Tiredness

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

Tiredness or daytime sleepiness is deemed an issue when it causes patient concern or is interfering with normal daily function.¹This is distinct from fatigue which is a subjective lack of physical and mental energy. The most common cause of daytime sleepiness is insufficient sleep which should be excluded first.² Approximate recommended amounts of sleep are detailed below:³

Age	Recommended sleep hours (including naps)	Approximate bedtime
0 to 3 months	14 to 17	N/A
4 to 12 months	12 to 16	7pm
1 to 2 years	11 to 14	7pm
3 to 5 years	10 to 13	7pm
6 to 12 years	9 to 12	7.30pm
13 to 18 years	8 to 10	9 to 9.30pm
> 18 years old	7 to 9	10pm

Pre-referral investigations

Sleep History: sleep hygiene sleep hours, snoring, restlessness.
Day consequences: naps, falls asleep in class, difficulty concentrating, emotionally dysregulated when tired.
Assessment: tonsillar size.
Blood tests: Full Blood Count, iron studies, coeliac serology, Thyroid Stimulating Hormone, Urea, Electrolytes and Creatinine, Liver Function Tests, random glucose, Vit B12 and folate, Epstein Barr Virus serology.

Pre-referral management

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 months⁴
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., Ngala or Child Health Nurse.

When to refer

If ongoing difficulties despite above, then refer to Respiratory and Sleep Medicine – sleep disorders along with results of investigations.

If symptoms of Obstructive Sleep Apnoea (such as snoring or apparent apnoeas in the presence of large tonsils) then refer to Ear Nose and Throat.

How to refer

Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals go to 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 Respiratory doctor on call.

Essential information to include in your referral

A detailed sleep history including sleep routine, snoring, the length of time sleep disturbances have existed.
Impact on day functioning.
Pre referral investigation and management – including results of blood tests.

References

Mansukhani, Meghna P., MD, Kolla, Bhanu Prakash, MD, MRCPsych, and Ramar, Kannan, MD. "International Classification of Sleep Disorders 2 and American Academy of Sleep Medicine Practice Parameters for Central Sleep Apnea." Sleep Medicine Clinics. J Med Libr Assoc [Internet]. 2014 [cited 2022 March 1] 9.1 (2014): 1-11. Available from:International Classification of Sleep Disorders 2 and American Academy of Sleep Medicine Practice Parameters for Central Sleep Apnea - ClinicalKey (health.wa.gov.au)
Owens, Judith. "Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences." Pediatrics (Evanston) [Internet]. 134.3 (2014) [cited 2022 Mar 1] E921-932. Available from: Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences | Pediatrics | American Academy of Pediatrics (health.wa.gov.au)
Paruthi, Shalini, Lee J Brooks, Carolyn D'Ambrosio, Wendy A Hall, Suresh Kotagal, Robin M Lloyd, et al. "Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine." Journal of Clinical Sleep Medicine [Internet] 12.6 (2016): 785-86. Available from: Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine (nih.gov)
Dye, Thomas J, Sejal V Jain, and Narong Simakajornboon. "Outcomes of Long-term Iron Supplementation in Pediatric Restless Legs Syndrome/periodic Limb Movement Disorder (RLS/PLMD)." Sleep Medicine 32 (2017): 213-19. Available from: Outcomes of long-term iron supplementation in pediatric restless legs syndrome/periodic limb movement disorder (RLS/PLMD) - ClinicalKey (health.wa.gov.au)

Reviewer/Team:	Respiratory and Sleep Medicine Department	Last reviewed:	Mar 2022
		Next review date:	Mar 2025

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