Emily Greenwald, MD (Host): Hello and welcome to Pediatric Voices, a conversation with the people who make up the healthcare team at Duke Children's Hospital. I'm Dr. Emily Greenwald. I'm a Pediatric Emergency Medicine Physician and Assistant Professor of Pediatrics at Duke Children's, and I am thrilled to be here today with Dr. Sujay Kansagra, who is a sleep expert at Duke. He's a Professor of Pediatrics and Director of Duke University's Pediatric Neurology Sleep Medicine Program. Sujay, did you know that dolphins sleep actually vertically and using only half their brain?

Sujay Kansagra, MD: That's fascinating. Yes, I did. Unihemispheric deep sleep or unihemispheric slow wave sleep. All these animals that need air when they're in the water, how do they sleep, right? It's got to be half the brain. You got to keep half the brain alert.

Host: Yeah. And for our parents listening, I mean, we all know that sleep is a really important thing for children, a really important thing for caregivers. And when you're getting great sleep, you feel great. And as soon as it gets interrupted in any way, you don't feel great. And so what is sleep and why do we do it?

Sujay Kansagra, MD: Yeah, I love this question. The definition of sleep has evolved and changed over time. If you looked at the textbooks back in the 1800s, they'd say sleep is just a step away from death, essentially. Nothing's going on in the brain. And then we invented this wonderful thing called the EEG. We could start reading brain waves and we found out there's a whole host of things that are happening while we sleep.

 So my definition of sleep, the one a lot of people use, it's a reversible behavioral state of behavioral mild arrest that's reversible. And you have decreased awareness of your environment during this reversible state. We know we have a decreased awareness because we're still somewhat aware of what's going on.

And we know about how much time has passed when we wake up in the middle of the night, if your alarm is going off, but in your dream state, thinking there's a fire alarm going off, you've incorporated some of your external stimuli into your dream state. So you have a decreased level of responsiveness, but you're not completely unresponsive.

Host: Yeah. And why do we need to do it?

Sujay Kansagra, MD: This question also has many, many answers. I joke, people are like, Hey, why do we sleep? And I'm like, I don't know, why do we wake? There's lots of reasons why we're awake. It's similar. There's lots of reasons why we sleep. We know that some of the theories are on energy conservation.

We don't need to be awake for 24 straight hours to meet our needs to survive. We think that there's lots of brain mechanisms that occur to help keep our brain functioning at its optimum. So we know that we can remove some memories into long term memory banks. We delete memories that we don't need. That's why you rarely remember what you had for dinner three nights ago, because you got rid of it while you slept. There's also some fascinating science regarding how our brain actually clears out a lot of toxic proteins that are building up throughout the day to help keep our brains essentially clean. Your sleep is scrubbing your brain cells clean all while you sleep. So, lots of reasons why we sleep.

Host: So, Sujay, I know that your expertise really is pediatric sleep, and in fact, you've written a book called My Child Won't Sleep, which is a step by step guide to fixing common sleep issues in children through the ages. I have three children and know that there are very different sleep problems in an infant than an older child, and I'm already not looking forward to the teenage years when I think kids prefer to sleep till lunchtime. So I'm curious, for our listeners, what do you suggest, as a top tips for children of all ages to optimize their sleep and for their parents?

Sujay Kansagra, MD: Well, you are absolutely right in that the nature of sleep disorders definitely changes as we get older. And I'll tell you that basic principles of good sleep, it all starts with a good sleep foundation, which we call sleep hygiene practices. You've probably heard of dental hygiene and personal hygiene, but sleep hygiene may be a little bit more foreign, but it's essentially, the things that you do behaviorally and the things in your environment that can hurt or help your sleep.

And so, the core pillars of sleep hygiene are one, having a great nighttime routine. This applies at all ages, infancy all the way up to 100 plus years of age. Having a great nighttime routine, 20 30 minutes prior to bed, calm, relaxing activities you do the same way leading up to bedtime. The second part is having a comfortable, quiet, relaxing sleep environment. Keeping it somewhat on the cool side. Typically, that's around 68 to 72 degrees. Everybody is somewhat different regarding their personal preferences, but cooler tends to be a bit better. The third pillar is avoiding things that could disrupt sleep. So that's excessive light at nighttime, caffeine intake. For our older individuals, alcohol, nicotine, those things will certainly disrupt sleep. The fourth thing is making sure you're giving yourself adequate opportunity to sleep. So trying to keep that schedule the same on the weekdays and weekends. And making sure you're getting somewhere between seven and nine hours of sleep, depending on what your body's sleep need is.

