Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Pediatr Clin North Am. Author manuscript; available in PMC 2012 June 1.
Published in final edited form as:
PMCID: PMC3100529

Sleep Problems in Children and Adolescents with Common Medical Conditions

Amy S. Lewandowski, PhD, Acting Assistant Professor,a Teresa M. Ward, RN, PhD, Assistant Professor,b and Tonya M. Palermo, PhD, Professorc


Sleep is critically important to children’s health and well-being. Untreated sleep disturbances and sleep disorders pose significant adverse daytime consequences and place children at considerable risk for poor health outcomes. Sleep disturbances occur at a greater frequency in children with acute and chronic medical conditions compared to otherwise healthy peers. Sleep disturbances in medically ill children can be associated with sleep disorders (e.g., sleep disordered breathing, restless leg syndrome), co-morbid with acute and chronic conditions (e.g., asthma, arthritis, cancer), or secondary to underlying disease-related mechanisms (e.g. airway restriction, inflammation) treatment regimens, or hospitalization. Clinical management should include a multidisciplinary approach with particular emphasis on routine, regular sleep assessments and prevention of daytime consequences and promotion of healthy sleep habits and health outcomes.

Keywords: Sleep, pediatric, chronic illness

Sleep is intricately connected to health and well-being. Over the past decade, research has increasingly recognized the importance of sleep and the adverse daytime consequences and health outcomes of untreated sleep disturbances and sleep disorders. Studies have shown associations among sleep problems and key physiologic health parameters including immune system functioning and metabolic/endocrine regulation1. In children, specifically, short duration of nighttime sleep has been associated with increased risk of subsequent overweight or obesity2.

Sleep disturbances are especially prevalent in children with both acute and chronic disease states (e.g., juvenile rheumatoid arthritis, asthma, cancer). Studies have shown that both acute and chronic medical conditions increase the risk of sleep disruptions36, and there is some evidence that sleep problems are more often chronic and persistent in youth with chronic conditions compared to those without chronic conditions7. The association between sleep problems and medical conditions may be related to underlying disease-related mechanisms (e.g. airway restriction, inflammation), treatment regimens (including medications), or hospitalization. Some medical conditions are associated with particular sleep disorders (e.g. sleep disordered breathing and atopic disease, restless legs syndrome and iron deficiency anemia). Regardless of the cause, sleep disturbances typically manifest as poor sleep quality, difficulty falling asleep, disrupted or fragmented sleep with frequent awakenings, and as inadequate amount of sleep. Unfortunately, sleep disturbances are too often undiagnosed and not routinely assessed by clinicians.

Poor sleep and untreated sleep disturbances pose significant adverse daytime consequences including problems with social and emotional functioning, deficits in neurocognitive performance, poor quality of life, school absenteeism, and poor school performance 812. Sleep disturbances are also associated with fatigue and daytime sleepiness1316. The impact of poor sleep in children with chronic medical conditions may be of more concern given the bidirectional relations between sleep and health. Sleep problems may worsen the chronic medical condition, and in turn, disease-related symptoms may contribute to sleep disruptions1719.

In this review, we summarize the data linking sleep disturbances and sleep disorders in children and adolescents with various medical conditions, and discuss the potential underlying mechanisms resulting in sleep problems. We also describe the potential impact of treatment-related medications on sleep. While it is beyond the scope of this review to provide a comprehensive review of sleep in all pediatric medical conditions, illustrative examples from common medical disorders and information on clinical evaluation and management are provided. We also refer the reader to other relevant articles in this issue pertaining to the relationship between obesity and sleep (Hart) and sleep in autism spectrum disorders (Malow) and therefore do not cover these conditions.

Medical conditions associated with sleep problems

Allergic Rhinitis

One of the most common medical problems in children is allergic rhinitis, a chronic inflammatory disease of the upper airway, affecting 10–30% of the population, with the greatest frequency found in children and adolescents20,21. Chronic allergies are associated with sleep problems and a known risk factor for sleep disordered breathing (SDB) including habitual snoring, obstructive sleep apnea and adenoid hypertrophy due to the chronic effects of inflammation22,23. Atopic symptoms can also impact sleep in children such as nocturnal pruiritis associated with chronic eczema24.


Childhood asthma, a condition defined by airway inflammation, is associated with sleep problems including decreased sleep time, less stage 4 sleep, more frequent nighttime arousals, and sleep-disordered breathing2528. Research has shown that asthma symptoms often worsen at night as a result of physiological changes (e.g., airway inflammation and resistance, episodic coughing, wheezing, shortness of breath, mucociliary clearance, and lower lung volume) (see review29). These nighttime exacerbations are related to circadian variations in lung function. Youth with asthma also show increased nocturnal awakenings compared to healthy youth. Asthma severity has been associated with both objective and subjective sleep reports26, and sleep disturbance has been shown to predict more severe asthma symptoms the following day17.


Children and adolescents with cancer commonly report nocturnal sleep disturbances but their etiologies are not well understood. Studies report frequent night awakenings, difficulty falling asleep, and increased wake time during hospitalization30,31 and at home3235. A recent study by Walker and colleagues32 found that adolescents with cancer reported poor sleep quality, with more problems going to bed, falling asleep, maintaining sleep, and reinitiating sleep compared to healthy adolescents. Sleep disturbances for children and adolescents with cancer likely has many causes. Brain tumors or intracranial neoplasms are believed to affect sleep by their impact on brain structures. Brain tumors can impact sleep regulation, particularly if the mass impinges upon brain structures affecting the circadian and homeostatic systems such as the hypothalamic-pituitary axis36. For example, craniopharyngiomas (tumors located in the basal forebrain near sleep regulating structures) have been linked to a host of childhood sleep disturbances, including night awakenings, inability to maintain sleep, and secondary narcolepsy37. Tumors located near the pineal gland can result in irregular melatonin secretion, contributing to sleep-wake disturbances38. CNS-mediated effects may also impact alertness. For example, neoplasms in the hypothalamus, thalamus, and brainstem have been linked to excessive daytime sleepiness as well as SDB39. Cranial radiation has also been linked to daytime sleepiness as well as sleep problems, particularly through injury to the optic nerve or retinohypothalmic track36.

Chronic pain conditions

Pain is common in youth with medical problems, and chronic pain may be a symptom or consequence of the medical problem (e.g., sickle cell, arthritis, or cancer) or pain can be the problem itself (e.g., headaches, chronic abdominal pain). Pain can make it difficult for children to settle and stay asleep. Youth with chronic pain report shorter sleep duration3,40, poorer sleep quality41,42, and more night wakings43 compared to healthy youth. Insomnia symptoms are also common; estimates from several studies show that over half of children with different chronic pain conditions (e.g., musculoskeletal pain, abdominal pain) report insomnia44,45. On actigraphy, youth with chronic pain demonstrate lower sleep efficiency compared to healthy youth42. Sleep disturbances are related to children’s pain intensity as well as to their depressive symptoms 46. A recent study of adolescents with mixed chronic pain conditions found that poor nighttime sleep was associated with higher next day pain47.

In terms of specific pain conditions such as headache, frequency and duration of migraine headaches have been associated with sleep disturbances including parasomnias and bedtime resistance48. Furthermore, one study examining associations among sleep and headaches in youth found that tension headaches were associated with bruxism; sleep-disordered breathing was frequent in youth with migraine and non-specific headache; and that children with severe and chronic migraine headaches had disrupted sleep architecture (shortened sleep time, prolonged sleep latency, reduced slow-wave and rapid eye movement sleep49).

Craniofacial abnormalities

Children diagnosed with genetic disorders such as Trisomy 21, Crouzon syndrome, and children with muscular dystrophy and cerebral palsy are predisposed for craniofacial anomalies. Children with craniofacial structural over or under development are at risk for and often diagnosed with SDB22. Retrognathia, macroglossia, or mid-facial hypoplasia is commonly seen in children with underlying genetic disorders and/or hypotonia, which impact the airway and sleep. For example, cleft lip/palate is associated with several airway structural anomalies that restrict the pharyngeal airway, increasing the risk for SDB (see review50). In one study, 87% of children with cleft lip/palate had symptoms of sleep-disordered breathing, with 28% demonstrating severe breathing problems during sleep51. Studies have shown that even after undergoing surgical repair, children may continue to experience nighttime sleep disturbances. A recent study by Rustemeyer and colleagues showed that 40% of children who underwent surgery continued to have posterior airway narrowing increasing the risk for SDB52.

Cystic Fibrosis

Sleep problems in children with cystic fibrosis (CF) have also been associated with airway restriction53. Cystic fibrosis is a hereditary disease of the exocrine glands that usually develops during early childhood. The disease affects the pancreas, respiratory system, and sweat glands and is characterized by the production of abnormally viscous mucus resulting in chronic respiratory infections and impaired pancreatic function. Studies have shown frequent sleep complaints, more nocturnal wakings, and alteration in sleep architecture in this population18. Children and adolescents with CF also demonstrate nocturnal hypoxemia, low sleep efficiency, prolonged REM latency, and a reduced percentage of REM sleep on polysomnography53,54. Structural alterations in airways of children with CF can result in obstructive sleep apnea55, although the frequency of sleep apnea in this population is currently unknown54. Recent findings suggest that the relations between sleep and symptoms secondary to cystic fibrosis are bidirectional18. Further longitudinal studies are needed on the impact of disturbed sleep on symptoms.


Children with epilepsy may manifest significant sleepiness as a result of disruptions in sleep architecture, such as longer Stage 1 sleep and latency to REM sleep56. Children with epilepsy have also been reported to have SDB and parasomnias14. The associations between epileptic seizures and sleep are thought to be bidirectional. Patients with epilepsy experience EEG discharges at night which may affect sleep, and sleep deprivation may subsequently influence EEG discharges and seizures (see review19).

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn, acid indigestion, and possible injury to the esophageal lining. During sleep periods, the esophageal mucosa has more contact time with acid, and acid clearance is reduced57. Often GERD is a common culprit of nighttime awakenings in infants. Children with reflux have demonstrated a high number of apneas and hypopneas (transient episode of shallow breathing or abnormally low respiratory rate) at night, particularly during REM sleep, and GERD is considered a risk factor for OSA58.

Rheumatological conditions

Rheumatological conditions including juvenile idiopathic arthritis (JIA) and juvenile fibromyalgia (JF) are associated with significant sleep disruption in children and adolescents. Youth with JIA report poor sleep quality and daytime sleepiness3,12,15,59, with children and their parents endorsing symptoms suggestive of sleep disorders, including insomnia, parasomnias (sleep terrors, sleepwalking), sleep-disordered breathing, and daytime sleepiness59,60. Objective reports of sleep in youth with JIA including polysomnography and multiple sleep latency tests (MSLT) show mild sleep disordered breathing, sleep fragmentation (e.g., sleep stage shifts, wake bouts), and daytime sleepiness12,16,61. For example, Passarelli and colleagues3 found that compared to healthy controls, children with JIA had reduced total sleep time, more transient electroencephalogram (EEG) arousals (brief shifts in the EEG to fast frequency without an awakening), and increased limb movements. Longer mean self-reported nap duration (~ one hour) and shorter mean sleep latencies12,15 in multiple sleep latency tests (MSLTs) have been reported in children with JIA compared to mean sleep latencies from previous studies of healthy children3,62. Pain related to arthritis has been identified as a correlate of sleep disturbances59 and is a potential mechanism.

Disruptions in sleep architectures in youth with juvenile fibromyalgia (JF) are also common63,64. Compared to controls, children with JF have prolonged sleep latency, less total sleep time, decreased sleep efficiency, and more periodic limb movements63, and sleep anomalies are related to the intensity of pain experienced by children. Roizenblatt64 found decreased sleep efficiency, increased arousals, and disturbed electroencephalogram frequency during slow-wave sleep in children with JF. The mechanisms accounting for sleep alterations in JF are unclear, and additional research is warranted.

