Caitlin Whyte (Host): Welcome to Children's Health Checkup, where we answer parents' most common questions about raising healthy and happy kids. I'm Caitlin Whyte, and with me today is Dr. Michelle Caraballo, a Pediatric Pulmonologist and Sleep Medicine Specialist at Children's Health. Today we're talking all about how iron affects sleep in kids, exploring the signs, symptoms, and solutions for parents who may be facing restless kids.

So doctor, how does iron impact sleep in children?

Michelle Caraballo, MD: Iron has been shown to primarily impact sleep through a child's restfulness, and so low iron stores are associated with restless sleep and restless leg syndrome in both kids and adults actually.

Host: And what are some signs or symptoms that might suggest a child's sleep problems are linked to low iron?

Michelle Caraballo, MD: So we're looking for, like I said, restless sleep, and that comes in a variety of complaints. Some parents will say their kids toss and turn a lot or kick their legs in sleep, or they wake up in the morning and their sheets are tangled or in a wad because they've been moving around so much throughout the night.

Some kids will complain of their legs bothering them, but it's very uncommon for children to say, I can't sleep because my legs are restless,  just because they lack that vocabulary. So sometimes we'll have kids use a variety of other colorful terms to describe this sensation of restlessness, like sometimes it's a sensation of a creepy crawly feeling or an itchy sensation in my legs, and some kids will actually report pain. And restless sleep and restless leg syndrome typically isn't actually a painful condition, but sometimes they'll say my legs hurt for kind of lack of other vocabulary to describe the sensation of an urge to move their legs.

Host: And just how common is low iron as a cause of sleep disturbances in kids?

Michelle Caraballo, MD: Well, we see it very commonly in the sleep clinic. The iron-rich foods that adults are more likely to eat, include green leafy vegetables like spinach and broccoli and red meat, and most kids' diets are not rich in iron. And so almost every time I check an iron level, it's usually low in kids.

Rarely do I find that it's in the range that we target for the treatment and the management of restless sleep.

Some kids with restless sleep or restless leg syndrome will present with these nighttime complaints, but some kids actually present with more daytime manifestations of poor sleep, like sleepiness in school, ADHD type symptoms like hyperactivity, irritability, difficulty focusing or paying attention in class. Sometimes mood disturbances and disorders and behavior problems. So we see restless sleep manifest both with the nighttime complaints, but also the daytime complaints, which are the consequences of poor sleep at night.

Host: And when should parents ask their pediatrician about testing their child's iron levels?

Michelle Caraballo, MD: Well, I would say anytime a parent is worried about their child's sleep, of course it's appropriate to bring that up to your pediatrician regardless of how small you think the concern might be. It's always worth bringing them up. But specifically if you're seeing your child toss and turn a lot in their sleep and it seems to affect the quality of their sleep to where they're just not well rested during the day, they don't seem to be getting that restorative benefit from sleep that they need; I think it's appropriate to bring that up to your pediatrician and mention checking the iron levels. The specific test that we usually order is called ferritin, which is a marker of iron stores in the blood.

It's worth pointing out that the levels that we target for the treatment of restless sleep in kids is much higher than what's considered normal according to laboratory standards. So sometimes we will have kids or have parents that say my pediatrician checked his iron level and it was fine, but it's still, even though it's normal, according to the laboratory standard, it's still lower than what we would target for the treatment of restless sleep.

So ferritin is the test that we check and usually levels below 50, we would put a child on an iron supplement if they have restless sleep that's impacting the quality of their sleep.

Host: So we go through the testing. Our child does have low iron. What are the safe and effective treatment options? You mentioned supplements. Let's get more into that and anything else that could help.

Michelle Caraballo, MD: Ferous sulfate is the most common iron supplement, and it's at a much higher dose of iron than what a child would get, for example, in a multivitamin with iron. So some families who are reluctant to put kids on iron will instead try to use a multivitamin with iron or maybe introduce more iron rich foods into their child's diet, and that's all perfectly fine to try.

But honestly, we need higher doses typically, if we're trying to get that iron level up into a higher range for the treatment of restless sleep. There are other treatments available for restless sleep, but in kids whose iron levels are low, first line therapy is considered iron supplementation, so we generally would try that first before we would consider other prescription medications for restless sleep.

Host: Are there any other conditions that mimic the issues caused by low iron? And how do doctors tell the difference?

Michelle Caraballo, MD: Well, any type of sleep disturbance or sleep disruption can manifest with those daytime symptoms of poor sleep. Breathing issues like sleep apnea or if the child's oxygen levels are low at night, or honestly, if they're just not getting enough sleep, those can all present with similar daytime symptoms of trouble in school, trouble focusing, difficulties with learning, or maybe declining grades and sometimes behavior problems.

So really, the daytime manifestations are pretty similar regardless of what the cause of the sleep disturbance is. Now if the cause is something more like sleep apnea, we would expect the parent to notice snoring. Sometimes they would notice their child pausing in breathing or gasping for air at night.

So if those symptoms aren't there and the child is breathing very comfortably and really the main concern is that they're tossing and turning and kicking their legs a lot, that would lead us more down the path towards checking the iron levels and treating with iron supplementation. But I will say, some kids just toss and turn and move a lot, and if it doesn't seem to disrupt the quality of their sleep and it's not bothering the child, I don't necessarily put them on iron in that case, if the restlessness is just there but not bothering them, if that makes sense.

But if the parent feels that it really is disturbing the quality of their sleep, they're not getting into those deep, restful stages of sleep because of their restlessness, or the child's waking up, you know, groggy and unrefreshed and not doing well during the day; that's when I would pursue treatment for it.

Host: And my last question today, what is your best advice for parents who are concerned about their child's sleep and want to be proactive about it?

Michelle Caraballo, MD: We always encourage parents to set up a really healthy, consistent sleep routine at bedtime. So kids and adults, both, everybody responds well to routine and your body knows what to expect, and so we want parents to instill some sort of structure to the evening, a certain time that the electronics get turned off every night, and then maybe shower, read a book or two, say a prayer, say goodnight, lights out, whatever it is.

Steps in your bedtime routine are we try to keep that consistent night after night and at the same time every night too, and that includes weekends and holidays from school. We want the kids to be going to bed at roughly the same time every night and waking up at roughly the same time every day.

Anytime the parent is worried about their sleep for any reason, I mean, whether it's daytime sleepiness or behavior problems in school, or it's really hard to get the kid out of bed in the morning because they seem poorly rested, or they're just really groggy and difficult in the morning. Any concerns that parents have is a totally appropriate reason to bring it up to the pediatrician, and certainly the pediatrician can refer that child onto a sleep specialist if they need further assistance.

Host: Well, doctor, just a joy to have you on the show today. Thank you so much for being with us. For more information, you can visit us online at children's.com/sleep. And thank you for listening to Children's Health Checkup. If you found this podcast helpful, please rate and review or share the episode and please follow Children's Health on your social channels.