Introduction to Sleep Health

Good health and childhood development rely heavily on sleep throughout all developmental stages

Kinan's Story

Kinan, a 10-year-old Native American boy, and his mother are at their local Indian Health Service clinic for an annual well child visit. During the appointment, his mother reports that he snores loudly when sleeping, and has nasal congestion. She reports he is getting in trouble at school for acting out in class. Kinan is falling asleep in class as well. Ms. Begay, FNP, is Kinan’s PCP who practices in the pueblo in which Kinan lives.

Family Information: Kinan lives with both parents, two siblings, and his maternal grandparents. Kinan’s father works in the construction industry and often travels far from home for weeks at a time. Several extended family members are obese. Two members of Kinan’s extended family have been diagnosed with Type 2 diabetes.

Social and environmental factors of the pueblo

  • Many roads are unpaved with a great deal of dust much of the year
  • Electrical service is unreliable and many homes are not wired for electricity
  • WiFi is not available in this pueblo
  • Most homes are heated by wood burning stoves
  • Many families in the pueblo have livestock
  • Both the school and health clinic are within walking distance for all residences
  • The nearest hospital is 70 miles away
Expert Insights

BEARS Screening for Kinan

As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Kinan's family.

Bedtime Problems

No bedtime problems are reported. Kinan falls asleep within 15-20 minutes of going to bed. There are no TV or electronic devices in his room. He shares a bed with his younger brother. Kinan’s brother told their mom that he has a hard time sleeping because Kinan snores loudly and gasps for air in his sleep. Kinan's bedtime is 9:00 pm during the school year. He gets up at 7:00 am.

Expert Insights
  • Snoring loudly and gasping for air during sleep may be signs of sleep apnea. Refer to Sleep Disordered Breathing Module.
  • Although electronic media use is not a factor here, it is a common cause of decreased sleep duration.
Excessive Daytime Sleepiness

Kinan has a hard time getting up in the morning. His mother has to tell him several times to get up. Kinan’s teacher sent a note home reporting that he falls asleep during class and awakens himself with a loud snore, which interrupts fellow students.

Expert Insights
  • Difficulty waking up, falling asleep in class, hyperativity and snoring may be signs of sleep disordered breathing or other sleep problems and need further investigation.

Kinan wakes up "to go to the bathroom" at least once per night.

Expert Insights
  • Nighttime awakenings may be a symptom of other sleep issues.
Regularity & Duration

Kinan has a consistent bedtime and wake up schedule. There are a few exceptions for special family celebrations or school activities.

Expert Insights
  • A consistent bedtime and wake up time are important in maintaining good sleep practices.
Sleep-Disordered Breathing / Snoring

Kinan snores loudly most nights, especially in the supine position. Kinan’s mother reports his sibling wakes Kinan up 1-2 times a night because he’s snoring. Kinan changes position and goes back to sleep quickly. He doesn’t remember it in the morning.

Expert Insights
  • See Sleep-Disordered Breathing Module for more information
  • Snoring is often positional with an incrased incidence in the supine position

Kinan's Evaluation & Diagnosis

What evaluation & diagnostic protocol should Ms. Begay use to diagnose Kinan’s snoring and “nodding off” in class behaviors? Check all that apply and click submit for feedback.
Check all that apply:

The evaluation protocol strategies we recommend for Kinan’s case are:

  • Determine elements of the child’s sleep history
  • Perform a physical exam
  • Obtain Medication History
  • Complete a Sleep Diary
  • Evaluate School Behaviors
  • Evaluate Safe Sleep/Sleep Hygiene Practices

Determine elements of Kinan's sleep history

Sleep History Case Specific Questions Kinan's Evaluation Results

What the child does at night

How long is Kinan sleeping at night? Why is he waking up?

Kinan goes to bed after finishing homework and having family time

Review timing of events at night (bedtime/waketime)

Is Kinan taking naps during the day?

Kinan’s mother reports that he usually goes to bed between 9 and 10 PM and awakens between 6:30 - 7:00 AM. There are no sleep related concerns in the past.  The snoring started about 7 months ago becoming more significant in the past 3 months.

Screen for other sleep issues (OSA, restless leg syndrome)

Is Kinan snoring or pausing in his breathing while sleeping?

