Paediatric sleep packages

To promote optimal health, the American Academy of Sleep Medicine recommends the following amounts of sleep for children on a regular basis:

12 to 16 hours per 24 hours (including naps)

11 to 14 hours per 24 hours (including naps)

10 to 13 hours per 24 hours (including naps)

Nine to 12 hours per 24 hours

Eight to 10 hours per 24 hours

Not all sleep disturbances in children are due to poor sleep hygiene. It is important for caregivers and clinicians to distinguish between behavioural sleep difficulties and sleep-related breathing disorders (SRBD), as the management approaches are fundamentally different.

Sleep hygiene issues typically present with bedtime resistance, difficulty falling asleep, frequent night wakings associated with parental intervention, or irregular sleep schedules. These problems generally improve with behavioural strategies, consistent routines, and the sleep hygiene measures outlined above.

Sleep-related breathing disorders (SRBD) such as obstructive sleep apnoea (OSA) are characterised by physical symptoms that persist regardless of good sleep habits.

• Loud or habitual snoring (most nights of the week)
• Observed pauses or cessations in breathing during sleep
• Mouth breathing, gasping, or choking during sleep
• Non-continuous or fragmented sleep despite a good sleep routine
• Excessive daytime sleepiness, irritability, or hyperactivity
• ADHD or developmental concerns (children on ADHD medications have significantly higher odds of SRBD)
• Morning headaches, bed-wetting, or poor school performance that does not improve with good sleep hygiene

Obstructive sleep apnoea occurs in 1% to 5% of children and may not be detectable through history and physical examination alone. A polysomnography (sleep study) is the gold standard for diagnosis. If any of the above red flags are present, please discuss these with your child's doctor promptly so that appropriate investigations can be arranged.

Disorders of sleep can affect a child's heart, brain, or behaviour – they may become either more hyperactive or more visibly tired. For instance, having a restless night might cause your child to be exhausted the next day and find it challenging to focus in class.

Before recommending a sleep study, your child must be assessed by a paediatrician. This assessment may include the use of validated tools, such as the Sleep-Related Breathing Disorder (SRBD) scale, along with a detailed clinical evaluation to determine whether further investigation is necessary. If your child has a sleep-related breathing disorder, it is critical to objectively confirm the diagnosis and identify the type and severity, which will guide treatment.

Certain factors, including ENT concerns, craniofacial structure differences, and neuromuscular or metabolic conditions, may increase the likelihood of sleep-related breathing problems. In such cases, a sleep study can help guide management decisions and treatment next steps.

A sleep study may also be recommended for children who are already receiving respiratory support (such as CPAP or other ventilation therapy) to evaluate effectiveness and make adjustments if required.

• Snoring or noisy breathing
• Gasping or choking during sleep
• Mouth breathing
• Abnormal breathing pattern
• Neuromuscular weakness
• Observed absence of breathing during sleep
• Restlessness during sleep
• Daytime sleepiness or fatigue
• Daytime irritability or hyperactivity
• Poor school performance
• Bed wetting
• Teeth grinding
• Early morning headache
• Weight gain (high BMI) or poor weight gain
• Difficulty waking up in the morning

• Adenotonsillar hypertrophy
• Obesity
• Family history of Obstructive Sleep Apnoea (OSA)
• Orthodontic problems (e.g. high narrow hard palate, overlapping incisors, crossbite)
• Craniofacial anomalies (e.g. retrognathia, micrognathia, midface hypoplasia)
• Achondroplasia

Several chronic/complex/genetic conditions that require routine sleep studies:

• Neuromuscular diseases (spinal muscular atrophy, Duchenne muscular dystrophy)
• Trisomy 21 (Down syndrome)
• Congenital central hypoventilation syndrome (CCHS)
• Mucopolysaccharidoses (e.g. Hunter syndrome and Hurler syndrome)
• Sickle cell disease
• Cerebral palsy
• Prader-Willi syndrome
• Cystic fibrosis

Additional reasons for a sleep study are:

• Parasomnias (sleep walking, night terrors, sleep talking etc.)
• Monitoring and adjustment of CPAP (continuous positive airway pressure) or BIPAP (Bi-level positive airway pressure) machines
• Determination of respiratory needs for oxygen and ventilator support
• Restless leg syndrome and periodic limb movement disorder

Objective assessment with polysomnography is recommended in children with complex medical conditions who present with signs and symptoms of sleep-related breathing disorder.

