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Asia's Only Sleep Singapore 2nd Sleep Dr Pang's Published Work in International Journals/Textbooks |
SNORING / OBSTRUCTIVE SLEEP APNOEA What is Snoring?
It is caused by vibrations of the soft palate, uvula, base of tongue and other soft tissues in the throat when one inhales. Snoring implies an increased resistance to the inflow of air during breathing at the level of the upper airways. As much as 50% to 60% of the male adult population, between the ages of 30 - 60 years, snores. Is Snoring a problem? Snoring is a social nuisance. However, it can be a potential problem, especially if it disturbs the bed partner. Snoring can lead to marital problems, irritation and anger at home. If a patient who snores has symptoms of tiredness, poor concentration, daytime sleepiness, choking sensations at night, this patient may have a serious medical problem called Obstructive Sleep Apnoea (OSA). What is Obstructive Sleep Apnoea (OSA)? OSA is a disorder that is characterised by repetitive collapse of the airway, resulting in low oxygen levels and an elevated blood pressure. Apnoea is defined as an absence or stoppage in breathing for 10 seconds or longer. Patients with severe OSA, may stop breathing as often as once every minute, over the entire night's rest. Diagnosis of OSA requires a thorough clinical examination and a flexible naso-endoscopy. A non-invasive painless sleep assessment is also strongly recommended.
Paediatric Snoring / OSA Children who snore at night may be suspected of OSA. These children may have nose block or narrow air passages due to big tonsils and adenoids. Children with OSA have insufficient oxygen at night. Hence, they are prone to behavioural disorders, short attention spans, and poorer school performances. Treatment of OSA in children can be curative. Treatment Of OSA
Weight loss Medical treatment Continuous Positive Airway Pressure (CPAP) Oral Appliances (OA) Surgical Treatment Surgical treatment has been shown to be effective and curative in certain subsets of patients. Surgery ranges from the use of laser techniques, palatal implants to reduction of the soft palatal tissue, minimally invasive tongue surgery and jaw advancement. Surgical options:
The average human spends about 6 to 8 hours per day sleeping, for some it can be up to 10 hours per day, while others can do with just 4 hours per day. Hence, we spend about one third of the day sleeping, and therefore, one third of our life time sleeping, yet so many of us take sleep for granted. Dolphins are intelligent mammals, they are able to rest half their brain and keep the other side of the brain awake while swimming and keeping watch. Lions snooze about 12 hours per day, and they precisely do so because they are the top of the food chain. Elephants only sleep about 4 hours per day, and they do so while standing up-right. While we might know of some people who can do just that, most people would find it difficult to sleep upside down like the bat would for 3 months during winter. Sleep is an active process Most of us assume that sleep is a passive event, where we close our eyes and all our bodily functions "turn / switch off". Contrary to popular belief, sleep is an active process involving complex interactions with increased metabolic functions and activities within the brain. Sleep is divided into 2 main phrases: dream sleep (rapid eye movement / REM) and non-dream sleep (non-REM). On average, dream sleep comprises about 25% to 30% of the entire sleep in an adult. In a child however, dream sleep may be as high as 50% of the entire night’s rest. Research done on metabolic activity of the brain during different phrases of sleep and wake states, demonstrated increased metabolic activity in most parts of the brain during dream sleep compared to non-dream sleep and even the wake state. Most sleep experts believe that dream sleep is crucial for the human. It is well accepted that dream sleep is important for well being, memory re-building, rejuvenation and mental alertness. Hence, dream sleep is vital to the human mind and body. There are some drugs that are selective non-dream sleep promoters, hence, these patients tend to be very tired and lethargic the next day and might attribute this to the side effect of the drug; in essence, it is due to the lack of dream sleep during that night’s rest. This however, works against the patient with a narrow airway, as the already narrowed airway will lose its tone during dream sleep