September 5, 2014

Schools Start Early, but Teens Need to Sleep Later

Although plenty of studies show that the natural sleep cycle of teenagers skews late, school hours start early. In addition to health problems, sleep deprivation can cause lower academic performance and increased risk of accidents.

The American Academy of Pediatrics (AAP) recently issued a new policy statement supporting the idea of a later start time for middle and high school. The academy recommends starting no earlier than 8:30 a.m., it says, to “align school schedules to the biological sleep rhythms of adolescents, whose sleep-wake cycles begin to shift up to two hours later at the start of puberty.”

The September issue of the journal Pediatrics published the statement, “Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences,” which referred to research showing that adolescents who get enough sleep enough lower their risk of being overweight, suffering depression and being in an automobile accidents. They also get better grades and report a better quality of life, according to Dr. Judith Owens, a pediatrician and lead author of the policy statement.

“Chronic sleep loss in children and adolescents is one of the most common – and easily fixable – public health issues in the U.S. today,” she said.

Mark Fischetti, a senior editor at Scientific American, voiced strong support for the movement toward later school hours.

“Ask any groggy teenager waiting for a bus or yawning in ‘home room,’” he wrote, “and he or she will tell you that it’s just too darn early in the morning to learn chemistry equations or analyze a narrative by some Russian novelist.

“Are they just lazy? No. Scientific studies of teen sleep patterns say they’re right. So do results from numerous schools across the country that have delayed start times: The later classes begin, the more academic performance improves. Bonus points: attendance goes up, teen depression goes down, and fewer student drivers get into car crashes.”

It’s all about circadian rhythms, the biological clock that makes you feel awful when you travel across several time zones (jet lag) and can disrupt workers whose shifts change from day to night to day.

Circadian rhythms, Fishchetti noted, shift during the teen years. Starting around age 13 or 14, the kids naturally stay up later and sleep later, a pattern that peaks between 17 and 19. Adolescents also need more sleep than an adult.

One study of 9,000 high school students in three states showed that grades in science, math, English and social studies rose when school began at 8:35 or later. Experiments at two North Carolina high schools and at the U.S. Air Force Academy also showed that academic performance improved when start times were later.

School districts might be reluctant to revise what they’ve always done, but Fischetti reported that their concerns about starting school later aren’t fulfilled — kids still can hold an after-school job, and participate in after-school programs.

“The issue is not the start time. It’s that the students are overly busy,” said Kyla Wahlstrom, one of Fischetti’s sources. “There is too much pressure to cram it all in just to have a good resume to get into college.”

Wahlstrom is director of the Center for Applied Research and Educational Improvement at the University of Minnesota. She said students, parents and school advisors should ratchet back the activities, and emphasize certain ones they enjoy or do well at, rather than participate in order to impress colleges. She said students should get eight, and preferably nine, hours of sleep every night.

Other countries seem to be learning this lesson. Studies in Brazil, Italy and Israel associate later start times with improved learning, and high-school level students in Europe seldom start before 9:00 a.m.

Even if it’s not about academics, it’s about safety. Fischetti referred to a high school in Wyoming that moved the start time from 7:35 a.m. to 8:55 a.m. and saw a 70% reduction in car crashes among drivers ages 16 to 18.

University of Kentucky researchers studied the issue and found that crash rates of teen drivers fell 16.5% in the two years after start times were delayed one hour, while the teen crash rate where they remained the same rose 7.8% in the same time period. The students in each of those groups, respectively, slept different amounts. In the reduced-crash group, those who got at least eight hours of sleep during weeknights rose from 36% to 50% percent, and those who got at least nine hours rose from 6% to 11%.

Your teen probably isn’t willing to go to bed earlier, and if he or she does, might not be able to fall asleep. But almost all of them would be willing to sleep later.

It’s time for school districts to wake up and smell the coffee.

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March 14, 2014

Sleep-Inducing Machines Might Invite Hearing Problems

It seems like such a good idea. As so many get-the-kid-to-sleep tricks do. But new research shows that using a machine that produces soothing sounds to lull a baby to sleep might damage his or her hearing.

A study published in Pediatrics last month analyzed 14 popular sleep machines at maximum volume and found that they produced between 68.8 to 92.9 decibels from 30 centimeters away. That’s about how far one might be placed from an infant’s head. Three of the machines exceeded 85 decibels, which is what the National Institute for Occupational Safety and Health deems the threshold of workplace safety for adults over the course of an eight-hour shift.

One of the baby machines was so loud that two hours of use would exceed workplace noise limits.

At 100 centimeters away, all the machines tested still were louder than the 50-decibel limit set in 1999 by an expert panel for an hour’s exposure in hospital nurseries in 1999.

