Episode 8: Things That Go Bump in the Night with Dr. Sujay Kansagra

Audio Sleep Edit 8 Sujay Kansagra
[00:00:00] Arielle Greenleaf:
[00:00:00] Welcome to the Sleep Edit, a podcast devoted to helping tired kids and parents sleep better. We focus on actionable evidence-based sleep advice, so everyone in your home can sleep through the night. Now, a quick disclaimer, this podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.
[00:00:27] Craig Canapari MD: No doctor patient relationship is formed. The use of this information and the materials linked to this podcast and any associated video content are at the user’s own risk. The content on the show is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay obtaining medical help for any medical condition they have
[00:00:53] or that their children may have, they should seek the assistance of their healthcare professionals for any such conditions. Nothing [00:01:00] stated here reflects the views of our employers or the employees of our guests. Enjoy the show.
[00:01:09] Okay. I am just doing the very important
[00:01:11] work of giving my 13-year-old more screen time on the Xbox, so he at least is not screaming during this.
[00:01:18] Arielle Greenleaf: Oh yeah.
[00:01:19] Sujay Kansagra: as I say, not as I do in the world of parenting.
[00:01:22] Craig Canapari MD: So listen, let’s
[00:01:23] get started from the top. welcome back to the sleep edit. I am Dr. Craig Canapari
[00:01:28] Arielle Greenleaf: I’m Arielle Greenleaf.
[00:01:30] Craig Canapari MD: it is my great pleasure to welcome my friend Dr. Sujay Kansagra on today.
[00:01:35] He’s a pediatric sleep doctor and neurologist. He attended Duke for medical school, went to UNC for residency and fellowship, and made, a triumphant return to Duke afterwards.
[00:01:44] Sujay Kansagra: Lost some friends during the transition, but yes.
[00:01:47] Craig Canapari MD: I gotta tell you, man,
[00:01:49] as a lifelong UConn basketball fan, I’ve got wild beef with Duke.
[00:01:53] Sujay Kansagra: Yes. I can understand that. Listen, people ask me now, who do I support? ’cause UNC is where I started as an undergrad, and so the [00:02:00] basketball allegiance still lies there. But for medicine, I’d cheer for Duke.
[00:02:03] Craig Canapari MD: I still remember UConn losing to Duke in 1990 the first time they made the tournament.
[00:02:09] Sujay Kansagra: I remember UConn beating Duke in the finals. This was probably 1999, 2000. we were very excited at UNC for your win.
[00:02:17] Craig Canapari MD: Oh yeah. And let me tell you that every time I’ve won a basketball pool, it’s because UNC has won..
[00:02:21] Sujay Kansagra: Yes.
[00:02:22] Craig Canapari MD: I just wanna talk a little bit about your online presence, because when did you start med school advice? ’cause that’s how you first came on my radar.
[00:02:31] Sujay Kansagra: This is like the original back when, the day we called it Twitter.
[00:02:35] I was still a resident. I was a child neurology resident and we were talking earlier, this was really the wild west of social media. Folks in medicine were just getting
[00:02:44] their foot in the door and learning to navigate the social media
[00:02:47] channels. And back then my goal was just to give, just advice because I grew up having an older
[00:02:52] sister that went to medicine that helped guide me and I’m like a lot of people that don’t understand, what it takes to consider medicine, what a life in medicine [00:03:00] is.
[00:03:00] So I started blogging in 2012 and I felt like at that point it was already too late, right? Because there were already like people out there who have been doing it since the early two thousands. I think Howard Luks was on from like the 1999 or something. when your pediatric sleep book came out and it’s great guys. You all should buy it. My Child Won’t Sleep. A quick guide to the sleep deprived parent. I’d been blogging for two or three years and I’m like, man, this guy wrote a book. I better up my game here.
[00:03:27] Yeah. Who is this guy yeah, I mean that book, it’s funny ’cause I was doing a lot of the research behind it when I was a new father and I was also reading all the books that are out there just to get some background information what is Weissbluth saying what is Ferber saying? We knew the techniques, but what do you have in these 400 pages? And, part of me, when it came to the techniques I was screaming at the book just
[00:03:48] tell me the technique. I already knew the technique, but I’m like, where is it? These are sleep deprived
[00:03:52] parents, I’m like, just where’s your technique?
[00:03:55] And that was the impetus behind the book. Just give it to them straight. Give it a step by step approach. And [00:04:00] it’s probably too slimmed down because unfortunately I glossed over a lot of the other issues like parasomnias and restless leg and sleep apnea. It’s just
[00:04:07] behavioral insomnia approaches. Cognitive behavioral therapy approaches for older kids.
[00:04:11] Delayed circadian rhythm stuff for older children as well. Just the core things that you can modify without needing a physician sometimes,
[00:04:19] Arielle Greenleaf: I think That’s really valuable in just in what I do. Parents are just, there’s so much information and they just need an answer and they don’t wanna sift through a million different things. And I will say those books are great now for me ’cause I dig through them and I look for research and all of that.
[00:04:39] But when I was a tired new mom, it was like, Just tell me what to do like you said, and ultimately I hired sleep consult because I just could not navigate my way out of it,
[00:04:48] so,
[00:04:49] Sujay Kansagra: I hear you. It’s tough. There’s a lot of information and people don’t know who to trust. everybody can come across with a beautiful marketing presence and be like, oh yeah, you should trust me ’cause look at my amazing graphics. [00:05:00] But, who can you truly trust when it comes to just vetted, science-based folks?
[00:05:03] Because we love using the science terms out there on social media when it comes to sleep, but who is truly, vetting what those terms mean and whether they apply to that
[00:05:11] particular situation. So yeah, that’s why I enjoy the social media
[00:05:14] world. It’s nice to be able to share and hopefully people trust us, like
[00:05:17] folks that are dedicated their lives to helping children
[00:05:20] with sleep.
[00:05:21] Craig Canapari MD: Well, Sujay, you’re very modest, But you’ve amassed a huge following and it’s because your content is great. It’s very approachable, it’s funny. What, do you think that you’ve done that has really resonated with parents?
[00:05:35] Sujay Kansagra: I think part of it. Was, attention spans are very short on social media. And TikTok actually puts in your face, it tells you like how long people are logged in every second of time. And by five seconds the majority of watchers are gone. They’re gone.
[00:05:50] And so I’ll tell you one thing I’ve learned is you have to have that entertainment portion. Otherwise people are just not sticking around. And I have no problem embarrassing myself, I kind of [00:06:00] joke, academicians are like, oh, you’re on social media, that’s great.
[00:06:02] What about all the manuscripts you should be writing? And I’m at this stage in my career where thankfully I just don’t care, and not in a bad way. I’m already full professor, I’m happy to write more manuscripts, but I feel like I can have the most
[00:06:14] impact on the most
[00:06:15] people by sharing
[00:06:16] information on social media.
[00:06:18] And I saw my admission friends, I’m like, why aren’t you on here? Like
[00:06:21] if a video that I post, I can get 10,000, 20,000 people to watch it. Five people are reading the articles that I write in journals. Like two of them are the reviewers, so that’s, so entertainment I think is important.
[00:06:33] So getting back to your question and I think just getting the core of the issues that are on people’s minds, like the simple topics where they hear lots of different things. Melatonin is sleep training harmful? What do we do about naps and how do we nap? And I’ve also tried to appeal to a broader sleep audience.
[00:06:49] Craig Canapari MD: Not just pediatric sleep, but just sleep in general and helping adults understand that they need to sleep and the impact a sleep ation has on them. So topics that have widespread appeal, and then making a fool of [00:07:00] myself, I think that’s the combination. Are there any sort of videos you’ve made that you’ve been absolutely shocked at how much traction they got?
[00:07:08] Sujay Kansagra: Yes, it usually it’s around the sleep, like the deep sleep science video. So I made one about time zones and how there’s this amazing research study that shows that where you live within your own time zone affects how much sleep you get, and that ends up having associative, effects on your wellbeing, like risk of obesity your productivity.