And then exercise is always great during the daytime. If you're having trouble sleeping, not exercising too close to bedtime, but we know exercise during the day, also wonderful to help with your sleep. So that's the foundation. And then we build on top of that based on the age and the nature of the sleep problem.

Host: A lot of the advice about sleep hygiene is great. And things that I've heard, even as a pediatric emergency medicine physician, I have to work overnight shifts and, while I can get by on less sleep now that I'm in my forties, I sort of wonder how much is the optimal sleep for each of these different aged children?

Sujay Kansagra, MD: We talk about sleep need as being a range, really at every age. And a lot of our sleep need is determined based on our genetics, essentially. It's whatever genetic hand we're dealt. If we have parents that tend to be on the longer sleeping side, chances are we're going to tend to be longer sleepers.

And so we talk about a range and that range kind of narrows over time. So when we're talking about the very young children, kind of ages of like zero and three months, the typical range is quite broad. It's 12 to 18 hours over a 24 hour period. And so that's inclusive of naps. As we get a little bit older and we're looking at one to three years of age, that's about 12 to 14 hours over a 24 hour period.

By the time we hit adulthood, the range is usually seven to nine hours. That incorporates the vast majority of adults. So the need decreases as we get older, but once we hit our adult years, it doesn't decrease all that much throughout the rest of our lives.

Host: Great. And so what should you do if your kid isn't achieving those goals? What are your suggestions? Moving bedtime up or trying to integrate a nap? What's the best strategy?

Sujay Kansagra, MD: Yeah, I mean, how many hours do we have for this podcast? There are so many things that we can talk about because it gets very detailed very quickly. And I'll tell you that first question is, is it a problem? And by, is it a problem? I mean, is it a problem for the child?

So are they doing well during the day? Are they, attentive, alert, able to have self regulation again, based on age appropriate self regulation behavior? Because sleep deprivation for young children manifests mostly in a behavioral way as opposed to excessive sleepiness or fatigue as we see in adults. So they become inattentive, sometimes hyperactive, impulsive, et cetera. So one, is it a problem?

Host: Agreed. And I think that isn't obvious to all parents and guardians that the way this presents in young children often is this behavior problem. And it's really that they're not getting enough sleep or their quality of sleep isn't good enough. And so really realizing that and trying to make a change with the earlier bedtime, et cetera, is actually something that we did for one of my children and made a huge difference, but it wasn't it all obvious.

 And in thinking about that, what about all of these sleep aids, right? There's melatonin, weighted blankets, all these various sort of storytelling devices that you can have. What do you think of all of those?

Sujay Kansagra, MD: The core of this comes down to, one, at what age is a problem occurring? Because we have some really, common patterns when it comes to sleep issues. So for infants, older infants, young toddlers, oftentimes they have something known as sleep onset associations, where they become overly reliant on some sort of external help to get them to fall asleep. And then the brain learns that I need this external help every time I wake up during a normal nighttime awakening, because everybody wakes up at night. And so sometimes that's

Host: Like a pacifier. We had a child that we put 10 pacifiers in the bed so they could find one.

Sujay Kansagra, MD: I hear this a lot. That's right. Yes. The multiple pacifier approach. That's right. Yeah. Or needing to be rocked every single night or needing to be fed to sleep. And that becomes kind of a habit. So sometimes we work on those behavioral strategies, breaking those habits. For older toddlers, it's oftentimes limit setting issues, right? They're learning what's right, what's wrong, how much they can get away with and they're pushing their boundaries at nighttime.

And so nighttime becomes a bit of a struggle regarding setting those limits. And so a lot of that is, parent teaching. As you get older, it becomes more of a circadian rhythm issue for our teenagers where they naturally want to go to bed late and wake up late, or they can also have insomnia in which, you know, they really have a hard time shutting down their brain at nighttime and can have multiple awakenings at night and have that same difficulty.

