Chapters Transcript Navigate Different Sleep Providers: Neurology, Pulmonary, Psychology Robert Rudock, MD, MBA, explains the common pediatric sleep related problems. All right. Well, thank you very much for inviting me to speak this morning. Um, today I'm gonna be talking about how to navigate through different sleep providers. Um, going through medical school and residency. This was always a mystery to me and it wasn't really until I started my sleep fellowship that I really understood how different sleep problems, um, could be best treated by different types of sleep providers. And, um, this is an area where I get questions on a regular basis. Uh I have different neurology and pediatricians and other types of physicians and providers who constantly ask me well, I have this type of patient who should I send them to or do I need to get a sleep study before I send them to sleep clinic? And so hopefully by the end of this talk, um, everybody here will have a better understanding of how we kind of figure those things out and what are the important clinical aspects of individual patients to help make that decision and there'll be uh time for questions at the end. All right. So I have no personal disclosures. Um I will be discussing however, um, the off label usage of hypnotic medications or sleep medications. Um, I say off label because there are no FDA approved sleep medications for Children, period. So everything we do is actually off label. These are our objectives for today. So, uh, we will start by identifying common pediatric sleep related problems. Um, and as we talk about those, I'm going to talk through my thought process about how we figure out then to which sleep provider to send somebody to. Um, we'll also be talking about how each individual sleep provider brings something kind of unique to the table. Um And then al also at the very end, we'll just review how to refer patients to uh children's and wash you. So sleep problems are common. As everybody here knows if you ask a family, does your child have a sleep problem? You have to be prepared to open Pandora's box and be um dealing with a whole laundry list of potential issues. 25% of Children develop a sleep problem, period. So given how many kids everybody here sees on a regular basis, um, chances are you're going to have several Children per day who have sleep problems that you're going to need to address. And in terms of sleep providers, you know, you can different sleep providers have all sorts of different backgrounds. So in order to do a sleep fellowship, you need a, you need to do a primary uh training program in any of these listed specialties. So you can be a sleep physician who is trained in general pediatrics. You can be trained in pediatric pulmonology, pediatric neurology, which I'm trained in internal medicine, adult pulmonology, adult neurology, psychiatry, anesthesiology and or otolaryngology or ent. And once you complete your sleep fellowship, regardless to whatever your primary specialty is, you are able to take care of almost every single type of sleep patient. I would say 95%. Plus there are a few different types of patients who are medically more complicated where it may benefit the patient to see somebody with neurology, subspecialty training or pulmonology subspecialty training. And we're going to talk about um trying to identify those types of patients uh today as well. So jumping right in uh I went through and um what figured out what are the most common sleep pro problems that we get referred um for? And this is the list. So generally insomnia is the most common. Ok. Followed by circadian rhythm disorders, sleep apnea, restless leg syndrome, and restless sleep parasomnias and NAR Psy. So let's jump into insomnia first in order to understand insomnia, we first need to understand how many hours of sleep a patient needs per day. This is a list, this is uh a list that's been accepted by the American Academy of Sleep Medicine and the American Academy of Pediatrics in terms of ages and how much sleep you should get per 20 four hours. I'm not gonna read all these numbers. But there are a few patterns here that I do want to point out. The first pattern is if you look at uh the age range between newborns and five years old, you see in parentheses over to the right that it says includes naps. So generally speaking, if you are five or younger, we expect you to nap. And right when you're about to get ready to go to kindergarten is when most of the time kids stop napping. Now, this is definitely a bell curve. And so some kids will stop napping a little earlier and some kids will stop napping a little later. But generally speaking, we use five as our cut off. So that means if you have a teenager who says, oh, I nap every single day after school, that's a problem that is pathology and that warrants further investigation. So five years of age is our cut off. Uh The other thing I want to point out here is that um our teenagers, 13 to 18 years old need more sleep than adults. So on average teenagers need 8 to 10 hours of sleep, which is a lot