[00:07:27] that was like my first video that blew up across platforms, like a million views on like 3 million on Instagram. People really craved the science and they were asking very nuanced, very savvy questions like, oh did they control for this?
[00:07:39] what do you think about this population? And so people out there really understand the science more than we oftentimes give them credit for. And they want it filtered in a way that’s, I think, approachable and not in the manuscript form that takes, an hour to read.
[00:07:51] So I was
[00:07:52] pleasantly surprised. And funny enough, the authors actually of that study found out and they reached out on Twitter thanks so much for that exposure. And I’m like, [00:08:00] Hey, by the way, my viewers have some questions for you. we created a video together in response to the questions that the audience had, which I think is like the most beautiful way of using social media, bringing people together, answering questions.
[00:08:11] Craig Canapari MD: You mean it’s not shouting at strangers.
[00:08:13] Sujay Kansagra: No, that too, that’s totally valuable and valid. Yes. but no, there are other ways of using social media.
[00:08:19] Craig Canapari MD: Yeah. I think I remember the, I don’t remember what it was, but I remember the first time I got a really mean comment somewhere. I’m a little bit taken aback, right? Because I don’t think you, you go through your life, you try to be a courteous person and there’s certain standards of socialization that get lost when people are commenting anonymously.
[00:08:37] And one of my friends who was said a more mature social media prevalence, she’s it’s just a measure of your power that if someone, you’re making someone angry in some ways, like just, just ignore them. But I’m sure you probably developed a thick skin just putting yourself out there like that.
[00:08:51] Sujay Kansagra: Yeah, absolutely. And I try, I try to,
[00:08:54] I know which posts are gonna generate controversy and I brace myself for it. And then I [00:09:00] actually, I try to be friendly as much as possible because I know at the receiving end, even if somebody that’s trolling me
[00:09:05] for me to then engage In a ill spirited way,
[00:09:09] it will leave a mark on them too, even though they, they’re
[00:09:11] gonna keep yelling back and forth.
[00:09:13] put that strain on anybody because then it affects people’s sleep and their wellbeing. And I’m a, everyone should sleep no matter how Ill spirit you are to me on social media, and I’m not gonna throw that back at you. Even like the one video that actually made me popular on Instagram was one where I did a clap back to somebody that was trolling me, and I was like, oh, this doctor doesn’t know what they’re talking about.
[00:09:32] They oppose sleep
[00:09:32] training. And then I made this video that’s actually no, I do know about pediatric sleep research because I published a lot of it
[00:09:38] and I
[00:09:38] did a like, scroll of all my
[00:09:40] papers. I am the researcher was my quote, I was being like that’s not me usually being like, arrogant and cocky.
[00:09:45] I was trying to actually be a little bit funny. People just ate that up and they loved it and they’re like, what did that lady say when she saw it? And I’m like, I never actually share that with her. I actually engaged her kindly on Facebook and was like this is the data behind sleep training.
[00:09:59] and [00:10:00] she, shot back a couple things about, we won’t mention which group she was with, but ones that are oftentimes against sleep training, which I know you both likely had
[00:10:08] Craig Canapari MD: Yeah. So at the end of the day, I don’t engage, even if I’ve made an amazing piece of video content that I would love to just show them, I’m not gonna do that.
[00:10:15] Arielle Greenleaf: Yeah.
[00:10:16] Craig Canapari MD: I think you. should have a masterclass on how to make those videos, man. ’cause they’re pretty amazing. And look, as someone with a background I’m like I just dunno how he edits these. They’re so good.
[00:10:25] Arielle Greenleaf: That’s too kind. I’ve just become very savvy with all the tools within Instagram and now Cap Cut is my newest, favorite video editing tool. I just dunno how you make all the content.
[00:10:36] Sujay Kansagra: That’s the other thing. It’s the funny thing is there are some pieces that I literally, I’m like, I’ve spent two or three hours making this video and editing it and
[00:10:43] et cetera, and then I’ll make one while I have a random thought and I’ll pull up
[00:10:47] my phone and just say it.
[00:10:48] Craig Canapari MD: And those videos end up doing much better. So listen, since I, am, not really a neurologist, I trained as a pulmonologist and I, do sleep medicine which encompasses a lot of. Topics honestly I, wanted [00:11:00] to be a child neurologist, but then I changed course.
[00:11:02] But we wanted to talk about some topics that are really, I think, in the neurology end of sleep medicine. And we wanna start with Parasomnias And I dunno if you
[00:11:12] maybe just start off by just defining what a parasomnia is.
[00:11:15] Sujay Kansagra: Sure. Yeah. So Parasomnias is a group of sleep disorders and they’re typically characterized by abnormal behaviors sometimes even complex thoughts or emotions that occur at the start or in the middle of sleep or even with arousals from sleep. And the vast majority of parasomnias are fascinating in that we used to think we spent the entirety of our consciousness,
[00:11:37] either in wake non REM or REM
[00:11:39] sleep.
[00:11:40] But the majority of parasomnias actually have
[00:11:44] a, mix of elements of two stages at once, oftentimes both in the
[00:11:48] brain of like deep sleep and awake, for example or aspects of REM sleep and
[00:11:53] wakefulness which make parasomnias just a fascinating category of sleep disorders.
[00:11:58] Craig Canapari MD: It’s funny how much of sleep medicine. [00:12:00] is actually where there’s a blurring between sleep and wake. I think about this all the time in narcolepsy, which is a whole other topic, but narcolepsy we think of it as sleepiness, intruding into wakefulness. and that’s very true, but it’s also wakefulness, intruding into sleep. And it’s like where there’s that dysregulation of these processes, a lot of problems happen, but a lot of interesting stuff as well.
[00:12:24] Sujay Kansagra: That’s right. We talk about this amazing time at the transition break to sleep. weird, interesting things happen. People can have these hallucinations, like exploding head syndrome. This phenomenon of feeling like something exploding inside your head. Oftentimes with visual, sensation as well.
[00:12:38] Even what we experience like common, like hypnic jerks that sometimes also have this semi dream-like imagery. There’s just a lot of weirdness at that transition. And it’s fascinating. I think there’s a lot of mystery around that time and a lot of fascination
[00:12:50] with that period.
[00:12:51] Craig Canapari MD: Yeah. And just for the listeners, the hypnic jerks are occurring when you’re falling asleep and you have that sensation of falling and you jerk awake.
[00:12:58] Sujay Kansagra: [00:13:00] yes, I think the evidence is probably pretty weak. And I think the challenge here is that stress is so common that you’re bound to see some sort of a link
[00:13:06] there, but yes, stress, I’ve heard, caffeine intake, certainly sleep deprivation, perhaps can, worsen hypnic jerks, all the things that are very common in our world, just because again, hypnic jerks are also common, so I think it’s hard to pinpoint.
[00:13:18] Craig Canapari MD: I feel like that’s, a good segue into Sleep talking or somniloquy, which one of those things like I think in the most recent international classification of sleep disorders, they don’t even call it a disorder, which to me is correct. Like sleep talking is more of a phenomenon than anything else.
[00:13:36] Sujay Kansagra: I’d be curious how often
[00:13:38] parents, for both of you, how
[00:13:40] Arielle Greenleaf: often are parents bringing up sleep talking? Not often at all.
[00:13:44] Craig Canapari MD: , it’s like on a questionnaire we administer in the office, but I do feel like it the idea that.
[00:13:49] it’s not a big problem has percolated out there. ’cause it doesn’t seem to generate a lot of concern.
[00:13:54]
[00:13:54] Sujay Kansagra: Same here. It’s only time I end up documenting it is when I have asked about it, and they’re like, oh, yeah, they talking their sleep. But it’s [00:14:00] never an initial concern, which, on the spectrum of sleep talking, if it’s a problem such that it’s happening every single night and we think it’s disrupting somebody’s sleep.
