Pediatric Sleep Screener Boosts Diagnoses, Referrals

Children’s poor sleep is associated with obesity, academic problems, suicide attempts, and other mental health concerns, but the issue is not consistently addressed in pediatric primary care. A new well-child-visit screening tool for primary care clinicians (PCCs) appears to help boost diagnosis and referrals, according to findings from a study published in JAMA Network Open.

Ariel A. Williamson, PhD, with The Ballmer Institute for Children’s Behavioral Health, University of Oregon, Portland, Oregon, and colleagues tested an electronic, age-based sleep screener that evaluated infant bed sharing, snoring three nights a week, short sleep time, perceived sleep problems, and adolescent daytime sleepiness.

The researchers conducted a retrospective, observational case-control study in the Children’s Hospital of Pennsylvania primary care network of 31 practices in Pennsylvania and New Jersey; 27 in suburban/rural settings and four in metropolitan settings.

During implementation, 204,872 patients completed the screening, with adoption in 89.5% of all well-child visits. The screening indicated that 9.7% of patients had frequent snoring, 12.2% had sleep problems, and 34.4% had insufficient sleep. Bed sharing was reported for 6.5% of infants and 14.7% of adolescents reported daytime sleepiness. The identification of sleep problems was followed by provision of family education resources.

Sleep Disorder Diagnosis 64% More Likely With Screener

Compared with the pre-implementation period, at well-child visits with a completed sleep screener, PCCs were significantly more likely to make a sleep disorder diagnosis (odds ratio [OR], 1.64; 95% CI, 1.56-1.73), order a polysomnogram (OR, 2.67; 95% CI, 2.32-3.20), and refer to sleep clinics (OR, 6.48; 95% CI, 5.03-8.34) or otolaryngology (OR, 4.46; 95% CI, 3.95-5.02).

Rupali Drewek, MD, a pediatric pulmonologist and co-medical director of the Sleep Medicine Program at Phoenix Children’s in Phoenix, who was not involved with the study, told Medscape Medical News the screener is promising and its proactive approach — even in children with no obvious symptoms — allows for earlier intervention and improved quality of life.

“Sleep problems affect up to half of children at some point,” she said, “yet they are rarely addressed unless parents bring them up. Implementing a standardized screening tool during routine pediatric visits ensures systematic identification of issues that might otherwise go unnoticed. Taking action early can lead to better health, better school performance, and less stress for families and the healthcare system.”

Adding a new screening tool should fit easily into a regular checkup without slowing workflow substantially, she said. “It offers a scalable, low‑cost solution to reach millions of children.”

Educating the medical team will be important to successful implementation, she said.

“Everyone on the care team needs to know how to read the results and what to do next if a child’s answers show there might be a sleep problem.”

Lessening Healthcare Inequities

In an accompanying editorial, Sarah M. Honaker, PhD, with the Department of Pediatrics at Indiana University School of Medicine, Indianapolis, and Stephen M. Downs, MD, MS, with the Department of Pediatrics, Wake Forest University in Winston Salem, North Carolina, said the screener, “offers a refreshing departure from this pattern of asking PCCs to know more and do more. [T]his is an opportune time to study the implementation of systems that will support PCCs in providing evidence-based care.”

The editorialists wrote that the broad screening at well-child visits could help lessen healthcare inequities. They noted that children from minoritized backgrounds with a lower socioeconomic status are more likely, for instance, to have obstructive sleep apnea (OSA) and are less likely to receive timely, evidence-based care. “For example, Black children are two to four times more likely to have OSA and less likely to receive a [polysomnogram] referral,” they wrote.

One of the main unanswered questions, Honaker and Downs wrote, is how much the educational components help once the problems have been identified and whether guidance about sleep duration results in actual improvements in sleep duration.

A key strength of the work is replicability in other health systems, with individual adaptations, the editorialists noted.

“[T]he system designed by Williamson and colleagues offers an excellent starting point for other healthcare systems seeking to support PCCs in prevention, identification, and management of pediatric sleep disruption,” they wrote.

Williamson reported receiving honoraria from the National Sleep Foundation, the American Academy of Pediatrics, and Wesleyan University and an honorarium and travel support from The Pennsylvania State University, outside the submitted work.

This study was supported by the Possibilities Project at Children’s Hospital of Philadelphia and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Honaker reported receiving consulting fees from Covington LLC; grants from the National Heart, Lung, and Blood Institute; equity ownership of For Dreamers LLC; and grants from the American Academy of Sleep Medicine Foundation outside the submitted work. Downs reported that he is the co-creator of the Child Health Improvement through Computer Automation (CHICA) software and cofounder of Digital Health Solutions LLC, which licenses CHICA. Drewek reported no relevant financial relationships.

Marcia Frellick is a Chicago-based, independent healthcare journalist and a regular contributor to Medscape Medical News.