Joey Wahler (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice. 

It's something that can adversely impact a child's health or quality of life. So we're discussing pediatric sleep disorders. Our guest, Dr. Allan Damian, practices Sleep Medicine at Skagit Regional Health.

This is Be Well with Skagit Regional Health. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Damian. Thanks for being with us.

Allan Damian, MD: Hi there, thanks for having me.

Joey Wahler (Host): Great to have you aboard. So first, just how common are sleep problems for children and at what age can they first develop?

Allan Damian, MD: Well, it probably is much more common than anybody thinks, including primary care physicians or pediatricians, mainly because there is a kind of under diagnosis of sleep disorders. I do have some numbers for you and this is taken from the ICSD 3 TR, that's the International Classification of Sleep Disorders, 3rd Edition, from the American Academy of Sleep Medicine. Insomnia, about 10 to 30 percent of children, and surprisingly, this can occur as young as 6 months of age. And it's much more common in adolescent girls compared to adolescent boys. And as far as sleep apnea, it can occur in up to 3 percent of all children, but snoring by itself can occur up to 10 percent of children.

And the other disorder is restless legs, which can occur in up to 4% of the population. So these are just some examples of some sleep disorders in children, which we see pretty common.

Joey Wahler (Host): So, when you say insomnia, and it seems like that's a fairly significant percentage of young kids that suffer from that. What constitutes insomnia, technically speaking?

Allan Damian, MD: So it's a very, very simple technical definition. So it's either the inability to initiate sleep or inability to maintain sleep or both, which is not due to any other sleep disorder. So that's fairly common. And what's very key to note here is that what contributes to the high number of children with insomnia is the fact that circadian rhythm disorders, which is a different type of disorder is often mistaken for insomnia. They just have a preference for sleeping much later in the 24-hour cycle. And so those are mistaken for insomnia.

Joey Wahler (Host): So, in other words, meaning that they might catch up on sleep when they nap later on?

Allan Damian, MD: Well, napping is actually something that may be a signal of something going not quite right, at night. Because napping is only for kids below six years of age. So, if they're not sleeping correctly, they will nap. And that points to an abnormal, or disrupted sleep pattern.

Joey Wahler (Host): Gotcha. And then you also mentioned something called restless legs. What is that?

Allan Damian, MD: So this is often mistaken as growing pains. I mean, there is a legitimate condition as growing pains, but, restless legs are frequently seen in older patients. And it's a kind of like abnormal sensation on the legs almost like bugs are crawling and you have to move your legs to get rid of those sensations.

It can happen in kids and they're just not able to verbalize it and it frequently happens, if there is a history of anemia which we often see in a lot of kids.

Joey Wahler (Host): And so, just to back up for a moment, we've talked a little bit there about some of those conditions that can affect kids on the negative side. What is normal sleep defined as for infants and for children?

Allan Damian, MD: So, well, normal sleep, would depend on the age group. But, there are three basic things to consider for normal sleep, both for kids and adults. First, the number of hours of sleep. And there is published data, or published guidelines, from the American Academy of Sleep Medicine endorsed by the American Academy of Pediatrics.

The second thing to consider is the pattern or the set of symptoms. And third is something that we determine in a sleep study, the sleep architecture. So I'll give just a couple of notes on the hours and pattern of sleep. Infants will want to eat and sleep, eat and sleep. They don't have a mature circadian rhythm, but by six months to one year, they should have an established preference for day and night.

Six years and above, they shouldn't be napping anymore. And so napping in the daytime may be a symptom of disrupted sleep at night or inadequate sleep at night. And then third thing is that teenagers should be getting anywhere between 8 and 10 hours of sleep. Adults, between 7 and 9 hours. And with the way, sometimes the demands of school, our teenagers are not getting that many hours of sleep at night. And so school performance will suffer, and that could be one of the main presenting symptoms of sleep disorder.

Joey Wahler (Host): Gotcha. And so what are some of the symptoms of pediatric sleep disorders?

Allan Damian, MD: So, one key thing to note is that pediatric sleep disorders present in a very different way compared to adults. Whereas adults will typically present with sleepiness and fatigue in the daytime when adults don't get enough hours of sleep at night or don't get, uninterrupted sleep at night. The opposite happens in kids.

