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When Should You Worry About Pediatric Snoring? · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Sarah Gubara (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:08
  Sarah Gubara.
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  And today, I'm joined by Dr.
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  Samira Naime, pediatric pulmonologist and sleep medicine physician at
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  Children's Mercy Kansas City.
• 0:19
  This morning, we're going to be exploring Pediatric Sleep 101.
• 0:24
  Dr.
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  Naime, thank you so much for taking the time to join us today.
• 0:29
  Dr. Samira Naime:
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  Thank you for having me.
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  I'm excited to be here.
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  Host: I'm excited to dive into this.
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  Now, Dr.
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  Naime, what are some of the most common sleep concerns that you see referred
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  to you, and which of these concerns can be managed in primary care?
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  Dr. Samira Naime:
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  I would say top three, let's say top three, to have something,
• 0:49
  you know, to be managed.
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  First one, I would say concerns for sleep apnea.
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  Obstructive sleep apnea is definitely up there.
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  The second one would be insomnia, so trouble falling asleep or staying asleep.
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  And then, the third one would be sleepwalking.
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  Just to kind of dive in a little bit.
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  So, you know, as far as how much can a pediatrician do or
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  what workup can be started.
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  So, I would say for concerns of sleep apnea, usually, snoring is the main
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  concern or the main symptom, and it's just like occasional snoring,
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  not persistent, not associated with like pauses, gasping, nighttime
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  awakening, just like, "Oh yeah, my kid snores," and it's mostly when they're
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  congested or during allergy season.
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  I think that's fair to say you don't need a sleep doctor at that point.
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  Maybe observation and a trial of like an allergy medication, like a nasal steroid
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  if it's like during allergy season.
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  But otherwise, if there is snoring and something else, usually pediatricians
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  are good about like referring to sleep medicine, which is fair.
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  There are some limitations of how much you can do in your own practice.
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  But every now and then, if you're able to order a sleep study and get the
• 2:02
  process started, some labs will allow like outside pediatricians to order
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  studies, so that's something they can start if they feel like there are multiple
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  symptoms concerning for sleep apnea, and they want to start that process.
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  Some of the labs are closed lab, what we call closed lab, meaning they have to
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  see a physician that works in that lab, like a sleep medicine physician that
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  works in that lab to be able to initiate the process in ordering a sleep study.
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  For insomnia, trouble falling asleep and staying asleep is very common,
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  and I kind of think about it twofolds.
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  I think about it in the younger kids.
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  The babies that need their parents to fall asleep or wake up and go to their parents.
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  And you have the older teens where electronics or different maybe mental
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  health disorders contributing to their insomnia, like just different things.
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  But I think, overall, insomnia is something pediatricians can work on for
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  sure in their clinic, especially when it comes to making sure kids or teens
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  have a proper sleep schedule, consistent sleep schedule, bedtime routine.
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  Some of those "sleep hygiene" that lots of pediatricians
• 3:14
  go through in their clinic.
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  I think that's very, very important, more than you can even imagine,
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  and will be helpful with insomnia.
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  Because most commonly, insomnia is really treated with non-medical interventions,
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  so really behavioral interventions and, with sleep psychology oftentimes as well.
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  So, I would say that's something that can be started at pediatrician's office.
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  As far as like the third common cause that I get in my sleep clinic, sleepwalking.
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  So, sleepwalking is usually something not to be too worried about, and the
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  most common treatment is education to the family, reassurance, unless
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  sleepwalking is associated with symptoms that are concerning for sleep apnea.
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  A kid who sleepwalks and has snoring, witnessed apneas, sleep
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  apnea can trigger these episodes, can make them more frequent.
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  But if the kid is only sleepwalking and have no other concerns, really
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  the main thing that is needed in this case is education for the family,
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  reassurance, telling them, "This is okay.
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  It happens," especially if it's in that, you know, age range, that eight to 12 or
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  around those if there's a family history.
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  The big thing in this case is making sure kids are safe.
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  So, locking doors, locking windows, making sure no harm is going to
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  result from their sleepwalking.
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  Not sleeping in the top bunk bed, sleeping on the ground
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  floor, things like that.
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  So, that's definitely something that pediatricians can tackle in their offices.
• 4:49
  Host: Thank you for walking us through some of the most common sleep concerns.
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  What are some key red flags that should prompt a referral to a sleep specialist?
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  Dr. Samira Naime:
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  So, to me, red flags is, like, really something very crucial or
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  absolutely needs to be done, like, kind of almost an emergency for me.
