Table 1 Treatment options in paediatric sleep disorders*

Sleep disorder	First line treatment	Second line treatment	Third line treatment	Comments
Sleep onset insomnia	Behavioural	Melatonin	Clonidine	See text for alternative medications. Behavioural approaches need to continue even if medication is adopted.
Sleep phase delay syndrome	Behavioural and chronotherapy	Morning bright light (blue or full spectrum white) for 20 min minimum	Melatonin 4–6 h before actual falling asleep time. Often low doses will be effective.
Night terrors	Reassurance	Scheduled waking
Confusional arousals	Reassurance	Scheduled waking	Low dose clonazepam if impairing quality of life, eg unable to go on school trips/sleepovers
REM behaviour disorder	Monitor carefully	Clonazepam		Careful diagnosis and search for underlying cause are required.
Rhythmic movement disorders	Reassurance	Scheduled waking	Low dose clonazepam if impairing quality of life, eg unable to go on school trips/sleepovers
Restless legs syndrome	Check ferritin and give iron supplements if low	Clonidine/melatonin (evidence for both weak but often used in children until more safety data on dopamine agonists in children are available)	Pramipexole/ropinarole/gabapentin (all off label for young children and careful assessment of risk/benefit ratio and informed consent required)	May not require treatment. Carefully assess severity of symptoms and impact on daytime functioning.
Obstructive sleep apnoea	Adenotonsillectomy/weight loss if required	Fluticasone intranasal spray – usually a temporary measure	Non-invasive night-time ventilation if required
Narcolepsy-daytime sleepiness	Explanation and facilitate scheduled naps at school	Methylphenidate (often slow release preparations)	Modafanil mornings and afternoons	Still no head-to-head comparison. More data exist on use of methylphenidate than modafanil in younger children.
Narcolepsy-cataplexy	Treat if frequent and severe	Antidepressants including SSRI and clompiramine	Sodium oxybate	Sodium oxybate is effective in adult trials, but very few data exist to guide use or safety in children.
Narcolepsy-fragmented night sleep	Exclude other factors such as obstructive sleep apnoea syndrome or poor sleep hygiene		Sodium oxybate	Sodium oxybate is effective in adult trials, but very few data exist to guide use or safety in children.
Kline Levin syndrome	Discuss natural history and do not treat pharmacologically	Stimulants for daytime sleepiness	Lithium to stabilise relapses	Very little evidence as so rare. Monitoring and risk of side effects make lithium difficult to use.

*This table summarises the content of the accompanying article and is not intended for stand-alone use. Given the lack of robust evidence in paediatric sleep pharmacology, this article reflects the author’s personal practice. Accurate diagnosis of the above sleep disorders is crucial to successful management.