Pediatric Sleep Disorders: Diagnosis and Management

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: October 15, 2023

Expiration Date: October 15, 2024

Estimated Time of Completion: 34 minutes

Pediatric Sleep Disorders: Diagnosis and Management

Vaishal Shah, MD, MPH

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases

• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

Podcast Series Director

Imad Najm, MD

Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Vaishal Shah, MD, MPH

Cleveland Clinic Sleep Disorders Center

Host

Glen Stevens, DO, PhD

Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Pediatric Sleep Disorders: Diagnosis and Management

Vaishal Shah, MD, MPH

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Imad Najm, MD	Eisai Advisor or review panel participant NIH Other activities from which remuneration is received or expected: Research Funding  LivaNova, PLC  Advisor or review panel participant
Glen Stevens, DO, PhD	DynaMed  Consulting

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP, Vaishal Shah, MD, MPH

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

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Go to: Neuro Pathways Podcast Oct 15 2023 to log into myCME and begin the activity evaluation and print your certificate. If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2023 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab and psychiatry.

Glen Stevens, DO, PhD: Sleep disturbances occur in approximately 25 to 30% of infants and children. While these issues are often temporary, they can negatively impact a child's development, daytime behavior and overall quality of life, and some can be long-lasting or associated with other conditions.

In this episode of Neuro Pathways, we're discussing the diagnosis and management of pediatric sleep disorders. I'm your host, Glen Stevens, neurologist/neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Vaishal Shah join me for today's conversation. Dr. Shah is a sleep disorder specialist and director of pediatric sleep operations in the Sleep Disorder Center within Cleveland Clinic's Neurological Institute and the Center for Pediatric Pulmonary Medicine within Cleveland Clinic Children's. Vaishal, welcome to Neuro Pathways.

Vaishal Shah, MD: Thank you.

Glen Stevens, DO, PhD: And I think one thing that I didn't mention, there was a neurologist here many years ago and when he saw a patient that had a headache, he said, "Headache for you, headache for me."

Vaishal Shah, MD: Yeah.

Glen Stevens, DO, PhD: And it reminds me of this a little bit, pediatric sleep problems, problem for the child, problem for the parent, not just the doctor but problem for the parents.

Vaishal Shah, MD: Absolutely.

Glen Stevens, DO, PhD: So definitely have to get these under controlled and established. So Vaishal, tell us a little bit about your background and where you came from and how you made it to the Cleveland Clinic.

Vaishal Shah, MD: I've been in Cleveland for almost, this is 15 years now. Finished my med school in India and then came straight to Cleveland. I had family member here. I had pursued my master's in public health at Cleveland State University. While doing so, I was working with Cleveland Clinic on some of the obesity project and eventually completed pediatric residency. During the residency, I had a number of patients in my clinic, and personally, I experienced sleep problems so maybe this is my career path. The calling is coming. So then I pursued the sleep fellowship at Cleveland Clinic and then joined as a staff in 2016, so I've been practicing sleep medicine since that time, and I've been leading the pediatric sleep operations since 2019, so that's where I've been.

Glen Stevens, DO, PhD: And your practice is primarily sleep or do you do other things as well or really just enough going out there? It sounds like you have 20 to 30% of infants and children have disorders. There's enough going around.

Vaishal Shah, MD: More than enough. Everybody sleeps so they're going to have some problem. I practice primarily pediatric sleep, but I see adult sleep too. Our training is for both.

Glen Stevens, DO, PhD: Okay, good. Well, that leads us really into our first question and maybe it depends exactly on what the age is, but tell us how much sleep a normal child should get. And maybe you can just tell us what people are getting versus what they should be getting.

Vaishal Shah, MD: Absolutely. So as you alluded, it depends on the age. For very, very young children, particularly babies, let's say newborn to infants, I generally jokingly tell parents that their job is to sleep, wake up, eat, look cute, poop, go back to sleep. So they can sleep, they have the cycles or what we call ultradian rhythm rather than a circadian rhythm where they take short naps, like 15 minutes to two hours, wake up, do other activities, go back to sleep, and they can sleep almost more than half of their day, 14 to 20 hours in a day.

