Transcription:
Pediatric Sleep Center Expands to Meet Demands of Growing Patient Population

Melanie Cole, MS (Host): Good sleep is certainly essential to a child’s health and wellbeing, but not all kids are getting the recommended amount of sleep that their bodies need for healthy growth. My guest today is Dr. James Kemp. He’s a Washington University pediatric pulmonologist and the medical director of the St. Louis Children's Hospital sleep center. Dr. Kemp, let’s start with some of the long and short term effects of lack of sleep, especially in the pediatric population.

James Kemp MD, FAAP (Guest): In little kids, the kids before they begin school, some of the short and intermediate complications are that they don’t gain well. The most important, I think, complication of poor sleep or sleep apnea in kids is behavioral disturbances that includes—particularly in school age kids—not being able to pay attention well in school. One thing that is characteristic of kids who don’t sleep well—unlike older people who don’t sleep well—is that older people who don’t sleep well will seem sleepy during the day, and very often kids who don’t sleep when they get to be earlier school age, they sort of behave in a hyperactive way. They sort of are overrevved up so to speak. So I think that the major and most important complication long term in kids is that their ability to sort of be quiet in school and pay attention in school and be pleasant to interact with can be compromised by sleep problems.

Host: Well it certainly can, and we’re going to get into some more of those in a little bit. What conditions do you see most often, and what do you feel are the most common causes of these sleep issues that you see?

Dr. Kemp: In terms of number, the most common thing we see is little kids who snore. Most of the time when kids who are before eight or nine or ten, when they snore they have big tonsils or big adenoids. After age 10 or so, their snoring and struggling to breathe at nighttime is indicative of obstructive sleep apnea more often than it’s due to being overweight. So that’s the most common problem we see. Also being in a referral hospital, we see a lot of children that have abnormalities of their face or nose and mouth—such as kids with Down syndrome, for example, who have relatively small mouths and small noses. They tend to have obstructive sleep apnea. Probably the third most common group of kids we see are kids who have insomnia. Either problems going to sleep or problems staying asleep that effects their attentiveness and their behavior the next day.

Host: At what point, Dr. Kemp, do you think a parent should be concerned or a pediatrician should refer a sleep study and to see a specialist?

Dr. Kemp: Again, the most common reason would be a kid who has really dramatic snoring and really struggles to breathe or gasp and nighttime. Particularly a little kid, a preschooler who’s not growing well, and a school aged child who has snoring and gasping and seems to have trouble being overactive during the day and having trouble paying attention in school. They absolutely should be referred I think.

Host: So tell us what's involved once you get a child into your sleep center and maybe you want to do a sleep study on them. We’ve heard about those with adults. How do children do with a sleep study and what's involved?

Dr. Kemp: Two things. First of all, if a practicing pediatrician wants to order a sleep study at our hospital, it’s not necessary for them to see a sleep physician beforehand. Obviously if there’s complications like heart disease or they have Down syndrome or something like that then we would prefer to see them in our clinic. Practicing pediatricians, practicing otolaryngologists, neurologists can send kids to our sleep for a study. What it involves is the child coming in about 7:00 p.m. in the evening with a parent or adult caregiver, and being prepared for the sleep study, which involves having EEG leads placed on the head, devices to measure flow into and out of the nose and mouth attached to the face. Things around the chest and around the abdomen to chart movement of the respiratory system. We also measure pulse oximetry.

The surprising thing about this, I think—it always surprises me—is you have kids who, for example, their parents say, “He’ll never do this. He’s hyperactive.” They come into the lab, they sort of get fascinated by what’s going on, and they understand that the purpose of them being there is to go to sleep. They do remarkably well. I mean I think that sometimes we don’t get useable information because for the most part—well over 90% of the time—we get information that’s highly useable. The Children’s Hospital website has a—I can't give you the exact instructions, but there's a nice video on five-year-old girl coming in for a sleep study that goes through in very specific detail about what happens in terms of what the rooms look like and what sort of things will be put on them. It’s not a process that hurts frankly. Another obviously important thing is that mother or father or other caregiver can stay with the child, needs to stay with the child. They're there for 7:00 p.m. to about 6:30 in the morning.

Host: That’s so interesting when you say that the children really don’t have a problem with it. I think parents probably have a bigger problem worrying about how the children will react to that.

Dr. Kemp: I think the technicians are really good now. They would probably say I'm underestimating how challenging some of these patients could be, but they are really quite remarkable in their ability to sort of reassure the parents about what’s happening, reassure the child about what's going to happen, reassuring them it’s not going to hurt, and kids almost always do better than the parents sort of expected that they would do. That’s very interesting and people have actually written about that that kids with lots of hyperactivity and so forth, when they come to the sleep laboratory, they tend to do okay which is reassuring I guess.

