Enterovirus D68 is Here– What Does That Mean for Your Child With Breathing Problems?

In the last several days, multiple parents have asked me about Enterovirus D68 infection which has received of press coverage. In the last week a few cases have been reported here in Connecticut, including one here at Yale New Haven.

First, some background: enteroviruses are a common group of viruses which can cause cold and stomach symptoms. In all likelihood, your child has had enterovirus infections in the past and you have not even known in. This particular strain of the virus is unique in that it has not previously been commonly seen in the US. In the Midwest, there have been clusters of children with severe respiratory illness. [Note that many children with mild symptoms may go undiagnosed so this virus may be more common than the data suggests]. Children with asthma seem to be particularly vulnerable, and those without asthma may present with asthma like symptoms of cough, shortness of breath, and difficulty breathing. Unlike bacterial infection, antibiotics will not help with these infections but they will run their course with supportive care. Interestingly, many of these children do not seem to have fevers at the time of presentation, which is different from other viral syndromes like influenza. At Yale New Haven we are able to test for the virus.
All parents should be on the the look-out for symptoms of cough, runny nose, and difficulty breathing. Hand washing is critical for preventing the spread of this disorder. In my practice I take care of children who are vulnerable to respiratory illness. It is especially critical for the parents of these children to make sure that their children are taking their breathing medications and doing their treatment regimens so that they are in the best possible shape if they have a viral illness, with EV-D68 or any other virus. Specifically:

  • Children with asthma who are on controller medications should have started their prescribed controllers with a spacer if they have slacked off over the summer (we did with my four year old). Also make sure there you have an adequate supply of albuterol.
  • Children with cystic fibrosis should be doing airway clearance treatments and taking aerosolized treatments regularly as prescribed.
  • Children with neuromuscular disorders such as Duchenne muscular dystrophy, spinal muscular atrophy, and other disorders should be using cough assist regularly, or at least their parents should verify that all treatment equipment (oximeters, cough assist devices, VESTs) are in good working order.

I’m a parent and a physician and always get concerned when I hear about a new virus in the news. I think that with preparation your child will be in good shape and will do well if they are exposed to EV-D68. If you are worried about your child, please call your physician and bring him or her to be seen.

Links:
Centers for Disease Control Information Page for enterovirus D68
Enterovirus D68: What Parents Need to Know via Web MD
12 states confirm Enterovirus D68 cases via CNN
What You Need to Know About Enterovirus d68 via Boston.com
EV-D68 in KC via KC Kids Doc

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Bedtime Fading: The “Secret Sauce” in Sleep Training

I often find that parents who see me in clinic have tried and failed to sleep train their children. (Obviously, the ones who had an easy time don’t need an appointment).  As I work with families to come up with plan to help their children fall asleep and stay asleep on their own, bedtime fading is one of the most useful tools that I use. In a nutshell, this involves moving their child’s bedtime later with the goal of having them be more sleepy at bedtime. In this video, I talk about how families can use bedtime fading to successfully sleep train their child. If you are interested, there is some interesting research that was published by Dr. Monique LeBourgeois which shows that children who have difficulty settling at night are frequently put to bed too early.

As stated in the video, the keys to successful bedtime fading include:

Have you tried moving your child’s bedtime with the goal of leading to a better night of sleep? How did that work for you?

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AAP Issues Call to Arms: Teens Should Start School At 8:30 AM

Let’s perform a thought experiment for a moment:

if you knew that in your child’s school there was a toxic substance that reduced the capacity to learn, increased chances of a car crash and made it likely that 20 years from now he would be obese and suffer from hypertension, you’d do everything possible to get rid of that substance and not worry about cost.

What would you do if you were worried about your child’s safety in school? In a nutshell, anything and everything it takes to resolve the situation. This quote, from Dr. Judith Owens, is not discussing a chemical; she is describing early school start times. We know that insufficient sleep caused by excessively early school start times:

  • Makes children irritable and obese
  • Causes insulin resistance analogous to a prediabetic state
  • Lowers standardized test scores
  • Increases the risk of accidents on the roads for all drivers in a community
  • Can lead to mood disorders, substance abuse, and school drop outs. 

Early school start times have effects like this the children in your community and in mine. [In my town, the two middle schools start at 8 AM and 7:50 AM, and the high school starts at 7:25 AM]. The arguments marshaled against changing school start times have nothing to do with the welfare of children, and only reference inconvenience and monetary expense. Importantly, communities that have changed school start times have found that the inconvenience and expense is actually less than anticipated, and the benefits are considerable. I’ve written before about the difficulties the teenagers have excessive homework and early school start times, and unfortunately there is a physiologic limit on how much teens can compensate for this, as their biological clock pushes them to stay up later as school start times get earlier.

This week, the American Academy of Pediatrics has added its voice to the chorus advocating for our children by recommending the school start times for middle schoolers in high school age children be no earlier than 8:30 AM. If you are a parent, and educator, or concerned citizen who cares about the welfare of your community, I would urge you to reach out to the school board and superintendent of schools of your community and to advocate for this change. Nothing will change unless you make it. There is a lot of inertia against changing the status quo. One good place to start in Start School Later, a national organization which has many local chapters working on precisely this issue. Here are some links which provides an extra information on this topic:
“Let Them Sleep: AAP Recommends Delaying School Start Times of Middle and High Schools to Combat Teen Sleep Deprivation”. Here is the complete report: “School Start Times for Adolescents”, by the Adolescent Sleep Working Group and Committee on Adolescence, and Council School Health.

“Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences” by Judith Owens. Pediatrics-2014–peds.2014-1697.

“Let Them Sleep, Start School Later”, from Seattle Mama Doc

“Surprise: Students Aren’t Getting Enough Sleep” by Jessica Lahey, in the Atlantic. 

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“Camping out” Sleep Training (with Video!)

I’m going to try something a little bit different today.  I have put together a brief video on the “camping out” sleep training method which is a gentler but still evidence based method of sleep training. 

Here is the pyramid from the video, courtesy of Ruth Fidino. I like this way of representing the process because the pyramid narrows as the distance from your child increases.

MEDtalk_AUG062014_Canapari_ppt

Please let me know if you think the video is helpful and if there are other topics that may benefit from this approach. Inspired by my colleagues Wendy Sue Swanson and Howard Luks, who are really good at making short videos. 

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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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