When my wife’s water broke, minutes after I went to bed back in January of 2002, I remember driving her to the hospital and anguishing over one thought: “I’m never going to be well rested again”. If there’s one things all new parents wish, it’s for a good night’s sleep.
Unfortunately, infants sometimes make that impossible. They wake up repeatedly, needing to be fed, changed, and comforted. Eventually, they reach an age when they should sleep through the night. Some don’t, though. What to do with them continues to be a topic of a heated debate in parenting circles. That’s the topic of this week’s Healthcare Triage.
This was adapted from a column I wrote for the Upshot. Links to further reading and sources can be found there.
The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
I remember thinking, after my pregnant wife’s water broke minutes after I went to bed, anguishing really, over one thought as we drove to the hospital: “I’m never going to be well rested again.”
If there’s one thing all new parents wish for, it’s a good night’s sleep.
Unfortunately, infants sometimes make that impossible. They wake up repeatedly, needing to be fed, changed and comforted. Eventually, they reach an age when they should sleep through the night. Some don’t, though. What to do with them continues to be a topic of a heated debate in parenting circles.
One camp believes that babies should be left to cry it out. These people place babies in their cribs at a certain time, after a certain routine, and don’t interfere until the next morning. No matter how much the babies scream or cry, parents ignore them. After all, if babies learn that tantrums lead to the appearance of a loved one, they will continue that behavior in the future. The official name for this approach is “Extinction.”
The downside, of course, is that it’s unbelievably stressful for parents. Many can’t do it. And not holding fast to the plan can make everything worse. Responding to an infant’s crying after an extended period of time makes the behavior harder to extinguish. To a baby, it’s like a slot machine that hits just as you’re ready to walk away; it makes you want to play more.
A modification of this strategy is known as “Graduated Extinction.” Parents allow their infant to cry it out for a longer period each night, until infants eventually put themselves to sleep. On the first night, for instance, parents might commit to not entering the baby’s room for five minutes. The next night, 10 minutes. Then 15, and so on. Or, they could increase the increments on progressive checks each night. When they do go in the room, it’s only to check and make sure the baby is O.K. — no picking up or comforting. This isn’t meant to be a reward for crying, but to allow parents to be assured that nothing is wrong.
Another choice is “Bedtime Fading.” The point of this plan is to teach your children how to fall asleep on their own at bedtime, in the hope that if they develop this skill, when they wake up in the middle of the night they’ll choose to employ it rather than call for you. With fading, you temporarily set bedtime later than usual and preface it with a good bedtime routine. Your babies learn that bedtime is fun, and have little trouble falling asleep because they’re more tired than usual. Then you move their bedtime earlier and earlier, so that infants learn how to put themselves to sleep when they are less and less tired.
A fourth method is “Scheduled Awakenings.” In this method, a parent tries to disrupt spontaneous awakening by getting up in the middle of the night to wake children 15 to 30 minutes before they usually wake up on their own. They then help the baby fall back asleep. The scheduled awakenings are later phased out.
Of course, even with fading and scheduled awakenings, it’s possible that your baby will wake up in the middle of the night, screaming. Then you face a choice: Go to them or wait it out?
Some people always choose to comfort the child. They think that making a baby cry it out is inhumane and could even lead to psychological problems. Others feel that giving in to babies prevents them from learning needed skills and leads to later problems.
A final thing doctors can do is “Parental Education,” which is closer to prevention. It involves talking to parents about many of these options, especially training infants to fall asleep on their own, before problems develop.
As a pediatrician, the first thing I do with parents who are experiencing problems is calm them down. Sometimes it feels as if it will never go away, but I try to remind them that few teenagers have this issue. They go to bed fine, and if they wake up in the middle of the night, they go back to sleep without anyone’s help. This almost always, eventually, gets better.
The good news is that almost all interventions work. In 2006, a systematic review was published in the journal Sleep that examined all the relevant research on the efficacy of these interventions. Ninety-four percent of the 52 reviewed studies found that the interventions led to improved sleep, and more than 80 percent of children who were treated improved significantly.
The strongest evidence supported the extinction method and parent education (i.e., prevention). Still, there was evidence that also supported the graduated extinction, fading and scheduled awakenings methods.
People become surprisingly heated about which method to use. This isn’t just because they think one works better than the other, but also because they think some are harmful. They worry about the long-term effects of some methods. Those concerns may be overblown, though. A small study published recently followed children who were randomly sorted to use graduated extinction, fading or parent education. Besides looking at the effectiveness of the intervention on sleep, researchers measured the cortisolhormone in infants’ saliva (as a measure of stress) as well as mothers’ moods and stress.