Kinan’s mother reports that his sibling wakes Kinan several times a night due to Kinan’s loud snoring.  Kinan does not awake on his own. Kinan’s mother also reports that his teacher has sent notes home that he is “nodding off” during class at times and awaken himself when he snores.

Assess for family history of sleep disorders



Perform a Physical Exam

Information to obtain includes: Case Evaluation Results

A physical exam should include height, weight, BMI, cardiovascular exam, ENT exam assessing for nasal airway patency and tonsillar size and a thorough neurologic exam.

Height: 140 cm (50-75%)

Weight: 55 kg (>95%)

BMI" 28.1kg/m2 (>95%)

Vital Signs: All within normal limits

HEENT: Nasal mucosa is erythematous with mild swelling of the inferior turbinates bilaterally; oropharynx is pink and moist, tonsils are 2/4 bilaterally without erythema or exudate.

Obtain Medication History

Information to obtain includes: Case Evaluation Results

What medications prescription and non-prescription does Kinan take?

He has not taken any prescription or non-prescription medications in the past 6 months.

Complete a Sleep Diary

Information to obtain includes: Case Evaluation Results
  • A sleep diary is a record made of a child’s sleep schedule, awakenings and nighttime behaviors which is reviewed with the patient and family.
  • It is important to note episodes of daytime sleepiness.

Download the Sleep Diary

Evaluate School Behaviors

Information to obtain includes: Case Evaluation Results
  • Does Kinan fall asleep during class?
  • Has school performance changed?
  • Any behavioral issues?

The teacher reports that Kinan behaves appropriately at school and this has not changed.
In the past few months, he has fallen asleep for a short period of time and awakens with a loud snore several times a week.  His classmates laugh when this happens.

 The teacher noted the Kinan has always been at the top of his class academically but recently has had a decrease in academic performance.

She has noticed that he doesn’t always seem to be paying attention.

Evaluate Safe Sleep/Sleep Hygiene Practices

Information to obtain includes: Case Evaluation Results
  • Is Kinan practicing appropriate sleep hygiene for his age?
  • Are there any additional environmental factors that may be contributing to Kinan’s snoring?

Kinan sleeps in the same bed with his younger brother with a mattress that is about 10 years old. His room does not have any electronics, he keeps a good schedule and maintains the same pre-bed routine of spending time with the family 30 minutes before going to bed.

Kinan is exposed to secondary smoke from a leaky wood burning stove, lives in a dusty environment, and is sleeping on an old mattress.

Red Flags

  • Are there any environmental factors which could be contributing i.e. poorly ventilated wood stove, dusty environment causing allergy symptoms
  • Daytime sleepiness should be evaluated for underlying cause
  • Physical findings that are abnormal for age i.e. large tonsils, obesity, deviated nasal septum

When evaluating a child,
consider how other health care providers may also need to be involved.

Expert Insights:
Triggers for Challenging Sleep

Evaluation & Diagnosis

Is Kinan’s sleep habits within normal ranges? What other factors might be contributing to Kinan’s symptoms?
Check all that apply:

Kinan’s signs and symptoms are consistent with:

  • Obstructive Sleep Apena.
  • Environmental Factors.

Kinan’s history, physical exam, sleep diary, and school behavior evaluation indicate that he is having abnormal sleep most likely obstructive sleep apnea.

Kinan's Treatment & Referrals

Now it’s time to recommend treatment options for Kinan.
Check all that apply:

The following treatment strategies are recommended for Kinan:

  • Prescribe nasal steroid and provide patient/family education on proper use of nasal steroid.
  • Kinan is scheduled to see the Sleep specialist in a few months.
  • Referral to registered Dietitian to assess Kinan’s diet and make recommendations.

Kinan's Results:

The nearest Pediatric Sleep specialist is in a city 200 miles away. Kinan is still awaiting his appointments.

  • The nasal steroid has helped decrease his nasal congestion but he is still snoring.
  • Kinan and his mother met with the Dietitian. Kinan is drinking more water rather than caffeinated sodas. He is eating more fruits and vegetables rather than chips and sweets. He is also trying to eat dinner or snack at least a couple of hours before bedtime.