Evo Terra (Host): Take it from me, insomnia stinks. But did you know that insomnia and other sleep disorders can affect children too? Let's find out more with Dr. Erick Viorritto, a pediatric neurologist at Le Bonheur Children's Hospital.

This is the Peds Pod by Le Bonheur Children's Hospital. I'm Evo Terra. Dr. Viorritto, thank you very much for joining me on the program today.

Dr. Erick Viorritto: Well, thanks for having me.

Host: So, my six-year-old granddaughter sleeps like a rock, but I know that is not the case for all children. So before we get into common sleep issues and some tips maybe to help manage them, let's start with the basics. Why is quality sleep important for the development of children?

Dr. Erick Viorritto: It sounds like a very basic question, but up until as recently as 2010, 2011, we really didn't know why people sleep. You know, if you asked William Dement, the Father of Modern Sleep Medicine, he was asked in an interview, "Why do people sleep?" And he said, "The only thing I can come up with that's really solid is if we don't, we get sleepy." So, we've learned a lot, even in the last two decades.

And sleep is important for a number of things. Sleep is important for learning, consolidating memory, we do most of that when we dream in what's called REM or rapid eye movement sleep. But non-REM sleep is equally important. It's where the brain is, especially in children, producing growth hormone at its highest levels to help with growth and development. It helps regulate cortisol, regulate inflammation. And really just in the last couple of years, we've learned that in our deepest stages of non-REM sleep, what we call slow-wave sleep, that's where our brain is actually flushing out a lot of the byproducts from all of those chemical reactions that are involved in us just thinking. Our normal brain function produces a lot of substances that we need to get rid of, and we don't do that until we enter slow-wave sleep. And all of this is absolutely vital in children whose brains are still developing.

Host: Yeah, fascinating. I had no idea there was that much going on. And it reminds me I need to take a nap right after we're done with this conversation just to be on the safe side. But back to children for a second. Let's talk about some common sleep disorders that children might be suffering from.

Dr. Erick Viorritto: Sure. And I kind of break this down in terms of what I see in our sleep clinic here, that we often will see children for excessive daytime sleepiness, a child who's sleepy when they shouldn't be sleepy. The flip side of that, obviously, is insomnia. The child who, or adult for that matter, who can't sleep when they should be able to sleep.

And then, there are whole arrays of other sleep disorders, what I like to call the children that go bump in the night, the sleepwalkers and sleep terrors and weird things people do when they're asleep, things like restless leg syndrome, all fall under the kind of category of sleep disorders.

Host: I wouldn't think of the restless leg syndrome in kids. But of course, that can work that way. I know about sleepwalking. My baby sister, who is not a baby any longer, I once found trying to walk out the patio door into the pool one night.

Dr. Erick Viorritto: Yes. And so in many cases, things like sleep talking and sleepwalking are relatively benign, but they can be very concerning to parents. They can disrupt the sleep of other people in the household and occasionally can lead to dangerous situations. So, it's important not to just kind of brush it under the rug.

Host: Yeah, that's a good idea. I mean, I already remind her every time I see her that I saved her life. So, that's important stuff. So, let's talk about parents out there. I know there are many that are thinking, "Hey, this is something I've noticed about my child." Let's talk about some general tricks, maybe some tips the parents might try with their children who are having some difficulty sleeping.

Dr. Erick Viorritto: Sure. I think that that's probably among the most common reasons folks come to see us in the sleep center, is insomnia. Insomnia is just difficulty falling to sleep, but it also can be difficulty staying asleep or falling back to sleep when someone wakes up at night and very common in children at all ages.

I think one of the things I talk to parents about a lot is what normal sleep actually looks like. Because we have in our mind this idea, and you hear it when parents talk to other parents. You know, they say, "Oh, is little Susie, is little Johnny sleeping through the night yet?" Right? And what does that term sleeping through the night mean? Believe it or not, if you have a child who sleeps through the night, and I were to put little stickies, little stickers on their scalp and monitor their brainwaves, they're probably waking up anywhere from two to seven times a night. And that is not a sleep disorder. That is normal sleep. Now, as a parent, we're not aware that our children are doing this because they hopefully wake up and then, within a minute or two, fall back to sleep. And it happens so quickly that even the child isn't aware that it's happening. But what that means is a child who's having a hard time falling asleep may not just have a hard time falling asleep at 7:00 p.m., 8:00 p.m., 9:00 p.m., whenever their bedtime is but they may also have this difficulty when they have to fall back to sleep because falling asleep is a process that every person has to do multiple times a night.

