Prevalence of Sleep Disorder 1 (Y.2010)

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Pediatrics. Author manuscript; available in PMC 2011 June 1.
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Pediatrics. 2010 June ; 125(6): e1410–e1418. doi:10.1542/peds.2009-2725.
Prevalence of Diagnosed Sleep Disorders in Pediatric Primary

Care Practices
Lisa J. Meltzer, PhDa,b, Courtney Johnson, PhDa,c, Jonathan Crosette, MPHd, Mark Ramos,
BSd, and Jodi A. Mindell, PhDa,e
aDivision of Pulmonary Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
bDepartment of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia,

Pennsylvania
cCenter for Sleep and Respiratory Neurobiology, School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania
dCenterfor Biomedical Informatics, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
eDepartment of Psychology, Saint Joseph’s University, Philadelphia, Pennsylvania
Abstract
OBJECTIVES—The primary aim was to determine the prevalence of International Classification
of Diseases, Ninth Revision (ICD-9), sleep disorders diagnosed by pediatric providers in a large,
primary care network. Secondary aims were to examine demographic variables related to these
diagnoses and to examine the frequency of prescriptions for medications potentially used to treat
sleep disorders.
METHODS—Electronic medical records were reviewed for 154 957 patients (0 –18 years) seen
for a well-child visit in 2007. Information collected included ICD-9 sleep diagnoses, demographic
variables, comorbid attention-deficit/hyperactivity disorder and autism spectrum disorders,
provider type, and medications.
RESULTS—Across all ages, 3.7% of youths had an ICD-9 diagnosis for a sleep disorder. The
most-common diagnoses were sleep disorder not otherwise specified, enuresis, and sleep-
disordered breathing. Predictors of sleep disorders varied according to developmental age group
and included growth parameters, comorbid attention-deficit/hyperactivity disorder or autism

spectrum disorder, and provider type. Potential sleep-related medications were prescribed for 6.1%
of the sample subjects.
CONCLUSIONS—This study is one of the first to examine comprehensively ICD-9 sleep
diagnoses given by primary care providers in a large representative sample of children 0 to 18
years of age. The 3.7% of patients with ICD-9 sleep diagnoses is significantly lower than
prevalence rates reported in epidemiological studies, which suggests that primary care providers
may be underdiagnosing sleep disorders in children and adolescents. Because sleep disorders are
treatable when recognized, the results from this study suggest a significant need for additional
Copyright © 2010 by the American Academy of Pediatrics

Address correspondence to Lisa J. Meltzer, PhD, Children’s Hospital of Philadelphia, Division of Pulmonary Medicine, 3535 Market
St, 14th Floor, Philadelphia, PA 19104. [email protected].
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml
Meltzer et al. Page 2
education and support for primary care providers in the diagnosis and treatment of pediatric sleep
disorders.
Keywords
sleep disorders; children; adolescents; primary care
Sleep disturbances are common in youth,1 including both medically based (eg, obstructive
sleep apnea [OSA], restless leg syndrome, periodic limb movement disorder, and
narcolepsy) and behaviorally based (eg, behavioral insomnia of childhood) sleep disorders.
Common complaints include trouble falling asleep, night waking, snoring, excessive
daytime sleepiness, and poor daytime functioning. These complaints often are signs of
treatable sleep disorders. However, several studies found that sleep disorders may be
underdiagnosed in pediatric practices.2–4 If sleep disorders are not diagnosed and are left
untreated, their negative impact on daytime functioning may be significant.5–7
Studies indicated that most parents do not report significant sleep concerns to their
pediatricians.2,4,8 One study found that <15% of children with current parent-reported sleep
disorder symptoms had chart notes indicating those sleep issues.3 Reasons for this
underreporting may include a lack of parent and provider awareness about the serious
consequences of insufficient or disrupted sleep and the lack of physician training and
comfort with the assessment and diagnosis of pediatric sleep disorders.9
Pediatric sleep disorders fall into multiple categories, with varying prevalence rates.
Approximately 1% to 3% of children have OSA, whereas 5% to 27% have primary
snoring.10–14 Behavioral insomnia of childhood, which involves bedtime problems and night
waking, affects 20% to 30% of infants and toddlers and up to 5% of school-aged
children.15–17 Rates of primary or psychophysiological insomnia range between 5% and
20%,11,18,19 with rates being higher among adolescents and youths with developmental
disorders. Parasomnia rates range from 5% to 35%, depending on the disorder (eg, sleep
terrors versus enuresis) and the child’s age.11,12,20,21 Sleep-related movement disorders
(periodic limb movement disorder and restless leg syndrome) are estimated to affect 2% to
8% of youths.12,22–24 Finally, the prevalence rate of narcolepsy among youths is yet to be
determined (the prevalence rate among US adults is 1 case per 2000 individuals), although
one-half of adult patients report the onset of symptoms before age 20.25
Although some of those prevalence studies used large populations, none examined
prevalence rates on the basis of diagnoses given by pediatric primary care practitioners.
Therefore, the primary aim of this study was to determine the prevalence of sleep disorders
in a large, representative sample of youths seen in pediatric primary care practices. Because
sleep disorders may vary according to demographic variables (eg, age, gender, and race), the
second aim was to examine the relationship between demographic variables and the
diagnosis of sleep disorders. Finally, although no medications have been approved by the
Food and Drug Administration for the treatment of sleep disturbances in children, multiple
studies have suggested that primary care practitioners frequently prescribe medications to
treat sleep difficulties in children.26–28 Therefore, the third aim was to examine the
prevalence of medications potentially prescribed to treat sleep difficulties in pediatric
primary care practices.