of sleep when school is starting so early as we know, and most teenagers are sleep deprived and don't get this amount of sleep. Ok? But it is more than adults, adults meaning 18 and up the recommendation is that they get approximately 7 to 8 hours. You'll notice here that um as soon as we get past 18, it just says adults, it doesn't say anything about. For example, 65 years, age, 65 years old and older, which means all adults, regardless of age need approximately 7 to 8 hours of sleep per night. There's a myth out there that says when you get older, you need less sleep. So old people need less sleep than younger adults. That's not true. Old people generally sleep less and they sleep poorly compared to younger adults. However, they still need 7 to 8 hours uh in total. So these are our references. This is where we start all the time. There are two primary types of insomnia. So some people have trouble falling asleep. Some people have trouble staying asleep and then there are some unfortunate people who have difficulty with both falling and staying asleep. When we think about what is driving those types of insomnia, aside from potential medical issues such as sleep apnea, there are two main causes of insomnia. I'm gonna start with the second one, which is the psychophysiologic insomnia because this is the one that I think a lot of us can personally relate to everybody's experienced insomnia, insomnia at some point in their lives. There's nobody who has had a great night of sleep every single night. It just doesn't happen. So, psychophysiological insomnia tends to be related to anxiety, intrusive thoughts if you can't turn off your brain when you're laying in bed and trying to fall asleep and your brain is pestering you. This can be due to um, poor sleep habits. So if you're drinking coffee late into the night, if you are watching TV, in bed, um, all those different things along with genetics. So this is the most co common type of insomnia that we see across all age ranges. The other type is called behavioral insomnia of childhood, which is a different type of insomnia than what teenagers and adults get. Behavioral insomnia is just like what it sounds like, it's behavioral. So the classic example is a child who has established a poor sleep association and then is having trouble falling and staying asleep. So sleep association is anything that you associate with falling asleep. So for example, I get into bed at night, I move my pillow around, I close my eyes and I go to sleep if I were to wake up in the middle of the night and notice that my pillow were missing. What do you think I would do? Hopefully everybody is saying to themselves, oh, well, you're gonna go look for your pillow and that's exactly right because I've associated my pillow with falling asleep. If you have a child who has a parent who lays with him or her to fall asleep, that child has established their parent as a sleep association. So that when they wake up in the middle of the night, they may go to mom or dad's room to find them to help themselves fall back asleep. Ok. So this is the classic behavioral insomnia um that we, we read about and we see every single day in sleep clinic, the other aspect of behavioral insomnia is limit setting. So Children, especially toddlers, what are they doing? They are pushing boundaries, they are trying to demonstrate more independence, they are trying to see what they can get away with. Um and sometimes that spills over into nighttime behaviors and nighttime patterns and then can negatively affect sleep. So, sleep associations and limit setting are the foundation of behavioral insomnia. I make this distinction because when we're thinking about treatment, the treatments are slightly different. First line treatment for insomnia is for uh is behavioral modifications and or cognitive behavioral therapy for insomnia. So behavioral modifications is primarily for behavioral insomnia of childhood, which means we will teach mom and dad how to modify that sleep association and how to implement limit setting in order to sleep better. And cognitive behavioral therapy for insomnia is more for the psychophysiological insomnia where we can teach you how to quiet your mind and improve your sleep hygiene to help you fall asleep. Better notice here that first line treatment has says nothing about medications, ok? Because the official recommendation from the American Academy of Sleep Medicine is to do these things first, before you even consider using a hypnotic medication. Ok? If you've done these things and you're then still struggling. That's when we talk and consider medications. So, ideally, um, if you're already on a medication and we can take advantage of it. So, for example, let's say you're on an anti anxiety medicine and you take that at night, maybe we can increase the dose of that medicine to make you a little more drowsy at night to make you fall asleep a little easier. Ok? If you're not on a medication or if you're on a medication that doesn't have uh the ability for us to use it in a two for one type fashion. That's when