October 14, 2022
We learn more and more every day about the impact that sleep has on both our physical and mental health. Despite this, many adults are chronically sleep deprived and many kids and teenagers also don’t get enough sleep. On today’s Talking Pediatrics, our Kid Expert from the Sleep Clinic, Dr. Ben Ryba-White, joins us to talk about the importance of sleep, the mysteries of melatonin and what we can be doing in the primary care office to help improve the sleep habits of our young patients.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. If there is one thing that we could all do to improve our lives and our health for the better, it’s probably to get more sleep. We are a country of chronically sleep deprived adults, and likely sleep deprived children. Sleep disorders and lack of sleep in kids can influence everything from their physical health to their mental health and has been linked to behavioral problems and attention issues in children. Here to talk to us today about how we can help kids get more sleep is one of our own kid experts from our sleep clinic, Dr. Ben Ryba-White, who is board certified in both pediatrics and sleep medicine. Welcome, Ben. Thanks for joining us today.
Dr. Ben Ryba-White: Thanks for having me.
Dr. Angela Kade Goepferd: I should preface this conversation by saying that Ben was one of my residents in pediatric continuity clinic. So I’m going to just go ahead and upfront take credit for all of your expertise that you’re going to share with us today. Are you comfortable with that, Ben?
Dr. Ben Ryba-White: Yep. You taught me everything I know.
Dr. Angela Kade Goepferd: All right, great. So let’s start with the basics. I think there’s a lot of misperceptions out there about how much sleep kids need. So can you walk us through, based on general age categories, how much sleep should kids be getting?
Dr. Ben Ryba-White: There are some guidelines from the National Sleep Foundation that were published for age groups. So starting in the newborn period, we expect 14 to 17 hours and then from there it just starts to kind of shrink down, infants somewhere between 12 and 15 hours, though there’s going to be a huge range, a lot of variation, toddlers between 11 and 14 hours, preschoolers 10 to 13, and then school age children nine to 11. Once you get into the adolescents, eight to 10 is the range.
Dr. Angela Kade Goepferd: And I think what I have found anyway is that in my primary care clinic, most kids are usually getting around eight to nine hours of sleep. However, like you mentioned, elementary school kids need more like nine to 11 hours of sleep. So I think there’s a lot of kids who are maybe missing out on an hour or two of sleep.
Dr. Ben Ryba-White: I think that’s right. I think it’s pretty common and especially in those school age range, it’s a wide age range and so there is going to be a lot of variation and it’s not a clear cut thing of like oh, at eight years old all of a sudden you need only nine hours or you need 11 the year before. So it’s tricky in that way and it really is important to know that it’s a range and everyone is going to have their own individual sleep need. And so that’s where it’s really incumbent upon us and parents to just really be thinking about that and seeing how are they doing during the day. And that can help inform us of how their nights are going.
Dr. Angela Kade Goepferd: And relative to individual needs and maybe individual families’ culture and kind of work life and things like that, what I often see is a range of when kids are getting that sleep and parents will often ask me, “When is a reasonable bedtime for my child?” And I have three kids and we’re kind of an early to bed, early to rise family, so they go down between 7:00 and 8:00 and they get up between 6:00 and 7:00 in the morning. Other families, because of the parents’ work schedule, kids don’t go to bed until 9:00 or 10:00 at night and maybe get up between seven and eight in the morning, and some kids even later than that. So does it matter what time kids are getting that sleep or is it more important that they’re actually getting the sleep?
Dr. Ben Ryba-White: I really think that both the duration and the timing do matter. It’s important that we are getting it, not only to be consistent night to night, that we’re getting it at the same times every day. There is some evidence that for young children, for example, a bedtime should be somewhere between 7:00 and 8:30, before 9:00 basically. There was a large survey done in the early 2000s which kind of looked over all the different factors that could be involved in sleep disruption and problems and so having a bedtime later than 9:00 p.m. was one of the big ones. We also have to understand that some cultures and some families are going to have their own way of doing things and so also, as long as things are going well in their setup, it doesn’t mean we have to change everything.