METHODS
Participants and Procedure
An electronic medical record review was conducted for all well-child care visits that
occurred between January 1, 2007, and December 31, 2007, in 32 urban or suburban
pediatric practices (with 175 physicians and 22 nurse practitioners) affiliated with a large,
tertiary care, children’s hospital. The sample included 154 957 children and adolescents
(Table 1). For children with >1 well-child care visit, only the most-recent visit was used.
Data Extracted
Demographic Characteristics—Participant information was collected through a
deidentified, institutional review board-approved query of electronic medical records,
including all patients and all patient visits in the network. Demographic variables included
age, gender, race, and zip code (used to determine median household incomes on the basis
of US Census data). Medical variables included head circumference (for children ≤1 year of
age), BMI (for children ≥2 years of age), and provider type (attending physician, fellow/
resident, or nurse practitioner).
Sleep Diagnoses—International Classification of Diseases, Ninth Revision (ICD-9),

diagnoses and codes were used to identify patients with diagnosed sleep disorders. Both new
and existing diagnoses were included (ie, diagnosis might not have been the result of the
current well-child visit but was part of the child’s medical record). Sleep diagnoses were
grouped into 11 diagnostic categories (see Table 2 for an inclusive list of ICD-9 codes and
groupings). Rates of attention-deficit/hyperactivity disorder (ADHD), autism spectrum
disorders (ASDs), asthma, and type 1 diabetes mellitus also were collected, for comparison.
Medications—Eight classes of medications (including 22 medications) were identified as

potential sleep medications on the basis of previous research (see Table 3 for an inclusive
list of medication classes and specific medications).26,29 It is important to note that all of
these medications might have been prescribed for other reasons.
RESULTS
Sample Demographic Characteristics
The overall sample included 154 957 children, with a mean age of 6.86 years (SD: 5.21
years; range: 0 –18 years). For data analyses, the sample was divided into 5 developmentally
based subgroups according to age, that is, infants (0 –12.0 months), toddlers (12.1– 47
months), preschool-aged children (4 –5 years), school-aged children (6 –12 years), and
adolescents (13–18 years). Detailed demographic information for all participants and all age
groups is provided in Table 1.
Frequency of Sleep Disorder Diagnoses

Overall, 3.7% of children (n = 5750) were given an ICD-9 diagnosis of a sleep disorder
(Table 2). Sleep disorder not otherwise specified (SD-NOS) was the most-common sleep
disorder diagnosis (n = 2193 [1.4%]), followed by nocturnal enuresis (n = 1915 [1.2%]),
sleep-disordered breathing (SDB) (n = 1615 [1.0%]), infant apnea (n = 299 [0.2%]),
insomnia (n = 76 [0.05%]), restless leg syndrome/periodic limb movement disorder (n = 30
[0.02%]), circadian rhythm disorder (n = 7 [0.005%]), bruxism (n = 6 [0.004%]), and
narcolepsy (n = 4 [0.003%]). In comparison, diagnostic rates for ADHD (n = 6440 [4.2%]),
ASDs (n = 1380 [0.9%]), asthma (n = 22 547 [14.5%]), and type 1 diabetes mellitus (n =
324 [0.21%]) were similar to those in previous studies.

The χ2 analyses revealed significant differences in sleep diagnoses according to age group,
although the effect size was small ( ; P < .0001; ϕ = .05). Posthoc analyses of
standardized residuals suggested that preschool-aged (4.3%; standardized residual: 4.2) and
school-aged (4.7%; standardized residual: 11.1) children were more likely to receive a sleep
diagnosis.
The most-common diagnosis within the infant age group was SD-NOS (n = 283 [1.3%]),
followed by infant apnea (n = 200 [0.9%]) and SDB (n = 113 [0.5%]). SD-NOS also was the
most-frequently diagnosed sleep disorder among toddlers (n = 720 [2.4%]), followed by
SDB (n = 417 [1.4%]). Preschool-aged children were most likely to receive a diagnosis of
SDB (n = 355 [1.6%]), SD-NOS (n = 346 [1.6%]), or nocturnal enuresis (n = 281 [1.3%]).
Similarly, school-aged children most-commonly received a diagnosis of nocturnal enuresis
(n = 1349 [2.6%]), SD-NOS (n = 598 [1.2%]), or SDB (n = 592 [1.1%]). Adolescents were
most likely to receive a diagnosis of nocturnal enuresis (n = 265 [0.9%]), SD-NOS (n = 246
[0.9%]), or SDB (n = 138 [0.5%]).
Diagnosed sleep disorders were more common among children from low-income areas (χ2 =
219; P < .0001; Cramer’s V = .038) (Fig 1). Posthoc analyses indicated that children from
areas with incomes of <25th percentile were more likely to receive a diagnosis (4.9%;
standardized residual: 12.0) than were children from areas with higher income levels (25th
to 50th percentile, rate: 3.5%; standardized residual: −1.9; 50th to 75th percentile, rate:
3.4%; standardized residual: −3.6; >75th percentile, rate: 3.0%; standardized residual: −7.1).
Growth parameters also were closely related to sleep disorder diagnoses (χ2 = 293.2; P < .
0001; Cramer’s V = .115) (Fig 2). Among children <1 year of age, small head circumference
(≤2 SDs below the mean) was related to increases in diagnosis. Overall, 11.7%
(standardized residual: 16.3) of children with small head circumference received a sleep
disorder diagnosis, compared with 4.2% (standardized residual: 2.4) of children with large
head circumference (≥2 SDs above the mean) and 2.2% (standardized residual: −3.6) of
children with normal head circumference. Among children >1 year of age, sleep diagnoses
were more common (7.7%; standardized residual: 17.9) for children with higher BMIs (≥2
SDs above the mean) (χ2 = 360.5; P < .0001; Cramer’s V = .054), compared with children
with normal (3.6%; standardized residual: −4.9) and low (3.4%; standardized residual: −1.1)
BMIs. BMI was not associated with any individual diagnosis (eg, OSA); high BMI values
were distributed across the different diagnoses.
Logistic Regression Analyses

