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Melanie: Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange county. Together, we can keep kids happy and healthy. I'm Melanie Cole. And today, I invite you to listen as we discuss help managing your child's sleep. Joining me is Dr. Chris Min. He's a pediatric psychologist and supervisor in integrated primary care with Children's Health of Orange County.

Dr. Min, it's a pleasure to have you join us today. As we get into this really important topic for parents, what is a normal sleep pattern for kids? What does sleep look like kind of throughout the various stages of a child's development?

Dr. Chris Min: Oh, that's a great question. So, I'll start right from the very beginning. As soon as kids are born from babies, they have, I guess, no semblance of what's daytime or nighttime. So their sleep is just kind of periodic throughout the day. So kids will generally take two naps a day when they're babies, late morning, early afternoon. That nap will then converge into one early afternoon nap until around preschool age. Generally until around four or five years of age is when kids then start to converge into one daytime nap in the early afternoon, and then a longer nighttime sleep. And then past preschool age, kindergarten and something like that, kids will drop their daytime nap and then will just kind of have it all concentrated at nighttime. And as far as throughout the lifetime at least in childhood, kids will go to sleep, you're looking at probably 11 to 12 hours or so, you know, for early elementary school or kindergarten, something like that. And then as they continue to grow, their need for sleep decreases a bit they get into adulthood. And there are some other things that happen in puberty, some issues that happen specifically during that time period, but I won't go too much into that right now.

Melanie: Well, thank you for that comprehensive overview. Now, as we're getting into managing our child's sleep, how do we know as a parent if our child is sleeping enough? What are some of the signs and symptoms that parents can really keep an eye out for for poor quality or not enough sleep? How would we know?

Dr. Chris Min: So one of the best things the parents can do is to monitor their child's daytime functioning. So when I say daytime functioning, I mean, things like how are they doing academically at school? How are they doing on the behavioral front at school? Are they irritable? Are they able to follow commands and directions? Are they able to follow through and do their daily activities or are they struggling? And if they're struggling, you want to find out if it is due to lack of sleep. One of the biggest things or signs when kids are not sleeping enough, they fall asleep. I mean, it's a very simple answer, but it's true. Oftentimes, parents will say that kids get into the car, they pick their kids up from school and their kids will fall asleep in the car. That's a sign that your child is not getting enough sleep.

Another sign is things with academics. Like I mentioned, there's trouble concentrating, almost like ADHD type symptoms. There's difficulty with hyperactivity, just moving around a lot and they're not able to focus. A lot of kids get misdiagnosed with ADHD when in fact kids are not sleeping. They either have not as good quality sleep at night or they're not sleeping enough. And so behavioral things are a lot of what we see, especially for young kids. And so what the research also shows as well as what we see in clinic is that kids who are not sleeping enough instead of acting sleepy or acting like they want to go take a nap or something like that, that's what we see in adults who are sleep deprived, instead what we see in kids are kids are irritable, they're cranky, they're moody and actually they have less regulation when it comes to their bodily movement and paying attention and focusing and things like that. So we see kids who, again act as if they have ADHD symptoms when in fact it may be sleep problems that they are actually experiencing.

Melanie: Well, we certainly are learning more about the relationship between kids' sleep and school performance, attendance, attentional issues, as you say, all of these things. So tell us a little bit about how to get the kids to sleep. I'm a mother of two older children now, but when they were little, I remember those nights. And for parents listening, those are long nights. Can you help us starting with the little kids on what you suggest for parents to make sure good sleep hygiene really to get our kids a good quality sleep? And then we'll move up to the ever-difficult teenagers.

Dr. Chris Min: Absolutely. So, this can also be done with the assistance of a healthcare professional. But as parents, you kind of want to find out, "Okay, what's the reason my kid isn't getting enough sleep?" And then you can get into the solution. So a good assessment or perhaps a good evaluation of why your child is not getting enough sleep or good quality sleep is the first thing. I'll start first with what we call sleep apnea. It's basically collapsing of the airway. We're not getting enough air or oxygen during sleep, and that will result in poor quality sleep. I won't focus on that too much. But that is one of the reasons that kids can often not get enough quality sleep.

Now, when we're looking at young kids, like you had mentioned, one of the most common reasons for a little kids not getting good enough sleep is that they're scared at night. And if you want to think about little kids, nighttime and going to sleep can be and is a very scary thing. Oftentimes during the day, they're with adults, they're with their parents or they're with their class or their teachers and things like that. But at nighttime, a lot of the times, they're alone. They're in a bed by themselves in the dark. And they haven't had the lifetime of training themselves to go to sleep like adults have. So it can be a scary time. So if that's what's going on and there's some anxiety or fear around going asleep at night, parents can do some things to help their children feel a little more secure and a little more safe at night.

Now, I want to be clear that this does not mean sitting with your child in bed and going to sleep with them in their bed. That's actually going to create more problems. It'll create something called sleep association where the child will need the parent by them to fall asleep at night. That's not what we want. We want to promote independent sleep in kids. What you can do is sleep routine or sleep hygiene, as you had mentioned. And that means prompting your child to go to sleep by having a good routine, including putting on their PJ's, having them relax doing a quiet activity that does not involve electronics. Other things like perhaps taking a bath, reading a story together, and then just a little bit of cuddle time right before going to bed. Those are some things that you can do to promote and help a child feel safe when it comes to bedtime.

