Sleep & Wellness Magazine by Sleep & Wellness

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Summer 2013 // Issue 5 Complimentary Copy

ADHDand

Sleep Disorders Healthy Food Makes Healthy Kids

NFL Players

Share Personal Experiences

Sleep Disorders

Associated With Down Syndrome

DOES SLEEP FASCINATE YOU? The need for trained sleep professionals is in high demand across the country. More than 100 million Americans suffer from some form of sleep disorder; 18 million Americans suffer from sleep apnea. Sleep technologists have competitive wages, and there are job opportunities found in hospitals and sleep disorder clinics, as well as in private labs. The American Sleep and Breathing Academy offers courses needed to become a Registered Polysomnography Technologist. The program is designed to prepare students to perform, monitor, and interpret sleep studies. Are you already a Sleep Professional? Join us every month for our Lunch Break Broadcast. The Lunch Break CEC is an hour-long broadcast with 1 continuing education credit for all participants. Every month features a different topic with speakers that are experts in the field.

Visit our website

www.americansleepandbreathingacademy.com for more details or call

866-272-3226

CONTENTS

Summer 2013 // Issue 5

Overcoming Sleep Disorders Associated with Down Syndrome

A Child’s Sleep Habits Effect The Entire Family

Sleep Study Through The Eyes of A Pediatric Patient

Written by Jennifer H. Breslin, Ph.D.

Written by Jenny Schermerhorn

Written by Alex Jones, RCP

ADHD and Sleep Disorders: Is There A Relationship? Written by Dr. Mark Rosenblum

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Health and Wellness: Healthy Food Makes Healthy Kids Written by Dana Woldow

54 When Things Go Bump In The Night Written by Brandon R. Peters M.D.

Finding A Way to Give Smiles Back to Kids: Narcolepsy Can Rob Kids of Simple Childhood Pleasures

NFL Players Share Personal Stories to Support OSA Patients

Clinical Case: Night Owl Written by Syed Nabi, MD

Written by Randy Clair

Written by Monica Gow

58 Tonsillectomy: What, Why or Why Not?

Info Graphic: The Truth about Co-Sleeping

Written by Vikas Jain, M.D. and Christian Guilleminault, MD, Biol.D.

ASBA Committee

Can sharing a bed with your baby determine what type of person they become? Take a look at the pros and cons to help your family decide. Families all over the world sleep together—some due to necessity, others because it works for the family.

13%

of parents share their bed with a child.

Co-sleeping gives you extra time to bond with your children, helping create a strong relationship. Co-sleeping babies cry a lot less, since the parent is right there to quickly respond to any of the baby’s needs. It is believed that co-sleeping creates more independent, more outgoing, and confident children.

ZZ Z

Babies who sleep with their parents are awake for shorter periods of time than solitary sleepers.

Studies show that babies who share a bed with their mothers tend to breastfeed more.

Co-sleepers’ babies as adults have higher self-esteem, better stress management, and possibly less intimacy issues than babies who sleep alone.

Q&A Night Terrors Written by Dr. Natasha Burgert

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

CONTRIBUTORS

AMERICAN SLEEP & BREATHING ACADEMY EDUCATION BOARD Syed I. Nabi, MD Tala’at Al-Shuqairat, MD Seth Wallace, MD Cindy Olsen, RPSGT Alex Jones, CRT

AMERICAN SLEEP & BREATHING ACADEMY DENTAL DIVISION Dr. David Gergen, Executive Director Dr. Steve Carstensen, President Dr. Richard Drake, Vice- President Mr. Randy Clare, Secretary Dr. Rudi Ferrate, Medical Director Dr. Wayne Halstrom, Sleep Director Dr. Elliot Alpher, Sleep Director Dr. Steve Marinkovich, Sleep Director Dr. Rod Willey, Standards Director Dr. Brad Eli, Pain Management Director Dr. Brian Blevins, Pain Management Director Dr. Harry Sugg, Archives Director Dr. Tara Griffin, Director

MANAGING EDITOR Jennifer Taylor

IT’S SOMETHING OF AN UNDERSTATEMENT to say that parents of newborns are generally affected by their baby’s sleep habits. Figuring out how to work sleep schedules for babies—and the adults who love them—is a challenge for all new parents. Sometimes, however, the challenges last far longer than they should and affect everyone in the family. This issue of Sleep & Wellness Magazine provides some great tips for parents to ensure that their children get the sleep they need and establish good sleep habits. When these skills are learned, both children and parents can be well rested. Sometimes it seems impossible to figure out why your child isn’t sleeping well, despite your best efforts to provide a good environment and positive routines. Suppose you think it may be advantageous for your child to have a sleep study done, but your child is afraid of the procedure. In this issue, you can read comments by two pediatric sleep study patients and share them with your child. These children’s comments will help lay your fears to rest—and that could be the first step toward better sleep for the important child in your life. Have you ever wondered about tonsils and whether it’s a good idea to have them removed? What about adenoids? This issue explains the basics of tonsils and adenoids, including their relevance to sleep. It gives pointers for when you should think about tonsils as a possible source of trouble. It also discusses the common procedures of tonsillectomy and adenoidectomy, when those procedures make sense, and when they can probably be avoided. Do you have a child with Down Syndrome, or do you know someone who does? There’s a good chance children with Down Syndrome experience some sleep disturbances. In this issue, you can learn about three issues that are especially prevalent among people with Down Syndrome: sleep apnea, bruxism (teeth clenching or grinding), and insomnia. Some ailments are more predominant among children, while others can affect people of any age. You can also read about preventive and corrective treatments that can help those who are affected. Everyone at American Sleep & Breathing Academy hopes you’ll find this magazine helpful as you pursue your busy life—and a good night’s rest. S&W

CONTRIBUTING WRITERS Jennifer H. Breslin, Ph.D. Dr. Natasha Burgert Christian Guilleminault, MD, Biol.D. Vikas Jain, M.D. Alex Jones, RCP Monica Gow Syed Nabi, M.D. Dr. Mark Rosenblum Jenny Schermerhorn Dana Woldow

HEALTH AND WELLNESS EDITOR Ja-Ann Wolsey

CREATIVE DIRECTOR Antoni Pham

PRODUCTION DIRECTOR Carline Risser

PUBLISHING Sleep & Wellness Magazine is produced, published, and distributed quarterly by The American Sleep and Breathing Academy, LLC, Ogden, UT. The American Sleep and Breathing Academy, LLC also produces and publishes Principles of Polysomnography, Principles of Polysomnography practice examination manual, Principles of Polysomnography pocket guide, and other written educational materials key in the field of sleep. Entire contents copyright 2013 American Sleep and Breathing Academy, LLC all rights reserved. Reproduction in whole or in part is prohibited. PRODUCED IN THE UNITED STATES OF AMERICA

CUSTOMER SERVICE The American Sleep & Breathing Academy (attn) S&W Magazine Customer Care 1464 East Ridgeline Drive, Suite 104 Ogden, Utah 84405 PHONE: 866.227.3226 E-MAIL: info@sleepandwellness.net BACK ISSUES are available in digital format for 3 months after original print date online at: www.sleepandwellness.net

Summer 2013 // SLEEP & WELLNESS MAGAZINE

OVERCOMING SLEEP PROBLEMS ASSOCIATED WITH

DOWN

SYNDROME Written by Jennifer H. Breslin, Ph.D.

DOWN SYNDROME (DS) IS A GENETIC DISORDER THAT RESULTS IN VARYING DEGREES OF INTELLECTUAL DISABILITY. IT IS ONE OF THE MOST PREVALENT NEURODEVELOPMENTAL DISORDERS, WITH AN INCIDENCE OF 1 PER 600 LIVE BIRTHS. PARENTS AND CAREGIVERS OF CHILDREN WITH DOWN SYNDROME OFTEN REPORT THAT THEIR CHILDREN EXPERIENCE SLEEP DISTURBANCES FROM AN EARLY AGE. SLEEP DISTURBANCE HAS A SERIOUS IMPACT ON CHILDREN WITH DS AS WELL AS THEIR FAMILIES, CAREGIVERS, TEACHERS, AND PEERS. PROBLEMS WITH SLEEP HAVE BEEN SHOWN TO NEGATIVELY IMPACT COGNITIVE FUNCTION, ACADEMIC PERFORMANCE, AND BEHAVIOR. SLEEP PROBLEMS ASSOCIATED WITH DS INCLUDE SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA, TEETH GRINDING (BRUXISM), AND INSOMNIA. WHY ARE THESE SYMPTOMS SO COMMON IN CHILDREN WITH DS? HOW CAN THEY BE TREATED?

CHILDREN WITH DS ARE AT INCREASED RISK FOR DEVELOPING SLEEP DISTURBANCE DUE TO A VARIETY OF FACTORS, BUT ALL OF THESE SYMPTOMS ARE TREATABLE.

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SLEEP & WELLNESS MAGAZINE // Summer 2013

“

OBSTRUCTIVE SLEEP APNEA IS THE MOST COMMONLY REPORTED SLEEP DISORDER IN DS, WITH REPORTED PREVALENCE RATES RANGING FROM 54% TO OVER 90%.

First, let’s focus on obstructive sleep apnea. Obstructive sleep apnea is the most commonly reported sleep disorder in DS, with reported prevalence rates ranging from 54% to over 90%. Obstructive sleep apnea is a condition in which the flow of air pauses or decreases during breathing because the airway has become narrowed, blocked, or floppy during sleep. Children with DS are at increased risk for developing obstructive sleep apnea due to a combination of physical features and frequently co-occurring medical conditions. Physical characteristics that predispose children with DS to develop obstructive sleep apnea include reduced muscle tone, limited space for the tongue in the pharynx due to underdevelopment of the bones in the upper jaw and placement of the tongue further back in the mouth, small upper airway, underdeveloped midface, and increased lymphoid tissue. Children with DS are also at increased risk of developing obesity, hypothyroidism, congenital heart disease, pulmonary hypertension, leukemia, ear infections, and scoliosis, all of which may in turn contribute to the development of obstructive sleep apnea.

“

There are several treatment options for obstructive sleep apnea in DS. The first line of treatment for obstructive sleep apnea in children is usually surgical removal of the tonsils and adenoids. While surgery will often reduce the severity of obstructive sleep apnea in children with DS, as many as 73% of children with DS require additional intervention after surgery. Although there have been no systemic trials evaluating the use of continuous positive airway pressure (CPAP) in children with DS, studies that have included children with DS have reported clinically significant improvements in obstructive sleep apnea symptoms. Case studies suggest that position therapies, or devices that help children to avoid the supine position during sleep, may also reduce the severity of obstructive sleep apnea in children with DS. Although they have not been studied in DS, dental interventions, such as mandibular advancement devices, have been demonstrated to reduce the severity of obstructive sleep apnea in adults.

CONTINUED >>

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

THE THIRD SLEEP DISORDER THAT HAS BEEN FREQUENTLY REPORTED BY PARENTS AND CAREGIVERS OF CHILDREN WITH DS IS INSOMNIA.

