Dr Susan Millard on the Choosing Wisely Campaign, Pediatric Sleep Recommendations

Aligned with recommendations published through the Choosing Wisely Campaign, pediatric sleep studies should be performed and interpreted by pediatric, not adult, standards, as sleep conditions can have extensive ramifications on a child’s development if not assessed properly, said Susan Millard, MD, FAAP, pediatric pulmonologist at Helen DeVos Children’s Hospital and associate professor of pediatrics at Michigan State University.

Transcript

AJMC^®: Hello, I’m Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care^® is pleased to welcome Susan Millard, MD, FAAP, a pediatrician and coauthor of a list of 5 recommendations that physicians and patients should question on pediatric pulmonology and sleep in children as part of the Choosing Wisely Campaign.

Great to have you on, Susan, can you just introduce yourself and tell us a little bit more about your work?

Dr Millard: Thank you, Matthew! I’m a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Michigan, and then the associate professor of Pediatrics at Michigan State University. I also am the section chief of our Pediatric Pulmonary and Sleep Medicine group here at the Children’s Hospital.

AJMC^®: To start us off, can you speak on the Choosing Wisely initiative? What goals are being targeted through this campaign?

Dr Millard: So, the Choosing Wisely Campaign was started by the American Board of Internal Medicine, and many partners in the United States of America are part of it to help patients, families, medical providers, physicians, nurse practitioners, and physician assistants understand what is the best type of medicine to provide, as opposed to just willy nilly going through what used to be rote practice and not have thought and consequences for people.

AJMC^®: What warranted the need to better educate physicians and patients on pulmonology and sleep-related aspects in pediatrics?

Dr Millard: Well, many parts of the American Academy of Pediatrics have worked with Choosing Wisely, including groups like neonatology, The Hospitalist. There are societies for otolaryngology, many different partners in all aspects of medicine. Their goal is really to help people with specific topics so that physicians and advanced practice providers can figure out what’s safest, best, and cost-efficient for patients and families.

AJMC^®: In 1 of the 5 recommendations listed by the Choosing Wisely campaign, it was noted that pediatric sleep studies should be performed and interpreted according to pediatric standards and not adult. Is this a prevalent issue, and how can parents ensure their child is properly assessed for sleep issues?

Dr Millard: Yes, that’s a great question. Unfortunately, there are many sleep labs that are out there that advertise for anyone to go to them, but pediatric patients are definitely a specific group. It’s not just kids that snore—we’re seeing an increased risk of obesity, we’re seeing children that might have other medical problems like congenital heart disease, patients with Down syndrome that really need special care, and are not appropriate for centers that don’t focus on pediatrics.

One of the big problems is that people understandably want to go to the closest place, but don’t investigate. Some sleep studies, they’ll do it on a 5-year-old patient and it’ll get performed, but they don’t do End-Tidal CO2 [carbon dioxide] monitoring, which is part of the pediatric recommendations for sleep studies.

They might not analyze the results as thoroughly as a pediatric-focused sleep doctor would. Sometimes things like shallow breathing, called hypopnea, can be difficult to analyze, and they could miss those. Also, adult criteria for sleep studies are more liberal for obstructive sleep apnea than pediatrics. And the developing brain really develops through early college years. So, it’s very important to be safe and somewhat conservative in how we’re diagnosing sleep apnea so that we’re not affecting a child’s development and ability to be a productive adult.

So it’s very important. We have patients that come from farther away that bring a sleep study from a local lab and the parents are upset when they have to have a second sleep study. The other problem is some of the adult labs will diagnose sleep apnea in a pediatric patient, but then not manage it. That’s a problem too because then they want us to manage it, but we need to have a study that’s appropriate for that patient. So, it’s duplication of services.