Better Sleep for Your Tired Teens with Dr. Sally Ibrahim

Podcast Transcript

Nada Youssef:  Hi, thank you for joining us. I'm your host Nada Youssef and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic Main Campus here in Cleveland, Ohio and we're here with Dr. Sally Ibrahim. Dr. Ibrahim is board certified in internal medicine, pediatrics, and sleep medicine. Thank you so much for being here today.

Dr. Sally Ibrahim:  Thanks for having me.

Nada Youssef:   Sure thing. And today we are talking about sleep. Specifically school-aged kids and how it affects them. So that goes from like kindergarten up, correct?

Dr. Sally Ibrahim:  Correct.

Nada Youssef:   Alright. And please remember, this is for informational purposes only and it's not intended to replace your own physicians advice. So before we jump into topic, I want to kind of ask you some questions to get to know you on a personal level if that's okay.

Dr. Sally Ibrahim:  Sure.

Nada Youssef:   Alright. So first of all, do you know any other languages besides English?

Dr. Sally Ibrahim:  I do know conversational Arabic and Spanish.

Nada Youssef:   How about your best travel destination.

Dr. Sally Ibrahim:  Oh gosh, Egypt maybe.

Nada Youssef:   Yeah.

Dr. Sally Ibrahim:  I have to say it's pretty cool.

Nada Youssef:   Cairo. You ever been to Cairo to see the pyramids? All that good stuff.

Dr. Sally Ibrahim:  I've been to Cairo, saw the pyramids, yep.

Nada Youssef:   Excellent. And then your favorite song of all time. Ooh hard one.

Dr. Sally Ibrahim:  Very hard one.

Nada Youssef:   What's your genre of music that you listen to?

Dr. Sally Ibrahim:  Everything. I love music. So every kind of music. Anything that pumps me up.

Nada Youssef:   Really, even country music?

Dr. Sally Ibrahim:  Oh, even country music.

Nada Youssef:   Good for you.

Dr. Sally Ibrahim:  Absolutely, I'm from Texas, yeah.

Nada Youssef:   Alright. Where from Texas?

Dr. Sally Ibrahim:  Houston.

Nada Youssef:   Houston. Amazing. Alright. Okay, well let’s jump into topic.

Dr. Sally Ibrahim:  Sounds good.

Nada Youssef:   So our brains are very active and they do a lot of work while we sleep.

Dr. Sally Ibrahim:  That's right.

Nada Youssef:   It's very critical to the brain health, so it really affects our cognitive and mental health. Today we're here to talk about sleep and school-aged kids and talk about what happens to their bodies with a lack of sleep. So first of all, sleep quantity varies for all ages, correct?

Dr. Sally Ibrahim:  Yes.

Nada Youssef:   So let’s talk about this, school-aged kids and how many hours they need.

Dr. Sally Ibrahim:  Sure. So school-aged kids starting from kindergartners all the way to teenagers obviously vary in what amount they need. If we take the very younger children it's gonna be anywhere from ten to 13 hours, starting that kindergarten age they lose that nap, so it's really critical to get that all at night. And then as they go, it’s sort of a moving target onward and by teenage years we're not yet adults at teenager, we still need that eight and a half to nine and a half hours and so a lot of families will come in saying they get enough sleep but they're getting seven to eight hours and they're not yet an adult so they're technically not getting enough sleep. It's still a moving target. It is less by the time they get to teenage years but not yet an adult.

Nada Youssef:   Okay. Great. So with napping, napping usually ends by like four?

Dr. Sally Ibrahim:  Usually around the four or five time, some mothers will tell you that there's no more naps earlier on and they deal with that, but usually by four or five we shouldn't nap and so that sometimes is a red flag if somebody is napping during the day, beyond that age we sort of say, "Hmm", you know are they getting enough sleep or are they getting quality sleep, etc.

Nada Youssef:   Sure. Okay, so in general, how do I make sure that my child is getting all the sleep that they need?

