Abstract
Objectives:
The American Academy of Pediatrics (AAP) recommends routine sleep problem screenings during child well-visits. However, studies suggest a discrepancy between caregiver- and clinician-reported child sleep problems. The present study examines whether caregiver-reported child sleep problems (i.e., habitual snoring, insomnia symptoms, poor sleep health) and clinician-documented child sleep problems and management are congruent.
Methods:
The sample included 170 caregiver-child dyads (child Mage = 3.3 years, range=2–5 years; 56.5% girls; 64.1% Black, 20.0% non-Latinx White, and 4.1% Latinx; 86.5% maternal caregiver reporter). Caregivers’ questionnaire-based reports of habitual snoring, insomnia symptoms, and sleep health behaviors (nighttime electronics, caffeine intake, insufficient sleep) were compared with clinician documentation in the electronic health record.
Results:
92.3% of children had at least one caregiver-reported sleep problem (66% insomnia symptoms, 64% electronics, 38% insufficient sleep, 21% caffeine, 17% snoring). In contrast, a substantially lower percent of children had a clinician documented sleep problem (20% overall; 10% insomnia symptoms, 7% electronics, 0% insufficient sleep, 3% caffeine, 4% snoring), sleep-related referral (1% overall; 0.6% Otolaryngology, 0.6% polysomnogram, 0% sleep clinic), or recommendation (12% overall; 8% insomnia symptoms, 4% electronics, 0% insufficient sleep, 1% caffeine).
Conclusions:
There is a vast discrepancy between caregiver-reported child sleep problems and clinician-documented sleep problems and management, with a higher proportion of caregiver reports. To benefit overall child health and well-being, future research and quality improvement initiatives should focus on enhancing screening tools and educational opportunities to improve clinician documentation and enhance family conversations about early childhood sleep problems.
Keywords: clinical screening, insomnia, primary care, sleep, sleep health, snoring
Pediatric sleep problems, including symptoms of sleep disorders and poor sleep health, are highly prevalent, particularly in early childhood. Medically-based sleep disorder symptoms, such as snoring, occur in 4–27% of preschoolers, while behaviorally-based sleep problems, including insomnia symptoms (e.g., difficulty falling asleep, frequent night awakenings), occur in 15% to 30% of young children.1 Insufficient sleep duration, or sleeping less than age-based recommendations, and other aspects of poor sleep health, such as bedtime electronics usage, are also prevalent in young children.2,3 Snoring, insomnia symptoms, and insufficient sleep have each been associated with adverse early childhood outcomes, including executive functioning impairments and externalizing and internalizing problems.4–7 Given the rapid growth and development that occurs in early childhood, preschoolers are an especially vulnerable population for the adverse consequences of untreated sleep problems. Thus, routine screening for these sleep problems in young children is critical for early identification and treatment of these problems.1,8
The American Academy of Pediatrics (AAP) recommends that all children be screened for snoring and other sleep disordered breathing symptoms at every well-visit, and that children with one or more additional symptoms be referred for further evaluation via polysomnography (PSG), a sleep specialist, or an otolaryngologist.8 The AAP guidelines for early childhood well-visits also recommend that clinicians encourage families to limit child electronics exposure and to implement a developmentally-appropriate child bedtime,9 which aligns with pediatric sleep health promotion.3 Sleep practitioners have similarly recommended routine well-visit screening for snoring, sleep health behaviors, and insomnia symptoms.10–12 Prior research indicates that primary care may be an optimal setting for initial sleep health promotion and insomnia symptom management from both the perspectives of primary care clinicians and families,11,13,14 although few studies have evaluated the efficacy of these approaches in primary care.
Despite the high prevalence of pediatric sleep problems and the clinical guidelines for primary care-based sleep screening, previous research has shown sparse documentation and management of such problems. In a retrospective study of 154,957 patients ages 0–18 years presenting for a well-visit, only 4% of children had a sleep disorder diagnosis, which is well below epidemiological prevalence rates.15 Additionally, of those with a diagnosed sleep disorder or identified sleep problem, only 5.2% received any sleep-related treatment recommendations from their primary care clinician.16 In another study piloting a tool for primary care clinician identification of sleep disordered breathing symptoms, only 76% of children ages 1–11 years with reported sleep disordered breathing symptoms received a clinical referral or guidance on symptom management.17 While these findings improve upon prior research on primary care clinician sleep documentation and referral management, this study was limited to sleep disordered breathing problems and may not generalize to most primary care contexts, which lack a specific tool for sleep disordered breathing screening. Furthermore, little is known about whether caregiver-perceived child sleep problems align with clinician documentation and management of these problems in primary care. This likely misalignment has implications for the development of screening methods to enhance primary care-based sleep problem management.
Thus, the purpose of this study was to compare rates of caregiver-reported child sleep problems and clinician sleep-related documentation, referral patterns, and any sleep-related guidance during preschoolers’ well-visits. To conform with clinical guidelines regarding sleep screening and to reflect the common early childhood sleep problems, we focused on the following sleep problems: (a) habitual snoring (3 or more nights per week),8 (b) insomnia symptoms (a behavioral sleep problem), and (c) sleep health behaviors, including insufficient sleep duration, caffeine consumption, and nighttime electronics usage. We hypothesized that the proportion of young children (2–5 years) with caregiver-reported sleep problems and the proportion of clinician documentation, referrals, and recommendations would be incongruent, with a higher proportion of caregiver-reported child sleep problems.
Method
Data for the current study were drawn from a larger study18 of caregiver-reported child sleep problems in a convenience samples of 205 young children ages 2 to 5 years (Mage = 3.3 years, SD = 1.1) presenting to 3 urban (large, metropolitan) and 2 suburban primary care sites within a large primary care network affiliated with a children’s hospital and integrated in a practice-based research network.19 Exclusion criteria included (a) acute or chronic medical condition, (b) neurodevelopmental or behavioral health diagnosis, (c) sleep disorder diagnosis, or (d) current medication that could impact sleep. The child’s legal guardian (87% mothers) who accompanied them to the primary care visit provided informed consent and families were compensated with a gift card upon completion of study measures. For the current study, caregiver-child dyads were included if the participating child had a well-visit encounter in the electronic health record (EHR) that occurred on the date of survey completion for the larger study. Primary care clinician sociodemographic information was not collected for this study. Prior research conducted in these care sites indicates that clinicians are primarily non-Latinx White (73%) and female (87%),13 which aligns with national data on pediatrician sociodemographic information.20,21 This study was approved by the Children’s Hospital of Philadelphia Institutional Review Board.
Procedure
Caregivers reported on child sleep patterns, problems, and snoring using well-validated questionnaires, described below. We assessed clinician documentation and referral patterns by coding information from the well-visit progress note and associated after visit summary (AVS), which were the locations where sleep problems would be mentioned in the EHR for the well-visit encounter.
Snoring.
Habitual snoring was assessed using a caregiver-rated item from the Sleep Related Breathing Disorder subscale (SRDB) of the Pediatric Sleep Questionnaire (PSQ),22 which has strong internal consistency, test-retest reliability, and validity in accurately identifying sleep disordered breathing in children ages 2 to 18 years. Caregivers rated the following question on a 3-item response set (yes= 1, no= 0, and I don’t know= missing): “While sleeping, does your child snore more than half the time?”
Insomnia symptoms.
Caregiver-rated child insomnia symptoms were assessed using items from the Brief Child Sleep Questionnaire (BCSQ),23,24 a widely-used measure of early childhood sleep patterns and problems. Items have shown good reliability and moderate validity in assessing child sleep patterns (e.g., sleep duration) when compared to actigraphy.23,25 BCSQ items assess the child sleep ecology (e.g., bedtime routine, child sleep arrangement) and child sleep patterns (e.g., sleep onset latency, sleep duration), as well as caregiver perceived child sleep problems (e.g., overall sleep problem, bedtime resistance), over the prior 2 weeks. The BCSQ does not have corresponding subscales or yield a total score. As in prior research,23–27 items are individually used to reflect different aspects of child sleep.
For the purpose of the present study, BCSQ items to reflect insomnia symptoms were chosen based on their alignment with pediatric insomnia diagnostic criteria26,27 The following symptoms were dichotomously coded and used to reflect insomnia, with corresponding BCSQ items listed in Table 1: bedtime resistance (somewhat difficult, moderately difficult, or very difficult=1), difficulty falling asleep (>3 nights per week = 1), sleep onset latency (>30 minutes), night awakenings (> 3 nights per week = 1), and caregiver-perceived sleep problem (small to severe problem = 1). and previous research.5,18,28 Overall insomnia symptoms were also coded dichotomously such that caregiver indication of 1 or more symptoms = 1.
