Corinn Cross, MD (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Cori Cross. Today, we're discussing pediatric sleep disorders and answering the important question: When should a physician refer patients for a sleep study?

We are joined by Dr. Syed Kamal Naqvi, Pediatric Pulmonologist and Medical Director of the Sleep Disorders Center at Children's Health and Professor at UT Southwestern. Dr. Naqvi specializes in treating sleep-disordered breathing in children with various chronic conditions, mechanical ventilation during sleep, asthma, and narcolepsy. Dr. Naqvi, thank you for joining us today.

Syed Kamal Naqvi, MD: Sure. It's my pleasure.

Host: Dr. Naqvi, we often hear parents dismiss snoring as cute or just a phase. But what signs should parents look out for if they're thinking that their child may need a sleep study, and when should a pediatrician refer?

Syed Kamal Naqvi, MD: Snoring is very common, as we know. About 13% of people actually snore without having sleep apnea. But snoring is a very good, loud, and obvious sign for something not right. If the snoring is persistent and it's loud, and it's present for several weeks without any intercurrent illnesses like cold or allergies and such, then snoring is important to be identified and then to be explored.

Host: As a pediatrician myself, there are other things though besides the snoring that often tee me up to think that this might be an issue.

Syed Kamal Naqvi, MD: Yes. There are some very important signs which are present in addition to snoring and are more sensitive than snoring actually. So, one of them is the witnessed apneic episode or a pause, and that a parent can notice that a child doesn't breathe for a few seconds during the sleep. An associated sign could be gasping for air or choking noise. So, those are common when it comes to sleep-disordered breathing. And many times, they are not paid attention to or overlooked because snoring becomes the main presenting complaint. But I think the related questions should include those other items like the apneic pauses and gasping

Host: Now, I often ask if a child is tired more than usual during the day, having difficulty concentrating. Are there other questions like this that pediatricians should be asking?

Syed Kamal Naqvi, MD: Yes. That's another good question. The interesting thing about children not sleeping well due to whatever is going on in their sleep, be it obstructive sleep apnea or other conditions, they appear more hyperactive and attention deficit type as opposed to being sleepy. It is very common in children. It is the difference between adult and pediatric sleep-disordered breathing, that adults would get sleepy. Children tend to have behavioral issues, like I just mentioned.

Host: That makes sense. Is there anything else that we should be looking for or asking about?

Syed Kamal Naqvi, MD: There are a couple of other things one can ask for. Sleep position, for example, is one. Some children would keep their necks very extended. They sleep in a bit awkward positions. They may be having enuresis, bedwetting episodes. They could be waking up frequently also. So, these are signs and sometimes symptoms if older children can actually mention some of this, but mostly signs.

The more important thing to see, the quality of their sleep is what is happening to the daytime. In other words, how is this sleep issue affecting the child during the day? So, school performance comes into play, and their mood and behavior issues. Sometimes some children, older ones, can get sleepy during the day. So, those are the consequences.

Host: And is this something that your body habitus, your weight, your physique changes your risk factor or should we be thinking about this for all children who might be snoring and having the other things that you described?

Syed Kamal Naqvi, MD: Most definitely. We are seeing an epidemic of obesity in children. So, that is very related to some sleep conditions. The most prominent of those would be obstructive sleep apnea. So yes, obesity is a condition which should raise a concern for whether sleep-disordered breathing is present or not.

Host: Got it. Now, the American Academy of Otolaryngology, their guidelines recommend sleep studies before a tonsillectomy for certain patients. Who are these high-risk patients, and why is it so important to do this testing?

Syed Kamal Naqvi, MD: Both the American Academy of Pediatrics and the American Academy of Otolaryngology suggest more or less the same thing. So, the guidelines include children who have certain conditions that are making them at high risk for sleep apnea. And those include obesity for one; being younger, like younger than two years of age puts them at a higher risk for sleep apnea. They also include conditions involving craniofacial abnormality syndromes for one. Hypotonia is another reason such as in trisomies and neuromuscular weakness conditions, as well as failure to thrive is another condition. Some softer ones are congenital heart conditions, sickle cell disease. Obviously, Down syndrome is a very frequent patient population for sleep conditions and sleep apnea. So, these are those conditions where one should consider a sleep evaluation by either a sleep specialist or getting a sleep study done.

Host: Got it. Now, when you decide to do a sleep study or to evaluate this, it's important to choose the right test. Now, there are both laboratory-based sleep studies and at-home sort of evaluations. Why is it that a laboratory-based sleep study is preferred to an at-home sleep testing?

Syed Kamal Naqvi, MD: I would answer it in a slightly different way. For now, the American Academy of Sleep Medicine does not recommend home sleep studies for children. So, that's a policy guideline. Now to expand that further, adults gets home sleep studies all the time, and it has been around for at least fifteen years or more. This will come to pediatrics at some point in maybe a select patient population. But for now, it is not available for most pediatric patients in the US.

Host: If you want your child to have a sleep study, either as a parent or a provider, they're going to be going to a sleep lab.