Host: What about sleep tips for parents and caregivers whose maybe teenagers are struggling with a sleep schedule?

Dr. Erick Viorritto: So often, parents will come to me and say, "Well, the problem is not falling asleep. My child falls asleep fine. I hold them in my arms. I rock them. Once they're asleep, I put them down. Then, I go to my room and I go to sleep." And they say, "The problem is not the falling asleep. It's that they wake up and they cry and they yell until I come back in the room and I have to pick them up and rock them." And actually, what they're usually experiencing is that the child has learned an association. Their brain is very pliable, very plastic, it's able to learn these associations really well, we rely on that, but it's learned a bad association, which is that it is unable to enter sleep without certain conditions. And that might be being rocked to sleep, it may be having, apparently, in bed with them. And what that means is every time the child wakes up at night, from one of these normal nighttime awakenings, those conditions need to be met again. Now, if that condition is, say, having a favorite stuffed animal, that's not necessarily a problem, because child's going to wake up at 2:00 in the morning, their favorite stuffed animal is right there, they go right back to sleep. If that association is having the parent laying next to them in bed, that's a big problem.

And so, often what surprises parents is we'll focus a lot at the beginning of the night, even when the thing that's disrupting the parent's sleep more is what's happening later in the night. Because when we can get kids falling asleep on their own, without any conditions that will be gone later, magically they start, you know, "sleeping through the night." And they're probably still waking up the same number of times. But they're falling back to sleep on their own, very importantly, the parents are staying asleep, and everyone's feeling much better. And we actually know that kids who have these sleep associations get on average one to two hours less sleep than kids who don't over the course of the entire night.

Host: That's a lot. I mean, obviously, if we need those brains doing their job that they're supposed to do while they're sleeping, we can't have them keeping up. so, back to the tips and tricks for a second. I mean, obviously, if a stuffed animal, great. Put the stuffed animal with them. But, you know, if it's a glass of milk that they want, or if it's sleeping with the parents, what else can they do?

Dr. Erick Viorritto: Right. So, what's very important for helping children, especially young children, infants, toddlers, preschool children, but also in this school age, is having a bedtime routine. And most families will say they have a bedtime routine, but when this has been studied pretty rigorously, most families only adhere to that routine about two-thirds of the nights. So, it's very inconsistent. And all the studies pretty much support that you lose the benefit of a bedtime routine if it's not applied consistently.

The other thing when people have looked at bedtime routines is a lot of bedtime routines include things that are relatively detrimental to falling asleep especially the use of electronic screens. So, you used to be watching television, now it's usually watching a tablet or a smartphone, which provides a lot of stimulation. It provides a lot of light, which directly inhibits the part of our brain that is supposed to trigger sleep onset. So, what parents can do is have a routine that's consistent, should be about 30 to 60 minutes long. It should include the things children have to do, you know, getting cleaned up, taking a bath or what have you. And also, some things that are enjoyable to them, maybe reading a book, listening to a song. It should be one directional. And what I mean by that is it should move towards the bed. So, you may start with a snack in the bedroom, then to the bathroom for a bath, then to the bed. It shouldn't go from the kitchen to the bedroom, to the bathroom, to the bedroom, back to the kitchen. And what's great is that children, even toddlers, can really kind of grasp this concept if it's used consistently with things like diagrams or charts that show the activities so they know what to expect.

And one key is that if there's one part of the bedtime routine that has to be done but the child just doesn't like, that should be early in the routine. You don't want to end on something that's going to lead to a tantrum, all that adrenaline rushing through the bloodstream. it's relatively counterproductive to falling asleep. The same way you and I know that when we're really worried about something, we can't fall asleep.

Host: Yeah, we don't want our kids to be worried about things, but kids do worry about things because they're humans, they're the way that we are. What about things like melatonin? Is that safe for kids? I mean, clearly, let's not give your kid an Ambien. But over-the-counter sleep aids for kids, are they worth it?

Dr. Erick Viorritto: Sure. It's really important to talk about this because melatonin is far and away the most commonly used supplement in this country. As a matter of fact, there was a large survey, it's relatively old now, it was from a survey of adults, and almost half of them reported having given a child under the age of 18 melatonin to help them sleep at some point. It's important to know that there is no FDA-approved medication for insomnia in children. It doesn't mean there are no treatments, and we have large array of behavioral treatments, behavioral therapies and interventions that are anywhere from 70-90% effective for insomnia in children, depending on the study.

