Daylight Saving Time And Your Child: Springing Ahead

This weekend we “spring ahead” on Sunday, March 9th by setting our clocks ahead an hour as we re-enter daylight saving time. If you do not have children (and are not working overnight), this is a bit of a bummer and you lose an hour of sleep.  If you do have kids, it may help you a bit but it can be complicated.

Interestingly, both with my boys (age 6 and 3), and in my sleep medicine practice, sleep disruption beyond a simple time shift seems to occur, most commonly in the form of night-time awakenings and irritability. I have found that this has seemed particularly exaggerated in children with autism and other developmental delays. It’s really important to adhere to your child’s schedule to minimize these effects.

If you have younger kids, this can be a net positive if your kids are early risers in that their apparent wake time will be an hour later. So if you child typically gets up at 5:30 AM and you are not happy about it, just wait a few days. In teenagers, it may be more problematic as most teenagers go to bed too late and get up too late as is. It may be difficult for them to adjust to going to bed an hour earlier on this Sunday night. Thus, for teens, it makes sense for them to move their bedtime earlier by 20 minutes a night for three nights if you can talk them into it. (Remember, it is always harder to go to be harder earlier than later, especially for teens). The critical part is that they get up at their “typical” time on Sunday (e.g. if they typically wake up at 10 AM on Sundays, they continue to even though they lose an hour of sleep.) They will be more tired on Sunday night and have an easier time going to sleep.

There’s a nice article summarizing recommendations from sleep expert Jody Mindell on this topic here.

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Why You Fall Asleep Part 2: Understanding the Body Clock

On the surface of it, the timing of falling asleep seems fairly easy to understand. Once you have been awake for a certain period of time, you become tired and eventually go to sleep. The technical term for increasing sleepiness over time is the homeostatic sleep drive, as I explained in a previous post. However, there is another system in the body which helps to regulate sleep and wake timing. This is referred to as the body clock, or circadian system. The body clock regulated multiple systems in the body even down to the functioning of individual cells. [For a technical review of the fascinating nature of this system you can read this article].

In the scientific literature, this system is described as the two process model of sleep. The role of the circadian drive is to keep you awake in the early evening. Under perfect conditions, the circadian drive slackens off in the late evening and then, during the night, plays a role in promoting sleep continuity as your sleep drive is reducing. Thus, the sleep drive and the body clock work together to promote both a sustained period of alertness and a sustained period of sleep (16 hours awake and 8 hours sleeping in adults). I would note that the circadian system is quite complex and sends signals which promote both sleep and wakefulness at various times of the day. Melatonin is one of the chemicals secreted in the brain to induce sleepiness as part of the biological clock.

Ideally, The wakefulness drive keeps you awake until it is time for bed but no longer.

Ideally, The wakefulness drive keeps you awake until it is time for bed but no longer.

As children enter puberty, the timing of the wakefulness signal shifts later, resulting in later times of sleep onset. Exposure to blue light frequencies (e.g. from computer, phone, television, or tablet screens) can shift this even later. Add in earlier school start times, and you have a recipe for chronic sleep deprivation in teenagers . Some authors have described the lack of synchronization of the body clock and school schedules as “social jet lag“, where teens only are sleeping in their physiologic sleep period on weekends, and feeling out of it and ill at ease during the week.

During adolescence, the wakefulness drive moves later, even as school start times get earlier. This leads to persistent sleep loss

During adolescence, the wakefulness drive moves later, even as school start times get earlier. This leads to persistent sleep loss

You can adjust the timing of the body clock, by the application of light or melatonin. It is tricky, however, as the timing of these interventions determines how strong the effect is, and even the direction of the effect. In general, light is the strongest stimulus for body clock adjustments. Light exposure in the evening will “wake you up” and shift your body clock later. Light exposure in the morning will move your body clock earlier. Exercise has similar effects, so teenagers and adults with insomnia may benefit from morning exercise outside, and avoidance of nocturnal exercise or screen time before bedtime. Melatonin in the early evenings at small doses may move the body clock earlier and help with sleep onset.

You can use light, exercise, and melatonin to adjust body clock timing.

You can use light, exercise, and melatonin to adjust body clock timing.

For more information, here is a great interactive diagram which depicts the relationship between these two systems in a dynamic manner. Note that the sleep drive is depicted upside down from in the diagrams above.

