Bedtime Problems – PediaCast 512

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Show Notes

Description

• Our Pediatrics in Plain Language Panel returns to the studio as we consider bedtime problems. From infants to teenagers, we explore problems that keep parents up at night: infant crying, bedtime routines, getting out of bed, night terrors, nightmares, fear of the dark… and more!

Topics

• Bedtime Problems
• Safe Infant Sleep
• Bottles at Bedtime
• Crying at Bedtime
• Crying Overnight
• Bedtime Routines
• Getting Out of Bed
• Night Terrors
• Nightmares
• Fear of the Dark
• Bed Wetting
• Healthy Sleep Habits
• Difficulty Falling Asleep
• Insomnia
• Snoring
• Obstructive Sleep Apnea

Guests

• Dr Mary Ann Abrams
  Primary Care Pediatrics
  Nationwide Children’s Hospital

• Dr Alex Rakowsky
  Primary Care Pediatrics
  Nationwide Children’s Hospital

Links

• Primary Care Pediatrics at Nationwide Children’s
• What To Do When Your Child Gets Sick
  • Discount Code: POD917 (40% Discount)
• Pediatrics in Plain Language Survey
• Pediatrics in Plain Language Playlist – SoundCloud
• Recommended Amount of Sleep for Pediatric Populations
• Potty Training, Bedwetting and Other Pee & Poop Problems – PediaCast 481
• Solving Sleep Problems – PediaCast 469

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 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 is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio.

It's Episode 512 for March 3rd, 2022. We're calling this one "Bedtime Problems". I want to welcome all of you to the program.

Our Pediatrics in Plain Language Panel joins us again this week. And the topic at hand are those pesky bedtime problems that tend to creep up really at all ages. With babies, we have to think about safe infant sleep, can be a big problem if we're not paying attention to that.

0:01:12

Bottles at bedtime are not a good thing and we're going to explain exactly why that is and alternatives if your child needs something in their mouth at bedtime. 

And then, crying at bedtime and overnight, boy, that can keep parents up. Doesn't really get better when you have toddlers. We have to think about bedtime routines and kids getting out of bed or calling for help. There's those night terrors.

And as they grow into school-aged kids, we still have to think about their routines, fear of the dark, bedwetting. And then, when they become teenagers, we do want to consider healthy sleep habits for that age group.

And what do you do for difficulty falling asleep or insomnia if you're up a lot during the night? We'll also consider snoring and obstructive sleep apnea.

We'll talk about the benefits of sleep and the risk of not getting enough sleep. And there's also risks of getting too much sleep. That's also an issue.

0:02:08

So, we have a hodgepodge of bedtime and sleeping topics for you this week at all the ages from infants through teenagers. And since our Pediatric in Plain Language Panel is here to explore these items with us, we will, as always, be intentional about using plain language throughout our discussion. Because during these episodes, we do take extra care to speak with words everybody can understand, even if you know absolutely nothing about medicine and healthcare.

Now, of course, we try to do that every week on PediaCast, but with these episodes, we really focus in and pay attention. And if we do happen to use medical jargon or it slips through by accident, sometimes, you have to use it because there's not a plain language term, a simple one, so we use the medical jargon. But then explain in a paragraph what exactly that means.

0:03:01

And during these episodes, we try to hold each other accountable and do our best to explain as we move along. We also try to cover pretty basic concepts of child health and wellness. Some of our past episodes with the Plain Language Panel includes "Your Child's Stomach". That was actually a two-parter.

Your child's breathing, their mouth and throat, and then ears and nose. We've talked about your child's eyes, fever and illness, newborn baby care, keeping kids safe, reading and family literacy, fitness facts and ideas. So, lots of past plain language content for you.

And you can find all of these episodes packaged together as a playlist on SoundCloud. Simply search for PediaCast in the SoundCloud app or on their website. And then look for the Pediatrics in Plain Language playlist.

You can also check out the show notes for this episode, 512, over at pediacast.org and I'll include a link to the playlist so you can find it very easily.

0:04:03

So, our Plain Language Panel, as you will recall is made up of two wonderful primary care pediatricians at Nationwide Children's, Dr. Mary Ann Abrams, and Dr. Alex Rakowsky. They will join us in a moment.

But first, our usual quick reminders, don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.

If you like what you hear, please remember to subscribe to our show so you don't miss an episode. Also, please consider leaving a review wherever you listen to podcasts. So that others who come along looking for evidence-based child health and parenting information will know exactly what to expect.

We're also on social media. We love connecting with you there. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.

And there's that handy Contact link at the website, pediacast.org, if you would like to suggest a future topic for the program.

Also, I want to remind you, the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.

0:05:12

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

So, let's take a quick break. We'll get our panel connected to the studio. And then, we will be back to talk about bedtime problems. It's coming up right after this.

[Music]

Dr. Mike Patrick: Our Pediatrics in Plain Language Panel is in the house once again. You will recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University College of Medicine and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital.

0:06:11

Dr. Alex Rakowsky is also an assistant professor of Pediatrics at Ohio State and a pediatrician at Olentangy Primary Care at Nationwide Children's.

Let's give a warm welcome back to our friends. As always, it is really great having you guys here.

Dr. Alex Rakowsky: Hey Mike, how are you?

Dr. Mike Patrick: Good.

Dr. Mary Ann Abrams: Great to be here. Good to see both of you.

Dr. Mike Patrick: Yeah, great seeing both of you as well.

Mary Ann, we always start with you because you have a particular passion surrounding plain language. Remind us what that is and why it's important.

Dr. Mary Ann Abrams: Yeah, I thought I'll keep it kind of short and sweet today. Plain language is what we call the kinds of words that you would use sitting around your living room or your family room talking with friends or family or neighbors. Words your grandmother would understand. Words that we take some care to make sure we don't use technical medical terms or words that may have similar meaning in everyday language compared to medicine.

0:07:07

So, we call that jargon. So, a simple word like diet, in everyday life, diet is something you take on. It's often considered restrictive or unpleasant. But we toss that word, diet, around all the time in medicine and say, "Hey Mike, tell me about your diet." And all I really want to know is what do you routinely eat every day? What kinds of fruits and vegetables? Do you eat a lot of junk food? Whatever.

So, in medicine, in healthcare and other places, whether you're a car mechanic or a lawyer or an engineer, we want people to use the kind of words that the people that they're speaking to can understand. And I know, I think, today, we're going to be talking about sleep.

A couple of examples came into my mind. We actually may have you talking about what we call sleep hygiene, which is I think is a hilariously funny way to talk about how well people sleep. Because most people when they hear the word hygiene, they think about bathing and all kinds of associated things. Sleep hygiene is like what your sleeping patterns are and how you go about making them hopefully as good as possible.

0:08:10

And then, I think we’re also going to be talking about enuresis. And while most people probably won't hear that word, you may hear it from your doctor or look it up on Dr. Google. An enuresis is just a very fancy word for wetting the bed and bedwetting. So, these are few examples of non-plain language and their plain language matches.