Sickle Cell Disease (SCD)

The clinical manifestations of SCD include episodes of severe pain (also called vaso-occlusive crises), infections (especially pneumococcal), cerebrovascular accidents, anemic episodes (aplastic crises or sequestration crises), and fragmented sleep. Excessive adenoidal and tonsillar growth occurs in children with SCD secondary to lymphoid tissue hyperplasia or recurrent tonsillitis65. Adenotonsillar hypertrophy is a risk factor for obstructive sleep apnea and vaso-occlusive crisis due to periods of hypoxemia66. Sleep patterns in children with SCD have not been well characterized, although studies report associations among nocturnal hypoxemia, SDB, and sleep disruption secondary to pain46,6769. Compared to healthy children, parents of children with SCD report more symptoms of sleep disordered breathing, nocturnal enuresis, parasomnias, and night wakings70. In children with greater SCD severity, these parents reported more restless sleep in their children compared to children with lower disease severity. A recent study using PSG reported prolonged sleep latency, decreased total sleep time, increased wake time, poor sleep efficiency, increased obstructive events, and periodic limb movements in children with SCD (HbSS, HbSC genotypes)71. In their sample, obstructive sleep apnea was also common. Compared to children with HbSC genotype, those with the HbSS genotype experienced more severe nocturnal oxygen desaturation.

Other Causes and Contributing Factors

Hospitalization and treatment-related factors

The experience of being in the hospital is associated with sleep disruptions for many children with medical conditions31,72,73. For example, 25% of hospitalized children with cancer reported poor sleep such as sleep fragmentation and night wakings72. Sleep disturbances may be due to disruptions in routine, fears and anxiety about separation from parents, loss of privacy, and frequent interruptions by medical staff. Children may also have to alter their sleeping position due to IV placement or location of surgical incisions. Sleep disruptions may also relate to specific treatment regimens. For example, children with chronic kidney disease experience sleep problems and this has been linked to both the pathology of the disease and the dialysis process74. In a sample of pediatric dialysis patients, 86% reported sleep problems, including daytime sleepiness (60%), SDB (46%), and restless leg syndrome (29%)74. Similarly, 49 non-dialysis youth (19 had undergone a renal transplant) also reported sleep problems, particularly restless leg syndrome/periodic limb movement disorder, and 37% of the youth met diagnostic criteria for a sleep disorder75.

Behavioral, emotional and psychological factors

Children with chronic medical conditions are at an increased risk for psychological problems76,77, therefore, it is important to consider the role of behavioral, emotional, and psychological factors that influence sleep. In youth with chronic conditions, behavioral and emotional problems were predictive of difficulties initiating and maintaining sleep6. Importantly, depression and anxiety symptoms have been associated with daytime sleepiness in female adolescents with chronic musculoskeletal pain43. In another study of adolescents with chronic pain, higher levels of depressive symptoms were related to more severe sleep disturbances (e.g. irregular sleep habits, prolonged sleep latency, and difficulties getting up in the morning) even after controlling for adolescents’ pain levels46. Among survivors of childhood cancer, greater symptoms of global distress predicted fatigue and continued sleep problems78. Symptoms of SDB have also been shown to predict behavior problems in children with asthma27. While depression, inattention, and oppositional behaviors were associated with sleep problems in children with epilepsy, the severity of epilepsy did not predict sleep disturbances79. Finally, it is important to consider the potential impact on sleep of psychotropic medications which may be used to treat comorbid psychiatric symptoms in these children.

Medication Effects on Sleep

Both over the counter and prescription medications used to treat chronic medical conditions impact sleep. Therefore it is important for the clinician to understand the effects on sleep of commonly used medications including antihistamines, antidepressants, anticonvulsants, corticosteroids, opioids, and benzodiazepines.


Anti-epileptic drugs (AEDs) are used for seizure control in youth with epilepsy. In addition, anticonvulsants such as gabapentin are commonly used agents for pain control in youth with chronic musculoskeletal pain. Anti-epileptic drugs (AEDs) have mixed effects on sleep, and these effects appear independent of their anticonvulsant actions. AEDs have the side effect of weight changes in children as well. A recent study by Kaleyias and colleagues67 report SDB, primary snoring, and PLMS in a cohort of 40 children with epilepsy. Children with poor control of epilepsy were more obese, had lower sleep efficiency, and higher arousal index in comparison with children with good seizure control or children free of seizures67.


Antidepressant medications may be prescribed to treat co-morbid conditions (e.g., chronic pain, depression, anxiety) in children with medical conditions, and may also be prescribed specifically to treat sleep disturbance, particularly insomnia. Antidepressants have several effects on sleep and daytime wakefulness, most of which has been learned from studies in adults. These studies show prolonged sleep latency, reduced REM latency, decreased slow wave sleep, and sleep fragmentation8082. Studies in adolescents also have found prolonged sleep latency and reduced REM latency8385. Most antidepressants suppress REM and increase latency to REM sleep, and abrupt withdrawal may lead to REM rebound86. Tricyclic antidepressants (TCAs; e.g., imipramine) prolong REM latency, decrease REM sleep, and abrupt withdrawal can result in REM rebound87. TCAs have sedating side effects and therefore may be considered for the patient with insomnia. However, sleep architecture disruptions are reported in children and adolescents treated with TCAs including REM sleep suppression, decreases in slow wave sleep, increases in stage 2 sleep, and sleep fragmentation88. Selective serotonin reuptake inhibitors (SSRIs) including prozac, zoloft, and paxil have less sedating effects than TCAs. Little is known about the influence of SSRIs on sleep architecture in children and adolescents. Armitage and colleagues89 examined fluoxetine use in depressed children and adolescents and found increases in stage 1 sleep, number of arousals, REM density, and oculomotor abnormalities.


Antihistamines such as diphenhydramine, chlorpheniramine, and hydroxyzine are first generation H1-histamine receptor blockers that have multiple effects on the central and peripheral nervous systems. These medications cross the blood-brain barrier and are rapidly absorbed through the gastrointestinal tract90. Many over the counter medications such as antiemetic, anti-allergy, and antitussive agents contain diphenhydramine. Clinically, antihistamines induce drowsiness and sleepiness, and are given to promote sleep. Sleep onset latency is shortened and these agents have little effects on sleep architecture91. Some of the side effects include daytime drowsiness, lethargy, and dry mouth. Antihistamines can also intensify primary sleep disorders such as restless leg syndrome92.


Benzodiazepines, such as clonazepam and diazepam, have both anticonvulsant and anxiolytic as well as hypnotic properties and thus used clinically for a variety of purposes. Randomized controlled studies of benzodiazepines for insomnia in children and adolescents are lacking, and it has been shown that BZDs can disrupt sleep architecture (e.g., suppressed delta sleep, prolonged REM latency, and increased Stage 2 sleep), worsen sleep-disordered breathing, and are associated with daytime sleepiness and cognitive effects93. Thus the use of these medications in the pediatric population is clinically limited94.


