Sleep as a superpower

Sleep is a superpower.  Inadequate or poor sleep has been linked to negative mental health and linked to depression and anxiety.  Find out the best tips to support families towards better health through improved sleep as host Dr. Sam Manger, talks with our sleep expert, Dr Honey Heussler. 

Dr Honey Heussler is a Developmental and Sleep paediatrician based at the Queensland Children’s Hospital. She is an Adjunct Associate Professor at the University of Queensland. She works clinically, is the Medical Director of Child and Youth Community health services as well as having a strong research program. 

Transcript

Health and Wellbeing Queensland acknowledges the Yuggera and Turrbal people and the traditional custodians on the lands on which this podcast was recorded and the traditional custodians on the lands of borders on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia's First Nations people. 

[Upbeat music] 

Associate Professor, Dr Honey Heussler [speaking over music]: During this period of kids being at home so much, that reliance on screens and things for external communication has actually grown, and so the screen, sort of, impact, I think, on sleep is probably, we're just starting to see the effects of that. 

Sam: Welcome to the Clinician's Guide to Healthy Kids, a podcast series for health professionals brought to you by Health and Wellbeing Queensland's Clinician’s Hub. I'm your host Dr Sam Manger and in this series, we'll be diving deep into the topics that matter most in childhood weight management. We'll be talking to Queensland experts across a variety of topics including sleep, disordered eating and higher weight children, prevention and healthy growth with healthy diets.  

Sam: Let's get started! Today, we're going to discuss sleep. We know it is a superpower that we all need enough of, but what does that mean for kids and adolescents. And how can we support parents in this 24/7 social media, social computer games, catch up TV, screening, adverts encouraging binge watching and all sorts of screens at our fingertips. We welcome Honey Heussler to discuss. Honey is a Developmental and Sleep Paediatrician, based at the Queensland Children's Hospital. She's an Adjunct Associate Professor at the University of Queensland, she worked clinically as the Medical Director of Child and Youth Community Health Services, as well as having a strong research program. That's fantastic. Thank you so much for joining us, Honey. 

Honey: Thank you, Sam. 

Sam: So, tell us a little bit about yourself and why you got into this area and where your passions are. 

Honey: So, sleep has always fascinated me because I think it's really, absolutely one of the fundamentals to wellbeing that we have. And when I started out, and I don't want to really focus too much on how long I've been in the game, but actually the role of sleep was – really, little was understood about the impact of that on children's health and wellbeing. In fact, I did my doctorate in this, and the impact of poor sleep on children's behaviour way back in the early 1990s, so it is something that's always interested me. And the impact, particularly on neurocognitive and behavioural facets I think has been something that's just fascinated me. I think the brain is just such an interesting thing. 

Sam: Well, we're going to get along just fine, Honey. It is fascinating, you're right! It is such an incredibly important area and very interesting over time as you say that it was, perhaps not dismissed, but not seen as the huge role that it is. And now luckily more and more people are talking about it.  

So, let's start with some current statistics about how much sleep Australian children adolescents are getting at the moment? 

Honey: I think the answer is probably not enough! There’s something like 20 to 25% estimated children not getting recommended amounts of sleep. It's a little bit difficult to actually tease that out appropriately, because there is a percentile range of what is normal for an individual, so having an absolute number will sometimes misinterpret the kids who aren't getting enough sleep. So, we would think that kids that fall within 2 standard deviations of that, are probably getting enough, so long as they're not tired during the day. To me, that's the important thing that should run through every conversation about sleep. 

Sam: Yeah, I've spoken to a number of sleep specialists and that is one of the common take homes you get is, the number matters to some degree but, how is their energy levels and fatigue during the day. That's what is a key indicator, regardless of number. 

Honey: Absolutely. And I think in early childhood, as kids start school in that sort of 5-year-old age group, there's still a proportion of those kids who aren't ready to give up daytime naps even, and we push them into being awake all day and so some of that, societal push to fit in, and fit a singular number sometimes is really tricky to manage, I think. 

Sam: And so, you say it's a distribution, so, like a bell curve sort of distribution where you have the majority in the middle. So, are there guidelines then on how much or what sort of sleep we should be getting? So, what's the sort of middle of that bell curve and what are the sort of ranges? 

Honey:  So, it depends on the age, and as you are aware, when we're little we need quite a lot of sleep. So, in infancy, we spend a good proportion of the day and then as we get older that reduces, and we have what we call biphasic sleep, where we have a daytime nap. So, we wean from frequent sleeps to biphasic sleep where we have a nap during the day and then into monophasic sleep where we have a single sleep period during the day. That varies for children, as to when they actually give that up, and when we think about that bell curve, there will be kids who still need 10, 11 hours of sleep, in primary school and there'll be other kids where 8 is probably okay, but it is primarily about the daytime function. So, there might be a child who's getting 10 hours of sleep but still needing a sleep during the day. So that's when the sort of red flags starts to arise. But if you've got somebody who's sleeping 8 hours and they're not sleepy, coping fine, no problems with school or academics or focus or mood, then that's probably okay. And we wouldn't chase it too hard. 

