Common sleep disorders in children: assessment and treatment
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* Farah Thabet
* Brahim Tabarki

## Abstract

Pediatric sleep disorders are a common, mainly among children with pre-existing disabilities, neurological conditions, and neurodevelopmental disorders. The consequences are variable, and sleep disorders may be associated with deficits in neurocognitive performance and growth failure. Rising awareness about sleep disorders among pediatricians will improve the early diagnosis and management of these disorders. This review describes normal sleep patterns in infants and children and provide a recent update on common sleep disorders that improve the diagnosis and treatment of children with sleep disorders.

**P**ediatric sleep disorders are common; their prevalence ranges from 10–28%.1,2 Children with pre-existing disabilities, neurological conditions, and neurodevelopmental disorders may be at a higher risk: up to 80% of children with epilepsy, 83% with autism spectrum disorder, and 73% with attention deficit hyperactivity disorder have comorbid sleep problems.3 An increased incidence of sleep problems has been observed following the coronavirus disease 2019 (COVID-19) pandemic and the use of electronic media devices has been observed.4,5

Sleep plays a crucial role in children’s brain development and growth, learning, memory processes, school performance, and general health. The consequences of sleep disturbances include daytime sleepiness, deficits in neurocognitive performance, poor school/academic performances, and growth failure.6,7

Pediatricians should be familiar with normal childhood sleep patterns and common sleep disorders. This review describes normal sleep patterns in infants and children and provides a recent update on common sleep disorders to improve awareness, diagnosis and treatment of children with sleep disorders.

## Normal sleep patterns in infants and children

Sleep patterns and structure changes with age during the first years of life. Neonates do not have circadian rhythm, and require the greatest total sleep time. The circadian rhythm (active; rapid eye movement [REM], and quiet; non-rapid eye movement sleep [NREM]) begins to emerge at 10-12 weeks. NREM sleep is further subdivided into three stages from stage 1, the lightest sleep, to stage 3, deepest sleep. When children grow older, sleep time declines.8,9 **Table 1** shows the approximate sleep needs at various age.10 Every child has unique sleep requirements; therefore, these are global norms based on age. The cultural milieu and environment are also important for understanding and evaluating child sleep duration and patterns.

View this table:
[Table 1](http://nsj.org.sa/content/28/2/85/T1)

Table 1 
- The average sleep needs at various age.

## Clinical assessment

Obtaining a detailed history, followed by comprehensive general and neurological physical examinations, appear to be a cornerstone for diagnosing pediatric sleep problems. The sleep history obtained from the parent/caregiver or child should focus on bedtime and rise time, sleep environment (e.g., child’s bed or parents’ bed), sleep-onset time, sensation of discomfort in the extremities, snoring, apneic events that occur during sleep, restless sleep, unusual nighttime events such as sleepwalking or confusion, daytime sleepiness, mood disturbances, alcohol, caffeine, and medications. The history should also focuses on the developmental milestones, the assessment of cognitive function, and any pre-existing neurological conditions, such as cerebral palsy or neurodevelopmental disorders, like autism. Physical examination should focus on the height, weight, body mass index, blood pressure, clubbing, cyanosis, dysmorphic features, craniofacial anomalies, tonsillar or adenoid hypertrophy, examination of the upper airway and nasal passages, auscultation of the lungs and heart, and neurological examination.

## Specific sleep disorders in children and adolescents. Pediatric chronic insomnia

Insomnia is defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunities and circumstances for sleep.11 Pediatric insomnia is common, with prevalence ranging from 10–40%. There is a high risk in children with pre-existing neurodevelopmental, or chronic medical conditions.12 Insomnia can be divided into 3 groups: transient sleep disturbances, psychophysiological insomnia, and behavioral insomnia which is the most important in childhood. The role of genetic and epigenetic influences is also gaining interest.13 Untreated chronic insomnia has potentially detrimental consequences, including neurobehavioral developmental problems, inattentiveness, hyperactivity impulsivity, emotional symptoms, poor school performance, and academic underachievement.14

The diagnosis of chronic insomnia in children is clinical. Polysomnography is rarely indicated.