we might consider starting a dedicated hypnotic medication. This is a list of commonly used, probably the most commonly used sleep medications out there for Children. Um And I just want to kind of go through this briefly. Um So, Melatonin is very common as everybody knows. Um Generally speaking, we think Melatonin is safe. You don't stop making your own melatonin. Um You uh may actually benefit from melatonin more if you have certain disorders such as autism, Children with autism, um have melatonin dysfunction, the melatonin receptors are different and so they often respond very nicely to melatonin and they may need higher than usual doses of melatonin. Recently, I've been getting a lot of questions from families about the utility of tart cherry juice um to help a child sleep. And the reason I've been getting that question is because Tart cherry tart cherry juice has a little bit of melatonin in it. So, if you get that question, um, that's, that's the reasoning behind it. So, Melatonin by far, the most commonly used hypnotic ramelteon is a Melatonin receptor agonist. Ok. So this is a prescription, um, for, uh, hypnotic for, for Melato, essentially stronger melatonin if you will, cloNIDine and guanfacine are also very commonly used. And I think a lot of people here have probably used these medications for sleep. I like to use these medications. Um specifically, if a kid has concurrent A DH D and or behavioral problems because it could be very helpful. The difference between quantity and guanine is the half life. So they work in almost the exact same way. But cloNIDine has a short half life and quantas has a longer half life. So cloNIDine tends to be more helpful for falling asleep while Guanfacine tends to be more helpful for staying asleep. So that's how we choose our hypnotics based on the half life, whether or not it's gonna help with falling or staying asleep. And the potential secondary benefits. Gabapentin is commonly used as well. Gabapentin can be used for pain. It's used for RLS for insomnia. Uh gabapentin is also kind of nice because we can use that in really young kids uh safely as well because there's good evidence for it. Doxepin is a tricyclic. Um and Doxepin um is helpful for more sleep maintenance. Uh Doxepin, even though it's a tricyclic at low doses, it works on the histamine receptors um and could be very sedating. Mertazapine is pretty similar. TraZODone um is often used and I get a lot of referrals for patients who are already on traZODone. Um I do wanna spend a minute talking about traZODone because traZODone um is actually listed by the American Academy of Sleep Medicine. Um as a medication that you should not put patients on. Let me repeat, the American Academy of Sleep Medicine says do not use traZODone as a first line hypnotic unless you absolutely have to. Ok. And the reason for that is because of the side effect profile, it affects um lipids, it can affect um metabolism and it has a lot of nasty side effects. So there's often a better medication that you can put a child on that. That's not to say that I don't use traZODone because I certainly do, but that's more of a last resort. So my recommendation for everybody here would be if you're using traZODone as a first line hypnotic change to something else. There are much better medications to use than traZODone. Zolpidem Zoon Zoic. These are the Ambien Lunesta. So sonata medications, um and they are essentially non benzodiazepine gaba receptor agonists. These medications are considered first line for adults, but we will occasionally use them in Children. Um We often will reserve these medications for our teenagers because studies have shown that these medications are less effective in young kids. We don't really know why it's probably something to do with brain maturation and receptors. Um but they don't tend to work very well in young kids. Suvorexant is an interesting medication. Uh Suva Xin acts on the rein receptor. If you remember from medical school, uh Rein is implicated in narcolepsy. So, Suvorexant essentially will temporarily if you will give a patient narcolepsy to help them fall and stay asleep and then clonazePAM, this is a, a benzodiazepine. Generally speaking, we don't like to put Children on long term benzos. Um, but sometimes we have to or sometimes we need to use it as a temporary medication. Overall. If you go on a sleep medication, we like the sleep medications to be temporary if possible. Um, while we work on, um, optimize all these behavioral modifications and the cognitive behavioral therapy for insomnia. So just a, a short list of insomnia medications there. So for insomnia, notice how we didn't talk about sleep studies at all. If you have a patient who only has insomnia and let's say they have no snoring. A PSG is not needed period. Ok? A PSG is not gonna be helpful because there's gonna be uh a low likelihood that's gonna come back positive for OS A. And if you have a child and a family describes classic behavioral insomnia with no snoring, no enlarged tonsils or anything, don't bother with the PSG, it's going to be a waste of time. A waste of money. And if it does come back with, let's say, very mild sleep apnea, that's probably not what is driving the majority of the symptoms. Anyway, we always recommend starting with behavioral interventions before medications. Ok. So optimize everything else before meds. Um, and then if you're still struggling, then please refer to sleep medicine and we will take it from there. Now, I do have to uh make a plug for sleep psychology. Uh Sleep psychology is the foundation for behavioral modifications and cognitive behavioral therapy for insomnia. Um However, pediatric sleep psychologists are exceptionally rare, exceptionally rare. There are some sleep trainers and some sleep coaches out in the community. Um But in order to find a formally trained clinical psychologist who has training in pediatric sleep, you're gonna struggle. In fact, there's only one who I'm aware of in the state of Missouri. And uh she's here at children's Doctor Kendra Creech who is wonderful because they uh sleep psychology is so rare. Only sleep medicine can now refer to sleep psychology. So if you have a patient who you think is gonna benefit from sleep psychology, you need to refer to sleep medicine first and then we can get them plugged into uh work with sleep psychology. This policy may change in the future, but this is just because the supply and demand are not. Um it's a problem, we just need more clinical sleep psychologists out there. All right, circadian rhythm disorders. So these are essentially sleep wake problems. So if you remember um when the sun is out and you have light entering the eye that goes to the brain, you are inhibiting melatonin release when it gets dark. Melatonin goes up. Ok. So during the day, melatonin is low at night. Melatonin rises and we have this pattern that you can see over to the right where night time is time locked to melatonin release. Daytime is time locked to Melatonin. Uh being very, very minimal, if not, not, if non-existent. Now, this is describing all the different types of circadian rhythm disorders that somebody can have. So, what we have here is uh if you look on the x axis, that's the time over the course of 24 hours and where it's grayed out, that's when it's dark. OK? And the light blue boxes represent when somebody's sleeping. So for example, if you go to sleep when it's dark and you wake up, when it's, it gets light out, you have a normal sleep phase or a norm a normal circadian rhythm. If you fall asleep early and you wake up very early, you can have an advanced sleep phase. OK. This is what we often think of in terms in uh the geriatric population. But this pattern is also more common in Children with autism where they have an advanced phase. If you fall moving down, if you fall asleep later and wake up later, that's called the delayed phase. OK. This is what we see very commonly in teenagers. So often we'll see teenagers in clinic and the chief complaint is insomnia. Um, but in reality, they have a delayed sleep phase and that's what's causing them to struggle with falling asleep. And that's why they're feeling tired in the morning. So if your brain is thinking that you need to be sleeping, uh, at 10 a.m. ok? And you have a delayed sleep phase and you're in school, you're gonna be tired. Ok? And so then we have to adjust that there isn't a regular sleep uh wake pattern where you just sleep in short periods and you're awake for short periods. And then the final one is a non 24 hour pattern where you slowly trend later and later in terms of when you go to sleep and when you wake up, um that can be seen more often in uh people who have uh visual processing problems or cortical blindness. So, what do you do about this? Well, the best thing you can do for Children is keep the same schedule on the weekends often. What will happen is kids wake up early and then um uh during the school week and then the weekend comes along, they stay up later, they sleep in. And when you sleep in, that's confusing the brain and it's causing, it's reinforcing a circadian rhythm problem waking up earlier is more important than going to sleep earlier. So what I tell my teenagers who have this delayed pattern where they go to sleep later and wake up later is I don't care when you go to sleep on the weekends. Ok. You can go to sleep at three in the morning for all I care. But I want you to be up by nine o'clock in the morning. So go to sleep at three, wake up at nine, ok. By waking up earlier, you end up causing more uh sleep pressure built up during the day. So then it is easier to go to sleep at night. So waking up earlier is more important than going to sleep. We all know you can't force yourself to sleep, but you can force yourself awake. All right. And then if you're still struggling, refer to sleep medicine and we'll take it from there. Obstructive sleep apnea. So now we're getting into um the utility of um referring to ent versus pulmono pulmonology versus a non pulmonologist. So, obstructive sleep apnea is basically obstructive an obstruction in the upper airway that occurs