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Pediatric Sleep Disorders - Dr Krishna

Online Health Chat with Dr. Jyoti Krishna


Friday, April 30, 2010

Introduction

Cleveland_Clinic_Host: 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.

Established in 1978, the Sleep Disorders Center at Cleveland Clinic was among the first in the nation dedicated to the diagnosis and treatment of sleep disorders in people of all ages. Accredited by the American Academy of Sleep Medicine, the Cleveland Clinic Sleep Disorders Center is staffed by physicians specializing in sleep disorders from a variety of disciplines, including adult and child neurology, pulmonary and critical care medicine, psychology, psychiatry, otolaryngology and dentistry. More Than 6000 Sleep studies are performed in our laboratories each year.

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.

To make an appointment with Dr. Jvoti Krishna, or any of the other specialists at the Pediatric Sleep Disorder Center at Cleveland Clinic, please visit us on our website: clevelandclinic.org/sleep or call us locally at 216.444.5559 or toll free at 800.223.2273 ext 4-5559.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Jvoti Krishna. We are thrilled to have them here today for this chat. Let’s begin with the questions.


Sleep in Your Baby’s First Year

mommyb: At what age should a baby start sleeping through the night? At what age would you start worrying?

Speaker_-_Dr__Jyoti_Krishna: Babies will start showing signs of sleeping through the night by 6 months of age or so. The caveat here is most people misunderstand what ‘sleeping through the night' means.

What actually happens is that the baby's longest single sleep period of the day begins to occur at night and may last 5-6 hours.

If your baby is sleeping for this amount of time at night, you should feel happy.

As the baby grows older, this period will increase, but don't expect an infant to sleep from 8:00pm to 8:00am without waking up, which is what a lot of parents misconceive as sleeping through the night.

kels1780: My husband and I are not fans of crying it out, what do you recommend for sleep training methods?

Speaker_-_Dr__Jyoti_Krishna: This is a difficult question to answer, because the method is tailored to the family's conditions and each family is different.

However, there are gradual methods that are more acceptable to parents than the crying it out technique, and may involve the delayed checking method, bed time fading or graduated extinction protocols. A good behavioral psychologist interested in sleep issues or a pediatric sleep specialist would be a great person for you to talk to, assuming you have already discussed this with your pediatrician.

There are plenty of self help books available and I am sure that you have read a few. In my experience, the most common reason why some of these methods do not work is because they have not been tried consistently enough for a long enough period.

tryit3: My seven month old son seems to have his night and day reversed. How do I go about putting it back to normal?

Speaker_-_Dr__Jyoti_Krishna: Usually, children who are 7-9 months old may begin to show signs of increased wakefulness in the night, and this may be just a passing phase that will settle. Make sure that environmental cues, such as dim lighting or darkness are maintained to help the body's natural rhythm to be reinforced. Try to keep more stimulating activities to the daylight hours.


Sleep in Toddlers and Preschoolers

JackieG: When young children don’t take naps, is this harmful to their growth or health?

Speaker_-_Dr__Jyoti_Krishna: If a child has naturally given up a nap and is otherwise showing no signs of sleepiness or problems with daytime functioning, than I would not consider this abnormal.


Sleep in Adolescents/Teenagers

mybad: My 15 year old son seems to sleep very little (about 4-5 hours a night). He doesn’t seem to be effected by this lack of sleep. Is this OK?

Speaker_-_Dr__Jyoti_Krishna: This is a great question, and I hope that there are other parents who have teenagers who are logging in. Most teenagers will tell parents that they are doing just fine with relatively few hours of sleep, and I am not surprised that your teen does this too. Often, this is really not true. The average teenager needs closer to 9 hours of sleep per night, based on research. Having said that, as for any other biological phenomenon, there are children who need less than 9 hours and others who need more than 9 hours.

The question to ask yourself is: 'If my teenager truly needs only 4-5 hours of sleep per day, then this should be true on weekends, vacation and when he is not consuming a lot of caffeinated beverages.'

Very commonly, we see in our practice that teenagers catch up their sleep at odd hours by napping, sleeping on the bus, or sleeping in on the weekends. When they do this, they are simply telling us that they are paying off their accumulated sleep debt.