Corticosteroids are frequently used in children with chronic conditions including asthma, JIA, and cancer. They have a wide range of effects on multiple organs and also effect sleep34,95,96. Prolonged sleep onset latency, increased wake time after sleep onset, and reduced REM sleep has been reported34,93,95,96. A recent study by Vallance and colleagues95 report increased frequency and dosage of dexamethasone was associated with increased wake after sleep onset, poor sleep efficiency, decreased total sleep time, and increased night awakenings as measured by actigraphy in children diagnosed with acute lymphoblastic leukemia (ALL). In pediatric cancer, studies have shown that daytime fatigue is highest during the first few days after the start of chemotherapy, and that corticosteroid use and hemoglobin values are associated with significant fatigue13,97. Often children receive intensive multi-agent chemotherapy agents, and each agent can produce immediate or delayed effects on sleep.


Opioid medications, such as oxycodone, commonly used for pain management, have also been linked to disruption of sleep architecture. There is a paucity of pediatric research on effects of opioids on sleep; however, adult studies have shown opioid use is associated with reductions in REM and slow wave sleep, and that chronic use of opioids is associated with obstructive sleep apnea98,99. Timing of opioids may also affect daytime alertness; short-acting agents often induce sleep during the day.

Evaluation of sleep problems

The clinical evaluation of sleep and its related disorders in children with medical conditions is challenging. Some sleep disorders or disturbances have a gradual onset and remain undetected for an extended period of time, in part due to the absence of adequate sleep assessment. Parents, children, and adolescents may not be familiar with the signs and symptoms (i.e., altered mood, daytime sleepiness, inattention and hyperactivity) or may attribute sleep disruptions to their underlying medical condition. Accurate assessment is critical for guiding identification and treatment of sleep problems in children with medical conditions. Differential diagnosis is key as it can be difficult to differentiate medical, psychiatric, and sleep disorders that commonly co-occur. Thus the assessment of sleep disorders in children and adolescents with medical conditions requires a multidisciplinary team that may include advanced practice nurses, staff nurses, neurologists, pediatricians, psychologists, psychiatrists, pulmonologists, otolaryngologists and dentists.

Similar to the assessment of sleep in the otherwise healthy child, evaluation should begin with a thorough sleep and medical history, psychiatric, developmental, and social health history, medication history, and physical examination. The physical examination should evaluate a child’s physical appearance focusing on: craniofacial characteristics (midfacial hypoplasia), nasal obstruction, the oral cavity (e.g., sizes of soft palate, tongue and tonsils, adenoidal tissue), a neurological evaluation for hypotonia, and an obesity assessment100. In the context of the medical condition, assessment of additional factors including the sleep environment and experience of nighttime symptoms will be important. For example, in children with allergies or asthma, assessment should include the child’s exposure to environmental allergens including pets in the household, mattress, linens and the living environment that might be associated with symptom exacerbations at night. Sleep assessment includes a thorough sleep history, addressing subjective and objective characteristics of sleep and sleep disturbances; related factors, and consequences (e.g., mood, fatigue, excessive daytime sleepiness). Where indicated, depending on the sleep disorder, specialized sleep testing in a sleep laboratory setting may be recommended. See articles in this issue for further details on evaluating sleep disorders (Babcock) and regarding sleep in the family (Meltzer).

In the general medical history evaluation, the clinician should pay particular attention to the child’s underlying chronic condition (e.g., pulmonary for a child diagnosed with asthma). Assessments should include cardiopulmonary (e.g., heart disease, lung disease), neurological (e.g., seizure disorder, restless legs syndrome), immune disorders (i.e., rheumatoid arthritis), gastroenterology (e.g., gastroesophageal reflux [GERD]), screening for psychiatric conditions (e.g., anxiety, depression, bipolar), as well as other pain-related conditions (e.g., juvenile fibromyalgia, sickle cell disease). In the family history, obtain information about sleep and psychiatric and medical conditions. For example, obtain history of family members or relatives who snore or are diagnosed with SDB, restless legs syndrome, narcolepsy, insomnia, or other problems such as fibromyalgia, depression, and anxiety.

In the medication review, in addition to consideration of the potential effects of medications on sleep and alertness outlined above, it is important to consider a number of other aspects of pharmacologic treatment. These include timing (i.e., direct vs. withdrawal effects), dosage (i.e., some sleep disruptive effects are dose dependent), and use of combinations of medications (i.e., synergistic effects of sedating drugs). During medication review, it is important to differentiate whether daytime sleepiness is secondary to symptom management (e.g., pain exacerbation), in response to taking sedating medicines during the day, or to compensate for sleep loss at nighttime.

Treatment of sleep problems

The clinicians’ approach to management of sleep problems in children with common medical conditions is challenging and complex. The goal of treatment involves promotion of healthy sleep habits, prevention strategies, and treatment of diagnosed sleep disorders. Similar to otherwise healthy children, treatment of SDB in children and adolescents with medical conditions includes tonsillectomy and adenoidectomy, pharmacological interventions, and the use of non-invasive ventilation devices (e.g., CPAP, BiPAP), as well as behavioral treatments and sleep education for any co-existing behaviorally-based sleep issues. In children diagnosed with obstructive sleep apnea, an adentonsillectomy is typically the first line treatment, particularly when there is evidence of adenotonsillar hypertrophy101. However, children with medical conditions may require additional monitoring in the postoperative period following surgical intervention. It is important for the treating clinician to know that despite surgical intervention, some children with medical conditions continue to have OSA due to underlying craniofacial anomalies or oropharyngeal features that impact the airway102. In these particular cases, non-invasive ventilation including continuous positive airway pressure (CPAP) or bi-level positive airway pressures (BiPAP) is commonly used to treat OSA. CPAP delivers a constant pressure of air to stent open the airway (CPAP) and BiPAP delivers an inspiratory and expiratory pressure to children during sleep through a face mask. CPAP has been effectively used in medical populations including children with sickle cell disease103 and young adults with cystic fibrosis104.

Pharmacological treatment

Prescription and over the counter medication have been used to treat sleep disturbances in youth with medical conditions. For example, exogenous melatonin has been successfully used to treat circadian rhythm disturbances and sleep-onset insomnia in children with epilepsy105, neurodevelopmental disabilities106, and in children who are blind107. Despite the use of prescription and over the counter medications, there is a paucity of knowledge on the pharmacologic management of sleep disturbances in children with medical conditions. In 2006, a consensus statement on the pharmacological management of pediatric insomnia was developed and reported concerns on the lack of clinical trials and knowledge about safety and efficacy particularly in children with chronic conditions108. Additional research is warranted on the pharmacologic practices for the management of pediatric insomnia in children with medical conditions.