Other things are things like what we call a transitional object. A transitional object is basically a nighttime-specific object that helps the child feel secure. I have two kids, one of my kids, she has a purple blanket that she's had since she was an infant and that is a transitional object. It helps her to feel safe, helps her to feel secure, and it's a nighttime-specific thing that she has and it helps her to know, "Okay, it's bedtime. And as long as I have my blankie, good to go to sleep." So those are just a couple of things that parents can do and implement right away.

Melanie: Well, that's great advice. And I remember the binky times as well, even up until they were a couple of years old when I'm like, "Okay. Binky, really?" But you're right. I mean, they do need those transitional things, something to keep with them, because it can be a little scary for kids. And now, moving up, because you gave us some really great advice on sleep hygiene for the little ones. It's a little tougher once they become tweens and teens, because there's the cell phones and all the social media and the blue lights and all of these distractions, which can contribute to a child not wanting to go to sleep, and then if they do go to sleep, then not getting a good quality sleep. Tell us a little bit about that and how we can help those kids in that age group get their way better nights' sleep.

Dr. Chris Min: Yeah, absolutely. So first I guess I'll comment on electronics and things like that. I think that when it comes to electronics and cell phone screens and things of that sort, parents oftentimes focus on only the light itself. Now, it is true that blue light is very arousing. It tells the brain to shut off melatonin production and tells the brain, "Hey, it's daytime," since that's the same frequency of light that we get from the sun. And so it is true that the type of light that we get through those devices, it's important to block that. But that does not mean that using the cell phone at night with say a blue light filter or a blue light blocker is going to be effective because at least what a lot of the research shows is that there is a level of social engagement and social arousal through social media, talking to friends, texting with people late at night, looking at Instagram, TikTok, all those kinds of things. That is arousing, perhaps not on the blue light level, but other parts of the brain that can prevent a child from going to asleep. And so that's kind of the reason why I say to parents who I'm seeing in clinic, tell them, "Hey, it's not just about the light. But it's about the other things that go along with having a phone and you want to remove that phone out of the child's room altogether." So that's definitely one of the things that we talk about.

When it comes to adolescence and puberty in particular, what we find is that there's this natural thing that comes along with adolescent development, where there's something called a circadian rhythm shift. Now, the circadian rhythm is basically a clock, an internal clock that we have that regulates sleep and wake time, so daytime and nighttime and things. Once puberty occurs, there is this natural propensity for kids to want to sleep later at night and wake up later in the morning. And so that often becomes a problem, especially as you know, what happens in high school, there's things like zero period or having to wake up earlier in the day right around when puberty happens. So a lot of time kids are sleep, deprived because they want to go to sleep later at night and wake up later in the day, which is kind of what's going on within their bodies naturally. But at the same time, you compound that with social media and using their phone late at night and things, so you're going to have a really, really sleepy kids during the day.

Melanie: Well, you sure are. And we all know what that's like. I mean, if you have kids that have poor sleep habits, you know how difficult it is for them to pay attention or to be in a good mood or any of those things. So before we wrap up, what kind of doctor would a parent see? First of all, they would go to their pediatrician, right? That would be their first step. Who is it that they look to when their child is having poor quality sleep or insomnia or apnea or any of these things?

Dr. Chris Min: That's a great question. So, I would say, and this is perhaps a little bit of a plug for the sleep team that we have at CHOC. But if you have access and are able to go to a multidisciplinary sleep clinic where you have a team of different providers, that would be the best choice. And so we at CHOC have a team that consists of neurology, pulmonology, psychology where we can all talk to one another. We can all interview the patients together and then come up with a plan altogether because sometimes it's just one type of issue that is affecting sleep. But I would say more often than not, it's a combination of issues. So even for a patient with sleep apnea or obstructive sleep apnea, who is seeing their pulmonologist, they're also having difficulties say with behavioral things like sleep hygiene is difficult, or the kid is really scared at night or they have to wear a PAP and they're very scared of wearing that. It's very restrictive and they don't like it, and so psychology can be a part of that to help acclimate and kind of get used to it and desensitize them when it comes to using the PAP. Or we also have patients who have other comorbid medical issues like epilepsy or on the autism spectrum. So when it comes to those patients, also having the input from neurology and then having the multiple disciplines there to help can be best.

If you don't have access to a multidisciplinary sleep center or a clinic of something like that, then I would say it depends on what the main issue is that is affecting your child's sleep. So if it is sleep apnea, then going to a pulmonologist is probably the best bet. If it is say something neurologically related, going to your neurologist is best. And if it is say more behavioral things, things like "My child won't go to sleep on his or her own tonight" or, "My child, I don't know, seems to be really afraid at night and won't want to go to sleep," then probably going to a behavioral health provider or psychologist would be best.

Melanie: What great advice. Something that every parent really wants to hear is that there is help out there for kids that are having issues sleeping, whether it's psychological or physiological. What great information you gave here today, Dr. Min. Thank you so much for joining us. And for more pediatric health and wellness tips, visit choc.org. You can visit choc.org to get connected with one of our providers. Thanks so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together, we can keep kids happy and healthy. Please remember to share these shows on your social channels, as we're all learning from the experts at Children's Health of Orange County together. I'm Melanie Cole. Thanks so much for listening.