Sleeping Angels

Why make it difficult to help save lives?

Dennis Rosen, M.D. — Sat, 14 Nov 2009 23:19:35 +0000

This morning I gave a talk at continuing medical education meeting being held here in Boston for physicians, nurse practitioners and nurses. More than 5000 people are participating in the three day meeting which includes lectures and workshops of different sizes. After the session in which I gave my talk had finished, I wandered through the exhibits section, hoping to find among the displays a vendor of medical textbooks who, I hoped, might have on display a certain book I wanted to look at. Unfortunately I was not successful, though I have to admit that I did not spend much time looking: the large number of drug company booths made me feel uncomfortable and I decided to leave. Near the exit, I was approached by a young woman wearing a bright blue wig looking for volunteers to have the insides of their cheeks swabbed for genetic material which would be processed and stored in a central registry at one of the major teaching hospitals in Massachusetts. The information collected will be used to identify potential bone marrow donors for people with cancer and other diseases in need of bone marrow transplant lacking a suitable donor.

I agreed, knowing how important this is and having cared for children who had received bone marrow transplants as well as for others for whom no donor could be found, during the course of my training. I accompanied her to a table where I was asked to fill out a form and have my cheeks swabbed.

Once this was done, she reviewed the inner portion of the form to make sure that all of my contact information had been filled out legibly (in my case, a real concern), and asked me for my health insurance information. I was surprised at this, assuming that the registry was either funded by the government or through donations. Not so, she explained. It turns out that per State law the health insurance companies are obligated to pay for the cost of the genetic testing for members who join a national donor panel. Excellent, I thought.

However, as I was gathering up my things to go, she handed me a small postcard with instructions for what to do in case I am sent a bill for the testing anyways, complete with a toll-free phone number I could call to get assistance.

I thought that this was sad and just one more example of what is wrong with our health care delivery system. As so many have pointed out, the lack of preventive care in this country relative to what is considered standard of care in most other developed countries results both in increased disease and higher costs to the individual and the system as a whole once complications occur (for those interested in reading about how health care is delivered in Canada, Britain, France, Germany and Japan, and how it compares with the current system in place in this country, T.R. Reid's book "The Healing of America" is an excellent resource). While a bone marrow donor registry doesn't quite fall into the category of preventative care, it certainly can save the lives of desperately ill children and adults who without being matched with a suitable donor would otherwise die. The fact that people who are otherwise willing to enroll in such a registry need to be intimidated by the prospect of invoices and bills from either their insurance companies or the labs doing the testing can significantly hamper the efforts to enroll as many people as possible so as to increase the chances of finding suitable donors. I know that when I was told that I might get caught up having to make phone calls and write letters to cancel charges I was promised I wouldn't have to bear, it made me wonder if I had made the right decision and whether it was worth the hassle. Despite all the demagoguery about the evils of "socialized medicine", facilitating this kind of registry, not hindering it, is exactly what I expect of my government. When I lived in Israel, which has universal health care, I enrolled in a similar donor registry, and the issue of payment for the testing never came up, because it was borne by the Ministry of Health.

While it is still unclear what health care reform will look like in this country, or whether the attempts to bring it about will even succeed, I can only hope that it will include provisions to make participation in something as clearly of benefit to the public good as a bone marrow donor registry easier than it is today.

Does sleeping in on weekends keep your weight down?

Dennis Rosen, M.D. — Thu, 05 Nov 2009 17:07:51 +0000

The connection between insufficient sleep and overweight and obesity in all ages is well recognized and has been demonstrated in multiple studies conducted over the last several years. In the November 2009 issue of Pediatrics, Wing et al* report the results of a study conducted in Hong Kong in which they looked at whether differences in sleeping patterns that allowed school age children to "catch up" on the sleep deficit acquired during the school week had an effect on their becoming overweight or obese. The researchers conducted their study by reviewing questionnaires completed by the parents of 5185 children between the ages of 5-15 in which the parents were asked to comment on what times their children usually went to bed and got up on weekdays, weekends, and vacation during the preceding 12 months. The investigators found that children who slept < 8 hours/night during the week and did not compensate for their sleep deprivation by sleeping in late on weekends or vacation were significantly more likely to be overweight than those who did.

However, there are many problems with this study. Among them: the wide age range of the children (5 year olds have quite different sleep needs and patterns than 15 year olds); the fact that the data collected was based upon a recollection of the typical patterns of an entire year (generating what is known as "recall bias"); and the very small numbers of children in the "non-compensated groups" (38 who did not sleep in on weekends and 29 who did not sleep in on vacations, both each less than 1% of the entire cohort) all make drawing meaningful conclusions from this study very difficult. In fact, when looking at the data of the entire cohort, one sees that the overweight and obese children slept only 6 minutes less on school nights, 9 minutes less on weekends, and 10 minutes on vacation than their non-overweight counterparts.