Dr. Mike Patrick: Yeah, and when I think about bedwetting and if I'm writing in a chart, it's really easy for me to type out enuresis. And then, in an exam room, it's just easy for that word to fly out without really thinking out about, "Hey, this family probably has no idea what the enuresis or nocturnal enuresis…"

Dr. Mary Ann Abrams: There you go.

Dr. Mike Patrick: If we want to go more specific of when the wetting occurs.

Dr. Mary Ann Abrams: That ends up in the note that you type for them to take home, that prints up. And because you're used to typing enuresis, and then they're like, "I didn't know my child had enuresis, oh my gosh."

0:09:03

Dr. Mike Patrick: Yeah, exactly. So plain language is important. We do have a book I want to remind everyone about. Not a book that we wrote but there is a book called What to Do When Your Child Gets Sick, which is intentionally written in plain language. It's from the Institute for Healthcare Advancement which a non-profit organization.

And we do have a discount code that we'll put in the show notes POD719. And the book's only $7.77. I did check to see if it had gone up and it hasn't. It's still that price. Of course, you can get it for full price at Amazon, Barnes & Noble. Wherever you get your books, you can find it.

But it's really a nice book, especially if you have a new baby at home because it really goes through things that you need to know for child health and wellness but using plain language. And then we also have a…Yeah, Mary Ann?

Dr. Mary Ann Abrams: When you said, it made me think too. It might be good for the youngster that's starting to do some babysitting. Or maybe a grandma who's going to be watching their grandchild during the day, or somebody that may not know your family quite as well when they start to take care of your child. It may be a nice handbook for them.

0:10:10

Dr. Mike Patrick: Yeah, absolutely. And then, I also want to remind everybody that we have a Pediatrics in Plain Language survey that you can get to, and I'll put a link to that in the show notes. Just to give us some feedback on these particular episodes and what you think, what we could do better, what you like, what works, that kind of thing.

There's also a playlist on SoundCloud where we packaged all of these plain language episodes together, because we've done a lot of them over the past several years.

And I mentioned some examples in the intro to this show, so folks can find that playlist on SoundCloud and also be linked to it in the show notes over at pediacast.org.

All right, so let's jump right in to "sleep". And Alex, I wanted to start with you. Remind us what are the benefits of sleep and what are the risks of not getting enough sleep.

Dr. Alex Rakowsky: Sleep is fascinating. I think, historically, people have been fascinated by the whole topic of something that you do basically a third of the day, in kids, almost half a day. Well, Mary Ann starts talking about the hours that they're sleeping.

0:11:11

So, it's still not fully understood, which is sort of ironic that one of the most common activities of humans is not fully understood. But some of the benefits that we are aware of are I'll start with physical benefits, where your body does get a chance to shut down, relax and heal. So appropriate sleep for any athlete, for example, is vital. And anybody who does exercising, it's vital.

It also has some mental benefits, where it helps with your memory. There have been a lot of studies that have looked at sleep deprivation in students in college, where if they're sleep deprived, they either have problems of long-term memory or with time, even their short-term memory just doesn't kick in as well as it should. So, it has a lot to do with how our functioning goes with memory.

And it definitely has some behavioral and emotional benefits. Adults and children who sleeps seem to be stable or muster stability that they can reach for their individual self. So, they have somebody who's low anxiety by nature, who just doesn't get enough sleep, they actually can ratchet up to higher anxiety. Or somebody who is high anxiety by nature can actually keep it coached a little bit better if they get enough sleep.

0:12:23

The rest tend to be physical, as far as not healing as well, not remembering things as well, and then also, just with personality, where people who tend not sleep tend to be a little more anxious, a little more irritable, tend not to enjoy life as much as others just because they're constantly tired.

And the last one I want to mention, just remembering fun things. We have a large family and for a while there, we were both sleep deprived, my wife and me. The kids remember things that we did, and I just remember being there. Because we have a magnet on the wall, my wife's like "I guess we rented that cabin because there is a magnet." But honestly, we don't remember a whole lot otherwise because we were sleep deprived to the time we went. I think everybody can remember moments like that.

0:13:05

Dr. Mike Patrick: Yeah, absolutely. Yeah Mary Ann.

Dr. Mary Ann Abrams: One thing you said, Alex, reminded me too of you talked a little bit about teenagers and students and college kids. And sleep is important for remembering, which is true.

I just want to expound on that a little bit, that a lot of kids that age pull all-nighters or stay up really late for a variety of reasons that we'll talk about in a little bit. Because we feel like they think or we think we're cramming it all in for a test or an exam or a project, but not just the remembering, but the fancy word is that sort of consolidation of learning.

It's like something goes on in your brain while you're asleep so that all that information that you have been studying and hopefully, building that knowledge, it has a better chance of embedding itself and being truly learned, as opposed to crammed into your head in the hopes that some of them will stay there for that exam the next day. That consolidation of learning is a really important function of sleep.

0:14:09

Dr. Alex Rakowsky: I think that has a really vital role for just kids as students and kids for learning, where the consolidation is really what kind of puts things into your brain the way it should be placed down the road to have long-term memories. And then, again, its adult things, just because PediaCast, not AdultCast. But there are like limits that we can have our resident’s work. I work with the residents. I was one for the program directors. Truck drivers, pilots, people have noticed it, people will make more mistakes if they're sleep deprived.

And there's a lot of very nice studies in adults where is sleep is vital and something that we tend to not understand why completely, but we know it's important. Otherwise, we wouldn't be doing it a third of the day or half a day, or if you're my dog, 90% of the day.

Dr. Mary Ann Abrams: And I don't know about you but sometimes, you're dealing with a really tough problem or concern, and it just feels like it's, "I've got to solve or figure it out," and it's very stressful.

0:15:08

And I've learned that often, sometimes, you go to bed, you get a good night's sleep, and somehow the answer has revealed itself in the morning. And it seems clear, it's not quite as worrisome as it was. I think that some of that work behind the scenes so to speak about the beauty of sleep and the importance of sleep.

Dr. Mike Patrick: Yeah so, it's important, as you've mentioned, for physical health, emotional health, mental health and cognitive health or learning. I have to explain that this is plain language. But I mean, it's just all-around really important that we get enough sleep. However, I also came across this, there is risk of sleeping more than the recommended amount of time.

That evidence-based in adults. So, this is not been tested in kids, but adults who sleep more than the recommended amount of time on a regular basis have increased risk of hypertension or high blood pressure, diabetes, obesity, and mental health problems. Although, you could argue maybe mental health problems are what causes you to sleep more, which is first, the chicken or the egg, we don't always know. But there is evidence-based associations with sleeping more than the recommended amount.

0:16:18

So, as we talk about minimum amount, getting enough or getting too much, that means that we have to have some understanding of how much we are supposed to get. And so, Mary Ann, that is my question for you, at the various ages how much sleep should kids be getting?

