The Best Curtain Call Ever?

As a sleep doctor, I hear a lot of creative excuses that children come up with as the try to extend their bedtime. In the business, we call these “curtain calls” and are a key feature of behavioral insomnia of the limit setting type.  My niece used to yell, “Julia’s hurt!” until her family came to check (she wasn’t). One mother in clinic told me how she pulled out four loose teeth on one occasion when her mother was having a friend over. I have heard children ask for:

  • Glasses of water
  • Another story
  • Going to the bathroom (multiple times)
  • For parents to check the closet/under the bed/ in the toy chest for monsters
  • The pacifier that he or she just threw on the floor.I was listening to NPR today and heard about a little boy named Noah Shaw who surpassed all of these other children. Noah was born with a cancer of the eye called retinoblastoma (you can read about more about Noah, whose diagnosis led his father to develop a way to detect this tumor in baby photos). As a result, he wears a prosthetic eye in his right eye socket. Some nights, after his parents, would put him to bed:

. . . he used to play this little game with his mom and dad. They’d put him down for bed, then they’d leave the room. And a few minutes later, Noah would take his eye out and throw it on the ground. It sounded like an M&M hitting the hardwood floor. And then of course, Mom and Dad would go rushing back into the room, which would make Noah terribly happy. Read the full story here.

I have to hand it to this little boy for creativity. Most parents would have a hard time not going into that room. What are the most creative delaying tactics that your children have come up with?

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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 would advise parents to think about the sleep habits of their children, and how they may need to be readjusted prior to restarting school.

  • 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. This is due to their natural body clock predisposition to stay up later and go to bed later, which can become exaggerated over the summer.

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) will move your child’s sleep schedule later.
  • 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:

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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Vacation “Sleep”

We just back from vacation. I thought that I would reshare some tips that have been helpful to me. 

There have been a lot of great recent articles on summer related  for children and families; many have been thoughtfully gathered by Dr. Heidi Roman in her Summer Safety article . I also really like this article from the New York Times on how not to ruin your own vacation. (In a nutshell, cut the virtual umbilical as much as you can– something I have struggled to do as you can see from my recent volleys of tweets).

We are having a great time here but are dealing with a bit of sleep disruption from the wee ones. Witness the usual view from the foot of my bed at approximately sunrise all week-long. Thus, clearly, I don’t have the secrets of perfect child sleep on vacation. However, I’ve gleaned a few lessons:

Sunrise happened soon after 5 every morning. I was alerted to this daily by my son.

  • Respect the routine: When we go on vacation we try really hard to maintain our kids’ bedtimes and nap times. Of course, we bend the rules for special occasions like fireworks. (I wish we had seen the display in San Diego where all the fireworks went off at once; all the excitement and home early for bedtime.) Also, some “sneaky sleep” may be unavoidable as the kids will be pretty tuckered out.
  • Go to bed early:  We were vacationing with cousins, and all the kids got up earlier than normal. If you want to catch up on your sleep, your best chance is by going to bed earlier than normal.
  • Make the room dark: Don’t hesitate to hang towels over the windows if you need to– that can make a huge difference in when your child gets up.
  • Get creative with the sleeping arrangements: We were staying with several cousins at a vacation home. Our older son shared a “room” (which was a walk in closet) with his 6 year cousin. That way they did not have to get up with their younger siblings (and tired parents) the next day. Of course, this is not perfect; my niece got up at 5:15 AM on the first day and awoken our son as well. Sharing rooms can be a bit tricky for children used to having their own room; older children should be instructed to let others sleep if they wake up early. They may also be a bit chatty at bedtime, but that is part of the fun.
  • Jet lag can be tricky: Jet lag occurs when travelling across time zones east or west. You can prepare a bit by putting your kids to bed later for a few days before travelling west or getting them up a bit earlier before travelling east. Children tend to adapt quickly if they have natural light exposure. For more on this topic there are some good articles here and here.
  • Be realistic: Remember long relaxing reading sessions by the pool and sleeping on the beach? Yeah, me neither.
  • Have fun: Although vacation with little ones may not exactly be restful, we had a ton of fun digging holes in the sand, looking at snails, riding bikes, and having lots of family meals.

Any crazy vacation sleeping stories out there? Please share.

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“Vamping”, Poor Sleep Hygeine, and Social Media in Teens

I’ve written at length about the dilemma of the teenager: how large amounts of homework and early school start times prevent adequate sleep, leading to problems with mood, academic achievement, safety, and many other issues. Many teens go through live in haze that one scientist has described as social jet lag, consuming excessive amounts of caffeine, napping, and worsening their chances of getting a good night’s sleep.

One of the arguments marshalled by opponents of later school start times is that this issue is the fault of the teens. Research has shown, however, that teenagers can’t simply move their bed times earlier for physiologic reasons related to their body clocks.

