Avoiding Problems When “Falling Back”: Daylight Saving Time and Your Child

3 months, 21 days ago

-Falling Back-Avoiding Sleep ProblemsAt the end of DST

Ahh, autumn. Halloween costumes, fall foliage, carving Jack-O-Lanterns and enjoying the crisp bite of a fresh apple. Those of use who live in New England often cite this season as the finest of the year, prior to the long nights and cold days of winter. There is one part of it that I don’t look forward to as a parent of small children, and a sleep doctor: the end of Daylight Savings Time (DST) when the clock falls back by one hour. This year, clocks in the United States will fall back by one hour at 2 AM on Sunday, November 4th. There is some evidence that DST is associated with adverse health and safety effects, but this is controversial; Ezra Klein nicely outlined this in the Washington Post.

“Daylight Saving Time” is Pretty Confusing

I always have to pause and think about these terms because they are pretty confusing. Here’s a brief primer:

When is daylight saving time? “Daylight Saving Time”  (or DST) refers to the practice of advancing the clock an hour later for the summer months for an extra hour of daylight. In 2016, it occurs between March 13th and November sixth.
What happens when daylight saving time ends? The end of DST occurs when the clock is dialed back an hour, which we call “falling back”.
Why do you keep calling it daylight SAVING time? Although it sounds weird, “daylight savings time” is incorrect; it is correct to say daylight saving time. But don’t be pedantic about correcting people.

Falling Back is a Bummer if You Have Small Kids

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

Your Teenager Will Dig This

Unlike little kids, teenagers naturally tend to stay up later and struggle to get up in the morning. Thus, “falling back” tends to feel pretty great for your teenager  as the world essentially moves closer to his or her natural sleep schedule. If you want to capitalize on this, I encourage teens to try to stay on the clock time and not use this as an excuse to stay up later. Practically speaking, this means continuing to going to bed a bit earlier based on clock time. For example, if your teen struggles to fall asleep before 11:30 PM, this is a good opportunity to have her go to sleep at 10:30 PM as it will “feel” the same.

How to Make This Less Annoying

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

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

I’d love to hear about your experiences with this. Has this been a problem for you in the past?

The post Avoiding Problems When “Falling Back”: Daylight Saving Time and Your Child appeared first on Craig Canapari, MD.

Read more: drcraigcanapari.com

How to Sleep Well in Hay Fever Season

4 months, 28 days ago

Unfortunately for some of us, hay fever season is now only around the corner. Starting in late March and ending in September, hay fever sufferers can often feel attacked for nearly all of spring and summer! The pollen season is split into three sections; tree pollen affects us from late March to mid-May, grass pollen flares up from mid-May to July and weed pollen is prevalent from the end of June to September.

Did you know that 95% of hay fever sufferers are allergic to grass pollen? What’s more, alcohol can worsen your symptoms too; beer, wine or spirits actually contain histamine, which is the chemical that sets off allergy symptoms in your body. So, for those of you who are dreading the upcoming hay fever season, you’re probably looking for solutions left, right and centre!

Allergy sufferers struggle with symptoms like a bunged up nose and sneezing, or sometimes it’s as bad as asthma or eczema. Nuts, pollen and dust are the most common allergens that we meet in our daily lives, with dust being one of the most annoying!

Sleeping in hay fever season

Allergy UK discovered that around 87% of those surveyed admitted their sleep is severely affected by hay fever in the spring and summer months. However, there are many different tips you can follow to help reduce the effects of hay fever, making sure you get a good night’s sleep through the summer. Many people will take tablets to combat the symptoms of hay fever, but there are so many other things you can do to help as well.

Showering before bed can help to get rid of any pollen that has stuck to your skin and hair throughout the day; this means it will transfer to your bed and make your symptoms worse through the night! You should also consider keeping your bedroom window shut to stop any pollen getting into the room; this can sometimes be tricky in the hot weather, but your nose will thank you later for it. Dust or vacuum your bedroom regularly to get rid of any pollen that has floated into your room through the day too.

Anti-allergy bedding

If you suffer from hay fever, you should wash and change your bedding regularly as it can help to remove traces of pollen. What’s more, fresh bedding is always so much more comfortable to sleep in! Make sure you don’t hang your sheets outside to dry; this will defeat the whole point as they will be infused with pollen by the time you bring them inside.

Buying anti-allergy bedding can be a huge step in helping to reduce your symptoms. Anti-allergy bedding will have been treated in a way that deters allergens like dust mites, which can add to your sleep troubles. Likewise, hypoallergenic bedding will be made from materials that are less likely to trigger allergies. We recommend having both anti-allergy pillows and duvets, as this will have a better impact on your sleep quality. The Silentnight Anti-Allergy Duvet – 4.5 tog is perfect for summer, while the Silentnight Anti-Allergy Pillow – 2 Pack will protect your room from dust mites and other bacteria.

So, before hay fever season ruins your sleep routine this summer, make sure you’ve followed our top tips!

Read more: sleepypeople.com

How Can Melatonin Supplements Benefit You?

5 months, 18 days ago

Table of Contents

What Is Melatonin?
Uses of Melatonin in Your Body
6 Ways to Optimize Your Melatonin Levels Naturally
Studies Regarding the Use of Melatonin Supplements
Benefits of Melatonin Supplement
Do Not Take Melatonin if You Have These Conditions
Side Effects of Melatonin
Consider Optimizing Your Melatonin Levels Naturally Before Taking a Supplement
Frequently Asked Questions

Sleeping is an essential human function, and at the heart of it is your circadian rhythm, also known as your body clock. It’s a natural, biological timer that helps your body recognize sleepiness and wakefulness over a period of 24 hours.

By sticking to a regular bedtime schedule, such as sleeping and waking up at the same time each day, you can maintain a steady circadian rhythm that will allow you to maximize your productivity while you’re awake, and get the right amount of sleep when nighttime arrives.1

Your circadian rhythm is largely dictated by your pineal gland. This gland is located near the center of your brain, with a shape that looks similar to a pine cone, hence the name. It’s estimated to be one-third of an inch long, and is made up of unique pineal cells and neuroglial cells that help support the gland.

Despite its small size, it plays a crucial role in your health because it produces a single hormone called melatonin, which is vital for controlling your body clock and, ultimately, your sleeping patterns.2

What Is Melatonin?

Melatonin, or N-acetyl-5-methoxytryptamine, is a hormone produced by the pineal gland.3 Your brain usually starts secreting melatonin around 9 p.m., which is the time most people go to bed. By increasing the amount, your body begins to recognize that bedtime is fast approaching, allowing you to sleep at an ideal time.4

To do this properly, you need to be aware of your exposure to light throughout the day and especially at night, because melatonin production depends on how much light your body absorbs.

If you stay awake past dark, light emitted by electrical devices hampers your body’s ability to produce melatonin. Ideally, you want to stop using gadgets an hour before sleeping to help increase melatonin production and maintain a steady circadian rhythm. Nightshift workers usually have it worse and constantly suffer from disrupted body clocks, because of their poor melatonin production.

3 Main Uses of Melatonin in Your Body

What is the role of melatonin anyway? Based on published research, it has been discovered to perform three main functions:

• Controls your circadian rhythm — Melatonin works as a sleeping aid by normalizing your circadian rhythm by convincing your body to prepare itself for bedtime.5 It’s a hormone that only “signals” your body to prepare for sleep, not one that actually makes you fall asleep.

• Functions as an antioxidant — Recent studies have found that melatonin not only affects your body clock, but also functions as an antioxidant that can help support your health. Specifically, it may help different aspects of your brain, cardiovascular and gastrointestinal health.6 It may even lower your risk of cancer, in some cases.7

• Boosts your immune system — Melatonin may benefit your immune system in various ways. In one study, researchers suggest that melatonin may help improve the treatment of bacterial diseases such as tuberculosis.8 In another study, melatonin has been suggested as a potential tool against inflammation, autoimmune diseases and Type 1 diabetes.9

6 Ways to Optimize Your Melatonin Levels Naturally to Improve Sleep Quality

According to the Centers for Disease Control and Prevention (CDC), an estimated 50 to 70 million Americans are suffering from a sleeping or wakefulness disorder.10 As a result, many of them turn to various remedies, such as behavioral and environmental changes, to get a good night’s rest.11

One of the first things you can do is to make sure that your body is producing enough melatonin. Optimizing your melatonin levels naturally is important because it helps keep your body functioning normally without relying on outside factors. So, instead of immediately relying on melatonin supplementation, here are a few lifestyle changes I suggest you try first to boost your melatonin production:

• Avoid using electronic devices an hour before sleeping — Gadgets such as cellphones, TVs and computers emit blue light, and exposure to it tricks your body into thinking it’s still daytime. By avoiding gadgets an hour before bed, your body can produce the melatonin needed to help you sleep at your intended time.

• Make sure to get regular sunlight exposure — Getting regular sun exposure in the morning or at noontime helps your body reduce its melatonin production, so that when nighttime arrives, your pineal gland produces the correct amount to induce sleepiness.

• Try to sleep in complete darkness — If possible, try to remove immediate light sources from your room to help improve your sleep quality. The slightest exposure to light can interfere with your body’s melatonin production and keep you up later than you need. Keep gadgets 3 feet away from your bed or use blackout window shades.

• Remove sources of electromagnetic fields (EMFs) in your bedroom — EMFs emitted by certain devices such as Internet routers can disrupt your pineal gland’s melatonin production. Ideally, you should turn off your wireless router, as well as other wireless devices connected to the Internet before sleeping.

• If you need a nightlight, use a low-wattage yellow, orange or red bulb — Low-wattage bulbs with a yellow, orange or red color do not interfere with melatonin production the same way that white and blue bulbs do.

• Wear blue light-blocking glasses — This special device can help keep your eyes from absorbing blue light that can affect your melatonin levels. It can be a useful tool to have around the house, especially if you’re constantly surrounded by gadgets and artificial light sources.

In addition, the following foods are known to contain small amounts of melatonin. Making them a part of your regular diet while practicing the aforementioned sleeping tips may help improve sleep quality:12

Grass fed meat (lamb, beef and pork)
Wild-caught salmon
Pasture-raised chicken and eggs
Raw, grass fed milk
Pineapple
Banana
Apple
Pomegranate
Mulberry
Tart cherries
Grapes
Onion
Garlic
Cauliflower
Turnip
Cucumber
Carrot
Radish
Beetroot
Tomatoes
Seeds (Flax, sunflower, fennel, mustard, alfalfa, celery and fenugreek)
Nuts (pistachio, almonds and walnuts)

If you’ve already tried everything, including incorporating melatonin foods in your diet, and you’re still having difficulty getting quality sleep, you may consider taking a melatonin supplement. In 2016 alone, 3.1 million adults in the United States turned to melatonin supplementation to help them sleep peacefully.13

Studies Regarding the Use of Melatonin Supplements

Since the discovery of melatonin, various studies have been conducted to discover how using it as a supplement can benefit your health. According to the Journal of Pineal Research, the melatonin secreted by your pineal gland enters every cell in your body and can even cross morphophysiologic barriers.

As a result, not only may it help you improve sleep quality,14 it also has certain anti-inflammatory compounds that may help reduce your risk of cardiovascular diseases, such as atherosclerosis and hypertension.15

In addition, a study published in Endocrine Journal reports that increasing melatonin intake may help improve your overall health, as this hormone can be an effective antioxidant that can help fight free radicals in your body.16

Another study suggests that melatonin may help obese people manage their weight. The researchers indicate that certain lifestyle factors suppress melatonin production, which results in sleep disruption that can lead to weight gain. By increasing melatonin production, adequate sleep can be reintroduced as part of a healthy lifestyle, along with other positive lifestyle changes, to help curb obesity.17

8 Potential Benefits of Melatonin Supplement

Melatonin may help boost your health in various situations, as shown in the table below. While each benefit is backed up with scientific research, always consult with a doctor before giving melatonin supplements a try:

• Insomnia — Melatonin is primarily used to help treat people who have sleeping disorders by inducing sleepiness quicker.18

• Jet lag — Melatonin may be used to help treat jet lag by adjusting your body to a new time zone. However, it’s generally recommended only for travelers who cross four to five time zones.19

• Heart disease — People who are struggling with heart disease may benefit from melatonin. A study has found that it may help lower your bad cholesterol levels by as much as 38 percent.20

• Menopause — Increasing melatonin consumption in menopausal women 42 to 62 years old may help improve mood and stave off depression.21

• Autism — Children diagnosed with autism who are also plagued with sleeping problems may benefit from melatonin supplementation. Research indicates that taking the hormone can lead to deeper sleep and better daytime behavior.22 However, I advise consulting your health care provider before giving any melatonin supplement to children.

Fibromyalgia — People affected with fibromyalgia are believed to have lower levels of melatonin. A group of researchers found that increasing the melatonin levels of fibromyalgia sufferers through supplementation helped alleviate their symptoms and improved sleep quality.23

Gallstones — Melatonin can help lower your risk of gallstones by inhibiting cholesterol absorption across the intestinal epithelium, as well as increasing the conversion of cholesterol into bile.24

• Tinnitus — If you have tinnitus, slightly increasing your melatonin may help improve your symptoms. In one study, participants who took 3 milligrams of melatonin supplements every night experienced a decrease in tinnitus intensity after the testing duration.25

Do Not Take Melatonin if You Have These Conditions

Here’s a crucial question you should ask yourself: Are you fit to take melatonin? While there are valid reasons for taking this supplement, remember that it can exacerbate certain health conditions as well. If you’re taking any of the following medications, you should not take melatonin as the mixture can have adverse effects to your health:26

• Anticoagulants and anti-platelet drugs

• Anticonvulsants

• Contraceptive drugs

• Diabetes medications

• Immunosuppressants

Taking melatonin while pregnant should be avoided as well, since there’s little knowledge in this field.27 If you’ve recently developed pregnancy-related sleeping problems, I advise you to consider behavioral and dietary changes before considering melatonin or other similar types of supplement.

Refrain from giving melatonin to children, including babies and toddlers, unless approved by your physician. While a 2016 study found that children with sleep difficulties who took melatonin did not develop any concerns or adverse side effects,28 it’s better to be safe.

10 Side Effects of Melatonin You Should Know About

Some of melatonin’s potential side effects include:29,30

Daytime sleepiness
Short-term depression
Irritability
Vivid dreams, or possibly nightmares
Mild anxiety
Headaches
Abdominal discomfort
Confusion
Body clock disruption
Dizziness

If you are already taking a melatonin supplement and begin to experience any of the mentioned side effects, stop taking it immediately and consult with a doctor for safer alternatives. In addition, melatonin and alcohol should not be taken together, as it can increase your chances of accidents because the sedative effects are amplified.31

Remember: Consider Optimizing Your Melatonin Levels Naturally Before Taking a Supplement

Melatonin is a crucial hormone that performs few but important functions. Low levels of it can lead to sleep disruption, increase your risk of certain diseases and lower your antioxidant capabilities. However, remember to always try and improve your sleeping habits and environment before attempting melatonin supplementation.

While there’s an abundance of scientific evidence that suggest melatonin supplementation can be beneficial to your health, too much of it can actually make you more wakeful. By primarily focusing on natural strategies, you forego this risk, as well as the chances of developing unpleasant side effects that can further disrupt your quality of sleep. If you do decide to take a melatonin supplement, seek guidance from a doctor first.

Frequently Asked Questions About Melatonin

Q: Is melatonin addictive?

A: Currently, there’s very little information regarding melatonin supplement addiction. However, beware that it can still be abused, although the chances of becoming dependent are lower compared to other types of medications or supplements.32

Q: How long does it take for melatonin to work?

A: The average time for melatonin supplements to work is generally 20 minutes. If you’re about to take melatonin for the first time, it’s recommended that you take it one to two hours before your bedtime.33

Q: Can you take melatonin supplements while pregnant?

A: As of the moment, there is a lack of scientific evidence regarding the use of melatonin supplements on pregnant women, but it’s theorized that it may hamper sex drive, reduce ovarian function and increase the risk of developmental disorders. If you’re pregnant, it is best that you avoid using this supplement and resort to natural remedies to correct sleeping problems.34

Q: Is melatonin safe to use for kids?

A: Melatonin supplements are generally safe for children. According to a study published in Canadian Family Physician, children with sleep difficulties who took melatonin had no concerns or adverse side effects, according to their parents.35 However, consult with your child’s pediatrician before giving them any type of melatonin supplement.

Q: When is the ideal time to take melatonin?

A: Taking a melatonin supplement two hours before bedtime can help you maximize its effectiveness.36

Q: How long does the effects of melatonin last?

A: The half-life of melatonin is very short, around 59 to 65 minutes only.37

Q: Can you overdose on melatonin?

A: Yes. While there are no reported deaths related to overdosing from melatonin, consuming more than the recommended amount can cause side effects, such as autoimmune hepatitis, a psychotic episode, seizures, headaches or skin eruption.38


Read more: articles.mercola.com

At Long Last: Sleep Training Tools For the Exhausted Parent

5 months, 30 days ago

Are you tired? Not sure how to help your kid sleep through the night? Here is my comprehensive guide to sleep training tools and methods to help tired parents and kids sleep better. These sleep training methods will work for infants, toddlers, and through school age. 

Free Bonus: I created a guide comparing my favorite sleep training techniques to help you figure out the best method for you and your child. It’s a quick two page PDF you can save and reference later as you try this yourself. Click Here to get the guide, free.

So, we’ve covered why fixing your child’s sleep problem is not selfish because it is good for you and for them. I imagine that lots of parents fix their kid’s sleep issues without a lot of difficulty. Then there are the parents who have made it to see me in Sleep Clinic. Generally, these parents have tried and failed to address their child’s sleep problem, for various reasons. Since there is a lot of information to cover, I’m going to break this out into a question and answer format, as I review all of the different effective sleep training methods .

 

What do you mean by sleep training?

When I refer to sleep training, I’m talking about behavioral (non-medication based treatment) of two common problems, sleep onset association disorder and limit setting disorder. Some kids have a mixture of both.

When should I consider sleep training?

I would wait until a child is at least 6 months of age, although some people have recommended trying it as early as two month of age (note that I don’t endorse this). I actually think that it is a bad idea to start before four months of age,  preferably once he is no longer feeding during the night. However, if your child is still feeding multiple times during the night and is over six months of age, that could be part of the problem. If your child has issues such as autism or developmental delay, these techniques will still work but must be applied more slowly.

When should I not start sleep training?

If you are worried that your child may have a medical problem which is disrupting sleep, please talk to your pediatrician.
If you want to pursue co-sleeping as a lifestyle, you may find it more difficult to adopt these recommendations, although they can be put into play if you are room or even bedsharing– it is just harder. I believe that cosleeping is associated with worse sleep long term for parent and child. If you are cosleeping and want to stop, here is my guide on how to stop the cosleeping habit.
If you have a major life event coming up– a move, a visit from the in-laws, a big project do at work.
If you have  major stresses in your that would make embarking on about a week of disruption.
For more on this, here is a comprehensive guide on when not to sleep train.

My child feeds at night. Is that part of the problem?

It certainly can be. Most formula fed infants are capable of sleeping through the night without feeding by six months of age; this milestone happens later for breast fed infants, probably between 9-12 months of age. Here’s my article on how and when to wean night feeds.

 

Ok, we’re ready. Whats the first step?
Free Bonus: I created a guide comparing my favorite sleep training techniques to help you figure out the best method for you and your child. It’s a quick two page PDF you can save and reference later as you try this yourself. Click Here to get the guide, free.

I think the most important thing is taking a hard look at your child’s bedtime ritual. I saw the great Jodi Mindell speak at the 2012 Sleep Meeting here in Boston. (Here’s a question and answer she did on some of these issues at Parents.com). She emphasized that bedtime need to be consistent, positive, and have a clear trajectory. High quality consistent bedtimes are associated with better sleep quality throughout childhood. Here’s a post explaining why this is. Let’s break this out a bit:

Consistency means bedtime happens about the same time on typical days, and has the same events in the same sequence. A good bedtime for babies and preschoolers through early elementary school age is between 7:30-8:30 PM.
Bedtime should included enjoyable, positive activities like stories and songs, with the last part occurring where the child sleeps. 
Bedtime should be short and sweet (<45 minutes), with a forward momentum. Meaning that you go to the bathroom, then the bedroom, then lights out. Keep things simple and moving. Don’t move your child towards bed, then away, then towards it again.
If your child has an aversion to being in their crib or room, it’s important to spend some pleasant, fun time playing there during the day to emphasize that it is a positive place.

In our house, we mark the start of bedtime by going upstairs with the boys between 7-7:15 PM. They brush teeth and bathe every other night. When one or the other attempts a digression (Wrestling! Running around naked! Peeing on the floor!) we firmly redirect them to the task at hand. They get in their pajamas, read stories, sing songs, and go to sleep on their own. If one parent is doing both bedtimes, the older one helps put the younger one to bed. Lights out is by 8:30 PM for the older boy. 

Recently, I’ve been reading The Power of Habit (affiliate link), which has some terrific insights into the importance of bedtime. Remember, the most powerful reinforcer of behavior by your child is positive reinforcement (kind words, contact, affection). This is WAY more effective than, say, sticker charts.

Habit cue reward.001

If you are reading this post, you and your child have likely fallen into some bad habits around bedtime (fighting, lying with them until falling asleep, eating a chicken dinner in bed, etc). By establishing a consistent time and pattern of bedtime, you are going to essentially revise these habits so that, with time, your child will actually crave their lovely and predictable bedtime.

If you are working on starting a good bedtime, here’s a video on how to start a good bedtime routine.

We already do all that stuff. Our child still can’t go to sleep without us and wakes up at night!

Here’s where it gets a little bit more complicated, and this is the place where many parents struggle– the realm of traditional sleep training methods. Children who can’t fall asleep on their own and who wake up frequently at night likely have inappropriate sleep onset associations and will require a little bit more intervention. The goal of all of these interventions is the development of the ability to self soothe– specifically, falling asleep solo at night.

 

There are a couple of evidence-based tools you can use if you put your child in bed and he cries or fusses until you come back into his room:

Bedtime fading: This strategy involves temporarily moving your child’s bedtime later while teaching him to fall asleep on his own. This can help use your child’s natural sleep drive to make falling asleep easier. Usually I recommend moving the bedtime later by 30-60 minutes depending on prior experience. For example, if the family has previously tried to put their son down and he cried for 45 minutes before they gave up, I will move the bedtime 45 minutes later or more. There is evidence that removing the child from bed if they do not fall asleep after 15-20 minutes then putting them to bed again a few minutes later (a “response cost”) is effective but I think that it is generally too complicated. Once your child can fall asleep within 15 minutes, you can move the bedtime earlier by 15 minutes every two days until you reach the desired bedtime (usually between 7:30-8:30 PM is best). It’s important to avoid letting your child sleep in in the morning or falling asleep in the late afternoon in the stroller or the car, as they will be less tired at bedtime. This is one “gentle” sleep training method. 

Avoiding “sneaky sleep” in the later afternoon.
Not allowing your child to sleep much later in the mornings, unless they are getting up at an uncomfortably early hour.

The “cry it out” approach:  The behavioral term for ignoring an undesirable behavior is “extinction”; obviously most parents don’t love the term. There are two ways to do this. Unmodified extinction involves putting your child down at the appointed hour, closing the door, and letting things play out. Many people struggle with this quite a bit. Graduated extinction (also known as the Ferber method), is where you check on your child at set intervals (e.g. 1 minute, 2 minutes, 3 minutes, then every five minutes until they fall asleep). When you check, the interaction should be very brief and without physical contact. Dr. Mindell recommends the script, “It’s night night time. I love you. I’ll see you in the morning”. This method is very effective but can be challenging to carry out. Some children may vomit. If this occurs, I recommend going in, cleaning up the child and bed, and leaving. It feels horrible, but you don’t want to reinforce vomiting as a tool to get what you want. Trust me. With time and experience, I’ve come to believe that this is pretty difficult to implement in children who have moved from a crib to a bed.
“Camping out” is another evidence based gentle sleep training method consisting of gradually withdrawing your presence from your child’s room at sleep time. It may result in less crying and be a better fit for some families, but takes longer than “cry it out.” This is another way that people use when they performing “gentle” sleep training.

Remember, when camping out, when your child looks to your for guidance, you have to provide, brief, minimal interactions. It helps to have a script. Look at your child and say, “I love you. It’s time to go to sleep. Good night.” Do this EVERY time.
Here’s a step by step guide for how close to be to your child, along with a video on how to do this. Each step should be between 1-3 nights. This starts if you are currently rubbing your child’s back to help her fall asleep. You move up the pyramid over time. Sleep_webinar_Ruth_FINAL__1__pptx

The “excuse me” drill is another gentle sleep training technique where you provide very frequent reassurance at first and withdraw it over time.

This gentle sleep training method is really for kids who are old enough to talk and have some abstract thinking– imagine age 3 and up. During the excuse me drill, the parent who usually stays with the child until he falls asleep (let’s say Mom in this case), will say, “excuse me, I need to step out and ___________ for a second. I’ll be right back!”. The excuse doesn’t really matter. Here are some suggestions:I need to…

check the soufflé
buy a lottery ticket
practice my breakdancing
bang out ten pull ups
(In all seriousness, boring excuses (“I need to check on your brother, take out the trash, etc”) work best

At first you will come back in very frequently– every few seconds on the first night. When you come back, you praise your child for staying in his bed, looking cozy, acting brave, etc. It is OK to touch him. Then you leave after making an excuse and come back a few minutes later. Over several nights, you reduce the frequency of checks. What makes this gentle is that you are not allowing your child to stress or be alone for more than a few seconds at first. The point is that nothing is more reinforcing for a child than parental attention and reassurance. Hopefully, your child will start falling asleep with you out of the room. Coupling this with bedtime fading is a great combination for an older, anxious child, and this has been studied in children with developmental issues (specifically Angelman syndrome) as well. Like all sleep training methods, it should be part of a detailed plan.
Nursing moms should try to avoid having nursing be the final activity prior to sleep onset. Ideally, the other parent should put the child to bed.
The binky can be challenging. The American Academy of Pediatrics recommends pacifier use up until 6 months as part of a number of interventions to reduce the risk of sudden infant death syndrome (SIDS). In older babies and toddlers you may find yourself replacing it frequently at night. If you are not ready to get rid of it, Dr. Mindell recommends keeping some pacifiers in the corner of the crib. When you put your child to bed, guide their hand to the binky and have her put it in her own mouth. That may help her find it on her own in the middle of the night.