Table 1.
Sociodemographic information for children included in the study
| Sociodemographic variables | Caregivers, mean (SD)/% | Children, mean (SD)/% |
|---|---|---|
| Female gender | 86.5% | 56.5% |
| Race: Black or African American | 60.0% | 65.3% |
| White | 25.9% | 21.8% |
| Other or multiple races | 7.6% | 9.4% |
| Asian | 5.9% | 3.5% |
| Native Hawaiian or Other Pacific Islander | 0.6% | 0% |
| Ethnicity: Hispanic/Latinx | 5.3% | 4.1% |
| Age | 3.3 years (1.1 years) | |
| <18 years | 0.6% | |
| 18–24 years | 17.6% | |
| 25–29 years | 27.6% | |
| 30–39 years | 41.8% | |
| 40–49 years | 10.0% | |
| >50 years | 2.4% |
Sleep health.
Items reflecting insufficient total (24-hour) child sleep duration, caffeine consumption, and nighttime electronics usage were used to reflect aspects of pediatric sleep health. As shown in Table 1, insufficient sleep duration and nighttime electronics usage were assessed by BCSQ items, while caffeine consumption was assessed using the corresponding National Sleep Foundation item.29 Individual items were dichotomously coded, as follows, in line with previous studies18,28,30: insufficient sleep duration (<11 hours total [24-hour] sleep duration for 2-year-olds and <10 hours total sleep duration for 3–5-year-olds = 1); caffeine consumption (consumption of > 1 beverage/day = 1); and nighttime electronics usage (using electronics < 1 hour before bed and/or while falling asleep = 1).
Clinician referral and documentation patterns.
Trained research assistants coded the content of well-visit progress notes and AVS information, including sleep specialty care referral orders, in the EHR for participating children. Codes for clinician documentation, specialty sleep referrals, and clinician insomnia management and/or sleep health guidance were dichotomized to reflect each sleep outcome of interest (see Table 2). These dichotomized outcomes included progress note documentation of snoring (=1), any insomnia symptom (=1), or poor sleep health (=1). Specialty sleep referrals included consultation with otolaryngology for snoring (=1), a consultation with the hospital’s sleep medicine clinic (=1), or a polysomnography order (=1). Clinician sleep guidance from the progress note and AVS included insomnia management recommendations (=1), sleep duration recommendations (=1), electronics screen time recommendations (=1), and caffeine avoidance recommendations (=1).
Table 2.
Items used to assess caregiver-identified and clinician-documentation/referral patterns by sleep construct
| Sleep construct | Caregiver identification | Clinician documentation | Relevant clinical referral | Clinician sleep-related guidance |
|---|---|---|---|---|
| SDB symptom: snoring | SRBD subscale item: “While sleeping, does your child snore more than half the time?” (yes= 1, no= 0, and I don’t know=missing) | Progress note indication of any child snoring = 1 No progress note indication = 0 |
Otolaryngology = 1 Sleep Clinic = 1 Polysomnography = 1 No referral= 0 |
-- |
| Insomnia symptoms (Summed score of 0 = 0; summed score > 1 = 1) | BCSQ item (sleep problem): “How much of a problem is your child’s sleep?” (small to severe problem = 1; no problem or a very small problem=0) | Progress note indication of any sleep problem, bedtime resistance, difficulty falling asleep, prolonged sleep onset latency, or night awakenings (=1) No progress note indication= 0 |
Sleep Clinic = 1 No referral = 0 |
Progress note and/or AVS recommendations related to having a bedtime routine, consistent sleep schedule, independent sleep training = 1 No clinical guidance documented = 0 |
| BCSQ item (bedtime resistance): “Typically, how difficult is bedtime for your child, for example, crying, fussing, protesting?” (somewhat difficult, moderately difficult, or very difficult = 1) | ||||
| BCSQ item (difficulty falling asleep): “How often, if ever does your child have a difficult time falling asleep at night?” (>3 nights per week = 1; not difficult = 0) | ||||
| BCSQ item (sleep onset latency): “How long does it typically take your child to fall asleep?” (>30 minutes = 1) | ||||