Dr. Sally Ibrahim:  So going by their norms. How much are they supposed to get for their age, and if they're getting that and they're functioning well we're probably doing okay. By functioning I mean, what are they supposed to do at that age? They're supposed to be behaviorally calm. They're supposed to be able to learn and grasp and focus and be social with their peers. And so these are sort of normal developmental children that we're talking about. And so if there's adequate functioning we're probably okay with the amount or quality of sleep. The other of course is that sometimes kids are functioning very well but there's something going on in that sleep period that says maybe there's some quality issues that we need to look at. But generally speaking, if you think your child is functioning well things may be okay.

Nada Youssef:   Great. So let's talk about teens a little bit.

Dr. Sally Ibrahim:  Sure.

Nada Youssef:   'Cause teens tend to have irregular sleep patterns across the week and you know they typically stay up late, they're on their phones, laptops, whatever it is, they sleep late on the weekends. How does that affect their quality of sleep and their quality of life when they're awake?

Dr. Sally Ibrahim:  Sure. So teenagers have this biological clock that tends to be a little bit more delayed, so by nature they tend to be a little bit more of that night owl already, and then they have to get up for school pretty early and sometimes they're not getting enough sleep, and then sometimes if that happens they may nap when they get home and then they stay up later and then they don't get enough sleep and then it's hard to wake up and so you see that cycle. And that's a very common teenage cycle that we see some teenagers in. Some of that may manifest as not being able to get up for school in the morning. Some of it may manifest as tiredness, especially during the morning hours or during the day altogether. It may even manifest as poor mood. We know that teenagers who don't get enough sleep at night tend to have poorer grades, poorer mood, and it's not uncommon that we see that even in adults. If we don't get enough sleep we obviously don't function as well.

Nada Youssef:   Right.

Dr. Sally Ibrahim:  Something happens that in the nighttime that's very restorative and reparative and one of those things is memory consolidation and how we function cognitively. We do a lot of restoration at night when we sleep. If we don't get enough sleep it's not surprising that we can't focus and have cognition and so it's also not surprising that we see teenagers who have poorer grades.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  And that goes for younger kids as well. And so we really try to maintain adequate sleep in that at least 24 hour period but definitely at night time so that they can get up and function and do well during their day.

Nada Youssef:   So a lot of people think that when you're sleeping your brain's just asleep, but your brain's actually very, very, very active.

Dr. Sally Ibrahim:  Very active.

Nada Youssef:   More active, right, when you're sleeping? Can we talk about that? What's actually happening in the brain while we're sleeping?

Dr. Sally Ibrahim:  Oh there's a ton of things. We didn't really know the function of sleep and we still kind of don't really understand it. It's kind of a bizarre thing. Some people make jokes about it, you know, this bizarre human that we go, we're kind of vulnerable for some time and then we get up and do it again. So it is kind of a bizarre thing but if we look at if we don't sleep then we know what happens to our bodies. And so by the lack of sleep we've found out what is the function of sleep. More recently there's been some really fascinating research looking at what's happening with even our brain production, the lymphatic system getting rid of sort of those toxins and inflammation in the body, so it tends to be restorative. And some of that actually works along the proteins in the spinal cord and the brain and so, yes there's cognitive issues that may occur as a result of lack of sleep.

And there's also some hormonal things that happen at nighttime with the onset of sleep there's certain, growth hormone for example that can happen at nighttime. There's also metabolic stuff, so sugar metabolism and all those functions. In fact if you take some healthy individuals and you sleep deprive them you see over time they actually become more glucose intolerant, or what we see with pre-diabetes. And so there's definitely a functioning with metabolism and so many other things, becomes very important for us to realize yes we're doing something very productive at night, so it is good to sleep.

Nada Youssef:   Right. Of course. Yes.

Dr. Sally Ibrahim:  It is good to sleep.

Nada Youssef:   And then I've read also that besides mental health, obviously physical health it can make you sick, something about skin care. Can teenagers get more acne from not sleeping? Is that right?