Again, all of the interventions worked to improve sleep. More important, none caused any concerning levels of stress. This confirmed the findings oftwo previous studies that found that infant sleep problems, and the interventions used to remedy them, do not predict long-term outcomes, even at 6 years of age.
Parents become stressed about infants who don’t sleep well. That’s understandable. What they don’t need to stress about is that fixing it will cause more harm or have long-term negative consequences. A good night’s sleep makes almost everything better.
The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
As a pediatrician, I find that there are few topics that parents want to discuss more than sleep. Parents worry about their own sleep deprivation when babies arrive. Later, they worry about their children’s. I almost never encounter patients who are convinced that they’re getting the recommended amount of sleep.
It’s harder than you might think to determine how much sleep an adult actually requires. Modern technology has significantly altered how and when we might naturally sleep. Electricity allows us to be productive long after the sun has gone down. Coffee and other stimulants allow us to wake up more quickly. Measuring “natural” levels of sleep would require us toreturn to a simpler time.
As part of a German science television show, five men and women volunteered to return to Stone Age conditions for eight weeks. They had no smartphones or Internet, no electricity or running water, no alarm clocks — or any clocks for that matter. Enterprising scientists took advantage of this to make some measurements.
Before the study, they went to sleep (median) about 20 minutes before midnight. Without interference from modern amenities, their bedtimes moved up about two hours. Before the experiment, they woke up (median) about 7 a.m. Under Stone Age conditions, they woke up about a half-hour earlier.
Counting the periods of awake time between going to sleep and waking up in the morning, they had been spending less than six hours asleep each night before the experiment, and without outside interference they slept about seven and a quarter hours a night. This might be the closest we’ll get to figuring out what a modern human body naturally requires.
Granted, many people probably aren’t getting that much. In 2013, the National Sleep Foundation released the results of a survey on sleep among people 25 to 55 in six countries. Canadians and Mexicans topped the list at 7.1 hours a night, followed by Germans at 7 and residents of Britain at 6.8. Bringing up the rear were Americans at 6.5 hours and Japanese at 6.4.
Sleeping hours are disproportionate across the socioeconomic spectrum as well. The more you make, the less you sleep. Almost half of people earning less than $30,000 a year sleep at least six hours a night, compared with about a third of those earning at least $75,000.
Americans also sleep less than we used to. In 1942, almost 85 percent of us slept at least seven hours a night. Today, less than 60 percent of us do.
But serious sleep deprivation in adults is most likely rarer than many think it is. After all, people in controlled studies of sleep deprivation are usually getting very, very little sleep. Complicating things, not all people react to sleep deprivation in the same way. Some people just need less sleep, and that may be somewhat genetic. Many news reports that highlight the dangers from too little sleep are assuming that all adults need at least eight hours. There’s just little evidence that’s so.
There’s one group where that may not be true, however. Younger people need more sleep than adults. The National Heart, Lung and Blood Instituterecommends that newborn babies get 16 to 18 hours of sleep a day. It’s likely that many of them get that, because we let them. As I tell parents all the time, only a fool wakes a sleeping baby. The usual recommendation for preschool children is 11 to 12 hours, school-age children 10 hours and teenagers about 9 to 10 hours a night.
It’s likely few teenagers are sleeping that much.
The most obvious reason for that is that the high school day generally starts so early. Next year, when my oldest heads to ninth grade, his bus will come for him around 6:45 a.m. To get nine hours of sleep, he will have to be asleep by 9:15. Going to bed early doesn’t seem to bother Jacob much, so I imagine he might just do that; most teenagers can’t, though.
Many of them are engaged in activities after school. They eat dinner late, so that they can be with their parents, who probably work late. They also need time to get their homework done, let alone to have any type of social life.
There’s no good reason school has to start this early, and starting it later might improve the amount of sleep teenagers get. A study published in 2014examined 9,000 students in eight public schools in three states. It found that in high schools where classes began at 7:30 a.m., about a third of children got at least eight hours of sleep a night. If they started at 8:35 a.m., about 60 percent of children achieved that goal.
Moreover, the later start time was associated with improvements in a number of subjects, as well as state and national achievement test scores. Attendance increased. Perhaps more important, the number of car crashes by drivers 16 to 18 was reduced by 70 percent when school start times were changed from 7:35 to 8:55.
It’s for reasons like these that the American Academy of Pediatrics released a policy statement in 2014 calling for a shift in school start times to 8:30 or later. Few school systems, however, have heeded the call.
Many media stories about sleep breathlessly worry that the average American is at grave risk because of sleep deprivation. Even if it were true, that could be improved for many of us by choosing to turn off our devices and shut our eyes just a little bit sooner. Too few stories focus on those who are really at risk for sleep deprivation, namely teenagers. It’s not their fault. We could fix this problem for them.