[00:14:09] Then yes it’s a problem even though it’s, quote unquote in the normal variant
[00:14:12] spectrum, but, I rarely, one does it rarely come
[00:14:15] to me as a primary problem, and two, rarely do. I feel like it actually ends up disrupting the quality of one’s sleep, just because it’s not pervasive enough throughout the night.
[00:14:23] and chances are they’re, even when, while they’re asleep talking, maybe still getting restorative sleep during that time. we don’t really know.
[00:14:29] I know that I’ve definitely talked in my sleep, but I wouldn’t know, like I’m told it, in the, morning so I’m not awake for it. My wife tells me I talk not infrequently and. It’s usually things that I’ve been working on the next day. She, or the day before, she’s yeah, you were working at night too. I’m like, all right p that I’m thinking about something.
[00:14:48] Yeah. it’s hustle culture, man. Grind when I sleep, although I have nightmares of still rounding, during residency, I’m not prepared for rounds, and rounds are about to start, and I’m like, gosh I remember doing residency. I’d have those [00:15:00] dreams. I’m rounding in my sleep at night.
[00:15:01] When am I not rounding? It’s,
[00:15:02] Craig Canapari MD: well. I, I.
[00:15:03] Sujay Kansagra: feel like my anxiety dreams go back to high school. that was much more of an anxiety provoking time, Yes. I think it probably relates to a lot
[00:15:12] of people. But I think for me, that sense of needing to be prepared and having all the information and then just the angst on taking care
[00:15:17] of patients, I’m like you can’t make a mistake.
[00:15:19] Patient care is at risk. I think that was probably hardest for me.
[00:15:23] That’s probably why it comes back in my dreams.
[00:15:25] Craig Canapari MD: So Arielle actually said something I wanted to amplify a little bit, which is like you mentioned night terrors as well as talking in your sleep. And I think It’s, important for us to talk about non-REM versus REM related parasomnias because it’s a, really useful part of the taxonomy when we’re trying to figure out what’s going on with the patient.
[00:15:43] Sujay Kansagra: Yep, yep. Yeah, happy to. When it comes to the core non-REM parasomnias, We think about confusional arousals, we think about night terrors.
[00:15:52] We talk about
[00:15:52] sleepwalking, and that’s, the majority. Now there are rare ones, sleep related eating disorder.
[00:15:57] In older
[00:15:58] folks there’s things Like, [00:16:00] sexsomnia, so there are other rare non-REM parasomnias. But the core are the confusional arousals,, night terrors, and sleepwalking. and I like to think of those as the non-REM and the characteristics of non-REM paradigms are typically the first third of the night.
[00:16:13] Lack of recollection of the event. Usually the order of seconds to minutes in rare cases can be longer
[00:16:19] and characterized by occurring in relatively young children.
[00:16:22] We talk about the age range of
[00:16:23] three to thirteen as a broad, and depending on which parasomnia some occur more commonly when you’re young, versus when you’re older.
[00:16:29] Versus rem
[00:16:30] parasomnias, the hallmark is REM behavior disorder, which in the pediatric population we rarely see unless it’s associated With narcolepsy. ’cause patients with narcolepsy oftentimes do have, REM behavior disorder, which is essentially an acting out of your dreams.
[00:16:42] You don’t have the normal muscle atonia, the normal paralysis that you’re supposed to have when you dream. It’s a very beneficial and safe thing our body does for us, right? It paralyzes us when we’re dreaming so we don’t act them out. REM behavior disorder, that paralysis isn’t there, or it’s partial.
[00:16:56] You can also have what we call recurrent isolated sleep paralysis. That’s also rem [00:17:00] parasomnia. Many people have experienced this, particularly during times of sleep deprivation, like during college, where either right when you fall asleep or right as you’re waking up, you have persistence of the rem atonia that paralysis.
[00:17:11] And so you wake up thinking you’re completely paralyzed and oftentimes associate with a sense of dread and fear, and as if somebody’s sitting on your chest like you can’t breathe. We also put that in the REM category, but REM parasomnias tend to usually tend to happen in the latter half of the night.
[00:17:25] particularly dreaming, recurrent dreaming or upon awakening with REM behavior, just not rem with isolated sleep paralysis.
[00:17:32] Craig Canapari MD: I wanna just actually talk a little bit about the sleep paralysis.
[00:17:35] ’cause it’s one of those things that’s absolutely terrifying to someone when it happens, right? And there’s also seems to be a certain flavor to the hallucinations that come along with it.
[00:17:45] So if they’re rising out of waking up from sleep, we call them hypnopompic hallucinations.
[00:17:56] And these don’t seem to be culturally determined. And I’ve [00:18:00] heard people commonly say they see glowing eyes in the room, like there are animals there, or they feel like someone’s breaking into the room. Sometimes, they’ll talk about there being an old crone in the room.
[00:18:11] It’s just fascinating that these things seem to be hardwired into people.
[00:18:15] Sujay Kansagra: Yeah it it’s frightening when people describe what they’re experiencing. I’ve had sleep paralysis once or twice, and yes, it’s really terrifying. You’re like sitting there hoping like somebody just touches your arms. You can snap out of
[00:18:27] this.
[00:18:28] it’s, it’s terrifying, but to have that associated with dream imagery, I never had dream imagery with it, but to
[00:18:33] have both together as absolutely terrifying. We talk about, hallucinations, like what you’re having, right as you’re transitioning to sleep.
[00:18:40] And so patients with narcolepsy oftentimes. For some reason those involve like aliens or people like in the room. There’s a very similar theme there too. People have called 9 1 1 because they feel there’s intruders in the room. They have
[00:18:52] these types of hallucinations about the transition to sleep.
[00:18:55] So I agree there’s probably something hardwired into our psyche that makes us have those,
[00:18:59] thoughts. Yeah.
[00:18:59] Arielle Greenleaf: [00:19:00] that doesn’t generally happen with the pediatric population, right?
[00:19:04] Sujay Kansagra: The
[00:19:04] Craig Canapari MD: I’m more like adolescents.
[00:19:05] Sujay Kansagra: Certainly. Yeah. In adolescents, there’s a peak. I’ve seen it down to four or five. I think the earliest case report was in a 1-year-old, I think that was actually at UNC. They report that it’s very hard to pick up excessive sleepiness in a 1-year-old. They proved it with I think CSF testing of orexin, which is one way of diagnosing narcolepsy.
[00:19:24] Craig Canapari MD: And, you’re talking about a child with narcolepsy.
[00:19:26] And of course
[00:19:26] like sleep paralysis is very alarming. If your child tells you have sleep paralysis, definitely worth l earning a little bit more about it, talking to your doctor, but
[00:19:35] to me it’s if they come in the office with
[00:19:37] this history, I’m like are they sleepy or
[00:19:38] not?
[00:19:39] If they’re sleepy, then we’re looking at narcolepsy
[00:19:41] testing. If they’re not,
[00:19:43] usually Im reassuring them And if it’s happening quite a
[00:19:45] bit, you could consider something like a course of an SSRI. I’ve never had to do that
[00:19:49] myself.
[00:19:50] Arielle Greenleaf: So I have a question for you guys. Narcolepsy, you’re talking
[00:19:54] about narcolepsy and what [00:20:00] triggers some so I’m thinking of pediatric, in pediatric cases. What would trigger someone to, what would the child be presenting with to even start the process of considering the fact that it could be narcolepsy?
[00:20:15] Sujay Kansagra: I’ll tell you the typical path for me, which is it’s usually disabling sleepiness, it’s socially impairing level of sleepiness that comes on in kind of a subacute over the course of weeks to months. And it’s usually school issues that kind of raise the red flag, which like they keep falling asleep in school and teachers can’t keep them awake.
[00:20:33] That’s usually the presenting factor with me, unless they also have cataplexy, which does occur in a certain portion of children that have narcolepsy in which they have sudden intrusion of that red muscle atonia that can lead to partial paralysis or actually full body
[00:20:47] paralysis.
