Sleep--It's Pretty Much The Most Important Thing Ever!

THIS EPISODE IS HAPPENING THE WEEK BEFORE SCHOOL STARTS—A TIME WHEN ALL FAMILIES PLAN FOR A GRADUAL TRANSITION FROM SUMMER CHAOS TO A REGIMENTED SCHOOL SCHEDULE.  INVARIABLY THOUGH FAMILIES THINK “OH NO, SCHOOL STARTS TOMORROW.  WE HAD ALL SUMMER TO PREPARE FOR THIS.  GOOD LUCK KIDS”

WHY DO WE NEED SLEEP?

HOW TO ESTABLISH HEALTHY BEDTIME ROUTINES

WHAT DOES BEDTIME LOOK LIKE

IS THERE A BEST TIME FOR GOING TO BED?

WHAT IS THE IDEAL ENVIRONMENT FOR BEDTIME?

YOU TALKED ABOUT DOING THE MATH TO ESTABLISH BEDTIMES FOR CHILDREN.

HOURS OF SLEEP FOR DIFFERENT AGES?

SOME SAY THEY NEED TO READ OR WATCH TV TO FALL ASLEEP.  HOW MUCH OF THAT IS TRUE?

WHAT IS THE RELATIONSHIP BETWEEN BLUELIGHT AND MELATONIN PRODUCTION?

WHAT ABOUT EXERCISE BEFORE BED?  AND SOMETIMES KIDS HAVE ACTIVITIES THAT RUN LATE AT NIGHT

WHAT ABOUT MUSIC AS A TOOL TO GO TO BED?

WHAT ABOUT NAPS AND DO NAPS DISRUPT NIGHTTIME SLEEP?

SLEEP DEFICIT AND TEENS WANTING TO SLEEP IN UNTIL NOON FOR SLEEP DEFICIT PAYBACK ON THE WEEKEND

IT SEEMS EASIER TO HAVE THE CHILD SLEEP WITH A PARENT INSTEAD OF SOLVING THE PROBLEM OF HAVING THEM SLEEP IN THEIR OWN BED?

IT MAY SEEM MORE EXHAUSTING TO TACKLE THE PROBLEM THAN JUST PUTTING UP WITH HOW YOU ARE DOING.

LET’S FIRST ADDRESS DIFFICULTY GOING TO SLEEP

What are solutions for children who have a difficult time falling asleep

WHAT IF WE DO ALL THESE THINGS AND WE STILL ARE HAVING A HARD TIME GETTING THEM TO SLEEP?

HOW DO YOU HELP KIDS WITH INSOMNIA

WHAT IF ANXIETY IS THE OBSTACLE TO FALLING ASLEEP

ARE THERE ANY MEDICATION SLEEP AIDS THAT YOU USE?

LET’S MOVE THE SECOND CATEGORY OF SLEEP PROBLEMS—DIFFICULTY STAYING ASLEEP

WHAT DOES THAT LOOK LIKE IN THE MIDDLE OF THE NIGHT?

WOULD YOU TRY TO FIGURE OUT WHY THEY ARE WAKING UP?

COULD WE BE MISSING ANY MEDICAL REASONS OR MEDICAL PROBLEMS THAT ARE CAUSING THEM TO WAKE UP AT NIGHT?

SLEEP APNEA

AND LET’S BRIEFLY MENTION RESTLESS LEGS SYNDROME AS AN UNCOMMON  PROBLEM THAT KEEPS PEOPLE FROM FALLING ASLEEP AT NIGHT

IS THERE A TREATMENT FOR IT?

FOR THE LAST SEGMENT, LET’S TALK ABOUT SPECIFIC CONDITIONS THAT ARISE DURING SLEEP AND THEY ARE GROUPED INTO SEGMENTS—

THE non-REM PARASOMNIAS ARE THE NIGHT TERRORS, SLEEP WALKING, AND SLEEP TALKING.  THE REM PARASOMNIAS ARE NIGHTMARES

LET’S COVER NIGHT TERRORS, SLEEP WALKING AND SLEEP TALKING FIRST.  

AND THEN FOR NIGHTMARES, THESE ARE DIFFERENT FROM THE OTHERS BECAUSE THE CHILD IS STILL IN REM SLEEP

AND YOU LIKE TO ADVOCATE FOR EMPOWERING CHILDREN?

A TIMELY TOPIC IS THE USE OF SLEEP EVALUATION DEVICES LIKE CELL PHONES OR WEARABLES.  HOW HELPFUL ARE THEY?

BUT YOU WOULD RECOMMEND A SLEEP STUDY IF NEEDED AT TIMES?

AND DO YOU HAVE ANY REFERENCES FOR SLEEP RESOURCES 

ANY LAST PARTING COMMENTS?

THAT WRAPS UP THIS EPISODE—HAPPY SLEEPING!

Healthy Sleep Habits, Happy Child--Weisbluth

Solve Your Child's Sleep Problems—Ferber

Medical Music

genotelab.com for sleep music, 1 month trial without cost.

Transcript

Sleep

THIS EPISODE IS HAPPENING THE WEEK BEFORE SCHOOL STARTS—A TIME WHEN ALL FAMILIES PLAN FOR A GRADUAL TRANSITION FROM SUMMER CHAOS TO A REGIMENTED SCHOOL SCHEDULE.  INVARIABLY THOUGH FAMILIES THINK “OH NO, SCHOOL STARTS TOMORROW.  WE HAD ALL SUMMER TO PREPARE FOR THIS.  GOOD LUCK KIDS”

And the biggest part of this transition is the sharp cliff kids fall off when they cannot sleep in as long as they want.

Summer light is a powerful signal to be up during the evening.

WHY DO WE NEED SLEEP?

Sleep is a Chance to reset and clear the brain overnight.

Everything about how your brain works goes through how well you sleep—headaches, seizures, mental health, academic and athletic performance are all affected.  Sleep is one of my three key pillars for good health along with hydration and nutrition

Parents often want to know how to establish healthy sleep routines, 

I believe that Sleep Hygiene is the most important component of healthy sleep—establish a consistent bed time for week nights and weekends with no more than one hour of variability on bedtime and waking up time.  Have a consistent routine that includes ALL screens off an hour before desired bed time and use that hour before bed to have relaxing activities—reading, writing, coloring, drawing, showering or bathing, etc.  Your need this transition time to sleep to allow your mind to relax.  And then when you are in bed, you are only there to fall asleep so no reading or screens.  Otherwise your brain is confused about what you want it to do—“are we staying awake to read or are we going to bed?”  So stay out of bed until you are ready to fall asleep.

WHAT DOES BEDTIME LOOK LIKE

Bedtime is based on math—start with when you need to get up and then work backward to get the amount of sleep that is needed for that child.  

Lots of variability from kid to kid.

If you go to bed when tired, and wake up spontaneously—what does that look like for you?

When should you go to bed?  Based on when you have to get up in the morning

We all have differences on when your body wants to go to bed and wake up.

Conflicts can arise for when an individual’s body natural bedtime and waking up time is because of school and work

Start with when you have to be awake—then come up with bedtime based on how much sleep you should be getting

IS THERE A BEST TIME FOR GOING TO BED?

Good question If you really want to know for your specific child:

How much sleep does this child need?  What is the right timing and amount for them?

Then have them to bed when sleepy (timing) and wake up naturally (amount of sleep) over a couple weeks .  Timing and Amount of sleep

This helps you determine how much time YOUR child needs

Then the best time to go to bed is affected by what they have to do the next day.  

SOUNDS GOOD.  LET’S GET BACK TO: WHAT IS THE IDEAL ENVIRONMENT FOR BEDTIME?

Make the routine a standard for the child.  Set the environment:

Establish the LIGHTING needs—should be as dark as possible without making them scared.  

Have the room on the cooler side—highs 60s to low 70s are best.

Room should be as quiet as possible.  May be spikes of noise throughout the night.  White noise can drown out inside or outside noises.

Pets in the room can be disruptive as they stir—all these things can fragment sleep and decrease the quality as a brain reacts to sounds and movements and stimulation.

SHOULD THEY HAVE A NIGHTLIGHT?

nightlight can be okay—we want the room as dark as possible and still feel comfortable and safe; avoid blue spectrum

YOU TALKED ABOUT DOING THE MATH TO ESTABLISH BEDTIMES FOR CHILDREN.

How many hours of sleep are needed for children of different ages?

Starting with Infants 14-16 hours between night and day sleeping

Decreasing amounts through adolescence until we expect 8 hours by the time they stop growing at about 15 for girls and 17 for boys.

So 11-14 hours for Toddlers, 10-13 hours for preschool kids, and 9-12 hours for school aged kids, and teenagers 8-10 hours.

These are general guidelines, and individual sleep needs may vary as I mentioned before about observing what they do if you allow a natural going to sleep time and waking up time. It's important for parents to observe their children's behavior and adjust sleep schedules accordingly.

In general: Most teens need more than they think or more than they get

SOME SAY THEY NEED TO READ OR WATCH TV TO FALL ASLEEP.  HOW MUCH OF THAT IS TRUE?

This is just an Excuse—these activities are stimulating the brain and prevent you from falling asleep—I think people do fall asleep reading and watching TV because eventually the brain becomes exhausted and you fall asleep.

WHAT IS THE RELATIONSHIP BETWEEN BLUELIGHT AND MELATONIN PRODUCTION?

Bluelight decreases melatonin so watching screens is bad but worse is Interacting with screens —phone and video games—which amplifies the melatonin suppression effect.  So no screens for at least one hour before desired bedtime

WHAT ABOUT EXERCISE BEFORE BED?  AND SOMETIMES KIDS HAVE ACTIVITIES THAT RUN LATE AT NIGHT

Exercise is helpful if not too close to bedtime— you want to be tired and this helps.  

It is common to have athletes home from dance or sports late and then have homework and then have to go to sleep. 

 If they are managing these well then great, but if they are fatigued and not doing well then there are Choices to be made—have to give some things up

We can be overscheduled and there is no way around that—cannot force the sleep if we have activities that prevent it.

See with mono when they get a disease or have a concussion—have to make choices on what matters most.

WHAT ABOUT MUSIC AS A TOOL TO GO TO BED?

Relaxing music can be good, BUT interacting with music on phone makes it worse

AND I will add that Using phone for alarm can be a problem as they have the phone close by and get alerts through the night.

Remove phone from room, use another device for alarms and for music if possible.

I like a resource called genotelab.com for it’s music protocols for sleep and relaxation.

WHAT ABOUT NAPS AND DO NAPS DISRUPT NIGHTTIME SLEEP?

Great question.  “Sleep pressure” refers to the pressure the body has to fall asleep—this pressure is relieved with a nap and decreases the correct timing of the pressure to fall asleep at night.

Naps

Stop at about 3 naturally

Avoid nap if having a hard time falling asleep

Scheduled "quiet time" after lunch to last one hour--can be used for sleep or for play in their room

WE HEAR A LOT ABOUT SLEEP DEFICIT AND TEENS WANTING TO SLEEP IN UNTIL NOON FOR SLEEP DEFICIT PAYBACK ON THE WEEKEND?

Paying back sleep deficit is a fallacy. 

If you are sleep deprived on weekdays—trying to catch up on the weekend—DOESN’T WORK

If you are struggling with fatigue—you need Consistency in your sleep schedule

Body knows what to expect—develops natural rhythms

Brain gets confused when we ask different things of it—“are you wanting me to stay awake or go to sleep?”

Bedtime and waking up time shouldn’t vary by more than an hour weekday to weekend IF we are trying to promote good sleep.

 IF you are okay being tired then don’t worry about being consistent with your routine

Some just require more discipline than others to NOT be fatigued—not fair, but if you struggle, this is part of the solution.  Try it for 2 weeks!

WE HEAR A LOT ABOUT IT BEING EASIER TO HAVE THE CHILD SLEEP WITH A PARENT INSTEAD OF SOLVING THE PROBLEM OF HAVING THEM SLEEP IN THEIR OWN BED?

IT MAY SEEM MORE EXHAUSTING TO TACKLE THE PROBLEM THAN JUST PUTTING UP WITH HOW YOU ARE DOING.

Dr. Sears talks about the Family Bed concept—just to have the kids in bed with you for years.  

This may work with a first child but as you have more kids you get too tired with kids kicking you in the face and you don’t get good sleep.

