Sleep Studies
Sleep laboratory studies are very helpful when indicated, but most common pediatric sleep problems do not require formal sleep laboratory testing. Most sleep problems resolve with behavioral treatments. Overnight polysomnography (PSG) and next-day multiple sleep latency tests (MSLTs) represent the most commonly used sleep studies. Clinical suspicion of any of the following disorders should prompt referral for sleep studies:
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Sleep-related seizurelike activity
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Sleep-related gastroesophageal reflux
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Nighttime asthma or persistent cough
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Attention deficit hyperactivity disorder (ADHD) [18] or Tourette syndrome associated with restless sleep and disrupted daytime functioning
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Restless legs syndrome (RLS) and periodic limb movement during sleep (PLMS) – Both are relatively common in these patients
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Recurrent rapid eye movement (REM) sleep behaviors
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Severe bruxism
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Snoring and hypopnea or apnea
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Recalcitrant or unexplained and daytime somnolence
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Suspected narcolepsy
MSLTs aid in clarifying unexplained excessive daytime sleepiness and narcolepsy symptoms but must be performed after the individual has stopped all psychotropic medications and has 2 weeks of sufficient sleep time.
Practice parameters for PSG and MSLT testing in children are based on the strength of evidence for respiratory [19] and nonrespiratory indications. [4] The articles define the "standard" recommendation as being generally accepted patient-care strategy based on overwhelming prospective studies and/or well-designed retrospective studies. "Guideline" recommendations are based on moderate clinical certainty, some number of well-controlled prospective and/or well-designed retrospective studies or a consensus of retrospective studies. The "option" recommendation reflects uncertain clinical use and inconclusive/conflicting evidence or expert opinion.
For respiratory indications, PSG is a standard indication for obstructive sleep apnea evaluation, following adenotonsillectomy for obstructive sleep apnea syndrome (OSAS), craniofacial anomalies that disrupt the upper airway, and neurological disorders (trisomy 21, Prader-Willi syndrome, and myelomeningocele). PSG should be standard in the titration of positive airway pressure in OSAS. Guideline recommendations are present for use of PSG in the assessment of congenital central alveolar hypoventilation syndrome, sleep-related hypoventilation related to neuromuscular disorders or chest wall deformities, and selected cases of primary sleep apnea of infancy. In infants with clinical evidence of sleep-related breathing disorder, PSG is a guideline recommendation for those with an apparent life-threatening event. In children being considered for adenotonsillectomy to treat obstructive sleep apnea, PSG is also only a guideline recommendation.
For nonrespiratory indications, standard use of PSG is indicated in children suspected of having periodic limb movement disorder (or RLS). MSLT preceded by nocturnal PSG is indicated for children being evaluated for narcolepsy. In children with non-REM (NREM) parasomnias, epilepsy, or nocturnal enuresis, PSG is a guideline recommendation if there is suspicion of sleep-disordered breathing or periodic limb movement disorder. MSLT preceded by nocturnal PSG is an option in children suspected of having hypersomnia for causes other than narcolepsy. PSG with an expanded EEG montage is an option in children to confirm a diagnosis of an atypical or potentially injurious parasomnia or to differentiate parasomnia from sleep-related epilepsy. PSG is an option for evaluating children suspected of having RLS.
Laboratory Studies
Routine dipstick urinalysis, growth/height trajectory, and blood pressure are used to exclude other medical causes of enuresis. Lumbar puncture to measure hypocretin and genetic testing may be helpful for diagnosing narcolepsy.
