Transcription:
Understanding Pediatric Sleep Norms and Problems

Trisha Williams: Hi, guys. Welcome to the third season of the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien: I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look of the various advanced practice roles at Children's Mercy.

Trisha Williams: We are so glad that you're joining us today. So sit back, tune in, and let's get started. Today, we are pleased to have Kristy Mohn with us. She is a family nurse practitioner who specializes in pediatric sleep at Children's Mercy. Welcome to the podcast, Kristy.

Kristy Mohn: Hi, guys. Thanks for having me.

Trisha Williams: You're so welcome. Tell us a little bit about yourself.

Kristy Mohn: So, I have been in the sleep clinic at Children's for almost five years. It'll be five years in January. And previously to that, I worked as a practitioner in ENT for two and a half years, and a practitioner in Asthma and Allergy for about six years. Prior to that, I was a nurse in the hospital for 11 years.

Trisha Williams: Okay. Has all of your career been at Children's Mercy?

Kristy Mohn: No, I have only been at Children's for the last five years. I was in private practice clinics with allergy and asthma and ENT, and then I worked at another large hospital in the city when I was on the floor.

Tobie O'Brien: We are so pleased to have you. We have something in common. I don't know if you knew this about Trisha and I, but we both are in the ENT clinic. I'm sure you see referrals from us constantly. You see all of our sleep kids that we need you to see. But we are excited to talk sleep with you today.

Will you kind of start us off by talking about sleep and really the importance of sleep? I mean, it's such a funny thing. We know it's so important and yet it can be so complex and people have so much trouble with it, and it's such a struggle sometimes for families and pediatricians and anyone working with kids knows how sleep can sometimes be a struggle. So, I wonder if you can talk a little bit about the importance of sleep.

Kristy Mohn: Sure. Sleep is important, obviously, from infancy until older age. As parents, it can be extremely stressful, not only when kids aren't sleeping, but then also that impacts other kids in the house and parents. As young, young children, we're growing and developing and if we're not getting the sleep we need, it can impact behavior at school as well as just the ability to grow. And then same, as we get older in the teen years, it becomes extremely important for these kids to get adequate sleep in order to continue to develop and function in school. But I think one thing to mention that I don't think people think about often is just the impact of lack of sleep that we see in any age child has a pretty phenomenal impact in the family dynamics, just causing a lot of stress and anxiety with parents and sometimes siblings if there is a child in the home that is not sleeping well.

Trisha Williams: That is a new concept for me. I'm just having this huge aha moment about the family stressors that is something definitely to keep in mind. I would also really like to know some tips and tricks or whatnot about best sleep practice. We talk a lot about sleep hygiene and things to that nature. What are some things that you can shed some light on in that?

Kristy Mohn: Yeah. So, sleep hygiene is probably the number one thing to think about with kids of any age. I use that term lightly, you know, down to very young toddlers to teenagers. No matter really what else is going on with sleep, whether there is a behavioral concern, underlying diagnosis such as like ADHD or autism that can impact a child's ability to get to sleep at night or a child has CPAP and they're using that at night to help them breathe, their sleep hygiene is also very imperative. And so, I think one thing is no matter what else is going on, knowing that that can impact the child's both ability to get to sleep and stay asleep.

And it starts when they're really young and I think that one thing that is kind of important, and we try to stress this in the sleep clinic, but it's the importance of routine. So, I would say that routine is the probably number one thing with sleep hygiene with kids. Kids thrive on routine and, without it, things start to kind of go amok. And so, routine could include both just the routine of bedtime, whatever that is, bath, books, whatnot. But also, just the consistency in providing a good environment for kids to sleep in. But also, families need to be consistent with those environments for both young children and teenagers.

Tobie O'Brien: Oh, for sure. A strict routine. And what do you guys say about screens? How much do you think that plays a part? I just feel like screens are everywhere now. I mean, people even have them in their rooms as their alarm clocks and such. So, I'm wondering if that is affecting kids more than it used to, just because there's so many more screens than there used to be.

