Video: Ep 12: Childhood and Adolescent Sleep Tips (A Better Night’s Sleep Podcast)
[music] [Dr. Julie Kinn] This is “A Better Night's Sleep,” the podcast about sleep, sleep disorders, and evidence-based treatment from military health sleep experts. I'm Dr. Julie Kinn with the Defense Health Agency. And today, I'm pleased to introduce Col. Brian Robertson from Walter Reed. Welcome, Col. Robertson. [Col. Brian Robertson] Hi, Julie. How are you doing today? [Kinn] I'm great…I am very excited today, if you could tell, because our listeners have been sending us many questions about sleep for children — and how to get kids started on a good night's sleep.
Since we are especially interested in improving readiness and resilience in the Defense Health Agency, we know it's important to also make sure our kids are getting a good night's sleep. If they're waking you up at 2 a.m., you are probably not going to feel well-rested when you wake up in the morning. I know you have several specialties, including allergies, which we'll get to in a future episode, and also children and family sleep issues. So today, I'm hoping you can walk us through some of the basics of helping kids get good sleep, so that we can, too. [Robertson] That sounds great. Let's talk about it. [Kinn] Well, why don't we start with elementary school-aged children? What do you recommend to parents to help them get a good night's sleep? [Robertson] So, there's three things that we recommend to parents.
The first is that children sleep on a regular basis. So that means going to bed and then waking up at the same time every day, give or take an hour…everybody sleeps a little late on the weekend, and that's OK, but we try to keep that sleeping late to just about an hour or so. The second thing is that they get enough quantity, and the quantity varies from child to child, and it also varies with age. So, we know that newborns sleep up to 19 hours a night for sleep, and then as you get older, you sleep less and less. By age 10, our rule of thumb is that 10 year-olds sleep about 10 hours a night. And that's the general recommendation. So if you're less than 10, a little bit more sleep. A 5 year-old might need something like 11 to 12 hours of sleep.
And then the third part that's…the third quality that's really important is quality of their sleep. So sleep needs to happen in a good environment for sleep, and the child needs to have…be relatively free of all kinds of conditions that can interfere with their sleep. [Kinn] Like what? What kind of conditions are we talking about? [Robertson] Well, so…one condition is having reflux. So, reflux from the stomach can actually cause people to stop breathing during their sleep, just briefly. And it also can cause inflammation in the upper airway, and that inflammation can make your airway a little tighter, and it can make it harder to breathe. Because children are small and their airways are small, even a little bit, even a few millimeters of inflammation can make a big difference in how easy it is for the child to breathe. [Kinn] So when you say inflammation, are we talking about mucus or cold symptoms? [Robertson] Right, good question.
So, it means both things. So it means the tissue that lines the inside of your nose and the back of your throat is actually swollen a little bit, just like your eye would swell if you got a black eye. And then it also means that there's more mucus — more mucus production. In fact, reflux is one of the reasons why children cough during the day and at night, and it's one of the reasons why people have inflammation in their upper airway and their back of their nose. [Kinn] So this isn't just when a child has a cold; this could be an ongoing condition? [Robertson] Right, right. So this is a chronic problem. And this is one of the things that we look for when we see children in our clinic, is we assess them for reflux symptoms. [Kinn] I always thought it was just something that affected babies and toddlers. [Robertson] It does affect babies and toddlers, but it affects adults, too, and it affects everybody in between, including all our elementary kids. [Kinn] Wow. This is going to strike a note with a lot of our listeners, I'm sure.
So, what do you recommend if we think our child might have reflux and that that's causing some of this inflammation or runny-nose symptoms? Should we make an appointment with an allergist or primary-care doc? Or are there at-home things we can try first? [Robertson] So, that's an interesting question. So, one of the things — so a risk factor for having reflux is being overweight or obese. Having, maintaining a good, healthy weight is important — that would be number one. There are certain foods that make reflux much more likely, especially during sleep. So, my favorite example of a bad food to eat before nighttime is pizza. [Kinn] Oh, really? [Robertson] Yeah. So pizza has a couple of things that will make reflux worse. The first is that there's a lot of fat involved, and, as you know, it takes a long time for our stomachs and intestines to digest fat, and that fat from pizza sits in the stomach for a long period of time, and it keeps your stomach full. A full stomach is more likely to reflux. The second thing is that there's tomatoes in there, especially cooked tomatoes. So cooked tomato increases the chance of reflux. There is a chemical in cooked tomatoes that makes the lower esophageal sphincter, which is this sort of muscle around the bottom of your esophagus that keeps food in your stomach– it makes that muscle loosen up, and that makes reflux more likely.
