"Sleep Concerns in Pediatric Populations with Special Needs" Caroline Okorie(9.30.2020)

October 02, 2020

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00:00Medicine family medical education
00:02faculty fellowship in patient centered
00:04care and fellowship in Sleep Medicine.
00:07She's currently a clinical
00:09assistant professor in the division
00:11of pediatric pulmonologist,
00:12asthma and Sleep Medicine at Stanford,
00:15an associate program director for
00:17the Stanford pediatric residency
00:19program in member of the Stanford
00:22teaching and mentoring Academy,
00:24she's received numerous awards for her
00:26clinical teaching and work in medical
00:29education and patient centered care.
00:32In her research concludes a project
00:34related to burnout among physicians.
00:36I personally have had the privilege
00:39of working alongside Doctorow Cory
00:40on the American College of chest
00:43position sleep Network Committee an.
00:45I was delighted when she accepted my
00:47invitation to share her expertise in
00:49pediatric Sleep Medicine with us today,
00:52so please join me in welcoming
00:54her and thanks for your patience
00:56with the technological challenges
00:58this morning or this afternoon.
01:03Thank you so much.
01:05Is very kind of you to say Lauren
01:08are doctor Tobias. It's been.
01:10Thank you so much for having me everybody.
01:12So I I this is not obviously exhausted.
01:15Talk about sleep in autism spectrum disorder,
01:17but I thought they might be helpful to
01:19get little perspective about what's out.
01:22There was kind of recent and
01:24leisure regarding this this issue.
01:25I even though what time for questions at
01:28the end if there's anything I say that's
01:30kind of out of Turner really spark some
01:33interesting debate you want to talk about?
01:36Please by all means just.
01:38I don't know.
01:39I think this way like raise your hand
01:41or put in the chat and we can try
01:43to have some lively discussion too.
01:44So I have no commercial support for this
01:47presentation or conflicts of interest report,
01:50so the my objectives include
01:52I'm helping us to understand.
01:54Sleep disturbance is very common
01:55among children and adults
01:57with autism spectrum disorder.
01:59Recall the common sleep disruption
02:00complaints in children and adults
02:02with autism recognize the role
02:04the comorbid medical and mental
02:06health conditions can play in the
02:08exacerbations of sleep complaints.
02:10Understand the consequences is specific to.
02:13Spectrum disorder and
02:15explore recommendations.
02:15How to develop a plan to evaluate and
02:17treats some concerns in these patients
02:20and even review some frequently
02:22considered pharmacologic therapies.
02:24So just very briefly,
02:25autism spectrum disorder is an early
02:27onset neurodevelopmental disorder with
02:29core features defined by the DSM 5,
02:32so effects point 61.7% of people worldwide.
02:35It's obviously a spectrum of symptoms
02:38with characterized by persistent
02:39difficulties in social interaction,
02:41communication, stereotypic behaviors,
02:42restricted interests,
02:43and atypical sensory activity.
02:45So an intellectual disability is
02:47observed in at least 50% of cases.
02:50And no,
02:50I mean the most of this data
02:53is from Children's.
02:55That's where most of the studies.
02:57The city's life.
02:59Most common sleep complaints
03:00are the most common.
03:02Complaints are sleep 50 to 80%.
03:04Children with ASD do have
03:06some sort of sleep complaints.
03:08The most common is delayed sleep onset and
03:11frequent nighttime awakenings were kind
03:13of right at the top short sleep duration.
03:16Early morning awakening,
03:17delayed sleep phase,
03:18erratic sleep patterns and daytime
03:21sleepiness are also very common.
03:23And when we look at objective measures
03:25of sleep during polysomnography,
03:27actigraphy,
03:28the studies at present have shown that
03:30we have decreased sleep efficiency,
03:33decreased REM sleep,
03:34decreased total sleep time,
03:36sleep onset latency,
03:37wake after sleep increased.
03:38Sorry, increased sleep onset,
03:40latency increase, wake after sleep onset,
03:42increased daytime naps.
03:44These, of course, are some SMS heterogeneity.
03:46Genetic studies.
03:47They are mostly pediatric.
03:49There's limited data.
03:50An adult with autism spectrum disorder,
03:52an intellectual disability due
03:54to the past having trouble.
03:56Then tolerating the sleep study actigraphy,
03:58and many of these patients
04:00have comorbid conditions,
04:01but at least it gives us some idea
04:03of how their sleep architecture
04:06can be can be perturbed by autism.
04:09And when we look at insomnia severity
04:11in adults with ASD sleep difficulties
04:13as we know tent from childhood to
04:15persist into adulthood and so in
04:17some nice trading adults with ASD
04:19is associated with hyper reactivity
04:21and social skills in Pyramid.
04:22So the hypothesis is that you have
04:25hyper reactivity to sounds light.
04:26Make sleep more difficult.
04:28Social skills impairments have
04:29lack of social skills are unable
04:31to organ impairment in the social
04:33skills so unable to go to school
04:35work unable to have a daily routine
04:37which we also know affect sleep.
04:39So it's a little bit of.
04:42Feeding into this issue.
04:45And then we look at consequences of
04:47poor sleep in patients with autism.
04:50We had increased sleep disruption,
04:51just positive, correlated with ASD symptoms.
04:53So it's almost like you have
04:55this self reinforcing loop where
04:57you have more autism symptoms,
04:59which leads to more sleep disruption which
05:01lead to more autism disruption, etc.
05:03Out some symptoms.
05:04You kind of keep getting into this
05:06unfortunate loop and that's associated
05:08with increased frequency of self
05:10harm or other challenging behaviors.