“These machines are capable of delivering noise that we think is unsafe for full-grown adults in mines,” Dr. Blake Papsin told the New York Times. He is senior author of the study, and the chief otolaryngologist (disorders of the ear, nose and throat) at the Hospital for Sick Children in Toronto.

“Unless parents are adequately warned of the danger, or the design of the machines by manufacturers is changed to be safer, then the potential for harm exists, and parents need to know about it,” Dr. Gordon B. Hughes, the program director of clinical trials for the National Institute on Deafness and Other Communication Disorders, told The Times.

Newborn brains are learning to differentiate sounds at different pitches even during sleep, according to Lisa L. Hunter, scientific director of research in the division of audiology at Cincinnati Children’s Hospital. “If you’ve conditioned them to white noise, there’s every indication that they might not be as responsive as they otherwise should be to soft speech,” she told The Times.

The idea behind infant sleep machines is that their white noise or nature sounds drown out the normal ambient sounds that can disturb a baby’s sleep — voices, vehicle noise, music, etc. The machines come in many forms, including embedded in stuffed animals, and frequently are recommended by parenting books and websites.

Even some sleep experts advise parents to use them all night, every night, and many parents say their babies become so used to the sounds of rainfall or birds that they will not nap without them.

Despite their apparent potential to damage hearing, sleep machines can be used safely, according to the researchers. Papsin suggested placing the devices farther away, lowering the volume and using them for shorter periods to deliver less sound pressure to the baby. That means you should be wary of the models designed to be affixed to the crib.

The researchers also recommended that device manufacturers limit the maximum noise level of infant sleep machines.

Dr. Marc Weissbluth, a pediatrician and author of “Healthy Sleep Habits, Happy Child,” agreed that you don’t necessarily have to throw out the baby noise machine with the bath water. He told The Times that parents could use one, if they were careful. “If it’s too close or it’s too loud, this might not be healthy for your baby,” he said. But “a quiet machine that’s far away may cause no harm whatsoever.”

Maybe. But one Times reader posted an interesting comment to the story: “If the sound of a sleep machine is dangerously loud, I hate to think about all of the noise my premie was exposed to while in the n.i.c.u. [neonatal intensive care unit] for several weeks. Constant beeping, lights on, etc. I don't think she's worse for the wear, but hospitals need to be much more mindful about all of the environmental noise babies are exposed to in the n.i.c.u.”

To learn more about babies and sleep, see our blog, “Getting Your Baby to Sleep.”

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August 30, 2013

Overcoming Bed-Wetting

A recent “explainer” posted on The Conversation will be welcome information for many parents. It’s about bed-wetting.

The writers of the report on The Conversation, an independent source of news and opinion for public consumption by members of Australia’s academic and research communities, are Caroline Walsh, a continence nurse at The Children’s Hospital at Westmead (Sydney), and Patrina Ha Yuen Caldwell, who heads the enuresis service for the hospital. “Enuresis” is lack of urinary control, especially nighttime bed-wetting.

Walsh and Caldwell say that bed-wetting, although embarrassing and traumatic, is common among children. It affects 15-20 out of 100 school-aged children, the vast majority of whom grow out of it. But there are treatments to hurry the evolutionary process.

Like adults, children usually wake up when they have a full bladder, but bed-wetters have a defective arousal response. They can’t wake fully. So when urine production exceeds bladder capacity, a child urinates in his or her sleep.

The disorder has a genetic link, so if you or your spouse had the problem, it’s more likely your kid will too. Bed-wetting is more common among boys, but women are more likely to pass the genetic inclination to their children. Gee, thanks mom!

Because bed-wetting carries such emotional baggage, and can affect a child’s self-esteem, mental health and early peer relationships, parents must handle the issue with sensitivity.

There are several treatments for bed-wetting, primarily alarm training, urotherapy and medication. Treatment is appropriate generally around the age of 6.

Alarm training

Usually, this is the first line of treatment, and the goal is to train the child to recognize the full-bladder signal before urinating in his or her asleep. There are two kinds of alarms:


  • Pad and bell alarms connect a mat to an alarm box placed on the child’s bed. The alarm activates when the mat senses liquid.

  • Personal alarm sensors are secured either in a panty liner or clipped to the child’s underpants. The alarm activates when the sensor detects liquid.

    This method requires patience. It should be used every night until the child achieves 14 consecutive dry nights. It can take two to four months of training before the child reacts consistently enough to the signal to be deemed fully effective.