Once they get to about toddler, it comes down to anywhere between about 11 to 14 hours and your cycle becomes more and more mature to become nocturnal, and that's what we call circadian rhythm. It means brain's ability to differentiate between night and day. They still may have naps, which could be one to three, ranging from a wide variety of amount, 15 minutes to three hours.

Once you get to preschoolers and school age, then your sleep gradually starts getting less, so most of the children get rid of the nap by the time they are in the school. Very few can still have it when most of them don't. Once you're in school, sleep needs are anywhere between nine to 11 hours.

And then finally, once you get to teenage, it's approximately eight to 10 hours, but that I hardly find. Most of the teenagers are not getting that much sleep and so forth.

Glen Stevens, DO, PhD: But that's how much they should be getting.

Vaishal Shah, MD: That's how much they should be getting based on what we know for their functioning and so forth. Generally, that's when we find most insufficient sleep in that age group. Even younger kids could have it, but we tend to find that problem less in the younger kids.

Glen Stevens, DO, PhD: I've actually started, when I'm on hospital service, I will actively ask each day the students and the residents how much they sleep the night before. Now I have no idea if they're telling me the truth or not, but it's always enlightening. It's rare that any of them report to me they sleep more than seven hours.

Vaishal Shah, MD: Yeah. I call it resident sleep syndrome. It's just my own invention, nothing official there, but generally, their cycle is in none of our sleep books so how do we describe? Because they can have calls, they can have different shifts and so forth. Although for their own functioning and for patient safety and outcome, as much as they can be disciplined on the days or times they're off and get enough sleep. Besides their social life or other commitments they have, that's probably advisable.

Glen Stevens, DO, PhD: And I know we're talking about kids today, but there's a lot of data coming out looking at cognitive impairment as we get older if we don't sleep enough.

Vaishal Shah, MD: Yeah.

Glen Stevens, DO, PhD: And if this starts with poor sleeping very early, it's only going to exacerbate the problem and maybe even make it worse while those brains are developing. So I think it's something that we really need to be paying ... I'm sure you would agree because that's what you do, that we need to be paying a lot more attention to this than we are.

Vaishal Shah, MD: Absolutely. At Cleveland Clinic, there is brain health study also looking exactly into that, that if your amount ... It's a lot of different things, but one part of it is if in the younger ages if your amount or quality of sleep is disrupted, is it a risk factor for developing, later on, the brain-related problems such as Alzheimer's disease and so forth? In my opinion, prevention is much better than cure. So earlier you intervene and earlier you work on your sleep, later on, it's going to be much less problems.

Glen Stevens, DO, PhD: So the sleep disorders that I see in my neuro-oncology practice, mostly snoring, obstructive sleep apnea, maybe some problems getting to sleep or initiating sleep. But what about kids? What do we see in kids, different types of problems, but what are you seeing?

Vaishal Shah, MD: Yeah. So the broader categories of sleep problems are similar, except that the degree and the prevalence is different. So for example, the six categories under which number of problems we see, most common in kids we tend to find are insomnia and/or circadian rhythm, it means body clock problems, and those are about 50% of our practice. So there is typically trouble falling asleep, staying asleep or in comparison to the time zone they live in or their social needs, their mismatch of body clock, which is very common in adolescents and so forth.

We are seeing a lot more of sleep apnea also due to a variety of different reasons. The risk factors are different in kids compared to adults, but with the epidemic of childhood obesity, we are seeing a lot more and more of the obstructive sleep apnea in younger patients. Followed by which, we tend to see hypersomnia such as narcolepsy or idiopathic hypersomnia. Generally narcolepsy, one of the common age it starts is adolescent and so forth. Many times, it's not picked up or not diagnosed for a long time because a lot of time, we blame these are just teenagers, they are lazy, they have depression, they are being difficult and so forth, until somebody looks into a medical rock.

And then lastly, we see what we call rhythmic movement disorder such as restless leg syndrome. That is less common compared to adults. It's much more common in adults. And are body rocking or similar rhythmic movement, more so common in children with autism spectrum disorder or neurodevelopmental. So there's wide range of things we see.

Lastly, we see quite a few of what we call parasomnias, which includes sleepwalking, sleep terrors, sometimes complex problem associated with those.