[00:20:48] that very quickly and seek evaluation, but it’s
[00:20:51] just the disabling sleepiness and they usually already see an endocrinologist and they’ve seen an infectious disease doctor by the time they’re 10 years later, finally get plugged in with a sleep doctor.
[00:20:59] The [00:21:00] median time to diagnose from the time of symptom onset for children is like 10 years. It’s really terrible that how much time is lost for these children.
[00:21:06] Craig Canapari MD: is our sleep medicine fellows, they mostly come from the adult side and they’re mostly internal medicine doctors. ’cause sleep medicine is a pediatric and adult specialty, and I order a lot of MSLTs because again, not in every child that’s sleepy if they have snoring or similar thing that looks like, maybe it’s just sleep apnea, but I just feel like it’s a real missed opportunity.
[00:21:28] you don’t want that kid to come back in five years and you saw them and you missed narcolepsy because it really can change to the trajectory of their lives if you diagnose them early
[00:21:37] Sujay Kansagra: Yes, Did you say S MLTs?
[00:21:40] Craig Canapari MD: Multiple sleep latency test. Thank you.
[00:21:43] you do an overnight test to make sure they get enough sleep and there’s nothing like sleep apnea, fragmenting their sleep, and then you offer them five nap opportunities the next day and you measure how quickly they
[00:21:52] fall asleep, But yeah I think in general, parasomnias are common, and I don’t want to seem [00:22:00] really alarmist to parents who are listening, but I think one of the red flags in general is if your child is having interrupted sleep at night and it’s very frequent or they’re sleepy during the day, I think those are absolute signs that it is worth pursuing. We can talk about these different phenomenon and what are the red flags in different situations, but I’d say that regardless of the type of thing that’s happening during the night, those are the sort of things that get my attention. Snoring. Frequent events daytime sleepiness or difficulty in school in general?
[00:22:34] Yeah, no, I like all of those. I’m always focused on the safety portion as well, and
[00:22:38] Sujay Kansagra: so I’ve had situations where the child is currently getting into situations that can be unsafe, older children that can manage to get outside of the house, for
[00:22:46] example I had a
[00:22:47] child that had a two level house and would always manage to open the window and
[00:22:50] actually on a few occasions, climbed out on the roof during a sleepwalking
[00:22:54] episode. and so I’m always thinking, what are the safety implications of what they’re doing? And [00:23:00] then, we’re always thinking about is it truly a parasomnia? Because weird things happen in sleep. And so we’re always ruling out some of the mimics as well. And we know there can certainly be just behavioral issues, right?
[00:23:09] is it truly a parasomnia
[00:23:12] versus is it more of a just a behavioral arousal or awakening?
[00:23:16] And then in my mind, I’m always
[00:23:17] thinking as the neurologist, I’m like, I can’t miss nocturnal epilepsy, which can present in really unusual ways.
[00:23:24] And so I’m also keeping that on the list. But I agree if something’s happening repetitively at nighttime and the child is having any sort of daytime manifestation, or you feel like their safety is at risk, certainly bring it up at least to your pediatrician and talk about it.
[00:23:37] Arielle Greenleaf: So from my perspective all of that is so helpful. What I see a lot
[00:23:43] is parents in mom groups or whatever on Facebook, Instagram saying, I don’t know what to do.
[00:23:52] My 10 month old is waking at night and really upset, and I have to go in there and it’s happening every [00:24:00] night.
[00:24:00] And the response. It’s almost
[00:24:02] always night terrors. Like people are like all about it being night
[00:24:07] terrors. And it doesn’t matter how young, sometimes they say six month olds. And my understanding is that it’s rare. It’s very rare for a baby or young toddler to be having that kind of parasomnia. I know nightmares can happen earlier, bad dreams.
[00:24:26] But when do night terrors really start to become more common, I would say. And then what is the prevalence of night terrors?
[00:24:37] Sujay Kansagra: Great questions. I’ll tell you what, of all the parasomnias and Craig feel free to jump in here, but, the confusional arousal sleepwalking, night terrors tends to be the least frequent, I’d say somewhere probably around three to 5%. I usually think of parasomnias at the earliest, typically like three and above in infants.
[00:24:53] It’s not
[00:24:54] gonna be a night terror, it’s gonna be usually just a behavioral awakening of some type. But that’s, yeah, [00:25:00] that’s my take Craig.
[00:25:01] Craig Canapari MD: And just to, I think for defining things for people. Confusional, arousals are where. A child doesn’t leave the bed. They may sit up, they may talk, they usually don’t seem lucid, but it seems pretty benign. Like you might notice it if you’re on vacation with your child and you’re in the same room as them, but unless you have a monitor, you might not notice this at all.
[00:25:22] A night terror is when your kid is screaming they don’t leave the bed but they have this fight or flight response where they may be sweating, they’re screaming and you cannot console them. the first time this happens, it is very scary to parents because, imagine being woken up by someone in your household screaming.
[00:25:42] Sujay Kansagra: It’s not a good feeling. And I remember my older son used to have a night terror every time we went to stay at our in-laws. Yeah, it’s just an excuse, Craig to not go to the in-laws.
[00:25:54] Arielle Greenleaf: So we don’t need to go to the in-laws anymore.
[00:25:56] Craig Canapari MD: my in-laws were lovely, but my mother-in-law had terrible insomnia. And my [00:26:00] father-in-Law, who’s not gonna listen to this, would just sleep on the couch all night with the TV blaring. But he would just be screaming. And my mother-in-law running and she’s what’s wrong?
[00:26:08] What’s wrong? And I’m like, I’ve got this. It’s okay. But it is once you’ve experienced it, it goes more from being something that’s really scary to something that is a nuisance. If it’s happening quite, frequently enough that it’s on your mind.
[00:26:23] Definitely talk with your pediatrician. ’cause any of The disorders of sleep fragmentation. We think about things like sleep apnea or medical conditions can trigger these events in people that are predisposed of them. Not every child
[00:26:37] is gonna have sleepwalk or have a night terror, but if you’re prone to that, I think there’ve been studies.
[00:26:41] If you take a kid that’s sleepwalking, you set them up at night, they’ll just get up and just motor out of their bed. So any underlying problem, say if they have
[00:26:49] asthma that’s poorly controlled and they’re coughing, eczema, they’re itching,
[00:26:52] it’s going to make them more
[00:26:53] likely to have these events. and that’s why it’s so important for people to
[00:26:57] work with their pediatrician.
[00:26:59] Arielle Greenleaf: [00:27:00] now can fevers.
[00:27:01] Be a cause of that? Or is it just illness in general? Because the only
[00:27:06] time my daughter has ever had, she’s only had two, and they were awful. And I’m sitting right next to her and she’s screaming for me, like reaching across the room yelling mama. And it’s like heartbreaking.
[00:27:19] But she had a fever
[00:27:20] both times and I just, maybe that’s just one of those triggering events that can cause Some people talk about emptying the bladder before bed can, having to go to the bathroom cause night terrors.
[00:27:36] Sujay Kansagra: I’ll tell you, it’s in my experience it’s a more rare provoking factor. But, just like Craig said, at the end of the day, when I’m taking it step by step in clinic, I’m like, first and foremost, are they getting adequate, length of sleep? Because we know sleep deprivation will definitely predispose you to having it because you spend more time in deeper stages of sleep out of which night terrors tend to occur.
[00:27:53] Number two, are there those internal disruptors, medical issues, reflux, ear issues, eczema, et cetera [00:28:00] sleep apnea, Are there external disruptors? Is the TV blaring in the house? Is it a busy street corner? has the family brought the child into their bed because this happened one time and now it’s happening every night
[00:28:09] that’s causing the, child to have multiple arousals and poor sleep. And so any of these things
[00:28:13] could potentially predispose you. But yes, fever illness
[00:28:17] for sure. Weird things happen in sleep when you have a fever. Absolutely.