On a side note, actual jet lag is the result of moving across time zones while your body clock stays the same. This can result in severe daytime sleepiness and nocturnal insomnia until your body clock habituates. Here’s an article which provides some guidance on how to combat jet lag.

Do you have any questions related to the functioning of the body clock? Have you tried to adjust your sleep wake schedule (or that of your child) via the application of light or melatonin?

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Why Asthma Won’t Keep Your Child Out Of the Olympics

The Olympics are a big deal in my house, especially to my wife, whose obsession with the Olympics is well documented. Personally, I love the Winter Olympics because I love the aesthetics, and the variety of the sports. Not coincidentally, the spectacle of athletes performing in the cold air makes me think of my asthma patients, who frequently have symptoms in the wintertime.

I frequently see children with asthma or suspected asthma in my pulmonology practice. When I make the diagnosis in children, their parents are crestfallen, and I can understand why. Asthma is a chronic disease. Many of these parents are around my age and remember friends with asthma (or were asthma sufferers themselves) and remember a time before the routine use of controller medications when children with asthma were frequently sick. (Although inhaled steroids were first produced in the 70s, they were not in wide use until the early 90s). Also, many parents are uncomfortable with using daily medications in their children which is necessary for many children with asthma.

The fact is, most children with asthma can easily be managed with available medications. The goal of treatment is minimal symptoms (less than twice a week). I routinely tell children and families that many athletes in the Olympics suffer from asthma, and that asthma will not prevent them from doing sports either.That’s why I was so pleased to read two articles by Alex Hutchinson on precisely this topic.

London 2012 Olympic medals made by The Royal M...

London 2012 Olympic medals made by The Royal Mint, Llantrisant / Medalau Llundain 2012 wedi’u cynhyrchu gan y Bathdy Brenhinol, Llantrisant (Photo credit: Welsh Government / Llywodraeth Cymru)

  • In his article in the Globe and Mail he explores asthma in elite athletes. More specifically, a disorder called “exercise induced bronchospasm (EIB)” which is quite common in athletes. [Essentially, EIB is narrowing of the bronchi (tubes carrying air throughout the lungs) occurring during exercise.]  It used to be thought that albuterol, the classic rescue medication used for asthma symptoms, was a performance enhancing substance, but more recent research suggests that this is not the case. It seems that EIB may actually confer a competitive advantage after warm up for a period of time called the refractory period.
  • Mr. Hutchinson provides more background information on the Sweat Science blog at Runner’s World, he references data from a study in the Clinical Journal of Sports Medicine suggesting that asthmatic athletes are more likely to medal than non-asthmatic athletes.

In the Globe and Mail article he also offers some good advice on warming up for athletes with asthma:

If you suffer from exercise-induced asthma, a proper warm-up can trigger a “refractory period,” which prevents your airways from narrowing during exercise. Some key elements:

Total duration should be at least 20 to 30 minutes.

Start with a gentle jog, cycle or swim, and gradually increase the pace.

Include several bursts at 80 to 90 per cent of maximum intensity, each lasting two to five minutes.

One extra layer I would add is that there seem to be certain sports which predispose athletes to asthma because of certain exposures. The lungs are exposed to the outside every time you take a breath; athletes breathe more deeply and rapidly and have more exposure. Thus cross-country skiing (cold air exposure), swimming (chlorine exposure) and sports occurring on an ice rink (nitrogen oxide exposures) may be associated with increased risk of asthma. (For an excellent review of this topic, I highly recommend this article by K.H. Carlsen: European Respiratory Journal 2011 CarlsenThe breathless adolescent asthmatic athlete).

Finally, here are some examples of athletes competing with asthma:

  • Jordan Malone is an American short track speed skater with a history of childhood asthma and ADHD.
  • Marit Bjoergen is a Norwegian cross country skier with seven prior Olympic medals. Note that her rival alleged that her asthma medications allowed her to win, but asthma medications when used as prescribed do not provide an unfair advantage. (For a more detailed review of this topic you can read this article).

Does anyone out there have any experience in participating in sports as an asthmatic, or as the parent of an asthmatic child?

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Why You Fall Asleep Part 1: Harnessing Sleep Drive for a Better Bedtime

When I see children or teenagers with sleep difficulties, the first questions in my mind are, “What is bedtime like? What time is it? How long does it take to fall asleep?”  One of the best treatments for insomnia is frequently adjusting the timing of bedtime at night. It does not entail any prescriptions or side effects, just a recalibration in the schedule of the child and the family. The goal of adjusting bedtime is to use the natural need for sleep to address sleep problems.