during sleep. So first uh picture right here, you can see the blue line shows nice smooth airflow going through while asleep. The second line, the soft palate is falling back back backwards with gravity and it's causing a narrowing of the airway. The last one is showing a complete obstruction of the airway in Children. What we usually see is partial obstruction and in adults, what we usually see is complete obstruction. Um, now Children with Os A don't always snore. Ok, let me repeat that. Children with Os A don't always snore. You can have more, Children can, uh, tend to have more subtle signs of sleep apnea compared to adults. So other questions to ask and other symptoms to inquire about would be, um, about witness apneas, uh, noisy breathing, mouth breathing is also a really great question to ask. And noisy breathing and mouth breathing are things you can just observe in clinic. You don't even need to ask about that to get a sense. Um Most of the time, uh mouth breathing is important because kids who mouth breathe often have enlarged adenoids. Ok? And so even though their tonsils might not look big, they could have the adenoids gasping, nocturnal sweating. Ok. I've had many, many Children who have isolated nocturnal sweating with no snoring or other symptoms who had really bad sleep apnea, which if you stop to think about what's happening, dirt with sleep apnea makes sense. So when you have an obstruction, you have that f is followed by an oxygen desaturation, which then has a sympathetic response and release of epinephrine because you can't breathe. And so you sweat, your heart rate goes up and that can become um a periodic pattern that occurs constantly throughout the night. If you don't treat the sleep apnea, morning headaches is also very common unexplained nighttime awakenings when they're doing everything well, with sleep hygiene. Um, and then unexplained daytime sleepiness, the three highest yield questions you can ask a family um, to screen for sleep apnea. Are, do you, does your child snore? Have you seen witness apneas? And, and the third one is, are you concerned about your child's breathing at night? If you ask those three questions, you're gonna screen for a 95% plus of all, all Children with OS A if you're considering um getting a sleep study, um I would strongly recommend that you refer to a dedicated pediatric sleep lab and this is for several reasons. One pediatric labs are more experienced working with Children. So the process tends to be less stressful for the kid and also the families um and pediatric criteria are different than adult criteria. So when we're looking at OS A events, the the criteria are completely different. Um And so if you have somebody who doesn't, isn't experienced with the specific criteria in kids, the study may not be accurate and we're seeing more and more of this lately because um in the adult populate in the in the adult sleep medicine world, in lab, sleep studies are becoming less common due to insurance reasons. So in so traditional sleep labs are doing more at home studies for adults. Um and that is resulting in less revenue for the sleep labs. And so in order for them to make up for that lost revenue, what they're trying to do is expand into the pediatric, um um part of um sleep medicine to do in lab studies because we only do in lab studies for kids. We don't do home studies for kids. And as a result, we're getting poor quality studies at these adult sleep labs. And so I on pretty much weekly will get a report from an outside lab for a child that I'm seeing in clinic. And the numbers don't even make sense and I don't have any faith in the result. And so I have to repeat the, the study anyway. Well, if you have OS A on your sleep study, what do we do? Ok. So surgery, this is where most, what most people think of. And so we may take out the tonsils, we may take out the adenoids, there can be other surgeries as well. Um So if you've had an adenotonsillectomy and you still have significant sleep apnea, uh ent will often perform what's called a dice or drug induced sleep endoscopy to look for other areas of obstruction in the airway and then design an individual, more individualized surgical um approach. Um So very common to have surgery. Uh CPAP, bipap, these are just some examples of the different types of masks that we use. Um Some are big, some are small, they come in different shapes and sizes and different types of headgear. Um very common to use CPAP. Um high humidity, high flow is a newer modality where basically it's a small nasal cannula that blows air into the nasal passage. Um and it doesn't really create significant um p or it doesn't stench open the airway, but that stimulation results in increased muscle tone and less obstruction while you sleep, oxygen is used, no sprays such as um intranasal steroids. Um and, or observation are things we think about. So how do we put all this together? Well, if you have a kid who you think has OS A, you may refer, you may think about referring to sleep medicine ent and or getting a sleep study. So let's say you have