| BCSQ item (night awakenings): “How often does your child wake during the night, if ever?” (>3 nights per week = 1) | ||||
| Sleep health behaviors | National Sleep Foundation Item (Caffeine): “Thinking about caffeinated beverages such as Coke, Pepsi, Mountain Dew, iced teas, and coffee, how many cups or cans of caffeinated beverages does your child typically drink each day?” (consumption of > 1 caffeinated beverages = 1) | Progress note indication of caffeine consumption = 1 No progress note indication= 0 |
-- | Progress note and/or AVS recommendations related to avoiding caffeine = 1 No clinical guidance documented = 0 |
| BCSQ Items (Electronics): “Which of the following usually occurred on most nights for your child in the hour before bedtime? (Please check all that apply) (choice=watch television)” and/or “How does your child fall asleep most of the time? (Please check all that apply) (choice= while watching television)” (watch TV < 1 hour before bed and/or fall asleep to TV = 1) | Progress note indication of electronic use = 1 No progress note indication = 0 |
-- | Progress note and/or AVS recommendations related to electronics usage and/or screen time = 1 No clinical guidance documented =0 |
|
| BCSQ item (sleep duration combined items): “How much total time does your child spend sleeping during the NIGHT (between 7:00 in the evening and 8:00 in the morning)?” and “How much total time does your child spend sleeping during the DAY (between 8:00 in the morning and 7:00 in the evening)?” (<11 hours total [24-hour] sleep duration for 2-year-olds and <10 hours total sleep duration for 3- to 5-year-olds = 1) |
Progress note indication of insufficient sleep duration = 1 No progress note indication = 0 |
-- | Progress note and/or AVS recommendations related to sleep duration = 1 No clinical guidance documented =0 |
Note. AVS = after visit summary; SRBD = sleep-related breathing disorder subscale of the Pediatric Sleep Questionnaire; BCSQ = Brief Child Sleep Questionnaire
Analyses
IBM SPSS 27.0 was used to conduct all analyses. We used proportions for all variables to generate descriptive statistics. For EHR coding, we calculated kappa (k) and raw agreement (for those cases in which one variable was a constant) across the coders on a random sample of 17% of cases that were double-coded; the average value suggested strong inter-observer agreement, with k = .87. We used McNemar tests to examine whether caregiver-reported child sleep problems corresponded with well-visit clinician documentation and related sleep management, across the following outcomes: snoring, insomnia symptoms, and sleep health behaviors (caffeine consumption, sleep duration, electronics, bedtime). A post-hoc power analysis indicated that our sample of 170 caregiver-child dyads had 98% power to detect small differences in the extent of caregiver-reported versus clinician-documented sleep problems using a McNemar test with a statistical significance of p<.05.
Results
Descriptive statistics for caregiver and child sociodemographic information for the included 170 caregiver-child dyads can be found in Table 1. Sample characteristics were reflective of patient/family sociodemographic information of the primary care sites where data collection occurred (see Williamson & Mindell for details).18
According to caregivers’ reports, 92.3% of preschoolers experienced at least one of the sleep problems of interest (i.e., habitual snoring, insomnia symptoms, and poor sleep health behaviors). As shown in Table 3, the most prevalent caregiver-reported child sleep issues included experiencing one or more insomnia symptoms (65.7%) and nighttime electronics usage (63.5%). Over one-third of caregivers reported insufficient child sleep (38.0%). Consuming one or more caffeinated beverage per day (21.8%) and habitual snoring (17.6%) were less prevalent but still impacted about one-fifth of the sample. Clinician-documented child sleep problems were much less prevalent (20.0%), with the most common documented problem being insomnia symptoms (10.0%), followed by electronics use (7.1%), snoring (4.1%), and caffeine consumption (2.9%). There was no documentation of insufficient sleep (0.0%).
Table 3.