So a lot of our treatment approaches when it comes to pure sleep from a sleep disorder standpoint is looking to see if it fits any of these patterns. Now, if it doesn't fit any of these patterns, that's when we get into some of these other do we need a sleep aid? Do you need like a sleep hack, like a weighted blanket or white noise machine, etc.

But I will tell you that the vast, vast majority of children that have sleep issues, you can usually pinpoint underlying sleep disorder, and the treatment should focus on addressing that underlying sleep issue.

Host: That's great advice. And so if a parent suspects that one of their children could be getting more or better sleep; is this something that they would want to partner with their pediatrician or do they need to go to a sleep expert right off the bat?

Sujay Kansagra, MD: Yeah, in many cases, pediatricians are well versed to handle these issues, particularly when it comes to older infants, toddlers. The difficult part of this is that we don't usually get specific training on sleep disorders during our residency training or medical school training. And so, if the challenge is kind of more nuanced, if it's related to sleep apnea or narcolepsy or restless leg or parasomnias, these nighttime events like night terrors and sleepwalking that are hard to get rid of; then in that situation, you may consider seeing somebody in a sleep clinic. But I would let your family medicine doc or your pediatrician be the first person that you speak with to decide what the best approach is going to be.

Host: I'm going to ask you really directly, because I get this question all the time is, what do you think of melatonin for children? And, what is the evidence that's out there? Is it safe? Is it something that you recommend or not? I mean, how should our listeners be thinking about this, especially for children?

Sujay Kansagra, MD: This is one of the most common questions I get. And then, you know, melatonin has kind of become the sleep candy of our world. Everybody's getting melatonin. And so the data behind melatonin, let's talk about that. The data behind melatonin is that it is a great circadian clock shifting medication.

What that means is, we all have a body clock. It's operating on a 24 hour time cycle, helps us stay awake at certain times and asleep at other times. And it's always running in the background. That's why a lot of people don't even realize all that it does for us. But this is why, time shifts when it comes to flying in different time zones or during daylight savings.

This is why that becomes challenging because your body clock likes to stay fixed. Melatonin can help shift the timing of your body clock. And that usually needs to be done when you have something like delayed sleep wake phase disorder, which is what a lot of our teenagers have. They cannot go to sleep early enough to wake up early enough to get to school.

And waking up is absolutely miserable. Or you're an older adult and you need to work at seven in the morning and you have a really hard time waking up at six because your brain actually wants to go to bed at like midnight. In that case, yes, melatonin can help shift that timing. It also works with shift work disorder or jet lag.

So that's where it has a lot of the data, really shifting the circadian rhythm. It also has data to support its use as a hypnotic agent, so a sleep inducing agent for children that have underlying neurocognitive sleep issues. And so that can involve children that have, for example, they're on the autism spectrum. We know that melatonin can be helpful as a sleep aid in that situation. But children that otherwise are completely healthy and don't have any other comorbid neurologic issue, usually their issue is either behavioral insomnia, so particularly our infants and toddlers, or it's insomnia in which case melatonin doesn't really play a role.

So it's all about getting to the core, that underlying issue, and addressing that issue instead of putting band aids. Most people that have another underlying sleep issue where melatonin doesn't help, they'll say, oh yeah, it helped for two or three days, and then we're right back to where we started. That's like a telltale sign that your issue is not going to be addressed by melatonin.

Host: That's good to know. And, thinking of daylight savings time coming up, I'm already thinking about how I'll shift my child's sleep time slightly different. And by one hour, it it's not as big of a deal and they tend to adjust. But certainly if you're traveling across time zones or have a big sleep disruption, that all makes sense to me.

When do you know, and you started to hint at it, when your child may have a sleep disorder and it's refractory to these other suggestions that you made and these things aren't working. When do you know and start to think about that? And what are some of the most common sleep disorders that you see that are often missed?

Sujay Kansagra, MD: So I'll tell you that typically, the behavioral interventions are usually very successful depending on how consistently and persistently a parent can implement them, particularly for young children. So that involves for infants, if they have sleep onset association issues, it's a broad category of interventions that are colloquially called sleep training.