This does not let teens or families off the hook, however. In an article in the New York Times this week by Laura M. Holson, she describes teenagers staying up late on their phones and computers– which some teens refer to as “vamping”

“You want to seem as cool as possible so you will post something at 2 in the morning, to just be like, ‘Oh, I’m part of this cool-kid group,’ ” one friend said, before Ms. Fagbenle added, “My friends and I see the same thing down our newsfeeds, posts about #breakingnight, also known as #notsleepingatall and #vamping.”

In the article, one teen is described as taking naps so that he can stay up late. Another mother has frequently found her 13 year daughter up late on a messaging app.

To be frank, I have little patience for this in my clinic. Parents need to send a strong message to teens that consumption of social media and use of electronic devices after bedtime is NOT OK. Here are some tips on how to do this:

  • Set a good example. Do you bring your phone into bed with you? As a society, I think it is time for us to put our phones down.
  •  From a young age, make your child’s bedroom a cool, calm, and quiet zone during sleep periods. And for goodness’ sake, get that television out of your kid’s room. Now.
  •  Lock down your internet so it is not available to your children during night-time hours.
  •  If your child needs his or her computer to complete homework, use software like f.lux to reduce blue/white light wavelengths which can delay the body clock.
  •  All electronic devices out of the bedroom after bedtime. No exceptions, including for you. Lock them in a drawer if you have to.

If your children are not yet teenagers, encouraging healthy use of screens and electronics from a young age will make this considerably easier for you.

One final note: If your teenager consistently cannot fall asleep before a very late hour, is routinely difficult to arouse or late for school, and tends to sleep all day during vacations and weekends, he or she may have delayed sleep phase syndrome or another sleep disorder and should be evaluated by a sleep expert.

Parents: do you struggle with this with your children? Do you struggle with regulating this in yourself? Anything that has helped at home?
Teens: what are your thoughts on this topic? Do you struggle to put down your phone?

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When Not To Sleep Train

There are lots of reasons that parents fail at sleep training their children. One of the most often overlooked is timing. If you pick the wrong time to start, you are doomed to failure. You really want to allow yourself about two weeks of time without any major changes in routine to maximize your chance of success. Some examples of when NOT to sleep train:

  • Before age 4–6 months of age.
  • When your mother-in-law is visiting
  • Right before a vacation
  • When your child is suffering from a cold/teething/working on another developmental task such as potty training or learning to walk
  • Immediately before or after a new sibling is born
  • Around the time of a big work deadline

I think of starting sleep training as analogous to quitting smoking. One of the important smokers are counseled to do when planning to quit is selecting a quit date. If you think of sleep training as quitting bad sleep, you want to pick a date for starting for sleep training as well. If you have selected your date for starting sleep training, I would recommend:

 

  • Marking it on your calendar
  • Telling family and friends (who are supportive) of your plans
  • If you have been unsuccessful in the past, reflect on what worked and what didn’t
  • Making a plan in advance of starting using proven strategies for sleep training

If you have any sleep training horror stories, please share them below. Do you think that timing may have been a factor?

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“Social Jet Lag” and the Teenager

I was interviewed last month at Wellocracy about way your body clock can work for you or against you. For most people, their schedule is working against their natural inclinations. If you are wondering how well your sleep schedule is meeting your needs, it is very easy to figure this out. On a typical day (work day or school day) do you need an alarm clock to wake up? If the answer is “no”, congratulations! You are in the minority.

If you are like me, you may hit the sleep button a few times before you blearily make your way down to the coffee maker. If you are a teenager, you are likely frantically trying to get up and out the door in time to catch the school bus or a ride to school because of the structural factors curtailing your sleep.

A German researcher, Till Roennenberg, coined the phrase “social jet lag” to describe the state of persistent sleep deprivation which results from having your external sleep schedule (e.g. when you need to get up for school or work) out of phase from your natural schedule. He actually has a survey you can take to determine your chronotype here. Brain Pickings has a great summary of his work, and he wrote a fascinating book for lay people called Internal Time: Chronotypes, Social Jet Lag, and Why You’re So Tired.

As a rough rule of thumb, your degree of social jet lag is the difference between the time you need to wake up on work or school days and on free days. This can be a bit more difficult to figure out than it seems. Many teens (and adults without small children) will be sleep deprived during the week and then make up some of the sleep on the weekends. Therefore, a better comparison is between work/school days and vacation days where the teen has been allowed to sleep on his or her own schedule for several days.

Let’s take the example of a teenager who needs to get up for school at 6 AM with difficulty but arises, feeling refreshed, a month into her school vacation at 9 AM. This implies three hours of social jet lag on every school day, equivalent to the jet lag of flying from San Francisco to New York five days a week. However, unlike travelling, there is no real habituation. Being jet-lagged every day sounds pretty awful, and it is the state the majority of our teens spend every day in.