Glen Stevens, DO, PhD: And just remind our listeners that if they have a patient with a lot of restless leg syndrome, they should be checking iron. Is that as I recall-

Vaishal Shah, MD: Yeah, iron is one of the most common reasons, actually more so in kids. The reason for that, there's a chemical in the brain called dopamine, and think of dopamine as a ship who has to dock on a port that's called receptor. And for this receptor to be able to properly functioning, iron is a very, very important molecule. So if the iron level, particularly the storage form called ferritin is low in the body, that's when this dopamine cannot function well. That's why somebody will experience restless legs.

Glen Stevens, DO, PhD: So I was reading that kids that have attention deficit disorder also had a 25% risk of obstructive sleep apnea, and I'm not sure I understood why that was.

Vaishal Shah, MD: Yeah. So more than this, there's a significant overlap. So about a third of kids with ADHD have obstructive sleep apnea or vice versa. There are twofold relationship. Generally sleep apnea does not cause ADHD itself. However, what we notice is if your sleep apnea, particularly moderate to severe obstructive sleep apnea, it makes ADHD symptoms worse because your quality of sleep is not good. And also, it is known that sleep apnea, moderate to severe or in some cases, we have seen in mild cases, can isolate at present as just attention problem or hyperactivity without a full-blown diagnosis of ADHD and so forth.

Glen Stevens, DO, PhD: Yeah. I think this is fascinating and really the sleep condition can be treated. So I think that people have been looking at ... And again, I'm an adult guy, but it sounds like maybe a lot of the ... If a quarter of the patients have this problem, then those primary care out there listening to this maybe start thinking about doing more sleep studies or sleep consults with your ADHD patients.

Vaishal Shah, MD: Yeah, or at least the screening. There are a number of tools that can implement in the office itself, very basic screening tools and so forth.

Glen Stevens, DO, PhD: Yeah. So while you're on that, why don't you just tell us a little bit about tools that you find helpful?

Vaishal Shah, MD: Yeah. The simple way to remember, there are a number of them, these simple five categories of symptoms we see.

Glen Stevens, DO, PhD: You say it's simple. I'm not sure I'm-

Vaishal Shah, MD: So can't fall asleep, can't stay asleep, can't wake up, too sleepy or something happening at night such as snoring or unexplained event. So those are five common symptoms we see. There's a mnemonic called BEARS, which represents a pretty broad mnemonic. B for bedtime problems, which is can't fall asleep. The E for excessive daytime sleepiness, which is too sleepy. A for awakenings, which is can't stay asleep. R is for regularity and timing of sleep. It means is it too late, too early compared to their social needs? And then S is snoring. So that's a simple tool they can utilize if they want to. In the clinic, it takes no more than three, four, five minutes. It is a starting point to guide them if they need to do more.

Glen Stevens, DO, PhD: Excellent. So I'm going to ask you a selfish question. I have a grandson that will sleepwalk. What's that a sign or a mark of?

Vaishal Shah, MD: So the straightforward sleepwalking, which is typical and not atypical in extensive research, majority of the cases are straightforward. It means they are not related to a specific brain pathology and so forth. There are different stages of sleep such as non-REM and REM sleep. REM means dream sleep. And in non-REM, there's a very deep or actually the deepest phase of sleep called slow wave sleep.

Now in a simple language, I tell parents that if your child has sleep walking, that means when they're to switch between the slow wave sleep, which is a lot more in the first half of the night, that's why sleepwalking happens a lot more in the first half of the night, and they have to switch between those stages. Their brain gets stuck between being half asleep and half awake, and that's exactly the state they're in. That's why you see behaviors of both. It means if you try to interact with them because their brain is sleeping, they may not interact or they may just look at you, glazed it as if they have seen a ghost, or they may try to talk something which doesn't make sense in time and place or sometime push or sometimes have conversation which is completely out of place. But on the other hand, they have behaviors of awake. It means walking is technically when you're awake or trying to move something is technically when you're awake.