Models—Logistic regression analyses were performed within each age group to analyze
risk factors associated with receiving a sleep disorder diagnosis. Independent variables
entered in the initial models included gender, ethnicity (white, black, Hispanic, Asian, or
other), income quartile, BMI (children >2 years of age), head circumference (infants only),
provider type, and comorbid developmental disorders (ADHD and ASDs). Nonsignificant
variables (P≥ .05) were trimmed from the final models (Table 4).
Infants—Logistic regression analysis revealed higher rates of sleep disorders among

infants with small or large head circumference. Infants cared for by a physician were 1.8
times more likely to receive a diagnosis than were those cared for by a nurse practitioner.
Black and other infants were less likely to receive a sleep disorder diagnosis than were white
infants.

Toddlers—Logistic regression analysis revealed higher rates of sleep disorders among

boys and toddlers with ASDs. Toddlers of other ethnicities were less likely than white
toddlers to receive a diagnosis.
Preschool-aged Children—Results of logistic regression analysis suggested that boys

and children with high BMIs were more likely to receive a diagnosis. Preschool-aged
children treated by an attending physician or a fellow/resident were more likely to receive a
diagnosis than were those treated by a nurse practitioner. Preschool-aged children of other
ethnicities were less likely than white preschool-aged children to receive a diagnosis.
School-aged Children—Logistic regression analysis revealed higher rates of diagnoses

for boys, children with high BMIs, black or Hispanic children, children with incomes
between the 25th and 50th percentiles, children who were treated by an attending physician
or fellow/resident, and children with ADHD or ASDs. In contrast, school-aged children of
other ethnicities and those with incomes of >75th percentile were less likely to receive a
diagnosis.
Adolescents—Logistic regression analyses revealed higher rates of diagnosed sleep

disorders for boys, adolescents with high BMIs, black adolescents, adolescents who were
treated by an attending physician, and adolescents with ADHD or ASDs. Adolescents of
other ethnicities and those with incomes of >25th percentile were less likely to receive a
diagnosis.
Frequency of Prescribed Sleep-Related Medications

Overall, potentially sleep-related medications were prescribed for 6.1% of children (n =
9441). Antihistamines were prescribed most commonly (n = 8367 [88.6%]), followed by
antipsychotic agents (n = 465 [4.9%]), α-adrenergic receptor agonists (n = 399 [4.2%]), and
selective serotonin reuptake inhibitors (n = 159 [0.1%]). The χ2 analyses revealed that boys
(n = 4965 [6.3%]) were significantly more likely than girls (n = 4476 [5.8%]) to receive
sleep-related medications, although the effect size was small (χ2 = 151.3; P < .0001; ϕ =−.
031).
The χ2 analyses also revealed significant differences in sleep-related medications according

to age group (χ2 = 847.2; P < .0001; Cramer’s V = .074). Posthoc analyses of standardized
residuals indicated that toddlers (7.7%; standardized residual: 11.2), preschool-aged children
(7.5%; standardized residual: 8.5), and school-aged children (6.7%; standardized residual:
6.0) were more likely to receive sleep-related medications than were infants (2.3%;
standardized residual: −22.7) and adolescents (5.1%; standardized residual: −6.8). Black
and Hispanic children were more likely to receive sleep-related medications (χ2 = 5347; P
< .0001; Cramer’s V = .186), with medications being prescribed for 13.3% of black children
(n = 5492) and 7.9% of Hispanic children (n = 263), compared with only 3.1% of white
children (n = 2753), 6.9% of Asian children (n = 223), and 3.8% of other children (n = 710).
DISCUSSION
This study is one of the first to examine comprehensively the prevalence of diagnosed sleep
disorders, on the basis of ICD-9 codes, in a large, pediatric, primary care network.
Surprisingly, only 3.7% of pediatric patients were given a sleep disorder diagnosis, which is
significantly lower than previous reports of sleep disorders in youth. Preschool-aged and
school-aged children were more likely to receive a sleep disorder diagnosis than were
patients in other age groups, with household income (determined on the basis of Census
data), growth parameters (head circumference and BMI), and comorbid developmental

