Transcript Sleep, Naturally - American Academy of Pediatrics

Sleep, Naturally
Kathi J Kemper, MD, MPH, FAAP
Caryl Guth Chair and Director of
the Center for Integrative
Medicine
Wake Forest University School of
Medicine
Winston-Salem, NC
Faculty Disclosure Information
In the past 12 months, I have had the following
financial relationships
with the manufacturer of commercial product(s)
and/or provider(s)
of commercial service(s) discussed in this CME
activity:
Author of Mental Health, Naturally, published by the
AAP in 2010.
The presentation will include no description of
any proprietary items for screening, diagnosis,
or treatment.
I do not intent to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
Objectives
 By the end of this
presentation, you will be
able to
 Identify the fundamentals for
healthy sleep
 Describe the evidence
regarding safety and
effectiveness of dietary
supplements, melatonin,
massage, and acupuncture
 Use evidence-based
resources to counsel patients
to make optimal behavior
changes to improve sleep
5 Fundamentals: Healthy Habits in
a Healthy Habitat
1. Food
2. Fitness
3. Friendship with self (stress
and emotional selfmanagement)
4. Friendship with others
(nurturing relationships)
5. Fields: Environment
Healthy Habits, Healthy Habitat
Relationships
Manage Stress
Food
Fitness
1. Food as Medicine
1. Food: Nutrition for Sleep
 Eat well earlier in day
 Avoid:
 Big, heavy meals late
 Caffeine (guarana, watch the
chocolate)
 Alcohol
 Bedtime snack: Protein
(tryptophan) + carb snack (milk,
peanut butter and crackers)
1. Food: essential nutrients
for optimal brain function
 Omega-3 fatty acids
 Amino acids (SAM-E,
Trp, 5-HTP)
 Vitamins (B vitamins,
Vitamin D)
 Minerals (Iron,
Calcium, Magnesium,
Zinc)
Top Foods (scores > 90/100)
Broccoli
Oranges
Green Beans
Pineapple
Radish
Summer Squash
Apple
Grapes
Green cabbage
Tomato
Clementine
Watermelon
Mango
NF Milk
Figs
Bananas
Yale’s Griffin Prevention
Research Center, 2008
“Eat
food. Mostly plants. Not too much.”
M. Pollan. FOOD RULES
2. Fitness: Activity/Exercise
 30 -60 minutes of vigorous
exercise earlier in day
 NO vigorous exercise within
2 hours of bed
 Gentle stretching, yoga, Tai
Chi is OK
3. Friendship with self (manage
stress and emotions)
 Stress is common
 Stress makes it hard to sleep
 Managing stress: exercise,
sleep, nutrition,
mind/emotion/body/spirit
 Meditation
 Biofeedback
 Hypnosis, guided imagery,
inspiring stories, prayer, time in
nature, CBT, artistic endeavors
3. Stress management:
Meditation
 Meditation training ↑ left-sided
anterior activation, a pattern
associated with positive affect, in
meditators compared with the
non-meditators
 Positive effects on sleep for
meditation and meditative
movement (yoga)
 Few side effects; can combine
mindfulness with CBT
Davidson RJ Psychosom Med, 2003
Britton WB. Psychosom Med, 2010
Stress, Emotion, and
Physiological Activation
High Arousal/High Energy
SYMPATHETIC
Low Arousal/Low
Energy
PARASYMPATHETIC
Institute of
HeartMath
Stress, Emotion, and
Physiological Activation
High Arousal/ High Energy
SYMPATHETIC
“Fight-or-Flight”
Negative
Positive
Emotion
Emotion
PARASYMPATHETIC
Low Arousal/
Low Energy
Stress, Emotion, and
Physiological Activation
High Arousal/High Energy
“Fight-or-Flight”
Frustration, Anger, Hostility,
Exhilaration, Passion,
Joy, Happiness
Fear, Worry Anxiety
Judgment, Resentment,
Feeling Overwhelmed, Anguish
Love, Care,
Negative
Positive
Emotion
Emotion
Hopelessness, Submission,
Despair, Depression
Kindness, Appreciation
Compassion, Tolerance,
Acceptance, Forgiveness
Burnout, Withdrawal,
Serenity, Inner Balance,
