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Um, and hopefully everyone is able to hear us. Um, good evening. Welcome to dear colleague. It is a new month. We are addressing a new topic. Um, we're delighted to have a guest speaker with us once again. Um and we will We will let Doctor Farquhar introduce himself in due course. Um, but as usual, like to just start off by explaining a little bit about what the concept of dear colleague is. Um, we in Queens University, Belfast G P society have been running dear colleague sessions now for a number of years. Um, previously, they had been, um, zoom sessions through the covid pandemic, where we invited, um, g p and secondary care colleagues to come and speak about a topic of medical education that perhaps isn't covered as widely in the curriculum or is up for some discussion and some debate. And in the past, we've looked at topics like domestic abuse, endometriosis, Parkinson's disease, addictions, and most recently, our last event was a face to face dear colleague in Belfast City Hospital, focusing on palliative care. Um, on this occasion, um, we're delighted that we have partnered up with yet another healthcare society locally at Queen's. Um, and it's my pleasure to have Hasna on the call with us. Who's the presidente of Queens Child Health Society? Um, and it's great to have her online and able to help with this evening's event as usual. Um, it is worth going through just a few housekeeping rules, Um, in terms of of how we're going to run this evening. The meeting is set up in a way that people should be able to, uh, interact with us using the chat. Um, and we'd encourage you to do that throughout adding in any questions or comments that you have based on what we're talking at about at the time, I'd really encourage you to do that, because it does make these sessions so much more valuable both for us. Um, and for you, we tend to get some really good discussion's going, um, it is a safe learning space. No silly questions to be asked in here. Um, it is somewhere where we can discuss tonight's topic in in detail. Uh, I would just remind you about confidentiality and social media use. Unfortunately, we don't have a patient with us tonight, but we will be addressing um, some concerns about, um, a patient who was planning to be with us. Um, and we will. We will, um, just ask you to keep those those comments on that to yourself. Social media use. Um, as far as I'm aware, no one who has the camera on here will have any issues. Um, with with any social media interaction, it would be great to see you if you're posting on Twitter or on other platforms are available. Be. Don't be afraid to tag us at Queen's University Belfast GP society. And finally, just a little note that it tonight won't be an individualized session. Um, they we cannot, um, address individual cases, Um, in tonight's session. But we're using your health care and personal experience. We're we're happy to address the general themes. And I should say that tonight's topic is covering the issues around pediatric sleep medicine. And we're delighted to have Doctor Farquaad. But before that, I will pass over just a hasna, um, to introduce herself and then to take over introducing our speakers for this evening. Thank you, Tim. Uh, so just to briefly introduce myself Hello, everyone. My name is Susan Akon and I'm the resident for the Child Health Society, Uh, at Queens. And I would like to thank Doctor Aqua and Doctor, uh, family joining us today, Um, for today's talk and just to briefly stop off, I would like to invite our speaker's to give us a brief introduction about themselves and on their role as well. So passing on to Doctor Gormley and Dr Fact now, Okay. Like like, Well, I go first and then. So thank you so much for the introduction. And thank you, Tim, for organizing tonight's event. I know it's a busy time for you. Also, really appreciate that. And hopefully we can make it worthwhile for you this evening. I'm Gerry Thornley, GP practice and GP, um, here in Belfast, just south of Belfast, but also an academic at Queen's University, Belfast, Um, looking into simulation, but, uh, have a clinical interest in sleeping adults, and I'm looking forward to learning loads this evening from Michael. Um uh, because I see it as a very real entity. Phenomena on impact lives in many ways, and I hope we can improve your knowledge and interest and awareness. And maybe maybe it might be a future pediatric sleep consultant in the making. We'll never know. Not many of us. Thank you very much. So thank you. Thank you. Thank you, Terry. Uh, pleasure to be here. Thank you so much for inviting me. My name is Mike, Far from a consultant in sleep medicine at Evelina London Children's Hospital. Um, I've been there for almost 10 years. 10 years? Next month. Um, I've got there through a fairly circuitous route. Training Glasgow Nottingham in Sydney On the street anymore. I am. That's me. Uh, that is great. Thank you so much. And again, just on behalf of G p society, thank you both for for giving up your time to join us. We can't run these sessions unless you have the experts to give us the answers. So it's it's it's great to have you have you both along. We really appreciate it. So look, folks, we will. We will kick off and we'll get into into the questions. Thank you to members in the audience who, when registering, did put in questions that really helps us form the basis for the session. So we're going to begin, um, with the question addressed more to to Dr Barker. But prof normally, by all means chip in, um, looking around this topic, what are the common state disorders in Children? And what causes these? So, first of all, I am always Mike, unless I'm in trouble. Uh, that's absolutely fine. Um, the most common sleep disorders actually are not disorders at all. The most common sleep disorders are the most common sleep problems. Or the fact that we don't talk enough to new parents to families about what normal sleep is in Children, particularly Children at the age of five. And the biggest problems are often that families are existing in such a way that when this lovely new person comes into their lives and disrupts their schedules and their sleep routines. But that can be very difficult to juggle when both parents are also trying to hold down a full time jobs and, you know, excel in every stage. And I think it's a huge expectation of families these days that, um, everybody gets back to work pretty quickly, and everybody's expected to just carry on doing everything as well as they can. We know from research that's been done. What's different countries across the years If you have a baby, it probably takes until you. The baby is about 6.5, 6 and a quarter years old before the parental sleep pattern will have completely got back to normal. Um, and usually for many families, a second child will have come along in that time that further, uh, affects things. Um, Children's sleep is a developmental process, so babies sleep very differently to 12 year olds to 18 year olds to adults, unlike everything that Children doing. So that that that first five years of life is all about those crucial first steps of development learning how to do things and sleep is a learned, habitual process. Um, there are physiological changes. There are habitual changes that happen in those first four or five years of life that will get you to a point where most Children sleep through the night. But newborn babies, when they're born, they wake up several times through the night to have 2 ft, and they disrupted sleep. Their parents, they will have destructive night makings. They'll be difficult to get back to sleep. I'm not talking about how much that impacts, and what is normal is I think one of the biggest problems around about infant sleep in particular, and I can talk about that absolute length. But that, for me is the biggest thing about when we're thinking about what families will be wanting help with for Children's sleep. It's often actually just about reassuring them that most things are normal and getting the expectations right and trying to maneuver people in the right direction so that Children are sleeping through as early as they can do. The actual sleep disorders are legion. Um, there are lots and lots of rare things. About 25% of the work of our clinic, for example, looks after kids with narcolepsy just pretty rare, one every 2.5 1000 people or something like that. But most kids, at some point we'll have some issue with their sleep. Uh, the ones that are really top of the list are things like sleep terrors, uh, sleepwalking, sleep apnea, breathing problems in sleep, nighttime wetting, nocturnal enuresis. Um, you know, most families, you know. So if you've got more than one kid, probably one kid in your family is gonna have something at some point that will have something like that. So these are the come bread and butter in terms of pediatric sleep again, most of these things are pretty, um well, certain things like the sleep. Seriously walking, terrifying experiences, but actually pretty normal, actually, in terms of what's going on physiologically, um, and all about explanation and reassurance. Um, I'll stop there because I've been talking for a while. That's lovely about my really great to hear. You sort of get that really eloquent overview, and it's sort of really resonated with me as a GP. Um, you know, trying to put it as best we can ourselves in the life shoes of families. You know where you know you have your routine, you got the rhythm of the day, your work. All of a sudden, uh, this little person put it out of out of kilter, and we have to gravitate to the world rather than our world, and, um, and it's rolling managing that and actually got me to think about, you know, with adults. Um, you know that many of us will have that sort of little mini weakening. You know, that little bit of light sleep, we open our eyes. And what I see is G P is often that when people they arrive at that, that sort of like awakening, they get really frustrated. Oh, I can't sleep and this is terrible, and then it just escalates. But actually, this is okay. You know, this is not a disorder. This is just, you know, um, this tracks back to another bugbear of mine, which is why I'm so delighted that it's the medical society. They've invited us to come and chat. You get very little teaching about sleep in medical school. Average medical student gets an hour of teaching about medical, uh, an hour of teaching about sleep. In medical school. You spend a third of your lives asleep. And actually, I will argue too long Blue in the face that sleep is one of the fundamental things that underpins everybody's health and well being. So and I heard of teaching in five years, probably not enough. You probably don't need a third of your curriculum talking about it, but certainly more than an hour, as J says. One of the things that the consequence is that is that people don't understand what normal sleep is. Sleep cycles. So from the age of five up. The average sleep cycle is about 90 minutes. At the end of each sleep cycle. We all wake up, we briefly wake up, we go back to sleep. We don't remember. We've been awake and we think we get to play games of evolutionary psychology. It probably makes sense from an evolutionary perspective. If your Zocor caveman back in the Stone Age unconscious for eight hours in a cave, then you are vulnerable to pray. So we have this evolutionary defensive mechanism where