Another sleep disturbance that is commonly noted in DS is bruxism. Bruxism has been defined as the forcible clenching or grinding of the teeth, or a combination of both of these behaviors. The reported prevalence of bruxism in children with DS ranges from 18% to 79%, with prevalence rates decreasing after adolescence. Bruxism may occur during the day or during sleep. Nighttime bruxing typically happens during rapid eye movement (REM) sleep. Risk factors for sleep-related bruxism in DS include nighttime gastroesophageal reflux, nighttime swallowing-related laryngeal movement, supine sleep position, and obstructive sleep apnea. When it co-occurs with obstructive sleep apnea, bruxism often responds to interventions designed to address the apnea. Bruxism may also be successfully treated with occlusal appliances, such as bite guards. The third sleep disorder that has been frequently reported by parents and caregivers of children with DS is insomnia. Childhood insomnia has been defined as repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age-appropriate time and opportunity for sleep, and which results in some form of daytime functional

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impairment for the child. Insomnia is reported by 25% to 40% of parents of children with DS. While there is no comprehensive model of insomnia for children, researchers agree that there are multiple factors related to the origins of childhood insomnia. Obstructive sleep apnea, bruxism, and other sleep disorders may increase the likelihood that a child with DS will develop insomnia. Children with DS may have co-occurring medical conditions, which may result in difficulties with sleep onset or maintenance. Pain and physical discomfort at bedtime may become associated with the bed or bedtime. Children with DS are also more likely to co-sleep with family members, which may help them to fall asleep more quickly but may lead to increased night waking. While there are several behavioral interventions that have been shown to be effective in the treatment of childhood insomnia, none of them have been systematically studied in children with DS. Treatments that may be effective for children with DS include sleep education, positive bedtime routines and sleep hygiene, bedtime fading, and graduated extinction techniques. Parents, caregivers, and older children with DS may benefit from learning about the

SLEEP & WELLNESS MAGAZINE // Summer 2013

differences between normal versus disordered sleep, organization of sleep stages throughout the night, and developmental changes in sleep. Sleep education may help to establish normal expectations and to decrease worry about insomnia symptoms. Positive routines involve a regular sequence of positive, rewarding, and relaxing bedtime interactions with the caregiver. Ideally, the routine begins 30 minutes before the child’s bedtime and moves from the common areas of the house (for example, snack in the kitchen) to the bathroom (for example, warm bath, teeth brushing) to the bedroom (for example, reading in chair, singing) and finally to the bed. Positive routines help the child to establish cues for sleep onset. Sleep hygiene training involves changing behaviors, sleep-related activities, or the sleep environment. Behavior changes include eliminating long daytime naps, establishing regular bed and wake times, and reducing or eliminating caffeine intake. To increase the association between the bed and sleep, activities other than sleep (such as reading, video games) should be done outside of the bed. Bedroom light and noise may need to be reduced, and temperature may need to be adjusted to establish an optimal sleep environment.

“

WHILE SURGERY WILL OFTEN REDUCE THE SEVERITY OF OBSTRUCTIVE SLEEP APNEA IN CHILDREN WITH DS, AS MANY AS 73% OF CHILDREN WITH DS REQUIRE ADDITIONAL INTERVENTION AFTER SURGERY.

To reduce the problem of the child spending too much time in bed for the amount of sleep needed, bedtime fading can be used; it involves delaying the child’s bedtime to match their natural sleep onset time and slowly advancing the bedtime to allow for an age-appropriate total sleep time. Bedtime fading increases the likelihood the child will experience quick sleep onset when placed in bed. For children who have difficulty sleeping independently, graduated extinction techniques, in which rewards for sleep avoidance are gradually withdrawn on a set schedule, are often helpful. Caregiver behaviors may be gradually modified, such as physical contact with the child, verbal responses, proximity to the child, and frequency and duration of check-ins. For a caregiver who regularly falls asleep next to the child, the first three nights of graduated extinction might involve sitting next to the child while holding his arm until he falls asleep. For the next three nights, the caregiver would then sit further from the bed while still talking to calm the child. The next step would be to sit in the room without interacting with the child for three nights. After that, the caregiver would check in every five minutes as long as the child stayed in bed for three nights. The next step would involve checking in on the child every ten minutes for three nights. The goal is for the child to be able to sleep independently at the end of the sequence of gradual steps. Children with DS are at increased risk for developing sleep disturbance due to a variety of factors, but all of these symptoms are treatable. If you care for a child with DS, it is important to follow up with your child’s pediatrician about any sleep concerns that you might have so that appropriate treatment can be initiated promptly. S&W

ABOUT THE AUTHOR Jennifer H. Breslin, Ph.D.Director of Program Development for Specialized Services, CODAC Behavioral Health, Inc., Tucson, AZ The author would like to acknowledge support from the Down Syndrome Research and Treatment Foundation and the Thrasher Research Fund.

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

HEALTHY FOOD

MAKES

HEALTHY

KIDS Written by Dana Woldow

WITH THE CDC REPORTING THAT 17 PERCENT OF KIDS AGES 2 THROUGH 19 ARE OBESE.

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SLEEP & WELLNESS MAGAZINE // Summer 2013

SCHOOL FOOD HAS BEEN MUCH IN THE NEWS, WITH EVERYONE FROM FIRST LADY MICHELLE OBAMA TO BRITISH CHEF JAMIE OLIVER WEIGHING IN ON HOW TO IMPROVE IT. With the CDC reporting that 17 percent of kids ages 2 through19 are obese, putting them at risk for health problems (during their youth and as adults) such as high blood pressure, high cholesterol, and Type 2 diabetes, better school meals make sense, since many children receive half or more of their daily calories at school. Recent changes to the regulations for school meals will bring them more into line with the Dietary Guidelines for Americans 2005, and include increased portions for fruits, vegetables and whole grains, and a reduction of calories. More than 30 years of studies have linked poor nutrition with low academic achievement; in today's test-driven educational climate, it's crucial to ensure that students are well nourished and ready to learn. Despite studies showing school lunches are generally healthier than lunches brought from home, the media often characterize school food as being of low quality. The recent revelation that the product called "lean finely textured beef" (aka "pink slime") was added to ground beef offered to schools as part of the USDA commodity program, captured headlines around the world. It's intuitive to think that the most important issue in school food is quality, and that those seeking improvements should start with that piece, but the reality is that experts in the field rarely rank food quality as the most pressing issue in school food reform. I recently surveyed six professionals active in the school food reform movement (three run healthy school meal programs or businesses, three are advocates who write about school food topics) to learn what their priorities are in the "fixing school food" debate. Their answers may surprise you. But first, some background. Both the National School Lunch Program and the School Breakfast Program are funded by Congress and overseen by the USDA; the regulations governing school meals are complex, and while revised every four to five years, they never seem to get streamlined, only increased. Regulations address everything from limits on sugar and fat, to whether a child must reach out and take a meal item, or if it can be placed on his tray by an adult. Schools are visited every four years by USDA inspectors to ensure all regulations are being followed, and if too many violations are found, reimbursement money can be withheld pending proof of corrective action. The government provides reimbursement to schools for meals served to students from qualifying low income families; however, the definition of "low income," based on a percentage of the Federal poverty guidelines, remains the same for both high and low cost of living areas. For example, the income cutoff point for subsidized school meals will be $42,643 for a family of 4 in 2012-13; while $42,643 may be

CONTINUED >>

CURRENTLY THE MEDIAN LUNCH PERIOD IS 25 MINUTES,

WITH SOME SCHOOLS HAVING A LUNCH PERIOD AS SHORT AS 15 MINUTES.

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

CONGRESS HAS NOT INCREASED THE FREE MEAL REIMBURSEMENT SUFFICIENTLY TO PAY FOR THE CHANGES, WITH JUST 6 CENTS OF EXTRA FUNDING ALLOCATED TO PAY FOR AN ESTIMATED 64 CENT INCREASE IN COST.

enough for a family of two working adults and two children to get by without government assistance in a low cost of living area like Lincoln, Neb., it would be nearly impossible in an expensive area like San Francisco. Likewise, the amount the government provides to pay for a subsidized meal remains the same for the lower 48 states (Alaska and Hawaii get more), and in 2011-12 tops out at $2.79. Again, this amount may be sufficient to cover the cost of food, labor and program administration in low cost of living areas, but is insufficient in higher cost areas. Students having enough time to eat and enjoy their lunch has become a serious issue in many schools, especially elementary schools. With lunch and recess lumped together, children antsy from sitting in class all morning are eager to rush out to play, even if it means gobbling their food, or leaving

much of it uneaten. Older adults may remember when lunch and recess were a full hour of the school day, but currently the median lunch period is 25 minutes, with some schools having a lunch period as short as 15 minutes. There is a stigma attached to school meals stemming from the fact that middle and high school students are well aware that meals are subsidized for low income kids; many students avoid the free lunch because they don't want to self-identify as poor in front of their peers. More than one study has noted this effect, and it has been well described in "Free for All: Fixing School Food in America," by Hunter College professor Janet Poppendieck. Reducing the stigma, so as to increase the number of students who feel comfortable eating in the cafeteria, remains a stubborn problem, especially in high schools.

Finally, there is a need for more nutrition education, to address issues like kids not recognizing fresh produce like eggplant, turnips or kiwi, and a more general ignorance about where food comes from; reluctance to try new foods; and students not making the connection between what they eat and how they feel. Thus, the list of primary issues related to school food includes quality of the food, underfunding of school meal programs, burdensome government regulations, lack of time to eat, the stigma, and the need for more nutrition education. So how did the experts rank the issues? One of the food writers refused to rank them, making the very valid point that, since they are all interrelated, it would be hard to fix one without addressing the others. Of the five remaining, four, CONTINUED >>

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What does HOPE look like?

Hope look kss lik lik kee Christine, k Christine, Jillian, Jillian,Tres, Jackson J and Thomas Mar y Tyler Moore and hher young friends have type 1 diabetes (T1D). Their hope lies in the worldwide research that JDRF is funding and the clinical trials that are underway. They want to be a part of their own cure. To learn more visit www.jdrf.org.

Summer 2013 // SLEEP & WELLNESS MAGAZINE

including all three who run school food programs or businesses, chose "underfunding" as the most pressing issue. Overall, underfunding was ranked twice as important as any other issue; second was food quality, followed closely by the need for nutrition education, insufficient time to eat, and burdensome regulations. Stigma drew low priority among almost everyone. Unfortunately, underfunding of the school meal program is probably the most difficult issue to address. Congress sets the funding level, and as recent successful pressure brought on Congress to continue to count the tomato sauce on pizza as a vegetable shows, our elected officials often side with the interests of business rather than the interests of student health. While the changes to school meal regulations are mostly positive, Congress has not increased the free meal reimbursement sufficiently to pay for the changes, with just 6 cents of extra funding allocated to pay for an estimated 64 cent increase in cost. Other issues are easier to tackle; for example, many schools have found success with sending children out to

One might think that the USDA would not need such prodding to provide only high quality food to our youth, but bear in mind that this is an agency which has the word "agriculture" in its name, but not "children" or "health." recess before lunch is served, rather than after. Studies show students who have had a chance to run around are more likely to eat more of their meal; school administrators also report students are calmer and more focused after recess-before-lunch, and thus instructional time is maximized. What's the best way for people to get involved with fixing school food? First, find out what is happening in your own community; since 2006, all

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school offering subsidized meals are required to have a wellness policy with guidelines and goals to promote healthy eating and activity. There is often a school committee to oversee the policy, and the public is supposed to be included. Contact your school district to find out when the committee meets, and go to a meeting; it should be open to the public. If you see an issue that you think needs to be addressed (maybe the schools are selling blue slushies and other junk food), ask the committee if they plan to tackle it, or better yet, volunteer to look into it yourself. Information on how to advocate for change in your school's food can be found at PEACHSF.org. Take inspiration from the "pink slime" campaign. Bettina Elias Siegel, a mom and kids-and-food blogger in Houston, was angry that these beef scraps, which are recovered from slaughterhouse trimmings and treated with ammonium hydroxide gas to kill bacteria, were included in USDA commodity beef sent to schools. She thought school children deserved better, so she created an online petition asking for the substance to be removed from school-bound ground beef; the petition quickly garnered a quarter of a million signatures, and in less than two weeks, the USDA said it would offer schools a choice of ground beef with or without fillers next year. One might think that the USDA would not need such prodding to provide only high quality food to our youth, but bear in mind that this is an agency which has the word "agriculture" in its name, but not "children" or "health." Kids don't vote and have little political power; they rely on adults to do what is best for them. Our children will only get the healthy food they need to thrive and learn if we demand it, and if we are willing to pay for it, but there is no better investment in our country's future than properly nourished children. S&W

Dana Woldow has been a school food advocate since 2002 and shares what she has learned at PEACHSF.org. Follow her on Twitter @nestwife.