The first step in the treatment of chronic insomnia is based on behavior interventions and good sleep practice.15 Pharmacological treatments mainly include hypnotic drugs (melatonin and sedating antihistamines) (**Table 2**). Several meta-analyses support melatonin as the safest choice for children, including children with neurodevelopmental disabilities such as autism spectrum disorders.16-18 The recommended dose of melatonin is 3 to 5 mg, 30 min before bedtime.

View this table:
[Table 2](http://nsj.org.sa/content/28/2/85/T2)

Table 2 
- Pediatric sleep disorders pharmacotherapy.

## Obstructive sleep apnea (OSA)

The OSA occurs in 1 to 5% of children,19 and is characterized by partial or complete upper airway collapse or obstruction despite thoracic and abdominal respiratory effort, which disrupts normal sleep patterns and ventilation. Obstruction is primarily due to hypertrophied tonsils and adenoids. Other etiological factors include obesity, neuromuscular disorders, Down syndrome, vitamin D deficiency, and malformations of the upper airway.19

Snoring and apneas are the classic signs of OSA. Primary snoring is the mildest form of OSA, occurring in 8% of children. The nocturnal symptoms of childhood OSA include habitual snoring, unusual sleeping positions (e.g., hyperextended neck, seated with open mouth), sleep-related paradoxical breathing, bed wetting, and morning headaches. Clinical manifestations of OSA during daytime include decreased attention, poor school performance, hyperactivity, and sleepiness.20 Patients with untreated OSA may develop metabolic syndrome, systemic hypertension, failure to thrive, or pulmonary hypertension.20

With a full history and physical examination, nocturnal polysomnography is the gold standard test to confirm OSA and its severity.21 Newer methods such as overnight pulse oximetry data can diagnose OSA. Home sleep apnea tests are not recommended for diagnosis of OSA in children.22 Other tests to evaluate children with OSA may include chest x-ray, cardiac evaluation, iron studies, and vitamin D level.

Management options of pediatric OSA includes medical treatments and surgical interventions, depending on the severity of the OSA. For mild to moderate OSA, intranasal corticosteroids at bedtime, usually in combination with leukotriene inhibitors, are the first line of treatment.23,24 If there is adenotonsillar hypertrophy, adenotonsillectomy is the mainstay of treatment.25 Other surgical options, such as supraglottoplasty, have limited data.26 Continuous positive airway pressure (CPAP) breathing device or bilevel PAP (in patients with neuromuscular disorders) should be considered for residual OSA.27 Any risk factor such as obesity or allergic rhinitis must be treated aggressively. In patients with residual OSA, rapid maxillary expansion (which is applied through orthodontic appliances, in which pressure is directly applied to the maxillary suture via anchor teeth) and myofunctional therapy, which consists of isotonic and isometric exercises targeted to oral and oropharyngeal structures, should be discussed.28,29

## Narcolepsy

Narcolepsy is a chronic neurological disorder characterized by excessive daytime sleepiness, cataplexy, hypnagogic and hypnopompic hallucinations, and sleep paralysis.30 It is further divided into 2 types according to the 3rd edition of the International Classification of Sleep Disorders (ICSD-3): type I, with cataplexy and/or deficient hypocretin-1 in cerebrospinal fluid; and type II, with normal hypocretin-1 levels with an absence of cataplexy.11 Cataplexy is characterized by a sudden and transient loss of skeletal muscle tone; the consciousness is preserved. It is generally triggered by emotions.31

It is estimated that approximately 1 in 2000 individuals are affected by narcolepsy; children with attention deficit hyperactivity disorder are at higher risk.32,33 Interestingly, up to 50% of individuals with narcolepsy are undiagnosed.32 Narcolepsy may present with a wide range of manifestations explaining, partly, its misdiagnosis, and include mainly excessive daytime sleepiness, sleep paralysis, and sleep disruption. Other possible symptoms include depression, aggression, and hallucinations.30

The ICSD-3 recommends polysomnography followed by the multiple sleep latency test to establish a diagnosis of narcolepsy.11 In narcolepsy type 1, hypocretin-1 is low in the cerebrospinal fluid, and can be used as diagnostic tool.30