Host: Then tell us about the expansion. How many more rooms, workspaces. How does the expansion benefit patients and patient care?

Dr. Kemp: The obvious one is we get people into the sleep laboratory sooner. We do upwards of 1,400 studies a year and we’re open seven days a week. When I started here 12 years ago, there was two beds. We’re up to 10 beds, and it just reduces out wait time for getting into the laboratory. Right now it’s between two and three weeks, which we think is maybe optimal because it gives parents a time to sort of get reorganized a little bit. We’re not going to say come in tonight or tomorrow night, but you have a couple of weeks to get reorganized without having to wait weeks and weeks. So three weeks is about where we are, two to three weeks. We also have the capacity with portable equipment to do studies on the floors in Children’s Hospital. So we can do more than 10 a night if there's a demand for studies on inpatients who are at Children’s.

So I think the primary benefit is that any child who needs to have a sleep study before further action is taken, or any child for whom there’s a concern about how good their sleep is, we can just get them in much more quickly. We think three weeks sounds about right. Now some people might say that sounds too long. I don’t think it’s probably too long in terms of getting people to be able to organize their lives so they can come to the sleep laboratory. So it’s dramatically cut down our weight time from about six or seven weeks to about three weeks.

Host: So how does a pediatrician refer to your sleep center and what can they expect from your team as far as receiving updates and your team approach?

Dr. Kemp: Let’s say it’s a three year old that snores a lot, and the pediatrician really wonders how bad the sleep apnea is. They can write, it’s called a referral, but it really functions as an order for a sleep study to the Children’s Hospital sleep laboratory. So they can go to Epic electronic health record or they can call the sleep laboratory, which is 314-454-4503. If they happen to call, they’ll be faxed an order that they can send back to our sleep lab indicating why they want to do a sleep study. I review these before every test is done. If it looks like from the reason for the test that the child needs to be seen by a sleep physician—and we have three board certified sleep physicians. We’re adding a couple more this summer—we’ll have them come to our clinic first before we schedule a sleep study.

So the majority of kids that are involved in the sleep center do not see a sleep physician. A straightforward three or four year old that has snoring and big tonsils will usually get a sleep study and will go to see an otolaryngologist if they have obstructive sleep apnea. Children with more complex issues, kids that have say cleft palate and obstructive sleep apnea will usually be seen in our clinic so we can tailor the testing and the intervention to what the child’s needs are. So the majority of tests are done without the child being first seen by a sleep physician.

Now, we have a very active group of otolaryngologists at Children’s Hospital and they're responsible for a large percentage of our referrals to the sleep laboratory. So those patients have virtually all the time, they’ve seen an otolaryngologist before a sleep test is done.

Host: As we wrap up, what else would a referring physician want to know about the sleep center at St. Louis Children's Hospital? Even counselling their patients—and I'm talking even teenage patients, Dr. Kemp who are on their electronics, and it’s so difficult to get them to sleep. They have a different sleep cycle anyway. What do you want pediatricians to know about the importance of counselling their patients on that good sleep?

Dr. Kemp: It’s very, very important. I think that most pediatricians—including my kid’s pediatricians of the past—will tell you there’s so many things they have to cover that it’s hard to figure out how to approach this. I think that for a school aged child, asking whether there's any evidence either in the kids mind or the parents mind that being sleepy impairs our ability to do schoolwork. If there is, then I think more detailed interviewing needs to be done by the pediatrician or they need to go to a sleep physician. I think that as kids get older and they take responsibility for their own behavior, if they’re successful—even if they're looking at their phone in the middle of the night—I don’t think we should try to do anything about it. If you have any sense that they're falling asleep while driving or they're doing badly in school because of their sleepiness, they absolutely should see a sleep doctor.

We also have really good psychologist at Children’s Hospital who see our children that have problematic insomnia or have gotten into habits that don’t allow them to sleep at nighttime. Susan Thompson and Casey Davis are also available for referral. A practicing pediatrician can refer to those psychologists here at Children’s without having them go through the sleep center. They're sort of part of the sleep center, but they're PhD psychologists who see kids with insomnia. A direct referral to them is welcome by them and they're very, very good with kids that have insomnia.

Host: Thank you so much Dr. Kemp. Great information about the pediatric sleep center at St. Louis Children's Hospital. That wraps up this episode of radio rounds with St. Louis Children's Hospital. To consult with a specialist or to learn more about services at the sleep center, please call Children’s Direct Physician access line at 1-800-678-HELP, or head on over to our website at stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider found this podcast informative, please share with other providers, share on your social media, and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.