disorders (ASDs and ADHD) also being related to whether a patient received a sleep
disorder diagnosis.
The low overall prevalence rates found in this study may be attributable to a combination of
factors, including primary care providers not asking about sleep and parents not reporting
significant sleep problems. The standard review of systems covered in well-child visits often
does not include an assessment of sleep. Even if providers inquire about sleep, however,
studies have shown a significant lack of education regarding sleep medicine for physicians
(with even less education regarding pediatric sleep medicine).9,34–37 Some providers may be
reluctant to ask much about sleep, given their lack of confidence in their ability to manage
identified sleep issues.9
Overall, the sleep disorder diagnosed most commonly by the health care providers was SD-
NOS. It is not clear what symptoms or concerns led to this diagnosis, and they likely varied
widely among practitioners, but it has been postulated that this diagnosis includes more-
benign sleep disturbances, such as sleep fragmentation and difficulties falling asleep or
staying asleep. In prevalence surveys based on parental reports, the sleep problems
identified most commonly included bedtime resistance and night waking,4,16,38 which may
be consistent with the use of this diagnostic code by health care providers.
The other 2 sleep disorders diagnosed most commonly were SDB and enuresis. The
relatively high rate of SDB diagnoses (compared with other diagnoses) likely is a result of
the American Academy of Pediatrics recommendation that all children should be screened
for snoring.39 However, the overall rate of combined SDB diagnoses we found in this study
(~1%) is still below the overall prevalence rates of 1% to 3% for OSA and 5% to 27% for
snoring.11–14 The relatively high rate of enuresis is potentially attributable to the significant
impact on family and social functioning. However, consistent with the overall findings, the
diagnosis of enuresis was still well below known prevalence rates.
One potential explanation for the low prevalence rates for all sleep disorders is that all
medical and psychiatric diagnoses are underdocumented, but this does not seem to be the
case. We also assessed the prevalence rates of diagnosed ADHD, ASDs, asthma, and type 1
diabetes, comparing the rates for our sample with national rates. ADHD was diagnosed for
4.2% of the children in our sample, which is comparable to rates in epidemiological studies
(3%–8%).40 Interestingly, children in the present study were more likely to have
documented ASDs (0.9%), compared with national prevalence rates (0.67%).41 For asthma
and type 1 diabetes, we found prevalence rates in our sample (asthma, 14.5%; type 1
diabetes, 0.21%) similar to national prevalence rates (asthma, 13.5%; type 1 diabetes,
0.17%–0.25%).42,43 Therefore, it is unlikely that the low prevalence rates of diagnosed sleep
disorders that we saw resulted from a general lack of documentation; rather, the findings
were specific to sleep disorders.
An interesting finding in this study was the relationship between income levels and
diagnosis rates. Overall, children from lower-income families were more likely to be
diagnosed as having a sleep disorder, starting at preschool age. This relationship may be
compounded by race and ethnicity. Previous studies found that black children were at
increased risk for SDB and sleep deprivation.14 Therefore, it is possible that health care
providers are more likely to consider sleep disturbances in lower-income and/or ethnic
minority families, with sleep issues being missed in other families. Finally, it is possible that
the types of sleep problems experienced by children differ across the social strata, with
diagnosable sleep disorders such as SDB being experienced more in lower-income families
and behaviorally based sleep problems (that may not result in a formal diagnosis) being of

greater concern in upper-income families. As we begin to evaluate sleep complaints further,

as recorded in the medical records, we should be able to address these issues.
A second interesting risk factor that increased the rates of diagnosed sleep disorders
involved growth parameters. In infancy, head circumference was associated with increased
risk for a sleep disorder diagnosis. Prematurity, for which data were not available, is likely
associated with microcephaly, whereas both microcephaly and macrocephaly may be related
to neurologic and developmental concerns,44,45 all of which may result in increased risks for
apnea of infancy and other sleep disturbances. For older children, BMI was a risk factor for
all sleep disorder diagnoses. Clearly, SDB is related to the increasing rates of obesity,
especially in adolescents. Studies indicated that obesity is associated not only with SDB but
also with short sleep duration,46–48 which might have contributed to the increased rate of
diagnosis of SD-NOS.
Although there are no Food and Drug Administration-approved medications for sleep in
youth, the rates of medications potentially used to treat sleep problems are similar to reports
of sleep medications used by pediatricians and pediatric psychiatrists and during pediatric
hospitalizations.26,29,49–51 It is important to note that, although the proxy method used in
this study was based on the paradigm used in previous studies, the current study results may
overestimate the use of medications recommended for sleep problems.27,29
This study has several strengths, including the use of a large, representative population of
youths and the examination of demographic, growth, and medical factors related to the
diagnosis of pediatric sleep disorders. However, there are several limitations that should be
noted. First, the use of diagnostic codes precluded identification of “sleep problems” such as
bedtime problems/night waking for young children or difficulty waking up for adolescents.
Although sleep problems may explain why SD-NOS was the most-common diagnosis, the
rates are still far below those in previous reports. Second, sleep problems might have been
discussed during the well-child visit but deemed not significant enough to warrant a
diagnosis. Third, although we used an approach to the identification of potential sleep
medications similar to that used in previous studies, this proxy method may overestimate the
use of medications prescribed for sleep disorders. However, the rates also may be
underestimates; for example, use of diphenhydramine, which can be obtained without a
prescription and is the most-commonly reported medication recommended for the treatment
of pediatric insomnia, would not be captured in these records.
Identified future directions include an additional analysis of sleep complaints, which are
provided as text within the electronic medical records. This should help elucidate whether
sleep problems are being discussed and noted even if diagnoses are not being given. A
review of treatment recommendations from text in the electronic medical records would
provide additional information on the care of sleep disorders in pediatric practices. Finally,
additional research needs to be conducted within the pediatric community regarding reasons
for the low rates of documented sleep-related disorders.
The results of this population-based study highlight the need for increased awareness of
pediatric sleep disorders, including additional education for health care providers regarding
the diagnosis and treatment of pediatric sleep disorders. Education about the importance of
sleep is needed for parents and youths of all ages. Because youths spend more than one-third
of their lives sleeping, more information about this part of a child’s day needs to become a
standard dialogue topic for primary care well-child visits, which would likely result in sleep
disorders becoming more widely recognized and treated.

