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Lights out! How sleep relates to health and what you can do to promote both in new families JENNIFER DOERING, PHD, RN ASSOCIATE PROFESSOR

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Presentation on theme: "Lights out! How sleep relates to health and what you can do to promote both in new families JENNIFER DOERING, PHD, RN ASSOCIATE PROFESSOR"— Presentation transcript:

1 Lights out! How sleep relates to health and what you can do to promote both in new families JENNIFER DOERING, PHD, RN ASSOCIATE PROFESSOR DOERING@UWM.EDU (414) 229-5716

2 Learning Objectives 1.Discuss how maternal and infant sleep patterns change over the first year after birth. 2.Recognize relationships between sleep deprivation and maternal depression symptoms. 3.Implement 3-5 strategies to promote the self-management of parent and infant sleep. Shout out your goals for this session

3 Take Home Messages Parent sleep is important to physical and mental health, home and work safety Postpartum sleep is highly fragmented Setting realistic expectations with families Postpartum sleep can take months to improve There are many practical and evidence-based suggestions you can help parents to integrate into their lives

4 Model of Impaired Sleep ADVERSE HEALTH OUTCOMES SLEEP DEPRIVATION SLEEP DISRUPTION Lee, 2003 Not enough sleep Fragmented sleep Physiological Cognitive/behavioral Emotional Social Safety/Injury

5 Two main causes of Sleep Loss people come to parenthood with 1) Lifestyle/occupational We are a sleepless society 24 technology (TV/Internet), lifestyle, pressures/busy, shift work Disrupted circadian rhythms 2) Sleep Disorders 50-70 million Americans believed to have a chronic sleep disorder Over 90 different disorders Obstructive sleep apnea, insomnias, restless leg syndrome, circadian rhythm disorders…

6 Societal Costs of Sleep Loss Sleep loss affects an individual’s: Performance Safety Quality of life Direct cost of insomnia (1995) was $13.9 billion $150 billion: Annual fatigue-related lost worker productivity, absenteeism, workplace accidents (2001) 20% serious car crash injuries sleep-related (unrelated to ETOH) (Connor, et al., 2002) Reaction time with 24 hours total sleep deprivation =.12 blood alcohol level Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem (2006) Board on Health Sciences Policy (HSP)

7 Effects of Sleep Deprivation And Nurses

8 General Consequences of Sleep Deprivation  Excessive daytime sleepiness  Performance impairment  Adversely affects attention, memory, reaction time, executive functions  Mood alterations  Severity of effect depends on whether sleep deprivation is partial, total, acute, or chronic  When sleep onset delayed, slow-wave sleep ↓, REM ↑ (healing implications)

9 Chronic sleep loss (< 7 hours sleep/night) Affects cardiovascular, immune, and nervous systems, including: ◦Obesity in adults and children ◦Diabetes and impaired glucose tolerance ◦Cardiovascular disease, heart attacks, hypertension ◦Stroke ◦Anxiety symptoms ◦Depressed mood ◦Alcohol use

10 Health Effects of Cumulative Sleep Loss Relationships often curvilinear where: Too little (< 5 hours) or Too much sleep (> 9 hours) Over time, either condition found 10% increased mortality risk from all causes 1 week of severe sleep deprivation (~4 hours/ night) can put a healthy, lean, fit person into pre- diabetetic state physiologically (Van Cauter et al., 2007)

11 Normal Sleep What Why How A very brief review….


13 Basic Adult Sleep Parameters (Morin, 1993) 2/3 of population sleep 7 - 8.5 hours/night Only a few sleep less (4-5 hrs) w/o impairments Sleep onset latency (time to fall asleep) Normal = 5 - 10 min < 2 minutes = sleep deprivation > 30 min = initiation insomnia Sleep efficiency (time asleep / time in bed) ≥ 85% Wake after sleep onset > 30 min = maintenance insomnia (plus other criteria)

14 Modern families

15 Why and How do we sleep? There are several models of sleep regulation…one example is: Two-process model says the sleep-wake cycle regulated by interaction between: ◦Sleep-dependent homeostatic process (process S) Meaning….we accumulate and release pressure to sleep over 24 hour day ◦Sleep-independent circadian process (process C) Meaning…sleep is regulated by diurnal day/night pattern of earth (Lee-Chiong, 2006) Image from:

16 Normal Sleep (Lee-Chiong, 2006; Morin, 1993) Two States Non-rapid eye movement (NREM) Rapid eye movement (REM)

17 NREM Repairs, regenerates tissues, bone, immunity Four Stages Stage 1 ◦3-8% total sleep time ◦transition stage wake -> light sleep Stage 2 ◦45-55% total sleep, begins ~10-12min after stage 1 starts Stage 3 and Stage 4 ◦Slow wave or ‘Delta’ sleep ◦15-20% total sleep time ◦Thought that physical healing is accelerated slow wave sleep ◦Important for feeling ‘rested’