Urotherapy

This covers a wide range of practices, primarily:


  • ensuring the child has an adequate daily fluid intake (5 to 6 drinks per day that do not contain caffeine, including chocolate milk);

  • avoiding the consumption of fluids late in the evening or close to bedtime;

  • avoiding or readily treating constipation, which can affect bladder function;

  • ensuring appropriate toilet posture, such as adequate foot support when sitting on the toilet (this supports complete evacuation of both the bowel and bladder);

  • taking bathroom breaks regularly throughout the day, and encouraging the child not to postpone a trip to the toilet when the urge occurs.


Medication

This approach should be for a short-term solution or as a last resort. It relies on desmopressin, a synthetic hormone that has an anti-diuretic effect. It acts on the kidneys to reduce overnight urine production. Effective in about 7 in 10 child cases, desmopressin might be useful for sleep-overs or school camps when alarm training isn’t practical. It can also be combined with other treatments to ensure a dry night.

Like all medicines, desmopressin can prompt a negative reaction when combined with some other drugs, so make sure your pediatrician has a complete record of what your child takes.

Imipramine was one of the first medications used to treat nocturnal enuresis, but because of its risky side effects, including thoughts of harming or killing oneself, it’s not recommended as a first-line treatment.

Other Options

Behavioral therapies can be helpful in treating bed-wetting. They include taking the child to the toilet during the night and rewarding him or her when he or she stays dry. “Try to create a positive environment and involve the child in decision-making,” the writers suggest, “so they can take ownership of the problem.”

But given the physiological nature of the disorder, psychological treatments often aren’t as effective as alarm training or medication.

Some complementary and alternative medicine interventions, such as hypnotherapy and acupuncture, have been tried, but the evidence to support their use is limited.

If your child doesn’t respond to common treatments, seek advice from a pediatric urologist. Or try to ride out what usually is a youngster’s affliction that does improve with age.

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July 5, 2013

Is Disrupted Sleep Worse for Kids or Parents?

Kids’ sleep issues are common complaints among parents, but a new study presented at the annual meeting of the Associated Professional Sleep Societies was unable to determine just who is harmed most by troubled sleep.

The study is preliminary, because it hasn’t been published in a peer-reviewed journal.

The most common reports of troubled sleep reported in the survey were waking up at night and snoring. Among 300 respondents at two Cleveland health clinics, irregular sleep was a common complaint of 1 in 5, and snoring by nearly 14 in 100. About 5 in 100 said that both problems affected the child's health or family life, according to the presenter, Dr. Jyoti Krishna of the Sleep Disorders Center at the Cleveland Clinic.

But Krishna told MedPage Today that "We were unable to tease out whether the child's sleep problem was more of a problem for the parent than for the child."

The American Academy of Pediatrics recommends that clinicians screen for pediatric sleep disorders. Pediatrician Mark Patterson said he tries to perform sleep screenings on a regular basis and cautions that sleep problems should be evaluated and diagnosed by a clinician because some parents would call any sleep disturbance a disorder, especially if it interrupts their own sleep.

"Some of these children's room monitors are so sensitive,” he said at the meeting, “they pick up any grunt or turn the child makes in his or her sleep.”

Pediatric sleep issues commonly are diagnosed by the BEARS questionnaire, a user-friendly screening tool whose name is an acronym of the questions it asks:

B - Bedtime


  • Does my child have trouble going to bed? Or
    trouble falling asleep?


E - Excessive Daytime Sleepiness

  • Is my child difficult to awaken in the
    morning?

  • Does my child seem sleepy or groggy during
    the day?

  • Does my child often seem tired during the
    day? (In children, tired may mean moody,
    hyperactive, “out-of-it,” as well as sleepy.)


A - Awakening During the Night

  • Does my child awaken during the night and have trouble going back to sleep?

  • Is anything else interrupting my child’s sleep?


R - Regularity and Duration of Sleep

  • How many hours of sleep does my child need at this age?

  • What time does my child go to bed and get up on weekdays? On weekends?

  • Does this allow my child to get enough sleep every day?


S - Snoring

  • Does my child snore? Loudly? Every Night?

  • Does my child stop breathing, gasp, or choke during sleep?


Although disorders identified by this measure are common, you have to ask yourself: If there are no or minimal effects on your child’s happiness or daily functioning, if the problem is solely disrupted sleep, is that a medical issue or an inconvenience?

For additional information and to help you determine if your kid’s sleep issue bears medical attention, see “Sleep Tips for Children and Infants” on the website of the American Academy of Pediatrics.

Also, see our blogs, “Getting Your Baby to Sleep,” and “Early Sleep Problems Signal Later Emotional Troubles.”

