Sarah Morsbach Honaker

Sleep in pediatric primary care: A review of the literature

Primary care is a critical setting for screening and management of pediatric sleep difficulties. This review summarizes studies examining the prevalence of sleep problems in primary care settings as well as current practices in screening, diagnosis, and management, including behavioral recommendations and medications. Potential barriers to effectively addressing sleep are also reviewed. Despite the high prevalence of pediatric sleep problems in primary care, rates of screening and management are low. Primary care providers receive minimal sleep training and have resulting gaps in knowledge and confidence. Parents similarly have gaps in knowledge and many factors contribute to their identification of sleep as problematic. Recommendations to improve the provision of sleep services in pediatric primary care are made in the areas of research, practice, and education.

Identification and Management of Behavioral/Mental Health Problems in Primary Care Pediatrics: Perceived Strengths, Challenges, and New Delivery Models

This study describes the experiences of and barriers for pediatricians in Kentucky in providing behavioral/mental health (B-MH) services in primary care settings. These data will serve as a foundation for improving service delivery. An online survey was completed by 70 pediatricians. Descriptive data are presented. More than 90% of the respondents said that they saw at least one patient a month with 1 of 10 specific B-MH diagnoses. Physicians’ comfort with diagnosing and treating disorders varied widely by diagnosis, age-group, and drug classification. Major barriers to providing optimal care were inaccessibility of mental health professionals for consultation and referral, lack of communication, and lack of knowledge. Respondents were more likely to favor consultation and co-location models over an integration model of care delivery. Overall, the authors found that pediatricians are dealing with patients with B-MH problems for which they may not have been adequately trained. Communication and collaboration needs were identified.

Bedtime Problems and Night Wakings in Young Children: An Update of the Evidence

Bedtime problems and night wakings in infants and young children are prevalent, persistent, and associated with a variety of impairments in youth and their families. Assessment strategies include clinical interview, sleep diaries, actigraphy, and subjective measures. A number of treatment approaches with varying degrees of empirical support are available, and several novel strategies have been evaluated in recent years. Appropriate sleep scheduling and a bedtime routine are important components of any treatment program.

Implementation of Sleep and Circadian Science: Recommendations from the Sleep Research Society and National Institutes of Health Workshop.

Sairam Parthasarathy, MD1; Mary A. Carskadon, PhD2,3; Girardin Jean-Louis, PhD4; Judith Owens, MD, MPH5; Adam Bramoweth, PhD6; Daniel Combs, MD1; Lauren Hale, PhD7; Elizabeth Harrison, PhD8; Chantelle N. Hart, PhD9; Brant P. Hasler, PhD10; Sarah M. Honaker, PhD, CBSM11; Elisabeth Hertenstein, PhD12; Samuel Kuna, MD13; Clete Kushida, MD, PhD14; Jessica C. Levenson, PhD10; Caitlin Murray, MA15; Allan I. Pack, MD, PhD13; Vivek Pillai, PhD16; Kristi Pruiksma, PhD17; Azizi Seixas, PhD4; Patrick Strollo, MD18; Saurabh S. Thosar, PhD19; Natasha Williams, MD4; Daniel Buysse, MD6

Stakeholder Perspectives on Barriers for Healthy Living for Low-Income African American Families

Background: Childhood obesity is a growing problem for children in the United States, especially for children from low-income, African American families. Objective: The purpose of this qualitative study was to understand facilitators and barriers to engaging in healthy lifestyles faced by low-income African American children and their families. Methods: This qualitative study used semi-structured focus group interviews with eight African American children clinically identified as overweight or obese (BMI ≥ 85) and their parents. An expert panel provided insights in developing culturally appropriate intervention strategies. Results: Child and parent focus group analysis revealed 11 barriers and no definitive facilitators for healthy eating and lifestyles. Parents reported confusion regarding what constitutes nutritional eating, varying needs of family members in terms of issues with weight, and difficulty in engaging the family in appropriate and safe physical activities; to name a few themes. Community experts independently suggested that nutritional information is confusing and, often, contradictory. Additionally, they recommended simple messaging and practical interventions such as helping with shopping lists, meal planning, and identifying simple and inexpensive physical activities. Conclusion: Childhood obesity in the context of low-resource families is a complex problem with no simple solutions. Culturally sensitive and family informed interventions are needed to support low-income African American families in dealing with childhood obesity.

The Sleep Checkup: Sleep screening, guidance, and management in pediatric primary care.

Few studies have examined strategies to address sleep difficulties and promote sleep health in pediatric primary care. The aims of the current study are to (a) describe the content, acceptability, and preliminary feasibility of the Sleep Checkup delivered by behavioral health providers in two urban primary care clinics and (b) report child sleep outcomes from the implementation of the Sleep Checkup. Participants were 83 children ages birth to 18 years, presenting to their primary care provider (PCP) for a sick- or well-child visit. Thirteen faculty PCPs responded to an anonymous survey about their perception of the service. The percentage of parents with concerns about their child’s sleep ranged from 0% for newborns to 41.6% for preschoolers. Of those reporting no concern, more than half subsequently reported sleep symptoms or practices suggesting a sleep problem or disorder. Providers reported overall high satisfaction. They rated the service as beneficial to providers (M = 4.85; 5 = strongly agree), to patients (M = 4.77), and to trainee learning (M = 4.77). Providers did not find the Sleep Checkup disruptive to patient flow (M = 1.08; 1 = strongly disagree). High rates of problematic sleep habits and symptoms of sleep disorders were found in an urban primary care sample, including in children whose parents denied any sleep concerns.

Unexplained Practice Variation in Primary Care Providers' Concern for Pediatric Obstructive Sleep Apnea

OBJECTIVE To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA. METHODS A computer decision support system that automated screening for snoring was implemented in 5 urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children aged 1 to 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site. RESULTS PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (P < .01; odds ratio [OR] = 0.13), Spanish language (P < .01; OR = 0.53), provider training (P = .01; OR = 10.19), number of training years (P = .01; OR = 4.26) and child age (P < .01), with the youngest children least likely to elicit PCP concern for OSA (OR = 0.20). No patient health factors (eg, obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range, 6-28%) and between specific providers (range, 0-63%). Of children referred for polysomnography (n = 100), 61% completed the study. Of these, 67% had OSA. CONCLUSIONS Results suggest unexplained small area practice variation in PCP concern for OSA among snoring children. It is likely that many children at risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification.

Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey

Objective To describe parental practices implementing behavioral sleep intervention (BSI) outside a clinical setting. Study design Parents (n = 652), recruited through a Facebook group designed as a peer support group for parents using BSI, completed an online survey about their experience using BSI with their infant or toddler. Results On average, parents implemented BSI when their infant was 5.6 (±2.77) months. Parents most often used modified (49.5%) or unmodified extinction (34.9%), with fewer using a parental presence approach (15.6%). Regardless of BSI type, more parents endorsed “a great deal of stress” during the first night (42.2%) than 1 week later (5.2%). The duration of infant crying was typically greatest the first night (reported by 45%; M = 43 minutes) and was significantly reduced after 1 week (M = 8.54 minutes). Successful implementation of BSI on the first attempt was reported by 83%, with a median and mode of 7 days until completion (79% by 2 weeks). Regardless of BSI type, after intervention parents reported their infant had less difficulty falling asleep, fewer night awakenings, and were more likely to sleep in their room and/or in their own crib/bed. Conclusions The majority of parents report successfully implementing BSI, with significantly reduced infant crying by the end of 1 week and success within 2 weeks. Few differences were found between behavioral approaches.