For all these reasons, it is very difficult to accept the authors' conclusions that children should be allowed to sleep in late on weekends as a means to prevent them from becoming overweight. In fact, there are compelling reasons not to adopt such a strategy. The two main forces which drive our sleep are the sleep deficit, which builds up the longer we remain awake, and the internal circadian clock. When the internal circadian clock is synchronized with the external clock, we start to feel sleepy around our usual bedtime and wakeful around our usual wake up time (provided, of course, that we have gotten enough sleep). However, it is relatively easy to desynchronize the internal from the external clock by shifting sleep onset and wakeup times, exposure to bright light in the evening and/or the morning, the consumption of melatonin. This is especially true for adolescents, who have a natural tendency to "push back" their internal clocks. When the clocks become desynchronized, it becomes quite difficult to fall asleep and to wake up at the appropriate "external clock" times, as anyone who has travelled across time zones and become jetlagged knows all too well.

The last thing a child who is not getting enough sleep during the week because she or he is getting to bed too late needs is to sleep in two, three, or four hours late on the weekend. While allowing the child to "catch up" on some of the lost sleep, it can also decouple the two clocks and make it very difficult for the child to get out of bed on Monday morning in time for school and to really get going before the school day is half gone.

Yes, getting enough sleep is very important, not just for controlling body weight, but for a whole host of other important reasons as well, including good cognitive function, development, school performance, and behavior. But a better solution would be to establish a schedule which gets the child to bed regularly at an hour which allows for an age appropriate amount of sleep, and maintains a regular wake up time on weekdays and weekends. One should also minimize exposure to bright light in the evening, eliminate caffeine at least 8 hours before bedtime, and remove distractions such as television, computers, video games, cell phones media players and pets from the bedroom. Doing all of the above will increase the likelihood of the child getting an adequate amount of sleep, with all the attendant benefits, and without turning weekday mornings into a nightmare for child and parents alike.

*Wing YK et al. The Effect of Weekend and Holiday Sleep Compensation on Childhood Overweight and Obesity. Pediatrics Vol. 124 No. 5 November 2009, pp. e994-e1000

It's bad to wake a sleeping baby: fact or fiction?

Dennis Rosen, M.D. — Wed, 21 Oct 2009 23:42:42 +0000

New parents are often told never to wake a sleeping baby. While this advice is no doubt well intentioned, it can, if followed, lead to substantial night time sleep disturbances which in turn can have a really negative effect on the sleep of the parents and the rest of the household.

While it does make sense not to proactively disturb a sleeping infant during the first few months of life, once a regular day/night circadian rhythm develops (usually between 3-6 months of age), there is no reason why babies and older children should not be getting most of their sleep at night, and only a small (and diminishing) portion during the day. The more one sleeps during the day, the less one needs to sleep at night, and this is true for everyone, young and old. After sleeping a certain number of hours, one can sleep no longer, wakes up, and has great difficulty falling back to sleep. This daily sleep requirement is roughly constant, though it varies between individuals, changes with age, and is influenced by factors such as sleep deprivation, alcohol, and medication. A good way of understanding this is to think about the 24 hour day as a pie from which a certain amount must apportioned for sleep. One can cut a single thick slice, or several thin ones, but the total amount removed from the pie stays about the same. And so, if one takes a two hour nap in the afternoon, it becomes more difficult to fall asleep that night. By the same token, an increase in the amount of sleep a child gets during the day reduces her need to sleep at night, and results in increased wakefulness. While this doesn't necessarily cause any hardship to the 14 month old who awakens and wants to play with her parents at 2 AM, it can be difficult for them if they need to wake up the following morning and get to work on time. Therefore, maintaining and enforcing a regular and balanced sleep schedule winds up making everybody's lives easier, even if it means keeping that toddler from taking a three hour nap in the middle of the day.

On God, ghosts, normal and abnormal

Dennis Rosen, M.D. — Fri, 16 Oct 2009 19:51:09 +0000

Last April I posted about a child and mother I saw in clinic who, while I was taking a history, told me very matter-of-factly about a ghost who inhabited their house. This piece was recently put on the main webpage of Psychology Today, and generated comments from several readers.