So it's that faulty switch where they get stuck in between and so forth. It's called parasomnia. It means events happening in sleep. About 10 to 15% of individual in a lifetime can have at least one episode. One issue with sleepwalking is the dangers associated with it. So if they get into injurious state situations and so forth, that's what we worry the most. So if there are frequent episodes or more than one episode, then there are a number of things we can do about, such as looking at triggers, making sure sufficient sleep and in some cases or in extreme cases, if it is too frequent or injury problems, after doing those, we can provide medication and so forth.

We also counsel parents a lot about safety during this time. The reason many times we have that approach is at least a large number, two-thirds or more, in typical cases without any problems may gradually grow out of it.

Glen Stevens, DO, PhD: Yeah, I was going to ask you that. How many grow out of it?

Vaishal Shah, MD: Yeah. So the latest data is somewhere between 70 to 80, but it depends. The problem is many times, it's too long time period to keep them safe without having an event. So therefore, we try to intervene if there are issues and stuff.

Glen Stevens, DO, PhD: And the old wives' tale was don't wake them up.

Vaishal Shah, MD: Yeah. Oh, no. Yeah.

Glen Stevens, DO, PhD: And is that true?

Vaishal Shah, MD: Yeah. So the reason is because the slow wave of sleep is very, very deep phase of sleep, they cannot come out of it very easily. So if you wake them up and if they're crying, pushing, punching, they can get belligerent or hurt you or hurt themselves without realizing. It's not in their hands.

So instead, what we suggest is during the episode management, first thing absolutely you need to make sure is they're safe. Once you make sure of that, if safety is compromised, you intervene. There is no doubt about that. Then you can ask three simple questions. Tell me your name, tell me my name and point out to something. This is easy test to know whether they're sleepwalking or they're fully awake. If they're not answering appropriately, you know that they're sleepwalking. So in that case, you gently just turn them around, get back to bed. 90% of time, brain cannot stay awake and sleep at the same time so choose to go back to sleep and therefore, they'll fall back asleep.

Glen Stevens, DO, PhD: Fascinating. Risk factors for sleep disorders.

Vaishal Shah, MD: Yeah. So it depends on the type of disorder, but the obstructive sleep apnea, for example, is one of the most common things we see. Number one reason, particularly younger children tends to be large adenoids and tonsils in comparison to adult. We are seeing a lot more with the obesity and excess BMI that the prevalence is increasing there.

Glen Stevens, DO, PhD: Well, in my generation, everybody got their tonsils taken out. Now nobody gets them taken out.

Vaishal Shah, MD: Yeah. So we do this stratification based on what we find in our history examination and sleep studies and so forth.

And then the other risk factor for that particular problem are number of children have either genetic syndrome or craniofacial problems and so forth, which is very common in younger kids. A lot of time, for example, children with Down syndrome, it is known that up to 80% of them can have sleep apnea, variety of degree of sleep apnea with them and so forth.

So those are three broad common risk factor. We are seeing more and more also orthodontic problems in kids which can cause or add to the sleep apnea and so forth. So for sleep apnea, those are the ones.

For insomnia, there could be underlying disorders that may include mood disorders in older children such as depression or anxiety or in younger children, either autism spectrum disorder, ADHD or neurodevelopmental delays. Those are most common risk factors we tend to see. And many times, it's behavioral. It means it is child's behavior but also parent's responses many times can add to the problem. So those are generally common risk factors for insomnia.

And most of the other disorder tends to have de novo. It means they may not have underlying risk factors such as narcolepsy. It is not necessarily a risk factor associated disorder. It may happen to anybody at any time.

Glen Stevens, DO, PhD: And COVID, what did it do to your business?

Vaishal Shah, MD: Oh, boy. So we saw a number of things with that. One, that social context was completely altered, particularly with the children going to school. So particularly in teenagers, we are seeing a lot more that isolated life then increased. Their pattern was completely all over the place because they had online schooling or no timing of schooling. Also, the psychosocial impact of not being in that friendly ... friends and other environment. We saw a lot more mood disorder then leading to insomnia and problems like that.

We actually published a paper on the adult side, and I am working on the pediatric side, and we saw that if there's low oxygen associated with COVID, it may increase your ... and if you have preexisting obstructive sleep apnea on top of that, particularly moderate to severe, it may increase your risk of hospitalization if you have severe COVID and so forth. So that's an overall impact we are seeing.