a child with snoring and tonsils are not big or the tonsils have been taken out. And that child you wanna refer to sleep medicine and probably get a repeat sleep study or a sleep study. If you have a child with snoring with big tonsils, you wanna refer to Ent and get the sleep study. The recommendation is prior is that prior to surgery, all Children have a sleep study. Ok. Now this doesn't always happen in practice. Ok. Sleep studies are imperfect tests. Um And sometimes you will refer to Ent, they'll have big tonsils and a really good story uh for Os A and they'll just take them directly to the or to take those, those tonsils out and there's nothing wrong with that. Um But I will say Ent pretty much always insists on getting a sleep study before surgery in Children who are less than four years old. And the reason for this is because younger kids um, often have more complications. Um, and younger kids, um, they can have more bleeding of the tonsils. And so for really young kids, sometimes E and T will start with just taking out the adenoids. Wait, so they get older and then go back and take out the tonsils. This is also helpful in terms of triaging after surgery. Uh Sometimes we will send kids home the day off. Sometimes we'll keep them overnight for observation and sometimes we'll keep them in the IC U overnight for observation, depending on what's going on. So if you have a young kid, less than four years old, order the sleep study because if you send them to ent they're gonna wanna get the sleep study anyway. And then the last point I want to make about OS A is that if you have a kid who has a history of respiratory failure for whatever reason, let's say, you know, they were on ox, they go on oxygen when they get sick or they're, they have a history of extreme prematurity. Um and uh chronic lung disease. Those are patients who probably would benefit more from seeing a pulmonology trained s sleep medicine physician. All right, moving on to restless leg syndrome and restless sleep. So restless leg syndrome is not the same as restless sleep. Um I have a lot of families who come in and they say that they have RLS and they don't. Um, RRLS has very specific criteria and these are the criteria you need to have the urge to move your legs has to affect both legs. It cannot affect just one. You have to have worsening of that sensation or urge with inactivity. The feeling needs to get better with movement. It has to be worse in the evening. Um and it can't be related to something else. So if you have, for example, neuropathy that would not qualify as uh restless leg syndrome. Ok. Restless sleep syndrome is different. Ok. It's probably along the same spectrum, but it's different. There's no universally accepted diagnostic criteria right now. In fact, restless sleep syndrome is in committee. Um and we're trying to come up with um diagnostic criteria at this time, but essentially what it is is tossing or turning that's observed by a caregiver on at least three nights per week that is felt to result in daytime symptoms or sleepiness, restless sleep can also be due to low iron stores just like RLS. And when we're checking for iron, what we're checking for is ferritin. Ok. We're not looking at the iron panel, we are looking at the ferritin specifically and our target is for levels that are greater than 75. Ok? 75 is higher than most lab ranges. Ok. So if you order a ferritin and it comes back at 35 and the normal range is like 10 to 40 listed by the lab and they have restless sleep. That's abnormal. Ok. So just be aware that the lab range values might not actually be helpful. Other labs that we consider getting when we get uh ferritin are a CBC to look for anemia. Uh low vitamin D can also result in RLS and restless sleep. And then sometimes the iron panel can be helpful in terms of Eva um interpreting the ferritin because we know ferritin is a acute phase reactant. So if you have a kid who's sick and you need to get labs, the ferritin might be falsely elevated and then you can use the iron panel to see if you need to um maybe repeat a ferritin in the future for these symptoms. You wanna refer to sleep medicine, parasomnias. So, parasomnias means around sleep and these are episodic behaviors, movements, emotions, perceptions and or dreams. Um they typically do not affect sleep quality. So typically kids do fine the next day. However, if in ex in our experience, if you have a kid, a child who has very frequent, let's say sleepwalking and sleep tears, those kids tend to be a little more tired the next day. And once you address the parasomnias, they usually feel better. Um they're mostly benign. Um they often are more distressing to parents than anything else. Um And the thing to be most concerned about with parasomnias is the possibility of injuries. Um And then parasomnias are often, um, it could be confusing to know if it's a true parasomnia or if something else is going on, this is a list of common parasomnias. Um, between, in, in, um, between 2.5 to 6 years old. What you see is the most common type of sleep, talking soy. Um, eight, like 84.4%. That's really high. So, when I have a parent who comes in their, oh, I'm sorry, you got muted somehow. There you go. Hello? Yeah, it's working now. You're good. Sorry about that guys. Uh So if you have um a child who talks in their sleep, that's normal essentially. Ok. Sleep terrors are very common. 