Sleep difficulty

Template

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TypeChoose oneFirst line

AssessmentChoose any

Breathing in sleepChoose one

Contributors presentChoose any

Contributors absentChoose any

Sleep habitsChoose any

Behavioral strategiesChoose any

MelatoninChoose one

ReferralChoose any

Follow-upChoose one

Counseling

Most sleep problems improve with a steady routine over a few weeks. Recommended supportive care with an emphasis on the same bedtime and wake time every day, a short, calming routine, screens out of the bedroom, and daytime physical activity. Return precautions given including loud snoring or pauses in breathing, daytime sleepiness affecting school, low mood or worry keeping your child awake, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Sleep difficulty
• Reviewed sleep schedule, bedtime routine, sleep environment, screens, caffeine, and daytime sleepiness
• No snoring, gasping, or pauses in breathing during sleep
• No concerns for anxiety, low mood, ADHD, or restless legs
• Discussed a consistent bedtime and wake time, a calming bedtime routine, a dark and quiet room, no screens in the hour before bed, no caffeine, and daily exercise
• Discussed melatonin as reasonable to try short term alongside good sleep habits; antihistamines not recommended for sleep
• Follow up if not improving

Most sleep problems improve with a steady routine over a few weeks. Recommended supportive care with an emphasis on the same bedtime and wake time every day, a short, calming routine, screens out of the bedroom, and daytime physical activity. Return precautions given including loud snoring or pauses in breathing, daytime sleepiness affecting school, low mood or worry keeping your child awake, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Type: onset, wakings, resistance, delayed phase, parasomnia
Directed history
Sleep-related breathing disorder screen
Anxiety, mood, ADHD, restless legs
Sleep hygiene
Independent sleep, bedtime pass, night terrors

Return precautions in the template

loud snoring or pauses in breathingdaytime sleepiness affecting schoollow mood or worry keeping your child awake

Sources

Pediatric Care Online, Sleep Disturbances
Cribsiders #99, Infant Sleep, Picky Eating, Potty Training (December 7, 2023)
Suicide clinical report (2024): counsel families on sleep hygiene

Few formal guidelines cover this topic, so the template also leans on expert opinion.