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Pediatric Sleep Disorders _ Jyoti Krishna MD

March 6, 2009

Introduction

Cleveland_Clinic_Host: Today's live chat with Dr. Jyoti Krishna is about pediatric sleep disorders. Sleep disorders are common in children, but often are under recognized. Sleep disturbances in some form are seen in as many as 25 to 30 percent of infants and children. They may range from insufficient sleep, bedtime settling problems and sleep walking to sleep apnea and narcolepsy. These disorders manifest as symptoms that are easily misleading to the casual observer. It is not uncommon to misdiagnose mood, attention or motivational problems and entirely miss the true underlying sleep problem. During today’s chat, Dr. Jyoti Krishna will discuss Pediatric Sleep Disorders.

Dr. Jyoti Krishna earned his medical degree from the Maulana Azad Medical College of the University of Delhi in New Delhi, India. He has completed residencies in pediatrics at Maulana Azad Medical College and at the Texas Tech University Health Sciences Center in Lubbock, Texas. He completed a two-year dedicated sleep medicine fellowship at the University of Louisville and Kosair Children’s Hospital in Louisville, Ky.

Dr. Krishna is board-certified in both pediatrics and sleep medicine. His specialty interests include pediatric sleep disorders: snoring and sleep apnea, circadian rhythm disorders, disorders of excessive daytime sleepiness, behavioral insomnia and parasomnia disorders. He has published many peer reviewed articles and frequently gives talks in the community and at local, regional and international meetings.

For additional information about Cleveland Clinic Pediatric Sleep Disorder Center, please visit us on our website: www.clevelandclinic.org/sleep or call us locally 216.444.5559 or toll free 800.223.2273 ext 4-5559.


Pediatric Sleep Disorders Overview

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Jyoti Krishna, MD. We are thrilled to have Dr. Krishna here today for this chat. Let’s begin with some general questions about children and sleep disorders.

newtonm: How do you know when a child should be seen by a pediatric sleep specialist versus his/her regular physician?

Speaker_-_Dr__Jyoti_Krishna: There is no good short answer to this. As for most medical problems, the pediatrician is a good starting point. But if the pediatrician is unable to help or you feel things are not improving, you may seek a self referral or ask the pediatrician for a referral depending on your insurance coverage.

Locally, you can contact the Cleveland Clinic Sleep Disorders Center at 216.444.5559 or visit the website www.clevelandclinic.org/sleep. We have an excellent fact sheet that you can download. (PDF)

Another good resource is The National Sleep Foundation. Their website is www.sleepfoundation.org for more information on particular sleep disorders.


Sleep Behavior: Bedtime & Awakening Struggles

winers: Our 9 year-old granddaughter has trouble getting to sleep and trouble staying asleep. Any suggestions?

Speaker_-_Dr__Jyoti_Krishna: Although I cannot be sure based on the brief scenario presented, your granddaughter may have behavioral insomnia of childhood. Other sleep disorders that could prevent sleep onset may include restless leg syndrome (RLS.) Still others could cause arousals (sleep apnea). However, make sure there is no other medical problem causing this issue. If this is truly a sleep problem, such cases usually require a detailed consultation.

cissieb: My 7 year old son has always been put to sleep by driving in the car. Even now, if the car ride is more than 20-30 minutes he often falls asleep. How can I stop this? It can be hard at times when we are going somewhere to then wake him up and get him moving.

Speaker_-_Dr__Jyoti_Krishna: Looks like your son has got what we call a sleep association problem. Since this is a behavioral issue, the treatment is not medical but rather behavioral. However if he is consistently falling asleep in the car despite adequate sleep at night [10-12 hrs for a 7 year old] you may want to consider a visit to a sleep specialist. Otherwise a good psychologist should be helpful with behaviorally problematic sleep routines.

punter1: My daughter has a very hard time waking up in the morning. It can take up to an hour for her “head to clear” and for her to be truly functional? Is this normal or does it imply she is not getting enough sleep? She gets at least 8 hours a night.