PEACHSF.org How to advocate for better school food, from people who have done it successfully. http://peachsf.org/ The Lunch Tray One of the best kids-and-food blogs, and home of the "pink slime" petition. http://www.thelunchtray.com/ Chef Ann Cooper's website The "renegade lunch lady", who transformed school food in Berkeley CA with the help of additional funding and enormous community support, offers advice and information. USDA Food and Nutrition Services website Get the facts on the National School Lunch Program and School Breakfast Program, meal program regulations, farm to school programs, and more. Food Research and Action Center The leading national nonprofit organization working to improve public policies and public-private partnerships to eradicate hunger and undernutrition in the United States. http://frac.org/about/

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As Health ealth EEditor ditor ffor or Sleep & Wellness Wellness M Magazine, agazine, Ja-Ann n adv advocates ocates tak taking ing rresponsibility esponsibility for for one oneâ&#x20AC;&#x2122;s â&#x20AC;&#x2122;s personal onal w wellbeing. ellbeing. TThe he road road tto o health is a process; ess; we we lear learn, n, change, change, and improve improve in stages. stages. Getting etting ng advic advice adv e and suppor supportt along yyour our jour journey ney is paramount mount to to success. success. Join Ja-Ann Ja-Ann in her pursuit of optimal timal h health at at da daywithjae.comywithjae.com- a healthy healthy living resource resource blog. blog. W With ith the rright ight inf information for ormation and motiv motivation ation amazing things can happen in everyday yday momen moments. ts. FFind ind helpful tips and support ort fr from om e experts xperts on sleep sleep,, yyoga, oga, nutr nutrition, ition, and fitness tness tto o guide yyou ou in yyour our personal health journey. ey.

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

ATTENTION DEFICIT-HY AND SLEEP DISORDERS:

ROUGHLY 2.7 MILLION CHILDREN IN THE UNITED STATES ARE ON PRESCRIPTIVE MEDICATION FOR ADHD.

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SLEEP & WELLNESS MAGAZINE // Summer 2013

YPERACTIVITY DISORDER Written by Dr. Mark Rosenblum

ATTENTION DEFICIT-HYPERACTIVITY DISORDER (ADHD) AND SLEEP DISORDERS ARE TWO AREAS OF HEALTH CARE THAT HAVE BEEN RECEIVING GREATER ATTENTION OF LATE. Four observations suggest that there is a relationship between these two types of conditions. First, a sleep-deprived childâ&#x20AC;&#x2122;s behavior looks very similar to someone with ADHD. Second, stimulant medications are frequently used to treat ADHD. Third, individuals with ADHD are at greater risk for having a sleep disorder. Last, the cognitive disturbances found in those experiencing sleep disorders can be similar to those seen in those with ADHD. This article reviews the nature of the relationship between these two areas of health care and provides resources for further assistance in the treatment of them. Most parents and other adults who have been around children who have not obtained sufficient sleep are familiar with how they act. They can become restless, agitated, and have difficulty sitting still. This is one reason parents are motivated to develop a schedule for sleep and napping. Children with ADHD are often identified similarly as restless, agitated, and also having difficulties sitting still. According to the Centers for Disease Control and Preventionâ&#x20AC;&#x2122;s Morbidity and Mortality Weekly Report (2007), roughly 2.7 million children in the United States are on prescriptive medication for ADHD. Stimulant medications are one of the most common treatments for ADHD. Despite an apparent paradox, stimulants reduce hyperactivity; they do not worsen it as one might expect. In fact, not only are stimulant medications helpful in managing ADHD symptoms, sedative medications can worsen them.

CONTINUED >>

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

COMMON DEFICITS FOUND IN THOSE DIAGNOSED WITH SLEEP DISORDERS INCLUDE WEAKNESSES IN EXECUTIVE FUNCTIONS, CONCENTRATION, AND WORKING MEMORY. EXECUTIVE FUNCTION INVOLVES PLANNING, ORGANIZING, AND LIMITING IMPULSIVE BEHAVIORS.

Early explanations for this paradox included that a child may react the opposite to a medication’s desired effect. However, a newer theory has emerged, which suggests that ADHD is a condition of hypoarousal and not hyperarousal. The body is under-stimulated, versus overstimulated. Support for this theory is found in that children with ADHD often show greater sleepiness on nap studies at sleep disorders centers. Individuals diagnosed with ADHD are at greater risk for having a sleep disorder. Although the exact figures of how many people are affected is still being determined, we know that Obstructive Sleep Apnea Syndrome (OSAS), Restless Legs Syndrome (RLS), Circadian Rhythm Sleep Disorders, and insomnia are all more common for those diagnosed with ADHD. OSAS is a breathing-related sleep disorder, where there is a reduction in the airflow and that travels through the body as a person sleeps, accompanied by a drop in the level of oxygen. RLS is a condition where a person experiences discomfort in their legs if they remain still while they sleep,

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and the discomfort is relieved when they move their legs. A common type of Circadian Rhythm Sleep Disorder seen in those with ADHD is of the delayed sleep phase type. This is the “night owl.” Essentially, a person has the natural inclination to stay up late and sleep late. Last, insomnia is difficulty with either falling asleep, remaining asleep, or waking up too early in the morning. Common deficits found in those diagnosed with sleep disorders include weaknesses in executive functions, concentration, and working memory. Executive function involves planning, organizing, and limiting impulsive behaviors. Concentration is made up of the ability to focus and sustain attention. Working memory is our ability to manipulate information in our thoughts. All of these abilities assist us with managing our lives. Deficits in these areas are also frequently found in those diagnosed with ADHD. So, is there a relationship between Attention Deficit-Hyperactivity Disorder and sleep disorders?

SLEEP & WELLNESS MAGAZINE // Summer 2013

Early evidence and observations support the belief that there is a relationship between the ADHD and sleep disorders, though the full extent of it is still being determined. The following lists may help you determine if you are affected by either disorder.

Signs of Sleep Disorders: Difficulties falling or staying asleep Snoring Weight gain Creepy/crawly sensation on legs while trying to sleep Sleepy or fatigued during the daytime

that sleep disorders are often found in those with ADHD, the behavioral and cognitive disturbances seen in both are similar, and they both can respond to a stimulant. Further, there is enough evidence showing the overlap between them that it is now considered appropriate to evaluate for both disorders when either one of them is suspected. If you believe you may have a sleep disorder or ADHD, you can locate a sleep specialist at www.sleepcenters.org and find resources for ADHD at www.chadd.org. S&W

ABOUT THE AUTHOR

Signs of Attention DeficitHyperactivity Disorder: Difficulties concentrating Easily distracted Problems organizing Fidgety Restless

It is premature to state that one disorder causes the other. However, we now know

Dr. Mark Rosenblum is a Sleep Psychologist and Director of the Minnesota Sleep Institute Insomnia Program. Dr. Rosenblum is certified in Behavioral Sleep Medicine by the American Academy of Sleep and is a founding member of the Society of Behavioral Sleep Medicine. Dr. Rosenblum is a member of Children and Adults with Attention Deficit-Hyperactivity Disorder (CHADD) and frequently presents on the topic of Sleep Disorders and Attention DeficitHyperactivity Disorder.

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

A CHILD’S SLEEP HABITS

AFFECT THE ENTIRE FAMILY Written by Jenny Schermerhorn

PEDIATRIC SLEEP APNEA CAN MANIFEST ITSELF WITH LOUD SNORING, PAUSES IN BREATHING, AND GASPING WHILE BREATHING.

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IT’S NORMAL FOR INFANTS AND CHILDREN TO WAKE EVERY 60 TO 90 MINUTES. THEY MAY ROLL AROUND A BIT, TALK, OR EVEN CRY OUT, BUT SHOULD BE ABLE TO GO BACK TO SLEEP IN ABOUT TEN MINUTES, BY THEMSELVES.

NORMAL OR DYSFUNCTIONAL SLEEP PATTERN? Dr. Daniel Hey, a physician boardcertified in Sleep Medicine and Family Practice and medical director of the Asheville Sleep Center, states “it’s normal for infants and children to wake every 60 to 90 minutes. They may roll around a bit, talk, or even cry out, but should be able to go back to sleep in about ten minutes, by themselves.” True sleep disorders commonly found in children include: periodic leg movement, pediatric sleep apnea, and several seizure disorders. Periodic leg movement is distinguished by kicking or moving of the legs that continues all night long and disrupts the sleep of the child. Pediatric sleep

“

NO ONE IS SURPRISED WHEN THE PARENTS OF A NEWBORN BABY POUR SALT INTO THEIR COFFEE OR FIND A SET OF LOST KEYS IN THE FRIDGE. Getting up all night with a two-week-old infant can test the endurance of the most stalwart adult. However, sleep disturbances and waking frequently in the night cannot be ascribed to infants alone. In fact, many families find their days negatively affected by the repeated waking of their children far past the baby stage. Let’s do a bit of diagnostic work, and then examine some tools that can help a child, and his entire family, sleep more soundly.

apnea can manifest itself with loud snoring, pauses in breathing, and gasping while breathing. Enlarged tonsils are most often the cause of this disorder. Seizure disorders show the stereotypical rhythmic seizure movement, sometimes limited to the right arm or right side. If you see any of these red flags, consult a sleep physician for diagnosis and care. It is also recommended that children who have been diagnosed with ADD see a sleep doctor, as they are much more likely to experience sleep issues.

THE PRICE SLEEPY CHILDREN PAY Whether it be from an inability to get back to sleep after waking or a more serious sleep disorder, children who do not get enough sleep at night pay the price during the day. Typical effects of lack of sleep in children include: excessive sleepiness, behavior problems, academic struggles (for older children), and disinhibition. Disinhibition is when lack of sleep causes children to become increasingly active or “hyper” while awake. Disinhibition seems counterintuitive, doesn’t it? I have heard parents comment, “Well, it’s bedtime, but he’s not tired. Just look at all that energy!” Parents need to recognize that this hyper-alert state may be pointing to extreme tiredness and an increased, not decreased, need for sleep. If parents see any of these symptoms in their children, they should consider the amount and quality of sleep their child is getting. “People focus on what happens at night, but really they need to focus on what is happening during the daytime. How is the family doing during the day? The daytime behavior of the child, and entire family unit, will point to the health or dysfunction of nighttime habits,” reports Dr. Hey.