Why Do You Fall Asleep?

In sleep medicine, we talk about two systems in the body which help people to fall asleep on time. Today we are talking about the homeostatic sleep drive. Although it has a complicated name, it is easy to understand. The longer you stay awake, the sleepier you are. Sleep drive essentially is your likelihood of falling asleep at a given time. Interestingly, this phenomenon is caused by the gradual accumulation of a neurotransmitter called adenosine during the day which is gradually reduce during sleep. The second system is called the circadian system or body clock and I will cover it in a later post.

During the day, sleep drive (need for sleep) increases gradually until sleep onset, then reduces overnight until wake time.

During the day, sleep drive (need for sleep) increases gradually until sleep onset, then reduces overnight until wake time.

When you look at sleep drive in a graph, it increases until you go to sleep, then it slowly decreases until you wake up in the morning.

Napping And Sleeping In Makes You Less Tired At Bedtime

Sleep Drive.002

Younger children require a nap, usually up until age three or four years of age. After that age, a nap, especially a long one, can make it difficult to fall asleep at night. “Sneaky sleep” in a preschooler in the back of Dad’s car on the way home from daycare may sabotage bedtime by reducing sleep drive at night. Likewise, many teenagers are sleep deprived because of structural issues in their schedules  and take prolonged afternoon nap. Additionally, prolonged sleeping in on the weekends can make it nearly impossible to fall asleep on Sunday night, perpetuating the vicious cycle of adolescent sleep

Sleeping in reduces sleepiness at bedtime.

Sleeping in reduces sleepiness at bedtime.

Staying Up Later Means Falling Asleep Quicker

The reason adjusting bedtime later can help with insomnia is that it harnesses the body’s natural sleep drive to make falling asleep easier. When we move bedtime later in a child, we call that bedtime fading . When we do that in a teenager or adult, we call it sleep restriction. Either way, the principle is the same. The key, either way, is ensuring that the wake time does not extend later as well, as the goal is maximizing sleepiness at bedtime.

Later bedtimes can help with falling asleep

Later bedtimes can help with falling asleep

In the next part of this serious I’m going to talk about the circadian system and how it interacts with sleep drive.

Parents– have you adjusted your children’s bedtime in the context of sleep training? Teenagers– have you found that sleeping in or napping affects your ability to fall asleep at night? Is Sunday a particularly difficult night for you?

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Join Me for a #SleepChat Today!

Today at 2 PM EST I am going to be participating in a Sleep Chat on Twitter courtesy of HuffPost Healthy Living and the American Academy of Sleep Medicine. I’m hoping to answer questions about sleep in children. Please send your questions my way with the hashtag #sleepchat and I’ll do my best to answer them.

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Daylight Savings Time And Your Child: Falling Back

Ahh, autumn. Halloween costumes, fall foliage, carving Jack-O-Lanterns and enjoying the crisp bite of a fresh apple. Those of use who live in New England often cite this season as the finest of the year, prior to the long nights and cold days of winter. There is one part of it that I don’t look forward to as a parent of small children, and a sleep doctor: the end of Daylight Savings Time (DST) when the clock falls back by one hour. This year, clocks in the United States will fall back by one hour at 2 AM on Sunday, November 3th. There is some evidence that DST is associated with adverse health and safety effects, but this is controversial; Ezra Klein nicely outlined this in the Washington Post.

If you don’t have children and don’t work nights (medical residents on call that night– I feel for you as you will be on call for another hour), congratulations! You get an extra hour of sleep. For those of us with little children who get up earlier, however, this can be painful. The reason is that little children tend to get up earlier than their parents would like them to. (Teenagers are a different story as they usually have problems with getting up late– thus they struggle with the beginning of DST, or “springing ahead.“) Thus, a child who is sleeping from 8 PM to 6 AM will now be on a 7 PM to 5 AM schedule. The sleep period has not moved, but the clock has:

The consequences of falling back

Fortunately this is pretty easy to address. Move your child’s sleep period later by 30 minutes for three days before “falling back” and then back to their old schedule on the “new time”, effectively moving their sleep period an hour later. In this example, you will have your child go to sleep at 8:30 PM to 6:30 AM for three days before falling back, then move them back to the old schedule at the new time (8 PM to 6 AM).

