Take sleep histories during adolescent well visits
Last week, I was precepting a student who was performing a well-child visit on a 15-year-old girl in the 10th grade. When the patient was asked if she had any concerns about her health, she reported that she was always “tired and sleepy,” and that this had been going on since the school year started.
The student asked additional follow-up questions about menses and multivitamin use. While the patient undressed for the physical exam, I asked the student what she though might be the cause. “Maybe a thyroid disorder or anemia?” she responded.
I then asked her how much sleep is recommended for a 15 year old. “Eight hours a night? Oh! I forgot to ask her about her sleep habits,” she replied.
Adolescents aged 13 to 22 years actually need nine to 10 hours of sleep a night. Upon further assessment it turned out that this young lady regularly turned her light off to go to bed between 1 am and 2 am, and woke up at 6 am in order to have enough time to perform her beauty regimen.
This kept the patient in the bathroom for at least an hour every morning, according to her mother. As a consequence, the patient frequently found herself falling asleep in school. When she got home from school, she usually took a nap for two to four hours.
Some poor sleep may be caused by physiologic factors such as obstruction and resultant apnea, either related to untreated allergic rhinitis or overweight/obesity. Difficulty sleeping can also be related to an underlying mental health disorder. However, much disordered sleep is caused by poor sleep hygiene.
A simple sleep history can help clinicians determine which factors are at play. The acronym BEARS can help you remember the key elements to assess:
- B – Bedtime problems
- E – Excessive daytime sleepiness
- A – Awakenings during the night
- R – Regularity and duration of sleep
- S – Snoring
A positive answer to one of these questions can indicate a specific sleep issue and possible cause. Our patient had a problem with regularity and duration of sleep. General recommendations to improve sleep regularity and duration are creating consistent routines (at least during the school week); 15-minute readjustments to bedtime; and no TV, computer games or cell phones in the bedroom.
Getting good sleep is one of the easiest and cheapest things we can do to maintain and improve our health. Lack of sleep affects our ability to learn new information, impairs reaction time and puts us at risk of accidents and injury.
Poor sleep has also been associated with chronic diseases like hypertension and diabetes and more recently with an increased obesity risk. It may also adversely impact mental health and our immune system.
We counseled this patient, but she was extremely unwilling to change her behavior at that time — a typical teenager with the confidence that she know best. For those of use who really do know better, let's practice what we preach and get some sleep!
Julee B. Waldrop, DNP, FNP, PNP, is the Director of the MSN-DNP Program and an associate professor at the University of Central Florida. She provides health care to children at a local community health center.