Boredom, Apathy
Reflection, Contentment
Low Arousal/Low
Energy
Stress management: biofeedback
 HRV biofeedback: useful adjunct for anxiety,
depression, pain – all adversely affect sleep
 “biofeedback and paradoxical intention are
individually effective therapies in the
treatment of chronic insomnia “Board of
Directors of the American Academy of Sleep
Medicine
 Significant improvements in sleep, even in
combat
McLay RN, Appl Psychophysiol Biofeedback. 2009
Morgenthaler T. Sleep, 2006
Stress Management: Compassion
Extend good will to self or
another:
 May you be safe and secure
 May you be healthy and
comfortable
 May you be peaceful and
content
 May you have good friends
 May life go easily for you
Supportive relationships
 Don’t go to bed mad (or sad
or worried)
 Social support protects
mental health
 Rx: spend time with friends
 Volunteer – those who help
others feel better about
themselves; mentor, tutor,
coach, babysit
 Join clubs, leagues, scouts,
church
Healthy habitat: Sleep
environment
 Bright light in early morning
 Sleeping room DARK (watch night
lights, electric clocks, computer
screens), cool, comfortable
 Turn off TV an hour before bed
 Quiet, white noise, or relaxing,
soothing (NOT dance along or sing
along) music
Sleep hygiene
 Daytime routines
 Exercise
 Light
 Healthy diet
 Good relationships
 Bedtime habits
Bedtime habits




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
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Regular time; Routine
Hot bath; cool, dark room;
Massage before bed
Lavender, chamomile, melatonin? 5HTP? Valerian?
No caffeine within 8 hours of bedtime
Music, calm, orderly, quiet
NO TV IN BEDROOM
NO vigorous exercise right before bed
GET MORE versus intentional sleep
reduction/deprivation
Aim for earlier; enough to awaken
refreshed
Extras
 Supplements
 Massage
 Acupuncture
 Electrotherapy
Melatonin
 Hormone, not herb
 Helpful for sleep onset insomnia
in ADHD (Bendz, LM. Ann Pharmacother, 2010)
 Can use for sleep EEG or
brainstem audiometry (Ashrafi MR, Eur
J Paediatr Neurol, 2010; Schmidt CM. Neuropediatrics,
2007)
 Dose: 0.3 – 3mg 1-2 hours
before bed
 Products: ConsumerLab.com
Sedative herbs: valerian, chamomile,
hops, lemon balm, passion flower)
 Valerian: yes 400 mg; smells bad, but
works (Morin CM, Sleep, 2005; Koetter U. Phytother
Res, 2007; Bent S. Am J Med, 2006)
 Chamomile tea; little data, generally
safe, allergies possible
 Hops: sleep pillow and teas;
sometimes combined with valerian
 Lemon balm; tea
 Passionflower: tea
Meolie AL. J Clin Sleep Med, 2005
Amino Acids: TRYP, SAM-E
 Acute tryptophan depletion leads to depression
 Dietary L-tryp -> 5-HTP -> serotonin -> melatonin
 Meta-analysis: 5-HTP and L-tryp better than placebo for
depression (Shaw K, Cochrane. 2002)
 DB Xover trial in infants; cereal supplemented with 225
mgtryp improved sleep
 Food sources – dairy, eggs, poultry, soy, nuts; WHEY
 Cubero J. Nutr Neurosci, 2009
 SAM-E Produced from ATP and methionine
 Meta-analysis: SAMe significantly improves depression,
comparable to antidepressant medications ; effects on
SLEEP are indirect via mood
 (http://www.ahrq.gov/clinic/epcsums/samesum.htm)
Massage
 Decreases itch, pain,
anxiety, depression; and
improves sleep (Field T,
multiple years and pubs)
 Can be done by parents
 Previously provided by
nurses
 Found in many nurseries
 Licensing for professionals
varies by state
Acupuncture
 Tiny needles, needles not
always necessary (pressure,
massage, laser, magnets,
cupping)
 Acceptable for kids with proper
demo (model on parents )
 Meta-analysis of 46 trials:
significant benefit (Cao H.