Sam: And what about up to adolescents and secondary school because there's also the concern about the phase shift that occurs, in the sense that they naturally prefer to what go to bed late, wake up late in school doesn't quite suit that very well sometimes. 

Honey: So, I think that it is a real issue in adolescence, and we think that part of the difficulty in adolescence is a decrease in their sensitivity to sleep pressure. So, when we go off to sleep, some of it is our circadian rhythm and ultradian rhythm, which is sort of the hour and a half, 2-hour timing, but then sleep pressure is a key focus of that. So how long was it since you last had slow wave sleep or deep sleep. And for adolescence their sensitivity to that is less.  

And so, they feel less tired for the same amount of time. So, it will take them longer to achieve the same amount of sleep pressure, which is why they stay up later and later. And the challenge is, that actually in adolescence you still need quite a lot of sleep, probably more than most adolescents would think! So definitely, in that 9-to-10-hour range is probably a healthy amount of sleep.  

The challenge is, if you're not feeling sleepy, and you've got lots of school and academic pressure, and homework pressure and trying to have some down time, it actually really impacts on that lead up to sleep, and contributes somewhat, I think, to them not accessing sleep or setting up good routines to get off to sleep and manage that reduced sleep pressure, which is hard to manage for some kids.  

Some kids are affected worse than others, but it is a really difficult thing. I try and take away from adolescents, that concept that they don't want to go to sleep and it's all about them just misbehaving and not wanting to go to sleep, because in fact, it is a real thing, that lack of sleep pressure. So, when you describe it like that and talk to them about managing sleep pressure, it's often a little bit less stigmatising and in terms of a voluntary control thing. So, that can be an easier way to approach that conversation with an adolescent who's really struggling to get off to sleep at the right time. 

Sam: That is fascinating because 9 hours for an adolescent is still a fair chunk, and if they're getting up – you have to get up at 6:30, or say, or 7:00 for school that means they need to be in bed by 10! And I don't think that there's many adolescents, that are going to bed clearly, as it were, in the sense of just straight to sleep without having any distractions by 10. 

Honey: Absolutely. I think it's really tricky for them. 

Sam: So, that sleep pressure you mentioned, is the sort of, the adenosine drive and other sort of factors that sort of play into the physiology there? 

Honey: Yes. When you look at the data over years that's been collected, the amount of slow wave sleep drops quite sharply in that, sort of, early adolescence. So that 12, 13 sort of age group. And that's where we start to see most of the problems, usually by the time kids are a bit older, they've got more into the run of things. But that sort of early high school thing is really problematic, and unfortunately for our 12 and 13-year-olds, these days they're dealing with a lot of societal peer pressures, things going on at the same time, you know, year 7 being in high school, year 9, you know. Teachers will all tell you, these are the really tricky years in terms of getting kids through that, so that, sort of, peer stuff, the mood stuff that can go on, you know, getting good quality sleep to be able to get yourself through that is really, really important. 

Sam: So that's perfect because it takes me to my next question about what is impacting child and adolescents' ability to sleep most? And you mentioned a number of factors there, but there are obviously some biological factors there. So, you see the sort of insensitivities to sleep drive and sleep pressure through adolescence. But then there's a lot of sociocultural factors. There's the schooling, there's the, as you said the pressure to go to Kindy and prep and not have that nap so much during the day at age 5. And so, there are varying factors that are impacting sleep, but what else are the sort of big factors that you see as an expert here? 

Honey: I think the big factors are often that, sort of, anxiety, trying to rehash and sort through things in your mind, for many kids. And I certainly deal with a population of people who have lots of challenges in development, and anxiety about how things are going to happen and what have you, and so that in itself, can be really problematic.  

So those kids who are a little bit anxious and, you know, I strongly believe that since COVID’s been here in the last couple of years, that has actually increased, and the numbers of kids who are finding it really difficult to get back out into the world, I think does impact on sleep. And I think, really, and this is probably as much personal experience as anything, that during this period of kids being at home so much that reliance on screens and things for external communication has actually grown, and so the screen, sort of, impact, I think, on sleep is probably – we're just starting to see the effects of that.  

The challenges with screens are really difficult. There is this, sort of, impact of white and blue light on melatonin production, which we know exists. How much we get from a screen and how much it really impacts, we're not entirely sure whether that's clinically significant yet. It's probably that there are some people who are more sensitive than others. But people are exploring now very much the role of engagement of what you're doing on screens, rather than actually it being solely a blue light issue, so that, you know, being really hard to put down the screen because you just want to scroll through another video or actually, all my friends are online now, so you know, I need to actually respond to that text message that somebody sent me, or that, Snapchat message, or what-have-you because there is always other people up.  

And I think that is where people have become less used to going out of the house and seeing people and having face-to-face interactions, that reliance on technology for your social interactions, I think, we're just seeing the tip of the iceberg here. And so, I see that with a lot of people who really struggle with social interaction and get very addicted to gaming at night because there's always somebody else in the world who's up, who can do online gaming with you. And if you struggle socially, you might perceive these people as being your friends and it's a social interaction for you, as opposed to a pure addiction.  

And then it becomes an addiction. So, it's a really complex sort of thing to try and tease out. And I think that that is something that would often be very difficult in a short consultation to try and tease out and work your way through and may need sort of additional supports. But exploring the motivation behind what goes on I think is really important. 

Sam: A good take home, yes, that's right. It is fascinating that whole conversation because it's clearly a relatively recent cultural phenomenon. The screens being so pervasively accessible, and then also so stimulating with social media and scrolling and that sort of stuff, when you have for these short videos and TikTok and things like that that are becoming the cultural norm and even surpassing other social medias. As you say, the blue light is fascinating in that, yes, some may be more sensitive to others, and that makes total sense given what we know about the general personalised nature of everything in the human being. But the nature of the screen use, so how stimulating it is, you know, you can imagine just a very high impact, very stimulating game, for example, those neurons are firing and when those eyes closed those neurons are still firing and the ruminating, as you say, the anxiety or the ruminating around the chat and conversations without that face-to-face, there's perhaps not as much closure and words and emojis are so easily misunderstood so that breeds that a sort of potential for autonomic negative thoughts to creep in and then anxiety to spiral and so on. 

Honey: Absolutely, and I do think that, you know, that age group particularly as we go into adolescence, that move for a proportion of the population to be less active at that time. I think one of the things I always talk about is making day different to, night. So, day being about activity, brain stimulation, doing all of those things and night being about calm and those sorts of things. But if your day is not very active, you're inside all day, you're on screens all day and you're doing the same things at night. Getting that switch, I think, is really difficult for people. And I often talk about being physically tired and brain tired and how you work your way through that can sometimes be helpful as well, if we're talking activity and its role in supporting sleep and that's daytime activity really, probably. 

Sam: Yes, that's a nice – again, another take home – when we think about what the changing activities are, between a daytime and a night-time scenario, and even just mapping that out and it can be helpful. I certainly know that a lot of parents themselves might engage in those behaviours at night-time too, because it might be the only time they get with their kids in bed and that's spirals that problem too.  

Honey: It can be helpful though, because if you can talk a parent through how they get over engaged in it, they can start to understand how their child might get over engaged in it. So, I often use that parental, sort of, online stuff to actually try and help them understand what the child is struggling to give up, because if the parents struggle to give up, the child's going to struggle to give up and you can actually use that sometimes, to actually talk a parent through the child's challenges. Because often they'll be asking something of a child that they're not doing themselves, and so supporting that can sometimes be a hook as well, a little bit. 

Sam: Yeah, great, now that's a good idea. The sort of lived experience of somewhat addictions, yes. We'll be back after this short break! 

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Sam: And now back to the show. And so, now we mentioned the impact, what happens to many children, most children, if they can't get enough sleep, and we've highlighted one there being sort of daytime somnolence and fatigue being a key one and we've also touched on a few other things and I'm curious to know what are the other symptoms that can flow into?  

You mentioned your PhD was in behaviour and so that can be one of those tricky ones where I, as a GP, I see it a lot where young children present with behavioural difficulties in school or attention problems etcetera at home and yes, it could be something like ADHD or some concern of that, but you've got to check sleep first. You absolutely have to check sleep first, because there's been a number of times where you fix the sleep, with one means or another, and their behaviours, you know, drastically improve. So, clearly in younger children, they're not going to come up to you and say I'm tired. Well, they might, but more likely they're going sort of be emotionally dysregulated in some way. 

Honey:  Yes. I think there's fairly good evidence, really, that poor sleep impacts mood, impacts focus and attention and regulation, and I think that's pretty clear in that evidence these days. What is less clear is the impact on learning and the impact on neurocognition, in terms of cognitive abilities, that may be a time factor.  

Maybe it's an exposure factor, but it is probably more that impact of focus, attention, concentration, hyperactivity as most of us who are parents will realise, you know, kids are busy when they're tired, they move more and they're trying to stay awake. Or they may watch TV and things like that because they're getting fast input, so it's keeping them awake. And so, thinking about those sorts of things in terms of trying to determine whether a child is tired during the day.  