And we're happy to delve into that. For toddlers that are having trouble kind of transitioning to sleep and really pushing their boundaries and those limits, we have behavioral interventions for limit setting for parents. If you have an insomnia issue that involves doing cognitive behavioral therapy for insomnia, very effective treatment and does much better long term than any of those sleep aids, even for adults, the sleep aids like Ambien, et cetera.

Cognitive behavioral therapy for insomnia is the approach. And then for delayed circadian phase, that's usually some combination of melatonin and bright light exposure in the morning. Now, those probably incorporate 90 percent of the core issues we see with falling asleep or staying asleep, but there are many other sleep disorders that are out there that are oftentimes missed.

One in particular is obstructive sleep apnea. Children can have obstructive sleep apnea just like adults. Oftentimes in our really young children, it's due to tonsils in the back of their throat and adenoids in the back of the nose. And those things can obstruct your airway. And so children that snore, snoring is usually something that should raise a little bit of a yellow flag for you and say, okay, my child is snoring.

Could this be something more than snoring? About a quarter of children that snore actually have sleep apnea. And that's defined as having repetitive blockages in your breathing that disrupt your sleep, disrupt the oxygen concentration in your body, wake you up and make you have poor quality sleep.

That's often missed. Restless leg is often missed in children. Misdiagnosis is growing pains, oftentimes due to low levels of iron in the body. And then narcolepsy is another sleep disorder that's often missed. And the hallmark of that is excessive sleepiness that comes on in a slow, mostly a subacute fashion over the course of weeks. And then children become excessively sleepy during the day without any clear cause. And that can be missed. On average, the median time from diagnosis is from symptom onset to diagnosis is 10 years for narcolepsy, which is really kind of sad.

Host: So let's go back through those because I think this may have caught, certainly some of our listeners attention here. So, obstructive sleep apnea, if you have a child who you hear is snoring quite often, and not just sort of during a respiratory illness, but more consistently, what should you do? And then how do you figure out if your child is one of those one in four that may actually have obstructive sleep apnea?

Sujay Kansagra, MD: The only real way to figuring out whether a child that snores has sleep apnea is through a polysomnogram, aka a sleep study. This is where sleep studies are actually useful. Looking for obstructive sleep apnea. They're not really good for insomnia. You know, so I kind of joked that a sleep study is not a sleepogram. It's not going to tell you everything about sleep. Really it's best for looking at breathing and looking for other disruptors of sleep quality. And so you can't really tell. I think snoring is a really good indicator to say whether you might be at risk of having sleep apnea. But then you really kind of need a sleep study.

The guidelines, so the American Academy of Pediatrics put out a paper that said, what should you look for in order to say, yes, you need a sleep study. And my party line here is snore plus one more. So the child snores plus has an additional sign or symptom that may be concerning for sleep apnea. Now, this list of signs and symptoms that the American Academy of Pediatrics has is pretty long and extensive. It can include snoring plus hearing your child stop breathing, snoring plus gasping for air at night, snoring plus having large tonsils, snoring plus having attention issues or having obesity or being underweight or having a small jaw or having underlying neuromuscular disorder.

So the list goes on and on and on. So it's usually snore plus one other thing And now the pattern of referral is usually straight to an ENT physician, which is fine, but I always recommend that the ENT physician can strongly consider doing a sleep study because you cannot diagnose sleep apnea just based on a physical exam.

Host: So it sounds like if a parent is concerned and they hear snoring plus one more, as you're suggesting, they should talk to their pediatrician. And then what happens?

Sujay Kansagra, MD: At that point, the referral patterns are all over the place, depending on what your pediatrician is used to doing. Oftentimes children go straight to an ENT physician to have them look at the airway. I strongly recommend before any surgical interventions are done that they have a sleep study.

And so if your pediatrician feels comfortable ordering it, great. If your ENT feels comfortable ordering it, fantastic. If you'd rather go to straight to a sleep clinic and have them order it, that's fine too, but you cannot diagnose obstructive sleep apnea just by looking at somebody's tonsils. And so even the best ENTs, they can't just look at your face and say, oh yeah, yeah, you have obstructive sleep apnea. You need surgery. You have to get a sleep study done to actually diagnose, to ensure that you actually have obstructive sleep apnea.

