Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.
Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon. Today, we’re talking about sleep hygiene in children.
Dr. Segeleon, tell us why you chose this topic.
Dr. Joseph Segeleon: Thanks. I’m just incredibly excited about this subject. Well, the simple explanation is that everybody sleeps. You hear so many parents talk and about getting their kids to sleep. How can I get my kids to sleep better? And right, we recognize how important it is for everything, for learning and for playing and for growth and health and yet it becomes a topic that a lot of people talk about. I think sleep as a topic is so incredibly important and for us to have a sleep specialist that we can call on as a resource for information, and his expertise is just really exciting. And I think our, our listeners are going to be really excited to hear what he has to say.
Host: And speaking of let’s welcome Dr. Arveity Setty. Dr. Setty, welcome to the conversation.
Dr. Arveity Setty: Thanks for having me here today. I’m excited to talk to you.
Dr. Segelon: Dr. Setty, it’s really great to have you here today, you know, before we begin, I think I shared with you earlier. I did critical care for 26 years, and I don’t really think I knew a pediatric sleep specialist. So for our listeners, tell us a little bit about the training and how you become trained in pediatric sleep.
Dr. Setty: Sure. I did my residency in Flint, Michigan. I was already a pediatrician before I moved to United States from India. And after that, I chose to do sleep medicine mainly because I was very interested in sleep medicine. And during my residency training, I used to shadow a lot in neurology and I used to read sleep study because the attending was also a sleep physician. It was very interesting to see all those way forms, which looks like worms. Obviously it took me about three to four months even to understand what those stages of sleeps were. But then I chose to go to Cincinnati Children’s, but continued my sleep fellowship planning there.
Dr. Segelon: Well, fantastic. We are just really fortunate to have you, so I’m going to get right to it because I know people want to, it’s the good information here as a provider, parents are always talking about how can I get my child to sleep? How can they sleep better? So, as a provider, what kind of information and advice can you give parents to foster good sleep hygiene?
Dr. Setty: Well, it’s always challenging to put a child bed if they do not have a very good sleep hygiene. So, I guess the question is what is a good sleep hygiene? So yeah, but a good sleep hygiene is which helps a child or a body to understand – or get a cue to the brain – that this is sleep time, and the brain starts secreting melatonin. So melatonin it’s very essential for us to understand the whole melatonin secretes. So we can talk about a sleep hygiene and how this is related to that. Melatonin is one of the earliest sleep chemical, which rises in the brain, and then all the other sleep chemicals go based on what the melatonin does. So usually melatonin is at its peak before you fall asleep and it stays peak for about few hours and then gradually it goes down. So, assume that you go to bed at 10 o’clock. So melatonin will be at its peak and by in the morning, when you wake up at, say, for example, 7:00 AM. So if you have gotten a good sleep quality of sleep and also a good duration of sleep, then melatonin will be at its lowest level at the time. But melatonin is pretty sensitive to two important things. It maintains a circadian rhythm, which we know that for sure. So the circadian rhythm depends upon the wake-up time, not necessarily the bedtime. So wake up time is more essential compared to the bedtime or the water important for a sleep hygiene don’t get me wrong… but it is the wake-up time, which is more helpful. So on weekends, some people try to go to bed a little later because they’re watching movie or maybe Super Bowl, whatever it is, but they still need to maintain their wake-up time at the same time so that the circadian rhythm is sinking to them. So the second reason melatonin is sensitive to is blue light. Now in this technology world, I mean, you can’t live without technology in this world, so you definitely need technology, but at the same time, you should be mindful of this technology at least one hour before you go to bed. So blue light, which is emitted by screen, it should be, it could be any screen. Doesn’t matter how big it is. It could be a small watch like your Apple Watch. It could be in the movie theater. So irrespective of that, the melatonin can be completely suppressed if you’re exposed to blue light. So when we say a blue light, it’s basically mostly for adolescents and teens, but nowadays, even anger kids have their own cell phones, but most importantly, in kids’ bedrooms, usually they have a projected glides which are blue colored, sometimes like a, imagine a Spiderman type of projected lights. But they’re real literally exposing them to a blue light. Now that is not very good. So stopping blue light exposure one hour before bedtime and do some relaxation techniques, which will be very helpful. In adults, we always talk about relaxation like mindfulness and all those things. But in kids, usually a family time is extremely important because they are, kids are going to school and parents are working, so they have very little time to spend as a family. So the family time is really very helpful. It builds a bonding between them, but it also helps them calm down. So they are not exposed. Now nobody’s exposed to blue light with this. So that is very helpful for them to calm down and then go to bed.
