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| Topics in Healthy Sleep 10 Steps to Better Sleep Everyone periodically has difficulty with sleep. Lack of sleep, however can be disruptive and life threatening, however, when it follows an established pattern and becomes the norm rather than the exception. A recent survey from the National Sleep Foundation found that about half of adults in the United States report driving while drowsy. Nearly one out of five admit to dozing off while driving. For most people, falling asleep at night is as easy as closing their eyes. People who sleep well have certain lifestyle and dietary routines that promote good sleep. These behaviors —referred to as sleep hygiene—can have positive effects on sleep throughout the night. These common sense ideas will help most people sleep better:
Why Do These Steps Work? Stimulants Caffeine stimulates the brain and interferes with sleep. Coffee, tea, colas, cocoa, chocolate and prescription and nonprescription drugs that contain caffeine should not be taken within 3-4 hours of bedtime. Although moderate daytime use of caffeine usually doesn’t interfere with sleep at night, heavy or regular use during the day can lead to withdrawal symptoms and to sleep problems. Nicotine is another stimulant that interferes with sleep. Nicotine withdrawal can also disrupt sleep throughout the night. Cigarettes and some drugs contain substantial quantities of nicotine. Once smokers overcome the withdrawal effects of nicotine, they can expect to fall asleep faster and wake up less during the night. Alcohol Alcohol slows brain activity. Alcohol may seem to induce sleep when consumed at bedtime, but it will disrupt sleep later in the night. A nightcap can lead to awakenings, nightmares and early morning headaches. Alcoholic beverages should be avoided within 4-6 hours before bedtime. Exercise Regular exercise helps people sleep better. Its benefits on sleep, however, depend on the time of day you exercise and on your overall fitness level. People who are in good shape should avoid exercising within 3 hours of bedtime. While exercising in the morning isn’t likely to affect your sleep at night, the same amount of exercise can disturb sleep if done too close to bedtime. Also, too little exercise and limited activity during the day can lead to a restless night. Always consult your physician before starting an exercise program. Environment A comfortable bed in a darkened, quiet room is the best setting for a good night’s sleep. Some people can adjust readily to changes in their sleep setting, but others can be easily disturbed by the slightest changes in their sleep surroundings. When too much light is a problem, darkened curtains and spot lighting can be a helpful change. Noise problems can be removed with a background noise device (white noise) or earplugs. Diet Eating a full meal just before bed can interfere with your ability to fall asleep. A light snack before bed, however, may actually help you sleep better. Dairy products and turkey, which contain a natural sleep inducing substance called tryptophan, are recommended as a light bedtime snack. Time in Bed Stress can contribute to a host of ills, including sleep problems. Frustrated, people sometimes begin to rely on poor strategies to help them cope with disrupted sleep. These can include:
After the source of stress has been resolved, these strategies can cause sleep problems to continue. Difficulty initiating sleep can lead to a cycle of increasing tension and a fear of sleeplessness. The bedroom then becomes associated with unsuccessful attempts at sleep, contributing to even more tension and anxiety. Some people who have trouble sleeping will begin sleeping on a sofa or recliner because they no longer are able to sleep in the bedroom. This is called conditioning and may be treated using stimulus control or sleep restriction. Stimulus control attempts to reestablish the connection between sleep and the bedroom by reducing the amount of time awake in bed. Try to sleep only when you are drowsy. If you can’t fall asleep, leave the bedroom and engage in a quiet activity elsewhere. Don’t fall asleep outside of the bedroom. Return to bed only when you feel sleepy and repeat as often as necessary through the night. Maintain a regular arise time even on the weekends or days off. Use your bedroom for sleep and sex only. Avoid napping during the day. If you absolutely can’t avoid napping, take one nap—but take it no later than 3 p.m. and set the alarm for one hour or less. Sleep restriction reduces the amount of time in bed to the estimated time actually spent sleeping. Sleep restriction techniques, under the advice of a sleep specialist, include the recording of time spent in bed and the time spent asleep each day for a two-week period. The amount of time spent in bed is adjusted to the actual amount of time spent sleeping. As sleep quality improves, the sleep schedule is adjusted accordingly. Alarm clocks and watches are a fact of life, but people with sleep problems should avoid watching the clock. Before going to bed, try setting the alarm, then turn the clock away from you. Most people with sleep problems sleep best when they don’t have to worry about time constraints. Managing Stress Stress from everyday life often adds to sleep problems. A relaxing activity near bedtime can help ease tension and encourage sleep. Clarifying problems and formulating solutions can have a positive effect on sleep quality. Talk to a trusted friend to air out troubles. Ask a psychologist, physician or other health care professional for advice on:
Designate "Worry Time" Assign time during the day to sort out problems and brainstorm solutions. Set aside 30 minutes in the evening to sit alone without interruption. Write down each worry on a 3-by-5-inch card. Sort the cards into three to five piles according to their priority. They all won’t have easy solutions, but even small progress can yield beneficial results when it comes to sleep. The next morning, review the cards and begin to work on resolving them. What if You Still Can’t Sleep? If you still have trouble sleeping, you may exhibit symptoms that may need further investigation. Symptoms include:
These can be caused by various sleep disorders, including:
For more information, contact Gaylord Sleep Services. Each year the National Sleep Foundation, in its annual poll of Americans, finds similar disturbing results: Too many people are living their lives in a sleep fog. A majority of Americans report not getting the recommended eight hours of sleep every night, and more than two-thirds of respondents say they experience frequent sleep problems. The challenge is to encourage individuals to talk about their sleep patterns. Remember to tell your doctor about any sleep problems you are experiencing. This is the first step to better sleep. Excessive daytime sleepiness is not a “normal” way to live. At a minimum, providing the following information can help your doctor:
10 Steps to Better Sleep
Resource: Hauri, Peter, Linde, Shirley, and Westbrook, Philip. No More Sleepless Nights. John Wiley & Sons, July 1996. Is there a link between sleep disordered breathing (SBD) in children and attention deficit/hyperactivity disorder (ADHD)? A new report suggests there may be. A study of 866 children between the ages of 2-13 found that youngsters who frequently snore or have sleep disorders are almost twice as likely to suffer from ADHD than those who sleep well. "Inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and—especially in young boys-snoring and other symptoms of SDB," wrote Dr. Ronald Chervin, a University of Michigan neurologist and sleep researcher. "If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact." The study was published in the March 3 issue of Pediatrics (http://www.pediatrics.org/cgi/content/abstract/109/3/449). The current NSF Alert with graphics is available at www.sleepfoundation.org/alert.html. Dr. Chervin is also the lead author for a study investigating connections between ADHD and restless legs syndrome (RLS) and periodic limb movements (PLMS) in children. A survey of parents of children between 2 and 14 showed "substantial associations between inattentive, hyperactive behavior and symptoms of PLMS and RLS," Dr. Chervin said. Mocha Lattes and the Caffeine Police Is caffeine the culprit in your pursuit of a good night’s sleep? Caffeine, a known stimulant, may provide you with a much needed kick start in the morning, but it also may inhibit your ability to fall asleep. Check out the Sleep Foundation’s Caffeine Calculator (http://www.sleepfoundation.org/caffeine.html) to see how much caffeine you are consuming—whether you know it or not—each day. Most scientists say that daily caffeine consumption of about 250 milligrams or less is fine. Just don’t indulge in a caffeine treat immediately before bedtime since it may affect your sleep. If you think insomnia—which is the difficulty falling and staying asleep—is your problem, you also might want to review Newsweek’s story, “In Search of Sleep” (http://stacks.msnbc.com/news/777061.asp). The article acknowledges that there are many sleep disorders that prevent people from sleeping well and may be life threatening, but it also shows that there are other factors that may pose obstacles for people getting the sleep that they need. The article specifically mentions caffeine as well as smoking, alcohol, lack of exercise, irregular hours, and poor sleep hygiene. While these “bad sleep habits” may seem minor, sleep experts warn people not to dismiss them. Sleep problems, the article states, are like any other medical issue and can be managed. Sun, Winter and SAD For millions of Americans, the winter months can literally become a “SAD” time. Seasonal Affective Disorder (SAD) affects about 10 million people with symptoms of clinical depression that seem to be triggered by the colder, darker months. SAD is more than a case of the winter blues. SAD can be a debilitating condition that is just as severe as serious deep depression. SAD is a form of a recurrent depressive or bipolar disorder characterized by a seasonal pattern of onset and reduction. This differs from other types of depression because it is directly linked to seasonal changes. Usually, SAD begins in early winter and dissipates by spring or summer. Studies show that 4-6 % of the population suffers from severe winter depression and that another 20% have mild winter depression. The disorder also may be genetically related to other forms of affective illness. For example, more than two-thirds of SAD patients have a close relative who suffers from a major affective disorder such as depression or bipolar. Women experience SAD four times more than men, affecting women between the ages of 20-40. While seen across all age groups, SAD generally isn’t seen in people younger than 20. The incidence and severity of SAD seem to increase the farther people live from the equator. SAD is more common in the northern hemisphere where the day are shorter. For example, SAD is seven times more prevalent in the state of Washington than it is in Florida. This disorder also affects those in closed environments or who work rotating or off-shift work. Scientists have long known about and studied the body’s circadian rhythms. This internal biological clock controls hormones, body temperature sleep-wake cycle, appetite, and other bodily functions independent of what the clock hanging on the kitchen wall says. That’s why it takes people a few days to adjust to daylight savings time or why some suffer from jet lag when they travel across time zones. Sunlight is a very important cue for setting and regulating the body’s circadian internal clock. For a person with SAD, his or her internal clock is very sensitive to the decreases in sunlight that occur during the winter. In a person with SAD, the body’s internal mechanism gets more out of sync with the clock on the wall, leading to serious consequences. Lack of sunlight and vitamin D during the winter months can cause the body to over produce melatonin, a sleep hormone, leading to extreme fatigue, depression and desire to compensate for lack of energy by eating more carbohydrates for fuel. It also decreases the serotonin production that identifies the chemical in the brain that plays a major role in sleep, mood, appetite, depression, and sometimes leads to radical mood swings. Diagnostic criteria includes a regular relationship between onset and disappearance and at least three episodes of mood disturbance in three separate years that demonstrates this waxing and waning onset of the disorder. Also, seasonal episodes of mood disturbance should outnumber any non-seasonal episodes by more than 3 to 1. Diagnosis of SAD also requires a pattern of seasonal depression over at least two consecutive winters followed by recovery in the spring or summer. Incidents of seasonal depression must also far outnumber incidents of non-seasonal depression. Symptoms of SAD typically peak in January and February and start to dissipate as spring approaches. Symptoms recur at about the same time every year. Not everyone experiences the same symptoms but the most common include:
Some people’s symptoms become so severe that they must be hospitalized. Most people, however, can be treated effectively on an outpatient basis. Fortunately, SAD is usually very treatable so people should seek help before the depression becomes unbearable. Now that doctors are beginning to understand more and more about this disorder, there is hope for even the darkest cases of the winter blues. The most effective form of treatment for SAD is light therapy. This works by exposing the patient to bright light or sunlight for 30 minutes or longer in the early morning. Light intensity is expressed in units of lux. Indoor lighting is typically under 500 lux. Outdoor light on a cloudy day is 1000-5000 lux. Mid-day summer light can reach 50,000 lux or higher. Light therapy utilizes 2500 lux for at least one to two hours each day. There is similar efficacy for 30 minutes at 10,000 lux exposures. Although positive effectives have been achieved at much lower levels, brief high intensity light treatments are much more easier to schedule into the day than the longer, dimmer sessions. Morning treatments are much more effective than evening. When a doctor suggests light therapy, the patient uses a special light box or visor that delivers a predetermined level of light brightness. SAD symptoms appear to subside after three to five days of light treatment, but two weeks of therapy may be required before an optimal response is achieved. The symptoms may recur in 3-4 days following discontinuation of treatment. Light therapy is safe when conducted under a doctor’s supervision. Potential side effects can include: eyestrain, headache, fatigue, irritability, and insomnia. Too much light or looking directly into the source light can cause eye damage. Tanning lights should never be used for light therapy. Light therapy regimens are not considered harmful to the human retina based on short-term studies, but long-term effects are not yet known. The good news is that even though SAD is relatively new in terms of scientific research, specialists have quickly made significant treatment options even if they don’t fully understand why some people are more profoundly affected by seasonal changes. If you think you are suffering from the winter blues, here are some easy steps to take on your own:
Topics in Snoring Comics on late-night TV may joke about snoring, but it can strain relationships and cause embarassment. The snorer is often unaware or undisturbed by the sound, but other members of the household may experience disturbed sleep. Spouses and children may have difficulty performing at work or school. Frequently feeling irritable or short-tempered can be an indication of poor sleep. In response, spouses of snorers may resort to using earplugs, or even sleeping in seperate bedrooms. Patients may not tell their physicians about their own snoring or that of family members because it has become the source of so many jokes. But it is a serious matter. Snoring has been associated with high blood pressure, heart disease, stroke, drowsiness and learning difficulties. As many as 34% of American adults report snoring, with those 30-64 years of age affected the most. Of those who snore, 19% are so loud they can be heard through a closed door. It is important to determine if an individual's snoring is a sign of sleep apnea. Approximately 4% of adult males and 2% of adult females have symptomatic obstructive sleep apnea but without the defining symptoms of drowsiness. Patients with asymptomatic sleep apnea are the most difficult to diagnose. Signs of Sleep Problems
Can Snoring Be Hazardous to Your Health? People who snore loudly have been fair game for cartoonists and comedians for decades. Loud, disruptive snoring—the kind that wakes other members of your household and sometimes even the neighbors—is nothing to laugh at. It may be a potentially life-threatening condition such as sleep apnea. Apnea is a Greek word that means "want of breath." Loud snoring is a distinctive sound created when air tries to force its way through the narrow passageway of soft tissues in the throat or upper airway it is not fully opened during sleep. For most of the estimated 10 percent to 30 percent of the adults who snore, snoring has no serious medical consequences. Extremely loud and habitual snoring, however, can be an early indicator of sleep apnea for an estimated five in 100 people. People with sleep apnea may breathe fine while awake but they don’t breathe properly during sleep. Studies show that those with severe sleep apnea may not breathe properly for up to 75 percent of the time they spend in bed. It is characteristic for a person with sleep apnea to exhibit a pattern of snoring with intermittent pauses that are followed by a gasp or loud snort. The sleeping individual experiences periods of breathing difficulty then resumes breathing with a loud snore. This interruption of the sleep cycle interferes with the flow of oxygen to the body. Left untreated, sleep apnea can lead to:
People who snore very loudly, in all body positions, should see their physician to investigate the causes. A consultation with a sleep disorder specialist may be recommended to discuss signs, symptoms, testing procedures, and treatments available. Fortunately, sleep specialists can detect breathing disorders in their earlier, more treatable stages. Warning Signs of Sleep Apnea Sleep specialists have recorded snoring levels as loud as jet planes and jackhammers. Snoring this loudly translates into frequent awakenings or arousals from sleep. This can lead to severe daytime fatigue affecting the snorer’s ability to work, drive or conduct routine daily activities. People with sleep apnea also have a two to five times higher incidence of having a car accident than those who don’t have this disorder. Other warning signs exhibited by people with sleep apnea may include:
These problems can occur suddenly or develop over time. The startling thing is that sufferers are usually unaware of these symptoms. Some family members have even gone so far as to tape record or video record an individual in an attempt to prompt him to seek evaluation and treatment. They become so accustomed to living with the symptoms that they think it is normal. Family members, friends and coworkers are often the first to recognize the signs and encourage the sufferer to seek help. People with sleep apnea may notice or complain of:
They may also lack enthusiasm for activities that they once enjoyed. Men may also complain of difficulty maintaining a state of sexual arousal. In children, sleep apnea has been linked to some cases of Sudden Infant Death Syndrome (SIDS). The exact relationship is still uncertain. Sleep apnea can be present in children who are overweight or who have enlarged tonsils. Children suffering from sleep apnea may snore, exhibit stridor (squeaking-type of noise), have difficulty breathing and sleep very fitfully or restlessly. It is not normal for a child to snore and parents should report their child’s snoring and habits to a health care provider or pediatrician. Older children with sleep apnea may seem overly lazy, slow and exhibit poor performance in school. Causes of Sleep Apnea During normal sleep, the muscles—including those used in breathing and supporting the upper airway—relax more than they do during awake periods. In some people, the throat muscles relax too much causing the breathing passage to become partially or totally blocked. This interferes with breathing throughout the night. Sleep becomes an increased time of risk. In others, these muscles relax normally during sleep, but the breathing passageway is narrower than normal and causes partial or total blockage to breathing. In less common cases, the brain "forgets" to send a signal to the muscles the control breathing. Types of Sleep Apnea Obstructive sleep apnea is the most common and severe type of sleep apnea. The muscles of the soft palate relax and sag, and when these muscles relax too much or block a narrowed airway, breathing can become struggled or noisy. When these airway walls collapse, breathing is completely blocked. When breathing periodically stops, a listener hears snoring broken by pauses. These pauses are apnea events. As the urge to breathe increases, the breathing muscles of the chest and diaphragm work harder to overcome the blockage in the airway. Sleep is then temporarily interrupted, the brain briefly shifts from a sleep to an awake state, and the throat muscles increase in tone and the blockage is relieved. Awakenings are usually so brief and incomplete that the sleeper does not remember them in the morning. Someone with obstructive sleep apnea may stop breathing for 10 seconds or longer and may experience hundreds of apnea events each night. Each time breathing stops, the level of oxygen in the bloodstream drops and the heart must worker harder to circulate blood. Blood pressure rises and may stay elevated after breathing restarts. The heart can also sometimes beat irregularly and may even pause for several seconds. These irregularities of the heart may account for some of the deaths during sleep of people who went to bed in apparent good health. Alcohol, sleeping pills, and sedatives taken at bedtime further reduce the muscle tone of the upper airway and make it more easily susceptible to collapse. One or more of the following conditions may contribute to sleep apnea:
Obstructive sleep apnea most often strikes overweight men. Female hormones and a slightly different upper airway anatomy may protect women until later in life. As both sexes grow older, the age gap narrows but never entirely disappears. Central Sleep Apnea In this type of sleep apnea, the airway may remain open, but the breathing muscles of the chest and diaphragm stop working. Decreasing levels of oxygen signal the brain to awaken the sleeper and restart breathing. Central sleep apnea becomes more common with age. About one in four persons over the age of 60 experiences disturbed breathing during sleep. Usually the problem is mild. It becomes more significant and severe in people with congestive heart failure or neurological disorders. People with central sleep apnea may be more aware of their frequent awakening during the night compared to those with sleep apnea. Going to See Your Doctor Your physician or sleep specialist will gather a detailed medical history from you and may want to talk with your bed partner or other members of your household to gain further information. A physician who suspects sleep apnea will refer the patient to a sleep disorders center or sleep physician for further evaluation and testing. The patient may need to spend one or two nights in a sleep diagnostics laboratory while being monitored by sleep specialists using highly specialized equipment. A sleep study will identify if sleep apnea or other sleep disorders are present and identify the best approach for treatment. Before arriving for a sleep study, such as those conducted through Gaylord Sleep Services, the patient is instructed to avoid caffeine, alcohol, smoking and naps. At Gaylord Sleep Services, the patient watches a brief instructional video that describes how the testing is performed. Small, thin wires are placed on the patient’s head, legs, and chest to monitor the muscle activity, brain waves and the heart. A finger probe is placed on the finger to monitor oxygen levels throughout the night. A thin wire is placed on the upper lip and two bands are wrapped around the chest and abdomen to monitor breathing. Once the patient is made comfortable in a private room, he or she is monitored until morning. It takes approximately two weeks for the referring physician to receive the final results of the interpreted information obtained during an entire night’s study. Treatment Options You can improve the quality of your sleep—whether you have sleep apnea or not—by following these options: Lose weight Avoid alcohol two hours before bedtime Avoid sleeping pills Take all drugs with care Sleep on one side Nasal decongestants Oral appliances Surgery Uvulopalatopharyngoplasty (UPPP or UP3) Oxygen Medication Continuous Positive Airway Pressure (CPAP) Topics in Drowsy Driving You know the feeling. Lulled by the hypnotic rhythm of the car’s tires rolling along the pavement, you can’t keep your eyes open. You open the windows for fresh air. You pass a familiar landmark and can’t remember driving the last five miles. You crank the volume on the car stereo, but it doesn’t help. You’re on the last leg of your trip and you’re determined to stay awake. Sleep, however, is winning the battle. You’re startled by the sound of your tires hitting the rumble strips on the side of the road. Some drowsy drivers have the good fortune to regain control of their cars. Others aren’t so lucky. The National Highway Traffic Safety Administration estimates that sleepy drivers cause at least 100,000 motor vehicle crashes each year. According to the National Center on Sleep Disorders Research, fall-asleep crashes are likely to be more serious, possibly due to high speeds and the driver’s delayed reaction time. In 1996, the AAA Foundation for Traffic Safety surveyed 101 members of the National Trooper Coalition for Traffic Safety and found that a drowsy driver is actually more dangerous than a drunk driver. The reason: A drunk driver will see the red light that he or she went through and stop. A drowsy driver may never see the traffic light. Drowsy drivers are people with “sleep debt.” Sleep debt can be incurred through untreated sleep-related problems or from society’s self-inflicted 24-hour lifestyle. People find extra hours in the day by stealing hours from sleeping time. Those with sleep debt, for example, can be shift-workers, truck drivers, airline pilots, students pulling all-nighters to finish a paper, people staying up late to go out with friends, or with untreated sleep apnea syndrome or narcolepsy. Sleeping less then four hours a night impairs the ability to function at peak performance. Research that shift workers receive approximately 1.5 hours less sleep than a dayshift worker every day. The midnight to 8 a.m. shift, in fact, carries the greatest risks. Sleep is the only cure for sleep debt. How can you tell if you or someone you know is a drowsy driver? Consider these questions:
If you answered yes to any of the questions, you may be a drowsy driver What can you do to help yourself from being a drowsy driver? Protect yourself—and others—by considering these tips:
If you do feel fatigued on the road, stop at a well-lit rest stop and take a 15- to 45-minute nap or switch drivers. Try not to drive during your normal lull period, which is typically between 1 p.m. and 4 p.m. and between 2 a.m. and 6 a.m. two and six a.m. Also, don’t count on the radio or having the windows open to keep you awake. A couple cups of coffee will give you a very short boost—just long enough to get you to that rest stop. Sleepy Teens Behind the Wheel and in Front of the TV Sleep-related issues are the biggest complaint parents bring to their children’s pediatricians, according to sleep medicine specialists with Gaylord Hospital. The first thing to understand is that sleep is not an equal opportunity employer. Sleep needs and issues differ among children and may change at various ages. A good sleep history is key. Parents should keep a diary of their child’s sleep habits, hour by hour, and then review it with a health care provider to uncover the specific issues. Teenagers Rule According to a study conducted by the National Sleep Foundation, teenagers are more likely to complain of being tired during the day than are younger children. “Our research has shown that biological changes during puberty affect an adolescent’s internal sleep-wake clock. Many adolescents are physiologically not ready to fall asleep until 11 p.m. or later,” explains Mary A. Carskadon, Ph.D., Sleep Research Lab Director at Bradley Hospital/Brown University and National Sleep Foundation Pediatric Council Chair. While the average teen needs about nine hours of sleep each night, many get less than seven, according to the study. A frightening figure provided by the National Sleep Foundation and the National Traffic Safety Board shows that 60% of parents who have children old enough to drive say that they have not discussed the dangers of falling asleep at the wheel with their children. Drowsy driving causes at least half of all teen crashes in the United States each year. Given teenagers’ sense of invincibility, many are not aware of the impact their drowsiness plays on driving ability. “Teens, especially young males, are pushing the envelope when it comes to dangerous, drowsy driving,” says Rochelle Turesky, M.D., a pediatrician who is working on a fellowship in sleep medicine at Gaylord. Pediatricians need to continue to ask their adolescent patients about their sleep habits, and to include the topic of late-night driving in their pre-college talk about drinking, drugs and safe sex. The TV Connection Parents concerned about their childrens’ sleep habits also may consider how much the television is on in the household. A survey of third- through eighth-graders revealed that as the number of hours of television viewing increased each day so did the prevalence of symptoms such as anxiety, depression and post-traumatic stress (Singer MI, et al. J Am Acad Child Adolesc Psychiatry. 1998; 37:1041-1048). The amount of television viewing—especially at bedtime—and having a television set in the child’s bedroom were factors significantly related to the frequency of sleep disturbances found in children in grades K-4, according to a survey reported by Pediatrics (Owens J., et al. Pediatrics. 1999; 104:e27). Nine percent of the parents surveyed reported that their child experienced nightmares related to television viewing at least once a week. While children are sensitive to and frightened by different things at different ages, media images can produce very real, lingering fears and anxieties in toddlers, teens and young adults. The American Academy of Pediatrics reports that children need reassurance when frightened and the encouragement to choose media that will promote rather than disturb their physical and emotional well-being. The bottom line for all those who care for children is that sleep is a requirement of good health. Every child deserves a good night’s sleep. Topics in Children & Sleep A child’s sleep is wondrous, often enviable. How many adults have relished the chance to say, “Oh, how I slept like a baby last night.” Sleep comes naturally to small children, but their sleeping habits are greatly determined by the patterns established at an early age. A steady dose of good sleep results in a happy, thriving child. A child who doesn’t get a restful night’s sleep can turn a household’s evening into a nightmare! An ill-rested child may experience problems in normal child development and exhibit behavior that can place undo stress on family members. A child’s sleep can be very puzzling to many parents, especially new ones. Many question how long a child should sleep at night, during naps, or whether they should wake their child at a scheduled time or on her own. The fact is that a child as young as six months can learn to sleep through the night for at least 9 hours. Every child is unique, but most have the potential to sleep throughout the night. Sleeping arrangements vary. Some children sleep by themselves, others share a room with a sibling or parent, and some share a bed for a while. Still, it is important to establish a good sleep pattern that encourages quality sleep for naps and a full night’s rest. While these arrangements can work, a parent needs to recognize problems in you’re a child’s sleep before the problems become difficult habits to break. Is There a Problem? Children with sleep problems tend to share one or more of the following signs:
Fortunately, most of these issues can be resolved swiftly once identified and treated with a dose of common sense and a little guidance. Sometimes comparing notes with other parents or consulting with a pediatrician may help. In other instances, consulting with a sleep disorders specialist might be recommended. Time For Bed A relaxing bedtime ritual can be one of the richest moments shared between a child and a parent. Yet getting a child ready for bed almost always initiates a feeling of separation anxiety between children and their parents. This is a normal. Parents naturally want to comfort their children. Waffling on requests, however, for “just one more story” or “another glass of juice” will inadvertently teach the child that bedtime can be extended and manipulated. Without established sleep routines, bedtime can be filled with tension, arguments and anxiety. A good bedtime routine starts with setting aside 10 to 30 minutes to do something special with the child. Choose something soothing and relaxing, like reading. Bedtime is not the time for overly stimulating activities such as