[00:28:21] Arielle Greenleaf: Is there anything you as doctors can, do for that? Because my understanding is that you just grow out of them, but I don’t know if that’s factual or medically factual.
[00:28:35] Sujay Kansagra: Yeah. No, Craig I’ll take your lead here about how much, medical stuff you wanna share, Because I don’t want people using techniques willy-nilly, but I happy to go over some of the basics of,
[00:28:44] Craig Canapari MD: I think that if anybody’s gonna listen to podcast, there are pediatricians and sleep consultants that listen as Well. I like to have more detail instead of less.
[00:28:52] Sujay Kansagra: So I will tell you that after I’ve assessed the sleep duration part of this to say, Hey, listen, we gotta make sure your schedule is adequate. if I can’t find any [00:29:00] internal disruptors or external disruptors to sleep, let’s say this is a teenager who out of the blue started having like night, it’s not a typical pattern.
[00:29:06] It didn’t start when they were young. there’s oftentimes a
[00:29:08] family history that we’d think there’s likely a genetic predisposition to having parasomnias. So things are occurring out of the blue and the child is like snoring, for example. I’m like that’s a little bit unusual.
[00:29:17] Let’s consider doing a sleep study to make sure we’re not missing any other disruptor of sleep. But in the absence of any disruptor that I can find, oftentimes what I’ll consider doing is scheduled awakenings scheduled. Awakenings has data to support it. What you do in this is you go in there about 20, 30 minutes prior to the time of their typical event.
[00:29:34] And you wake them up. And the advice I like to give is wake them up enough that they can say their name and then let
[00:29:39] ’em go back to sleep. Just so you know that they’re relatively fully
[00:29:42] awake. And then let them be for the rest of the night. If you do this for two or three weeks straight in the majority of children, for some reason, it hits the reset switch in their brain and these episodes go away.
[00:29:51] This includes night terrors, it includes sleepwalking. Again, as Craig mentioned, there is probably a role, there’s some data to also support [00:30:00] melatonin. And again, this is something you gotta talk to your pediatrician about.
[00:30:03] But there is a role, I think for melatonin, whether it actually gets to the pathophysiology and the underlying mechanisms by which this happens. Or is it just increasing total sleep duration? Who knows? But there is some data there.
[00:30:14] Arielle Greenleaf: And then I hear people who say that those things increase with the use of melatonin. Or he gets more, he got night terrors from them.
[00:30:23] Sujay Kansagra: Yeah, I’m always curious distinguishing nightmares from night terrors. Melatonin can certainly cause nightmares and if in my world, a family links a particular side effect the initiation of a medication or a supplement, then we just stop it and see if it resolves and if it does, and I still think it’s beneficial, we reintroduce and see if the symptoms come back just to make sure it actually is causative.
[00:30:43] There are some stronger, more potent medications that I’ve probably prescribed like less than five times in my 10 plus year career. That can also help, but it helps by decreasing deep non-REM sleep, which is not something that I like to do
[00:30:57] for children.
[00:30:58] You
[00:30:58] we like to keep them in deep non-REM [00:31:00] sleep.
[00:31:00] Yeah.
[00:31:00] Craig Canapari MD: and actually there’s just two things I wanna double click on that Sujay said. The first step in looking at these is actually making sure the child’s getting adequate sleep. Because insufficient sleep is a very clear trigger of non-REM parasomnias. And it’s very common and we see it sometimes in adolescents where they had a sleepwalking when they were a kid, it went away, then they hit adolescents and all of a sudden they’re staying up super late, school starts too early, or they go to college and they have these crazy schedules.
[00:31:27] I think that is really important for parents to know too. And sometimes you’ll see if your kid’s up super late one night you’re on vacation, it’s a holiday, they’re gonna have a parasomnia that
[00:31:37] night because they’ve been shortchanged on sleep
[00:31:39] a little bit. But I think just to talk a little bit more about sleepwalking, where safety is an issue, for kids that are frequent sleepwalkers, you do need to be really careful, especially if you’re staying in
[00:31:48] a location that’s different from home. And I’m thinking of people who are staying in hotels where there’s a balcony or unfamiliar locations.
[00:31:57] I have kids that Sleepwalk [00:32:00] intermittently. And some kids are agitated when they sleepwalk, they might even be violent. Others are just calm, but they still get into mischief. I agree with Sujay, I tend not to write meds for these kids unless I’ve had a few where they’re nightly events especially when kids going college or they’ve really gotten they’ve eloped from The home they’ve gotten injured, other people have gotten injured
[00:32:21] Sujay Kansagra: Yeah. Another example is I had a child who lived in a trailer home, had eight other people in the trailer home with sleepwalk every night, and wake everybody up, and it was leading to complete dysfunction and disarray, and that’s the situation. I said, okay, that probably merits,
[00:32:36] The other thing I’d love to emphasize is that, we’ve talked about night terrors versus nightmares, and oftentimes
[00:32:41] There’s a confusion there. Nightmares is vivid dream imagery. Your child is fully awake and telling you, I’m scared because I just saw a monster in my dream.
[00:32:47] Whereas night terrors, they’re not aware typically that you’re even there. And oftentimes if you are there, even if
[00:32:52] they’re calling for you, they’re like pushing you away and completely frightened, as Craig mentioned, they have that sympathetic activation.
[00:32:57] are, they’re terrified, they look terrified and they [00:33:00] usually do not remember it.
[00:33:00] The next day, if they do remember, it’s usually after their night
[00:33:03] terror is complete and they woke up from the night terror. And then they
[00:33:05] might remember that they, but they
[00:33:07] typically don’t remember the event itself. And parents oftentimes go to what just happened during the day? What trauma did they experience to start
[00:33:15] beginning to have.
[00:33:15] night terrors? And the answer is they didn’t, we don’t think it’s actually due to any underlying trauma or psychological distress, even though it looks very distressing, like they’re truly in distress. I think that’s also important just to provide some reassurance to families that it’s likely not due to some sort of daytime trauma they experienced.
[00:33:32] Craig Canapari MD: So let’s segue to nightmares then, because nightmares are incredibly common. I don’t think there’s anybody that hasn’t had a nightmare I don’t think we know when kids start having nightmares because infants can’t tell us, right? we’ve all had our kids cry in our sleep.
[00:33:45] I can definitely remember when my kids were babies they wouldn’t be screaming their heads off for me, but they this
[00:33:49] sort of pious crying. I’m like, I don’t know, maybe they had a bad dream. It’s hard to say,
[00:33:53] right?
[00:33:53] Arielle Greenleaf: Yeah.
[00:33:54] Craig Canapari MD: But as Sujay said, they tend to happen in the second half of the night and they have a clear
[00:33:59] [00:34:00] narrative to them. They have a story, and if someone wakes up from a nightmare or a dream for that matter, they’re lucid. Whereas if you try to wake someone out of a non-REM parasomnia, they’re coming out of non-REM sleep, they’re often pretty out
[00:34:11] of it.
[00:34:12] Arielle Greenleaf: My question about that.
[00:34:14] Is it in the best interest Of everybody to not wake or attempt to wake someone who is sleepwalking or having a night terror.
[00:34:24] Sujay Kansagra: Yeah. People always used to say, do not wake up some of that sleepwalking thinking that it’s gonna hurt them. But what happens is if you wake somebody up that’s they might become scared and agitated and frightened and lash out, et cetera.
[00:34:35] and so the usual approach is gently guide them back to the bed if you can, without alarming them or being too stimulating. Yes, arousing them out of the event will stop the event, but perhaps the detriment of kind of everybody’s wellbeing. ’cause they’ll be shocked and surprised and maybe angry.
[00:34:51] Arielle Greenleaf: The first thing I was taught in sleep doctor school is that if you do die in your dream, you do die for real. Oh, stop.
[00:34:56] Sujay Kansagra: that’s, they tell us that from the beginning,
[00:34:59] Arielle Greenleaf: Oh
[00:34:59] Craig Canapari MD: Yeah. [00:35:00] Day one.