Kristy Mohn: Yeah, definitely. I think that it's just an ongoing and never ending stressor for both kids and adults, and it impacts all of us. It's probably the last thing most of us look at before we go to bed at night. Kind of the generic recommendation is really no screens in the bedroom would be ideal. We definitely don't like to see kids have TVs, video games, things like that in their bedroom, just because a lot of times parents aren't even aware with those older kids how much time they're spending on them. They're kind of shocked sometimes when they come to clinic and they're honest with us that, "Yeah, I'm up 'til midnight or one o'clock playing video games." So, kind of a generic recommendation is 30 to 60 minutes before bedtime, we would like kids to avoid screen time. It's not just the blue light, it's also just the brain process. It kind of can get you revved up. It can make it harder to shut things down. And so, trying to avoid whether it's iPad, a calming video that families watch with kids to help them relax before bed. We try to suggest different things that can be actually more relaxing for the brain, like reading books or listening to calming music. And the kids that have the phones in the room for alarm clocks, the suggestion I try to give is keep it across the room so that you're not looking at it or flipping it. But I honestly really try, even teenagers, I just suggest get the phone out of the room. Don't leave it in there at night. Go put it in a safe spot, parent's room, kitchen so that they don't have access to it to be distracting, whether it's beginning of the night or in the middle of the night.

Trisha Williams: I heard a wives' tale, I think, I don't know, a few years ago that the rule used to be two hours before bed. I think it's more realistic now to say an hour before bed or something to that nature for screen time. But I always thought that it was related to the blue light and like it stops the body's natural ability to secrete melatonin. So, it's interesting, you're also right, like the brain punching, your brain needs to calm down and settle down before sleep, but so it's multifactorial is what I'm hearing from you, correct?

Kristy Mohn: Yes. It's not just that light that can be stimulating, but it's just when you're watching something, whether it's a YouTube video, you just kind of get caught up in it. And so, you can kind of go down that rabbit hole of your thoughts are just kind of following with it or it's just very stimulating to that brain. And so, trying to keep that distanced from when you are laying down to go to sleep is ideal. And I will say, you can't make a blanket statement that fits everyone. There are certain situations where it may be the best environment for them to watch a very short video or something, and so I don't want to a hundred percent say that's always the recommendation, but it's definitely not what we would like to see on a regular basis with

Tobie O'Brien: Right.

Trisha Williams: Sure. So, I have one more question about sleep hygiene, just because it's so interesting to me because I have two teenagers and they're both very different sleepers and have always been very different. But we did things differently when they were very young. My first child, we went through a lot of trials and tribulations to get her. I had a lot of postpartum depression, so I held her all the time. My son, we had 20 months later and you all know we don't have time to like-- we need that kid to sleep. So, we learned a lot and grew from that experience. And so, my daughter at the age of 18 is still a terrible sleeper. My son is an amazing sleeper. He goes to bed at 10:00, 10:30. He wakes up ready to go in the morning. And so, is there research supporting this? What are your thoughts on establishing an early sleep pattern so that they have a lifelong history of good sleep? Does that make sense?

Kristy Mohn: Yeah. I get what you're asking. And I think that it's a very common thing, that families struggle with. Every kiddo is different. And even if you did the same thing with each one, they would've reacted probably differently to whatever environment you created. And so, it's that initial kind of routine and setting up a good environment to help them thrive. It doesn't mean it's always going to work with each kiddo. And the research, probably half of it would tell you that yes, it's those initial days and what you do with routine that's going to set them up. Others are going to say, it's more internal and that there's things that you can impact, but more it's their body's response to how they're growing. So, I don't know that there's like a really good answer to why some kids have different kind of tendencies towards sleep. But I will say the sooner we can get kids to be independent in falling asleep on their own, that is the big thing.

So, we have both kind of with sleep hygiene, I guess we can kind of transition a little to talk about falling to sleep on your own versus like night awakenings. And so, we kind of try to focus on if kids are struggling both with falling to sleep on their own and then needing somebody if they wake up at night, we focus on that independency and getting to sleep on their own. And so, I think that that's something that sometimes, whether it's a colicky baby or you're just in a situation where you have the ability to hold them and cuddle them and you don't realize that you're maybe causing some long-term concerns with their sleep. I think establishing that independence and falling to sleep on their own without somebody holding them until they're asleep, it does truly impact kind of going forward their ability to get to sleep, initiate sleep, but also maintain sleep. I don't know, had you done something differently with your daughter that she'd be much better sleeper? But I do think that it does impact their sleep for years to come on how it's handled when they're super young.

Trisha Williams: The old saying of self-soothe and being able to self-soothe and you know that you're okay, I guess. Correct?

Kristy Mohn: Exactly. Yeah. And that's the hard thing. We kind of try to let parents know, like they're safe, but it's a hard thing. Not every parent can handle that cry-it-out type of environment in the same way. And so, we do have a great sleep psychologist in our department, but if a family's really struggling with some of those kind of hygiene, more behavioral things, that we will refer them to him to help with much more specific kind of ongoing support in that. And there are a lot of kids that have medical reasons. You can't let them just like cry it out and it can impact other health concerns that they might have. But definitely, in a healthy child letting them kind of figure out how to get to sleep on their own and reassuring the family, they're okay, this is temporary, this will pass, it can be hard because a lot of families or parents don't want to let their child cry. So, it can be difficult to say, "It's okay. We're going to get you through it."

