July 8, 2024 • 56 mins
In this episode of the Sleep Edit, Craig and Arielle are thrilled to welcome Dr. Sujay Kansagra of Duke University to discuss the weird and wonderful world of parasomnias, restless leg syndrome, and restless sleep disorder in children. Parasomnias include NREM parasomnias (sleep walking, hypnic jerks, night terrors) and REM parasomnias (sleep paralysis and nightmares).
- 00:00 Introduction and Disclaimer
- 01:09 Parenting Anecdotes and Guest Introduction
- 02:22 Journey into Medical Social Media
- 05:21 The Importance of Engaging Content
- 10:50 Understanding Parasomnias
- 15:25 Non-REM vs REM Parasomnias
- 24:26 Night Terrors and Sleepwalking
- 28:17 Fever Dreams and Sleep Disruptions
- 28:58 Genetic Predispositions and Sleep Studies
- 29:21 Scheduled Awakenings and Melatonin
- 30:23 Nightmares vs. Night Terrors
- 31:39 Sleepwalking Safety Tips
- 37:43 Understanding Restless Leg Syndrome
- 48:58 Restless Sleep Disorder
- 53:38 Final Thoughts and Parenting Advice
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
Welcome to the Sleep Edit, apodcast devoted to helping tired
kids and parents sleep better.
We focus on actionable evidence-basedsleep advice, so everyone in your
home can sleep through the night.
Now, a quick disclaimer, this podcastis for general informational purposes
only and does not constitute thepractice of medicine, nursing, or
other professional healthcare services,including the giving of medical advice.
(00:27):
No doctor patient relationship is formed.
The use of this information andthe materials linked to this
podcast and any associated videocontent are at the user's own risk.
The content on the show is not intendedto be a substitute for professional
medical advice, diagnosis, or treatment.
Users should not disregard ordelay obtaining medical help for
(00:51):
any medical condition they have
or that their children may have,they should seek the assistance
of their healthcare professionalsfor any such conditions.
Nothing stated here reflectsthe views of our employers or
the employees of our guests.
Enjoy the show.
Okay.
I am just doing the very important
(01:11):
work of giving my 13-year-old morescreen time on the Xbox, so he at
least is not screaming during this.
Oh yeah.
as I say, not as I do inthe world of parenting.
So listen, let's
get started from the top.
welcome back to the sleep edit.
I am Dr.
Craig Canapari
I'm Arielle Greenleaf.
it is my great pleasureto welcome my friend Dr.
(01:33):
Sujay Kansagra on today.
He's a pediatric sleepdoctor and neurologist.
He attended Duke for medical school,went to UNC for residency and
fellowship, and made, a triumphantreturn to Duke afterwards.
Lost some friends duringthe transition, but yes.
I gotta tell you, man,
as a lifelong UConn basketballfan, I've got wild beef with Duke.
(01:53):
Yes.
I can understand that.
Listen, people ask menow, who do I support?
'cause UNC is where I started asan undergrad, and so the basketball
allegiance still lies there.
But for medicine, I'd cheer for Duke.
I still remember UConn losingto Duke in 1990 the first
time they made the tournament.
I remember UConn beatingDuke in the finals.
This was probably 1999, 2000.
(02:14):
we were very excited at UNC for your win.
Oh yeah.
And let me tell you that everytime I've won a basketball
pool, it's because UNC has won..
Yes.
I just wanna talk a little bit aboutyour online presence, because when
did you start med school advice?
'cause that's how youfirst came on my radar.
This is like the original backwhen, the day we called it Twitter.
(02:35):
I was still a resident.
I was a child neurology resident andwe were talking earlier, this was
really the wild west of social media.
Folks in medicine were just getting
their foot in the door and learningto navigate the social media
channels.
And back then my goal was justto give, just advice because
I grew up having an older
sister that went to medicine thathelped guide me and I'm like a lot
of people that don't understand,what it takes to consider medicine,
(02:58):
what a life in medicine is.
So I started blogging in 2012and I felt like at that point
it was already too late, right?
Because there were already likepeople out there who have been doing
it since the early two thousands.
I think Howard Luks was on fromlike the 1999 or something.
when your pediatric sleep bookcame out and it's great guys.
You all should buy it.
(03:19):
My Child Won't Sleep.
A quick guide to thesleep deprived parent.
I'd been blogging for two or three yearsand I'm like, man, this guy wrote a book.
I better up my game here.
Yeah.
Who is this guy yeah, I mean that book,it's funny 'cause I was doing a lot
of the research behind it when I was anew father and I was also reading all
the books that are out there just toget some background information what is
Weissbluth saying what is Ferber saying?
(03:40):
We knew the techniques, but whatdo you have in these 400 pages?
And, part of me, when itcame to the techniques I was
screaming at the book just
tell me the technique.
I already knew the technique,but I'm like, where is it?
These are sleep deprived
parents, I'm like, justwhere's your technique?
And that was the impetus behind the book.
Just give it to them straight.
Give it a step by step approach.
And it's probably too slimmed downbecause unfortunately I glossed over a
(04:02):
lot of the other issues like parasomniasand restless leg and sleep apnea.
It's just
behavioral insomnia approaches.
Cognitive behavioral therapyapproaches for older kids.
Delayed circadian rhythm stufffor older children as well.
Just the core things that you can modifywithout needing a physician sometimes,
I think That's reallyvaluable in just in what I do.
(04:23):
Parents are just, there's so muchinformation and they just need an
answer and they don't wanna siftthrough a million different things.
And I will say those books are greatnow for me 'cause I dig through them
and I look for research and all of that.
But when I was a tired new mom,it was like, Just tell me what to
do like you said, and ultimately Ihired sleep consult because I just
(04:46):
could not navigate my way out of it,
so,
I hear you.
It's tough.
There's a lot of information andpeople don't know who to trust.
everybody can come across with abeautiful marketing presence and be
like, oh yeah, you should trust me'cause look at my amazing graphics.
But, who can you truly trust when itcomes to just vetted, science-based folks?
Because we love using the scienceterms out there on social media
when it comes to sleep, but whois truly, vetting what those terms
(05:10):
mean and whether they apply to that
particular situation.
So yeah, that's why Ienjoy the social media
world.
It's nice to be able to share andhopefully people trust us, like
folks that are dedicated theirlives to helping children
with sleep.
Well, Sujay, you're very modest, Butyou've amassed a huge following and
it's because your content is great.
It's very approachable, it's funny.
What, do you think that you've donethat has really resonated with parents?
(05:35):
I think part of it.
Was, attention spans arevery short on social media.
And TikTok actually puts in your face,it tells you like how long people
are logged in every second of time.
And by five seconds themajority of watchers are gone.
They're gone.
And so I'll tell you one thingI've learned is you have to
have that entertainment portion.
Otherwise people arejust not sticking around.
(05:56):
And I have no problem embarrassing myself,I kind of joke, academicians are like,
oh, you're on social media, that's great.
What about all the manuscriptsyou should be writing?
And I'm at this stage in mycareer where thankfully I just
don't care, and not in a bad way.
I'm already full professor, I'mhappy to write more manuscripts,
but I feel like I can have the most
impact on the most
people by sharing
(06:16):
information on social media.
And I saw my admission friends,I'm like, why aren't you on here?
Like
if a video that I post, I can get10,000, 20,000 people to watch it.
Five people are reading thearticles that I write in journals.
Like two of them are thereviewers, so that's, so
entertainment I think is important.
So getting back to your questionand I think just getting the core
of the issues that are on people'sminds, like the simple topics where
(06:40):
they hear lots of different things.
Melatonin is sleep training harmful?
What do we do aboutnaps and how do we nap?
And I've also tried to appealto a broader sleep audience.
Not just pediatric sleep, but justsleep in general and helping adults
understand that they need to sleep andthe impact a sleep ation has on them.
So topics that have widespread appeal,and then making a fool of myself,
I think that's the combination.
(07:02):
Are there any sort of videos you'vemade that you've been absolutely
shocked at how much traction they got?
Yes, it usually it's around the sleep,like the deep sleep science video.
So I made one about time zones and howthere's this amazing research study
that shows that where you live withinyour own time zone affects how much
sleep you get, and that ends up havingassociative, effects on your wellbeing,
(07:23):
like risk of obesity your productivity.
that was like my first video that blewup across platforms, like a million
views on like 3 million on Instagram.
People really craved the scienceand they were asking very nuanced,
very savvy questions like,oh did they control for this?
what do you think about this population?
And so people out there reallyunderstand the science more than
we oftentimes give them credit for.
(07:45):
And they want it filtered in away that's, I think, approachable
and not in the manuscript formthat takes, an hour to read.
So I was
pleasantly surprised.
And funny enough, the authorsactually of that study found out
and they reached out on Twitterthanks so much for that exposure.
And I'm like, Hey, by the way, myviewers have some questions for you.
we created a video together in responseto the questions that the audience had,
(08:05):
which I think is like the most beautifulway of using social media, bringing
people together, answering questions.
You mean it's not shouting at strangers.
No, that too, that'stotally valuable and valid.
Yes.
but no, there are otherways of using social media.
Yeah.
I think I remember the, I don't rememberwhat it was, but I remember the first time
I got a really mean comment somewhere.
(08:26):
I'm a little bit taken aback, right?
Because I don't think you, you go throughyour life, you try to be a courteous
person and there's certain standardsof socialization that get lost when
people are commenting anonymously.
And one of my friends who was said a moremature social media prevalence, she's
it's just a measure of your power that ifsomeone, you're making someone angry in
some ways, like just, just ignore them.
(08:47):
But I'm sure you probablydeveloped a thick skin just putting
yourself out there like that.
Yeah, absolutely.
And I try, I try to,
I know which posts are gonna generatecontroversy and I brace myself for it.
And then I actually, I try to befriendly as much as possible because
I know at the receiving end, evenif somebody that's trolling me
for me to then engageIn a ill spirited way,
(09:09):
it will leave a mark on themtoo, even though they, they're
gonna keep yelling back and forth.
put that strain on anybodybecause then it affects people's
sleep and their wellbeing.
And I'm a, everyone should sleepno matter how Ill spirit you are
to me on social media, and I'mnot gonna throw that back at you.
Even like the one video that actuallymade me popular on Instagram was
one where I did a clap back tosomebody that was trolling me, and
(09:30):
I was like, oh, this doctor doesn'tknow what they're talking about.
They oppose sleep
training.
And then I made this video that's actuallyno, I do know about pediatric sleep
research because I published a lot of it
and I
did a like, scroll of all my
papers.
I am the researcher was my quote, Iwas being like that's not me usually
being like, arrogant and cocky.
I was trying to actuallybe a little bit funny.
People just ate that up and theyloved it and they're like, what
did that lady say when she saw it?
(09:51):
And I'm like, I neveractually share that with her.
I actually engaged her kindlyon Facebook and was like this is
the data behind sleep training.
and she, shot back a couple thingsabout, we won't mention which group
she was with, but ones that areoftentimes against sleep training,
which I know you both likely had Yeah.
So at the end of the day, I don't engage,even if I've made an amazing piece
(10:12):
of video content that I would love tojust show them, I'm not gonna do that.
Yeah.
I think you.
should have a masterclass onhow to make those videos, man.
'cause they're pretty amazing.
And look, as someone with a backgroundI'm like I just dunno how he edits these.
They're so good.
That's too kind.
I've just become very savvy with all thetools within Instagram and now Cap Cut is
my newest, favorite video editing tool.
(10:33):
I just dunno how you make all the content.
That's the other thing.
It's the funny thing is there aresome pieces that I literally, I'm
like, I've spent two or three hoursmaking this video and editing it and
et cetera, and then I'll make one whileI have a random thought and I'll pull up
my phone and just say it.
And those videos end up doing much better.
So listen, since I, am, notreally a neurologist, I trained
as a pulmonologist and I, do sleepmedicine which encompasses a lot of.
(10:58):
Topics honestly I, wanted to be a childneurologist, but then I changed course.
But we wanted to talk about sometopics that are really, I think, in
the neurology end of sleep medicine.
And we wanna start withParasomnias And I dunno if you
maybe just start off by justdefining what a parasomnia is.
Sure.
Yeah.
So Parasomnias is a group of sleepdisorders and they're typically
(11:20):
characterized by abnormal behaviorssometimes even complex thoughts
or emotions that occur at thestart or in the middle of sleep
or even with arousals from sleep.
And the vast majority of parasomnias arefascinating in that we used to think we
spent the entirety of our consciousness,
either in wake non REM or REM
sleep.
(11:40):
But the majority ofparasomnias actually have
a, mix of elements of two stagesat once, oftentimes both in the
brain of like deep sleep and awake,for example or aspects of REM sleep and
wakefulness which make parasomnias just afascinating category of sleep disorders.
It's funny how much of sleep medicine.
is actually where there's ablurring between sleep and wake.
(12:04):
I think about this all the time innarcolepsy, which is a whole other
topic, but narcolepsy we think of it assleepiness, intruding into wakefulness.
and that's very true, but it's alsowakefulness, intruding into sleep.
And it's like where there's thatdysregulation of these processes,
a lot of problems happen, but alot of interesting stuff as well.
(12:24):
That's right.
We talk about this amazing timeat the transition break to sleep.
weird, interesting things happen.
People can have these hallucinations,like exploding head syndrome.
This phenomenon of feeling likesomething exploding inside your head.
Oftentimes with visual, sensation as well.
Even what we experience like common,like hypnic jerks that sometimes also
have this semi dream-like imagery.
There's just a lot ofweirdness at that transition.
(12:46):
And it's fascinating.
I think there's a lot of mystery aroundthat time and a lot of fascination
with that period.
Yeah.
And just for the listeners, the hypnicjerks are occurring when you're falling
asleep and you have that sensationof falling and you jerk awake.
yes, I think the evidenceis probably pretty weak.
And I think the challenge here isthat stress is so common that you're
bound to see some sort of a link
there, but yes, stress, I've heard,caffeine intake, certainly sleep
(13:09):
deprivation, perhaps can, worsen hypnicjerks, all the things that are very
common in our world, just becauseagain, hypnic jerks are also common,
so I think it's hard to pinpoint.
