SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
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Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.