and collapse, leading to upper airway obstruction, cessation of breathing and lack of oxygen. Therefore, this leads to stress on the heart, brain and other organs in the body. This condition is called obstructive sleep apnoea (OSA). Obstructive sleep apnoea is the commonest sleep disorder. It results in interrupted sleep, sleep fragmentation and poor sleep quality. This is similar in patho-physiology to, what we so commonly encounter in our daily life, called sleep deprivation. During the day, the patient is excessively sleepy, has poor concentration, poor memory and becomes irritable. Long term health consequences include high blood pressure, heart disease, strokes and sudden death during sleep. Sleep Deprivation Everyone has to sleep at some point during the day. When work or training demands pushes us beyond the limit, and we go sleepless for more than 24 hours, our sleep deficit builds up, our reflexes and mental function begin to slow down. This sleep deficit builds up throughout the week, and causes us to become less productive at work, irritable, depressed and sleepy behind the wheel while driving. Sleep Deficit Kills Performance
1. The homeostatic drive for sleep at night is determined mainly by the number of consecutive hours that we’ve been awake. Throughout the waking day, we build up a stronger and stronger need for rest. Most of us think we’re in control of this need to sleep, and that we choose when to sleep and when to wake up. The fact is that when we get so tired and exhausted, the brain seizes control involuntarily, and we fall asleep. 2. The second factor is the total amount of sleep that one has over the past several days. If one gets at least eight hours of rest per night, then the level of alertness should remain stable throughout the day, but if one has a sleep disorder like obstructive sleep apnoea, or if one has not been sleeping for several days, one will develop a sleep deficit that will make it more difficult for the brain to function. 3. The third factor has to do with sleep circadian rhythm - the time of day in the human body that says "it’s midnight" or "it's dawn". A neurological timing device called the "circadian pacemaker" responsible for this. This tells our body when is “night” and when is "day". Hence, shift workers may constantly feel tired as they may sleep during the day for a few days, then shift bask to sleep during the night the next few days. 4. The last factor that can affect performance is what’s called the "sleep inertia". This is the grogginess most people experience when they first wake up. Just like a car engine, the brain needs time to "warm up" when we wake. The part of the brain that is responsible for memory consolidation doesn’t function well for 5 to 20 minutes after we wake up and doesn’t reach its peak efficiency for a couple of hours. There exists a transitional period between the time we wake up and the time our brain becomes fully functional.
Women undergo unique life changes such as the menstrual cycle, pregnancy, caring for a new baby, lactation and menopause. These life changes may affect the lady’s sleeping habits. Although usually temporary, these can have ill effects on the lady. However, should one experience poor sleep, lasting more than a week or two, or poor sleep is affecting your daytime functions, do consult your sleep specialist doctor. A good night’s sleep is important for one’s mental and physical health. The Menstrual Cycle During the menstrual cycle, women often experience emotional and physical symptoms, including abdominal cramps, lethargy, fatigue and irritability. These symptoms usually cease after menstruation begins, and in many cases, sleep may be affected and disrupted. Maintaining a healthy lifestyle, regular exercise regimen and a healthy diet, low in salt, sugar and fat can ease your symptoms. Occasionally, analgesics may be helpful to relief the aches and pains associated with the menstrual cycle. Pregnancy Due to hormonal, emotional and physical changes, getting a good night’s sleep can be a challenge in late pregnancy. Menopause Women undergoing menopause often complain about insomnia or poor sleep. This may be caused by hormonal disturbances, psychological and physical factors. Frequent complaints include hot flushes, night sweats, sleep arousals or frequent passing of urine at night. Depression or anxiety may also be contributory factors. The incidence of sleep disordered breathing (snoring and apnea) also increases significantly after menopause.
