Sleep_ Naturally by wpr1947


									      Sleep, Naturally

Kathi J Kemper, MD, MPH, FAAP
 Caryl Guth Chair and Director of
         the Center for Integrative
Wake Forest University School of
              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
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.
 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-
       4. Friendship with others
         (nurturing relationships)
       5. Fields: Environment
Healthy Habits, Healthy Habitat

       Relationships   Food

    Manage Stress
1. Food as Medicine
1. Food: Nutrition for Sleep
     Eat well earlier in day
     Avoid:
        Big, heavy meals late
        Caffeine (guarana, watch the
        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,
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,
         Meditation
         Biofeedback
         Hypnosis, guided imagery,
          inspiring stories, prayer, time in
          nature, CBT, artistic endeavors
3. Stress management:
     Meditation training ↑ left-sided
      anterior activation, a pattern
      associated with positive affect, in
      meditators compared with the
     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

       Low Arousal/Low
                              Institute of
 Stress, Emotion, and
Physiological Activation
  High Arousal/ High Energy

        Negative                       Positive
        Emotion                    Emotion


         Low Arousal/
          Low Energy
                                  Stress, Emotion, and
                                 Physiological Activation
                                        High Arousal/High Energy
       Frustration, Anger, Hostility,                                                        Exhilaration, Passion,
               Fear, Worry Anxiety                                                           Joy, Happiness

        Judgment, Resentment,                                                                       Love, Care,
Feeling Overwhelmed, Anguish
                                              Negative                       Positive
                                              Emotion                    Emotion               Kindness, Appreciation

    Hopelessness, Submission,                                                                     Compassion, Tolerance,
         Despair, Depression                                                                       Acceptance, Forgiveness

                      Burnout, Withdrawal,                                              Serenity, Inner Balance,
                          Boredom, Apathy                                               Reflection, Contentment

                                             Low Arousal/Low
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
 Significant improvements in sleep, even in
                   McLay RN, Appl Psychophysiol Biofeedback. 2009
                                      Morgenthaler T. Sleep, 2006
Stress Management: Compassion
      Extend good will to self or
       May you be safe and secure
       May you be healthy and
       May you be peaceful and
       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,
Healthy habitat: Sleep
  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 vigorous exercise right before bed
   GET MORE versus intentional sleep
   Aim for earlier; enough to awaken

 Supplements
 Massage
 Acupuncture
 Electrotherapy
 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,

 Dose: 0.3 – 3mg 1-2 hours
  before bed
 Products:
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
 (
 Decreases itch, pain,
  anxiety, depression; and
  improves sleep (Field T,
  multiple years and pubs)
 Can be done by parents
 Previously provided by
 Found in many nurseries
 Licensing for professionals
  varies by state

 Tiny needles, needles not
  always necessary (pressure,
  massage, laser, magnets,
 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.
(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

    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
           For exercise, go from sedentary, to 5
            minute walks with the dog 5 days a
           Be specific (with or without an MP3
            player; with or without a friend;
            regardless of weather?; distance vs.
   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
          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

           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

                    PRO                      CON
 Change     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)
Sample:                M   T   W   Th   Fri Sa   Su   Total
Walk dog 5 minutes 5
days a week            √       √   √    √   √          5
Week 1
Week 2
Week 3
Week 4
Next steps?
 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
 Massage, acupuncture, electrosleep
 Make a SMART plan consistent with family
  values and goals; follow-up
            More resources
 Mental Health, Naturally
   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

To top