep study at The Children’s Hospital could prove helpful to determine if sleep disordered breathing is present. While oftentimes the physical examination of children with sleep complaints is normal, it is important to do a complete Head Eyes Ear Nose and Throat (HEENT) examination. Is there an anatomic abnormality like midface hypoplasia or micrognathia? Are the nares patent or narrow? Is there nasal congestion? Is the palate high arched? Is there tonsillar enlargement? Is the adenoid enlarged? In the Sleep Clinic, we further explore this last concern with potential visualization (laryngoscopy) or a lateral neck x-ray. Inspecting the airway can also help determine if there are muscle tone issues or possibly pinpoint the location of suspected obstruction. While tonsillectomy is recognized as the treatment of choice for Obstructive Sleep Apnea, 30-50 percent of children can remain symptomatic despite surgery.⁷   So do not make the assumption that a child’s sleep issue is cured because they have had surgery. If a child has persistent sleep issues, then strongly consider a formal sleep study, even if they have had a surgical intervention. We recommend a sleep study three months after surgery if they did not have one prior, to be assured that the sleep disordered breathing has resolved.

Conclusion

After completion and review of a two-week sleep diary, AJ was diagnosed with Delayed Sleep Phase Syndrome, a Circadian Rhythm Disorder that often is misdiagnosed as “insomnia.” AJ was only sleepy during the morning hours, when her body preferred to be asleep. This was only a problem because she was expected to be in school at the same time. We implemented a strict treatment plan that included Bright Light Therapy, melatonin and modified sleep hygiene behaviors. AJ was able to correct her internal clock and adjust to a more acceptable sleep schedule that allowed her to get back to school. Her grades improved and she felt she was able to enjoy life more by being awake for it.

Get more information, including a PDF of the two-week sleep diary.

References

1. National Sleep Foundation (www.sleep foundation.org), 2004.

2. Owens JA, The practice of pediatric sleep medicine: results of a community survey. Pediatrics 2001 Sep; 108(3):E51.

3. Rosen RC et al, Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep 1993 Apr; 16(3):249-54.

4. Ramos KD et al, Parenting Advice Books About Child Sleep: Cosleeping and Crying It Out, Sleep 2006, Vol. 29 (12), 1616-1623.

5. American Academy of Sleep Medicine. International classification of sleep disorders, 2nd ed: Diagnostic and coding manual, American Academy of Sleep Medicine, Westchester, IL 2005.

6. O’Brien, Louise M. et al, Neurobehavioral Implications of Habitual Snoring in Children, Pediatrics 2004 114: 44-49.

7. Guilleminault C et al, Adenotonsillectomy and obstructive sleep apnea in children: A prospective survey Otolaryngology - Head and Neck Surgery February 2007,
Vol. 136, (2), 169-175.