Behavioral and psychological treatments

There is also a paucity of research on behavioral and psychological treatments for sleep problems in children with medical conditions. Cognitive-behavioral therapy (CBT) is a psychological treatment that incorporates both cognitive strategies and behavioral techniques to promote more adaptive behaviors that facilitate sleep. CBT for insomnia (called CBT-I) has been well-described for treatment of adults and has received much empirical support in diverse populations of adults with medical conditions109. Only a few studies of behavioral treatments for sleep problems have been conducted in pediatric medical populations. The findings are promising however, showing improvements in sleep quality and reductions in pain and fatigue in children and adolescents with fibromyalgia and cancer36,110.

Given the importance of sleep for health and well-being, strategies to heighten clinician and parental awareness and educate children, adolescents, and parents about the importance of sleep in health outcomes (e.g., school and work function, quality of life, psychosocial functioning) is essential in the management of pediatric medical conditions.

Conclusions and Recommendations

Sleep is an important consideration in the management of common medical conditions in children and adolescents. Sleep loss carries specific health risks that may exacerbate a chronic condition and disease-related symptoms. Because of the adverse effects of inadequate sleep and untreated sleep disorders on health outcomes, routine screening for sleep disturbances and disorders, and sleep assessments are needed to improve the clinical care of children and adolescents with medical conditions. Future research is needed on sleep disturbances using subjective and objective measures to better understand the relationship among sleep, disease-related symptoms, and health outcomes in children and adolescents with medical conditions. Such knowledge will enable optimal tailoring of sleep interventions to the unique needs of different medical populations.


This work was supported in part by Grants No. HD05343 and HD060068 from the National Institutes of Health (TP).


The authors have nothing to disclose.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.


