What could be causing my child's nocturnal diaphoresis (night sweats)?

Nocturnal Diaphoresis in Children: Diagnostic Approach

Night sweats in children are most commonly associated with obstructive sleep apnea, allergic rhinitis, tonsillitis, and other sleep-related breathing disorders, rather than serious systemic illness. 1

Epidemiology and Common Associations

• Night sweats occur in approximately 11.7% of school-aged children, with boys more commonly affected than girls 1
• The condition is significantly associated with obstructive sleep apnea symptoms, allergic rhinitis, tonsillitis, insomnia, and parasomnia 1
• Children with night sweats are more likely to exhibit hyperactivity and frequent temper outbursts 1

Primary Diagnostic Considerations

Sleep-Disordered Breathing (Most Common)

• Obstructive sleep apnea is the leading cause of nocturnal hyperhidrosis in children, resulting from sympathetic nervous system overactivity during apneic episodes 1, 2
• Specifically ask about: snoring, witnessed apneas, restless sleep, mouth breathing, and daytime sleepiness 3
• Evaluate for adenotonsillar hypertrophy on physical examination 1

Respiratory and Atopic Conditions

• Allergic rhinitis and tonsillitis are independently associated with night sweats in pediatric populations 1
• Assess for nasal congestion, chronic rhinorrhea, eczema, and food allergies 3, 1
• Nocturnal asthma can present with night sweats, though this typically occurs with other respiratory symptoms like wheezing or cough 3

Gastroesophageal Reflux Disease

• GERD commonly causes nocturnal symptoms including sweating in both children and adults 3, 4
• Ask about heartburn, regurgitation, feeding difficulties, and chronic cough 3

When to Consider Serious Pathology

Tuberculosis Screening

• In high TB prevalence settings, screen children with night sweats for TB regardless of cough duration, particularly if accompanied by fever, weight loss, or hemoptysis 5
• Chest radiograph should be performed when resources allow 5
• Consider XpertMTB/RIF testing over sputum microscopy when available 5

Malignancy Evaluation

• Lymphoma and other malignancies can present with night sweats, though this is infrequent in modern pediatric practice 6
• Red flags include: unexplained fever, unintentional weight loss, painless lymphadenopathy, bone pain, and fatigue 5, 6
• If constitutional symptoms are present, obtain complete blood count, erythrocyte sedimentation rate/C-reactive protein, and chest radiograph 6, 4

Systematic Evaluation Algorithm

Initial Assessment

1. Detailed sleep history: snoring patterns, witnessed apneas, sleep position, daytime somnolence 1, 2
2. Respiratory symptoms: chronic cough, wheezing, nasal congestion, recurrent tonsillitis 1
3. Constitutional symptoms: fever, weight loss, fatigue, decreased appetite 5, 6
4. Atopic history: eczema, allergic rhinitis, food allergies, family history of atopy 1

Physical Examination Focus

• Assess adenotonsillar size and nasal patency 1
• Evaluate for lymphadenopathy, hepatosplenomegaly 5, 6
• Document growth parameters and compare to previous measurements 5
• Examine for signs of atopic disease 1

Laboratory and Imaging Strategy

If history and examination suggest sleep-disordered breathing or atopic disease (most common scenario):

• Referral to pediatric sleep medicine or otolaryngology for definitive evaluation 1, 2
• Consider polysomnography if obstructive sleep apnea is suspected 2

If constitutional symptoms or examination findings raise concern for systemic disease:

• Complete blood count with differential 6, 4
• Tuberculosis testing (purified protein derivative or interferon-gamma release assay) 5, 6, 4
• Chest radiograph 5, 6, 4
• Thyroid-stimulating hormone 6, 4
• C-reactive protein or erythrocyte sedimentation rate 4

If initial workup is unrevealing:

• Consider HIV testing in at-risk populations 6, 4
• Vitamin B12 level (rare cause but responds dramatically to supplementation) 7
• Computed tomography of chest/abdomen only if specific clinical suspicion warrants 4

Critical Pitfalls to Avoid

• Do not immediately pursue extensive malignancy workup in otherwise well-appearing children without constitutional symptoms, as serious pathology is uncommon 6, 4, 1
• Do not overlook obstructive sleep apnea, which is the most prevalent and treatable cause in pediatric populations 1, 2
• Do not attribute night sweats to "growing pains" or dismiss as benign without evaluating for sleep-disordered breathing and atopic conditions 1
• In high TB prevalence areas, do not delay TB screening even in the absence of chronic cough 5

Reassurance and Monitoring

• If comprehensive evaluation is negative and the child is otherwise thriving, reassurance and continued monitoring are appropriate 4
• The presence of night sweats alone, without other concerning features, does not indicate increased mortality risk 4
• Re-evaluate if new symptoms develop or night sweats worsen despite treatment of identified conditions 4