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CHAPTER
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31
ach year more than 10 million Americans seek
E
medical help for sleep problems. Patients report
insufcient or nonrestorative sleep, despite adequate
opportunity, that results in some form of daytime impairment. Insomnia is prevalent in 30% to 40% of the
adult population, with 10% to 15% reporting that it is
chronic, severe, or both. More than 40% of parents
report sleep problems in their children, and 20% of
these are considered signicant. The consequences of
chronic sleep problems include difculty with concentration, fatigue, lack of energy, and irritability. Sleep
disturbances in the elderly can result in increased falls
and accidents. In children, sleep disturbances can produce learning and behavior problems, alter physical
development, and affect family functioning.
Sleep has two separate stages: rapid eye movement
(REM) sleep, which is linked to dreaming, and nonREM (NREM) sleep, which is a deeper sleep state.
NREM is further divided into four sleep stages. In each
stage the sleep is progressively deeper. An individual
generally moves through NREM sleep from stage 1 to
stage 4. Stages 3 and 4 are the deepest stages. At the
end of stage 4, a person goes backward in stages toward the progressively lighter sleep of stage 1. The
rst REM sleep stage then follows. Movement from
stage 1 to the end of REM is termed a sleep cycle. This
cycle usually lasts 90 minutes in adults and approximately 50 minutes in infants. In one night, ve cycles
are usually completed. As an adult goes through the
sleep cycles, the REM period increases in length from
10 minutes to occupying most of the 90-minute cycle.
Also, the proportion of stage 2 increases, with stages
3 and 4 decreasing in length. The total amount and
composition of sleep change throughout life. Sleep
quality is often judged by the amount of time spent in
stage 4 sleep. People who do not have adequate REM
sleep feel they have had too little sleep.
Newborns fall directly into REM sleep. This REM
sleep in infancy is thought to provide the brain stimulation necessary for maturation. At age 5, REM sleep in
Sleep Problems
children decreases to that of the adult, which is
approximately 20% of total sleep. The REM portion of
sleep is constant through all age ranges; however
stages 3 and 4 of NREM sleep begin to decline in adolescents, and in the elderly, stages 3 and 4 disappear.
The elderly may experience more frequent awakenings
during the night; some need to compensate for this
with rest periods during the day. Some elderly clients
view their pattern of diminished sleep with frustration;
whereas others accept it as an opportunity to have
more time for other activities.
Sleep is regulated by two primary processes: the
body’s circadian rhythm, which causes an increase in
sleepiness twice during a 24-hour period (usually between midnight and 7 am and for a brief period in the
midafternoon), and the physiologic need for sleep,
which is increased by sleep loss and sleep disruption.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Dene the nature of the problem.
Key Questions
l
How would you describe your (or the child’s) sleep
problem?
l
Are you having difculty falling asleep?
l
Are you having difculty staying asleep?
l
Are you having difculty staying awake during
the day?
l
Have you taken medications for sleep? If so, what
are they?
l
How long has the problem existed?
Nature of the Problem
Sleep disorders include sleeplessness (insomnia), episodic disturbance of behavior associated with sleep
(parasomnias), and excessive sleepiness (hypersomnia). The most common childhood sleep disorders are
night awakening, inability to fall asleep, problems
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Chapter 31 • Sleep Problems
going to bed, circadian rhythm problems, and parasomnias. Often it is the caregiver, not the child, who
factors, illness, depression, pain, or use of medications
or alcohol.
perceives the sleep disturbances to be a problem. The
BEARS instrument (Table 31-1) provides a comprehensive screening tool to identify sleep disorders in
children.
Daytime Sleepiness
Nighttime insomnia and daytime sleepiness are not
isolated symptoms. Daytime sleepiness may be related
to an increased need for sleep because of nighttime
Difficulty Falling Asleep
Difculty in falling asleep is often related to poor sleep
hygiene practices, use of medications or stimulants, or
sleep loss, or it may represent narcolepsy. Daytime
sleepiness could also be medication induced or due to
psychological causes.
disruption in circadian rhythms. Difculty falling
asleep also can occur as a result of pain or as a symptom
of anxiety.
Medications
Over-the-counter and prescription medications used to
promote sleep can have side effects, such as daytime
Difficulty Staying Asleep
Difculty staying asleep occurs when the sleep cycle
is disrupted; this may be related to physiological
Table 31-1
The “BEARS” instrument is divided into five major sleep domains, providing a comprehensive screen for the major sleep
disorders affecting children in the 2- to 18-yr-old range. Each sleep domain has a set of age-appropriate “trigger questions”
for use in the clinical interview.