[00:35:01] Sujay Kansagra: I’ve been on alert ever since.
[00:35:03] Arielle Greenleaf: gosh.
[00:35:04] Sujay Kansagra: I’ve been mainlining rem suppressive drugs since that day. Oh, don’t do true kids.
[00:35:09] You don’t die. Although I will tell you that if you feel like you’re having dreams of like drowning or suffocation or you can’t breathe, you may have sleep apnea. Anecdotally, I’ll tell you, some people do experience this sensation of I’m being suffocated, recurrent, and you wake up gasping.
[00:35:23] Craig Canapari MD: It’s like you may have sleep apnea, so you may wanna look into that. it’s interesting. Nightmares in my world are very seldom the reason someone comes to sleep clinic. and I think because it is such a common shared experience that people generally, Are fairly comfortable with it. That being said there are certain things to be aware of that especially for practitioners that patient, people who’ve experienced trauma often do have issues with severe nightmares.
[00:35:51] my colleagues who work at the VA with veterans deal with this all the time. unfortunately there are many children that have experienced trauma as
[00:35:57] well. And I would say to parents, if your [00:36:00] kid’s having a nightmare, it doesn’t mean that they’ve
[00:36:01] experienced some hidden trauma.
[00:36:03] The parents almost always know about the
[00:36:05] trauma. It’s more important for providers to recognize that if someone’s coming in, they’re endorsing a lot of nightmares, they have insomnia. It seems disproportionate to what you would expect from what you’re being told. Oftenif you ask in a sensitive way, you can uncover with a family a little bit of a trauma history. I feel like this is something we just see sometimes kids with very severe sleep disruption and nightmares. they’re dealing with something and dealing with trauma is something that you really need mental health providers to help
[00:36:36] you with. It’s not something certainly that I feel comfortable dealing with.
[00:36:40] not even every mental health provider deals with trauma. You really need experts.
[00:36:44] Sujay Kansagra: Yes. Wholeheartedly agree. We, I think we’re,
[00:36:48] great at screening because we know the role that it plays when it comes to sleep overall when it comes to mental health. And, even, our patients, older patients that experience depression and anxiety and how that’s affecting their sleep So I think we’re great at [00:37:00] screening for it, but I agree, we really have to lean on our mental health colleagues to jump in and help for sure.
[00:37:06] Craig Canapari MD: I was gonna say we’re coming up on eight o’clock. I don’t know if you guys
[00:37:12] want to push through and we could go through RLS and rest is sleep disorder or Sujay if you guys drop off
[00:37:17] Arielle Greenleaf: don’t know.
[00:37:18] Craig Canapari MD: what your
[00:37:18] deal is
[00:37:19] Arielle Greenleaf: I’m here. We could talk for hours.
[00:37:21] Craig Canapari MD: Yeah.
[00:37:22] Arielle Greenleaf: um, I’m happy to push through. happy to chat about those.
[00:37:26] Craig Canapari MD: Yeah.
[00:37:26] Arielle Greenleaf: restless leg
[00:37:27] is, yeah.
[00:37:29] I try to medically screen people so that I
[00:37:31] can, if something seems off, I just send them to the doctor,
[00:37:35] but I’m not quite sure what I would need to be looking for with regard to restless leg.
[00:37:42] Craig Canapari MD: Su Sujay. Why don’t you just explain what rests his leg syndrome is?
[00:37:47] Sujay Kansagra: Restless leg syndrome, like all of our sleep disorders, we have a set number of diagnostic criteria, but it’s essentially characterized by an abnormal sensation of either discomfort, pain, something that you feel like is uncomfortable, [00:38:00] that is experienced predominantly in your legs, that is worse or only present at nighttime.
[00:38:05] When you move your legs, it actually helps the symptoms and when you’re still, the symptoms tend to be worse and it’s not better explained by another underlying medical disorder like neuropathy, et cetera, and should cause some sort of kind of dysfunction when it comes to sleep loss, et cetera.
[00:38:23] So that’s the typical definition of restless leg, what it can start very early and it’s, and unfortunately when we ask
[00:38:30] adults, a good proportion of them will say, my symptoms began prior to when I was 20 years
[00:38:34] old. And a good chunk of those will also say, it actually began before I
[00:38:38] was 10, but I couldn’t adequately explain what was happening Pediatricians have so many things to screen for. I do not, I’m not trying to throw pediatricians under the bus here, but oftentimes they’re like, ah, it’s just growing pains, and they’ll be fine. And it’s missed for many years. We do think it has something to do with dopamine regulation in the brain.
[00:38:55] Perhaps a decrease in dopamine due to a circadian [00:39:00] pattern of synthesis, of dopamine in the brain, such that it tends to be lower at nighttime. And we think that iron plays a role as a co-factor in the creation of dopamine. That’s why we’re oftentimes screening for iron deficiency in hopes of making sure that patient has adequate amounts of dopamine.But, a lot of children that have restless leg also have what we call periodic limb movements of sleep. And so this is kinda the sister diagnosis of restless leg. Restless leg is what you experience while you’re awake. Oftentimes you have limb movements while you’re asleep.
[00:39:27] like 80% of patients that have RLS will also have periodic limb movements of sleep, and that can also disrupt the quality of your sleep. So yeah, that’s a broad overview,
[00:39:35] Craig Canapari MD: And periodic limb movements of sleep are something that get detected in an overnight sleep test. They can be subtle, but they’re just leg kicks that happen in series of four or more. Where Sujay and I sit in the pediatric clinic, ’cause we have children that are often too young to really express this.
[00:39:52] And we also deal with children who are not always neurotypical and may not have even if they’re old enough, they don’t have language to describe these things. [00:40:00] So we’re almost have to infer it. I’ve had parents tell me that their kids will kick a lot. They’ll try to press their feet into them.
[00:40:07] They may say that their feet are hot or cold at night. True story. I was studying for my sleep medicine boards the first go around and I read this sentence and it said, kids with restless leg may say they have too much energy in their legs. And that’s what I used to say to my folks when I was a kid, if I had too much caffeine and caffeine makes restless leg worse. And then I realized I’ve got a little bit of restless leg. It doesn’t happen that often, but if I’m anxious or I’ve had too much caffeine, that is I get that
[00:40:35] feeling. And I feel like we this is the art of pediatrics sometimes, and it makes our adult colleagues crazy when they come with us.
[00:40:42] And we’re
[00:40:43] trying to guess what’s what, what’s going through a two year old’s mind,
[00:40:47] Sujay Kansagra: Yes.
[00:40:48] Craig Canapari MD: what parents are telling us. I think in the hierarchy of restless leg. The other thing is
[00:40:52] the criteria that Sujay mentioned. Often in younger kids, they don’t necessarily fit those [00:41:00] criteria perfectly.
[00:41:01] There may not the symptoms may not be worse in the evening or for example, they, I think there’s probable and possible restless leg if there’s a family history and a first degree relative that helps you with the diagnosis. The first line treatment in kids is checking a blood iron marker called a ferritin and treating.
[00:41:18] We usually treat for values less than 50. I don’t know what you guys do.
[00:41:22] Sujay Kansagra: Same. Yeah, we try to get them to 50 in some cases, 50 is the goal. it, can be challenging to get a child to a level of 50,
[00:41:29] Arielle Greenleaf: What is ferritin for the lay person?
[00:41:32] Sujay Kansagra: Yeah, it’s essentially a measure of iron stores in the body and the challenge with ferritin is if you’re sick, it’s what we call an acute phase reactant and that it actually increases just in the setting of kind of inflammation in the body.
[00:41:41] And so you don’t wanna check it when you’re
[00:41:42] sick. You wanna check it when you’re otherwise
[00:41:44] well, and the goal
[00:41:45] is, yeah trying to get above 50. And again, all with the premise that we think it works as a co-factor in, I
[00:41:50] think tyrosine
[00:41:50] hydroxylase, which ends up making dopamine for your brain.
