| Predominant symptom(s) | Potential diagnoses, causes, and risk factors | Clinical features | Evaluation and management |
| Excessive daytime sleepiness (EDS) |
| | Multiple causes: - Physiologic effects of cancer (especially brain cancer)
- Effects of cancer-directed therapies (especially dexamethasone)
- Obstructive sleep apnea (described below)
- Circadian rhythm disturbance (described below)
- Chronic insomnia (described below)
| - Difficulty remaining alert during daytime activities
- Increased duration of sleep time
- Increased daytime napping
| - Distinguish EDS from fatigue
- Diagnose and treat specific underlying sleep disorders
- Address behavioral or environmental contributors
- Pharmacotherapy for refractory cases
|
| Insomnia |
| Bedtime resistance; frequent or prolonged awakenings | Chronic insomnia, behavioral insomnia of childhood subtype: - Due to inadequate parental limit-setting or sleep-onset associations
- Can be related to parents' caretaking at night, which may condition the child to require parental presence at bedtime
- Common in preschool- or school-aged children
| - Resistance to going to bed at night
- Awakenings with refusal to go back to sleep without presence of the parent
| - Sleep hygiene*
- Parental education about limit-setting and sleep-onset associations
|
| Difficulty with sleep onset or maintenance | Chronic insomnia, psychophysiologic insomnia subtype (also known as conditioned insomnia): - Common in school-aged children or adolescents
| - Concern or anxiety specifically about difficulty sleeping causes or exacerbates the insomnia
- Difficulty sleeping at specific times of the night becomes habitual
| - Sleep hygiene*
- Refer for cognitive-behavioral therapy for insomnia
- Evaluate and treat any underlying anxiety or mood disorder that may be contributing
|
| Difficulty with sleep onset or maintenance, in the setting of chronic or recurrent sleep-wake rhythm disruption | Circadian rhythm sleep-wake disorder: - Brain tumors (direct effects)
- Dexamethasone, radiotherapy
- Environmental contributors:
- Frequent or prolonged hospitalizations
- Low daytime activity or light exposure
- Nighttime stimulation (eg, electronics)
- Adolescence
| - Presence of risk factors
- Complaints of disrupted circadian patterns, if not explained by sleep hygiene
| - Optimize sleep hygiene and emphasize regularity of sleep schedule
- Consider melatonin supplementation
- Consider bright light therapy
|
| Urge to move legs or related dysesthesias | Restless legs syndrome (RLS): - Iron deficiency, with or without anemia
- Family history of RLS
| - Unpleasant sensation with urge to move legs, exacerbated when sedentary, worse in the evening, and ameliorated by walking or movement
- Children may describe a wide range of sensations and may report pain that is difficult to distinguish from "growing pains"
- May interfere with sleep onset or maintenance
- Leg discomfort is essential to the diagnosis but may not be the presenting complaint
| - Measure serum ferritin
- Consider iron replacement therapy
- Refer to UpToDate topic review on RLS in children for details and options for management
|
| Snoring or breathing problems |
| | Obstructive sleep apnea, eg, from: | - Frequent or loud snoring, witnessed apnea or labored breathing, obesity, behavioral changes (eg, daytime inattention, hyperactivity)
- May or may not cause EDS
| - Polysomnography
- Assess behavioral symptoms (eg, ADHD)
- Refer to UpToDate topic reviews on sleep apnea in children
|
| Fatigue |
| | Many contributors | - Subjective feeling of physical, emotional, or cognitive tiredness
| - Determine if there is a component of EDS, anxiety, or depression, and treat as indicated
- Diagnose and treat any underlying sleep disorders, which can contribute to fatigue even in the absence of reported sleepiness
- Optimize sleep hygiene*
- Encourage physical activity
- Consider bright light therapy
|