1. Bedtime
problems
2. Excessive
daytime
sleepiness
3. Awakenings
during the night
4. Regularity and
duration of
sleep
5. Snoring Does your child snore a
From Mindell JA, Owens JA: A clinical guide to pediatric sleep: Diagnosis and management of sleep problems, Philadelphia, 2003, Lippincott
Williams & Wilkins.
C, Child-directed question; P, parent-directed question.
BEARS Sleep Screening
EXAMPLES OF DEVELOPMENTALLY APPROPRIATE TRIGGER QUESTIONS
TODDLER/PRESCHOOL (2-5 yr) SCHOOL-AGE (6-12 yr) ADOLESCENT (13-18 yr)
Does your child have any
problems going to bed?
Falling asleep?
Does your child seem
overtired or sleepy a
lot during the day?
Does he or she still
take naps?
Does your child wake up
a lot at night?
Does your child have a
regular bedtime and
wake time? What are
they?
lot or have difficult
breathing at night?
sleepiness and headaches. Long-term use of sleep medica-
tions often produces tolerance and a need for an increased
dosage. Some agents, particularly the benzodiazepines,
Does your child have any
problems at bedtime? (P)
Do you have any problems
going to bed? (C)
Does your child have difficulty
waking in the morning,
seem sleepy during the
day, or take naps? (P)
Do you feel tired a lot? (C)
Does your child seem to
wake up a lot at night?
Any sleepwalking or night-
mares? (P) Do you wake
up a lot at night? Do you
have trouble getting back
to sleep? (C)
What time does your child go
to bed and get up on
school days? Weekends?
Do you think he/she is
getting enough sleep? (P)
Does your child have loud or
nightly snoring or any
breathing difficulties at
night? (P)
Do you have any
problems falling
asleep at bedtime? (C)
Do you feel sleepy a lot
during the day? In school?
While driving? (C)
Do you wake up a lot
at night? Have
trouble getting
back to sleep? (C)
What time do you usually
go to bed on school
nights? Weekends?
How much sleep do
you usually get? (C)
Does your teenager snore
loudly or nightly? (P)
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are habituating with long-term use; stopping them may
cause withdrawal symptoms.
Duration of the Problem
Sleep disorders can be transient (lasting a few days),
short term (lasting weeks), or chronic (lasting months
to years). An acute problem, lasting a few days to a
few weeks, can be caused by stress, acute illness, environmental disturbance, or jet lag. A chronic problem
may be due to a specic sleep disorder, a mood disorder, or the use of medications or stimulants. Primary
insomnia is diagnosed when no underlying cause can
be identied.
Is this a specic sleep disorder?
Key Questions
l
Do you have a creeping, crawling, or uncomfortable
feeling in the legs that is relieved by moving your
legs?
l
Does your bed partner report that your arms or legs
jerk during sleep?
l
Do you (or the child) snore loudly, gasp, choke, or
stop breathing during sleep?
l
Do you (or the child) have difculty staying awake
during the day or do you fall asleep during routine
tasks (for adults, especially driving)?
l
Do you have episodes of muscle weakness?
Limb Sensation
Restless legs syndrome includes the sensation of crawling, pulling, and tingling with an irresistible urge to
move the legs. Symptoms increase in the evening, especially when the person is lying down and remaining
still. Patients often have coexisting periodic limb
movements in sleep.
Limb Jerking
Periodic leg movements during sleep are common in
people older than 65 years. Bilateral, repeated, rhythmic jerking or twitching movements, primarily in the
legs, characterize periodic limb movement disorder.
Less frequently, movement occurs in the arms.
Snoring
Obstructive sleep apnea (OSA) is characterized by
loud snoring, mouth breathing, and restless sleep
patterns. The patient may report insomnia but more
commonly notes excessive daytime sleepiness.
Parental smoking can be a risk factor for snoring in
children. Passive smoke inhalation can provoke mucosal
edema and inammation, resulting in a narrowing of the
pharynx and causing snoring. In addition, allergic respiratory diseases may cause snoring.
Daytime Dozing, Excessive Daytime Sleepiness,
and Muscle Weakness
Excessive daytime sleepiness may be caused by narcolepsy. Adults with narcolepsy report falling asleep
while driving or performing routine tasks. Initially,
children with narcolepsy have great difculty getting
up in the mornings. When awakened, the child may
appear to be confused or may be aggressive or verbally
abusive. The child may fall asleep at school, in the
vehicle on the way home from school, or while watching television. Cataplexy is common in adults. This
disorder is identied as episodes of sudden muscular
weakness and atonia generally instigated by an emotional trigger. The patient will have to lean against
a wall for support because his or her legs feel rubbery.
The degree of daytime sleepiness can be quantied
using the Epworth Sleepiness Scale (Box 31-1).
Could the sleep problem be secondary to a health
condition?
Key Questions
l
Have you been ill recently?
l
Do you have a chronic health condition?
l
What medications (prescription and over-the-counter)
do you take?
l
Do you have depression or anxiety?
Illness: Acute or Chronic
Acute illness can be a cause of sleep disturbance. Nocturnal pruritus, associated with chronic eczema, may
also cause awakening.
In children, otitis media and chronic serous otitis,
even without acute infection, can disturb sleep. Some
believe that middle ear pressure rises when the child is
supine at night and report sleep improvement with treatment of otitis. In children, enlarged adenoids and upper
airway obstruction may cause awakening. Children with
asthma have a greater incidence of night awakening.
Gastroesophageal reux disease (GERD) may cause
night awakening but produces few symptoms during
the day. GERD, chronic obstructive pulmonary disease, peptic ulcer disease, and congestive heart failure
are associated with paroxysmal nocturnal dyspnea,
which frequently disturbs sleep and is often interpreted
by the patient as insomnia. Prostatic hypertrophy may
cause nocturia and thus disturb sleep.
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Chapter 31 • Sleep Problems
Box 31-1
The Epworth Sleepiness Scale may be used to evaluate daytime sleepiness. The scale is a simple questionnaire that measures
the general level of daytime sleepiness by gauging the probability of falling asleep in a variety of situations. On a scale of 0 to
3, the patient rates the likelihood that he or she would doze in each of eight different situations as part of his or her “usual way
of life in recent times.”
The patient’s responses are added together, and the total score can range from 0 to 24. The normal range is from 2 to
10, with a modal score of 6. Scores increase linearly in patients with obstructive sleep apnea syndrome according to the
severity of the apnea. Any score higher than 10 is considered significant.
The Epworth Sleepiness Scale has high test-retest reliability in normal subjects (r 5 0.82, P ,0.001). It is a unitary scale
with high internal consistency (Cronbach coefficient alpha 5 0.88). It is simple, easy to understand, and a very inexpensive
measurement of daytime sleepiness.
On a scale of 0 to 3, indicate the likelihood that you would fall asleep in the following situations, taking into account your
usual way of life in recent times. Using the scale below, choose the most appropriate number for each situation:
0 5 Would never doze
1 5 Slight likelihood of dozing
2 5 Moderate likelihood of dozing
3 5 High likelihood of dozing
SITUATION: LIKELIHOOD OF DOZING
Reading while seated __________________
Watching TV __________________
Sitting, inactive, in a public place such as a theater or meeting __________________
As a passenger in a car for an hour without a break __________________
Lying down to rest in the afternoon when circumstances permit __________________
Sitting and talking to someone __________________
Sitting quietly after a lunch during which you did not drink alcohol __________________
In a car, while stopped for a few minutes in traffic __________________
Total: __________________
The Epworth Sleepiness Scale
Modified from Johns MW: Daytime sleepiness, snoring and obstructive sleep apnea. The Epworth Sleepiness Scale, Chest 103:30, 1993. Permission
conveyed through Copyright Clearance Center, Inc.
Medications
Many medications can have stimulating effects and
cause sleep disruption. Common offenders include antidepressants, decongestants, bronchodilators, b-blockers,
thyroid preparations, phenytoin, methyldopa, and
corticosteroids. The potential sedating effects of
medications should also be considered in patients who
report excessive daytime sleepiness. Medications such
as antihistamines often cause sleep disturbances.
Pain
Pain may interfere with sleep onset or contribute to
early awakenings. Patients with chronic pain may have
mood and cognitive disturbances that contribute to
insomnia and early morning awakening.
Psychological Causes
Psychological conditions causing insomnia include depression, anxiety disorder, panic disorder, mania, and
acute psychosis. People with depression tend to have
early morning awakening; whereas those with anxiety
disorder have trouble falling asleep (see Chapter 4).
Could this be related to sleep hygiene?
Key Questions
l
What is your bedtime routine?
l
What else do you do in your bedroom?
l
Do you consume alcohol, nicotine, or caffeine before
bedtime?
l
Do you exercise before bedtime?
l
How do you put your child to sleep?
l
Where does your child sleep?
Bedtime Routine
Sleep hygiene is related to health practices and environmental inuences on sleep. It is important to consistently go to bed at the same time and wake up at the
same time.
Environment
Using the bedroom for other activities, such as work or
watching television, can produce an environment that
disrupts sleep. Lights and a television produce awakening cues. Routinely using the bedroom for other activities may also condition the patient to an arousal state
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373
while in the bedroom. Noise may affect sleep by leading to increasing amounts of wakefulness, increase in
light sleep, and decrease in REM sleep, causing daytime sleepiness. Room temperatures above or below
normal may disrupt the ability to stay asleep.
