Sleep in Special Populations (Pediatrics, Pregnancy, Aging)
Pediatrics
Sleep architecture and duration change dramatically with development: neonates have polyphasic sleep with high REM proportion; slow-wave sleep is prominent in young children; sleep duration declines with age. Behavioral insomnia of childhood includes sleep-onset association type and limit-setting type; management is behavioral (extinction variants, bedtime routines). Obstructive sleep apnea in children commonly presents with snoring, mouth breathing, and adenotonsillar hypertrophy; adenotonsillectomy is first-line for most children with OSA and adenotonsillar hypertrophy. Home sleep apnea testing is not validated for pediatric OSA; polysomnography is the test of choice. Parasomnias (sleepwalking, sleep terrors) are common and usually benign. Restless legs can occur in children and is associated with iron deficiency.
Pregnancy
Physiologic changes include increased estrogen/progesterone, nasal congestion, and increased risk of OSA and restless legs; snoring and sleep-disordered breathing should be evaluated. Supine sleep position in late pregnancy is associated with stillbirth risk, and left lateral positioning is recommended. Insomnia and restless legs are common; iron deficiency should be assessed. Treatment of OSA in pregnancy includes CPAP when indicated.
Aging
Older adults have reduced slow-wave sleep, more fragmented sleep, advanced circadian phase, and higher rates of insomnia. Screen for sleep-disordered breathing, restless legs, and REM sleep behavior disorder; be cautious with sedative-hypnotics because of falls and cognitive risk. Depression and polypharmacy are common contributors.
Traps
Do not apply adult home-testing criteria to children; do not assume parasomnias in children require pharmacotherapy; remember supine sleep risk in late pregnancy.