Dr. Mary Ann Abrams: Well, as you've said, the amount of sleep a child should get does depend on their age. I think another testament to how important sleep is, is the amount of sleep that babies and young children or toddlers and young preschool children need. If they're spending so much time sleeping, that must mean there's a lot going on in their bodies while they're sleeping oblivious to the outside world.

So, babies, in their first year of life, can anywhere from say 12 to 16 hours a day, and that does include naps. So, they don't sleep a solid 12 or 16 hours. But if you add that all up, anywhere in that range can be normal.

0:17:15

And then for the next year of life, from one to two years that goes down just a little bit, maybe 11 to 14 hours a day including naps. And then up to school age, so say it’s from three to five years, 10 to 13 hours and a lot of those children will still be taking naps.

I think one of the things we have to be careful of as parents is to say every child of age five has to take a nap. Some kids needs a morning nap and an afternoon nap. Some only need one nap in the afternoon. And some outgrow that need for a nap. By the time they're four, forcing them to take a nap is also not ideal either.

So, by the time they get into school, like 6 to 12 years old, they can move into single digits, maybe they need about 9 hours up to about 12 hours. And then, adolescents, teenagers may be 8 to 10 hours. As you move into adult range, eight give or take.

0:18:15

Clearly, that need for sleep changes over time, but it's also what you've heard me say is there's a range. And some people need eight hours when they're a teenager, some are going to need 10 or 11.

Dr. Alex Rakowsky: That's a great point because we have seven children. Well, they're all mostly adults now. And they were all over the board. I think it's important to tell parents that there will be a range. But the parents can figure out, "Okay, I have a toddler who's only sleeping eight hours a night and no naps." And she was completely fine. But we have to monitor the fact that you're sleeping about four hours less than the other kids did and you're still functioning completely normal.

So, these are recommended numbers, I think a lot of parents say, "Well, my child is not sleeping for 12 hours, what's wrong with my child?" And some kids just don't. As long they're developing normally, happy kids who otherwise don't seem to need to sleep, that just maybe them. But you just can't assume, "Well, Johnny is sleeping six hours, that's normal," if he's cranky all the time. That may be why he's cranky all the time.

0:19:17

Dr. Mike Patrick: You guys make really good points, that it's important to look at outcomes. And so, if everything's going great and there are no physical, mental, academic, cognitive, thinking kind of problems, then what amount of sleep you're getting is probably fine. But if you are having any of those issues, then that's one thing you definitely want to examine, are you getting enough sleep and are you within that range that suggested for that particular age?

And by the way, it may be difficult to remember all those numbers, I am going to put a link in the show notes to the recommended amount of sleep for pediatric populations, which is a consensus statement of the American Academy of Sleep Medicine. These are people who know what they're talking about, this is all evidenced-based and I'll put a link to that.

0:20:02

By the way, I chart it out just as you said Mary Ann because I have written down the numbers from that consensus statement, and they are exactly what you shared.

Let's change our focus here for a moment on age-specific sleep problems. So, I wanted to start with infants, and I wanted to sort of at the very beginning of talking about babies and sleep, remind us Mary Ann about the rules for safe infant sleep, because these are really really important.

Dr. Mary Ann Abrams: They are really really important, we have to say that because, we've talked a lot about them, there's some evidence or research that shows that we don't maybe talk about them as much as we should, or we don’t talk about them in a way that people remember or in the right way. So, while we have made progress, and I'll tell you why I'm saying that, over the last several years, we still have ways to go.

0:21:00

And of course, the main thing, the reason you ask that question is because there's a lot of discussion, a lot of good research to show there is a right way to put a baby down to sleep. And some of that requires changing patterns and habits that people have used for many years.

The most important rule of thumb is that a baby needs to be laid on their back alone, with nobody else, not a sibling, not a parent, not a pet, not another baby, on a firm surface, not a soft fluffy, cuddly surface. Alone on their back, in a bed or a crib or some other safe contained surface that's designed for babies.

And the other thing we need to really work on I think is not just making sure they're alone in terms of other living breathing people, but also alone in terms of other stuff in the bed, cute fluffy blankets and stuffed animals and little cushions to theoretically help support them, and bumper pads, and all those things.

0:22:11

We've learned over time that all of those compose a risk factor for what can be called sudden infant death where a baby rolls over or somehow ends up not being able to breathe because they got faced down or kind of snuggled up against one of those soft surfaces that we talked about. Or if they're sharing a bed with the parents, sometimes the parent can overlay or lay over the baby. So that was a long thing, alone on their back on a firm surface.

Dr. Mike Patrick: So, ABC, if you can't remember that, Alone, on their Back, in the Crib or other baby approved container. Okay, and then what about bottles? Are bottles at bedtime a good idea and if not, why not?

Dr. Mary Ann Abrams: Yeah, that's I think another long-standing habit. But I think the easiest thing to say is no bottles in bed. There's a lot of good reasons not to do that. First of all, there's no need for it. Second, bottles often have either formula or breast milk that might have been pumped. And none of that is good for a baby's teeth as they develop over time.

0:23:23

Also, it gets them used to having to have that and a kind of habit develops where they think they need to have that in order to go to sleep. So, it kind of sets them up for later. And say the bottles roll out their mouth and they don't have developed arms and muscles yet to put it back in their mouth. So that can create a crying baby who really doesn't need to cry because they really aren't hungry, they're just used to having that. So, for a lot of reasons, we do not recommend bottles at bedtime.

Dr. Mike Patrick: And then, it violates the first rule of safe baby sleep of being alone in the crib. And if you have a bottle in the crib, they're not alone.

Dr. Mary Ann Abrams: There you go.

0:24:04

Dr. Mike Patrick: People say, "Well, they have to be sucking on something." But that's only because they have developed that habit, that comforting habit. But it's really safest not to have something in the bed with them, not to have something in their mouth that creates a possible choking hazard, too. And so, really, no bottles, no pacifiers, nothing in the bed except the baby. And if they don't like it, they'll come around. They'll get used to it with time.

And that really leads me into the next question, and this is probably foremost in a lot of parents' mind if you have young baby at home. And that is what do you do when they're crying, when they're crying when you lay them down to go to bed or they wake up in the middle of the night and they're crying? And this really causes a lot of distress for a lot of parents. What can we do about that?

Dr. Mary Ann Abrams: Yeah, there's a couple of different ways to think about that. I think early on in those first few months of life, a baby who's crying, you want to check on them. Make sure they really are okay, that they aren't sick, they don't have a fever. Something hasn't irritated them, even sometimes their little fingernails could scratch the part of their body or their eye, or something like that. So, you do want to check a young baby who's crying.

0:25:18

And sometimes, they'll wake up in the middle of the night, especially those newborn babies, because they are hungry, and they need to be fed. So those first few months, I think, check on them, make sure they're safe, make sure they're fed, make sure they're dry, make sure there's nothing else going on. And then, quietly, lay them back down and leave the room and let them go back to sleep.

Because our ultimate goal is wanting to have babies who grow into young toddlers and children who can learn to put themselves back to sleep. So, as they get older, sometimes, we get used to those patterns that, "Oh, my baby's crying. I'm jammed up but I need to feed them."

And to tell you the truth, that happened to me. It's like, "I'm such a good mom. I'm just so responsive." And then, one day, I woke up and I was like, "She doesn't need to keep feeding in the middle of the night. I need to let her learn how to put herself back to sleep."

0:26:11

And the other problem with responding to that constantly is they don't learn how to put themselves back to sleep. And you really want them to build that ability because we all like them to be able to wake up and roll over and go right back to sleep.

So, after a few months, that's when you want to start spreading out those response times, checking on them maybe just to make sure they're okay but not going in and fixing what is not really a problem by some action that you take as a parent.

Dr. Mike Patrick: Kind of what you're describing is that cry-it-out method and it's also been called the Ferber Method because there was a doctor, Dr. Ferber, who described in his book, How to Solve Your Child's Sleep Problems. And then there has been pushback like, "Well, if I let my baby just cry all night for hours at a time, is it going to cause anxiety and then we'll have problems down the road?" And there has been no evidence to suggest that this is true.

0:27:07

And you can also look at it as getting your child to be able to soothe themselves once they get to be a few months old is an important skill for them to learn in life. And our jobs as parents sometimes is not easy that we have to, as much as it hurts us to want to hold them and comfort them and make them stop crying, part of being a parent is also teaching our kids how to be able to do some things for themselves, including soothing themselves.

And these crying babies also keep parents up at night and parents then are sleep deprived. And you're not going to be as good of a parent if you're operating on very few hours of sleep night after night after night. So, getting this under control in your kids is not only good for your kid, it's really good for your own mental health as well.

So, I am definitely a proponent for go in and check on them for sure, but then, they don't really need anything, just let them cry and they will go to sleep. And as long as you don't reinforce, crying doesn't get them out of bed, then they hopefully will extinguish. It just takes a few nights.

0:28:12

And then they get sick, and they get an ear infection and then you do cuddle them and love them. And then, you're kind of starting at square one once they're feeling better because they get used to that. So those are the bumps up and down in the road for sure.

Alex, do you have any comments on that?

Dr. Alex Rakowsky:  I was just going to talk about this when we discuss toddlers, but since we're in the topic already, so you had a really good episode with one of our buddies, Jack Stevens, awhile back. And he had a great quote about part of our parental obligation is to have our kids learn some grit in a loving way.

And we all get up every two, two and a half hours because of our sleep cycles. And if I got up and wanted somebody to cuddle me or kind of soothe me every two hours, one, it will be a problem at home. And two, I wouldn't function.

And so, as an adult, that's something which is just innately done. We get up. We don't even know we get up in the middle of the night and then we go back to sleep. And so, Jack's comment was exactly what you said is that it's part of our job to, in a loving way, teach your kids to develop some grit about things that are vital to know down the road.

0:29:16

And the Ferber method does work. I'll get into that a little bit more with toddlers, but there will be some pushback and I can get into that when we get to that question.

Dr. Mike Patrick: And I have two very well-developed normal functioning young adult children who the Ferber method was used on both of them to help them sleep through the night. And there really was no issues with that at all. Other than, after a few nights, it was a nice quiet peaceful evening in the home, usually.

Dr. Mary Ann Abrams: I'll add to both of what you just said, we also did that. And when I talked with parents about it, I say, you will have a few tough nights. So don't decide you're going to do this the night before you have a big job interview or some important meeting or something that's really critical going on.

0:30:10

But both of you together need to decide starting next Wednesday evening, maybe Thursday, Friday, Saturday, so you can get a little extra sleep on the weekend, we're going to do it. And your point about if you really adhere to that, it does drop pretty dramatically after a few nights, maybe four or five.

Some people do sort of gradual Ferber thing, where they just sit in the room and then they stand on the door. And that could work also but it does take more time. So, I think, forewarned, let people know that it will be a little hard, and I understand that, but it won't hurt your baby, as long as they're alone, on their back, on the crib, or a toddler.

Dr. Mike Patrick: Yeah, absolutely. You can imagine especially these young babies when they have colic. We've talked about colic before, and I don't want to go down that path. We could spend the rest of an hour talking about colic. But you can kind of see how babies get shaken, like when you hear a baby crying and you just want them to stop crying, and you've just had enough, and you're sleep deprived.

0:31:14

And so, it really is okay to walk away from crying baby and let them cry. You make sure that they're safe but go do something else, because they can really get on you every last nerve and we certainly don't want to harm our children because of that.

You did mention, Alex, that episode with Dr. Jack Stevens. He's a psychologist here at Nationwide Children's Hospital. I'm going to put a link to that show in the show notes as well. It's Episode 469 called "Solving Sleep Problems", and it really takes a deeper dive into behavioral problems involving sleep.

Dr. Alex Rakowsky: He did a great job on that episode.

Dr. Mike Patrick: Yeah, yeah. It was really well done. And so, we'll put a link on that for folks.

So, let's move on to toddlers. Alex, bedtime routines are really important, and we all know kids like to do the same things over and over again, watch the same shows over and over again, play with the same toys over and over again. And there's something comforting about having a bedtime routine that can really help them be successful at falling asleep, right?

0:32:13

Dr. Alex Rakowsky: Yeah. So, I'm going to start off with the fact that toddlers are like sports cars. When they get rolling during the day, they're all over the place. And that's why they need more sleep. So have you to sort of ratchet them down the hour before sleep occurs.

And I want to also throw out the fact that for both this and the next question you have to have everybody at home on the same page. So, if mom or dad are doing a sleep hygiene routine, we'll talk about that, but grandma and grandpa are busy watching TV, or the older sibling is blaring their music, it kind of kills the whole effect.

So, you really have to have the whole house on board with not only sleep hygiene, but also how do you respond to toddler getting up in the middle of the night.

So as far as routines are concerned, a couple of big ones, all electronics should be off at least an hour or two hours before sleep time. One, because they're stimulating and two, because of the blue light that kind of hits the gland in our brain, that kind of tells us, get up.

0:33:12

So, number one is just geared to the electronics, at least an hour, some people say two hours. We had a two-hour rule in our house when the kids were younger.

Then something sort of soothing to kind of ratchet them down, reading, snuggling, singing a song, playing a simple game like a puzzle or a drawing, something where they can still focus but they're slowing down physically.

The third thing is the hygiene part, like real hygiene part, let's brush your teeth, let's wash your face, let's change into pajamas. We're actually doing your last bit of things before you actually go to sleep.

And then, four, for a lot of families, there is the important either prayer time or together time or do something cultural where that's the last thing you're going to do before a child goes to sleep.

And that's sort of like a fourth step, stop electronics, do something mental but not physically strenuous to kind of focus them in, do some hygiene things, change into pajamas. And then do something special like prayer time or meditation time or sing a quite song. Lullabies actually were designed for this and that's sort of like your classic sleep routine for toddlers. But again, you have to have everybody on board.