Consumption of Stimulants
Caffeine, diet pills (with ephedrine), and nicotine are
stimulants that can cause sleep disruption. Although
the consumption of alcohol before bedtime promotes
sleep onset, alcohol tends to shorten total sleep time
and exacerbate other conditions, such as GERD and
sleep apnea. Alcohol withdrawal in a heavy drinker
may be associated with restlessness and sleep disturbance that can continue for a prolonged period after
alcohol cessation.
Exercise
Vigorous exercise is a stimulant; it should be avoided
for 1 to 2 hours before bedtime.
Child’s Routine
A child who is put to bed while still awake and learns
to fall asleep using self-comforting measures is often
able return to sleep when he or she rouses in the middle
of the night, as do most children and adults. Toddlers
are fearful of separation, and routines need to be established before bedtime. A routine gives the toddler a
sense of predictability and security; having a nightly
routine is helpful.
their parents; however some infants who sleep with
parents have sleep problems. As parents arise or move
from the bed, the infant awakens because of the lighter
sleep state.
Could this be related to lifestyle?
Key Questions
l
Are you a shift worker?
l
Do you sleep in the same bed each night?
l
Do you travel frequently?
Shift Work
Shift work, particularly periodic shift work, can cause
sleep disruption. It may interrupt the usual circadian
rhythm or alter usual sleeping patterns and habits.
Sleep Environment
Sleeping in unfamiliar surroundings affects the quality
of sleep and increases sleep latency. It is associated
with more wakefulness, an increased amount of light
sleep, and a shorter REM sleep stage.
Travel
Jet lag is a common cause of sleep disruption. It may
interrupt the usual circadian rhythm or alter usual
sleeping patterns and habits. Even 1 to 2 hours of time
zone change can disrupt the usual sleep/wake pattern.
Could this be related to age?
Infant Sleeping Environment
The sleep environment should be quiet and dark, and
the room temperature should be comfortable. Infants in
waterbeds, on very soft bedding, on couches with pillows, or in any situation in which their heads may slip
between the mattress and a wall or bedpost are at risk
of suffocation. In many cultures, infants sleep with
EVIDENCE-BASED PRACTICE
Eleven case-control studies were included in this meta-analysis.
Data from a total of 2464 cases and 6495 control subjects
were included, with bed sharing in 710 cases (28.8%) and
863 control subjects (13.3%). All studies found an increased
risk for sudden infant death syndrome (SIDS) with bed shar-
ing. The summary odds ratio (OR) for bed sharing was 2.89.
Four studies reported the risk of SIDS and bed sharing with
smoking mothers. In this subgroup analysis, the risk of SIDS
Data from Vennemann MM, Hense HW, Bajanowski T, et al: Bed sharing and the risk of sudden infant death syndrome: Can we resolve the debate?
J Pediatr 160:44, 2012.
Key Questions
l
How old is the patient (e.g., child, adolescent, older
adult)?
l
At what age did the problem begin?
l
Does the child have problems going to bed?
l
Does the child refuse to go to sleep?
l
Does the child wake up screaming at night?
Is Bed Sharing With Infants Safe?
with maternal smoking and bed sharing was almost six times
that of the risk with nonsmoking mothers. In addition, in
three studies reporting the infant’s age, the risk was 10 times
higher in infants less than 12 weeks old; the risk for infa nts
more than 12 weeks old was not elevated. The authors
concluded t hat bed shari ng strongly increases the risk of
SIDS. This risk is greatest when parents smoke and when
infants are less than 12 weeks of age.
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Chapter 31 • Sleep Problems
Age: Child
Newborns wake every 20 minutes to 4 hours during a
24-hour period, reecting their sleep/wake cycle. This
cycle changes between 3 and 6 months with the establishment of a diurnal sleep/wake rhythm. During this
time, an initial “settling” period that typically takes 10
to 20 minutes begins to occur. Daytime sleep decreases
over the next 3 years and consolidates at night. At age
4, most children no longer nap. School-age children
sleep approximately 8 hours a night.
Problems Going to Sleep, Sleep Refusal
Toddlers have a strong attachment to their caregiver,
and separation from this person at bedtime causes distress and sleep problems. Older toddlers who are in the
preoperational stage are developing a sense of autonomy and use going to bed as an issue of control and/or
a general pattern of oppositional behavior. Examination of the child’s naptime is important. In the schoolage child and adolescent, problems going to sleep may
be caused by anxiety, negative conditioning, delayed
sleep phase (often due to caffeine), or a bedtime that is
too early. Vigorous activity before bedtime may delay
sleep onset.
Waking Up Screaming at Night
Night terrors are nocturnal episodes in which the child
sits straight up in bed, screams, and is inconsolable for
up to 30 minutes before relaxing and falling back to
sleep. This occurs within the rst few hours of sleep.
The child is not readily awakened, although he or she
may seem to be awake, and has no recollection of the
event the next day.