Host: That's helpful. And what happens in a sleep study? What would a parent expect or a child expect?

Sujay Kansagra, MD: It's nice to prepare your child for this. And so there are lots of great videos online where you can also look to see, hey, what to expect from your child's sleep study. But essentially it's lots of wires, lots of wires that are kind of hooked up. They're pasted on the head to look at the brain waves. They're pasted around your chin to see how your chin muscles are doing. There's little tubes that sit under your nose and over your mouth to see how you're breathing. There's a belt that goes around your chest and your belly to see how you're moving as you're trying to breathe. There's oxygen monitors, there's an EKG, there's monitors on your legs, lots and lots of wires.

Now, it's important to know that nothing hurts. None of this is painful per se, but you're hooked up to tons and tons of wires so it's not going to be a perfect night of sleep. The parent will routinely stay right there in the room with the child. That's the rule, essentially, for children coming into a sleep lab.

And then the goal is to get as many hours to sleep as possible and get into all the different sleep stages, ideally, through the night to see how you're breathing in each of those stages.

Host: Yeah, it's amazing that children can actually fall asleep, but I know that they do and that we get great information from these. So, before we move on, I just have to share in reading about sleep, I also found out that octopuses apparently change color in their REM sleep. And I heard you mentioning the phases of sleep. So they think they may actually dream. And what can you tell us about the different phases of sleep especially REM sleep? We all hear about REM sleep and I don't truly understand why it's important.

Sujay Kansagra, MD: Yes, let's talk about it. This is great. So, there are three places you can spend the entirety of your consciousness. You can spend it in wakefulness, you can spend it in non REM sleep and you can spend it in REM sleep. Those are the three states. And then we go on to divide non REM sleep into like light sleep and deep sleep, etc.

But the hallmark is that each of these stages of sleep have a distinct kind of hallmark. And usually a very distinct electrical signature coming from your brain when you're in these states. Now, non REM sleep is where it spans from light stages right when you fall asleep all the way to the deep stages where you're having nice, slow brain waves and everything's very synchronized and you're harder to arouse.

So, that's non REM sleep, but during REM sleep, which is AKA dream sleep, which is where we have most of our vivid dream imagery, what happens is that your brainwave activity almost mimics how it looks when you're awake. Your brain is actually very active and all of the muscles in your body, the skeletal muscles are totally paralyzed, which is fascinating.

You're essentially in a state of paralysis except for your eye movements and that's why we call it rapid eye movement sleep or REM sleep. And your diaphragm, thankfully, so you keep breathing, and like a small muscle in your ear, we don't know why that one's still active, but those are the core muscles that are still active, but everything else is paralyzed.

Your breathing becomes irregular, your temperature starts to drop, because you're essentially cold blooded at that point, because you're not generating any heat from your muscles. And so your body temperature starts to drop, you can have this dream imagery. And it's just a fascinating state.

And it's usually you're spending more time in REM sleep during the latter half of the night. You're spending more time in the deep stages of non REM sleep in the earlier part of the night. And we do think that REM sleep plays a really important role in rejuvenating our brain, memory consolidation, etc. The stages of sleep are absolutely fascinating.

Host: Yeah, absolutely. I think that's a fun stage as long as it's a good dream. Definitely the fun stage. So how about restless leg syndrome? You know, that's something certainly, some of us have heard about, and you mentioned it may be due to low iron stores, but when might you suspect that that is what's going on?

Sujay Kansagra, MD: So children with restless leg, it can be a little bit more challenging because adults we're usually a little bit better at describing unusual sensations that we're having and can express that easily to our physicians. Children can have a hard time and they usually just say, my legs hurt at nighttime.

Restless leg, there's no blood test or sleep study test that would diagnose restless leg. There are things that might point us in that category, but restless leg is a clinical diagnosis, meaning we make it based on just the interaction that we have with families and the history that we're getting from the child.