we briefly wake up our brain does a quick subconscious check. Is everything okay? As long as you're reassured back, you don't sleep. You don't remember you've been awake. That ability to settle back into sleep is a learned behavior. So when they wake up in the night, will not necessarily be able to immediately get back to sleep until a bit older. And the thing that we think that is really important with that is if you think about in that stone Ages of the caveman's safety check way, if something has changed in the environment, that makes you wake up more and deal with whatever the perceived threat is, and for toddlers. You know, if they fall asleep with mom or Dad lying next to them, Mom or dad, then exit once they fallen asleep, they have one of these. Safety check wakeups Mom or Dad are no longer there. They get an alarm signal going. Something has changed. And suddenly you've got a wider weight. Toddler appearing at the end of your bed going. I want to go back to sleep or not go back to sleep. But it's all basic, uh, sleep physiology. But we don't really teach you very much about that. Yeah, totally. Echo that. And, you know, we strive to do our best. Um, but but it could be just on a sort of public health message. You know, when a graduate societal message that you know, sleep sleep is not just close your eyes is a complex phenomenon, but there's patterns and things not to be alarmed about, Um um and and so and And that's for one of the I mean, obviously there are actually sleep disorders, which you talked about, which is which is love to hear more about that in a moment or two. But, you know, for for many of us You know, these many weaklings are fine, but it's that I see the GPS, that frustration, uh, and then more often not, You know, folks will then go to their phone to try and, you know, uh, you know, the mobile device to sort of, you know, uh, a few minutes before they can attend that cycle, all of a sudden they read the email, they get triggered about something, and then I just Yeah, so we used to do a lecture. I used to lecture by to sleep, but I got every student to put their hands up with. The use of mobile phone is a long talk. Pretty much 100%. I do as well, so But I'm going to try and make make make that change. But can I Can I ask you, uh, just reflecting the GP. You know when when you know parents come in and talk about the child doesn't sleep, and we can talk about the impact of that. But often they compare that you know, my other child slept like a you know, and they all this kind of one of the norm for everybody. I don't know if you have any to thought like that. Well, I've got lots of lots of everything. So it's like again, this comes back, in fact, that we don't talk enough about what normal sleep is. Um, those of you who have done your pediatric attachments, which practice attachments will, I'm sure, be very familiar with central charts for height and weight. If I say to you, how tall should a 14 year old boy be? You will say, Well, there isn't an answer to that question. There is a range of normal for a 14 year old boy that we would expect, and at the extreme ends, we might say, we might need to look into this a bit more. Sleep is exactly the same, so not everybody needs the same amount of sleep. There is a natural variation in the amount of sleep that any of us need any particular age as a general rule. The younger we are, the more we need sleep, and the older we get, the less sleep we need. But at any single age, the range of normal is quite wide. And if you look, um, uh, adolescent, I spent a lot of time talking about adolescent sleep. Um, the median amount of sleep that adolescent needs is probably around about nine and a quarter 9.5 hours. The range of normal is anywhere between about seven hours and 11 hours. Now, if you're an adolescent that only genuinely needs seven hours of sleep, then life is fairly straightforward. That's not too difficult to get. If you're an adolescent, these 11 hours of sleep, then life is rubbish because it's really difficult for lots of reasons, for adolescents get good sleep. But thing 11 hours of sleep into a 24 hour day along with everything else is really, really, really difficult. And that variation applies in lots of different ways. So you know the kind of the stereotypical you know, some people are light sleepers, and some people are deep sleepers. We all go through different stages of sleep and getting light sleep and deep sleep through the night. But some people probably have lower thresholds at which an external noise or something happening will arouse them and make them wake up. And if you have a higher arousal threshold, then the same noise is not going to wake you up, and you will sleep soundly, and we see these variations within families. So just like you can have three kids in the family and one's really tall and one's really short and once in the middle. And that's just the way the genes have landed. Um, you can have the same variations in sleep, but I completely agree. I think it really often drives because people, particularly people, have had a in a very common good sleeper for their first child. If the second child is within the range of normal, but is a worse sleeper, there is often a real drive to want to pathologize that what is wrong with my child? And I think it drives a lot of investigations. And, uh, you're looking for reflux or pain or something. And actually, a lot of the times it's just normal. But if they're differently normal to their settling, which is probably a good thing. Yeah, and, you know, I I actually consultations recently on that exact You know this child my child is so different. There must be something wrong. The reality is I wish I I wish I had that Santyl chart