THE SIBLING AND PARENTS AFFECTED When a child wakes up during the night, he isn’t the only one who loses sleep, is he? Parents, and even siblings, can be negatively affected by the nighttime wakings of a child. Kirsten, mother of two, shares the struggles their family faced after their second child was born. “About the time my second daughter (Anika) was born, my first (Lilyanne) was giving up her afternoon nap. They had separate rooms but shared a wall and could hear each other. When Lilyanne talked loudly or cried during her rest time, she woke her sleeping sister up. And vice versa. At night, Anika would wake up crying and awaken Lilyanne. It was such a mess—and very frustrating.”

CONTINUED >>

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I thought all “good” parents had a monitor on any time their child was asleep. “I’m not in favor of monitoring. What are you going to do with this information? Sometimes it’s better to not have the information if it’s going to cause you to intervene needlessly.

away as they get older. “It’s hard to take twelve teddies and a noise machine to camp,” shares Dr. Hey. He adds, “It is very helpful to have a bedtime ritual, especially for young children, but it should be short and moving constantly toward the goal. What’s the goal? The goal is: the child, in his or her bed, with the lights off and no parent in the room.” It is common for siblings to affect each others’ sleep. I asked Kirsten if she felt like her family was being negatively affected by wakings of her children. “I was getting less sleep, and I definitely noticed my patience suffering. And Lilyanne was affected too: she would fall apart at the smallest things, and I knew it was because she was exhausted.” Worn out parents and children do not often create homes characterized by peace and cooperation. So, if sleep disruption is a problem, what can we do about it?

TOOLS AND TIPS If you’ve ruled out true sleep disorders that are medical conditions, here are some tested tools that can help get your child and entire family into a healthy nighttime pattern. Trim Down the Routine. Some routine is good, but keep it short and sweet. A long, involved routine gives your child too many opportunities to derail the process and makes it more difficult for your child to go back to sleep during the night. For example: One family’s bedtime routine lasts two hours, and necessitates his mother lying down with her child until he falls asleep. When he wakes up in the night, his body says, “I can’t go back to sleep. I don’t have Mom next to me!” A simpler routine, like a story, a hug, and a teddy, would allow this child to go to sleep in an environment that he will be able to re-create at 2 a.m. Excessive routine and props can also be a handicap when families travel or children go

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Less is More in the Middle of the Night. Parents and caregivers can do a great deal toward helping their children develop a healthy sleep pattern. Children need to learn how to fall asleep by themselves after they wake up in the night. Dr. Hey advises parents to cut out any rituals that involve feeding in the night after six months. “After that point, unless your physician tells you otherwise, your child does not need that feeding nutritionally and is just enjoying a nice snack and some company after waking up. If you feel you must go in and check on your child, it should be for 5-10 seconds. Don’t turn the lights on, just peek in, say quietly “Mom/Dad is here, we love you, but it’s time to sleep.” And then leave. Over time, children will learn that waking up does not mean it is time to party. And their improved sleep will benefit them and their entire family. Working up to this 5-10 second check-in, or even no response at all, can be a difficult process for parents. Parents could try slowly eliminating elements of their current routine: dropping a feeding, then rocking and singing, etc. until all they do is stand at the door and reassure their child. Turn off the Monitor. This sleep tip shocked me. I thought all “good” parents had a monitor on any time their child was asleep. “I’m not in favor of monitoring. What are you going to do with this information? Sometimes it’s better to not have the information if it’s going to cause you to intervene needlessly. Is your goal to improve your child’s sleep? If so, less intervention is better,” shared Dr. Hey.

SLEEP & WELLNESS MAGAZINE // Summer 2013

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IT IS VERY HELPFUL TO HAVE A BEDTIME RITUAL, ESPECIALLY FOR YOUNG CHILDREN, BUT IT SHOULD BE SHORT AND MOVING CONSTANTLY TOWARD THE GOAL.

Try a Sleep Clock. Have you seen those alarms in stores? Plush animals whose faces light up when 6:30 a.m. rolls around (or whatever time you set), or a clock with a picture of a moon that shows at night, and a sun that comes up when it is time to get up? These clocks give some of the responsibility to the child (which they love), while also setting healthy limits. If your child is crawling into bed with you at 1, 3, and 5 a.m., try setting the clock for 30 minutes before you get out of bed, and let the child know you welcome them to come snuggle when the clock goes off.

“

I hesitantly switched off my monitor a few weeks ago. I’d been listening in on my two-and-a-halfyear-old for, well, two and a half years. She wakes up at night a few times a week and talks to herself and sometimes calls my name. I don’t go up, but I’d usually stay awake listening to her until she fell back asleep. Now, I’m sleeping through the night more often. She’s still doing the same thing, but without me as an audience. I know she is healthy and safe, and I have enjoyed the lessinterrupted sleep.

This allows better sleep for both parent and child, without eliminating closeness and family time together at the start of the day. Sleeping well is a necessary foundation for healthy daytime functioning. Without consistent sleep, children and their parents and siblings suffer. When parents understand the value in helping children learn to fall asleep on their own, they can adjust their routine and nighttime reactions accordingly. With some appropriate adjustments, parents everywhere can stop salting their coffee and lead their children and families on a journey toward better sleep. S&W

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

It was painless. I liked how they explained as they were going.

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I thought it was cool feeling when they put paste in your hair & they drew on it.

SLEEP STUDY

SLEEP & WELLNESS MAGAZINE // Summer 2013

THROUGH THE EYES OF A PEDIATRIC PATIENT Written by Alex Jones, RCP

HAILEY RANAE AND PAISLEY MORGAN ARE HAVING A SLEEPOVER, JUST NOT THE SAME TYPE OF SLEEPOVER THAT THEIR FRIENDS ARE HAVING WITH DOLLS, GIRL TALK, AND A GAME OF TRUTH OR DARE. These two girls are attending their local sleep clinic to go through a sleep study (or Polysomnography).

For an adult patient, a sleep study can be a scary thing, and may even be a factor in detouring the diagnosis and treatment of a sleeping disorder. Sleep disorders are not limited to the adult population, and neither is the fear of sleep studies. In fact, many parents and pediatric patients are afraid to participate in a sleep study. Hailey and Paisley help others lay this fear aside, stating, “It isn’t as bad as you think will be,” when asked about the things that they would like to tell other kids that are going to have a sleep study done. Hailey and Paisley are a hundred percent right. The sleep

CONTINUED >>

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THERE ISN’T ANYTHING TO BE AFRAID OF. IT WAS ACTUALLY FUN. THE TECH WAS NICE AND EXPLAINED EVERYTHING TO ME, WHAT THE WIRES WERE, AND WHAT THEY WERE GOING TO TELL THEM.

“

Summer 2013 // SLEEP & WELLNESS MAGAZINE

study, though a different experience, is nothing to be afraid of. In fact, most sleep clinics are set up to have a feel similar to that of a hotel room. “And there was even a place for my mom to sleep,” Paisley mentioned. “I knew what a sleep study was. I had one done before,” said Paisley Morgan. In contast, Hailey reported, “I had no idea what it was or why they were doing it. I was a little nervous about it.” Children often don’t understand why they are going into the doctor or having a test done. This uncertainty can add to the fear and anxiety that they may be experiencing. So what is a sleep study? A sleep study is an overnight medical test that evaluates for sleeping disorders. Information about what to expect for your child’s sleep study often can be supplied by the clinic that you will be attending. At any rate, Both Paisley and Hailey agree that, “There isn’t anything to be afraid of. It was actually fun.” Hailey even found the staff helpful, “The tech was nice and explained everything to me, what the wires were, and what they were going to tell them.”

disorders. With that in mind, Paisley suggests, “Bring something to do.” Hailey adds the advice, “Bring your own pillow. They will let you bring almost anything you want to keep yourself comfortable.”

Even though most labs are equipped for some entertainment prior to bedtime, the lab is intended to diagnose sleep

Please don’t let fear keep your child from a diagnosis and treatment of any sleeping disorder. S&W

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

GETTING AT LEAST 20 MINUTES OF PHYSICAL EXERCISE PER DAY FOUR TO FIVE HOURS BEFORE BEDTIME CAN ALSO IMPROVE SLEEP QUALITY.

FINDING A WAY TO GIVE

SMILES BACK TO KIDS Narcolepsy can rob children of simple childhood pleasures Written by Monica Gow

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SLEEP & WELLNESS MAGAZINE // Summer 2013

FOR JASON, AGE 15, HAPPINESS IS NOTHING TO GIGGLE AT. “If he’s laughing hard and he hasn’t taken his medication, he collapses to the floor,” says Kelly, his mom. “So he avoids laughter, even smiling, at all cost. It’s very hard on him.” Jason is one of some 200,000 Americans and 3 million worldwide living with cataplexy, a debilitating symptom of narcolepsy, the sleep disorder characterized by excessive daytime sleepiness (EDS). In most cases, symptoms first appear between the ages of 7 and 25; however, the disease may appear at a younger age or in older adults.

When Casey was diagnosed, at age 10, his folks could still control bedtime, “Now, at 15,” says his mom, “he thinks he can do whatever he wants and still function. A kid with narcolepsy has to to adhere to a strict bedtime, and sleepovers with friends are rare to non-existent due to his sleep patterns and his nighttime medication schedule.” Narcolepsy victims ride a grinding, endless roller coaster – in and out of deep sleep at night due to the loss of brain cells that regulate sleep and wakefulness. For someone without the disorder, it would be like going without sleep for 48-72 hours, day after exhausting day. Narcolepsy with cataplexy causes sudden, brief episodes of muscle weakness or paralysis. These episodes are similar to the paralysis that occurs naturally during REM sleep, except the victim remains fully conscious.

AM I DYING? Generally, the tendency to lose muscle control is brought on by an emotion, such as laughter, happiness or fear. Cataplexy, present in up to 70% of narcoleptics, can be a terrifying event, especially when first experienced and particularly in children.

If left undiagnosed and untreated, childhood-onset narcolepsy can interfere with psychological, social, and cognitive function and can challenge academic and social activities. For some young people, low selfesteem that results from poor academic performance may persist into adulthood. Even when treated with the best medicines, narcolepsy is extremely difficult to manage in children. Kids with narcolepsy – and their families – often find this crucial time of growing up, with its associated peer pressure, especially challenging. “My son Casey, a freshman in high school, has to nap at school, after school and sometimes once more before bedtime,” says his mom. “Somehow, he has to squeeze in sports and homework.” She adds, “Casey just wants to blend in with his classmates, even though he deals with constant sleepiness at school. A boring class is beyond torture for kids with narcolepsy.”

“

CATAPLEXY, PRESENT IN UP TO 70% OF NARCOLEPTICS, CAN BE A TERRIFYING EVENT, ESPECIALLY WHEN FIRST EXPERIENCED AND PARTICULARLY IN CHILDREN.

