Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. And today, I'm joined by Dr. Samira Naime, pediatric pulmonologist and sleep medicine physician at Children's Mercy Kansas City. This morning, we're going to be exploring Pediatric Sleep 101. Dr. Naime, thank you so much for taking the time to join us today.

Dr. Samira Naime: Thank you for having me. I'm excited to be here.

Host: I'm excited to dive into this. Now, Dr. Naime, what are some of the most common sleep concerns that you see referred to you, and which of these concerns can be managed in primary care?

Dr. Samira Naime: I would say top three, let's say top three, to have something, you know, to be managed. First one, I would say concerns for sleep apnea. Obstructive sleep apnea is definitely up there. The second one would be insomnia, so trouble falling asleep or staying asleep. And then, the third one would be sleepwalking.

Just to kind of dive in a little bit. So, you know, as far as how much can a pediatrician do or what workup can be started. So, I would say for concerns of sleep apnea, usually, snoring is the main concern or the main symptom, and it's just like occasional snoring, not persistent, not associated with like pauses, gasping, nighttime awakening, just like, "Oh yeah, my kid snores," and it's mostly when they're congested or during allergy season. I think that's fair to say you don't need a sleep doctor at that point. Maybe observation and a trial of like an allergy medication, like a nasal steroid if it's like during allergy season.

But otherwise, if there is snoring and something else, usually pediatricians are good about like referring to sleep medicine, which is fair. There are some limitations of how much you can do in your own practice. But every now and then, if you're able to order a sleep study and get the process started, some labs will allow like outside pediatricians to order studies, so that's something they can start if they feel like there are multiple symptoms concerning for sleep apnea, and they want to start that process. Some of the labs are closed lab, what we call closed lab, meaning they have to see a physician that works in that lab, like a sleep medicine physician that works in that lab to be able to initiate the process in ordering a sleep study.

For insomnia, trouble falling asleep and staying asleep is very common, and I kind of think about it twofolds. I think about it in the younger kids. The babies that need their parents to fall asleep or wake up and go to their parents. And you have the older teens where electronics or different maybe mental health disorders contributing to their insomnia, like just different things.

But I think, overall, insomnia is something pediatricians can work on for sure in their clinic, especially when it comes to making sure kids or teens have a proper sleep schedule, consistent sleep schedule, bedtime routine. Some of those "sleep hygiene" that lots of pediatricians go through in their clinic. I think that's very, very important, more than you can even imagine, and will be helpful with insomnia. Because most commonly, insomnia is really treated with non-medical interventions, so really behavioral interventions and, with sleep psychology oftentimes as well. So, I would say that's something that can be started at pediatrician's office.

As far as like the third common cause that I get in my sleep clinic, sleepwalking. So, sleepwalking is usually something not to be too worried about, and the most common treatment is education to the family, reassurance, unless sleepwalking is associated with symptoms that are concerning for sleep apnea.

A kid who sleepwalks and has snoring, witnessed apneas, sleep apnea can trigger these episodes, can make them more frequent. But if the kid is only sleepwalking and have no other concerns, really the main thing that is needed in this case is education for the family, reassurance, telling them, "This is okay. It happens," especially if it's in that, you know, age range, that eight to 12 or around those if there's a family history.

The big thing in this case is making sure kids are safe. So, locking doors, locking windows, making sure no harm is going to result from their sleepwalking. Not sleeping in the top bunk bed, sleeping on the ground floor, things like that. So, that's definitely something that pediatricians can tackle in their offices.

Host: Thank you for walking us through some of the most common sleep concerns. What are some key red flags that should prompt a referral to a sleep specialist?

Dr. Samira Naime: So, to me, red flags is, like, really something very crucial or absolutely needs to be done, like, kind of almost an emergency for me. A real red flag, I would say, in sleep medicine would be someone with excessive daytime sleepiness despite having a good or reasonable sleep schedule.

So, a kid who sleeps the normal hours or what you expect for their age, and then they still fall asleep any chance they have. They might fall asleep in a birthday party. This is unusual for, like, a little kid who's so excited to go and play and just be active. Or maybe an older kid who falls asleep in a theater. I don't know, they're going for a play and they've been looking forward to it, or a concert, and then they fall asleep in the concert. These are situations that are unusual, and if it does happen, it should definitely trigger something. I'm like, "Okay, you need to see a sleep doctor."

You know, conditions that I'm thinking about are like, is this narcolepsy? Is this idiopathic hypersomnia? Like, what's going on? The concern would be if it is narcolepsy, especially with cataplexy, which might not show up at the very beginning, there is a safety issue there. You know, you don't want a teen behind the wheels or even a child or a teen that is swimming, for example. If they do have an episode of cataplexy, like, that can be detrimental. So, this is, for me, a real red flag. So, it's the one extreme.

Another red flag, which is probably more likely to happen than narcolepsy, since narcolepsy is rare, thankfully. I mean, we really don't know the exact numbers for narcolepsy, especially in pediatrics, because the numbers are all over the place, but it's not very common.

The other thing that might be seen more often is failure to thrive. So, like, if a child is having problems with gaining weight and there are concerns for sleep problems, then that would be another red flag. Usually, it's with severe sleep apnea. Usually, it's, like a younger child. I would say, if it's a young child with failure to thrive, I would be concerned or at least think of if there's any sleep disorders that are contributing to failure to thrive.

Host: That makes sense. What are some initial things that families or pediatricians can do as they're doing the initial evaluation or screening in their clinic? What do you recommend for primary care physicians?