Two readers wrote that, in their opinion, there is no difference between communicating with a spiritual entity who shares one's home, and doing so with one that resides in the heavens. This raises a very interesting question: what is normal behavior and what is abnormal; and who decides, or is even in a position to make that determination? Different societies are distinguished by marked variation in what are considered desired, acceptable, and unacceptable behaviors, and so it must be clear that there is no one right answer. In this case, someone who believes in God knows that there is a huge difference between God and a simple poltergeist, whereas an atheist might see both as equally ridiculous confabulations. The "truth" is clearly in the eye of the beholder, and shaped by his or her preexisting conceptions and biases.

I'd like to share another example illustrating how cultural norms shape our perceptions of what is normal and not normal. I practiced pediatrics in Israel for a number of years, and it was not unusual to see infant boys brought to the emergency room because of a bleed following ritual circumcision at home on their eighth day of life. This was considered a normal, if unfortunate occurrence, something which could be expected to happen every so often. The fact that the circumcisions were being done at home, and not in the hospital was not something which seemed unusual or negligent on the part of the parents, or even as a sign of excessive risk taking; this is simply how it is done in Israel (full disclosure: my son was circumcised in his grandparents' living room surrounded by family and friends). On the other hand, we would also see infants brought in who had been born to new immigrants from Ethiopia, whose uvula (the dangling piece of flesh at the back of the throat) had been removed, in fulfillment of an Ethiopian Jewish tradition passed down through the generations, and which sometimes resulted in a bleed, infection or dehydration. The nurses in the ER were always horrified when they saw this, not understanding how such barbarity, as they saw it, could be perpetrated on a helpless infant. Nothing could convince them that objectively, there was no difference between deciding to electively perform either a circumcision or uvulectomy on an otherwise healthy infant with no say in the matter, and their cultural biases were clearly reflected in their outrage. And yet, in other societies, circumcision itself is perceived as barbaric, only a step (or less) away from child abuse.

And so we are all, ultimately, the products of the societies and cultures in which we live, and much of what we hold to be self evident and true may, in the eyes of others, not be so clear cut. In general, tolerance of the beliefs of others and their ways of doing things, so long as they do not harm others or interfere with their way of life, goes a long way towards enabling us all to live together peacefully.

(https://www.psychologytoday.com/blog/sleeping-angels/200904/ghost-in-the-house)

Can giving infants pumped breast milk lead to disrupted sleep patterns?

Dennis Rosen, M.D. — Sun, 04 Oct 2009 22:04:21 +0000

I recently came across a study in the journal "Nutritional Neuroscience" in which a group of researchers from Spain looked at the levels of certain substances (nucleotides) in breast milk, which are known to induce sleep. The researchers found that there was a definite pattern to when their levels were higher and lower, and that those known to induce sleep were, not surprisingly, higher in breast milk produced during the evening and nighttime than in breast milk produced during the day. In the paper (cited below), the authors also mention previous studies demonstrating that breast milk levels of melatonin, a hormone secreted prior to sleep onset, also vary in relation to the time of day, with melatonin found in breast milk produced at night, but undetectable in breast milk produced during the day.

Both of these findings, in addition to those of other studies mentioned in the paper raise questions about whether the common practice of new mothers to pump breast milk for later use, may have disruptive effects upon the organizing sleep patterns of their children. The rationale for pumping this is that it allows the mother to return to work while maintaining her ability to continue to produce milk despite long periods when she is unable to nurse, as well as being able to supply milk for the caregiver to feed the baby with. While there are compelling reasons for feeding an infant human breast milk, some of which have been discussed in previous posts, if the milk itself contains compounds which can induce (or ward off sleep), one has to ask if giving milk produced in the morning, to a baby in the early evening, might have negative effects upon the baby's sleep patterns, which in turn, may lead to both short and long term consequences.

I am certainly not suggesting that women should stop pumping breast milk and start their children on formula at age 2 months. However, it may be worthwhile to label the milk with the time it was produced so that it can later be given to the baby at approximately the same time of day, thereby reducing the potential for disruption of the developing sleep patterns.

Sánchez CL, Cubero J, Sánchez J, Chanclón B, Rivero M, Rodríguez AB, Barriga C. The possible role of human milk nucleotides as sleep inducers. Nutr Neurosci. 2009 Feb;12(1):2-8.

No napping on Rosh Hashana

Dennis Rosen, M.D. — Sun, 20 Sep 2009 13:03:01 +0000

This weekend is Rosh Hashanah, the start of the Jewish New Year, which marks 5770 years since the creation of the world, according to tradition. Rosh Hashanah also begins a ten day period known as the "Days of Awe" and the "10 Days of Repentance", during which Jews are called upon to reflect on the previous year, repent for transgressions and sins against God, and beg forgiveness directly from those they have wronged. On Rosh Hashanah, we are taught, the fate of every Jew is written, and then sealed on Yom Kippur, 10 days later. This period allows us an opportunity to repent and try and remedy the sins and misdeeds we have committed during the previous year, and to plead our case before God for a better fate and so our names will be written in the Book of Life.