Dr. Sally Ibrahim:  So there's some restorative properties in the dermatology sleep literature. So for example, at the response to UV and reactions to UV, people that don't get enough sleep versus people that do, they can have a better restoration when they do sleep. So there is something to even down to the skin.

Nada Youssef:   Wow.

Dr. Sally Ibrahim:  You know, what's happening to the restoration of skin and processes. It probably gets down to, and we don't know for sure, but down to sort of the mechanisms at the cellular level. Well we're looking at inflammation of the body. And there's been a lot of research looking at if you don't get enough sleep sure enough your inflammatory markers do go up. So there's probably something to that affect.

Nada Youssef:   So obviously waking then would be a big one as well.

Dr. Sally Ibrahim:  And waking is another thing. It turns out that if we don't sleep well or enough there's appetite regulating hormones that are off and so ghrelin makes us hungry and want to eat, leptin not so much, and so they're off balance and we have more of that need to eat the longer we stay awake and/or how sleep deprived we are.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  And sure enough if you've ever been up really late you get the munchies.

Nada Youssef:   Yeah. Right.

Dr. Sally Ibrahim:  And you're not gonna go after carrots.

Nada Youssef:   An apple, yeah.

Dr. Sally Ibrahim:  That hormone is really looking at I need energy and so it's gonna want sugar and sort of that not so good energy.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  And so yeah, getting to bed, getting your water, getting to bed, getting a good nights sleep.

Nada Youssef:   Yeah. Right, so we've been talking about how important sleep is. I want to kind of jump onto solutions. I want to talk about habits. Can we talk a little bit about healthy habits that parents should adopt to make sure their school-aged kids are getting the best out of their sleep?

Dr. Sally Ibrahim:  Sure. So the younger kids we're really good about putting to bed on time. There's a bedtime and they're really good about it. When they start to say, "Maybe not", and they start to have negotiating strategies it's a little bit harder to enforce that. But it is true that if we enforce bedtime and a lot of studies will support this, if you have a bedtime for a child they're more likely to get enough sleep and do well the next day. And so enforcing bedtime and the regularity of sleep is super important. And so, one day you're going to bed at nine, one day you're going to bed at 11, and that could really be off. It can really offset our own circadian biological rhythm to sleep and the amount of sleep. So regular going to bed times and wake times too.

Nada Youssef:   Wake times.

Dr. Sally Ibrahim:  That's also important.

Nada Youssef:   Consistent as well.

Dr. Sally Ibrahim:  Consistent. Right.

Nada Youssef:   Even weekends? What about weekends? So maybe I'm a little lenient on my kids on the weekends. I let 'em maybe stay an extra hour, watch a movie, and then they can wake up whenever they want versus wake up at like six or five thirty in the morning for school days. Is that okay?

Dr. Sally Ibrahim:  A little wiggle room is okay.

Nada Youssef:   Okay.

Dr. Sally Ibrahim:  So by an hour, that's probably reasonable.

Nada Youssef:   Okay.

Dr. Sally Ibrahim:  If we start to see a really big difference then we're gonna get into some issues with their biological clock sometimes.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  And so I often say to parents, for example, if their bedtimes should be ten o'clock and their going to bed by two o'clock we're basically going to California on the weekend and then coming back to the east, New York, you know by Monday morning, every weekend. And so it's not uncommon then that we have this social jet lag. We can't get up in the morning and we're sort of "eh" getting through those first three days and then you sort of struggle. By the end of the week you're pretty tired. And so we try to say, well try not to be so socially jet lagged. Keep it within a reasonable time. That might be one hour and more than that we start to get a little bit in trouble.

Nada Youssef:   Socially jet lagged. I like that.

Dr. Sally Ibrahim:  Yeah.

Nada Youssef:   And obviously with sleep hygiene lights off, keep it quiet, all that good stuff.

Dr. Sally Ibrahim:  Yes.

Nada Youssef:   Let's talk about TV before bed, because I mean my child when she was much younger than this age, she used to have night terrors and my pediatrician would say it's from maybe something she's watching in her active imagination. But then when you look at teenagers, try to tell a teenager to not look at their phone for an hour or two before bedtime, what do you suggest?

Dr. Sally Ibrahim:  It's so interesting. We used to worry so much about the TV and now we have all these walking things that come in the room.

Nada Youssef:   Yes, now it's in us.

Dr. Sally Ibrahim:  We used to say no TV in the room or at least keep it off and it's not the TV anymore, it's really not. TV's still is an issue, so I always say, if you have a TV in the room, which I don't like, I fought with my husband for ten years about this. We still don't have a TV in our room. It's best for sleep if you don't. It's linked with lack of sleep over time, and obesity. And so it's really important that we try to avoid TV. So if there is some need to have some TV on then I would say as a parent we want to put parental controls on the time of TV, and have a timer. Make sure it's off before bedtime.

Nada Youssef:   Okay.

Dr. Sally Ibrahim:  And then the electronics we have to sort of try to limit those. And it's becoming exceedingly hard to do that. We have to contend with the fact that some of our homework is done, for example, on the computer. And so real-life situation, realistically, we have to sort of contend with some of these electronics and so what we'll say is, if somebody has a difficulty going to sleep, and/or if they don't if they want to practice good sleep hygiene, we want to make sure the backlight of any device that we use at night doesn't have sort of these bright lights coming from the back of the light, of the device, excuse me.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  And so by doing that, you can do that on your phone, you can do it on your computer, there are things online that you can sort of download that can also limit the brightness of the computer backlight. Lux.com I believe is one of those things that can sort of help do that. You have settings now. A lot of the sort of manufactures of the devices are doing things like bedtime and so it would be very important to say if the child does not have that lets put those things on. So let's try to limit the time that they are having that bright light. It'll dim down on its own if you put that nighttime mode. The other thing of course is just making sure that your children are not up at night texting and doing all these other things.

I'll give you an example of a child I had. She was coming in for an evaluation for sleepiness and so the father made the appointment. In the meantime, he was doing his own investigation. So she was falling asleep in class and she wasn't doing very well. Her grades were dropping. And so we were actually going to evaluate or she was being referred for narcolepsy. So he did his own little investigation and he turns out that she was on her computer up until maybe two or three in the morning.

Nada Youssef:   Wow.

Dr. Sally Ibrahim:  And so by the time they came and saw me that made my job very, very easy of course.

Nada Youssef:   Yeah.

Dr. Sally Ibrahim:  And said, "Okay lets just try to sleep instead, see what happens." Of course there were some other things that were going on that he had to deal with and that whatever she was doing on the computer that late.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  But obviously that wasn't good for her and produced her sleepiness. And she was better after that point, after they regulated that. So it's really important for parents to see what their children are doing. I often tell my own kids, "You have no privacy."

Nada Youssef:   Yeah I was gonna say, is it excessive to even take away electronics at night?

Dr. Sally Ibrahim:  I don't think so, personally. And so we have to give our kids adequate freedom as they age but always know what your children are doing. That goes beyond sleep. It goes with safety concerns with social media and online. We have to know exactly who they're talking to, what's happening online.

Nada Youssef:   Yeah. 'Cause it's everywhere. Social media now is everywhere.

Dr. Sally Ibrahim:  It's everywhere. Yeah.

Nada Youssef:   Yeah, so okay, so let's jump onto nutrition. How does nutrition affect school-aged kids. Throughout the day how could it help them sleep better and before they sleep should they eat before they sleep, should they sleep on a empty stomach? What kind of stuff should they eat? Let's talk about nutrition a little bit.

Dr. Sally Ibrahim:  Yeah, nutrition. There's some literature to suggest that the kinds of foods we eat certainly can raise inflammation and make us fatigued during the day. And so nutrition will be very important for just adequate health in general. There's also really important regulatory signals that occur when we do eat. It turns out we have signals all over our body, one of which is the gut, to say when we do things. Our circadian rhythm and our clocks are all over the body. So sometimes I'll have adolescents who have sort of this delayed problem with sleep and it turns out they're eating is off and so we try to implement regular eating times. Making sure we have some kind of breakfast and a lunch and a dinner. And then they certainly don't need, most children, and I'll say most children don't need to eat right before they go to sleep.

