Sleep: A talk for every visit

Transcription

1 1 Sleep: A talk for every visit Shawn Sorrell, M.D., F.A.A.P. University of Kentucky College of Medicine Dept. of Pediatrics Division of Adolescent Medicine

2 2 Goals of Discussion Understand the epidemic of sleep deprivation Review Sleep Physiology Define what is happening to our teens as a result Review Newest and Evidence Base Recommendations

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10 10 Sleep Epidemiology... National Sleep Foundation Sleep in American Poll 75% of High School seniors are sleeping less than 8 hours compared with 12% of 6th graders US and International Studies show that as students get older sleep durations decline.

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12 12 Sleep Physiology

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14 14 Why do we sleep? Poorly understood Energy Restoration Energy conservation Memory Consolidation Growth

15 15 Types of Sleep

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17 17 Non REM stage 1 Stage 1 sleep is a transition period from wakefulness to the other 3 stages of non-rem sleep. It is of short duration, usually lasting only from 1 to 7 minutes. Stage 1 sleep is characterized by low voltage, mixed frequency EEG, as well as some slow, rolling eye movements and some relatively higher EMG activity. The brain activity is shown below in the following EEG recording.

18 18 Non REM Stage 2 Stage 2 makes up the bulk of an average person's sleep each night, around 40 to 45 percent. A sleep researcher can easily recognize stage 2 sleep because of the presence of sleep spindles and K-complexes in the EEG waves. A sleep spindle is a rapid wax and wane of the EEG waves in a 1 to 2 second interval, while a K-complex is a large wax and wane of the wave that somewhat resembles a mountain.

19 19 Non REM Stage 3 Stage 3 and stage 4 are similar and both fall into the category of slow wave sleep. They are so named because of the high amplitude waves in the EEG. In order to qualify as stage 3 sleep, these slow waves must be present in no more than 50 percent of the epoch. The waves are also referred to as delta waves.

20 20 Non REM Stage 4 Stage 4 is the other slow wave sleep period. In order to qualify as stage 4 sleep the high amplitude delta waves must be present in more than 50 percent of the epoch, like in the EEG recording below.

21 21 Sleep Physiology REM Sleep Brain is highly active Activated EEG (similar to wakefulness) Marked decrease in muscle tone Episodic bursts of Rapid Eye Movement Dreaming occurs

22 22 Sleep Physiology

23 23 So key points Non REM and REM (really important) Non- REM stage 1, 2, 3 and 4 REM and Non REM (1,2,3,4) = Once Cycle Most adults get 4-5 cycles Good quality of sleep is noninterrupted 4-5 cycles

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25 25 How do children/teens differ in sleep? REM is 50% of sleep in infants- 8 hours in REM! Time spent in REM stabilizes at age 10 Declines at age 60 Age 70 only 45 minutes is spent in REM Decrease in sleep duration Decrease in slow wave sleep beginning in puberty

26 26 How do adolescents/children differ?

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28 28 Adolescent Sleep Physiology Teens onset of sleep is later Onset of pubertal development- circadian rhythm regulation of sleep is delayed Onset of secondary sexual characteristicspeak of delayed circadian rhythm Studied across cultures and mammalian species! Hagenauer, 2009

29 29 Consequences of Sleep Restriction Decreased Cognition-decreased school assignments Increased Weight Gain Increased Disease Morbidity Substance Abuse Reckless Behavior Increase mental health morbidity

30 How does sleep affect school? 30 **Quality of sleep **Inability to complete tasks

31 31 Sleep Disordered Breathing and Academic Performance Galland et al meta analysis published in Pediatrics 2015 Significant amount of literature describes the relationship between a spectrum of Breathing Abnormalities (snoring, obstructive sleep apnea, upper airway resistance syndrome) that decrease not only quality but duration of sleep that result in the following: Intelligence (standardized testing) Memory Executive Function Attention Hyperactivity

32 32 Media and Homework October 21, 2016 AAP Conference: Media Affect on Academics and Sleep Dr. Rubenstein, Brown University of Public Health- 64,000 children ages 6-17 Any Use of Digital Device: For every 2 hours of additional device use there was a significant decrease in the ability of children to complete homework

33 33 Consequences of Poor Sleep Decreased Cognition-decreased school assignments Increased Weight Gain and Disease Morbidity Substance Abuse Reckless Behavior Mental Health Morbidity

34 34 Sleep and Obesity Mischell, et al published a study in Pediatrics students entering the 9 th grade and followed them every 6 mos through the 12 th grade and found that each additional hour of sleep was associated with decreases in BMI This association between BMI and sleep duration was much higher at the higher levels of BMI distribution.

35 35 Sleep and Glucose Metabolism Spiegel, et al published research that reviewed sleep loss as a risk factor for insulin resistance and type 2 Diabetes Mellitus- Two Groups Recumbant- no activity, fasting Asleep- (no activity, fasting) Marked changes in glucose metabolism: increase insulin resistance Stable glucose levels

36 36 Consequences of Poor Sleep Decreased Cognition-decreased school assignments Increased Weight Gain Increased Disease Morbidity Substance Abuse Reckless Behavior Mental Health Consequences

37 37 Lack of Sleep and Risky Behaviors CDC: 5 Risky Behaviors and found (national level) 86.1% of students surveyed do not use bicycle helmets frequently 30.3% text while driving 26% rode in a car while driving with someone who had been drinking 8.9% drove after drinking 8.7% do not use seatbelts frequently All five were significantly more common if teens are getting less than 7 hours or less of sleep.

38 38 Sleep and Mental Health Chen et al published study in Pediatrics Collected data in rural and metropolitan areas of South Australia 2588 students grades 4 th -6 th grades 765 students grades 9 th -10 th

39 39 Sleep and Mental Health Completed questionnaires and had standardized measures of 4 health behaviors : Eating behavior Sleep pattern- duration of sleep Sedentary behavior - >2 hours of screen time per day with no physical activity Physical activity- number of days students were physically active (60 min with no screen time during that day)

40 40 Sleep and Mental Health Compared 4 health behaviors to Quality of Life Defined Quality of Life: Worried, sad, homework, pain, annoyed, sleep patterns (sleep diary), ability to join in activities Researchers found that there was decreased quality of life was associated with going to bed one hour later and one additional hour of sleep had increased quality of life.

41 41 Sleep and Mental Health (Chen, 2014) Quality of Life: worried, sad, struggles with homework, pain, annoyed, decreased ability to join in activities Decreased quality of life Going to bed one hour later

42 42 Sleep and Mental Health Gangwisch JE, et al published study in 2010 in Sleep-studied information gathered from 15,659 students and their parents: Average sleep duration: 7 hr 53 min Correlation was found between depression and suicidal ideation and self reporting going to bed later. Correlation with increased depression and when parents had low expectations for when the bedtime was set (teen perception of how much parents care)

43 43 Now we know... what next?

44 44 Sleep Recommendations AAP June based on Am Acad of Sleep Medicine (13 Sleep Experts reviewed 864 scientific journals)- metanalysis 4-12 mos 1-2 years 3-5 years 6-12 years includes naps hours hours hours 9-12 hours 8-10 hours

45 45 Treatment of Restricted Sleep Journal of Educational Psychology As regards to the school child, the wisest course in all probability is for us to make the conditions such that the child will spontaneously sleep as many hours a day as he wants to sleep, while avoiding all conditions which would tend to abbreviate or unduly prolong the sleep beyond the standard.

46 46 Sleep Hygiene Routine Media/Electronic Devices Caffeine Exercise Diet Modification Tobacco

47 47 Sleep Hygiene Nathanial Kleitman -originally from Moldova and eventually immigrated to New York City and then finally joined faculty at University of Chicago. Instrumental in Early Studies of Sleep Coined the term Sleep Hygiene that demonstrated behavioral techniques for the treatment of insomnia Developed Ovaltine that was used to help treat insomnia Used the early EEG to determine the REM of Sleep Studied sleep in Mammoth Cave, Kentucky and submarines during WWII

