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The Practice of Pediatric Sleep Medicine: Results of a Community Survey

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The Practice of Pediatric Sleep Medicine: Results of a Community Survey The Practice of Pediatric Sleep Medicine: Results of a Community Survey Judith A. Owens, MD, MPH ABSTRACT. Objective. To assess knowledge, screen- orders, and in the translation of that knowledge into ing, evaluation, treatment practices, and attitudes regard- clinical practice. Despite their acknowledgment of the ing sleep disorders in children and adolescents in a large importance of sleep problems, many pediatricians fail to sample of community-based and academic pediatricians. screen adequately for them, especially in older children Design. Cross-sectional survey. and adolescents. Additional educational efforts regard- Participants. Six hundred twenty-six pediatricians in ing pediatric sleep issues are warranted, and should Rhode Island, Massachusetts, and Connecticut. be targeted at the medical school, postgraduate training, Instrument. The Pediatric Sleep Survey, a 42-item and continuing medical education levels. Pediatrics 2001; questionnaire assessing general and specific sleep 108(3). URL: http://www.pediatrics.org/cgi/content/full/ knowledge categories; clinical screening, diagnostic, and 108/3/e51; pediatrician, sleep knowledge. treatment practices for common pediatric sleep disorders; and practitioner attitudes regarding the impact of sleep disorders in the clinical setting and as a public health ABBREVIATIONS. OSA, obstructive sleep apnea; ADHD, atten- issue. tion-deficit/hyperactivity syndrome; RLS, restless legs syndrome; PLMD, Periodic Limb Movement Disorders. Results. On the knowledge section, the mean Total Knowledge score for the respondents was 18.1 ؎ 3.5 out of 30 items, with 23.5% of the sample responding cor- umerous studies have shown that clinical rectly on half or less of the items. Pediatricians scored sleep disorders are associated with signifi- highest on items relating to developmental and behav- cant morbidity, functional impairment, de- ioral aspects of sleep and parasomnias, whereas the mean N creased quality of life, and substantial direct and percentage of correct responses was <50% for items re- 1–3 lating to sleep disordered breathing, excessive daytime indirect economic costs. Despite this empirical ev- sleepiness, and sleep movement disorders. Although idence, inadequate attention is often paid by medical only 16.5% and 18.2% of the sample reported not screen- professionals to sleep disorders and their serious ing routinely for sleep disorders in infants and toddlers, health consequences.4,5 This discrepancy may be, in this percentage rose to 43.9% in adolescents. Further- part, related to the fact that sleep and sleep disorders more, only 38.3% regularly question the adolescents have traditionally received little attention in medical themselves about their sleep. Only about one quarter of school curriculae.6–8 Even as recently as 1990, a sur- the respondents screen toddlers and school-aged chil- vey by the National Council on Sleep Disorders Re- dren for snoring. In evaluating and treating pediatric search found that 29% of medical schools offered sleep problems, 53.2% of the sample never or rarely order 7 overnight sleep studies to assess for obstructive sleep little to no formal sleep education. This lack of train- apnea and few use alternative treatment strategies, such ing has resulted in serious gaps in the knowledge as continuous positive airway pressure. A quarter of the and skills of practicing physicians in recognizing, sample at least occasionally recommends diphenhydra- diagnosing, and treating sleep disorders, and in lim- mine and almost half suggests a psychological evaluation ited awareness on the part of medical professionals for children with night terrors. Finally, the percent of of the diverse etiologic factors and consequences of pediatricians rating the impact on children of sleep prob- impaired sleep.9,10 lems in a variety of domains as important or very impor- For a number of reasons, this knowledge deficit tant ranged from 49.7% (nonintentional injuries) to 92.6% may have a particularly significant impact in regards (academic performance). However, only 46% of the sam- to the recognition by primary care physicians of ple felt confident or very confident about their own 11 ability to screen for sleep problems, whereas 34.2% and sleep disorders in children and adolescents. First, 25.3% similarly rated their ability to evaluate and treat there is considerable evidence that the prevalence sleep problems in children. of both transient and chronic pediatric sleep disor- Conclusions. The results of this survey suggest that ders is high, increasing the likelihood of the primary there are still significant gaps among practicing pediatri- care physician