18 REM Sleep 20-25% of total sleep time Dreams Purpose not certain Two Stages Tonic ◦Atonia of muscle groups (body paralyzed) Phasic ◦Rapid eye movements, BP swings, HR, irregular respirations, tongue movements, myoclonic twitching chin & limb muscles

19 NREM-REM Cycle Sleep is highly organized 1 cycle ~ q 90 minutes ~ 4 - 6 cycles/sleep episode Variations within cycles Slow-wave sleep occurs earlier in night (key point for postpartum women) REM more frequent later in night

20 NREM-REM Cycle (~90 minutes) Drowsiness -> Stage 1 (~5 min) -> Stage 2 (10-20 min) -> Stages 3 and 4 (20-40 min) -> Stage 2 -> REM REM starts 70-90 min after sleep onset. Initial REM is brief lasting 5-15 min, increases subsequent cycles

21 Group Case study: Kelly Kelly is a 26 y/o first time mom with a 1 week old baby. Kelly had a c- section and has been home for 4 days when you visit her. Kelly’s is managing her pain ok, but still feels like her uterus is going to ‘fall out’ when she bends forward. She’s been really struggling to breastfeed more than formula feed, get adequate amounts of sleep and describes her life so far as ‘complete chaos’. Kelly’s own mother is staying with her the first 6 weeks and has been very helpful and gotten up to feed the baby with the baby a couple times, but Kelly thinks she should be able to take care of the baby at night herself. “I should be able to do it all, but I’m just so exhausted”. Question: Based upon what you know about slow-wave sleep, what practical suggestions could you make to Kelly and her mother to maximize Kelly’s sleep?

22 Some Common Sleep Disorders Insomnia ◦Problems initiating or maintaining sleep Narcolepsy ◦Excessive daytime sleepiness and muscle weaknesses ‘sleep attacks’ at inopportune times Restless Legs Syndrome (RLS) ◦Creeping sensation in the legs relieved by movement, common in pregnancy Obstructive Sleep Apnea ◦Breathing stops during sleep, airway obstructed

23 Perinatal Sleep and Sleep Loss Setting the stage

24 Barbara Katz Rothman (1989) “New parenthood in America is experienced as above all else an exercise in sleep deprivation”

25 Sleep During Pregnancy 1 st trimester 10-15% report disturbed sleep due to nausea, vomiting, backaches, urinary frequency 2 nd trimester Fetal movements, heartburn 3 rd trimester Self-report average 2.6 awakenings/night, 7.5 hrs sleep Objective measures: 7 hrs sleep, awake 12% of night Sleep quality decreases as labor approaches

26 Sleep During Pregnancy Last month pregnancy, ↓ slow wave sleep Through pregnancy sleep efficiency ~ stable at 90% ( < 85% pathological) Sleep quality decreases as labor approaches.

27 Sleep during labor and birth (intrapartum) Women who sleep < 6hrs/night for a few weeks leading up to birth have Average 12 hours longer labor 4.5x more likely to have c/s than women who sleep >7hrs Sleep loss in labor associated with early postpartum emotional distress Lee, 2006 chapter in SLEEP

28 How much sleep is normal postpartum? ◦50 primip and multip mothers followed 2-16 weeks postpartum ◦Avg 27 yrs, college educated, middle-class, white ◦Total night sleep average: 7.2 (±0.95) hours/night over 4 months ◦Total nighttime sleep did not change significantly weeks 2-16 ◦Total sleep efficiency did improve 2-16 through less sleep fragmentation Montgomery-Downs et al. 2010 Am J Ob & Gynec In comparison: ◦My study results of 118 low-income women in Milwaukee at 4 and 8 weeks postpartum, 72% African-American, 12% Hispanic ◦Spent 8 hours in bed/night ◦5.4 hours asleep/night ◦Length of sleep did not improve from 4 to 8 weeks

29 Postpartum sleep Moms of infants who ‘room-in’ (hospital) have: Lower sleep efficiency, shorter REM latency No difference in slow-wave-sleep or REM sleep amount Sleep efficiency drops from 90% in 3 rd trimester to: 77% in first-time moms in 1 st month 84% in mothers having 2+ child In all moms, ↑slow wave sleep, ↓ stages 1 and 2 Sleep fragmentation (waking 2+ times/night) More disrupted sleep birth to 3 months: First-time momsC/section When I wanna go to sleep, she don't wanna go to sleep, and I gotta fight through the sleep, and try not to fall asleep while I'm feeding her. (209)

