Pediatric Sleep Medicine at UPMC Children’s – The Effects of COVID-19 and a Durable Shift Towards Telemedicine to Expand Access for Patients

Deepa Burman, MD, FAASM, associate professor of Pediatrics in the Division of Pediatric Pulmonary Medicine, and co-director of the Pediatric Sleep Evaluation Center at UPMC Children's Hospital of Pittsburgh, explains that an interesting phenomenon occurred in many, if not all, of the program's child and adolescent patients at the beginning of the COVID-19 pandemic: they all started to get better.

"The reason we saw this sort of collective improvement seemed to make sense in the beginning," says Dr. Burman. "Collectively, our entire society is chronically sleep deprived – adults, children, and adolescents alike. During the first month or two of pandemic closures and lockdown, we all had more time for sleep, allowing our bodies to follow their optimal sleep-wake patterns. This was particularly true in adolescents whose internal body clocks are shifted towards a later bedtime and waketime. Since they no longer had to wake up early for school, the total amount of time they slept increased transiently."

But, as Dr. Burman explains, the gains or positivity of the situation fell apart, and rather rapidly. With a lack of set schedules, particularly in older children and adolescents, coupled with the ongoing nature of the pandemic and the anxiety and forced social isolation accompanying it, sleep disturbances got worse and more people began experiencing sleep issues, and a lot of them were children and adolescents.

“You probably couldn’t plan a better way to affect the sleep of individuals and increase the severity or incidence of sleep disturbances than what we have gone through with COVID-19, explains Dr. Burman. “Lack of schedules, prolonged isolation from friends and school, anxiety about the future – lots of bad news 24/7 in the media and social media, was the perfect storm for ramping up sleep disturbances and disorders.”

And, as Dr. Burman explains, once someone begins to have pronounced difficulties with sleep, it is very easy for them to go down on spiral pattern and get progressively worse.

“Once there is a trigger for insomnia, or a patient is experiencing a lack of sleep, unless we work to change the cognitive factors at play or the counterproductive management approaches that people will sometimes employ to try and compensate, like napping at inopportune times or turning to alcohol or drugs to try and fix the problem, the difficulties and consequences usually get worse,” says Dr. Burman.

Younger children experiencing sleep difficulties tend to be more irritable or hyperactive; they become more emotional or prone to outbursts or tantrums. School-age children and older adolescents have difficulty focusing and with attention; they may fall asleep in class or show other behavioral manifestations.

"Our sleep medicine patient load became much busier during the initial phase of COVID-19, but it has also continued to increase for several reasons," says Dr. Burman. “This has been true for both younger and older children. COVID-19 has not gone away, and I think some of the effects we are seeing are directly related to those early months when the lives of these individuals were upended. But we also live in a world that makes it easy for sleep to suffer, especially in older children. Society hasn’t fully caught on to the fact that children and adolescents have very distinct optimal sleep needs and sleep-wake patterns that can be incompatible with how their daily schedules are structured.

A Necessary Embrace of Telemedicine May Have Lasting Impact – Increased Specialist Access

By necessity, hospitals and healthcare systems were forced to rapidly pivot and expand telemedicine services for patients during the early phases of the pandemic as a means of continuing care as efficiently as possible.

Dr. Burman says, “Because we were quickly able to adapt to telemedicine and switch to a virtual setting, our clinic volumes were well maintained and continued to be very effective in delivering care even during the peak stages of the pandemic. Patient needs and access didn’t disappear because everyone was stuck at home. In fact, for our services, we were needed more than ever because of how disruptive and stressful the world became for all of us, but for children and adolescents, and how this manifested in worsening sleep disorders or the appearance of new ones.”

As Dr. Burman explains, sleep medicine is one of those disciplines in which telemedicine can effectively interact with and manage patients.

"I've had a long-standing personal interest in trying to develop a telemedicine option for sleep patients, but there have always existed a lot of roadblocks around such things as insurance coverage and technical issues with virtual platforms," says Dr. Burman. "Even before the pandemic, you could easily justify a telemedicine approach because there are insufficient pediatric sleep medicine specialists to manage the need in this country. Outside of areas with academic medical centers or tertiary care children's hospitals like Pittsburgh, it can be challenging to find a pediatric sleep specialist. Outside of larger cities, there are very few pediatric sleep specialists, even in areas surrounding the Pittsburgh region. Those patients must travel, and many come to our program. Several patients travel more than 2 or 3 hours to attend clinic evaluation and follow-up visits."

But travel for healthcare needs can be difficult, expensive, or simply not an option for many families and patients. And for some conditions, travel may not be necessary if a viable alternative such as telemedicine is available.

"For sleep specialists, we can easily assess the adequacy and efficacy of medications prescribed to our patients during a telemedicine visit," says Dr. Burman. "We can conduct limited exams, discuss and work through optimal care management and counseling remotely."

For newly diagnosed and complex patients with insomnia or those who need behavioral sleep psychology visits, the frequency of visits during the early phases of treatment is higher. But again, geography or other restrictions may exist that make it difficult to get to the clinic reliably. Telemedicine allows specialists like Dr. Burman to closely monitor these individuals from afar.

Telemedicine also comes with unique challenges that providers must be cognizant of and have a plan for managing. Computer network or connection issues sometimes need to be taken care of on virtual platforms. At other times caregivers or proxies are present for a visit without the patient, or even may try to do a visit while driving, which is not optimal. Vital signs are unable to be obtained reliably, or the caregiver/patient is in a public place. Since telemedicine visits are medical appointments with the same medico-legal implications as traditional office visits, they should mirror traditional office visits in appropriate conduct and occur in HIPAA-compliant locations where patient privacy can be maintained.

By and large, patients and providers have embraced the use of telemedicine and its benefits, and more likely than not, telemedicine will continue to evolve and grow across the entire spectrum of healthcare.

UPMC Children’s and its many Divisions, some with already existing robust telemedicine platforms, were able to quickly adapt and expand this essential method for continuing to see and manage patients – locally but also more distantly and contribute to increased access to care.

"Without optimal sleep, children and adolescents suffer. Adults too, but the effects can be much more profound and long-lasting in children. For our discipline – pediatric sleep medicine – telemedicine is the only viable way to quickly increase capacity and access for patients who otherwise would go without specialty care," says Dr. Burman. "Our program and Division will continue to offer telemedicine for our patient population and look for ways to increase its efficacy and ability to serve a broader population of children and their families.

Learn more about Dr. Burman and the Pediatric Sleep Program at UPMC Children’s.