Often, sleep training may be more difficult for one parent than the other. When we did this, I sent my wife out for the first night so she wouldn’t have to listen to our older son crying. It may be a good idea to turn off the monitor if you can hear your child anyway.

What do we do if she wakes up at night once we start this?

If you fix bedtime, the nocturnal awakenings will go away over time. I usually recommend that parents just do what they have been doing in the past for nocturnal awakenings. The middle of the night is all above survival.
It’s not working. Help!

The most common reason why you have not been successful is being inconsistent. You need to be almost robotic in executing the same plan every night. Here’s my inventory of the top ten sleep training mistakes.

My child is an older and primarily has issues with bedtime. Any specific tips on working on this?

Bedtime fading as noted above can be really helpful in this context.
A bedtime chart showing what is expected of your child every night can be really helpful. Here’s a nice one you can purchase here. Sticker charts can be helpful as well. Dr. Wendy Sue Swanson has tips on implementing this here. Dr. Deborah Gilboa discusses the limitations of sticker charts here.
One strategy which I love is the bedtime pass. This works like a hall pass. Give it to your child and explain that she can use the pass to come out of the room one time for a curtain call e.g. a glass of water or another trip to the bathroom. After that one instance, she is expected to stay in her room and will be brought immediately back if she comes out. The research on this technique showed that kids tended to hoard the pass and not use it at all. Dr. Greene has a great summary of how to implement this. From Dr. Greene’s site:

So how do you use bedtime passes? Simple.

Give your child a special card good for one free trip out of their room each night or one visit from a parent – for a brief, acceptable purpose such as a drink and a hug. Many families decorate the cards, often with the child.
Require the child to get in bed at bedtime, but be sure the free pass is close at hand.
When the child uses the pass, the card is surrendered for the rest of the night.
If children leave the room again that night, they are walked back without a word and without eye contact.

You may need to carry out an extinction strategy which is more challenging to implement in a child in their bed who can easily get out of his bed, and out of his room. I strongly advise against locking children in their room. If your child comes out of his room, take him back to his room with the brief speech noted above (“It’s night night time. I love you. I’ll see you in the morning”.) If he comes out, put him back in his bed and close the door for one minute. If he is not in his bed when you reopen the door, close it for two minutes. Keep increasing the interval until he gets the message that you expect him to be in his bed. Another alternative can be putting a gate or two in the doorway of the room. (The second, higher gate is for kids that can climb).

 

What else do we need to know to succeed?
Free Bonus: I created a guide comparing my favorite sleep training techniques to help you figure out the best method for you and your child. It’s a quick two page PDF you can save and reference later as you try this yourself. Click Here to get the guide, free.

You can carry out these steps gradually. Let’s say your child falls asleep nursing in your lap in the rocking chair. You can stop nursing to sleep for a few nights (often useful to nurse earlier and have the non-nursing parent put the child to sleep), then stop rocking for a few nights, then put your child to sleep drowsy but awake.
Keep sleep diaries so you can monitor your progress. Here’s the log we use in clinic:PEDIATRIC SLEEP LOG
Be consistent. Intermittently giving in is a very strong way to reinforce undesirable behavior.

Will my child hate me? Does sleep training hurt my child?

There is no evidence to suggest that sleep training causes any damage to children, and lots of evidence that it helps– that children and adults are both happier and better adjusted after sleep training. This is touched on in the AASM article below. Dr. Mindell noted in her presentation that she is publishing a review of 35 studies which showed no significant evidence of harm. Over at Science Of Mom, there is a great review of this science as well.

There was a great summary published by the American Academy of Sleep Medicine in 2006 which reviews the evidence for all of these recommendations. You can download it here:  Practice Parameters for Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children.

If you are consistent, your child should be sleeping better within a week. Remember, things get a bit worse (the “extinction burst” of worsening behavior) often on the second or third night. Don’t give up!

Parents: please share your experiences in the comment section below. What worked? What didn’t? Are you still struggling with these issues? If you are, let me know and I’ll try to help.

I hope that you have found this helpful. If so, you can support this site by shopping at in my store at Amazon.  Any purchases through that link (even it if is not in my store) will provide a small amount of support to the website at no cost to you. I have curated some of my favorite sleep hygiene products and bedtime stories.   Thanks!

The post At Long Last: Sleep Training Tools For the Exhausted Parent appeared first on Craig Canapari, MD.

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Melatonin For Children? A Guide for Parents

7 months, 1 day ago

Pediatricians  frequently recommend melatonin for children with sleep problems, or parents might try it themselves. However, the proper use of melatonin is frequently misunderstood. Here is a guide for parents and pediatricians to decide if a child should try it, and to understand how it should be used.

A common thread I find in children coming to Sleep Clinic is that many or all of them have been on melatonin at some point, or are taking it currently. Melatonin is an important tool in the treatment of sleep disorders in children, and because it is naturally derived, there is a widespread perception that it is safe. However, I have become concerned by the frequency of its use, especially in an unsupervised way.

Melatonin sales have doubled in the past ten years, increasing from $90 million in 2007 to $260 million in 2012. I worry that the widespread availability of melatonin has led to some parents using it as a shortcut to good sleep practices. An article in the Wall Street Journal (which also provided the sales figures above), quoted a father’s review on Amazon:

OK, yes, as parents my wife and I should do a better job starting the bedtime routine earlier, turning off the TV earlier, limiting sweets, etc., etc. Well, for whatever reason, this is not our strong suit. This 1 mg light dosage of melatonin is very helpful winding our kids down and getting them ready for bed.

In one regard it is safe— unlike many other medications which cause you to fall asleep, you cannot overdose on it. However, parents need to know that melatonin is a hormone with effects throughout the body and we do not yet know what the long-term effects of melatonin use will be. Many parents in the US would be surprised to know that melatonin is only available with a prescription in the European Union or Australia.

NOTE: For the vast majority of kids, I recommend behavioral interventions to treat insomnia, commonly referred to as sleep training. Here’s an overview of the best sleep training techniques. Start there before trying melatonin. 

What is melatonin? What does melatonin do?

Melatonin is a hormone which is naturally produced by the pineal gland in your brain. It is both a chronobiotic agent, meaning that it regulates your circadian or body clock; and a hypnotic, meaning that at higher doses it may induce sleep. Melatonin is usually used for its hypnotic effect, but it does not have this effect in everyone. Only the chronobiotic effect occurs in all individuals.
The natural rise of melatonin levels in the body 1-3 hours before sleep onset is known as the “dim light melatonin onset” (DLMO). This is the signal involved in body clock scheduling of sleep and corresponds to the end of the “wakefulness” signal produced by the circadian system. Children with insomnia may be given melatonin after their scheduled bedtime passes; what this means is that their bodies are not yet ready for sleep. This is one reason why bedtime fading can be so effective for some children. The doses used clinically (0.5–10 mg or higher) greatly exceed the amount secreted in the body.

There are a few things to be aware of:

Blue-white light exposure in the evenings shift the DLMO later. This is why bright light exposure in the evenings can worsen insomnia. I highly recommend eliminating ANY screen time for preschool through elementary school children for an hour prior to bedtime. That means no light emitting Kindles, iPads, smartphones, computers, or (God forbid) television in the bedroom For students in junior high and beyond who need to use computers to complete school work, I highly recommend lowering brightness settings and using software to reduce the blue light frequencies. (For more on this read my post about going on a “light diet” here).
The effect of dosing melatonin (and light therapy for that matter) are phase dependent. What that means is that the timing of giving melatonin determines both the magnitude and direction of effect. Many people do not realize that the optimal time to dose melatonin for shifting sleep period is actually a few hours before bedtime– that is to say, before the DLMO. The other facet of this is that in teenagers with severely shifted sleep schedule (delayed sleep phase syndrome) may actually have a later shift in their sleep schedule if this is not dosed correctly. Thus I would leave the timing of this to a sleep physician. Jet lag is a similar case[1].
“All natural” melatonin is from cow or pig brains and should be avoided. Most preparations around now are synthetic, which is preferable.

Here’s a short video I put together to explain how when you give the melatonin dose really matters. (Maybe just for the supernerds out there like myself).

How effective is melatonin for sleep problems in children?