[Kinn] No kidding. [Robertson] So pizza is a bad choice. [Kinn] So what's a good choice? [Robertson] A good choice would be something that's light, so relatively low fat, and small. So small portions, not too large of a portion. A healthy salad or some vegetables with perhaps some lean protein would be an excellent meal. [Kinn] So does this generally resolve on its own, or is reflux something that needs to be managed? [Robertson] We do use medications to treat it, and those medications are primarily involved in decreasing the amount of acid that is in the stomach contents. It doesn't stop the fluid from coming up, but it makes it hurt less, and decreases the amount of inflammation that is present. [Kinn] It just strikes me that there's a lot of similarities to sleep apnea. [Robertson] So, it's funny you mention that. Esophageal reflux is one of our CORE diseases, is what we call them.
The “C” stands for cough or asthma, the “O” for obstructive sleep apnea, the “R” stands for rhinitis, so inflammation in the nose, and then “E” for esophageal reflux. [Kinn] I imagine that some of our listeners are experiencing a couple of those. [Robertson] Well, they often go together. So when we see one, we look for the others. And these diseases, through a lot of research, what we've found is that these things are related to each other, and they affect each other. So, if you have bad reflux, you tend to have more nasal inflammation for the reasons I've already described, and you also tend to have more obstructive sleep apnea, and actually, you tend to have more asthmatic symptoms. Something happens that's called micro-aspiration where a little bit of those stomach contents gets breathed — you breathe it in to the upper airway, and that causes inflammation.
[Kinn] It strikes me that our episode that's going to come up down the road about allergies, we’ll also, we'll need to bring up these CORE symptoms again. [Robertson] We'll bring them up again, too. [Kinn] OK, listeners. So please stay tuned for that one. So I'd like to come back to the quantity of sleep. You mentioned that 10 year-olds should get about 10 hours of sleep or so. What about as our kids get a little bit older into junior-high, high-school aged? How do we help them get a good night's sleep? We're not really doing the bedtime routines anymore of the nightly bath and reading them a story. What do you suggest? [Robertson] We treat people of all ages from newborns to people in their 90s. The people that seem…the one group of people that seem to have the most problems with sleep tend to be high schoolers. And there's… [Kinn] Really? [Robertson] Yes, so, there's a couple reasons for it.
So one is that they — so high school tends to start a little bit early, earlier than high schoolers are used to waking up. And if you have a high schooler at home or you've been a high schooler, you know that you want to do two things, and that is you want to stay up late and you want to wake up late. This is not compatible with most high-school schedules; in fact, in some parts of the country, including nearby here in Fairfax County, Virginia, there's been a move to move high-school start times later, to accommodate this natural phase shift in the sleep patterns of adolescents. [Kinn] Can we get you to weigh in on that? What do you think? [Robertson] Sure. I think it's a great idea. So, it is just very difficult. I can recall…and I'll tell you a story. So one of my patients had what we call phase delay. This is where that tendency to go to bed late and wake up late is very severe. This particular teenager was homeschooled.
And it actually didn't cause him any problems. He was a very good student, and what he would do is stay up until three or four in the morning, get up around noon, do his homeschool work until he was finished. It took him about four hours typically. And then he had the rest of the day free. And that was how he lived his life. And because of this accommodation in his schedule that was allowed him by his parents and by his homeschool schedule, it worked well for him. But, that is the exception. The general…most of our children are not homeschooled, and those children have to get up early. Sometimes they have to get up early because of school start times, and sometimes it's because of sports. And sometimes it's because of their parents' schedule, too. Starting the day later is one of the best things you could do for your teenagers. And I urge parents that have concerns about their teenager's schedule, and the amount of sleep that they're getting, to talk to their schools. It is possible for school times to change.
[Kinn] That is really fascinating. I know I've read about that in the news before, but it's really fantastic to hear about it from an expert. So, what other things can we do as parents to help our teenagers get good sleep? [Robertson] So, prevention is best. If you want to have good sleep, it's important not to develop sleep problems and bad sleep habits. So, a couple of things that we can do for just general, good sleep health: The first is your sleep environment. So, if you think about the best situation for your sleep, you want it to be quiet. You want it to be relatively cool. We know that people sleep better when the air temperature is a little bit cooler than…it needs to be usually around 70 to 75 degrees. It needs to be dark. Even some light coming in through the window can disrupt your sleep, so a dark, quiet room. I always think of a hotel room, a good hotel room, as one of the ideal places.