Descriptive statistics and correspondence between caregiver-reported and clinician-documented child sleep outcomes
| Sleep problems | Caregiver-reported [95% CI] | Clinician documentation [95% CI] | McNemar comparisons* |
|---|---|---|---|
| Habitual snoring | 17.6% [11.9%, 23.3%] | 4.1% [1.1%, 7.1%] | p < .001 |
| Any insomnia symptom+ | 65.7% [58.5%, 72.9%] | 10.1% [5.6%, 14.6%] | p < .001 |
| Sleep onset latency >30 min | 48.5% [41.0%, 56.0%] | -- | |
| Bedtime resistance | 29.4% [22.6%, 36.2%] | -- | |
| Night awakenings >3 times/week | 25.3% [18.8%, 31.8%] | -- | |
| Difficulty falling asleep >3 times/week | 20.6% [14.5%, 26.7%] | -- | |
| Sleep problem | 14.7% [9.4%, 20.0%] | -- | |
| Poor sleep health behaviors | |||
| Caffeine consumption | 21.9% [15.7%, 28.1%] | 2.9% [0.4%, 5.6%] | p < .001 |
| Electronics use before bed | 63.5% [56.3%, 70.7%] | 7.1% [3.2%, 11.0%] | p < .001 |
| TV < 1 hour before bed | 55.9% [48.4%, 63.4%] | -- | |
| Fall asleep to TV | 32.4% [25.4%, 39.4%] | -- | |
| Insufficient sleep | 38.0% [30.4%, 45.6%] | 0% [0%, 1.9%] | p < .001 |
|
| |||
| Clinician management | McNemar comparisons* | ||
|
| |||
| ENT referral | 0.6% [0%, 6.0%] | p < .001 | |
| Sleep clinic consultation | 0% [0%, 1.8%] | p < .001 | |
| Polysomnography order | 0.6% [0%, 6.0%] | p < .001 | |
| Behavioral sleep recommendation | 8.3% [4.1%, 12.5%] | p < .001 | |
| Sleep health recommendations | |||
| Caffeine | 1.2% [0%, 2.8%] | p < .001 | |
| Electronics in bedroom | 4.1% [1.1%, 7.1%] | p < .001 | |
| Sleep duration | 0% [0%, 1.9%] | p < .001 | |
Note.
reflects 1 or more child insomnia symptoms for caregiver-reported data and any progress note indication of a child behavioral sleep problem documented by clinicians.
Clinician management was compared against caregiver-reported child sleep problems, see Table 2 for details.
Comparisons for caregiver-reported versus clinician documented child sleep problems
Although most preschoolers had at least one caregiver reported sleep problem (92.3% (95% confidence interval 88.1%, 96.5%), only 20.0% (14.0%, 26.0%) of children had a clinician documented sleep problem.
Habitual snoring.
Significantly more children experienced caregiver-reported habitual snoring (17.6% [11.9%, 23.3%]) compared to clinician-documentation of this problem (4.1% [1.1%, 7.1%]), p < .001. Only 13.3% (8.2%, 18.4%) of children whose caregivers reported that their child snored habitually had clinician documented snoring in the child’s well-visit note.
Insomnia symptoms.
Similarly, there was a significantly higher proportion of caregiver-identified insomnia symptoms (65.7% [58.5%, 72.9%]) compared to clinician-documented insomnia symptoms (10.1% [5.6%, 14.6%]), p < .001. For those children whose caregivers reported child insomnia symptoms, few (13.5% [8.3%, 18.7%]) had a clinician documented insomnia symptom.
Poor sleep health behaviors.
Significantly fewer clinicians documented any child sleep health behaviors compared to caregiver report across all outcomes. Whereas 21.9% (15.7%, 28.1%) of caregivers reported child daily caffeine consumption, there was little clinician documentation of this problem (3.0% [0.4%, 5.6%]), p < .001. Caregiver-reported child nighttime electronic usage was highly prevalent (63.5% [56.3%, 70.7%]); however, evening electronics usage was only noted in 7.1% (3.2%, 11.0%) of clinical progress notes, p < .001. Compared to the 38.0% (30.4%, 45.6%) of children with caregiver-reported insufficient sleep duration, 0% (0%, 1.9%) of clinicians noted child sleep duration in their progress note, p < .001. Of those children whose caregiver reported any poor child sleep health behavior, very few had clinician-documented caffeine consumption (10.8% [6.1%, 15.5%]) and nighttime electronics usage (8.3% [4.2%, 12.4%]).
Comparisons for caregiver-reported versus clinician-managed sleep problems
The proportion of clinician documented sleep problem management (12.9% [7.9%, 17.9%]) was similar to the proportion of clinician documented sleep problems (20.0% [14.0%, 26.0%]). However, only 1.2% (0%, 2.8%) of children received a clinician documented referral and 12.4% (7.4%, 17.4%) of children received a clinician documented recommendation.
Habitual snoring.