Dr. Angela Kade Goepferd: What are some of the more common sleep problems or sleep disorders you see in kids? And maybe we can break that up by age group, younger kids, kind of school age kids and then teenagers.
Dr. Ben Ryba-White: So if we were to start with toddlers or age one to five, let’s say toddlers and preschoolers, it’s going to be a lot of behavioral challenges, a lot of things that are developmentally appropriate. So pushing back on maybe bedtime routine, limit setting, things like that, how we are learning to fall asleep as small kids, so that’s really important, how are we going to sleep at bedtime? And just the problems that come with some of those challenges and maybe the ways that we as parents who are trying to do our best maybe are reinforcing behaviors we actually don’t want to be happening inadvertently. So that’s a really common one in toddlers and kind of preschoolers. Into elementary school, insufficient sleep is a big one and there’s a lot of factors there. As they’re aging, they’re getting more independent. We may have less parental awareness on what’s actually going on at bedtime and how is falling asleep going.
For example, electronic use is becoming more and more of a factor and it’s creeping into the bedrooms perhaps. And then throughout both of those age ranges, certainly we should be screening for sleep apnea, so snoring, obstructive sleep apnea or sleep disordered breathing are things we should be thinking about, parasomnia, so behaviors coming out of sleep, confusional arousals, sleep walking in the older kids and night terrors, things like that we see more often. And even things like restless sleep, so like motor restlessness during sleep that may be impacting the quality. So then moving into teenagers, you still might see some of those things, but insufficient sleep is by far the number one problem. It’s estimated that 72% of high school students are not getting the recommended amount of sleep that they need.
It’s similar issues, increased need for autonomy and independence, and between your school and extracurricular activities and sports and family things, that tends to come around bedtime. And a lot of their social life more and more is occurring over screens and social media and things like that, so there’s that pressure to stay up later too. And I’ll just say that also for teenagers, just the additional factor is that they do have a physiological delay, or shift, in their bedtime through puberty and so their natural bedtime shifts one to two hours later though our school star types may not reflect that, and so their sleep is getting squeezed for a number of reasons. And then in teenagers you’re going to see that kind of circadian problems that come in more commonly, so like delayed sleep phase as well as kind of classic chronic insomnia. And you may even see more rare things like hypersomnia, like narcolepsy and things like that in that age range.
Dr. Angela Kade Goepferd: As a parent, I run into it frequently with my kids even who are elementary school age, that they’ll have activities that they’ll be playing soccer or something until 7:30 or 8:00 at night, which is usually when we’re tucking into bed. So that gets in the way and definitely have experienced my elementary school kids start school at 9:00, but their high school that they would track to start school at 7:30, which seems a little bit backwards to me in terms of sleep schedule.
Dr. Ben Ryba-White: Yeah. And that’s something that both the American Academy of Pediatrics and the American Academy of Sleep Medicine are really encouraging school districts to think about moving that start time back for teenagers. And there is some data that’s showing that when we do that, it does help and they do actually sleep more.
Dr. Angela Kade Goepferd: Well, you mentioned a bit earlier about circadian rhythms and how that changes for adolescents as they get older. One commonly used substance to keep us or impact our circadian rhythms as melatonin. Melatonin can sometimes be prescribed by a sleep specialist or in the primary care office, but often is purchased over the counter. Target’s full of melatonin gummies and other products. Can you talk to us a little bit more about melatonin and maybe let’s talk with how melatonin works to impact our sleep?
Dr. Ben Ryba-White: So melatonin is a hormone that is secreted by the pineal gland in our brain in response to when the light gets dim or darkness. And so I think it’s important to start there that really this is a hormone, this is a medication, even though it has that designation as a supplement and is not regulated by the FDA and therefore can be purchased over the counter. The way that melatonin works primarily is when the light gets dim, it starts to be released and it kind of creates that sleepiness sensation and then a couple hours later usually we’re ready for bed. And it’s also one of the primary ways that our circadian rhythm is entrained and that’s kind of that light dark cycle and melatonin’s a part of that.