Now. So, as I said before, you should have a bedtime routine too. Now, a bedtime routine, it’s up to a family and how they want to do, but we always talk about the ‘Rule of B’s: book reading, brush, bath and then bed … but they could do it in any way. It does not have to be this it’s just like relaxing before they go to bed. For some reason, shower usually helps them to calm their body down because internally, the body cools down when you’re taking a warm shower because of the blood vessels on the skin dilate and more blood flow onto the skin. So internally it cools down. So that is helpful for the body to relax and then it fall asleep. So if they have a bedtime routine, they need, if they don’t have one, they have to have one. And in a same fashion is what gives a cue to the brain. And that is when the melatonin starts secreting. Now, if you have a bedtime routine, but it is very inappropriate. I mean, you do however you want on it everyday, but you think that you’re doing it, the brain may not be getting any cues. So it does not know if it’s has to secrete melatonin. So that may be hard for it.
Dr. Segeleon: You mentioned blue lights. And I just happened to, to think about it myself. Every night before I go to sleep, I use an electronic book reader. Does that decrease melatonin?
Dr. Setty: Well, there is a lot of talk on this, I mean good and bad because if you’re using any other screen apart from Amazon e-reader, I would say so only that that is a different technology I have read, and it does not emit blue light, like Kindle e-readers. But I’m not sure about it because I also read some other information that it’s stating that it doesn’t matter, even if it is an e-read or they emit blue light. Most what I have read is it does not emit blue light, but it’s always better to be safer and reading a regular book rather than an e-reader.
Dr. Segeleon: Well, great. That’s good. That’s good to know. As we’re talking about sleep hygiene, I, the thought just occurred to me also. And I know there’s so many different ages that we can talk about, but what about naps do daytime naps affect nighttime sleeping and when for our providers out there that have young children in that come to their primary care clinic, toddlers, and then early school age, what’s the story with naps?
Dr. Setty: Well, that’s a pretty good question. So maybe I left melatonin pathway in between, so to continue with that. So now when you wake up, say around seven o’clock, so melatonin will be at its lowest level. So as the day goes by, it starts to creep up a higher and higher and higher. And by the end of the day, when you’re trying to fall asleep, obviously it is at its peak. So it will help you fall asleep, provided, you know, you did everything right. When you take a nap, so that melatonin, which was creeping higher and higher is going to fall down. So to creep up again, it’s going to take longer time. So that is why we discourage taking nap, unless it is very essential for your job where you take a power nap for about 15, 20 minutes, or if you have a narcolepsy. So we recommend them taking a scheduled naps. Otherwise after five years of age, we never talk about naps in any other situations. And we call that a biphasic sleep, because you should have a uniphasic sleep. You just go to bed one time and just wake up, and then you’re not going to look at bed. You should not be doing that, but less than five, yes, they do take a nap. But statistically, with the current information we have, about 50% of the kids give up nap by two years. And about 85% by three years, about 93% by about four and about 99.9% by five years. There are still a few kids who actually take a nap, but I still think it is inappropriate unless it is situation driven.
Dr. Segeleon: Wow. Okay, great. Good to know. I can even remember that if you’re over five, no naps? Okay. I can remember that. You know, we talk about sleep hygiene and that was great information. Do kids get insomnia? Is that an entity in children?
Dr. Setty: That’s right. In fact, actually about 50% of the kids I see in my clinic is insomnia. Now there are different types of insomnia. Now, most people think it’s primary insomnia, which is just there almost since birth. So there is no precipitating cause, but that’s one of the greatest insomnia I see. I do not see them at all. It’s it’s almost very rare. But then what is the most communist insomnia do I see in kids? Well, depending upon the age, behavioral insomnia is the most common. Out of 50% of the kids I seen in the clinic, I would say about 35% of behavioral insomnia. And most of them are association type. Now there are two types of behavioral insomnia. One is association type. Now you might have seen many kids associate themselves with some toys or some teddy bear. They want to snuggle with it or a blanket or whatever it is. They want to snuggle with it. They’re associating with the toy or a blanket to go to bed. And that helps them fall asleep easily. But when they start associating themselves with a parent or a guardian or some human being, now this becomes trouble. Now, usually by about six months of age, if child sleeps in a different room than you would not see this problem, if parents tried to help the kid, whether with respect to rocking or putting them on there on, you know, to help them fall asleep in any manner, even laying down next to a kid, patting them until they fall asleep, whatever you do. But if you are present, when the child is falling asleep, the child assumes that you were presence is necessary for me to fall asleep. So by about six months, until about six months, it should be usually fine. It’s not a big deal. But after six months, if you, your culture is different than like me in my culture or kids sleep with us. So that’s a different story. But if there’s no problem, right, if your kids sleep with you and the kid is not kicking you in the bed, then that’s fine. You sleep, right? But here, the culture is different. So they want the kid to be sleeping in a different room. If that is what you want to do, then the kids should be left to sleep on his or her own in their own bed by six months of age. Every month after that, it gets tougher and tougher. So usually I see them by about two years or one and a half year by then, it is solidified. It’s very difficult to get rid of this behavior. So that is association type of behavior Insomnia.
Now, limit setting is, as the name says it is limit setting. I mean, the parents don’t have pretty good limit. I mean, yes, this is common. When I see parents are very relaxed, our parents are separated. The child, you know, spends half of the time in a mom’s house off of a time in dad’s house, in one location that is no rule, other location, there’s other role. So they get confused. So there is no limit for them. So usually how do you see this? You see this probably around like eight, nine, 10, 11, 12 years of age kids where they go to bed, but 10 minutes later, they’re out. I want a glass of water. They’ll come out. I want that. I want this. So, you know, I mean, you know, he’s fooling around. I mean, it’s, it’s not true. You don’t need it. You’re healthy.
Dr. Segeleon: I’ve seen that action before, by the way.
Dr. Setty: So that is limit settings and that’s easy to fake. So I do not see most of those things because I’m pretty sure PCPs talk about that. And parents also understand, you know, we don’t have a limit, so, you know, they have to change it, but we have insomnia something very common for me to see.
Dr. Segeleon: What about the teenager that has insomnia?
Dr. Setty: The number one cause for teenage insomnia is inadequate sleep hygiene, especially as we talked about, like with the technology and advancement, and now even with COVID, you know, they have to do homework on the computer. Some may be unavoidable, but mostly it is their willingness to look into the form of Facebook or Twitter or whatever they are doing. They want to do it until they fall asleep. So that is inappropriate obviously. So that is inadequate. Sleep hygiene is the number one cause, and it is increasing in incidents. The number two cause is anxiety and depression. So in adolescents that is a number two cause in most situations, when I see a kid, actually I had to refer them to psychiatry because they have all the symptoms of depression. So we about 85% of the kids with depression, usually present with some sort of insomnia because that may be the primary or primary symptom. That is the first symptom anybody could see, but they are seeing only as insomnia, but they are, somebody is not seeing through that this child actually has a depression, even anxiety. I mean, when they always think excessively like for BR panic anxiety, whatever it is, if they are thinking excessively on the same topic, they just can’t fall asleep. They’re worried about it. So the other insomnia, there are many other insomnia per like us central sleep apnea, like restless leg syndrome or even obstructive sleep apnea. So those are all solid sleep problems, but you will definitely see other symptoms, not just insomnia in those kids,
Dr. Segeleon: Since you brought up apnea, I think let’s, let’s go ahead and talk about that a little bit. We know in the adult world, we, you know, a lot of people are on CPAP for obstructive sleep apnea. As a provider, what should I look for in children that I might suspect obstructive sleep apnea?
Dr. Setty: That’s a pretty good question. So the incidence of obstructive sleep apnea is much more than what anybody could imagine in kids. It’s about 1% to 5%, depending upon which article you’re looking to but that I think is pretty huge. That means 1 to 5 out of every hundred kid has obstructive sleep apnea. When I looked into the incidents too, I felt it was too much. That’s a lot. So there is no way that a PCP should be missing to ask these questions. So obstructive sleep apnea symptoms are very similar to in adults. There is no difference. They usually will present with snoring, apnea, gasping, very restless, sleeping, mouth breathing, and non-restorative sleep. It doesn’t matter how long they have slept. They still wake up very tired in the day. In the daytime, they could be depending upon the age. It is again, a consequence of sleep problems is less than nine to 10 years of kids, they usually present to us as hyperactivity. After that they usually present to us as sleepy. So if somebody is diagnosing a child with the ADD’s, do they want to make sure that they are not dealing with sleep disorders because any type of sleep disorder can present to a provider as ADHD. So that will be a wrong thing to diagnose us without ruling out any sleep issues. So, in general, sleep apnea is diagnosed by sleep studies, but not everybody needs to undergo a sleep study. Why? Because we know tonsils and adenoids physiologically enlarge in size by about four to eight years of age. And they shrink in size because of lymphoid tissue growth. So tonsil centered are pretty good size. They are going to obstruct the operator way. So it’s easy for the provider to send these kids to ENT for tonsillectomy and adenoidectomy.
So then what is the role of a sleep physician? Well, for us, we would like to do a sleep study for everybody who has suspicion for sleep apnea But being only one in the whole of Sanford Health network and our sleep center being very busy. So we do not want to do it. And also it adds onto the cost also now based on American Academy of Otolaryngology, if they have all the symptoms of sleep apnea, which we discussed and also data and behavior and if the child is more than three years old and less than I would say about 9 to 10, because after that, the success of tonsillectomy and adenoidectomy is not great. So I wouldn’t usually refer any child after eight, nine years of age to tonsillectomy… which you might have seen too many adults. They have undergone tonsillectomy, but it doesn’t really help them. Sometimes yes, but most of the times it does not. So, so if these kids are in between these age groups and they’re healthy and the tonsils are big, you can directly refer those kids to otolaryngology to get an operative assessment. And if appropriate, let them take a transistor adenoids. About six to eight weeks later, if they still have symptom of sleep apnea, then they have to come to the sleep center for a sleep study, because that means the symptoms probably are better, but not to an extent that we would have expected. Great. So the other kids whom you should definitely not refer them to us is less than three year old kids because of high risk of surgery, bleeding disorders clearly official malformation because it may be affecting the operator but you don’t want to intervene unless you really know it needs an intervention. Cardiopulmonary issues. So if they have obesity, I mean, you know, the primary reason for them to have obstructive sleep apnea is because of the fatty tissue surrounding the neck. So even if you take out the tonsils, it might decrease the, you know, a symptom of sleep apnea but I do not think it will completely go away. So somebody whose BMI is much significantly higher, more than 95th percentile. So it’s appropriate to do a sleep study for them to
Dr. Segeleon: Great. Well, thank you. And I think you hit upon as primary care provider who should be referred to you. As I was thinking about this podcast today, I heard something the other day that I said, I’m going to run this by Dr. Setty. So I heard something that was interesting to me and it basically and I think it was in probably some very scientific journal, like like on, on the TV news or something like that. But it was basically what it was saying was if you wake up prior to your alarm clock going off, you have had enough sleep. You’ve your body is saying it’s time to get up. That fascinated me because I seem to always wake up before my alarm clock. So I’m looking for reaffirmation here from you. So is that, is that a reasonable comment?
Dr. Setty: The role of sleep is restorative. So in that terms, if you wake up early and if you’re fully restored and you are not tired in the day until you go to bed, then probably that duration of is sufficient for you. Now, National Sleep Foundation is the best place to look for the duration of sleep for the age. Now, although they give a, a range of sleep duration, I’ll say for example, 6 years to have a 13 year old kids need about 9 to 11 hours of sleep. Not everybody gets 9 to 11 hours of sleep, right? But that is just a gauge. And so you have, you know, a range. But I have seen many kids in my practice they need about 11 hours of sleep otherwise they won’t perform well. We have done actigraphy, we have done sleep studies, nothing came up. But if the child sleeps for about 11 hours of duration, he performs great. So that is his need of sleep. And also, I have seen many kids who just sleep only for seven hours. So reinforce them, you know, you have to, you have to get more duration of sleep, but they don’t because he won’t sleep child wakes up in the morning and he is absolutely fantastic, does great in school… So why do worry about that? And so, yeah, the important role of sleep is restorative. So if you’re restored, you’re good.
Dr. Segeleon: I like that restoration. That’s, that’s a good way to think about that. And, and, and it’s true that consistency matters as well, correct? That’s right. So you shouldn’t really sleep 12, 15 hours on the weekend, right?
Dr. Arveity Setty: You bring up another good point too. So you cannot make up a lost sleep. For example, if you lost sleep last night and probably are going to lose sleep tonight, you probably will make it up by sleeping longer tomorrow but not after that. So most kids are adolescents. They think, you know, I’m going to sleep for 15 hours, just like you said on the weekend. So I can make up for all those lost sleep I had the day will not recover that they probably will be called for Thursdays and Friday night’s sleep, but not, but not all the lost sleep for the week.
Dr. Segeleon: I think quite frankly, I think I could talk to you for hours about this. This is such a great topic and we might have to have you back for a part 2, but I want to thank you so much for for your expertise and for your advice. I know that sleep is so very important. You know that as a parent, your own sleep is important, your child’s sleep is important and I know our providers out there get lots of questions. So we really appreciate you.
Host: Thank you, Dr. Setty. Our Called to Care Podcast series focusing on children continues right here with our own Sanford Health experts. Thank you for being here today. We’ll see you soon.
Posted In Children's, Physicians and APPs