Download Sleep Hygiene

Jamie Neal, APRN
10/24/14
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Explain the importance of sleep
Describe the symptoms of insomnia
Identify treatment of insomnia
Describe the symptoms of restless leg
syndrome (RLS)
Identify treatments for RLS
Describe good sleep hygiene techniques
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Insufficient sleep can
lead to:
Mood disturbances
◦ Irritability, emotional
lability, depression, anger
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Fatigue and daytime
lethargy
Cognitive impairment
◦ Memory, attention,
concentration, decision
making, problem solving
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Daytime behavior
problems
◦ Over activity, impulsivity,
noncompliance
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Risk taking behaviors
Academic problems
◦ Chronic tardiness, falling
asleep in class
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Use of stimulant meds
◦ Other alertness enhancers
like caffeine, nicotine
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Infant
Toddler
Preschool
School age
Adolescents
By Age
14-15 hrs
12-14 hrs
11-13 hr
10-11hrs
9.5 hrs
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Infant
Toddler
Preschool
School age
Adolescents
12.7 hrs
11.7 hrs
10.3 hrs
9.5 hrs
7 hrs
What they are really
getting
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Difficulty with sleep initiation, duration,
consolidation or quality that occurs despite
adequate time and opportunity for sleep and
results in daytime impairment
Acute (adjustment) insomnia-short lived due
to life circumstances (identifiable stressor)
◦ i.e.: can’t fall asleep because of a test the next day,
it’s the first day of school
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Chronic insomnia-at least 3 nights a week for
3 months.
◦ Can be associated with a comorbidity, but not
always.
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Behaviorally induced
Insufficient sleep
Psycho physiologic
Paradoxical
Medical problems
Psychiatric conditions
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Relies on inappropriate sleep association
Usually presents with frequent night time
awakenings
The process of falling asleep is associated
with a specific habit, object, or setting
Child becomes unable to fall asleep within a
reasonable time in the absence of these
conditions
Examples: extended rocking, parent has to
sleep with child or vice versa
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Stalling or refusing to go to bed
When parent enforces limits, child falls asleep
quickly
Problem arises when parent has trouble
setting and maintaining limits and managing
the stalling behavior (inconsistent)
Child’s stalling techniques are based on what
they have learned will work
Examples: refusing to put on pajamas, get in
bed, saying they are scared, need kisses, etc
Daytime anxiety may trigger night time fears
◦ Bedtime or middle of the night fears
◦ Begin in the preschool years, disappear age 5-6
◦ May be provoked by anxiety, stress, traumatic
events
◦ Treatments:
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Try monster spray
Have a pet sleep in the room
Security objects
Night lights
Have the child involved in the solution
◦ Frightening dreams that cause waking, are
upsetting and require comfort
◦ Start around age 2
◦ Treatment: think happy, pleasant thoughts at
bedtime
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Heightened mental arousal and learned sleeppreventing associations
May be associated with emotional reactions
Hyper vigilant about sleep
Can complain of “racing main”
The more the person tries to sleep, the more
irritated they become and the less able one is to
fall asleep
People who sleep better when they are not in
their own bedroom
May be associated with people who are
overanxious about their overall health
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Complaints of severe insomnia that occurs in the
face of a normal sleep study or without evidence
of an objective sleep disturbance
The severity of the night time complaint is not
matched by evidence of pathologic daytime
sleepiness
◦ still complain of being tired
◦ may not be falling asleep at school, work
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No other psychiatric illnesses
No suspicion of malingering
Overestimate of how long it takes to fall asleep
and underestimate total sleep time
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Persistent failure to obtain the amount of
sleep required to maintain normal levels of
alertness and wakefulness
Voluntary but unintentional chronic sleep
deprivation
Sleep history of the current sleep patterns
reveals disparity between the amount of sleep
they are getting and the amount of sleep they
need!