05:12Increased difficulty attending
05:13school or securing employment.
05:15And just increased stress on the family.
05:16For those of you,
05:17take care of patients with with
05:18autism or offices in the family,
05:20you know it can really affect the
05:21whole family in the quality of life.
05:25So a lot of questions that
05:27people are wondering. So wait.
05:29So does autism cause sleep disruption
05:30or do sleep problems cause autism.
05:33And so I think this question.
05:35These are just some of the more recent
05:37explorations into this question.
05:39There's of course several others,
05:40but studying 2017 found that maybe
05:42they saw a few patients asleep.
05:44Problems may have a pathogenic
05:46role leading to autism.
05:47Another study showed that.
05:49Well, maybe there was a perspective
05:51Association between having infant
05:52sleep problems at 12 months of age.
05:54And ASD symptoms later on 24 months of age,
05:58and it gives more predict if
06:00another study was prospective cohort
06:02study did not find sleep issues,
06:04were antecedent ASD necessarily,
06:05but kind of Co curd?
06:07So really,
06:08essentially the question remains more,
06:10studies are needed.
06:13So when thinking of contributing factors,
06:15so we'll just highlight a few,
06:17but learned behaviors that can delay sleep.
06:19Delayed melatonin peak will
06:20talk about that a little bit on
06:23circadian rhythm dysfunctions,
06:24regularity related to that, melatonin.
06:27Normality.
06:28You can also have restless leg symptoms
06:30and patients who are nonverbal,
06:32specially pediatric patients.
06:33They just have a hard time
06:35describing what they're experiencing.
06:37Mental health, comorbidities,
06:38GI complaints,
06:38neurologic conditions such as you
06:40and epilepsy, and, of course,
06:43medication side side effects.
06:45So learn behaviors just to highlight
06:48could be for separations, compulsions,
06:50ritualistic behaviors that really
06:51prevent this easy transition into arrested,
06:54relaxed state.
06:54Then when checked melatonin in
06:56these patients.
06:57So I think as we all know,
07:00melatonin naturally synthesized hormones
07:02are created mainly from the pineal gland.
07:04It helps regulate regularly
07:06participates in the regulation of our
07:08behavioral and physiologic processes,
07:10including our sleeping wakefulness cycle.
07:14You know an adaption adaptation to
07:16seasonal changes are daylight savings, etc.
07:18As we we know,
07:20light sensor inhibits melatonin
07:21production secretion,
07:22darkness, pensis stimulated,
07:23and so the thought is that in
07:26patients with a C or the findings
07:29I should say is that there are low
07:32melatonin levels that were noted.
07:34Melatonin level was inversely associated
07:36with severity of ASD symptoms,
07:37so there's growing evidence that
07:39low melatonin may be due to outer
07:42mountains and melatonin synthesis pathway.
07:44An abnormal melatonin metabolism.
07:45I started to really read a lot
07:48about this and I found I felt
07:49that was talking of itself.
07:51Really interesting stuff,
07:51but I don't go into too much detail here,
07:54but if anyone happens to be
07:55doing research and so loved here,
07:57you know if you found anything new.
07:59But that's kind of at least where
08:01the literature is pointing to,
08:02and low melatonin may be associated
08:04actually with anxiety, pain,
08:05sensory processing issues,
08:06even,
08:06maybe even relate to the GI dysfunction.
08:08Allow these patients have in addition
08:10to insomnia,
08:10so it's not to actually have a more
08:14global effect.
08:14And talking about these ungi factors
08:16so children with autism have
08:18higher instance of Asafa Gitis,
08:20inflammatory bowel disease related
08:21to inflate inflammation.
08:22Dysregulating dysregulated gut
08:23motility and Constipation.
08:24And then we just know that also,
08:27patients who are nonverbal have a
08:29higher rate of GI symptoms as well,
08:31and then GI symptoms relieved to more
08:34compulsive and repetitive behaviors,
08:35which, as we talked about can affect sleep.
08:38So all of these things are really related,
08:41and kids and adults with autism.
08:45And then talking a bit more about
08:48comorbid psychiatric conditions.
08:49So I found this is staggering
08:52statistics at 6979% of individuals
08:54are estimated to have a comorbid
08:56psychiatric condition in addition
08:58to their autism spectrum disorder.
09:00So, anxiety, depression, ADHD,
09:02all associated with increased arousals,
09:04delayed sleep onset latency.
09:05Zan general insomnia.
09:09There aren't a lot of studies in adults,
09:12but there's one that was just
09:13published September this year.
09:14This month I should say about
09:16looking at the relationship
09:18in adults with ASD and ADHD,
09:19so there's a lot in children,
09:21but I just wanted to highlight this
09:23one that was not noting adults,
09:25and I found what we are,
09:27not what we all kind of know,
09:29which is that we have increased sleep onset,
09:31latency, decreased sleep efficiency,
09:32increase weight after sleep onset,
09:34and there's a lower perceived sleep quality.
09:36So this finds that we see in
09:38childhood persistent to adulthood.
09:40You have the comorbid ADHD.
09:43AC and intellectual disability.
09:45Like I said, we estimate the 50%
09:47of from the studies children have
09:49intellectual significant intellectual
09:50disability with autism adults.
09:52I think that's a less studied and
09:55especially in terms of their sleep issues.
09:57That's also an area that we really need.
10:00Have to look into.