0:34:23

Dr. Mike Patrick: Yeah, yeah absolutely. I'll just add, if you have smart bulbs or smart switches at home, start dimming those lights or before bedtime and just create that mood of calmness. That can definitely be helpful.

Okay so, you get him in bed, and we've all had this. If you've ever had a toddler in your home, you finally get him to bed and you're all excited, its adult time, you're going to have a glass of wine and watch some TV or whatever. And the toddler keeps getting out of bed and keeps calling for you. And they want you, and just on and on. How can we help our toddlers manage that bedtime without needing our help?

0:35:03

Dr. Alex Rakowsky: I'm going to start some upstream kind of comments. The first is, if the toddler has that much energy at night, they may not need that second nap, or even they may not need a nap at all during the day. In other words, if they're active enough they should be exhausted enough, that once you do the sleep routine, they should be crashing and going to sleep for at least one cycle.

If I have families that come into clinic and say, "They get up all night long." And then I ask if they take a nap right after dinner? They're going to be up. So, either stop the naps completely or move the nap up by a lot of hours.

Number two, increase the activity level. And it's not just physical activity level and that's why that second thing is like a mental activity level. Do something where you're still using the brain, which is going to use some energy. And your kind of focusing the brain in but you're still using enough that it kind of slows them down.

That's I think the two upstream things to do. The third thing is, I work at occasionally in a clinic called Hilltop and Hilltop, actually, the average number of rooms in a house is two. And you'll have up to three generations living in a two-bedroom house.

0:36:11

Or they're living in an apartment complex, where there is so much noise going on, that it's hard to kind of have that toddler not get up or not be stimulated as soon as they fall asleep. And that may be something where, "We're all going to go to Uncle Joe's house down the street to watch a movie and have one person stays here with the kids." Because otherwise, it's really hard to kind of establish that.

And I think that's important to kind of build into the discussions with everybody in the house. And even your neighbors, may, you know, "If my toddlers screams, they're not being tortured. It's because we're doing a Ferber method for a couple of days."

And then the fourth thing is if they're getting up, try to figure out the reason why. But a lot of it, if they just want to get up, then it's a matter of doing the Ferber. Where I think it's easier in toddlers and to kind of discuss with them, "You have to be here for half an hour and then we can discuss," and most kids are going to go back down.

0:37:08

Also, soothing things, we played Yanni and Barry Manilow in the background for a one son who liked to get up all the time. We would have like nightlights that had a non-blue sort of soothing color, humidifiers in the dead of winter, have that soothing kind of white noise. Some scents, some people like scents and some cultural, some of the immigrant families actually do a lot of lavender or sandalwood where they kind of have that scent. And the kids, when they get up and smell, they're like, "Oh, I'm fine," and go back to sleep.

So, there are a lot of things you can try. But toddlers, they're high energy and they're very independent, so it's going to vary from family to family. But a lot of it really is just deciding how to have multiple ways to approach it, but you've got to wear them out during the day.

Dr. Mary Ann Abrams: I think one other thing I would add, those are all super-super tips. And I really think it's great that you emphasized how important it is that, again, everybody in the house needs to be in the same page and how to come up with some strategies if you have several people that are sharing the same room, to sleep in or to live in.

0:38:13

But the other thing is, if they get up, it's usually because they want attention, because they love being with their family. So, in that situation, when you finally put them to bed you want to say, "Good night. Sleep tight. Mommy loves you. And we'll see you in the morning." So, they know that they're safe and loved.

But then, when they get up in the middle of the night, you just very matter-of-factly walk them back to bed or carry them back to bed. But you don't get in bed with them, and you don't repeat the routine because if you do, then you're reinforcing "Oh, they got exactly what they wanted by getting up, so of course I'll keep doing that."

So, you don't want to get mad, but you don't want to be warm and fuzzy, either. It's more of a mechanical thing, "Okay, time to go back to bed."

0:39:01

Dr. Alex Rakowsky: That's a great point. So, the clinic I'm at, and a lot of our clinics have a large immigrant population. We have some immigrant populations that will never do the Ferber method. It's so counterculture to the way they've been raised or the way they think about sleep.

But at least we agree upon the fact that if your child gets up two hours in, don't give them a lot of attention, dark dim room, dim responses, make it matter of fact. And some families will not buy the Ferber. So, I think that's a great compromise for the families that if Mary gets up, you walk her back and gently, lovingly, but don't make a big commotion out of it.

And after a while, they're like, "Oh, it's probably not worth me getting up because I'd rather listen to Yanni and have lavender smells in my room."

Dr. Mary Ann Abrams: Not a young toddler, but an older toddler or a young preschool, or three- or four-year-old, you could potentially consider liking a little sticker reward chart. And you have to kind of build what your goal is, if your goal is for them to stay in bed for at least an hour or so, or whatever you agree on is the goal.

0:40:11

If they succeed in meeting that goal, they get a sticker and you can start to do some little rewards, "Oh, you stayed in bed all night last night, now you get some larger reward." They have to be able to associate that reward with their behavior but that's another…

Dr. Mike Patrick: Yeah, we had a three-strikes-you're-out policy. So, we had a sticker chart. And this is for my daughter. My son, it's funny how kids are so different even in the same family, my son, you put him to bed, he went to sleep. But my daughter, this was always a big issue.

We had a sticker chart for her, and it was three strikes and you're out. So that would mean you get two times that you can call us or get out of bed. And that's fine, but if you did it a third time, then you didn't get a sticker in the morning. And if it was only two strikes, then in the morning, she get to put a sticker on her sticker chart.

And you get five stickers and then you get, we actually bought this toy set. They had like a bunch of parts to it. And so, she could pick out like one part when she had five stickers.

0:41:09

And then, we go back, and the big box would go back in the closet. And then, after five more stickers, "Oh now, you can pick out another part of this set." That worked pretty well.

That wouldn't work for other kids. Like Alex, you said, you have to judge it based on what motivates your particular child.

Dr. Alex Rakowsky: All right Mike, I know you, too. You're a big softie. You probably gave her a couple foul balls also there.

Dr. Mike Patrick: Probably.

[Laughter]

Dr. Mary Ann Abrams: I like your reward system a lot, that it was part of a bigger picture and a part of that. Because it's very natural to say, "Oh, you get an ice cream cone," or whatever. Of course, an ice cream cone is fine once in a while. But we're also trying for all those healthy eating and not associate food with reward.

So, I love what the reward was. So that also, again based on the age of the child, helps build that deferred gratification that working in their own little way towards achieving something that's of value to them.

0:42:06

Dr. Mike Patrick: Yeah, and it allowed us to have nice quiet evenings.

[Laughter]

Dr. Mary Ann Abrams: Yeah, there is that.

Dr. Mike Patrick: Yeah, there is that. Okay, Alex, there is this thing that parents may have heard about called "night terrors" that can happen especially during the toddler years and young childhood. They're different from nightmares, right? What are night terrors? They sound terrifying.

Dr. Alex Rakowsky: I'm glad we're not covering sleepwalking or nightmares because we'd be here, literally, two hours. So, night terrors is where a child just comes popping out during sleep and they're screaming and yelling. And they seem to be completely out of tune with everything around them.