So what can be done about this:

  • Going to bed earlier. You are unlikely to be able to go to sleep three hours earlier, no matter how tired you are. However, every little bit helps, and a bedtime 30 minutes earlier every night translates to 3.5 hours of extra sleep a week– almost half a night of sleep for an adult.
  • Light exposures in the morning can shift your body clock earlier. Light box therapy has been proven to be helpful, and newer devices like this one from Phillips have lower light intensities than prior models
  • Advocating for later school start times is critical. If you want to get involved, head to Start School Later and find out how you can advocate in your community for this issue.

For what it is worth, I took the chronotype questionnaire and found that I was actually a “slight early type” to my great surprise. I have always thought of myself as a night owl; I will say that I have become much more of a morning person by necessity since I am the parent of two small boys.

Chronotype_pdf__page_2_of_3_

So: do you think that you have “social jet lag”? Do your children? If you took the sleep quiz, is your chronotype different than you expected?

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Notes from Grand Rounds, Bridgeport Hospital

Today I was honored to give Grand Rounds at Bridgeport Hospital. I am making my syllabus and slides available for download. If you attended the talk, feel free to leave any follow-up thoughts or questions below.

 

Bridgeport Overview Sleep Medicine slides Canapari Sleep Medicine Syllabus 6_11_14

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Is Your Sound Machine Harming Your Child’s Hearing?

I do not remember who recommended a sound machine for us as we were planning on the birth of our first child; we registered for and received our beloved Marpac Sound Conditioner which we have run nightly in the room of our older son. When my second son came along, we purchased another one and have been happily using it ever since. The devices seem to be unbreakable and provide uniform sound output. They are a bit bulky but the sound has less of the tinny quality of an electronic device . I have found it very useful when traveling as our older son especially is a light sleeper.

The principle behind the use of sound machines is the idea that constant sound prevents intermittent sounds (doors closing, siblings crying, etc) from interrupting sleep. For newborns, Dr. Harvey Karp popularized the idea that white noise louder than a baby’s crying replicated the sound in the womb and thus recommended white noise from a vacuum or loud “shushing” would help soothe a fussy baby (with my older son, this did seem to be true. You don’t know how loud you need to shush until you watch the video).

A recent study, however, has made me question the ongoing use of sound machines in our home. A group in Canada studied the amount of ambient noise generated by 14 infant sound machines (which were not identified by name). They used sophisticated techniques to measure sound levels; specifically, they used a sound booth and a device to simulate the size of an infant’s ear canal. They also corrected for the properties of the hearing of a six month old (thus, findings in the study are reported as A-weighted decibels, or dBA). They measured at three distances: 30 cm/ 11.8″ (as on a crib rail), 100 cm/ 39.4″ (as on a table next to the crib), and 200 cm/ 78.7″ (as if across the room). They found that:

1. All sound machines exceeded the maximum recommended sound exposures when placed on the crib rail.

2. Three machines produced volumes exceeding safe sound levels recommended for ADULTs (85 dBA) at the crib rail distance.

3. Although the sound levels were lower at the maximum distance, 13/14 machines generated levels greater than recommended volume (50 dBA) when at the loudest volume.

To put these findings in perspective, it is important to note that the recommend sound levels for infants in the hospital is quite low (50 dBA is quieter than normal conversation (60 dB) by about a factor of ten).

After reading this study, I wanted to measure the sound output from our sound machines to see how they compared.  I used Cateater’s Sound Pressure Meter  because I am powerless before a good looking app, but you can get a free app like Decibel 10th which will do the same thing for free.

Love to cool analog look on this app.

Love to cool analog look on this app.

The best number to use is the average as the max number is very sensitive to throat clearing, doors closing, or the laughter of your children “trying to be quiet while Daddy works”.The second and third distances represent the distances from the machines to the approximate head position of my sleeping 3 and 6 year olds.

Sound levels

I found that the sound levels were within safe limits for both of my boys (less than normal conversation), but they did exceed the very conservative limit for infants on the higher settings.

To give some perspective: normal conversation is 60 dB. For more on safe sound levels, the CDC has a good information page on safe sound levels and hearing loss in children.

So what should you do if you have been using a sound machine?

  1. Don’t panic!  You likely have not done your child any harm. If you are worried about his or her hearing, your pediatrician can arrange screening. First off, moving your sound machine out of your child’s crib or bed is probably a good idea.
  2. It is probably a good idea to move your child’s sound machine out of their crib or bed and to the other side of the room.
  3. You can get a rough idea of how loud your device is by downloading a sound pressure meter application from your phone.
  4. You can also turn off your sound machine after your child goes to sleep. This is what we have started doing. Another option is to use a timer like this one which is what one of my colleagues who works in ENT does with his son.
  5. Don’t use the loudest volume settings if you can help it.

We have changed our practice by turning off the sound machines when we go to bed, although my six-year-old tends to get up and turn his back on. Did we do any permanent damage to our sons’ hearing when they were little? It is unclear, but I do not think so. (They don’t listen, but I don’t think that is due to their hearing).

Do you use sound machines for your children? If so, does this make you change your practice?

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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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