48 48 Sleep Hygiene Routine, Routine, Routine Make the bedroom (at least bed) a sleeping santuary... not for homework, music, etc Make a to do list of bedtime routine Pick a calming routine including warm shower, calm music, etc Start an hour before expecting to sleep Remove all electronic devices from the ROOM

49 49 Sleep Hygiene: Media Media/Electronic Device Shutdown (and out of the room) Blue Light Emission: Shorter wave length from electronic devices, LED lights, energy efficient lights- Melatonin is suppressed by 90 minutes after 8 hours of blue light exposure. (2 hr shut off before bed) Cognitive Engagement- flight of fight response to certain media events Neuronal activity- less likely to be in restful state

50 50 Caffeine Use and Tobacco Adolescent Population: Caffeine boosts neurotransmitters dopamine, serotonin, acetylcholine Caffeine use is higher in those using late night media Increase caffeine use is related to higher nicotine use Recommend abstinence or decreased use after 2 pm

51 51 Medications for Sleep Aid Most Commonly prescribed or recommended for children and adolescents: antihistamines alpha agonists- antidepressants OTC natural sleep aids (melatonin)

52 52 Medications as Sleep Aids What We Know (very little) Identify and treat the underlying disorder. Very limited data that supports pharmacologic interventions for sleep disorders- minimal research in the area of ADHD, ASD, and Neurodevelopmental Disorders

53 Consensus Statement 2006 Pediatrics (Mindell, Jodi. et al) 53 Pharmacologic Management of Insomnia in Children and Adolescents: Consensus Statement...WE NEED MORE INFO

54 54 H 1 Antagonists First Generation: Diphenhydramine Crosses blood brain barrier: Histamine release during the day helps stimulate arousal; at night the reduction in histamine aids in regulation of circadian rhythm Significant effects on the sleep wake cycle: decreases cognition, memory, decrease sensory motor performance, decreases REM March 2007 Pediatricians urged FDA for regulation and recommended that first generation H1 blockers not be available under age 6

55 55 Melatonin Naturally synthesized hormone made by the pineal gland and regulated by the hypothalamus (suprachilasmatic nucleus) Short term studies show it to be helpful for use in short term sleep onset: Children 2.5 mg - 3 mg Adolescents 5mg-10 mg No Long Term Studies Possible decrease in seizure threshold. Not used in children with immune disorder or on immune modulating treatments.

56 56 Main Points... Obesity Depression Anxiety ADHD Poor Academic Performance Dysfunctional Family Relationships... Sleep should always be a part of the treatment plan.

57 57 Thank you

58 58 References Galland, Barbara, et al. Sleep Disordered Breathing and Academic Performance: A Meta Analysis. Pediatrics. October (4). Rubenstein, et al. Digital Media Exposure in School Aged Children Decreased Frequency of Homework. Presented at AAP Conference October Mischell Jonathan, et al. Sleep Duration and Adolescent Obesity. Pediatrics. May 2013 Taveras, Elsie, et al. Chronic Sleep Curtailment and Adiposity. Pediatrics. June ( ). Spiegel, Kaine et al. Sleep Loss: A Novel Risk Factor for Insulin Resistance and Type 2 Diabetes. Journal of Applied Physiology. November (5) Lack of Sleep Associated with Risky Behaviors. AAP News. CDC MMWR April Chen, et al. BMI, Health Behaviors and Quality of Life in Children and Adolescents: A School Based Study. Pediatrics. April (4). Gangwisch, JE, et al. Earlier Bedtimes may Protect Teens Against Depression. Sleep (97-106). Terman, L. The sleep of school children, its distribution according to age, and its relation to physical and mental efficiency. Journal of Educational Psychology. April (4)

59 59...References Jenco, M. Recommended Amount of Sleep for Pediatric Populations. AAP News: American Academy of Sleep Medicine. June Hagenauer, M. Adolescent changes in the homeostatic and circadian regulation of sleep. Dev Neurosci June 31 (4) Nathaniel Kleitman. In Wikipedia. Retrieved November 12, Mindell J., et al. Pharmacologic Mangement of Insomnia in Children and Adolescents: Consensus Statement. Pediatrics (6).