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Restless leg syndrome
Central apnea
Pain-low back pain, chronic pain
GI issues such as reflux
Arthritis
Endocrine issues such as hyperthyroidism
Neurological conditions such as Parkinson’s
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Bipolar disorder
Depression
◦ Insomnia can be a symptom of depression,
especially middle of the night waking
◦ Increased risk of severe insomnia in the face of
major depressive disorder
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Anxiety
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Tension
Ruminating about past events
Worrying about future events
Feeling overwhelmed
Feeling over stimulated
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A sensory disorder characterized by an
uncomfortable sensation in extremities
accompanied by an urge to move the
extremities while awake
Sensations relieved by movement (walking,
rubbing, stretching, shaking, rocking)
Legs and arms can be affected
Episodes occur or are exacerbated by
episodes of rest (sometimes with exercise)
Worse in the evening
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Ants, spiders, bugs crawling on legs
“Lightening in my legs”
Squeezing, tingling, itching, aching, or hurting
“My legs feel wiggly”
“My legs want to run”
“My legs won’t stay still”
“Lava running down my legs”
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Low brain iron stores leads to disrupted
dopamine synthesis in the CNS= reduction
of dopamine availability within critical
regions of the brain= development of
RLS/PLMD
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Genetic link, especially first degree relative
Sleep deprivation
Medical Conditions: iron deficiency
anemia, end stage renal disease,
hypothyroidism, DM
Pregnancy
Medications: antihistamines,
antidepressants, antipsychotics,
antiemetic
Caffeine and alcohol may increase RLS
symptoms
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First line treatment in children with ferritin levels
less than 50 ng/mL
Goal is to increase peripheral iron levels and to
increase iron stores
Ferritin acts as a marker for the stored iron levels
in the body
Goal for iron treatment is a ferritin between 50-70
ng/mL
Dose for oral iron : 3-6 mg/kg/day for 3 or 6
months
Iron is continued for 3 month intervals and iron
and ferritin levels are assessed along with clinical
improvement (improved RLS sensations, less
difficultly with sleep onset, maintenance)
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Sounds easy, right?
 Oral iron is poorly absorbed
 Compliance with medications for many months is
difficult
 Liquid iron tastes bad! (We have them take it with
orange or apple juice)
 Calcium, magnesium, zinc all bind with iron and
decrease absorption
 Anti reflux medications decrease iron absorption
 Side effects: most common is constipation
 Iron toxicity a risk of acute iron overdose
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Iron is not the same as lead!
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Dopamine agonists
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Act like dopamine
Pramipexole (Mirapex)
Ropinirole (Requip)
First line treatment for adults (not FDA approved for
kids)
Anticonvulsants
◦ Gabapentin (off –label)
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Alpha 2 agonists
◦ Clonidine (short term use only)
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Dim lights 1 hours before bed
Room darkening shades and curtains
Colors and decorations that are relaxing
Room temp between 60 and 67 degrees
Comfortable mattresses, pillows and sheets
Reduced noise with white noise or fan
Keep the TV off while asleep
Relaxing scents like lavender
 National sleep foundation
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Watching television is the most popular activity
(76%) for adolescents in the hour before bedtime
◦ surfing the internet/instant-messaging (44%)
◦ talking on the phone (40%)
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Nearly all adolescents (97%) have at least one
electronic item in their bedroom.
◦ 6th graders=2 items, 12th graders=4
Adolescents with four or more items are 2x likely to fall
asleep in school and while doing homework.
• National Sleep Foundation 2006, 2011 Sleep in America Poll.
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27% of parents of teens who leave electronic
device ON rate their teen’s sleep as excellent
53% of parents of teens who leave devices OFF
rate their teen’s sleep as excellent
17% of parents said that their child read or sent
electronic communications after initially going to
bed
On school nights, teens who leave their TV or
iPod on get 1 hour less sleep than those who
don’t
On school nights, teens who leave their phone on
get 2 hours less sleep than those who don’t
 National Sleep Foundation
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Kids using electronics as a sleep aid to relax
at night have later weekday bedtimes fewer
hours of sleep per week and report more
daytime sleepiness
Teens with a TV in their bedroom have later
bedtimes, more trouble falling asleep and
shorter total sleep times
Texting and emailing after bedtime, even
once per week, increases self-reported
daytime sleepiness among teens
 National Sleep Foundation
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Improve the sleep hygiene!
Regular bedtime routine and bedtime
1 hr of sunlight exposure early in the day
Regular physical activity
Dim lights in the evening
No stimulating activities (TV, video/computer
games) for at least 1 hr prior to bedtime
◦ No caffeine or chocolate,
◦ Bath time earlier?