10:03I just want to highlight that a lot of
10:05patients with these comorbid conditions
10:06are often prescribed an antidepressant
10:08medication or something to help
10:10manage their behaviors and their mood,
10:11and so it's just, you know,
10:13one of the things I actually just saw,
10:16I mean, clinic this morning,
10:17this afternoon,
10:18and I actually just had a patient
10:20who has a 6 year old with autism,
10:22and I always just look at the medication
10:24just to get a sense of you know
10:27what could be affecting her sleep,
10:29what could be contributing to it.
10:30So looking at things that affect.
10:33Quantity, quality and sleep architecture.
10:34So this is a I just love this really
10:37neat review paper that kind of goes over.
10:40We all love tables right?
10:41It just gives you kind of an idea
10:43of which sedative Tri cyclics what
10:46they do for sleep architecture.
10:48Sri's you know a lot of us are
10:50familiar with and use frequently
10:52and how that affects sleep,
10:53namely suppressing REM sleep etc.
10:55So I just always like to be aware
10:57of which antidepressants might
10:59be affecting sleep as well.
11:01So where do you start?
11:03You have patient come in like I had
11:05this morning and really just obviously
11:08getting a really good sleep history,
11:10which I know many of us already do.
11:12And then considering common
11:14diagnosis such as still sleep
11:16disordered breathing are less PMD.
11:19And you know, just to make sure that
11:21I'm also just doing the standard
11:23sleep evaluations, a sleep diary
11:24or sleep Journal is really helpful.
11:26I find a lot of parents really
11:28just struggle to be able to fully
11:30say what their kids are doing.
11:31I think they have an idea,
11:33but I you know, I just say, hey,
11:35just take a piece of paper and start to
11:37write down what time your child is dead,
11:39what time they woke up,
11:41and you know how the day went.
11:43Afterwards, consider actigraphy.
11:43There's a lot of studies now
11:45bout looking at Actigraphy,
11:46and children without similar really great
11:48papers talking about different ways to.
11:50So in pockets into pajamas to actually
11:52help them if they don't tolerate
11:54having that activity on their wrists
11:56and just to get a sense of what
11:58their sleep wake cycles really are.
11:59And consider Poly sonography,
12:00I think as a pediatrician is
12:02a PS person you know,
12:04I think it's really important.
12:05Acclamation will be really important.
12:07Set your families up well.
12:08So what we have a little video that we
12:10show parents so they can know what to expect.
12:13Also,
12:13pulmonologist so you know sometimes will
12:15have like a little nasal cannulas that
12:17the kids can just put in their nose,
12:19then get used to that sensory issue.
12:21So I think you're going to sleep.
12:24In a child with autism,
12:25I think just being my Angel,
12:27they likely probably need acclimate to it.
12:28You have to simply sensitisation before,
12:30but it's possible.
12:33There's also questionnaires and then sure,
12:35many of you are aware of.
12:37There's the children sleep
12:39habits questionnaire developed in
12:402000 by judo wins in a group.
12:42This is a parent reported screening
12:44designed for ages 4 to 10.
12:46There's 35 questions.
12:478 domains looking at bedtime resistance,
12:50sleep onset, delay, sleep duration,
12:51anxiety night awakenings,
12:52daytime sleepiness, parasomnias,
12:53and sleep disordered breathing.
12:55It's a nice,
12:56comprehensive screening that you can help
12:58get out what parents really worried about.
13:00There's a modified version looking
13:02specifically at behavioral problems,
13:03and it just really.
13:05Takes out the questions about Parasomnias
13:06and sleep disordered breathing,
13:07so it shortens it a little bit.
13:09I think down about 20 three questions again,
13:11if it just kind of helps parents,
13:13I think know where to start when they're
13:16thinking about what their concerns are.
13:18There's also a sleep habits questionnaire
13:19for children with autism spectrum disorder
13:21developed by Doctor Mallo in her group.
13:23So just kind of going through
13:25what's the families sleep habits,
13:26'cause I mean,
13:27as we know what happens during the day
13:30often affects how the child sleeps at night,
13:32so really kind of getting a sense of
13:34you know are the active during the day.
13:37Do they have a routine?
13:38Those kinds of things I think
13:40are really important.
13:41I don't necessarily always use
13:42these questionnaires very family,
13:43but I think the questions that within
13:46these or Wednesday I generally often ask.
13:48And so I think it's just a helpful way to
13:51start.
13:54In terms of guidelines,
13:55there actually is really nice.
13:57American Academy of neurology recently
13:58released practice guidelines for treatment
14:00for insomnia and disrupted sleep
14:02behavior in children and adolescents,
14:03specifically with autism.
14:04So I thought this was.
14:06This was great that something just came out.
14:09In summary, we're first recommendation
14:10is screened for an address comorbid
14:12conditions in any contribute medications.
14:14So, just like we've already talked about
14:16looking for comorbid anxiety depression,
14:18are they taking medications
14:20that are contributing,
14:21making them drowsy during the day, etc.
14:23Anything that full assessment
14:25is step one and then two.
14:27It's behavioral strategies are first line,
14:29so this is things like family,
14:32cognitive, behavioral therapy,
14:33unmodified extinction,
14:34or the colloquialism of cried out as
14:36some people say, graduated extinction,
14:38positive routines or bedtime fading.
14:40So just for those who maybe it's
14:43been awhile since you've done your
14:45Pediatrics rotations or it's been awhile,
14:48but I modified.
14:49Extinction is just the caregiver imposes,
14:51has a bedtime and awake time.
14:54And really ignores all protests.
14:56And you know,
14:57after bedtime and before the wait time,
14:59so it's kind of put the child in the
15:01room and you just kind of plug your
15:03ears and ignore cries afterwards.