You'll have some of the younger toddlers who and this is not a talk about toddlers but we'll have some young children who don't get enough to eat at dinnertime and will be hungry and it is important to make sure that they eat and go to bed adequately fed. As long as they're not using it as an excuse. And so some children will do the curtain calls, "I need another. I'm so hungry Mom. I need one more drink." I need, those kinds of things, so just limiting say, "Okay, we're gonna eat now and then that's it." And making sure we have enough nutrition before going to bed, that's important.

Nada Youssef:   Good. And then obviously so exercise. A daily workout will wear them out, but also if you exercise or there's a lot of kids that do sports after school, right before sleep it can energize you.

Dr. Sally Ibrahim:  Yes.

Nada Youssef:   So how do we balance these two out?

Dr. Sally Ibrahim:  Yeah. Things at night are difficult to sometimes rearrange our life. But exercise is good for sleep for the most part. We have better quality sleep. So we want to try to exercise, implement activity, physical activity during the day as much as possible. And there's gonna be some adolescents who do have later games and they have to come back home. I just say, try to do some routine that's very swift and get back into a pattern as quickly as possible. They're gonna have to have some wind down time. It is true that if you exercise just before going to bed that might hinder sleep and if you're too sore and have pain that may also translate into poorer sleep. But for the most part exercise and physical activity is excellent for sleep quality.

Nada Youssef:   So it sounds like consistency is key when it comes to sleep. Like the bedtime, everything like that. But then, so we have spring break is coming up or some actually already had it, some are going through it. What do you tell the parents that are transitioning their kids to go back to school after maybe being on vacation and things like that? So can we wean them off like daytime just slowly, it's getting later out, how do we do that?

Dr. Sally Ibrahim:  Yes. So if your child is really off the time that they're waking up, so you can sort of see when are they waking up. If they're waking up closer to noon, we have to make some changes to be able to get up on time for school. And if they're waking up close to the time that they're getting from school that's great and just try to implement that bedtime by Thursday going into that Monday would be helpful, just to get a good pattern going. What you don't want is to wait till Sunday night and say, "Everybody go to bed. We have to go to school tomorrow." You'll get your kids there but they won't fall asleep probably. They're not in that pattern yet. We have to sort of start a little bit earlier.

Kids don't like it when they start too early of course because you're limiting their vacation time but sort of Thursday's probably a good negotiated time to start getting, it's not the weekend to stay up late and be at a sleepover and those kinds of things, and so we try to. Then there's the real world. People coming and they're traveling from spring break coming back on Sunday night. I always tell people if I have that opportunity to talk with them, try to come a little bit earlier and get into a routine.

Nada Youssef:   I never have a problem putting my kids early to sleep. It's like, "Yes, go sing in your bed."

Dr. Sally Ibrahim:  And do they go to sleep?

Nada Youssef:   Well sometimes.

Dr. Sally Ibrahim:  Sometimes, okay.

Nada Youssef:   It depends. If it's the weekends they can like read or maybe play toys and they do share a room, so that's another thing. They keep each other up sometimes or if one's sleepy, the one's not, that can kind of mess things up.

Dr. Sally Ibrahim:  Sure.

Nada Youssef:   But I am guilty of waiting till the very last minute to be like, "Okay you're going to sleep at eight." So let's talk a little bit about sleep disorders. What sleep disorders are most commonly known to be affiliated with this age group?

Dr. Sally Ibrahim:  You talked about night terrors. We see that kind of diminish over time, but night terrors will maybe children with night terrors may grow up to have some level of sleep walking and so the propensity for the parasomnia we call that bucket of sleep disorders would happen maybe later on as they grow up. And so there's sort of sleep walkers that once they start being able to walk of course, you know, they can get out of bed and start having some sleep walking episodes. Sometimes I'd like to mention too that if sleep walking episodes or night terrors are not getting better we do have to look for another sleep disorder like sleep apnea that could be augmenting that process. In fact if they get worse I often tend to have to get a sleep study to sort of look at what's happening in their nighttime. What is the arousal that's causing maybe some of these things.