[00:41:53] The challenge is if you
[00:41:54] check a ferritin in any toddler,
[00:41:56] it’s gonna be below
[00:41:57] 50. In my experience, nobody’s, [00:42:00] so I usually
[00:42:00] want to be, fairly sure that before I put somebody on full fledged iron supplementation, which by the way, can be dangerous ’cause iron overload is a super dangerous phenomenon.
[00:42:10] But, I wanna be fairly certain that we are in the realm of, probable process thing.
[00:42:14] If we pick up periodic limb movements of sleep on a sleep study, that could also serve as kinda another surrogate marker that pushes us more towards likelihood, restless leg, if they don’t fill all the classic criteria. But there’s something that I wanna sink my teeth in to be like, okay, they have a sleep disruption due to a restless phenomenon that’s affecting their sleep before I put them on iron.
[00:42:33] Sometimes I’ll hedge my bet and say let me put you on a multivitamin with iron, which isn’t a full fledged iron supplement, but hopefully stabilize you where you are and not make your iron deficiency any worse. But it can be a challenging diagnosis to pin down
[00:42:44] Arielle Greenleaf: And is iron the only course of action for treating it?
[00:42:50] Sujay Kansagra: there are other medications. It’s funny, at the recent sleep conference I wasn’t able to attend, but the big brouhaha now is that for adults, we’re no longer recommending dopamine agonists. So we [00:43:00] used to recommend dopamine agonists for adults and oftentimes they’d be used on the adult side very early, much earlier than I would ever feel comfortable with doing even in adults.
[00:43:08] But medications like Mirapex were used really early. The typical, even for adults, I think the typical approach should be what’s your iron status? And if it’s low, you gotta supplement. The next line is typically medication in the realm of the gabapentin family. And so gabapentin and its sister pregabalin or Lyrica are the ones that we oftentimes go to, which can really help with the symptoms of restless leg.
[00:43:30] And now on the adult side, I think they’re starting to use low dose opioids instead of the DOPA agonists.
[00:43:37] And I think most families would also be somewhat opposed unless it’s a really kind of severe
[00:43:41] situation. But then a lot of it is also sleep hygiene, like avoiding the things that worsen this..
[00:43:46] So caffeine; antihistamines are notorious for just making restless leg symptoms much, much worse. And so sometimes we can help from a, just a avoidance standpoint of things that will make the symptoms worse.
[00:43:57] Stretching leg massage. Cold [00:44:00] plunging.
[00:44:00] Cold plunging. What do you
[00:44:01] Craig Canapari MD: Sorry. we’ll get Huberman on here next.
[00:44:04] Sujay Kansagra: Yeah, that’d be great. Everybody will be on magnesium glycinate.
[00:44:08] Craig Canapari MD: Oh, I love
[00:44:09] Arielle Greenleaf: that.
[00:44:10] I It helps me sleep.
[00:44:12] Craig Canapari MD: You’re skeptical. And I have the receipts from my Oura ring.
[00:44:15] I’m not gonna
[00:44:15] this today, but we definitely should talk about this. But the I wanted to ask a little bit about gabapentin actually. ’cause I remember I had a,
[00:44:23] I had one parent who was in law enforcement, they moved it from the south and we talked about gabapentin for a child and she said, I’m not gonna give that ’cause it’s a drug of
[00:44:31] abuse.
[00:44:32] And I think that’s a little bit of an exaggeration. But I remember going to sleep meeting and Suresh Kotagal, who’s a very smart sleep
[00:44:41] doctor has written a lot about restless leg, said that has come up in his practice as well. And I think it’s more of a concern in the South than it is in the northeast, is have a, has a parent ever said that to you?
[00:44:51] Sujay Kansagra: Yes. And interestingly, when I Googled it, there was some article that was coming up very high on the Google search that said something about [00:45:00] gabapentin being worse than opioids. And this was something that I think a lot of people latched onto.
[00:45:05] Any drug you’re using in the right way, at the right doses with access that you are actually monitoring is not gonna be a drug of abuse. Even our stimulants, when we’re using in for narcolepsy in the right way, it’s not gonna end up turning into a drug of abuse. gabapentin can help with neuropathic pain. And there are some indications for seizures, but we rarely use it for seizures. But no, when it comes to the kinda euphoric effect, for example, or the addictive effect of gabapentin, it’s just not there.
[00:45:34] Craig Canapari MD: Yeah the doses, I think clear there, there were mega doses of it, like four or five grams, and there was also taken with other drugs. So it’s just, but just to reassure parents, first of all, your pediatrician wouldn’t be prescribing this for you. I think that usually restless leg is something that your pediatrician is gonna be familiar with
[00:45:51] sleep apnea, they’re gonna be familiar with sleep walking.
[00:45:54] So I think if your child’s complaining about their legs at night, I would just encourage
[00:45:57] to see if you could make an appointment with your friendly neighborhood [00:46:00] sleep doctor and drill down on this a little bit further because it is a, it’s a nuanced conversation.
[00:46:04] Even things like supplementing iron aren’t always straightforward. They’re various
[00:46:09] preparations. Do you dose it every day? Do you dose it every other day? There’s some, I like the NovaFerrum preparations, but not everybody can afford them. Like they’re palatable.
[00:46:19] Hey Craig.
[00:46:21] Had a listener question.
[00:46:22] Arielle Greenleaf: Yeah, that’s what I was wondering if that was appropriate to ask or not. Okay, so we got a listener question in our email, Gmail. thesleepeditshow@gmail.com. Please send us your questions. Anna l asked my sleep. Sleep trained three-year-old has restless leg syndrome diagnosed by a sleep.
[00:46:45] Medicine doctor via sleep study, blood tests and symptoms. However, we’ve gotten his ferritin levels above 50 and he still wakes multiple times a night. Melatonin makes it worse. His doctors said it will eventually improve with [00:47:00] time as he gets older. He is well rested during the day, even with the awakenings, but we are not.
[00:47:05] Any other tips for parents and kids struggling with restless leg syndrome,
[00:47:11] Sujay Kansagra: I, Craig, I’d love to hear your, I’ll tell you my approach, which is. Restless leg is difficult
[00:47:18] to diagnose in that young of a child. And every sleep practitioner is
[00:47:24] different and the practice of sleep medicine is a lot of art as Craig alluded to, and sometimes not so much
[00:47:31] science. So for me, a lot of times I’d wanna diagnose
[00:47:35] them myself and see them in clinic be like they truly have
[00:47:39] restless leg, or do they just tend to be a restless sleeper that has another issue, or behavioral insomnia of childhood or something else
[00:47:44] that’s causing them to wake up
[00:47:45] frequently. I would certainly, as I do with all my patients, would still screen for being able to transition to sleep independently at the start of the night.
[00:47:54] Are they able to do that well?
[00:47:55] constant assistance? Is a caregiver coming back in and getting them back to sleep relatively quickly?[00:48:00]
[00:48:00] Is it truly a discomfort issue that’s waking ’em up?
[00:48:02] Or is it more of a habitual due to, sleep onset associations? And so we’re making everything else as perfect as possible.
[00:48:09] And if I’m still left with a child that is complaining of their legs, truly bother them and has evidence of disrupted sleep besides after doing all the sleep hygiene and the behavioral insomnia and stuff really well, then yes, I am still going back to my core therapies to say, okay, if we’ve gotten iron up that high and we’re running into side effects of constipation or lack of palatability and the parent child is refusing to take more, then I am exploring other options like gabapentin.
[00:48:34] But I cannot think of a single time where I’ve put a three-year-old in gabapentin for us leg, to be honest. I would be surprised if it was true real deal with us leg at that age. Yeah.
[00:48:42] Craig Canapari MD: Yeah, I’d wanna see a sleep test in this kid, and I’d wanna see the movement index through the roof. If I’m gonna be saying this is the cause of these nighttime awakenings. Maybe it’s been done, but certainly worth the ha a sleep test hasn’t occurred worth doing, especially if the child’s falling asleep independently. So let’s close with talking [00:49:00] about restless sleep disorder, which is a pretty new diagnosis
[00:49:03] from 2017 or 2018. and I thought it was very clever what they did with this because I thought when they created this taxonomy, I’m like, oh, I see these patients all the time and I haven’t known what to do with them.