One parent/guardian is encouraged to spend the night with the child, and will be responsible for them at all times. No other children are permitted in the sleep laboratory during the sleep study. Do not forget to bring the following items:

• Your child's ventilator (for example, CPAP or BiPAP) if this is used while at home. Bring all equipment (ventilator, masks, tubing etc).
• Anything else that your child usually sleeps with, such as a soft toy, or favourite book for bedtime stories. Linens, pillows, and blankets will be provided but please feel free to bring your child's own special pillows, duvets, or blankets to make your child feel more comfortable.
• Comfortable sleepwear, such as pyjamas. No one-piece footed pyjamas are allowed.
• Any medication, formula, special foods, or medical equipment your child usually needs. Please bring baby wipes and diapers, if necessary.
• For patients less than 18 months of age, please bring an extra pair of socks to cover the child's hands and prevent sensors and electrodes from being removed.

The day of the sleep study should be a normal day for your child. They can take their maintenance medications (unless directed otherwise by the referring physician) and there are no strict food or drink restrictions, though your child should limit caffeinated products (coffee, tea, chocolate, soda etc.) at least 24 hours before the study.

Wake your child earlier than normal and keep him/her awake and active throughout the day. Limit nap time to a minimum to maximise tiredness in advance of the study.

Bathe the child before coming to the sleep laboratory. Make sure that your child has clean, dry hair. Please do not apply product of any kind (e.g. oil, wax, or gel) in the hair or on the scalp. The child should have a light dinner before coming for the sleep study.

The sleep technologist will take you to your child's bedroom to get settled then talk to you about the sleep study in more detail. This is a chance for you to ask any questions you may have. Please inform the sleep technologist if your child has any allergies (e.g. to latex or tapes) or has other devices fitted (e.g. a pacemaker).

While awake and ready for bed, your child will be prepared for the study. The following sensors will be attached:

• Two sticky ECG electrodes on your child's chest to measure heart rhythm
• Two sticky electrodes on each leg to monitor your child's leg movements
• A soft sensor around the toe or finger to record oxygen levels and heart rate while asleep
• Two stretchy bands/belts around the chest, usually over the night clothes, to record breathing movements and efforts
• A small sensor on the chest to record sleeping position
• A sensor on the child's neck to monitor snoring vibrations
• A nasal cannula at the edge of the nostrils to monitor breathing
• A small sensor on the collarbone or forehead to record transcutaneous carbon dioxide
• Small gold disk electrodes in various locations on the child's face to measure eye movements and muscle tone during sleep.
• Additional gold disk electrodes on your child's scalp, attached with a washable paste, to monitor stages of sleep.

A video and audio recording of your child's sleep will also be made.

TV is available in the room for your child to watch during the preparation process. Cell phones and tablets can also be used to distract the child. Once all sensors have been attached, your child will be allowed to sleep and all electronic use should be discontinued. Your child will sleep on a bed with full length side rails.

A sleep study requires a one night stay at the hospital. You will be informed in advance if it is likely to be any longer (for example, if minimum six hours total sleep time is not met or if the optimal pressure is not yet obtained for patients on CPAP or BIPAP titration).

Sleep studies are painless, and no needles are involved. There are no risks or long term effects, so your child will be able to return to their normal routine once they leave. The child should eat a light dinner before coming to the test to avoid delays.

The sleep technologist will remove the sensors once enough data is obtained and your child wakes up in the morning. The sensors will be removed at 6am to 6.30am and you may leave once the discharge process is done. The sleep laboratory closes at 8.30am so please ensure you are ready to leave the unit before this time.

The doctor will review the analysis of the sleep study and will meet you within a week to discuss the results and any potential treatments.