30 To know how a mom sleeps, look to how her newborn Sleeps Newborns sleep 70% of every 24 hours Have 3 sleep states: active sleep (REM), quiet sleep (NREM) and indeterminant sleep (non-REM or NREM) 10-12 weeks is a period of re-organization Sleep behavior and physiology matures Total sleep time (TST) in a 24 hour period Birth = 16-17 hours 16 weeks = 14-15 hours 6-8 months = 13-14 hours

31 Newborn and Infant Sleep At 3 weeks, the average length of longest sleep is 3.5 hrs 6 months = 6 hrs Sleep periods lengthen between 3 and 6 weeks By 6 wks, longest sleep period occurs at night Instead of randomly distributed during the day Sleep is the primary activity of the brain during early development Teach parents importance of sleep for newborn and children as they grow

32 Case Study: Erin You are visiting Erin (24 years) at 3 weeks postpartum. Erin had an uncomplicated vaginal birth of her second baby at 37 weeks. This baby is nothing like her first, who at 3 years old now, was an ‘easy’ baby and slept rather well. Erin is very distressed, because her baby ‘sleeps all day’ and is ‘up all night’ while her 3 year old sleeps all night and naps once during the day for about 2 hours. You want to set some realistic expectations about newborn sleep. What can you tell Erin about how newborn sleep to help relieve Erin’s distress? Start to think about what practical suggestions you might offer Erin get her baby’s sleep schedule better aligned with her family’s….

33 Sleep and adult depression Sleep abnormalities/complaints Diagnostic components of depression Initiation insomnia Maintenance insomnia Feeling unrested upon awakening Persist beyond remission/treatment of depression Increase risk of suicide and depression relapse 30% with depression experience hypersomnia (12-14 hrs/night)

34 Sleep changes in depression Changes to sleep architecture include: ↑ sleep latency, ↑ stage 1 ↑ wakefulness after sleep onset ↑ total REM time Early onset REM ↓ slow wave sleep

35 Postpartum depression 10-20%: Lifetime incidence of depression 1 in 5 women will have depression in pregnancy or postpartum 50% + will go undetected and undiagnosed Untreated depression can become chronic, episodic Moderate-severe impact on infant neuro-biological development

36 Postpartum Depression Symptoms at least 2 weeks to make a diagnosis – see DSM-5 criteria Symptoms start anytime in first year after birth ◦Most symptoms start 2-4 months postpartum Anxiety often is a major feature (co-morbid) Episodic, but without treatment can turn chronic ◦Most moms will feel better in 6 months even without treatment, but then will re-occur. ◦Moms with untreated depression that turns chronic are likely to still have depression symptoms at 2 year (Horowitz, 2007, 2009)

37 Sleep and Postpartum Depression Hallmark symptom ◦Being unable to fall asleep easily or return to sleep once woken in the night ◦Problematic with an infant who wakes every 2-3 hrs Is a mom just exhausted/fatigued/over-tired? ◦Or is she depressed? How might see sleep, depressive symptoms and anxiety interacting specifically in your postpartum clients? I have five kids and it’s exhausting and I don’t know how to get no sleep at all. (202, 1 month)

38 Screening for sleepiness Know about it – consider whether worth using in your practice ◦This tool commonly used in primary care and sleep clinics Epworth Sleepiness Scale [See Handout] ◦Free ◦Brief ◦Excellent first step ◦Sleepiness is a major sign of underlying sleep problems ◦Increase awareness there might be an issue ◦Scoring ◦Score 9 or higher, seek medical advice for assessment for underlying sleep disorders

39 Interventions to promote sleep All the following interventions need adaptation to the individual and family context

40 Rallying Social Supports Be strategic with social support use to maximize benefit to both ◦Splitting the night ◦One partner wakes with baby for a 6 hour period ◦8p-2a, 2a-8a; 9p-3a, 3a-9a, 10p-4a, 4a-10a ◦Allows for 5-straight hours of sleep (with time to fall asleep). Helps reset circadian rhythms ◦Some ‘straight sleep’ better than no straight sleep ◦Goal: twice/week? Alternate nights so 1 partner gets 5 straight hours of sleep each night? ◦Preference is for mother to sleep first ◦Promote postpartum healing by maximizing slow wave sleep Other strategies women describe: ◦Mother up early, returns to bed to sleep later into morning ◦Weekend sleep (ship kids off to a relative and sleep 12+ hours) 5 hours uninterrupted sleep is important physiologically Creatively work with clients to figure out how to get it

41 Nutrition/diet Interventions to promote sleep Limit Caffeine (recommend none after 2p) Alcohol Suppresses REM and slow wave sleep Helps put you asleep, then wakes you up Fluid intake after 7-8p (nocturia) Overall diet quality & portion control Refer to

