Transcription:
It's Back to School Time: Are Your Kids Sleeping Well?

Melanie Cole (Host): Sleep disorders in children and adolescents are way more common than you might think. Many studies have shown that poor sleep habits in children can be associated with problems such as academic performance, behavioral issues, and more. My guest today is Dr. Anita Bhola. She’s the Medical Director of the St. Luke’s Cornwall Sleep Center. Dr. Bhola as kids head back to school, why is sleep such an important issue to begin a routine for?

Anita Bhola, MD, FCCP, FAASM (Guest): Hi Melanie. Thanks for having me back. I’m really glad that we are discussing this topic. I, myself have two teenage kids, so this topic is very dear to my heart. So, the reason why sleep is such an important issue to begin a routine with, is because sleep is important for learning, memory, brain development and your mental and physical health and even growth in children. Growth hormone is excreted during sleep as well.

Most teens, 11-17 years of age, do need about 8.5 to 9.5 hours of sleep per night to be alert, productive, happy and healthy and perform. Younger kids, middle school kids would probably even need up to 10 hours of sleep to perform optimally. The problem is that when kids head back to school, especially after a long summer holiday; a number of them get used to staying up late and sleeping late. It’s a condition called social jetlag. And this can lead to difficulties transitioning back into their normal pattern that is required for waking up for school. Because now their body clocks are used to a delayed bedtime. And this is especially true of adolescents who are probably the most sleep deprived of all age groups.

As you know, adolescents have their schedules packed with homework, and standardized tests and academic demands and extracurricular activities and in addition, their biological clocks change during puberty where their bedtime is delayed. So, in other words, they become night owls. And this coupled with the early school start times as you know, especially on the east coast, most schools start early. This results in a very sleep deprived child. So, that’s why sleep is such an important issue when you are beginning a routine for school.

Melanie: Well I can certainly relate as I have two teens myself. So, what is the relationship between kids’ sleep and school performance and attendance and as you say some schools start earlier than others; although kids are pushing for this later start time. Some people are pushing for it. What is that relationship? How does it affect their performance and attendance?

Dr. Bhola: So, insufficient sleep in children results in poor memory and concentration and their academic performance suffers, especially if you have got morning math tests and this is even true in kids who are in college, who put in all-nighters thinking that they are going to do well on the test the next morning. If they put in an all-nighter, they are likely not going to perform well even if they studied enough. Morning sleepiness can also result in tardiness. So, kids will often miss the school bus, or they’ll have poor attendance. Additionally, insufficient sleep in kids leads to a higher rate of mental health issues and we know that kids – a number of kids have anxiety and depression, and this can – is often seen with insufficient sleep. There is also increased use of stimulants. So, kids will drink caffeinated beverages or even sometimes prescription medications to counter the effects of chronic sleepiness on their academic performance. And studies have shown, that there is a higher prevalence of addiction and substance abuse in kids who have insufficient sleep.

Now also, on another note; as you know, adolescents start driving and they are inexperienced drivers and those who have insufficient sleep have a higher incidence of drowsy driving related to crashes which is a huge problem. So, insufficient sleep in teenagers is a huge big public health issue.

Melanie: So, now we are trying to adjust them, because it was maybe the summer or vacations and they are sleeping late, going to bed late; how can we adjust them back to their sleep routines for school? What’s a parent supposed to do?

Dr. Bhola: Right, so recognize that if your kids have been staying up late and sleeping late during the holidays, they will need a sleep tune up and that should really begin not the night before but maybe a week or two weeks before school starts. So, work with your child to return them to a school appropriate sleep schedule. So, every night, have them go to bed a bit earlier and wake up a bit earlier while making sure that they are getting the normal amount of sleep that they need for their age group per night. And if you work on this gradually over one to two weeks; the kids will return to a normal sleep schedule. Also, establish a relaxing bedtime routine, making sure that the child has the ability to wind down at night, they are not watching a horror movie or something at night. And then once they maintain their sleep schedule; make sure that your child’s sleep schedule remains established throughout the year and they stick with it. Don’t let them use the weekend to catch up on sleep because this can mess up their circadian rhythm all over again.

Melanie: Oh, that’s really a great point Dr. Bhola. Really good advice. What about you want us to get them ready, get them back into that routine, not to watch certain things at night, but what about all the white light and noise, electronics, homework on the computer, distractions. It’s not that easy to get a kid to put their phone down or shut their computer and say, okay just go to bed now.

Dr. Bhola: Right. So, anyone who has walked into their kid’s room in the middle of the night is well-aware that the electronics are often on throughout the night. So, what this does is these devices, your smart phones, your computer screens, tablets, television; they all emit what is called blue light and this prevents the secretion of melatonin. Now we know, that melatonin is available over the counter as a sleep aid as a medication to help you fall asleep, but what we may not know is that melatonin is actually secreted by the pineal gland in our brain and it is secreted at night and responds to darkness and it is responsible for inducing sleep. So, now by exposing yourself to bright light from all these devices; you are preventing the secretion of melatonin and hence the child’s bedtime is delayed. So, it’s really important to initiate a – what is called a digital curfew, but it’s not just for your kid. It has to be for the entire family. You need to set a time, let’s say about an hour before bedtime where everybody, you and your kids all turn your electronic devices off for the night. And if electronic devices must be used; use them with blue light filters or screen protectors, they even have blue light blocking glasses now which you can wear at night.

