Diagnosing and Treating Sleep Issues

Ruth McDonald, MD
Vice President and Associate Chief Medical Officer, Medical Operations
Seattle Children’s

Nearly all parents express concern about their child’s sleep at some point. It’s always important to assess these concerns (which can have significant impact on family function) and determine whether they are rooted in (mis)perception, a behavioral issue, or an underlying medical issue.

Initial assessment and first steps:

  1. Evaluate the impact of “poor sleep” on daytime function and alertness. Red flags include behavioral problems, cognitive and school performance issues, and poor overall health.
  2. Ask about the child’s sleep habits, and coach for good sleep hygiene.
  3. Assess for indications of obstructive sleep apnea, like enlarged tonsils and adenoids, open-mouth breathing, and reports of snoring.
  4. Consider the patient’s history. Children with special needs, including genetic syndromes and neurological issues, have a higher risk of organic sleep disorders.

To treat insomnia:

  1. Coach for appropriate sleep environment and sleep habits, such as consistent wake and sleep times every day, limits on caffeine, and removing electronics and phones from the sleeping space.
  2. Assess the family dynamic when the child can’t meet their own (or their family’s) expectation for sleep. Behavioral coaching – for parents and child – may be needed when there’s negative interaction around sleep and waking.
  3. Encourage parents to model good sleep habits.
  4. Any consideration of sleep medication should come after an assessment for underlying causes of sleep problems and in conjunction with behavioral modification. It’s important to note that, at this time, there are no FDA-approved medications for sleep in children in the U.S.

 Refer when:

  1. Patients might have a breathing issue that interferes with sleep.
  2. Sleep issues persist even after coaching for sleep hygiene.
  3. There is a negative dynamic when the child is unable to meet their, or their family’s, expectations around sleep.
  4. The assessment or coaching interventions needed are beyond the scope/time allotment of a primary care visit.


  1. Maida Chen will present Up When Everyone Else Is Sleeping: Adolescent Sleep Problems at the pediatric grand rounds on March 8, 2018 at Seattle Children’s Hospital.
  2. Podcasts with Seattle Mama Doc Dr. Wendy Sue Swanson on topics ranging from “why babies wake up” to “improving parents’ sleep”
  3. The National Sleep Foundation