Dr. Samira Naime: So, I think over the last 10 years or so, there is a bigger awareness in the primary care setting about sleep disorders. So, I think overall pediatricians are doing a very good job about screening for sleep disorders or sleep apnea, one important thing I would say is checking on sleep habits and sleep schedule.

We know electronics and social media and all that stuff is a big thing these days. So, I think, not just like, "Hey, are you snoring? Do you have pauses, gasping?" But also kind of looking a little bit into their sleep habits, sleep schedule. Is there any bedtime routine? And that's important across all ages, to be honest.

Insufficient sleep and, like, sleep deprivation is very common these days for a lot of different reasons. And I feel like part of it is probably the lack of knowledge of how important sleep is and thinking that maybe I'll catch up on the weekend or, if my child's not falling asleep in school and is not in trouble and they're doing well, then we're good and we're in the clear.

So, I think just making sure that, overall, kids are getting sufficient sleep and not three or four-year-olds staying up till 10 in the evening or 11 in the evening and having to wake up for school. Some of the things that we see sometimes is not normal, even if it's not affecting them at that time.

Host: That makes a lot of sense. What are a few simple evidence-based interventions pediatricians can start with their patients today?

Dr. Samira Naime: I keep going back to it just because it's very important, but I think just trying to prioritize sleep and, like, educating families on how important sleep is. Sleep is important for all your organ systems. It's important for learning, memory consolidation. It's important for immunity. It's important for mental health. It's important for growth. So, I think starting that process early on and trying to teach families about how important sleep is and prioritizing sleep when possible. And then, advising families to start simple bedtime routines, even in your infants, starting early, doing something simple. It doesn't have to be an elaborate 40 minutes or an hour. Even if it's, like, a 10-minute routine that families can squeeze in depending on their schedule, just to have this repetition of the same routine every day, simple, consistent, does help kids give them that sense of security and safety. They know what to expect. Even if your kids have complex medical issues or they have some developmental delays or maybe they have some autism spectrum disorder, it can be beneficial, that repetition, the cues that they use at nighttime.

So, those things are very important, and I think starting early on can be a big win in the long run, as opposed to waiting until problems occur and then trying to counsel them on all the turn off the lights at night and have no noise and no TV and no electronics.

So, I think starting the process early and educating them is important. And the tips that they give might evolve as the kids grow. But just starting early, even in infancy and the codependency, trying to avoid that if possible, and just be there and counseling them from the get-go.

Host: Thank you for sharing some of those interventions. Is there anything that a family can do if they are anticipating a shift in some of those cues or routines? Let's say there's a road trip or a move. Do you have any recommendations for some of those interventions that pediatricians can guide families during times of transition?

Dr. Samira Naime: If it's a trip, like a vacation, short-lived, the time difference can play a role. So sometimes you just have to pick and choose what is priority and, like, at least try to keep some normalcy in there might be helpful.

If a transition is something that's going to—let's say, different households, right? Like moving houses or maybe having two separate households when before you had one household. So, if that's the case, I think the routine or having at least some similarities in the routines in both households would be very important.

If both parents can do something similar for bedtime routine just so that the kids know what to expect, I think that would be a good thing to do for the kids. And it would be beneficial for them to know, "Okay, my boundaries and my routines are the same." And so, I can't just stay up all night in one household and then have strict rules in the other because that can also contribute to developing some issues when it comes to bedtime schedules and sufficient sleep.

Host: That makes a lot of sense. What's one common misconception about pediatric sleep that primary care physicians should rethink?

Dr. Samira Naime: I think knowing that teenagers tend to have a biological clock that shifts to a delayed phase, meaning that most kids, once they become teenagers, they tend to want to stay up later and sleep in later. And that's really, like, built into your biological clock. And so, kind of knowing that and being aware of that, I think is important because it's not just a teenager who's being lazy and doesn't want to wake up in the morning or sleeping through the classes because they choose to do so or being rebellious or whatever. Teens do tend to shift. And so, their bodies usually tend to want to sleep late. And then, unfortunately, with most high schools starting early, in the morning, they have to get up, so they're not getting the amount of sleep needed, which can cause trouble waking them up and falling asleep in class.

So, I think that a teenager with daytime sleepiness or sleeping in class, I think one important thing for them is to see are they getting enough sleep? So, it's not always a sleep problem per se, but they might be getting less sleep than they need because of that shifted biological clock or what we call delayed sleep phase disorder or syndrome.

Host: Thank you for teaching us about that. I had no idea there was a delayed shift for teens, so they obviously deserve so much more grace. I appreciate you sharing all of this with us, Dr. Naime. Is there any recommendation or anything that you think we should keep in mind, especially with all this new sleep technology recording your sleep, using apps. What are your thoughts on sleep and technology? Is that something that has been useful in your experience?

Dr. Samira Naime: Lots of people know more about their sleep because of the technologies. However, a lot of these technologies out there, we don't have robust scientific data to verify how accurate this data is. So, it's good to know. It's like some people like to know, but take it with a grain of salt. So, if there is a real concern, discuss it with your primary care physician or provider. Talk to a doctor or specialist more before you start getting convinced that you have a sleep problem and that it needs to be treated.

I occasionally every now and then get someone who's like, "Oh, my Fitbit says I move this many times," or, "I don't think I'm sleeping because it says, I got this many hours." So, we don't really know exactly how accurate this data is. So, take it with a grain of salt. Talk to your specialist for sure.

Host: Thank you so much. It was a pleasure talking Pediatric Sleep 101 with you. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast.