Sleep Problems – PediaCast 270

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Dr Mark Splaingard joins Dr Mike in the PediaCast Studio to talk about sleep problems from infancy through the teenage years. Topics include infants crying in the night, bedtime resistance in toddlers, fears and nightmares, night terrors, sleep walking, insomnia, obstructive sleep apnea, sleep studies, and daytime problems made worse by poor sleep.

Topics

  • Infant Sleep Problems

  • Toddler Sleep Problems

  • Childhood Sleep Problems

  • Teenage Sleep Problems

  • Sleep Studies

  • Infants Crying at Night

  • Bedtime Resistance

  • Fears and Nightmares

  • Night Terrors

  • Sleep Walking

  • Insomnia

  • Obstructive Sleep Apnea

  • Poor Sleep & Daytime Problems

Guest

Links

 

Transcription

Announce 1: This is PediaCast.

[Music]

Announce 2: Welcome to PediaCast, a pediatric podcast for parents. And now direct from the campus of Nationwide Children's, here is your host Dr. Mike.

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast, it's a pediatric podcast for moms and dads, this Dr. Mike coming to you from the campus of Nationwide Children's Hospital, we're in Columbus, Ohio it is October 30, 2013 it's episode 270, we're calling this one sleep problems. I want to welcome everyone to the program. I have a giant nuts and bolts program lined for you today and it's a tall order to be sure covering sleep problems that span from infancy thru adolescence.

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Things like babies crying in the night, toddlers wandering the house, bedtime resistance, fears and nightmares, night terrors and sleep walking. How to help your child fall asleep and stay asleep, also school age children with sleep problems that turn into day problems, how the sleep affect behavior, attention and concentration. And what about obstructive sleep apnea? What is it? How is it diagnosed? What complications can arise from it? How is it treated? Really lots of ground to cover this week and it's ground that you, the PediaCast audience has asked me to cover. For instance, Sammy in Brooklyn, New York ask, "Could you please do an entire show with a sleep specialist?" Yes I can, and we're going to do it today. Jason in Vancouver, British Columbia says, "I love your show and recommend it to all my friends and co-workers. I would like to ask you about my daughter who is two years old and for the last two to three months has began waking up in the middle of the night."

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"She was previously a good sleeper who would regularly go to sleep at 8:30 pm and not wake up until seven the next morning. Now she wakes up at three or four in the morning and screams for mom to pick her up and bring her into our bed. In order to get some sleep we have complied with this request, in addition it reduces the chances of waking up her older sister. I was wondering, what is going on, and what may have caused this change in behavior? In addition, what can be done to encourage her to sleep through the night? By the way we have tried talking to her and asking her to go back to sleep and we've also tried to give her a stuffy when she is placed into the crib, but she refuses. Thank you for the opportunity to ask my question." Devin in Hershey, Pennsylvania says, "Hi Dr. Mike I'm a new listener. PediaCast was recommended by another medical illustrator mom on our association listserv I've listened to three episodes and I'm hooked. I have a three year old girl and a boy who will turn five next month. My son has exhibited new and substantial fears for the last three weeks, initially he claimed to be afraid of a bear he saw on the cartoon, but now his fear seems none specific."

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"He refuses sleep at bed time unless we lie with him and then he wakes us two to three times each night. He doesn't have nightmares but is afraid to be alone. He seems to be getting worse and resist being alone during the day, he suddenly needs to be accompanied to the bathroom or his bedroom when I'm just a room away. He'd always been an independent child, sometimes even asking for privacy. He started the all-day pre-school this year and says he loves it, there's some family stress because my husband has been out of work. I think his fears are genuine, we have tried although not always succeeded to be gentle when he wakes us at night. We are all suffering from lack of sleep, should we co-sleep until he outgrows his fears? When should we seek a pediatric psychiatrist? I already plan to discuss this with our pediatrician at his annual exam. Thank you in advance for your help." And Sarah in Gladstone, Michigan says, "I love your podcast, I'm the mother of a two and four year old, I also work with infants and toddlers with developmental delays."

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"One of the children I work with is been diagnosed with night tremors, what are these? How do they affect sleep, and how are they different from seizures?" Lots of interest in sleeps problems amongst your fellow audience members, and this is just a sampling of the questions that you've asked on sleep issues. We'll wait no longer, answers are on the way and help me tackle these problems. We have a sleep expert in the studio today, Dr. Mark Splaingard is the director of the Sleep Disorder Center at Nationwide Children's Hospital. We're getting to him in a moment, first I want to remind you that PediaCast is your show. We cover the topics you want to hear and we approach each topic in an evidence based fashion, so you can trust what you hear. I shared questions from four of our listeners today, and if those four hadn't written in, we might not be covering sleep problems today, we'd probably talking about something different. If there's a question that you have, or a topic that you like me to cover, ask away. I'd love to hear from you, your question may become the basis of an entire episode and it's easy to get touch, you just head over to pediacast.org and click on the contact link.

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I also want to remind you, the information presented in PediaCast is for general educational purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individual. If you have a concern about your child's health, be sure to call your doctor and arrange a face to face interview and hands on physical examination. Also, your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org. Let's take a quick break and we'll get Dr. Splaingard settled in to the studio and return a ginormous discussion on sleep problems, its coming your way right after this.

[Music]

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Dr. Mike Patrick: We are back, Dr. Mark Splaingard is a pediatric pulmonologist at Nationwide Children's Hospital. He serves as director of the Sleep Disorder Center at Nationwide Children's, and is a professor of pediatrics at the Ohio State University, College of Medicine. Dr. Splaingard's research includes a focus on sleep disorders in children including a project with modified smoke alarms design to awaken children during deep sleep. This is Dr. Splaingard's first appearance on PediaCast, and it's with a warm welcome that we say hello, thank you for joining us today.

Dr. Mark: Thank you Dr. Mike, it's great to be here.

Dr. Mike Patrick: We really appreciate you stopping by. This is a big broad topic that we are covering, sleep disorders, and we could devote nearly an entire show to some of these. Things like babies waking up and crying in the night, bed time resistance, night terrors, sleep walking, insomnia, obstructive sleep apnea, really lots of ground to cover.

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We've divided the material by age group with the understanding that some of these problems really span multiple ages. But I think a good place to start is with babies. Dr. Splaingard let's talk about sleeping babies, what sort of normal in terms of how long babies sleep?

Dr. Mark: Mike, we used to think that all babies would sleep about 14 to 15 hours when they were born, but some of the more recent researches had shown that there's a wide variability. And some normal babies will only sleep like 9 or 10 hours, and some babies that are also normal will sleep 18 and 19 hours. What happens is, sleep like a lot of things is really pretty variable in trying to define what is abnormal, it's a challenge for the whole field.

Dr. Mike Patrick: And I bet a lot of parents have some anxiety when they give that one number and if their baby is not doing it, it causes some anxiety and concern on part of the parents.

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Dr. Mark: Absolutely, It's like saying, all children walk by a year of age. If after their first birthday your child is not walking, you wonder, "Is there something wrong here?"

Dr. Mike Patrick: But there's a wide range of what's normal, and this is where you just talking with your pediatrician when you have this concern is a good idea because they hear from parents all the different varieties of what's normal and they can provide some reassurance for you. Now in terms of feeding, every time that they wake up in the middle of the night, is there something that a lot of moms and dads want to know. With their crying, do I need to go in and feed them? Does it mean that they're hungry if they wake up and they're crying as a baby?

Dr. Mark: I think for sure, for little babies, that's clearly a concern and you would feed an infant when they wake up at night. But most of the time, once a child gets to be about 14 to 15 pounds, they probably don't need to eat at night, and often times what we find happens is not so much that they need to eat at night, but they fall asleep either breast feeding or bottle feeding.

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And that becomes their association with falling asleep, so that when they wake up a little bit in the middle of the night, which everybody does, they think that the only way they can go back to sleep is by feeding. And unfortunately they can't feed themselves, they require mommy or daddy to feed them, and so mommy and daddy know about it when they're awake.

Dr. Mike Patrick: That's one of those things, you want to do it when the baby has nutritional need or they need to do it in order to stay hydrated. But you don't want to continue to do it otherwise it becomes a habit.

Dr. Mark: Often times we will say is that we really like you to be able to put your child to sleep, and again this is probably after four or five months of age. But you want to put your child to sleep while they're still a little bit awake, don't let them completely fall asleep when they're eating and then put them in bed, but let them finish eating a little bit and then go ahead and put them in bed.

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They'll maybe fuzz a little bit but they will learn to what called self-soothe that they have the ability when they're by themselves in their crib, they can fall asleep on their own, and once they develop that then you'll have a lot less problems during the night.

Dr. Mike Patrick: We hear about the crying it out method or Dr. Ferber I think was one of the guy that describe this in terms of getting your baby to cry. They're going to cry but I don't have to necessarily rush in and see what they need immediately. But a lot of parents have some guilt about doing that or develop a fear that it'll cause personality disorders down the road if their baby was crying at night and no one came in, what would you think about that?

Dr. Mark: Well you know the Ferber method is a form of extinction and that's basically how you stop a behavior. Extinction, if you just completely always ignore the behavior, eventually the behavior will extinguish. But the problem is somewhere between 10 and 15% of children are really though,

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and that they will cry, they will scream, they will beat their head against the wall, they will vomit and most of us don't have the stomach for following through with extinction with those children. There're actually ways of doing graduated extinction where you may put them down, they'll cry, you'll come in within a minute, just tell them everything's OK, don't pick them up or anything just let them know everything's OK, walk back out, wait another minute, go back in, same thing wait, two minutes maybe go back in. They'll eventually start to settle after a few nights. What you don't want to do is to be inconsistent in your reinforcement because that becomes like a slot machine, where the baby learns sometimes when they cry, they "leave me alone". But if I cry long enough and hard enough, they finally pick me up, and so you perpetuate that in.

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And so you want to be consistent, and I say for any child under a year of age you should only go about a minute before you go and kind of soothe them. But then again you don't have to pick them up, not to rock them, in fact you don't want to physically rock them at that point, just want to let them know you're there, you can see everything's OK and then you walk back out.

Dr. Mike Patrick: Because if you pick them up and feed them, then suddenly they have this positive reinforcement so that in the next time that's what they're expecting.

Dr. Mark: That's right they won the lottery, they won the slot machine.

Dr. Mike Patrick: If you start with a minute then the next night maybe go a minute and a half? And the next night maybe going to push it a little bit?

Dr. Mark: Some of my parents are engineers and they'll have their lunch on and go a minute and 10 seconds and 70 seconds. But what I always teach people is that it's easy to talk about this but psychologically for parent it's hard to do. What you need to do is start some place that's you're comfortable with, and for some of our parents who try the Ferber method, they try it for a couple of nights and then it didn't work so they stop.

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Now that baby or that young child has learned that, that doesn't go any more. For some of those parents, what they'll do is watch and just have them put a chair on the room and say, you sit three feet from the child's bed. You don't respond to him for a couple of minutes but you're there, you're watching and you start moving your chair out of the room. Then maybe a foot or two each night, get out and the child gets used to them, they can settle themselves. That's what you're going for, self-settling and this is pretty successful for normal kids, for kids who have any special needs though because you may have other kinds of medical problems. You should really talk to your pediatrician about this.

Dr. Mike Patrick: There's not a one size fits all approach. Each parent/baby combo is going to be unique and what's going to work for one family is not necessarily going to work for another family.

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In terms of movement in the middle of the night, one of our listeners that wrote in talked about working with some babies, they had night tremors. What are some the movements that babies make when they're sleeping the parents can expect? And what's normal, and what's not normal?

Dr. Mark: This is a classic question that I get a lot. Babies when they're first born will often have characteristic movements that indicate that they're in a certain sleep stage called act of sleep. And those movements will be little fiddling of their hands, little grins and smiles, and sometimes even little jerks and you'll see all kind of little tiny movements and people wonder about this, "What's going on with the baby?" That's really a normal phenomenon. Some kids, as they're falling asleep have what's called a hypnic jerk, in fact some adults have this one. As you fall asleep, you suddenly do a startle and people get nervous about that because they go, "Oh the baby had a seizure", well in fact that's just a very normal phenomenon.

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I think you should probably be worried about movements when they are repetitive and stereo type, and what I mean by that is, if they are moving one arm in a jerking fashion or they are moving their arms and legs in a jerking fashion and seem to be staring off, or had their eyes closed, those are the kinds of things we think more about seizures rather than just regular kind of movements. But there's a wide variety of regular goofy moments that babies, and toddlers, and young children make.

Dr. Mike Patrick: And again this is something that parents should bring up with their pediatrician. With phones being able to record, it's easy to say, "OK this is what my baby is doing", take it into the pediatrician and say, "Watch this". This is what the kind of thing I'm talking about and then your doctor may have a better idea of whether this is something normal or something to be worried about.

Dr. Mark: I probably look at one recording off a phone about every week. Somebody brings in something and most of the time we can reassure people that this looks like a very normal phenomenon.

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Sometimes it is hard to know though and you do need to do a little more investigation.

Dr. Mike Patrick: And you want to know too what's happening during the day, do they have unusual movements during the day time or is it just when they're sleeping? And when did it start? Is it becoming more often? Lots of that historical stuff you need to know.

Dr. Mark: That really helps a lot to figure that out.

Dr. Mike Patrick: One thing a lot of parents worry about especially with little babies is, are they going to stop breathing when they're sleeping? I think that that's a reason especially when you have a brand new born is to have the crib in the bedroom with mom and dad, and so we have baby monitors and such. Is that a real thing that parents should be worried about?

Dr. Mark: You should always balance the worry about the probability of their being a bad thing and honestly we know for some pretty sophisticated studies that have been done over the last 20 years that little babies can have relatively long pauses and breathing.

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15, 20 seconds that may even be normal. The fact that a child doesn't have a breath for 15 seconds, that may be part of the normal variation. The big things to watch for are, if the child clearly turns blue, if the child looks like they're struggling to breath, if the child's vomiting, or coughing, or gagging, or if the child seems to have one of those stereo typical repetitive movements, then I think it's probably worth talking with a PDA the nutrition about. Sometimes babies will have fairly dramatic episodes where they suddenly stop breathing, they'll turn blue and you to shake them to get them to start breathing again. And those are should be brought to your pediatricians' attention.

Dr. Mike Patrick: The kids that we're more worried about, you might be a little bit more on the lookout for that sort of thing, or babies who are born premature, or those with underlying medical conditions that may pre-dispose them to have in that kind of problem.

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Dr. Mark: If you have a family history of young babies that have difficulty with breathing or the other things that you really talked about, that would be when you have a little more heighten suspicion. But sometimes I have people come in and say, "You know, I actually"… And again, people are very concern about their children and they'll tying this events and they'll say there was a 13 second pause for my child to not breath. In an otherwise normal baby, who wouldn't be too concern about that?

Dr Mike: Let's move on to toddlers, are you suppose we talk about babies there's a big range of normal of what babies sleep looks like, is that true for toddlers as well?

Dr. Mark: The toddlers, I was actually telling about the infant feeding phenomenon as sleep association disorder that's common in why little babies have difficulty sleeping. Toddlers can have the same thing, they can have a variation of,

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for example if they're being rock to sleep a lot or there's a whole lot of repetitive activity that goes into them falling asleep at night, then when they have that wake up after 60 to 70 minutes falling asleep, that little short wake up that they should be able to go back to sleep, they want to reproduce those circumstances. And so they want mommy to read to them, or they want daddy to rock them and they will make that known. Everybody in the household will know that they are upset and they are awake.

Dr. Mike Patrick: If you're a parent with a brand new baby at home, you want to start right from the beginning in terms of they're not being associations with when I fall asleep. The self-soothing thing is really important like right out of the gate.

Dr. Mark: I always tell people honestly that I let them do pretty much what they want to do by four months of age. We don't have good melatonin secretion until we're about four months of age. At that point we can start to have a longer sleep period at night than during the day time. And at that point that once you get to be about four months of age, you can start to do some of the stuff where you feed them, put them in a crib, let them settle a little bit, and start to work on that a little bit.

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Dr. Mike Patrick: Toddlers, one of the big things that parents face is the kid not being ready for bed. You have a bed time, you're trying to establish routine and there's a lot of resistance. How can parents overcome that resistance?

Dr. Mark: Well I tell people that it's a stalling behaviors or curtain calls where you put them to bed and they scream in their bedroom, they want one more story, they want to see daddy, or they want to hug mommy one more time, that's pretty common. What I explain is that you best want to do what's called limit setting behavior modification during the day time. The sleep issues can be dealt with in the same way that you would modify a behavior that's occurring during the day that you don't like.

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Except the problem with doing it at night before you do it during the days, they got you at the weak point, you're tired and they're not. And that's when often time's parents were very good at limit setting during the day time. It becomes more difficult than that and I think that the same kind of behavior strategies work very well for children, toddlers and young children.

Dr. Mike Patrick: Positive reinforcement of the good behaviors and sticker charts and reward systems.

Dr. Mark: We're real big on stickers than anybody over 3, actually. Stickers work very well.

Dr. Mike Patrick: We added when my kids are little, then once they collected so many stickers, then they could turn those in for a bigger reward.

Dr. Mark: That's a great idea.

Dr. Mike Patrick: What about fears? One of the listeners had written in about a child that has seen a cartoon with a bear, and now they're afraid when they go to bed at night that there's a bear in the room, or when they wake up in the night they're afraid there could be a bear.

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How do you help toddlers separate what's real and what's make belief? And how that goes along with fears?

Dr. Mark: Our behavioral psychologist works in our sleep clinic with us and they have taught me a lot about this. As I was hearing about the child with the fears at the beginning of the program, they were having fears also during the day time. If the fears are also during the day time, then you can address the fear during the day time. If it's strictly at night time, then we will do some simple things, for example we may have a little squirt gun and we'll squirt a little bit for the monsters to be away. And we do a little squirting as they go to bed, we finish our squirting now the monsters aren't going to come, let's go to sleep.

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And the Psychologists have very simple techniques that it doesn't take psycho analysis for five years to handle this, it's pretty direct and pretty concrete thing.

Dr. Mike Patrick: And I think at the end of the day it's what works. You may have some people who would say, well if you squirt a gun then you're saying, yeah there could be monsters, and in the kids head there might be. How you handle it in your family? At the end of the day you want the kid to be able to go to sleep and not worry about monsters and probably a few months from now it's going to be a different concern anyway.

Dr. Mark: Little kids can have a lot of anxieties and I think part of what we have to teach them is, it isn't so much using a squirt gun or any particular thing. We have to teach them that they can control the environment a little bit. But they're not at the mercy of everything that they are afraid of, they can take a positive approach of their fears.

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And there's all kind of very clever ways that people can do that.

Dr. Mike Patrick: We're going to talk specifically about the sleep disorders clinic here at Nationwide Children's, but being a multi-disciplinary clinic you have your disposal, the behaviorist and the psychologists to help families through that thing if they aren't able to do it on their own.

Dr. Mark: I have to say though that our pediatricians are very good with this and talking with your pediatrician, going through things with them, we tend to see the cases of kids who are unusual or who have had a lot of problems. I think probably 90% of these are easily cared for within a pediatricians' office.

Dr. Mike Patrick: It's a good point as a practicing pediatrician, when I did that you do hear a lot of stories from parents, and you get some ideas in your head of what work for other families, and then you can share those as folks down the line have the similar issues.

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Dr. Mark: We have more teaching now about pediatric sleep with our curriculum. It would be 20 years ago when I was going through pediatrics and things, you didn't learn much about pediatric sleep. Most of what people learn was in magazines and none medical books. Now it's part of the curriculum for a lot of medical schools and for pediatric training program. The pediatricians are pretty well-versed in this and they can help you, they can be your first line.

Dr. Mike Patrick: What about toddlers who wake up at night and then start wandering the house. This is another area where once when a baby is in the crib and they wake up, OK they may cry and you may have to go in and soothe them, but they're not going anywhere. Once we have a toddler they're able to get out of bed and can roam the house, how do parents deal with that?

D. Mark: There's a couple of other things you have to think about, and as a sleep doctor what I'm always trying to differentiate is, is this child conscious and awake when they are wandering the house? As supposed to, they are wandering the house and they're sleep walking.

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And being able to differentiate that, and sometimes the easiest way to do that is, can the child remember the next morning what happened? That helps me to figure out what is going to be my approach. What I mean by that is if it's clear that the child's wandering the house and they're awake then I'm going to work on a limit-setting technique. These are the kinds of things we're going to do, we don't want you to be walking by yourself while you're awake around the house looking for food in the refrigerator for example. And we can work that in a limit setting way, but on the other hand if the child's really sleep walking then a limit setting approach is not going to work with that, we're going to have do some other kind of strategies and that's the first differentiation.

Dr. Mike Patrick: And then I would imagine safety as a concern, if you do have a toddler who's wandering the house, you're going to be more likely to have the house as danger proofed as possible.

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Dr. Mark: We always tell people that we'd like to have the bedroom as safe as possible, no sharp objects nothing that can hurt themselves within the bedroom. And then there's also this relatively and inexpensive door alarms which you could buy at the any of the national chain hardware stores. But for a small price when you open the door you get an alarm and you as a parent then can know that your child has opened the door and they're probably moving out of the door.

Dr. Mike Patrick: That you can be there to redirect them and look to your limit setting thing. Now there's something that we call night terrors. When kids scream in the night or very emotional crying, talk to us about those, what's going on with night terrors?

Dr. Mark: The good news about night terrors is that the children are in a very deep stage of sleep.

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A deeper stage of sleep where they're getting lots of good things, birth hormone, all kind of things that they're good for them. The fascinating thing about night terrors is that the kids are going through all these different behavior which is very disturbing to parents. It's often a blood curdling scream that starts everything off and then the most common thing that I hear from parents is that they look like they're possessed. Their eyes are open, they're sweating and they're screaming at the top of their lungs and we're so concerned that something is hurting them. They're unaware of what's going on and they're in a deep stage of sleep and most of the time these events will occur over about a three to five minute period, they usually get over in about five minutes. Even though the child looks like they're just exhausted, they will often just fall asleep by the end of it.

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And they won't remember it the next morning, that's one of the key things, they won't remember anything. What will happen, sometimes I caution parents you don't want to talk to them too much about this because what happen is they start remembering what you're telling them about what happened last night. If every night they do this rehearses what happened last night, then after a while it will sound like that they do remember what's going on.

Dr. Mike Patrick: Are they dreaming? Are they responding to a bad dream? Or is this just the brains upset center firing?

Dr. Mark: This is a very interesting phenomenon that we know a little about but we don't understand it. It's in the early part of the night usually during what's called deep restorative sleep or slow wave sleep. It's almost predictable for some children, it's within about an hour to two hours of falling asleep they will have one of these episodes. Some of the kids can have a couple of the episodes during the night, it's rare to have the episodes after about 3:00 in the morning with most kid's bedtime.

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Our dreams normally occur during rem sleep which is at the end of the night, 3:00 am, 4:00 am, 5:00 am, 6:00 am is when we have our most vivid dreams and that's when we have our nightmares. But this kind of sleep terrors are usually going to be within the first couple of hours of falling asleep and the kids won't have any memory of what is going on. As suppose to the nightmare that happens at 3:00, 4:00, 5:00 am, sometime a little early but usually around that time. They will be able to tell you a very complicated story about dragons, and monsters and they'll remember it all.

Dr. Mike Patrick: But those usually aren't the kids who wake up screaming.

Dr. Mark: They scream but they settle, the nightmares generally settle quickly with the families as suppose to the sleep terrors.

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What we tell families to do is, don't try to intervene with them, don't try to comfort them, don't mess with them, just make sure they're safe, let them sit, let them scream and they will settle down relatively quickly. But the more you try to interfere, it's almost like they got their sleep gears stock and they can't get out of slow wave of sleep and the more you interfere with them the longer sometimes it will last.

Dr. Mike Patrick: But if you leave it alone usually within five minutes or so, would you.

Dr. Mark: Usually within five minutes it's should be gone and you can talk to your pediatricians about that there's something weird about what's going on, but that's the usual thing.

Dr. Mike Patrick: Is there any reason to wake them up before this happens? If you can time it, if it's always an hour and a half into their sleep, if you kept a log and that may arrest it, but do you really need to do that?

Dr. Mark: The thing is there was a few papers probably 25 years ago that talked about it, if you could anticipate.

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For example some families can tell me, I put my child to sleep at 8:00 at night, at 9:55 every night they do this behavior. The old pediatric practice is wake them up about ten minutes before 9:55, force them to wake up and that won't happen. That works for about 1 out of 10 children. It works just enough that it's probably worth a try but it's probably not going to be a very successful strategy.

Dr. Mike Patrick: And even if it did work you'd still have to do that, I mean maybe a month later we'll just start back up again.

Dr. Mark: The good news about all this is that a lot of the sleep walking, the vast majority of children outgrow this. Now the bad news about it is they may not outgrow until they're 10 years old and 12 years old. But usually it becomes less frequent and it is unlike it's really harming them, it's a sign if they're getting deep slow wave sleep which is good for them.

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I tell families the good and the bad news of this, if you can ignore it, that's probably the best way to go.

Dr. Mike Patrick: I guess too it comes down to, you have to look at the individual family situation, if there's a parent or sibling who's also trying to sleep and the night terrors wake them up and then they're not able to get back to sleep and so there's other dynamics involved then you might be more likely to try to eliminate the night terrors, but if you are fine with it then great.

Dr. Mark: This is probably worth our comment because I will have people come who, like own a bed and breakfast and they cannot have a child screaming in the middle of the night for their guest. And this becomes difficult because we do have some medications that will reduce the frequency of night terrors.

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 The problem is that those medications work generally by getting rid of the slow wave sleep and we don't want to do that, we want the children to have slow wave sleep. And this becomes a double edge sword here, are you treating something more for a social reason than for a biologic reason? And That's why you really need to talk with your pediatrician, maybe even see a sleep specialist because there are some things that can perpetuate, things like night terrors, obstructive sleep apnea, restless legs syndrome. Occasionally you can have a child who's having those things that may make this things persistently every night for a long period of time.

Dr. Mike Patrick: If you could address those other problems then you hopefully you would address the night terrors as well.

Dr. Mark: The other thing about night terror is, often there's a family history of this and that's really the first thing I want to know is did mom or dad had this as a child?

0:35:03.4

Did uncles and aunts had this? Are there other kids and family often times with the kids who have really bad sleep terrors. What we find is that there's a very strong family history and that family history can help us because people can't understand that everybody grow out of this.

Dr. Mike Patrick: If there's a family pattern where everyone grow out by age, then you'd feel a little confident that for your kid you'd follow that same family pattern.

Dr. Mark: It is reassuring at that point.

Dr. Mike Patrick: What about school age children? Now we're going to go to a little bit older kids, do you find that as kids get older that they need less sleep, or more sleep?
 Dr. Mark: I talked about the infants and how parents had done questionnaires to figure out how much time infant slept. And the kind of standard reply for a school age child, from 6 to 10 years of age is that child should have probably 11 hours of sleep. But when you look at what parents report, there's about an hour and a half on each side of that.

0:36:05.5

This is a very difficult area because what I always tell people is how much sleep you require depends on how you're functioning during the day with that amount of sleep. If you're yawning all day, if you're falling asleep all day then you're probably getting insufficient sleep. But if on the other hand you sleep nine hours, and you feel fine, and your performance is fine you aren't falling asleep, then nine hours is enough sleep for you even though the book may say that while you should be sleeping 11 hours. It's always couched in what is the child's day time behavior and performance like? The children that we try to get quizzed the most about or see the most are the kids who are having difficulty during the day, maybe with behavior. Kids who don't get enough sleep at night, and unlike adults who would be tired and falling asleep,

0:37:03.3

those kids who don't get enough sleep at night tend to be more inattentive and hyper active. And I'm saying the code words now for ADHD, this is a big concern because we'll often see children who are relatively young, five and six years of age who are exhibiting behaviors of inattention, impulsivity, can't sit still, they say he's hyperactive and it may won't be that his lack of either enough or unbroken overnight sleep maybe causing him to have day time problems.

Dr. Mike Patrick: Have you seen kids who once you get the sleep issue under control, they don't need medicine anymore?

Dr. Mark: It's true but I always caution people that if you ask me, and I'm only speaking with myself now, because this is an area that people I've really tried to study but it's difficult to study.

0:38:00.4

I would say somewhere between 5 and 10% of kids who are believed to have ADHD probably have a primary sleep problem and if you can't take care of that overnight sleep problem, I think you can dramatically improve their ADHD. Now that doesn't mean that you can't help a child with ADHD if you can't help their sleep. It means that we have to be careful saying that all ADHD is just a sleep problem, I think there're kids who have ADHD even though they sleep pretty well.

Dr. Mike Patrick: And so again we have to take each individual kid and their circumstances because we can't do cookie cutter decisions here. If a parent is concern that their child is having sleep problems and they think, OK my kid needs more sleep because there are some daytime issues here. What can they do to get their kid to fall asleep quicker more easily?

0:39:00.3
 Dr. Mark: This is hard because you have to have some sense of what is normal. I often recommend that the families got a calendar and they start to write down what time the child goes to bed? What time the child seem to be asleep? And what time they woke up in the morning? Because often times it becomes easier when you see a pattern over a month of what their sleep is like, what time they're going to bed? It just starts to understand that they're having more problems towards the weekend. They're having more difficulty on Sunday night with getting asleep in order to be able to wake up for school on Monday morning. You start to get some of that pattern because some much of when we go to sleep depends on how tired we are and when our previous night sleep was like. And so we're going to talk about this a little more with the older kids who have sleep phase delays.

0:39:59.8

But even at younger kids we keep everybody up late on Friday night and then we don't realize it but we let them sleep very late on Saturday, and then they may do the same thing even on Sunday and by Monday they're off schedule and you can see that when you start to look at the schedule.

Dr. Mike Patrick: Does routines come in to play here?

Dr. Mark: Routines are good, kids like routine and I think the more structured you can be, potentially the better but unfortunately for many of us, I don't know how your house is, but my house can be pretty chaotic sometimes. The good news is that they're not violets, they're more like green beans. Kids, if you give them a reasonable amount of sunlight and you give them a reasonable amount of order, it isn't like you have to have them get in bed at 7:56 every night.

0:41:01.8

You can have some variability but you should try to keep things on a routine, generate a certain time especially I think for the little kids, watching TV, electronic devices, those probably need to be turned off about an hour before bedtime. The bed should be used only for sleep for children, they shouldn't be watching TV in bed, they should probably not have a TV in their bedroom.

Dr. Mike Patrick: There're lot of kids to have that, I can't tell you how many times we see kids in the emergency department for concussions and we tell them to take it easy and not watch movies. I can't tell you how many times a kid say, "I can't watch TV in my bedroom?"

Dr. Mark: The electronic devices are a huge issue, it becomes worse in the teenagers but even with the six and seven year old have learned to use the remotes and frequently they're kind of, mommy and daddy leave the bedroom and they're awake watching TV.

0:42:04.4

Dr. Mike Patrick: We talked about that you wake up frequently during the night and for toddlers and babies, if there were something that they're associating with getting to sleep then they may expect it when they do wake up in the middle of the night. With school age kids, when they wake up frequently at night what can parents do to help them get back to sleep?

Dr. Mark: Most common thing when a school age or older child wakes up at night is that frequently they will start to think about, after they've had a few sleep cycles of about 70 to 90 minutes they get towards the 2:00, 3:00, 4:00 am time. Now when they wake up sometimes the underlying anxiety or worries start to come out for that, it's almost like, I have big test tomorrow and at that point the pressure to sleep becomes a little bit less because they've had four or five hours of sleep now and that's when those anxieties and those worries can start to cause them to have difficulty.

0:43:07.7

The first thing is that you want to know when a child is waking up at night is what's going on in your mind and frequently the kids will be.

Dr. Mike Patrick: They will be able to tell you because they were thinking about it all night.

Dr. Mark: Absolutely, they can tell you that I started worrying about school tomorrow morning, or I'm starting to worry about the ball game that I have tomorrow morning. And again those kind of behavioral techniques for relaxation, all the different things that we can do can help them.

Dr. Mike Patrick: Maybe the parent's weren't even aware that they had those concerns and so if that's something that you can reassure and help them through during the day, then that might help to eliminate the night time problem.

Dr. Mark: We always want to focus on do as much during the day time as we can to try to help with our time at night.

Dr. Mike Patrick: Let's talk about sleep walking, how is it that you can be asleep and walk?

0:44:00.5

Dr. Mark: This is pretty interesting because I run a sleep lab about 2000 sleeps that is a year and I always tease the text because we can almost make everybody sleep walk or sleep talk if we go in at a certain time during slow wave sleep and jostle them. People will wake up, it will appear on the outside if they are completely awake, their eyes are open, they're sitting up in bed, but in fact I'm looking at their EEG and I can tell you they're completely asleep. It's a very interesting phenomenon but sleep walking is very common, it often times happens when kids are over tired, even somebody who isn't used to sleep walking. If you all of a sudden start an exercise program or something and I often find like at the beginning of football practices for little kids they're absolutely exhausted, they've been out doing exercise, they come home and they have a very deep night sleep, deep slow wave sleep and that's the night that the child starts sleep walking.

0:45:02.9

And everybody's just horrified that Johnny was wandering the house last night, often times it's because that Johnny was just exhausted and had deep slow wave sleep and that's when you tend to do those behaviors, again within the first couple of hours of falling asleep.

Dr. Mike Patrick: For kids who are repeat sleep walkers, is there anything that parent can do to help ensure that they're safe? And is there something that they need to try to eliminate, you know it's not really behavior I guess but.

Dr. Mark: I think some of the things that you can be aware of maybe your son as a child is really tired and sometimes a short nap in the afternoon, 20 to 30 minute nap maybe enough to take off the pressure that they are quite so tired as their getting into deep slow wave sleep at night. Now people this hasn't really been scientifically proved. People haven't actually tried done a randomized control trial is, but sometimes within a sleep center we'll go try that just to see if that will reduce the amount of sleep walking.

0:46:02.1

There also some medications they might be on that precipitate them, also they'll do a little more sleep walking with those medications. They should talk about the pediatrician if you find that there's a timing we start to serve medicine and he starts sleep walking, that's probably something to really talk to your doctor about.

Dr. Mike Patrick: if you find that they're over tired, I mean it may not be a bad idea after football practice to have a little nap. Is there such thing as 20 minute power nap?

Dr. Mark: Yes you can. 20, 30 minutes is really enough, we don't want kids sleeping for two and three hours in the afternoon who are over seven or eight years of age. Again little kids nap, that's appropriate, that's common but older kids they shouldn't be taking two and three hour naps after school.

Dr. Mike Patrick: And is that because the type of sleep patterns that you're getting into, then it's more difficult to wake up?

0:47:00.5

Dr. Mark: It is more difficult to wake up, you may feel there's a phenomenon called sleep inertia where you feel almost drugged when you wake up and you may also have more trouble falling asleep at next night because now you napped. The classic thing for the child who stays up till 2:00 am on Friday night, Saturday morning they sleep late and now they can't go to sleep the next night because they didn't wake up till 3:00 in the afternoon, they're not ready to go to sleep at 8:00.

Dr. Mike Patrick: I just taught about this, can you get too much sleep? Sometimes I sleep too long and then the next day you feel sleepy.

Dr. Mark: This is a phenomenon that hasn't been studied extensively, we can have people who are too sleepy though and the other side of the insomnia coin is that we ordinarily assume that if somebody's tired during the day time it's because they didn't get either sufficient or the right kind of sleep overnight.

0:48:06.8

But there are some medical diagnosis that are related to being excessively sleepy that is you have your 11 hours of sleep and your child had their 11 hours and they're still sleepy for two to three hours during the day time, that's worth talking your doctor about because we do diagnose children and adolescents with things like narcolepsy which are related to a too much sleep.

Dr. Mike Patrick: and then we can start to get into depression type problems or anxiety type problems that could interfere with sleep and day time performance as well.

Dr. Mark: I think one of the things that we always worry about is when we see a child who's excessively sleepy, who's getting enough overnight sleep and are also tired during the day, we start to think about things like mononucleosis or if they've had any history of head injury, those were some of the things that may cause that.

0:49:00.5

Dr. Mike Patrick: Let's move on into more teenagers now, you had mentioned insomnia, is this a common problem that teens have at some point or another?

Dr. Mark: Yes, Insomnia in teenagers, and sleep problems in teenagers is really an epidemic. Quite candidly, electronic devices and just the pressure that children in middle school and in high school face. The schedules are very none biologic, for some of the schools you will be getting up at 6:00 in the morning in order to go to school to have your extracurricular activity and you'll be working at night doing homework until 11:30 at night. And so you fall asleep maybe at midnight, you wake up at 6:00 in the morning, you're not really well rested, you try to catch up on the weekends, it's difficult to do that, it can be very difficult.

0:50:01.4

For many children and many high school this is a big problem.

