Algorithm for Differential Diagnosis of Sleep Disorders in Children

Fig. 7.1

Bedtime. Complaint: problems going to bed/problems falling to sleep

Parent or caretaker reports the child has one or more of the following symptoms:

Difficulty falling to sleep.
Difficulty staying asleep.
Early morning wakings, earlier than desired.
Bedtime struggles at an age-appropriate time of the night.
Parental/caretaker intervention required for easy transitioning to sleep.
Daytime symptoms are present^*.
There is adequate and appropriate environment and opportunity to sleep.
Symptoms are present for more than 3 nights per week.

Acute Insomnia Disorder ⇦ ⇨ Chronic Insomnia Disorder

Symptoms have been present for less than 3 weeks Symptoms have been present for more than 3 weeks.

^*Symptoms might include one or more of the following: complaint of daytime fatigue; attention, concentration, or memory problems; school learning difficulties; socialization problems; mood difficulties; behavior problems; hyperactivity; impulsiveness; motor restlessness; fidgetiness; unusual aggression; difficulty with motivation; accidents; and parents are dissatisfied with the youngster’s sleep.

Other Sleep Disorders (see Table 7.1)

Table 7.1

Other pediatric sleep disorders (May present with problem sleeplessness, problem sleepiness, or both)

Symptoms	Sleeps well somewhere and/or under certain circumstances	Daytime dysfunction	Excessive noise, light, temperature	Medications (even over the counter)	Other medical/psychological problems
Diagnoses
Conditioned sleeplessness	++^a	+/−	−	−	−
Environmental factors	+	+/−	++	−	−
Psychological problems	+/−	+/−	+/−	+/−	++
Inappropriate caretaker’s expectations	++^b	+/−	−	−	−
Inadequate sleep hygiene	−	++^c	+	+/−	+/−
Medications	−	+/−	−	++	+
Adjustment sleep disorder	−	+	−	−	+^d
Medical disorders	−	+/−	−	++	+^e

++ = Cardinal symptom(s), + = Typically present, +/− = May or may not be initially reported as present, − = Typically absent

^aThe child can sleep well when transitional objects and/or situations are present; they cannot transition well into sleep or fall back to sleep until these transitional objects and/or conditions are retrieved at night

^bParent’s/caretaker’s expectations of the child’s sleep habits are significant inconsistent with normal sleep/wake habits and patterns for the child’s chronological age

^cNighttime schedules and patterns are irregular and chaotic. Daytime schedules and patterns are also chaotic

^dThere may be situational stressors identified, including but not limited to holidays, travel, social stressors, and school pressures

^eSigns and/or symptoms of other medical disorders may be present

Although Environmental Sleep Disorders was listed in ICSD-2 (REF), it is unclear whether this is a specific sleep-related disorder or part of the home environment, such that when the environment is different, sleep complaints resolve. This, however, is not the case for many children with problem on sleeplessness, where a physiological conditioning has created a biological problem that may be developmentally related.

Excessive Daytime Sleepiness (see Fig. 7.2)

Fig. 7.2

Excessive daytime sleepiness

Inquiry Design:

1.

Does the child have difficulty waking in the morning?

(Must differentiate whether the child “cannot wake up” or “does not want to wake up”.)
2.

Does the child experience unintentional sleep episodes or sleep attacks?
3.

If the child is over 6 years of age, does he/she habitually nap?
4.

Does the child fall, feel weak, become wobbly, or develop an unusual facial expression when laughing, giggling, or emotional?
5.

Are there nightmares (particularly at wake-sleep transition)?
6.

Does the child act out dreams?
7.

Does bedtime and morning wake time significantly differ between school days and weekends?
8.

Are there problems paying attention? Frequent daydreaming?
9.

Are there school performance problems?
10.

Does the child wake at night? How long? How many times?
11.

Does the child walk or scream during sleep? Is there amnesia for the events?
12.

What is the typical length of total sleep each 24 h?
13.

Does the child have any acute or chronic medical illnesses or on any medication?
14.

Are symptoms recurrent?
15.

Does the child snore, pause, snort, gasp, choke, or cough during sleep?

Note: There is considerable overlap of symptoms and findings. Similar symptoms and comorbidities are common. See specific sections for differential diagnosis.