The management options for children with narcolepsy include counseling and pharmacological treatment (Table 2). The patient and family should be informed that there is no cure for narcolepsy. Behavioral, lifestyle changes, avoiding of alcohol, and regular physical activity are important components of the treatment.34,35 Pharmacologic therapy for narcolepsy depends mainly on the dominant symptoms that impair the quality of life of the child.34,35 First-line treatment for excessive daytime sleepiness include methylphenidate, amphetamine, or modafinil. Conversely, if cataplexy is more predominant, sodium oxybate (+-hydroxybutyrate) is recommended.36 Tricyclics, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors are also effective against cataplexy with dysphoria.34,35

## Restless leg syndrome (RLS)

The prevalence of RLS in childhood is approximately 7.7% of persons referred to a sleep center.37 It occurs equally among boys and girls. RLS is multifactorial; iron deficiency, vitamin D deficiency, medications, diabetes Mellitus, sleep instability, and genetic susceptibility are the main causes.38,39

The RLS is characterized by frequent recurrent movements during sleep, involving large muscle groups, and is described by parents as frequent repositioning or disruption of bed sheets. Essential diagnostic criteria according to International Restless Legs Syndrome Study Group are the following (1) duration of symptoms more than 3 months; (2) movements during sleep that occur for at least 3 nights/week; (3) video polysomnography showing five or more large body movements per hour; (4) presence of symptoms, which include sleepiness, behavioral concerns, or cognitive deficits; and (5) exclusion of other conditions that might cause restless sleep. The physical examination is usually normal.40

The first line treatment of childhood RLS is the correction of systemic iron deficiency (ferritin levels below 30 ng/ml) which may take weeks or months, together with correction of vitamin D deficiency.39,41 It is also crucial to avoid medications that tend to trigger or worse RLS, such as risperidone and antiemetics. Low doses of gabapentin at bedtime may help relieve discomfort and pain symptoms associated with RLS. Evening light exercise is advised. The use of dopaminergic agents such as ropinirole, pramipexole, or rotigotine skin patches in adolescents, is mainly empiric.38

## Parasomnias

Parasomnias affect up to 50% of children.42 Sleepwalking (somnambulism), confusional arousals, sleep-talking, and sleep terrors are the most common parasomnias in children. Parasomnias that happen during NREM sleep include sleepwalking, sleep-talking, and sleep terrors, whereas nightmares are REM-related parasomnias that happen more during the second part of the night. Common triggers for parasomnias include obstructive sleep apnea, sleep deprivation, gastroesophageal reflux, and medication.11,43

In sleepwalking, the child usually sits up in the bed and opens the eyes, and/or crawls around the bed, or develops more complex and agitated episodes, leaving the house or becoming violent. The child typically has no memory of the event. Sleep terrors are characterized by sudden arousal accompanied by autonomic (tachycardia, sweating, and mydriasis) and behavioral manifestations of intense fear. The child is not responsive, agitated, with complete amnesia. Nightmares are characterized by vivid and terrifying well-remembered dreams; associated with negative emotions such as anxiety or fear, anger but are not as intense as sleep terrors. Nightmares seems very real for children.43

Differential diagnoses of parasomnias include certain types of sleep-related epilepsy such as frontal lobe or temporal lobe epilepsy. Overnight electroencephalogram may be indicated.44

The treatment of parasomnias is mainly based on reassurance, reduction of precipitating factors, and increase in total sleep time. Parents must be aware that parasomnia is a neurodevelopmental phenomenon that often resolves spontaneously during adolescence. Healthy sleep habits are important; adolescents should avoid caffeine. Preventive measures to secure a safe home must be taken to prevent patients from hurting themselves. During the event, parents must avoid awakening the child because this might scare her/him. Instead, they can gently guide the child back to the bed. Pharmacological treatment of parasomnias may be indicated in children who exhibit violent or harmful behaviors. Benzodiazepines are usually used as the first-line treatment.45 In the case of non-response, tricyclic antidepressants may be used (Table 2). L-5-hydroxytryptophan may be helpful in sleep disorders.45 Treatment for nightmares involves reassurance and behavioral therapy, if necessary.

## Circadian rhythm sleep-wake disorders

Circadian rhythm sleep disorders are prevalent in pediatric population, including in children with neurodevelopmental disorders. There are different forms of the disorder, including delayed sleep-wake phase disorder, advanced sleep-wake phase disorder, and shift work disorder. Delayed sleep-wake phase disorder is the most frequent sleeping disorder during adolescence, as it affects up to 16% of adolescents.46 Patients typically report difficulties in initiating sleep and/or with waking in the morning.46.47 The therapy usually starts with modifying life style such as no daytime naps, regular bedtimes and wake times during the week and weekends, no stimulating drinks or food in the evening, and no electronics in the bedroom. If this fails, chronotherapy is indicated, where bedtime is gradually delayed until the desired hour of falling asleep is reached. Melatonin, administered 3 to 5 h before bedtime, can sometimes help to reset the sleep-wake cycle.47

## Conclusion

Pediatric sleep problems are common and can compromise social, academic, and neurobehavioral functioning. Therefore, the concept of sleep medicine should be integrated into pediatric practice. The pediatrician has a major role in identifying children’s sleep problems in order to improve management and prevent impact on cognitive outcomes.

## Footnotes

*   **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company.

*   Copyright: © Neurosciences

Neurosciences is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work.

## References

1.  1.Byars KC, Yolton K, Rausch J, Lanphear B, Beebe DW. Prevalence, patterns, and persistence of sleep problems in the first 3 years of life. Pediatrics 2012; 129: e276–e284.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1542/peds.2011-0372&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=22218837&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=000300395100004&link_type=ISI) 

2.  2.Ipsiroglu OS, Fatemi A, Werner I, Tiefenthaler M, Urschitz MS, Schwarz B. [Prevalence of sleep disorders in school children between 11 and 15 years of age]. Wien Klin Wochenschr 2001; 113: 235–244. German
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=11383383&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=000168271600005&link_type=ISI) 

3.  3.Ogundele MO, Yemula C. Management of sleep disorders among children and adolescents with neurodevelopmental disorders: A practical guide for clinicians. World J Clin Pediatr 2022; 11: 239–252.
    
    

4.  4.Liu Z, Tang H, Jin Q, Wang G, Yang Z, Chen H. Sleep of preschoolers during the coronavirus disease 2019 (COVID-19) outbreak. J Sleep Res 2021; 30: e13142.
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

5.  5.Chindamo S, Buja A, DeBattisti E, Terraneo A, Marini E, Gomez Perez LJ. Sleep and new media usage in toddlers. Eur J Pediatr 2019; 178: 483–489.
    
    

6.  6.Ward TM, Archbold K, Lentz M, Ringold S, Wallace CA, Landis CA. Sleep disturbance, daytime sleepiness, and neurocognitive performance in children with juvenile idiopathic arthritis. Sleep 2010; 33: 252–259.
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=20175409&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

7.  7.Nosetti L, Zaffanello M, Katz ES, Vitali M, Agosti M, Ferrante G, et al. Twenty-year follow-up of children with obstructive sleep apnea. J Clin Sleep Med 2022; 18: 1573–1581.
    
    

8.  8.Elias MF, Nicolson NA, Bora C, Johnston J. Sleep/wake patterns of breastfed infants in the first 2 years of life. Pediatrics 1986; 77: 322–329.
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=3951913&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=A1986A317600009&link_type=ISI) 

9.  9.Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics 2003; 111: 302–307.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1542/peds.111.2.302&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=12563055&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=000180709100028&link_type=ISI) 

10. 10.National Sleep Foundation (NSF). How much sleep do we really need? [nationalsleepfoundation.org/article/sleep](http://nationalsleepfoundation.org/article/sleep). Accessed August 6, 2022. [www.sleepfoundation.org](http://www.sleepfoundation.org)
    
    

11. 11.Sateia MJ. International classification of sleep disorders-third edition: highlights and modifications. Chest 2014; 146: 1387–1394.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1378/chest.14-0970&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=25367475&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

12. 12.Bruni O, Angriman M. Pediatric insomnia: new insights in clinical assessment and treatment options. Arch Ital Biol 2015; 153: 144–156.
    
    

13. 13.Bruni O, Sette S, Angriman M, Baumgartner E, Selvaggini L, Belli C, et al. Clinically Oriented Subtyping of Chronic Insomnia of Childhood. J Pediatr 2018; 196: 194–200.e1.
    
    

14. 14.Fernandez-Mendoza J, Lenker KP, Calhoun SL, Qureshi M, Ricci A, Bourchtein E, et al. Trajectories of insomnia symptoms from childhood through young adulthood. Pediatrics 2022; 149: e2021053616.
    