Nightmares are bad dreams that awaken the dreamer.
They occur later at night than night terrors. Unlike
night terrors, the dream is remembered and the child is
awake and may be consoled by the caregiver.
Age: Adolescent
Adolescents require an increased amount of sleep;
about 9.5 hours per night. Many adolescents do not get
this amount, leaving them with a concomitant sleep
debt. To recover from the debt, the adolescent usually
sleeps later on weekends.
Age: Menopausal Women
Menopause-related changes may contribute to or cause
sleep disturbance. Hot ashes promote arousal from
sleep. Menopause is associated with reduced total sleep
time, prolonged time to initiate sleep, and reduced
REM sleep.
Age: Older Adult
Total sleep time generally remains the same or is
slightly decreased (6.5 to 7 hours/night). However,
older adults may take longer to initiate sleep, spend
more time in the lighter stages of sleep, and experience
increased fragmentation of the entire sleep cycle. Older
adults have more nighttime arousals and awakenings
and may feel sleep deprived even if the total sleep time
remains the same.
If the onset of sleep is not correspondingly earlier,
excessive daytime sleepiness may result. Daytime napping may compound the problem by reducing the drive
for sleep at the usual bedtime hour.
Could this be conditioned insomnia?
Key Questions
l
Are you able to fall asleep easily in places other than
the bedroom?
l
If a child: What does the child do when he or she
awakens at night?
l
If a child: What actions do you take to get the child
back to sleep?
Sleep Location
Most cases of insomnia develop initially in response to
a psychosocial stressor. As sleeplessness persists, the
patient begins to associate the bed with wakefulness
and heightened arousal rather than sleep. The patient
may fall asleep easily outside the bedroom (e.g., while
watching television or reading in another room) but
feels wide awake in bed.
Child’s Need for Comfort or Food
Infants who are soothed and cuddled and placed in bed
when they are asleep do not learn how to settle themselves; when these infants are aroused at night, they
require the same routine to fall back asleep. Children
who do not have self-comforting behaviors will be unable to fall asleep on their own. They awaken, cry, and
want to be held or rocked before they can go back to
sleep. An infant older than 6 months who continues to
wake during the night is considered a trained night
crier.
Children who need to be fed after they are awakened
at night are trained night feeders. The child does not
need the additional nutrition but becomes conditioned
to a feeding to go back to sleep. Caregivers often bottlefeed or breastfeed the child until the child falls back
to sleep. The intake of nighttime feeding after 7 or
8 months of age may prevent the development of a
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more mature circadian rhythm. This rhythm is a
digestive-endocrine-sleep/wake cycle that adjusts to a
day/night cycle, resulting in a consolidation of sleep.
Could this be somnambulism?
Key Question
l
Do you (or the child) sleepwalk?
Sleepwalking usually occurs only once a night and
lasts about 15 minutes. The person gets out of bed and
moves about slowly and in an automatic manner with
a blank facial expression. The person may mumble.
After a great deal of effort, the person can be awakened
and will have little or no memory of the episode.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Obtain Growth Parameters and/or Body Mass
Index
Children with OSA may present with failure to thrive.
In adults, obese middle-age men are most often
affected by sleep apnea.
Inspect the Ears
Otitis media and serous otitis may cause wakefulness
in infants and children, especially when they are in the
supine position, because of the pressure of uid accumulation in the middle ear.
Inspect the Nose
Obstruction of the nose by secretions may cause sleep apnea in infants younger than 6 weeks. In children older than
6 weeks or in adults, nasal obstruction may cause OSA.
Inspect the Mouth, Throat, and Nose
Look for a narrow pharyngeal space, a long or edematous uvula, and enlarged tonsils and adenoids. Enlarged tonsils may cause obstruction while the person
is sleeping. In adults, increased neck circumference
(.17 inches in men, .16 inches in women), lateral
peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated/enlarged uvula, high arched/narrow
hard palate, or nasal abnormalities (polyps, deviation,
turbinate hypertrophy) may be found with OSA.
Auscultate the Lungs and Heart
Nighttime wheezing in patients with asthma often
causes sleep disturbances. Congestive heart failure is a
risk factor for sleep apnea.
Palpate the Abdomen
GERD may elicit upper abdominal pain on palpation.
LABORATORY AND DIAGNOSTIC STUDIES
Sleep Diary
A sleep diary should be kept for 1 to 2 weeks. Have
the patient record bedtime, total sleep time, time until
sleep onset, number of awakenings, use of sleep
medications, time out of bed in the morning, rating of
quality of sleep, daytime symptoms, daytime naps,
number and time of alcoholic drinks, and life stresses.