15:04You know, within reason,
15:05keeping an eye out for things of pain,
15:07hunger,
15:08you know that you're really
15:09worried about your child,
15:10but you really just kind of ignore
15:12all protests and hope the child
15:13eventually will go to sleep.
15:14It's brutal for parents,
15:15but it's actually been shown to be effective,
15:18and it works for.
15:20Especially neurotypical kids.
15:23For graduated extinction,
15:24this is where the caregiver ignores
15:26bedtime resistance for specified period.
15:28So if you could be fixed or
15:31progressively longer so they say.
15:33McElwain,
15:33until he cries for 10 minutes
15:35or in the next time I go,
15:36it'll be another 15 minutes, etc.
15:38So when responding,
15:39the caregiver has very minimal interactions
15:40to avoid reinforcing behavior,
15:41so it doesn't pick the child up.
15:43Doesn't climb into bed with the child,
15:45but just kind of puts.
15:46Maybe a reassuring hand on the back, etc,
15:48and tries to help the child fall back asleep.
15:52Positive routines is just where the
15:54caregiver developed some strictly adheres
15:56to regular pre bed calming rituals.
15:58So to clarify,
15:59this is like this can help counter these
16:01learned behaviors of perseveration,
16:03compulsions and rituals,
16:04ritualistic behavior,
16:05so this can help.
16:06Basically trying to transition
16:08the child into arrested state,
16:10so this can I would consider for a couple
16:13autism some of visual night routine chart.
16:16So here's an example of just
16:18things where taking bath,
16:19wash hair brush teeth.
16:21You have these visual.
16:22Q Think Child can look too and say yes.
16:24This is what we're supposed
16:25to do now and then.
16:27You can actually have the
16:28child interact with the chart,
16:29so either they check it off themselves,
16:31they point to what the next step
16:32is there involved in it as well.
16:34So that's actually found defective,
16:35not just for nighttime routine,
16:36but in general for kids autism.
16:39And then another behavior strategy
16:41is called bedtime fading.
16:42So especially the 10th keeps Boston
16:44tend to have delayed sleep phase,
16:46so they tend to go to bed at 10:00 PM.
16:48So apparently, but I wanted to go to bed 7,
16:51you know or whatever time,
16:53so I always tell the caregiver 1st put
16:55the patient in bed close to whatever time
16:57that they currently are falling asleep,
16:59and then gradually adjust that bedtime.
17:01Little by little.
17:02I consider I recommend doing it almost so
17:04it's almost imperceivable to the child.
17:06So I say 15 to 30 minutes every
17:08two to three days.
17:10It's very slow,
17:10but I found in my experience at
17:12the slow adjustment is much more
17:14effective than trying to just
17:16shifting faster the younger the kid.
17:18I think the slower the adjustment typically,
17:20or the more neurologic compromise
17:22the kid that's lower the transition.
17:25Melatonin so recommended if behavioral
17:26strategies have not been helpful and
17:29comorbid conditions of the we talked
17:30about have already been addressed.
17:32So if possible prescribed melatonin,
17:34I think many of us are probably
17:36familiar with the study.
17:37Try to talk about few years ago where
17:40they actually were looking at the
17:42different doses of melatonin with over
17:44the counter of Formulations and found
17:46that the doses were highly variable,
17:48so if possible they record
17:49the American Academy.
17:50Neurology recommends prescribing
17:51the melatonin get farm school
17:53grade and get reliable dosing.
17:55This isn't always possible with insurance,
17:57but it's something to consider.
18:00And they also talked briefly about
18:01complementary and alternative
18:02medicine approaches.
18:03Really,
18:03there's were lacking really great
18:05high quality studies right now,
18:07but that's not to say that
18:09these aren't worth trying.
18:10So a lot of them,
18:11such as a weighted blanket,
18:13there's something called Sound
18:14asleep mattress.
18:15There's white noise machines.
18:16All these different things that
18:18I'm sure a lot of your families
18:20may consider that have low or no
18:22adverse events associated with them,
18:24but really have failed to show
18:26a significant difference,
18:27statistically speaking.
18:27But I actually still recommend it.
18:29For a lot of patients and parents usually
18:33find him to be quite pleasing to try.
18:36Couple of the words melatonin.
18:37This is one of the most commonly
18:39used therapies for sleep concerns,
18:41as we know for the pediatric studies
18:43it's actually safe and effective.
18:44There are not the 10 or 20 year
18:46studies that we just don't have,
18:48but we have a few few studies
18:50that are coming out.
18:51There is immediate release for sleep onset
18:53versus extended release for melatonin.
18:55For sleep maintenance.
18:56Think it's important to know
18:57that the extended release tends
18:59to be a pill which is harder.
19:01In my population of Pediatrics 'cause
19:02not every child can take those,
19:04so that is.
19:05Site limitation and we look at long
19:08term use again on doctor mouse
19:10group had published study recently
19:12earlier this year that exam and
19:15long term effects of nightly along
19:17release melatonin at doses 25 and 10
19:21for up to two years in patients.
19:23I'm sorry for I didn't put the ages on here.
19:26I feel like they were relatively
19:28young up until teenage years.
19:29I'm sorry, I forgot to note the ages here,
19:31but they also work followed by two
19:33week withdrawal period, placebo period.
19:34Just to see if there was any
19:36concerns of withdrawal, etc.
19:39She know, observe detrimental
19:40effects on the patients growth,
19:42people development,
19:42and no withdrawal or safety issues
19:44related to discontinue the medication.
19:46The most common side effect that
19:48there were complications who did
19:50have some daytime drowsiness,
19:51especially those higher doses.