Nada Youssef:   I see.

Dr. Sally Ibrahim:  And it's not uncommon that we find things like sleep apnea that when we do then treat it those night awakenings and perhaps the sleep walking episodes may diminish. As far as insomnia, right away we know that there's some self-soothers in the baby population and some of those sort of those kids. There's different types of insomnia as we see them grow up. And so in the very younger it might be association, needing something to fall asleep. As we get a little older and we have some negotiation it might be limit setting. I want to get out of bed. I don't want to sleep. Those kinds of things. And as we start to get a little bit older we start to see maybe fears. You know, so the kindergartners may have fears at night and anxiety and some other things that may creep up. And then there's insomnia related to maybe thoughts and cognition and behaviors that develop.

We call that maybe psychophysiological insomnia. The mind, body insomnia, the ruminating thoughts. And that can happen even as young as, I was surprised to see it in my clinic so young but any child whose able to think about the next day and the consequences of not sleeping. Maybe they're overthinking sleep and so they say, "I have to go to sleep 'cause I have a test tomorrow. I'm not gonna function." And so we try to target that. That's called psychophysiological insomnia and that can happen very early but we see it commonly maybe teenager years. Associated with teenager years is a myriad of other things. Caffeine late, the hygiene issues, we talked about the electronics and those kinds of things. But something that emerges teens and maybe even some tweens I see in my clinic is a delayed circadian rhythm. Meaning that their biological clock wants to sleep a little bit later. And so maybe you're putting them to bed at ten and they're saying, "I can't sleep." And it may not be true insomnia. It may actually be a circadian problem, a clock problem.

Nada Youssef:   Okay.

Dr. Sally Ibrahim:  And we know that by a few things. So one, is they can't go to sleep and another is they cannot wake up in the morning and then they tend to have better bad sleepiness in the morning that gets better with time, and they're kind of night owls. They're super, super awake at night. And so if you have that sort of pattern you wonder about could there be some clock issue, and that is very common for teenagers, and it's so common that nationally there's some movement to look at school start times. Because what are we doing to teenagers. Their biological clock is delayed, and we're asking them to get up really, really, really early for school and some of the elementary schools were looking at you know they start at eight, but the teenagers get to start earlier than that and so it's sort of against their biological clocks, so there is some movement nationally to look at delayed school start times.

And it turns out that the states that have implemented that do see that their teenagers are sleeping more. And so, you may be hearing about that in the future in legislation on the state level and national level.

Nada Youssef:   Very interesting. So the biological clock that you're talking about with teenagers, this is not something that mom or dad conditioned into them putting them to bed late. This comes with age, is that natural?

Dr. Sally Ibrahim:  It's more common to happen in teenager years.

Nada Youssef:   I see.

Dr. Sally Ibrahim:  It's also sometimes runs, and some people have that tendency for being a night owl even as adults.

Nada Youssef:   Right.

Dr. Sally Ibrahim:  And some of these teenagers they're such night owls that they know once they get to college they're not gonna get the 8:00a.m. class. They're not the ones that will do that. They will function a little bit later. And even as adults they may not want the early jobs, seven o'clock meetings, and all the other things that come along with that. So to each his own in terms of how they respond to or what their biological clock needs are. Generally speaking, teenagers tend to be a little bit more delayed. We have to work around the fact that they do have to wake up and so we try to maintain some kind of rhythm for them. And if they have to be seen clinically to help correct a rhythm we sometimes have to help correct that rhythm for them.

Nada Youssef:   So then they should definitely see a sleep medicine specialist to be able to, if they're having any of these disorders there's nothing that you can do like a natural remedy or anything. Is melatonin okay for a certain aged kids?