Sleep Studies
Objective assessment of sleep uses polysomnography
(PSG) to assess sleep apnea, specic sleep stage abnor-
malities, nocturnal myoclonus, and unusual nocturnal
behaviors. It is not recommended for routine evaluation
of chronic insomnia. PSG includes an electroencephalo-
gram, electrooculogram, electromyelogram, electrocar-
diogram, measures of oxygen saturation, carbon dioxide
values, nasal and oral airow, thoracic and abdominal
respiratory movements, and leg muscle activity. The
PSG is taken during sleep, usually for the entire night.
A multiple sleep latency test is a series of four or ve
nap opportunities, each separated by a 2-hour interval.
The 15- to 20-minute naps are used to assess sleep
disorders such as OSA and narcolepsy.
Home Sleep Studies
Home medical devices to assess for OSA are available.
A home testing device should be validated against
an in-laboratory PSG to ensure that it functions at an
adequate level.
Actigraphy
Actigraphy is a technique to record activity during
waking and sleeping without application of any elec-
trodes. An actigraph is worn on the wrist and is about
the size of a watch. It records movement and nonmove-
ment data plotted against time for 1 or 2 weeks. The
patient wears the device continuously during sleep and
daily routine activities. Actigraphy is suitable for
extended examination of the sleep/wake cycle.
Ferritin Level
Serum iron stores (measured by serum ferritin) have
been shown to correlate inversely with restless legs
syndrome. Iron is a cofactor in tyrosine hydroxylase,
the rate-limiting enzymatic step in the conversion of
tyrosine to dopamine.
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Chapter 31 • Sleep Problems
DIFFERENTIAL DIAGNOSIS
Restless Legs Syndrome
Restless legs syndrome includes the sensation of crawling, pulling, and tingling with an irresistible urge to
move the legs. Symptoms increase in the evening, especially when the person is lying down and remaining
still. The symptoms occur before sleep, causing a delay
in sleep onset. Patients often have coexisting periodic
limb movements in sleep. Restless legs syndrome may
also be associated with iron deciency, Parkinson disease, kidney failure, diabetes, peripheral neuropathy,
and pregnancy.
Periodic Leg Movement
Periodic leg movements during sleep are common in
people older than 65 years. Bilateral repeated, rhythmic jerking or twitching movements, primarily in the
legs, characterize periodic limb movement disorder.
Less frequent movement can occur in the arms. The
movements occur every 20 to 90 seconds and can
cause brief arousal that disrupts sleep and decreases
the amount of time in the deep stages of sleep. The
patient may not report waking up but reports that sleep
was not refreshing. The condition commonly coexists
with restless legs syndrome.
Obstructive Sleep Apnea
Clinically, OSA is dened by the occurrence of daytime
sleepiness, loud snoring, witnessed breathing interruptions, or awakenings due to gasping or choking, in the
presence of at least ve obstructive respiratory events
(apneas, hypopneas, or respiratory effort-related arousals) per hour of sleep. OSA hypopnea syndrome is
characterized by daytime somnolence, snoring, difcultto-control hypertension, refractory arrhythmias, angina,
and heart failure.
During sleep, the normal tone of the airway muscles
is relaxation, especially during REM sleep cycles.
However, the diaphragm during this time is active. The
activity of the diaphragm unchecked by the airway
muscles leads to collapse of the upper airway. Associated with this is any anatomic barrier, such as enlarged
adenoids, with resulting obstruction. The signs, symptoms, and consequences of OSA occur as a result of
repetitive collapse of the upper airway, sleep fragmentation, hypoxemia, hypercapnia, marked swings in
intrathoracic pressure, and increased sympathetic
activity.
Risk factors for sleep apnea include obesity, congestive heart failure, atrial brillation, treatment of
refractory hypertension, type 2 diabetes, stroke, nocturnal dysrhythmias, and pulmonary hypertension.
Physical ndings that may suggest the presence
of OSA include increased neck circumference (.17
inches in men, .16 inches in women), body mass
index .30 kg/m2, lateral peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated/enlarged
uvula, high arched/narrow hard palate, and nasal abnormalities (polyps, deviation, turbinate hypertrophy).
In children, OSA is generally the result of enlarged
tonsils and adenoids after age 6 weeks. Children ages
4 to 6 years are most prone to this condition. Most
children presenting with OSA have failure to thrive
and may also exhibit nocturnal enuresis, hyperactivity,
learning problems, and morning headaches.
The patient may report insomnia but more commonly notes excessive daytime sleepiness. Hundreds
of apneic episodes occur during the night. The frequent
interruptions coupled with repeated drops in blood
oxygen saturation may cause a marked decline in
daytime alertness and performance. The patient should
be evaluated in a sleep laboratory (see the EvidenceBased Practice box).