Others will fight sleep with caffeine, with or without their parents' knowledge. A true short sleeper will not show signs of sleepiness and have normal day time functioning, day after day, without the aid of stimulants.

Ideally, all children including teens should get their full quota of sleep on a daily basis, rather than playing catch up. Although they may not realize it, a brain that lacks sleep is less effective at learning in the classroom and is prone to more moodiness in social interactions.


Healthy Sleep Habits

crackerjack: Any way to get kids to not grind their teeth while sleeping?

Speaker_-_Dr__Jyoti_Krishna: There is no good way to stop them. Sometimes grinding can be because of sleep apnea or dental problems. It may also be seen in certain disorders, such as cerebral palsy. Anxiety and stress can also cause teeth grinding that can result in headaches, dental pain and the wearing down of teeth.

Attention to the above factors may help reduce the problem. A visit to the dentist can also be helpful.  Sometimes, dental appliances can be worn. Medications are rarely used in childhood for this problem.

kels1780: My 6 mo old daughter just started sleeping about 8 hours at a time only a few weeks ago. Do you agree that bad sleep habits in babies relay to the child/teen years? We provide the same bedtime routine every single night to try and help her, but nothing seems to be working to keep her in a routine...

Speaker_-_Dr__Jyoti_Krishna: Habits set in early childhood can carry over to later childhood and beyond. This is not always a rule, but can often be seen. I think you are doing a great job trying to stick to a routine, but just remember that routines should not be so rigid as to become a problem, since the human organism varies from day to day and is not a robot.

All of us feel differently every day, eat differently every day and sleep differently every day. So, within the context of reasonable allowances, a routine is good.

hollyhobby: Is it okay for my kids to read or watch TV or listen to the radio before/when they go to sleep?

Speaker_-_Dr__Jyoti_Krishna: We sleep doctors like to use the words 'sleep hygiene' very commonly. We usually like to have activities that are sleep promoting to occur in the time period 1/2 to 1 hour prior to bedtime. Such activities may include quiet reading and a stable bedtime routine, such as a bath, brushing teeth, story time, etc.

TV watching, use of computers, cell phones and other forms of similar entertainment is generally not considered conducive to sleep.  Nor is horseplay or exercise close to bedtime. Good sleep habits are best set in childhood, so that they can carry over into adulthood.


Nighttime Awakenings

kels1780: My daughter is 6 mo old. For about a week and a half she has been up all night, meaning every hour, two hours. We don't know what to do anymore. We gave her Tylenol because we thought she might be teething. That didn't work. Same for Orajel® and Mylecon® for gas. She wakes up kicking and screams like she is in pain, and then goes back to sleep after we console her. Any thoughts as to what could be going on?

Speaker_-_Dr__Jyoti_Krishna: The first thing you need to do is go to your Pediatrician and make sure your daughter is not sick in any way. Sometimes these can be transient disturbances that settle, especially if your daughter was sleeping normally before.

What you don't want to do is to start rocking, cuddling or soothing your baby (especially if she is not sick) with each awakening, because this can then turn into a learned habit.

If in spite of this, things don't improve, you might want to consult a sleep specialist.


Obstructive Sleep Apnea

handyman: What causes sleep apnea in children? How dangerous is it for children and can it be cured or will they suffer with it their whole lives? Can children use the nose strips when they sleep?

Speaker_-_Dr__Jyoti_Krishna: Sleep apnea in children may have multiple causes. Most commonly it is from large adenoids or tonsils, and obesity. However, other factors such as the anatomy of the jaw, the size of the tongue, problems with nerves or muscles and various medical disorders like Downs Syndrome, etc. may predispose a child to sleep apnea. Hormonal factors such as low thyroid function may also sometimes be seen.

In the extreme, untreated sleep apnea can cause problems with the heart, blood pressure and poor growth. More commonly however, we see problems with mood, behavior, memory and learning, as well as poor school performance in children. Some children may behave as if they have ADHD and can appear 'hyper or lacking focus.'

Help is available. If it is suspected, one of the most common hallmarks of sleep apnea is the above medical problems in a snoring child. If your child snores, you may want to think that they may have sleep apnea and discuss this with your doctor.

It is difficult to diagnose sleep apnea simply on a clinical visit, as it can lead to either a false diagnosis or a misdiagnosis. The best way, at our current level of understanding in diagnosing sleep apnea, is an overnight sleep study.