Tobie O'Brien: Absolutely. I think that we're so lucky to have a sleep clinic that we can send our kids to and outside PCPs or internal PCPs, people can send their kids to talk with you just because we can tell them routine, no screens, they need to fall asleep on their own, but ultimately sometimes it takes just coming in to seeing you and talking with you in more in depth, just because you can kind of dive in deeper to all of those questions that maybe other people kind of aren't quite as in tune with. Can you talk a little bit about the kids that come to see you in sleep clinic and what types of kids are typically referred to you? And if maybe, you know, someone out there in our area that refers to or would consider referring to the sleep clinic, like what are kids that you think are really great candidates to come in and visit with you?

Kristy Mohn: Yeah. So, we obviously receive a lot of kiddos that have insomnia is a big one, and that can be a very generic term. And then, we also have the snoring, breathing-related sleep disorder, potential sleep apnea type of kids. Insomnia, I would say is probably one of the biggest things that we see, and that obviously can include a kiddo that has trouble falling to sleep or trouble staying asleep, whether that is a three-year-old that can't sleep without a parent or a 17-year-old that lays awake for hours, the brain won't shut down. So, it can be a very broad type of referral that we get. And obviously, we have to kind of look at are there any medical things going on? Are they restless? Do we need to check a ferritin level? And that can be sleep 101. I think, for us, it's looking at is there something that's making it hard for them to relax and get comfortable and fall asleep or stay asleep. And then also, are there breathing concerns? Usually, families are aware with young children especially, if there's concerns about snoring or gasping, things like that at night, that may indicate they need a sleep study to further evaluate why they're having trouble with their sleep, which may be that they're coming in because they're having daytime fatigue due to poor quality of sleep. So, I would say that a majority of the kiddos that come into us, it's kind of in the lanes of either like insomnia or a breathing concern or question.

Trisha Williams: Can you expand a little bit on for our listeners that maybe not know why ferritin, low ferritin is related to sleep issues?

Kristy Mohn: Yeah, sure. And it's something that's kind of fascinating to me. There is a lot of research that supports ferritin with sleep. And so, it's hard because there are times where you have people ask about like magnesium and sleep and there's not a lot of research that really gives us data on that. But we have good data that supports ferritin, which ferritin are the iron stores. So if ferritin level is I call it low for sleep, so their ferritin level is almost always medically normal. So, there's a big difference between what is medically normal, which means that you have adequate iron in your diet or you're processing your iron, there's no concern for underlying absorption issues, things like that, there's a level for that. And then, we have a much higher level, but we like to see if there are sleep concerns.

So if somebody comes to us and they're complaining that they're restless at night, their legs bother them when they try to fall asleep or they're kicking their sheets off throughout the night or they're getting adequate sleep, but they're still tired in the morning, one of the first things that we recommend is checking a ferritin level. And so, if that ferritin level is lower, then starting an iron supplement can push that level up. And like I said, it's a much higher threshold than what is considered medically normal. So, it's again not an absorption issue, not an underlying health concern. It's truly related to what we're seeing with sleep. If we can push that level up, we will usually see an improvement in the restlessness at night, the trouble getting comfortable, trouble falling to sleep, and sometimes those night awakenings. The ferritin level can also sometimes impact the kiddos having night terrors or episodes of sleepwalking, those can all be connected to that ferritin level. And ferritin, it binds with chemicals in the brain. And so, if we can get that level up, it can help kind of calm some of those types of nighttime behaviors.

Trisha Williams: It's interesting that it's related to sleep walking and talking in your sleep, that's the night terrors. That's interesting. So, it binds with dopamine, correct?

Kristy Mohn: Binds with dopamine. Exactly.

Trisha Williams: Okay. Perfect.

Tobie O'Brien: So, this is kind of a funny story, but recently a colleague of mine, her daughter had a sleep study. And we send kids all the time to you and then sometimes we refer them directly to get a sleep study. But I've never been in the sleep lab to see what happens. I've seen some videos and stuff. But my colleague showed me pictures of her daughter getting ready for the sleep study and we were just giggling because I don't think I realized I definitely haven't prepared my patients that I send over there for what to expect probably as well as I could have. So, will you talk a little bit about what a kiddo could expect or family might expect if they did get a sleep study?