And again, I often bring it back to the parents. They're saying their kids are having more tantrums or what-have-you, and I say, ‘well, how do you feel when you haven't had enough sleep?’ And most people will agree they've got a short fuse, they're less happy with stuff, and you can start to talk them through why sleep might be important and impacting on their child's behaviour a little bit, to try and get that motivation for modification of sleep behaviour and time. What isn't really clear, always, is whether it's amount of sleep or fragmentation of sleep that is having the biggest impact on that. So, the jury is still out a little bit on that sort of stuff. 

Sam: That's very interesting and very interesting to hear what comes of all of this. Is there much evidence around impact on development? 

Honey: So, there is a little bit out there, but it's still a little bit, you know there's some that say yes, there's some that say no. 

Sam: It's very complex, obviously as well. 

Honey: So, most of its still around obstructive sleep apnoea. In terms of behavioural intervention and development, it is less certain. But remember to learn and do all those sorts of things we require in development, you actually need to be able to pay attention, you need to be able to self-regulate and you need to be able to cope with change and moving on, and when you're tired, that's not very easy to do.  

So, is it those things that is having an impact on the development, or is the poor sleep having an impact directly? And it's a little bit confounding still as to which is the greater impact on the actual developmental trajectory for those kids. Does that make sense?  

Sam: Yeah, it does. No, watch this space is the take home, I think. 

Honey: Yes, watch this space, and I think where you've got a child who's presenting with some of those dysregulations, mood, attention, and focus, absolutely questioning about sleep is probably your first step. The challenges are that if we've got someone who has a disorder of hypersomnolence, per se, actually what we do is we use stimulants to manage that, so it gets a bit confusing sometimes for families to be able to understand what we're doing and how we're treating them. 

Sam: And the reasoning, yes. Now on the other end of the spectrum, what happens if a child sleeps too much? 

Honey: OK, so if a child is sleeping too much, there are what we call Disorders of Excessive Sleepiness, so D.O.E.S, which is what we would call them, as opposed to Disorders of Initiating and Maintaining Sleep, which is where they're not getting enough. So, the first thing is if you've got that, is to check whether the child is truly getting enough sleep. So, once you get to about 7 or 8, parents don't always wake up when a child wakes up, so it's really important to understand what that child's sleep is like. You know, we have kids that might be awake for 3 hours during the night and their parents are no longer aware because they don't go and get their parents anymore.  

Sam: Yes, so it's a false positive as it were. 

Honey: Yes, absolutely. So, you’ve got to be clear the child is actually getting enough sleep, but if they're then getting too much sleep, there are a number of disorders of hypersomnolence, and there are some things that we need to check out and make sure that are not there. So, you know, for example, thyroid function, you know, those sorts of things that we would need to make sure, post-viral syndromes, those sorts of things that need to be excluded.  

And then there's 2 or 3 particular disorders such as narcolepsy, where we need to do some further investigation to make sure that those kids don't actually have a true disorder of excessive sleepiness. There are specific tests that we would do in a sleep laboratory to look at that, but what are the key questions to try and work out whether a person might have narcolepsy is actually, do they fall asleep in unusual situations? So, do they fall asleep, you know, face planted on the dinner table, or do they fall asleep sitting on the stairs, or do they fall asleep at a party hanging onto Mum's leg? 

So, most of those things are really important. It's really hard to make that diagnosis before about the age of 8, though, so we will often try and manage and work out what is happening before that, but most of those disorders become much clearer in that late primary, sort of, age group. But the key question is, do they fall asleep in weird places. 

Sam: Yes. And trying to get a really accurate sleep assessment in history really matters. So that takes me to the next question about – because you're a sleep specialist, so you obviously do lots of consults on this with children and families – so, can you briefly describe what your assessment would be and how long would that take? 

Honey: I probably do it in quite a lot of detail because the population I see are often kids with developmental problems as well. So, I really need to clearly understand the personality and the temperament of the child and how they fit within the family. I ask about the sleep environment. So, are they in a room with 5 other kids or are they in a room on their own? Do they live next to a highway? You know, those sorts of questions.   

Then probably the 3 key questions I would ask are: Are they tired during the day? Are they hard to wake up in the morning? And are they difficult to get to sleep at the beginning of the night? And if I had to have a fourth, it would be: Do they wake up during the night? And the additional questions would be around whether they snore or whether there might be other reasons for waking up during the night.  

So that might be, if they have seizures or snoring or severe eczema, asthma, those sorts of things can wake you during the night. So, I would ask about those medical things. And then, those, well, they're 4 questions, aren't they really: the tiredness during the day, the regular wake-up time, are they hard to wake up? You can often tease it up by asking if they sleep in on the weekends and how long that sleep in might be and then are they difficult to get off to bed at the beginning of the night. 