As the baby grows and his or her nervous system matures, your baby can stay awake longer between feeds. By three months, many babies sleep for as long as five hours during the night. By six months, sleeping through the night with stretches of nine to twelve hours is possible. You will find that the night feed (just before putting the baby to sleep) is important; with a full tummy, the baby would sleep better and hopefully, longer. Here are some tips to help your baby acquire better sleep habits: 2. Monitor your baby's daytime naps. Regular naps are important — but avoid letting the baby sleep for long periods of time during the day, as this may leave your baby wide awake when it is time to sleep at night. 3. Follow a consistent bedtime routine. Try relaxing favorites such as bathing, cuddling, singing or reading bedtime stories. 4. Put your baby to bed drowsy but awake. This will help your baby associate bed with the process of falling asleep. 5. Give your baby time to settle down. Your baby may fuss or cry before finding a comfortable position and falling asleep. If the crying doesn't stop, speak to your baby calmly and stroke his or her back. 6. Keep night time care low-key. When your baby needs care or feeding during the night, use dim lights, a soft voice and calm movements. This will tell your baby that it's time to sleep — not play. Sleep and Parenting the Infant
Richard Ferber's method is known for teaching babies to "soothe themselves" to sleep — a method so closely associated with him it's often called "Ferberizing." This method is also referred to as "cry it out," although he never calls it that. Over the years, the Ferber's method of sleep training has sparked controversy among parents, pediatricians, and sleep experts alike: Some swear by the Ferber approach, while others claim that it creates lifelong emotional scars. This may be exaggerated and misunderstood. Parents are instructed to pat and comfort their baby after each predetermined period of time, but not to pick up or feed their baby. This routine is called "progressive waiting". The suggested waiting time, which Ferber charts in his book, is based on how comfortable you are with the technique. After a few days to a week of gradually increasing the waiting time, the theory goes, most babies learn to fall asleep on their own, having discovered that crying earns nothing more than a brief check from you. Not all parents and parenting experts believe it's okay to leave a small child alone to cry, even for a few minutes. Some experts also argue that it could undermine a child's sense of security in the world. A pediatrician Dr William Sears, is the most prominent opponent of the Ferber method. He advocates his so-called attachment parenting approach that dictates, among other things, that parents respond to their children on demand, day or night. Dr. Sears has long advised parents to sleep with their children and to view nighttime as a chance to do more parenting. A lot of controversy lies within the "correct" parenting method, the American Academy of Pediatrics has also suggested a series of pronouncements on sleep strategies, from a task force convened to combat sudden infant death syndrome. Among some suggestions: Parents should try using a pacifier to soothe infants to sleep -- despite concerns artificial nipples may interfere with breast feeding. The group recommended for the first time against the increasingly popular practice of babies sharing their parents' beds, after concluding that it is associated with a higher risk of Sudden Infant Deaths Syndrome (SIDS). But they said the crib should be in the parents' room, so as to remain close. Pediatrician Dr Marc Weissbluth, who wrote the book, "Healthy Sleep Habits, Happy Child" emphasizes frequent naps and putting the child down drowsy but awake. Elizabeth Pantley who published a sleep book focused on toddlers and preschoolers, "No Cry Sleep Solution" advises gradual bedtime routines as a middle ground between the "nighttime neglect" of the Ferber method, and the demands on parental sleep that comes with Dr. Sears's method Hence, there is no real "perfect" method for putting a child to sleep, most would agree on a gentler approach, rather than the Ferber technique, but also not forgetting to allow the parents to enjoy some form of “life” for themselves and not let their lives revolve around the child’s but letting the child’s schedule revolve about the parents’. If you're frustrated with your baby's sleeping habits, especially if your baby still needs attention several times during the night by age 6 months, ask your doctor for suggestions.