We had one child who had night terrors for about six months and they're very sporadic, and then the whole house is up. And then you're just waiting for the next night terror to occur.

The kids don't remember this happening. A lot of kids are going to remember their nightmare. So, this seems to be a very deep sleep sort of scenario, where they just get up and they act out like they're in horrible distress.

0:43:07

They are dramatic, speaking from experience, and talking to families that have seen this. Commonly seen in the mid-toddler to early school year age. The good news is that almost everybody outgrows this. It doesn't mean that you're going to have sleep issues down the road.

Most times, there's no reason for these to occur. But it can be because the child's hungry, sick, cold, full bladder, peed in their pull-up. There could be a physical reason to kind of get this rolling.

Some kids with anxiety, some kids who have a PTSD because of an unfortunate abuse incident, can have more night terrors. But again, it's still going to be a small percentage of what causes most night terrors. In most kids, you don't know the reason.

The way you respond to it is to essentially just ride it out. And I remember one time, our child just popped out of bed, screamed, and yelled for about five minutes and went back to sleep. Now, my wife and I were then up for the next nine hours, as well as all the older siblings, just waiting for her to do it again.

0:44:05

In the morning, it was like nothing happened and that was how we dealt with it the few other times it happened. It was like "Okay, she's having a night terror and she'll outgrow this." And she did it about six months to a year.

They're common. They're a lot more common than people realize and they scare the living daylights out of you when it happens, or nightlights out of you.

Dr. Mike Patrick: Yeah, and they don't remember it? That's the key.

Dr. Alex Rakowsky: They have no idea it happened. No idea it happened, yeah.

Dr. Mike Patrick: Okay, so those are night terrors. Let's transition to school age. We talked about routines in the toddlers. Mary Ann, what do you think about school-age kids? How do we adjust that bedtime routine as our kids get a little older?

Dr. Mary Ann Abrams: Well, a couple things. First, a bedtime routine is just as important for school-age kids and teenagers and adults, as it is for these little ones that Alex talked about. And also, what does a routine mean? It means that you have the same familiar pattern that you have every time you go to bed, with a rare exception.

0:45:04

So, it becomes part of the way your mind and body function. And it becomes calming and comfortable because it is routine. And a lot of those parts of the routine that he talked about; they make look a little different, but they apply to the school-age kids as well.

First, you want to get off all those electronic stuffs at least an hour, if not bit longer, before it's about time to get ready to go to bed. And also, not have those electronics be in the room even or something that's part of their bedtime routine. They should stay out of the room and not engage them and not have them look at that light, et cetera.

And then, try to lead up to that time with more calm, calming activities. You don't want to watch a crazy television show or a wild rock game or whatever just before you're trying to get people, little ones, and kiddos, to calm down.

0:46:10

The other thing that might be something more common in this age group is caffeine. Kids maybe drinking a soft drink, soda pop or whatever. And unfortunately, some of those school-age kids may be drinking, I hope they're not drinking Red Bull, but other caffeinated beverages.

So do a little bit of a deep dive and make sure those things aren't inadvertently or purposefully part of what they're eating or drinking. Or drinking a coke with dinner, for a lot of reasons, that's not good.

So those are some of the things that might complicate a school-age routine as well. I like the part about getting ready for bed first. So, get your pajamas on and brush your teeth. Some kids, people like don't doing all that. So, get that stuff out of the way. And then start to transition into a quieter activity, reading together. I love reading together, soft music, dim, softer lighting, as quiet as it can be. Fan in the background may help muffle some of the extra noise that might be nearby.

0:47:16

The room doesn't have to be super warm. I think lots of times we think, "Oh, my goodness, I don't want him to be cold in bed," but keep the temperature high 60s. That's what blankets are for, right?

And also, don't have them think about their room or their bed as a punishment. You want them to think of it as a place of rest and relaxation.

And then spend some quiet time together, reading, saying nighttime prayers, just cuddling to make it a very pleasant transition. And then, obviously, it's always good to leave the room when they're still a little bit awake. So, they'll get used to being in their bed awake and knowing it's okay.

Dr. Mike Patrick: Yeah, absolutely. And then you're going to have kids around this age, as you try to do that, who are saying they're afraid of the dark or they're afraid of being alone.  What's the best way to deal with that issue?

0:48:13

Dr. Mary Ann Abrams: I am a fan of not bright, but nightlights. I think a nightlight, it just changes… I think the light can be calming, but it also keeps those little dark corners from being full of imaginative things.

Sometimes I think kids can hear sounds that are part of the way just every house or apartment has. But suddenly if you're alone in the dark, "Is that a bad guy?" or "Is that just the sound of the refrigerator kicking on?" or whatever. So, I think it's worth maybe exploring that with them, if they bring that up, "I heard a funny noise."

But I think a nightlight, leaving the hall light on, if that works instead. I don't know if it's a bad thing to agree to sort of sit outside their room. I think I've seen parents find that to be a useful strategy. You're not going to go to sleep with them, in bed with them. You're not going to stay there all night with them, but you'll be nearby, and they know you're nearby in case anything goes wrong, at least in their perception.

0:49:17

And to downplay it. I don't think, "Okay, let's look and see if there's anybody under the bed," because I think that just creates more opportunities for potential fear.

Dr. Mike Patrick: Yeah, and to go along with Alex's previous analogy of upstream behavior, you really want to watch what your kids are exposed to, especially if they're going to be sensitive to that. So, you know if it's a kid who already has complained, "I'm afraid of the dark," there are certain shows and certain books that you may want to hold off on exposing them to.

And one thing that I learned is if there's a movie that you're excited to share with your kids, but it's been a long time since you've watched it, maybe watch it again before you watch it with them. Because "Gremlins" that did not turn out well, when my kids were little.

0:50:05

I remember Gremlins are these fuzzy little fun animals. I wanted to share that with my kids. And then, you know what happens after dark when they get wet and all that business, and it went south from there very quickly. So, something else to think about, what they're exposed to.

Dr. Mary Ann Abrams: I think the bar has changed a lot. G and PG, what I used to consider R is now PG. So, I think people, at least the adults, have a very different perspective is what is appropriate for kids. And looking at that through critical eyes, I think, is a good idea.

Dr. Mike Patrick: Yeah, absolutely. Let's move on to bedwetting. This is another common issue both for school-age kids and then also for some teenagers as well. Why do some kids wet the bed and what can we do about that, Mary Ann?

Dr. Mary Ann Abrams: Bedwetting. I think one of the most important things for everybody to know is that it's common. It's a lot more common than people realize. And in general, most of the time, it's only a problem because of how it affects a family or the child and what they want to do and maybe their self-esteem.

0:51:19

So, it basically has to do with how the different nerves that control our bladders and our ability to feel like, "Oh, I have to get up and go to the bathroom." And I feel like I woke up and I have to go all of a sudden." And all of that is developing just like all the other things are developing in the older child's body and a teenager.