The overall effects of melatonin include falling asleep more quickly and an increase in sleep time. Like all medicines used to help children fall asleep, there is fairly limited information available. This means that most studies have small groups followed for short periods of time. Furthermore, melatonin not regulated as a pharmaceutical in the U.S. Thus, there is no large pharmaceutical company bankrolling larger and long-term studies (more on this below) . Rather it is regulated as a food supplement by the FDA.  For a terrific review, including dosing recommendations, I highly recommend this article by Bruni et al.

Chronic sleep onset insomnia and Melatonin:

Problems with falling asleep are common in children, just like in adults. In children with chronic difficulty falling asleep within 30 minutes of an age-appropriate bedtime. [2] Use of melatonin results in less difficulty with falling asleep, earlier time of sleep onset, and more sleep at night. The initial studies used pretty high doses, but later studies comparing different doses showed that dose didn’t matter, and that the lowest dose studied was as effective as the highest.[3] This is likely due to the fact that ALL these doses were well above the amount produced naturally in the children. Timing between 6–7 PM was more effective than later doses. The authors point out that a midafternoon dose would have the best effect (due to the phase response curve) but that afternoon dosing would have the unpleasant side effective of making children sleepy in the afternoon. (For more info, read here and here and here).

Autism and Melatonin

Sleep problems are common in children with autism. Multiple types of problems occur, including prolonged time to fall asleep, less sleep during the night, and problems with nocturnal and early morning awakenings. Some children with autism have decreased levels of melatonin as well as decreased variation in melatonin secretion throughout the day. Because of this, melatonin has commonly been used in autistic children, which seems to result in less difficulty falling asleep and more sleep at night. Some studies used immediate release preparations, whereas others use long acting forms of melatonin. The majority of studies involved melatonin dosing 30–60 minutes prior to bedtime.
Interestingly, these studies also demonstrated improvement in other domains in some children– specifically, communication, social withdrawal, stereotyped behaviors, and anxiety.

A recent trial looked at a time released melatonin preparation called PedPRM at doses of 2-5 mg. The children in this trial slept 57.5 minutes more (compared with the children who did not receive the medication, who slept 9 minutes more). Most of the benefit seemed to be due to improvement in falling asleep– on average, treated children fell asleep 39 minutes faster. This medication is not yet approved by the FDA but is in the pipeline for approval.

As in other children, melatonin should be added to a behavioral management plan. For pediatricians, there is a great practice pathway which suggests the addition of medication only after a behavioral intervention has failed. Two great resources for families are the Autism Speaks Sleep Toolkit, and the book Solving Sleep Problems in Children with Autism Spectrum Disorders: A Guide for Frazzled Families(affiliate link). Here is a terrific review article on this topic as well.

ADHD and Melatonin

Attention deficit hyperactivity (ADHD) is commonly associated with sleep problems, just as sleep problems can cause attentional issues. As many as 70% of children with ADHD may have sleep problems. Sleep problems include difficulty falling asleep, abnormalities in sleep architecture (e.g. the proportions of different stages of sleep), and daytime sleepiness. Trials of melatonin (in doses ranging from 3–6 mg) showed that it helped children with ADHD to fall asleep more quickly, although there was no evidence of improvement in attentional symptoms during the day. Side effects reported included problems with waking up at night and daytime sleepiness in some children. There is a nice review article here.

Delayed Sleep Phase Syndrome and Melatonin

Delayed sleep phase syndrome (DSPS) is a common disorder in teens, where their natural sleep period is shifted significantly later than the schedule which their commitments (usually school) mandates. Thus, teens with this disorder an unable to fall asleep by 1–2 AM in the morning or even later. I have seen kids who are routinely falling asleep between 4–5 AM. Melatonin has a clear role in this disorder, as small doses 3–4 hours earlier than sleep onset (along with light exposure limitation, sleep hygiene measures, and gradual changes in schedule [chronotherapy]) can be effective in managing this disorder. The reason for the delay is a marked delay in the DLMO, so melatonin dosing can move sleep periods earlier. For children with DSPS, giving a dose 4–6 hours prior to the current time of sleep onset, then moving it earlier every 4–5 days, is recommended, with low dose preparations. Of all the conditions mentioned here, this has the clearest benefit from melatonin. Here is a terrific review article.

Children With Neurodevelopmental Delay and Melatonin

Children with various causes of neurodevelopmental delay may have significant insomnia and melatonin may help. However, in some children melatonin use caused persistently high daytime blood levels of melatonin (and daytime sleepiness).

Blindness and Melatonin

Some children with blindness may have issues with sleep wake time as they do not have light regulating their circadian clock and may thus develop sleep disorders. Very small trials in adults have shown benefit (here’s one) but the data is very limited.

Eczema and Melatonin:

Eczema is associated with dry, itchy skin and kids with it can have problems with insomnia and non-restorative sleep. Some research has suggested that children with eczema may have low melatonin levels, and a recent trial suggest that melatonin may be helpful.

It sounds great. Why should I worry about melatonin?

There are several areas for concern, specifically known and theoretical side effects, and problems with preparations.

Side effects (known): In the short-term, melatonin seems to be quite safe. Unlike many other sleep inducing agents, “no serious safety concerns have been raised” (from Bruni review below). The most common side effects include morning drowsiness, bedwetting, headache, dizziness, nausea, and diarrhea. These effects are generally mild, and in my practice only the morning drowsiness seems to be significant. It can also interact with other medications (oral contraceptives, fluvoxamine, carbemazepine, omeprazole, and esomeprazole, to name a few).
Side effects (theoretical): Melatonin given to children may lead to persistently elevated blood melatonin levels throughout the day. This can be associated with persistent sleepiness, but the other effects are unclear. It is important to know that melatonin has NOT been tested as closely as a pharmaceutical as the FDA regulates it as a food supplement. The studies following children who have been using melatonin long-term have relied mostly on parental reports as opposed to biochemical testing. A physician in Australia named David Kennaway has published two editorials this year pointing out the inadequacy of information on long-term use in children. (You can read these here and here). He states his point of view in a pithy fashion]”

…parents should always be informed that (1) melatonin is not registered for use in children, (2) no rigorous long-term safety studies have been conducted in children and by the way (3) melatonin is also a registered veterinary drug used to alter the reproduction of sheep and goats .”

Problems with preparations– poor labeling:Melatonin preparations have been shown have to variable concentrations from preparation to preparation. Moreover, the amount that a child’s body absorbs may vary.  Remember how I told you that melatonin was treated as a food supplement by the FDA?
melatoninThis is a common preparation. . .
melatonin. . .but the label is not clear that it is 0.25 mg in each dropperful. Many parents think it is 1 mg / dropperful.

This means there is substantially less regulatory oversight in terms of safety and efficacy. I also find that the labelling of preparations is frequently misleading. Take the example of this liquid preparation, which many of my patients have tried. It is labeled as “1 mg” but each dropperful contains 0.25 mg.

You need to go to the web to get this information as it is not on the bottle. (It may be in the package insert, but I suspect few people read these).
Problems with preparations– inaccurate dosing: A recent study showed that the amount of melatonin can vary anywhere from -83% to +478% from the labeled dose. This means that if you are giving your child a dose of 3 mg, the actual dose may actually be anywhere from 0.5 mg to 14 mg. Moreover, the lot to lot variability was as high as 465%– meaning that you may buy a different bottle of medicine, from the same manufacturer, and still one bottle may have more than four times as much as melatonin as another, Finally, the researchers found serotonin (a medicine used in other conditions, and also a neurotransmitter) in 71% of samples. To me, this is the most concerning issue with melatonin– you don’t know what you are getting. 

 My child is already on melatonin. Do I need to freak out?

I don’t think so, as there is little concrete evidence of significant harm. However, if you started melatonin on your own I beg you to discuss it with your child’s physician to see if it is really necessary. If your child has been using it long-term and sleeping well, you can consider slowly reducing the dose and seeing if it is still really necessary. Try to use it as needed as opposed to nightly. Also, I would take a hard look at sleep hygiene and ensure that you are ensuring good bedtime processes such as a high quality bedtime routine and avoidance of screen time for at least an hour prior to bedtime. I would try to reduce the dose, and potentially only use it as needed as opposed to nightly.

My doctor and I have talked about it. What should we consider regarding how and when to give melatonin?

Melatonin can be a tricky medication to dose. Effects change depending on when you give it compared to your child’s usual sleep schedule. Thus, a small dose a few hours before bedtime can have more of an effect than a large dose given at bedtime. In some situations (as with people whose sleep schedules may be flipped to a daytime sleep schedule) dosing may the opposite effect. This is a special case and should be addressed with your physician. A couple of rules of thumb.