Speaker_-_Dr__Jyoti_Krishna: Initially, I would want to know how old is your daughter? If she is a teenager or close to puberty, she could be having a delay in her biological clock. Mind you, even for a teenager, 8 hours is not enough sleep. The average teen needs 9 hours of sleep and a mid-school age child needs 10-11 hours of sleep.

If your daughter is not in this age range, and increasing sleep time does not help, then consider a disorder of excessive daytime sleepiness and consult with a sleep specialist.

newtonm: My 14 year old daughter is a “night owl,” and always has been. She would stay up all night and sleep all day, if I let her. Even when younger, I would put her to sleep earlier and wake her up earlier to try and shift this behavior. She would just lie in bed and play by herself, talk to herself, or just lay there, without going to sleep. She seems to function OK during the day without as much sleep, although on the weekends when I let her sleep in she does so. How detrimental is the lack to sleep to her and is there any way to shift her internal clock?

Speaker_-_Dr__Jyoti_Krishna: Similar to the previous question, being a 'night owl' in clinical parlance is called "delayed sleep phase syndrome." This can be mild, and not require complicated treatment other than good sleep habits on weekdays as well as weekends. However, in the extreme, a tailored regimen consisting of melatonin, bright light therapy and behavior modification may be useful. Such a regimen is best discussed with someone who is comfortable dealing with these disorders.

Wrong timing of the above treatments relative to the sleep period may actually make matters worse.

sentry10: Is it normal for young children to stop taking or needing naps? My 3 1/2 year old hasn’t taken a nap in quite a while, but seems to do OK.

Speaker_-_Dr__Jyoti_Krishna: This is a very good question that I hope others are going to pay attention to as well.

We often read many books as parents, and we hope that our children fall into the molds that are described. This rarely happens. All biological phenomena [normal height, normal weight, normal blood pressure, etc.] are best described as ranges of normal rather that any one particular number.

There are many normal people who are short sleepers, just as there some people who are long sleepers. We recognize them, just as you do your child, by the fact that they seem to behave normally when they get their quota of sleep. I would not consider your child abnormal and would also let you know that there are some 1st graders who still need a nap.

centerring: My 6 month old still gets up once or twice a night. At what age do you start diagnosing sleep disorders?

Speaker_-_Dr__Jyoti_Krishna: Yes, I believe this would be normal. What you do not want to do is to interact with your child during these awakenings. You should train them to self soothe themselves. Children between 6-9 months of age generally will begin sleeping ‘through the night.’ It may help you to know that ‘sleeping through the night’ means closer to 5-6 hours at a stretch, not 10 hours at this young age.

By the time they are 9-12 months old, children generally stop need nutrition at night. So be careful if you find yourself using a bottle to soothe the baby. What you want to do as your baby grows is to let him or her learn that at night time, lights are low, interaction is minimal and everybody needs to put themselves back to sleep [self-soothe]. A transitional object like a teddy bear may be helpful for security too but not a TV!

You may find more information on the National Sleep Foundation website (www.sleepfoundation.org.)

patti_from_florida: My child has early morning awakenings and daytime behavioral issues. Can you provide any local resources in Florida and any resources for normal sleep study data which my child has already has completed? We have seen an ENT and allergy treatment is not helping.

Speaker_-_Dr__Jyoti_Krishna: Regarding normative sleep study data for children of the 3-8 yr age group, an excellent article was published in a journal called PEDIATRICS Volume 117, Number 3, March 2006. The title is Polysomnographic Characteristics in Normal Preschool and Early School-Aged Children. This data is exhaustive but needs to be taken with a pinch of salt. When you read it, make sure you understand that every value reported has a range. Trying to fit a particular child into averages can be problematic.

The American Academy of Sleep Medicine (AASM) has a web site (www.sleepcenters.org) where accredited Sleep Centers can be researched by state location. Local Children's Hospitals can also be contacted to determine if they have sleep specialists.

bellaburgh: I have a four year old daughter with Cerebral Palsy that I have been trying to get on an earlier sleep schedule. She has been quite resistant. Not only is she resistant to going to bed early but she usually wakes at least twice in the night. She is not a snorer (unless she's just that tired), but still awakes. Whether she naps or not during the day is irrelevant - it doesn't seem to affect her sleep schedule. What can I do to facilitate an earlier sleep schedule and keep her asleep?