    

15. 15.Dewald-Kaufmann J, de Bruin E, Michael G. Cognitive behavioral therapy for insomnia (CBT-i) in school-aged children and adolescents. Sleep Med Clin 2019; 14: 155–165.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1016/j.jsmc.2019.02.002&link_type=DOI) 

16. 16.Bruni O, Alonso-Alconada D, Besag F, Biran V, Braam W, Cortese S, et al. Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol 2015; 19: 122–133.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1016/j.ejpn.2014.12.007&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=25553845&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

17. 17.Schroder CM, Banaschewski T, Fuentes J, Hill CM, Hvolby A, Posserud MB, et al. Pediatric prolonged-release melatonin for insomnia in children and adolescents with autism spectrum disorders. Expert Opin Pharmacother 2021; 22: 2445–254.
    
    

18. 18.Williams Buckley A, Hirtz D, Oskoui M, Armstrong MJ, Batra A, Bridgemohan C, et al. Practice guideline: treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2020; 94: 392–404.
    
    

19. 19.Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 2008; 5: 242–252.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1513/pats.200708-135MG&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=18250218&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

20. 20.Savini S, Ciorba A, Bianchini C, Stomeo F, Corazzi V, Vicini C, et al. Assessment of obstructive sleep apnoea (OSA) in children: an update. Acta Otorhinolaryngol Ital 2019; 39: 289–297.
    
    

21. 21.Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130: e714–e755.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1542/peds.2012-1672&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=22926176&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=000309409300035&link_type=ISI) 

22. 22.Kaditis A, Kheirandish-Gozal L, Gozal D. Pediatric OSAS: Oximetry can provide answers when polysomnography is not available. Sleep Med Rev 2016; 27: 96–05.
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=26146027&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

23. 23.Chan CC, Au CT, Lam HS, Lee DL, Wing YK, Li AM. Intranasal corticosteroids for mild childhood obstructive sleep apnea–a randomized, placebo-controlled study. Sleep Med 2015; 16: 358–363.
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

24. 24.Kheirandish-Gozal L, Bandla HP, Gozal D. Montelukast for Children with obstructive sleep apnea: results of a double-blind, randomized, placebo-controlled trial. Ann Am Thorac Soc 2016; 13: 1736–41.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1513/AnnalsATS.201606-432OC&link_type=DOI) 

25. 25.Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013; 368: 2366–2376.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1056/NEJMoa1215881&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=23692173&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=000320601700006&link_type=ISI) 

26. 26.Lee CF, Hsu WC, Lee CH, Lin MT, Kang KT. Treatment outcomes of supraglottoplasty for pediatric obstructive sleep apnea: A meta-analysis. Int J Pediatr Otorhinolaryngol 2016; 87: 18–27.
    
    

27. 27.Rana M, August J, Levi J, Parsi G, Motro M, DeBassio W. Alternative Approaches to Adenotonsillectomy and Continuous Positive Airway Pressure (CPAP) for the Management of Pediatric Obstructive Sleep Apnea (OSA): A Review. Sleep Disord 2020; 2020: 7987208.
    
    

28. 28.Camacho M, Chang ET, Song SA, Abdullatif J, Zaghi S, Pirelli P, et al. Rapid maxillary expansion for pediatric obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 2017; 127: 1712–1719.
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

29. 29.Zhang F, Tian Z, Shu Y, Zou B, Yao H, Li S, et al. Efficiency of oro-facial myofunctional therapy in treating obstructive sleep apnoea: A meta-analysis of observational studies. J Oral Rehabil 2022; 49: 734–745.
    
    

30. 30.Bassetti CLA, Adamantidis A, Burdakov D, Han F, Gay S, Kallweit U, et al. Narcolepsy - clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol 2019; 15: 519–539.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1038/s41582-019-0226-9&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=31324898&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

31. 31.Wang YG, Benmedjahed K, Lambert J, Evans CJ, Hwang S, Black J, et al. Assessing narcolepsy with cataplexy in children and adolescents: development of a cataplexy diary and the ESS-CHAD. Nat Sci Sleep 2017; 9: 201–211.
    