Timing: For shifting sleep schedules earlier 3–6 hours before current sleep onset is best. For the sleep onset effects, 30 minutes before bedtime is recommended. Remember, not every child gets sleepy with melatonin.
Dosing: In general, I would start at a low dose (0.5–1 mg) and increase slowly. Recognize that melatonin, unlike other medications, is a hormone, and that lower doses are sometimes more effective than higher ones, especially if the benefit of it reduces with time.
Good Sleep Hygiene is Critical: Melatonin is not a substitute for good sleep hygiene practices and should only be used in concert with a high quality bedtime, limitation on light exposure, and an appropriate sleep schedule.
When possible, purchasing a USP Verified preparation may indicate that the product is manufactured to the requirements of the U.S. Pharmacopeial Convention, which could mean that the quality controllers are tighter.

What is the take home? Should my child take melatonin?

I have not met a parent who is eager to medicate their child. Such decisions are made with a lot of soul-searching, and frequently after unsuccessful attempts to address sleep problems via behavioral changes. Treatment options are limited. There are no FDA-approved insomnia medications for children except for chloral hydrate which is no longer available. Personally, I use it commonly in my practice. It is very helpful for some children and families. I appreciate Dr. Kennaway’s concerns but I have seen first hand the consequences of poor sleep on children and families. I always investigate to make sure that I am not missing other causes of insomnia (such as restless leg syndrome). My end goal is always to help a child sleep with a minimum of medications. I know that this is the goal of parents as well. Some children, especially those with autism of developmental issues, will not be able to sleep without medication. So, melatonin may be a good option for your child if:

Behavioral changes alone have been ineffective
Other medical causes of insomnia have been ruled out
Your physician thinks that melatonin is a safe option for your child and is willing to follow his or her insomnia over time

By the way, here’s a great article from the Chicago Tribune on alternatives to melatonin.

So, this has been quite a long post. Do you have questions about melatonin use in children and teens? What has your experience been?

A special thanks to Bob Young R.Ph (aka the legendary “Bob from Pharmacy”) for his assistance with this.

If you would like more information on this I recommend this Cochrane review on the topic, and this WebMD article.  ↩
An age appropriate bedtime was defined as 8:30 PM + 15 minutes x (age in years – 6). These children had had problems for at least a year for at least four nights per week.  ↩
The initial trials both used 5 mg around 6 PM. A later trial tried multiple doses. Interestingly, the dose did not matter, and the lowest dose (0.05 mg/ kg of the child’s weight) was equally effective. [So, for a 40 lb child– 40/2.2 = 18. 2 kg. 18.2 * 0.05mg/kg = 0.91 mg].  ↩

 

I hope that you have found this helpful. If so, you can support this site by shopping at in my store at Amazon.  Any purchases through that link (even it if is not in my store) will provide a small amount of support to the website at no cost to you. I have curated some of my favorite sleep hygiene products and bedtime stories.   Thanks!

The post Melatonin For Children? A Guide for Parents appeared first on Craig Canapari, MD.

Read more: drcraigcanapari.com

Improve Your Health by Optimizing Your Circadian Rhythm

7 months, 19 days ago

Satchidananda Panda, Ph.D., is a leading researcher in a very important field of study: the circadian rhythm, which is the topic of his book, “Circadian Code: Lose Weight, Supercharge Your Energy and Sleep Well Every Night.” It’s a great read, written at a level that is easy to understand.

Growing up on a farm in India, he was initially intrigued by the fact that he slept best during the summertime. Then, going through agricultural school, he realized that different plants flower at certain times of the day.

“A few years later, when I was thinking about grad school, I realized there are so many things about biology of time,” Panda says. “Every biological system depends on time; just like throughout the day we have a clear timetable when we should be doing this and that — meeting people and having conversation and having dinner.

Every organism has that [but] we haven’t learned the biology of time. That’s why I got excited about circadian rhythms, because this is a universal timing system, starting from pond scum to humans … Every organism has to go through this 24-hour timing schedule.

If this is disrupted, then plants will flower at the wrong time and animals will not reproduce well. In humans, lots of different diseases can happen. That’s why I got excited about circadian rhythms and got into my Ph.D. Now I’m at the Salk Institute, a nonprofit research organization in San Diego, California.”

Circadian Rhythms Are Under Genetic Control

Last year, the Nobel Prize in Physiology or Medicine was awarded to three U.S. biologists — Jeffrey Hall, Michael Rosbash and Michael Young — for their discovery of master genes that control your body’s circadian rhythms.1,2,3,4,5 Panda explains:

“The bottom line is almost every cell in our body has its own clock. In every cell, the clock regulates a different set of genes, [telling them] when to turn on and [when to] turn off.

As a result, almost every hormone in your body, every brain chemical, every digestive juice and every organ that you can think of, its core function rises and falls at certain times of the day [in a coordinated fashion].

For example, your growth hormone might rise in the middle of the night, in the middle of sleep. At the same time, if there is not [too much] food in your stomach, then the stomach lining will start to repair. For that repair to work perfectly, the growth hormone from the brain has to coincide with the stomach repair time.

In that way, different rhythms in different parts of our body have to work together for the entire body to work optimally. In fact, to have these daily rhythms and sleep-wake cycle, being more alert in the morning, having the bowel movement at the right time, having better muscle tone in the afternoon, these rhythms are the fountain of health. That’s the indication of health.”

Shift Work Disrupts Your Circadian Rhythm

The idea that you could possibly micromanage this intricately timed system from the outside is foolish in the extreme. As Panda notes in his book, the key, really, is to pay attention to and honor ancient patterns of waking, sleeping and eating.6 By doing that, your body more or less takes care of itself automatically.

“Yes, to leverage these daily rhythms that are so ingrained in our body, we just have to do a few things: sleep at the right time, eat at the right time, and get a little bit of bright light during the daytime. That’s the foundation. We can do very simple things to reap the benefits of the circadian rhythm and the wisdom of our body,” Panda says.

One of the most common circadian anomalies in today’s modern world is shift work. If you’re like me, you might be under the misconception that it’s a relatively small minority of people that engage in this activity, but Panda cites research showing a full 20 to 25 percent of the American nonmilitary workforce disrupt their natural circadian rhythm by working nights.

In his book, shift work is defined as any work that requires you to stay awake for three hours or more between 10 p.m. and 5 a.m. for more than 50 days a year (basically once a week).

The fact that 1 in 4 is exposed to this circadian rhythm aberration is bad enough, but on top of that there are the health effects of dirty electricity and the unhealthy light spectrum emitted by pulsing light-emitting diodes (LED) and fluorescent lighting, which further exacerbates the problem.

“Only in the last 16 years we have come to understand the impact of light on our health,” Panda says. “Before this, we thought that lighting is only for vision. Our eyes just have retinal cone cells to guide us throughout the world. Sixteen years ago, myself and two others … discovered this blue light-sensing light receptor called melanopsin.

These light-sensing cells in the retina — 5,000 of them per eye — are hardwired to many parts of the brain, including the master clock in the hypothalamus, and the pineal gland that makes … melatonin.

That discovery completely changed how we look at light. It’s not only lighting for safety or security. We have to now think about lighting for health … We [also] have to now think about blue light.

It’s not that we should get rid of blue light completely. We need more blue light during the daytime, and we need less at least three to four hours before going to bed.

The bottom line is in the last 100 to 150 years, we have cleared the man-made world without paying attention to circadian rhythms. Now we have the excellent opportunity to recreate and rebuild this entire world that will optimize our health.”

The Price You Pay for Chronic Sleep Disruption

It’s extremely difficult to estimate the price paid for widespread sleep disruption, but what is known is what happens when you chronically disrupt your circadian rhythm. Panda explains:

“Starting from babies all the way to 100-year-olds, we know that a few nights of staying awake for three to four hours or even eating at the wrong time can cause irritation, foggy brain, mild anxiety, loss of productivity and insomnia.

At the same time, this can flare up underlying autoimmune disease … We can look at shift workers in controlled clinical studies. When we make a list of diseases that circadian rhythm disruption contributes to, it’s a huge list.

It goes from mental health issues such as depression, anxiety, bipolar disease, attention-deficit hyperactivity disorder, autism spectrum disorder and post-traumatic stress disorder [to] obesity, diabetes, cardiovascular disease and fatty liver disease …

Many of these affect more than 10 percent of the population. And then you bring in gastrointestinal diseases: irritable bowel syndrome, irritable bowel disease, and even heartburn and ulcerative colitis.

If you combine all of these, then we can see clearly why nearly one-third of all adults in the U.S. have one or more of these chronic diseases, more than two-thirds of adults at the age of 45 have some of these chronic diseases. Nine out of 10 at the age of 65 have two or more of these chronic diseases.

Now, the question is, ‘How much of this is due to circadian rhythm disruption and other factors, or maybe circadian rhythm disruption with underlying genetic cause?’ We cannot come up with a clear figure, but it’s very clear that if we optimize circadian rhythm, we can really move the needle.”