Having your child in bed to have them fall asleep with you—complicates the problem.

Takes a commitment to  break the cycle

Be strong when you are ready

Cannot go back and forth from night to night—need to be all in OR—will reinforce to kids to keep looking for exceptions for when they can get in your bed

Be consistent

Short-term pain but beneficial in the long run

LET’S TALK ABOUT How to deal with sleep disturbances—AND THERE ARE REALLY two kinds—difficulty falling asleep and difficulty staying asleep

LET’S FIRST ADDRESS DIFFICULTY GOING TO SLEEP

What are solutions for children who have a difficult time falling asleep

• Establish a calming bedtime routine that we discussed with all of the sleep hygiene and consistency
• Make sure you have the Comfortable Sleep Environment that is cozy and optimized for darkness and temperature and sound
• Review screen time habits
• Utilize all the relaxing and mindful activities in your toolbox
• Consider exercise to help increase fatigue—but not too close to bedtime
• Make sure they had their second dinner so they are not hungry
• For older kids be careful about whether they are taking in any caffeine which can impact sleep 6 hours later

WHAT IF WE DO ALL THESE THINGS AND WE STILL ARE HAVING A HARD TIME GETTING THEM TO SLEEP?

Try to understand what issue is at the core of the difficulty falling asleep.

There may be problems with insomnia or anxiety.

HOW DO YOU HELP KIDS WITH INSOMNIA

With Insomnia I am really trying to figure out Obstacles to falling asleep

electronics, 

distractions

anxiety

I try to review their SCHEDULING

I say: TELL US WHAT BEDTIME LOOKS LIKE STARTING WITH GETTING HOME FROM SCHOOL

What is their ROUTINE? How is their sleep Hygiene, how late are they doing homework?, cannot just close book and fall asleep

They Need time to wind down.  If they don’t have that time then what is interfering with that?  Work toward the ideal

WHAT IF ANXIETY IS THE OBSTACLE TO FALLING ASLEEP

With ANXIETY we have Trouble quieting thoughts at night—brain brings all these things up when it is quiet and cannot fall asleep

Techniques to work through that can come through counseling and I will refer people for therapy to work on that.

And some have what we call “Psychophysiologic insomina”—lay in bed for a long period of time and cannot fall asleep, and it becomes a cycle unto itself.  

They Identify with being a bad sleeper and that alone makes it hard to fall asleep

For this—Try to do all the bedtime activities outside the room and out of the bed.

The bed is used only to fall asleep.

ARE THERE ANY MEDICATION SLEEP AIDS THAT YOU USE?

I will discuss pharmacologic sleep aids—melatonin—sleep inducing activity, 

It is best with helping to manipulate circadian rhythm—

30 minute to a couple hours before sleep or desired bedtime, 

We are trying to mimic natural melatonin and it is most helpful to move bedtime to a best time, 

I use 2-3 mg, up to 10 mg in larger patients, 

There has been discussion about side effects of early onset of puberty and nightmares for some but if used properly it is safe; 

It is helpful in correcting jet lag; 

People ask about long-term risk of suppressing natural melatonin? no studies showing this; 

I don’t like using antihistamines like benadryl because of the hangover effect the next day and still tired, 

There are a couple other medications like prescription clonidine and trazodone

In general, I Prefer to address underlying issues rather than medicating

LET’S MOVE THE SECOND CATEGORY OF SLEEP PROBLEMS—DIFFICULTY STAYING ASLEEP

We all wake up at night. The question is what do we do when we wake up. Can we manage it by ourselves or do we need some help to manage going back to sleep?

No rewards for the child waking up. Consider that the child is trying to figure out what works. If there is some reward like spending time with you then they will keep coming to you at night.

How we address nighttime waking up episodes looks a lot like how we address sleep at the start of the night so it is most important to create expectations with the child for how to go back to sleep the same way they went to sleep the first time.

So a key to manage sleep in the middle of the night is how we manage sleep at the start of the night?

Well, for example, Consider: What happens when they wake up?  Can they soothe themselves back to sleep?

If they cannot—call out for mother.  Then you go back to the bedtime routine and however that goes.

If at theStart of the night—Child has learned to fall asleep with a parent—mom or dad lays with me until falling asleep then the transitional object is the parent.

Wake up at night and want the same—habit, expectation, don’t know any other way to go back to sleep.  Only know how to go back to sleep if mom or dad is there—it all begins with the start of the night.

Remember that it's normal for children to wake up briefly during the night. 

The goal is to help them develop the ability to self-soothe and fall back asleep independently. 

Consistency in your responses and patience will go a long way in helping your child establish healthy sleep patterns.

WHAT DOES THAT LOOK LIKE IN THE MIDDLE OF THE NIGHT?

It is calm and consistent reassurance and redirection back to their bed.  It is avoiding stimulating activities or feeding them.  They want to interact and play and do things with you but you need to be consistent to get them right back to bed so there is no reward for their behavior—even if they are sad.  They are going to use the big guns—I am scared, I am thirsty, I am hungry—all the most basic needs that resonate with us and push our kind-hearted buttons.

WOULD YOU TRY TO FIGURE OUT WHY THEY ARE WAKING UP?

Definitely.  Is there too much light—decrease it?  Is the temperature off?  Is there too much noise and white noise would be helpful to filter that.  If they are afraid make sure they have their magic blankets for protection and weapons to keep them safe like light sabers and Nerf guns to empower them.  Help them find their transitional objects— their bears or dollies to comfort themselves back to sleep instead of you having to be the transitional object to fall back to sleep.

COULD WE BE MISSING ANY MEDICAL REASONS OR MEDICAL PROBLEMS THAT ARE CAUSING THEM TO WAKE UP AT NIGHT?

Definitely If night awakenings persist, consider factors such as allergies, sleep apnea, or other medical conditions that may be affecting your child's sleep and I can help with that.

We are trying to understand:  Why are they waking up?

Are there issues with breathing?  They might have Sleep Apnea. Evaluate

WOULD YOU SAY THAT ONE OF THE MOST COMMON MEDICAL PROBLEMS AFFECTING SLEEP IS SLEEP APNEA?

Yes.  This is very common.  It isn’t as common as snoring which gets people thinking about sleep apnea.  They can snore pretty badly and still not have sleep apnea.

With sleep apnea, they actually have pauses in their breathing where they are trying to breathe but they cannot and so they have to change position and disrupt their sleep to continue breathing and this happens all through the night so they may have a good number of hours in bed but their sleep QUALITY is terrible.  

Other symptoms are: They will breathe through their mouth a lot and they will be tired and grumpy in the day.  Also important to evaluate poor sleep as a possibility when they have poor school performance when your are considering ADHD.

HOW DO YOU EVALUATE SLEEP APNEA?

Sleep apnea questionnaire and if positive for sleep apnea then I will refer to ENT.

A sleep study can also be very helpful with sleep-disordered breathing.  This is best done someplace that works frequently with children.

WHAT IS THE TREATMENT FOR SLEEP APNEA?

It continues to be removal of the tonsils and adenoids by an ENT surgeon.

There are some positioning devices and CPAP like for adults that can be used.

AND LET’S BRIEFLY MENTION RESTLESS LEGS SYNDROME AS AN UNCOMMON  PROBLEM THAT KEEPS PEOPLE FROM FALLING ASLEEP AT NIGHT

This is an Uncomfortable sensation in legs that is

Worse at night and is

Worse at rest and

Better with movement

Interferes with ability to fall asleep or stay asleep—beginning of the night

Interferes with the duration of sleep—very disruptive and disabling

IS THERE A TREATMENT FOR IT?

Treatment—check iron levels including ferritin

With a goal to get these levels to higher range

There are some medications that can be used: Neurontin and Benzodiazepines

FOR THE LAST SEGMENT, LET’S TALK ABOUT SPECIFIC CONDITIONS THAT ARISE DURING SLEEP AND THEY ARE GROUPED INTO SEGMENTS—THE non-REM PARASOMNIAS AND REM PARASOMNIAS.

THE non-REM PARASOMNIAS ARE THE NIGHT TERRORS, SLEEP WALKING, AND SLEEP TALKING.  THE REM PARASOMNIAS ARE NIGHTMARES

LET’S COVER NIGHT TERRORS, SLEEP WALKING AND SLEEP TALKING FIRST.  WHAT IS THE BASIS BEHIND THESE CONDITIONS?

With these, awake activity has slipped into times of deep sleep.  They are NOT awake but are doing these awake-appearing behaviors.

They usually happen during the First couple hours after falling asleep

Shouldn’t remember the next day

Should behave the same the next day—behavior, mood

HOW DO WE BEST MANAGE THEM?

Keep them safe.  SAFETY FIRST.

This is a confused state for the patient—guide them back to bed.

DO NOT awaken them—there can be harm to patient or caregiver.

This can be very troubling to watch especially the night terrors but stay calm while helping the child by managing back to the safety of their bed with minimal interaction and soft guidance.

Alarms: One key for sleep walking is to make sure that the home is secured with locks or alarms to make sure a child doesn’t wind up outside without our knowledge

ARE THERE THINGS WE CAN DO TO PREVENT THESE CONDITIONS?

Worsened by sleep deprivation so a consistent sleep schedule and bedtime routine reduces the occurrence of night terrors.

Said the other way—they are worsened by irregular sleep-wake schedule

Manage any factors that might contribute to night terrors, such as stress, sleep deprivation, or illness.

High temperatures—fevers or room too hot; keep room cool

IS THERE A TREATMENT FOR THEM?

Remember that most children outgrow night terrors as they get older.

No medications unless a perceived danger to themselves or others

Benzodiazepine at bedtime

AND THEN FOR NIGHTMARES, THESE ARE DIFFERENT FROM THE OTHERS BECAUSE THE CHILD IS STILL IN REM SLEEP

Yes, the child has lost the usual lack of tone that should happen with REM sleep so they are acting on their dreams and thoughts during REM sleep.

WHAT CAN WE DO FOR PREVENTION?

Because we can hear what they are concerned about or they can remember their nightmare—I try to limit exposure to the stimulus that worries or scares them, limit their anxiety or fears—and it may even be something benign like purple cartoon dinosaurs.  But limit exposure to content that scares the child or may be considered scary

MAYBE LIMITING THEIR MEDIA EXPOSURE IN GENERAL IS A GOOD IDEA HERE.

Agreed.  The less the better.

AND YOU LIKE TO ADVOCATE FOR EMPOWERING CHILDREN?

Empower kids when they have nightmares--magic blankets to keep them safe, lightsabers and Nerf guns to provide security.  This can go along with an imaginary friend or protector such as one of their stuffed animals that can keep the child safe.  I recommend providing comfort from things they are afraid and reassurance that they are safe while not minimizing their concern that something is real while empowering them to be stronger than what they are afraid of.

Also talk about their fears during the day to help them with perspective.

A TIMELY TOPIC IS THE USE OF SLEEP EVALUATION DEVICES LIKE CELL PHONES OR WEARABLES.  HOW HELPFUL ARE THEY?

First, we want to limit phones being in the room anyway because it leads to people interacting with them even if the original intent was good.

Second, Smart phone and devices—not very accurate but good attempt.  Not accurate REM and deep sleep assessments—don’t spend money on them to evaluate sleep quality

BUT YOU WOULD RECOMMEND A SLEEP STUDY IF NEEDED AT TIMES?

Yes, but still these are useful for evaluating disordered breathing or disordered movements during sleep and they are also Not telling them how well they sleep.  Very artificial environment to be in a strange room, attached to wires and tubes and people visiting you all night long

AND DO YOU HAVE ANY REFERENCES FOR SLEEP RESOURCES 

Healthy Sleep Habits, Happy Child--Weisbluth

Solve Your Child's Sleep Problems—Ferber

Medical Music

genotelab.com for sleep music, 1 month trial without cost.

ANY LAST PARTING COMMENTS?

Illness and vacation throw off great routines but get back in the saddle when kids are better and when you are back from vacation—or better said a “family trip” if you took the kids with you so it wasn’t  a real vacation

THAT WRAPS UP THIS EPISODE—HAPPY SLEEPING!

Sweet dreams!



Healthy Sleep Habits, Happy Child--Weisbluth

Solve Your Child's Sleep Problems—Ferber

Medical Music

genotelab.com for sleep music, 1 month trial without cost.