Once diagnosed, sleep apnea can be treated with simple surgery, such as a tonsillectomy or adenoidectomy, or weight loss. In some cases, CPAP therapy, such as the kind used for adults, may be needed in children as well.

Many children will be cured after surgery and/or weight loss, but some may require long term treatment with other means.


Nightmares/Night Terrors

sandstorm: What causes night terrors? My nephew has recently begun having them. Are the causes psychological or physical?

Speaker_-_Dr__Jyoti_Krishna: Night terrors are commonly seen in preschool to early school year children. They may occur by themselves or with other parasomnias, like confused arousals, or sleepwalking. Most commonly they occur in children who are otherwise normal. While we do not know the exact cause for night terrors, they can be very scary for parents. We do know that certain conditions can trigger parasomnias and these include, illness, fever, lack of sleep, stress and anxiety. Some may have a family history.

The good news is that most children out grow them.


Narcolepsy/Daytime Sleepiness

newtonm: My son is sleepy throughout the day. He is 11. What can I do?

Speaker_-_Dr__Jyoti_Krishna: Daytime sleepiness is rare in normal children in this age group. In fact, once children give up naps in their preschool years, they are normally not very sleepy during the day and tend to get all their sleep in one long sleep period at night, lasting 10-11 hours.

While I don't know what other symptoms your child has, in broad strokes sleepiness during the day could be the result of insufficient sleep at night, poor quality sleep at night, a shifting of the biological clock to become a "night owl," or it could be something more rare, such as narcolepsy. Amongst all of these, the most common reason for daytime sleepiness at this age, is either lack of sufficient sleep at night or a problem with the biological clock shifting to a later bedtime and rise time. You should consult a sleep doctor to make sure that the other problems mentioned above are not pertinent to your child. Poor quality sleep can occur from many sleep disorders, such as sleep apnea and limb movement disorders.

Narcolepsy, although rare, most commonly begins in the second decade of life and needs specific sleep studies for diagnosis.


Bedwetting

pocky: My six year old daughter seems to sleep so deeply sometimes that she is hard to awaken and can wet the bed. Should I be concerned?

Speaker_-_Dr__Jyoti_Krishna: Bed wetting is fairly common in childhood and mostly begins to disappear by the time the child is ready for school. Bladder control seems to occur sooner in girls than in boys. However, not all children are dry by night at 6 years of age. I will assume your daughter is otherwise normal and does not have other urinary problems. If this is the case and you feel that the frequency of bedwetting seems to be decreasing over the last several months, then your daughter may simply be a late to mature. If you have not had her urine checked at her pediatrician, I would start there. Sometimes snoring children may have sleep apnea, which has been associated with bedwetting. Please make sure this is not the case with your daughter either. Most often, bedwetting resolves over several months, as the child grows and this should be the case with your daughter, I hope.


Sleepwalking

haverhill: What exactly causes sleepwalking? My son, who is 7, will get up, go to the bathroom (not necessarily in the bathroom), get something to drink, etc. and he is not awake. When I am aware of what he is doing, I try to ease him back into bed. How can I stop this?

Speaker_-_Dr__Jyoti_Krishna: See the response above to sleep terrors. Sleep walking is similar. It may occur in slightly older children. The precipitating factors are the same as for night terrors.

The thing I would be most concerned about would be safety. Please make sure you have safety latches on doors and maybe gates installed in stairwells to prevent injuries to your child.

For the most part, these episodes are benign and resolve if the precipitating factors are removed or with advancing age, since they appear to be more of a childhood phenomenon.

I will submit however, that a small fraction of children will continue to have parasomnias into adulthood. Sometimes, other sleep disorders such as sleep apnea may be a trigger for parasomnias.

Extremely rarely, seizures may masquerade as night time parasomnias.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Jvoti Krishna is now over. Thank you again Dr. Krishna for taking the time to answer our questions about pediatric sleep disorders.

Speaker_-_Dr__Jyoti_Krishna: Thank you for joining me here today. I hope you were able to get the information that you needed. I realize that we could not get to all the questions that were posted, but I tried to sample a wide variety to keep the scope of our conversation as broad as possible. If you have further questions, please see your child's pediatrician, or we would be happy to see you here at our Pediatric Sleep Disorders Center.


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