The proportion of caregivers reporting habitual child snoring was significantly higher than management of sleep disordered breathing documented in the EHR, which included an otolaryngology consultation (0.6% [0%, 1.8%], p < .001), a sleep clinic consultation (0% [0%, 1.8%], p < .001), or a polysomnography order (0.6% [0%, 1.8%], p < .001). Of the 17.8% of children whose caregivers reported child habitual snoring, very few received a clinician referral to otolaryngology (3.3% [0.6%, 6.0%]), sleep clinic consultation (0% [0%, 1.8%]), or a polysomnography order (3.3% [0.6%, 6.0%]). It should be noted that a robust, interdisciplinary sleep clinic (over 15 medical/psychology attendings) exists at this institution.31
Insomnia symptoms.
Of the 65.7% (58.5%, 72.9%) of children with a caregiver-reported child sleep problem, none received a clinician referral for a sleep clinic consultation (0% [0%, 1.9%]), p < .001. In addition, clinician insomnia management recommendations in the AVS (8.3% [4.1%, 12.5%]) were significantly less prevalent than the proportion of children with a caregiver-reported child sleep problem, p < .001. Only 9.9% (5.4%, 14.4%) of children with a caregiver-reported insomnia symptom had a documented behavioral sleep recommendation from their clinician.
Poor sleep health behaviors.
The proportion of clinicians documenting sleep health recommendations in the child’s AVS was significantly less than the proportion of caregivers reporting poor child sleep health behaviors. This statistically significant difference was apparent across all outcomes, including caffeine consumption (1.2% [0%, 2.8%] clinician-documented guidance, p < .001), nighttime electronics usage (4.1% [95% CI 1.1%, 7.1%] clinician-documented guidance, p < .001), and insufficient sleep (0% [0%, 1.9%] clinician-documented guidance). Of those children whose caregiver reported poor child sleep health behaviors, very few had a clinician-documented recommendations for caffeine (2.7% [0.3%, 5.1%]) and electronics usage (3.7% [0.8%, 6.5%]); there were no documented recommendations related to insufficient sleep.
Discussion
This study examined the alignment between caregiver-reported preschool child sleep problems and clinician-documented sleep problems and sleep management in the primary care setting. According to parent report, almost all children (92.3%) in the current sample experienced at least one of the sleep problems of interest (i.e., habitual snoring, insomnia symptoms, and poor sleep health behaviors). Additionally, across these caregiver-reported sleep problems of interest, the proportion of children with a caregiver-reported sleep problem was significantly greater than the proportion of children who had a clinician-documented sleep problem (20.0%) or provided with a referral or recommendation (12.9%).
An overwhelming majority of the children in this sample experienced symptoms of snoring, insomnia, and/or poor sleep health behaviors. Nighttime electronics usage (63.5%) and experiencing one or more symptoms of insomnia (65.7%) were the most prevalent caregiver-reported child sleep problems, with proportions exceeding those identified in previous research with young children (14–43% and 15–30%, respectively).1,2 Meanwhile, insufficient child sleep was prevalent in over one-third of the sample and caffeinated beverages and snoring were prevalent in approximately one-fifth of the sample, which are similar to rates found in previous early childhood studies.1 Overall, these findings support the importance of child well-visit screening and management of sleep problems, in line with AAP guidelines and recommendations from the sleep field.1,3,8,9
Although routine well-visit screening for sleep problems is especially recommended in early childhood,10–12 very few preschool-aged children across the sample had any clinician documentation of sleep or related sleep recommendations. This limited clinician documentation of child sleep problems and related management was observed albeit the existence of caregiver-reported habitual snoring, insomnia symptoms, and/or poor sleep health behaviors. These findings are consistent with previous research showing sparse clinician documentation of sleep problems and sleep management in pediatric primary care,15–17 despite more recent research suggesting that primary care may be the optimal setting for behavioral-related sleep management.11,13,14 The most common documented advice provided was behavioral in nature, with minimal follow-up of snoring although approximately one-fifth of children had habitual snoring. Only 3% were referred to ENT or had an order placed for polysomnography. Surprisingly, no children were provided a referral to a sleep clinic for either snoring or insomnia symptoms, although a robust interdisciplinary sleep clinic, with approximately 15 providers (pulmonary, neurology, psychiatry, psychology), exists at this institution.
