Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:
Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.
Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.
Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.
Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html
A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.
The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.
Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.
We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.
Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.
This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.
In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.
It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.
School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).
Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.