Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

obstructive sleep apnoea

1st line – adenotonsillectomy

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obstructive sleep apnoea
1st line – 

adenotonsillectomy

Adenotonsillectomy is first-line treatment in children with obstructive sleep apnoea (OSA) and adenotonsillar hypertrophy.[30]​​[34][60][88]​​[89][90]​ This is generally curative in 79% to 92% of children, although some studies have demonstrated complete resolution of obstruction in smaller numbers, especially in obese children.[91][92][93][129][130]​ One small randomised controlled trial in otherwise healthy children, between 2 and 4 years of age, with mild to moderate OSA showed significant improvement in quality of life following adenotonsillectomy for those with moderate disease, but no major difference between those treated and those not treated with mild disease. This suggests watchful waiting is a recommended strategy in children with mild disease, but further studies are needed.[95]

Adenotonsillectomy improved most quality-of-life and symptom severity measurements in children aged approximately 5 to 10 years, but resulted in clinically significant weight gain even in children overweight at baseline.[94][96]​​[97]​​​[98]​​​

Consider – continuous positive airway pressure

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obstructive sleep apnoea
Consider – 

continuous positive airway pressure

Additional treatment recommended for SOME patients in selected patient group

May be used in cases where adenotonsillectomy does not cure the obstructive sleep apnoea.[34]​[102][103]​​​​​ Successfully using continuous positive airway pressure requires patience, a multidisciplinary approach, and close follow-up to achieve good compliance and adherence.

Consider – treatment of any precipitants or related disorders

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obstructive sleep apnoea
Consider – 

treatment of any precipitants or related disorders

Additional treatment recommended for SOME patients in selected patient group

Treatment of modifiable conditions such as gastro-oesophageal reflux or obesity.

Avoidance of environmental tobacco smoke or precipitating medications.

Avoidance of certain sleep positions if the OSA is only present while maintaining them.

Consider – montelukast or intranasal budesonide

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obstructive sleep apnoea
Consider – 

montelukast or intranasal budesonide

Additional treatment recommended for SOME patients in selected patient group

When mild residual disease persists after adenotonsillectomy, the use of montelukast and intranasal budesonide has been demonstrated to improve or resolve the obstruction.[34]​[99]​​​ These agents may be used in combination.

The US Food and Drug Administration has strengthened its warnings for montelukast about the risk of serious behaviour and mood-related changes.[100]

Primary options

montelukast: children 2-5 years of age: 4 mg orally once daily; children >5 years of age: 5 mg orally once daily

and/or

budesonide nasal: children >5 years of age: 32 micrograms (1 spray) in each nostril once or twice daily

2nd line – continuous positive airway pressure

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obstructive sleep apnoea
2nd line – 

continuous positive airway pressure

In younger children, and especially in infants, there is sometimes reluctance to proceed with adenotonsillectomy because of concern about bleeding and other postoperative complications.[101] In these cases, continuous positive airway pressure (CPAP) is initiated. CPAP may also be used in cases where adenotonsillectomy does not cure the obstructive sleep apnoea or in instances when surgery is not feasible.[34]​[102][103]​​​​​ Successfully using CPAP requires patience, a multidisciplinary approach, and close follow-up to achieve good compliance and adherence.

Consider – treatment of any precipitants or related disorders

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ONGOING
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obstructive sleep apnoea
Consider – 

treatment of any precipitants or related disorders

Additional treatment recommended for SOME patients in selected patient group

Treatment of modifiable conditions such as gastro-oesophageal reflux or obesity.

Avoidance of environmental tobacco smoke or precipitating medications.

Avoidance of certain sleep positions if the OSA is only present while maintaining them.

Consider – montelukast or intranasal budesonide

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ONGOING
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obstructive sleep apnoea
Consider – 

montelukast or intranasal budesonide

Additional treatment recommended for SOME patients in selected patient group

In children who are not treated with surgery, intranasal budesonide and montelukast may be used as additional treatments for mild OSA, and OSA worsened by allergy. However, one 2020 systematic review of anti-inflammatory medications for OSA in non-surgically treated children found insufficient evidence in support of intranasal corticosteroids, and only short-term beneficial effects of treatment with montelukast.[105] If used, these agents may be given in combination.

The Food and Drug administration has strengthened its warnings for montelukast about the risk of serious behaviour and mood-related changes.[100]

Primary options

montelukast: children 2-5 years of age: 4 mg orally once daily; children >5 years of age: 5 mg orally once daily

and/or

budesonide nasal: children >5 years of age: 32 micrograms (1 spray) in each nostril once or twice daily

Consider – otolaryngological and craniofacial intervention

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obstructive sleep apnoea
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with craniofacial anomalies
Consider – 

otolaryngological and craniofacial intervention

Additional treatment recommended for SOME patients in selected patient group

If underlying craniofacial structural abnormalities are present, craniofacial, maxillary, and/or mandibular surgeries are sometimes indicated in addition to more extensive procedures.[34]​ Surgery may also be indicated if a patient cannot tolerate continuous positive airway pressure.[106][107] Orthodontic interventions such as maxillary expansion have been demonstrated to treat obstructive sleep apnoea effectively.[108]

chronic insomnia disorder

1st line – behavioural modification and parental education

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chronic insomnia disorder
1st line – 

behavioural modification and parental education

Behavioural interventions should be the mainstay of treatment for chronic insomnia disorder in children.[9][109][110][111]

The American Thoracic Society outlines a number of treatments that can be used for sleep-onset difficulties; extinction, modified extinction, extinction with parental presence, faded bedtime with positive bedtime routines, and scheduled awakenings.[9]​ Though all are generally found to be effective, there is insufficient evidence to recommend one intervention over another. Parental acceptance of the modified extinction or extinction with parental presence method tends to be higher than the unmodified extinction method.[63]​ All interventions are associated with a reduction in tantrums.[112] 

For limit-setting behaviours, the use of a gate at either the child’s or parent’s bedroom door can be highly effective in establishing boundaries in younger children who refuse to stay in bed without causing additional distress (e.g., anxiety caused by closing the bedroom door).[113]​ Depending upon their age, the child should be actively involved in modifying the sleep-related behaviour. With older children, delineating the desired outcome and devising a graded reward system to give positive reinforcement for following through works well.[65]​ If there is a significant component of separation anxiety that has resulted in the parent having to sleep in the same bedroom as the child (or the child in the parent's bed or bedroom), implementing a modified extinction protocol for this can be effective. Lengthen intervals until the child no longer requires the parent's presence.

To facilitate the success of these behavioural interventions, parents should be educated on general positive sleep habits. These include implementing a consistent bedtime routine, ensuring a regular sleep schedule for both night-time sleep and daytime naps, and making sure that the child is in bed for an age-appropriate amount of time. All of these methods have been shown to be effective.[63] If the child has multiple carers, it is also extremely important that they agree upon the approach to be taken; conflicting messages often result in the child not understanding what is expected of them, which leads to unsuccessful behavioural modification.[5][9]​​​

Consider – melatonin

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chronic insomnia disorder
Consider – 

melatonin

Additional treatment recommended for SOME patients in selected patient group

Melatonin is not a treatment for chronic insomnia disorder, except in very specific circumstances. Although it is available in many countries without prescription, the effectiveness and long-term effects of its use in children are largely unknown.[114]​ Melatonin has been used to induce sleep in children with ADHD and autistic spectrum disorder with good results, although the optimal dose is still unclear, and determining it is made difficult by the fact that it is not a regulated substance and can vary widely between manufacturers.[112]​[115]​​[116][117][118][119]​​[131]​​​​

Initiation and dosing should be supervised by a specialist.[120]

Behavioural interventions should be used first in otherwise healthy children. Melatonin may give a small added benefit.[112]

Primary options

melatonin: consult specialist for guidance on dose

delayed sleep-wake phase disorder

1st line – light exposure regulation

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delayed sleep-wake phase disorder
1st line – 

light exposure regulation

Exposure to bright light in the mornings needs to be encouraged, as well as reinforcement of the notion that the wake-up time denotes the hour at which the patient gets out of bed, not at which he or she enters into 2 hours of drifting in and out of sleep while continuing to lie in bed. Reduction of exposure to bright light at least 2 hours prior to bedtime is important.

Consider – chronotherapy

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delayed sleep-wake phase disorder
Consider – 

chronotherapy

Additional treatment recommended for SOME patients in selected patient group

In instances where the circadian phase shift is extreme, using chronotherapy to further delay the bedtime by 3-hour increments around the clock until it is brought back to the desired hour can be very effective. It is also important to keep in mind that if there is a large circadian phase shift, exposure to bright light in the morning may in fact only serve to further delay the circadian sleep-onset time.

Consider – global measures

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delayed sleep-wake phase disorder
Consider – 

global measures

Additional treatment recommended for SOME patients in selected patient group

Involves keeping to a regular schedule, both weekdays and weekends, during the school year and while on holidays, with special emphasis on the wake-up time. Education about proper sleep hygiene, sleep drives, and the effects of caffeine and certain medications is important.

Sleep hygiene involves elimination of caffeine consumption in the 8 hours prior to sleep; minimising bright light exposure in the 2 hours prior to bedtime; removal of electronic media from the bedroom, including televisions, video games, computers and mobile phones, and avoidance of falling asleep wearing headphones; removal of pets from the bedroom; keeping the bedroom dark, quiet, and at an ambient temperature.

Consider – melatonin

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delayed sleep-wake phase disorder
Consider – 

melatonin

Additional treatment recommended for SOME patients in selected patient group

Using melatonin has been shown effective to advance the circadian phase.[112][121]

The optimal dose is still unclear, and determining it is made difficult by the fact that it is not a regulated substance and can vary widely between manufacturers.[116][117]

The behavioural, schedule, and sleep hygiene issues should be addressed first. It should be clear that these are really what will make a difference, and that the problem will not be solved just by taking a pill. There are no formal criteria for starting melatonin.

Initiation and dosing should be supervised by a specialist.[120]

Primary options

melatonin: consult specialist for guidance on dose

narcolepsy

1st line – frequent scheduled naps

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narcolepsy
1st line – 

frequent scheduled naps

Treating narcolepsy involves having the child take frequent scheduled naps.

Consider – pharmacotherapy

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narcolepsy
Consider – 

pharmacotherapy

Additional treatment recommended for SOME patients in selected patient group

Various drugs are approved to treat narcolepsy in children, including stimulants (e.g., methylphenidate, dexamfetamine, modafinil, armodafinil), as well as other drugs, including sodium oxybate (and other oxybate salts), pitolisant, and solriamfetol.[124][125][126][127]​​​ Fluoxetine, venlafaxine, and clomipramine have been used with some success.[128]​ These agents should be prescribed under specialist use only. See Narcolepsy.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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