Stepping your child’s schedule later can help avoid problems

Not everyone’s child will sleep in 30 minutes later but the important thing is to move bedtime. This approach will hopefully cushion the landing from “falling back” and help you get a little more shuteye.  I have found this to be useful in my household and my clinic, where the ramifications of DST seem to extend beyond a simple shift; many children seem to have disrupted sleep at night as well around this transitional period. In my experience, these difficulties may be exaggerated in children with autism, so it may be worth a more gradual transition in sleep periods.

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An Overview of Pediatric Sleep Medicine for the Adult Provider: 
A 50,000 Overview

I’m giving a talk today here at Yale as part of the State Sleep Society Lectures, hosted by Dr. Meir Kryger. Here is a the Pedi sleep med for adult providers syllabus handout. Here is a PDF of my slides: Sleep Overview adult sleep med slides

As always, please let me know if you find these material useful.

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A Great Video on Sleep For Teens, By A Teen

The American Sleep Medicine Foundation held a contest for teenagers to put together a short film about sleep. The winner was Jasper Lown, a senior in high school in Chicago.

There’s a number of things I like about Jasper’s video:

  • The editing is short and to the point, and he uses great visuals to get his points across.
  • He covers the vicious cycle of adolescent sleep
  • He has a bunch of great common sense recommendations for his peers.

Check it out!

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“Inhale. Exhale. Repeat.” Waiting For A Lung Transplant With Cystic Fibrosis

Renu Linberg is a 25 year old woman living with cystic fibrosis. She is waiting for a life saving lung transplant due to progression of her lung disease. I have known Renu for nine years and consider her to be a friend. I have always been struck by her sunny disposition and positive outlook in circumstances that are quite difficult. I asked her to write a piece about how she has stayed so positive and upbeat.

Renu is unfortunately like many others waiting for a life-saving solid organ transplant. According to Organdonor.gov, almost 120,000 people are waiting for organ transplantation, and eight die every day. One donor can save eight lives. If you aren’t already registered, please do so

I was diagnosed with cystic fibrosis at birth, at a tiny community hospital in western Massachusetts, and twenty-five years later I am awaiting a double lung transplant. Life with a chronic illness is something that I’m still learning to navigate, and the world of transplant is relatively new to me. Despite this new challenge, I have found that I’m able to remain optimistic and content with my life, and its wildly unpredictable ways.

My early life was never defined by CF, and I was able to stay out of the hospital until I was a teenager. My parents and grandparents played a huge role in keeping me healthy. They educated themselves early on, and helped to guide me through my childhood and teenage years without placing a heavy emphasis on what CF might mean later in life. They kept life normal, never made a big fuss about chest pt, and signed me up for every sports league, gymnastics team, and ice skating lesson that they could find. I was active, and my lungs were happy.

My parents did a lot of research about cystic fibrosis centers once I reached high school and the hospital admissions started. Massachusetts General Hospital was a trek from our home, but one of the best in the country, and for that we’ve all been grateful. Despite more frequent admissions, I remained active. My parents maintained an open dialogue about drinking, drugs, and smoking, and the effects it would have on my lungs and overall well-being. I rebelled by dying my hair and piercing my nose instead. I found a group of very active friends who chose to kayak and hike and partied with root beer and pizza, and that worked in my favor.

The author, looking forward

The author, looking forward

When I began college, CF moved to the forefront, and quickly became a priority over higher education, a career, and my dream of traveling and studying abroad. I struggled immensely with the idea of temporarily letting go of my college dreams to spend time in a hospital instead. CF can be an uphill climb, one with no degree or graduation ceremony at the end. It was an adjustment period where I realized that while I would prefer to expend my energy in an outward direction, towards earning degrees and exploring the world, I would have to shift instead to focusing my energy inward, to my lungs. That was a few years ago, and I am just now on the verge of getting a transplant. This has been a long and challenging process of letting go of my ego and learning to accept what I’ve been handed. However, I am optimistic. I enjoy life, and always have, and that hasn’t been lessened by a chronic illness.

On the contrary, healthy days and time spent at home are a gift, and I’m positive that having CF has opened my eyes to how appreciative I am of this life. I never enjoy sitting in my car, even in a traffic jam with a broken air conditioner in July, as much as I do after a long hospital stay. Moments with friends and a warm cup of tea are most delicious when unaccompanied by an IV pole, and a good night’s sleep is hard to top.