42 Nutrition Interventions Small protein snack before bed Protein increases ability to make protein- based hormones like melatonin to regulate circadian rhythms Consider screen for Iron-deficiency Anemia Low hemoglobin can predict depression symptoms Resources about food and sleep -topics/food-and-sleep

43 Smoking and sleep Nicotine (stimulant) ◦Increase time to fall asleep ◦Spend less time in deep sleep (nicotine withdrawal may be mechanism) ◦Feel less rested than non-smokers Support cessation and relapse prevention ◦80% who quit smoking in pregnancy relapse postpartum (stress thought to be a key factor)

44 Sleep Environment Interventions Decrease exposure to nocturnal light TV Computer Cell phone, alarm clock If light needed, use indirect light (not shining in your face) Foot of bed, low to ground Reduce environmental noises White noise (fan, white noise machine) can help reduce awakenings Consider quality of sleeping place Mattress, pillow, couch

45 Environmental Interventions In the bedroom Sleep and Sex. Early morning natural light Open those curtains Helps both mom and baby (develop cycles) Sleep cooler = sleep better Turn down heat, put on more blankets Ideal sleeping temp with an infant is 65-72F Resources “Sleep Hygiene”: expert/sleep-hygiene expert/sleep-hygiene

46 Lifestyle Interventions Exercise Morning/early pm exercise ↑ body temperature, regulates circadian rhythm Exercise is the most effective non-pharmacologic intervention for depression, mood-regulator Exercise in evening – heats core body temp – may inhibit sleep initiation

47 Lifestyle Interventions Establish sleep routine Important for mom AND baby sleep (often overlooked) Listen to body- when tired Don’t try to ‘forget about the fatigue’ Healthy coping Treating the symptom (caffeine) versus treating the problem (getting more/better sleep) Go to bed about same time each night Don’t delay sleep late into night if possible Early sleep more healing/restful Partners and Pets Does a partner have a sleep disorder or need a sleep study?

48 Postpartum Coping Techniques Mothers Use SHORT-TERM: SYMPTOM FOCUSED Drinking coffee or tea Napping Try to forget about the fatigue by watching TV or keeping busy Showers Conserve energy by withdrawing from family interactions (Runquist, 2006, Doering & Durfor, 2011) TREATING FATIGUE (ROOT CAUSE) Take a nap Go to bed early or sleep in late Ask for help with infant or older children Change the diaper before feeding the baby Get the baby into a routine Get everyday life organized Increase amount of time between feedings by keeping baby awake until baby is completely full Keep baby up during day

49 Baby Interventions Recognize infant sleep cues Babies must be taught how to calm down and fall asleep Comforted by someone else until they learn to self-comfort Expose baby to natural outdoor light morning or early afternoon Establish own internal clock (circadian rhythm) Comfort, put down to sleep when sleepy, before completely asleep Allow baby to cry few minutes and self-settle before picking up

50 Baby Interventions No evening TV/computer screen exposure Dim or no light in sleeping place Establish a bedtime routine Cues baby into sleep time No more than dim light for night feedings Make night feeding procedural, not playtime

51 Self-management and health behavior change Hundreds of studies on health behavior change state the same thing: ◦Teaching health information alone doesn’t work ◦Health care creates about 10% of a person’s total health Studies that DO result in sustained change over time ◦Facilitate self-management by facilitating: ◦The client to take charge – e.g., client sets the agenda/goal (not the clinician) ◦Client’s personal engagement and activity, not perfection ◦Practice using health knowledge/information in one’s daily life over time ◦Evaluate whether actions worked; give feedback ◦An understanding that the client is in control, not the clinician Ryan & Sawin, 2009


53 Pages from Helping U Get Sleep (HUGS) Intervention Promoting self-management of sleep and fatigue with clients Currently writing proposal to test efficacy of the intervention, but you are welcome to use parts of these in your practice if useful Practice what you’ve learned: Groups of 2 – talk through this worksheet with a partner – 10 min Feedback and discussion – 10 min

54 Take Home Messages Parent sleep is important to physical and mental health, home and work safety Postpartum sleep is highly fragmented Setting realistic expectations with families Postpartum sleep can take months to improve There are many practical and evidence-based suggestions you can help parents integrate into their lives

55 Some Helpful References Academic site: American Academy of Sleep Medicine: Consumer website sponsored by the American Academy of Sleep Medicine: Health Sleep Tips by the National Sleep Foundation (to adapt to individual needs) ◦ Postpartum Support International: (Main advocacy group for perinatal mood disorders) Other references available upon request: Thank you!

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