Last week we talked about sleep. We talked about how much the average person needs, and how much they get. We also talked about how you can’t just rely on “averages” to determine how much you need. Sleep in a personal thing, and we all need different amounts.
But sleep is incredibly important. You have to do it. Not getting enough, or sleep deprivation, is a real, and bizarre thing. It’s also the topic of this week’s Healthcare Triage.
For those of you who came here for references or want to read more, here you go:
Sleep! It’s probably the one single thing we spend the most time doing. Sleeping eight hours a night means that you’d spend literally one third of your life asleep. But most of us are getting less than that, and we probably need more.
Sleep is important! It’s also the topic of this week’s Healthcare Triage.
For those of you who want to read more, here you go:
Boston, Mass., November 19, 2012 – The Institute for Clinical and Economic Review (ICER) has posted the draft supplementary report “Diagnosis and Treatment of Obstructive Sleep Apnea in Adults” as a complement to the full review of the same name from the Agency for Healthcare Research and Quality (AHRQ). Both will be the subject of deliberation and vote at the next public meeting of the New England Comparative Effectiveness Public Advisory Council (CEPAC) on Thursday, December 6, 2012 in Hartford, Connecticut. The report prepared for CEPAC includes supplementary analyses to the original AHRQ review, including budget impact and cost-effectiveness analyses.
This supplementary report aims to help the members of CEPAC, and the public, understand the latest evidence on the relative effectiveness and value of different management options for adults with obstructive sleep apnea. The report will be available for public comment until Monday, November 26, 2012.
Members of the public wishing to attend the meeting must register by December 4, 2012 by visiting the “Contact Us” section of cepac.icer-review.org. The website also includes instructions for those wishing to submit written comments ahead of time, and those requesting the opportunity to make public comments at the meeting. Members of the public wishing to deliver an oral comment during the public meeting must register to do so no later than Thursday, November 29, 2012. An audio recording of the CEPAC meeting will be made available on the CEPAC website following the meeting for members of the public unable to attend the in-person meeting.
No Easy Day: The Firsthand Account of the Mission That Killed Osama Bin Laden, by Mark Owen and Kevin Maurer: It beats me why this ended up on my book reading list. Probably I heard something about it that made it sound good. Not to take anything away from the dedicated, military professionals that serve our country in ways I never have or could, it really wasn’t. It wasn’t a total bust either. Only Chapter 9 to the end was directly about killing Osama Bin Laden, and I found some enjoyment in reading the tale. But the filler up to Chapter 9 did little for me. Your mileage may vary.
Dreamland: Adventures in the Strange Science of Sleep, by David Randall: I probably didn’t need to read this one since I’m pretty well versed in the science of sleep. If you’re not, though, I recommend it. I was pleased to see some pages devoted to cognitive behavioral therapy for insomnia. I enjoyed learning about the intersection of professional (and Olympic) athletics and sleep science. A taste:
The Stanford researchers dug through twenty-five years of Monday night NFL games and flagged every time a West Coast team played an East Coast team. Then, in an inspired move, they compared the final scores for each game with the point spread developed by bookmakers in Vegas. The results were stunning. The West Coast teams dominated their East Coast opponents no matter where they played. A West Coast team won by 63 percent of the time, by an average of two touchdowns.
You’ll have to read the book to learn how sleep explains why West beats East, on average.
Before this electrically illuminated age, our ancestors slept in two distinct chunks each night. The so-called first sleep took place not long after the sun went down and lasted until a little after midnight. A person would then wake up for an hour or so before heading back to the so-called second sleep.
It was a fact of life that was once as common as breakfast—and one which might have remained forgotten had it not been for the research of a Virginia Tech history professor named A. Roger Ekirch, who spent nearly 20 years in the 1980s and ’90s investigating the history of the night. As Prof. Ekirch leafed through documents ranging from property records to primers on how to spot a ghost, he kept noticing strange references to sleep. In “The Canterbury Tales,” for instance, one of the characters in “The Squire’s Tale” wakes up in the early morning following her “first sleep” and then goes back to bed. A 15th-century medical book, meanwhile, advised readers to spend their “first sleep” on the right side and after that to lie on their left. A cleric in England wrote that the time between the first and second sleep was the best time for serious study.
The time between the two bouts of sleep was a natural and expected part of the night, and depending on your needs, was spent praying, reading, contemplating your dreams or having sex. The last one was perhaps the most popular. A noted 16th-century French physician named Laurent Joubert concluded that plowmen, artisans and others who worked with their hands were able to conceive more children because they waited until after their first sleep, when their energy was replenished, to make love.