◦ Relaxing activity when first getting in bed?
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Naps may help to improve:
◦ Alertness
◦ Performance
◦ Memory recall
◦ Short nap(under 45 minutes)
 Only if no sleep onset/
maintenance problems
Ficca et.al., Sleep Medicine Reviews, 2010
Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006
 Exposure
to light before sleep can
inhibit production of melatonin
◦ Decrease/avoid light at night
◦ Increase exposure during the day
Horrocks and Pounder, Working the Night Shift: Preparation,
Survival and Recovery, 2006
Bonnefond et al., Industrial Health, 2004
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Melatonin
Sleep Time Tea
Natural supplements
Marley’s Mellow Mood
Lazy Cakes
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Secreted by pineal gland
Tryptophan → 5HTP → serotonin → melatonin
Natural melatonin levels rise at night about
1-2 hours prior to bedtime
Give melatonin 1-2 hours prior to bedtime
Adult doses range from 0.3mg to 10mg
NSF warns against using in patients with
immune system disorders, cancers, taking
corticosteroids or immune suppressants
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Not regulated by FDA
Considered dietary supplement
Works best in children with
◦ Circadian rhythm disorders
◦ Mid-line brain defects such as agenesis of the
corpus callosum
◦ Blindness
◦ ADHD
◦ Autism
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Stick to the same
bedtime and wake
time, even on the
weekends
Have a relaxing
bedtime ritual
Avoid naps, especially
in the afternoons
Exercise daily
Adjust your sleep
environment
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Sleep on a comfy bed
Use bright light to help
manage your circadian
rhythm
Avoid alcohol, cigarettes
and heavy meals in the
evening
Give yourself some wind
down time
Go to another room and
do something relaxing
until you are tired
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Scaring your child to sleep i.e.: the bogeyman
Talking negatively about ghosts
Letting kids watch scary movies, TV shows
Discussing vampires, werewolves and
zombies
Letting kids play scary video games
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Que Viene el Coco (Here comes the bogeyman)
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An imaginary creature used to scare
children into behaving well
Aka “If you don’t go to bed right now, the
boogeyman is going to get you”
There is a similar creature in many cultures
and countries
Usually male
He has a sack to carry naughty children
away
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Guide to Your Child’s Sleep.
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Take Charge of Your Child’s Sleep.
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George J. Cohen, M.D., F.A.A.P.
Judy Owens, M.D., and Jodi Mindell, Ph.D.
Sleeping Through the Night.
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Jodi Mindell, Ph.D.
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American Academy of Pediatrics Section on Pediatric
Pulmonology. 2011. Pediatric Pulmonology.
American Academy of Pediatrics.
American Academy of Sleep Medicine. 2005. The
international classification of sleep disorders. 2nd
edition. American Academy of sleep medicine.
Mindell, J.A & Owens, J.A. 2003. A clinical guide to
pediatric sleep: diagnosis and management. 2nd
edition. Wolters Kluwer.
Sheldon, S.H., Ferber, R., Kryger, M.H. 2005.
Principles and practice of pediatric sleep medicine.
Elsevier Inc.
Panitch, H.B. 2005. Pediatric Pulmonology The
Requisites in Pediatrics. Elsevier Inc.
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Eggermont S., & Van den Bulck J. 2006. Nodding off
or switching off? The use of popular media as a sleep
aid in secondary-school children. Journal of
Paediatrics Child Health. Vol 42 (7-8) pp 428-433b
Shochat, T., Flint-Bretler O., &Tzischinsky O. 2010.
Sleep patterns, electronic media exposure and
daytime sleep-related behaviours among Israeli
adolescents. Acta Paediatrics Vol 99 (9) pp 12201223
Pelayo, R., & Dubik, M. 2008. Pediatric Sleep
Pharmacology. Semin Pediatr Neuro. 15: 79-90.
Picchietti, D., Allen, R.P., Walters, A.S., Davidson,
J.E.Myers, A., et al. 2007. Pediatrics. Restless legs
syndrome: Prevalence and impact in children and
adolescents the pediatric REST study. 120; 253-266
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