Narcolepsy
Narcolepsy is a disorder of excessive daytime sleepiness. It is characterized by sudden, irresistible attacks
of daytime sleepiness that last 10 to 30 minutes. Most
adults with narcolepsy also experience cataplexy, a
EVIDENCE-BASED PRACTICE
In this review of the evidence the authors concluded that
questionnaires, physical examination, and clinical prediction
rules estimate the pretest probability of obstructive sleep
apnea (OSA) hypopnea syndrome, but they are not specific
enough to make the diagnosis. The Epworth Sleepiness Scale
is a reliable measure of daytime sleepiness. Physical examination offers clues: Decreased visibility of the posterior
Data from Jacobs CK, Coffey J: Clinical inquiries. Sleep apnea in adults: How accurate is clinical prediction? J Fam Pract 58:327, 2009.
Diagnosing Obstructive Sleep Apnea
pharynx when the patient opens his mouth and sticks out his
tongue, truncal obesity, and a waist-to-hip ratio .1 in men
and .0.85 in women make the occurrence of OSA more
likely, but they are not sufficient to make a diagnosis. The
bottom line is that in patients with suspected OSA, additional
evaluation is required for diagnosis.
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sudden loss of muscle tone in response to sudden emotional stimuli. Although the episodes are typically
brief, the person is at risk for falls or other accidents
because he or she cannot move or speak. Cataplexy is
not commonly seen in children. People with narcolepsy usually experience sleep paralysis once or twice
a week at the time of sleep onset. There is a period of
mental alertness, but the person is paralyzed except for
respiratory and eye musculature. Hypnagogic (brief,
vivid, dreamlike) hallucinations typically occur at
sleep onset. Involuntary daytime sleep attacks may
begin in adolescence or young adulthood, and people
may have symptoms for years before the disorder is
diagnosed. Not all people with narcolepsy experience
all symptoms. Narcolepsy is uncommon in children.
Delayed Sleep Phase Syndrome
This is an extreme shift in sleep/wake schedule seen in
adolescents. The adolescent goes to bed but does not
fall asleep for many hours and is then awakened for
school, having had only a few hours of sleep. On the
weekend, the adolescent, when allowed to sleep, will
sleep at least 8 hours.
Secondary to a Health Condition or Medications
(Comorbid Insomnia)
GERD, chronic obstructive pulmonary disease, peptic
ulcer disease, and congestive heart failure are associated with paroxysmal nocturnal dyspnea. Sleep disturbance is often interpreted by the patient as insomnia.
Prostatic hypertrophy may cause nocturia and thus
disturb sleep.
Many medications can have stimulating effects and
cause sleep disruption. Common offenders include
antidepressants (activating selective serotonin reuptake
inhibitors), decongestants, bronchodilators, b-blockers,
thyroid preparations, phenytoin, methyldopa, and
corticosteroids.
Pain may interfere with sleep onset or contribute
to early awakenings. Patients with chronic pain may
have mood and cognitive disturbances that contribute
to insomnia and early morning awakening.
Psychological conditions that cause insomnia include
depression, anxiety disorder, panic disorder, mania, and
acute psychosis.
Poor Sleep Hygiene
Sleep hygiene is related to health practices and environmental inuences on sleep. Bedtime routines, environmental distracters, and stimulants affect the ability to
fall asleep. Lights and televisions produce awakening
cues. Routinely using the bedroom for other activities
may also condition the patient to an arousal state while
in the bedroom. Noise may reduce the amount of REM
sleep and lead to daytime sleepiness.
Caffeine, diet pills, and nicotine are stimulants
that can cause sleep disruption. Alcohol consumed
before bedtime tends to shorten total sleep time and
exacerbate other conditions, such as GERD and sleep
apnea.
A child who is put to bed still awake and learns to
fall asleep using self-comforting measures is often able
to return to sleep when he or she rouses in the middle
of the night, as do most children and adults. Toddlers
are fearful of separation, and bedtime routines need to
be established.
Infants who sleep with their parents may have sleep
problems. As parents arise or move from the bed, the
infant awakens because of the lighter sleep state.
The American Academy of Pediatrics recommends
that all infants sleep on their backs for the rst
6 months of life to decrease the risk of sudden infant
death syndrome. The sleep environment should be
quiet and dark and the room temperature should be
comfortable.
Lifestyle
Shift work, particularly periodic shift work, has been
reported to cause sleep disruption. It may interrupt the
usual circadian rhythm or alter usual sleeping patterns
and habits.
Sleeping in unfamiliar surroundings affects the
quality of sleep and increases sleep latency. It is associated with more wakefulness, an increased amount of
light sleep, and a shorter REM sleep stage.
Jet lag is a common cause of sleep disruption. It
may interrupt the usual circadian rhythm or alter usual
sleeping patterns and habits. Even 1 to 2 hours of time
zone change can disrupt the usual sleep/wake pattern.