Study findings have implications for enhancing primary care-based sleep screening, documentation, and management. Primarily, there is a need for validated screening tools to facilitate the process of identifying sleep problems among children of all ages presenting to well-visits. Having screening tools that are efficient and address the most commonly seen pediatric sleep problems would be particularly useful given limited time available to cover many important health domains by pediatric providers during well-visits.12,32 Studies show that screening tools completed prior to child well-visits by caregivers or during the well-visits by clinicians are user-friendly and acceptable strategies for improving problem identification in primary care.12,33,34 However, to date, available research on sleep-specific screening tools is limited to a handful of studies.12,17,35 Development of tools that can comprehensively screen for the most common pediatric sleep problems, while also being short enough to minimize family and clinician burden, is needed.
Even with such tools, however, prior research shows that even with an EHR-integrated screening tool for obstructive sleep apnea and targeted guidance for clinician management of these symptoms, there is variation in clinician practices.17 It could be that limited sleep training among pediatricians contributes to variation in sleep problem identification as well as management. Making sleep-related educational opportunities more accessible for pediatricians could help increase appropriate referrals and recommendations for children with identified sleep problems, given that formal sleep training for pediatricians has been associated with increased confidence in regards to their sleep management abilities.36 Similar to the research on clinical decision support for obstructive sleep apnea symptoms,17,35 future work should focus on creating screening tools and decision support that integrates clinician education. Additionally, future work should focus on creating related sleep resources for families, given limited caregiver knowledge regarding child sleep.37 Furthermore, although publicly available and evidence-based sleep health guidance is limited, there is great interest in these resources. For example, a consumer health information website on infant and toddler sleep attracts high rates of worldwide traffic, highlighting the potential benefits of these resources for older children as well.38
There are several limitations to the current study. Primarily, findings from this study are limited to one primary care network, although the limited documentation of sleep problems in this study is consistent with research in other primary care networks.10 We also did not collect clinician sociodemographic information or assess their perspectives on the child patient’s sleep. Future research examining primary care clinician behaviors should collect data from these providers to better understand primary care sleep screening and management. It is also possible that clinicians verbally screened for these sleep problems but determined these issues were within normal limits and/or did not document them in the child’s progress notes or AVS.
In addition, information on the chronicity of child sleep problems was limited, as caregivers were asked to report on child sleep problems over the prior two weeks. Thus, during the well visit clinicians may have identified an acute rather than a chronic problem, which in turn impacts whether any recommendations for management were provided. Although caregivers reported a high number of sleep problems in their preschool-aged child, they may not raise these issues in the well-visit. It could be that caregivers do not perceive their child’s sleep problem as being concerning enough to mention to their provider, or do not view this problem as something their provider could help with. Lack of knowledge regarding what constitutes a sleep problem could also contribute to limited reporting, as thus limited provider documentation, of child sleep problems in well visits. For instance, previous research suggests that, overall, caregiver knowledge of child sleep is limited,37 and this may be especially true for sleep health information, such as the recommended hours of total sleep by age.
It should also be noted that habitual snoring in and of itself does not necessarily indicate the need for further evaluation for potential sleep disordered breathing; additional symptom screening and in some cases watchful waiting is recommended. Nonetheless, these limitations underscore the need for additional research focused on standardized screening tools and more educational opportunities to facilitate caregiver and clinician conversations surrounding child sleep problems and broad sleep health, as well as clinician management of pediatric sleep problems. This topic would be particularly relevant for a quality improvement project aiming to develop, implement, and evaluate a sleep screening tool and educational resources to support consistent clinician screening and management behaviors during well-child care.
This study identified a large, but modifiable, discrepancy between caregiver-reported child sleep problems and clinician-documented child sleep problems and management. Among those children whose caregivers reported a child sleep problem, very few had clinician documented sleep problems, relevant referrals, or recommendations. Study findings provide directions for future research and quality improvement initiatives, primarily around enhanced screening tools and educational opportunities to encourage clinician and family conversations about early childhood sleep problems. These strategies could result in earlier identification of child sleep problems and improved sleep-related care in the pediatric primary care setting, which may in turn benefit overall child behavior, health, and wellbeing.
Funding:
Ariel A. Williamson was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23HD094905)
Footnotes
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Conflicts of Interest: The authors have no conflicts of interest to disclose.
This study found a vast discrepancy between prevalent caregiver-reported early childhood sleep problems (snoring, insomnia symptoms, poor sleep health) and limited clinician-documentation and management of sleep at well-visits, underscoring the importance of enhanced sleep screening and management tools in well-visits.
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