19:52And there were some reports of some
19:55potential nightmares and a few kids,
19:57but it seems like overall it was.
19:59It was reassuring.
20:00Oh, and Hi,
20:02said that these patients all
20:04had autism in this study.
20:06Ramelteon is another one that's
20:07being considered in these patients,
20:09and this is Milton Receptor agonist.
20:11It's FDA approved already for insomnia in
20:13adults are really limited studies for autism,
20:15and hopefully that's that's the
20:17next step we can see if it helps.
20:20So what about other medications?
20:21So at in Pediatrics,
20:23always like to remind patients
20:24in my colleagues at,
20:25there really are no FDA
20:27approved sleep drugs for kids,
20:28so a lot of them,
20:30a lot of it,
20:31is experience really kind of weighing risk,
20:33benefits and kind of having discussion
20:35with the families and other
20:37colleagues is the best way to go.
20:39But here is,
20:40I thought this was I looked at
20:42a lot of different reviews.
20:43I thought this was pretty good 'cause it
20:46actually also looked at Children and adults,
20:48so this was a research 1018 looking at
20:50sleep disturbance pharmacological approach.
20:52Sleep disturbances in autism
20:54with psychiatric comorbidities.
20:56So just to go through this table,
20:58we've already talked about melatonin here.
21:01In affected in children and we
21:03know effective in jet lag as well.
21:05The dose range they have one to three.
21:08Obviously we've seen in the litter that
21:10people have got higher with the dose,
21:12but I I tend not to go too high because
21:15I have that daytime drowsiness.
21:17So I try to avoid that.
21:19Some antipsychotics that were tested
21:21that have been tested in patients
21:22autism include olanzapine and risperidone.
21:24This is especially effective if
21:26there's comorbid maladaptive behavior,
21:27self injury,
21:28aggression and things like that.
21:30So potential side effects include
21:31daytime drowsiness.
21:32Weight gain type of cluster linea
21:34diabetes and prolactin elevation
21:35and then antidepressants.
21:37The one that they really kind of mentioned.
21:39I mean,
21:40there's a lot of antidepressants
21:42I've been considered,
21:43but the one that's been most tested
21:45with Trazodone in this population,
21:47and this is thought to be useful
21:50in comorbid depression.
21:51It is among one of the more sedating
21:54antidepressant medications.
21:54Which is why it's so commonly
21:57used for insomnia.
21:58But you do have side effects of dizziness,
22:01morning drowsiness,
22:01or possible prism, and hypotension.
22:03So that's something to be
22:04aware of and I gotta be honest,
22:06I just really haven't really
22:08used Trazodone and really young
22:09kids, but it's something to consider.
22:11Alpha adrenergic agonist and this is
22:13actually more commonly used in children,
22:15so things like Clonidine, guanfacine.
22:17This is typically uses recommended sleep
22:19initiation and maintenance. Insomnia.
22:20I just want to add I think guanfacine and now
22:23there's a neurologist in the in the group,
22:26but I think it's often using kids
22:28who also have like tic disorder.
22:30Another kind of things that keep them
22:32from from being able to fall asleep.
22:34So that's I've seen this and some of
22:37my patients and it's been helpful.
22:39The common side effects are hypotension,
22:41bradycardia, irritability.
22:41REM suppression,
22:42dry mouth and then as we know these are
22:45medications that you can't abruptly stop.
22:47You usually have to wean them off or you get
22:51rebound hypertension or rebound increase ram.
22:54Anti histamines,
22:54very commonly over the counter.
22:56Your diphenhydramine useful
22:57and transient insomnia.
22:58In Pediatrics,
22:59we always have to be really worried
23:01for side effects not mentioned here,
23:03but we get some patients get
23:05a paradoxical reaction.
23:06Anecdotally,
23:07I feel like a lot of my patients with
23:09autism can often have this paradoxical
23:11reaction to diphenhydramine as well,
23:13so I'm more cautious about parents
23:15are using and I just have them.
23:18Be careful. And obviously it's not.
23:20Usually it's not designed to
23:22be a long term therapy as well.
23:24So you have a side effect of sedation
23:27anticholinergic effects including fever,
23:29blurred vision, dry mouth Constipation, etc.
23:33Such that it is the only one of the
23:36most testing in children is clonazepam,
23:40which has been done betrayed to treat
23:43parasomnia spiritual movements,
23:44nocturnal,
23:45biting the side effects are obvious.
23:47Then this would benzodiazepine
23:49you have sedation headaches,
23:51dizziness and dependence,
23:52so it's not one that we usually go
23:56to from jump to iron supplements
23:59because there is actually relatively
24:01well known say Hi But.
24:03That could be an issue that
24:05patients are having.
24:06Apparently movements are are less
24:08symptoms that they just can't verbalize.
24:10So checking if Barrett and I think
24:12it's really important in these
24:14patients and supplementing with iron.
24:16As indicated,
24:17and then one thing that I as
24:18a pediatrician haven't really
24:20prescribed allotted nepas ill,
24:22which is an Alzheimer's medication.
24:23It's been studied,
24:24kind of recently been looking at
24:26'cause we know there's decreased
24:28REM sleep in autism.
24:29There's been some studies looking
24:30to see if we can increase REM sleep
24:33thinking that we can actually increase
24:35the restful quality of sleep etc.
24:37So I don't have personal experience
24:39using this,
24:39but it's been really interesting
24:41reading the literature that that's
24:43something that some people are are
24:45using and there was a clinical trial.
24:47I think even though I'm a couple years
24:50ago with this, I'm going to try to.