Stunned by suddenly being unable to move, many fear that they may be forever paralyzed or even dying. Yet, even when the episode is severe, cataplexy does not result in permanent dysfunction. After episodes end, people rapidly recover their full capacity to move and speak. Among cataplexy sufferers, episodes can differ greatly in intensity. They can include arm weakness, sagging jaw, drooping head, slumping shoulders, slurred speech, generalized weakness, or knees buckling. Attacks typically last from a few seconds to several minutes. Fortunately, Jason’s narcolepsy was diagnosed when he was in first grade, and medication has made a world of difference in his quality of life. Sadly for many sufferers, however, sometimes it takes up to 10 years to have the disease diagnosed. Imagine living for years with such devastating symptoms. Narcolepsy affects both men and women at any age without regard for ethnicity, although narcolepsy symptoms are usually first noticed in teens or young adults. Narcolepsy can also develop early in life, probably more frequently than is generally recognized. Children as young as three years old have been diagnosed with narcolepsy.

MISDIAGNOSIS IS COMMON Frequently, when a child falls asleep repeatedly in class, teachers – if they are unfamiliar with the disease – misdiagnose the behavior as laziness, lack of motivation, or a discipline or drug problem. CONTINUED >>

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“

GENERALLY, A 30-MINUTE NAP BRINGS REFRESHMENT – BUT OFTEN FOR JUST A FEW HOURS.

Fortunately, school staffs are becoming better informed. For Casey, says his mom, “The school bent over backward to help us, and we caught it quickly. The teacher called us to say Casey fell asleep in class and fell down at recess, and kids told him he looked ‘drunk’ because of his cataplexy.” “Cataplexy can be really tough for a happy kid that likes to laugh,” she adds. “Many kids with undiagnosed and untreated cataplexy teach themselves to hide their emotions. Your heart goes out to them.” Typically, people with EDS describe life as a stubborn sense of mental murkiness, an absence of energy, a depressed mood or severe exhaustion. “Imagine trying to pay attention in class, take notes, or work on a computer while fighting crushing sleepiness,” Jason’s mother observes. Generally, a 30-minute nap brings refreshment – but often for just a few hours. This creates a punishing agenda for the entire family. Imagine the logistical and social challenges confronting a child or teen who has to nap every three to four hours. How does he make and keep friends, a critically important building block in a child’s development? Which friends should learn of the child’s narcolepsy, and when? Not surprisingly, many children are embarrassed by their condition and guard their friendships and privacy judiciously. For the family, life often revolves around managing where he child is when sleepiness comes on. Outings often have to cut short. “When your child has a medical problem,” says Casey’s mom, “they naturally receive the most attention, so it can be tricky and challenging to make sure all the children in the family feel like they’re getting the equal notice.”

RESEARCH TO FIND A CAUSE AND A CURE Over the past 15 years, scientists have made considerable progress in understanding the causes of narcolepsy. This work has shown that narcolepsy and cataplexy often develop because of a loss of brain cells that produce hypocretin, a neurotransmitter that regulates wakefulness. Neurotransmitters are chemicals that neurons produce to communicate with each other and to regulate biological processes. Loss of hypocretin results in an inability to regulate sleep. Cell loss generally begins in the teens or young adulthood and results in lifelong narcolepsy. The cause remains unknown but appears to be autoimmune in nature. That is, the body’s immune system selectively attacks hypocretin-containing brain cells. People living with narcolepsy are genetically predisposed and the gene is triggered normally in their youth. One in four people in the U.S. carry the genetic marker for narcolepsy

Summer 2013 // SLEEP & WELLNESS MAGAZINE

WHAT TREATMENTS ARE AVAILABLE? Research to find a cure for narcolepsy continues. Medicines, lifestyle changes and other therapies can help relieve many of the symptoms, and treatment is based on the type and severity of the indicators.

Medication Though the loss of hypocretin is believed to be irreversible and permanent, excessive daytime sleepiness and cataplexy can be controlled in most people through drug treatment. As with all such matters, you should talk with your doctor about what medication is right for your child.

Medications to relieve Excessive Daytime Sleepiness (EDS) • Sodium Oxybate (XYREM®), also FDA-approved for reducing cataplexy • Wakefulness Promoting Medications including Modafinil (Provigil®) and Armodafinil (Nuvigil®) • Central Nervous System Stimulants such as Methylphenidate (Ritalin®, Ritalin SR®, Methylin®, Methylin ER®), Mixed Amphetamine Salts (Adderall IR®, Adderall XR®), Dextroamphetamine (Dexedrine®, Dexedrine SR®), and Lisdexamfetamine (Vyvanse®)

Medications to reduce cataplexy (partial or full muscle weakness) and other REM sleep disturbances • Sodium Oxybate (XYREM®), also FDA-approved for reducing EDS • Antidepressants that repress REM sleep, such as: – Serotonin Norepinephrine Reuptake Inhibitors, like Venlafaxine (EffexorSR®) – Norepinephrine Reuptake Inhibitors, like Atomoxetine (Strattera®) – Selective Serotonin Reuptake Inhibitors, like Fluoxetine (Prozac®) and Sertraline (Zoloft®) – Older Tricyclic Antidepressants, like Protriptyline (Triptil® and Vivactil®), Imipramine (Janimine® and Tofranil®), Desipramine (Norpramine® and Pertofran®), and Clomipramine (Anafranil®)

Advocating at School Your voice as a parent advocate can make all the difference with your child’s school and physician. The doctor can help by authoring letters describing specific accommodations needed at school. At school, seek out and stay connected with a teacher, guidance counselor or nurse who will be your in-school advocate. Schools should be encouraged to modify class schedules of children and adolescents with narcolepsy. And parents should inform school personnel of their child’s special needs, including medication requirements during the school day.

CONTINUED >>

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

Use your child’s situation as an opportunity to educate the school about narcolepsy. You may be pleasantly surprised by the warm reception you’ll receive.

Behavioral Strategies to Help Children Medication alone won’t enable kids and adolescents with narcolepsy to consistently maintain a fully normal state of alertness, so behavioral strategies play a crucial role in treating the disease. Many kids take short, regularly scheduled naps at times when they tend to feel sleepiest. Improving the quality of nighttime sleep can reduce, but not cure, EDS and help relieve persistent weariness. Common-sense measures to enhance sleep quality can be especially important for young people with narcolepsy, including: • Maintain a regular sleep schedule • Avoid caffeine-containing beverages for several hours before bedtime • Maintain a comfortable, adequately warmed bedroom environment • Engage in relaxing activities such as a warm bath before bedtime.

Getting at least 20 minutes of physical exercise per day four to five hours before bedtime can also improve sleep quality. Exercise has also been shown to help people with narcolepsy avoid excess weight gain, a common side effect of the disease. Sports, whether organized or individual, can help kids with narcolepsy both physically and socially. “Otherwise,” says Casey’s mom, “it can seem as if they have little more than school and sleep. It’s really hard to throw a sport into the mix, but in the long run it’s worth it for Casey’s overall well-being.”

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Although the disorder itself is not fatal, safety precautions, particularly when driving, are vitally important for anyone living with narcolepsy. People with untreated symptoms are involved in automobile accidents roughly 10 times more frequently than the general population. Accident rates are normal, however, among individuals who have received appropriate medication. Finally, because people with narcolepsy may become socially isolated due to embarrassment about their symptoms, support groups can prove beneficial. The empathy and understanding that these relationships offer narcolepsy sufferers can be crucial to their overall sense of well being, providing them with a network of social contacts who can offer practical help and emotional support.

REASON FOR OPTIMISM For its sufferers, living with narcolepsy can mean lifelong, debilitating weariness, cataplexy and a compromised lifestyle. Slowly, the public is becoming more aware of the disease and its consequences, leading to advances in research toward a cure. For the thousands of young people and adults living with narcolepsy, these developments are providing more than optimism. They are leading to proven treatment. Jason’s mom sums it up. “Treatment has given our son his smile back. But only through more research can he hope for a normal life someday.” S&W ABOUT THE AUTHOR Monica Gow is Executive Director of Wake Up Narcolepsy, a non-profit organization dedicated to raising awareness of narcolepsy and finding a cure for this debilitating neurologic disorder. www.wakeupnarcolepsy.org. Monica is also a parent of a child with narcolepsy.

Info Graphic

Summer 2013 // SLEEP & WELLNESS MAGAZINE

13%

of parents share their bed with a child.

Babies who sleep with their parents are awake for shorter periods of time than solitary sleepers.

Studies show that babies who share a bed with their mothers tend to breastfeed more.

Co-sleepers’ babies as adults have higher self-esteem, better stress management, and possibly less intimacy issues than babies who sleep alone.

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SLEEP & WELLNESS MAGAZINE // Summer 2013

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www.sleepandwellness.net 41

NFL PLAYERS

PPHA by the numbers Attendance: 435 Total pro players: 30 Patients who booked appointments before and after the event: 80 All five local and one national media network carried stories about this event. See http://ksaz.m0bl.net/r/1d22i3 for the KSAZ Fox News coverage. You can also see information on the Pro Player Health Alliance Facebook page, www.facebook.com/ProPlayerHealthAlliance.

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PERSONAL STORIES TO SUPPORT

OSA PATIENTS Written by Randy Clair

DR. ROGER BRIGGS AND DR. ALAN BERNSTEIN of the Pro Player Health Alliance had a patient education event in Phoenix, AZ, on January 10, 2012. The turnout was unprecedented, with over 435 people in the audience. Attendees were a mixture of current patients, individuals seeking possible treatment, sleep professionals, and health providers. Many current patients were there simply for the fellowship: they wanted to be around their heroes and share their common experiences with obstructive sleep apnea (OSA) diagnosis and treatment. The football greats were fabulous. Their stories were heartfelt and engaging. Ron Wolfley was funny and entertaining. Mark Walzcak made a huge impact with his description of his diagnosis and ultimate treatment with a Herbst appliance for his OSA. Derrick Kennard shared a powerful presentation about the impact OSA has had on his family with the passing of his brother; his story highlighted the importance of the work being done by those in the sleep industry.

CONTINUED >>

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(L-R) Mark Walzcak (Arizona Cardinals), Derrell Klack (Dallas Cowboys), Ron Pritchard (Houston Oilers), David Gergen (President of Pro Player Health Alliance), Dave Kreig (Seattle Seahawks), Roy Green (Arizona Cardinals), Ron Wolfley (Arizona Cardinals). Seated: Derek Kennard (Dallas Cowboys)

> Former Arizona Cardinal, Mark Walzcak, tells his story about Junior Seau and how Junior’s passing made Mark take his condition more seriously. Mark was unable to tolerate CPAP but is welltreated with a Herbst oral appliance. ^ This is a full room 435 registered attendees. Sleep-interested dentists, physicians, DME, and therapists came to the event to learn more about sleep apnea and treatment for it.

> A former member of the Cleveland Browns, Steve Holden weight 195 pounds when he played football. He has gained a little weight and requires combination therapy CPAP and OA to manage his sleep apnea.

The speakers were carefully chosen to represent multiple courses of treatment. There were speakers who use CPAP, oral appliances, and combination therapy. Attendees who had a diagnosis but were ignoring the condition were positively influenced by the speakers to seek treatment. Surprisingly, there were a number of patients in the room with a current diagnosis, not just individuals with symptoms who were exploring alternative therapies. There appeared to be as many contented CPAP wearers as patients who were still working on finding a therapy they could comply with. Attendees included Ruchir Patel, M.D., a Scottsdale sleep physician, and Roy Meyers from Global Sleep Diagnostics, a Phoenix-based sleep lab owner. Medical professionals who attended the meeting were generally seeking improved fit and function of therapeutic devices. Personal stories at patient-focused events, such as AWAKE meetings or PPHA events, inspires

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< A former player for the Arizona Cardinals and voice of the KTAR radio “Doug and Wolf Show, ” Ron Wolfley shared a dramatic story that left people laughing. Wolfley uses CPAP to manage his sleep apnea successfully.

