In search of the elusive good night’s sleep

Did you sleep well last night? Did you wake up feeling refreshed?

If you answered no, you are not alone. According to the results of the 2017 national FinHealth study carried out by the Finnish Institute for Health and Welfare, one in four adults in Finland feel they are not getting enough sleep. Half of men and almost two thirds of women reported insomnia symptoms in the past month.

Hannele Hasala, associate chief physician at the sleep clinic based at Tampere University Hospital, has seen a sharp rise in sleep disorders in recent years.

“People lead such busy lives that they have trouble finding enough time for sleep. If the little sleep they are getting also happens to be of poor quality because of sleep apnoea, for example, they are likely to suffer from excessive daytime sleepiness and seek treatment sooner than those who experience sleep problems without an underlying medical condition,” she says.

In the past five years, referrals to the sleep clinic have more than doubled and the number of appointments has tripled. The majority of patients coming to the clinic suffer from sleep apnoea, but insomnia and sleep deprivation are also becoming increasingly common.

Advice on how to sleep better is simple: stick to a regular sleep schedule, eat healthily, exercise – but not too late in the day – and relax before bedtime. We should also take short breaks during the day to avoid our bodies going into overdrive at night.

“These are easy tricks that are often overlooked. If we respect ourselves, we should respect our sleep, too,” Hasala points out.

 

Night awakenings can wear down the whole family

Sleep deprivation is particularly common among parents of small children, but the experts argue that parental burnout should not be seen as unavoidable.

“Families may not have fully realised the importance of sleep. They may assume that exhaustion comes with the territory of parenting a baby, but broken nights affect the infant, too,” says Outi Saarenpää-Heikkilä, paediatric neurologist and associate chief physician at Tampere University Hospital.

Tampere University is involved in the CHILD-SLEEP project led by Pirkanmaa Hospital District and the Finnish Institute for Health and Welfare, which focuses on children’s sleep and sleep disorders. Saarenpää-Heikkilä is heading a sub-project that explores whether sleep problems in children could be prevented by providing more expert advice and guidance to parents.

“In my experience, sleep problems are becoming increasingly prevalent among small children. They are often related to sleep onset associations. For example, babies who are nursed to sleep may be unable to get back to sleep if they wake up alone in their crib.”

As a child’s sleep problems can affect the whole family, it is important to seek help early. The first point of contact is the local child health clinic.

Breaking a negative sleep onset association may require sleep training, a technique for teaching infants to self-soothe and fall asleep on their own. Sleep training is suitable for babies over six months of age.

“Sometimes a baby's night awakenings may be caused by a medical condition, such as allergies or acid reflux, which can be treated,” Saarenpää-Heikkilä points out.

 

Fragmented sleep can also affect the child

Doctoral student Tiina Mäkelä is writing her dissertation in psychology at Tampere University. Her study is based on data collected during the CHILD-SLEEP project.

Mäkelä’s research looks at children who at the age of eight months woke up at least three times between midnight and 6 am. Their development is being compared with children who woke up no more than once a night.

“Previous research has demonstrated that persistent sleep problems in children are associated with emotional, behavioural and attention problems,” Mäkelä says.

The results of the study send a reassuring message to all parents: waking up at night frequently does not appear to affect the general psychomotor development of children between 8 and 24 months of age. They develop similarly to children who sleep through the night.

However, the study did find small differences in attention skills and executive functioning between the two groups in an eye-tracking experiment: the children were placed in front of a computer screen where a monkey jumped from one side of the screen to the other. The sound sleepers were quicker to learn where the monkey would turn up next.

“Based on this study, it is not possible to conclude what causes these differences, but a persistent pattern of interrupted sleep may interfere with the development of executive functioning skills,” Mäkelä notes.

Mäkelä’s next study will examine whether children’s night awakenings are linked to their social information processing and emotional development. The results may be out before the end of this year.

 

Previous research has demonstrated that persistent sleep problems in children are associated with emotional, behavioural and attention problems

Daylight saving time interferes with sleep  

The CHILD-SLEEP project has yielded a number of interesting results. For example, maternal depression has been found to be associated with infant sleep problems.  

