Synopsis
Assess paediatric sleep in developmental and family context, distinguish behavioural insomnia and normal parasomnias from respiratory, neurological and mental-health disease, implement collaborative behavioural treatment, and reserve medicine for selected specialist indications with safe monitoring.
- First-line assessment is a sleep history plus a 2-week diary recording sleep opportunity, estimated sleep, awakenings, naps, events, caffeine, screens and daytime effects.
- Set one consistent wake time every day, provide age-appropriate sleep opportunity, use morning light and daytime activity, and build a predictable calm wind-down.
- For behavioural insomnia, first-line management is a collaboratively chosen routine plus behavioural strategy such as bedtime fading, graduated checking or consistent low-interaction return to bed.
- Bedtime fading starts near the time the child actually falls asleep, then advances earlier in 5–15-minute steps once sleep onset is reliably quick.
- Typical night terrors occur from deep sleep in the first part of the night with autonomic distress, poor responsiveness and no next-day memory; protect from injury and do not force awakening.
- Polysomnography is the reference-standard test for suspected obstructive sleep apnoea, but referral and local prioritisation depend on clinical severity and service pathway.
- Melatonin is not first-line for ordinary bedtime resistance. Consider it only after behavioural and environmental work when a specialist indication and product-specific plan are clear.
Key red flags
Cyanosis, prolonged breathing pauses, marked chest recession, stridor or difficult arousal during sleep requires urgent respiratory assessment.
Habitual loud snoring with witnessed apnoeas, gasping, restless sleep, morning headache, growth concern or daytime behavioural change suggests obstructive sleep apnoea.
Stereotyped events, tonic posturing, rhythmic jerking, incontinence, lateral tongue injury, prolonged confusion or events many times nightly raises nocturnal epilepsy.
Cataplexy, irresistible daytime sleep attacks, sleep paralysis or hypnagogic hallucinations requires specialist evaluation for narcolepsy.
Painful urge to move the legs at rest, relief with movement and evening predominance suggests restless legs; assess iron risk and mimics.
Frequent dangerous sleepwalking, leaving the home, injury, safeguarding concern or family collapse requires an immediate safety plan and specialist support.
Night terrors beginning after age 5, or continuing beyond age 12, should prompt neurological assessment under NICE guidance rather than automatic reassurance.
Investigation priorities
Quantify schedule, opportunity, latency, waking, naps, events, triggers and daytime function before and during intervention.
Measure sleep state, airflow, respiratory effort, gas exchange, heart rhythm and movements when sleep-disordered breathing is suspected.
Management branches
Sleep timing, night events or daytime function concerns the family.
- Screen for respiratory compromise, seizure, acute mental-health risk, overdose, regression and safeguarding or supervision danger.
- Take an age-appropriate sleep, health, medicine and environmental history and start a 2-week diary with wake time, naps and events.
- Classify behavioural, circadian, respiratory, movement, parasomnia or neurological pattern and investigate only what the clinical question requires.