24:52I didn't see the full report out,
24:55but there's of course side effects
24:57of GI issues, vivid dreams, insomnia,
24:58Brady, Cardia, hypertension.
25:01And I just wanted to mention Doxepin,
25:04so this wasn't in that table.
25:05But this is a low dose Doxepin
25:07as many of
25:08us know as a medication has been approved
25:11for adults for insomnia for maintenance.
25:13Insomnia hasn't really been
25:15approved for children,
25:16but there's a single center retrospective
25:18study that did only 29 kids were in it.
25:21They just 217 all had autism.
25:22They already failed.
25:24Behavioral intervention and melatonin and
25:26they started median starting dose is 2
25:28milligrams median maintenance dose was
25:30all the way up to 10 milligrams which
25:32I know is a little bit higher than.
25:34The typical low dose not low dose toxin
25:37that we prescribe for maintenance insomnia,
25:39but the results were were were
25:41kind of where reassuring.
25:43It showed that 27.8% showed
25:45modern improvement, 34 mild,
25:4610 minimal or no improvement
25:48in 13 discontinuously,
25:49but it wasn't helping at all.
25:51Or they may be thought they had side effects.
25:54So two patients that have increased
25:57aggression in your racist but the rest of
25:59didn't have any significant side effects.
26:01So the conclusion that's potentially safe,
26:04well tolerated option for our
26:06pediatric patients with autism.
26:07To consider and I actually have a
26:09couple of patients and I started on it
26:11and it actually had some good success.
26:13What about the Z drugs?
26:15So the non benzodiazepine's are resulted etc.
26:17So these have a relatively short half-life,
26:20may have a safer profile then are
26:22compared to Benzodiazepine's,
26:23but Dayton uses eat Rosie drugs in
26:26children is generally quite limited
26:28and the data shows clearance of drugs
26:30in children is 3 times higher than
26:33adults which can cause medication
26:34effectiveness but increase risk
26:36of abnormal sleep behaviors.
26:37So more sleepwalking or sleep.
26:39Early hallucination and studies with
26:41kids with autism just are really are.
26:44There aren't a lot of studies as well,
26:45so but this is something to consider.
26:48So I'm just briefly my my approach and
26:50I'd love to hear if other people have
26:53experiences with their approaches.
26:55Are is, you know,
26:56I take a good sleep history,
26:58get a good sleep screening,
27:00and then I really try to understand
27:02the expectations of the family. How?
27:04What are they hoping from this visit?
27:07How much sleep do they want their
27:09child to have?
27:10How much are there sleep issues
27:12really affecting the overall family
27:14quality of life or their child's
27:16health and then extreme for any
27:18issues of comorbid conditions,
27:19address medications?
27:20Of course, don't just change.
27:22Medications are prescribed by someone else,
27:24but maybe talk to the family.
27:25Reach out to that doctor and see
27:27what we can do to adjust and then
27:30help the family established
27:31individualized routine or schedule.
27:33If they don't have one already,
27:35I try non pharmacological
27:36interventions first.
27:37The weighted blanket,
27:38the white noise machine etc.
27:39And then I try melatonin.
27:41I have a pretty low threshold
27:42to try it in this population,
27:45especially having trouble falling
27:46asleep and then I might consider
27:48other medications and usually I'm at.
27:50Akron, which imagined.
27:51Alright Yeah where we have a lot
27:53of complex patients who have a lot
27:55of sub sub specialist,
27:56so I usually will do this
27:58in conjunction with the
27:59neurologist, developmental
28:00pediatrician and psychiatrist milk.
28:01I've come with a plan together
28:02just so the right hand is
28:04with the left hand is doing.
28:08So I think just bottom
28:10line and hopefully good.
28:11I wanted to have lots of time
28:13for discussion and questions.
28:15So basically sleep disruptions
28:16common in autism severity of autism
28:18is correlated with degree of sleep
28:21disruption and behavioral interventions
28:22really should be the first line
28:24and considered first regardless
28:25of severity of options symptoms,
28:27knowing they may not be enough,
28:29but at least they should be in place.
28:32Pharmacologic therapies are often
28:33used in this population, but really,
28:36there's not a lot of evidence
28:38for which are most effective.
28:40But there's there's emerging evidence,
28:41and it's nice to see this in the
28:43literature and more research.
28:45Really,
28:45looking at autism in adults is really needed,
28:48particularly those with
28:49intellectual disability.
28:49They I fear a lot of them
28:51may not be getting well.
28:53It may not be recognized or not,
28:55may not be getting all the therapies.
28:58So I just know to couple
29:00I'll just keep this here.
29:01If you want a screenshot this but a
29:03couple of key citations to explore.
29:05I thought these were like really helpful
29:08reviews just to kind of approach the topic.
29:12I think that's that's all
29:13the day I have for slides,
29:15and hopefully I want to get
29:16plenty of time for us to talk,
29:18so I hope thank you for your attention and.
29:21Hopefully we can just trying
29:22to talk from here.
29:24Thanks so much. That was wonderful.
29:26I will open it up to questions.
29:28Actually I think we have enough time
29:30that it folks would like to just unmute
29:32an ask their questions directly.
29:34That would be great.
29:35I'm going to check the chat room,
29:37but I didn't see anything.
29:40Just yet, when I last looked,
29:42I know that we, I think we have a few
29:44pediatricians at least on the call.
29:47Does anyone have any questions or
29:49comments? I'd love to hear.
29:50Kind of your experience and yeah.
29:59Well. She put the last slide back
30:03on for a second one, the. Sure,
30:07let me let me reshare.