Dr. Sally Ibrahim:  So sometimes you can do things by implementing sleep hygiene, getting a regular pattern, those kinds of things and doing some sort of minimal strategies. If that's not affective, it may be time to see the pediatrician. And sometimes there's some additional things that they could do. And then I tend to see kids and other sleep specialists tend to see kids when things are just not improving or getting worse or if it's just a more difficult case and so we rely on the referrals and/or for parents to come and see us if needed. There's a lot of hype on melatonin, so we get a lot of questions about melatonin. Melatonin is actually not over-the-counter in other countries such as Europe or something like that.

Nada Youssef:   Really.

Dr. Sally Ibrahim:  And so the criticism in our country is that we have it over-the-counter and it's sort of loosey-goosey and anybody can use it and maybe we're improperly using it and things like that, and so it is helpful in certain populations. And so it acts in a couple of ways, one is a hypnotic, so hypnotic meaning a sleep aid. I go to sleep, it makes me sleepy enough to go to sleep. The other is the circadian rhythm, the biological clock, so it's a good sleep regulator. And we often use it in combination with other therapies for the circadian biological clock delay. It's very helpful, for example, for children who have that tendency for that delay. It helps to regulate that sleep to be able to continue at a certain pattern. There's some ADHD kids, for example, that it helps regulate their patterns. There're some other kids who really do respond very well to melatonin when it's used as a regulatory kind of sleep aid it is really, really low dose. It is at a really low dose and actually I don't see that low dose anymore over- the-counter.

Nada Youssef:   What is a low dose of melatonin that we should be taking?

Dr. Sally Ibrahim:  It's less than what you'll see over-the-counter.

Nada Youssef:   I see, okay.

Dr. Sally Ibrahim:  So it used to be that I saw a .125 milligram over-the-counter. I don't see that hardly anymore and sometimes there's specialty shops where you can see that. If you go to your local pharmacy I don't see that personally in our local pharmacies but there are still some manufacture that will make that low of a dose. So I often say if the least you see is one milligram then take that one milligram half it or fourth it or do whatever you can to it and use that.

Nada Youssef:   As least as possible.

Dr. Sally Ibrahim:  Yeah.

Nada Youssef:   And then how old can kids, are they okay to take that at seven, at eight, at nine or are we talking a little bit older?

Dr. Sally Ibrahim:  So because it's not really regulated, we don't have necessarily FDA regulations around.

Nada Youssef:   Oh I see.

Dr. Sally Ibrahim:  Around the use of melatonin and so I would often say if it's really a young child speak to your pediatrician before doing it. At least have some advice about how to do it.

Nada Youssef:   So melatonin is not FDA approved?

Dr. Sally Ibrahim:  Correct.

Nada Youssef:   Oh, I did not know that.

Dr. Sally Ibrahim:  It's sort of the nutritional over-the-counter sort of thing. It is used in a variety of other sleep disorders at higher doses. It could be used as a hypnotic and in adults for a particular disorder it's called REM sleep behavior disorder. It's really used at a very high dose. So their dosages over-the-counter may not be for everyone and so it's always nice to consult with your doctor if you can to say, "Okay how much can I give my child if needed?" It's good for the biological rhythm, sometimes that, but melatonin by itself will not regulate a teenagers sleep.

Nada Youssef:   Okay.

Dr. Sally Ibrahim:  And I want to say that, because a lot of people will say melatonin didn't work. It's melatonin plus regulatory patterns, it's waking them up at a particular time, it's light, avoidance of light at night, light during the morning hours, that helps the regulation. It's a combination of things. So melatonin by itself will not work. It will be everything you do around melatonin.

Nada Youssef:   Very, very good. Okay, one more question before I let you go.

Dr. Sally Ibrahim:  Sure.

Nada Youssef:   Now I know this seems to be more of younger children's issue when they get up and come to mom's bedroom or dad's, but it grows with them, and then you'll see kids that are eight or nine or ten that still get up at night to go sleep with mom and dad. What do you say to that? How do we change that habit? Do you just say, no, close that door? Do you make 'em cry themselves to sleep? What do you do?