Those places are designed for people to get a good night's sleep, and they have those qualities. They're quiet, they're dark, and they're relatively cool. [Kinn] OK. So a follow-up question about quiet: What do you think about white noise machines or fan noises? I know some parents like having noise machines to dull some of the extra noise, but others say, "No, I want my kids to get used to outside noise and dogs barking, so that they can sleep through anything later on." What do you think? [Robertson] First of all, there's not a lot of literature on is this a good idea or not. So, from a medical perspective, I can't really say that you should or shouldn't do this. I can tell you one of the reasons people do use them is that people sometimes have trouble falling asleep and quieting their minds. And sometimes giving your mind something to focus on, just a little bit, helps people fall asleep. One of the techniques we use for people with insomnia, for instance, is actually having them not try to go to sleep, we actually want them to just stare at the ceiling.
And the reason that we do that is to give their minds a place to focus. If you're just laying there with your eyes closed and you're not ready to go to sleep, what happens? You start thinking. Right? You start thinking about your day. You start thinking about tomorrow. You start thinking about all the problems that you have, and then you can start dwelling on these things. What you have to do is be able to clear your mind, and this is one way to do it. These noise machines do the job. Staring at the ceiling does the job. Some really easy forms of meditation often do the job. For religious people, often a rote prayer can actually work well for this purpose. [Kinn] I just want to remind listeners about one of our other podcasts, called the “Military Meditation Coach,” that does take you through a huge variety of meditation and mindfulness exercises, some of which we made specifically for children and families. And of course, we have the Virtual Hope Box app, which includes diaphragmatic breathing training and some guided meditations, as well as the Breathe2Relax mobile app, also can teach you how to do deep-belly breathing.
All of these are free for military beneficiaries and civilians. I know we're almost out of time, so are there any last words you've got about prevention to help our kids get on a good start towards a lifetime of good sleep? [Robertson] Well, children are a little bit different than adults in one important way: When adults get sleepy, we tend to nod off, sitting in the easy chair or something like that. We move slower and take it easy. Children are not like this, and all the parents out there will know this…this is what happens: Your child gets tired. They start getting emotional, crying very easily over very, very small inconveniences to their plans. Sometimes they can get very hyper, too. So a sign of a child being very sleepy, is that they're actually a little bit hyperactive. And a lot of those phenomenon happen right before children go to bed. So, one of the psychologists I work with talks about the “forbidden hour”. So it's that hour…it's about an hour and a half to two hours before they go to bed when children get very amped up and active, and they want to play and run around.
And if they get corrected, they're kind of emotional about it. They may start crying about things. So know that that happens. Don't get angry with your child. And this is when you need to help them get ready for bed. And so children, and everybody else, we're all operating at a high level. When we go to sleep, we’ve got to bring things down. And think of a plane flying at 30,000 feet. It's got to land. You’ve got to calm down before you can get to sleep, and so children need to get to that point where they're quiet, still, and relaxed. Most parents do this by reading a bedtime story or singing songs with their children. Those are awesome ideas. For as many children out there, there's probably as many — and parents — there's probably just as many ways to get everybody to calm down and relax.
Meditation works, it works for young children, you can do that with them. Prayers work. That's another good method that's tried and true. Some way to get from operating at 30,000 feet to landing on the ground and falling asleep, that's what they need. [Kinn] It sounds like parents could fall into this trap, I know I have fallen into this trap, of when your kids bring up some sensitive topic right at bedtime, I tend to think, "Oh, they're just trying to avoid going to sleep." But it could just be that they truly are more sensitive at this time of the evening. And it sounds like we should avoid having deep, philosophical conversations, especially about death and the meaning of life, right at the end of the night, especially since our children might be touchier and grouchier when they're tired, just like many of us are touchier and grouchier when we're tired, too.
[Robertson] Right. So that's a great point. So it isn't just the children that are a little bit more emotional than usual, but it's the adults, too. You've had a long day. The kids are acting up. You just want to go to bed so you can get some rest. And so you have to remember that you're probably not dealing with confrontation well at this time of the day either. And this isn't the time to solve your problems; it's the time to relax, and it's time to go to sleep. [Kinn] Right. Not the best time to solve these problems; they can wait. What was it you said? Quiet, still, and relaxed? [Robertson] Quiet, still, relaxed. So this is what I would ask parents and children to remember when they want to go to sleep. You need to be quiet — you need to stop talking. You got to hold your body still, or relatively still. And then you got to relax your mind and just let yourself fall asleep. [Kinn] Great.
Thank you so much, Colonel Robertson. [Robertson] You're welcome. It was great to be on the show. [Kinn] [music] Thank you so much to those of you who've sent in questions and feedback. We are on Facebook and Twitter @MilitaryHealth, or you could just use the email address in the show notes. Thank you very much for rating and subscribing to us on iTunes or wherever you get podcasts. “A Better Night's Sleep” is produced by the Defense Health Agency. [music].