Dr. Angela Kade Goepferd: One of the things I was surprised to learn at our recent children’s mental health for primary care clinic is that the way that most people use melatonin, and I think often the way that pediatricians prescribe it, is actually not the way that we should be using melatonin. So can you talk a little bit about both the timing and the dose of melatonin and how it can effectively improve sleep versus how most people are using it?
Dr. Ben Ryba-White: There’s kind of two ways that we think about melatonin. One is just being a simple hypnotic and that’s how it’s being used largely in the country. People are taking it often I think 30 minutes before bed and so that’s just working as a hypnotic to make you feel sleepy and go to sleep. But there is also some evidence that giving it in small doses earlier on can actually help to move our natural sleep window, so move our bedtime earlier and our wake time earlier. And that’s one of the ways that we’re using it mainly in our practice for teenagers who we suspect have more of a delayed sleep phase. So their natural sleep clock is later in the middle of the night is when their bedtime is, thus they’re having trouble getting up for school, for example. If we are using melatonin more just to help with sleep onset, there’s some suggestion that it probably helps to give it maybe even an hour or two hours before bedtime as opposed to right before bed is that’s when our natural melatonin is being released. So we’re just kind of providing an extra boost.
And as far as dosing goes, I mean I’m of the opinion that less is more, and so that’s what I’m often telling my families who are deciding to use it or who we’re deciding together to use it. So in small children, one to three milligrams and then honestly for older kids and teenagers, I’m usually not going above five milligrams personally, I just don’t think there’s much benefit. In addition to that, I think it’s just important to be honest with families about it and what we know about it and for one thing, there’s more studies in adults, but there are some studies for kind of short term and medium term use and they have been pretty favorable as far as adverse outcomes, serious side effects, things like that. There’s pretty limited long-term data on the use of melatonin and so we just want to be clear about that. And then I think it’s just worth noting that this isn’t the case everywhere, it’s not considered a supplement everywhere and there are many developed nations that do not consider it to be a supplement. It is able to be prescribed, but it’s not available over the counter.
Dr. Angela Kade Goepferd: When you kind of define short, medium and long-term, what would long-term therapy look like and what would sort a shorter term therapy look like?
Dr. Ben Ryba-White: Well, I just think for long-term what we’re thinking about with safety data is like what does it do if you’re on melatonin nightly for 10 years, for 15 years? Those are the kind of questions we don’t have that much information about. Whereas for short term a couple years, we haven’t seen that there’s significant adverse effects with that, not to say that there’s tons of data out there. In my sleep practice, I’m not using medications super commonly. It’s not one of the first things I’m turning to, and I do consider melatonin a medication, so kind of putting that in the same basket with the other medications I might use, we’re really using those as a last line when either behavioral interventions or these other things haven’t worked or maybe are not appropriate to do or as an adjuvant to those things, that’s typically where we’re using it. And most commonly that’s going to be in our patients that have other neurodevelopmental disorders or challenges, so most commonly like autism spectrum disorder or maybe ADHD, things like that.
Dr. Angela Kade Goepferd: So the message I’m hearing from you is that we should be able to do behavioral modifications and kind of lifestyle modifications and interventions to address the vast majority of sleep problems and we may consider something like melatonin as an additional tool to use, but not our primary go-to when it comes to sleep disorders.
Dr. Ben Ryba-White: I think that’s right. I mean, there is lots of good data to suggest that behavioral intervention sort of shows that behavioral interventions are very effective, especially for young children. So I really think that’s where we want to start, we really want to maximize those things before we start using these other kind of additional elements. And even if we’re not worried necessarily about the safety of something, there’s also just that idea that when we’re giving something for sleep, we are potentially creating a habit there. We are sending the message that potentially to that child, “I need this to go to sleep. I need to take this to go to sleep.” And that may not be true. So I think the best thing we can do in busy primary care practices is if they are using melatonin, that can be a good opportunity to just ask some more questions about what’s going on or why are we using it and those kind of things.