ABBREVIATIONS
ADHD attention-deficit/hyperactivity disorder
ASD autism spectrum disorder

ICD-9 International Classification of Diseases, Ninth Revision
OSA obstructive sleep apnea
SDB sleep-disordered breathing
SD-NOS sleep disorder not otherwise specified
Acknowledgments
This study was supported in part by National Institutes of Health grant K23 MH077662.
We thank the network of primary care physicians for their contribution to clinical research through the Pediatric
Research Consortium at the Children’s Hospital of Philadelphia. We also thank Hannah Benson for her assistance
with this project.
REFERENCES
1. Owens, JA. Epidemiology of sleep disorders during childhood. In: Sheldon, SH.; Ferber, R.; Kryger,
MH., editors. Principles and Practices of Pediatric Sleep Medicine. Philadelphia, PA: Elsevier
Saunders; 2005. p. 27-33.
2. Blunden S, Lushington K, Lorenzen B, Ooi T, Fung F, Kennedy D. Are sleep problems under-
recognised in general practice? Arch Dis Child. 2004; 89(8):708–712. [PubMed: 15269066]
3. Chervin RD, Archbold KH, Panahi P, Pituch KJ. Sleep problems seldom addressed at two general
pediatric clinics. Pediatrics. 2001; 107(6):1375–1380. [PubMed: 11389260]
4. Smedje H, Broman JE, Hetta J. Parents’ reports of disturbed sleep in 5–7-year-old Swedish children.
Acta Paediatr. 1999; 88(8):858–865. [PubMed: 10503686]
5. Fallone G, Owens JA, Deane J. Sleepiness in children and adolescents: clinical implications. Sleep
Med Rev. 2002; 6(4):287–306. [PubMed: 12531133]
6. Gregory AM, Caspi A, Moffitt TE, Poulton R. Sleep problems in childhood predict
neuropsychological functioning in adolescence. Pediatrics. 2009; 123(4):1171–1176. [PubMed:
19336377]
7. Quach J, Hiscock H, Canterford L, Wake M. Outcomes of child sleep problems over the school-
transition period: Australian population longitudinal study. Pediatrics. 2009; 123(5):1287–1292.
[PubMed: 19403493]
8. Stein MA, Mendelsohn J, Obermeyer WH, Amromin J, Benca R. Sleep and behavior problems in
school-aged children. Pediatrics. 2001; 107(4) Available at: www.pediatrics.org/cgi/content/full/
107/4/e60.
9. Owens JA. The practice of pediatric sleep medicine: results of a community survey. Pediatrics.
2001; 108(3) Available at: www.pediatrics.org/cgi/content/full/108/3/e51.
10. Ali NJ, Pitson D, Stradling JR. Sleep disordered breathing: effects of adenotonsillectomy on
behavior and psychological function. Eur J Pediatr. 1996; 155(1):56–62. [PubMed: 8750813]
11. Archbold KH, Pituch KJ, Panahi P, Chervin RD. Symptoms of sleep disturbances among children
at two general pediatric clinics. J Pediatr. 2002; 140(1):97–102. [PubMed: 11815771]
12. Liu X, Liu L, Owens JA, Kaplan DL. Sleep patterns and sleep problems among school-children in
the United States and China. Pediatrics. 2005; 115 suppl(1):241–249. [PubMed: 15866858]
13. Gregory AM, Rijsdijk FV, Eley TC. A twin-study of sleep difficulties in school-aged children.
Child Dev. 2006; 77(6):1668–1679. [PubMed: 17107453]
14. Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-
disordered breathing in children: associations with obesity, race, and respiratory problems. Am J
Respir Crit Care Med. 1999; 159(5):1527–1532. [PubMed: 10228121]

15. Mindell JA, Kuhn BR, Lewin DS, Meltzer LJ, Sadeh A, Owens JA. Behavioral treatment of
bedtime problems and night wakings in infants and young children. Sleep. 2006; 29(10):1263–
1276. [PubMed: 17068979]
16. Blader JC, Koplewicz HS, Abikoff H, Foley C. Sleep problems of elementary school children: a
community survey. Arch Pediatr Adolesc Med. 1997; 151(5):473–480. [PubMed: 9158439]
17. Owens JA, Spirito A, McGuinn M, Nobile C. Sleep habits and sleep disturbance in elementary
school-aged children. J Dev Behav Pediatr. 2000; 21(1):27–36. [PubMed: 10706346]
18. Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence:
lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006; 117(2)
Available at: www.pediatrics.org/cgi/content/full/117/2/e247.
19. Roberts RE, Roberts CR, Duong HT. Chronic insomnia and its negative consequences for health
and functioning of adolescents: a 12-month prospective study. J Adolesc Health. 2008; 42(3):294–
302. [PubMed: 18295138]
20. Byrd RS, Weitzman M, Lanphear NE, Auinger P. Bed-wetting in US children: epidemiology and
related behavior problems. Pediatrics. 1996; 98(3):414–419. [PubMed: 8784366]
21. Baskin, LS.; Kogan, BA. Handbook of Pediatric Urology. Philadelphia, PA: Lippincott Williams &
Wilkins; 2005.
22. Bokkala S, Napalinga K, Pinninti N, et al. Correlates of periodic limb movements of sleep in the
pediatric population. Pediatr Neurol. 2008; 39(1):33–39. [PubMed: 18555170]
23. Picchietti D, Allen RP, Walters AS, Davidson JE, Myers A, Ferini-Strambi L. Restless legs
syndrome: prevalence and impact in children and adolescents: the Peds REST study. Pediatrics.
2007; 120(2):253–266. [PubMed: 17671050]