Speaker_-_Dr__Jyoti_Krishna: There is no good short answer to this dilemma. The problem you are facing is very common among children with cerebral palsy. A developmental pediatrician, a good children's psychologist or a pediatric sleep specialist may be consulted.

Options may include: use of melatonin, light therapy, behavioral sleep interventions and in rare cases, sedatives. A sleep study may reveal a reason for arousals.


Sleep: Bedwetting and Urinary Incontinence

wonderwoman: My daughter had a very bad urinary infection when she was young (around 3 ½ -4 years old) and this affected her ability to hold her urine. By the time she went to school, she more or less had control during the day, although could still have accidents. I was told that when she went to the bathroom, she was not completely emptying her bladder, even though she felt that she was, and would have to go again in 15 to 20 minutes. She still has a hard time going through the night without an accident and can have “leaking” problems through the day. We have done the things our pediatrician has suggested; with various amounts of success (she is now 9). Will she ever outgrow this?

Speaker_-_Dr__Jyoti_Krishna: Because your daughter also has daytime urinary incontinence, you should consider talking to your pediatrician about a referral to a pediatric urologist. Make sure that severe constipation is not part of the problem.


Sleep Apnea and Snoring

abc1234: Can children have sleep apnea? Are there any signs during the day that could be looked for?

Speaker_-_Dr__Jyoti_Krishna: Yes indeed children can experience sleep apnea. It has been reported that 2 out of 100 children in elementary or middle school will have sleep apnea. The most important sign to look for is habitual snoring at night. You may also notice breathing pauses, snorting, gasping, dry mouth, sweating and catching of breath at night. During the day, children may be tired, cranky, out of focus or have problems with school performance.

Children with some "syndromes' (such as Down Syndrome) are particularly at risk as are otherwise normal obese children. Other who are at risk include children with neuromuscular disorders, abnormalities of face and jaw and those with large tonsila and adenoids. At risk, does not mean they will have ti, but that they should be screened.

tricity: What are the treatments for childhood sleep apnea? Are they the same as for adults? What could happen if a child does have sleep apnea and it does not get diagnosed or treated?

Speaker_-_Dr__Jyoti_Krishna: Great question!!! The treatment for children’s sleep disorders is different than for adults.

Usually, treatment for sleep apnea involves tonsil and adenoid surgery (T&A). However, keep in mind that not all children who snore or who are suspected to have sleep apnea by a clinician, or have large tonsils and adenoids actually do have sleep apnea when tested by a sleep study.

So, before you go consider a tonsillectomy for suspicion of sleep apnea, it is my opinion that you should have the diagnosis confirmed by obtaining a sleep study.

As stated earlier, 2 out of 100 children in this age category (pre-elementary to middle school age) have sleep apnea. A lot more (up to 10%) will snore habitually. A sleep study will distinguish the simple snorers from the true apneics and therefore avoid unnecessary surgery.

If a child is not treated for sleep apnea, then depending on the severity, we may find problems with behavior, memory, school performance and learning, bedwetting, daytime sleepiness, mood disorders such as depression, hyperactivity and out of focus behavior similar to ADHD.

In more severe cases, there could be problems with the heart including enlargement of the right side of the heart, elevated blood pressure, and pulmonary hypertension as well as problems with some of the hormones that control feeding and lipid and other metabolism.

Speaker_-_Dr__Jyoti_Krishna: In extreme cases, children may fail to gain weight or grow normally, and in extremely rare cases they may even die from untreated severe sleep apnea.

sitterstill: Should I be concerned if my son snores?

Speaker_-_Dr__Jyoti_Krishna: I believe this question has been previously answered when we talked about sleep apnea. It is important to determine the cause of your child’s snoring and the first place to start is with your pediatrician. It may be a sign of sleep apnea.