1. Bryant PA, Trinder J, Curtis N. Sick and tired: Does sleep have a vital role in the immune system? Nature Rev Immunol. 2004;4(6):457–467. [PubMed]
2. Bell JF, Zimmerman FJ. Shortened nighttime sleep duration in early life and subsequent childhood obesity. Arch Pediatr Adolesc Med. 2010;164(9):840–845. [PubMed]
3. Passarelli CM, Roizenblatt S, Len CA, et al. A case-control sleep study in children with polyarticular juvenile rheumatoid arthritis. J Rheumatol. 2006;33(4):796–802. [PubMed]
4. Yuksel H, Sogut A, Yilmaz O, Demet M, Ergin D, Kirmaz C. Evaluation of sleep quality and anxiety-depression parameters in asthmatic children and their mothers. Respir Med. 2007;101(12):2550–2554. [PubMed]
5. Huntley ED, Campo JV, Dahl RE, Lewin DS. Sleep Characteristics of Youth with Functional Abdominal Pain and a Healthy Comparison Group. J Pediatr Psychol. 2007;32(8):938–949. [PubMed]
6. Hysing M, Sivertsen B, Stormark KM, Elgen I, Lundervold AJ. Sleep in children with chronic illness, and the relation to emotional and behavioral problems--a population-based study. Journal of Pediatric Psychology. 2009;34(6):665–670. [PubMed]
7. Sivertsen B, Hysing M, Elgen I, Stormark KM, Lundervold AJ. Chronicity of sleep problems in children with chronic illness: a longitudinal population-based study. Child Adolesc Psychiatry Ment Health. 2009;3(1):22. [PMC free article] [PubMed]
8. Warren S. Sleep in medically compromised children. Med Health. 2006;89(3):100–101. [PubMed]
9. Long AC, Krishnamurthy V, Palermo TM. Sleep disturbances in school-age children with chronic pain. J Pediatr Psychol. 2008;33(3):258–268. [PMC free article] [PubMed]
10. Bartlet LB, Westbroek R, White JE. Sleep patterns in children with atopic eczema. Acta Derm Venereol. 1997;77(6):446–448. [PubMed]
11. Wirrell E, Blackman M, Barlow K, Mah J, Hamiwka L. Sleep disturbances in children with epilepsy compared with their nearest-aged siblings. Dev Med Child Neurol. 2005;47(11):754–759. [PubMed]
12. Ward TM, Archbold K, Lentz M, Ringold S, Wallace CA, Landis CA. Sleep disturbance, daytime sleepiness, and neurocognitive performance in children with juvenile idiopathic arthritis. Sleep. 2010;33(2):252–259. [PubMed]
13. Zwerdling T, Konia T, Silverstein M. Congenital, single system, single site, Langerhans cell histiocytosis: a new case, observations from the literature, and management considerations. Pediatr Dermatol. 2009;26(1):121–126. [PubMed]
14. Maganti R, Hausman N, Koehn M, Sandok E, Glurich I, Mukesh BN. Excessive daytime sleepiness and sleep complaints among children with epilepsy. Epilepsy Behav. 2006;8(1):272–277. [PubMed]
15. Zamir G, Press J, Tal A, Tarasiuk A. Sleep fragmentation in children with juvenile rheumatoid arthritis. J Rheumatol. 1998;25(6):1191–1197. [PubMed]
16. Ward TM, Brandt P, Archbold K, et al. Polysomnography and self-reported sleep, pain, fatigue, and anxiety in children with active and inactive juvenile rheumatoid arthritis. Journal of Pediatric Psychology Apr. 2008;33(3):232–241. [PubMed]
17. Hanson MD, Chen E. The temporal relationships between sleep, cortisol, and lung functioning in youth with asthma. Journal of Pediatric Psychology. 2008;33(3):312–316. [PubMed]
18. Amin R, Bean J, Burklow K, Jeffries J. The relationship between sleep disturbance and pulmonary function in stable pediatric cystic fibrosis patients. Chest. 2005;128(3):1357–1363. [PubMed]
19. Parisi P, Bruni O, Pia Villa M, et al. The relationship between sleep and epilepsy: the effect on cognitive functioning in children. Dev Med Child Neurol. 2010;52(9):805–810. [PubMed]
20. Dykewicz MS, Fineman S, Skoner DP. Joint Task Force summary statements on Diagnosis and Management of Rhinitis. Ann Allergy Asthma Immunol. 1998;81(5 Pt 2):474–477. [PubMed]
21. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1–84. [PubMed]
22. Bixler EO, Vgontzas AN, Lin HM, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009;32(6):731–736. [PubMed]
23. Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999;159(5 Pt 1):1527–1532. [PubMed]
24. Meltzer EO, Blaiss MS, Derebery MJ, et al. Burden of allergic rhinitis: results from the Pediatric Allergies in America survey. J Allergy Clin Immunol. 2009;124(3 Suppl):S43–70. [PubMed]
25. Kales A, Kales JD, Sly RM, Scharf MB, Tan TL, Preston TA. Sleep patterns of asthmatic children: all-night electroencephalographic studies. J Allergy. 1970;46(5):300–308. [PubMed]
26. Sadeh A, Horowitz I, Wolach-Benodis L, Wolach B. Sleep and pulmonary function in children with well-controlled, stable asthma. Sleep. 1998;21(4):379–384. [PubMed]
27. Fagnano M, van Wijngaarden E, Connolly HV, Carno MA, Forbes-Jones E, Halterman JS. Sleep-disordered breathing and behaviors of inner-city children with asthma. Pediatrics. 2009;124(1):218–225. [PMC free article] [PubMed]
28. Dean BB, Calimlim BC, Sacco P, Aguilar D, Maykut R, Tinkelman D. Uncontrolled asthma among children: impairment in social functioning and sleep. J Asthma. 2010;47(5):539–544. [PubMed]
29. Suratwala D, Brooks LJ. Pulmonary disorders affecting sleep in children. In: Butkov N, Lee-Chiong T, editors. Fundamentals of Sleep Technology. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 575–579.
30. Hockenberry MJ, Hooke MC, Gregurich M, McCarthy K, Sambuco G, Krull K. Symptom clusters in children and adolescents receiving cisplatin, doxorubicin, or ifosfamide. Oncol Nurs Forum Jan. 2010;37(1):E16–27. [PubMed]
31. Hinds PS, Hockenberry M, Rai SN, et al. Nocturnal awakenings, sleep environment interruptions, and fatigue in hospitalized children with cancer. Oncol Nurs Forum. 2007;34(2):393–402. [PubMed]
32. Walker AJ, Johnson KP, Miaskowski C, Lee KA, Gedaly-Duff V. Sleep quality and sleep hygiene behaviors of adolescents during chemotherapy. J Clin Sleep Med. 2010;6(5):439–444. [PubMed]
33. Zupanec S, Jones H, Stremler R. Sleep habits and fatigue of children receiving maintenance chemotherapy for ALL and their parents. J Pediatr Oncol Nurs. 2010;27(4):217–228. [PubMed]
34. Hinds PS, Hockenberry MJ, Gattuso JS, et al. Dexamethasone alters sleep and fatigue in pediatric patients with acute lymphoblastic leukemia. Cancer. 2007;110(10):2321–2330. [PubMed]
35. Gedaly-Duff V, Lee KA, Nail L, Nicholson HS, Johnson KP. Pain, sleep disturbance, and fatigue in children with leukemia and their parents: a pilot study. Oncol Nurs Forum. 2006;33(3):641–646. [PubMed]
36. Rosen GM, Shor AC, Geller TJ. Sleep in children with cancer. Curr Opin Pediatr. 2008;20(6):676–681. [PubMed]