wrestling, running, ghost stories, or scary movies. Quiet, happy activity is best. Early Childhood Sleeping Disorders Sleep-onset Association Disorder “I’m completely exhausted. My child wakes up during the night, and I end up rocking her. It’s the only way I can get her to sleep.” Does this sound familiar? Some children learn to associate the act of falling asleep with a specific action such as being rocked or patted on the back. When the action is removed, the child is unable to fall asleep. This is sleep-onset association disorder. Most people wake up briefly a number of times during the night, especially during dream sleep—or rapid eye movement (REM) sleep. These brief awakenings usually go unnoticed and people return to sleep rather quickly. Parents, however, may feel obligated to help the child return to sleep. The child quickly associates the helping activity with sleep and will soon be unable to fall asleep without assistance. The sleepy child starts to cry when awake, and a vicious cycle begins. What is an equally sleepy, frustrated parent to do? Parents need to know that a child can—and will—fall asleep on his own if he has the opportunity and when the reinforcing behavior is removed. Learning How to Sleep No one suggests that parents ignore their baby’s cries. Adults must always make sure the child is safe, not hungry, sick or wearing a soiled diaper. To correct the baby’s sleep problem, parents must teach the child to fall asleep at bedtime, naptime, and after awakenings with a new set of associations that do not require a response from the parent. It’s best to start this relearning process at night, but naptime is fine too. The following technique will help the child learn to fall asleep more easily without evoking feelings of anxiety, alarm or abandonment. 1. Expect the child to cry. Remember, you are not abandoning the child. With encouragement and reinforcement, the child can learn to fall asleep by herself.Pacifiers may be used as a comfort measure, but their use is discouraged after the child is six months old because they tend to fall out repeatedly during the night. Cuddle toys such as blankets or stuffed animals usually don’t create a major problem, as these items should still be in the crib or bed when the child wakes up. 2. To help a child six months to three years old learn to sleep on his own, place the child while awake or drowsy into the crib or bed after a quiet bedtime routine. Say goodnight and leave the room. Make sure a little light shines into the room. If the child is still crying after two minutes, return to the room. Don’t turn on the lights. Don’t hug the child or lift him from the crib. Don’t give in to any new requests. Comfort the child with words or gently touch him to show him that he isn’t being abandoned. Leave again promptly and don’t stay in the room longer than a minute or two. 3. If the child continues to call out or cry, you should extend the amount of time that goes by before you re-enter the room. Waiting can be difficult for parents. A crying child often tugs at the heartstrings. The retraining process is actually tougher on the parents than it is on the child. Sticking to this regimen is important to transition the child successfully. Parents usually notice a significant difference after three nights, when following the guidelines consistently. Those who don’t see any improvement after five nights should review how religiously they followed the guidelines. Keep in mind that it may take some children longer to adapt to the change in sleep routine. Even so, it is vital that both parents stick to the same regimen and don’t bend the rules. Any deviation will delay the relearning process. Desensitizing the Older Child Sometimes an older child may have difficulty falling asleep after becoming frightened. The following technique works well and is a desensitization method that should be used for all naps and nighttime awakenings. 1. Tell the child that you will be near the bed, but not in the bed, while the child falls asleep. 2. After several nights of his falling asleep with you sitting near the bed, move your chair progressively farther away from the bed over the next several nights until you are outside the room. 3. The door could be left open for a child who does not get out of bed, but you may need to close the door completely for the child who does. 4. Depending on the child and how long this routine has been followed, desensitization may take from one to three weeks. For an older child, a reward program could be used to speed up the relearning process. Small prizes or a star chart on the refrigerator are excellent methods. If you want your child to sleep alone, be sure to praise the child for excellent behavior. Nighttime Eating/Drinking Disorder “My child is hungry during the night and eats or drinks all night long. I’m exhausted.” This complaint is a sign of excessive nighttime feeding disorder, which is more common among young children and infants. Excessive is a relative term, and can mean several feedings through the night for a baby who is a few months old. A child of six to seven months who requires an extra feeding may also fit this description. Kids can be hungry during the night, then wake up and be unable to fall asleep without being fed. A child who is accustomed to being fed several times during the night may be awakening out of habit, not hunger. The parent’s role may be to teach the child to be hungry at more appropriate times during the day. A child of five to six months who drinks greater than eight ounces of liquid during the night is probably drinking more than he or she needs. This can also be said for a child who nurses more than once or twice, or for longer than two to three minutes at a time. If the child’s diaper is soaked whenever he awakens during the night, he might be experiencing a nighttime eating/drinking disorder. To eliminate the nighttime feeding habit, gradually reduce the frequency and number of feedings. Nursing mothers should gradually wean babies away from nighttime feedings. For an infant who feeds at night about every hour and a half, the parent should wait at least two hours between feedings the first night, and then increase the time span to two and a half hours the second night. Increase the interval between feedings until all nighttime feedings are eliminated. This can take from one to two weeks to complete. If your child is bottle-fed, try decreasing the amount of food offered at each feeding by an ounce each night. Limit Setting Problems When a child refuses to go to bed, stalls for time, or makes it difficult for a parent to leave the bedside, limit-setting problems may be at work. Limit setting problems (which tend to show up after two years of age) can occur at bedtime, napping, or during nighttime awakenings. Parents must keep a firm bedtime routine