That’s not to say a chronic illness is always easy, life never is, and hard days are inevitable. I’m trying to get comfortable with being uncomfortable, with the stressful days, with the breathless, can’t-get-off-the-couch days. I am learning to sit through those moments, and acknowledge the anxiety, or fear, or stress. For once those emotions get acknowledged, they seem to have less of a hold on my mind, as though that’s all they wanted in the first place. However, as my body has slowed down, my ability to cope has changed. Where I was once able to go for a swim or a hike, I can now only walk very slowly with a lot of oxygen pumping into my nose. I practice a much-modified version of yoga which is primarily stretching or relaxing in child’s pose. I am still able to meditate, and frequently find myself taking a few quiet moments away from the television and phone and daily life distractions. I will sometimes pick up a book, and attempt to lose myself in fiction for awhile. It feels healthier than watching hours of television, but sometimes I do that, too. And I often reach out to my parents and close friends for love and support. A good support system is one of the main things that has allowed me to remain sane while on the waiting list, their love and humor and Starbucks deliveries are invaluable.

And while it certainly isn’t a conventional life, the best ones never are, I am grateful for this opportunity to slow down and be present. That is something I will take with me long after a transplant

You can follow Renu’s progress on her page Inhale.Exhale.Repeat. Please register to be an organ donor here. If you would like to read another first hand account of a young woman with cystic fibrosis, please read about Emily’s Entourage at Seattle Mama Doc

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The Back To School Sleep Tune-Up

Cape Cod, Summer 2012

Note that this article is republished from last summer. 

Summer, sadly, is coming to an end. It’s been great for us. Long, lazy days at the beach. Dripping ice cream cones. Bike rides. Long days and lazy mornings. Well guess what, campers? That is coming to an end. (Many school districts now start in the last week of August). To me, professionally, what this means is that it is time for a sleep tune-up. I usually schedule my patients with sleep disorders, especially body clock or circadian problems, to make sure that they are on the right trajectory to re-enter school successfully. I was recently quoted in an article in the Washington Post on how to prepare children to re-enter school after a summer of going to bed late and sleeping in. (Thanks to my friend Lizzie Skurnick who connected me with the author, Amy Joyce). I wanted to expand on this topic a bit.

  • For elementary school age children, their schedule tends not to deviate too much during the summer. (Even if you want them to when you are on vacation, they don’t sleep in). As with other major developmental steps, a little of night time sleep disturbance is common but should resolve rapidly.
  • Teenagers are a bit more problematic. Teenagers have a natural predisposition to go to bed later and stay up later. If they have time shifted later by more than an hour, you can anticipate some difficulty in the first week of school.

I have a couple of thoughts about the best way to gently help an older child ease back into the fall routine.

  • Roll the clock back, slowly. You can only move the schedule back by about 15 minutes a day. So if your teenager is sleeping from 1-10 AM and your target sleep period is 10 PM-7AM, you will need about 12 days to make the move.
  • Open those blinds. Early morning exposure to light will help to shift your child’s sleep schedule earlier. Conversely, late night light light exposure (usually from TVs, iPads, phones, gaming consoles).
  • Enlist your child. If there is one thing I have earned as a sleep doctor is that a parent’s (or doctor’s) best laid plans are doomed to fail if the child is not on board. Discuss your concerns with your child in terms that they get.
  • Recognize when things are a bit out of control. Some teens with a condition called delayed sleep phase syndrome may have a severe, marked delay where their day/night schedules become reversed.
  • If your kid is already in school and having trouble sleeping all is not lost. It is key to continue to observe good sleep hygiene, including nap avoidance and avoidance of excessive weekend sleep (e.g. past 10 AM) will ensure habituation to the school schedule.

I also want to share some related links:

  • This interactive graphic at the Harvard Healthy Sleep website explains the interaction between body clock and sleep drive very clearly.
  • My friend and colleague Dr. Christina Scirica has launched her new blog with an article entitled A Healthy Start on Back-To-School which  provides great advice on planning for healthy nutrition for your child during the school day.
  • Two of the child psychiatrists at MGH, Drs. Gene Beresin and Steve Schlozman provide some great advice in Back to School Psychology 101: Tips for Parents.

I remember having marked difficulty sleeping before the first day of school as long as I can remember, perhaps due to my undiagnosed restless leg syndrome. Finally, I’d love to close by ask if any parents have any useful tips (or horror stories) about the back to school transition for their children.

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