Kristy Mohn: Sure. So, one thing I kind of would want to say also is just because you get referred to the sleep clinic does not mean that your child is going to need a sleep study. I feel like that's one expectation that can be either just perceived as part of getting referred to the sleep clinic or that's just kind of how it's presented to you, that you're going to go get a sleep study. But being seen in the sleep clinic is truly for an evaluation to see what we can do to help sleep, but also to see if you need a sleep study. So, I would just kind of want families to know just being seen in our clinic does not mean that your child 100% needs a sleep study. That's kind of why you're seeing us first, is to decide if that's needed.

That being said, our sleep lab is in Overland Park. So another thing, a lot of families just assume it's down in the Adele main campus, but we do our sleep studies on the Kansas side. And there is a great two-minute video. It's on the Children's website, so you can go to childrensmercy.org and put in sleep lab and there is a video of a kiddo getting set up for a study in our sleep lab. So that way, families, I always tell parents, watch it first. If you feel like it would be helpful for your child to see it, let them watch, but sometimes it can stress kids out. So, I want families to watch it first to see kind of what they think. But the night of the sleep study, I always tell kids there's no needles, there's no pokes. There's a lot of stickers and wires. And so, it takes about 45 minutes for the setup from the time they get there until they get them kind of ready for bed. Kids can wear their own pajamas. They don't have to wear a gown. They can bring their own pillow blanket, stuffed animal, whatever they like to have with them. Kids have their own bed to sleep in or a crib if it's a small child. We try to let the families have much of a normal routine as they would at home. So if families read to them, they can bring those books in, they can kind of do that. But we do want to try to make sure that we're utilizing the time in the sleep lab to get the adequate sleep that we need to see on the study for the evaluation that we are looking for.

So they come in, they get taken to the room and they get their stickers and wires on the head, on the chest, a couple on the legs. They do have a little kind of probe. Actually, it looks like an oxygen tubing that goes under the nose that has just a little monitor there. It's not going to be blowing anything on them, it's measuring their breathing out. They also have a couple little Velcro belts that go around their ribs and their tummy. So, they do have a lot of cords and wires, but they are still able to move and roll around in their bed. There's a bathroom in their room. If they need to get up at night, then they are able to do that. So, I always try to tell kids like you can still move. You, you know, don't feel like you have to lay still. They try to keep kids on a same sleep schedule that they are on at home. So, they try to have kids come in about an hour or so before their normal bedtime to accommodate that routine. Obviously, if a teenager's going to bed at midnight or one, we try to get that set back before they come in to let them know we need you to get to bed sooner.

So then, once we get them set up, then they're not going to have a technician in there with them all night. But the person may come in to adjust equipment or reposition the child with the parents in the room with the kiddo all night. And then, they come back in about 6:00 in the morning, you know, get them all unhooked and send them home. And then, it generally takes within two weeks usually, the physicians have analyzed that data and then we are getting in touch with the families to let them know the results and recommendations based on those findings.

Tobie O'Brien: Fantastic. So, kind of takeaway for people listening in is really sending them to you guys first in the clinic is probably going to be best. You can really take inventory of everything that's going on and then decide if a sleep study's even worthwhile or what information it would yield if it would be beneficial. And I love hearing you describe it. I think you did a great job describing it. And so, I think that's really helpful for people referring to sleep or for providers having kiddos that they think are having sleep issues, kind of understanding what is involved with the sleep study, I think is super helpful. So, thanks for going into that.

Trisha Williams: Sure. So for us non-sleep people, there's people from all different types of subspecialties that listen in to our podcast and like to take away little helpful practice tips. And we know that sleep affects every part of our physical health. So for us, non-sleep advanced practice providers, what are like some best advice that you can give us to incorporate in what we do to educate our families regarding sleep?

Kristy Mohn: I think the main thing is sometimes letting families know that just because their child doesn't follow textbook doesn't mean there's anything wrong. And so, if kids aren't napping as babies, if they're not napping the two hours in the morning, two hours in afternoon, and then, sleeping through the night by six months, it doesn't mean there's anything wrong. But also, just kind of looking at the bigger picture of-- I think the main thing is truly getting an idea of what is their sleep hygiene. So, it's hard for somebody outside of sleep to get kind of in the nitty gritty of what may be causing some of their concerns.

But I think, from somebody on the outside, a parent likes to think they know what's going on with their kid, especially any age, we all want to think that we know what is going on with our kids, even with sleep. We do know as they get older, we're not necessarily in the room. You know, I don't know necessarily that my kiddo's snoring at night because I'm not in there with them all night. But just being present in knowing kind of, "Is my kid really up playing video games 'til the middle of the night?" Because if they come to us and it's for daytime fatigue and then we start asking questions and find out the kid's sleeping five hours at night, yeah, that's a good reason to be tired during the day. So, maybe just kind of looking a little bit deeper into kind of what's the routine, what's going on, what else could be causing that fatigue or the trouble sleeping and getting a little bit into what is truly bedtime. Not what time are you getting in bed to lay down, what time are you shutting things down to go to sleep? So, those are just a couple things that I think anybody, even a parent, could maybe do a better job of if they feel like their kiddo is struggling with.

