From the cradle to the grave, sleep is one of the most important and one of the hardest things to get right.
As a medical student, I spent a year studying infant sleep.
I was researching dysfunctional autonomic control and reduced arousability during sleep in babies who died of sudden infant death syndrome (SIDS). At the time, I was interested in neonatology and thought I might pursue a career in paediatrics (spoiler: I did not). However, I did share an office with a group of researchers who were largely all studying infant or child sleep or sleep-related disease like obstructive sleep apnoea – and I learnt a lot about sleep.
Boy, has that been helpful for general practice. I am constantly surprised by how much knowledge and expertise I am expected to have about sleep. From birth, every one to two months we see changes in infant sleep pattern until about the age of six months, by which point the overnight sleep should be the longest sleep of a baby’s day. Over the next few years, children lose their daytime naps and function with one single long sleep. This overnight sleep, of course, persists through adulthood, slowly shortening in duration, until older age when it often becomes half the duration of younger adulthood sleep and is again frequently supplemented with a daytime nap.
I see a lot of young families, so unsurprisingly, I see a lot of teary, irritable, and frustrated parents struggling with babies who don’t sleep like the textbooks instruct. Babies who like to stay awake all night, in full playfulness. Toddlers who refuse to sleep in their own beds and wake immediately on being moved. Babies whose grandmothers have coddled them and conditioned them to expect continuous rocking for hours of sleep, then left them for tired parents to deal with.
I am a big advocate for sleep school. There’s so much parental nervousness about perceived cold and hurtful approaches to sleep training, but there isn’t evidence for this. Dysfunctional sleep in babies and toddlers can be devastating to parents; maternal exhaustion is the primary diagnosis in my referrals for sleep school. Helping babies with sleep training can have a profound impact on quality of life for the entire family; and we know that sleep deprivation can both mimic and exacerbate postnatal anxiety and depression.
Sleep problems are also very common in teenagers and younger adults. As a general rule, this group probably needs much more sleep than our society realises – seven to 10 hours each night. We have countless consultations daily for young people with “tiredness” which is usually multifactorial in cause and not quick to treat. I always talk to my patients struggling with tiredness or fatigue about sleep. Late nights with phone use, television binges and social media scrolling are commonplace for both younger and middle-aged adults, and damaging for emotional regulation, stress management, social connectedness (social media is quite antisocial) and sleep quality and quantity.
Difficulties with clear boundary setting between “work” and “personal”, shift work and cognitively demanding work can impact normal wind-down and sleepiness cycles. Stimulants including medications, many recreational drugs, sugar and caffeine probably all impact sleep, despite common insistences that they’ve “worn off” or “don’t affect me”. A multitude of small environmental factors can so easily accumulate and impair the very delicate balance of our healthy sleep cycles, and the modern western world, full of technology, is not protective of human sleep.
Medical conditions also start to cause problems with and during sleep: restless legs syndrome, nocturnal cramps, obstructive sleep apnoea, bruxism, polydipsia, nocturnal incontinence and more.
Sleep apnoea and snoring tend to be the biggest disruptors I see in middle-aged patients and can devastate familial relationships; and unlike with babies, sleep school isn’t an option to help the unhappy relatives. A single loud snorer can destroy the sleep of the entire household, if loud enough, and they often are. Old-fashioned beliefs that sleep apnoea is treated by large, equally obstructive and noisy CPAP machines are a huge barrier to encouraging patients to seek treatment. “Just try it, the newer machines are so small and quiet, and it’ll change your life” is a daily plea from me.
In recent years, I’ve also seen really interesting presentations of delayed or atypical sleep phases. One young patient of mine explained that he naturally woke up at 11am and slept at about 4am; he performed very highly in work roles that accommodated this but constantly struggled to perform in a conventional 9-5 office job.
Ideally, our society should accommodate natural circadian variances with flexible work hours, shifts designed around individual sleep patterns, and “late” schooling hours – but I think this is very close to impossible.
Melatonin isn’t especially helpful in creating new circadian patterns but is commonly used anyway in an attempt to reset sleep onset.
Sleep hygiene is possible the best and most realistic option we have to try and preserve our sleep, in addition to treating specific sleep-related medical conditions. Ideally, it can be done despite shift work, changing bedtimes, shared beds or bedrooms, and location. Sleep hygiene works. It’s been shown repeatedly to be effective in treating insomnia, improving sleep quality and sleep deprivation. The problem is it’s hard to do and is entirely in the control of the individual. Create a low-stimulus sleep environment. No phones. No television. Low gentle light and read a book or listen to gentle music. No caffeine after 2pm and minimise the stimulants. Sleep in a dark cool room without other lights and create a strong wind-down routine. Implement and practise this every night continuously. Continuously.
Optimising sleep and trying to create the healthiest and most restorative sleep is well worth the impacts on physical and mental health and cognitive performance, but it’s really tough to do. Not just for patients – I imagine the idea of no phones before bed is rather unsettling to many doctors, too. But with the rapidly mounting evidence showing the complications of chronic poor sleep (increased risk of dementia, increased metabolic disease, worsening mental health, immune dysfunction, and increased risk of some cancers), it seems unbelievable that sleep isn’t a standard aspect of preventative care in both adults and children.
Sadly, I suspect sleep will just continue to pay the price of humanity’s technological evolution, but I deeply hope instead we get a sleep revolution.
Dr Pallavi Prathivadi is a Melbourne GP, adjunct senior lecturer at Monash University, 2024 RACGP Mentor, and newly appointed member of the Eastern Melbourne PHN Clinical Council. She holds a PhD in safe opioid prescribing and was a Fulbright Scholar at the Stanford University School of Medicine, and previous RACGP National Registrar of the Year.