^ If you wanted a sleep study but don’t want to go to the sleep lab how would you do that? Randy Clare describes a home sleep testing while Aundrea McPhee- dental assistant, Serina Briggs- registered hygienist from Dr. Briggs staff demonstrate one of their Nox T3 by Carefusion home devices.

attendees and help professionals refocus on the importance of sleep diagnosis and therapy. For example, one attendee was a 20-year-old woman who came to the meeting because her father has a sleep problem and is resisting a visit to his physician. When her father falls asleep, he begins to have seizures that are so intense that a family member stays awake to monitor him. The man has not visited a doctor for help with his sleep issue. He drives a commercial vehicle for a living and is the primary breadwinner for the family; he fears a diagnosis of sleep issues will have unacceptable implications for his employment. Hearing this story was a stark reminder that sleep professionals have much to do in the way of educating the public, so people realize that there are solutions that will protect their health and greatly improve their quality of life. This courageous young person was able to meet with one of the doctors at the meeting for advice and guidance for her father. S&W

The mission of Pro Player Health Alliance is to help “Medical Partners” achieve their marketing goals and strategic communication objectives by using our “NFL Player” relationships and by providing the tools, education and events to assist in growing their practice. We deliver the highest levels of professionalism and experience.

www.facebook.com/proplayerhealthalliance

www.proplayersleep.com

Summer 2013 // SLEEP & WELLNESS MAGAZINE

CLINICAL CASE

Written by Syed Nabi, MD

The following case is a true story of a patient I saw and treated in the clinic.

A 15-YEAR-OLD GIRL CAME IN TO SEE ME WITH HER MOTHER. She has trouble falling asleep at night, a problem that has been present for the last several years. She says that it sometimes takes two to three hours for her to fall asleep and that at night she lays in bed consciously aware of her surroundings, trying to fall asleep. She loves to read, but it does not help her to sleep, nor does it make her tired enough to go to sleep. Bedtime is generally between 9 and 10 PM. On weekends it is later, sometimes as late as 3 AM. On weekdays she has to be up by 7:15 AM. On weekends she can stay asleep until noon. She usually sleeps very well during the day and falls asleep faster on weekends. Her mother says the patient is very hard to wake up in the morning. The mother claims to be a morning person and says that the patientâ&#x20AC;&#x2122;s father is a night person. Over the last two to four years, the patient has tried melatonin (over the counter) and Trazodone (prescribed by her regular physician). Bothworked temporarily but lost their effectiveness within one to two weeks. The patient also complains of cold feet at night; however, she has no reports of snoring, witnessed apnea, heart racing, palpitations, sleep walking, sleep talking, or loss of bladder. She has been on Adderall 30 mg for the last three to four years and takes it at 7 AM. Her medical history includes Aspergers with some anxiety and depression. For the last three years, she has taken Celexa 30 mg for her depression, and she has been on and off Klonopin for the last six months for anxiety. She has no known drug allergies, and her family history is insignificant for sleep problems. She does not smoke and does not consume caffeine or alcohol. Her physical exam is typical for a teen of her age.

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Insomnia is a symptom and not a diagnosis in itself. It is a feature of a lot of sleep problems. In this age group, common diagnoses include Restless Legs Syndrome, Delayed Sleep Phase Syndrome, sleep apnea, poor or inadequate sleep hygiene, and behaviorally induced insufficient sleep time. My Working Diagnosis: Delayed Sleep Phase Syndrome The inability to fall asleep until the early morning hours, accompanied by difficulty arising until late morning or late afternoon, is known as Delayed Sleep Phase Syndrome (DSPS). People with DSPS typically describe themselves as “night owls.” They are awake when the majority of people are asleep, and they are not ready to wake up when society tells them they should. The number of hours they sleep and the quality of sleep they experience is not necessarily an issue; it is that their sleep-wake clock has shifted and is not in tune with the environment. For example, this patient’s internal clock wants her to sleep in the morning; she feels confused and disoriented in the morning—but her mother wants her to wake up and be on time for school. Factors that commonly play a role for an individual suffering from DSPS include school or work hours, continued exposure to light late in the evening and expectations in relation to sleep. Onset is usually during adolescent years, commonly right after summer break, when students are trying to make the transition from a more relaxed sleep-wake schedule to a more regimented one. Diagnoses are usually made clinically by history, although maintaining a sleep diary helps. Rarely does one need a sleep study to look for any other sleep disorders. Once a diagnosis is made, Bright Light Therapy is recommended in the morning hours to “train” the internal sleep-wake clock to a new routine. This therapy requires perseverance on the part of the patient and their family. Additionally patients need to minimize their light exposure late in the evenings. Medicines like melatonin can be used but have varying results. If you suspect you have DSPS, the following tips are things you may want to try before consulting a sleep physician: 1. Avoid caffeine, especially after noon. 2. Maintain a sleep diary. 3. Engage in regular exercise – but not four to five hours prior to bedtime. 4. Create a sleep ritual: bath, read a book, diary, listen to music, etc. 5. Consider a career as a sleep technician: you go to work late, and stay up all night! S&W

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

Q&A

Written by Dr. Natasha Burgert

IF THE KID IS HAVING NIGHT TERRORS, YOU CAN WAKE HIM OR HER UP 15 TO 30 MINUTES BEFORE YOU THINK HE OR SHE IS GOING TO HAVE THE NIGHT TERROR.

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Q: What are night terrors? A: Night terrors are really, really scary. A lot of patients and parents come in really wondering what is happening to their child at night when they are having these odd behaviors. Kids who are experiencing night terrors are usually younger, anywhere from as young as toddlerhood to early elementary typically. Parents describe their kids waking up screaming and thrashing and unable to awaken and very panicked and unable to wake for a brief period of time. Although the child doesn’t remember those events in the morning, the parent certainly does.

Q: What causes night terrors? A: Night terrors are really a disorder of sleep. They’re a problem with how the person is trying to be aroused or un-aroused from sleep. So it is kind of considered a parasomnia or a sleep problem. Night terrors occur when there is a disruption in the early parts of the sleep period in a specific type of sleep called non-REM sleep. During non-REM sleep their body tries to arouse them but they are not fully awake.

Q: How long after the child goes to sleep does he or she experience night terrors? A: Usually happens in the early part of the night sleep period. Usually the first third or so of the night. Probably within the first hour and a half to two hours after falling asleep.

04 Dr. Natasha Burgert is a general pediatrician who has worked in a private practice in Kansas City, Mo. for almost six years. She specializes in early childhood development and early patient education. She shares her expertise with her patients one on one, through her blog, www.kckidsdoc.com, through Facebook (Pediatric Associates Kansas City), twitter (apedsassoc) and with her practice group in Kansas City.

Q: How long do they typically last? A: I think it is pretty varied. Most of the ones I hear about are usually between five and 10 minutes. I’ve had a few patients tell me they can go as long as 30 minutes. Usually they’re somewhere between there. It’s not a fairly quick event, meaning a minute or less, but usually enough that the parents are pretty alarmed because it doesn’t seem like things are changing or they are unable to wake them for what seems like a fairly long period of time.

Q: How can you safely awaken your child from a night terror? A: I tell parents that although it is difficult, the best way to wake them, if you even can, is using very calm words and very calm voices. As parents, our natural reaction when our kids are thrashing and sweaty, going crazy and bolting upright in bed is to run to them, put our arms around them, and yell their name, shake them and try to wake them up. In doing so, if the kid does wake up, then he or she wakes up in a panic because you are yelling at him or her. Plus, you’re grabbing the child. In order to really transition them into a more wakened state is to remain very calm, to use some firm restraints, tight hugs, no loud voice and see if they can arouse in a calmer environment.

CONTINUED >>

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Q&A

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What is the significance if night terrors occur 09 Q: during adulthood?

A: It can be seen in adults but that is kind of outside the range of my expertise., Typically it is a continuation of what has happened in their childhood, so that is usually part of their sleep rhythm or sleep dysrhythmia, but as far as true experiences that is kind of outside my scope.

How is a diagnosis of night terrors made? 10 Q: A: I really think that the vast majority of kids the diagnosis of the night terrors can be made on history alone. As far as associated factors with that, I always ask parents about levels of stress at home, level of anxiety, talking about how they may or may not have good sleep habits, good regular sleep habits, and a good regular bedtime routine, which can all kind of contribute to the frequency of them. Most kids are going to grow out of them on their own, in due time without any intervention at all. The events themselves are not harmful; they’re not anything that needs to be prevented. Although, clearly, they cause a lot of family disruption they are not harmful for the child. Usually we let them play out on their own. Usually by grade school they are gone, if they have started in the toddler or preschool time period.

What is the difference between a night terror 11 Q: and a nightmare?

Q: Why doesn’t a child acknowledge the parent during a night terror? A: They’re not aware that this is going on. Their nervous system is not in a fully awake state. They are literally kind of out of control. They are yelling and moving without cognition.

What are the symptoms associated with night 07 Q: terrors? A: In their waking life, we know that kids that are a little more anxious or more stressed are more prone to night terrors. But that is very difficult to determine if that is the situation in a toddler for instance. For the vast majority of kids, there are no symptoms that you are going to see during the day.

Is there a specific age range that is typically 08 Q: affected by night terrors?

A: Most people think of it as the preschool age, like toddler to preschool. I have had a few kids into late grade school that still experienced them. If a kid is going to have them in a later part of life, typically they are going to be starting in the toddler to preschool time period, somewhere between 2 to 6. I think that actual peak is somewhere around 3 to 4.

A: Nightmares can happen over a range of ages. It’s really specific to that toddler or preschool ages. With nightmares, kids, when they wake up, remember what they just dreamed. They remember the event into the next part of the day. They are easily wakened from the bad dream that they are experiencing. Most kids who have nightmares just whimper, cry or moan. They are not waking up thrashing and screaming and being inconsolable at that the time. Night terrors are also associated with the nervous system kind of going crazy. So, a child’s heart rate is going to be really high., They are going to be sweaty; they can be staring off into space, and not really making eye contact. The night terror experience is a lot more physical than the nightmare is.

Are there treatment options for night terrors? 12 Q: A: It’s hopeful to decrease the frequency they happen. Kids, in general, like to have very predictable events in their lives, and sleep is certainly under that umbrella. So, by trying to avoid being over tired, to have a routine schedule seven days a week, to have a good bedtime routine that is relaxing—that is going to have your kid be engaged in the activity of sleep will certainly be helpful. A couple of pitfalls that I found parents getting into, especially when they are traveling, is using medication that they typically don’t use. For example, cold or cough mediCONTINUED >>

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Q&A

cines, or antihistamines, and then all of a sudden, they are having these horrible night terrors. Sometimes with drug exposure you have unexpected consequences of sleep disruption. So, just making sure we are avoiding those kinds of stuff can help decrease the frequency for some kids that have more of a predictable night terror. For example Monday, the first day back to school after the weekend, is a more exhausting day and is more predictable for sleep disruption. If the kid is having night terrors, you can wake him or her up 15 to 30 minutes before you think he or she is going to have the night terror. This kind of knocks them out of that sleep cycle and tries to prevent the night terror from happening. I have had some parents use this very successfully, if it is predictable. You don’t always have that luxury. If it is predictable, it is a good trick.

