Sleep disorder		Epidemiology	Clinical features	Diagnostic criteria	Treatment options
Obstructive sleep apnea		Prevalence: 1% to 5% Onset between 2 and 8 years of age Affects males and females equally More common in blacks and in persons with craniofacial abnormalities (e.g., micrognathia, retrognathia, midfacial hypoplasia), Down syndrome, neuromuscular diseases, choanal atresia	Snoring Unusual sleep positions (e.g., hyperextended neck, seated with open mouth) Sleep-related paradoxical breathing Nighttime enuresis or diaphoresis Morning headaches Cognitive/behavioral issues (e.g., depressed mood, poor concentration, decreased attention) Excessive daytime sleepiness (less common) Enlarged tonsils and adenoids Pectus excavatum	PSG is required for diagnosis (apnea-hypopnea index greater than 1.5 per hour)	First line: Adenotonsillectomy Other: Continuous positive airway pressure, nasal steroids, rapid maxillary expansion (i.e., orthodontic device widens the upper jaw)
Parasomnias
	Sleepwalking (somnambulism)	Prevalence: 17% in children, 4% in adults Peaks between 8 and 12 years of age More common in males Familial history of sleepwalking: 1 parent = 45% risk 2 parents = 60% risk	Ambulation during sleep Difficult to awaken during episode Eyes open Confusion/agitation Unusual or dangerous behaviors Rapid return to sleep Usually occurs during the first half of the sleep period, with no memory of the event Patient may have coexisting confusional arousals and/or sleep terrors	Diagnosed by history PSG not required	Reassurance (usually resolves spontaneously) Increase total sleep time Scheduled awakenings Bedroom/home safety counseling Screening for precipitating factors (e.g., sleep deprivation, obstructive sleep apnea, gastroesophageal reflux disease, acute stress, medication or illicit drug use) Benzodiazepines
	Confusional arousals	Prevalence: 17.3% in 3- to 13-year-olds, 2.9% to 4.2% in those older than 15 years Affects males and females equally Strong familial pattern	“Sleep drunkenness” Inappropriate behavior Slowed responsiveness Slurred speech Confusion after awakening (forced or spontaneous) Usually occurs during the first half of the sleep period, with no memory of the event	Diagnosed by history PSG not required	Reassurance (usually resolves spontaneously) Increase total sleep time Scheduled awakenings Bedroom/home safety counseling
	Sleep terrors	Prevalence: 1% to 6.5% in children, 2.2% in adults Onset in early childhood Affects males and females equally	Perceived intense fear (e.g., screaming, crying, confusion, walking) Difficult to awaken from episode Potentially dangerous activities Usually occurs during the first half of the sleep period, with no memory of the event Considerable overlap with other parasomnias	Diagnosed by history PSG not required	Reassurance (usually resolves spontaneously) Increase total sleep time Scheduled awakenings Bedroom/home safety counseling Benzodiazepines
	Nightmares	Prevalence: 10% to 50% in 3- to 5-year-olds Onset between 3 and 6 years of age, peaks between 6 and 10 years of age Affects males and females equally	Unpleasant dreams Increased sympathetic response (increased heart and respiratory rates, diaphoresis) Usually occurs during the second half of the sleep period, with clear memory of the event Reluctance to sleep increases May be associated with mood disorders or posttraumatic stress disorder	Diagnosed by history PSG not required	Reassurance (usually resolves spontaneously) Increase total sleep time Scheduled awakenings Bedroom/home safety counseling Cognitive behavior therapy Medications that suppress rapid eye movement sleep (selective serotonin reuptake inhibitors; off-label use)
Behavioral insomnia of childhood		Prevalence: 10% to 30% Affects males and females equally	Sleep-onset association type: Difficulty initiating or maintaining sleep when sleep-specific conditions are not present (e.g., a parent rocking the child to sleep) Frequent nighttime awakenings common Falling asleep is a timely process, demanding for parents Symptoms represent a disorder only when they are persistent and highly demanding, or cause significant parental distress Limit-setting type: Difficulty initiating or maintaining sleep Bedtime refusal/stalling Refusal to return to sleep after nighttime awakenings Parents fail to set boundaries and give in to the child (e.g., allow the child to sleep in the parents' bed)	Diagnosed by history PSG not required	Prevention, parental education, and extinction techniques are effective See Table 4
Delayed sleep phase disorder		Prevalence: 7% to 16% in adolescents Onset in adolescence, with the peak age in the 20s It is unknown whether it is more common in one sex 40% of those affected have a family history of the condition	Difficulty falling asleep and waking up at socially acceptable times (at least a two-hour delay) “Night owl”	Diagnosed by history Use of sleep diary and/or actigraphy (i.e., an accelerometer that approximates sleep-wake times) for at least 1 week PSG not required	Sleep hygiene education Regular sleep-wake schedule Avoidance of bright lights before bedtime Melatonin, 0.3 to 5 mg given 1.5 to 6.5 hours before desired bedtime Bright light therapy, 2,000 lux for first 1 to 2 hours after awakening Continued use of sleep logs to monitor progress
Restless legs syndrome		Prevalence: 2% based on limited studies More common in women; unknown if it is more common in boys or girls Family history: Early onset associated with primary restless legs syndrome (genetic)	Urge to move the legs with associated discomfort Often begins in the evening, worsens with rest, eases with movement May be associated with iron deficiency Associated with negative behavior and mood, and decreased cognition and attention Higher prevalence in those with attention-deficit/hyperactivity disorder	Diagnosed by history PSG may be indicated When the child is unable to describe the symptoms, a diagnosis can be made if the history is consistent and at least two of the following are present: a sleep disturbance, a first-degree relative has the condition, or five or more periodic limb movements per hour of sleep during PSG	Avoidance of nicotine and caffeine Discontinue offending medications (antihistamines, selective serotonin reuptake inhibitors, and tricyclic antidepressants) Iron replacement if ferritin level is less than 50 mcg per L; recheck in 3 months Severe cases: levodopa, dopamine agonists, gabapentin (Neurontin), opioids, benzodiazepines (all off-label uses)