encountering sleep problems in the cians both in basic knowledge about pediatric sleep dis- context of daily clinical practice. Numerous epidemi- ologic studies of sleep disorders from a variety of From the Division of Pediatric Ambulatory Medicine, Rhode Island Hospi- populations have documented high levels of sleep tal, Providence, Rhode Island. disturbances in children. These include difficulty set- Received for publication Feb 26, 2001; accepted May 10, 2001. tling and frequent night wakings in up to 40% of Address correspondence to Judith A. Owens, MD, MPH, Division of Pedi- infants12–14; bedtime resistance, delayed sleep onset, atric Ambulatory Medicine, Rhode Island Hospital, 593 Eddy St, Potter Bldg, Ste 200, Providence, RI 02903. E-mail: [email protected] and disruptive night wakings in 25% to 50% of pre- 15–18 PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- schoolers, a 27% prevalence of marked bedtime emy of Pediatrics. resistance19 and a 37% prevalence of parent-reported http://www.pediatrics.org/cgi/content/full/108/3/Downloaded from www.aappublications.org/newse51PEDIATRICS by guest on September Vol. 10824, 2021 No. 3 September 2001 1of16 problematic sleep behaviors in school-aged chil- gaps in a sample of practicing pediatricians surveyed dren,20 and significant daytime drowsiness in 10% to about a number of sleep topics. 40% of high school students.21–23 The prevalence of Thus, an increased understanding of how child obstructive sleep apnea (OSA) in toddlers and pre- health professionals screen for, evaluate, and treat schoolers is conservatively estimated to be 1% to sleep disorders in the practice setting could serve as 3%24 and the prevalence of partial arousal parasom- a “needs assessment” in terms of advocating for and nias ranges from 3.5% for sleep terrors25 to 15% to developing pediatric sleep medicine curriculae both 40% for sleepwalking.26 at the medical school and residency training levels, Childhood sleep disorders may also extend their as well as in the context of continuing medical edu- impact by causing increased stress for parents, add- cation. The purpose of the following study was to ing to marital disruption, and resulting in negative survey a large sample of both academic and commu- effects on parental sleep and daytime function.27 nity-based pediatricians, using a comprehensive tool Thus, inadequate recognition and treatment may that assesses knowledge, screening practices, and have significant repercussions not only for the indi- evaluation and treatment practices regarding sleep vidual child, but also for the family as a whole. In disorders in children and adolescents. The survey addition, the protean clinical manifestations of sleep also assessed practitioners’ attitudes toward the im- disorders in children, which may include mood dis- pact of pediatric sleep disorders, both in the clinical turbances and a variety of internalizing and external- setting and in the context of sleep as a public health izing behavioral problems,25,26 increase the possibil- issue. ity of misattribution by physicians of symptoms to other causes, including primary psychiatric diag- METHODS noses such as attention-deficit/hyperactivity disor- Participants and Procedure 27 der (ADHD). Alternatively, coexisting sleep disor- The Pediatric Sleep Survey (Appendix) was sent to a sample of ders may contribute significantly to the morbidity 2740 practicing pediatricians and family practitioners in Rhode experienced by children with a variety of mental Island, Massachusetts, and Connecticut. The sample consisted of health disorders.28 physicians included on a comprehensive, regularly updated con- Finally, considerable evidence supports the con- tinuing medical education mailing list for pediatric practitioners that covered the Southern New England region. The mailing list cept that sleep disorders such as obstructive sleep sample was 39.5% female, and 46.0% were under the age of 45 apnea syndrome in children and adolescents have years. One thousand six hundred fifty-two (60.3%) individuals on the potential to result in serious long-term conse- the sample mailing list were identified as pediatricians, 36.2% as quences, including cognitive deficits and academic family practitioners, 2.4% as internists, and 1.1% as adolescent 29,30 medicine specialists. Fifty-nine percent of the original mailing list failure. Thus, the application of therapeutic inter- sample was practicing in Massachusetts, 30.5% in Connecticut, ventions in childhood and adolescence may also rep- and 10.5% in Rhode Island. resent an important opportunity for primary and secondary prevention of sleep problems.31 A consid- Instrument erable body of literature exists that suggests that The Pediatric Sleep Survey is a 42-item questionnaire devel- many sleep disorders described principally in adults oped by the author to assess
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