40%. Um, bed wetting. I'm sure everybody here sees that almost on a daily basis given how prevalent it is confusional arousals. Um Confusional arousals typically are exactly what it sounds like. So the kid is kind of interacting somewhat confused. Maybe they sit up in bed. Uh Some embolism is sleepwalking. Uh kids for Children, the parasomnia can happen more in boys than adults or boys than compared to girls, right? And boys who have sleepwalking often will have nocturnal inures and, or urinate in unusual places. Ok. This doesn't affect girls. We don't know why. Um But you, if you have a boy who is sleepwalking, um, it's possible that he may have urinated somewhere. Um, about a year ago. I had a, a young young man who had sleepwalking and he did have an episode of urinating where he walked into the living room and actually urinated on his grandfather who was sleeping in a recliner. Um, but you know, that's something we do see fairly common uh in boys who sleepwalk, uh sleepwalking at night terrors often go hand in hand and they often occur together. Parasomnias often happen in the beginning of the night. And this is because at the beginning of the night, you have more stage three sleep, uh common triggers for parasomnias are OS A. So if you have a kid who has bad snoring and is sleepwalking, what we usually will do is test for OS A treat. The OS A and then the sleepwalking usually goes away completely. Um The most common trigger for um parasomnias, however, is sleep deprivation. So if you're not getting enough sleep, you're more likely to have um sleep terrors, sleepwalking, confusional arousals, et cetera. That's why, that's one of the first places we start when we're addressing and trying to evaluate a kid with a sleep problem. That's why I listed the correct amount of sleep. Uh for age para is usually uh resolved with age. I'm gonna quickly talk about uh night terrors or sleep terrors and sleepwalking. So sleep terrors are very common. 40% OK, of kids will get sleep terrors. Um Typically this involves suddenly screaming or crying. You can also have running. Um The kid is usually inconsolable or somewhat consolable but not interacting completely uh with mom or dad. Um And then I underlined here a really, really powerful um um uh question to ask in terms of trying to tease out whether or not something is a sleep terror or something else. Kids who have sleep terrors often have sweating, facial flushing and or tachycardia because there is a sympathetic, very sympathetic response when somebody has a sleep terror. So if you're concerned about sleep terrors, you should ask about this. Do they look red? Are they sweating? And if they are that strongly supports a diagnosis of sleep terrors, they tend to last 5 to 20 minutes, they can last longer. Um, the reason I list the duration here is because uh, parasomnias last a lot longer than seizures. Seizures tend to be very short. They can last seconds to a couple of minutes. It's unusual to have a prolonged seizure. So, if the event is really, really, really short at night, it could be a seizure. But if it's like 20 minutes, it's very unlikely to be a seizure. And kids don't remember these sleepwalking, um, is exactly what it sounds like. It peaks at age 11 years old. Um, and it tends to be associated with a DH D. All right. So what do you do with parasomnias? If they're infrequent and not dangerous, you can observe because most kids will outgrow them. Um, if they are dangerous, that's when we consider the use of medications. Um, what you wanna do in clinic is definitely make sure the child's getting the correct amount of sleep first. Talk about safe sleeping practices. Ok. So safe sleeping practices means lock the doors, lock, lock the windows, move away sharp or dangerous objects from the bed and if there are guns at home, disarm them and lock them away. Ok. Consider referring to sleep medicine if it's a problem and consider referring specifically to a sleep neurologist. If there are clinical concerns for nocturnal seizures for narcolepsy, basically what I wanna say here is refer to sleep medicine. Ok. This is profound daytime sleepiness that may or may not have cataplexy. Um In order to work this up, you need to see a sleep physician, non sleep physicians are not permitted at our sleep lab um at children's or um wash you to order MS LTs multiple sleep latency tests. And, and the reason for this is because we have to control for certain medications that may influence test results. And we actually have to do uh um documentation of sleep times and durations before the tests for the te in order for the test to be accurate. So if you order and try to order an MS LT, it will be denied. Ok. So if there's any concern for narcolepsy, just refer to sleep medicine