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January 4, 2013

TVs Don’t Belong in Kids’ Bedrooms

If the post-holiday gift haul has overwhelmed you with a wave of electronic diversions, a story in the Los Angeles Times issues a kind of tsunami warning. It’s a bad idea, says a study published in the American Journal of Preventive Medicine, to put a TV in a child's bedroom.

For most American households, says The Times, it’s too late: In the U.S., 7 in 10 kids between 8 and 18 have a television in their bedroom.

As research has long shown, more "screen time" is linked to higher rates of obesity. (See our post about screen time and fitness .) The new study says that not only do kids with a TV in their bedroom tend to watch more TV, but compared with television watched in other household settings (the family room), the screen time a kid logs in the bedroom is associated, hour for hour, with more belly fat, higher triglycerides (blood fats) and overall greater risk of developing heart disease and diabetes.

The new study compared kids with about the same diets and the same levels of physical activity. The ones with a TV in their bedrooms had more cardiometabolic risk factors—that is, test results indicating greater risks to heart function and greater insulin resistance—than the ones who must watch TV in one of their home's common rooms.

The study’s lead author said that beyond the effects of sitting too long in front of a TV, a television in the bedroom has the potential to disrupt sleep patterns and interfere with shared family meals. Sleep deprivation is another risk factor for obesity and metabolic dysfunction. And family mealtimes seem to promote more healthful eating, lower obesity rates and less use of alcohol, drugs and tobacco by kids.

Vicky Rideout, an independent consultant who has written extensively about children's media exposure and its effects, told The Times that "Research has consistently shown better outcomes for kids who don’t have a TV in their bedroom than for those who do, whether we’re talking about obesity, sleep or academic achievement."

In addition to removing the TV from the kids’ rooms, Rideout wants parents to pay attention to all newer technologies as well. "Keep an eye on your child’s smartphone and computers too, because food companies are now marketing games, websites and mobile apps designed to boost consumption of foods kids should be eating less of, not more of," she told The Times.

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November 16, 2012

Sleep-Deprived Teen Athletes Suffer More Injuries

When you’re sleepy you’re more likely to make mistakes. And, it appears from research presented last month at a conference of the American Academy of Pediatrics, lack of sleep puts adolescent athletes at greater risk of injury.

Researchers studied middle- and high-school athletes in grades 7 to 12 for nearly two years. They found that those who slept eight or more hours every night were significantly less likely—68 percent—to be injured playing their sports than those who regularly slept less.

The study admittedly was small—it surveyed kids at only one California school. And it relied on students remembering and communicating accurately. But the premise, really, is a no-brainer: Insufficient sleep is not good for you, in many ways.

In addition to their sleep habits, students were asked about what sports they played, the time they spent playing sports either at school or in other programs, if they used a private coach, if they participated in strength training and how much they enjoyed their athletic endeavors. Split nearly evenly between boys and girls, 112 of the 160 students completed the survey, which was done in conjunction with Children’s Hospital Los Angeles.

The study’s author, Dr. Matthew Milewski, said, “While other studies have shown that lack of sleep can affect cognitive skills and fine motor skills, nobody has really looked at this subject in terms of the adolescent athletic population.”

In addition to hours of sleep per night being clearly associated with the incidence of injury, results showed that the higher the grade level of the athlete, the higher the likelihood of injury. Each additional grade level was associated with a 2.3 higher chance of getting hurt playing sports. No other element—gender, duration/hours of participation, number of sports played, strength training, private coaching or “fun” factor—showed a significant association with injury.
Milewski said that the association between higher grades/ages and increased chance of injury might reflect the cumulative effect of playing sports for several years as well as the fact that older kids are bigger, faster and stronger.

As reported on MedPage Today, the injuries involved multiple body parts. Most common, however, were injuries to the hand or wrist, knee, shoulder, ankle, back and head.

More than 38 million children participate in organized sports each year, according to MedPage Today. Approximately 1 in 10 is treated for a sports injury. Milewski said about half of all injuries probably are related to overuse, and half of those are probably preventable.

During the school study, nearly 6 in 10 athletes were injured; nearly 4 in 10 were hurt multiple times.

As MedPage reports, the Centers for Disease Control and Prevention and the National Sleep Foundation define insufficient sleep for high schoolers as fewer than eight hours per night. And the eight-hours threshold in this age group, Milewski said, is regularly missed—approximately 7 in 10 high schoolers don’t sleep that much. More than 3 in 4 four students involved in the survey said they slept fewer than eight hours. (See our post about how teenagers’ love of texting contributes to sleep deprivation.)

If parents needed another reason to nag their kids, the greater risk of getting hurt at play is a pretty good one: Tell your kid to log off of Facebook, turn off the smartphone and go to bed.