30:15Oops. Sorry, one moment.
30:17Did you have a question about that
30:19or just wanted to see the resources?
30:25Is it this this line? Yes, OK.
30:31I guess I'll start with a question
30:34Caroline is do you find any
30:38differences in how receptive
30:40parents of children with ASD R2,
30:43either behavioral or pharmacologic?
30:47Interventions than patients without autism.
30:51Oh, that's a great question.
30:52Like is there? Do they tend to prefer
30:55for pharmacological agents or not?
30:57Or is there?
30:58You know, I could imagine there could
31:00be more reluctance or hesitance to
31:02attempt behavioral interventions
31:03just because of the kind of constant
31:06daily challenges that beast,
31:07but I would love to hear
31:09your perspectives on that.
31:11No, that's a great question. I.
31:13I think in my experience and they
31:15tend to be more open to pharmacologic
31:17interventions for when they when their kids
31:19have autism compared to those who don't.
31:21And I think it's typically,
31:23as I say, I've referral bias,
31:24insured, slotted you do by the
31:26time you're coming to me.
31:28You tried a few other things
31:30and you really are.
31:31We allowed the parents come
31:32to me somewhat frustrated,
31:34so usually they feel it depends
31:35on the degree of.
31:37I think in touch will
31:39compromise the kids have.
31:41I think it's a relatively still
31:43kind of high functioning.
31:44I think the parents are willing
31:45to really try some behavioral
31:46things that they really struggle.
31:48Obviously there are more.
31:50Try to do more of just the medication,
31:52even to the point where sometimes
31:54when I I try say, well, sure,
31:55yes we can think about that.
31:57But you know,
31:58here's some things about
31:58getting a schedule you know.
32:00Can we try to turn the
32:01light on in the morning?
32:02Have a regular bedtime sleep time sometimes,
32:04or even resistant to that and just
32:06want the medicine so it's a little
32:07bit of a discussion and trying.
32:11Forming a partnership.
32:12Because honestly,
32:12I think these medications help,
32:14but I don't know and I love to hear
32:16peoples experience. I don't know.
32:18I've seen any kid who remains on one
32:20regiment for a long time and their set,
32:22so I feel like they keep changing.
32:24So I think it it's a little bit of dance
32:27with the kid and ever changing needs.
32:31Great thanks. So I have a question so.
32:37The parents of a child who's autistic
32:40who wanders around at night, can't sleep.
32:44What do you do for for the parents
32:47to give them some respite? Yeah,
32:49I. I think if there, if they're wondering,
32:53is the point of certainly. Endangering them,
32:56I think that's where we maybe go towards
32:59seeing some sedating medications faster
33:01than maybe we would for another kid.
33:03Just thinking of weighing the
33:05safety or not, I think for.
33:09Alarms are not alarmed, but like sex.
33:11I had some patients who have such
33:13bad sleepwalking, they leave.
33:14They will leave the apartment.
33:15They leave the house.
33:16So I think trying to help them having the
33:18extra lock at the top of the top of the door,
33:21having like a Bell on the door,
33:22something to alert them if they're going
33:24to actually go out into get unsafe.
33:26But I think those kids I think they may be.
33:28I tend to try to lean towards.
33:30Well, let's see what we can do for medicines.
33:32Maybe a little bit sooner than
33:33they would for other kids.
33:34If they are a danger.
33:37You know,
33:38I I hear your point of just like how do we
33:40get parents to sleep when their kids aren't?
33:42It's tough.
33:42I mean it's a lot of I give
33:44these parents a lot of credit.
33:46I when I first meet them I feel
33:47like I do a lot of discussions.
33:49We need a lot through my.
33:52My telephone and video visits really
33:54quickly in the first month until we
33:55kind of come up with an individualized
33:57plan that seems to work best for them.
33:59It's like there's not one way
34:00I do for the families,
34:02but a lot of negotiation of
34:03what works best for them.
34:09This is Ian. We're like I do
34:11mostly adult Sleep Medicine.
34:12I have a handful of adult ASD patients
34:15and one of the things that we struggle
34:18with is sort of balancing the sort
34:20of once of the patient with the
34:22ones of the parents or caregivers.
34:24And sometimes they are in conflict.
34:26One another long is lined with the issue
34:29with the wandering at night.
34:31Maybe it's a safety issue,
34:32but sometimes it's not there just up and
34:35they're playing video games,
34:36or they're doing something and.
34:38And but their caregivers
34:40are very disturbed by that,
34:41and I always really reluctant
34:43to sort of medicate those
34:45patients if they don't really
34:46have any kind of major special.
34:48They're not having a lot of
34:50datetime dysfunction, so how
34:51do you sort of balance between the
34:54patient and the family or caregiver and
34:56and in terms of treatment?
34:59Yeah, no, that's it, yeah. It's tough.
35:03I think it's that's where really
35:04the having a lot of discussion,
35:06like for instance when another thing that
35:07I see as I have a parent who just wanted
35:10her kid to sleep 14 hours every day.
35:12She's like I want him to fall asleep
35:14at 6 and not get up until you know
35:168:00 AM the next day and it's like.
35:19I mean I should like some schema pill
35:21that does that and it's like no.
35:23So you know, so I think it's a lot
35:25of discussion resetting expectations,
35:27which is not easy,
35:28and I think you have the unique problem.
35:31Two of having adult patients least
35:33most of mine are are, you know minors.
35:35So the parents. Usually there's.
35:37I guess it's a little bit easier.
35:39I think to navigate.
35:40I think when there when their kids,
35:43but I think that the teenager,
35:44for instance of a few patients who
35:46have autism with teenagers. But I.