and we'll take it from there. This is a summary of kind of the thought process and what we just talked about. So if you have a child who has just insomnia, symptoms, refer to sleep medicine. All right, you do not need to get a sleep study for just insomnia. If you have snoring with absence or removed, uh or um absent tonsils or very small tonsils, you can get a sleep study and refer to sleep medicine. If you have snoring with big tonsils, sleep study and ent would be the appropriate referral if you have snoring and a history of respiratory failure, refer to sleep medicine, specifically pulmonology and they will then decide what kind of sleep study to get. Ok. For RLS and restless sleep, refer to sleep medicine, circadian rhythms, parasomnias, also sleep medicine. Um if you're having parasomnias, but you're not quite sure could it be seizures? Then uh sleep neurology is the best place for narcolepsy. Refer to sleep medicine. Um Most of the patients where there's concerns for narcolepsy end up going to sleep neurology. And then if you have a child who has multiple sleep problems, which is probably one of the mo more common situations. Um because it's very rare for me just to diagnose one or two sleep problems in sleep clinic, I'm usually diagnosing like four or five. So if you have a kid with multiple sleep problems, refer to sleep medicine and specifically refer to the multidisciplinary sleep clinic. So, what is the multidisciplinary sleep clinic? This is a special clinic that we started in 2020. It occurs twice a week at children's and also CS CC, West County. And it's a clinic where all of our different sleep providers are present. So all sleep providers means um uh s uh sleep medicine with training in neurology, pulmonology and or general pediatrics, ent sleep psychology and also our sleep technologists who assist us with PAP and or uh sleep study issues. Um So everybody's there and all the different sleep providers meet before clinic to discuss the cases and to coordinate care. This clinic allows the patient to potentially see multiple sleep providers in a single visit, which is really nice because it often takes a while to get into sea sleep medicine. But if you come to this clinic, then you may see sleep medicine and then we may have you see sleep psychology that very same day as well as our sleep technologist or if you see sleep medicine, we usually can get you in to see ent also that very same day. Um which I can tell you the feedback we're getting from families is that they love it because it's a significant reduction in the number of visits that they have to make over time and we can start to treat and uh improve their quality of sleep, improve their sleep and their daytime quality of life um sooner rather than later. So how do we refer? So a lot of you may have are, are probably familiar with this. Um screenshot. So this is from epic uh and this is the referral. Um it's ambulatory referral to sleep medicine. And if you look where that red exclamation mark is, there are three boxes and these are hard stops, you have to click either a clinic, visit, sleep study or clinic visit and sleep study and then under comments you can specify whatever you need to specify. Um So if you think they have multiple sleep problems and they would benefit from the multidisciplinary sleep clinic, just write that in there and we will triage this and get them uh plugged into a clinic slot where all when all of us are present so that they can see multiple providers if needed. If you think the patient needs to see uh sleep pulmonology because they were on oxygen when they were much younger, you just put that in the comments section and we'll take care of it if you're unsure, just describe what's going on and we'll have somebody review it and plug them into the right place. Ok. So this is the epic referral process. If you don't use epic to refer to sleep medicine, um you may be using our form which you can just fax over. You'll notice here, there's a lot of questions about different sleep problems and medical conditions. The reason we include all these different medical conditions and sleep problems is in order to triage and get the pa patient plugged into the correct clinic and seeing the correct sleep provider. So the more information you put here the better. Ok. And then I also lastly wanted to mention the online video. So we have lots of kids who are anxious or families who are anxious about getting a sleep study. Um So if you go to children's website and here the websites at the bottom and or just Google pediatric sleep study, uh youtube, you'll come to the video that we create years ago. There have been a, this has been a tremendously successful video um that people from all over the country have referred to and it just walks you through in six minutes, what it's like for a child to get a sleep study. Um and it tends to alleviate a lot of that anxiety that families have going into it. All right. And that is everything. So that's a whirlwind. Created by Presenters Robert Rudock, MD, MBA Pediatric Neurology View full profile