Falling to sleep by 9pm at night is usually not an issue; it is the problem of maintaining sleep beyond 2 to 3 am that the elderly are faced with. The opportunity to nap during the day also increases with retirement and older age, hence, these patients tend to take daytime naps, and this disrupts their sleep patterns further by keeping them awake at night. Although older people spend about the same amount of time in REM (dreaming) sleep as younger people do, they get less of the deeper stages of sleep they need and awaken more frequently. Studies show that some people over age 60 may awaken briefly well over a hundred times a night, resulting in some daytime fatigue. Due to the frequent night time awakenings (arousals), their sleep is fragmented and hence, they get poor quality sleep and these result in daytime sleepiness. Another factor that may compromise the sleep process as we get older is the likelihood of developing chronic medical conditions such as chronic obstructive lung disease, asthma, heart disease and arthritis. With heart failure, the patient cannot lay flat supine, as this leads to breathlessness. With chronic lung disease, the patient is always breathless and hence, cannot sleep well. Arthritis leads to joint pains and therefore, disrupted sleep. The overuse of prescription drugs and over-the-counter drugs by older people to aid sleep is of concern. Some research suggests that these medications may not be effective in older people, in some cases sleep problems actually worsened.
Did you know that as high as 20% or 1 in 5 children snore nightly and 30% or more snore occasionally? This may be caused by nasal congestion, blocked nose, allergic rhinitis or enlarged adenoid and tonsils. Children who struggle to breathe while sleeping may suffer from Obstructive Sleep Apnea (OSA). In these cases you may hear a snort or gasp for air as they snore and their chest may appear to "suck in". OSA is described as cessation of breathing while asleep. The stoppages in breathing are usually caused by the airway being partially or completely collapsed during sleep. How do I know if my child’s snoring is serious? Sleep specialists commonly place snoring into two categories, primary snoring and snoring associated with Obstructive Sleep Apnea. Simple snoring is considered "normal" and is not harmful. Children with OSAS will typically experience some difficulty sleeping at night and behavioral problems during the day. Undiagnosed OSA has physical, mental and social impact on the child. The child may encounter problems in school; poor school results, delayed growth and development, and even heart failure. Although OSA is more commonly seen in boys, it can affect girls as well. Sleep apnea may be present in children who are overweight and those who have enlarged tonsils and adenoids. Children with sleep apnea may snore, have difficulty breathing and interrupted sleep. Older children who have sleep apnea may seem sluggish and may perform poorly in school. Sometimes they are labeled "slow", "lazy”, or children with “learning problems”. Because some of these symptoms are similar to those described in children with attention deficit hyperactivity disorder (ADHD), some children are misdiagnosed as having ADHD when they are actually suffering from OSA. How do I know my child has Sleep Apnea? 1.Frequent loud snoring with short periods of stoppages in breathing during the night, followed by snorting, gasping for air or completely waking up 2.Restless or wakeful sleep at night 3.Difficulty waking up, even though it seems that he/she has had adequate sleep 4.Headaches in the morning, or often during the day 5.Falling asleep or excessive daydreaming 6.Irritable, aggressive or cranky 7.Poor school results, performance or other behavioural problems If you have noticed some of the above symptoms in your child, or if you are not sure if your child has sleep apnea, you should consult a sleep specialist today.
