Because of the high prevalence of sleep disorders in children, taking a sleep history is the first and most important step in assessing pediatric patients. The best time to do this would be during the child's routine yearly examination or when the parents bring the child for evaluation because of sleep-related complaints or behavioral/emotional problems. A sleep history along with a neurodevelopmental and psychiatric history, in conjunction with a physical examination, are the essential parts of a comprehensive sleep assessment. BEARS (bedtime, excessive daytime sleepiness, awakenings, regularity, and snoring) is an easy-to-remember mnemonic that can be used to help gather the history of symptoms.17
Several validated questionnaires have been developed to screen for the most common sleep problems in children and adolescents. Chervin and colleagues18 validated their pediatric sleep questionnaire for evaluation of sleep-disordered breathing, daytime sleepiness, snoring, and behavioral problems (hyperactivity, impulsivity, and inattentiveness) in children aged 2 to 18 years. The Children's Sleep Habits Questionnaire developed by Owens and colleagues3 consists of 8 subscales that reflect the major domains of behavioral and medical sleep disorders and a total score indicating the extent and severity of sleep-related problems. The Sleep Disorders Inventory for Students, introduced more recently, is a validated parent-report screening for children aged 2 through 10 years and for adolescents aged 11 through 18 years.19
Sleep diaries can provide information on the child's bedtime, sleep onset time, rise time, and number of nocturnal awakenings and are typically kept for a period of 2 weeks. Sleep diaries are usually filled out by parents or caregivers for younger children; adolescents can fill out their own sleep diaries. Because they are based on observations, the diaries lack objective measurements of sleep.
Actigraphy is an activity-based sleep-wakefulness monitoring method that provides continuous objective data of patients' sleep with night-to-night variability. It can detect nocturnal awakenings and unreported circadian sleep disturbances. Actigraphy uses a small device worn on the wrist that counts movements per minute and translates "activity count" into sleep-wakefulness measurements using a specially designed algorithm.
Nocturnal PSG is the objective gold-standard procedure to study sleep. PSG involves recordings of electroencephalogram, electro-oculogram, electromyogram, airflow, respiratory and abdominal efforts, oxygen saturation, end tidal CO2 level, and limb muscle activity. It requires that the child spend a night in the sleep laboratory, usually accompanied by a parent. Ambulatory home-based studies have also been conducted in children; however, because of the technical challenges associated with home-based monitoring, it is not routinely used for clinical purposes. PSG is indicated for the diagnosis of sleep-disordered breathing in children. With PSG, the presence and degree of OSA, central apnea, alveolar hypoventilation, snoring, and upper airway resistance syndrome in children can be assessed. PSG is also used to establish the diagnosis of PLMD and to evaluate the possible presence of nocturnal seizures.
The Multiple Sleep Latency Test (MSLT) uses a series of 4 or 5 naps conducted at 2-hour intervals that begin 2 hours after the final morning awakening following nocturnal PSG. The MSLT is used to assess daytime sleepiness. It helps establish a diagnosis of narcolepsy and to objectively quantify sleepiness that is either associated with OSA or idiopathic hypersomnia or is due to chronic sleep loss.
The Maintenance of Wakefulness Test (MWT) is similar to the MSLT but the patient is asked to remain awake while sleep latency is measured. The MWT is rarely used in the pediatric population since it has not been validated in children.
The Epworth Sleepiness Scale provides a means for assessing sleepiness and has been modified recently for use in children and adolescents20; it is a helpful instrument for screening subjective propensity to fall asleep in certain situations and measuring treatment outcome.TREATING PEDIATRIC SLEEP DISORDERS