There are many traditions specific to Rosh Hashanah and Yom Kippur, including the eating of apples with honey (symbolizing the hope for the coming year to be sweet) and pomegranates (symbolizing the wish that the coming year should be as full of blessings as the pomegranate is of seeds), and hearing the shofar, an instrument made from a ram's horn, the sound of which, according to the Mishna Torah, sends a message saying "Wake up from your (moral) sleep. You are asleep. Get up from your slumber. You are in a deep sleep. Search for your behavior. Become the best person you can. Remember God, the One Who created you."

This year, I learned of another tradition, one I had not heard of before. According to the Talmud, one should not sleep during the day on Rosh Hashanah (afternoon napping being one of my favorite parts of Jewish holidays, right up there with the holiday meals) because "if one sleeps at the beginning of the year, his good fortune also sleeps." The recommendation: one should study Torah instead.

So now, in addition to everything else, I have yesterday afternoon to ask forgiveness for as well...

Shana tova u'metuka, may this be a healthy and good new year for everyone.

Poor sleep increases the risk of infection

Dennis Rosen, M.D. — Thu, 03 Sep 2009 09:32:53 +0000

I recently came across a study published this year in the Archives of Internal Medicine looking at the association between sleep habits and susceptibility to the common cold.

In this study, 153 healthy men and women between the ages of 21-55 were asked to record their sleep duration and sleep efficiency (the amount of time they actually slept divided by the amount of time in bed) on a daily basis for 14 days. At the end of this period, they were placed in isolation, and given nose drops containing rhinovirus, the virus which causes the common cold. Cold symptoms were monitored starting one day prior to exposure and during each of the 5 days following exposure to the cold virus.

66 participants (43%) developed a cold following exposure to the virus. The researchers found that those study participants who slept fewer than 7 hours/night on average during the 14 days preceding the exposure were almost three times more likely to develop clinical signs of a cold than those who slept 8 or more hours/night on average during that time. Likewise, people with sleep efficiency less than 92% were five and a half times more likely to get sick than those whose sleep efficiency was greater than 98%. The differences in developing a cold could not be explained by differences in levels of antibodies to the cold virus, the season, the participants' body weight relative to height, age, or socioeconomic status. There was no correlation between whether a participant reported feeling well rested after a night's sleep and whether or not s/he became infected.

Why is insufficient sleep associated with an increased susceptibility to infection? The researchers suggest that this may have to do with the way sleep regulates the expression of inflammatory mediators, and that alterations in their levels may, in turn, lead to variability in the way that symptoms are expressed. The lack of correlation between feeling well rested or not and infection suggests that there is a need for a certain quantity of sleep, and that even though we may not feel sleepy, this does not change the body's basic need.

As described in previous posts, insufficient and/or poor quality sleep is associated with a whole host of health problems, all of which are more serious than coming down with a cold. Still, the protective effects of getting adequate sleep may well extend to other types of infections, and as we all know, there's no such thing as being too healthy. This gives one more reason to turn off (the TV, computer, cell phone), tuck in, and get a good night's sleep.

Going viral

Dennis Rosen, M.D. — Sat, 29 Aug 2009 19:53:22 +0000

These last couple of days I have witnessed firsthand one of the cooler and more intriguing aspects of the internet: watching how something relatively obscure suddenly heats up and gets a lot of notice, for no apparent reason. Since yesterday morning, I have received 9 comments on a post written and published on March 10th about what the best time is for high schools to start classes. When I last checked to see how many people had read it, I was astonished to see that it had gotten over 1700 hits during the last 27 hours, more than it had during the 5 ½ months between the time it was published and this past Thursday. This flurry of activity made it the second most read and emailed post on the Psychology Today blog website yesterday.

In short: it went viral. Unfortunately, I am not able to track how that happened, but I am really curious: how did it reach the critical tipping point at which it burst onto center stage and attracted so much attention? Did someone getting ready for the return to school come across it and link it to a popular website? If so, which one?

My cousin, who is a post graduate student studying geography at the University of Colorado, and who is also an accomplished DJ with an international career and reputation, had told me about this phenomenon when I was out there visiting this spring. He told me a story about another DJ he knows who had posted a clip on YouTube, which had gotten fewer than 50 hits for 6 months, until one day it was discovered, went viral, and got over a million hits within a week. While I was able to understand how that could happen with music, I never imagined that it would occur (admittedly on a much smaller scale) with a piece on adapting school schedules to the natural sleep tendencies of teenagers.