Dr. Sally Ibrahim:  Well it sorta depends on the age, the development of the child, and their comorbidity, so if they're really, really anxious we gotta deal with that. If they're really developmentally challenged we have to be kind of softer on how we do things. I often say if there's some other sleep disorder we gotta address that too, one of which is sleep apnea. So if there's a lot of awakenings at night and they snore, for example, and they have some other symptoms with big tonsils we have to probably look at something like sleep apnea before we do behavioral therapy. So looking at things from a comprehensive standpoint would be helpful. So if that's really a chronic problem. If you tried a few little things and it's still not getting better, it may be time to sort of visit with someone like your pediatrician, to say okay what's going on with this sleep.

There are a variety of things you could do behaviorally and there's a lot of fun things you can do. One of my favorite is a bedtime pass and so a bedtime pass is a way for a child to know that if they get up they have to use the bedtime pass. They're very good about, okay this is next to their bed if you have to come to mommy and daddies room you've gotta give up your bedtime pass and you only get that one chance. But if you don't, you can put it for a token in the morning and you could have sort of a token reward system. Some kids would really, really like that. Depends on their age. And so the younger they are they're not gonna get that concept. They'd much rather have mommy or daddy as their reward rather than whatever reward you're talking about.

The older kids get it though. They know rewards very well and so they may hold on to that pass and not use it and turn it in the next morning. And then there's a ha, ha hurray good job and we want to positive reinforce as much as possible. Positive reinforcement works so much better than negative reinforcement. Like, "Don't you get out of your bed or else." We want to do some positive reinforcement, so, "Good job, Johnnie", whoever, "Good job. We'll give you a token in the morning." And so I love the bedtime pass for that 'cause it can really work as a positive reinforcement method. It's also important to see if the younger kids really know the concept of when it's time to get up. So what happens to these younger kids is they go through stages of sleep.

They're gonna go through their really, really deep sleep, so mom and dads know they got three to four hours. I've got my own time and then they start waking up 'cause they're dreaming. And so they're gonna go through dream cycles and in that dream cycle they may actually wake up and come to mommy and daddy's bed and if that's the case, if that's the pattern, they may not actually conceptually know when it's time to get up.

Nada Youssef:   Sure.

Dr. Sally Ibrahim:  Like in Cleveland here it'd be dark.

Nada Youssef:   It's always dark.

Dr. Sally Ibrahim:  It'd be dark. They don't know,  so it's time to get up, lets go to mommy and daddy's room. And so what we can do is give them some cues to know. So sometimes we'll plug something in, for example, you can plug in a little timer that will come on when it's time to get up or off when it's time to get up, whatever you want to do. And so the child will know that cue. They'll look over and say, "Okay well maybe it's not time to get up yet. Okay is it time to get up?" That's a really good cue for them and you can teach your child to say, "Hey it's not time to get up until this happens."

Nada Youssef:   Yeah.

Dr. Sally Ibrahim:  There's some little fancy clocks that you can get, all these other things, and so for them to conceptualize that time would be very important because we can't expect some of these younger kids to really understand when it's time to get up. And so helping them to stay in bed is very important.

Nada Youssef:   Great. Thank you so much. It's been a pleasure.

Dr. Sally Ibrahim:  Of course. Likewise.

Nada Youssef:   This information is very, very interesting to know, all this good stuff. Thank you.

Dr. Sally Ibrahim:  Yeah. Of course.

Nada Youssef:   If you would like to make an appointment with a sleep specialist for your child you can call Cleveland Clinic Sleep Disorder Center at 216-636-5860. I'll say that again, it's 216-636-5860, or you can visit clevelandclinic.org/sleep. Thanks again for our listeners for listening and if you'd like to listen to more of our podcasts from Health Essentials with our Cleveland Clinic experts make sure you go to clevelandclinic.org/hepodcast or you can subscribe on iTunes and make sure you're following us on Facebook, Twitter, SnapChat, and Instagram for all the latest health news, tips, and information. Thank you so much for listening. We'll see you again next time.