Excessive sleepiness may be difficult to establish in preschool-age children as physiological daytime napping may still occur at this age. Usually, however, most 3–4-year-olds take one nap per day that lasts about 1–2 h. Sleepiness in excess of this is generally abnormal. Sometimes daytime hyperactivity can be a manifestation of sleepiness at this age as sleepiness can lead to loss of affect control that is mediated by the ventrolateral prefrontal cortex. In children of school-going age, mood swings, inattentiveness, and executive dysfunction may occur on a similar basis. There may be a decline in school grades as a consequence of impaired attention span due to hypersomnolence. In children of school-going age, there may be reappearance of the tendency to take daytime naps. The child may be subjected to bullying by peers. Patients with depression may have a flat affect or admit to feelings of sadness or anhedonia. Obesity and precocious puberty may accompany daytime sleepiness of narcolepsy–cataplexy [7]. Cataplexy, a condition characterized by abrupt muscle weakness in response to emotional stimuli like laughter or surprise, is seen in patients with narcolepsy–cataplexy (for details, please refer to the section dealing with narcolepsy). Sleepiness can be documented using questionnaires. Some of the questionnaires that are available to the practitioner include the Pediatric Daytime Sleepiness Scale, the modified Epworth Sleepiness Scale, the Sleep Disturbance Scale for Children, the Cleveland Adolescent Sleepiness Scale, the Pediatric Sleep Questionnaire, and the Children’s Sleep Wake Scale [8]. The clinician is advised to utilize the questionnaire that best meets the demands of the individual practice. The author utilizes the Pediatric Daytime Sleepiness Scale because of its ease of use and numeric representation of the results.

The sleep history should also inquire into the bed-onset time and sleep-onset time, whether there is significant departure in the sleep time from school nights to non-school nights, feelings of restlessness in the legs prior to sleep onset, hypnagogic hallucinations and sleep paralysis, habitual snoring, periods of observed apnea, restless sleep, and the morning awakening time and whether the patient feels tired or refreshed upon awakening. Patients with delayed sleep-phase syndrome generally indicate an inability to fall asleep prior to midnight or early morning and find it hard to awaken prior to the mid-morning hours.

Elements of the general medical history that are relevant include changes in weight and appetite over the preceding year, thyroid dysfunction, and use of medications that might impact weight such as corticosteroids. The history should explore the possibility of alcohol or substance abuse. If there have been previous sleep evaluations, their date and result should be documented. Medications previously used for treating sleepiness and response to them should be recorded.

Wrist actigraphy and sleep diary maintained for 2–3 weeks are useful in the case of suspected circadian rhythm sleep disorders like delayed sleep-phase syndrome. The wrist actigraph in delayed sleep-phase syndrome will demonstrate delayed sleep onset, relative absence of sleep fragmentation, but persistence of sleep into the mid-morning hours. A urine drug screen should be used in adolescents whenever there is a suspicion of drug-seeking behavior. Nocturnal polysomnography is indicated in patients with hypersomnia suspected to be related to sleep disordered breathing, narcolepsy, or Idiopathic hypersomnia or sleepiness related to conditions like head injury or encephalitis. Polysomnographic findings are discussed under specific sleep disorders. The multiple sleep latency test (MSLT) is generally conducted on the morning after a nocturnal polysomnogram. The test helps to quantify the degree of daytime sleepiness and the nature of the transitions from wakefulness to sleep, i.e., whether into REM or NREM sleep. Normal values for the MSLT in children and adolescents vary with age and Tanner stage of sexual development (Table 7.2).

This entity can occur along with other sleep disorders or may be the sole clinical disturbance. It is usually encountered in adolescents. There may be relatively late bed-onset time on school nights or non-school nights, with consequent late onset of sleep. If the morning wake time, especially for school days remains unaltered around 6:00 a.m., there is a likelihood of daytime sleepiness simply due to insufficient sleep at night. The history may reveal other factors that predispose to late sleep onset such as excessive consumption of caffeinated beverages; heavy use of electronic media such as cell phones, computers, and television in the 2–3 h prior to bed time; or exercising late in the evening. A warm bath in the 2–3 h prior to bedtime might also postpone sleep by artificially raising body temperature. The diagnosis can be facilitated by wrist actigraphy for 2–3 weeks and concurrent sleep logs. There may be a discrepancy between the patient’s record of bed-onset time and the actigraphically derived sleep-onset time.

The management consists of a frank discussion with the adolescent patient and his or her parents during which the importance of receiving adequate sleep and the adverse effects of sleep deprivation are discussed. It is sometimes a good idea to build a buffer of 30–45 min of “quiet time” for reflection prior to entering bed in which the use of electronic media is avoided. The importance of avoiding nicotine, alcohol, and excessive caffeine should be also stressed.