Reasoning GP · Algorithm · 1-page summary
Sleep problems in children
Core rule: most childhood sleep problems are behavioural, but only call it behavioural after asking about snoring with breathing pauses, stereotyped night-time events and safeguarding, and plotting growth. Melatonin is never first-line in primary care.
0Stop — call 999 now
- Breathing now: current respiratory compromise, cyanosis, persistent apnoea, not breathing, reduced consciousness or failure to recover → 999
- Seizure lasting 5 minutes or more, repeated seizures without recovery, significant injury or failure to return to baseline → 999
- Acute safeguarding emergency → 999 and the local safeguarding pathway.
- Not 999: stable habitual snoring or witnessed pauses → prompt paediatric sleep/ENT referral (block 2).
1Triage by age — what to look for first
| Age | Think of |
|---|---|
| 0–2 y | Night waking can be normal beyond 6 months. Sleep associations, reflux, eczema, pain; safe sleep. |
| 2–5 y | Bedtime resistance, "curtain calls", night terrors, confusional arousals; bed-sharing and safe sleep. |
| 5–12 y | Anxiety, OSA, restless legs or "growing pains", ADHD, parasomnias. |
| 13–18 y | Delayed sleep phase, screens, anxiety and depression, substance use, narcolepsy onset, snoring. |
2Screen — one row is enough
- Possible OSA: habitual snoring with witnessed apnoeas, choking, laboured or mouth breathing, restless sleep, daytime sleepiness or behaviour change → Prompt sleep/ENT referral (local pathway)
- Seizure features: stereotyped, clustered events, tonic stiffening or rhythmic jerking, lateral tongue biting, injury, incontinence, post-event confusion, daytime events, abnormal neurology → Urgent paediatrics, seen ≤2 weeks (NG217). Ask for a video.
- Developmental regression or serious underlying illness (weight loss, growth faltering) → Urgent paediatrics, discussed same day
- Falling asleep in hazardous situations (roads, water, cycling, school travel) → Same-day GP assessment: OSA, narcolepsy, insufficient sleep, medicines.
- Safeguarding: neglect, abuse, unsafe supervision or co-sleeping, unexplained bruising, fear of going to bed → Same-day local safeguarding pathway. Co-sleeping or parental exhaustion alone is not abuse.
3Assess
☐ 2-week sleep diary ☐ Growth chart (faltering = medical cause) ☐ Tonsils, mouth breathing, nasal obstruction ☐ Development, mood, ADHD/autism, ACEs, safeguarding ☐ BEARS screen
Tests only if targeted: FBC and ferritin for restless legs or suspected iron deficiency; TFTs or HbA1c only with symptoms. Oximetry, sleep studies and EEG via the specialist pathway.
4Classify — only if the screen is negative
- Sleep association — only falls asleep with feeding, rocking or a parent; persistent and impairing → behavioural plan.
- Limit-setting (age 2–8) — refuses bed, repeated requests → firm consistent routine, bedtime pass, rewards.
- Night terrors or sleepwalking — first third of night, no memory → do not wake; make home safe.
- Nightmares — second half of night, recalls the dream, comforted → reassure; treat anxiety if persistent.
- Delayed sleep phase (teenager) — late onset, normal sleep at weekends → regular wake time and morning daylight.
- Uncertain — identical, clustered events may be nocturnal frontal lobe epilepsy: treat as block 2.
5Treat today
- Family-agreed behavioural plan: graduated checking, parental presence fading, camping out, positive reinforcement. Controlled crying is not mandatory.
- Sleep hygiene: consistent wake time incl. weekends, screens out of the bedroom, no caffeine or energy drinks, dark quiet room. Safe sleep for infants: on the back, clear cot, smoke-free; never share a sofa or armchair with a baby.
- Treat itch, reflux, constipation and pain; support parental wellbeing and consistency.
- Melatonin only specialist-initiated (usually neurodevelopmental, after a plan fails); GP continues under shared care, doses per BNFC and local protocol. No antihistamines, benzodiazepines, Z-drugs or antipsychotics.
6Refer routinely
- Infant or toddler behavioural problems → Health Visitor or sleep support service (Sleep Charity helpline 03303 530541).
- Persistent despite a structured plan, complex neurodisability → community paediatrics. Anxiety, PTSD nightmares, teenage chronic insomnia → CAMHS.
- Daytime sleepiness with cataplexy (narcolepsy), or teenage delayed sleep phase needing melatonin or light → paediatric sleep specialist.
7Never reassure by
- A "behavioural" label without a snoring and breathing history.
- Small tonsils or a normal oximetry study.
- Calling identical, clustered night events "night terrors".
- "Growing pains" without considering restless legs and iron deficiency.
- Teenage late sleep put down to laziness or poor sleep hygiene.
- Melatonin repeat prescriptions continued without specialist review.
8Safety-net — say it, then document it
999 “Call 999 if your child turns blue, stops breathing or keeps pausing and can't recover, can't be woken properly, or has a fit lasting 5 minutes or more or fits without recovering in between.” Same day: “Contact us today if your child falls asleep somewhere dangerous, night episodes become longer or more frequent, or there is tongue biting, wetting or confusion after an episode.”
Follow-up: review the diary at 2 weeks and again at 4–6 weeks. If the plan fails, check consistency, then reassess for OSA, a medical, mood or neurodevelopmental cause, and safeguarding.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Snoring, pauses and seizure features asked about
Growth plotted; safeguarding considered
Behavioural plan agreed; diary and review date set
Safety-net given; no melatonin outside specialist pathway
Summary of the full Reasoning GP sleep problems in children algorithm, which holds the detail, age-specific history, techniques and evidence. Sources: BTS paediatric sleep-disordered breathing (2023); NICE CG170, NG217; local melatonin shared-care protocol; NHS safe-sleep advice; RCPCH; The Sleep Charity. Clinical reference — follow local pathways and check doses in the current BNFC.