Excessive Daytime Sleepiness (Hypersomnias) (See Table 7.2)

Table 7.2

Excessive daytime sleepiness (hypersomnias)

Symptoms	Unintentional sleep episodes and/or sleep attacks	Habitual napping	Cataplexy	Hypnagogic hallucinations	Sleep paralysis	CSF hypocretin <110 pg/mL	Abnormal MSLT SOL <8 min and 2+ SOREMPS	Increased total sleep time	Recurrent symptoms	Other symptoms
Diagnosis
Narcolepsy type 1	++	+	++	+/−	+/−	+	+^a	+/−	−	^b
Narcolepsy type 2	++	+	−	+/−	+/−	−	+^c	+/−	−	^d
Narcolepsy due to medical disorder	+	+	+/−	+/−	+/−	−	+	+/−	−	^e
Hypersomnia due to medical disorder	+	+	−	−	−	−	+^f	+	−	^g
Idiopathic hypersomnia	+	+	−	−	−	−	+^h	++	−	ⁱ
Kleine-Levin syndrome (recurrent hypersomnia)	+	+	−	−	−	−	+/−^j	+	++	^k

++ = Cardinal symptom(s), + = Typically present, +/− = May or may not be initially reported as present, − = Typically absent

^aDuring childhood, if narcolepsy Type 1 is strongly considered and MSLT findings are not conclusive, repeat testing in 6 months to 1 year is recommended. MSLT findings that might suggest (but are not diagnostic of) the presence of excessive daytime sleepiness include shorter than expected mean sleep onset latency for age, consolidated sleep on three or more naps on five nap attempts, and frequent micro-sleep episodes on nap attempts. Symptoms that are not diagnostic of but may suggest excessive sleepiness include but are not limited to hyperactivity, attention span difficulties, motor restlessness, learning difficulties, impulsivity, and behavior problems. These symptoms might alternate with sleepiness. Symptoms of cataplexy might be mistaken for syncope; hypnagogic hallucinations might be mistaken for nocturnal fears and/or nightmares; sleep paralysis might be mistaken for difficulty waking in the morning (resisting waking up rather than inability to move upon waking)

^bREM sleep behavior disorder/REM sleep motor abnormalities might be present; nocturnal sleep, although normal in length, is considerably fragmented

^cDuring childhood, if narcolepsy Type 1 is strongly considered and MSLT findings are not conclusive, repeat testing in 6 months to 1 year is recommended. MSLT findings that might suggest (but are not diagnostic of) the presence of excessive daytime sleepiness include shorter than expected mean sleep onset latency for age, consolidated sleep on three or more naps on five nap attempts, and frequent micro-sleep episodes on nap attempts. Symptoms that are not diagnostic of but may suggest excessive sleepiness include but are not limited to hyperactivity, attention span difficulties, motor restlessness, learning difficulties, impulsivity, and behavior problems. These symptoms might alternate with sleepiness

^dCataplexy is notably absent

^ePara-neoplastic syndromes; Prader-Willi syndrome; myotonic dystrophy; head trauma

^fMean sleep latency may be short (≤8 min), but ≤1 SOREMP is present

^gSymptoms of associated medical disorder may be notable on history and/or physical examination

^hMean sleep latency may be short (≤8 min), but ≤1 SOREMP is present

ⁱTotal sleep time is significantly greater than expected for age for each 24 h period

^jMSLT may be significantly abnormal during episodes and normal during inter-episode periods

^kAssociated recurrent features might include hyperphagia and behavioral abnormalities (e.g., hypersexuality/sexually acting-out behavior)

The parent(s) and/or caretaker(s) report the child has one or more of the following symptoms:

Falling asleep at unusual times
- The child may fall to sleep while eating meals, talking on the telephone, playing a game, at a party, or on the playground.
- Note: Many children will fall to sleep as passengers in a car or watching television. Falling to sleep at unusual times means the child is consolidating sleep at a time that is not expected for this youngster’s chronological and maturational age.
The child feels sleepy during the day.
Teachers or other observers report the child looks sleepy during the day.
Attention problems/concentration problems.
Hyperactivity/motor restlessness/fidgetiness.
Impulsiveness.
Learning difficulties in school.
Difficulty waking in the morning.

Awakening (See Fig. 7.3)

Fig. 7.3

Awakening

Inquiry Design:

1.

Does the child wake at night? How many times? At what time?
2.

How long does the child remain awake?
3.

Does the youngster seem fully awake or is the child confused/disoriented?
4.

Is there amnesia for the event?
5.

Does the child report a dream?
6.

Is there trouble falling back to sleep after the waking?
7.

What is the sleeping environment like?
8.

Are there lights on in the bedroom?
9.

Does the child have “screen time” before bed?
10.

Are there any acute or chronic illnesses?

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