Sleep Deprivation Induces Glucose Intolerance in as Little as Four Days

Research by Eve Van Cauter, director of the Sleep, Metabolism and Health Center at the University of Chicago, also shows that sleeping less than six hours a night dramatically increases your risk of insulin resistance, which is at the core of most chronic diseases, including those mentioned above. There’s actually a daily rhythm in insulin sensitivity.

For example, if you do a glucose tolerance test in the morning, it may be normal, but done in the evening, it may suggest you have prediabetes. She also showed that when otherwise healthy people are deprived of sleep and allowed to sleep only five hours or less per night, they develop glucose intolerance in as little as four days. As noted by Panda:

“That’s really eye-opening. Because many of us go through that kind of disruption on a monthly or weekly basis. Shift workers go through that half of their life. That might explain the rise in glucose intolerance and having 85 million prediabetics in [the U.S.].”

Melatonin Production and Sleep Disorders

In his book, Panda discusses how melatonin production changes with age. With increasing age, melatonin production starts going down such that a 60-year-old may produce one-tenth the melatonin of a 10-year-old. As noted by Panda, reduced melatonin production is at the heart of many sleep disorders seen in the elderly.

So, how can you optimize your melatonin production as you age? One common solution is to take a melatonin supplement. Melatonin receptor agonist drugs are also available. However, a simpler solution that anyone can do, which costs nothing, is to control your lighting.

“Just imagine, 150 years ago, the firelight, the lamplight or even the full moon light was only 1 to 5 lux. Full moon light is maximum 1 lux. Now, we have 50 to 100 lux. In some department stores you can get 600 to 700 lux of light in the evening. That’s a tremendously high amount of light. That would slam your melatonin [production] down to almost zero,” Panda says.

Ideally, replace LEDs and fluorescent light bulbs in key areas where you spend time in the evening with low-watt incandescent bulbs, and avoid electronic screens for a few hours before bedtime.

An alternative is to wear blue-filtering eyeglasses at night. Just make sure don’t wear them during daytime. Also, make sure the glasses filter out light between 460 to 490 nanometers (nm), which is the range of blue light that most effectively reduces melatonin. If they filter everything below 500 nm, you should be good to go.

The Importance of Meal Timing

Panda has also investigated the impact of meal timing on circadian rhythm. Just like many cleanout functions occur in your brain during deep sleep, all other organs also need downtime. Many organs actually need between 12 and 16 hours of rest, meaning a minimum of 12 hours without food, to allow for repair.

In time-restricted feeding trials, Panda has shown that mice whose feedings are restricted to a window of eight to 12 hours are protected from obesity, diabetes, cardiovascular disease, systemic inflammation, high cholesterol and a host of other diseases. This, despite the fact they’re eating the same amount of calories and the same type of food as animals allowed to graze throughout the day and night.

More importantly, when fat mice are placed on an eight- to 10-hour time-restricted feeding schedule, many of these diseases can be reversed. Human trials suggest the same results can be obtained in humans who adopt a time-restricted eating schedule where all food is eaten within a window of eight to 10 hours.

According to Panda, at bare minimum, you should fast for 12 hours a day — that’s eight hours of sleep, plus three hours of fasting before bed, plus another hour in the morning, to allow your melatonin to level off. At 12 hours of fasting per day, you will maintain your health, but you’re unlikely to actually reverse disease. For that, you need to fast longer.

“The question is how short one can go. This is where there is some limitation in doing controlled studies like we do on animals, where we can do this for a long period of time, because if you reduce access to food for less than six hours in many animals, they will reduce their caloric intake.

So, then we cannot figure out whether the benefit or harm we are seeing is due to the reduction in calories or reduction in timing,” Panda says.

The way I look at it, 12-hour time-restricted eating is something everybody should do. It’s like brushing your teeth every day. What is surprising is only 10 percent of the population consistently eat within 12 hours … [Then] once every six months or once a year, [go down to] eight-hour eating for a month or so.”

There’s an App for That

Panda has developed a very helpful free app, available on Android and iOS, called myCircadianClock. By using this app, you will contribute to Panda’s circadian research.

“We ask people to self-monitor themselves for two weeks, because we know their weekdays and weekends might be different. We just want to get a broader picture of what is your lifestyle from one day to another. And then after two weeks, people can self-select whether they want to eat all their food within 10 hours, 12 hours or eight hours.

You’re free to do whatever you want to do … Over a long period of time, we can figure out what is good or bad for people. In this new app, you can log your food. It also has other bells and whistles. The app can be paired with your Google Health or Apple Health Kit. It can extract your step count, sleep, et cetera. …

After 12 weeks, we also want you to enter your body weight. If you have been collecting lots of other health data, then it’s good to enter that. That’s how it will help to figure out, at the epidemiological level, in real life situations, what our habits are and how we can change it.

The same app is being used in many controlled clinical studies. There are nearly 10 different studies going on in different parts of the world that use the same app … In that way, we can benefit from a controlled study as we launch this large open-to-all kind of studies.”

According to Panda, most people will notice improvements in their sleep within two to three weeks of time-restricted eating. Symptoms of heartburn will also typically begin to resolve. Between weeks four and six, daytime energy levels typically increase while evening hunger pangs are reduced.

Between six to 12 weeks, people with prediabetes or diabetes will begin to see improvements in fasting blood glucose. Those with mild hypertension also tend to notice improvements at this time, as do those with irritable bowel syndrome, as the microbiome improves and the gut begins to repair.

“Once the gut repair improves, then systemic inflammation goes down. Between eight to 12 weeks, that’s when a lot of people report that their joint pain goes down, because that’s a good sign of inflammation.

Once in a while, we get random reports. For example, some people who have inflammatory disease or autoimmune disease, they sometimes say the severity has gone down,” Panda says.

On NAD and Circadian Rhythm

Nicotinamide adenine dinucleotide (NAD+) — one of the most important metabolic coenzymes in your body that helps redox balance and energy metabolism — is primarily generated through a salvage pathway rather than de novo or building NAD+ from scratch pathway.

The rate-limiting enzyme is nicotinamide phosphoribosyltransferase (NAMPT), which is also under circadian control. When your circadian rhythm gets disrupted, it causes NAMPT impairment. NAMPT also helps set the circadian rhythm. In short, by optimizing your circadian rhythm, you’re going to optimize your NAD production. Panda explains:

“Studies say it goes both ways, because NAD also affects sirtuins, and sirtuins integrate with circadian rhythm. Nicotinamide adenine dinucleotide phosphate (NADPH) ratio also affects your [circadian] clock and transcription factors bind to DNA.

The bottom line that we have seen with circadian rhythm is if the clock regulates something, then there is a reciprocal feedback regulation from that output into the clock. That’s the best way you can clear the homeostatic system. It’s the chicken and egg story.”

More Information

To learn more, be sure to pick up a copy of “Circadian Code: Lose Weight, Supercharge Your Energy and Sleep Well Every Night.” Also consider downloading myCircadianClock. It’s free of charge, and will help you track your circadian rhythm while simultaneously contributing to Panda’s research. 

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Children’s Lack of Sleep Is a Hidden Health Crisis

8 months ago

By Dr. Mercola

It’s recommended that school-age children get nine to 11 hours of sleep a night, while teens need eight to 10. Preschoolers and toddlers need even more to function optimally — ranging from 10 to 14 hours a night.1 But many kids are falling short on fulfilling this basic need, putting their physical and mental health at risk.

In England, sleep disorders among children are also on the rise, an investigation by The Guardian revealed. The number of children and teens aged 16 years and under admitted to a hospital due to a sleep disorder rose from about 6,500 in 2012-2013 to nearly 9,500 in 2017.2 Most of the admissions were due to sleep apnea, with 8,274 admissions alone in 2017-2018.

Why Are Children Finding It Hard to Sleep?

One of the joys of childhood should be the ability to drift off to sleep without a care in the world, or at least without the difficulty that plagues many adults. Children, however, may be kept awake at night due to anxiety over everything from school and peer pressure to social media and terror incidents.

At one private sleep clinic in London, The Guardian reported there had been a 30 percent rise in anxiety-related referrals for sleep issues among children in the past year alone.3 Not only can anxiety make sleep difficult, but — in a vicious cycle — lack of sleep can trigger more anxiety.

Practical issues may also be playing a role. With parents sometimes working late, children may not have regular bedtimes or bedtime routines that are conducive to sleep.

Vicki Dawson, founder of The Children’s Sleep Charity, which provides support to families for children’s sleep, told The Guardian, “We are increasingly seeing families where both parents are out working and this can mean that bedtime becomes later, bedtime routines may be rushed or abandoned all together … A good sleep routine is key in supporting a better sleep pattern.”4

Dawson mentioned dietary issues as well, including excessive sugar consumption or intake of energy drinks that children may consume because they’re tired during the day. Both can interfere with getting a sound night’s sleep. This ties in with obesity, another factor that may be influenced by diet and which can significantly interfere with sleep.

Is Obesity to Blame for Kids’ Sleep Problems?