Sleep Behavior: Sleep Talking

planter: Does talking in your sleep signify anything? My son talks a lot in his sleep. He even laughs and has punched out in his sleep.

Speaker_-_Dr__Jyoti_Krishna: In general, sleep talking is an innocuous nocturnal phenomenon. And in fact, the most recent international classification of sleep disorders lists the behavior of sleep talking under the category "Isolated Symptoms, Apparently Normal Variants and Unresolved Issues." Emphasis should be placed on the word 'apparently.'

There are sleep disorders where people can actually act out their dreams, but this is very rare in childhood. If your child is in danger or may cause injury, you should consider visiting a sleep specialist.

However some laughing, smiling, talking or even limb movements during sleep are not out of the realm of normal.


Sleep: Night Terrors or Nightmares?

clearview: Can you tell me more about night terrors? My son has some pretty bad nightmares. How do you differentiate between them?

Speaker_-_Dr__Jyoti_Krishna: Many people confuse night terrors [NT] and nightmares [NM]. NT are seen usually in the first 1/2 of the night, usually in the first 3 hours of sleep onset, and involve sudden extreme fearful crying episodes with the emphasis placed on the word ‘sudden.’ Breathing and heart rate may be elevated. Attempts to talk or hold conversations with the child are futile or only confused non-sense answers will be received. A Night Terror episode subsides in 5-15 minutes with normal sleep after and no recall of the event the next morning.

On the other hand NM usually happen in the second 1/2 of the night. If the child is woken up, a very detailed story might be verbalized.


Sleep Hygiene: Bedtime Routines

sitterstill: What can I do to my daughters room or bedtime routine to help?

Speaker_-_Dr__Jyoti_Krishna: This is a question near and dear to my heart because a good proportion of all sleep disorders that I see can benefit from what we sleep docs call good 'sleep hygiene.'

I will discuss good sleep hygiene under the following sub-headings: daytime lifestyle; diet; environment and bedtime routines.

1. Daytime lifestyle

  • Avoid late night exercise
  • Avoid daytime napping (does not apply to infants, toddlers and pre-schoolers)
  • Keep consistent and reasonable wake up times on weekdays and weekends.

2. Diet

  • Avoid caffeine and remember some clear sodas and chocolate also contain caffeine.
  • Avoid heavy meals at bedtime

3. The Environment: The Bedroom

  • A quiet, dark, comfortable room that is not too warm. [70 degrees F or less if comfortable]
  • Preferably no pets sleeping in the bed (or asking to be let out at 3am.)

4. Bedtime routines

  • Calming activities (no TV, Xbox games, etc.)
  • No distractions such as cell phones, iPods or computers within one hour of bedtime.
  • Reading: A nice, non-racy 'book reading' in relatively low light in a comfortable chair is ideal.
  • Warm baths also help some people to sleep.

plunckett: Do you think relaxation or yoga classes will help my daughter go to sleep at night?

Speaker_-_Dr__Jyoti_Krishna: Depending on the age of your daughter, relaxation techniques may be helpful. Yoga is a form of exercise so very physical yoga should not be done before bedtime. However, some of the calmer meditative yoga exercises may be tried.

Bear in mind, I am not a yoga expert. Other relaxation methods may include: guided imagery training, cognitive behavioral therapy, abdominal breathing exercises and biofeedback. These can be discussed with any good psychologist interested in sleep behavior.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Jyoti Krishna is now over. Thank you again Dr. Krishna, for taking the time to answer our questions today.

Speaker_-_Dr__Jyoti_Krishna: Thank you all for giving me this opportunity. I hope you enjoyed this as much as I did and found this information useful. We are sorry if there were more questions waiting that we could not accommodate. We are always happy to see you in person at the Cleveland Clinic Sleep Disorders Center.


More Information

  • For additional information about Cleveland Clinic Pediatric Sleep Disorder Center, please visit us on our website www.clevelandclinic.org/sleep or call us locally 216.444.5559 or toll free 800.223.2273 ext 4-5559.
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This online line health chat occurred on March 6, 2009.

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