Sam: So that makes sense. So, you get a good sleep history first and the sense of, as you said, time to get to sleep, maintenance of that sleep, and then waking and what that experience is like and then the sleep environment and the context of their sleep, including pre-sleep, routines or what they do before bed and then the sleep environment.  

And then once you've got a really good sleep assessment, then you're thinking about what potential causes are. And that could be medical conditions like the itch of eczema or obviously sleep apnoea, and other problems and consequences of that. So, daytime fatigue, mental health changes, behavioural changes, etcetera. So that seems to be sleep assessment cause and consequence and a nice way to sort of break it up. And what are the most common sleep disorders we see in young Australians? I mean, in adults we see obstructive sleep apnoea, restless legs and then good old-fashioned insomnia. What's the sort of distribution in young Australians?  

Honey: So, in young children, well, there's often still a lot of obstructive sleep apnoea in that sort of 4 to 6 age group when their tonsils are maximum size. But about 80% of those are cured by getting their tonsils out.  

So that aside, we often see things like Limit-setting Disorder, where children will come in and out of the room quite a lot. Now, whether that's related to what translates to insomnia in adulthood is a little bit of a question, but setting clear limits can be really helpful. The other thing that is really common in young children, particularly early childhood, but does go through to primary school is that sleep association. So, setting yourself up in the way and the environment that you're going to wake up during the night. So, as we all know, we arouse multiple times during the night, as we transition between sleep stages. And for most of us when we arouse, we sort of open half an eye – everything's the same as when we went to bed – we go back to sleep and that's pretty normal.  

However, when kids fall asleep on a couch with the TV on, mum and dad around, and then get transitioned to a room where nobody else is around and they wake up for their first arousal and it's dark, there's no noise, and no parents around. All of a sudden, they're fully awake and they need to recreate that situation to be able to get back to sleep. And so, these are the kids who might fall asleep in mum and dads' bed, or cuddling up to them, and then come in all night wanting to sleep in mum and dad’s bed. And the parents might try to get them back to bed, but then eventually give up because they're exhausted themselves. And so, you get that reinforcing of that behaviour. So that sleep association of the conditions that you need to be able to go off to sleep is really, really key to set that up well, right in the beginning. And the sooner you can do that and work with it, the better.  

So, there might be times when you need to be with your child, or the child needs to be with a parent to go off to sleep – if they're unwell or something. But as soon as they're well, it needs to go back to the same sleep association. So going to bed in their own bed or going to bed with similar lighting – these people that use music to get off to sleep, well, then that music needs to play all night.  

Sam: Exactly, yes. 

Honey: You know, those sorts of principles are really, really key. By the time the parents get to a sleep specialist however, they're exhausted, because they've been trying to push back against this forever. And so, what we would generally do there is get the people to set up the beginning of the night really well and just go with the flow for the rest of the night. So really manage the beginning of the night with routine sleep environment, set up the night as you mean to go on, and see how that goes. That can be really tricky as you're adjusting that sleep associations, so getting a parent out of the room. You know, often parents will get to the door, and then it becomes really tricky so we might use something called a checking in method where the parent goes out, comes back, goes out, comes back – so that the child gets used to the parent ducking out for a bit and eventually you extend that time, and the child will fall asleep. So, lots of really key little tweaks you can do that will actually start the beginning of the night in the right way as you're trying to get that sleep association right. To not involve a parent, waking up other people, all of those sorts of things. 

Sam: That’s some fantastic tips that you’ve mentioned. I'll just summarise a few, you mentioned the snoring and we have to check those tonsils. So, you got a child with behavioural concerns, mood concerns or daytime fatigue; open the mouth, look at the back of the throat, number one, make sure there's no giant tonsils there obstructing their sleep. 

Honey: Tonsils and nose actually. 

Sam: And adenoids. Yes, so be careful of those. And sleep associations being very important, especially to try and anchor that well and establish that well at the beginning of the night and then see where it takes you. But setting them up in the environment, in the setting, where they're going to ideally going to stay the whole night at some point!  

So, this takes us to sleep hygiene because this is a term that is used a lot. So, I was wondering if you could just define this a little bit for us and you've already given us a raft of quite practical goals to work with around sleep environments, sleep associations and obviously some things to keep an eye on. Are there any other high yield sleep hygiene practices that you find are foundational to good sleep? 

Honey: I think the biggest things are having a routine and making sure that you don't have bright lights on. So, the dim light is really key. Having calming activities and calming activities don't include loud music or action movies or those sorts of things. They need to be calming. So, they might be playing cards or reading or something that is much calmer. Some of those children that are really busy still – and as they get tired, they get busier – we will often advocate, particularly when they're younger, their parents read a book and actually sit them on their lap, so they've got their arms around them to try and teach the child to calm a little bit. So that can be a helpful thing.  

Sam: So, like role model stillness in some regard.  

Honey: Yeah. Modelling stillness. You know, you can do all those games when kids are like that – statues and things like that to help kids get movement and still in, sort of, as part of their repertoire over time, but that's those little tricks can sometimes help kids learn to be calm and still.  

You can teach them breathing, relaxation things, those sorts of things. But one of the key things we're learning more and more is actually the wake-up time is key and setting a key wake-up time and everybody sticking to that. And sticking to it on the weekends as well, not letting it slide more than half an hour. We’re all guilty of, you know, relishing the odd weekend sleep in. But more and more we're starting to understand that variability in sleep is a problem, and so keeping that wake-up time fairly solid actually is part of sleep hygiene, as well as early in the night. So not eating too close to bed but making sure it's good quality GI (glycaemic index) food that's going to last during the night, making sure that we've got, you know, teeth cleaned, routine, calm activities, lower light if we can, and setting that up appropriately.  

Some people these days do need, a little bit of music and in ideal world, no music. But for those kids that are bit anxious and everything that goes bump in the night or live next to a highway, sometimes a bit of white noise can actually block out those other noises, you know, possums in the trees, those sorts of things that can alarm young children. So, just thinking through those things as an individual. But if you do start it, it needs to be there all night. It needs the sort of key setup, I think. 

Sam: Yeah. Fascinating. The key wake-up time is very interesting, too. I'd love to spend a whole another hour with you talking sleep physiology, but sadly our limits are existing. 

Honey: That's true. 

Sam: So, we touched on screen time earlier and how that this is a growing challenge; but there are obviously opportunities there. So, I'm not trying to be ideological about it, but what's your advice around screening usage before bedtime? In that, as you said, in which we're trying to change activities from day to night so, is your advice no screens? But, if we must have screens, is there at least some less pathological styles that we can do? 

Honey: So, I think you know, there's no evidence really, but I would be suggesting that sort of calmer things would be more appropriate. So instead of a game, maybe a movie and a movie that a parent has some control over. So not action movies or aggression or things that are scary, you know. It's still quite surprising to me how many kids are watching movies that I wouldn't watch before I went to bed. So just being really clear about what kids might have on in the room.  

If possible – as not all parents can read well enough or can engage in that reading – although we would like them to read and we know the benefits of reading to young children, but some parents really struggle with that. So, for families like that, I will often advocate trying to get some audio books that the kids could listen to of nice, calming sorts of stories that have nice endings, you know, those sorts of things that can be very calming but are actually a story for a child. And especially if it's associated with a book that the child could read. And then encourage the parent to be there, because some parents don't find that easy and so transitioning a child from watching movies to an audio book or an audio story might be the next thing. And I've tried that successfully with a few kids, so that can sometimes be helpful. But then again if they fall asleep listening to that.  

There needs to be something going on all night and something that's suitable that the child's not going to get up and watch something they shouldn't be during the night. So, if possible, I try to make sure that it gets turned off before the child actually goes to sleep, because that's the key thing. It's that sleep association isn't it – where if you go to sleep listening to something, then you kind of need it on to get back to sleep. So, if you can actually get the child to listen to something, then turn it off, and then go to sleep – it is often the way to try and work through that, so I might get them doing that, but then it goes off at a certain time and then they try and get to sleep. 

Sam: And that fits into the routine idea, you know, it's done now, now it's time to wind the body down and self soothe as it were. But what about adolescents? So, this is probably one of the hardest questions you'll get. But, certainly as a GP, I'm seeing this, as you said, ‘COVID has really increased this’ – but this was certainly a trend that was increasing before COVID. It is the amount of, you've mentioned, gaming before. So gaming is a real thing and often kids are sort of locked in their room, their parents are asleep and they're just gaming until who knows when – 2am in the morning – and/or smartphone access and just sort of scrolling through social media. So, have you reflected on much about what we can do about this in a practical way because it's a real challenge? 

Honey: I think education is key. It is really difficult because for many of these kids, as I said before, this has been a key factor of their social engagement for the last 2 or 3 years and I agree it was increasing before COVID, but I think COVID has just exacerbated it. I do try and talk kids through access, but limited to daytime, and so that you know that old adage of phones charging in a parent's bedroom, or something during the night so kids don't have access to them during the night. But again, that needs to be modelled, I think, with parents, because kids will often go to bed, and parents might be scrolling through their own social media stuff. And actually, maybe, it should be a rule that everybody in the family has them locked in the kitchen. You know, those sorts of things.  

Sam: Yeah, do as I say, rather than, not what I do. 

Honey: Or do as I do, rather, you know, doing some more modelling. 

Sam: Yes, that's what they should be doing. 

Honey: I think that what I try and do in a sort of clinic, where somebody's really struggling with that, I try and talk them through what that social media stuff is. Is it about the social engagement or are they just bored, you know, what is it? And if it's about social engagement, what I try and do is talk them through, limiting the time they're on it, but then rewarding themselves with a social activity. So, seeing if their parents could reward them with some movie tickets with a friend or something that can be a goal for them to work through that might replace some of that social thing.  

I think families are so busy too. You know, the old days where kids were driven around and had social activities after school is really sort of limited. Kids used to do a lot of social stuff, hang out with the kids on the street, go and do other things, but often they come home and just are home after school and so trying to engage in external activities, I think. Which is limiting in this day and age. I think is actually really key.  

So, sport activities, you know those sorts of things, I think are really key. Not exact science, I have to admit, but trying to find avenues to get them out and engaging socially separate from that, so that they can see the difference between a purely social online engagement versus face-to-face. 

Sam: Yeah, it's very hard to remove one thing and not replace it with something – especially if that's a very, you know, clearly on the social media sort of things from just the dopamine reward drive and other aspects are clearly ‘rewarding stimuluses. I mean rewarding in the sense of sort of neurotransmitter rewarding and you've got to replace it with something that is at least as engaging. And ideally more so because it's face to face and, as you said, it's common sense to some degree returning to those roots of health, social engagement, good physical activity, so that as you said, that's a clear daytime activity, night-time we’re winding down. So, it makes a lot of sense. We'll be back after this short message. 

[Community message]: Unhealthy weight is one of our greatest public health challenges. Two in 3 Queensland adults and one in 4 children live with overweight or obesity. We need to shift the dial. That's why Health and Wellbeing Queensland has created Clinician’s Hub for you, our clinical workforce. Clinician’s Hub is a digital ecosystem of initiatives, resources and tools, including this Podcast Series for multidisciplinary health professionals to support best practice prevention, identification, treatment and management of overweight or obesity, and it offers a variety of clinical tools and training to help you transform health for children, adults and families. Find out how Clinician’s Hub can help you at hw.qld.gov.au/hub 

Sam: And now back to the show. Now, are there any red flags that we've missed in our conversation that you think listeners – who are healthcare professionals – really need to keep an ear out or an eye out for? 

Honey: I think some of the red flags are that falling asleep in uncontrolled places. I think that absolutely needs to be managed. I think red flags with obstructive sleep apnoea, particularly with increasing weight in young children, I think, is really important. You know, when I started doing sleep medicine, we didn’t have as much obesity, and we saw a different profile of obstructive sleep apnoea. But as times progressed, we're seeing much more of that adult obstructive sleep apnoea, obesity-type of picture.  

So, I think that is one thing that is a real red flag for us and they're probably the kids that do need to be really referred so that we can actually manage the obstructive sleep apnoea to allow that person to be much less tired, to actually be able to action some strategies. Because if you're overweight, you've got obstructive sleep apnoea, you're tired during the day, your chances of being able to manage that and manage intake and manage activity are probably markedly reduced. And so that to me is a really key red flag if you suspect there's obstructive sleep apnoea.  

Other medical things need to be managed, so those sorts of things we talked about such as severe eczema and then probably that falling asleep during the day. The other thing I’d be really keen for us to try and get on top of really early is where there's that increasing difficulty in getting someone off gaming. Because I think if that's really entrenched, it is so hard to move. So, the earlier we can get on top of that the better. 

Sam: Fantastic. Now you mentioned there around a few indications for referral to a sleep specialist and you said they’re around some case of obstructive sleep apnoea where there's also comorbid metabolic or higher weight concerns. And what are the other – and narcolepsy being one of these, as you say, daytime falling asleep in odd places during the day – would be a very clear indication for a referral. Are there any others? I imagine there is quite a list, but what are the other main conditions which you would really want to see, from a sleep specialist point of view, be referred to? 

Honey: I think as a sleep specialist, the key things when we do a sleep study, for example, so lots of people get referred for a sleep study, but the key things we do in a sleep study is actually rule out obstructive sleep apnoea or look for neurological causes such as seizures or those sorts of things.  

But if it's more about getting off to bed, frequent waking, that's probably not going to come out in a sleep study, and it's probably those sorts of things we can investigate using other things such as activity monitors, diaries, those sorts of things.  

In terms of referrals, I think, where someone is concerned about obstructive sleep apnoea and again, tiredness during the day is often a key factor with that – the snoring on its own, without pauses or disrupted sleep or tiredness during the day we're happy to see, but won't always proceed directly, if there's no sort of craniofacial features that we might think. 

The other things are where we have kids with developmental disabilities and basic sleep hygiene and those things have not been able to work, then I think some of those kids will need a sleep review or a specialist review. Just because of the additional challenges for kids with neurodevelopmental disabilities can have.   

We still apply the same sleep hygiene and the same management strategies, but they can be a little bit more resistant to those strategies and sometimes need a little bit more adaption of the basic premises of sleep hygiene to be able to get some traction on the sleep difficulties that those kids have. So, they're probably the 3 things – that excessive tiredness during the day and impact on learning development behaviour. 

Sam: Yep, function. 

Honey: Often, I would recommend that actually if people have been able to work on the sleep hygiene, the sleep associations, those things beforehand, that should be able to be managed within a primary care setting. But when that isn't working, I think it is a very valid referral through to sleep physicians. 

Sam: Great to know. I might be opening a can of worms here, but you mentioned activity overnight so actigraphy, do you ever use those? Because there's loads of devices these days, I know they're for adults, primarily, rings and watches and phones, obviously, and other aspects that you can use to monitor sleep. And I know that there are pros and cons of those and varying degrees of accuracy and all that sort of stuff. Do you ever use it for children to see, and if so, what devices might you use? 

Honey: So, there are activity monitors that are validated for use in children, and we do use those, mainly for total sleep time, sleep onset latency, those sorts of things, they're quite reasonable when compared against PSG (polysomnography – sleep study), so we will use those. When you use commercial products there are varying degrees of validity, so if that's all you could use, then you would use it, but take it with a grain of salt. If they put up something that was particularly alarming, you might have a look at it, but you would potentially look mainly for change within an individual rather than comparing their results to everybody else. Does that make sense?  

Sam: Yes, that makes total sense. And the trend – so their actigraphy looks like ‘X’ and that might demonstrate some concerns and that may correlate with your sleep assessments – so frequent waking or something like that and then you say, okay, now let's do an intervention of some sleep hygiene association management things. And now keep monitoring – ‘oh we're seeing improvements’, so we know that we're probably making a difference – or we're not seeing improvements, so this might be time to refer off or something like that. 

Honey: And sometimes I'll use it where somebody might be remote and the mum's got a Fitbit [sleep tracker] or something like that. So, you pop it on the child overnight, mainly to check and see if there's a large wake period. And so, what you might find in an 8- or 9-year-old is that they might have 3 hours awake during the night that parents aren't aware of, and while we don't necessarily always take that as gospel, it would warrant further investigation if that was there so I might use it as a bit of a screener but with a grain of salt! 

Sam: With a few grains of salt! 

Honey: Yeah, but where people are concerned about potential obstructive sleep apnoea, we will often use an overnight oxygen run to look at clusters of desaturations in REM [rapid eye movement], which is pretty characteristic of obstructive sleep apnoea. So, we might use that in some circumstances to try and prioritise or try and figure out whether they're going to fit into a more severe category of obstructive sleep apnoea. So, we will use those occasionally. But that's done from a sleep clinic per se, yeah. 

Sam: And you mentioned there around patients who are in potentially rural or remote situations, they might just use what they can get. So, obviously Queensland is a very big place and there's lots of rural and remote communities. So, if they don't have a sleep specialist visiting or in the local area, what’s the advice for them? Do you do a lot of remote monitoring in that sense? Is that how you work as a central system? 

Honey: So here in Queensland, we are a centralised service, so the Queensland Children's Hospital has the sleep service for the state – which can be kind of difficult. There are people who are trained in sleep medicine in Townsville as well. 

But we do a lot of telehealth. So just because you're remote, doesn't mean we can't do a lot online or via telehealth. I often prefer to work with local clinicians, mainly to try and support them in understanding what's going on, but also so they can look in the mouth and look in the nose and things for me. So, if they've already done that, then I'm often happy to telehealth to families.  

Unfortunately, the internet access is not always fantastic. So, in those sorts of circumstance, I really advocate for telehealth to the local hospital because that will often work quite well. So, I do regular telehealth in every clinic I do around the state. So that rural and remote should not be a barrier to seeking access or to referral at all. 

Sam: Great to hear. Now my last question, thank you so much for your time. What resources do you recommend that are for health professionals or the public that you find just consistently reliable, whether it's online things or handouts or courses, things like that. 

Honey: So probably the 2 ‘go to’ for the Australian context are probably the Raising Children's Network, which has a number of sleep handouts that are good for primary care and for families. And the Australasian Sleep Association has a number of resources on their website that can be particularly useful, particularly around strategies for management as well. The American Sleep Association has some strategies as well, a little bit Americanised, so they sometimes jar a little bit for Australian context, but those are probably the 3 ‘go to’ that I would use, particularly the Raising Children's Network for handouts for management for families. 

Sam: Wonderful. Alright, well, thank you so much for your time today. It was an absolute pleasure and very interesting to learn all that from you. So yes, thank you once again Honey. 

Honey: No problem, thank you. 

Sam: Today we've been talking to Dr Honey Heussler from the Queensland Children's Hospital. For more information on today's topics, visit the Health and Wellbeing Queensland website at hw.qld.gov.au We’ll see you next time on the Clinician's Guide to Healthy Kids.