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 self-management) 4. Friendship with others (nurturing relationships) 5. Fields: Environment
Healthy Habits, Healthy Habitat Relationships Food Fitness Manage Stress
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 Green cabbage Oranges Tomato Green Beans Clementine Pineapple Watermelon Radish Mango Summer Squash NF Milk Apple Figs Grapes 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 Instituteof HeartMath PARASYMPATHETIC
Stress, Emotion, and Physiological Activation High Arousal/ High Energy SYMPATHETIC “Fight-or-Flight” LOW PERFORMANCE HIGH PERFORMANCE Negative Emotion Positive Emotion PARASYMPATHETIC Low Arousal/ Low Energy
Stress, Emotion, and Physiological Activation High Arousal/High Energy “Fight-or-Flight” Frustration, Anger, Hostility, Exhilaration, Passion, Fear, Worry Anxiety Joy, Happiness Judgment, Resentment, HIGH PERFORMANCE Love, Care, LOW PERFORMANCE Feeling Overwhelmed, Anguish Negative Emotion Positive Emotion Kindness, Appreciation Hopelessness, Submission, Compassion, Tolerance, Despair, Depression Acceptance, Forgiveness Burnout, Withdrawal, Boredom, Apathy Serenity, Inner Balance, 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, ApplPsychophysiol 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 • Regular time; Routine • Hot bath; cool, dark room; • Massage before bed • Lavender, chamomile, melatonin? 5-HTP? 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 PaediatrNeurol, 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. NutrNeurosci, 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 NervMentDis, 1975) • No RCTs in children • No serious adverse effects reported
SMART Action plans • Specific, • Measurable • Achievable • Relevant • Time-specific)
Pick a specific strategy • 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 providetheir own rationalefor 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!
Plan celebrations/rewards • Pick a tangible rewardand 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).
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