JACM, 2009)
2009 meta-analysis Acupuncture
 46 RCTs with 3811 patients
 Meta-analyses showed a beneficial effect of acup
compared with no treatment (p = 0.02; 4 trials) and real
compared with sham acup(p = 0.04; 2 trials) on
Pittsburgh Sleep Quality Index.
 Acup superior to medications for total sleep duration
increased for >3 hours (p < 0.0001).
 Acupuncture plus medications better than med alone
on total sleep duration (p < 0.0001).
 Acup + herbs better than herbs alone (p = 0.01).
 There were no serious adverse effects related to
acupuncture treatment in these trials.
Electrosleep
(Cranio-electrotherapy stimulation)
 TENS-like device applied to earlobes
or occiput bilaterally
 Invented in USSR 1949
 Most studies in Russia and France
 Can help with insomnia, even anxiety,
depression or those going thru drug
withdrawal (Philip P. Biol Psych, 1991; Gomez E, Br J
Psychiatry, 1979;Templer DI. Can Psychiatry Assoc J, 1975;
Carwright RD. J Nerv Ment Dis, 1975)
 No RCTs in children
 No serious adverse effects reported
SMART Action plans
 Specific,
 Measurable
 Achievable
 Relevant
 Time-specific)
Pick a specific strategy




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More exercise early in day
Better nutrition
Judicious use of supplements
Healthier environment
Stress management;
biofeedback; journal; meditation
 Massage, psychotherapy,
acupuncture or other
professional help
Identify a small, achievable step
 Rome was not built in a day; habits
are not changed overnight: BABY
STEPS.
 For exercise, go from sedentary, to 5
minute walks with the dog 5 days a
week.
 Be specific (with or without an MP3
player; with or without a friend;
regardless of weather?; distance vs.
time)
How important is this to you?
0 1 2 3 4 5 6 7 8 9 10
Not
Very
Why did you pick that number and not a lower
number? (e.g. a 7 instead of a 5)
Asking this question helps the patient/family provide
their own rationale for why this is important. They
talk themselves into it!
How confident are you that
you can do this for one
month?
0 1 2 3 4 5 6 7 8 9 10
Not
Very
If they pick an 8 or higher (pretty confident), proceed with
next step of making a chart and planning rewards and
follow-up.
If they pick a number less than 8,
“What would it take for you to go from the number you
picked to a higher number?” Begin to explore their
ambivalence…. It’s OK to be ambivalent about change!
Identify Pros and Cons
Change
PRO
CON
More cheerful
Change routine
More fit and cool
Brother might tease
Clothes fit better
Yucky dog clean up
Better sleep
No Change
Easy
Continued mood probs
Mom does yucky job
Get fat
Feel ugly
Sleep badly
Unhappy with myself
Plan celebrations/rewards
 Pick a tangible reward and
timing (will it be offered after
week 1, 2, 3, 4?)
 Samples: new walking shoes;
stickers; choice of movie.
 Support the patient’s choices.
 Emphasize the importance of
the reward/celebration. If the
patient says they expect “good”
behavior, suggest they consider
celebrating it (instead of
rewarding it).
Sample behavior diary (OK to copy)
Goal
Sample:
M
Walk dog 5 minutes 5
days a week
√
Week 1
Week 2
Week 3
Week 4
Re-evaluate.
Celebrate.
Next steps?
T
W
Th
√
√
Fri Sa
√
√
Su
Total
5
SUMMARY
 Focus on fundamentals: food (watch
caffeine, alcohol, xs meals; bedtime
snack?);fitness; friendship with self
(manage stress and emotional states);
friendship with others; healthy environment
 Routines at bedtime; no TV in bedroom
 Supplements: melatonin, valerian/hops;
lavender aromas; chamomile, lemon balm
tea
 Massage, acupuncture, electrosleep
 Make a SMART plan consistent with family
values and goals; follow-up
More resources
 Mental Health, Naturally
 www.wfubmc.edu/cim
 Action Plan Trackers for Change･
 Pros and Cons of Change Worksheet･
 Action Plan Tracker for Successful Change
for One Week･
 Action Plan Tracker for Successful Change
for Four Weeks
 Action Plan Tracker for Several Changes