History and exam

Key diagnostic factors

common

snoring, gasping, choking while asleep (obstructive sleep apnea)

While snoring is often a prominent symptom of obstructive sleep apnea (OSA), not all children who snore have OSA. Studies have found that between 3% and 15% of children snore on a regular basis, especially between 3 and 6 years of age (13%-35%).[28]​​

In high-risk groups, such as children with Down syndrome, the absence of snoring does not rule out OSA. In the presence of other signs and/or symptoms, proceeding to a sleep study should be considered.[81]

night sweats (obstructive sleep apnea)

Often a consequence of labored breathing.

breathing through an open mouth (obstructive sleep apnea)

Often associated with adenoidal hypertrophy.

sleeping with hyperextended neck (obstructive sleep apnea)

May be seen as the child attempts to maintain a clear airway during sleep.

restless sleep and periodic limb movements (obstructive sleep apnea)

Brought about by effort during sleep to maintain a clear airway.

secondary nocturnal enuresis (obstructive sleep apnea)

Nocturnal enuresis that reappears after a child has been dry for at least 3 months is considered secondary nocturnal enuresis, and is often seen with obstructive sleep apnea.

hypertension (obstructive sleep apnea)

May be seen.

inability to fall asleep (sleep association disorder)

Sleep association disorder is associated with apparent inability to sleep through the night, which does not appear to have any outward effect during the day.

cataplexy (narcolepsy)

Sudden temporary loss of muscle tone. Diagnostic for narcolepsy type 1.

hypnagogic or hypnopompic hallucinations (narcolepsy)

Represents REM intrusion into wakefulness. Hypnagogic hallucinations occur as one falls asleep. Hypnopompic hallucinations occur as one awakens.

sleep paralysis (narcolepsy)

While common in the general population, a component of narcolepsy thought to represent REM phase intrusion into wakefulness.

erratic sleep schedule (delayed sleep-wake phase disorder)

Especially if sleep is erratic between weekdays and weekends.

Other diagnostic factors

common

excessive daytime sleepiness

Can be present in many sleep disorders, and thus nonspecific. Often presents with history of falling asleep in school. Can be found with insufficient sleep in adolescents, circadian rhythm disorders (especially delayed sleep-wake phase disorder), obstructive sleep apnea (more common in older, obese children, than in younger, thinner children), restless legs syndrome, periodic limb movement disorder, narcolepsy, Kleine-Levin syndrome, Smith-Magenis syndrome, secondary to medications.

difficulty awakening in the morning

Present in many sleep disorders, and thus nonspecific. Can be found with insufficient sleep in adolescents, circadian rhythm disorders (especially delayed sleep-wake phase disorder), obstructive sleep apnea, restless legs syndrome, periodic limb movement disorder, Kleine-Levin syndrome, Smith-Magenis syndrome, secondary to medications.

sleepwalking or talking (obstructive sleep apnea)

Associated with confusional events either falling asleep or during awakening in narcolepsy.

sleep attacks (narcolepsy)

Associated with sudden sleep onset particularly brought on by emotional states.

refusal to sleep in own bedroom (chronic insomnia disorder)

Also associated with anxiety or PTSD.

Risk factors

strong

craniofacial abnormalities (obstructive sleep apnea)

Abnormal craniofacial structure, including maxillary hypoplasia, retrognathia, micrognathia, and congenital syndromes associated with craniosynostosis all reduce the aperture of the upper airway and narrow its caliber. Examples of these conditions include Down syndrome, along with rarer entities such as Robin sequence and Collins, Pfeiffer, and Apert syndromes.[5][22]​​[45][46][57][58][59]

adenotonsillar hypertrophy (obstructive sleep apnea)

Enlargement of the tonsils and adenoids results in narrowing of the upper airway, reducing its caliber, and leading to obstruction. Removal of the tonsils and adenoids resolves obstructive sleep apnea (OSA) in most cases, although some studies have shown recurrence of OSA with long-term follow-up.[60][61][62]

macroglossia (obstructive sleep apnea)

An enlarged tongue as is found in Down syndrome, Beckwith-Wiedemann syndrome, or certain storage diseases, can narrow the caliber of the upper airway, leading to obstruction.[48]

gastroesophageal reflux (obstructive sleep apnea)

Can cause inflammation of the soft tissues of the upper airway, narrowing its caliber and increasing its tendency to collapse with the negative pressures exerted during inspiration.[49]

allergic rhinitis (obstructive sleep apnea)

Can narrow the caliber of the upper airway, increasing its tendency to collapse with the negative pressures exerted during inspiration.[50]

environmental tobacco smoke exposure (obstructive sleep apnea)

Has been shown to be an independent risk factor for developing obstructive sleep apnea, likely through a direct inflammatory effect on the mucosa of the upper airway.[51]

obesity (obstructive sleep apnea)

Clearly shown to increase the risk for obstructive sleep apnea (OSA) in both adults and children.[25][26]

Also seen in Down syndrome or Prader-Willi syndrome. These contribute to OSA.

hypotonia (obstructive sleep apnea)

Low baseline muscle tone and/or central hypotonia all reduce upper airway caliber and predispose to obstructive sleep apnea.[53]

alcohol (obstructive sleep apnea)

Obstructive sleep apnea is worsened in response to alcohol.[54]

medications (obstructive sleep apnea)

Obstructive sleep apnea is made worse by certain medications such as benzodiazepines and baclofen.[55]

Down syndrome (obstructive sleep apnea)

Of the genetic syndromes, Down syndrome is particularly associated with development of obstructive sleep apnea (OSA).[22]​ Thirty percent to 60% of people with Down syndrome will develop OSA.[23]

evening light exposure (delayed sleep-wake phase disorder)

Heightened sensitivity to evening light exposure may cause the circadian clock to be delayed.​[5][43]​​​

inconsistent parenting style or unrealistic sleep expectations (chronic insomnia disorder)

Limit-setting behaviors in chronic insomnia disorder (previously behavioral insomnia of children: limit-setting type) can be caused by a child testing the limits of what parents consider acceptable. A lack of consistency in parenting styles between the parents can send mixed messages to a child and lead to an unstructured sleep environment, resulting in differing perceptions by the parents of appropriateness. Parents may also predispose children to insomnia by assigning too much time in bed or putting them to bed too early.[5]

age <6 years (chronic insomnia disorder or obstructive sleep apnea)

Chronic insomnia disorder is very common, and affects 20% to 30% of children ages 5 and younger.[8]​[63]​​​​

The peak incidence for obstructive sleep apnea in children is between age of 3 and 6.[27] Tonsils and adenoids reach their largest relative size to the upper airway at this time.

adolescent age (delayed sleep-wake phase disorder)

Delayed sleep-wake phase disorder is commonly seen in adolescents.​[5][12]​​​

Without external cues to entrain their internal circadian body clock, adolescents tend to delay their sleep phase and adopt a circadian rhythm that is >24 hours.[41] It is often brought on by a combination of poor sleep hygiene and external pressures such as school work, social engagements, and sports activity. These all delay going to sleep. Insufficient sleep during the week is coupled with a tendency to sleep in late on weekends in order to catch up on lost sleep. The syndrome may also stem from a heightened sensitivity to evening light exposure, and in some cases from genetic differences in clock genes.[5]​[43][44]​​​​

distractions in bedroom (delayed sleep-wake phase disorder)

Lack of darkness and quiet, pets in the room, and use of a computer, television, or cell phone may distract the child from falling asleep.

traumatic or stressful life events (chronic insomnia disorder)

Life stressors that might impact sleep in children include the development of a medical or psychiatric illness; emotional, physical, or sexual abuse; exposure to negative parental interactions or separation; death of a parent; and placement in an alternate care setting, such as foster care.[5][64]​​

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