of sleeping and say, actually, you're you're somewhere on here. But anyway, uh uh, thank you, Doctor Fox. Oh, and Doctor Gormley providing us on insight on the common sleep disorders and the reasons behind that. So the next question from the audience that addresses to Doctor Gormley is what constitutes a good sleep routine and what interferes with his child sleep. Um wow, right. Good question. And and again, I, uh, you know this this idea about periodic sleep, and as a father, um, I'll try to give him a best advice. But, you know, I suppose in general term, it is trying to tune in to what is your rhythm? You know that? You know what? What's your circadian cycle? You know, I, for example, have 10 Every night, I get a little bit sleepy. That's my point of entry. And I just know that's what I have to go. If I stay up a little bit, then it's, you know, it's 12 o'clock. So it's really trying to overtake my life to what I'm like, you know? And I suppose as a is a busy, busy medic and and father, uh, there's so many other demands of my time that, you know, I can't shift my Gen X to move my circadian rhythms, but it's turning into that. But it's about routine, I suppose it's about, you know, the importance of sleep. You know, sometimes there's a little bit bravado I can only survive in a few hours. And it was, as Mike said, you know, sleeps a lecture of life. Uh, it's the one thing that for me as a GP that if we can help a patient with the outcomes for that are just phenomenal. Tangible? Uh, it's not an overnight thing. It's not over. You know, it's about working and helping that family adjust to to where they are. And it's all the usual things around. You know, trying to dial down any stimulation, have that gradual entry point into your your sleep time at night, getting the right temperature, you know? Not too hot, not too cold. I'm waiting for Mike to correct me here. So, uh, but but it's making sure that you have all those conditions, Uh, important. Um, you know about light. Yeah. You know, it's dark now, this time of year, but we've got lots of lights and led lights and house, you know, it's it's important that they're all you know. You you You get that sort of like that. You can leave in time. But when you're up during the day to make sure you get a that photon shower, get out there, get that sunlight. Um, uh, to to help with your overall cycles. Uh, And then I suppose, with, you know, it's about, you know, looking at trying to, you know, look at your your health hygiene through the day, you know, make sure, like generally, you know, child, make sure they're active, get their physical activities during the day. Um, and really looking around, you know, screen behavior. Uh, I'm sure like, you see a lot of it, and that's, you know, as a GP for 20 years, um, this phenomena of mobile devices screens has been really intrusive. You know, we have, you know, we have, uh, you know, triggers potentially anytime day or night. You know, from me as an academic G p. I get that reject email from a journal that I just submitted to. I'm not going to sleep after that. Um, and the potential entry point to really start to, you know, to your bullying and things like that. So it's really looking at your kind of screen help for your child being a role model. But I get the other side of the coin. I mean, my two kids are down the corridor. If I switched off intruders now, you would hear well, hell break loose, you know? So it's about generating the behave viewers. And that one type that I've got is that we We try to charge all our phones downstairs. Um, and there's a simple device you plug in about six phones, I do it most times. Um, just that sort of routine behavior. Get an old fashioned alarm clock to get you up in the morning time. Um, it's something that we that I would give some advice to parents. Um um, I feel like Mike wants to jump in now and unpack and say all of that. No, not at all. I think that's I don't agree with any of that. I I think so. A couple of things that I completely agree. So first of all, I think because you mentioned it first is that idea of the circadian body clock and again, we don't teach you very much about sleep physiology. The circadian drive The body clock is one of the strongest drives there is in your body. Is trying to keep you awake in the daytime. Sleep at nighttime Very roughly. It's a little bit more complicated. Um, if you go on holiday far enough to get checked Lab. That's because you're out of sync with your body clock. Write a sink with your body clock. Things don't feel great. We feel rotten physically. Mentally. It takes us a while to to reset. Um, the body clock has a really important role in regulating lots of things that we do. And actually, you look, you know, a really a really interesting part from my point of view of medicine because, uh, the Nobel Prize was given to researchers and securing physiology a few years ago. And I think by the time you are Juries, age and my age, the understanding of circadian impact on everything that we do is going to be much greater. We already know that if we take into account somebody's unique circadian physiology, if they're going to have major cardiac surgery, if we time, they're surgery for a good point in their circadian cycle. they will recover quicker than every time a bad point in their security cycle. And I think the understanding of this is going to get a lot more nuanced as you guys come into the profession and practice over the next few decades, Um, but everybody's body clock is different. You will probably know whether you're a morning lark or a night owl. You know, whether you're up with birds in the morning and then your bed relatively early. Whether you don't want to get a bed in the morning and you tend to go to bed later, you will probably be predominant night owls, because, physiologically, most of you are probably still adolescent. Um, and all adolescents tend to shift in tonight Alamo for a little while. Um, but that timing is really important. If you've got a three year old that signal that Jerry was talking about, he gets a half past 10 if that three year old just happens that their signal doesn't kick in till half past eight. But the parents have decided that bedtime is half past seven, then you're gonna have an hour of hell as you try and persuade this three year old was wide awake, and it's not ready to go anywhere near bed yet from a physiological point of view, um, that they want to head towards bed. So it's It always seems paradoxical when people talk to me about this and have you tried delaying the bedtime a little bit later and they go, Are you insane? Why would we do that? It's bad enough as it is. They delay the bedtime, and actually, it sinks better with the child's own rhythms. And suddenly sleep becomes a lot more straightforward. So understanding your own circadian rhythm and working with that as Jerry says, it's absolutely fundamental. And then I completely agree with everything said, Um, it's all about routine. It's all about doing simple things. Well, um, you need to be a little bit careful with things like routine, particularly with kids. Um, that you don't get too stressed about it. You know, if you've got a routine, it's like you must be, you know, brushing your teeth at 7 31 and you must be in your pajamas at 7 34 and you must be in bed at 7 38 and then something happens, and that's knocked off. Then suddenly everything's going to port. So what we encourage is flexible consistency. You're aiming for roughly the same things and roughly the same order most nights, aiming to go to bed at roughly the same time. You get up at roughly the same time each day. And then, as Jerry said, it's all about doing those really simple things. Well, so lots of activity and exercise in the daytime is good for everybody. Sleep lots of light exposure in the daytime helps that circadian clock to to be where it's meant to be. Avoiding light in the evening, particularly electronic light, helps again because otherwise you confuse the clock and stop melatonin being produced, which is helpful for sleep. Uh, eating at the right times, not drinking too much caffeine. You know, all the really basic, simple stuff is actually really important, but flexible consistency understand your own sleep rhythms and work to them. And then the point that Jeremy right at the beginning is you have to value sleep. Um, you know, you're not going to get good sleep if you were up till midnight. Medical students, by the way, are awful when you look at medical students. Uh, the incidents of sleep problems and medical students is much higher than the rate in the, uh there appear matched population, including other groups of students. Um, you you need You need sleep to learn. If you're up till midnight, I promise you, you won't be remembering and processing all the things you're learning as well. So, you know, it's all that kind of stuff as well. Yes, completely. I have to have to admit I'm entirely guilty of being found in the McLay library. Which for you, Mike, is our university library. The latest I've ever been there is two. AM and then I was like, I need to go home. Absolutely again. I do a lot of talking to adolescents, actually, um, your brain has a finite amount of knowledge. It can take it in the day, basically, and one of the things that sleep does it's like clearing your email cash. Um, you know, you need to clear out everything before you can take more information. And that's one of the things that your brain does for using sleep. So if you haven't had a decent night's sleep the night before you're studying, you won't take information as well and be able to remember and retain it. More importantly than that. As you sleep at night, your brain is processing everything that you've in the daytime. It's deciding what it's going to keep, how it's going to keep that, how it connects. And if you don't get good sleep, that doesn't happen as well. If I take half of the audience here tonight and give you a 15 digit string of numbers to remember and I sleep deprived half of you and then the other half sleep properly tonight, the ones that are not sleep deprived will remember that number string much better in three days time than the ones are sleep deprived. And if that's true, the 15 digit string numbers, it's probably true of the Krebs cycle or any of the other things I've forgotten from music, you know, So that really resonates with me like and you know what I've learned with time and my own personal and sort of sleep. So I'm so I'm a I'm a morning person. Um, if I get some tricky issues that I'm trying to respond to an email, I know I'm a very content. I will do that in the morning time and just some way I find the solution. Um, sometimes I can rattle it through my brain and struggle at nighttime, but I've really learned to self just close the laptop. Um, you know, I've also to do my my to do list. You know, we all have those, but it's kind of I do that mental dump I can forget about it. Um, just some way I find the solution the next day. You know, in the morning time, just I've turning into what your your cycle is, and those can. There's research to back that up. Actually, one of the things that really helps people sleep, particularly people who are in pressured, working, studying all the rest of it is doing that and getting it out of your brain, writing it down even if you've not done all the things on you to do this. Just writing them down and getting them out of your brain, because