[00:49:14] Arielle Greenleaf: What do they look like?
[00:49:15] Craig Canapari MD: they describe kids that are not having sensory phenomenon so they don’t have restless leg, but when they’re in bed at night, they have these large, full body movements and people may talk about them flopping like a fish or moving around like hands around a clock during the night.
[00:49:33] The sort of kids that nobody wants to share a bed with on vacation. And the key is that there, there’s some daytime effects as well. Like they’re sleepy or they’re having problems, paying attention in school, et cetera.
[00:49:47] Sujay Kansagra: Yeah I think that’s dead
[00:49:50] on. And I agree. It’s this phenomenon that we’ve
[00:49:53] seen and now they’ve put formal diagnostic criteria on this. And so we’re like, okay we could potentially diagnose you based on [00:50:00] the diagnostic criteria.
[00:50:00] It does involve actually getting a sleep study to confirm that they’re having, I think, more than five movements per hour that are large and fit the bill. But it’s still tough. For me
[00:50:09] it’s I mean it still comes down
[00:50:11] to really
[00:50:12] iron, is it seems to be the go-to even for children that have restless body
[00:50:16] Type phenomenon. And then I really don’t have a great sense still of
[00:50:20] chicken and egg. We have children that have baseline attention issues that tend to be on this A DHD type spectrum that we know their brain engine idles at slightly higher level, right?
[00:50:30] Like we’re working on, yeah, they gotta get down to here. Whereas most of us, it’s gotta go from here to fall asleep. And they’re always idling here.
[00:50:37] I don’t know if that neurochemistry milieu makes you more likely to experience these types of phenomenon. I do think there’s still a lot of debate regarding what actually causes this phenomenon. um, but it, it’s, it’s, it still comes down to I think the basics. I think some of the studies they look fairly robust. look at a large number of kids typically six to 18 years of age. And so it seems like [00:51:00] yes, there’s probably something going on, but to me I would always be hesitant because a lot of families bring in for example, monitor data.
[00:51:06] They say, oh my sleep monitor picked up this many movements at nighttime. And one thing that I’m always harping on is of course, how does your child look during the day? Are they doing okay? ’cause there are a lot of kids that move around a lot, particularly really young children, toddlers, early school aged children are notorious for just being active sleepers, but yet their brain is still getting the sleep that they need.
[00:51:24] And so one thing I’m always asking them is, okay, first, how does your child look for Sure. And then number two if you are experiencing this. Is it occurring in a format such that they have a lot of restlessness and then they go the next hour and you know they’re gonna be fine. And then they have another spurt of
[00:51:39] restlessness
[00:51:39] If it is a perpetual, constant motion to point where you’re like how are they getting good quality sleep? Because they’re always moving. Every few minutes they’re moving, boom. That’s when the yellow flag goes up and I’m like could this potentially be something that’s truly disrupting sleep quality?
[00:51:53] Craig Canapari MD: Yeah, No I think that’s true and it is always so tricky because often these things come to light when, [00:52:00] again, not to imply that everybody’s kids have their own, like many of our families, they’re sharing
[00:52:05] rooms. They may even be sharing beds. Other parents, all of a sudden they go on vacation with their kids.
[00:52:10] They share bed for two nights, and it’s
[00:52:12] a catastrophe, right? They’re like, oh my God, he’s snoring, he’s moving, et cetera. And I think it is very important to look at the child’s functioning during the day. That’s a really good barometer of
[00:52:23] how things are going And I agree with you. I feel like that in the Venn diagram
[00:52:28] of whatever restless sleep disorder is
[00:52:30] in A DHD, there’s probably a large amount of
[00:52:32] overlap there. And that being said, If their ferritin’s pretty low,
[00:52:38] give them a trial of it, and they’re doing better. And that correlates
[00:52:40] with an in, in the ferritin going up.
[00:52:43] I think that’s useful. And sometimes, I don’t know, I, in our lab I feel like we be, we’ve had a trouble getting agreement about what scoring these large body movements.
[00:52:53] Do you guys actually index these in your lab?
[00:52:55] Sujay Kansagra: we don’t index. And I’ll tell you that it’s very rare that I have ordered a sleep [00:53:00] study. If I,
[00:53:00] have a child that’s really restless and it’s affecting daytime function and I have nowhere else to turn, I’m usually still going down the ferritin route and saying ’cause there are a lot of movement issues So I think we’ve gone down that route anyway. So it’s rare that sleep study, particularly looking for this to make this the diagnosis Let’s look at iron, see what happens.
[00:53:16] Craig Canapari MD: In the yeah the at the end of the day, even with all the difficulty of
[00:53:20] getting a good ferritin value, dosing iron, finding a palatable format,
[00:53:25] it’s still, I think everybody’s a little bit more comfortable with it providers and parents than like prescription sleep
[00:53:31] medication, right? It just feels like a lower
[00:53:35] tier intervention.
[00:53:36] Sujay Kansagra: absolutely.
[00:53:38] Craig Canapari MD: so listen guys, I think we covered what we set up to cover. This has been amazing.
[00:53:43] Sujay Kansagra: Absolutely.
[00:53:44] Arielle Greenleaf: I’ve definitely learned.
[00:53:46] Craig Canapari MD: Now
[00:53:47] Suji, you’ve got a pretty big footprint online.
[00:53:50] I’ve got your professional profile, your Instagram, your TikTok, your
[00:53:54] links. Is there anything else you want us to share online here?
[00:53:58] Sujay Kansagra: no, [00:54:00] just pri you know, the one thing I do like to share on all podcasts that are like parent facing is I always like to say that everyone is looking for that perfect, magical solution for everything when it comes to like potty training, when it comes to feeding, when it comes to extracurricular activities and sleep.
[00:54:18] There are like a million right ways to raise a thriving, happy child. Yeah. And let’s rule out sleep disorders, but when it comes to even the behavioral approaches to sleep, there are a million right ways to do it. So I tell families, there’s no one right way.
[00:54:32] Take some of the pressure off. If your child is happy and they’re thriving, you’re doing it right? Every parent struggles, everybody has opinions. I get it. Let’s be kind to other parents.
[00:54:43] I dunno why parenting has turned into a blood sport online and like these threads, let’s just be kind to one another. Go a long way if we’re just kinder. And if you feel cranky all the time, consider getting more sleep.
[00:54:54] Craig Canapari MD: Yeah.
[00:54:55] Absolutely.
[00:54:56] We’ll put a pin in it. I’m Craig.
[00:54:59] Arielle Greenleaf: [00:55:00] I’m Arielle Greenleaf,
[00:55:01] Craig Canapari MD: the sleep edit, and if you please trying to get this started, please share online Ariel, what’s our email inbox again?
[00:55:08] Arielle Greenleaf: the Sleep Edit show@gmail.com.
[00:55:12] Tell your friends. Okay. Thanks a lot guys.
[00:55:15] Thanks so much for listening to the Sleep edit. You can find transcripts at the web address Sleeped show. You can also find video of the episodes at that address as well as in my YouTube channel. You can find me at Dr. Craig canna perry.com and on all social media at D-R-C-A-N-A-P-A-R-I. You can find Ariel at Instagram at Ariel Greenleaf.
[00:55:47] That’s A-R-I-E-L-L-E-G-R-E-E-N-L-E-A. If you like the flavor of the advice here. Please check out my book. It’s Never Too Late to Sleep. [00:56:00] Train the Low Stress Way to high Quality Sleep for babies, kids, and parents. It’s available wherever fine books are sold. If you found this useful, please subscribe at Spotify or Apple Podcast and share it with your friends.
[00:56:13] It really helps as we’re trying to get the show off the ground. Thanks