So, we know that about 15% of children at the time they are at school roughly still wet the bed. It's a little bit more common in boys than in girls. But we also know that for most kids, about every year, more kids outgrow it.

So that it's pretty rare for somebody to be still be wetting the bed when they're 15 or 16. Occasionally, people can still be wetting the bed at that age.

0:52:11

What we like to do is to check these questions that we can always ask, to make sure that there's not something else going on causing this. It's important for us to sort out if children had stopped wetting the bed and then started again. Because sometimes, that can mean that there has been some development of some underlying health condition that might now be causing them to make more urine and wet the bed for that reason.

For most kids who have what we call kind of routine normal bedwetting, we can reassure children and families that they'll outgrow it. Sometimes parents are more concerned about it than the kids. And some parents can get angry. So, it's not the child's fault. And it's certainly not the parent's fault. It's just the way it is.

But making sure that children aren't punished, that you sort of build in ways to manage it. And there's really nice sort of waterproof pads that you can put under the sheets, things like that to minimize the amount of laundry and uncomfortableness.

0:53:17

And then, deciding with the family overtime, whether they want to try to cut back on it or help the child maybe just be dry if they're going to go to camp or have a sleepover, going to stay with grandma for a week or whatever. And we can talk about that in a minute. I'll pause for a second.

Dr. Alex Rakowsky: If I can add, so our brain, once we fall asleep produces a hormone that tells your kidneys to slow down. So, we're going to produce less urine when we're sleeping. It's called the antidiuretic hormone, or ADH. And there are some kids where their hormone doesn't kick in until one or two sleep cycles end.

So, they'll fill up a bladder in two hours in their first sleep cycle. So, try to wake them up two hours in. In a quiet way, just go to the bathroom. And that's sells probably around 25 to 30% of the kids who have bedwetting at night just to kind of break them up. And they may be one of those that once they emptied their bladder and then the brain kind of kicks in with the hormone, they're fine.

0:54:15

And then, there are some kids that the house can blow up and they're still sleeping. They have no idea that they're getting full. And that's where bed alarms may come in handy, where any little pee on the pad, it just screams bloody murder and then the whole house gets up because the alarm's going off. And then their brain is sort of like primed up, "Oh, I'm about to go and I hate that noise that goes in my ear. So, I'm going to get up and go to the bathroom."

So almost like, waking them up, getting them a little bit more aware of their bladder in the middle of the night. So, two other ways you can potentially work on this during school years and teen years.

Dr. Mary Ann Abrams: And you can work some of those other things, too. Like making sure they're not drinking a lot of caffeine before they go to bed and make sure they go the bathroom right before they go to bed. Or if they wake up on their own, you can make sure they go to the bathroom done, as opposed to waking them up.

0:55:04

Also, you don't need to drastically cut back on fluid in the evening but take a look at how much they're drinking and see if you can maybe shift some of that to earlier in the day. And then, if you do want to treat it as Alex pointed out, there's bed alarms, and then there are some medications that can be used.

Again, you want everybody in the family on board. If you're going to have the alarm, go off at night, even though you want the child to be the one to wake up, other people are going to wake up, too.

Dr. Mike Patrick: Yeah, another episode that I want to point people to is PediaCast Episode 481. And I'll put a link to this in the show notes as well. That was called "Potty Training, Bedwetting, and Other Pee and Poop Problems". And we do talk about bedwetting in considerable detail over the course of that episode. So, if you want to learn more about it, check out that particular episode of the podcast.

Let's move on to teenagers. Alex, you introduced the term "sleep hygiene" to us. And Mary Ann had pointed out that we're not talking about brushing our teeth and washing our face. What did you mean by the term sleep hygiene? And what are some of the good guidelines for teenagers?

0:56:14

Dr. Alex Rakowsky: I think it starts off with having teenagers realize the importance of sleep. And I think adults have the same exact problem or thinking that sleep is something I need to conquer and is something that is vital to my health. So, I think sleep hygiene starts off with the fact that just realizing that I need to get X number of hours, probably 8, 9 or more to be a functional teenager who can study and be happy and do well in school and in life.

So, I think sleep hygiene starts with the fact that a teen has to bind to the realization that come a certain hour, I need to start ratcheting down for sleep and kind of prep the day around that. So, if you have a chatroom that's going to open up at 10:00, you're not going to get to sleep until probably midnight.

0:57:03

If you're playing a game with your buddies in Hungaria, like my sons, when they get online, they have all these buddies around the world, and they'll play some game, and if you're doing that right before sleep, you're not going to fall asleep.

So, a lot of these is convincing the teen that for that hour before sleep, you're expected sleep time or needed sleep time, you have to start slowing down. So, sleep hygiene will include same things as before, cut back all electronics. Essentially have nothing to do with anything that can stimulate your brain and also anything for blue light. So, one hour before, you want to read, you want to do something mental, that's great. But nothing electronic.

Number two is really trying to turn off the day, and I think this is hard for teenagers, even for adults to do. Where for about 10 or 15 minutes I love gratitude journals, where you just basically sit there and say this is what I'm thankful for and then here are the problems I have before I go to sleep. And I'm going to throw them into this book. And then, I'm not going to worry about them until tomorrow. And like Mary Ann mentioned earlier, that sometimes, your problems get solved after you have a good night sleep.

0:58:09

And the third thing is to have some kind of routine. And that can be for teenagers, I have chamomile tea, or I have something non-caffeinated to drink or something warm. And then, I'll go to my room, and I'll meditate, or I'll say a prayer. I'll stretch or nothing too physical. And then, go to my room to get sleep.

And also, part of sleep hygiene is not to use your room for anything but sleep. So, if your bed is your desk and is your place to study, and is your place where you get stressed out about where friends are commenting on your phone, it's going to be hard to sleep because we now associate your room with all those activities,

Some people can't help it, that's all they have. That's the only place they can go to. But if you have the ability to use your bed just for sleeping, then perfect.

And then the fourth thing is that go on upstream again, get activities, try to get some walks in, get physical activities, try not to take a nap during the middle of the day. So, if you get home from school and you take a two-hour nap, you're not going to sleep at night, then you need a long stretch of time off in the middle of the night.

0:59:11

Sleep hygiene, I threw a lot of ideas out there, but it's really a miss-or-hit thing for the teenagers.

Dr. Mike Patrick: What about the ones who they're lying-in bed and they just cannot fall asleep, or they wake up in the middle of the night and an hour goes by and they're still just lying there. What are some ideas for when you're just lying in bed and you can't sleep?

Dr. Alex Rakowsky: And again, Dr. Stevens talked about this at length in his episode. But just to kind of summarize, again, go off stream, get the activity. If you come home from school and you're anxious or you're stressed out, go for a walk.  If it's like it was here, five degrees… No, two weeks ago, or three weeks ago, remember when we had the ice storm, do something at home. Do yoga at home, do kind of jumping jack, something to burn off some of that stress when you get home.