otherwise your brain is going to carry on going over all that when you're trying to wind down. So even really simple things like that can actually make a big difference for some people not for everyone. Yeah, and that also extends beyond sleep to some issues. You know, some people who can ruminate or anxious about things that really have free for those thoughts. It's like a washing machine. But getting these thoughts into words is actually a process of trying to rationalize, uh, externalize and maybe get a different perspective on it. So all those all those things are they sound little small, mundane, but actually can be extraordinary for for some individuals. Can I jump in with a question? I used to be an idol, but now I'm a morning lark. Is that going to Is that going to counter current against my genetics or or just the the lifestyle that has maybe more person? Is it good or what do you think? It's natural history of aging. I love the way you suddenly diplomatically dropped them. Uh, variation. And some, you know, most of us will know whether we are larks RL's, um, adolescents, Um uh, for again, probably evolutionary psychology reasons. As adolescents go through puberty, they all physiologically shift to become night owls. And if you think again about, you know, Stone Age hunter gatherers groups, it probably made evolutionary sense for young people of that age, bearing in mind that in Stone Age teenagers were actually would have been adult members of the tribe and some of the fittest and healthiest and best able to defend Well, actually, if their sleep pattern shifts later into the night whilst everybody else's asleep, then actually that gives. So we think we might. You know, all the evolutionary psychology can make all sorts of stuff up. But fundamentally adolescent sleep shifts later, as we promote of adolescence, it tends to drift back to the median point as we get older and again Stone Age biology. Any of us who are over 40 which I suspect is definitely put you on a, um, once you're over 40 you know, every year that we live beyond 40 is a sign of how intelligent we are as a species. Basically, um, you know that that's that's That's what we've done. We've extended our lifespan hugely, but our bodies and our biology is changing. Um, from that point and one of the things that changes asleep. So once you get beyond 40 the proportion of time that you spend a week after you first fall asleep goes up your sleep. Fragmentation tends to go up. The quality of the sleep we get tends to be life's good. Um, and one of the other things that we see is a shifting of what we call an advanced sleep phase that the older we get, the earlier we tend to go to sleep and the earlier we tend to wake up just as part of that shift in changing biology. Uh, very, very rarely see advanced sleep phase in Children, young people. And when we do, it's almost always a genetic disorder, whereas we see delayed sleep phase going to bed later much more commonly, particularly teenagers. Uh, that's really interesting, really, really interesting about the 90 minute cycles. And even as you say, going about finding that time of the day that works for you to be productive, that's, uh, that's very, very interesting. And apart from the all absolute golden nuggets that Mike has given us, everybody will now see Jerry as the tribal elder in this cave community. Um, the other thing about that, with the cycles is so I said, you're the body clock awake in the day. I sleep at nighttime It's a little bit more complicated than that. Um, and actually, we all have a lull after lunch where we, the kind that are sleepiness, is governed by an interaction very, uh, simplistically between two processes. One is what we would call sleep pressure, which is a bit like Congress or sleep. The longer you've been awake, the more you need to be asleep, and that builds up fairly linearly through the daytime until you go to bed at night. But most of us don't feel linearly more sleepy with every passing minute of the day, and the reason for that is the counter to that comes from the body clock. The circadian drive. It's a bit like endogenous Red Bull. It's a, uh, an alerting signal to keep you awake to counter that sleep pressure. So at the beginning of the day, your sleep pressure is low. Your alerting signal is role is low as the day goes on and the sleep pressure increases. So, too, does the alerting signal, and that keeps your level of alertness or relatively even keel. But around about lunchtime the early afternoon, the alerting signal just doesn't increase at the same pace as the sleep pressure does. So we all get in the tug of war, the sleep pressure winds. We all feel a bit more sleepy around about lunchtime, and then after that, the alerting signal goes into overdrive. So actually, then feel much more awake and alert in the evening than we have done earlier in the day. And that's because the alerting signals now high at bedtime, the alerting signal drops off to zero. The sleep pressure is unopposed and off we go to sleep. That mid afternoon low is why many societies have a siesta. You know that that's built in and again evolutionary psychology. It probably made evolutionary sense when we revolving plains of Africa not to be out in the midday sun. Um, so you know, all kind of fits when we think about where we've come from as a species, but we were still living with those consequences. So yeah, it's It's always a pleasure as a sleep position to come to be asked to do the first talk in the afternoon because you kind of like, Well, everyone is good. I'm writing an email to my line manager. I want to have a so we're hoping spaced him. Uh, this you're not not not at all, but I I am. I am interested and thankful to the folks