Last reviewed: 3 Feb 2021
Last updated: 02 Sep 2020



History and exam

Key diagnostic factors

  • presence of risk factors
  • snoring, gasping, choking while asleep (obstructive sleep apnoea)
  • night sweats (obstructive sleep apnoea)
  • breathing through an open mouth (obstructive sleep apnoea)
  • sleeping with hyperextended neck (obstructive sleep apnoea)
  • restless sleep and periodic limb movements (obstructive sleep apnoea)
  • secondary nocturnal enuresis (obstructive sleep apnoea)
  • hypertension (obstructive sleep apnoea)
  • inability to fall asleep (sleep association disorder)
  • cataplexy (narcolepsy)
  • hypnagogic or hypnopompic hallucinations (narcolepsy)
  • sleep paralysis (narcolepsy)
  • erratic sleep schedule (delayed sleep phase disorder/syndrome)

Other diagnostic factors

  • excessive daytime sleepiness
  • difficulty awakening in the morning
  • sleepwalking or talking (obstructive sleep apnoea)
  • sleep attacks (narcolepsy)
  • refusal to sleep in own bedroom (sleep association or limit-setting disorder)

Risk factors

  • craniofacial abnormalities (obstructive sleep apnoea)
  • adenotonsillar hypertrophy (obstructive sleep apnoea)
  • macroglossia (obstructive sleep apnoea)
  • gastro-oesophageal reflux (obstructive sleep apnoea)
  • allergic rhinitis (obstructive sleep apnoea)
  • environmental tobacco smoke exposure (obstructive sleep apnoea)
  • obesity (obstructive sleep apnoea)
  • hypotonia (obstructive sleep apnoea)
  • alcohol (obstructive sleep apnoea)
  • medications (obstructive sleep apnoea)
  • Down's syndrome (obstructive sleep apnoea)
  • evening light exposure (delayed sleep phase disorder/syndrome)
  • inconsistent parenting style (limit-setting disorder)
  • age <6 years (behavioural insomnia of childhood or obstructive sleep apnoea)
  • adolescent age (delayed sleep phase disorder/syndrome)
  • distractions in bedroom (delayed sleep phase disorder/syndrome)

Diagnostic investigations

1st investigations to order

  • sleep diary
  • polysomnogram (PSG)
  • multiple sleep latency test (MSLT)

Investigations to consider

  • lateral neck films
  • nasal endoscopy
  • overnight oximetry
  • actigraphy
  • audiovisual recording
  • HLA typing

Emerging tests

  • pneumogram
  • cerebrospinal fluid hypocretin levels

Treatment algorithm


Associate Medical Director

Center for Pediatric Sleep Disorders

Boston Children's Hospital

Assistant Professor of Pediatrics

Harvard Medical School




DR declares that he has no competing interests.

Peer reviewersVIEW ALL

Consultant in Paediatric Neurodisability

Evelina Children's Hospital

St Thomas' Hospital




PG is lead applicant on the ongoing MENDS trial, which is concerned with the use of melatonin in children with neurodevelopmental disorders and impaired sleep.

Associate Professor of Pediatrics

Division of Pediatric Pulmonary & Sleep Medicine

University of Chicago




LKG is an author of a number of references cited in this topic.

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