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  A real red flag, I would say, in sleep medicine would be someone with excessive
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  daytime sleepiness despite having a good or reasonable sleep schedule.
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  So, a kid who sleeps the normal hours or what you expect for
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  their age, and then they still fall asleep any chance they have.
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  They might fall asleep in a birthday party.
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  This is unusual for, like, a little kid who's so excited to
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  go and play and just be active.
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  Or maybe an older kid who falls asleep in a theater.
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  I don't know, they're going for a play and they've been looking
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  forward to it, or a concert, and then they fall asleep in the concert.
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  These are situations that are unusual, and if it does happen, it
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  should definitely trigger something.
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  I'm like, "Okay, you need to see a sleep doctor."
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  You know, conditions that I'm thinking about are like, is this narcolepsy?
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  Is this idiopathic hypersomnia?
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  Like, what's going on?
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  The concern would be if it is narcolepsy, especially with cataplexy, which might
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  not show up at the very beginning, there is a safety issue there.
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  You know, you don't want a teen behind the wheels or even a child or
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  a teen that is swimming, for example.
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  If they do have an episode of cataplexy, like, that can be detrimental.
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  So, this is, for me, a real red flag.
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  So, it's the one extreme.
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  Another red flag, which is probably more likely to happen than narcolepsy,
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  since narcolepsy is rare, thankfully.
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  I mean, we really don't know the exact numbers for narcolepsy, especially in
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  pediatrics, because the numbers are all over the place, but it's not very common.
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  The other thing that might be seen more often is failure to thrive.
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  So, like, if a child is having problems with gaining weight and there are
• 6:53
  concerns for sleep problems, then that would be another red flag.
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  Usually, it's with severe sleep apnea.
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  Usually, it's, like a younger child.
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  I would say, if it's a young child with failure to thrive, I would be
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  concerned or at least think of if there's any sleep disorders that are
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  contributing to failure to thrive.
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  Host: That makes sense.
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  What are some initial things that families or pediatricians can do as
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  they're doing the initial evaluation or screening in their clinic?
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  What do you recommend for primary care physicians?
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  Dr. Samira Naime:
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  So, I think over the last 10 years or so, there is a bigger awareness in the primary
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  care setting about sleep disorders.
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  So, I think overall pediatricians are doing a very good job about screening
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  for sleep disorders or sleep apnea, one important thing I would say is checking
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  on sleep habits and sleep schedule.
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  We know electronics and social media and all that stuff is a big thing these days.
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  So, I think, not just like, "Hey, are you snoring?
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  Do you have pauses, gasping?"
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  But also kind of looking a little bit into their sleep habits, sleep schedule.
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  Is there any bedtime routine?
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  And that's important across all ages, to be honest.
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  Insufficient sleep and, like, sleep deprivation is very common these
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  days for a lot of different reasons.
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  And I feel like part of it is probably the lack of knowledge of how important
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  sleep is and thinking that maybe I'll catch up on the weekend or, if my child's
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  not falling asleep in school and is not in trouble and they're doing well,
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  then we're good and we're in the clear.
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  So, I think just making sure that, overall, kids are getting sufficient sleep
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  and not three or four-year-olds staying up till 10 in the evening or 11 in the
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  evening and having to wake up for school.
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  Some of the things that we see sometimes is not normal, even if
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  it's not affecting them at that time.
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  Host: That makes a lot of sense.
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  What are a few simple evidence-based interventions pediatricians can
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  start with their patients today?
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  Dr. Samira Naime:
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  I keep going back to it just because it's very important, but I think just trying
• 9:11
  to prioritize sleep and, like, educating families on how important sleep is.
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  Sleep is important for all your organ systems.
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  It's important for learning, memory consolidation.
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  It's important for immunity.
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  It's important for mental health.
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  It's important for growth.
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  So, I think starting that process early on and trying to teach families
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  about how important sleep is and prioritizing sleep when possible.
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  And then, advising families to start simple bedtime routines,
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  even in your infants, starting early, doing something simple.
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  It doesn't have to be an elaborate 40 minutes or an hour.
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  Even if it's, like, a 10-minute routine that families can squeeze in depending
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  on their schedule, just to have this repetition of the same routine every day,
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  simple, consistent, does help kids give them that sense of security and safety.
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  They know what to expect.
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  Even if your kids have complex medical issues or they have some developmental
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  delays or maybe they have some autism spectrum disorder, it can
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  be beneficial, that repetition, the cues that they use at nighttime.