Recent polysomnographic findings demonstrate that eight-month-old babies are getting less deep sleep in the spring compared to the autumn. The differences became more marked when daylight saving time begins and the clocks are pushed forward one hour.   

“This suggests that more daylight in the evenings interferes with children’s sleep,” says Saarenpää-Heikkilä. 

Saarenpää-Heikkilä claims that many sleep problems could be avoided if parents taught their children to fall asleep on their own. This would give babies a good chance to start sleeping through the night by the time they are six months old.    

“Sometimes parents can be almost too good and may not even let their children to try to fall asleep on their own,” she says.  

With the current recommendations that babies be breastfed exclusively for the first six months, night-time feedings may continue for a long time. 

“Early interaction and the importance of breastfeeding are much talked about nowadays, and rightly so, but it is also important for families to get enough sleep,” Saarenpää-Heikkilä states. 

 

Finnish sleep clinics faced an influx of patients

Sleep apnoea is by far the most common condition treated at Tampere University Hospital’s sleep clinic. More than 95% of patients who visit the clinic are diagnosed with the disorder.   

Sleep apnoea causes one’s breathing to repeatedly stop during sleep. If left untreated, it may not only cause snoring and intense fatigue but also increase the risk of cardiovascular disease. Most sleep apnoea patients benefit from continuous positive airway pressure (CPAP) therapy, which involves wearing a mask while sleeping.  

Last spring, Tampere University Hospital was flooded with referrals when the death of well-known Finnish singer Olli Lindholm generated widespread public discussion about sleep apnoea, which he had battled. The publicity surrounding his death convinced many with similar symptoms to seek treatment. 

Even before Lindholm’s death, the sleep clinic had seen a steep increase in sleep apnoea referrals.  

“The number of new cases has been climbing over the past ten years, and at an accelerating pace. This may be partly because of improved patient access to sleep apnoea evaluation, but the prevalence of sleep apnoea also mirrors trends in population ageing and obesity levels,” Hasala says. 

Many of the patients who visit the sleep clinic have already been diagnosed with sleep apnoea at their local health centre. In a primary care setting, patients with suspected sleep apnoea may undergo an in-home sleep test that monitors, among other things, their breathing, heart rate and blood oxygen levels.  

In a hospital setting, it is possible to perform a full polysomnography (PSG), which also monitors brain activity. It is a diagnostic tool for the evaluation of rare neurological sleep disorders and parasomnias.  

“Sometimes a full PSG may be performed on patients with severe insomnia who are suspected of having paradoxical insomnia, also called sleep state misperception. This means that they misperceive the amount of sleep they are getting,” Hasala says.  

 

Hospitals see only the tip of the iceberg of insomnia cases  

According to Hasala, the number of people with insomnia is increasing, but only a fraction are referred to the sleep clinic for specialist care.  

“The majority of insomniacs are managed in primary care or occupational health clinics. Only the most severe cases are referred to us,” she says. 

As Tampere University Hospital does not have the resources to offer treatment for insomnia, patients are usually referred back to outpatient clinics or, for example, advised to join the sleep programmes offered by Uniliitto, an umbrella organisation for sleep associations in Finland. 

Some patients with insomnia have been referred to online therapy provided by the Hospital District of Helsinki and Uusimaa. It has been found to be as effective as face-to-face treatment.   

Hasala says we should all make sleep a priority.  

“Sleep is an active process. It gives our body time to recover and allows our brain to sift through the barrage of information we encounter every day. It is downright vital we get enough good quality sleep,” she stresses.  

 

What is CHILD-SLEEP? 

• The CHILD-SLEEP project, led by Pirkanmaa Hospital District and the Finnish Institute for Health and Welfare, examines the importance of sleep for children's health and development. The project investigates the role of the family environment and genetics in the development of sleep disturbances and sheds light on the mechanisms involved in the onset of sleep disorders and their prevention.  
• The longitudinal study is following 1,400 children who were born in the Tampere region between 2011 and 2012 into adulthood.   
• CHILD-SLEEP brings together researchers from the Finnish Institute for Health and Welfare, Pirkanmaa Hospital District, Tampere University, the University of Helsinki and the University of Eastern Finland. The project is carried out in collaboration with health centres in and around Tampere.  

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