Melanie: That’s so important. As we know, it’s not easy, but we still have to really be very vigilant about trying to get our kids to put all that stuff down. Speak a little bit about pediatric sleep apnea. What’s different about pediatric and adult apnea. You have been on here before to discuss adult apnea; but how is it different in children and how would a parent know if a child has sleep apnea?

Dr. Bhola: Right, so pediatric sleep apnea is like adult sleep apnea. It’s a sleep disorder that occurs when your child’s breathing passages become either partially or completely blocked, but repeatedly, during sleep. And this causes a state of sleep fragmentation and about two to four percent of children have sleep apnea and this typically occurs between ages two and eight. The most common cause of sleep apnea in children is enlarged tonsils and adenoids because this crowds up – these crowd up the back of the throat and cause obstruction of the airway at night. But other risk factors include childhood obesity and as we know, there is an epidemic of childhood obesity in our country.

And then it can also be seen in other conditions such as Down’s syndrome, or kids with neuromuscular disease or other craniofacial abnormalities such as jaw abnormalities. These kids often snore, and they are mouth breathers and often they will sleep with their necks hyperextended. But the way they differ from adults is that while adult patients with sleep apnea predominantly present with excessive daytime sleepiness; kids on the other hand often present with symptoms of hyperactivity, short attention span, learning and behavioral issues such as impulsive behavior, but also on an academic front, these kids can suffer from academic problems and executive dysfunction and they have often been referred to the school committees for evaluation and this is often a mistaken for ADHD.

Melanie: Well you just got to the next question was the relationship and how interesting Dr. Bhola that adults exhibit sleepiness, but children it could be just the opposite that they exhibit this hyperactivity. Can a child, let’s turn it around a little bit, can a child that’s on ADHD meds, can that contribute to poor sleep?

Dr. Bhola: So, I’m not actually suggesting that undiagnosed sleep apnea is the reason behind all children who have ADHD; but it is coincidental that about two to four percent of kids also have ADHD and it’s shocking to know that about 50% of these kids are on some sort of prescription medications which are stimulants such as Adderall or Ritalin. So, as far as I’m concerned; ADHD is a diagnosis of exclusion so, whoever is diagnosing ADHD should first go through the kid’s sleep habits and whether they have sleep apnea and first eliminate those possibilities before making the diagnosis of ADHD and starting the kid on medications because these are stimulants and even though they are not really habit forming in the doses that are used to treat ADHD; but there is always the potential for abuse and addiction like there is with any stimulant medication. But in addition, because these are stimulant medications; it could be hard to wind down at night and sometimes these medications cause insomnia and they can worsen the kid’s sleep from another standpoint.

Melanie: So, what is the treatment for pediatric sleep apnea and what a good point you are making if somebody is thinking their child might have ADHD to get them checked for pediatric sleep apnea while they are trying to diagnose the situation. What is the treatment for pediatric sleep apnea?

Dr. Bhola: Right, if your kid is snoring regularly or has other breathing problems during sleep and sometimes even the kid starts bedwetting after a period of stopping for a while and or if they have learning or behavioral issues and hyperactivity; they should bring this to the attention of the pediatrician to refer the child for an overnight sleep study. If the child has been found to have sleep apnea; then the number one, number two and number three cause of pediatric sleep apnea is enlarged tonsils and or adenoids and the best treatment option is with adenotonsillectomy. So, the child should be referred to an ear, nose, throat physician or an ENT physician who should examine the child’s airway thoroughly and determine whether the child has enlarged tonsils or adenoids and if that’s the case and they have sleep apnea; then they should perform an adenotonsillectomy because in addition to curing the sleep apnea and the behavioral issues, this often also reduces the rate of ADHD and the need for stimulant medications. But if the child has sleep apnea, and the tonsils are not enlarged and if they happen to be obese; then they could be started on CPAP.

Melanie: So, wrap it up for us Dr. Bhola because what a wonderful segment. You have gone through this information so clearly for parents on how to get our kids back to sleep. Give us your best advice for good sleep hygiene. What can we tell our kids? What do you want parents to know?

Dr. Bhola: So, parents should really ensure bedtime rules and make the children understand that they need to sleep a minimum of eight and a half to nine and a half hours of sleep. They should ensure a digital curfew. They should make sure that their kids are eating well, and physical exercise is very important to promote good sleep. Avoid big meals close to bedtime because this may prevent the child from falling asleep easily. The child should avoid caffeine, especially caffeinated beverages within at least six hours of bedtime because this can make it difficult for them to fall asleep and I would say that if you are a parent of a high school student, you may consider advocating for delaying school start times because there have been studies that in cities such as Minneapolis where the school start times have been delayed to 8:30 a.m.; there was less depression and obesity and less car accidents and there was a significant improvement in the kids’ grades and their attendance. So, the American Academy of Pediatrics has recommended that middle and high school they delay the start of classes. It remains a challenge in the area where I am. But wherever you can, try and get involved. And then lastly, as a parent, be a role model. Set a good example for your kids because you need to establish your own sleep cycle and show the kid that listen this is when you go to sleep, and this is when you wake up and you need to maintain a home that has healthy sleep. So, if you don’t set a good example, the kid will not follow.

Melanie: Great advice Dr. Bhola. Absolutely excellent advice. Thank you again for coming on and helping to clear some of this up for the parents out there who are worried about sleep issues with their children. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information please visit www.stlukescornwallhospital.org, that’s www.stlukescornwallhospital.org. I’m Melanie Cole. Thanks so much for listening.