who are putting some comments in the chat here as well. Um, we first of all, have a have a question. Just kind of define what night terrors are. Why did it happen in Children? And what should parents do? Um, when a child is having an I turned, I assume that is to try and settle that down and help them get back over after. You know, any thoughts there, So Well, I do this one, Jerry, you go for it. Right? So this is where in the older days before covid, when people came to my clinic, I had a big pad of paper and sharp piece, and I'd be drawing hypno grants and sleep cycles and showing you So you're just gonna have to bear with me as I describe it. Um, we sleep in cycles. Um, as we said, those cycles are about 90 minutes long. Within each sleep cycle, we go through the different stages of sleep in a fairly, fairly predictable fashion. So we start off awake, we transition into light sleep fairly quickly. And, as the name implies, light sleep quite easy to wake you up from, Uh, lots of things are going to like sleep. It's important for learning, amongst other things. We're in light sleep for a short bit of time at the beginning of the night. Then we go into deep sleep and, as you can apply from the name deep sleep much more difficult to wake you up from. If you are walking up from deep sleep, you tend to be a bit punch drunk. It takes you a while to get going. You're a bit groggy. You're a bit disorientated and confused. Deep sleep is again. There's lots of things, but it's really important for physical recharging, your batteries giving you energy. We spent a long period of time in deep sleep sleep in the first sleep cycle. Then we transition back from deep sleep into light sleep and then from light sleep. We transition into R E M sleep dream sleep at the end of the sleep cycle, and that constitutes a sleep cycle that that pattern of light, deep light rem um, is one sleep cycle, and at the end of each cycle, cycle. We usually briefly wake up those cycles, then repeat. But as we go through the night, although the pattern stays very similar, the proportion of time that we spend in each stage of sleep changes. So we tend to get most of the deep sleep we're going to get towards the beginning of the night. As the night goes on, we spend much more time proportionately in light, sleep and dream sleep with me. So for so if you imagine what's happening there, if you imagine that each move between a sleep stage is like shifting a gear in a car, Um, normally, just as if you're driving and you're shifting gears most of the time, those gear changes happen very straightforwardly, with no problems. Okay, if you are drivers or you've been encouraged, people drive. You'll see every now and then. When people are changing gears, they make a mistake. They get stuck between two gears, and they probably swear they sort it out and then carry on. But that kind of analogy of a gear shift going wrong is what underpins what we call the partial arousal. Parasomnias Children's brains are phenomenally chaotic places, um, Children's brains are growing. Developing neurons are literally synapses and growing and pruning and all sorts of stuff, particularly as we sleep at night. And they are still learning that ability to move smoothly between the different stages of sleep is one of the reasons why Children sleep is a bit more vulnerable to to other things. What that means is it is not at all uncommon for Children as they are doing those gearshift changes for one of those to go wrong. And when that happens, what we're basically saying is happening is the child's brain is getting stuck between two different stages of sleep at the same time, and what we think happens the parcels of Parasomnias is that it's a gear shift change where the brain is heading from deep sleep heading towards awake point, and it kind of gets stuck somewhere between deep sleep and being awake at the same time. Okay, with me so far, that then results in a confused brain. And in young Children, confused brains do not have very many places to go, and the most common place for a confused toddler brain to go is panic, so it triggers all of the kind of responses that you would see if somebody had just run up behind you and shouted Boo very loudly. So what we see is a confused brain that triggers these kind of automatic panic responses. But fundamentally, although they're stuck between the two different sleep stages, they are more asleep from they are awake. Okay, that's really important from the outside looking in. What you will then see is a toddler in their bed. They're caught who looks like they've suddenly woken up. They'll sit bolt upright. Their eyes will be wide open. They will start shouting and screaming, and they will often be shouting things like Mom or Dad or stop or help things that we would associate with panic or terror. If you stick your hand on their chest, their heart will be racing. They will often go very pale because their blood is being redirected towards muscles. They might need to be able to run away or fight or whatever. And if you try and do anything with them, they will fight you off because they're not. They're not conscious. They're kind of operating on autopilot. They'll fight you off. They'll run around in circles. They look like they've been possessed in the olden days. That's exactly what people thought had happened. And they used to get taken down to the parish minister, who would douse them with holy water and to try and get rid of the demons that possess them. I do far less exorcisms in my clinic these days than I think would have been done in olden times, anyway. Um, that is basically what sleep terrorists. It's a gear shift change stuck between two different stages of sleep, triggers the panic response