Studies show that this type of sleep is so ingrained in our nature that it will reappear if given a chance. Experimental subjects sequestered from artificial lights have tended to ease into this rhythm. What’s more, cultures without artificial light still sleep this way. In the 1960s, anthropologists studying the Tiv culture in central Nigeria found that group members not only practiced segmented sleep, but also used roughly the same terms to describe it.
Randall winds up his piece with this bit of wisdom, “The secret to a good night’s sleep may very well be acknowledging that it takes work.” Yep. If you want to do that work, look here.
We all need 8 hours of sleep per night for good health, right?. And the more sleep we get, the better health we’ll enjoy, yes? It turns out the evidence doesn’t support either claim. The optimal sleep length may be closer to 7 hours than 8, and it may be worse to sleep more than 7 hours than it is to sleep less than that amount.
23 prospective cohort studies that examined the associations between sleep duration and all-cause and ⁄ or cause-specific mortality. Findings from the quantitative analyses indicate that among both males and females, short sleepers and long sleepers are at increased risk for all-cause mortality compared to individuals who report, on average, a medium amount of sleep per night (generally defined as 7 to 7.9 h).
In fact, the pooled relative risks for all-cause mortality, as well as cardiovascular- and cancer-related mortality, was higher for long sleepers than short sleepers, relative to those who slept between 7 and 8 hours.* So sleeping longer may, in fact, be bad for you.
That conclusion is also suggested in the following chart from “Mortality associated with sleep duration and insomnia,” by Daniel Kripke, Lawrence Garfinkel, Deborah Wingard, Melville Klauber, and Matthew Marler. In the figure, the “hazard ratio” is for mortality. Also, this figure is for women, but one for men telling the same basic story is also provided in the paper. Notice that sleeping 8, 9, or 10 hours is actually worse than sleeping 6, 5, or 4, respectively. In fact, 8 hours is worse than 4. Seven hours of sleep appears optimal, and insomnia isn’t so bad! And, yes, the researchers controlled for some stuff (see footnote**).
Even with all their controls, though, can we be sure it’s sleep duration that drives the mortality results? No, of course not. I know from personal experience, it doesn’t take much to disrupt sleep. For example, a bad back or depression can shorten sleep duration. They’re not among the controls in the study. There are many medications that lengthen it, not all of which were controlled for, among other things. Sleep researchers know this.
Much of the data indicates that some but not all of the excess mortality among the long and short sleepers is due to differences in the characteristics of the individuals who comprise these groups; for example, individuals who report shorter and longer sleep times are more likely to be in poorer overall health and to have been diagnosed with medical conditions, including depression, than individuals who report average sleep times (Ayas et al., 2003a; Ferrie et al., 2007; Kohatsu et al., 2006; Patel et al., 2006). Further, lower income has been shown to be associated with both shorter and longer sleep (Ferrie et al., 2007; Patel et al., 2006); therefore, it has been hypothesized that the association between short sleep and mortality may be due to socio-economic status.
The socio-economic hypothesis is fascinating. Of course there is also a connection between it and mortality, so it’s the perfect culprit, possibly explaining why sleeping more or less than about 7 hours is associated with higher mortality. Still, it’s only a hypothesis. And, I don’t really understand what mechanism would relate socio-economic status to shorter and longer duration sleep.
Both under adjustment and over adjustment present concerns. Not adjusting for enough variables could mean that some relationships are driven by third factors, and not by sleep duration. Over adjusting may remove some of the causal effects of sleep, if the covariate is on the causal pathway between sleep and mortality.
By the way, in a companion review some of the same authors write,
Over 40 years of epidemiological studies have examined the association between habitual sleep duration and risk of mortality. These studies, spanning several decades and continents, and including millions of study participants, have replicated the pattern that ‘‘short sleep’’ and ‘‘long sleep’’ (with varied definitions across studies) are associated with increased mortality relative to those in the normative group–usually this consists of those sleeping 7–8h. In addition, studies comparing several sleep duration groups have generally found that the further the deviation from the normative range, the greater the increase in mortality risk.
But notice the continual use of “associated” and nary a use of “cause.” All we can say is that sleeping about 7 to 8 hours is what healthy people tend to do. There’s no evidence sleeping longer is helpful, and it could be harmful.
* Not all studies used exactly the same comparison group, but the vast majority used 7-8 hours.
** Here are their control variables: age, race, education, occupation, marital status, exercise level, smoking at intake, years of smoking, churchgoing, fat in diet, fiber in diet, reported sleep duration, insomnia frequency, self reported illness or being “upset,” body mass index, leg pain, history of heart disease, hypertension, cancer, diabetes, stroke, bronchitis, emphysema, or kidney disease, sleeping pills, Valium, Librium, blood pressure medication, diuretics, Tylenol, Tagamet.
Austin and Aaron are participants in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com.
09/13/2016
Aaron Carroll
