Paediatric Sleep History

Sleep Schedule

• Usual time of going to bed: 20:30 on school nights; 21:30 on weekends
• Usual time of waking: 06:45 on school days; 08:00 on weekends
• Naps (how often, how long, and when): None; occasionally falls asleep in the car after school for 20 mins
• Consistency of the sleep timetable: Generally consistent on weekdays, ~1 hr phase delay on weekends

Sleep Environment

• Sleeping area arrangement (bed, pillows, and covers): Twin bed with head elevated on 15 cm blocks for reflux; 2 pillows, cotton duvet
• Ambient noise: Quiet; uses a continuous white noise machine
• Exposure to light: Blackout curtains in place; dim amber nightlight in hallway
• Room temperature: 20 °C
• Devices or electronics in the bedroom: None kept in bedroom overnight

Sleep Hygiene

• Routine before sleep: Warm shower at 19:45, brushing teeth, reading with parents for 20 mins
• Caffeine use (quantity and timing): 1 cup of iced tea (approx. 350 mL) or chocolate milk with lunch around 12:30; none after 14:00
• Physical activity (type, duration, and timing): Football practice 3x/week for 60 mins, finishing at 17:30
• Screen use before sleep: Tablet/TV use ceases at 19:30

Sleep Onset

• Time required to fall asleep: 45–60 mins
• Problems initiating sleep: Frequent difficulty settling due to retrosternal burning and throat clearing
• Thoughts or concerns present while trying to sleep: Mild worry about stomach aches occurring overnight
• Physical unease or inability to remain still: Tossing and turning due to epigastric discomfort; no true urge to move legs

Sleep Maintenance

• Awakenings during the night: 2–3 times per night
• Length of each awakening: 15–30 mins
• Returning to sleep after waking: Requires parental reassurance and sips of water to resettle
• (Reasons for waking, such as noise, restlessness, or the need to urinate): Acid brash, nocturnal cough, and epigastric pain

Sleep Quality

• Sense of refreshment on waking: Unrefreshed; difficult to rouse for school
• Sleepiness or tiredness during the day: Moderate daytime fatigue; yawning in afternoon classes
• Problems with attention or recall: Teacher reports mild distractibility in morning lessons
• Changes in mood: Increased irritability and low frustration tolerance by late afternoon

Sleep Behaviours

• Snoring during sleep: Mild, intermittent snoring when congested
• Gasping or choking episodes: Occasional waking with a choking sensation or sour taste in mouth (~2x/week)
• Apnoeas observed by another person: None observed by parents
• Restless legs or repetitive limb movements: Restless sleep with frequent position changes, likely secondary to GI discomfort
• Talking or walking during sleep: Occasional sleep talking; no somnambulism
• Disturbing dreams or night terrors: Occasional bad dreams (~1x/month); no night terrors
• Teeth clenching or grinding (bruxism): Audible nocturnal bruxism reported by parents

Previous Sleep Studies

• Investigation performed (for example, polysomnogram or MSLT): Overnight polysomnography (PSG) with concurrent 24-hour multichannel intraluminal impedance-pH (MII-pH) monitoring
• When and where it was performed: 14/11/2024 at Children's Hospital Sleep Center
• Findings and diagnosis: AHI 1.2/hr (normal); frequent proximal reflux episodes temporally correlated with cortical arousals and nocturnal awakenings. Diagnosis: Sleep fragmentation secondary to poorly controlled GERD.

Medications

• Sleep-related medicines currently taken: Melatonin 3 mg PO QHS
• Sleep medicines used previously: Diphenhydramine (Benadryl®) 12.5 mg PO QHS PRN (discontinued due to next-day grogginess)
• Other medicines with possible effects on sleep: Omeprazole (Prilosec®) 20 mg PO BID; fluticasone propionate (Flovent®) 110 mcg 2 puffs INH BID; salbutamol (albuterol, ProAir®) 90 mcg INH PRN (causes mild jitteriness if used near bedtime)

Medical History

• Health problems that could influence sleep (for example, chronic pain, GERD, or asthma): Severe GERD, suspected eosinophilic oesophagitis (EoE - awaiting endoscopy), mild persistent asthma, allergic rhinitis
• Mental health history (for example, anxiety or depression): Mild generalised anxiety related to school performance and somatic symptoms
• Neurological history (for example, restless legs syndrome or narcolepsy): Negative; normal serum ferritin (45 ng/mL) ruling out secondary RLS

Family History

• Relatives affected by sleep disorders: Father has obstructive sleep apnoea (on CPAP); mother has history of insomnia
• Relatives affected by psychiatric or neurological disorders: Maternal aunt with generalised anxiety disorder

Social History

• Employment or school timetable (shift work or irregular hours): 4th-grade student; school hours 08:00 to 15:00, Monday to Friday
• Household arrangements and sleeping partner: Lives with both parents and 6-year-old sister; sleeps alone in own bedroom
• Travel and effects of jet lag: No recent travel across time zones

Other Notes

• Parents instructed to eliminate late-evening snacks (no food within 2.5 hrs of bedtime) to reduce nocturnal acid reflux events. OGD (EGD) with biopsies scheduled for 24/04/2025 to evaluate for EoE.