despite a child’s pleas. As seasoned parents know, children can come up with an endless stream of delay tactics. Parents need to set limits and be consistent to reinforce these behaviors. Older children may get in and out of bed repeatedly during the night. Try placing a gate in the child’s doorway or—if everyone is comfortable with it—close the door until the child successfully stays in the room all night. Let the child know that the door will remain open when she stops trying to leave the bedroom. For those who climb over the gate, consider using a taller gate, two gates, or closing the bedroom door all night. Avoid going into the bedroom to comfort the child, but you could stand on the opposite side of the door or gate to talk to the child in a calm, soothing voice. Gradually extend the time between your visits. If you use a gate, remain out of sight from the child. A child can sometimes fall asleep near the gate or the door during this relearning process. Gates are preferred until the child gets too big. For older kids, a warning that you may close the door may motivate them into staying in bed. Make sure you carry through on your warnings. When using the closed-door method, the intervals are much shorter, from a few seconds to just a few minutes. The idea is to teach the child a new way to fall asleep—not scare them to sleep. Rules For Helping Your Child Sleep Better A successful nighttime routine can usher y our child into peaceful dreamland. Here are some general guidelines to get you and your child on the way:
Helping Our Children to "Sleep Like Babies" Sleep-related issues are the biggest complaint parents bring to their children’s pediatricians, according to sleep medicine specialists with Gaylord Hospital. The sleep issues don’t fade once bleary-eyed parents graduate from their child’s infancy. More pediatricians are seeing older children with sleep issues and teens who show signs and symptoms of sleep disorders. When it comes to sleep, the pediatrician isn’t just treating the child, but the family as well. A child’s sleep problems can affect parents and other siblings. In fact, according to the National Sleep Foundation’s 2001 Sleep in America poll, adults with children get less sleep and report more sleep problems than their counterparts without children. The first thing to understand is that sleep is not an equal opportunity employer. Sleep needs and issues differ among children and may change at various ages. A good sleep history is key. Parents should keep a diary of their child’s sleep habits, hour by hour, and then review it with a health care provider to uncover the specific issues. Remember, too, that not every sleep complaint is a disorder. A good sleep history will help the health care provider distinguish between a disorder and a complaint. When sleep complaints are behavior problems, the health care provider should also consider the family’s level of tolerance. What may be acceptable for some families may not be acceptable for others. Rock-a-Bye Baby For example, in infants and toddlers, the question of what is the appropriate amount of sleep is always an issue: “How long should my baby sleep?” “How many naps should my child take?” “When should my baby sleep through the night. A parent may want her toddler in bed by 7 p.m., and then become frustrated when the child refuses to cooperate with the bedtime routine. The parent and the health care professional need to look at sleep patterns throughout the day and night to assess the child’s sleep needs. “How much sleep is the child getting?” “Does the child sleep in the car or in the stroller? If so, how long and how often?” How many daytime naps does the child take?” “How long does the child nap?” “How often does the child eat?” Based on the information gleaned from the history, the child’s nap schedule or feedings may need to be adjusted. Acceptable sleep behavior can be established as early as infancy. Many new parents will rock their babies to sleep instead of allowing them to fall asleep on their own. Infants then learn to associate sleep with the movement. When they awaken, they find themselves alone and can’t transition back to sleep. “I compare this to an adult who goes to sleep in bed then wakes up in the kitchen,” says Rochelle Turesky, M.D., a pediatrician who is working on a fellowship in sleep medicine at Gaylord. “You can imagine how startled and unsettling that would be for an adult. Imagine how a baby would react after falling asleep in the comfort of his mother’s arms only to awaken in a crib with no mother in sight.” Sleep association is, therefore, a behavioral issue that can be addressed through various methods. Parents should take solace in knowing that babies and children can learn to fall asleep naturally. (For more information on sleep behavior and sleep problems in children, visit the American Academy of Sleep Medicine at www.aasmnet.org or National Sleep Foundation at www.sleepfoundation.org.) I’m a Big Kid Now For toddlers, the big sleep issue is the transition into the child’s own bed. Parents may have trouble setting limits for the child in various settings—and sleep is just one. Sleep, however, is frequently the trigger that brings limit setting to the forefront. When a child refuses to go to bed, stalls for time, or makes it difficult for a parent to leave the bedside, limit-setting problems may be at work. Limit-setting problems (which tend to show up after two years of age) can occur at bedtime, napping, or during nighttime awakenings. Parents must keep a firm bedtime routine despite a child’s pleas. As seasoned parents know, children can come up with an endless stream of delay tactics. Parents need to set limits and be consistent to reinforce these behaviors. Off to School In older children, the symptoms of sleep deprivation are often overlooked or erroneously attributed to attention deficit disorder and behavioral issues. During well-child check-ups, health care providers still need to ask parents about their child’s sleep. Children, for example, should not snore. Loud snoring could be a sign of sleep apnea, restless sleep, or irregular sleeping. Spotting sleep problems in older children is more difficult. Remember, children don’t complain about not sleeping. Children also don’t yawn or rub their eyes the way an adult would when sleepy or overtired. They may, however, be more irritable, lack concentration or exhibit behavioral problems. The lack of adequate sleep can also result in decreased performance in the classroom or extracurricular activities. Other sleep disorders that are seen in older children include night terrors, sleepwalking and sleep talking. Teenagers Rule According to a study conducted by the National Sleep Foundation, teenagers are more likely to complain of being tired during the day than are younger children. “Our research