Some of them could present with symptoms of inattention or even hyperactivity. So the complete opposite. And then you will see further down the line, behavior symptoms, mood symptoms, as well as a decline in school performance.

Joey Wahler (Host): Interesting. And so, what is it that typically causes sleep disorders in children?

Allan Damian, MD: Well, it really depends on the disorder they have. Like in the case of sleep apnea, and the most common form of sleep apnea is obstructive sleep apnea or OSA. And so it's mainly an anatomic problem. And in kids, the narrowing’s correspond usually, with the enlargement of the tonsils or adenoids.

In the cases of insomnia, it's mainly environmental or social factors. I mentioned earlier that insomnia in kids could be diagnosed as early as six months of age. And in those cases, it's usually, I have to say poor habits that have been acquired And, the third thing is when I mentioned about RLS, it could be related to low iron in the brain.

Joey Wahler (Host): And so, you mentioned there a few things. With regard to sleep apnea, we hear about that quite a bit in older people and adults. When we're talking about kids, how young could someone be diagnosed with that, Doctor?

Allan Damian, MD: Well, as young as an infant in the NICU or in the neonatal ICU. Sometimes some kids are born with craniofacial anomalies; where certain structures in the oral airway, just do not permit an easy flow of air, and so it could present as early as in the first couple of weeks of life.

But for most kids, they usually will present between two and three years of age, and that usually corresponds with the age where, the tonsils and adenoids, start becoming a bit more enlarged in that child.

Joey Wahler (Host): And then you also mentioned a moment ago that sometimes parenting is responsible for sleep issues in younger people. How so?

Allan Damian, MD: So, one example of a subtype of insomnia is called behavioral insomnia of childhood. And so, sometimes the parents, intentionally or inadvertently because they are too busy, they tend to employ certain behaviors such as conditioning their children to get a certain, object or a certain reward before going to sleep. I mean, we all know that invisible blue light from screens can be disruptive to one's circadian rhythm, and so sometimes, you know, some parents would allow that, and the child would kind of get used to getting something before bedtime, and later on, you they're just so used to it, they can't sleep without it, but then the blue light will also delay bedtime to a certain extent.

Joey Wahler (Host): And so for the handful of conditions that you've gone over; what are the best, most common treatment options available for those?

Allan Damian, MD: For sleep apnea, we'd like to do a full night diagnostic sleep study in order to gauge the severity of sleep apnea. And actually, this is a hard recommendation from multiple medical associations. The AAP, the Association for ENT, the European Respiratory Society, as well as the AASM, that if a child has snoring for more than half the week, they should be sent to sleep medicine for further evaluation, and then eventually if we do find sleep apnea, or anything else during the sleep study, then we can send them to ENT for possible, tonsillectomy.

And then as far as the other sleep disorders are concerned, for insomnia, for circadian rhythm disorders, what we usually recommend is something called CBTI or Cognitive Behavioral Therapy for Insomnia. Basically, we're trying to teach techniques to unlearn poor sleep habits and learn healthier sleep habits.

And finally, for RLS, or Restless Legs, we usually do an iron evaluation first. And usually correcting iron for most people and children will usually address the RLS symptoms so that we don't have to rely on medication.

Joey Wahler (Host): Understood. So in closing here, Doctor, to summarize from your experience, do you think parents may tend to overlook sleep disorders in their kids as a possible reason for why they might not be in the best health or be exhibiting the best behavior?

Allan Damian, MD: Exactly. And I think not only parents but a lot of probably in primary care as well. I mean, I was a pediatrician before I became a sleep physician and when I was in training, there was no sleep medicine rotation and for many, many, many years, many cultures and societies have seen snoring as a physical trait rather than as a possible marker for a disease or a medical condition. And so it's never been taken seriously or looked into.

Joey Wahler (Host): But you're here to try to change that, aren't you?

Allan Damian, MD: Definitely.

Joey Wahler (Host): Absolutely. Well, folks, we trust you're now more familiar with sleep disorders in children. Dr. Allan Damian, valuable information indeed. Thanks so much again.

Allan Damian, MD: Thank you again for having me.

Joey Wahler (Host): And for more information, please visit SkagitRegionalHealth.org. Again, that's SkagitRegionalHealth.org. Now, if you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for listening to Be Well with Skagit Regional Health.