Can medications induce, or be a trigger of 13 Q: night terrors?

A: Yeah they can. Especially antihistamines like Benadryl.

Parents commonly can use them to help their kids go to sleep at times, which we certainly don’t recommend, but that does happen. Antihistamine type medications can induce night terrors. For older adults, illicit drugs, alcohol and sleeping pills will increase sleep disruption. For little kids, a trigger could be as simple as a fever, to cause those sleep disruption. Kids do all sorts of goofy things when they have a fever, and night terrors can be among these.

On average what percentage of children is 14 Q: affected by Night Terror?

A: I think that the literature quotes around 15 percent.

Practically I don’t hear about them that often. I would probably say less than 5 percent in my practice. Nightmares are more common than night terrors.

Are night terrors genetic? 15 Q: A: Absolutely, they definitely run in families. It is not very specific as far as direct genetic transmission or anything like that.

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How frequent do they occur in a child that 16 Q: suffers from night terrors?

A: That’s a good question. The older they are the less frequent they happen. For example a toddler may have a night terror one time a week, an older kid, a school age kid, it may be one time a month. If you are having events that are very frequent, incredibly predictable, happening every night, certainly without fail, then that is something that needs to be addressed with a medical professional. Because typically night terrors are something that is more intermittent.

What should be considered in protecting a 17 Q: child with night terrors?

A: Kids can be pretty violent when they are thrashing around and they don’t really have control over their body very well. We definitely want to make sure they are in a safe place, make sure they are not sleeping on a top bunk for example. If a kid is experiencing these, he or she needs to be in a safe sleeping environment. For kids that have associated night terrors and sleep walking, try to be aware of the sleeping environment of their room but also their security to get out of the room if that is the situation. I think also just watching the associated things that are going on with night terrors. For example: a night terror should be around five minutes or so. If you have a really, really rapid event that is associated with vomiting, pooping, peeing, or something else that Is going on at the time that kind of changes the differential of what things could possibly be. So simply observing what their child is experiencing, and as calmly as possible taking note of what they are observing so that we can make sure that we are going to get the right diagnosis.

What other diagnosis could there be? 18 Q: A: On very rare instances kids can have seizures in the night that they will cry out, have a blank stare, and not be very responsive. Those are typically short lived, by that I mean seconds, and then they can rouse very easily after the event is over. That is very atypical of a night terror, so if there is something like that that they are noticing, I am sure that their doctor would like to know.

Are night terrors associated with other forms 19 Q: of sleep disorders? A: Not that I am aware of. I do have some kids that experience night terrors are also sleep walkers. That’s kind of the same stage of sleep where kids can kind of get up and walk or move in the night. I do see kids that if they are headache kids, or if they went to bed with a migraine or a really bad headache that night. Those kids kind of have an increased experience with night terrors. S&W

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

WHEN THINGS GO BUMP IN THE NIGHT Parasomnias May Disrupt Children’s Sleep Written by Brandon R. Peters M.D.

1% TO 6% OF CHILDREN EXPERIENCE SLEEP TERRORS.”

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LIKE A DAGGER TO THE HEART OF A PARENT, A CHILD’S SCREAM PIERCES THROUGH THE STILL OF THE NIGHT. When discovered, the young boy is sitting bolt upright, stricken with panic, wailing incon-solably, and yet – curiously – asleep. Though the episode is not soon forgotten by his concerned parents, upon awakening the next morning, the boy remembers nothing. This event, known as a sleep terror, is just one of the many nocturnal behaviors that may manifest in children as pa-rasomnias.

WHAT ARE PARASOMNIAS? From the Latin meaning “around sleep,” parasomnias are a group of sleep disorders that are characterized by abnormal behaviors during sleep. Parasomnias may also include undesirable movements, intense emotions, mistaken perceptions, or the enactment of dreams. These actions typically occur unconsciously and go unremembered by the child experiencing the parasomnia. To an observer, the affected individual may appear to have a purpose or goal in mind. The behaviors can be extraordinarily complex, especially considering that the person remains asleep. Parasomnias may occur during any part of sleep. The night is divided into different sleep stages, representing various depths and types of sleep.Depending on the underlying sleep stage, different parasomnias may manifest. Some occur more commonly during deep or slow-wave sleep (which is espvecially common in children during the first part of the night). However, other examples are associated with dream or rapid eye movement (REM) sleep. The spectrum of parasomnias that may afflict children is as diverse as it is fascinating. Fortunately, many of the signs are easily recognized. These sleep disruptions can be distressing. It is, therefore, important to recognize some of the factors that may contribute as well as the potential effects of untreated parasomnias.

It is estimated that 10% of children sleepwalk at least once between the ages of 3 and 10. Older children and adolescents who continue to sleepwalk may be subject to something called “confusional arousals.”

TERRORS IN THE NIGHT One of the most dramatic parasomnias that occur in children is referred to as a sleep terror. Much like the episode described above, these events can be terrifying to behold. Fortunately, the fearsomeness of sleep terrors vastly exceeds any serious consequences. It is estimated that 1% to 6% of children experience sleep terrors. More often than not, sleep terrors affect boys, especially those who are aged 3-8 years. These episodes occur during slow-wave sleep, typically during the first few hours of the night. Sleep terrors are nocturnal episodes characterized by intense fear, anxiety, and panic. Children may cry, moan, or scream and be inconsolable. There may be associated quickening of the breathing or pulse. The child will remain deeply asleep, is often difficult to arouse, and if awakened will be confused. These episodes are typically not remembered by the child. CONTINUED >>

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The cause of sleep terrors is not fully understood, but it may relate to immaturity of the central nervous system (specifically the brain). Stress or fatigue may trigger the episodes. As some sleep-related seizures may trigger behaviors similar to sleep terrors, it may be important for a child who experiences multiple sleep terrors to have a sleep study, called a polysomnogram, to establish the diagnosis. Fortunately, sleep terrors are not harmful, do not require treatment, and often go away on their own. It is best to comfort your child during one without waking them and ease them back into bed.

EXPLORING OTHER MINOR PARASOMNIAS There are other minor parasomnias that may commonly affect children’s sleep. Sleep talking, or somniloquy, often consists of the utterance of words or phrases that may not correspond to reality. Sometimes entire conversations can be

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held without your child remembering a thing. In addition, many children are prone to sleepwalking. Sleepwalking, or somnambulism, is walking that occurs in a sleep-like state. It is estimated that 10% of children sleepwalk at least once between the ages of 3 and 10. Older children and adolescents who continue to sleepwalk may be subject to something called “confusional arousals.” In these occurrences, the child does not fully awaken from deep sleep and may remain in a subconscious state. These children may be more likely to experience sleep terrors. There are a few other sleep disorders that are thought to provoke sleepwalking. If your child has trouble breathing at night, manifest by snoring or pauses in the breathing called sleep apnea, this may make sleepwalking more likely. In addition, movement disorders called restless legs syndrome (RLS) and periodic limb movement disorder may incite the behavior. In addition, illness may bring out a tendency to sleepwalk.

SLEEP & WELLNESS MAGAZINE // Summer 2013

“

25% OF CHILDREN WILL HAVE SLEEP PROBLEMS THAT ARE CHARACTERISTIC OF A SLEEP DISORDER.

atric problems. If specific triggers such as illness, fatigue, or stress can be identified and eliminated, many parasomnias can be managed without other intervention. More than 25% of all children will have troubles sleeping that are characteristic of a sleep disorder at some point during development. And, to be certain, sleep disorders can have serious adverse effects on your child’s health. When sleep is disrupted by difficulties breathing, as occurs in sleep apnea, it may lead to problems with attention, development, and growth. Unlike adults, children do not become sleepy when their sleep is disrupted. Conversely, children may seem irritable, restless, and even hyperactive. Some children who are diagnosed with attention deficit hyperactivity disorder (ADHD) instead suffer from various sleep disorders.

“

Learning problems and poor school performance may result, but when the underlying sleep problem is corrected, improvement is seen.

Minor parasomnias like these may not require treatment. In the case of sleepwalking, it is important to keep your child safe. Careful monitoring or a bed alarm may be helpful. There are also medication options if the problem warrants such. If one of the underlying conditions mentioned above, such as sleep apnea or RLS, is contributing, this should be properly addressed.

THE EFFECTS OF PARASOMNIAS Parasomnias such as sleep terrors, sleep talking, and sleepwalking are unlikely to be harmful to your child. Many times the events are forgotten by the morning and no harmful effects persist. The episodes may be distressing, however, and you may be rightly concerned about your child’s safety. Parasomnias may disrupt the household, and for this reason, treatment may be sought. It may also be important to rule out other serious conditions that might appear similar to parasomnias, including seizures or other psychi-

It is fascinating to consider the effects of poor sleep on growth. Sleep deprivation in children is strongly associated with weight gain and obesity, possibly because it disrupts the metabolic processes of sleep. Early in the night, growth hormone is released during deep sleep. If this sleep is disrupted, as may occur in sleep apnea, the affected child grows more slowly. In fact, children with sleep apnea who are treated often undergo a rebound growth spurt. Parasomnias may not have the same consequences to your child, but sleepwalking and other behaviors may endanger them. Safety concerns arise when a sleeping child accesses dangerous locations like the stairs, a window, or the kitchen. In rare circumstances, children may even leave the home. In these situations, the real risk of harm from parasomnias may warrant further intervention. If you are concerned about your child’s sleep or a potential parasomnia, you should start by speaking with your pediatrician. Fortunately, most children will outgrow parasomnias. Though the episodes may be concerning -- and even frightening -- this reassuring fact often helps lay parents’ fears to rest. S&W

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

ENLARGED TONSILS CAN ALSO CONTRIBUTE TO SLEEP APNEA.

TONSILLEC WHAT, WHY OR WHY NOT? Written by Vikas Jain, M.D. and Christian Guilleminault, MD, Biol.D.

TONSILLECTOMY IS A PROCEDURE THAT HAS BEEN PERFORMED FOR OVER 3000 YEARS. Removal of the tonsils and adenoids was once thought of as a cure all for recurrent throat infections or breathing problems for many adults. Although the frequency of the procedure has declined, it is still one of the most commonly performed procedures in children today. Before you start buying cartons of ice cream, it is important to understand not only when the tonsils and adenoids should be removed, but also when they should not.

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“

IT IS IMPORTANT THAT JUMPING AND EXERCISE BE AVOIDED FOR 1 WEEK TO 10 DAYS AFTER A TONSILLECTOMY. MOST CHILDREN ARE ABLE TO RETURN TO NORMAL ACTIVITIES WITHIN A WEEK AFTER THE OPERATION.

“

CTOMY: WHAT ARE THE TONSILS AND ADENOIDS? The tonsils are a pair of glandular tissue that are located on both sides of the back of the throat. The adenoids are a grape-like mass of tissue located in the back of the nose and above the tonsils. Together, tonsils and adenoids work as part of the body’s immune system. They help fight infection by trapping invading bacteria and viruses and producing antibodies to defend the body. These tissues are thought to be very active during childhood

The tonsils and adenoids are barely visible in infants and generally grow in size in children between the ages of two and five. They then slowly shrink over time and are usually atrophied by late adolescence.

