by Richard M. Kravitz, M.D., FAAP
“Doctor, my child just won’t go to sleep” or “he is tired
all the time” are two of the more common complaints
that pediatricians encounter during their career. Despite
spending more than one-third of our lives asleep, little
formal education about sleep medicine and sleep disorders is offered in medical school or residency.
Sleep medicine is a growing field, with recognition
by the American Board of Medical Specialties in 2007.
Board certification is offered after completion of a one-year fellowship and passing a comprehensive examination. There are about 5,800 board-certified sleep
specialists in the United States, but only about 270 are
pediatricians. Therefore, it is vital for pediatricians to
have a basic understanding of sleep physiology so they
can offer initial assessment and management of common sleep complaints that present to their practice.
How much sleep is needed
In addition to a comprehensive medical history, the
pediatrician will need to focus on sleep-related questions. These can be grouped into complaints related to
problems with sleep quantity or quality. Understanding
what constitutes normal sleep is an important starting
point. Infants spend up to 16 hours per day sleeping.
Their sleep requirement gradually decreases over the
first two decades of life, until the typical eight hours
of sleep is reached in adulthood.
The American Academy of Sleep Medicine recently
published a consensus statement as to what should be
considered a normal amount of sleep (Paruthi S, et
al. J Clin Sleep Med. 2016;12:1549-1561; Paruthi S,
et al. J Clin Sleep Med. 2016;12:785-786), which was
endorsed by the Academy:
• ages 4-12 months: 12-16 hours (including naps)
• ages 1-2 years: 11-14 hours (including naps)
• ages 3-5 years: 10-13 hours (including naps)
• ages 6-12 years: 9-12 hours
• ages 13-18 years: 8-10 hours
Sleep is divided into non-rapid eye movement
(NREM) sleep (about 75% of sleep) and rapid eye
movement (REM “dream”) sleep. NREM sleep is further divided into Stages N1 (transitional), N2 (about
50% of sleep time) and N3 (slow wave or “deep sleep,”
accounting for about 25% of sleep time).
NREM and REM sleep form a sleep cycle typically
lasting from one to two hours, for four to six cycles per
night. Between cycles, we awaken for a brief amount
of time before entering another cycle. Should something prevent a child from entering the next cycle, he
or she might fully awaken and then have difficulty
Determining causes for this abnormal waking (
behavioral vs. organic) is instrumental for correcting the
problem. Inappropriate awakening from N3 sleep can
be associated with confusional arousals, night terrors
and/or sleep walking (parasomnias). Recognizing this
pattern can lead to parental reassurance and appropriate interventions.
The development of good sleep hygiene (setting a
proper sleep environment, consistent bedtime and regular wake time) often is key to treating behavioral sleep
problems such as insomnia.
Sleep diaries are useful in supplementing the history provided by the family. Common behavioral sleep
problems (sleep onset association disorder, sleep lim-it-setting disorder or delayed sleep phase syndrome)
can be diagnosed with a detailed history and sleep diary,
preventing the need for a polysomnogram.
Once a child’s sleep habits and schedule have been
assessed, investigating sleep quality is indicated as poor
sleep quality can influence wakefulness. This may manifest as daytime sleepiness, behavioral problems or academic difficulties.
The Academy recommends that routine child health
screening include assessment for possible sleep-dis-ordered breathing (Marcus CL, et al. Pediatrics.
2012;130:576-584). Common symptoms
with which obstructive sleep apnea (OSA)
can present include snoring, apneic pauses
and restless sleep.
Medical history alone cannot distinguish
between primary snoring and obstructive
sleep apnea, though validated screening tests
(such as the Pediatric Sleep Questionnaire:
Sleep-Related Breathing Disorder Scale)
may be useful. Ultimately, polysomnogra-phy is needed to distinguish between these
two conditions. Primary snoring is common
in children (incidence of 7%-10%), especially when tonsillar hypertrophy is at its
peak ( 2 to 7 years old), while OSA is less
frequent (incidence of 2%-4%).
The most common treatment options for OSA include adenotonsillectomy vs. continuous positive airway pressure therapy. In milder cases of OSA, watchful
waiting is a reasonable choice (Marcus CL, et al. N Engl
J Med. 2013;368:2366-2376).
Patients with disruptive sleep should be screened for
restless leg syndrome (RLS). Effective treatment for
RLS can improve sleep quality.
Excessive sleepiness in the presence of an otherwise
benign medical and sleep history raises the concern for
possible narcolepsy. While the diagnosis often is not
established until a patient is in his or her 20s, historical
data suggest that excessive sleepiness can develop in
the first decade of life. Pediatricians, therefore, should
consider this diagnosis in their differential for children
with excessive sleepiness.
Finally, other illnesses that can interfere with sleep
(such as poorly controlled asthma, allergic rhinitis or
gastroesophageal reflux) should be identified and treated before one pursues further testing.
Given the small number of pediatric sleep specialists
available, the primary care physician must be able to
take a thorough sleep history and provide initial diagnosis and treatment interventions for children with
potential sleep disorders. Referral to a sleep specialist
should be considered for more complex cases and/or if
additional testing is indicated.
Dr. Kravitz is a member of the AAP Section on Pediatric Pulmonology and Sleep
Medicine Executive Committee.
Focus On Subspecialties
by Aristides I. Cruz Jr., M.D., M.B.A., FAAP, and
Theodore J. Ganley, M.D., FAAP
Increased organized sports participation among children and adolescents has led to a rise in the number of
injuries in this population.
Knee injuries are particularly common, and anterior
cruciate ligament (ACL) injury continues to command
the attention of athletes, parents, coaches and medical
professionals due to the increasing rate of injury and
subsequent reconstruction over the past two decades.
A recent study reviewed the incidence of ACL injury
in patients ages 6-18 years from 1994-2013 (Beck NA,
et al. Pediatrics. 2017;139:e20161877). The authors
found an overall ACL injury rate of 121 injuries per
100,000 person-years with the highest rates in 17-year-
old males (422/100,000) and 16-year-old females
(392/100,000). Perhaps a more important finding
was that over the 20-year period, there was an average
annual increase in the injury rate of 2.3%.
There also has been a commensurate increase in
ACL reconstruction (ACL-R) surgeries in pediatric
patients over the same period. An examination of a
state-based database found that from 1990 to 2009,
the rate of pediatric ACL-R increased from 17. 6 to
50. 9 per 100,000 (Dodwell ER, et al. Am J Sports Med.
Certain athletes at increased risk
As these studies have shown, high school athletes are
at particularly high risk for sports-related ACL injury.
In addition to age and sex, choice of sport also is linked
with risk of ACL injury.
A recent meta-analysis quanitfied this risk and found
that while ACL injuries are overall more common in
boys, the rate of injury risk per athlete exposure (e.g.,
Shortage of pediatric sleep specialists puts onus on primary care doctors
Injury prevention programs key to decreasing ACL tears in young athletes
See ACL, page 17