Age-Related Sleep Disorders
Night Awakening
Newborns wake every 20 minutes to 4 hours during a
24-hour period, reecting their sleep/wake cycle. This
cycle changes between 3 and 6 months of age when a
diurnal sleep/wake rhythm is established. During this
time an initial “settling” period, which typically takes
10 to 20 minutes, begins to occur. The infant drifts
from stage 1 NREM sleep to stage 3 or 4. The infant
may return to stage 1 and cycle again. After one or two
cycles of NREM sleep, the infant enters REM sleep at
about 60 to 90 minutes. The initial one third of the
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Chapter 31 • Sleep Problems
night is mostly deep sleep (NREM stages 3 and 4). The
last half of the night is predominantly stage 2 NREM
and REM. Daytime sleep decreases over the next
3 years and consolidates at night. At age 4, most children no longer nap. School-age children sleep approximately 8 hours a night. Stage 4 sleep decreases to 75 to
80 minutes. This decline is associated with an increase
in stage 2 sleep. The onset of REM sleep decreases
from about 140 minutes in the 6- to 7-year-old to
124 minutes in the 10- to 11-year-old child.
Sleep Refusal
Toddlers are emerging from a sensory-motor period to
a preoperational period. They have a strong attachment
to their caregiver, and separation from this person at
bedtime causes distress and sleep problems. Further,
older toddlers who are in the preoperational stage are
developing a sense of autonomy and use going to bed
as an issue of control and/or a general pattern of oppositional behavior. Examination of the child’s naptime is important. In the school-age child and adolescent, anxiety, negative conditioning, delayed sleep
phase (often caused by caffeine), or a bedtime that is
too early may be the cause. Also, vigorous activity
before bedtime may delay sleep onset.
Night Terrors
Night terrors are nocturnal episodes in which the child
sits straight up in bed, screams, and is inconsolable for
up to 30 minutes before relaxing and falling back to
sleep. It occurs within the rst few hours of sleep.
Children at around the age of 3 years have NREM
occurring more in the rst part of the night; this may
account for the night terror. The child is not readily
awakened, although he or she seems to be awake, and
has no recollection of the event the next day. Night
terrors occur between the ages of 3 and 10 years.
Nightmares
Nightmares are bad dreams that awaken the dreamer.
They occur later at night than night terrors and occur
during REM sleep, which in children is near the end of
the sleep cycle. Unlike night terrors, the dream is remembered and the child is awake and may be consoled
by the caregiver. Nightmares occur at any age.
Adolescent Patterns
Adolescents have an increase in slow-wave sleep with
an increase in the amount of sleep required. However,
most adolescents are in a sleep debt because they tend
to leave less time for sleep. Repeated changes in the
sleep cycle (short sleep periods followed by occasional
long sleep periods) may disrupt the circadian rhythm,
causing a delayed sleep phase syndrome.
Menopausal Women
Menopause-related changes may contribute to or cause
sleep disturbance. Evidence that sleep difculties are related to the hormonal changes of menopause is mixed.
Hot ashes and night sweats promote arousal from sleep.
Older Adult Patterns
Sleep in older adults is characterized by more nighttime
awakenings and reduced or nonexistent deep states of
NREM sleep. However, REM sleep tends to be preserved. That older adults sleep less than younger adults
may reect their ability to sleep, not their need to sleep.
Although a mild deterioration in sleep quality may be
normal in the aging process, signicantly disrupted
nighttime sleep or excessive daytime sleepiness is not
considered part of normal aging. Older people have a
circadian rhythm disruption and tend to awaken earlier
in the morning. If the onset of sleep is not correspondingly earlier, excessive daytime sleepiness may result.
Daytime napping may reduce the drive for sleep at the
usual bedtime hour. In the night owl pattern, bedtime is
delayed until early morning hours, and the condition
may progress to day-night reversal, where sleep does not
begin until dawn and continues until midday.
Conditioned Insomnia
Trained Night Crier
Children who do not have self-comforting behaviors will
be unable to fall asleep on their own. They awaken, cry,
and want to be held or rocked before they can go back to
sleep. An infant older than 6 months who continues to
wake during the night is considered a trained night crier.
Trained Night Feeder
A child who needs to be fed when awakened at night is
considered a trained night feeder. The child does not
need the additional nutrition but becomes conditioned
to requiring a feeding to go to sleep. Caregivers often
bottle-feed or breastfeed the child until the child falls
back to sleep. Nighttime feeding in an infant older
than 7 or 8 months may prevent development of a more
mature circadian rhythm. This rhythm is a digestiveendocrine-sleep/wake cycle that adjusts to a day/night
cycle, resulting in consolidation of sleep. Continued
nocturnal feeding keeps the infant in a recurrent
interruption pattern of frequent night awakening and
prevents consolidation of sleep.
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