There are four main criteria for restless leg. One, there's an uncomfortable or painful sensation in the legs, or predominantly in the legs. Number two, it occurs exclusively or more prominently at nighttime. So you can have it all throughout the day, but it'd be more prominent at nighttime. The third is that when you move your legs, it actually feels better. And the fourth criteria is when you stop moving your legs, it makes this uncomfortable sensation worse. Those are the four core criteria for restless leg. And if your child has those four and doesn't have other underlying medical disorder, like something that causes nerve injury and neuropathy, et cetera, then they likely have restless leg syndrome.

Now iron, we know plays an important role. It plays a role in many things that our body does, but one thing that plays an important role in is creation of dopamine for our brain. And so we know dopamine plays an important role in modulating restless leg. And so, older toddlers, young school age children are notorious for not wanting to eat iron rich foods.

And so if they have restless leg, and their iron stores, which we check based on a ferritin level, is what we look at. If that's below 50, we supplement with iron. Now the challenge here is that you want to do this with the help of your physician because iron overload is also a really big problem.

You never want to give a child excessive amounts of iron, so you want to be really careful with this supplement. Even though it's available over the counter, you want to make sure someone's tracking their iron levels and doing it in a very safe way. But a child's sleep, the quality of sleep, the ability to fall asleep, can rapidly improve if you address the underlying restless leg.

Host: Great advice. You know, I think we've given a lot of ideas about when you might want to partner with your pediatrician and then when your child may actually have a sleep disorder, as well as just, good sleep hygiene for all, but as a parent, and I know you're a parent, too, there are times where parents just don't get good sleep. Our kids are up with a cold or something's going on and we have sleep deprivation. And so what advice do you give in general for those days where things just haven't gone right overnight?

Sujay Kansagra, MD: Well, first, we are not immune as adults to the consequences of sleep deprivation. We have lots of studies showing that we cannot get accustomed to sleep deprivation, no matter how long we've tried to practice getting accustomed to it.

You just can't train your brain in that way based on the best tests that we have. Whenever I make recommendations for young children, particularly for infants, to help them sleep better, there may be some, you know, semblance of guilt, and it's particularly during sleep training processes, and I get that, but I always say that parental sleep is also important.

Of course, your child's sleep is important, but you as a parent being well rested is important, both for yourself and for your child. You being a well regulated human and being able to control kind of your temperament and your anger levels and your behavior, being safe behind the wheel, being productive at work; all those things are important for the wellbeing of your child as well. Now, if you have just one bad night, there's a supplement for that, which is a nap. I love naps. You know, if you have acute sleep deprivation, there's nothing wrong with taking a nap. We don't recommend it if you have chronic insomnia and you're trying to figure out how to sleep better at nighttime, but in setting of acute deprivation, if you have the opportunity, yes, taking a 20 to 30 minute nap or taking a full 90 minute nap, so you get through a full sleep cycle and trying to avoid time in between, even though it's going to be helpful when you wake up, you're going to feel terrible. Like you just got hit by a Mack truck because you're like, I got a headache. I feel groggy. That's because you've woken yourself up out of deep sleep during a nap.

It's still help you down the road later on that day, but right when you wake up, you have sleep inertia, the sense of wanting to go back to sleep and it does not feel good. So naps are great for acute sleep deprivation and also expectation setting, which is yes, sleep is great, but there are going to be nights where it's not so great and you're going to go on vacation and you're going to have fun, but you're not going to sleep very much.

I always say it's okay. Even, even the sleep doc, even I have times where I'm sleep deprived and I'm like, you know what? We're going to make the most of the day anyway. It's okay. Every night can't be perfect. And being okay with that, being okay with things not being perfect all the time with your sleep.

Host: Okay. So we've gone through obstructive sleep apnea, restless leg syndrome, and the last one that you mentioned is narcolepsy, a sleep disorder that's often missed. And I believe you mentioned sometimes it goes undiagnosed for 10 years. So it feels like we should learn something about that.

Sujay Kansagra, MD: Let's talk about it. Yeah, I'd love to put this blurb out there about narcolepsy because it is something that I think many people are just undiagnosed forever and it's really unfortunate. Anytime you have a child that suddenly starts feeling excessively sleepy for unclear reasons; in my book, that's an automatic referral to a sleep medicine clinic. And it's something that should be taken fairly seriously. You know, referral patterns oftentimes are like, okay, if a child is sleepy, I'm going to send them to endocrinology to look for thyroid dysfunction. I'm going to send them to infectious disease, looking for something like Mono or EBV.