We are also seeing, particularly in young adults, a lot more tiredness and sleepiness. I don't think we have figured out exact reasons why. Those are the additional issues we are noticing.

Glen Stevens, DO, PhD: And you alluded to it a little bit with some of the screening tools, but tell us about the diagnostic workup and, again, there are different categories of workup that you did.

Vaishal Shah, MD: Yeah. So there are a number of tools either pediatrician or us as a sleep specialist have at our disposal after clinical history and the examination, depending on what you are further looking for. So we have sleep studies, popularly known as that. In medical language, we call them polysomnogram. Poly is multiple. Sonogram, while sleeping, you have multiple channel studies. The most common ones tend to be in lab sleep study, which is utilized quite a bit in pediatric age group, commonly utilized to diagnose or rule out obstructive sleep apnea, and in some cases, either atypical parasomnias or if you're not sure whether child has periodic limb movement associated with restless leg or other and so forth.

The other type of tools we have are daytime sleep test called multiple sleep latency or nap test or similar testing, which is done to evaluate for sleepiness disorder. That may include narcolepsy or idiopathic hypersomnia commonly.

There are variable devices, either medical grade, what we call actigraphy, and there are commercial variable devices, some are gradually improving quality to get to that route. The actigraphy is what we call a wrist monitor. It's an activity monitor. Depending on the device, it may have different sensors in that, but it helps us measure rest period versus awake period, and indirectly helps us measure your sleep wave pattern, which is utilized many time in patients with circadian rhythm or body clock problem or prior to the MSLT or narcolepsy, our center actually performs actigraphy on all the patients to make sure that they don't have insufficient sleep or their body clock is not disrupted. Then simple sleep clocks many times we use for patients with insomnia to understand their sleep pattern, how good or bad their sleep is. So there are a broad range of tools we have at the moment at our disposal.

Glen Stevens, DO, PhD: And like a lot of things, because there's different causes, it sometimes takes a village to look after these people. Who's involved with managing patients, psychiatrists, psychologists, behavioral problems, hypersomnias, the insomnias?

Vaishal Shah, MD: Yeah. So most commonly for obstructive sleep apnea, commonly from a sleep standpoint, the sleep disorder specialist and ENT is most common collaboration. Many times, we collaborate with other providers that may include the obesity management clinic, the pulmonary providers if they have combined problems and so forth. Sometimes even we have sent patients to our orthodontic or dental provider and so forth. So many times, their medical home for sleep disorders with us but then we are collaborating with those. For insomnia or circadian rhythm, several times, we work with the psychologists and they are trained in what we call behavioral sleep medicine or advanced trained psychologist to provide lots of therapy-based services. Many times, depending on reason for insomnia or body clock problems such as mood disorder, we'll collaborate with our psychiatric team or outside providers if need be. But those are typically most common collaborations we have to help kids.

Glen Stevens, DO, PhD: And for children, how old, and again, I'm sure there's variability, but in order to utilize the CPAP, how old, what's the age?

Vaishal Shah, MD: Yeah. So the FDA has approved it about seven years or 40 pounds. However, the American Academy of Sleep Medicine came up with a very recent statement that it is potentially safe in younger kids even though it may not be tested. So many times, we can use it as young as a young infant to typically above one years of age and so forth. However, it depends really on a lot of factors, including whether the patient can tolerate it or not. In younger kids, getting family help, they need to be able to improve their tolerance because it's many times not easy.

Glen Stevens, DO, PhD: Yeah, I think it would be very difficult. Right?

Vaishal Shah, MD: Yeah. So the CPAP could be utilized in all ages, but younger the kids are, a little bit more difficult. Once we get to older ages, we have easier times working with them on tolerance.

Glen Stevens, DO, PhD: And what percentage of teenagers with OSA are getting tonsils and adenoids taken out now, do you know?

Vaishal Shah, MD: Yeah. So actually, tonsils and adenoids is a lot more effective in younger kids, generally up to about eight to 10 years of age and non-obese patient. So in adolescent, we are seeing combination of problem, and particularly obesity is quite a bit high at the moment. So in younger kids, that's the first line treatment. However, in older kids, we many times utilize multimodal approach and adenotonsillectomy could be part of that. It may not be the only or always the first line treatment. That depends on the patient's physiology, including, as I mentioned, the obesity or not obesity.