Dr. Mike Patrick: What can parents do? What can teenagers do to help alleviate insomnia?

Dr. Mark: The first thing I talked about is trying to understand yourself a little bit. All of us have anxieties in life and that's just part of life, pressure and some anxiety and some anxiety may be good. On the test what we try to do behaviorally is we try to get people about a half hour worry time, where in the evening you turn off your electronic devices and about an hour before he go to his bed and then you basically have a 15 to 30 minute time where you can think about the issues that are in your mind. And you can try to put those to rest, you can talk to your parents about it, talk to councillors about it. Have some strategies for how you can help yourself relax.

0:51:00.7

Then you go to sleep and you get in bed, you don't want to be in bed for more than 20 minutes not sleeping. Once it's more than 20 minutes you probably should get up, sit in a chair, read something that fairly neutral. This should be the most interesting novel you've ever picked up, it should be something fairly neutral or you can listen to not stimulating music, all the times classical music is good and you just try to relax a little bit, and you get in bed then when you're tired. We want people to learn the association that the bed is for sleeping, the bed not for worrying, the bed is not for tossing and turning. This is part of the really good sleep hygiene, that's what we talked about.

Dr. Mike Patrick: You really have to figure out those boundaries, don't you? I mean you have to be able to say, "OK now is the time I'm going to worry, I'm going to think about this things but then I'm going to put those worries in a box and I'll get them back out tomorrow but I'm not going to think them through in my mind while I'm lying there…. That takes really some effort.

0:52:02.5

Dr. Mark: It does, and some people need some help doing that, your pediatrician, school psychologist, there are people that can help with those kind of relaxation, cognitive behavioral therapy techniques are what people talk about, that's the formal term, cognitive behavioral therapy. But you can do that with high school.

Dr. Mike Patrick: What about snoring? Snoring in of self, is it necessarily an issue? I know a lot of people when I was in primary care pediatrics would say their child snores, they may have obstructive sleep apnea. You can't diagnose obstructive sleep apnea based on snoring.

Dr. Mark: Unfortunately you can't and this is a difficult terror. There's been a lot of research on this over the last 10 years and what I can tell you is that we know that probably about 10 to 15% of five year olds habitually snore. What that means is that you snore three or more nights a week.

0:53:06.8

It isn't just that you snore once in a while but three nights, four nights, five nights, six nights, seven nights a week you're snoring. Of that 10% of kids who habitually snore, we know that only about 2% of them have obstructive sleep apnea which means that you are closing your air way, at least part of the way four periods during your breathing at night. And that air way closure can cause you to either drop your oxygen saturation or cause you to arouse out of sleep, and it's above a certain point it's not good for you. Now the good news in pediatrics is that we have a pretty good treatment for obstructive sleep apnea, that's taking out somebody's tonsils and or their adenoids, and during a tonsillectomy and adenoidectomy it's one of the most common procedures done in pediatrics, can relieve many children all obstructive sleep apnea.

0:54:03.2

The only problem now is that there are some other reasons to have obstructive sleep apnea beside big tonsils and adenoids and one of the most common is being a big person, and being overweight, or having obesity predisposes you to close your air way during your breathing at night. So we're seeing now children who are overweight or obese who have a lot of snoring at night. So if your child is overweight or obese and snores at night you probably need to bring that to the attention of your pediatrician.

Dr. Mike Patrick: And then I guess parents should also understand that if they get their tonsils and adenoids out, for most kids it's going to help the obstructive sleep apnea but there are going to be a percentage of kids that wouldn't necessarily help.

Dr. Mark: We think it's probably a 3rd depending on how overweight you are the tonsillectomy and adenoidectomy may not work for us a 3rd to a 1/2 other children depending on that degree.

0:54:59.3

Dr. Mike Patrick: Can you also look at day time behavior and what the kids like during the day to determine if an issue or not? In other words if they snore but they're doing well on school, they're fine behaviorally, they don't seem excessively sleepy during the day then does that snoring need to be brought to anyone's attention or is it more if there's day time problems then you are going look at the snoring a little differently?

Dr. Mark: Clearly if there are day time problems, for example, your child's been diagnosed with ADHD, or they're having behavioral problems in school, or they're having depression, and they're also snoring clearly you would want to bring that snoring to someone's attention. But also we even have for fairly subtle abnormalities associated with obstructive sleep apnea, they're still pretty significant. I mean we have people like they really didn't realize it they were very tired during the day or that they were having trouble but once we treated their obstructive sleep apnea with their CPAP they feel wonderful.

0:56:00.3

And that is basically just air pressure through a mask and that's usually the treatment for adults but we have a lot of adults that, it's like I'm just been kind of in for a while and I didn't realize it, you put me on the CPAP and I feel great.

Dr. Mike Patrick: It's like I didn't know I could feel so good.

Dr. Mark: I think probably snoring in especially more than three times a week, two or three more times a week probably is worth a just a mention to the pediatrician. They can do a good physical exam, they can do an excise. There's all kind of things you can do to figure out there's maybe something we need to investigate.

Dr. Mike Patrick: So what are some of the hottest topics right now in sleep medicine research?

Dr. Mark: Well you always want to think that what you're doing is a hot topic. We're interested in fire alarms. We found about seven or eight years ago that you can have a fire alarm go off that's three times lower than normal. During a child's slow wave sleep that period when they tend to sleep walk and have all those funny things happen at night then the first couple of hours you can have a very loud fire alarm and they will not wake up.

0:57:12.9

And so Gary Smith the head of the Injury Prevention Center here at Children's and some of us have been working together to try to figure out is there a way to wake kids up during that slow wave sleep period. It's really been fascinating to sit in and we've found that parents voice seems to work very well, your mother's voice even during that slow wave sleep period will wake up many children. Johnny wake up get out of bed leave the room, recorded voice wakes up the kids.

So we're trying to figure out if there's something a little easier because I'm not sure personalize fire alarms are going to be the way to go here, so we really like to figure out another way to do that but that's one thing we're working on. And now I think around the country people really interested in obstructive sleep apnea and how much fragmenting your sleep because you're waking up with these obstructions during the night affects kids and how we can treat that better and what are new therapies you might want to do.

