To say that the world of children has been turned upside down by the pandemic is an understatement. Anecdotally, there has been a significant increase in reports of disturbed sleep. Is this to be expected, even in those kids for whom quality sleep was never an issue?
Dr Melisa Moore
Medscape spoke with Melisa E. Moore, PhD, a psychologist in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children’s Hospital of Philadelphia, about her own practice and her advice for pediatric primary care clinicians.
Has the pandemic changed the volume or type of sleep complaints you are seeing in your practice?
Early on, like most places, we were seeing fewer patients in person and more on video. Those children who were coming in were being seen for severe concerns, such as breathing problems during sleep and obstructive sleep apnea. Now that we have gotten into the rhythm of telehealth and video visits, we are packed with all kinds of different patients. Anxious children who can’t fall asleep. Patients with funny feelings in their legs that might have restless leg syndrome. Sleep terrors. Frequent night awakenings. As is true across the country, we’re seeing more kids for a wide range of concerns.
Clearly this would be different for kids of different ages, but what are the red flags that PCPs should know?
Our antennas should always be up for things like daytime sleepiness, snoring, disrupted breathing during sleep, that kind of thing. In terms of daytime sleepiness, naps are, obviously, normal for younger kids, and some of our teenagers also take naps to compensate for not getting enough sleep at night. But elementary schoolers really should not be that sleepy during the day. So a child that age who exhibits daytime sleepiness is a red flag for us.
During the pandemic, I’ve been thinking about two things. First, sleep disorders that affect our circadian clock ― a big concern for kids not on a schedule because they are at home and not physically present at school. So, if you have a patient that’s falling asleep at 3:00 AM and waking up at 2:00 PM the next day, that might be an issue they can’t just fix on their own and would be a red flag.
The second is anxiety that leads to real difficulty in falling asleep. We are seeing a lot of kids worrying about COVID and the impact of the pandemic on their families and their school. That has led to a lot of insomnia ― both problems falling asleep and also waking up during the night and worrying.
Are there management tips for this unsettling time beyond the tried and true suggestions ― good sleep hygiene, age-appropriate reassurance, comfort objects, and routine ― that PCPs typically recommend to parents?
The right amount of reassurance is key for kids who are worried. You don’t want to give too much reassurance because, paradoxically, that gives kids the message that there really is something wrong. The message that parents should offer is that most of the time, bad things don’t happen. But even the youngest kids will recognize that a promise that all will be well — without any caveats — is not a promise that can be made.
There’s been a lot written for kids and on TV for kids that addresses COVID in a way that toddlers and preschoolers can understand. For infants and toddlers, the Pediatric Sleep Council is a not-for-profit organization with sleep experts from all over the world, and their advice is based on research. The Sesame Street website also has great resources for sleep as well as COVID resources.
Older kids need messages that are age-appropriate ― including information about how to keep themselves safe as well as what parents are doing to keep the whole family safe. The CHOP Sleep Center and the National Sleep Foundation are great for all ages.
The other mainstay of management, as pediatric clinicians well know, is consistency. Early on, when so much was turned upside down, many parents relaxed schedules. Understandable ― but kids need consistency in bedtime schedules and daytime routine. It’s fine to let teens awaken a bit later — but they still need to awaken. And at the same time, more or less, every day.
Is there any role for antihistamines, nonbenzodiazepine sedative hypnotics, or melatonin in children? Teens?
I’m not a physician, but I can tell you what the research says. Most research on melatonin has been conducted in kids with developmental conditions. There haven’t been as many studies in typically developing kids and teenagers.
But what those studies have told us is that melatonin is safe and effective if you are trying to pull a child’s circadian rhythm earlier. In that case, you’re not using it as a sedative, hoping that a child or teenager is going to fall asleep in 10 minutes. You’re really using it to help the overall process of moving the schedule earlier. And remember that circadian disorders can have very serious ramifications, ranging from car accidents in teen drivers who are too sleepy to drive to parents being late for work because they can’t get their child up and moving in the morning.
When does a child’s sleep disturbance warrant a referral to a sleep medicine specialist?
That’s a good question. Any child who exhibits snoring, gasping, pauses in breathing that suggest obstructive sleep apnea, those who complain of weird feelings in their legs, and children with daytime sleepiness ― all should be referred to a sleep center quickly. That hasn’t changed.
We’re seeing kids now who, before COVID, might have exhibited less than ideal sleep habits but now have progressed to a circadian disorder. If your patient is a child with significant anxiety who can’t fall asleep until 2:00 AM, then that is more serious. And I would say in general if sleep habits aren’t improved at the 2-week mark, then I would refer to a sleep center or, in the case of anxiety, a cognitive-behavioral therapist.
Should PCPs proceed with ordering sleep studies prior to referring a child to a sleep clinic?
Yes, if there are straightforward symptoms — snoring, gasping, pauses in breathing — I’d suggest going ahead and ordering the sleep study. Daytime sleepiness is a symptom of obstructive sleep apnea, but it is also a symptom of a lot of other things, like restless legs, insomnia, or a circadian problem.
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