Glen Stevens, DO, PhD: And is there a guideline that if you lost 10% of your body mass, it will get rid of 50% of sleep apnea or something? Does something like that exist or no?

Vaishal Shah, MD: There are some concrete data in adults. In pediatric, in adolescent, we have two or three papers, not guideline. There is no one specific number. However, we have seen correlation between the degree of weight loss and a degree of reduction in obstructive sleep apnea. So higher the weight loss you have, you may have a higher degree of improvement in that, but there is no specific yet numbers about that.

Glen Stevens, DO, PhD: Yeah. I was thinking if you could lose 10%, that would be something that maybe people could manage. If you tell them you got to lose a hundred pounds, they're going to go, well, it's tougher.

Vaishal Shah, MD: Yeah. So in adults, approximately 10%, there are certain data. And there is a range, so each individual responds differently, but approximately 25% less chance of sleep apnea. But in kids, we don't have a clear data on that.

Glen Stevens, DO, PhD: Well, there's no question I'd send my patients to you right away, but when should someone send them to a sleep specialist?

Vaishal Shah, MD: Yeah. So first, if you have any of those symptoms and if you're comfortable at least doing some of the initial evaluation and treatment, a number of providers out there are comfortable, then go ahead and do so. And if you're not making headway, certainly should send them. However, if you're not comfortable to begin with, we're always here to help from the beginning. So if you're seeing those problems, as I mentioned, can't fall asleep, can't stay asleep, hard to wake up, too sleepy, the nighttime events like parasomnias, unexplained events, snoring or daytime problems, including attention issues and you think sleep disorder might be causing those issues and so forth, those are the times you want to consider sending the patient.

Glen Stevens, DO, PhD: So it would be okay for me to order a sleep study if patients are having those issues?

Vaishal Shah, MD: At least at Cleveland Clinic, we are an open lab system. It means if a provider is comfortable and confident then they can order a sleep study and opt in it without needing a sleep consult.

Glen Stevens, DO, PhD: Do you do the home sleep studies in children or no?

Vaishal Shah, MD: No. There were and there are attempts to validate in children, but we have not been able to generate equivalent results as in lab sleep study, and there's quite a bit difference so we haven't been able to validate it. So we are not there yet.

Glen Stevens, DO, PhD: And I see the commercials on TV for surgical devices that affect tongue movement, those types of things. What's the age for that?

Vaishal Shah, MD: Yeah. So I actually lead the hypoglossal nerve stimulator program besides the pediatric sleep operation. So it just very recently got FDA approved for 13 years and above, but only for children with Down syndrome, and there are specific criteria for that to be candidate. It was already approved for 18 years and above for any patient but with specific candidate criteria for that. So it's an implant, which in a simple language, it's a nerve stimulator. So the nerve which supplies the muscle of the tongue, it stimulates that at night and therefore, it moves your tongue forward with each breath you take, instead of tongue collapsing backwards, and that's why it opens up the airway and that's how it treats obstructive sleep apnea.

Glen Stevens, DO, PhD: Are there any surgical procedures to make the tongue smaller or is that not possible?

Vaishal Shah, MD: No, there are. Actually, the multilevel surgeries are many times we have to utilize in patient who are refractory to other treatment. Most common example is children with Down syndrome or Beckwith-Wiedemann or certain other genetic syndrome and so forth. So those surgeries may include reduction in the tongue size or trimming the palate called palatoplasty or uvulopalatoplasty. Sometimes, there are second set of tonsils behind the tongue called lingual tonsils. Sometimes, you're having those help. Or if they have laryngomalacia, it means floppy voice box, then treating that can help.

So each individual patient, if they need additional surgeries beyond adenoids, tonsils or CPAP or other treatment, then it's evaluated by eye, ear, nose, throat doctor either in office or with something called drug-induced sleep endoscopy; it means in their operation room with sleep medication or sedating medication. They look at what level and what degree of collapse there, and whether to go for tongue reduction or other type of surgery is determined by that. The success is less compared to adenoids and tonsils and CPAP, however, many patients may not have other options or they may need those kind of surgery in order to improve their sleep.