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September 27, 2012

Getting Your Baby to Sleep

Earlier this year, our post about infants with breathing problems during sleep cautioned parents to monitor the quality of their baby’s slumber. But simply getting a baby to sleep and keeping him or her in a restful state can be one of the more bedeviling challenges of early parenthood.

A new study published in the journal Pediatrics might save some parents from constant worry if they’re getting bedtime routine right.

As reported on MedPage Today, certain behavioral techniques for getting babies to sleep by themselves, such as initially remaining in the child’s room, can be effective without any adverse emotional outcomes in the long term for either the kid or the parents.

The study followed up with 6-year-olds who had been studied as infants. Any problems with the youngsters were not significantly more common among those who had been “trained” to sleep alone versus those who hadn’t.

Many parents worry about long-term harm if they don’t respond immediately to a crying baby in a crib, having been influenced by older practices of letting a kid “cry it out” that causes harmful distress.

But the study showed that "camping out" to get kids to fall asleep and "controlled comforting" to help learn how to settle down on their own by gradually lengthening intervals at which parents respond to crying improved infants' sleep. It also reduced depression among mothers by 60 percent.

Among the 225 families followed through the child’s sixth birthday, there were no differences between the group that underwent behavioral training and the one that didn’t in outcomes for:


  • sleep habits;

  • parent-reported psychosocial functioning;

  • child-reported psychosocial functioning;

  • chronic stress as measured by cortisol (a hormone produced in response to stress) levels on a nonschool day;

  • child-parent closeness;
  • conflict between parent and child;

  • overall quality of the relationship between parent and child;

  • disinhibited attachment (emotionally and socially remote behavior);

  • depression, anxiety and stress scores in the mother;

  • authoritative parenting (deemed the optimal parenting style demonstrating warmth and control).


The researchers noted that their inability to follow up on about one-third of the families initially involved with infants meant the study couldn't rule out small harms or benefits long term. But, they concluded, “Nonetheless, the precision of the confidence intervals make clinically meaningful group differences unlikely."

“…[P]arent education programs that teach parents about normal infant sleep and the use of positive bedtime routines could effectively prevent later sleep problems," they concluded.

For more information, see “Getting Your Baby to Sleep” on the website of the American Academy of Pediatrics.

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March 26, 2012

Early Sleep Problems Signal Later Emotional Troubles

A milestone in child development, at least for many parents, is when the kid finally sleeps through the night. But a recent study suggests that it’s a good idea for parents to monitor how the wee ones are sleeping as well as how long.

Published in the journal Pediatrics, the study shows that children who have problems breathing while they sleep are more likely to experience behavioral problems such as hyperactivity and aggressiveness when they get older. They’re also more likely to have emotional issues such as difficult peer relationships.

Researchers from the University of Michigan and the Albert Einstein College of Medicine at Yeshiva University followed the sleeping patterns of more than 11,000 children for six years. They found that kids who snored, breathed heavily through their mouths and experienced apnea—long pauses between breaths during sleep—were at risk.

Collectively known as sleep-disordered breathing (SDB), the problem peaks when children are between 2 and 6 years old, but can occur when they are younger. Approximately 1 in 10 children snores regularly and 2 to 4 in 100 have sleep apnea, according to the American Academy of Otolaryngology–Health and Neck Surgery (AAO-HNS). Common causes of SDB are enlarged tonsils or adenoids, but be wary of the “quick-fix” of tonsillectomy—as we have reported, that surgical procedure is often unnecessary, and to conclude that tonsils contribute to sleep disorders requires careful diagnosis.

Quite simply, the study’s authors said, “Parents and pediatricians alike should be paying closer attention to sleep-disordered breathing in young children, perhaps as early as the first year of life.”

Although earlier studies indicated sleep problems could signal later difficulties, they involved only small numbers of patients, short follow-up of a single symptom or limited control of individual traits such as low birth weight that could be responsible for some symptoms.

In the new, more substantial study, children whose symptoms peaked between the ages of six and 18 months were much more likely to experience behavioral problems when they were 7 compared with children who breathe normally during sleep. Children whose SDB symptoms persisted throughout the evaluation period, and were most severe at 30 months, expressed the most severe behavioral problems.

Researchers theorize that SDB might be responsible for behavioral problems because of its effect on the brain. Decreased oxygen levels and increased carbon dioxide interrupts the restorative process of sleep and disrupts various chemical systems. Such malfunctions can impair one’s ability to pay attention, plan ahead and organize. They also impede one’s ability to regulate emotions.

To learn more about SDB and treatment options, consult the AAO-HNS fact sheet.

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