24. Picchietti DL, Underwood DJ, Farris WA, et al. Further studies on periodic limb movement
disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder. Mov
Disord. 1999; 14(6):1000–1007. [PubMed: 10584676]
25. Ohayon MM, Ferini-Strambi L, Plazzi G, Smirne S, Castronovo V. How age influences the
expression of narcolepsy. J Psychosom Res. 2005; 59(6):399–405. [PubMed: 16310022]
26. Owens JA, Rosen CL, Mindell JA. Medication use in the treatment of pediatric insomnia: results of
a survey of community-based pediatricians. Pediatrics. 2003; 111(5) Available at:
www.pediatrics.org/cgi/content/full/111/5/e628.
27. Rappley MD, Luo Z, Brady J, Gardiner JC. Variation in the use of sleep medications for children. J
Dev Behav Pediatr. 2003; 24(5):394.
28. Stojanovski SD, Rasu RS, Balkrishnan R, Nahata MC. Trends in medication prescribing for
pediatric sleep difficulties in US outpatient settings. Sleep. 2007; 30(8):1013–1017. [PubMed:
17702271]
29. Meltzer LJ, Mindell JA, Owens JA, Byars KC. The use of sleep medications in hospitalized
pediatric patients. Pediatrics. 2007; 119(6):1047–1055. [PubMed: 17545369]
30. Sheldon, SH.; Glaze, D. Sleep in neurologic disorders. In: Sheldon, SH.; Ferber, R.; Kryger, MH.,
editors. Principles and Practice of Pediatric Sleep Medicine. Philadelphia, PA: Elsevier Saunders;
2005. p. 269-292.
31. Herman, JH. Circadian rhythm disorders: Diagnosis and treatment. In: Sheldon, SH.; Ferber, R.;
Kryger, MH., editors. Principles and Practice of Pediatric Sleep Medicine. Philadelphia, PA:
Elsevier Saunders; 2005. p. 101-111.
32. Nguyen BH, Perusse D, Paquet J, et al. Sleep terrors in children: A prospective study of twins.
Pediatrics. 2008; 122(6):e1164–e1167. [PubMed: 19047218]
33. Laberge L, Tremble RE, Vitaro F, Montplaisir J. Development of parasomnias from childhood to
early adolescence. Pediatrics. 2000; 106(1):67–74. [PubMed: 10878151]
34. Mindell JA, Moline ML, Zendell SM, Brown LW, Fry JM. Pediatricians and sleep disorders:
training and practice. Pediatrics. 1994; 94(2):194–200. [PubMed: 8036073]
35. Rosen R, Mahowald M, Chesson A, et al. The Taskforce 2000 survey on medical education in
sleep and sleep disorders. Sleep. 1998; 21(3):235–238. [PubMed: 9595601]
36. Rosen RC, Rosekind M, Rosevear C, Cole WE, Dement WC. Physician education in sleep and
sleep disorders: a national survey of US medical schools. Sleep. 1993; 16(3):249–254. [PubMed:
8506458]

37. Stores G, Crawford C. Medical student education in sleep and its disorders. J R Coll Physicians
Lond. 1998; 32(2):149–153. [PubMed: 9597633]
38. National Sleep Foundation. Sleep in America poll 2004: children and sleep. Available at:
www.sleepfoundation.org/article/sleepamerica- polls/2004-children-and-sleep
39. American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on
Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of
childhood obstructive sleep apnea syndrome. Pediatrics. 2002; 109(4):704–712. [PubMed:
11927718]
40. Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder: data and
statistics. Available at: www.cdc.gov/ncbddd/adhd/data.html
41. Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders: Autism and
Developmental Disabilities Monitoring Network, 14 sites, United States, 2002. MMWR Surveill
Summ. 2007; 56(SS-1):12–28. [PubMed: 17287715]
42. Centers for Disease Control and Prevention. Lifetime asthma prevalence percents by age, United
States: National Health Interview Survey. 2006. Available at:
www.cdc.gov/asthma/nhis/06/table2-1.htm
43. Centers for Disease Control and Prevention. National diabetes fact sheet, United States. 2005.
Available at: www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf
44. Fattal-Valevski A, Toledano-Alhadef H, Leitner Y, Geva R, Eshel R, Harel S. Growth patterns in
children with intrauterine growth retardation and their correlation to neurocognitive development.
J Child Neurol. 2009; 24(7):846–851. [PubMed: 19617460]
45. Dementieva YA, Vance DD, Donnelly SL, et al. Accelerated head growth in early development of
individuals with autism. Pediatr Neurol. 2005; 32(2):102–108. [PubMed: 15664769]
46. Bayer O, Rosario AS, Wabitsch M, von Kries R. Sleep duration and obesity in children: is the
association dependent on age and choice of the outcome parameter? Sleep. 2009; 32(9):1183–
1189. [PubMed: 19750923]
47. Cappuccio FP, Taggart FM, Kandala NB, et al. Meta-analysis of short sleep duration and obesity in
children and adults. Sleep. 2008; 31(5):619–626. [PubMed: 18517032]
48. Verhulst SL, Van Gaal L, De Backer W, Desager K. The prevalence, anatomical correlates and
treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev. 2008;
12(5):339–346. [PubMed: 18406637]
49. Owens JA, Rosen CL, Mindell JA, Kirchner LH. Use of pharmacotherapy for insomnia in child
psychiatry practice: A national survey. Sleep Medicine. In press.
50. Owens JA, Babcock D, Blumer J, et al. The use of pharmacotherapy in the treatment of pediatric
insomnia in primary care: rational approaches: a consensus meeting summary. J Clin Sleep Med.
2005; 1(1):49–59. [PubMed: 17561616]
51. Mindell JA, Emslie G, Blumer J, et al. Pharmacologic management of insomnia in children and
adolescents: consensus statement. Pediatrics. 2006; 117(6) Available at: www.pediatrics.org/cgi/
content/full/117/6/e1223.