    

32. 32.Dye TJ, Gurbani N, Simakajornboon N. Epidemiology and pathophysiology of childhood narcolepsy. Paediatr Respir Rev 2018; 25: 14–8.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1016/j.prrv.2016.12.005&link_type=DOI) 

33. 33.Kim J, Lee GH, Sung SM, Jung DS, Pak K. Prevalence of attention deficit hyperactivity disorder symptoms in narcolepsy: a systematic review. Sleep Med 2020; 65: 84–88.
    
    

34. 34.Franceschini C, Pizza F, Antelmi E, Folli MC, Plazzi G. Narcolepsy treatment: pharmacological and behavioral strategies in adults and children. Sleep Breath 2020; 24: 615–627.
    
    

35. 35.Bassetti CLA, Kallweit U, Vignatelli L, Plazzi G, Lecendreux M, Baldin E, et al. European guideline and expert statements on the management of narcolepsy in adults and children. Eur J Neurol 2021; 28: 2815–2830.
    
    

36. 36.Lecendreux M, Plazzi G, Dauvilliers Y, Rosen CL, Ruoff C, Black J, et al. Long-term safety and maintenance of efficacy of sodium oxybate in the treatment of narcolepsy with cataplexy in pediatric patients. J Clin Sleep Med 2022; 18: 2217–2227.
    
    

37. 37.DelRosso LM, Ferri R. The prevalence of restless sleep disorder among a clinical sample of children and adolescents referred to a sleep centre. J Sleep Res 2019; 28: e12870.
    
    

38. 38.Howard H, Kamat D. Restless Legs Syndrome in Children. Pediatr Ann 2018; 47: e504–e506.
    
    

39. 39.Prono F, Bernardi K, Ferri R, Bruni O. The Role of Vitamin D in Sleep Disorders of Children and Adolescents: A Systematic Review. Int J Mol Sci 2022; 23: 1430.
    
    

40. 40.Picchietti D, Bruni O, de Weerd A, Durmer JS, Kotagal S, Owens JA, et al. International restless legs syndrome study group. Pediatric restless legs syndrome diagnostic criteria: an update by the international restless legs syndrome study group. Sleep Med 2013; 14: 1253–1259.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1016/j.sleep.2013.08.778&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=24184054&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

41. 41.Trotti LM, Becker LA. Iron for the treatment of restless legs syndrome. Cochrane Database Syst Rev 2019; 1: CD007834.
    
    

42. 42.Petit D, Touchette E, Tremblay RE, Boivin M, Montplaisir J, et al. Dyssomnias and parasomnias in early childhood. Pediatrics 2007;119: e1016–e1025.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1542/peds.2006-2132&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=17438080&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 
    
    [Web of Science](http://nsj.org.sa/lookup/external-ref?access_num=000246153300041&link_type=ISI) 

43. 43.Bruni O, DelRosso LM, Melegari MG, Ferri R. The Parasomnias. Child Adolesc Psychiatr Clin N Am 2021; 30: 131–142.
    
    

44. 44.1.  Panayiotopoulos CP
    
    Vigevano, F, Specchio N. Parasomnias in Early Childhood that Mimic Epileptic Seizures. In: Panayiotopoulos CP, editor. Atlas of Epilepsies. Second edition. Springer; London (UK): 2010. [https://doi.org/10.1007/978-1-84882-128-6_96](https://doi.org/10.1007/978-1-84882-128-6_96).
    
    

45. 45.Idir Y, Oudiette D, Arnulf I. Sleepwalking, sleep terrors, sexsomnia and other disorders of arousal: the old and the new. J Sleep Res 2022; 31: e13596.
    
    

46. 46.Sivertsen B, Pallesen S, Stormark KM, Bøe T, Lundervold AJ, Hysing M. Delayed sleep phase syndrome in adolescents: prevalence and correlates in a large population based study. BMC Public Health 2013; 13: 1163.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1186/1471-2458-13-1163&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=24330358&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom) 

47. 47.Pavlova M. Circadian Rhythm Sleep-Wake Disorders. Continuum (Minneap Minn) 2017; 23: 1051–1063.
    
    [CrossRef](http://nsj.org.sa/lookup/external-ref?access_num=10.1212/CON.0000000000000499&link_type=DOI) 
    
    [PubMed](http://nsj.org.sa/lookup/external-ref?access_num=28777176&link_type=MED&atom=%2Fnsj%2F28%2F2%2F85.atom)