37. Palm L, Nordin V, Elmqvist D, Blennow G, Persson E, Westgren U. Sleep and wakefulness after treatment for craniopharyngioma in childhood; influence on the quality and maturation of sleep. Neuropediatrics. 1992;23(1):39–45. [PubMed]
38. Gapstur R, Gross CR, Ness K. Factors associated with sleep-wake disturbances in child and adult survivors of pediatric brain tumors: a review. Oncol Nurs Forum. 2009;36(6):723–731. [PubMed]
39. Rosen G, Brand SR. Sleep in children with cancer: case review of 70 children evaluated in a comprehensive pediatric sleep center. Support Care Cancer. 2010 [published online ahead of print Jun 2 2010] [PubMed]
40. Tsai SY, Labyak SE, Richardson LP, et al. Actigraphic sleep and daytime naps in adolescent girls with chronic musculoskeletal pain. Journal of Pediatric Psychology. 2008;33(3):307–311. [PubMed]
41. Haim A, Pillar G, Pecht A, et al. Sleep patterns in children and adolescents with functional recurrent abdominal pain: objective versus subjective assessment. Acta Paediatr. 2004;93(5):677–680. [PubMed]
42. Palermo TM, Toliver-Sokol M, Fonareva I, Koh JL. Objective and subjective assessment of sleep in adolescents with chronic pain compared to healthy adolescents. Clin J Pain. 2007;23(9):812–820. [PMC free article] [PubMed]
43. Meltzer LJ, Logan DE, Mindell JA. Sleep patterns in female adolescents with chronic musculoskeletal pain. Behav Sleep Med. 2005;3(4):193–208. [PubMed]
44. LaPlant MM, Adams BS, Haftel HM, Chervin RD. Insomnia and quality of life in children referred for limb pain. J Rheumatol. 2007;34(12):2486–2490. [PubMed]
45. Palermo TM, Wilson AC, Lewandowski AS, Toliver-Sokol M, Murray CB. Behavioral and psychosocial factors associated with insomnia in adolescents with chronic pain. Pain. In press. [PMC free article] [PubMed]
46. Palermo TM, Kiska R. Subjective sleep disturbances in adolescents with chronic pain: relationship to daily functioning and quality of life. J Pain. 2005;6(3):201–207. [PubMed]
47. Lewandowski AS, Palermo TM, De la Motte S, Fu R. Temporal daily associations between pain and sleep in adolescents with chronic pain versus healthy adolescents. Pain. 2010;151(1):220–225. [PMC free article] [PubMed]
48. Miller VA, Palermo TM, Powers SW, Scher MS, Hershey AD. Migraine headaches and sleep disturbances in children. Headache. 2003;43(4):362–368. [PubMed]
49. Vendrame M, Kaleyias J, Valencia I, Legido A, Kothare SV. Polysomnographic findings in children with headaches. Pediatr Neurol. 2008;39(1):6–11. [PubMed]
50. MacLean JE, Hayward P, Fitzgerald DA, Waters K. Cleft lip and/or palate and breathing during sleep. Sleep Med Rev. 2009;13(5):345–354. [PubMed]
51. MacLean JE, Fitzsimons D, Hayward P, Waters KA, Fitzgerald DA. The identification of children with cleft palate and sleep disordered breathing using a referral system. Pediatr Pulmonol. 2008;43(3):245–250. [PubMed]
52. Rustemeyer J, Thieme V, Bremerich A. Snoring in cleft patients with velopharyngoplasty. Int J Oral Maxillofac Surg. 2008;37(1):17–20. [PubMed]
53. Naqvi SK, Sotelo C, Murry L, Simakajornboon N. Sleep architecture in children and adolescents with cystic fibrosis and the association with severity of lung disease. Sleep Breath. 2008;12(1):77–83. [PubMed]
54. de Castro-Silva C, de Bruin VM, Cavalcante AG, Bittencourt LR, de Bruin PF. Nocturnal hypoxia and sleep disturbances in cystic fibrosis. Pediatr Pulmonol. 2009;44(11):1143–1150. [PubMed]
55. Ramos RT, Salles C, Gregorio PB, et al. Evaluation of the upper airway in children and adolescents with cystic fibrosis and obstructive sleep apnea syndrome. Int J Pediatr Otorhinolaryngol. 2009;73(12):1780–1785. [PubMed]
56. Maganti R, Sheth RD, Hermann BP, Weber S, Gidal BE, Fine J. Sleep architecture in children with idiopathic generalized epilepsy. Epilepsia. 2005;46(1):104–109. [PubMed]
57. Orr WC. Sleep and gastroesophageal reflux: what are the risks? Am J Med. 2003;115(Suppl 3A):109S–113S. [PubMed]
58. Halpern LM, Jolley SG, Tunell WP, Johnson DG, Sterling CE. The mean duration of gastroesophageal reflux during sleep as an indicator of respiratory symptoms from gastroesophageal reflux in children. J Pediatr Surg. 1991;26(6):686–690. [PubMed]
59. Bloom BJ, Owens JA, McGuinn M, Nobile C, Schaeffer L, Alario AJ. Sleep and its relationship to pain, dysfunction, and disease activity in juvenile rheumatoid arthritis. J Rheumatol. 2002;29(1):169–173. [PubMed]
60. Labyak S, Stein L, Bloom B, Owens J, Lunsford V. Sleep in children with juvenile rheumatoid arthritis. Sleep. 2001;24(Suppl):A15.
61. Lopes MC, Guilleminault C, Rosa A, Passarelli C, Roizenblatt S, Tufik S. Delta sleep instability in children with chronic arthritis. Braz J Med Biol Res. 2008;41(10):938–943. [PubMed]
62. Palm L, Persson E, Elmqvist D, Blennow G. Sleep and wakefulness in normal preadolescent children. Sleep. 1989;12(4):299–308. [PubMed]
63. Tayag-Kier CE, Keenan GF, Scalzi LV, et al. Sleep and periodic limb movement in sleep in juvenile fibromyalgia. Pediatrics. 2000;106(5):E70. [PubMed]
64. Roizenblatt S, Tufik S, Goldenberg J, Pinto LR, Hilario MO, Feldman D. Juvenile fibromyalgia: clinical and polysomnographic aspects. J Rheumatol. 1997;24(3):579–585. [PubMed]
65. Tripathi A, Jerrell JM, Stallworth JR. Cost-effectiveness of adenotonsillectomy in reducing obstructive sleep apnea, cerebrovascular ischemia, vaso-occlusive pain, and ACS episodes in pediatric sickle cell disease. Ann Hematol. published online ahead of print Aug 17 2010. [PubMed]
66. Wali YA, al Okbi H, al Abri R. A comparison of two transfusion regimens in the perioperative management of children with sickle cell disease undergoing adenotonsillectomy. Pediatr Hematol Oncol. 2003;20(1):7–13. [PubMed]
67. Kaleyias J, Mostofi N, Grant M, et al. Severity of obstructive sleep apnea in children with sickle cell disease. J Pediatr Hematol Oncol. 2008;30(9):659–665. [PubMed]
68. Jacob E, Miaskowski C, Savedra M, Beyer JE, Treadwell M, Styles L. Changes in sleep, food intake, and activity levels during acute painful episodes in children with sickle cell disease. J Pediatr Nurs. 2006;21(1):23–34. [PubMed]
69. Hargrave DR, Wade A, Evans JP, Hewes DK, Kirkham FJ. Nocturnal oxygen saturation and painful sickle cell crises in children. Blood. 2003;101(3):846–848. [PubMed]
70. Daniel LC, Grant M, Kothare SV, Dampier C, Barakat LP. Sleep patterns in pediatric sickle cell disease. Pediatr Blood Cancer Sep. 2010;55(3):501–507. [PubMed]