RISKS OF UNTREATED, RECURRENT INFECTIONS? Generally, when the tonsils and adenoids respond to infection, they become swollen. If the infection is short-lived, the tissues may shrink back down in size. In some children, the tonsils and adenoids may CONTINUED >>

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Summer 2013 // SLEEP & WELLNESS MAGAZINE

remain enlarged. This may be an indication of recurrent or persistent throat infections. If left untreated, these infections can cause more serious complications, as they may spread deeper into surrounding tissues. If the infection is caused by certain strains of streptococcal bacteria, it can even enter the bloodstream and may affect the heart, kidneys, joints, and other tissues. Enlarged tonsils can also contribute to sleep apnea.

WHAT IS THE RELATIONSHIP BETWEEN TONSILS AND SLEEP APNEA?

HOW AND WHEN ARE PROBLEMS WITH TONSILS OR ADENOIDS TREATED? While a child can have an infection or enlargement of the tonsils or adenoids at any age, typically tonsillectomy alone is performed infrequently before the age of 3 and adenoidectomy alone is performed infrequently after the age of 14. Generally, if your child has enlarged tonsils, you should take him or her to see your pediatrician. If there is evidence of an infection, your pediatrician may prescribe a course of antibiotics. If the swelling is significant and affects breathing, swallowing, or speech, your child may be referred to an Ear, Nose, and Throat (ENT) specialist for surgery. If your child is experiencing symptoms during sleep, you may also consider evaluation by a sleep specialist. A diagnostic sleep study can determine if he has underlying sleep disordered breathing, including obstructive sleep apnea. A child who is found to have evidence of sleep apnea may be treated with rapid maxillary expansion, tonsillectomy/adenoidectomy, or nasal CPAP, depending on the specifics found during the sleep study. If tonsillectomy is required, it is typically performed under general anesthesia. During surgery, the tonsils and/or adenoids are removed and left to heal on their own. On occasion, a child may require an overnight stay in the hospital, but most patients are able to recuperate at home.

WHAT ARE THE IMMEDIATE RISKS ASSOCIATED WITH TONSILLECTOMY? Since the tonsils and adenoids sit in the back of the nose and throat, enlargement of these tissues can narrow the airway and block airflow in and out of the lungs. Generally, this is not an issue for most children when they are awake. However, during sleep, the muscles of the airway relax; the combination of relaxed muscles with a narrow airway may lead to a collapse of the airway, otherwise known as apnea. When this occurs, the child must fight against the collapse and often may awaken gasping for air. Obstructive Sleep Apnea is diagnosed when these events occur continuously throughout the night, disturbing normal sleep. The repetitive, irregular breathing places stress on the cardiovascular system and can contribute to high blood pressure. The repetitive disturbance of sleep can also lead to bedwetting and excessive daytime sleepiness, which in many children can manifest as hyperactivity, irritability, and difficulties at school.

WHEN SHOULD I HAVE MY CHILD EVALUATED The following symptoms may warrant a medical evaluation of your child: • Frequent mouth breathing • Noisy breathing throughout the day • Persistent foul taste or breath • Recurrent ear infections • Snoring during sleep • Holding breath during sleep • Restless sleep • Frequent or persistent throat infections

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There is a slight risk of bleeding (this risk has been evaluated at 3 to 5%), and typically the bleeding will stop on its own. If the bleeding persists, the child must be brought back to the operating room and a suture point must be placed. Tonsillectomy and adenoidectomy are relatively painful .. Your child may have a sore throat for several days after the procedure. Generally children will be given a soft diet, including ice cream and soups. It is important that jumping and exercise be avoided for 1 week to 10 days after a tonsillectomy. Most children are able to return to normal activities within a week after the operation.

WILL THE TONSILLECTOMY AFFECT MY CHILD’S IMMUNE SYSTEM? Tonsils are lymphoid tissues. We have many other lymph glands including some in the neck; these glands will easily take over the role of tonsils. If you are concerned about your child’s tonsils or adenoids, or have any questions regarding sleep apnea in children, it is best to consult with your medical provider. S&W

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For more information, call BryanLGH Center for Sleep Medicine 402-481-9646 or 1-800-742-7845 x19646 www.bryanlgh.org

St. Patrick Hospital Sleep Center is accredited by the American Academy of Sleep Medicine. We have two Board certified Sleep Physicians and a team of RPSGT, RRT, R.EEG T., CRTT, and LPN staff. We are located between Glacier and Yellowstone Parks in Missoula, a major medical hub in western Montana. Our 4 bed sleep lab, and full neurodiagnostics dept., are here to serve the needs of our community and surrounding area.

As a comprehensive center, The Sleep Disorders Center of Gwinnett Pulmonary Group deals with the diagnosis and treatment of all sleep disorders. The most common disorders are Obstructive Sleep Apnea Syndrome, Narcolepsy, Periodic Limb Movement Disorder, Restless Legs Syndrome, and Insomnia. Please contact us anytime! We look forward to hearing from you. Gwinnet Sleep Center 631 Professional Dr., Suite 350 Lawrenceville, Ga 30046 Phone: 678-942-5982 Fax: 770-623-1485 www.gwinnettsleep.com

St. Patrick Hospital Sleep Center/Neurodiagnostics Services Missoula, MT 59802 406-329-5650 www.saintpatrick.org

United Sleep Diagnostics, Inc. (USD) is a JCAHO accredited and Medicare certified sleep diagnostic company. USD provides comprehensive diagnostic sleep testing and treatment in our state-of-theart sleep laboratories, the patient's home or hospital environment. Our service is designed to ensure high quality, cost effective sleep services to physicians and their patients.

MNAP Sleep Disorders Center brings together Board-Certified Sleep Specialists and staff to diagnose problems in an advanced, 4-room, sleep center. While patients sleep, Polysomnographic Technologists observe the sleep patterns in a separate room. Brain activity, breathing patterns, muscle activity, and heartbeat are monitored. MNAP Sleep Disorders Center can improve patients' health and quality of life by diagnosing a full range of disturbances.

United Sleep Diagnostics, Inc 2241A N. University Dr. Pembroke Pines, FL 33024 Phone: 954-442-8694 Fax: 954-442-8695 www.unitedsleepdiagnostics.com

MNAP Diagnostic Center 9908 E. Roosevelt Blvd. Philadelphia, PA 19115 Phone: 215-464-3300 ext.1345 Fax: 215-464-0835 www.mnap.com

THE SLEEP CORNER SLEEP SPECIALIST IN YOUR AREA, GUIDNG YOU TO BETTER SLEEP

St. Vincent Hospital’s Regional Sleep Disorders Center is accredited by the American Academy of Sleep Medicine (AASM). The Center provides a full range of diagnostic and treatment procedures for disorders of sleep and maintaining wakefulness for both children and adults. St. Vincent Regional Sleep Disorders Center 1821 S Webster Ave Green Bay, WI 54301 Phone: 920-431-3053 Richard Potts DO, FCCP, FAASM- Medical Director Marla Van Lanen RRT RPSGT, Supervisor Marla.vanlanen@stvgb.org www.stvincenthospital.org

The Board of Registered Polysomnographic Technologists (BRPT) administers the Registered Polysomnographic Technologist (RPSGT) and the Certified Polysomnographic Technician (CPSGT) exams based on best credentialing practices, which measure the knowledge, skills and abilities of technologists and technicians in the field of sleep medicine. The BRPT fosters ethical practices and requires the continued competence of those who successfully complete the RPSGT and the CPSGT exams. BRPT 8400 Westpark Drive, 2nd Floor McLean, VA 22102 Phone: 703-610-9020 www.brpt.org

Athens Center for Sleep Disorders provides a comfortable and convenient alternative to hospital-based sleep studies. We provide an environment that is soothing and inviting, with comfortable amenities and friendly, welcoming faces. Athens Center for Sleep Disorders is the first sleep disorders center in Henderson County to be eligible for accreditation by the American Academy of Sleep Medicine. Athens Center 704 South Palestine Athens, TX 75751 Phone: 903-675-1717 or e-mail: sleep@athenssleepcenter.com Fax: 903-675-3338 www.athenssleepcenter.com

Houston Sleep & Neurology Consultants

A speciality medical practice devoted to Sleep Medicine, Neurology, and Clinical Research Trials. We offer three convenient locations in the Greater Houston area. Cypress • Katy • Memorial "Improving the Quality of your Life by Improving the Quality of your Sleep" Houston Sleep & Neurology Consultants Todd J. Swick, MD, ABSM, Medical Director Houston, Texas 713-465-9282 www.houstonsleepcenter.com www.toddswickmd.com

Central Washington Sleep Diagnostic Center is a specialized medical facility. It treats all varieties of sleep disorders in adults and children, including but not limited to, insomnia, narcolepsy, obstructive sleep apnea, and complex sleep apnea, all with the goal of getting people rested, healthy and back to a normal, productive life. Accepting most Insurance and Medicare. Eric Haeger, MD Board Certified Sleep Medicine Central Washington Sleep Diagnostics Center 410 Washington St Wenatchee, WA 9880 Phone: 509-663-1578 www.cwsleepcenter.com

We are fully AASM accredited 6-bedroom Sleep Disorders Center with additional OCST accreditation. We are also Centermember of National Sleep Foundation. We offer unsurpassed patient access and comfort, state-of the art diagnostic and treatment resources and professional services provided by the board certified sleep specialists. BMC Sleep Disorders Center 165 Tor Court Pittsfield, MA 01201 Phone: 413-447-2701 Fax: 413-447-2101 www.berkshirehealthsystems.org

Gergens Ortho and Sleep Appliance Lab is family owned and has serviced the United States since 1985. Based out of Phoenix, we employ over 45 tech and support personnel. We fabricate ortho, pedo, TMJ and Sleep Apnea appliances We have built our reputation on great quality, customer service, and having knowledgeable technicians. Our customers from across the United States share a common characteristic: They genuinely care about their patients and want them to have the finest dental appliances available. 1745 W. Deer Valley Road Building 1, Suite 112 Phoenix, AZ 85027

Roper St. Francis Health Sleep Center is located in Charleston, South Carolina. We are a 10-bed Sleep Center testing at various facilities within the Roper St. Francis Healthcare System. Our Roper Hospital Sleep Center in downtown Charleston is accredited by the AASM, recently receiving reaccreditation for 20 years now. We have 9 board-certified sleep specialists with our Center and all RPSGTs on our clinical staff.

Chase Dental SleepCare is a treatmentoriented facility, which concentrates on sleep apnea, snoring and sleep breathing disorders. There are several convenient locations for patients to visit. Each practice is equipped with state of the art technology, knowledgeable staff and Dentists that treat all patients with above standard care. If you or someone you know suffers from Sleep Apnea or Snoring, or cannot tolerate their CPAP machine, please call to schedule a free consultation.

Roper Hospital 843-724-2000 316 Calhoun Street Charleston, SC 29401 www.ropersaintfrancis.com

Chase Dental Sleepcare Headquarters 324 South Service Road, suite 116 Melville, New York 11747 Tel: 631 393 6888 www.ChaseDentalSleepCare.com www.sleepandwellness.net 63