In the U.S., over 18 percent of teens and nearly 14 percent of young children are obese,5 which raises the risk of sleep apnea. The most common type of sleep apnea is obstructive sleep apnea (OSA), which causes the airway to become blocked during sleep, leading to reduced or blocked airflow.

If a child is obese, there’s extra stress put on the upper airway, which can cause it to collapse, leading to sleep apnea. Left untreated, pediatric sleep apnea can lead to:6

Behavior issues such as hyperactivity and poor impulse control

Cognitive dysfunction and inattentiveness

Heart disease later in life, especially if the child is, and continues to be, obese

Mood problems

According to the American Sleep Apnea Association, studies suggest as many as 25 percent of children diagnosed with attention-deficit hyperactivity disorder (ADHD) could be suffering from OSA.7

As such, many of the behavior problems and learning difficulties attributed to ADHD might actually be consequences of chronic fragmented sleep. Further, there are other contributors to sleep apnea in children aside from obesity. One of the first may be lack of breastfeeding, as breastfeeding longer than one month is linked to a lower risk of habitual snoring and apneas.

Researchers believe there may be a “beneficial effect of the breast in the mouth on oropharyngeal [middle part of the throat, behind the mouth] development with consequent protection against upper airway dysfunction causing sleep-disordered breathing.”8

It’s thought that breastfeeding helps expand the size of the child’s palate and shift the jaw forward, helping prevent sleep apnea by creating enough room for unobstructed breathing. That being said, if your child is obese, losing weight can dramatically improve sleep apnea (and therefore overall sleep quality) by reducing pressure on the abdomen and chest, thereby allowing the breathing muscles to function more normally.

Obesity is another double-edged sword in that it may contribute to sleep problems while lack of sleep may also contribute to obesity. Michael Farquhar, a consultant in sleep medicine at the Evelina London Children’s Hospital, told The Guardian:9

“We have two main epidemics among children. One is obesity and the other is mental health, and underpinning both of these is sleep … We always thought sleep was a consequence of obesity but there is an increasing understanding that sleeplessness contributes to obesity.

When you are sleep-deprived, your body responds by altering the hormones that affect appetite and hunger … you crave unhealthy things when you are tired.”

US Teens Short on Sleep: Could Later School Start Times Help?

According to a Sleep in America Poll, 58 percent of teens average only seven hours of sleep a night or less,10 which is significantly less than the recommended eight to 10. One challenge is certainly electronics, with many teens staying up late to browse social media or play video games. However, teens are also wired with different sleep and wake patterns, which favor staying up late and getting up later.

Despite this, many middle and high schools start the day as early as 7 a.m., leaving teens little chance to sleep in. One National Sleep Foundation poll revealed that 60 percent of kids aged 18 and under say they’re tired during the day while 15 percent said they’ve fallen asleep at school.11

They’re now urging educators to use later school start times for teens to facilitate better sleep, along with adopting sleep education curriculum to teach students about the importance of sleep and the negative effects of getting too little.

Mary Carskadon, director of the Chronobiology and Sleep Research Laboratory at E.P. Bradley Hospital in East Providence, Rhode Island, told ABC News, “Teenagers are getting way too little sleep … They are being asked to get up at the wrong time. They are being asked to be in school when their brains are asleep.”12

In 2014, the American Academy of Pediatrics also issued a policy statement urging middle and high schools to delay the start of class to 8:30 a.m. or later in order 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.”13 Dr. Judith Owens, lead author of the policy statement, explained:14

“The research is clear that adolescents who get enough sleep have a reduced risk of being overweight or suffering depression, are less likely to be involved in automobile accidents, and have better grades, higher standardized test scores and an overall better quality of life …

Studies have shown that delaying early school start times is one key factor that can help adolescents get the sleep they need to grow and learn.”

Why It’s Risky for Teens to Skimp on Sleep

Lack of sleep has major effects on health, performance, mood and more. At least one study suggests that teens who start school at 8:30 a.m. or later had improvements in academic performance, attendance and tardiness.

In a survey of over 9,000 high school students, the later start time allowed more than 60 percent of them to get eight hours of sleep a night, and the number of car crashes for teen drivers was reduced by 70 percent when a school changed its start time from 7:35 a.m. to 8:55 a.m. Further, the researchers reported:15

“Teens getting less than eight hours of sleep reported significantly higher depression symptoms, greater use of caffeine, and are at greater risk for making poor choices for substance use.”

What’s more, research suggests that high school students who sleep six hours or less each night are twice as likely to engage in risky behaviors as those who sleep for eight hours (and only 30 percent of the students in the study averaged eight hours of sleep a night).16 This includes:

Using alcohol, tobacco, marijuana or other drugs

Driving after drinking alcohol

Carrying a weapon

Being in a fight

Sleeping less than six hours a night was also linked to a threefold increased risk of considering or attempting suicide. Lead author Matthew Weaver, Ph.D., associate epidemiologist in the Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, said in a news release:17

“We found the odds of unsafe behavior by high school students increased significantly with fewer hours of sleep … Personal risk-taking behaviors are common precursors to accidents and suicides, which are the leading causes of death among teens and have important implications for the health and safety of high school students nationally.”

Electronics Play a Major Role in Childhood Sleep Issues

Electronics are a formidable force when it comes to childhood sleep quality, with 56 percent of the parents in one survey blaming them (including social media and cell phones) as the primary reason why their teen has trouble falling asleep or staying asleep.18

What’s more, among those teens with frequent or occasional sleep problems, 72 percent said their doctor had recommended turning off electronics and cell phones to address sleep problems. Exposure to LED-backlit computer screens or TVs at night significantly suppresses melatonin production and feelings of sleepiness.

When your brain “sees” blue light at night, the mixed message can add up to serious health issues. In 2011, for instance, researchers found that evening exposure to LED-backlit computer screens affect circadian physiology. Among 13 young men, exposure to five hours of an LED-lit screen at night significantly suppressed melatonin production along with sleepiness.19

If your child views screens at night, it’s therefore essential to block exposure to blue light while doing so. In the case of a computer, you can install a program to automatically lower the color temperature of the screen. Many use f.lux to do this, but I prefer Iris software for this purpose.

In addition, when watching TV or other screens, be sure to wear blue-blocking glasses after sundown. For children and teens, however, electronics should be shut off ideally at least one hour before bedtime and preferably as soon as it gets dark.

Top Strategies to Help Your Child Sleep

Sleep deprivation, or a lack of quality sleep, has a significant impact on your overall health and may lead to the following:

Increased risk of car accidents

Increased accidents at work

Reduced ability to perform tasks

Reduced ability to learn or remember

Reduced productivity at work

Reduced creativity at work or in other activities

Reduced athletic performance

Increased risk of Type 2 diabetes, obesity, cancer, high blood pressure, osteoporosis and cardiovascular disease

Increased risk of depression

Increased risk of dementia and Alzheimer’s disease

Decreased immune function

Slowed reaction time

Reduced regulation of emotions and emotional perception

Poor grades in school

Increased susceptibility to stomach ulcers

Exacerbation of current chronic diseases such as Alzheimer’s, Parkinson’s, multiple sclerosis and cancer

With just one hour less sleep a night, increased expression of genes associated with inflammation, immune excitability, diabetes, cancer risk and stress20

Accelerated premature aging by interfering with growth hormone production, normally released by your pituitary gland during deep sleep

It’s therefore essential to help your child develop healthy sleep habits early on. If you believe sleep apnea is the issue, have your child evaluated by a professional to get a proper diagnosis and treatment plan. You may also have considered natural remedies like melatonin, but be aware that there are other options.

While occasional melatonin supplementation in healthy children may help sleep and is unlikely to cause harm, most sleep problems should be addressed via improved sleep hygiene and behavioral changes.

However, there is some evidence that melatonin supplementation may help children with autism, ADHD or other neurodevelopmental or psychiatric conditions.21 In particular, Canadian Family Physician suggested:22

Napping during the day should be avoided

Dinnertime should be at least two hours before bedtime

Screen time (watching television, playing computer or video games) should be discontinued at least one hour before bedtime

Regular bedtime routine including routine sleep and wake-up times should be maintained

Children should sleep in their own beds

Sleep environment should be dark and quiet; room should not be too hot

Caffeine, nicotine and alcohol should be avoided

In addition, I’d add installing blackout drapes in your child’s bedroom, avoiding exposure to blue light at night, having your child wear blue-light blocking glasses after the sun sets and getting exposure to bright light in the morning as much as possible to help reset your child’s circadian clock daily.

Even doing homework too late at night may make it difficult for your child to fall asleep, so try to have any responsibilities wrapped up early so your child has time to unwind before bed.

Being a good role model is also important, including limiting your own exposure to electronic devices and blue light at night, and finishing up your work prior to bedtime so you can be fully present and help your child through a relaxing bedtime routine.

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