FIGURE 1.
Sleep disorder prevalence according to income quartile.

FIGURE 2.
Sleep disorder prevalence according to head circumference (0 –1 year of age) (A) and BMI
(2–18 years of age) (B).

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
TABLE 1
Demographic Variables According to Age Group
Variable 0–12 mo 12–36 mo 4–5 y 6–12 y 13–18 y All Ages

(N = 22 427) (N = 30 208) (N = 21 661) (N = 51 810) (N = 28 851) (N = 154 957
Meltzer et al.
Patient’s gender, %
Male 51.4 51.9 51.0 51.9 49.1 50.5
Female 48.6 48.1 49.0 48.1 50.9 49.5
Patient’s age, mean ± SD, y 0.33 ± 0.30 2.14 ± 0.70 4.48 ± 0.50 8.87 ± 2.02 15.06 ± 1.58 6.86 ± 5.21
Patient’s race, %
White 48.7 54.4 59.8 59.7 59.0 57.0
Black 28.1 27.6 24.5 26.0 27.0 26.6
Hispanic 3.3 2.9 2.2 1.7 1.3 2.1
Asian 2.5 2.8 2.5 2.0 1.1 2.1
Other 17.3 12.4 11.1 10.7 11.7 12.2
Median household income, mean ± SD, $ 50 870 ± 19 466 52 364 ± 19 709 55 103 ± 20 232a 55 527 ± 20 596a 55 495 ± 20 304a 54 169 ± 20 210
a
Column means were not significantly different (Tukey’s honestly significant difference posthoc test).

Page 13
TABLE 2
Rates of Sleep Disorder Diagnoses in Previous and Current Studies
ICD-9 Diagnostic Codes Sleep Disorder Grouping Rates of Diagnosis in Rates in Current
Previous Studies, % Study, %
327.53 Bruxism 5–3511,12,30 0.004

780.55, 307.45, 327.39 Circadian rhythm disorder 5–1031 0.005
307.43 Hypersomnia Unknown 0.004
770.81, 770.82 Infant apnea 25–84 (preterm), <0.5–2 0.89 (0–12 mo)
(term)
307.41, 307.42, 327.02, 327.09, 780.52 Insomnia 5–2011,18,19 0.05
347.00, 347.10 Narcolepsy Unknown 0.003
788.36, 788.30 Nocturnal enuresis 15–20 (5 y), 1–2 (≥15 y)20,21 1.2 (≥4 y)
307.46 Parasomnias 14–3711,32,33 0.05
327.51, 333.94 Periodic limb movement disorder/ 2–822–24 0.02
restless leg syndrome
327.20, 327.21, 327.23, 327.26, 780.51, SDB 1–3 for OSA, 5–27 for 1.04 (OSA plus snoring)
780.53, 780.57, 786.03 snoring11–14
307.40, 307.47, 780.50, 780.58, 780.59 SD-NOS Unknown 1.4
314.00, 314.01 ADHD 3–836 4.2

299.00, 299.01, 299.80, 299.81, 299.90, ASDs 0.6737 0.9
299.91
430.90, 430.91, 430.92, 100493.901, Asthma 13.538 14.5
100493.902, 100493.903, 100493.904
250.01, 250.03, 250.11, 250.43, 250.91 Type 1 diabetes mellitus 0.17–0.2539 0.21

TABLE 3
Sleep-Related Medication Classes and Individual Medications Included
Medication Class Medications
α2-Adrenergic receptor Agonists Clonidine

Guanfacine
Antidepressants Imipramine hydrochloride
Trazadone
Selective serotonin reuptake inhibitors Citralopram
Escitalopram oxalate
Mitrazapine
Antihistamines Diphenhydramine
Hydroxyzine
Promethazine
Antipsychotic agents Olanzapine
Risperidone
Benzodiazepines Alprazolam
Clonazepam
Diazepam
Flurazepam
Lorazepam
Temazepam
Triazolam
Hypnotic agents Zaleplon
Zolpidem
Melatonin Melatonin
Chloral hydrate Chloral hydrate

TABLE 4
Final Logistic Regression Models for Variables That Predicted Sleep Disorder Diagnoses, According to Age
Group
Predictor Variable B, Estimate ± SE Odds Ratio

(95% Confidence Interval)
Infants
Head circumference
≤2 SDs below mean 2.01 ± 0.01 7.50 (5.94–9.54)a
≥2 SDs above mean 0.46 ± 0.22 1.59 (1.03–2.44)b
Ethnicity
Black −0.55 ± 0.11 0.58 (0.46–0.72)a
Other −0.42 ± 0.13 0.66 (0.51–0.84)a
Physician provider 0.59 ± 0.20 1.80 (1.21–2.65)a
Toddlers
Male 0.23 ± 0.06 1.26 (1.12–1.42)a
Other ethnicity −0.42 ± 0.11 0.66 (0.53–0.81)a
ASD 0.70 ± 0.29 2.01 (1.14–3.56)b