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  So, those things are very important, and I think starting early on can be
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  a big win in the long run, as opposed to waiting until problems occur and
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  then trying to counsel them on all the turn off the lights at night and have
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  no noise and no TV and no electronics.
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  So, I think starting the process early and educating them is important.
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  And the tips that they give might evolve as the kids grow.
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  But just starting early, even in infancy and the codependency, trying to avoid
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  that if possible, and just be there and counseling them from the get-go.
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  Host: Thank you for sharing some of those interventions.
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  Is there anything that a family can do if they are anticipating a shift
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  in some of those cues or routines?
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  Let's say there's a road trip or a move.
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  Do you have any recommendations for some of those interventions
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  that pediatricians can guide families during times of transition?
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  Dr. Samira Naime:
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  If it's a trip, like a vacation, short-lived, the time
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  difference can play a role.
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  So sometimes you just have to pick and choose what is priority and,
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  like, at least try to keep some normalcy in there might be helpful.
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  If a transition is something that's going to—let's say, different households, right?
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  Like moving houses or maybe having two separate households when
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  before you had one household.
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  So, if that's the case, I think the routine or having at least some
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  similarities in the routines in both households would be very important.
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  If both parents can do something similar for bedtime routine just so that the
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  kids know what to expect, I think that would be a good thing to do for the kids.
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  And it would be beneficial for them to know, "Okay, my boundaries
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  and my routines are the same."
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  And so, I can't just stay up all night in one household and then have
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  strict rules in the other because that can also contribute to developing
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  some issues when it comes to bedtime schedules and sufficient sleep.
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  Host: That makes a lot of sense.
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  What's one common misconception about pediatric sleep that primary
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  care physicians should rethink?
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  Dr. Samira Naime:
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  I think knowing that teenagers tend to have a biological clock that shifts to
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  a delayed phase, meaning that most kids, once they become teenagers, they tend to
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  want to stay up later and sleep in later.
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  And that's really, like, built into your biological clock.
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  And so, kind of knowing that and being aware of that, I think is important
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  because it's not just a teenager who's being lazy and doesn't want to wake
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  up in the morning or sleeping through the classes because they choose to do
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  so or being rebellious or whatever.
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  Teens do tend to shift.
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  And so, their bodies usually tend to want to sleep late.
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  And then, unfortunately, with most high schools starting early, in the
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  morning, they have to get up, so they're not getting the amount of sleep
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  needed, which can cause trouble waking them up and falling asleep in class.
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  So, I think that a teenager with daytime sleepiness or sleeping in class, I
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  think one important thing for them is to see are they getting enough sleep?
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  So, it's not always a sleep problem per se, but they might be getting less
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  sleep than they need because of that shifted biological clock or what we call
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  delayed sleep phase disorder or syndrome.
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  Host: Thank you for teaching us about that.
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  I had no idea there was a delayed shift for teens, so they obviously
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  deserve so much more grace.
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  I appreciate you sharing all of this with us, Dr.
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  Naime.
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  Is there any recommendation or anything that you think we should
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  keep in mind, especially with all this new sleep technology
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  recording your sleep, using apps.
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  What are your thoughts on sleep and technology?
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  Is that something that has been useful in your experience?
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  Dr. Samira Naime:
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  Lots of people know more about their sleep because of the technologies.
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  However, a lot of these technologies out there, we don't have robust scientific
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  data to verify how accurate this data is.
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  So, it's good to know.
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  It's like some people like to know, but take it with a grain of salt.
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  So, if there is a real concern, discuss it with your primary
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  care physician or provider.
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  Talk to a doctor or specialist more before you start getting convinced
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  that you have a sleep problem and that it needs to be treated.
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  I occasionally every now and then get someone who's like, "Oh, my Fitbit
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  says I move this many times," or, "I don't think I'm sleeping because
• 15:02
  it says, I got this many hours."
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  So, we don't really know exactly how accurate this data is.
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  So, take it with a grain of salt.
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  Talk to your specialist for sure.
• 15:13
  Host: Thank you so much.
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  It was a pleasure talking Pediatric Sleep 101 with you.
• 15:19
  And as a reminder to our audience, claim your CME credits after listening
• 15:24
  to this fascinating episode today.
• 15:26
  You can do so by visiting cmkc.link/cmepodcast
• 15:33
  and then click the Claim CME button.
• 15:37
  If you enjoyed this podcast, please share it on your social channels
• 15:41
  and check out the entire podcast library for topics of interest to you.
• 15:46
  I'm Dr.
• 15:47
  Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast.