Dr Jim Papadopoulos: The Sleeping Child

Do you know that there is a specialist who can help you with your sleep problems, too? We've talked a lot about getting adequate sleep, but I don't think we've covered everything there is to know about it.

Today, we are talking to one of Australia's leading experts in this field. It's Dr Jim Papadopoulos. Jim is a Paediatric, Respiratory and Sleep Medicine Physician. He is widely known for his work with sleep studies in children, and in particular, children with special needs, orthodontic problems, and gastrointestinal issues.

Dr Jim Papadopoulos: The Sleeping Child Introduction

Well, we’ve focussed on sleep many times and I don’t actually think you can focus on it enough. It’s like tapping a hoop along. You just need to keep tapping it along to make sure that it’s rolling along and moving along nicely through life. As soon as you stop tapping that hoop it props and so does your health with it if sleep is being that metaphor for the hoop.

Well today, we are talking to one of Australia’s leading experts in this field. It’s Dr Jim Papadopoulos. Jim is a Paediatric, Respiratory and Sleep Medicine Physician. We cover a wide range of topics here. It’s so good to catch up with Jim. I refer many patients to him. I have done it for over 10-15 years. He is quite literally brilliant and I’m sure you’re going to find him to be so as well. I hope you enjoyed this conversation I had with Dr Jim Papadopoulos.

Podcast Transcript

Dr Ron Ehrlich: [00:00:00] Before I start, I would like to acknowledge the traditional custodians of the land on which I am recording this podcast, the Gadigal people of the Eora Nation and pay my respects to their elders past, present and emerging.

Hello and welcome to Unstress. My name is Dr Ron Ehrlich. Well, we’ve focussed on sleep many times and I don’t actually think you can focus on it enough. It’s like tapping a hoop along. You just need to keep tapping it along to make sure that it’s rolling along and moving along nicely through life. As soon as you stop tapping that hoop it props and so does your health with it, if sleep is being that metaphor for the hoop.

Dr Ron Ehrlich: [00:00:45] Well today, we are talking to one of Australia’s leading experts in this field. It’s Dr Jim Papadopoulos. Jim is a Paediatric, Respiratory and Sleep Medicine Physician. We cover a wide range of topics here. It’s so good to catch up with Jim. I refer many patients to him. I have done for over 10-15 years. He is quite literally brilliant and I’m sure you’re going to find him to be so as well. I hope you enjoyed this conversation I had with Dr Jim Papadopoulos. Welcome to the podcast, Jim.

Dr Jim Papadopoulos: [00:01:20] Hi, Ron. How are you going, mate?

Dr Ron Ehrlich: [00:01:21] I’m going very well. I’m going very well. I’ve been looking forward to this discussion. We’ve been, well, we’ve been sending you patients for many years and are always so impressed with your whole approach. And I’ve been looking forward to getting you on the programme just to share you with all of our listeners. 

You know, the medical profession divides up specialities in so many different ways. It’s sometimes surprising for patients to hear, and sometimes even surprising for medical practitioners themselves to hear that there are Sleep medicine physicians, let alone paediatric, respiratory and sleep medicine physicians. Can you tell us a little bit about your speciality?

Dr Jim Papadopoulos: [00:02:03] Well, I was surprised that there were sleep specialists as well when I was training. I intended to be a general paediatrician, and when I got to the end and you got to choose like three years of electives, I thought, what don’t I know much about? And one was developmental delays and disabilities, and I thought that would be important. First, for a general paediatrician and sleep medicine at Sydney Children’s, there was a, you know, there was a fellowship available and I decided to do that.

And after I did the fellowship, I realised that I needed to change course and become like a general paediatrician of the night because that’s what sleep medicine is. Paediatric sleep medicine is how you fix things in the paediatric world, which are really important things like, you know, concentration, behaviour, learning, anxiety, all these the hard things that people try and address during the day with medication and other interventions. 

I realise that they could be, you know, sorted and improved and sometimes even cured by fixing the sleep problem, which was underlying and causing it. And that’s the mentality, which I think isn’t out there enough yet.

Even though the research into children in their sleep, like the first sort of paper were published in 1981 by Christian [Inaudible 00:03:17], who sadly passed away a few years ago, into how sleep affects concentration, behaviour, learning in children and then the first sort of papers are published about obstructive sleep apnoea and its effect and how treating it would then help all of these issues. 

And then it became obvious that anything that wrecked your sleep would have those consequences on you during the day, it didn’t have to be obstructive sleep apnoea. It could have been just not getting enough hours of sleep or getting poor quality sleep for some other reason – Reflux, allergies, asthma.

Dr Jim Papadopoulos: [00:03:48] So there are general paediatric issues which affect your sleep, right, and then have consequences during the day and people suddenly became aware, or at least in sleep medicine, became aware that it was the chicken and the egg question that came up: “Is the child anxious because of their sleep problem? Or do they have a sleep problem because they’re anxious?” And it became more and more obvious that, for example, with anxiety, it was the poor sleep which was causing the anxiety. 

Or did they have A.D.D. and then don’t sleep well because of their A.D.D.? Or is it that they’re not sleeping well and that’s causing the A.D.D. or contributing to it, at least.

And that’s where it became obvious that sleep was actually the chicken and it was laying eggs during the day and we needed it. Yeah. So that’s how I got interested in it. And it’s not a new speciality. So, for example, it was back in the early 90s, the first sort of professors of paediatric sleep were sort of appointed in it. 

For example, in Boston and stuff. So and it’s actually and the other really interesting thing is that it’s been since 2011, which is more than 10 years ago now that it was recommended that sleep studies be done in children. We used suspected obstructive sleep apnoea as a standard, not as an option.

And even that’s lagging in terms of its implementation. 10 years later and you know, as well as I do that, that’s not the way things are done in most cases, partly because of the availability of sleep medicine specialists and the sleep studies. Obviously, it’d be better if we could have more of these facilities around to actually cater for the huge need. 

But you know, if you think about how many people are affected by sleep disorders and in children like I can talk to the paediatric population, 30% of children will have a clinical sleep disorder – 30%. And in the end, a developmental delay in the disability area rises to 60 %. And then if it’s autism, for example, it’s 80% of those kids are going to have sleep problems. Right?

Dr Jim Papadopoulos: [00:05:48] So there’s a huge need out there for people to recognise that sleep medicine is an important part of managing children’s health, not just mental health, but also their physical health. Because sleep disorders affect your growth. If it can affect your heart and your lungs, that can affect all sorts of other things – your immune function, et cetera, et cetera, et cetera, especially immune function lately has been important, isn’t it?

Dr Ron Ehrlich: [00:06:11] Yeah.

Dr Jim Papadopoulos: [00:06:11] You know. Yeah, and it affects you. And then as I developed in my practise, I realised that orthodontic issues were linked to sleep as well. And that’s where you’ve come in and you’ve recognised that for many years now, and that’s why you’re serving your patients well by getting their sleep sorted as well as their aesthetic and orthodontic and, you know, dental issues, you’re helping them with their mental and physical health, not just short term, but long term as well. Because if you pick up these sleep disorders in kids, you pick them up early, you save more IQ points. 

The earlier you pick them up, you get better orthodontic outcomes, you get better academic outcomes, you get better social outcomes and then you end up with kids who can outgrow their sleep disorders and even sleep apnoea is treatable and outgrow. So that ended up adults who snore and have an increased risk of stroke, high blood pressure, heart attacks, car accidents. You know, when all the family disruption and stuff that comes from having one or both parents who are always cranky, you know. Sleep problems.

Dr Ron Ehrlich: [00:07:15] Yes. Well, I think the message that our listeners will have got over the many years we’ve had this podcast is that sleep is without a doubt the most important part of the day. I’ve heard it described as your built-in life support system. Non-negotiable, hopefully, but you’re looking at it, not just from an ENT perspective, not just from a respiratory perspective, you’re looking at it from a whole-body perspective. And what sets people up for problems?

Dr Jim Papadopoulos: [00:07:42] I think one of the main things I learnt was that physical sleep disorders are the main issue, and behavioural sleep disorders come as very often as baggage because people have got a physical sleep disorder. So the physical sleep disorders get set up by your genetics. These things run in families, so you often find, say, for example, with obstructive sleep apnoea that one or both parents will snore.

It’s an especially strong gene if it’s the mother who snores. Not so much the dad, but to say if the mother’s a snorer, it’s like twice as likely that their kids are going to have sleep apnoea than which is not, for example. So genetic factors play a role.

And it’s the same with the gut issues they usually inherited, as well. As one or both parents or other extended family members will have if they’ve got… If the child has, say, reflux or irritable bowel like gut issues disturbing their sleep, the parents will have that as well. Same with restless leg syndrome. Same with, you know, allergies and asthma and same tendency to be, say, a late sleeper, light waker. All of these things can be hardwired in us and run in families. And the consequences then also seem to run in families.

So you’ll have the kids who have trouble with concentration, behaviour, learning, anxiety, irritability, et cetera, insomnia. And the parents and siblings will also similarly have issues like that. And it’s because they have the same physical issues at night, disturbing sleep leading to the same daytime consequences. 

So really, what sets you up is that and what the tragedy is that these sleep disorders are eminently treatable and eminently diagnosable. Like if you take one step back, you can figure out what’s wrong with people and with kids especially, and you can figure it out early.

Dr Jim Papadopoulos: [00:09:32] Sleep studies are done down to zero years of age, and the most important age group in terms of sleep apnoea and diagnosis actually is between one and two years of age. When they’re at risk of having severe sleep apnoea. 

So people often don’t know that they don’t, well, have to wait till they’re five years old to have a sleep study or something. And that’s not true. And the sooner you get it, the better. The sooner you figure out what the sleep disorder is, the better. Figuring out the sleep disorder is a really important thing, Ron. I think that’s a real key to get things sorted of.

Dr Ron Ehrlich: [00:09:59] I’m going to tweak and talk about the diagnosis and the treatment. Now, I’d just come back to genetics because it’s often said that genes load the gun, but it’s nutrition and environment that pulls the trigger. And in my observation, when I see someone come into my practise with all 32 of their teeth through an imperfect alignment because we know the size and shape of the mouth fixed the size and shape of the upper airway, it is so rare. I mean, literally, it would be less than five… 95% of people do not have enough room for all of their teeth. 

So we’re kind of… That’s quite a shocking statistic. But in my clinical observation, I think that science may bear that out. But my clinical observation is that so you know, we start with narrow jaws and of course, people within families are eating the same diet. So if something’s upsetting the parents’ digestive system, it’s invariably going to upset the child.

But coming back to diagnosis? And I’ve often been intrigued by sleep studies because I’ve done one myself. I’ve done it at home. I’ve been strapped up with electrodes all over my body and the little finger thing on my finger and around my chest and this nut. And first, my first reaction is the clinician who really recommends this to patients is: How accurate? Well, tell us firstly, what a sleep study is.

Dr Jim Papadopoulos: [00:11:24] Okay, so…

Dr Ron Ehrlich: [00:11:25] Let’s start from the beginning. I got to hear it myself.

Dr Jim Papadopoulos: [00:11:27] I know I get this question all the time, and it’s actually quite like in kids, it’s easy. In adults, it might be a bit different because there are home sleep study options. But in children, you have to do sleep studies in labs. You can’t do it in any other way simply because you need to monitor them all night and go in and adjust things so that you get a very accurate result and accurate result is accurate for someone having a sleep study in a lab in a child. Right? 

So if you get a thousand children having sleep studies in the lab, you can then develop statistics as to what sleep looks like in children having sleep studies in labs. We don’t know how they sleep at home. So we know, for example, that in a lab, a child should have less than one obstruction per hour of sleep. More than one per hour is, you know, it is very unlikely to be normal, less than 0.3%. We’re looking at the statistics. But if you got more than one obstruction per hour, you actually still normal.

So the statistics can be built, and they were built back in the 80s and 90s, so we’ve known for a long time that sleep studies are accurate in terms of diagnosing what the difference is between normal and abnormal sleep because all the kids have the same procedure in a lab, right? So they all have the whys on them. They all have nasal prongs, they all have stretchy belts. And their sleep ends up looking like x y z, right? Whereas at home, they’ll sleep differently. 

But we don’t measure it at home, so we don’t know what normal is at home, right? But we do know what normal is in the lab. And in a lab, the studies have shown that you can do five nights in a row or five weeks in a row. You get the same results ifs not. Because looking at a whole night of sleep with lots of sleep cycles in it.

Dr Jim Papadopoulos: [00:13:07] And that statistically becomes very robust. It’s like doing a study on having 5000 participants instead of having just five. You’re going to get statistics that mean something and that are robust. And, you know, for example, arousals per hour should be less than 10 per hour in a sleep study. Restless leg, periodically movements per hour should be less than five per hour. 

The percentage of dream sleep should be between 20 and 25 when they reach that sort of age group about eight or nine. And it’s more that… We know all of the statistics, and then we can interpret the results of a sleep study done in a lab, done right, done according to the rules by experienced people and then interpreted by experienced people. Then you get results, which means something.

Dr Ron Ehrlich: [00:13:52] So, let’s start with what is a normal or an ideal night’s sleep. And of course, the time varies with age in terms of requirements. Can you just give us a sort of 101: What is an ideal, you mentioned a few things there, but what’s an ideal night’s sleep? What’s a good night’s sleep?

Dr Jim Papadopoulos: [00:14:10] So, say, you expect that you expect in terms of the hours of sleep, that’s a lot of people ask about, but that can vary. If you’re over, sort of, 16 to 18, you need about eight hours of sleep or eight or nine. Between sort of 12 and 16 to 18 adulthood. You need about nine hours of sleep. Surprisingly enough. Yeah, a lot of 15 and 14-year-olds are not getting nine hours of sleep. 

Between the ages, sort of, you know, 4 or 5 and 12, that sort of childhood period, you need about 10 hours of sleep. And under that when you’re napping, you might get an extra half hour up until, you know, between the ages of sort of 4 and 5. And then you shouldn’t have naps during, you shouldn’t need any naps during the day up to age five.

And then we go down into the infant sort of the toddler groups and the infants, and they need sort of 11 hours. And then in the under one-year-olds, there’s a whole range like it’s too gritty to really go into here. But everyone knows that the newborn infant, for example, will sleep and wake according to their feeding cycles. 

After about three months of age, they tend to sleep through the night. Will start to sleep through the night after 12 weeks, and then they might have, you know, 12 hours of sleep at night and another two or three during the day with naps and stuff. So it becomes, that’s it as a general rule.

But if you’re looking at a maybe orthodontic age group or whatever the paediatric age group, they should fall asleep within half an hour. They should be able to fall asleep on their own without a parent there. They should stay asleep, maybe like once for toileting, you know? But and then in the morning, when they wake, they should wake on their own and look refreshed in morning. They shouldn’t be hyperactive in the mornings. They shouldn’t be cranky in the morning. 

During the day, they should have normal sort of concentration and behaviour, and that varies with age as well. You don’t expect a two-year-old to act the same way as a five or six year old. But if they’ve got age-appropriate behaviour, then that’s a good, good sign that they’re getting decent sleep.

Dr Jim Papadopoulos: [00:16:06] Learning issues and stuff could be a hallmark that your child’s not sleeping well, even if they’re sleeping or not if they have issues with, say, concentration or irritability, especially in the afternoons or when they wake up. 

The trouble with language-related things is common in sleep disorders, and I’m not sure why that is, but it seems to me that the developing language really needs good sleep and it can be pronunciation difficulties as well because maybe the way that your jaws are forming and you’re using your tongue in the way that you chew stuff and interferes with how you can pronounce things. And then there are tongue ties and lips, and all of that can interfere with the pronunciation, which is also linked to sleep disorders, either respiratory or other.

And the other thing that’s really important to point out is that a lot of these kids have issues with feeding, with eating and stuff during the day, restrictive diets, avoiding chewy foods, preferring milk and dairy, being thirsty a lot. All these can be hallmarks that your child’s actually got reflux, and that reflux really mimics obstructive sleep apnoea. And it can present with snoring and sleep difficulties the same way as sleep apnoea does. And in fact, I know I’ve gone off on a tangent, but…

Dr Ron Ehrlich: [00:17:14] No, no, no. I’ve already got a question for you on that tangent. That’s important.

Dr Jim Papadopoulos: [00:17:17] Because I think that we need to get into that.

Dr Ron Ehrlich: [00:17:19] Yeah.

Dr Jim Papadopoulos: [00:17:20] If you do, so, around about 10% of children snore. You know, out of 30% have got sleep difficulties, 10% snoring. Snoring can be either vibratory or non-verbal, but non-vibratory snoring is actually more common than vibratory snoring. And that means heavy breathing in sleep and mouth breathing. So that sort of thing is snoring in children. 

They should be quiet when they sleep. Especially if you know. And often you ask the question, “Does your child snore?”, and the parent says, “No, they don’t.”, and you say, “Well, can you tell if they’re asleep by their breathing?”, And say, “Yes. We can hear them at the door.” That’s quite loud snoring.

And so of the 10% who snore, one-third of them will have obstructive sleep apnoea. Snoring with sleep difficulties, I’m talking about. The other seven don’t, but they’re still snoring and having sleep difficulties. So what’s the rest? And often, you know, a lot of the time we do the sleep studies on kids who everyone thinks for sure they’ve got obstructive sleep apnoea because they’ve got big tonsils, they’ve been snoring, they’ve noticed their pauses in the breathing when they sleep, nasal congestion all the time, they’re cranky, they wake up in the second half of the night. 

Well, sometimes they sleep through the night, but also the next day. We did a sleep study and there’s no obstructive sleep apnoea. But there are a lot of arousals and it’s a very restless sort of sleep and we can pick that up. Sometimes there are periodically movements and sleep as well. Anyway…

And those kids often have gut issues disturbing sleep. Because reflux gives you nasal congestion. Reflux gives you snoring, especially if it yeah. And reflux makes sleep apnoea worse too. They go together and sleep apnoea makes reflux worse, so it becomes a bit of a mixed part. 

That’s why you need a good sleep study to work out which of these things are affecting you so you don’t get your tonsils out for anything. Or, you know, taking out your tonsils and adenoids usually is a very good treatment for snoring, right? So to make you breathe quietly at night, but then afterwards, did your sleep improve or not? Because you can help snoring, but still have sleep difficulties afterwards. 

And sometimes you know, and I think that could be even two-thirds of the time, according to the statistics. Yes. The sleep apnoea component may have been sorted, but you also had another, gut issue. But other times it’s all gut issues.

Dr Jim Papadopoulos: [00:19:29] My three-year-old, when he was three, he’s 11 now, had big tonsils, snoring, a family history of sleep apnoea. Two of his siblings had sleep apnoea. We did his study and he had he was swallowing and gulping in his sleep. He was stopping breathing because the acid was coming up, and when acid comes up, there’s a reflex. 

We have to stop reading so you can actually see pauses and gasping in kids with reflux. So it’s not diagnostic of sleep apnoea, of obstructive sleep apnoea – to have snoring pauses, gasping, big tonsils. It’s not diagnostic. You know, they can have the narrow palate right and overjets, Ron, which you know about, right?

Dr Ron Ehrlich: [00:20:05] Yeah, yeah.

Dr Jim Papadopoulos: [00:20:05] And you think, oh, straight away, that sleep disorder breathing. But if you’ve got nasal congestion for any reason, it gives you that orthodontic outcome. It doesn’t have to be obstructive sleep apnoea. It can easily be. And in fact, more likely is something like just an allergy in your nose or reflux, according to the statistics. 

And that’s why I get excited because well, you can do so much good by figuring these kids out before you do any operations. And that’s why they made the recommendations in 2011 that you study children where here you suspected of obstructive sleep apnoea. The answer is no, not to take out tonsils and adenoids straight away. The answer is to do a sleep study first.

Dr Ron Ehrlich: [00:20:45] I’ve often heard, I actually use the analogy that taking tonsils out is something like driving along in the car and a hazard warning light comes on on your dashboard and you actually remove the globe in the dashboard to solve the problem. And actually, we did a podcast…

Dr Jim Papadopoulos: [00:21:00] Not always.

Dr Ron Ehrlich: [00:21:01] No, no, no. I know, I know. And sometimes it can really make a huge difference. But I did a podcast with a gastroenterologist, Dr Pran Yoganathan and Pran said something that really… Oh gee, I’d never thought of it. He said that he feels like a lot of reflux is a function of diaphragmatic sarcopenia, meaning underdeveloped diaphragm, which shallow breathing, shallow breathing, not using your diaphragm from a very early age could create an underdeveloped diaphragm. 

Not to mention some of the crappy food we’re eating. You know people are eating. Tell me why. Another thing we focus on is mouth breathing versus nasal breathing and people kind of know that’s interesting. Why are noses so important?

Dr Jim Papadopoulos: [00:21:47] You meant to breathe through your nose to help your breathing function properly? And it’s not just the filter, but it’s also a humidifier so that the air that gets down into your lungs is appropriate for the environment down there. You know, you don’t want to, but if you this is just during the day. It protects you to breathe through your nose.

But if you if you’re a mouth breather at night, then it potentiates it’s sort of how can I put it? It’s both a chicken and an egg. It causes problems. But it also is the result of problems. So it can act as a red flag, suggesting that you’ve got issues which are not related to your airway, which are affecting your health in a sense. So that’s the importance of the mouth breathing side of things. 

And it’s interesting how many dentists and orthodontists are aware of this stuff now and then look into what the other medical issues could be, which are leading to the mouth breathing and the bruxing and the dental enamel erosion and the not just about malalignment of teeth or, you know, not having a proper bite. 

You know, people ending up with headaches because they’re grinding their teeth or not because they reached their reflux and there is swallowing or they grinding their teeth because they’ve got periodically movement sort of restless legs and their jaw muscles are affected just like their legs are crunching through the night. Their jaws are crunching through the night or obstructive sleep apnoea is linked to that as well – the bruxing.

Anyway, so bruxing and mouth breathing tend to go together. When you see the wear on the teeth from bruxing and you see the wear on the top of the molars, sometimes you also see normally rising on the sides with a dent is coming through and you can see the yellow underneath the white.

Dr Ron Ehrlich: [00:23:28] Yup.

Dr Jim Papadopoulos: [00:23:29] Well, that is a that’s a red flag for acid getting up into the back of your teeth, especially at night when you sleep when you’re lying down flat and burning away the enamel. How many kids have you seen or your colleagues where you kept the teeth, the molars, because there’s enamel erosion and then you find out, “OK, they’re mouth breathers.” And you yourself, “It’s because they’re mouth breathing that the enamel is eroding.” It kind of probably is something else as well. Or instead of that, you know, then you’ve got acid reflux and you’ve got silent reflux. 

So the kids are not complaining and they’re not getting the burping, the hiccups, the bad breath, the stomach pains, the vomit burps during the day, but they just go to pause sleep at night, ending up with nasal congestion. Mouth breathing and the acids coming up and pushing the back of their teeth. And then they go off and they have their adenoids out, they have their turban and straight back. 

They have all sorts of intake procedures to try and fix the nasal congestion. But it doesn’t work, and they continue to be mouth breathers in sleep, and they have orofacial myology interventions, they have their tongue ties and stuff divided, and they’re still mouth breathing when they sleep. 

And you go, what’s going on now? Because you’ve missed the elephant in the room, which was that they have silent reflux. And silent reflux is actually 40% of reflux is silent, only affects your sleep, doesn’t affect you during the day.

Dr Ron Ehrlich: [00:24:50] Yes. Would you be interested to know Jim we’re doing a whole programme on laryngology? How do I pronounce that? Talking about that very subject, silent reflux. It’s huge and undiagnosed.

Dr Jim Papadopoulos: [00:25:07] And it affects your diet, Ron. You know how you think about your diet. I want to sort of do that, sort of chicken and egg thing with you flipping it around a little bit.

Dr Ron Ehrlich: [00:25:16] Mm-Hmm.

Dr Jim Papadopoulos: [00:25:17] Okay. If you’re a kid, if you’re a baby right and you’ve got reflux and you’re sucking on milk all the time because you’ve got, you need to treat your acid reflux with something because no one’s recognising reflux as an issue in babies. They’re not giving them any treatment. 

They need to breastfeed frequently every half hour. They need something to suck on, and they end up co-sleeping with their parents, and they’re driving their parents nuts because they have to be held upright all the time and stuff. Otherwise, they scream every time they’re put down.

When they move on to solids. They don’t like solids. They don’t like chewy foods. They don’t want to chew. And if you don’t chew, you don’t develop your jaws. And you see that as underdeveloped jaws… But their diet becomes a mushy diet or bland diet. They don’t have meat in their diets. Because things like the chewy or if they have made, it’s going to be minced or it’s going to be sausages or it’s going to be chicken nuggets, it’s going to be something soft that goes down easily, you know, because swallowing through a burnt food pipe can be painful or they do it once something gets stuck and they go, I’m never touching that food again. 

At the age of sort of two or three. And they become children who never use their jaws and don’t chew, and they have just sort of processed foods all the time. And that and that’s not good for their health. But it’s also is it the chicken or the egg? Their diets become that are poor and you try and fix their diets. 

But the child, if you haven’t fixed their reflux stuff, right, then they don’t want to eat the new food that you’re telling them, “This is what’s good for you.” Because it’s not comfortable for them to eat it and they don’t like it. They still prefer their old diet. And you’re trying to change someone’s habits. You’re pushing it uphill. Whereas if all of a sudden, like if we’ve diagnosed the reflux, the silent reflux, we treat the kids with the anti-reflux regime.

They start to eat meat on their own, they start the foods on their own. They stop having all of the milk and dairy and all the rest of it that they’re addicted to. They try new foods, they try textured foods. And this is not just the kids who are normal in the sense that, but it also in kids who’ve got sensory processing disorders, so the autistic related spectrum kids, start to eat a variety of foods instead of just restricted just having white bread all the time, you know? And that change in their diet… How good is that? 

Just from a nutrition and general point of view, just because you went, you got down to the cause, which they inherited from their parents, which is the gut issues that then determines what the preferred diet’s going to be. And their preferred diet, we think, “Oh, we change the diet. Let’s change the diet. It will fix everything.” But you’re not. You haven’t fixed the problem yet. You’ve done your offering Panadol for a toothache. You haven’t sorted out what’s wrong with the tooth? Hmm. I mean, melatonin.

Dr Ron Ehrlich: [00:28:01] Same with melatonin. Now hang on, you just screw that in, we’re going to come back to that one too. But I just wanted to come back to this reflux for a young child that’s breastfeeding because having had now four grandchildren and watched it all happen, I realise that what’s often overlooked is a young child, a young baby is being breastfed and may have colic. Is that the reflux? Is that common?

Dr Jim Papadopoulos: [00:28:26] Yeah. Yeah, that’s common.

Dr Ron Ehrlich: [00:28:27] Yeah, yeah. But what’s not addressed is the mother’s diet. But there is something within the mother’s diet that is causing this.

Dr Jim Papadopoulos: [00:28:36] Hundred percent. And you know, the first thing you do when you’re trying to treat infant reflux, is not put them on medication, but you eliminate cows’ milk from the mother’s diet. If they’re breastfeeding, you avoid the occasional protein. That’s the most common sort of allergen that affects their sleep. 

And all of a sudden, a lot of like. And that’s in the recommendations from 2018 International Society of Gastroenterology. Like they did an article the European Society and the American Society got together and did: How do you approach reflux in infants and children? In infancy, it’s definitely not medication, it’s the diet in the mother and avoiding the council issues.

First up, you know, that’s the first step that you do and that because it helps so many of these kids and it’s not forever. Obviously, they can start to tolerate cows’ milk and things, especially after age 12 months and stuff. Our bodies change to be able to tolerate these sorts of allergens and irritants better, but not always. But, you know, that’s a really important thing.

Dr Ron Ehrlich: [00:29:40] But some of the people that we see coming through who probably have just been seen by their GP with a young kid, an infant with reflux are on Somac with some protein pump inhibitor or something like that.

Dr Jim Papadopoulos: [00:29:55] In infancy, you don’t do that first. When they’re over 18 months of age, when they’re over 18 months of age, if they’ve still got reflux, it’s the sort of reflux that needs a paediatric gastroenterologist. Because that’s the sort of reflux… That’s not the usual sort of physiological reflux of irritant related stuff and things that you outgrow. 

If you’ve still got problems after 18 months, that could be a whole range of issues that might need further investigation and treatment because they can, you know, worst-case scenarios, you can end up with permanent scarring, for example, of your oesophagus. Obviously, if you have untreated conditions like just reflux, or it could be even allergic reflux, they assume as they’re oesophagitis.

And that can present with, that often presents with snoring and sleep difficulties. Hmm. Right. And in these kids and very, very often end up having a sleep study after they’ve had their tonsils and adenoids out and as it works, whereas, you know, I’d contend that it’s good to get things to… Did the diagnostic study first and then work out what you’re dealing with, I mean, who would go and have the headache treated with brain surgery before having an MRI scan to see? Is there a tumour? That’s the thing.

Dr Ron Ehrlich: [00:31:04] What does our children’s… Another topic, you’ll love this Jim. Another topic that we sometimes phrase that I use is: “What does your poo say about you?” Because every day we get a report card from our body.

Dr Jim Papadopoulos: [00:31:17] Yes.

Dr Ron Ehrlich: [00:31:17] And it’s one worth looking at. It’s cheap, and it’s very personalised medicine. What do poos tell us about a kid’s digestive system?

Dr Jim Papadopoulos: [00:31:28] Well, okay, I’ll start at the beginning. With the infants who’ve got the calcium protein allergy. But the obvious ones, they often have mucousy bowel motions or may even have blood in their bowel motion. But not necessarily, they could still have sort of normal infant poos and have significant benefit from eliminating the cow’s milk from the mother’s diet. If the child’s breastfed or going on a special form which is predigested, you know to make it easier for them to deal with.

So in the older age group when you’re looking at poos in nappies, you know, toddlers and things the poo it shouldn’t be dry. It shouldn’t be a poo, which sort of is like a pad which falls off the nappy that’s sort of too firm. And that could be an indication that you’re dealing with the degree of constipation. But constipation is tricky because sometimes there’s the poo is just normal, but there’s lots of it, and a lot of kids are constipated. 

Well, let’s not call it constipation, let’s call it faecal loading and do several poos a day. But it’s like the M5 tunnel, sometimes it’s full of cars and the cars are coming out all the time. It’s full of cars. It’s loaded. And other times there are cars coming into minutely and it’s not loaded inside. It’s the faecal loading which is the issue because when the colon is stretched out and it often is in families who are predisposed to these issues, it sends a signal back to the stomach to tell it to slow down it’s empty. 

And so you end up with more reflux at the top, if your colon is stretched out and it could be stressed out by hard poop, could be stressed out by soft poo. If there’s the faecal loading issue there and you can feel it in kids’ tummies, you can fiddle whether it is faecal loading or not.

We don’t do x rays to check for that. But if in general, like if a child doesn’t have a sleep problem and they’re doing a poo every one to two days and it’s sort of like comes out like a sausage and stuff, then it’s normal. You know, they’ve got the Bristol Stool Chart, then there’s nothing to worry about. 

But if there’s a sleep disorder, if there’s trouble sleeping, we focus a lot more on the poos, and we think especially if they’re diagnosed with reflux at the top end. The approach needs to include getting the poo to be as soft as porridge so that the bowel can be unstretched over time, and then it allows the stomach to start to flow faster. And that’s how you can cure the reflux in older kids 95% of the time. Okay.

Dr Jim Papadopoulos: [00:33:59] And you can change diets and things as well. But it’s important not to increase fibre too much. Because if you increase, if you give kids fibre supplements, you’ve got the fibre, the psyllium, for example, in Metamucil and all of that is like sawdust. And when you add water to sawdust, it expands. 

So you give someone psyllium when they’re in that situation and it expands the gut more instead of decompressing it. And you think you’re doing something good, but you end up with more stomach pains and all the rest of it. That’s why Osmolax is used in that specific situation.

And now remember, I’m not talking about a normal kid, a kid who doesn’t have sleep problems. Let them have Metamucil or lots of fibre in their diet and all the rest of it. And we should have fruit and we should have the normal amounts of vegetables, even if we’ve got gut issues. And the more the better. 

But at the same time, if you’re trying to get over that speed up and treat someone, it needs to be under the care of an experienced gastroenterologist and it needs to be with some Osmolax on board as well. As you know, you talked about the Somac, the Somac is really useful. My three year old was cured. You know how I told you how he was diagnosed. He was on Somac and Osmolax for about six months.

Dr Ron Ehrlich: [00:35:09] Right.

Dr Jim Papadopoulos: [00:35:09] And then he came off it and he was fine after that. And then it came back again when he was five. He started snoring again and I thought, ‘Okay, this time for sure, he’s got sleep apnoea.” We did a second sleep study and it was all the same issues again. And we treated him again and it went away, and he’s been fine ever since. So this is the thing people are predisposed to by genetics. 

They have sluggish bowel issues and it shows up in one family member has irritable bowel, another person has lactose intolerance, another person has severe reflux disease, another person has got sinus problems and they’ve had multiple operations and the nose just doesn’t get cleared up. Never does. It’s been reamed out several times and they still have sinus problems, headaches, bruxing and stuff.

And then they might have bad breath as well. And it’s so and they’ve been diagnosed with an allergy because their skin prink tests, they’ve got dust mite allergy. Well, you can have a dust mite allergy and reflux at the same time. But if you treat the allergies and you don’t respond, then it’s non-allergic rhinitis that you’ve got.

Dr Ron Ehrlich: [00:36:12] Mm-Hmm. Yeah.

Dr Jim Papadopoulos: [00:36:14] The non-allergic rhinitis is reflux until proven otherwise.

Dr Ron Ehrlich: [00:36:17] Yeah. Gee, Jim, I love this. This focus on… There are clues on the whole body. Wow, what an approach. I mean, I know it’s obvious. I know it’s obvious, but it’s not often practised or not practised often enough.

Dr Jim Papadopoulos: [00:36:34] I’ve the benefit, Ron, of working with the hardest kids in the disability clinic. I started it in 2003 and this is with autistic kids and Down syndrome and all the rest of it, right? And I had to make it work. It wasn’t good enough to just do this. “OK, you’ve done a sleep study. Doesn’t show sleep apnoea. 

Sorry, you’ve got to go and get your Ritalin.” Because these were kids who weren’t sleeping. I had to do something to help. And yeah, look, I was blessed by being involved with lots of colleagues who come from other disciplines and talking with them and then working with them and then picking up the clues that OK, in the gastroenterology field, this is what’s relevant to sleep, in the dental field is relevant to sleep, in the artificial biologists this is what’s relevant to sleep and putting it all together and then over time, finding solutions for these kids. 

I know this is a bit off track with the gut issues. But for example, in Down syndrome, 80% of those kids have got sleep apnoea in Down syndrome. When you take out their tonsils and adenoids, the chance of cure is a lot less than in the general population. Most of them still have some sleep apnoea afterwards, and in many cases, it’s accepted as okay, that’s the best we can do. Because these kids, there’s no way that we can treat them with orthodontics and we can’t treat them with CPAP. There’s no way they would tolerate and it’s tried, but I couldn’t do that. 

So I persevered. And I’ve treated so many kids with Down syndrome who still got sleep apnoea with CPAP, and they take like the way that we do it, the approach it’s logical and it’s stepwise and it’s a little bit pedantic, but it gets there at the end. Kids with autism with CPAP, kids with Down syndrome with CPAP, and that makes a huge difference to their lives. 

And now moving on, I’ve graduated them to the adult services, a lot of my kids who arrived as children now become adults with CPAP, with Down syndrome. And the thing you need to know about Down syndrome is the main causes of death like early death in Down syndrome, people in their late 20s, early 30s is right heart failure and the right heart failure comes from untreated severe obstructive sleep apnoea over many years. They don’t have to go…

Dr Ron Ehrlich: [00:38:51] And compliance, Jim, for these challenging kids?

Dr Jim Papadopoulos: [00:38:54] 10 hours a night, 9-10 hours a night.

Dr Ron Ehrlich: [00:38:57] They comply?

Dr Jim Papadopoulos: [00:38:58] Well, you got to get the right mask. You’ve got to get the right pressure. So they need safe filtration. And you can’t just put them on an automatic machine. And you can’t put them on an automatic machine for one night or two nights and then do a titration. They’ve got to get used to wearing it at home for a while before you bring him into the titrations. You got to do that the titration properly. You know, I don’t know if you noticed this, [Inaudible 00:39:21] private is the only sort of private lab which is accredited for CPAP studies.

Dr Ron Ehrlich: [00:39:24] Right? I didn’t know that.

Dr Jim Papadopoulos: [00:39:26] Well, NATA. And the other place you get CPAP studies is in the public hospitals, of course, right? So because as I said I threw myself in the deep end, I got the chance to work with lots of patients in this situation. I get the nitty-gritty of how you do this. And with the dental side of things, you know, I worked with Professor Darendililer, he’s the Professor of Orthodontics, Sydney Uni. Mm-Hmm. In a dental hospital, for many years and I had my adult colleague, Dr Andrew Ng, special interest in dental sort of sleep medicine. He did his PhD back ages ago in the mandibular advancement splints and stuff and how they fit adult sleep apnoea.

Anyway, we did a clinic week, you know, at the dental hospital, picking up all the patients coming through their chairs and we would do sleep studies on them and 90% of them didn’t have sleep apnoea, even though they had all orthodontic changes. They were all gut issues. But the ones who did still have sleep apnoea and did the orthodontic work, we found that when you put the plates in to do their maxillary expansions, the sleep apnoea would get worse while the plates were in. 

Or if they were on CPAP already, the CPAP pressure rate would go up while the plates were in. It’s only in after the course of treatment. When you take the plates out and you stop the CPAP, you can choose whether they’ve been cured or not. About 30% chance of cure after orthodontic work for sleep apnoea. In normal people and stuff.

But you know, we learnt from that and the professor knows and all of these, all of the orthodontic students, the master’s students are going through there because we were giving him like all the way through learnt that, you know, if you’re going to do an expander on someone has got sleep apnoea. They have to be covered by CPAP at the same time. So then the next sleep apnoea for the nine months that they’re on these experiments. 

The rapid makes [Inaudbible 00:41:13] and it’s important to have a fixed appliance. If you’re going to do CPAP because you got to use a full face mask for them, you know, if you have a removable appliance, it’s a choking hazard with the CPAP, right? So these are all the little things that came up out of all the years that I’ve been working in dental, with the gastroenterologists, and all that with the disability stuff. And when you say it sounds like you approach things in a holistic way, it’s because I had to. Otherwise, I wasn’t getting any results for any of my kids.

Dr Jim Papadopoulos: [00:41:42] They weren’t sleeping better after they’d come and have their sleep studies and their tonsils and adenoids out and fixed. “Doc, the elephant out of the room, which was the obstructive sleep apnoea, but left the rhinoceros and the monkeys running around still.” You know? You gotta get older now.

Dr Ron Ehrlich: [00:41:58] Now, you’ve mentioned a few special needs people, and I remember years ago when we spoke on a podcast many, many years ago, you once said something like ADHD. ADHD is a pretty big problem. I think I’ve heard the statistic one in 10 kids are diagnosed. Is that true?

Dr Jim Papadopoulos: [00:42:14] 6%. The population rate is 6% over ADHD. In sleep apnoea, in one study, 48% of the kids who had sleep apnoea had been diagnosed with ADHD and treated with stimulant medication. Thank you very much.

Dr Ron Ehrlich: [00:42:29] That’s the stat. I remember you once telling that to me, and that’s a huge statistic. What about autism? You mentioned 80% of kids with autism…

Dr Jim Papadopoulos: [00:42:38] …have got sleep problems. So that could be trouble falling asleep, trouble staying asleep, wanting to sleep, being acting sleep deprived during the day. Now the thing with autism, which is really special is that they’ve got these sensory processing issues? 

OK, so they’re more sensitive than everybody else is to things like changes in their routine, for example, so the psychological things that they’re more sensitive too, but also, you know, bright lights, smells, sounds and internal feeling. Internal sensations. The sensation of allergy in someone with autism is 10 times worse than in someone who doesn’t have autism, the sensation of reflux, the sensation of constipation, sensation of restless legs.

It makes your sleep so much more than it does, you know, your sibling who doesn’t have an autistic spectrum disorder. And so they sleep like the princess and the pea. Slight thing, a bit of discomfort, and it wrecks their sleep. So for me to help autistic kids sleep better, I’ve got to make them super comfortable when they sleep. 

So if they’ve got allergies, I need to treat them. If they’ve got sleep apnoea, I need to treat it. If they’ve got the reflux, if they’ve got constipation, if they’ve got the, you know, all of those things, we need to treat them. We need treatment effectively and all of a sudden they sleep better.

And then because sleep disorders make you more sensory, if you don’t sleep well, you’re more irritable the next day. But not just psychologically, but everything bothers you. Loud noises, bright lights, internal and external sensations and anxiety levels go up when you don’t sleep well, so you reduce all of that. 

And all of a sudden they’re sleeping better at night, and during the day, they’re less inattentive, irritable and anxious. And so they can start to learn that they can start to focus better during the day on what they’re supposed to learn and then at night when they sleep, that can be consolidated from short term memory into long term memory and translated into skills.

Dr Jim Papadopoulos: [00:44:39] Building skills only happens at night, you can teach someone how to do something during the day and they might get it. They go to sleep. If they don’t sleep well the next day, they don’t learn. They haven’t got that skill, it doesn’t translate into a longer-term benefit for their language or for their reading or for their social skills and stuff. So they start to learn and then the speech therapist starts to make progress, and then the occupational therapists start to make progress and the teachers start to make progress and they go, “Well, we need to look out for kids like this. 

They’ve got sleep problems and refer them for their sleep assessments and sleep treatment so that we can start to make progress with our programmes.” Which the NDIS is funding and they get zero bang for their buck. If the kids sleep-deprived. It comes, it’s a real integral part of trying to address developmental delays, disabilities.

But it’s not just… We mustn’t forget that they’re highly functioning kids out there, right, who are top of the class, but who are irritable and anxious. Their concentration might be better than not, like fantastic and they might be getting top marks and everything, but socially they’re a bit isolated. They might be a bit withdrawn, a bit anxious, a bit irritable, clingy. And they’ve got a sleep disorder, too. 

But because they’ve been blessed with higher abilities in a certain area, It masks it and they never thought of us having a possible sleep disorder. But they’re taken to, you know, psychologists and things for their help with their anxiety or their phobias or, I don’t know, their withdrawal and stuff, or sometimes not even recognise this stuff, and they’re going off. It’s just that’s the way that’s their personality. Doing well at school so it doesn’t matter.

Dr Ron Ehrlich: [00:46:21] Then, when you see kids of all ages when you see, what are the warning signs or the alarm bells go off for you when an infant or toddler, say an infant is brought in and you kind of think, Wow, this is, you must have seen it many times that this is developing into autism or this could be developing into autism. How early can you call it?

Dr Jim Papadopoulos: [00:46:45] I don’t. I don’t. I never call it, Ron. Sorry. That’s the answer to that question.

Dr Ron Ehrlich: [00:46:50] But are there some warning signs that you know, are all those things like poor sleep, difficulty in eating, fussy, you know, all these kinds of things? Give us some warning.

Dr Jim Papadopoulos: [00:47:00] So the way that we’re trained as paediatricians is to say there are warning signs. But until you do the interventions, you don’t know if they’re reversible or not. So we never call it, and I’m not going to go there, I’m going to say that if you see these signs, then you should look for help. And then with intervention, with diagnosing and treating it, you can get rid of all of that. It can just go away. 

And that’s not autism, right, or autism spectrum disorder. It’s just you’ve inherited a personality, which might be a little bit more sensitive. And because you had something else going on in your life which was wrecking your sleep or you have difficulties with between the parents or siblings or financial situations and stuff, the more stress and it shows up, as you know, when people are more stressed, they act autistic, don’t they? You relate, that’s what your podcast is about.

Dr Ron Ehrlich: [00:47:55] Mm-Hmm.

Dr Jim Papadopoulos: [00:47:56] OK. Relieving stress helps people’s mental health, and you don’t know you don’t want to diagnose or label any children at all until you’ve had a chance to help them and intervene. And it’s going to be a holistic approach and it’s going to include sleep. I know I’m pushing that a lot today, but…

Dr Ron Ehrlich: [00:48:11] No, no, no, you can’t push it often enough in this programme.

Dr Jim Papadopoulos: [00:48:14] Well, I think you got to address this sleep when you’ve got issues with that.

Dr Ron Ehrlich: [00:48:18] Jim, there you mentioned restless legs a few times and as has the thing, and I’m guessing it’s almost self-explanatory, isn’t it? You lying in bed and there’s limb movement. A lot of excessive limb movement. Is that what restless legs is? Or is that too obvious?

Dr Jim Papadopoulos: [00:48:33] Okay, look, that’s what everyone thinks it is.

Dr Ron Ehrlich: [00:48:35] Okay.

Dr Jim Papadopoulos: [00:48:36] But when we do the sleep studies and you see the restless legs is happening, they’re usually small movements, little contractions of the tibia and it can be in your arms and they’re like little squeezes and it can be in your jaw as well. Usually, it’s all of it, but we have the sensor on the biggest muscle that’s most usually affected, to be honest, the interior in your leg, at the front of your leg. 

And then it picks up these movements. And I show people the videos of restless legs and they go, Well, I didn’t see anything, and I go, Well, that’s restless legs. What you’re describing, the tossing and turning the big movements and all the rest of it is usually not restless legs.

Dr Ron Ehrlich: [00:49:12] Okay.

Dr Jim Papadopoulos: [00:49:12] Big movements in sleep with the chance obviously tossing the sheets and all the rest of it. It can have a component of restless legs, but usually, it’s the discomfort due to obstructive sleep apnoea, waking up and moving, or reflux or constipation and stuff that are making you uncomfortable when you sleep and tossing and turning and causing arousals. So if there are lots of tossing and turning, that could be restless legs, but it might be, it’s usually not what we see when we see restless legs on sleep studies.

Dr Ron Ehrlich: [00:49:44] Mm-Hmm. And what about night terrors or sleepwalking?

Dr Jim Papadopoulos: [00:49:48] This is interesting, and I like it. I like that you brought that up because one of the first things that taught me how important gut health is with those issues with a child who came in and was having night terrors every single night. Every single night waking up usually it’s a couple of hours after you go to sleep before midnight as you go into your deep sleep. 

It’s not during sleep and you come partially awake and your brain is not switched on. The thinking part of your brain is not switched on, just your instincts part of your brain is switched on, which the only instincts you have at that point are fight or flight. So you scream or you fight and if someone stimulates you or tries to calm you down, you react and it gets worse and you escalate.

Same with sleepwalking. Sleepwalking happens to the older age range group of kids and night terrors of the younger age group. So maybe two to four to night terrorism, maybe two to six, two to five. And then after that, it becomes sleepwalking in the same person.

What they are is a symptom of sleep deprivation. They’re not because you’ve been abused or because you’ve been traumatised, that causes nightmares, which are dreams that you remember the next day, which happened in the second part of the night. Night terrors and sleepwalking are because you’re overtired, so there’s usually an underlying sleep disorder, which is making you overtired. Unless you’re someone who just sleeps three hours a night and all the time, and you’re sleep-deprived because of that and you get your nightmares.

Dr Jim Papadopoulos: [00:51:15] So what I found are that this kid had a sleep study and it showed just some restlessness in sleep, and they had faecal loading where they were doing very large but soft power motion every day, twice a day. It was actually. And when you felt the time, it was full. So I treated them with Osmolax and within a week they stopped having night terrors. It was all from the lower end. To the top end, there was no sort of symptoms of reflux and stuff. 

So I just treated them with the constipation treatment that time and it worked brilliantly. And I’m going, how many kids do we see as well through the diagnostic clinic is through the disability clinic. It’s almost taken for granted that a child with a disability, whatever is constipated, know they go every two or three days and they like rocks or, oh, they soiling their pants. And they think that that’s not. People think that that’s normal and acceptable but usually soiling of the pants is an overflow of soft poop around the hard cannonball, which is in your rectum.

Dr Ron Ehrlich: [00:52:18] Hmm.

Dr Jim Papadopoulos: [00:52:19] And they soil their pants by having accidents all the time. And you treat that constipation and it goes away and their sleep improves and everyone is now got clean undies and stuff, and everyone’s happy anyway.

But back to the sleepwalking and night terrors it can be because of sleep apnoea, undiagnosed reflux and undiagnosed restless legs and can be undiagnosed anything else. I saw one kid and I often see this where if they’ve got asthma and allergy, they’re snoring and having sleep difficulties and they could have sleepwalking and night terrors as well. 

You do their sleep study and it comes back normal. Right, not restless and not snoring and not having sleep apnoea, because in the sleep lab, it’s free of dust mites. And you treat those kids with Nasonex, and they’re sleepwalking, night terrors, sleep problems go away will get better like a lot better.

A lot of them have got other allergies as well or need help from a paediatric allergist if they need desensitisation or all the rest of it. But you can nail these diagnoses by showing up on the sleep studies.

Dr Ron Ehrlich: [00:53:22] Look, because I love this, Jim, we can keep on talking all morning long. But listen, one other one I wanted to ask you about was bedwetting because I mean, kids in nappies, yes they went their bed. But you know, when it’s five or six, nine, 10, 12-year old is still wetting the bed.

Dr Jim Papadopoulos: [00:53:37] Okay.

Dr Ron Ehrlich: [00:53:37] Talk to us about bedwetting in your case.

Dr Jim Papadopoulos: [00:53:40] So Enuresis, often runs in families, but it needs to be treated when they’re over age six or seven. Right? The causes of it, the first thing that they ask you about when you get an enuresis clinic is, are you constipated? Because a big poo in the rectum means there’s no room for the bladder. And so overnight, your bladder has problems. That’s the first thing that people in an enuresis clinic will treat – your constipation first.

Sleep apnoea is linked to bedwetting as well. So if you got sleep apnoea and you treat it, 80% of those kids get better with their bedwetting. 50% of them, it will go away altogether. If you’ve had treat your sleep apnoea. And so if you say a child has got bedwetting and is snoring, mouth breathing got sleep difficulties, et cetera. Think about it as don’t put them on the bedwetting alarm first, right? Because that’s that’s the standard way to treat bedwetting. 

If you’ve fixed everything else up but they’re still bedwetting, a bedwetting alarm can help, and if that doesn’t work within three months, then they can go onto oral tablets and stuff to help the bedwetting and then it with time it usually resolves. They can be kids who’ve got actual bladder problems and kidney problems and stuff. So usually if the simple things don’t work, then a urologist needs to get involved.

Dr Ron Ehrlich: [00:55:01] Jim, just saying the last two years have been a challenging time is an understatement. But as respiratory, the paediatric respiratory and sleep medicine physician. Have you seen anything different in the last two years walking into your practise that has, you know, changed?

Dr Jim Papadopoulos: [00:55:20] The thing that I’ve seen is different, Ron, and actually, I got a text message from an ENT surgeon at the beginning of this year, sort of January, February, and his text message said, “Jim, did COVID 19 cure obstructive sleep apnoea?” And so what we’ve seen is a lack of referrals. Total sort of. It’s gone by the by. 

Yeah, it’s gone totally under the radar for the last two years. And I think that’s because people have had bigger fish to fry and maybe also people reluctant to visit doctors offices, go to and a lot of things being done by remote learning. Teachers not picking up as much about what’s going on with the kids in the classes.

Anyway, there’s a whole range of reasons and this podcast that you’re doing, Ron, today, I’m hoping is going to raise the awareness again.

Dr Ron Ehrlich: [00:56:12] Yes.

Dr Jim Papadopoulos: [00:56:12] …Of these issues and how important they are and the sooner you treat them, the better. With sleep apnoea if you don’t treat it by age six, there was one study which showed that those kids were about four times more likely to be in the bottom 25% of the class. And you’re right, even if you treated them at age six.

Dr Ron Ehrlich: [00:56:28] Wow, wow. That’s it.

Dr Jim Papadopoulos: [00:56:29] So you’ve got to get it when there’s sort of two, three, four years old. Ideally. It’s but how many percent chance of improvement and fixing and getting better even after age six. The earlier you pick these things up, the better.

Dr Ron Ehrlich: [00:56:42] Jim, one last question and thank you for today. Listen, you know, we’re all on a health journey as individuals. Putting aside your hat as a specialist, what do you think the biggest challenge is for an individual on their journey through life in this modern world?

Dr Jim Papadopoulos: [00:56:57] You know, I think it’s anxiety.

Dr Ron Ehrlich: [00:57:00] Mm. I think.

Dr Jim Papadopoulos: [00:57:01] I think we… Look, the world has become a very uncertain place, even for children. I mean, the children used to have bits of it, so carefree I was. But children nowadays have worries as well, and it’s just so sad and parents have worries as well and more worries than they used to.

I think the biggest challenge for our society is being in anxiety and fear and terror in some minds. And that’s a bit philosophical, but that’s my opinion. You know, I think if we can. If we can find ways within ourselves too, I don’t know, be less anxious have that less anxiety feeds through to a more positive outlook on life. Positivity then helps everyone, not just yourself internally, but everyone around you. And that ripple effect is what we need. We need more positivity and less negativity.

Dr Ron Ehrlich: [00:58:09] Well, well, that’s a great note to finish on, Jim, and I knew I was looking forward to speaking to you for quite some time, and now I’m pretty sure most of my listeners understand why. So thank you so much for your time today, and thanks for sharing your knowledge and wisdom with us.

Dr Jim Papadopoulos: [00:58:24] I have to thank you and thank your listeners for their patience with my rambling. I go off on tangents too much so…


Dr Ron Ehrlich: [00:58:30] Perfect tangents for this programme, Jim. Thank you so much. Well, I think you can now see why I said I was so looking forward to having Dr Jim Papadopoulos on the podcast and sharing him with you. The last time I had the opportunity to speak to Jim like that was in a podcast I did with him about eight or nine years ago on The Good Doctors.

And it’s so interesting to see where he has gone in these last 10 years. And wouldn’t you love every single specialist to have that kind of approach? Very open-minded approach. A very holistic approach. Yes, he is a respiratory physician. He is a sleep medicine physician. But here he is looking at gut health and of course, he is a paediatrician as well as that. So of course, he would be looking at that.

But I thought, you know, in medicine now, over the last 10 years, it has been accepted that gut health is so critically important to our health. Hardly surprising, really, because you are what you eat. That thing’s been around for a long time. And the truth of that saying has been around for even longer. 

You are literally what you eat and you know, when you have a gut feeling, that’s because the gut is now described as the second brain. So it’s where so many neurotransmitters, those things that give us mood like serotonin and other neurotransmitters are actually produced. 80% of the body’s serotonin is produced in the gut.

So it was great to talk to Jim and to get that perspective, that update and to realise that there were so many that was so often undiagnosed. And it’s interesting to also see a practitioner, especially a specialist like that, who is clearly very patient-centred, and we use that expression a lot in our practise and we want and people are more patient-centred. What’s the alternative to a patient-centred practise? You would think that’s the way every medical practise should function. Well, it’s not the case.

The other alternative is a symptom-based practise. If you, for example, have a snoring problem, then you can’t see the intake specialist and that is their speciality. And so they will remove your adenoids or tonsils. 

And yes, your snoring may improve in the next few weeks, or maybe even the next few months after that. But has it addressed the entire underlying cause? It may not have. Or you might go in for an infection and you have an antibiotic and inflammation, you get an anti-inflammatory, you feel depressed, you get an antidepressant and so on. That is a very symptom-based approach.

A practitioner-based approach is very much just focussed on the practitioners’ speciality and what their particular area of interest is. So it’s great for Jim to share that knowledge with us and for us to realise that there are many factors in and it’s interesting to hear silent reflux being such a common and often undiagnosed problem in 40% of cases. I think the figure was something like that. And silent reflux is really something that, well, the name implies you don’t really know what’s going on, but it is affecting your health. 

It may affect your health as a chronic cough for clearing your throat all the time, not sleeping well, feeling restless, not breathing, as well as you might. A whole range of things. Mood affected, your energy levels affected, and this can be about silent reflux. And we’re going to be exploring that in one of our very soon to be released podcasts with laryngologist and speech pathologist, Nikki Martin.

So it was just great to have Jim on and for him to share his expertise and knowledge. I thought, well, I always like to ask practitioners, “On a personal level, what do you think the biggest challenge is?” And Jim identified anxiety as that and I think that is one of the features of the last two years that have become particularly pronounced. But I think we’ve done some other podcasts on Digital Nutrition with psychologist, Jocelyn Brewer. And Nir Eyal talking about the impact of the digital world on our wellbeing.

And we’re going to be exploring anxiety, depression and trauma in the coming weeks and months. Anyway, we’re going to have links to Jim’s website, so that will be a resource that is well worth looking into if you need it. I hope this finds you well. Until next time. This is Dr Ron Ehrlich. Be well.



This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.