Glen Stevens, DO, PhD: So you mentioned you're also leading some of the surgically based trials with tongue movement, those types of things. Other there things on the horizon?

Vaishal Shah, MD: Specifically for kids, so certainly the hypoglossal nerve stimulator, our hope is there are early encouraging results. It's a process. It's not something as simple as adenotonsillectomy. It takes time to get there. Within that technology, there are more advances coming, and our hope is it may also, at some point in the next few years, it may become available to more children who do not have Down syndrome and so forth. We don't know whether it's going to be available yet to younger patients or not. That's certainly coming.

In adults, there are bilateral stimulation or different type of technology coming out. There are other experimental treatments such as negative pressure devices in adults and/or just inside the mouth, stimulation and so forth but they're very, very early phase. So it may take a few years before that technology materializes.

Glen Stevens, DO, PhD: Should we throw the kid's cellphones away?

Vaishal Shah, MD: So I still joke that in this generation, the younger kids before they get potty-trained, they get cellphone-trained because even my child knew how to look at his picture before he learned to be potty-trained. Cellphones or electronics have been part of our life, and I don't know if we can completely get rid of them and so forth. However, a judicious controlled use for positive purposes is probably the best way forward and so forth. Sometimes, it's a battle between autonomy of the child, how much they can do it by themselves versus a parent and trying to help them and so forth. But as long as they can come to the terms with what is best for the kid's health, that includes sleep, I think that's the best way for it. I don't think so we'll be able to get rid of completely technology because it has upside too.

Glen Stevens, DO, PhD: Well, I know they talk about different lights, blue light and this light and maybe the answer is just you shouldn't be having your phone. You shouldn't be looking at your phone regardless when you're trying to sleep.

Vaishal Shah, MD: So generally, minimum recommendation is 30 to 60 minutes before. Think of it this way, that when you wake up, why don't we just jump in the car and go to work? Our brain needs a little bit time to get ready and get to work more and so forth. So we allow that time in the morning like we may brush, shower, breakfast, other things. Many times, in this wired world, we are on our electronics and then this hope that brain will right away turn off, that switch and shut down. So we forget that it needs buffer to wind down also. So therefore, a buffer zone where you don't have electronics for 30 to 60 minutes, staying in a quiet, dark area or having relaxing or really boring activity, which can then promote you feeling sleepy and fall asleep is the best possible way.

Glen Stevens, DO, PhD: And resources for providers out there, do you have any that you can share?

Vaishal Shah, MD: Yeah, there are a number of them. One of my favorite website is babysleep.com. It's actually developed by sleep providers and parents combined, including sleep doctors, the behavioral sleep health providers and so forth. It nicely gives you idea about at what age, how much sleep you need, nice, good basic techniques on how to help kids learn to sleep, but also some of the troubleshooting.

There are a number of resources on our website. Also, healthychildren.org is there. Dr. Richard Ferber's book is one of my personal favorite. He talks about solving your child's sleep problems. There are a couple of other ones out there, more so for providers, from Dr. Judith Owens for primary care provider, nicely described basic things they can do, very practical in their clinic and so forth. And there is a behavioral sleep book also and so forth. So there are a number of those out there. But for parents, the first few, the ones that I mentioned are probably the best tool.

Glen Stevens, DO, PhD: So any final words of advice for our listeners out there?

Vaishal Shah, MD: Final words are that in my opinion, I think sleep is the best medicine. Why? Because everybody sleeps and it's free and it doesn't require prior authorization to sleep. So therefore, please, please pay attention. If you think about it, a third of our day we spend sleeping, but that's the first one we sacrifice the most when other commitments arise. But that might be the most important one to be able to take and so forth. So please make sure you make sleep as one of the most important part of your life and don't sacrifice on that.

Glen Stevens, DO, PhD: Well, Dr. Shah, thank you very much for joining me today. It's been a very insightful conversation and I really appreciate your time and getting to know you a little better.

Vaishal Shah, MD: Thank you so much for inviting me.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening