Sleep disruption

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction

Night waking and sleep disruption are very common, occurring in 20-30% of children^1. In most cases, the causes and solutions are behavioural in nature, rather than requiring any investigation or medication. Effective and independent sleep initiation is vital to reducing sleep disruption with most strategies focussed on bedtime routine 2. Sleep should be initiated without parental intervention, in the child’s own space and without the need for any parental presence or other external stimulus that cannot be maintained throughout the night. If this routine can be maintained then, in an otherwise healthy child, night-time waking will usually lessen².

Investigations and assessments are usually to exclude any other concurrent issues which may be impacting the ability to settle and/or sleep through the night but should be guided by the clinical picture.

Pre-referral investigations

Sleep history:

• Sleep Hygiene
• Sleep Hours
• Ability to self-settle
• Snoring
• Restlessness

Day consequences:

• Naps
• School Performance
• Mood Disorder

Assessment:

• Tonsil Size

Consider Blood Tests:

• Full Blood Count
• Iron Studies
• Coeliac Serology
• Thyroid Stimulating Hormone
• Urea, Electrolytes and Creatinine
• Liver Function Tests
• Random Glucose
• Vitamin B12
• Folate

Pre-referral management

• Discuss sleep hygiene
• Discuss approaches to facilitate self-settling at bedtime ²
• Educate on adequate sleep hours for age
• To improve sleep quality, consider 3 months of oral iron if Ferritin < 50 (refer to PCH Pre-referral Guideline on Iron Deficiency). 3-6 mg/kg/ day of elemental iron - retest after 3 months ³
• Consider trial of oral melatonin at bedtime if persistent sleep onset difficulties.
• Consider trial of Nasonex nasal spray if coexisting snoring.
• Consider additional support options e.g. clinical psychologist familiar with childhood sleep issues, Ngala or Child Health Nurse. (see additional information below).
• Consider directing to available community resources for sleep training and behavioural strategies (see Useful Resources section).

When to refer

If sleeping difficulties continue despite above management, then refer to Respiratory and Sleep Medicine along with results of investigations and management tried.

If symptoms of obstructive sleep apnoea are present (such as snoring, apparent apnoeas and large tonsils) then refer to Ear Nose & Throat.

How to refer

• Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
• Routine non-urgent referrals from private hospitals are made via the PCH Referral Office.
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with the Respiratory doctor on call. 

Essential information to include in your referral

• A detailed sleep history including sleep routine, snoring, length of time patient has had sleep disturbances
• Impact on day functioning.
• Pre referral investigation and management – including results of blood tests.
• Correspondence and details from any other sleep services used. 

Useful resources

• Sleep tips for children - Healthdirect
• Sleep better tips - Raising Children Network
• Sleep Health Foundation Fact Sheets
• Melatonin and Children - Sleep Health Foundation
• Sleep Matters Program (6 years and over) 
• How your baby sleeps - Ngala
• Ngala Parenting line
• Child Health Centres - CAHS Community Health
• Triple P Positive Parenting Australia
• Circle of Security International - Early intervention program for parents & children

References

1. Burnham MM, Goodlin-Jones BL, Gaylor EE, Anders TF. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry. 2002;43(6):713.
2. Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A. Practice Parameters for Behavioural Treatment of Bedtime Problems and Night Wakings in Infants and Young Children. Sleep. 2006;29(10):1277-1281.
3. Simakajornboon N, Kheirandish-Gozal L, Gozal D,etal. A long term follow-up study of periodic limb movement disorder in children after iron therapy. Sleep2006; 29 (Suppl):A226.

Reviewer/Team:	Respiratory and Sleep Department	Last reviewed:	Mar 2022
		Review date:	Mar 2025

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