But obviously, medications and supplements are commonly used. Melatonin is a chemical that our brain produces, and it has two effects at high doses. It can make you sleepy. And at lower doses it helps regulate our natural body clock, what's called our circadian rhythm. So, it's important to know that when you give someone anywhere from 1 to 3 mg of melatonin, when parents talk to me about melatonin, they say, "Well, melatonin's natural." It's natural in that it's a substance our brain makes, but you're really taking advantage of a side effect of very high levels of melatonin in terms of making people drowsy.

The other thing that is important to realize is that melatonin is a supplement which is regulated at a different level than medications. And multiple studies have shown that over-the-counter melatonin supplements can vary wildly in the amount of melatonin in the supplement. Anywhere from having a fifth of what's listed on the label to 500% more than what's in the label. Additionally, a large number of these manufactured supplements had substances other than melatonin in them even though they weren't listed on the label, so contaminants.

Do I use melatonin in my practice? Yes, there are plenty of studies showing that it can be beneficial, especially for kids with underlying neurodevelopmental differences like autism. What I tell families is, if they're already taking melatonin when they come to my clinic, that our goal is to get their child sleeping well so that we can get them off of it eventually, that there's never really been any benefit shown to using very high doses. So once you get above 3 milligrams or so, if it's not working, you shouldn't keep pushing it higher and higher. More is not always better.

I tell them they should treat it like any other medication. It shouldn't be in reach of the child. Remember, a lot of these are gummies or chewables that can look like candy. And there's been an alarming increase in calls to poison control centers for melatonin overdoses, including several hospitalizations. So at high, high doses, it's not necessarily benign.

The other thing I tell them is that they should look for a supplement that has something called a USP verification. It stands for the United States Pharmacopeia. It is a voluntary process that a supplement manufacturer can submit to where they're required to show that their dosing is within certain parameters based on the label that their product is manufactured under appropriate conditions, is free of contaminants. And I wouldn't use a supplement, not just melatonin, but any supplement that doesn't have a USP verification,

Host: Yeah, good advice there. So, moving away from over-the-counter and trying to do things at home to help other kids, at some point in time, there are children who need to see someone like yourself. They need to go to a professional to be assessed. When should parents make that move?

Dr. Erick Viorritto: For children who are starting to have trouble sleeping, pediatricians are great at kind of helping to pinpoint what we call sleep hygiene issues, things about the sleep environment that might be causing a child to start to have trouble with their sleep. Once it's become chronic, if it's been going on for more than two or three months, simply correcting sleep hygiene issues typically will not reverse the insomnia.

And so, there are some more involved behavioral interventions that go by fancy names like modified extinction and graduated extinction. And these are kind of set processes that, as a sleep physician, I can provide to the family and help them work through. Certainly if a child seems sleepier than they should, and it's important to realize too that sleepiness in a young child may not look the same as sleepiness in you or I. When we're sleepy, what do we do? We sit here, we yawn, we kind of doze off. But to a young child, what ends up happening when they're tired is that the parts of their brain, we'll call the frontal lobes, the part responsible for decision-making, restraint, benefit-consequence calculations doesn't work as well. And so, children who aren't getting enough sleep will have more tantrums. They may have difficulty learning. They may have trouble staying on task or paying attention in school. It can look exactly like ADHD.

And so, if you're seeing those symptoms and you've got some other inkling that your child isn't sleeping well, maybe they're snoring really loudly at night, maybe they're restless, they're all over the bed at night, then it's probably worth seeing someone about whether there may be a sleep issue causing those symptoms.

Host: Good advice. Kind of a bonus question here before I talk about something else. What about kids that sleep too long? May be for teenagers that want to sleep until 2:00 in the afternoon or even children who don't like getting up. Is there a too long sleep? Can that also be a problem?

Dr. Erick Viorritto: So, two issues, one is sleeping too long and the other is sleeping at the wrong time. So, there are conditions that cause excessive sleepiness, irrespective of how much time you've slept. And the classic one most people have heard of is called narcolepsy. In people with narcolepsy, it's about one in every 2,000 people. And the part of the brain that produces a certain chemical called hypocretin that keeps us awake and alert actually gets destroyed. Our immune system attacks it. It stops making that chemical. And someone with narcolepsy is going to be sleepy no matter how much sleep they get. And it typically starts in childhood or adolescence.

And time and again, I see teenagers who are falling asleep in class who were told for years, "You're just not getting enough sleep at night" or who said, "I just thought it was normal for a teenager to fall asleep in class." Well, if they're up all night, yes, it's normal to fall asleep in class. The average teenager should get eight to 10 hours of sleep. And if that's what they're getting and they're dozing off, something is either wrong with the sleep they're getting, or they may have a condition of excessive sleepiness, like narcolepsy. And the sooner we can figure that out, the sooner we can get them treated so that they can go back to doing the things that they enjoy doing, doing the things they need to do. I see time and again teenagers who've struggled for your two, three, four years, who've gone from being straight A students to failing classes before we finally get them into sleep clinic and find out that what they have is narcolepsy.