35:48Talk to parents about daytime symptoms,
35:50how much it's really affecting their life.
35:52The same thing like you just said, right?
35:54It's like if they're doing relatively
35:55well and sure,
35:56it's annoying that they get up
35:57and play video games, but.
35:59You know,
35:59are they able to still go to school or are
36:02they still able to function pretty well?
36:04Can we negotiate a time or you can get up,
36:06but you have to go to bed in half an hour.
36:09You know afterwards, like you know,
36:10it's a little bit of a long discussion
36:12to be honest, but I do struggle,
36:13especially with the kids.
36:14We have a little bit more ability
36:16to just do what they want to do.
36:20I do have one Kitty tried.
36:21They always wanted to leave the
36:23house in mill and I and I think we
36:24were able to just get him to agree.
36:26That was not a good idea so he just
36:27wanted to play in the backyard
36:28at three in the morning and like.
36:32So there's some. There's some guardrails.
36:35I will, I'll just read a question
36:38from the chat for someone who's
36:40Mike is not functioning well,
36:42so this is from Debbie did one of our
36:45former Sleep Fellows, whose Nestle
36:47faculty he says in my experience,
36:49parent to like the effect of melatonin
36:51end up increasing and increasing the dose
36:54and buying 5 to 15 milligram gummies,
36:56which I am appalled, exist.
36:58Not sure why he says that this might work,
37:01but I'm concerned about those dosages.
37:03How do you address that or?
37:05Do you feel it is OK to give
37:08those parents that much leeway?
37:09Also, which brand melatonin do you recommend?
37:12There's so much variability in the
37:13trudeaus among the different brands.
37:15Yeah, I think I agree.
37:16I
37:17I was surprised at why people were giving
37:19their kids all these 1520 milligram
37:21doses myself and I went to target.
37:23Is trying to see like what's
37:25out there and I'm like, Oh,
37:27it's because that's what's out there.
37:29So I agree. I think it's unfortunate that
37:31those are the doses that are available.
37:33I tried to recommend actually the
37:35droppers and I do recommend low dose and
37:38I kind of warn them about the siding.
37:40Fact of the drowsiness in the Karate
37:42NIST next day, and usually that
37:45actually is sufficient to kind of.
37:47At parents, to keep the doses down, you know,
37:50and I I think I've been knock on wood.
37:53Pretty successful gain them not to just
37:56give them 2030 milligrams of melatonin at
37:59night in terms of the brands you know.
38:01I had been told when I was asleep fellow
38:04that there's a company, sundown Naturals.
38:06I think that was involved in one
38:09of the chronobiology research.
38:11Um? A few years ago,
38:14so I think that was a brand
38:15that I have been recommended.
38:17I gotta be honest, I can try to do a verify.
38:20That information. I got.
38:21Someone else knows that.
38:22Please let me know, but that's one Brandon.
38:24I've been told,
38:25czar bees seem to be a very popular
38:27brand and they come in low doses.
38:291 milligram, half a milligram,
38:313 milligrams,
38:31so those are ones that I tend to recommend.
38:34But you know, do I know that?
38:36So their justice is reliable.
38:39You know,
38:39I I'd warn parents that you know.
38:43I tell him about the study and
38:45how we know when they looked at
38:47was a 20 brands of melatonin.
38:49They were all variable,
38:50so I think those are the two
38:51that I tend to recommend.
38:53And then I think if they're
38:54really not having any effect or
38:56something is really weird, I try to.
38:58Scribe it, and so if maybe their
39:00insurance covers that they can
39:01get from the pharmacist and I'm
39:03hoping that dose is more reliable.
39:06Great, thank you.
39:07And I guess David was appalled David
39:10was appalled about the gummies,
39:12just 'cause kids like gummies.
39:13So of course they'll overdose on gummy's.
39:16Actually yesterday they saw another kid
39:17with autism who ate the whole bottle.
39:20Mom said a couple years ago of their gummies,
39:22she's nine and she just took the whole
39:25thing and they called poison control.
39:27And they're like I think she's fine.
39:29She ended up being OK, but you're right.
39:31I mean this should be like the gummies,
39:34it's like her sleep candy,
39:35which is why I actually pen.
39:37I personally don't recommend.
39:39I'm not. I don't push the gummies,
39:41I don't like it to be associate
39:44with candy 'cause this girl she
39:46ate almost a whole bottle of.
39:48Well I have a question yes.
39:50What is the timing
39:52of the taking of the melatonin
39:54compared to the desired?
39:56Sleep onset time.
39:57Think it's an excellent
39:59question, I'm sorry, did.
40:00I didn't talk about that.
40:02That's actually a very great
40:04fundamental question. I recommend,
40:05so using it kind of as a hypnotic.
40:07I say 30 to 60 minutes before bed,
40:10adjusting a little bit as needed.
40:12That's usually what I recommend for.
40:14You're just helping the first sleep onset.
40:22Great, so if there are no other questions,
40:25I think we'll end there and thanks
40:28everyone so much for your attention.
40:30Thank you doctor Cory.
40:32Thank you, I appreciate it.
40:34I think I put my email in the chat.
40:37If anyone has you know any questions
40:40or just wants to talk kids and autism,
40:43feel free to send me an email again,
40:46I'd love. I'm still learning.
40:48I picked this topic because
40:51I wanted to learn more.
40:53So I'm open to other ideas. That's how
40:55we all become experts.
40:56Pick up something and learn about it.
40:59Great thank you so much. Alright?
41:01Take care, everybody have a great week.