Dr. Angela Kade Goepferd: You mentioned most kids should not need medication unless they have some other maybe behavioral or neuro atypical sort of profile. Are there other things that you see often prescribed for sleep or that you are prescribing for sleep or that people are picking up over the counter for sleep that we should be aware of?
Dr. Ben Ryba-White: It’s important to note that, just like melatonin included, there is no FDA approved medication for sleep in children, but that doesn’t mean we’re not using them and that we don’t turn to them at times. The most common things that I will use in my practice beyond melatonin are things like clonidine, Trazodone, and Doxepin, and none of those medications were meant for sleep, but they’ve all been used enough in kids and they have a good safety profile that I feel comfortable using them. I don’t encourage or endorse anyone using them that doesn’t feel comfortable with it. But those are the typical go-tos.
So they’re really not the same medications that you might see in adults. I’m not using the like Z drugs or ambien or things like that. And as far as over the counter things go beyond melatonin, there are some different calm gummies, maybe magnesium included in them or a lavender supplement, I’m not too concerned about people taking, I don’t think there’s good evidence that they’re going to help per se. I think in older teenagers and things, we should be screening for things like CBD and even THC gummies now with the new law.
Dr. Angela Kade Goepferd: Do you have thoughts on the use of things like CBD gummies and things like that for children for sleep?
Dr. Ben Ryba-White: I’m pretty skeptical of their use for sleep in general in adults as well. I do think CBD has the potential to create some improvement in maybe our stress or anxiety and that in turn may help with our sleep. So, that certainly could be possible. But I think in terms of it as specifically for sleep, there’s not good evidence for that. And I’m skeptical that there will be.
Dr. Angela Kade Goepferd: I think we all would love, for many problems including sleep disorders, that one thing that’s going to make it better and I think what the evidence tends to show us over and over again is that it’s really about habits and kind of good behavioral practices.
Dr. Ben Ryba-White: Absolutely, totally agree. And I also fully understand the challenges that come with this, that it’s a time consuming thing to work on in a busy primary care practice. Asking one question about sleep may lead to 15 other questions or problems with it. So I totally get it. It still just shows that even simple interventions like working on bedtime routines and just the foundations of sleep can really make a big difference.
Dr. Angela Kade Goepferd: Before we close up, I want to talk about a couple of key things. So the first thing I want to talk about is medical symptoms or signs that a child is not getting enough sleep. So what might we look for in a kid who is not getting enough sleep to lead us to ask some questions about sleep?
Dr. Ben Ryba-White: In kids, it’s not necessarily going to be the same as an adult where you’re going to see sort of sleepy adults who can’t make it through their work meetings. In kids, it tends to be sort the opposite, hyperactivity, kind of signs like ADHD, so focus, concentration problems, maybe having trouble at school, you just seeming driven by a motor and maybe even irritability, moodiness, acting out, more tantrums, things like that too.
Dr. Angela Kade Goepferd: One common presentation that happens in the primary care office would be a parent who’s bringing a child in because the school has asked that they be brought to their pediatrician because of some of the concerns that you mentioned. Where should we start in terms of some good kind of basic questions about sleep or screening questions about sleep to find out if that might be the cause of the problem?
Dr. Ben Ryba-White: I think some great starter questions are just asking not only what time is bedtime, but how often is bedtime at that time. What is it usually? What is the difference between how much sleep they get during the week and on the weekends? How long does it take to fall asleep? Do you have to wake them up every day for school? Those are all great signs that there may be something wrong and just a great place to start, I guess, when we’re thinking about sleep. And easy screening question for things like sleep apnea is are they snoring and are you hearing snoring? So that can also be quickly implemented in a busy practice.