Preschool-aged children
Male 0.24 ± 0.07 1.27 (1.11–1.45)a
BMI ≥2 SDs above mean 0.42 ± 0.12 1.52 (1.22–1.91)a
Other ethnicity −0.34 ± 0.13 0.71 (0.56–0.92)a
Income percentile
25th–50th −0.40 ± 0.11 0.67 (0.54–0.84)a
50th–75th −0.46 ± 0.11 0.63 (0.50–0.79)a
>75th −0.37 ± 0.12 0.69 (0.55–0.88)a
Provider
Physician 0.37 ± 0.13 1.44 (1.11–1.87)a
Fellow/resident 0.51 ± 0.19 1.66 (1.16–2.39)a
School-aged children
Male 0.36 ± 0.04 1.44 (1.32–1.57)a

Ethnicity
Black 0.20 ± 0.06 1.22 (1.08–1.37)a
Hispanic 0.29 ± 0.14 1.33 (1.01–1.77)b
Other −0.32 ± 0.09 0.72 (0.61–0.85)a
Income percentile
25th–50th 0.18 ± 007 1.19 (1.05–1.36)a
>75th −0.30 ± 0.07 0.74 (0.65–0.85)a
Provider type

Predictor Variable B, Estimate ± SE Odds Ratio

(95% Confidence Interval)
Physician 0.22 ± 0.08 1.25 (1.08–1.44)a

Fellow/resident 0.41 ± 0.11 1.50 (1.22–1.86)a

Other diagnoses
ADHD 0.70 ± 0.06 2.00 (1.77–2.27)a
ASD 0.33 ± 0.14 1.39 (1.05–1.84)a
Adolescents
Male 0.24 ± 0.08 1.27 (1.08–1.49)a
Ethnicity
Black 0.48 ± 0.11 1.61 (1.29–2.02)a
Other −0.53 ± 0.18 0.58 (0.41–0.84)a
Income percentile
25th–50th −0.26 ± 0.13 0.77 (0.60–0.99)b
50th–75th −0.32 ± 0.13 0.72 (0.56–0.94)b
>75th −0.40 ± 0.15 0.67 (0.50–0.90)a

Physician provider 0.32 ± 0.15 1.37 (1.02–1.84) b
Other diagnoses
ADHD 0.95 ± 0.11 2.57 (2.10–3.16)a
ASD 0.56 ± 0.28 1.76 (1.02–3.03)b
Odds ratios are from trimmed logistic regression analyses in which all nonsignificant variables were eliminated from the final models. Only
significant results are presented. Odds ratios of >1 represent increased odds of a sleep disorder diagnosis. Odds ratios of <1 represent decreased
odds of a sleep disorder diagnosis. B indicates standardized β. Comparison groups for odds ratios were as follows: white, female, nurse provider,
income of <25th percentile, and BMI and head circumference within 2 SDs of the mean.
a
P < .01.
b
P < .05.

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Pediatrics. 2010 June ; 125(6): e1410–e1418. doi:10.1542/peds.2009-2725.

Prevalence of Diagnosed Sleep Disorders in Pediatric Primary

bDepartment of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia,

eDepartment of Psychology, Saint Joseph’s University, Philadelphia, Pennsylvania

and included growth parameters, comorbid attention-deficit/hyperactivity disorder or autism

Copyright © 2010 by the American Academy of Pediatrics

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Sleep Diagnoses—International Classification of Diseases, Ninth Revision (ICD-9),

Medications—Eight classes of medications (including 22 medications) were identified as

Frequency of Sleep Disorder Diagnoses

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Logistic Regression Analyses

Infants—Logistic regression analysis revealed higher rates of sleep disorders among

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Toddlers—Logistic regression analysis revealed higher rates of sleep disorders among

Preschool-aged Children—Results of logistic regression analysis suggested that boys

School-aged Children—Logistic regression analysis revealed higher rates of diagnoses

Adolescents—Logistic regression analyses revealed higher rates of diagnosed sleep

Frequency of Prescribed Sleep-Related Medications

The χ2 analyses also revealed significant differences in sleep-related medications according

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Pediatrics. Author manuscript; available in PMC 2011 June 1.

greater concern in upper-income families. As we begin to evaluate sleep complaints further,

Pediatrics. Author manuscript; available in PMC 2011 June 1.

ASD autism spectrum disorder

Pediatrics. Author manuscript; available in PMC 2011 June 1.

2007; 120(2):253–266. [PubMed: 17671050]

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Variable 0–12 mo 12–36 mo 4–5 y 6–12 y 13–18 y All Ages

Pediatrics. Author manuscript; available in PMC 2011 June 1.

327.53 Bruxism 5–3511,12,30 0.004

314.00, 314.01 ADHD 3–836 4.2

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Medication Class Medications

α2-Adrenergic receptor Agonists Clonidine

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Predictor Variable B, Estimate ± SE Odds Ratio

ASD 0.70 ± 0.29 2.01 (1.14–3.56)b

BMI ≥2 SDs above mean 0.73 ± 0.06 2.07 (1.84–2.32)a

Pediatrics. Author manuscript; available in PMC 2011 June 1.

Predictor Variable B, Estimate ± SE Odds Ratio

Physician 0.22 ± 0.08 1.25 (1.08–1.44)a

Fellow/resident 0.41 ± 0.11 1.50 (1.22–1.86)a

>75th −0.40 ± 0.15 0.67 (0.50–0.90)a

Pediatrics. Author manuscript; available in PMC 2011 June 1.

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