has shown that biological changes during puberty affect an adolescent’s internal sleep-wake clock. Many adolescents are physiologically not ready to fall asleep until 11 p.m. or later,” explains Mary A. Carskadon, Ph.D., Sleep Research Lab Director at Bradley Hospital/Brown University and National Sleep Foundation Pediatric Council Chair. While the average teen needs about nine hours of sleep each night, many get less than seven, according to the study. A frightening figure provided by the National Sleep Foundation and the National Traffic Safety Board shows that 60% of parents who have children old enough to drive say that they have not discussed the dangers of falling asleep at the wheel with their children. Drowsy driving causes at least half of all teen crashes in the United States each year. Given teenagers’ sense of invincibility, many are not aware of the impact their drowsiness plays on driving ability. “Teens, especially young males, are pushing the envelope when it comes to dangerous, drowsy driving,” Dr. Turesky says. Pediatricians need to continue to ask their adolescent patients about their sleep habits, and to include the topic of late-night driving in their pre-college talk about drinking, drugs and safe sex. The TV Connection Parents concerned about their childrens’ sleep habits also may consider how much the television is on in the household. A survey of third- through eighth-graders revealed that as the number of hours of television viewing increased each day so did the prevalence of symptoms such as anxiety, depression and post-traumatic stress (Singer MI, et al. J Am Acad Child Adolesc Psychiatry. 1998; 37:1041-1048). The amount of television viewing—especially at bedtime—and having a television set in the child’s bedroom were factors significantly related to the frequency of sleep disturbances found in children in grades K-4, according to a survey reported by Pediatrics (Owens J., et al. Pediatrics. 1999; 104:e27). Nine percent of the parents surveyed reported that their child experienced nightmares related to television viewing at least once a week. While children are sensitive to and frightened by different things at different ages, media images can produce very real, lingering fears and anxieties in toddlers, teens and young adults. The American Academy of Pediatrics reports that children need reassurance when frightened and the encouragement to choose media that will promote rather than disturb their physical and emotional well-being. The bottom line for all those who care for children is that sleep is a requirement of good health. Every child deserves a good night’s sleep. Topics in Sleep and Menopause Why does it seem that women complain about sleep problems more than men? That is because sleep problems affect more women than men. The quality and quantity of a woman’s sleep change as she ages. Not only do women need a good diet and exercise for optimal health, but they also need sleep. Without good sleep women start the day with a poor functioning ground floor. A poor night’s sleep can lead to daytime fatigue, increased accidents, poor work quality, and possibly increase in illnesses. According to a survey conducted by the National Sleep Foundation (NSF) in 1998, women tend to sleep only an average of six hours and 41 minutes a day during the work week. Sleep quality is affected by changes that occur in a woman’s body. In a woman of menstruating age, the changes are affected by the stage in her cycle. Women have reported having poor quality sleep during the beginning days of menstruation but have reported feeling more sleepy and fatigued after ovulation. During the premenstrual period women may report having more sleep disturbances. These would include: more vivid dreams, excessive daytime sleepiness, fatigue and longer sleep hours according to the American Association of Sleep Medicine (AASM). The NSF and the AASM recommend a few tips for women:
Pregnancy Pregnant women may experience other sleep issues. During the first trimester, there are reports of daytime fatigue and sleeping longer hours during the night. This is possibly due to the changes in the progesterone hormone levels. During the middle part of pregnancy, sleep tends to be better but sleep related problems return during the last trimester of the pregnancy. These sleep-related problems tend to be due to physical changes. These include: leg cramps, backaches, heartburn, fetus movements, and increased need to urinate. Women may find themselves snoring during the final stages of pregnancy even if they have never snored before. The NSF reports that about 30% of pregnant women snore because of the increase in swelling of their nasal passages. Women who experience loud snoring and severe daytime sleepiness should consult their doctor. Up to 15% of pregnant women report having restless legs during the last trimester. This starts as a crawling or moving sensation in the leg or foot and is relieved with movement but returns once the leg is still again. Sleeping tips for pregnant women are:
Once the baby is born it is still important to get enough of rest. Try to nap when the baby naps. Menopause Menopause brings other sleep disturbances with which to contend. These include hot flashes and night sweats. For comfort, try to control bedroom temperature, and eliminate caffeine, sugar and alcohol. Also increase your intake of vitamin E. Estrogen replacement therapy under the direction of a physician may also be helpful. Postmenopause In postmenopausal years women may be plagued with sleep-disordered breathing. They may also be affected by their psychosocial environment, physical health and emotional state, according to the AASM. In the Textbook of Women’s Health by Lila A. Wallis, M.D., M.A.C.P., the complaints by women of poor quality sleep increase with age and that approximately half of the population over 65 suffer from chronic sleep disturbance. The body’s temperature rhythm changes with age, thus causing body temperature to rise at a different time which leads to a disturbance in sleep. Thyroid dysfunction can also cause sleep disturbances. Women may also experience other sleep-related problems such as insomnia, narcolepsy, nocturnal sleep-related eating disorder, and nighttime pain. The pain conditions that consist of migraines, tension headaches, chronic fatigue syndrome and fibromyalgia are more common among women according to the NSF. Occasional sleep disturbances happen to anyone, but when the disturbance is severe enough to affect a woman’s daily functioning, relationships or sense of well being they may want to consult a physician. The AASM offers key sleep hygiene points that women can follow to help decrease their sleep disturbances:
Remember to see a physician before beginning any exercise program. |
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