Screening for Sleep Problems

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]

Key Points

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.

Practice Guidelines

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

Which Patients to Screen

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:

Neurodevelopmental disabilities History of trauma or abuse (Toxic Stress Screening)
Obesity in Children &Teens Asthma or chronic lung disease
Behavior problems Gastroesophageal Reflux Disease
Genetic disorders Chronic pain (Pain Management)
Neuromuscular disorders or hypotonia Nighttime tube feeding (Feeding Tubes & Gastrostomies in Children)
Airway or craniofacial malformations (Cranial Deformation and Craniosynostosis) Nighttime respiratory equipment use (Home Ventilators)
Crowded living conditions Seizures & Epilepsy
School or academic problems Persistent nocturnal enuresis (Toilet Training Children with Complex Medical Conditions)
Exposure to second-hand smoke or other drugs (Substance Use Disorders) Growth problems (Nutrition & Growth in Children with Complex Conditions)
Unsafe home/neighborhood settings Premature infants (Premature Infant Follow-Up)
Insecure housing and/or food supply Polypharmacy or medication side effects
Poor nutrition (Feeding & Nutrition) Sickle Cell Disease
Trisomy 21 (Down Syndrome)

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.

Sleep Screeners

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 (PDF Document 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) (PDF Document 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.

What to Do with a Positive Screen

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) (PDF Document 193 KB) and Sleep Tips for Children (Medical Home Portal) (PDF Document 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.

Services and Referrals

Pediatric Otolaryngology (ENT) (see UT providers [10])
For uncomplicated, suspected obstructive sleep apnea, refer to pediatric otolaryngology (ENT) for consideration of tonsillectomy and/or adenoidectomy. [Marcus: 2012]

Sleep Study/Polysomnography (see UT providers [4])
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 UT providers [55])
For difficult-to-manage behavioral sleep problems or consultation on pharmacological management of sleep problems, consider referral to a Pediatric Psychiatrist.

Resources

Tools

BEARS Sleep Screening Tool (PDF Document 197 KB)
BEARS is divided into 5 major 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 to 18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview. The screen is free to use.

Children’s Sleep Habit Questionnaire (CSHQ) (PDF Document 78 KB)
A parent-reported screening survey designed to assess behavioral and medically based sleep problems in school children 4-10 years old. This questionnaire is frequently used in research.

Services for Patients & Families in Utah (UT)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Abdelgadir IS, Gordon MA, Akobeng AK.
Melatonin for the management of sleep problems in children with neurodevelopmental disorders: a systematic review and meta-analysis.
Arch Dis Child. 2018;103(12):1155-1162. PubMed abstract

Carter KA, Hathaway NE, Lettieri CF.
Common sleep disorders in children.
Am Fam Physician. 2014;89(5):368-77. PubMed abstract

Mombelli S, Bacaro V, Curati S, Berra F, Sforza M, Castronovo V, Ferini-Strambi L, Galbiati A, Baglioni C.
Non-pharmacological and melatonin interventions for pediatric sleep initiation and maintenance problems: A systematic review and network meta-analysis.
Sleep Med Rev. 2023;70:101806. PubMed abstract

Authors & Reviewers

Initial publication: February 2019; last update/revision: February 2024
Current Authors and Reviewers:
Author: Claire K Turscak, MD, MS
Reviewer: Brian McGinley, MD
Authoring history
2023: update: Claire K Turscak, MD, MSA; Jennifer Goldman, MD, MRP, FAAPSA
2019: first version: Jennifer Goldman, MD, MRP, FAAPA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Abdelgadir IS, Gordon MA, Akobeng AK.
Melatonin for the management of sleep problems in children with neurodevelopmental disorders: a systematic review and meta-analysis.
Arch Dis Child. 2018;103(12):1155-1162. PubMed abstract

Blackmer AB, Feinstein JA.
Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review.
Pharmacotherapy. 2016;36(1):84-98. PubMed abstract

Carson M, Cicalese O, Bhandari E, Stefanovski D, Fiks AG, Mindell JA, Williamson AA.
Discrepancies Between Caregiver Reported Early Childhood Sleep Problems and Clinician Documentation and Referral.
Acad Pediatr. 2023. PubMed abstract / Full Text

Carter KA, Hathaway NE, Lettieri CF.
Common sleep disorders in children.
Am Fam Physician. 2014;89(5):368-77. PubMed abstract

Honaker SM, Gopalkrishnan A, Brann M, Wiehe S, Clark AA, Chung A.
"It made all the difference": a qualitative study of parental experiences with pediatric obstructive sleep apnea detection.
J Clin Sleep Med. 2022;18(8):1921-1931. PubMed abstract / Full Text

Honaker SM, Meltzer LJ.
Sleep in pediatric primary care: A review of the literature.
Sleep Med Rev. 2016;25:31-9. PubMed abstract
This review summarizes studies examining the prevalence of sleep problems in primary care settings as well as current practices in screening, diagnosis, and management, including behavioral recommendations and medications.

Honaker SM, Schwichtenberg AJ, Kreps TA, Mindell JA.
Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey.
J Pediatr. 2018;199:106-111.e2. PubMed abstract / Full Text
Study examining parental practices in successfully implementing different behavioral sleep intervention (BSI) outside a clinical setting and duration until improved sleep.

Honaker SM, Street A, Daftary AS, Downs SM.
The Use of Computer Decision Support for Pediatric Obstructive Sleep Apnea Detection in Primary Care.
J Clin Sleep Med. 2019;15(3):453-462. PubMed abstract / Full Text

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
Practice guideline focusing on uncomplicated childhood OSAS, (OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child); American Academy of Pediatrics.

Mombelli S, Bacaro V, Curati S, Berra F, Sforza M, Castronovo V, Ferini-Strambi L, Galbiati A, Baglioni C.
Non-pharmacological and melatonin interventions for pediatric sleep initiation and maintenance problems: A systematic review and network meta-analysis.
Sleep Med Rev. 2023;70:101806. 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

Ngai P, Chee M.
Pediatric Obstructive Sleep Apnea: Update for the Primary Care Provider.
Pediatr Clin North Am. 2022;69(2):261-274. PubMed abstract