I feel like that's, a good segue intoSleep talking or somniloquy, which one
of those things like I think in the mostrecent international classification of
sleep disorders, they don't even callit a disorder, which to me is correct.
(13:31):
Like sleep talking is more of aphenomenon than anything else.
I'd be curious how often
parents, for both of you, how
often are parentsbringing up sleep talking?
Not often at all.
, it's like on a questionnaire weadminister in the office, but I
do feel like it the idea that.
it's not a big problemhas percolated out there.
(13:51):
'cause it doesn't seem togenerate a lot of concern.
Same here.
It's only time I end up documenting itis when I have asked about it, and they're
like, oh, yeah, they talking their sleep.
But it's never an initial concern,which, on the spectrum of sleep talking,
if it's a problem such that it'shappening every single night and we
think it's disrupting somebody's sleep.
Then yes it's a problem even thoughit's, quote unquote in the normal variant
(14:12):
spectrum, but, I rarely,one does it rarely come
to me as a primary problem,and two, rarely do.
I feel like it actually ends updisrupting the quality of one's
sleep, just because it's notpervasive enough throughout the night.
and chances are they're, evenwhen, while they're asleep
talking, maybe still gettingrestorative sleep during that time.
we don't really know.
I know that I've definitelytalked in my sleep, but I wouldn't
(14:34):
know, like I'm told it, in the,morning so I'm not awake for it.
My wife tells me I talknot infrequently and.
It's usually things that I'vebeen working on the next day.
She, or the day before, she's yeah,you were working at night too.
I'm like, all right p thatI'm thinking about something.
Yeah.
it's hustle culture, man.
Grind when I sleep, although I havenightmares of still rounding, during
(14:54):
residency, I'm not prepared for rounds,and rounds are about to start, and I'm
like, gosh I remember doing residency.
I'd have those dreams.
I'm rounding in my sleep at night.
When am I not rounding?
It's,
well.
I, I.
feel like my anxiety dreamsgo back to high school.
that was much more of ananxiety provoking time,
Yes.
I think it probably relates to a lot
of people.
But I think for me, that senseof needing to be prepared and
(15:15):
having all the information andthen just the angst on taking care
of patients, I'm likeyou can't make a mistake.
Patient care is at risk.
I think that was probably hardest for me.
That's probably why itcomes back in my dreams.
So Arielle actually said something Iwanted to amplify a little bit, which
is like you mentioned night terrorsas well as talking in your sleep.
And I think It's, important for usto talk about non-REM versus REM
(15:37):
related parasomnias because it's a,really useful part of the taxonomy
when we're trying to figure outwhat's going on with the patient.
Yep, yep.
Yeah, happy to.
When it comes to the core non-REMparasomnias, We think about confusional
arousals, we think about night terrors.
We talk about
sleepwalking, and that's, the majority.
Now there are rare ones,sleep related eating disorder.
(15:57):
In older
folks there's things Like, sexsomnia, sothere are other rare non-REM parasomnias.
But the core are theconfusional arousals,, night
terrors, and sleepwalking.
and I like to think of those asthe non-REM and the characteristics
of non-REM paradigms are typicallythe first third of the night.
Lack of recollection of the event.
Usually the order of seconds tominutes in rare cases can be longer
(16:19):
and characterized by occurringin relatively young children.
We talk about the age range of
three to thirteen as a broad, anddepending on which parasomnia some
occur more commonly when you'reyoung, versus when you're older.
Versus rem
parasomnias, the hallmark is REMbehavior disorder, which in the
pediatric population we rarely seeunless it's associated With narcolepsy.
'cause patients with narcolepsy oftentimesdo have, REM behavior disorder, which is
(16:41):
essentially an acting out of your dreams.
You don't have the normal muscleatonia, the normal paralysis that
you're supposed to have when you dream.
It's a very beneficial and safething our body does for us, right?
It paralyzes us when we'redreaming so we don't act them out.
REM behavior disorder, that paralysisisn't there, or it's partial.
You can also have what we callrecurrent isolated sleep paralysis.
That's also rem parasomnia.
Many people have experienced this,particularly during times of sleep
(17:03):
deprivation, like during college, whereeither right when you fall asleep or right
as you're waking up, you have persistenceof the rem atonia that paralysis.
And so you wake up thinking you'recompletely paralyzed and oftentimes
associate with a sense of dread andfear, and as if somebody's sitting
on your chest like you can't breathe.
We also put that in the REM category, butREM parasomnias tend to usually tend to
happen in the latter half of the night.
(17:25):
particularly dreaming, recurrent dreamingor upon awakening with REM behavior, just
not rem with isolated sleep paralysis.
I wanna just actually talk a littlebit about the sleep paralysis.
'cause it's one of those thingsthat's absolutely terrifying to
someone when it happens, right?
And there's also seems to be acertain flavor to the hallucinations
that come along with it.
(17:50):
So if they're rising out ofwaking up from sleep, we call
them hypnopompic hallucinations.
And these don't seem tobe culturally determined.
And I've heard people commonly saythey see glowing eyes in the room, like
there are animals there, or they feellike someone's breaking into the room.
Sometimes, they'll talk about therebeing an old crone in the room.
(18:11):
It's just fascinating that these thingsseem to be hardwired into people.
Yeah it it's frightening when peopledescribe what they're experiencing.
I've had sleep paralysis once ortwice, and yes, it's really terrifying.
You're like sitting there hopinglike somebody just touches your arms.
You can snap out of
this.
it's, it's terrifying, but to havethat associated with dream imagery, I
(18:31):
never had dream imagery with it, but to
have both together asabsolutely terrifying.
We talk about, hallucinations,like what you're having, right
as you're transitioning to sleep.
And so patients withnarcolepsy oftentimes.
For some reason those involve likealiens or people like in the room.
There's a very similar theme there too.
People have called 9 1 1 because theyfeel there's intruders in the room.
(18:52):
They have
these types of hallucinationsabout the transition to sleep.
So I agree there's probablysomething hardwired into our
psyche that makes us have those,
thoughts.
Yeah.
that doesn't generally happen withthe pediatric population, right?
The
I'm more like adolescents.
Certainly.
Yeah.
In adolescents, there's a peak.
I've seen it down to four or five.
I think the earliest casereport was in a 1-year-old, I
(19:14):
think that was actually at UNC.
They report that it's very hard to pickup excessive sleepiness in a 1-year-old.
They proved it with I think CSFtesting of orexin, which is one
way of diagnosing narcolepsy.
And, you're talking abouta child with narcolepsy.
And of course
like sleep paralysis is very alarming.
If your child tells you have sleepparalysis, definitely worth l
earning a little bit more aboutit, talking to your doctor, but
(19:35):
to me it's if they come in the office with
this history, I'm like are they sleepy or
not?
If they're sleepy, thenwe're looking at narcolepsy
testing.
If they're not,
usually Im reassuring themAnd if it's happening quite a
bit, you could consider somethinglike a course of an SSRI.
I've never had to do that
myself.
So I have a question for you guys.
Narcolepsy, you're talking
about narcolepsy and what
(20:00):
triggers some so I'm thinking ofpediatric, in pediatric cases.
What would trigger someone to, whatwould the child be presenting with to
even start the process of consideringthe fact that it could be narcolepsy?
I'll tell you the typical pathfor me, which is it's usually
disabling sleepiness, it's sociallyimpairing level of sleepiness that
(20:22):
comes on in kind of a subacuteover the course of weeks to months.
And it's usually school issues thatkind of raise the red flag, which like
they keep falling asleep in schooland teachers can't keep them awake.
That's usually the presenting factorwith me, unless they also have cataplexy,
which does occur in a certain portionof children that have narcolepsy in
which they have sudden intrusion ofthat red muscle atonia that can lead to
(20:44):
partial paralysis or actually full body
paralysis.
that very quickly andseek evaluation, but it's
just the disabling sleepinessand they usually already see an
endocrinologist and they've seenan infectious disease doctor by the
time they're 10 years later, finallyget plugged in with a sleep doctor.
The median time to diagnosefrom the time of symptom onset
for children is like 10 years.
It's really terrible that how muchtime is lost for these children.
(21:06):
is our sleep medicine fellows, theymostly come from the adult side and
they're mostly internal medicine doctors.
'cause sleep medicine is a pediatric andadult specialty, and I order a lot of
MSLTs because again, not in every childthat's sleepy if they have snoring or
similar thing that looks like, maybeit's just sleep apnea, but I just feel
(21:27):
like it's a real missed opportunity.
you don't want that kid to come backin five years and you saw them and you
missed narcolepsy because it reallycan change to the trajectory of their
lives if you diagnose them early
Yes,
Did you say S MLTs?
Multiple sleep latency test.
Thank you.
you do an overnight test to make surethey get enough sleep and there's
nothing like sleep apnea, fragmentingtheir sleep, and then you offer them
(21:49):
five nap opportunities the next dayand you measure how quickly they
fall asleep, But yeah I think in general,parasomnias are common, and I don't
want to seem really alarmist to parentswho are listening, but I think one of
the red flags in general is if yourchild is having interrupted sleep at
night and it's very frequent or they'resleepy during the day, I think those are
(22:13):
absolute signs that it is worth pursuing.
We can talk about these differentphenomenon and what are the red flags in
different situations, but I'd say thatregardless of the type of thing that's
happening during the night, those arethe sort of things that get my attention.
Snoring.
Frequent events daytime sleepinessor difficulty in school in general?
(22:34):
Yeah, no, I like all of those.
I'm always focused on thesafety portion as well, and
so I've had situations where the childis currently getting into situations that
can be unsafe, older children that canmanage to get outside of the house, for
example I had a
child that had a two level house andwould always manage to open the window and
actually on a few occasions, climbedout on the roof during a sleepwalking
episode.
(22:55):
and so I'm always thinking, what are thesafety implications of what they're doing?
And then, we're always thinkingabout is it truly a parasomnia?
Because weird things happen in sleep.
And so we're always ruling outsome of the mimics as well.
And we know there can certainlybe just behavioral issues, right?
is it truly a parasomnia
versus is it more of a just abehavioral arousal or awakening?
(23:16):
And then in my mind, I'm always
thinking as the neurologist, I'm like,I can't miss nocturnal epilepsy, which
can present in really unusual ways.
And so I'm also keeping that on the list.
But I agree if something's happeningrepetitively at nighttime and the child is
having any sort of daytime manifestation,or you feel like their safety is at
risk, certainly bring it up at leastto your pediatrician and talk about it.
(23:37):
So from my perspectiveall of that is so helpful.
What I see a lot
is parents in mom groups orwhatever on Facebook, Instagram
saying, I don't know what to do.
My 10 month old is waking at nightand really upset, and I have to go in
(23:57):
there and it's happening every night.
And the response.
It's almost
always night terrors.
Like people are likeall about it being night
terrors.
And it doesn't matter how young,sometimes they say six month olds.
And my understanding is that it's rare.
It's very rare for a baby or young toddlerto be having that kind of parasomnia.
(24:22):
I know nightmares canhappen earlier, bad dreams.
But when do night terrors really startto become more common, I would say.
And then what is theprevalence of night terrors?
Great questions.
I'll tell you what, of all theparasomnias and Craig feel free to
jump in here, but, the confusionalarousal sleepwalking, night terrors
(24:43):
tends to be the least frequent, I'd saysomewhere probably around three to 5%.
I usually think of parasomniasat the earliest, typically like
three and above in infants.
It's not
gonna be a night terror,it's gonna be usually just a
behavioral awakening of some type.
But that's, yeah, that's my take Craig.
And just to, I think fordefining things for people.
(25:04):
Confusional, arousals are where.
A child doesn't leave the bed.
They may sit up, they may talk,they usually don't seem lucid,
but it seems pretty benign.
Like you might notice it if you're onvacation with your child and you're in the
same room as them, but unless you have amonitor, you might not notice this at all.
A night terror is when your kid isscreaming they don't leave the bed but
(25:28):
they have this fight or flight responsewhere they may be sweating, they're
screaming and you cannot console them.
the first time this happens, itis very scary to parents because,
imagine being woken up by someonein your household screaming.
It's not a good feeling.
And I remember my older son usedto have a night terror every time
(25:48):
we went to stay at our in-laws.
Yeah, it's just an excuse,Craig to not go to the in-laws.
So we don't need to goto the in-laws anymore.
my in-laws were lovely, but mymother-in-law had terrible insomnia.
And my father-in-Law, who's not gonnalisten to this, would just sleep on the
couch all night with the TV blaring.
But he would just be screaming.
And my mother-in-law runningand she's what's wrong?
(26:08):
What's wrong?
And I'm like, I've got this.
It's okay.
But it is once you've experiencedit, it goes more from being
something that's really scaryto something that is a nuisance.
If it's happening quite, frequentlyenough that it's on your mind.
Definitely talk with your pediatrician.
'cause any of The disordersof sleep fragmentation.
(26:28):
We think about things like sleepapnea or medical conditions can
trigger these events in peoplethat are predisposed of them.
Not every child
is gonna have sleepwalk or have anight terror, but if you're prone to
that, I think there've been studies.
If you take a kid that's sleepwalking,you set them up at night, they'll just
get up and just motor out of their bed.
So any underlyingproblem, say if they have
(26:49):
asthma that's poorly controlled andthey're coughing, eczema, they're itching,
it's going to make them more
likely to have these events.
and that's why it's soimportant for people to
work with their pediatrician.
now can fevers.
Be a cause of that?
Or is it just illness in general?
Because the only
time my daughter has ever had, she'sonly had two, and they were awful.
(27:11):
And I'm sitting right next to herand she's screaming for me, like
reaching across the room yelling mama.
And it's like heartbreaking.
But she had a fever
both times and I just, maybe that's justone of those triggering events that can
cause Some people talk about emptyingthe bladder before bed can, having to
(27:31):
go to the bathroom cause night terrors.
I'll tell you, it's in my experienceit's a more rare provoking factor.
But, just like Craig said, at theend of the day, when I'm taking
it step by step in clinic, I'mlike, first and foremost, are they
getting adequate, length of sleep?
Because we know sleep deprivationwill definitely predispose you to
having it because you spend moretime in deeper stages of sleep out
of which night terrors tend to occur.
(27:53):
Number two, are there those internaldisruptors, medical issues, reflux,
ear issues, eczema, et cetera sleepapnea, Are there external disruptors?
Is the TV blaring in the house?
Is it a busy street corner?
has the family brought the child intotheir bed because this happened one
time and now it's happening every night
that's causing the, child to havemultiple arousals and poor sleep.
And so any of these things
could potentially predispose you.
(28:15):
But yes, fever illness
for sure.
Weird things happen insleep when you have a fever.
Absolutely.
Is there anything you asdoctors can, do for that?
Because my understanding is that youjust grow out of them, but I don't know
if that's factual or medically factual.
(28:36):
Yeah.
No, Craig I'll take your lead hereabout how much, medical stuff you wanna
share, Because I don't want peopleusing techniques willy-nilly, but I
happy to go over some of the basics of,
I think that if anybody's gonna listento podcast, there are pediatricians and
sleep consultants that listen as Well.
I like to have moredetail instead of less.
So I will tell you that after I'veassessed the sleep duration part of
this to say, Hey, listen, we gottamake sure your schedule is adequate.
(28:58):
if I can't find any internal disruptorsor external disruptors to sleep,
let's say this is a teenager whoout of the blue started having like
night, it's not a typical pattern.
It didn't start when they were young.
there's oftentimes a
family history that we'dthink there's likely a genetic
predisposition to having parasomnias.
So things are occurring outof the blue and the child is
like snoring, for example.
I'm like that's a little bit unusual.
Let's consider doing a sleep studyto make sure we're not missing
(29:19):
any other disruptor of sleep.
But in the absence of any disruptor thatI can find, oftentimes what I'll consider
doing is scheduled awakenings scheduled.
Awakenings has data to support it.
What you do in this is you go inthere about 20, 30 minutes prior
to the time of their typical event.
And you wake them up.
And the advice I like to giveis wake them up enough that they
can say their name and then let
'em go back to sleep.
(29:40):
Just so you know thatthey're relatively fully
awake.
And then let them be forthe rest of the night.
If you do this for two or three weeksstraight in the majority of children, for
some reason, it hits the reset switch intheir brain and these episodes go away.
This includes night terrors,it includes sleepwalking.
Again, as Craig mentioned, thereis probably a role, there's some
data to also support melatonin.
(30:00):
And again, this is something yougotta talk to your pediatrician about.
But there is a role, I think formelatonin, whether it actually gets to
the pathophysiology and the underlyingmechanisms by which this happens.
Or is it just increasingtotal sleep duration?
Who knows?
But there is some data there.
And then I hear people who say that thosethings increase with the use of melatonin.
Or he gets more, he gotnight terrors from them.
(30:23):
Yeah, I'm always curious distinguishingnightmares from night terrors.
Melatonin can certainly cause nightmaresand if in my world, a family links a
particular side effect the initiationof a medication or a supplement, then
we just stop it and see if it resolvesand if it does, and I still think
it's beneficial, we reintroduce andsee if the symptoms come back just to
make sure it actually is causative.
(30:43):
There are some stronger, more potentmedications that I've probably
prescribed like less than fivetimes in my 10 plus year career.
That can also help, but it helps bydecreasing deep non-REM sleep, which
is not something that I like to do
for children.
You
we like to keep themin deep non-REM sleep.
Yeah.
and actually there's just two things Iwanna double click on that Sujay said.
The first step in looking atthese is actually making sure the
(31:05):
child's getting adequate sleep.
Because insufficient sleep is a veryclear trigger of non-REM parasomnias.
And it's very common and we see itsometimes in adolescents where they
had a sleepwalking when they werea kid, it went away, then they hit
adolescents and all of a sudden they'restaying up super late, school starts
too early, or they go to collegeand they have these crazy schedules.
(31:27):
I think that is really importantfor parents to know too.
And sometimes you'll see if yourkid's up super late one night
you're on vacation, it's a holiday,they're gonna have a parasomnia that
night because they'vebeen shortchanged on sleep
a little bit.
But I think just to talk a little bitmore about sleepwalking, where safety
is an issue, for kids that are frequentsleepwalkers, you do need to be really
careful, especially if you're staying in
(31:48):
a location that's different from home.
And I'm thinking of people who arestaying in hotels where there's a
balcony or unfamiliar locations.
I have kids that Sleepwalk intermittently.
And some kids are agitated when theysleepwalk, they might even be violent.
Others are just calm, butthey still get into mischief.
I agree with Sujay, I tend not towrite meds for these kids unless I've
(32:11):
had a few where they're nightly eventsespecially when kids going college or
they've really gotten they've elopedfrom The home they've gotten injured,
other people have gotten injured
Yeah.
Another example is I had a child wholived in a trailer home, had eight other
people in the trailer home with sleepwalkevery night, and wake everybody up, and
it was leading to complete dysfunctionand disarray, and that's the situation.
(32:34):
I said, okay, that probably merits,
The other thing I'd love to emphasize isthat, we've talked about night terrors
versus nightmares, and oftentimes
There's a confusion there.
Nightmares is vivid dream imagery.
Your child is fully awake andtelling you, I'm scared because
I just saw a monster in my dream.
Whereas night terrors, they're notaware typically that you're even there.
And oftentimes if you are there, even if
they're calling for you, they'relike pushing you away and completely
(32:54):
frightened, as Craig mentioned, theyhave that sympathetic activation.
are, they're terrified,they look terrified and they
usually do not remember it.
The next day, if they do remember,it's usually after their night
terror is complete and theywoke up from the night terror.
And then they
might remember that they, but they
typically don't remember the event itself.
And parents oftentimes go to whatjust happened during the day?
What trauma did they experience to start
(33:15):
beginning to have.
night terrors?
And the answer is they didn't, we don'tthink it's actually due to any underlying
trauma or psychological distress,even though it looks very distressing,
like they're truly in distress.
I think that's also important just toprovide some reassurance to families
that it's likely not due to some sortof daytime trauma they experienced.
So let's segue to nightmares then,because nightmares are incredibly common.
(33:36):
I don't think there's anybody thathasn't had a nightmare I don't think we
know when kids start having nightmaresbecause infants can't tell us, right?
we've all had our kids cry in our sleep.
I can definitely remember when my kidswere babies they wouldn't be screaming
their heads off for me, but they this
sort of pious crying.
I'm like, I don't know,maybe they had a bad dream.
It's hard to say,
right?
Yeah.
But as Sujay said, they tendto happen in the second half of
(33:58):
the night and they have a clear
narrative to them.
They have a story, and if someonewakes up from a nightmare or a dream
for that matter, they're lucid.
Whereas if you try to wake someone out ofa non-REM parasomnia, they're coming out
of non-REM sleep, they're often pretty out
of it.
My question about that.
Is it in the best interest Of everybodyto not wake or attempt to wake someone who
(34:20):
is sleepwalking or having a night terror.
Yeah.
People always used to say, do notwake up some of that sleepwalking
thinking that it's gonna hurt them.
But what happens is if you wakesomebody up that's they might
become scared and agitated andfrightened and lash out, et cetera.
and so the usual approach is gently guidethem back to the bed if you can, without
alarming them or being too stimulating.
(34:41):
Yes, arousing them out of the event willstop the event, but perhaps the detriment
of kind of everybody's wellbeing.
'cause they'll be shocked andsurprised and maybe angry.
The first thing I was taught in sleepdoctor school is that if you do die
in your dream, you do die for real.
Oh, stop.
that's, they tell usthat from the beginning,
Oh
Yeah.
Day one.
I've been on alert ever since.
(35:03):
gosh.
I've been mainlining remsuppressive drugs since that day.
Oh, don't do
true kids.
You don't die.
Although I will tell you that if youfeel like you're having dreams of like
drowning or suffocation or you can'tbreathe, you may have sleep apnea.
Anecdotally, I'll tell you,some people do experience this
sensation of I'm being suffocated,recurrent, and you wake up gasping.
(35:23):
It's like you may have sleep apnea,so you may wanna look into that.
it's interesting.
Nightmares in my world are very seldomthe reason someone comes to sleep clinic.
and I think because it is such a commonshared experience that people generally,
Are fairly comfortable with it.
That being said there are certainthings to be aware of that especially
(35:44):
for practitioners that patient, peoplewho've experienced trauma often do
have issues with severe nightmares.
my colleagues who work at the VA withveterans deal with this all the time.
unfortunately there are many childrenthat have experienced trauma as
well.
And I would say to parents, ifyour kid's having a nightmare,
it doesn't mean that they've
experienced some hidden trauma.
The parents almost always know about the
(36:05):
trauma.
It's more important for providersto recognize that if someone's
coming in, they're endorsing a lotof nightmares, they have insomnia.
It seems disproportionate to what youwould expect from what you're being told.
Often if you ask in a sensitiveway, you can uncover with a family
a little bit of a trauma history.
(36:25):
I feel like this is something we justsee sometimes kids with very severe
sleep disruption and nightmares.
they're dealing with something and dealingwith trauma is something that you really
need mental health providers to help
you with.
It's not something certainly thatI feel comfortable dealing with.
not even every mental healthprovider deals with trauma.
You really need experts.
(36:45):
Yes.
Wholeheartedly agree.
We, I think we're,
great at screening because we know therole that it plays when it comes to sleep
overall when it comes to mental health.
And, even, our patients, older patientsthat experience depression and anxiety
and how that's affecting their sleepSo I think we're great at screening
for it, but I agree, we really have tolean on our mental health colleagues
to jump in and help for sure.
(37:07):
I was gonna say we'recoming up on eight o'clock.
I don't know if you guys
want to push through and we couldgo through RLS and rest is sleep
disorder or Sujay if you guys drop off
don't know.
what your
deal is
I'm here.
We could talk for hours.
Yeah.
um,
I'm happy to push through.
happy to chat about those.
Yeah.
restless leg
(37:27):
is, yeah.
I try to medically screen people so that I
can, if something seems off, Ijust send them to the doctor,
but I'm not quite sure what Iwould need to be looking for
with regard to restless leg.
Su Sujay.
Why don't you just explainwhat rests his leg syndrome is?
Restless leg syndrome, like all ofour sleep disorders, we have a set
(37:50):
number of diagnostic criteria, butit's essentially characterized by an
abnormal sensation of either discomfort,pain, something that you feel like
is uncomfortable, that is experiencedpredominantly in your legs, that is
worse or only present at nighttime.
When you move your legs, it actuallyhelps the symptoms and when you're
still, the symptoms tend to be worseand it's not better explained by
(38:14):
another underlying medical disorderlike neuropathy, et cetera, and should
cause some sort of kind of dysfunctionwhen it comes to sleep loss, et cetera.
So that's the typical definition ofrestless leg, what it can start very early
and it's, and unfortunately when we ask
adults, a good proportion ofthem will say, my symptoms began
prior to when I was 20 years
(38:34):
old.
And a good chunk of those will alsosay, it actually began before I
was 10, but I couldn't adequatelyexplain what was happening Pediatricians
have so many things to screen for.
I do not, I'm not trying to throwpediatricians under the bus here, but
oftentimes they're like, ah, it's justgrowing pains, and they'll be fine.
And it's missed for many years.
We do think it has something to dowith dopamine regulation in the brain.
(38:55):
Perhaps a decrease in dopamine dueto a circadian pattern of synthesis,
of dopamine in the brain, such thatit tends to be lower at nighttime.
And we think that iron plays a role asa co-factor in the creation of dopamine.
That's why we're oftentimesscreening for iron deficiency in
hopes of making sure that patienthas adequate amounts of dopamine.
But, a lot of children that haverestless leg also have what we call
(39:18):
periodic limb movements of sleep.
And so this is kinda the sisterdiagnosis of restless leg.
Restless leg is what youexperience while you're awake.
Oftentimes you have limbmovements while you're asleep.
like 80% of patients that haveRLS will also have periodic limb
movements of sleep, and that can alsodisrupt the quality of your sleep.
So yeah, that's a broad overview,
And periodic limb movements ofsleep are something that get
detected in an overnight sleep test.
(39:39):
They can be subtle, but they'rejust leg kicks that happen
in series of four or more.
Where Sujay and I sit in the pediatricclinic, 'cause we have children that are
often too young to really express this.
And we also deal with children who arenot always neurotypical and may not have
even if they're old enough, they don'thave language to describe these things.
(39:59):
So we're almost have to infer it.
I've had parents tell me thattheir kids will kick a lot.
They'll try to press their feet into them.
They may say that their feetare hot or cold at night.
True story.
I was studying for my sleep medicineboards the first go around and I
read this sentence and it said,kids with restless leg may say they
have too much energy in their legs.
(40:21):
And that's what I used to sayto my folks when I was a kid,
if I had too much caffeine andcaffeine makes restless leg worse.
And then I realized I've gota little bit of restless leg.
It doesn't happen that often, butif I'm anxious or I've had too
much caffeine, that is I get that
feeling.
And I feel like we this is theart of pediatrics sometimes, and
it makes our adult colleaguescrazy when they come with us.
(40:42):
And we're
trying to guess what's what, what'sgoing through a two year old's mind,
Yes.
what parents are telling us.
I think in the hierarchy of restless leg.
The other thing is
the criteria that Sujay mentioned.
Often in younger kids, they don'tnecessarily fit those criteria perfectly.
There may not the symptoms may not beworse in the evening or for example,
(41:05):
they, I think there's probable andpossible restless leg if there's a family
history and a first degree relativethat helps you with the diagnosis.
The first line treatment in kidsis checking a blood iron marker
called a ferritin and treating.
We usually treat for values less than 50.
I don't know what you guys do.
Same.
Yeah, we try to get them to 50in some cases, 50 is the goal.
(41:27):
it, can be challenging toget a child to a level of 50,
What is ferritin for the lay person?
Yeah, it's essentially a measure of ironstores in the body and the challenge with
ferritin is if you're sick, it's what wecall an acute phase reactant and that it
actually increases just in the settingof kind of inflammation in the body.
And so you don't wannacheck it when you're
sick.
You wanna check it when you're otherwise
well, and the goal
is, yeah trying to get above 50.
And again, all with the premise thatwe think it works as a co-factor in, I
(41:50):
think tyrosine
hydroxylase, which ends upmaking dopamine for your brain.
The challenge is if you
check a ferritin in any toddler,
it's gonna be below
50.
In my experience, nobody's, so I usually
want to be, fairly sure that beforeI put somebody on full fledged iron
supplementation, which by the way,can be dangerous 'cause iron overload
is a super dangerous phenomenon.
But, I wanna be fairly certain that we arein the realm of, probable process thing.
(42:14):
If we pick up periodic limb movementsof sleep on a sleep study, that could
also serve as kinda another surrogatemarker that pushes us more towards
likelihood, restless leg, if theydon't fill all the classic criteria.
But there's something that I wannasink my teeth in to be like, okay,
they have a sleep disruption due to arestless phenomenon that's affecting
their sleep before I put them on iron.
Sometimes I'll hedge my bet and say let meput you on a multivitamin with iron, which
(42:36):
isn't a full fledged iron supplement, buthopefully stabilize you where you are and
not make your iron deficiency any worse.
But it can be a challengingdiagnosis to pin down
And is iron the only courseof action for treating it?
there are other medications.
It's funny, at the recent sleep conferenceI wasn't able to attend, but the big
brouhaha now is that for adults, we'reno longer recommending dopamine agonists.
(42:59):
So we used to recommend dopamine agonistsfor adults and oftentimes they'd be
used on the adult side very early,much earlier than I would ever feel
comfortable with doing even in adults.
But medications like Mirapexwere used really early.
The typical, even for adults, Ithink the typical approach should
be what's your iron status?
And if it's low, you gotta supplement.
The next line is typically medicationin the realm of the gabapentin family.
(43:21):
And so gabapentin and its sisterpregabalin or Lyrica are the ones that
we oftentimes go to, which can reallyhelp with the symptoms of restless leg.
And now on the adult side, I thinkthey're starting to use low dose
opioids instead of the DOPA agonists.
And I think most families wouldalso be somewhat opposed unless
it's a really kind of severe
situation.
(43:42):
But then a lot of it is alsosleep hygiene, like avoiding
the things that worsen this..
So caffeine; antihistamines arenotorious for just making restless
leg symptoms much, much worse.
And so sometimes we can help from a,just a avoidance standpoint of things
that will make the symptoms worse.
Stretching leg massage.
Cold plunging.
Cold plunging.
What do you
Sorry.
we'll get Huberman on here next.
(44:04):
Yeah, that'd be great.
Everybody will be on magnesium glycinate.
Oh, I love
that.
I
It helps me sleep.
You're skeptical.
And I have the receipts from my Oura ring.
I'm not gonna
this today, but we definitelyshould talk about this.
But the I wanted to ask a littlebit about gabapentin actually.
'cause I remember I had a,
I had one parent who was in lawenforcement, they moved it from the
(44:26):
south and we talked about gabapentinfor a child and she said, I'm not
gonna give that 'cause it's a drug of
abuse.
And I think that's a littlebit of an exaggeration.
But I remember going to sleep meeting andSuresh Kotagal, who's a very smart sleep
doctor has written a lot aboutrestless leg, said that has
come up in his practice as well.
(44:46):
And I think it's more of a concern in theSouth than it is in the northeast, is have
a, has a parent ever said that to you?
Yes.
And interestingly, when I Googledit, there was some article that was
coming up very high on the Googlesearch that said something about
gabapentin being worse than opioids.
And this was something that Ithink a lot of people latched onto.
Any drug you're using in the rightway, at the right doses with access
(45:09):
that you are actually monitoringis not gonna be a drug of abuse.
Even our stimulants, when we're using infor narcolepsy in the right way, it's not
gonna end up turning into a drug of abuse.
gabapentin can help with neuropathic pain.
And there are some indicationsfor seizures, but we
rarely use it for seizures.
But no, when it comes to the kindaeuphoric effect, for example,
(45:30):
or the addictive effect ofgabapentin, it's just not there.
Yeah the doses, I think clearthere, there were mega doses of it,
like four or five grams, and therewas also taken with other drugs.
So it's just, but just to reassureparents, first of all, your pediatrician
wouldn't be prescribing this for you.
I think that usually restless legis something that your pediatrician
(45:51):
is gonna be familiar with
sleep apnea, they're gonna befamiliar with sleep walking.
So I think if your child'scomplaining about their legs at
night, I would just encourage
to see if you could make an appointmentwith your friendly neighborhood
sleep doctor and drill down on thisa little bit further because it
is a, it's a nuanced conversation.
Even things like supplementingiron aren't always straightforward.
They're various
preparations.
(46:11):
Do you dose it every day?
Do you dose it every other day?
There's some, I like theNovaFerrum preparations, but
not everybody can afford them.
Like they're palatable.
Hey Craig.
Had a listener question.
Yeah, that's what I was wondering ifthat was appropriate to ask or not.
Okay, so we got a listenerquestion in our email, Gmail.
(46:34):
thesleepeditshow@gmail.com.
Please send us your questions.
Anna l asked my sleep.
Sleep trained three-year-old has restlessleg syndrome diagnosed by a sleep.
Medicine doctor via sleepstudy, blood tests and symptoms.
However, we've gotten his ferritinlevels above 50 and he still
wakes multiple times a night.
(46:55):
Melatonin makes it worse.
His doctors said it will eventuallyimprove with time as he gets older.
He is well rested during the day, evenwith the awakenings, but we are not.
Any other tips for parents and kidsstruggling with restless leg syndrome,
I, Craig, I'd love to hear your,I'll tell you my approach, which is.
(47:15):
Restless leg is difficult
to diagnose in that young of a child.
And every sleep practitioner is
different and the practice of sleepmedicine is a lot of art as Craig
alluded to, and sometimes not so much
science.
So for me, a lot oftimes I'd wanna diagnose
them myself and see them inclinic be like they truly have
(47:39):
restless leg, or do they just tendto be a restless sleeper that has
another issue, or behavioral insomniaof childhood or something else
that's causing them to wake up
frequently.
I would certainly, as I do with allmy patients, would still screen for
being able to transition to sleepindependently at the start of the night.
Are they able to do that well?
constant assistance?
Is a caregiver coming back in and gettingthem back to sleep relatively quickly?
(48:00):
Is it truly a discomfortissue that's waking 'em up?
Or is it more of a habitual dueto, sleep onset associations?
And so we're making everythingelse as perfect as possible.
And if I'm still left with a child thatis complaining of their legs, truly bother
them and has evidence of disrupted sleepbesides after doing all the sleep hygiene
and the behavioral insomnia and stuffreally well, then yes, I am still going
(48:20):
back to my core therapies to say, okay, ifwe've gotten iron up that high and we're
running into side effects of constipationor lack of palatability and the parent
child is refusing to take more, then I amexploring other options like gabapentin.
But I cannot think of a single timewhere I've put a three-year-old in
gabapentin for us leg, to be honest.
I would be surprised if it was truereal deal with us leg at that age.
(48:42):
Yeah.
Yeah, I'd wanna see a sleep testin this kid, and I'd wanna see the
movement index through the roof.
If I'm gonna be saying this is thecause of these nighttime awakenings.
Maybe it's been done, but certainlyworth the ha a sleep test hasn't
occurred worth doing, especially if thechild's falling asleep independently.
So let's close with talking aboutrestless sleep disorder, which is a
pretty new diagnosis from 2017 or 2018.
(49:05):
and I thought it was very clever whatthey did with this because I thought when
they created this taxonomy, I'm like,oh, I see these patients all the time
and I haven't known what to do with them.
What do they look like?
they describe kids that are not havingsensory phenomenon so they don't have
restless leg, but when they're in bed atnight, they have these large, full body
(49:25):
movements and people may talk about themflopping like a fish or moving around like
hands around a clock during the night.
The sort of kids that nobody wantsto share a bed with on vacation.
And the key is that there, there'ssome daytime effects as well.
Like they're sleepy or they'rehaving problems, paying
attention in school, et cetera.
(49:49):
Yeah I think that's dead
on.
And I agree.
It's this phenomenon that we've
seen and now they've put formaldiagnostic criteria on this.
And so we're like, okay we couldpotentially diagnose you based
on the diagnostic criteria.
It does involve actually getting a sleepstudy to confirm that they're having,
I think, more than five movements perhour that are large and fit the bill.
But it's still tough.
For me
(50:09):
it's I mean it still comes down
to really
iron, is it seems to be the go-to evenfor children that have restless body
Type phenomenon.
And then I really don'thave a great sense still of
chicken and egg.
We have children that have baselineattention issues that tend to be
on this A DHD type spectrum thatwe know their brain engine idles
at slightly higher level, right?
(50:30):
Like we're working on, yeah,they gotta get down to here.
Whereas most of us, it's gottago from here to fall asleep.
And they're always idling here.
I don't know if that neurochemistrymilieu makes you more likely to
experience these types of phenomenon.
I do think there's still alot of debate regarding what
actually causes this phenomenon.
um, but it, it's, it's, it stillcomes down to I think the basics.
(50:53):
I think some of the studiesthey look fairly robust.
look at a large number of kidstypically six to 18 years of age.
And so it seems like yes, there'sprobably something going on, but
to me I would always be hesitantbecause a lot of families bring
in for example, monitor data.
They say, oh my sleep monitor pickedup this many movements at nighttime.
And one thing that I'm alwaysharping on is of course, how does
your child look during the day?
(51:14):
Are they doing okay?
'cause there are a lot of kids that movearound a lot, particularly really young
children, toddlers, early school agedchildren are notorious for just being
active sleepers, but yet their brain isstill getting the sleep that they need.
And so one thing I'm alwaysasking them is, okay, first, how
does your child look for Sure.
And then number two ifyou are experiencing this.
Is it occurring in a format suchthat they have a lot of restlessness
(51:35):
and then they go the next hour andyou know they're gonna be fine.
And then they have another spurt of
restlessness If it is a perpetual,constant motion to point where you're like
how are they getting good quality sleep?
Because they're always moving.
Every few minutes they're moving, boom.
That's when the yellow flaggoes up and I'm like could this
potentially be something that'struly disrupting sleep quality?
Yeah, No I think that's true and itis always so tricky because often
(51:57):
these things come to light when,again, not to imply that everybody's
kids have their own, like manyof our families, they're sharing
rooms.
They may even be sharing beds.
Other parents, all of a sudden theygo on vacation with their kids.
They share bed for two nights, and it's
a catastrophe, right?
They're like, oh my God, he'ssnoring, he's moving, et cetera.
And I think it is very important to lookat the child's functioning during the day.
(52:21):
That's a really good barometer of
how things are going And I agree with you.
I feel like that in the Venn diagram
of whatever restless sleep disorder is
in A DHD, there'sprobably a large amount of
overlap there.
And that being said, Iftheir ferritin's pretty low,
give them a trial of it,and they're doing better.
And that correlates
with an in, in the ferritin going up.
(52:43):
I think that's useful.
And sometimes, I don't know, I, inour lab I feel like we be, we've had
a trouble getting agreement about whatscoring these large body movements.
Do you guys actuallyindex these in your lab?
we don't index.
And I'll tell you that it's very rarethat I have ordered a sleep study.
If I,
have a child that's really restlessand it's affecting daytime function
(53:03):
and I have nowhere else to turn, I'musually still going down the ferritin
route and saying 'cause there area lot of movement issues So I think
we've gone down that route anyway.
So it's rare that sleep study,particularly looking for this
to make this the diagnosis Let'slook at iron, see what happens.
In the yeah the at the end of theday, even with all the difficulty of
getting a good ferritin value, dosingiron, finding a palatable format,
(53:25):
it's still, I think everybody's a littlebit more comfortable with it providers
and parents than like prescription sleep
medication, right?
It just feels like a lower
tier intervention.
absolutely.
so listen guys, I think wecovered what we set up to cover.
This has been amazing.
Absolutely.
I've definitely learned.
(53:46):
Now
Suji, you've got a prettybig footprint online.
I've got your professional profile,your Instagram, your TikTok, your
links.
Is there anything else youwant us to share online here?
no, just pri you know, the one thing Ido like to share on all podcasts that
are like parent facing is I always liketo say that everyone is looking for that
(54:09):
perfect, magical solution for everythingwhen it comes to like potty training,
when it comes to feeding, when it comesto extracurricular activities and sleep.
There are like a million right waysto raise a thriving, happy child.
Yeah.
And let's rule out sleep disorders,but when it comes to even the
behavioral approaches to sleep, thereare a million right ways to do it.
(54:29):
So I tell families,there's no one right way.
Take some of the pressure off.
If your child is happy and they'rethriving, you're doing it right?
Every parent struggles,everybody has opinions.
I get it.
Let's be kind to other parents.
I dunno why parenting has turned into ablood sport online and like these threads,
let's just be kind to one another.
Go a long way if we're just kinder.
(54:50):
And if you feel cranky all thetime, consider getting more sleep.
Yeah.
Absolutely.
We'll put a pin in it.
I'm Craig.
I'm Arielle Greenleaf,
the sleep edit, and if you please tryingto get this started, please share online
Ariel, what's our email inbox again?
the Sleep Edit show@gmail.com.
(55:12):
Tell your friends.
Okay.
Thanks a lot guys.
Thanks so much forlistening to the Sleep edit.
You can find transcripts atthe web address Sleeped show.
You can also find video of theepisodes at that address as
well as in my YouTube channel.
(55:33):
You can find me at Dr.
Craig canna perry.com and on allsocial media at D-R-C-A-N-A-P-A-R-I.
You can find Ariel atInstagram at Ariel Greenleaf.
That's A-R-I-E-L-L-E-G-R-E-E-N-L-E-A.
(55:55):
If you like the flavor of the advice here.
Please check out my book.
It's Never Too Late to Sleep.
Train the Low Stress Way to high QualitySleep for babies, kids, and parents.
It's available whereverfine books are sold.
If you found this useful, pleasesubscribe at Spotify or Apple Podcast
and share it with your friends.
It really helps as we're tryingto get the show off the ground.
(56:16):
Thanks.
Welcome to the Sleep Edit, apodcast devoted to helping tired
kids and parents sleep better.
We focus on actionable evidence-basedsleep advice, so everyone in your
home can sleep through the night.
Now, a quick disclaimer, this podcastis for general informational purposes
only and does not constitute thepractice of medicine, nursing, or
other professional healthcare services,including the giving of medical advice.
(00:27):
No doctor patient relationship is formed.
The use of this information andthe materials linked to this
podcast and any associated videocontent are at the user's own risk.
The content on the show is not intendedto be a substitute for professional
medical advice, diagnosis, or treatment.
Users should not disregard ordelay obtaining medical help for
(00:51):
any medical condition they have
or that their children may have,they should seek the assistance
of their healthcare professionalsfor any such conditions.
Nothing stated here reflectsthe views of our employers or
the employees of our guests.
Enjoy the show.
Okay.
I am just doing the very important
(01:11):
work of giving my 13-year-old morescreen time on the Xbox, so he at
least is not screaming during this.
Oh yeah.
as I say, not as I do inthe world of parenting.
So listen, let's
get started from the top.
welcome back to the sleep edit.
I am Dr.
Craig Canapari
I'm Arielle Greenleaf.
it is my great pleasureto welcome my friend Dr.
(01:33):
Sujay Kansagra on today.
He's a pediatric sleepdoctor and neurologist.
He attended Duke for medical school,went to UNC for residency and
fellowship, and made, a triumphantreturn to Duke afterwards.
Lost some friends duringthe transition, but yes.
I gotta tell you, man,
as a lifelong UConn basketballfan, I've got wild beef with Duke.
(01:53):
Yes.
I can understand that.
Listen, people ask menow, who do I support?
'cause UNC is where I started asan undergrad, and so the basketball
allegiance still lies there.
But for medicine, I'd cheer for Duke.
I still remember UConn losingto Duke in 1990 the first
time they made the tournament.
I remember UConn beatingDuke in the finals.
This was probably 1999, 2000.
(02:14):
we were very excited at UNC for your win.
Oh yeah.
And let me tell you that everytime I've won a basketball
pool, it's because UNC has won..
Yes.
I just wanna talk a little bit aboutyour online presence, because when
did you start med school advice?
'cause that's how youfirst came on my radar.
This is like the original backwhen, the day we called it Twitter.
(02:35):
I was still a resident.
I was a child neurology resident andwe were talking earlier, this was
really the wild west of social media.
Folks in medicine were just getting
their foot in the door and learningto navigate the social media
channels.
And back then my goal was justto give, just advice because
I grew up having an older
sister that went to medicine thathelped guide me and I'm like a lot
of people that don't understand,what it takes to consider medicine,
(02:58):
what a life in medicine is.
So I started blogging in 2012and I felt like at that point
it was already too late, right?
Because there were already likepeople out there who have been doing
it since the early two thousands.
I think Howard Luks was on fromlike the 1999 or something.
when your pediatric sleep bookcame out and it's great guys.
You all should buy it.
(03:19):
My Child Won't Sleep.
A quick guide to thesleep deprived parent.
I'd been blogging for two or three yearsand I'm like, man, this guy wrote a book.
I better up my game here.
Yeah.
Who is this guy yeah, I mean that book,it's funny 'cause I was doing a lot
of the research behind it when I was anew father and I was also reading all
the books that are out there just toget some background information what is
Weissbluth saying what is Ferber saying?
(03:40):
We knew the techniques, but whatdo you have in these 400 pages?
And, part of me, when itcame to the techniques I was
screaming at the book just
tell me the technique.
I already knew the technique,but I'm like, where is it?
These are sleep deprived
parents, I'm like, justwhere's your technique?
And that was the impetus behind the book.
Just give it to them straight.
Give it a step by step approach.
And it's probably too slimmed downbecause unfortunately I glossed over a
(04:02):
lot of the other issues like parasomniasand restless leg and sleep apnea.
It's just
behavioral insomnia approaches.
Cognitive behavioral therapyapproaches for older kids.
Delayed circadian rhythm stufffor older children as well.
Just the core things that you can modifywithout needing a physician sometimes,
I think That's reallyvaluable in just in what I do.
(04:23):
Parents are just, there's so muchinformation and they just need an
answer and they don't wanna siftthrough a million different things.
And I will say those books are greatnow for me 'cause I dig through them
and I look for research and all of that.
But when I was a tired new mom,it was like, Just tell me what to
do like you said, and ultimately Ihired sleep consult because I just
(04:46):
could not navigate my way out of it,
so,
I hear you.
It's tough.
There's a lot of information andpeople don't know who to trust.
everybody can come across with abeautiful marketing presence and be
like, oh yeah, you should trust me'cause look at my amazing graphics.
But, who can you truly trust when itcomes to just vetted, science-based folks?
Because we love using the scienceterms out there on social media
when it comes to sleep, but whois truly, vetting what those terms
(05:10):
mean and whether they apply to that
particular situation.
So yeah, that's why Ienjoy the social media
world.
It's nice to be able to share andhopefully people trust us, like
folks that are dedicated theirlives to helping children
with sleep.
Well, Sujay, you're very modest, Butyou've amassed a huge following and
it's because your content is great.
It's very approachable, it's funny.
What, do you think that you've donethat has really resonated with parents?
(05:35):
I think part of it.
Was, attention spans arevery short on social media.
And TikTok actually puts in your face,it tells you like how long people
are logged in every second of time.
And by five seconds themajority of watchers are gone.
They're gone.
And so I'll tell you one thingI've learned is you have to
have that entertainment portion.
Otherwise people arejust not sticking around.
(05:56):
And I have no problem embarrassing myself,I kind of joke, academicians are like,
oh, you're on social media, that's great.
What about all the manuscriptsyou should be writing?
And I'm at this stage in mycareer where thankfully I just
don't care, and not in a bad way.
I'm already full professor, I'mhappy to write more manuscripts,
but I feel like I can have the most
impact on the most
people by sharing
(06:16):
information on social media.
And I saw my admission friends,I'm like, why aren't you on here?
Like
if a video that I post, I can get10,000, 20,000 people to watch it.
Five people are reading thearticles that I write in journals.
Like two of them are thereviewers, so that's, so
entertainment I think is important.
So getting back to your questionand I think just getting the core
of the issues that are on people'sminds, like the simple topics where
(06:40):
they hear lots of different things.
Melatonin is sleep training harmful?
What do we do aboutnaps and how do we nap?
And I've also tried to appealto a broader sleep audience.
Not just pediatric sleep, but justsleep in general and helping adults
understand that they need to sleep andthe impact a sleep ation has on them.
So topics that have widespread appeal,and then making a fool of myself,
I think that's the combination.
(07:02):
Are there any sort of videos you'vemade that you've been absolutely
shocked at how much traction they got?
Yes, it usually it's around the sleep,like the deep sleep science video.
So I made one about time zones and howthere's this amazing research study
that shows that where you live withinyour own time zone affects how much
sleep you get, and that ends up havingassociative, effects on your wellbeing,
(07:23):
like risk of obesity your productivity.
that was like my first video that blewup across platforms, like a million
views on like 3 million on Instagram.
People really craved the scienceand they were asking very nuanced,
very savvy questions like,oh did they control for this?
what do you think about this population?
And so people out there reallyunderstand the science more than
we oftentimes give them credit for.
(07:45):
And they want it filtered in away that's, I think, approachable
and not in the manuscript formthat takes, an hour to read.
So I was
pleasantly surprised.
And funny enough, the authorsactually of that study found out
and they reached out on Twitterthanks so much for that exposure.
And I'm like, Hey, by the way, myviewers have some questions for you.
we created a video together in responseto the questions that the audience had,
(08:05):
which I think is like the most beautifulway of using social media, bringing
people together, answering questions.
You mean it's not shouting at strangers.
No, that too, that'stotally valuable and valid.
Yes.
but no, there are otherways of using social media.
Yeah.
I think I remember the, I don't rememberwhat it was, but I remember the first time
I got a really mean comment somewhere.
(08:26):
I'm a little bit taken aback, right?
Because I don't think you, you go throughyour life, you try to be a courteous
person and there's certain standardsof socialization that get lost when
people are commenting anonymously.
And one of my friends who was said a moremature social media prevalence, she's
it's just a measure of your power that ifsomeone, you're making someone angry in
some ways, like just, just ignore them.
(08:47):
But I'm sure you probablydeveloped a thick skin just putting
yourself out there like that.
Yeah, absolutely.
And I try, I try to,
I know which posts are gonna generatecontroversy and I brace myself for it.
And then I actually, I try to befriendly as much as possible because
I know at the receiving end, evenif somebody that's trolling me
for me to then engageIn a ill spirited way,
(09:09):
it will leave a mark on themtoo, even though they, they're
gonna keep yelling back and forth.
put that strain on anybodybecause then it affects people's
sleep and their wellbeing.
And I'm a, everyone should sleepno matter how Ill spirit you are
to me on social media, and I'mnot gonna throw that back at you.
Even like the one video that actuallymade me popular on Instagram was
one where I did a clap back tosomebody that was trolling me, and
(09:30):
I was like, oh, this doctor doesn'tknow what they're talking about.
They oppose sleep
training.
And then I made this video that's actuallyno, I do know about pediatric sleep
research because I published a lot of it
and I
did a like, scroll of all my
papers.
I am the researcher was my quote, Iwas being like that's not me usually
being like, arrogant and cocky.
I was trying to actuallybe a little bit funny.
People just ate that up and theyloved it and they're like, what
did that lady say when she saw it?
(09:51):
And I'm like, I neveractually share that with her.
I actually engaged her kindlyon Facebook and was like this is
the data behind sleep training.
and she, shot back a couple thingsabout, we won't mention which group
she was with, but ones that areoftentimes against sleep training,
which I know you both likely had Yeah.
So at the end of the day, I don't engage,even if I've made an amazing piece
(10:12):
of video content that I would love tojust show them, I'm not gonna do that.
Yeah.
I think you.
should have a masterclass onhow to make those videos, man.
'cause they're pretty amazing.
And look, as someone with a backgroundI'm like I just dunno how he edits these.
They're so good.
That's too kind.
I've just become very savvy with all thetools within Instagram and now Cap Cut is
my newest, favorite video editing tool.
(10:33):
I just dunno how you make all the content.
That's the other thing.
It's the funny thing is there aresome pieces that I literally, I'm
like, I've spent two or three hoursmaking this video and editing it and
et cetera, and then I'll make one whileI have a random thought and I'll pull up
my phone and just say it.
And those videos end up doing much better.
So listen, since I, am, notreally a neurologist, I trained
as a pulmonologist and I, do sleepmedicine which encompasses a lot of.
(10:58):
Topics honestly I, wanted to be a childneurologist, but then I changed course.
But we wanted to talk about sometopics that are really, I think, in
the neurology end of sleep medicine.
And we wanna start withParasomnias And I dunno if you
maybe just start off by justdefining what a parasomnia is.
Sure.
Yeah.
So Parasomnias is a group of sleepdisorders and they're typically
(11:20):
characterized by abnormal behaviorssometimes even complex thoughts
or emotions that occur at thestart or in the middle of sleep
or even with arousals from sleep.
And the vast majority of parasomnias arefascinating in that we used to think we
spent the entirety of our consciousness,
either in wake non REM or REM
sleep.
(11:40):
But the majority ofparasomnias actually have
a, mix of elements of two stagesat once, oftentimes both in the
brain of like deep sleep and awake,for example or aspects of REM sleep and
wakefulness which make parasomnias just afascinating category of sleep disorders.
It's funny how much of sleep medicine.
is actually where there's ablurring between sleep and wake.
(12:04):
I think about this all the time innarcolepsy, which is a whole other
topic, but narcolepsy we think of it assleepiness, intruding into wakefulness.
and that's very true, but it's alsowakefulness, intruding into sleep.
And it's like where there's thatdysregulation of these processes,
a lot of problems happen, but alot of interesting stuff as well.
(12:24):
That's right.
We talk about this amazing timeat the transition break to sleep.
weird, interesting things happen.
People can have these hallucinations,like exploding head syndrome.
This phenomenon of feeling likesomething exploding inside your head.
Oftentimes with visual, sensation as well.
Even what we experience like common,like hypnic jerks that sometimes also
have this semi dream-like imagery.
There's just a lot ofweirdness at that transition.
(12:46):
And it's fascinating.
I think there's a lot of mystery aroundthat time and a lot of fascination
with that period.
Yeah.
And just for the listeners, the hypnicjerks are occurring when you're falling
asleep and you have that sensationof falling and you jerk awake.
yes, I think the evidenceis probably pretty weak.
And I think the challenge here isthat stress is so common that you're
bound to see some sort of a link
there, but yes, stress, I've heard,caffeine intake, certainly sleep
(13:09):
deprivation, perhaps can, worsen hypnicjerks, all the things that are very
common in our world, just becauseagain, hypnic jerks are also common,
so I think it's hard to pinpoint.
I feel like that's, a good segue intoSleep talking or somniloquy, which one
of those things like I think in the mostrecent international classification of
sleep disorders, they don't even callit a disorder, which to me is correct.
(13:31):
Like sleep talking is more of aphenomenon than anything else.
I'd be curious how often
parents, for both of you, how
often are parentsbringing up sleep talking?
Not often at all.
, it's like on a questionnaire weadminister in the office, but I
do feel like it the idea that.
it's not a big problemhas percolated out there.
(13:51):
'cause it doesn't seem togenerate a lot of concern.
Same here.
It's only time I end up documenting itis when I have asked about it, and they're
like, oh, yeah, they talking their sleep.
But it's never an initial concern,which, on the spectrum of sleep talking,
if it's a problem such that it'shappening every single night and we
think it's disrupting somebody's sleep.
Then yes it's a problem even thoughit's, quote unquote in the normal variant
(14:12):
spectrum, but, I rarely,one does it rarely come
to me as a primary problem,and two, rarely do.
I feel like it actually ends updisrupting the quality of one's
sleep, just because it's notpervasive enough throughout the night.
and chances are they're, evenwhen, while they're asleep
talking, maybe still gettingrestorative sleep during that time.
we don't really know.
I know that I've definitelytalked in my sleep, but I wouldn't
(14:34):
know, like I'm told it, in the,morning so I'm not awake for it.
My wife tells me I talknot infrequently and.
It's usually things that I'vebeen working on the next day.
She, or the day before, she's yeah,you were working at night too.
I'm like, all right p thatI'm thinking about something.
Yeah.
it's hustle culture, man.
Grind when I sleep, although I havenightmares of still rounding, during
(14:54):
residency, I'm not prepared for rounds,and rounds are about to start, and I'm
like, gosh I remember doing residency.
I'd have those dreams.
I'm rounding in my sleep at night.
When am I not rounding?
It's,
well.
I, I.
feel like my anxiety dreamsgo back to high school.
that was much more of ananxiety provoking time,
Yes.
I think it probably relates to a lot
of people.
But I think for me, that senseof needing to be prepared and
(15:15):
having all the information andthen just the angst on taking care
of patients, I'm likeyou can't make a mistake.
Patient care is at risk.
I think that was probably hardest for me.
That's probably why itcomes back in my dreams.
So Arielle actually said something Iwanted to amplify a little bit, which
is like you mentioned night terrorsas well as talking in your sleep.
And I think It's, important for usto talk about non-REM versus REM
(15:37):
related parasomnias because it's a,really useful part of the taxonomy
when we're trying to figure outwhat's going on with the patient.
Yep, yep.
Yeah, happy to.
When it comes to the core non-REMparasomnias, We think about confusional
arousals, we think about night terrors.
We talk about
sleepwalking, and that's, the majority.
Now there are rare ones,sleep related eating disorder.
(15:57):
In older
folks there's things Like, sexsomnia, sothere are other rare non-REM parasomnias.
But the core are theconfusional arousals,, night
terrors, and sleepwalking.
and I like to think of those asthe non-REM and the characteristics
of non-REM paradigms are typicallythe first third of the night.
Lack of recollection of the event.
Usually the order of seconds tominutes in rare cases can be longer
(16:19):
and characterized by occurringin relatively young children.
We talk about the age range of
three to thirteen as a broad, anddepending on which parasomnia some
occur more commonly when you'reyoung, versus when you're older.
Versus rem
parasomnias, the hallmark is REMbehavior disorder, which in the
pediatric population we rarely seeunless it's associated With narcolepsy.
'cause patients with narcolepsy oftentimesdo have, REM behavior disorder, which is
(16:41):
essentially an acting out of your dreams.
You don't have the normal muscleatonia, the normal paralysis that
you're supposed to have when you dream.
It's a very beneficial and safething our body does for us, right?
It paralyzes us when we'redreaming so we don't act them out.
REM behavior disorder, that paralysisisn't there, or it's partial.
You can also have what we callrecurrent isolated sleep paralysis.
That's also rem parasomnia.
Many people have experienced this,particularly during times of sleep
(17:03):
deprivation, like during college, whereeither right when you fall asleep or right
as you're waking up, you have persistenceof the rem atonia that paralysis.
And so you wake up thinking you'recompletely paralyzed and oftentimes
associate with a sense of dread andfear, and as if somebody's sitting
on your chest like you can't breathe.
We also put that in the REM category, butREM parasomnias tend to usually tend to
happen in the latter half of the night.
(17:25):
particularly dreaming, recurrent dreamingor upon awakening with REM behavior, just
not rem with isolated sleep paralysis.
I wanna just actually talk a littlebit about the sleep paralysis.
'cause it's one of those thingsthat's absolutely terrifying to
someone when it happens, right?
And there's also seems to be acertain flavor to the hallucinations
that come along with it.
(17:50):
So if they're rising out ofwaking up from sleep, we call
them hypnopompic hallucinations.
And these don't seem tobe culturally determined.
And I've heard people commonly saythey see glowing eyes in the room, like
there are animals there, or they feellike someone's breaking into the room.
Sometimes, they'll talk about therebeing an old crone in the room.
(18:11):
It's just fascinating that these thingsseem to be hardwired into people.
Yeah it it's frightening when peopledescribe what they're experiencing.
I've had sleep paralysis once ortwice, and yes, it's really terrifying.
You're like sitting there hopinglike somebody just touches your arms.
You can snap out of
this.
it's, it's terrifying, but to havethat associated with dream imagery, I
(18:31):
never had dream imagery with it, but to
have both together asabsolutely terrifying.
We talk about, hallucinations,like what you're having, right
as you're transitioning to sleep.
And so patients withnarcolepsy oftentimes.
For some reason those involve likealiens or people like in the room.
There's a very similar theme there too.
People have called 9 1 1 because theyfeel there's intruders in the room.
(18:52):
They have
these types of hallucinationsabout the transition to sleep.
So I agree there's probablysomething hardwired into our
psyche that makes us have those,
thoughts.
Yeah.
that doesn't generally happen withthe pediatric population, right?
The
I'm more like adolescents.
Certainly.
Yeah.
In adolescents, there's a peak.
I've seen it down to four or five.
I think the earliest casereport was in a 1-year-old, I
(19:14):
think that was actually at UNC.
They report that it's very hard to pickup excessive sleepiness in a 1-year-old.
They proved it with I think CSFtesting of orexin, which is one
way of diagnosing narcolepsy.
And, you're talking abouta child with narcolepsy.
And of course
like sleep paralysis is very alarming.
If your child tells you have sleepparalysis, definitely worth l
earning a little bit more aboutit, talking to your doctor, but
(19:35):
to me it's if they come in the office with
this history, I'm like are they sleepy or
not?
If they're sleepy, thenwe're looking at narcolepsy
testing.
If they're not,
usually Im reassuring themAnd if it's happening quite a
bit, you could consider somethinglike a course of an SSRI.
I've never had to do that
myself.
So I have a question for you guys.
Narcolepsy, you're talking
about narcolepsy and what
(20:00):
triggers some so I'm thinking ofpediatric, in pediatric cases.
What would trigger someone to, whatwould the child be presenting with to
even start the process of consideringthe fact that it could be narcolepsy?
I'll tell you the typical pathfor me, which is it's usually
disabling sleepiness, it's sociallyimpairing level of sleepiness that
(20:22):
comes on in kind of a subacuteover the course of weeks to months.
And it's usually school issues thatkind of raise the red flag, which like
they keep falling asleep in schooland teachers can't keep them awake.
That's usually the presenting factorwith me, unless they also have cataplexy,
which does occur in a certain portionof children that have narcolepsy in
which they have sudden intrusion ofthat red muscle atonia that can lead to
(20:44):
partial paralysis or actually full body
paralysis.
that very quickly andseek evaluation, but it's
just the disabling sleepinessand they usually already see an
endocrinologist and they've seenan infectious disease doctor by the
time they're 10 years later, finallyget plugged in with a sleep doctor.
The median time to diagnosefrom the time of symptom onset
for children is like 10 years.
It's really terrible that how muchtime is lost for these children.
(21:06):
is our sleep medicine fellows, theymostly come from the adult side and
they're mostly internal medicine doctors.
'cause sleep medicine is a pediatric andadult specialty, and I order a lot of
MSLTs because again, not in every childthat's sleepy if they have snoring or
similar thing that looks like, maybeit's just sleep apnea, but I just feel
(21:27):
like it's a real missed opportunity.
you don't want that kid to come backin five years and you saw them and you
missed narcolepsy because it reallycan change to the trajectory of their
lives if you diagnose them early
Yes,
Did you say S MLTs?
Multiple sleep latency test.
Thank you.
you do an overnight test to make surethey get enough sleep and there's
nothing like sleep apnea, fragmentingtheir sleep, and then you offer them
(21:49):
five nap opportunities the next dayand you measure how quickly they
fall asleep, But yeah I think in general,parasomnias are common, and I don't
want to seem really alarmist to parentswho are listening, but I think one of
the red flags in general is if yourchild is having interrupted sleep at
night and it's very frequent or they'resleepy during the day, I think those are
(22:13):
absolute signs that it is worth pursuing.
We can talk about these differentphenomenon and what are the red flags in
different situations, but I'd say thatregardless of the type of thing that's
happening during the night, those arethe sort of things that get my attention.
Snoring.
Frequent events daytime sleepinessor difficulty in school in general?
(22:34):
Yeah, no, I like all of those.
I'm always focused on thesafety portion as well, and
so I've had situations where the childis currently getting into situations that
can be unsafe, older children that canmanage to get outside of the house, for
example I had a
child that had a two level house andwould always manage to open the window and
actually on a few occasions, climbedout on the roof during a sleepwalking
episode.
(22:55):
and so I'm always thinking, what are thesafety implications of what they're doing?
And then, we're always thinkingabout is it truly a parasomnia?
Because weird things happen in sleep.
And so we're always ruling outsome of the mimics as well.
And we know there can certainlybe just behavioral issues, right?
is it truly a parasomnia
versus is it more of a just abehavioral arousal or awakening?
(23:16):
And then in my mind, I'm always
thinking as the neurologist, I'm like,I can't miss nocturnal epilepsy, which
can present in really unusual ways.
And so I'm also keeping that on the list.
But I agree if something's happeningrepetitively at nighttime and the child is
having any sort of daytime manifestation,or you feel like their safety is at
risk, certainly bring it up at leastto your pediatrician and talk about it.
(23:37):
So from my perspectiveall of that is so helpful.
What I see a lot
is parents in mom groups orwhatever on Facebook, Instagram
saying, I don't know what to do.
My 10 month old is waking at nightand really upset, and I have to go in
(23:57):
there and it's happening every night.
And the response.
It's almost
always night terrors.
Like people are likeall about it being night
terrors.
And it doesn't matter how young,sometimes they say six month olds.
And my understanding is that it's rare.
It's very rare for a baby or young toddlerto be having that kind of parasomnia.
(24:22):
I know nightmares canhappen earlier, bad dreams.
But when do night terrors really startto become more common, I would say.
And then what is theprevalence of night terrors?
Great questions.
I'll tell you what, of all theparasomnias and Craig feel free to
jump in here, but, the confusionalarousal sleepwalking, night terrors
(24:43):
tends to be the least frequent, I'd saysomewhere probably around three to 5%.
I usually think of parasomniasat the earliest, typically like
three and above in infants.
It's not
gonna be a night terror,it's gonna be usually just a
behavioral awakening of some type.
But that's, yeah, that's my take Craig.
And just to, I think fordefining things for people.
(25:04):
Confusional, arousals are where.
A child doesn't leave the bed.
They may sit up, they may talk,they usually don't seem lucid,
but it seems pretty benign.
Like you might notice it if you're onvacation with your child and you're in the
same room as them, but unless you have amonitor, you might not notice this at all.
A night terror is when your kid isscreaming they don't leave the bed but
(25:28):
they have this fight or flight responsewhere they may be sweating, they're
screaming and you cannot console them.
the first time this happens, itis very scary to parents because,
imagine being woken up by someonein your household screaming.
It's not a good feeling.
And I remember my older son usedto have a night terror every time
(25:48):
we went to stay at our in-laws.
Yeah, it's just an excuse,Craig to not go to the in-laws.
So we don't need to goto the in-laws anymore.
my in-laws were lovely, but mymother-in-law had terrible insomnia.
And my father-in-Law, who's not gonnalisten to this, would just sleep on the
couch all night with the TV blaring.
But he would just be screaming.
And my mother-in-law runningand she's what's wrong?
(26:08):
What's wrong?
And I'm like, I've got this.
It's okay.
But it is once you've experiencedit, it goes more from being
something that's really scaryto something that is a nuisance.
If it's happening quite, frequentlyenough that it's on your mind.
Definitely talk with your pediatrician.
'cause any of The disordersof sleep fragmentation.
(26:28):
We think about things like sleepapnea or medical conditions can
trigger these events in peoplethat are predisposed of them.
Not every child
is gonna have sleepwalk or have anight terror, but if you're prone to
that, I think there've been studies.
If you take a kid that's sleepwalking,you set them up at night, they'll just
get up and just motor out of their bed.
So any underlyingproblem, say if they have
(26:49):
asthma that's poorly controlled andthey're coughing, eczema, they're itching,
it's going to make them more
likely to have these events.
and that's why it's soimportant for people to
work with their pediatrician.
now can fevers.
Be a cause of that?
Or is it just illness in general?
Because the only
time my daughter has ever had, she'sonly had two, and they were awful.
(27:11):
And I'm sitting right next to herand she's screaming for me, like
reaching across the room yelling mama.
And it's like heartbreaking.
But she had a fever
both times and I just, maybe that's justone of those triggering events that can
cause Some people talk about emptyingthe bladder before bed can, having to
(27:31):
go to the bathroom cause night terrors.
I'll tell you, it's in my experienceit's a more rare provoking factor.
But, just like Craig said, at theend of the day, when I'm taking
it step by step in clinic, I'mlike, first and foremost, are they
getting adequate, length of sleep?
Because we know sleep deprivationwill definitely predispose you to
having it because you spend moretime in deeper stages of sleep out
of which night terrors tend to occur.
(27:53):
Number two, are there those internaldisruptors, medical issues, reflux,
ear issues, eczema, et cetera sleepapnea, Are there external disruptors?
Is the TV blaring in the house?
Is it a busy street corner?
has the family brought the child intotheir bed because this happened one
time and now it's happening every night
that's causing the, child to havemultiple arousals and poor sleep.
And so any of these things
could potentially predispose you.
(28:15):
But yes, fever illness
for sure.
Weird things happen insleep when you have a fever.
Absolutely.
Is there anything you asdoctors can, do for that?
Because my understanding is that youjust grow out of them, but I don't know
if that's factual or medically factual.
(28:36):
Yeah.
No, Craig I'll take your lead hereabout how much, medical stuff you wanna
share, Because I don't want peopleusing techniques willy-nilly, but I
happy to go over some of the basics of,
I think that if anybody's gonna listento podcast, there are pediatricians and
sleep consultants that listen as Well.
I like to have moredetail instead of less.
So I will tell you that after I'veassessed the sleep duration part of
this to say, Hey, listen, we gottamake sure your schedule is adequate.
(28:58):
if I can't find any internal disruptorsor external disruptors to sleep,
let's say this is a teenager whoout of the blue started having like
night, it's not a typical pattern.
It didn't start when they were young.
there's oftentimes a
family history that we'dthink there's likely a genetic
predisposition to having parasomnias.
So things are occurring outof the blue and the child is
like snoring, for example.
I'm like that's a little bit unusual.
Let's consider doing a sleep studyto make sure we're not missing
(29:19):
any other disruptor of sleep.
But in the absence of any disruptor thatI can find, oftentimes what I'll consider
doing is scheduled awakenings scheduled.
Awakenings has data to support it.
What you do in this is you go inthere about 20, 30 minutes prior
to the time of their typical event.
And you wake them up.
And the advice I like to giveis wake them up enough that they
can say their name and then let
'em go back to sleep.
(29:40):
Just so you know thatthey're relatively fully
awake.
And then let them be forthe rest of the night.
If you do this for two or three weeksstraight in the majority of children, for
some reason, it hits the reset switch intheir brain and these episodes go away.
This includes night terrors,it includes sleepwalking.
Again, as Craig mentioned, thereis probably a role, there's some
data to also support melatonin.
(30:00):
And again, this is something yougotta talk to your pediatrician about.
But there is a role, I think formelatonin, whether it actually gets to
the pathophysiology and the underlyingmechanisms by which this happens.
Or is it just increasingtotal sleep duration?
Who knows?
But there is some data there.
And then I hear people who say that thosethings increase with the use of melatonin.
Or he gets more, he gotnight terrors from them.
(30:23):
Yeah, I'm always curious distinguishingnightmares from night terrors.
Melatonin can certainly cause nightmaresand if in my world, a family links a
particular side effect the initiationof a medication or a supplement, then
we just stop it and see if it resolvesand if it does, and I still think
it's beneficial, we reintroduce andsee if the symptoms come back just to
make sure it actually is causative.
(30:43):
There are some stronger, more potentmedications that I've probably
prescribed like less than fivetimes in my 10 plus year career.
That can also help, but it helps bydecreasing deep non-REM sleep, which
is not something that I like to do
for children.
You
we like to keep themin deep non-REM sleep.
Yeah.
and actually there's just two things Iwanna double click on that Sujay said.
The first step in looking atthese is actually making sure the
(31:05):
child's getting adequate sleep.
Because insufficient sleep is a veryclear trigger of non-REM parasomnias.
And it's very common and we see itsometimes in adolescents where they
had a sleepwalking when they werea kid, it went away, then they hit
adolescents and all of a sudden they'restaying up super late, school starts
too early, or they go to collegeand they have these crazy schedules.
(31:27):
I think that is really importantfor parents to know too.
And sometimes you'll see if yourkid's up super late one night
you're on vacation, it's a holiday,they're gonna have a parasomnia that
night because they'vebeen shortchanged on sleep
a little bit.
But I think just to talk a little bitmore about sleepwalking, where safety
is an issue, for kids that are frequentsleepwalkers, you do need to be really
careful, especially if you're staying in
(31:48):
a location that's different from home.
And I'm thinking of people who arestaying in hotels where there's a
balcony or unfamiliar locations.
I have kids that Sleepwalk intermittently.
And some kids are agitated when theysleepwalk, they might even be violent.
Others are just calm, butthey still get into mischief.
I agree with Sujay, I tend not towrite meds for these kids unless I've
(32:11):
had a few where they're nightly eventsespecially when kids going college or
they've really gotten they've elopedfrom The home they've gotten injured,
other people have gotten injured
Yeah.
Another example is I had a child wholived in a trailer home, had eight other
people in the trailer home with sleepwalkevery night, and wake everybody up, and
it was leading to complete dysfunctionand disarray, and that's the situation.
(32:34):
I said, okay, that probably merits,
The other thing I'd love to emphasize isthat, we've talked about night terrors
versus nightmares, and oftentimes
There's a confusion there.
Nightmares is vivid dream imagery.
Your child is fully awake andtelling you, I'm scared because
I just saw a monster in my dream.
Whereas night terrors, they're notaware typically that you're even there.
And oftentimes if you are there, even if
they're calling for you, they'relike pushing you away and completely
(32:54):
frightened, as Craig mentioned, theyhave that sympathetic activation.
are, they're terrified,they look terrified and they
usually do not remember it.
The next day, if they do remember,it's usually after their night
terror is complete and theywoke up from the night terror.
And then they
might remember that they, but they
typically don't remember the event itself.
And parents oftentimes go to whatjust happened during the day?
What trauma did they experience to start
(33:15):
beginning to have.
night terrors?
And the answer is they didn't, we don'tthink it's actually due to any underlying
trauma or psychological distress,even though it looks very distressing,
like they're truly in distress.
I think that's also important just toprovide some reassurance to families
that it's likely not due to some sortof daytime trauma they experienced.
So let's segue to nightmares then,because nightmares are incredibly common.
(33:36):
I don't think there's anybody thathasn't had a nightmare I don't think we
know when kids start having nightmaresbecause infants can't tell us, right?
we've all had our kids cry in our sleep.
I can definitely remember when my kidswere babies they wouldn't be screaming
their heads off for me, but they this
sort of pious crying.
I'm like, I don't know,maybe they had a bad dream.
It's hard to say,
right?
Yeah.
But as Sujay said, they tendto happen in the second half of
(33:58):
the night and they have a clear
narrative to them.
They have a story, and if someonewakes up from a nightmare or a dream
for that matter, they're lucid.
Whereas if you try to wake someone out ofa non-REM parasomnia, they're coming out
of non-REM sleep, they're often pretty out
of it.
My question about that.
Is it in the best interest Of everybodyto not wake or attempt to wake someone who
(34:20):
is sleepwalking or having a night terror.
Yeah.
People always used to say, do notwake up some of that sleepwalking
thinking that it's gonna hurt them.
But what happens is if you wakesomebody up that's they might
become scared and agitated andfrightened and lash out, et cetera.
and so the usual approach is gently guidethem back to the bed if you can, without
alarming them or being too stimulating.
(34:41):
Yes, arousing them out of the event willstop the event, but perhaps the detriment
of kind of everybody's wellbeing.
'cause they'll be shocked andsurprised and maybe angry.
The first thing I was taught in sleepdoctor school is that if you do die
in your dream, you do die for real.
Oh, stop.
that's, they tell usthat from the beginning,
Oh
Yeah.
Day one.
I've been on alert ever since.
(35:03):
gosh.
I've been mainlining remsuppressive drugs since that day.
Oh, don't do
true kids.
You don't die.
Although I will tell you that if youfeel like you're having dreams of like
drowning or suffocation or you can'tbreathe, you may have sleep apnea.
Anecdotally, I'll tell you,some people do experience this
sensation of I'm being suffocated,recurrent, and you wake up gasping.
(35:23):
It's like you may have sleep apnea,so you may wanna look into that.
it's interesting.
Nightmares in my world are very seldomthe reason someone comes to sleep clinic.
and I think because it is such a commonshared experience that people generally,
Are fairly comfortable with it.
That being said there are certainthings to be aware of that especially
(35:44):
for practitioners that patient, peoplewho've experienced trauma often do
have issues with severe nightmares.
my colleagues who work at the VA withveterans deal with this all the time.
unfortunately there are many childrenthat have experienced trauma as
well.
And I would say to parents, ifyour kid's having a nightmare,
it doesn't mean that they've
experienced some hidden trauma.
The parents almost always know about the
(36:05):
trauma.
It's more important for providersto recognize that if someone's
coming in, they're endorsing a lotof nightmares, they have insomnia.
It seems disproportionate to what youwould expect from what you're being told.
Often if you ask in a sensitiveway, you can uncover with a family
a little bit of a trauma history.
(36:25):
I feel like this is something we justsee sometimes kids with very severe
sleep disruption and nightmares.
they're dealing with something and dealingwith trauma is something that you really
need mental health providers to help
you with.
It's not something certainly thatI feel comfortable dealing with.
not even every mental healthprovider deals with trauma.
You really need experts.
(36:45):
Yes.
Wholeheartedly agree.
We, I think we're,
great at screening because we know therole that it plays when it comes to sleep
overall when it comes to mental health.
And, even, our patients, older patientsthat experience depression and anxiety
and how that's affecting their sleepSo I think we're great at screening
for it, but I agree, we really have tolean on our mental health colleagues
to jump in and help for sure.
(37:07):
I was gonna say we'recoming up on eight o'clock.
I don't know if you guys
want to push through and we couldgo through RLS and rest is sleep
disorder or Sujay if you guys drop off
don't know.
what your
deal is
I'm here.
We could talk for hours.
Yeah.
um,
I'm happy to push through.
happy to chat about those.
Yeah.
restless leg
(37:27):
is, yeah.
I try to medically screen people so that I
can, if something seems off, Ijust send them to the doctor,
but I'm not quite sure what Iwould need to be looking for
with regard to restless leg.
Su Sujay.
Why don't you just explainwhat rests his leg syndrome is?
Restless leg syndrome, like all ofour sleep disorders, we have a set
(37:50):
number of diagnostic criteria, butit's essentially characterized by an
abnormal sensation of either discomfort,pain, something that you feel like
is uncomfortable, that is experiencedpredominantly in your legs, that is
worse or only present at nighttime.
When you move your legs, it actuallyhelps the symptoms and when you're
still, the symptoms tend to be worseand it's not better explained by
(38:14):
another underlying medical disorderlike neuropathy, et cetera, and should
cause some sort of kind of dysfunctionwhen it comes to sleep loss, et cetera.
So that's the typical definition ofrestless leg, what it can start very early
and it's, and unfortunately when we ask
adults, a good proportion ofthem will say, my symptoms began
prior to when I was 20 years
(38:34):
old.
And a good chunk of those will alsosay, it actually began before I
was 10, but I couldn't adequatelyexplain what was happening Pediatricians
have so many things to screen for.
I do not, I'm not trying to throwpediatricians under the bus here, but
oftentimes they're like, ah, it's justgrowing pains, and they'll be fine.
And it's missed for many years.
We do think it has something to dowith dopamine regulation in the brain.
(38:55):
Perhaps a decrease in dopamine dueto a circadian pattern of synthesis,
of dopamine in the brain, such thatit tends to be lower at nighttime.
And we think that iron plays a role asa co-factor in the creation of dopamine.
That's why we're oftentimesscreening for iron deficiency in
hopes of making sure that patienthas adequate amounts of dopamine.
But, a lot of children that haverestless leg also have what we call
(39:18):
periodic limb movements of sleep.
And so this is kinda the sisterdiagnosis of restless leg.
Restless leg is what youexperience while you're awake.
Oftentimes you have limbmovements while you're asleep.
like 80% of patients that haveRLS will also have periodic limb
movements of sleep, and that can alsodisrupt the quality of your sleep.
So yeah, that's a broad overview,
And periodic limb movements ofsleep are something that get
detected in an overnight sleep test.
(39:39):
They can be subtle, but they'rejust leg kicks that happen
in series of four or more.
Where Sujay and I sit in the pediatricclinic, 'cause we have children that are
often too young to really express this.
And we also deal with children who arenot always neurotypical and may not have
even if they're old enough, they don'thave language to describe these things.
(39:59):
So we're almost have to infer it.
I've had parents tell me thattheir kids will kick a lot.
They'll try to press their feet into them.
They may say that their feetare hot or cold at night.
True story.
I was studying for my sleep medicineboards the first go around and I
read this sentence and it said,kids with restless leg may say they
have too much energy in their legs.
(40:21):
And that's what I used to sayto my folks when I was a kid,
if I had too much caffeine andcaffeine makes restless leg worse.
And then I realized I've gota little bit of restless leg.
It doesn't happen that often, butif I'm anxious or I've had too
much caffeine, that is I get that
feeling.
And I feel like we this is theart of pediatrics sometimes, and
it makes our adult colleaguescrazy when they come with us.
(40:42):
And we're
trying to guess what's what, what'sgoing through a two year old's mind,
Yes.
what parents are telling us.
I think in the hierarchy of restless leg.
The other thing is
the criteria that Sujay mentioned.
Often in younger kids, they don'tnecessarily fit those criteria perfectly.
There may not the symptoms may not beworse in the evening or for example,
(41:05):
they, I think there's probable andpossible restless leg if there's a family
history and a first degree relativethat helps you with the diagnosis.
The first line treatment in kidsis checking a blood iron marker
called a ferritin and treating.
We usually treat for values less than 50.
I don't know what you guys do.
Same.
Yeah, we try to get them to 50in some cases, 50 is the goal.
(41:27):
it, can be challenging toget a child to a level of 50,
What is ferritin for the lay person?
Yeah, it's essentially a measure of ironstores in the body and the challenge with
ferritin is if you're sick, it's what wecall an acute phase reactant and that it
actually increases just in the settingof kind of inflammation in the body.
And so you don't wannacheck it when you're
sick.
You wanna check it when you're otherwise
well, and the goal
is, yeah trying to get above 50.
And again, all with the premise thatwe think it works as a co-factor in, I
(41:50):
think tyrosine
hydroxylase, which ends upmaking dopamine for your brain.
The challenge is if you
check a ferritin in any toddler,
it's gonna be below
50.
In my experience, nobody's, so I usually
want to be, fairly sure that beforeI put somebody on full fledged iron
supplementation, which by the way,can be dangerous 'cause iron overload
is a super dangerous phenomenon.
But, I wanna be fairly certain that we arein the realm of, probable process thing.
(42:14):
If we pick up periodic limb movementsof sleep on a sleep study, that could
also serve as kinda another surrogatemarker that pushes us more towards
likelihood, restless leg, if theydon't fill all the classic criteria.
But there's something that I wannasink my teeth in to be like, okay,
they have a sleep disruption due to arestless phenomenon that's affecting
their sleep before I put them on iron.
Sometimes I'll hedge my bet and say let meput you on a multivitamin with iron, which
(42:36):
isn't a full fledged iron supplement, buthopefully stabilize you where you are and
not make your iron deficiency any worse.
But it can be a challengingdiagnosis to pin down
And is iron the only courseof action for treating it?
there are other medications.
It's funny, at the recent sleep conferenceI wasn't able to attend, but the big
brouhaha now is that for adults, we'reno longer recommending dopamine agonists.
(42:59):
So we used to recommend dopamine agonistsfor adults and oftentimes they'd be
used on the adult side very early,much earlier than I would ever feel
comfortable with doing even in adults.
But medications like Mirapexwere used really early.
The typical, even for adults, Ithink the typical approach should
be what's your iron status?
And if it's low, you gotta supplement.
The next line is typically medicationin the realm of the gabapentin family.
(43:21):
And so gabapentin and its sisterpregabalin or Lyrica are the ones that
we oftentimes go to, which can reallyhelp with the symptoms of restless leg.
And now on the adult side, I thinkthey're starting to use low dose
opioids instead of the DOPA agonists.
And I think most families wouldalso be somewhat opposed unless
it's a really kind of severe
situation.
(43:42):
But then a lot of it is alsosleep hygiene, like avoiding
the things that worsen this..
So caffeine; antihistamines arenotorious for just making restless
leg symptoms much, much worse.
And so sometimes we can help from a,just a avoidance standpoint of things
that will make the symptoms worse.
Stretching leg massage.
Cold plunging.
Cold plunging.
What do you
Sorry.
we'll get Huberman on here next.
(44:04):
Yeah, that'd be great.
Everybody will be on magnesium glycinate.
Oh, I love
that.
I
It helps me sleep.
You're skeptical.
And I have the receipts from my Oura ring.
I'm not gonna
this today, but we definitelyshould talk about this.
But the I wanted to ask a littlebit about gabapentin actually.
'cause I remember I had a,
I had one parent who was in lawenforcement, they moved it from the
(44:26):
south and we talked about gabapentinfor a child and she said, I'm not
gonna give that 'cause it's a drug of
abuse.
And I think that's a littlebit of an exaggeration.
But I remember going to sleep meeting andSuresh Kotagal, who's a very smart sleep
doctor has written a lot aboutrestless leg, said that has
come up in his practice as well.
(44:46):
And I think it's more of a concern in theSouth than it is in the northeast, is have
a, has a parent ever said that to you?
Yes.
And interestingly, when I Googledit, there was some article that was
coming up very high on the Googlesearch that said something about
gabapentin being worse than opioids.
And this was something that Ithink a lot of people latched onto.
Any drug you're using in the rightway, at the right doses with access
(45:09):
that you are actually monitoringis not gonna be a drug of abuse.
Even our stimulants, when we're using infor narcolepsy in the right way, it's not
gonna end up turning into a drug of abuse.
gabapentin can help with neuropathic pain.
And there are some indicationsfor seizures, but we
rarely use it for seizures.
But no, when it comes to the kindaeuphoric effect, for example,
(45:30):
or the addictive effect ofgabapentin, it's just not there.
Yeah the doses, I think clearthere, there were mega doses of it,
like four or five grams, and therewas also taken with other drugs.
So it's just, but just to reassureparents, first of all, your pediatrician
wouldn't be prescribing this for you.
I think that usually restless legis something that your pediatrician
(45:51):
is gonna be familiar with
sleep apnea, they're gonna befamiliar with sleep walking.
So I think if your child'scomplaining about their legs at
night, I would just encourage
to see if you could make an appointmentwith your friendly neighborhood
sleep doctor and drill down on thisa little bit further because it
is a, it's a nuanced conversation.
Even things like supplementingiron aren't always straightforward.
They're various
preparations.
(46:11):
Do you dose it every day?
Do you dose it every other day?
There's some, I like theNovaFerrum preparations, but
not everybody can afford them.
Like they're palatable.
Hey Craig.
Had a listener question.
Yeah, that's what I was wondering ifthat was appropriate to ask or not.
Okay, so we got a listenerquestion in our email, Gmail.
(46:34):
thesleepeditshow@gmail.com.
Please send us your questions.
Anna l asked my sleep.
Sleep trained three-year-old has restlessleg syndrome diagnosed by a sleep.
Medicine doctor via sleepstudy, blood tests and symptoms.
However, we've gotten his ferritinlevels above 50 and he still
wakes multiple times a night.
(46:55):
Melatonin makes it worse.
His doctors said it will eventuallyimprove with time as he gets older.
He is well rested during the day, evenwith the awakenings, but we are not.
Any other tips for parents and kidsstruggling with restless leg syndrome,
I, Craig, I'd love to hear your,I'll tell you my approach, which is.
(47:15):
Restless leg is difficult
to diagnose in that young of a child.
And every sleep practitioner is
different and the practice of sleepmedicine is a lot of art as Craig
alluded to, and sometimes not so much
science.
So for me, a lot oftimes I'd wanna diagnose
them myself and see them inclinic be like they truly have
(47:39):
restless leg, or do they just tendto be a restless sleeper that has
another issue, or behavioral insomniaof childhood or something else
that's causing them to wake up
frequently.
I would certainly, as I do with allmy patients, would still screen for
being able to transition to sleepindependently at the start of the night.
Are they able to do that well?
constant assistance?
Is a caregiver coming back in and gettingthem back to sleep relatively quickly?
(48:00):
Is it truly a discomfortissue that's waking 'em up?
Or is it more of a habitual dueto, sleep onset associations?
And so we're making everythingelse as perfect as possible.
And if I'm still left with a child thatis complaining of their legs, truly bother
them and has evidence of disrupted sleepbesides after doing all the sleep hygiene
and the behavioral insomnia and stuffreally well, then yes, I am still going
(48:20):
back to my core therapies to say, okay, ifwe've gotten iron up that high and we're
running into side effects of constipationor lack of palatability and the parent
child is refusing to take more, then I amexploring other options like gabapentin.
But I cannot think of a single timewhere I've put a three-year-old in
gabapentin for us leg, to be honest.
I would be surprised if it was truereal deal with us leg at that age.
(48:42):
Yeah.
Yeah, I'd wanna see a sleep testin this kid, and I'd wanna see the
movement index through the roof.
If I'm gonna be saying this is thecause of these nighttime awakenings.
Maybe it's been done, but certainlyworth the ha a sleep test hasn't
occurred worth doing, especially if thechild's falling asleep independently.
So let's close with talking aboutrestless sleep disorder, which is a
pretty new diagnosis from 2017 or 2018.
(49:05):
and I thought it was very clever whatthey did with this because I thought when
they created this taxonomy, I'm like,oh, I see these patients all the time
and I haven't known what to do with them.
What do they look like?
they describe kids that are not havingsensory phenomenon so they don't have
restless leg, but when they're in bed atnight, they have these large, full body
(49:25):
movements and people may talk about themflopping like a fish or moving around like
hands around a clock during the night.
The sort of kids that nobody wantsto share a bed with on vacation.
And the key is that there, there'ssome daytime effects as well.
Like they're sleepy or they'rehaving problems, paying
attention in school, et cetera.
(49:49):
Yeah I think that's dead
on.
And I agree.
It's this phenomenon that we've
seen and now they've put formaldiagnostic criteria on this.
And so we're like, okay we couldpotentially diagnose you based
on the diagnostic criteria.
It does involve actually getting a sleepstudy to confirm that they're having,
I think, more than five movements perhour that are large and fit the bill.
But it's still tough.
For me
(50:09):
it's I mean it still comes down
to really
iron, is it seems to be the go-to evenfor children that have restless body
Type phenomenon.
And then I really don'thave a great sense still of
chicken and egg.
We have children that have baselineattention issues that tend to be
on this A DHD type spectrum thatwe know their brain engine idles
at slightly higher level, right?
(50:30):
Like we're working on, yeah,they gotta get down to here.
Whereas most of us, it's gottago from here to fall asleep.
And they're always idling here.
I don't know if that neurochemistrymilieu makes you more likely to
experience these types of phenomenon.
I do think there's still alot of debate regarding what
actually causes this phenomenon.
um, but it, it's, it's, it stillcomes down to I think the basics.
(50:53):
I think some of the studiesthey look fairly robust.
look at a large number of kidstypically six to 18 years of age.
And so it seems like yes, there'sprobably something going on, but
to me I would always be hesitantbecause a lot of families bring
in for example, monitor data.
They say, oh my sleep monitor pickedup this many movements at nighttime.
And one thing that I'm alwaysharping on is of course, how does
your child look during the day?
(51:14):
Are they doing okay?
'cause there are a lot of kids that movearound a lot, particularly really young
children, toddlers, early school agedchildren are notorious for just being
active sleepers, but yet their brain isstill getting the sleep that they need.
And so one thing I'm alwaysasking them is, okay, first, how
does your child look for Sure.
And then number two ifyou are experiencing this.
Is it occurring in a format suchthat they have a lot of restlessness
(51:35):
and then they go the next hour andyou know they're gonna be fine.
And then they have another spurt of
restlessness If it is a perpetual,constant motion to point where you're like
how are they getting good quality sleep?
Because they're always moving.
Every few minutes they're moving, boom.
That's when the yellow flaggoes up and I'm like could this
potentially be something that'struly disrupting sleep quality?
Yeah, No I think that's true and itis always so tricky because often
(51:57):
these things come to light when,again, not to imply that everybody's
kids have their own, like manyof our families, they're sharing
rooms.
They may even be sharing beds.
Other parents, all of a sudden theygo on vacation with their kids.
They share bed for two nights, and it's
a catastrophe, right?
They're like, oh my God, he'ssnoring, he's moving, et cetera.
And I think it is very important to lookat the child's functioning during the day.
(52:21):
That's a really good barometer of
how things are going And I agree with you.
I feel like that in the Venn diagram
of whatever restless sleep disorder is
in A DHD, there'sprobably a large amount of
overlap there.
And that being said, Iftheir ferritin's pretty low,
give them a trial of it,and they're doing better.
And that correlates
with an in, in the ferritin going up.
(52:43):
I think that's useful.
And sometimes, I don't know, I, inour lab I feel like we be, we've had
a trouble getting agreement about whatscoring these large body movements.
Do you guys actuallyindex these in your lab?
we don't index.
And I'll tell you that it's very rarethat I have ordered a sleep study.
If I,
have a child that's really restlessand it's affecting daytime function
(53:03):
and I have nowhere else to turn, I'musually still going down the ferritin
route and saying 'cause there area lot of movement issues So I think
we've gone down that route anyway.
So it's rare that sleep study,particularly looking for this
to make this the diagnosis Let'slook at iron, see what happens.
In the yeah the at the end of theday, even with all the difficulty of
getting a good ferritin value, dosingiron, finding a palatable format,
(53:25):
it's still, I think everybody's a littlebit more comfortable with it providers
and parents than like prescription sleep
medication, right?
It just feels like a lower
tier intervention.
absolutely.
so listen guys, I think wecovered what we set up to cover.
This has been amazing.
Absolutely.
I've definitely learned.
(53:46):
Now
Suji, you've got a prettybig footprint online.
I've got your professional profile,your Instagram, your TikTok, your
links.
Is there anything else youwant us to share online here?
no, just pri you know, the one thing Ido like to share on all podcasts that
are like parent facing is I always liketo say that everyone is looking for that
(54:09):
perfect, magical solution for everythingwhen it comes to like potty training,
when it comes to feeding, when it comesto extracurricular activities and sleep.
There are like a million right waysto raise a thriving, happy child.
Yeah.
And let's rule out sleep disorders,but when it comes to even the
behavioral approaches to sleep, thereare a million right ways to do it.
(54:29):
So I tell families,there's no one right way.
Take some of the pressure off.
If your child is happy and they'rethriving, you're doing it right?
Every parent struggles,everybody has opinions.
I get it.
Let's be kind to other parents.
I dunno why parenting has turned into ablood sport online and like these threads,
let's just be kind to one another.
Go a long way if we're just kinder.
(54:50):
And if you feel cranky all thetime, consider getting more sleep.
Yeah.
Absolutely.
We'll put a pin in it.
I'm Craig.
I'm Arielle Greenleaf,
the sleep edit, and if you please tryingto get this started, please share online
Ariel, what's our email inbox again?
the Sleep Edit show@gmail.com.
(55:12):
Tell your friends.
Okay.
Thanks a lot guys.
Thanks so much forlistening to the Sleep edit.
You can find transcripts atthe web address Sleeped show.
You can also find video of theepisodes at that address as
well as in my YouTube channel.
(55:33):
You can find me at Dr.
Craig canna perry.com and on allsocial media at D-R-C-A-N-A-P-A-R-I.
You can find Ariel atInstagram at Ariel Greenleaf.
That's A-R-I-E-L-L-E-G-R-E-E-N-L-E-A.
(55:55):
If you like the flavor of the advice here.
Please check out my book.
It's Never Too Late to Sleep.
Train the Low Stress Way to high QualitySleep for babies, kids, and parents.
It's available whereverfine books are sold.
If you found this useful, pleasesubscribe at Spotify or Apple Podcast
and share it with your friends.
It really helps as we're tryingto get the show off the ground.
(56:16):
Thanks.
Popular Podcasts
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.