Being tired, I think that's the biggest thing as kids get older is that daytime fatigue and it's something that anybody in or out of sleep can kind of look at, "Okay, why are they tired?" We make it almost impossible for teenagers to get the recommended sleep that they need, which I think is an important thing to also say. You know, teenagers should be getting eight to nine hours of sleep at night when they have to be at school by 7:00 and they're in activities all evening. It's hard. We don't create a great environment for them, but doing what we can to help them try to obtain that sleep, and just being aware of kind of what they're really doing at night is something anybody could be looking at.

Tobie O'Brien: And it is funny because they have all these activities at night and it's like activities are okay to go later for these older kids, but yet they start school before everybody else. So it's always been, I think, a challenge to kind of figure out and protect that for them because they do need their sleep. And I think we just kind of forget and let them go do their thing. And then, before you know it, they're exhausted during the day and we're like, "Why? Why are they tired?" But yeah, kind of tuning into that and try and possibly as a parent or provider to kind of remember to attempt to protect that time for those kids because they don't want to protect that time for themselves, do they?

Kristy Mohn: Right. Nobody wants to miss out on activities and nobody wants to be the parent that, I mean, my kids have always told me, "So and so can stay out later than me," and they know better than to really talk back about stuff because it's not going to change how I handle it. But we just never let our teenagers put-- They always have their phones in our room at night. My 17-year-old still puts their phone in my room at night. It's not a trust issue, it's not a punishment. It's me being a parent and protecting that environment, that hygiene part of it.

And the other thing too, don't let your teenager take a job that keeps them at work until 11:00 on a school night. Things like that are just really-- I mean, sometimes you don't have a choice, they need to work, but just trying to protect that and being the parent and calling this like, we need to find something else that we can do to help them. Because yeah, it's hard. The kids are definitely going to make choices based on what they want versus what they need.

Trisha Williams: Because that frontal lobe's not developed yet, right? So that's why they have parents.

Kristy Mohn: Right.

Trisha Williams: So Kristy, we really appreciate your time and your expertise today. It's been very enlightening and informational and we love to hear from you.

We really like to kind of end each episode with the same question. And this season's question is in what way do you love to encourage your colleagues? But we do know you are the only advanced practice provider in the sleep clinic, so we can kind of change the question if you would like to tailor that. But you do also have colleagues in your clinic. You have physician colleagues and RN colleagues and care assistants and things to that nature. So, do you want to answer that question or do you want us to give you a new one?

Kristy Mohn: No. I mean, I think that if you're in the exact same role as someone, or you're just collaborating with someone, I think just especially the physicians in my practice, I'm collaborating with them constantly and they are just amazing people and providers. And I think that trying to just remind them how much they're appreciated and just telling them how much I love working with them, because I truly do. I've never been in a job where I truly respect and love the providers that I work for and just letting them know how much they're appreciated and just kind of having fun with them too, just kind of getting personal with them, you know, asking about their families and just kind of reminding everybody like why are we doing this and that we are making a difference. And even there's a social worker that I work pretty closely with and she's just phenomenal.

And I think just saying thank you and just saying how much you appreciate somebody really goes a long way. I think just showing some appreciation is a great way to support people, whether it's just a quick note or even just saying thank you. But I do work with a phenomenal team. The nurses, even the care system. And when I'm at college, which is where I'm in clinic, I just have great people that I work with. So just letting them know how much I appreciate their help, because I couldn't see these patients without them. So, it takes the whole team in order to make this work. And I'm grateful, is really the word that I would describe that I am to have this ability to work in this clinic.

Tobie O'Brien: I love that.

Trisha Williams: Gratitude goes a long way. I love it.

Tobie O'Brien: Absolutely. Yeah, I love hearing you talk about your team, and it's so fantastic to work in an environment that you love the physician providers and the nurses that you work with and CAs. I'm so happy to hear that. So, I love ending on that positive note. So thank you again, Kristy, for joining us.

And to all of our listeners, thank you so much for listening in. If you have a topic that you would like hear about, or if you yourself would like to be a guest on our podcast, please email us at tdobrien@cmh.edu or twilliams@cmh.edu. And once again, thanks so much for listening to the Advanced Practice Perspectives podcast.