Approximately 15 percent of children wet the bed after the age of three 1.Many more boys than girls wet their beds 2.Bedwetting runs in families 3.Usually bedwetting stops by puberty 4.Most bed-wetters do not have emotional problems 5.Some believe bed wetting may to related to stress Rarely, persistent bedwetting beyond the age of three or four may be due to a kidney or bladder problem. Bedwetting may sometimes be related to a sleep disorder. In most cases, it is due to the development of the child's bladder control being slower than normal. Bedwetting may also be the result of the child's tensions and emotions that require attention. Snoring FAQ
It's believed that these abnormalities occur in a mixed state of sleep and wakefulness, where the person is alert enough to perform complex behaviours, yet remains unaware of his or her actions. Younger children are more likely to experience parasomnias; however, typically these occurrences do not indicate significant psychiatric or psychological problems. Walking during while in the state of sleep is referred to as sleepwalking (somnambulism). The patient can be walking around the room, rearranging the furniture, talking and even eating during sleep. Sleepwalking is a rapid eye movement (REM) behavior disorder occurring in the dream stage of sleep. It is believed that during this REM sleep phase, the body releases a chemical that paralyzes the body. However, those who sleepwalk do not have this chemical trigger, hence the patient is able to walk during this period of REM sleep. In children, the cause is usually unknown but may also be related to fatigue, prior sleep loss, stress or anxiety. In adults, sleep walking is usually associated with a disorder of the mind but may also be seen with reactions to drugs and/or medications and alcohol, and medical conditions such as partial complex seizures. In the elderly, sleep walking may be a symptom of an organic brain syndrome or REM behavior disorders. Night terrors are common in young children. These children often wake up crying and screaming, eyes wide open, with a look of fear and panic. Although it will seem like they are awake, the children will be inconsolable and might not recognize you. Parents are usually very disturbed and alarmed by the episodes. Typical night terrors last about 5 to 30 minutes and afterwards, children usually return back to sleep. If you are able to wake your child up during a night terror, he is likely to become scared and agitated, mostly because of your own reaction to the night terror, especially if you were shaking or yelling at him to wake up. Instead of trying to wake up a child having a night terror, it is usually better to just make sure he is safe, comfort him if you can, and help him return to sleep once it is over. The child often cannot recall the event and unlike nightmares, sleep terrors are not associated with vivid dreams or nightmares that are remembered upon awakening. Hypnagogic hallucinations are brief periods of dreaming while between the stages of sleep and consciousness. These dreams can be frightening and can often cause a sudden jerk and arousal just before sleep onset. For the brief seconds or so, the surrounding environment becomes so intense and clear, the sounds may become very enhanced and louder. Occasionally, you may see yourself falling and awaken with a sudden jerk, just before impact. Sleep paralysis is the sensation of feeling paralyzed upon awakening, usually immediately following a dream. This is commonly associated with the loss of muscle tone during dreams, called atony. This loss of muscle tone during the dream sleep (REM) stage, prevents one from acting out his or her dreams. It is believed to be one of the instances were sleep and wakefulness are not mutually exclusive. It is believed that during the REM sleep, where there is complete muscle inhibition, suddenly the mind wakes up, but there is still atonia, hence, the person if fully awake but cannot move (paralyzed) for that few seconds (sleep paralysis). This can be a scary experience. Our body muscles, with the exception of those used in breathing are usually paralyzed during REM (dreaming) sleep. In some cases this paralysis is incomplete or absent, thus allowing dreams to be acted out. Behaviour such as this can be violent and result in serious injuries to the victim and bed-partner. After awakening, the person will usually be able to recall vivid dreaming. This can be treated with medication Grinding of the teeth during sleep or bruxism, is a very common occurrence. Many believe that there is little evidence that it is associated with other medical or psychological problems. However, some authorities believe that it may be related to some stress in life. In some cases where teeth are being worn out, oral appliances are used to reduce dental injury. Bruxism may also cause sleep fragmentation and disturbance, resulting in daytime sleepiness and poor concentration during the day.
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Conservative measures
Sleep is a very basic human need that appears to be a fundamental process. Sleep is defined as a transient reversible state of perceptual disengagement from the environment. 
Some sleep related factors affect performance. 
Women and Hormonal Changes 
Newborns (neonates – less than 28 days old) typically sleep 16 to 20 hours per day — but in short one to two hours stretches at a time. The pattern may also be erratic at first. 
Raising the child and providing the best sleeping method or technique is most interesting and challenging. One can a whole seminar just discussing the best method of helping a child sleep.
As we grow age, our body’s ability to sustain sleep decreases. Hence, geriatric patients (above 65 years of age) may have difficulty maintaining sleep. 
Does your child snore?
Most children begin to stay dry at night around three years of age. When a child has a problem with bedwetting (enuresis) after that age, parents may become concerned. 
Parasomnia is defined as an abnormal event during sleep, and this often includes sleepwalking, night terrors, and disoriented arousals.