0:58:12.7

One of the things that we're interested here at Children's is insomnia in toddlers that kid between six months and three years of age who have trouble sleeping at night. And we think that behavioral therapy is the best way to handle this children, they aren't medications primarily for sleep in children, there aren't any approved by the FDA and so any kind of medicines people use are off label or used for something else but they may make you a little sleepy. And so we'd really like to figure out if we can do behavioral therapy for these little children six months to three years of age and if we can help them with that.

0:59:00.0

So we got a project going on now that we're anxious to enroll people for sure in the Columbus area.

Dr. Mike Patrick: If parents were interested in learning about that particular study, I know there's a phone number that they can call and I'll put that phone number in the show notes, so folks go to pediacast.org and look for the show notes for episode 270. We'll have information if they do have a six months old, two or three year old whose having some sleep problems, if they might be interested in learning more about that study we can get them connected.

Dr. Mark: We ask you some questions about we don't want to study children with any kind of medical problems or we'll ask you whether or not the child snores, we don't want snoring children in that study but there's a lot of things, if you had a DVD, there's certain things you'll be asked and if you qualify sure we'd love to have you being in the study.

Dr. Mike Patrick: So we will put that information over at pediacast.org. Let me ask you too about who should be referred to a sleep specialist?

1:00:05.4

So we talked about talking to your regular doctor about the problems first because they probably have lots of great ideas on things that you can do to improve your child's sleep, whether it's getting to sleep or staying asleep. But at what point does it become necessary to see someone like you?

Dr. Mark: I think that for most children if you've seen your pediatrician and you've also seen an ear, nose, and throat doctor or an allergist, try to help with snoring, help with problems during the night time, noises at night, breathing at night and your child's still has insomnia or excessive day time sleepiness, I think it's probably worthwhile to think about seeing pediatric sleep specialist. Unfortunately there aren't a ton of these people around the country and often times they're going to be in the larger urban areas.

1:01:02.4

People can make referrals generally to children's hospitals who will have sleep specialist who can at least begin to try to help you with the issues. Sleep problems are interesting because you can have multiple different specialties involved, some of the sleep problems will be best addressed by neurologist some by psychiatrists, depression, anxiety, ADHD, developmental pediatricians. We tend to see probably 80% of the kids in our clinic, there's going to be some variation of insomnia.

Dr. Mike Patrick: And we'll put a link in the show notes to the sleep center here at Nationwide Children's as well so that both parents and pediatricians who would want to make referrals can get in touch pretty easily, so that'll all be in the show notes at pediacast.org. I guess the sleep study is the biggest tool in your tool box?

Dr. Mark: I always teach people about it is that sometimes we end up having to do a sleep study but there are some conditions, for example insomnia.

1:02:06.4

If your child doesn't sleep at night then the sleep study is not the appropriate first test unless you give a very compelling history that the child may have obstructive sleep apnea, they snore three or more times a week, you can see them struggling at night or that they have what's called restless leg which is, they can tell you that they complain of their legs hurting at night, their legs are kicking at night, it bothers them to fall asleep. Often times families will have history of restless legs, it may will be 5 to 10% of adults at that a certain age we'll have restless legs. If you have a family history of that and your child has difficulty sleeping then you need to at least mention that to your doctor but this life study is, people always ask me, because we have to put all this EEG electrodes on and all this different sensors on the chest and on the air way and we have entitle CO2's and things on their fingers for their pulse oximeter and people say, how do you ever get children to talk right this?

1:03:12.4

And I have to be honest that we have sleep technicians who are very good with children and we're probably successful I would say probably 97, 98% of the time to be able to, it may not be a perfect sleep study and that we get a perfect night sleep but we get enough sleep that we can make the diagnosis or rule out something going on. I think for most people it's a reasonable experience, I wouldn't say it's pleasant but it's reasonable.

Dr. Mike Patrick: We really appreciate you stopping by and talking to us today, we've talked for about an hour and covered from babies through teenagers and I still feel like on many of these topics we just skimmed the surface. We may have to break this down in the future and have you come back and just talk about one thing or another and go a little bit deeper.

1:04:03.3

Dr. Mark: Sure, and I have some partners in different sub-specialties who are really wonderful in what they do too.

Dr. Mark: Again we appreciate you stopping by and thank you. Alright we are going to take a quick break and then I'll be back to wrap up the show right after this.

[Music]
1:04:56.3

Dr. Mike Patrick: Alright we are back and Dr. Mark Splaingard has one more thing to leave us with and I think you do a better job with this thing.

Dr. Mark: I always teach people I love my Angelu and I think she said what I think is a very important thing about sleep. She was talking about life in general, but she said do the best you can until you know better, then when you know better do better.

Dr. Mike Patrick: That is great, that is really something to think about. Again we really appreciate you stopping by today. So my final word this week, Halloween is tomorrow and so my final word this week is just a reminder to stay safe, keep an eye on your kids, wear reflective clothes and watch out for traffic, only accept candy from those you know and trust and don't let your kids overdo it on the sampling because believe me you and I will regret it in the morning. So I have a safe trick or treat and a happy Halloween and that's my final word. I want to thank all of you for taking time out of your day to make PediaCast a part of it, we really appreciate all of our listeners and the many of you who write in with questions and topic ideas, I just really appreciate your participates in the show.

1:06:06.6

I also want to thank Dr. Mark Splaingard for educating all of us on sleep problems this week. Don't forget, PediaCast and our single topic short format programs PediaBytes are both available on iHeart Radio Talk which you'll find on the web and in the iHeart radio app for mobile devices. A reviews and comments on iHeart radio and on iTunes would be most helpful as our links mentions, shares, re-tweets, re-pens all those good things. PediaCast is on all the major social media sites, we're on Facebook, Twitter, Google Plus and Pinterest so if you just share our statuses we would really appreciate it to help us get the word out about the program. Be sure to tell your family, friends, neighbors and co-workers about the show and most of all tell your child's doctor just when you're in for next sick office visit or well check-up, just say there's a evidence based pediatric podcast aimed at moms and dads from Nationwide Children's Hospital and let them know where you can find this at pediacast.org. Posters are also available under the resources tab.

1:07:05.9

Again if you like to get in touch, just head over to pediacast.org and click on the contact link. I read each and every one of those that come thru and again I really appreciate your participation in the show. Alright until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids, so long everybody.

[Music]

Announce 2: This program is a production of Nationwide Children's, Thank you for listening. We'll see you next time on PediaCast.

1:07:47.1

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