It also demonstrates (yet again) the truth that once something is posted, it remains in cyberspace, available for all to see, read and forward on to whomever they please. While a lot of people don't think about this when posting stuff on Facebook or Myspace, there have been lots of stories about things coming back to haunt people, including pieces written for college newspapers, personal photos or videos sent to others they are no longer close with, etc.

My thanks to all of you who have written comments and feedback on this and other posts.

http://www.psychologytoday.com/blog/sleeping-angels/200903/should-high-school-start-11-am

Getting the kids to bed and staying there... without the battles!

Dennis Rosen, M.D. — Tue, 25 Aug 2009 18:32:43 +0000

A reader wrote:

I have an 8 and a 5 year old. I have not really kept them on a schedule and now that they are both in school I am trying to get them on a bed time schedule and it is not working. They find every reason in the book to get up. I am hungry. I need to use the restroom and so on. They will normally fall asleep about 2 hours after I get them in bed the first time. Do you have any ideas on how to get them to bed at 8:30? They will not need to get up until 6:30 for school. Please give me some ideas. I am going crazy at bed time now.

From your description it sounds as though there may be a few things going on. There are two main drives for sleep: sleep deprivation, or the amount of time one has been without sleep, and the internal circadian clock, which tells us when it is time to sleep and time to be awake. The lack of a regular schedule can cause the internal circadian clock to become delayed, especially if the children are being allowed to sleep in until late in the morning. This can result in their not feeling sleepy at what otherwise could be a very appropriate time for them to start getting ready for sleep. In addition, by sleeping in, they may not have enough pressure from the sleep deprivation to sleep. If they are also being allowed to nap during the day, this, too, can prevent them from feeling sleepy at the designated bedtime.

As it is impossible to force a child to sleep, one can control the schedule by enforcing a regular wake up time. This needs, however, to be consistent and stable both weekdays and weekends. As school is just around the corner, it would be reasonable to start waking them up at 6:30 now. It is important that they not be allowed to lie in bed or veg out in front of the television after rolling out of bed, but instead make sure that they are dressed, eating breakfast, and exposed to plenty of light so that their brains "understand" that it is daytime.

In the evening, establishing a regular, fixed routine (bath, stories, bed, reading on one's own, final lights out) can set the tone for the onset of sleep. Minimizing bright light exposure for at least two hours before bedtime, and making sure the bedroom is dark, quiet and free of distractions such as music, computers, television, pets is also very important.

Children this age generally need between nine and a half to ten and a half hours of sleep a night, so it is important to make sure that the bed and wake up times reflect this. If they are waking up at 6:30 AM, a bed time of 8:30 is certainly reasonable.

Once these measures are implemented, it may become much easier to convince the children that bedtime really is when it's time to go to sleep, as their bodies will be sending them the same message, and the struggles may resolve. If not, giving a firm and consistent message to the children about what is and is not allowed after they are tucked in (i.e. must stay in bed, are allowed only one trip out to use the bathroom if needed) is important so that they understand that the new rules are meant to be taken seriously.

Exercise more and get a better night's sleep

Dennis Rosen, M.D. — Fri, 21 Aug 2009 14:26:26 +0000

I came across a very interesting study in the Journal of Adolescent Health this week. 434 Swiss teenagers were studied to see what the effect of exercise on sleep patterns was. 258 of the participants were athletes, who averaged 17.7 hours/exercise a week, and 179 were non athletes, who averaged 4.7 hours/exercise a week. All of the participants kept sleep and exercise diaries for 7 consecutive days and completed a number of questionnaires about the quality of their sleep and other psychological measurements.

The researchers found that the athletes had better sleep quality, and that it took them less time to fall asleep at night than the non-athletes. The athletes also had fewer awakenings during the night than the non-athletes. The athletes were less sleepy and had better concentration during the day, as well as less anxiety and fewer depressive symptoms than the non-athletes. The findings were more pronounced in males than in females.

Exercise has many health benefits, both physical and mental. It improves mood, and reduces the risk of heart disease, osteoporosis, diabetes, and some cancers. Exercise keeps weight down, and improves sexual function. It also has a number of positive effects on sleep. It increases deep sleep, and as shown in this study, helps one fall asleep faster and stay asleep, improving daytime concentration and overall function. This effect doesn't seem to be because of physical exhaustion, but due to actual changes seen in brain wave patterns, as another study by the same group, published in the World Journal of Biological Psychiatry in July 2009, demonstrated.

One more reason, if one was even needed, to get off the couch and get active.