Syed Kamal Naqvi, MD: That is correct. So, the in-lab sleep study is the gold standard for evaluating a child for sleep breathing conditions.

Host: Now, parents and sometimes children are nervous about this experience. Could you walk us through what a sleep lab experience is and what they should expect?

Syed Kamal Naqvi, MD: That's a very related question and is one that a lot of parents are concerned about. I totally agree with those concerns. So, sleep study is an interesting test. It's a long test where a child will have to come and stay for the whole night. A parent would be with the child in the same room and be able to sleep on a separate surface. That's the setup. We apply a number of sensors on their body from head to almost the feet in order to detect many body systems. For example, we look for brainwaves, and we look for EEG, and we monitor their breathing and pulse oximetry, and then muscle movements, and some others. And there's a simultaneous video recording going on in addition to audio for the snoring. This is the standard setup. We apply sensors and stickers and wires. So, there is some sensory sort of tolerance that is required by the child. On the other hand, there is nothing that hurts. So, there is no needle, there is no blood test. None of that is there, yes.

But another important thing is that by the time the test ends, most children who are slightly older, like elementary school age and onwards, they are actually very happy with the experience. And when you ask them after the fact, they said they had a good experience. It is almost like a hotel night stay. It's a clean room. It's a pleasant environment, and it's quiet. So, it's actually a good setup. Most people end up liking the experience.

Host: So, it doesn't feel so clinical. My question for you is that you're describing this process where the parent can stay with the child, is that anywhere, or is that specific to Children's Health? Because that to me would alleviate, I think, most of the concerns for both parents and patients, that if they're in the same room together, it seems just an awful less scary. So, is that something that's specific to you, or is that common?

Syed Kamal Naqvi, MD: No, it is the standard. We do not do any testing for children where a guardian or a parent is not present.

Host: That's wonderful. So, sleep studies though, they're not just for obstructive sleep apnea, right? They can diagnose or uncover other sleep disorders. Could you speak to that a little bit?

Syed Kamal Naqvi, MD: Sleep apnea also means obstructive sleep apnea in most cases. But there are even other types of sleep apnea, such as central sleep apnea, which is slightly different breathing condition, and also can be diagnosed by a sleep study. There are other reasons to do a sleep study.

For example, when we try children on positive pressure devices like CPAP or BiPAP, that is another type of sleep study that is done to find the right settings where all the problems have been alleviated and resolved. So, that requires a sleep study. There are times when we do a sleep study to look for a jerky leg condition like periodic limb movement disorder. There are times when we do a sleep study to evaluate children for their readiness of a tracheostomy tube removal. Those are called decannulation studies. We do those frequently.

And then, there is a very specific sleep study type that we perform for children who are sleepy. So, we evaluate them for conditions like narcolepsy and hypersomnia. Those are some commonly done tests in both adults and children. But other than sleep apnea, there are a number of other conditions that can be diagnosed on a sleep study.

Host: When we talk about Children's Health, our listeners should know that Children's Health is the largest dedicated pediatric sleep center in North Texas and performs thousands of sleep studies each year. How does that level of pediatric expertise and the American Academy of Sleep Medicine accreditation benefit referring providers and their patients?

Syed Kamal Naqvi, MD: You're correct in saying that we are large at Children's Health. We perform over 5,000 sleep studies in children in a year, and that is larger than many other centers. In fact, we may be the largest or second largest for the number of sleep beds that we have in the country.

With this experience of doing so many sleep studies, and we have seven other sleep specialists that are part of the sleep center and are involved in evaluating patients and reading sleep studies and such. So, it's a fairly large group of highly expert physicians and sleep specialists that we have. We also have a sleep psychologist, just to mention, because that's a very unique resource that we have available at Children's.

With our size and the fact that we only do pediatric studies, our staff that perform the sleep study also are very experienced in taking care of children with complex medical conditions and very highly specialized needs. We take pride in saying that more than 99% of the times, we are able to perform a sleep study in a child with any medical condition that they may have and get a very good data for sleep study that we can evaluate and help the child. So with our size and the fact that we are accredited by the American Academy of Sleep Medicine, which has very stringent, strict criteria high standards that we have to meet, we have been accredited with the American Academy for the last more than twenty-five years at Children's Health. That provides us with the confidence that we are able to help these children, and we are able to do the test, which is reliable.

Host: Well, as a pediatrician and as a mom, it sounds like Children's Health is just the gold standard for the Pediatric Sleep Center in North Texas. And I think you have really made it a lot less scary for patients and providers to understand exactly what a sleep study entails, and that it's just not really a scary experience. In fact, who doesn't like going to a hotel for a night? Thank you, Dr. Naqvi, for taking the time to speak with us today.

Syed Kamal Naqvi, MD: It was my pleasure.

Host: If you would like more information about sleep apnea and the sleep clinic at Children's Health, please visit childrens.com. Thank you so much for your time with us today and to our audience for listening to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childrens.com. And if you found this podcast helpful, please rate, review, and share this episode, and please follow Children's Health on your social channels.