But if a child is otherwise well, doesn't have any other signs or symptoms apart from excessive sleepiness, I would strongly encourage you to send them to a sleep clinic. Narcolepsy, the hallmark, is excessive sleepiness. When they're awake and moving around and active, they can stay awake fine. You put them in a boring situation like a car ride or watching a video or in front of a screen at school, the sleepiness is such that they will almost always have a hard time staying awake. If not, just completely start dozing off. That's the nature of narcolepsy. Hard to stay awake in boring, monotonous situations. You can have additional features, they don't have to be there, but you can have additional features like sleep paralysis, where a child complains when they woke up, they couldn't move anything.

That can be seen in narcolepsy. It can also be seen in sleep deprivation for like, you know, college students, etc. But narcolepsy, we see really vivid dreams, oftentimes right when you're falling asleep. And in some instances, we can see something known as cataplexy, in which the body starts feeling suddenly weak, the head starts drooping, the shoulders sag, the knees start to buckle, in the setting of emotional stimuli such as laughter or anger.

And that's called cataplexy. That happens in a subsection of children with narcolepsy. But going back to the main thing, which is if you think a child has suddenly gotten sleepy and a parent brings that child to a clinic, narcolepsy can occur very, very early. Now I've seen as early as four or five years of age. The youngest case report is around one year of age, believe it or not. So narcolepsy can happen early. Just keep that on your radar, both for parents and for pediatricians that are listening.

Host: Yeah, absolutely. This is fascinating. And what percentage of the population suffers from narcolepsy? Give us an idea.

Sujay Kansagra, MD: Yeah, it's about one in 2,000, in the U.S. It's different based on geographic region of the world. In the U.S., it's about one out of 2,000. So, not exceedingly uncommon. So, most pediatricians, if they have a patient profile of over 2,000 patients, you'll probably have at least one patient that has narcolepsy, statistically speaking.

Host: Important thing to remember for sure. And, certainly if, your child or child you're caring for has any of those characteristic patterns, definitely worth getting checked out. All right, Sujay, this has been fantastic. I want to mention a couple things. One, if anyone has, other questions or curiosities, Dr. Kansagra has over 400,000 followers on social media, and you can find him @ thatsleepdoc, because we are not the only people curious about your expertise. Certainly, at Pediatric Voices Podcast, there are a lot of folks out there as sleep is a main thing that we do in life. And when there's problems with it, we all feel it.

So before we go, I have one final question for you, Sujay, what kind of dinosaur loves to sleep?

Sujay Kansagra, MD: What kind of dinosaur loves to sleep? I don't know. Which dinosaur?

Host: All right. A stegosnourus

who might have sleep apnea. We just found out. Yes.

Sujay Kansagra, MD: I thought you were going to say Tyrannosaurus Rex. I didn't want to give away the joke, but that's a good one. That's a one. I like yours.

Host: Both of them. Well, thank you for being a guest on the show, Sujay. I think we've only really scratched the surface of a super important topic here. And many say good, consistent sleep is a key component of longevity and health span. So something we should be focusing on, even from an early age. and I'm already looking forward to having you back for a part two. Our listeners should be sure to hit subscribe and then submit any sleep questions in the comments that we could even address on a subsequent episode.

Sujay Kansagra, MD: Thank you so much. I really enjoyed it and I look forward to coming back.

Host: Pediatric Voices is brought to you by Duke Children's Hospital and the Department of Pediatrics at Duke University Medical Center in sunny Durham, North Carolina. Pediatric Voices is hosted by Dr. Angelo Malazzo and me, Emily Greenwald. Courtney Sparrow keeps us on track and organizes our work.

Special thanks to Debbie Taylor, Dr. Anne Reed, and the wonderful people at Dr. Podcasting. Find our podcast, and like I said, hit subscribe so that you can follow this favorite show. Connect with us online at our website. You can also connect with us on the usual social media channels and at dukechildrens.org.

 We'd love to hear from you, leave comments, give us a like, or a review. Thanks for being part of the show, and we'll see you next time.