Last reviewed: 2 Feb 2021
Last updated: 02 Sep 2020



History and exam

Key diagnostic factors

  • snoring, gasping, choking while asleep (obstructive sleep apnea)
  • night sweats (obstructive sleep apnea)
  • breathing through an open mouth (obstructive sleep apnea)
  • sleeping with hyperextended neck (obstructive sleep apnea)
  • restless sleep and periodic limb movements (obstructive sleep apnea)
  • secondary nocturnal enuresis (obstructive sleep apnea)
  • hypertension (obstructive sleep apnea)
  • 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 apnea)
  • sleep attacks (narcolepsy)
  • refusal to sleep in own bedroom (sleep association or limit-setting disorder)

Risk factors

  • craniofacial abnormalities (obstructive sleep apnea)
  • adenotonsillar hypertrophy (obstructive sleep apnea)
  • macroglossia (obstructive sleep apnea)
  • gastroesophageal reflux (obstructive sleep apnea)
  • allergic rhinitis (obstructive sleep apnea)
  • environmental tobacco smoke exposure (obstructive sleep apnea)
  • obesity (obstructive sleep apnea)
  • hypotonia (obstructive sleep apnea)
  • alcohol (obstructive sleep apnea)
  • medications (obstructive sleep apnea)
  • Down syndrome (obstructive sleep apnea)
  • evening light exposure (delayed sleep phase disorder/syndrome)
  • inconsistent parenting style (limit-setting disorder)
  • age <6 years (behavioral insomnia of childhood or obstructive sleep apnea)
  • 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┬áhypocretin 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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