71. Rogers VE, Lewin DS, Winnie GB, Geiger-Brown J. Polysomnographic characteristics of a referred sample of children with sickle cell disease. J Clin Sleep Med. 2010;6(4):374–381. [PubMed]
72. Jacob E, Hesselgrave J, Sambuco G, Hockenberry M. Variations in pain, sleep, and activity during hospitalization in children with cancer. J Pediatr Oncol Nurs. 2007;24(4):208–219. [PubMed]
73. Cureton-Lane RA, Fontaine DK. Sleep in the pediatric ICU: an empirical investigation. Am J Crit Care. 1997;6(1):56–63. [PubMed]
74. Davis ID, Baron J, O’Riordan MA, Rosen CL. Sleep disturbances in pediatric dialysis patients. Pediatr Nephrol. 2005;20(1):69–75. [PubMed]
75. Sinha R, Davis ID, Matsuda-Abedini M. Sleep disturbances in children and adolescents with non-dialysis-dependent chronic kidney disease. Arch Pediatr Adolesc Med. 2009;163(9):850–855. [PubMed]
76. Bennett DS. Depression among children with chronic medical problems: a meta-analysis. J Pediatr Psychol. 1994;19(2):149–169. [PubMed]
77. Lavigne JV, Faier-Routman J. Psychological adjustment to pediatric physical disorders: a meta-analytic review. Journal of Pediatric Psychology. 1992;17(2):133–157. [PubMed]
78. Zeltzer LK, Recklitis C, Buchbinder D, et al. Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study. J Clin Oncol. 2009;27(14):2396–2404. [PMC free article] [PubMed]
79. Becker DA, Fennell EB, Carney PR. Sleep disturbance in children with epilepsy. Epilepsy Behav. 2003;4(6):651–658. [PubMed]
80. Oberndorfer S, Saletu-Zyhlarz G, Saletu B. Effects of selective serotonin reuptake inhibitors on objective and subjective sleep quality. Neuropsychobiology. 2000;42(2):69–81. [PubMed]
81. Clark NA, Alexander B. Increased rate of trazodone prescribing with bupropion and selective serotonin-reuptake inhibitors versus tricyclic antidepressants. Ann Pharmacother. 2000;34(9):1007–1012. [PubMed]
82. Emslie GJ, Rush AJ, Weinberg WA, Rintelmann JW, Roffwarg HP. Children with major depression show reduced rapid eye movement latencies. Arch Gen Psychiatry. 1990;47(2):119–124. [PubMed]
83. Dahl RE, Ryan ND, Matty MK, et al. Sleep onset abnormalities in depressed adolescents. Biol Psychiatry. 1996;39(6):400–410. [PubMed]
84. Goetz RR, Puig-Antich J, Dahl RE, et al. EEG sleep of young adults with major depression: a controlled study. J Affect Disord. 1991;22(1–2):91–100. [PubMed]
85. Emslie GJ, Roffwarg HP, Rush AJ, Weinberg WA, Parkin-Feigenbaum L. Sleep EEG findings in depressed children and adolescents. Am J Psychiatry. 1987;144(5):668–670. [PubMed]
86. Walter TJ, Golish JA. Psychotropic and neurologic medications. In: TLL-C, MJS, MAC, editors. Sleep Medicine. Philadelphia, PA: Hanley and Belfus; 2002. pp. 587–599.
87. Sharpley AL, Cowen PJ. Effect of pharmacologic treatments on the sleep of depressed patients. Biol Psychiatry. 1995;37(2):85–98. [PubMed]
88. Shain BN, Naylor M, Shipley JE, Alessi N. Imipramine effects on sleep in depressed adolescents: a preliminary report. Biol Psychiatry. 1990;28(5):459–462. [PubMed]
89. Armitage R, Emslie G, Rintelmann J. The effect of fluoxetine on sleep EEG in childhood depression: a preliminary report. Neuropsychopharmacology. 1997;17(4):241–245. [PubMed]
90. Buysse DJ, Schweitzer PK, Moul DE. Clinical pharmacology of other drugs used as hypnotics. In: Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine. 4. Philadelphia, PA: Saunders; 2005. pp. 452–467.
91. Ten Eick AP, Blumer JL, Reed MD. Safety of antihistamines in children. Drug Saf. 2001;24(2):119–147. [PubMed]
92. Ondo WG. Restless legs syndrome. Curr Neurol Neurosci Rep. 2005;5(4):266–274. [PubMed]
93. Roux FJ, Kryger MH. Medication effects on sleep. Clin Chest Med. 2010;31(2):397–405. [PubMed]
94. Witek MW, Rojas V, Alonso C, Minami H, Silva RR. Review of benzodiazepine use in children and adolescents. Psychiatr Q. 2005;76(3):283–296. [PubMed]
95. Vallance K, Liu W, Mandrell BN, et al. Mechanisms of dexamethasone-induced disturbed sleep and fatigue in paediatric patients receiving treatment for ALL. Eur J Cancer. 2010;46(10):1848–1855. [PMC free article] [PubMed]
96. Moser NJ, Phillips BA, Guthrie G, Barnett G. Effects of dexamethasone on sleep. Pharmacol Toxicol. 1996;79(2):100–102. [PubMed]
97. Yeh CH, Chiang YC, Lin L, et al. Clinical factors associated with fatigue over time in paediatric oncology patients receiving chemotherapy. Br J Cancer. 2008;99(1):23–29. [PMC free article] [PubMed]
98. Wang D, Teichtahl H. Opioids, sleep architecture and sleep-disordered breathing. Sleep Med Rev Feb. 2007;11(1):35–46. [PubMed]
99. Lydic R, Baghdoyan HA. Neurochemical mechanisms mediating opioid-induced REM sleep disruption. In: Lavigne GJ, Sessle BJ, Choiniere M, Soja PJ, editors. Sleep and Pain. Seattle: IASP Press; 2007. pp. 99–122.
100. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004;69(5):1147–1154. [PubMed]
101. Schechter MS. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):e69. [PubMed]
102. Arens R, McDonough JM, Costarino AT, et al. Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2001;164(4):698–703. [PubMed]
103. Marshall MJ, Bucks RS, Hogan AM, et al. Auto-adjusting positive airway pressure in children with sickle cell anemia: results of a phase I randomized controlled trial. Haematologica. 2009;94(7):1006–1010. [PubMed]
104. Regnis JA, Piper AJ, Henke KG, Parker S, Bye PT, Sullivan CE. Benefits of nocturnal nasal CPAP in patients with cystic fibrosis. Chest. 1994;106(6):1717–1724. [PubMed]
105. Gupta M, Aneja S, Kohli K. Add-on melatonin improves sleep behavior in children with epilepsy: randomized, double-blind, placebo-controlled trial. J Child Neurol. 2005;20(2):112–115. [PubMed]
106. Phillips L, Appleton RE. Systematic review of melatonin treatment in children with neurodevelopmental disabilities and sleep impairment. Dev Med Child Neurol. 2004;46(11):771–775. [PubMed]
107. Palm L, Blennow G, Wetterberg L. Long-term melatonin treatment in blind children and young adults with circadian sleep-wake disturbances. Dev Med Child Neurol. 1997;39(5):319–325. [PubMed]
108. Mindell JA, Emslie G, Blumer J, et al. Pharmacologic management of insomnia in children and adolescents: consensus statement. Pediatrics. 2006;117(6):e1223–1232. [PubMed]
109. Perlis ML, Junquist C, Smith MT, Posner D. Cognitive behavioral treatment of insomnia. New York: Springer; 2005.
110. Degotardi PJ, Klass ES, Rosenberg BS, Fox DG, Gallelli KA, Gottlieb BS. Development and evaluation of a cognitive-behavioral intervention for juvenile fibromyalgia. J Pediatr Psychol. 2006;31(7):714–723. [PubMed]