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.