Host: I wouldn't have thought about narcolepsy as being an issue, like you say, it's pretty common for kids to fall asleep. But yes, if that eight to 10 hours is not doing the trick, then yeah, it's time to see someone to help with that. Now, I know that your training is neurology. And obviously, you're specializing sleep medicine, but we talked a little bit about kids having those underdeveloped frontal lobes causing problems, but what's the neurology at work here with sleep disorders with children?

Dr. Erick Viorritto: Our brain is what regulates our sleep. Our brain tells us when we should feel tired, when we should feel alert, when we fall asleep, it helps regulate how long we stay asleep. And as I mentioned, a lot of these processes that happen when we sleep are about maintaining the brain, developing those important connections in our neurons.

So, one of the things that drew me to sleep was seeing many sleep difficulties were there in children and adolescents who we see in Neurology Clinic for other conditions. Things like down syndrome, things like autism, things like epilepsy. The other side of the sleep point is that our breathing changes drastically when we sleep. And so, so many breathing issues come out during sleep. The classic example being sleep apnea. And so, when you look at the array of what sleep medicine is, you can kind of break it down into the neurologic issues, the breathing issues, and then some of the behavioral issues such as insomnia.

Host: That is great information. I'm jumping out of character for a moment to ask you a question. The last thing I have here is about sleep tips, for a child struggling with sleep schedule, but I think you covered that already, about the sleep schedule, talked about how it was not followed all the time, and make sure you do it, and make sure that the terrible thing is first. Was there something else you wanted to add about that, or do you think we've covered that adequately?

Dr. Erick Viorritto: I do think the other key issue about sleep scheduling really has to do with my teenagers, my adolescent patients. And I say this as a father of a 14-year-old daughter. As I said, our brain has an internal clock that tells us when we should feel sleepy, when we should fall asleep. And in adolescence, that clock shifts forward by a couple of hours. It's called a circadian shift. And so when teenagers say they can't fall asleep at 9:00 p.m., they're being truthful. There is an actual biological mechanism where that may be the point where their circadian rhythm is actually at its highest, most alerting, most wake promoting level. And this can become a huge issue, especially when we look at our middle schools and high schools, some of which start at 7:15, 7:20, 7:30 in the morning. Because at that point, you've really set up a situation where an adolescent, a teenager is never going to get the right amount of sleep on that schedule. It's why the American Association of Sleep Medicine, the American Academy of Pediatrics, and about a dozen other professional societies that study sleep have issued a position statement that says that middle schools and high schools should not start earlier than 8:30 a.m., and we've got the evidence to back that up. Later school start times lead to higher grades, fewer sports injuries, fewer car crashes, less obesity, less depression, less suicidal ideation. There's never been shown any health benefit to earlier school start times once you get into that pre-teen, teenage age group.

Host: So whether or not we have the political will to follow through with that remains to be seen.

Dr. Erick Viorritto: That is always the issue, and I'll be the first to admit there are a lot of other factors that come into consideration. But, on this, at least as medical professionals, it's a pretty unified front because the data is so strong and so overwhelming about the benefits of a school start time that reflects the biologic reality of the changes that go on in our young people's brains.

Host: Excellent information, Dr. Viorritto. Thank you for all the information you've shared with us today. Any other parting thoughts before we go, or should we wrap it there?

Dr. Erick Viorritto: I think the only thing I would really stress is, you know, pediatricians deal with a lot in these normal, yearly physicals and everything, and sometimes things can fall through the cracks. And so, if a parent has concerns about their child's sleep, the important thing is to bring it up, to not let it get lost in all of the other issues that need to be discussed. Because deep down, if you think about it, we spend a third of our life asleep. And things that go on during that and the problems that children may be experiencing during that third of their life are still important. And I would encourage parents to talk about these things with their physicians.

Host: More great advice. Dr. Viorritto, thank you very much for joining me today.

Dr. Erick Viorritto: Thanks for having me.

Host: Once again, that was pediatric neurologist Dr. Erick Viorritto. And for more information about the Peds Pod, please visit lebonheur.org/podcast. That's L-E-B-O-N-H-E-U-R.org/podcast. If you found this episode helpful, please share it on your social channels. I'm Evo Terra, and this has been the Peds Pod by Lebonheur Children's Hospital. Thanks for listening.