Dr. Angela Kade Goepferd: Often there tends to be a lot of conflict in families around sleep, so when I start talking about sleep hygiene in the room, I’ll hear parents chiming in with, “The doctor says no screens before bed,” or, “The doctor says you have to go to bed at this time.” And I appreciate that and I also appreciate the challenge that the adolescent might be having in that case of not feeling tired at 10:00, 10:30 at night. Any tips for how we might mitigate that parental child conflict around sleep or help them find some middle ground?
Dr. Ben Ryba-White: The most important thing is just providing that education, trying to give them the why of you know what we’re saying, not just telling them, “Don’t use your screens at night because I’m the doctor and I say.” Or parents telling you not to, but explaining to them that the lights from these screens are potentially suppressing your own melatonin release and making it even harder for you to fall asleep, and that’s our concern with using them at night. It’s not that we don’t want you to talk to your friends or do the things you like to do, it’s just that we want to find a way for you to do those things perhaps at another time or earlier on and that isn’t going to affect you getting to sleep. And then even talking to them about the sort of natural rhythm of their body, that it is normal for them to be going to bed a little bit later, but it’s very easy to have that end up being even later as we’re doing all of these things that may get in the way of our sleep.
Dr. Angela Kade Goepferd: One of the sort of mantras that I’ve held with me, whether I’m teaching resident physicians or leading a team here at the hospital is that I would never ask someone to do something that I’m not willing to do myself, and I sometimes pass that along to parents. Many of us, myself included, struggle with not looking at our screens before a bedtime and I think it’s a little unreasonable for a parent to ask their teenager not to look at their screen before bedtime when they themselves are spending an hour, 30 minutes or more on their phones right before bed and often recommend that the parents do the same thing that the child is doing. One, just to feel how hard that is and then two, maybe they can problem solve together ways to get rid of those screens at night because it’s not just the kids who on their screens before bed.
Dr. Ben Ryba-White: Yeah, absolutely. Yeah, having like a family bedtime or at least a family time for the electronics to be off is something we sometimes talk about. For kids where we recognize it’s going to be tough for you to fully be off, we might compromise with blue blocking sunglasses that they wear at night, just making sure they’re aware of the blue light filter on their phone or turning down the brightness and all of those things, doing everything we can, even if we don’t necessarily have great data that those things are super successful.
Dr. Angela Kade Goepferd: Before we close, I wonder if you might share with us some resources for sleep, things that as folks taking care of kids, places we can go to learn more, and or if we have families that have chronic sleep problems that we’re not able to address, how we can get them in touch with you and your team?
Dr. Ben Ryba-White: Absolutely. So in terms of things that are available online, the National Sleep Foundation is really great and has a ton of good resources and it’s all explained without the medical jargon and things like that. So those can be really good resource. So babysleep.com can be good for those kind of new parents that are wanting to learn about the different things they should be thinking about.
In terms of getting in touch with us at the sleep clinic, like we are here at Children’s, we want you to send your children to us if you’re having trouble or you’re not sure, we want to be a resource to you. So we are there if you just call, we will get back to you. You’ll get in touch with a doctor generally the same day, maybe the next day. So we want to be there to help and to have our advice and be a resource to you. And our clinic also, we do a lot of telehealth so we can see those kids that are out or kind of further away from town and it’s harder to get in in-person, we can absolutely see them and kind of get the ball rolling. So I feel like with sleep there’s no better time to start working on it than that day.
Dr. Angela Kade Goepferd: Well thanks, Ben, for joining us today. I’m feeling tired just talking about sleep.
Dr. Ben Ryba-White: I have that effect on people.
Dr. Angela Kade Goepferd: Yes. So thanks for joining us with those helpful tips. We really appreciate it.
Dr. Ben Ryba-White: No problem at all. It was a pleasure to be here.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.