And then after dinner, do something else to kind of bust the stress down a little bit. So, you need to do some upstream activities to begin with. And try not to have any sleep during the day. Try to avoid caffeine at least two hours before sleep. So, you have all those sorts of physical reasons that you're not falling asleep to kind of get out of the way.

1:00:16

Looking at sort of like behavioral reasons, again, the gratitude journal or my put-away journal where here are three or four things that went well today. And here are three or four things that I'm going to put in the book and not worry about until tomorrow morning. Just to kind of have them not to think about them.

And that's your way of saying, I'm closing my chapter on this big exam I have on Friday. And it's Wednesday night, I know tomorrow’s going to be a bad nigh studying for it. That's okay, you put it in the book, and you forget about it.

And then, I think Dr. Stevens mentioned that if you're not asleep in 20 minutes or so, just get up. You shouldn't be just lying in bed for hours on end. Because now all of a sudden, you're anxious about the fact that you're not sleeping.

Do something with a dim light. Go to a comfortable chair and then start meditating, praying, thinking about your journal. Do something quieter. And then, once you start feeling groggy, go back to bed. I think lying in bed for hours on end is a horrible idea just because now suddenly, you're stressed out that you're lying in bed for hours on end.

1:01:15

Dr. Mary Ann Abrams: So, limit how long you’re going to try to go back to sleep and do exactly what you described, Alex. But whatever you do, don't start checking your phone, because as soon as you start that cycle of another hit of "Oh, that's interesting," or "Look what they said," or "I did not have that to worry about," you're going to just get all problem.

Dr. Mike Patrick: And don't turn the TV on. Don't play video games. You want non-stimulating activities. Maybe reading or working a jigsaw puzzle or something that's not quite stimulating as screen time.

All right, one final sleep-related topic for teenagers and that is snoring and this idea of obstructive sleep apnea. If a kid is snoring, does that mean they have obstructive sleep apnea and how do we approach those issues?

1:02:05

Dr. Alex Rakowsky: Great question and kind of hard to answer. So, I think you have to start off with the position that you're sleeping in. You can take anybody and have them crash on a two-foot couch at grandma's house and they'll snore. Or somebody sleeping in the car in the back seat kind of quick and they'll snore.

Snore is a going to be a positional issue for a large percentage of teenagers that are snoring. So, try to make sure that you're stretched out on the bed, have a good airway, kind of positioned when you're sleeping.

So, get a good pillow. Make sure the pillows are at a right height. Make sure you're sleeping in a way that you can stretch out that neck and airway. And you can tell if you're snoring, but ask somebody, "Am I snoring all night long?" If you have just occasional snoring, it's fine, not sleep apnea. But there may be something else going on.

It could be allergies; it could be large tonsils. It could be that the room's dry and then you have a dry nose and you're kind of breathing through it. But it's something to consider that I need to find the reason for it. Talk to one of us in clinic. If you have pauses when you're sleeping.

1:03:06

Or the parent or older sibling said, it sounds like you're choking while you're sleeping, or you stopped for ten seconds. Now, all of a sudden, you have what we call apnea where you're actually stopping for a while and you seem to be fighting to get your airway open, to get things back down to the lungs.

It can be a brain issue, something called central sleep apnea. But the vast majority of the times, for teenagers, it's called obstructive. There's something blocking that airway. And when you fall asleep, the airway just kind of gets more relaxed and now you can't catch your breath. It's dangerous. You can actually have long-term complications from sleep apnea.

So, I think the big question, is it positional? No. Is this something that's just a sporadic or occasional? No. So does it sound like it's every night or you have spells where it sounds your son's not catching his breath? Yes. You need to go to ENT so they can take a look what's causing obstruction or get a sleep study or both. That's something we really need to go to a physician or a nurse practitioner to kind of figure out what's going on.

1:04:09

Dr. Mike Patrick: Yeah, absolutely. So, snoring, especially if they have those pauses that you mentioned, definitely talk to your doctor about that. And even if they don't have the pauses, if they're not getting enough sleep and it's causing them to have behavioral problems the next day or they're having trouble with school, whether it be with friends or with academic work, with their schoolwork.

They may be waking up more often than you think at night. And so, sleep study could kind of tease out whether there's really something there or not. But definitely talk to your doctor about that, very important.

Dr. Mary Ann Abrams: Thinking about this daytime sleeping, do they fall asleep when they're driving like in a red light? Or that kind of things because it has these safety implications as well.

Dr. Mike Patrick: Absolutely. Well, this has been wonderful conversation about sleep topics and sleep problems from infancy to teenagers.

Before we go, Alex, tell us about Primary Care Pediatrics at Nationwide Children's Hospital.

1:05:08

Dr. Alex Rakowsky: So, I hope we won't put you to sleep with the description, but we have I currently think 14 clinics that we run. And we have a 15th standalone clinic. We have I think a dozen school-based clinics and then we have a mobile van that goes around to do some school events and health events.

We cover close to 100,000 children now, with about a quarter million visits. So, it's a very large system. I think we're still the largest system in the country that's based out of the children's hospital. I have about 100 buddies in Primary Care including Mary Ann that work in the division. We have some phenomenal staff that helps out.

It really is a way for us to take care of the kids in the area as best as we can. It's a task, and we have leadership to kind of help out with Primary Care. But it's a lot of kids that we're seeing in a lot of different clinics and the residents see them also.

1:06:04

Dr. Mike Patrick: And we'll put a link to a Primary Care Pediatrics at Nationwide Children's in the show notes. We also have the Primary Care referral line if you need to call to find a physician for your child and you're in the Central Ohio area. We'll put that phone number in the show notes as well.

Then, also, we'll have all the links that I had mentioned that relate to plain language, including that Plain Language playlist with all the past episodes over in SoundCloud and then those other PediaCast episodes that have to do with sleeping and bedwetting and all that. You'll find all of those things in the show notes over at pediacast.org.

So once again, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital, thank you both so much for being here today. We always love it when you stop by.

Dr. Alex Rakowsky: Thanks for the invite. Take care, guys.

Dr. Mary Ann Abrams: Thanks so much. Have a great day. Bye-bye.

[Music]

1:07:23

Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time to make PediaCast a part of your day. We really do appreciate that.

Also, thanks to our guests this week, Dr. Mary Ann Abram, and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital.

Don't forget, you can find us wherever podcasts are found. We are in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.

Our landing site is pediacast.org. You'll find our entire archive of past programs there, along with show notes, our Terms of Use Agreement, and that handy Contact page if you would like to suggest a future topic for the program. 

1:08:01

Reviews are helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show. And we love connecting with you on social media. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.

Don't forget about our sibling podcast, PediaCast CME. That stands for Continuing Medical Education. It's similar to this program. We do turn the science up a couple notches and offer free Continuing Medical Education credit for those who listen. Of course, that includes doctors, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.

And since Nationwide Children's is jointly accredited by all of these professional organizations, it's likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements. Of course, you want to be sure the contents of the episode matches your scope of practice.

Shows and details are available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.

1:09:00

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.

[Music]

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