exactly, Like if I've given you a shot of adrenaline or something like that looks awful and the parents are usually absolutely terrified, which is really where the name comes from. More than anything else. If you leave it to itself, it will burn out. And what happens is the brain kind of realizes it's made a mistake, and usually it will redo the gears. Most of the time, it will force the gears back, so the child goes back into deep sleep. Every now and then, it'll go the other way and they actually properly wake up and they'll go. Oh, Mommy, Daddy, why are you here? And why are you so scared looking. Um, but they'll they'll actually wake up and be able to interact with you. Um, most of the time, they go back to deep sleep. They can last anywhere between a few seconds and the most extreme, they can be over half an hour, which is terrifying for the families involved. But if you leave them, they will burn out. Um, if you try and wake the child up, um, so the old fashioned old wives kind of things don't wake up a sleepwalker. Don't wake up. Somebody sleep How you kill them, You're not going to kill them. But what you will do is if you wake up a child in the middle of one of these, they are going to suddenly wake up with all the physiological manifestations of fear and terror. And they are just gonna be oh, so don't make them up. Not because you're gonna kill them just cause it's not very nice. Um, and all you have to do is make sure they're safe. Um, you don't need to poke a problem. You don't just make sure they're safe, Let it burn out. They'll go back to sleep. And once it's done. Parents can go off and have a glass of wine or a junior. Whatever they need to come. They're nerds. Um, sleep is really common, but 15 to 20% of kids, particularly pre pre school kids, will do these regularly. They run in families. There's a genetic predisposition that makes it a little bit more likely that you'll do this or you want. But I said 15 to 20% of kids are going to do that at some point. Um, and many of them will do it frequently. Sleep walking is exactly the same thing, but it's just a bit more sophisticated in sleepwalking. The brain is a bit older, a bit more mature, a bit more developed. And when it gets that confused state instead of triggering the panic response, what the brain instead does is goes. Have no idea what's happening. Let's just act cool and hope nobody notices, and basically it triggers all the kind of things that you're used to doing an ultimate. So if you look at the behaviors of kids when they sleep, walk, they do the kind of things that you would do without thinking about. You know they'll navigate to the toilet, they'll navigate to the country and they'll navigate up and down stairs. Um, sometimes you make mistakes. My sister is like, Well, she used to pee and my parents chest of drawers because she got a little bit you can use it when she was in the rest of it. But generally speaking, they will do things that make sense, things that you do on autopilot without thinking about. Okay, that means you can do some pretty complex behaviors. So you know kids can run up and down stairs when they're sleepwalking and their sound asleep. You know, they're not consciously aware they're operating on the mental map of their house. And there are people always go how they must be awake because they're running up and down. So that's because they run up and down the stairs 100 times a day. They used to do a lot of pilot. They're not thinking about it, but if they're siblings left a roller skate halfway down, they won't see that roller skate because the roller skates not in their mental map, and that's where sleepwalking becomes a risk. It's the risk of accidental harm more than anything else but again, with sleepwalkers, you do exactly the same thing. You just you don't wake them up. You turn them around, you push them back towards bed, they'll go back to sleep and that they won't. And the other thing with both these things, we don't remember in the morning because they're asleep. Uh, incredibly interesting that the way the way you describe that as well, like, is just so understandable and incredibly interesting. I'm loving myself. It's a long time. Um and you know, I may not appreciate you all to become a be pediatric sleep physicians, but I think it's one of the great things about being a pediatrician and a GP as well, Actually, very, um, is that when you spend a lot of time talking to Children, Children don't take any nonsense and, you know, you have to have a way of talking that makes sense to them. I think that is a useful thing to be applied across many of them. Can I just say that was just absolutely fascinating? I mean, I'd love just to capture that and have it ready for the parents that I do see. I mean that that was such an eloquent description were right with you, Mike, you know, and that can go ahead. Go ahead. Go ahead. Uh, the The thing is, it works. Now, if you ask me to, then go and, you know, explain the neuroscience of partial razzle parasomnias to a group of neuroscientists. I will have a very different conversation with you about it. But that explanation is you know, there's lots of things in medicine that are true enough in terms of what we're doing and get it across. And it makes sense. Um, you know, so you know, if you break it all down, then it's a little bit more complicated than that. But actually, I think that's, you know, for me, it works. And it's an explicit because from my point of view, when these families get to my clinic, which actually very rarely do because most of these things are dealt with very, very, uh, competently by primary care and secondary care colleagues. Um, my main goal is to stop them panicking. It's to explain and reassure and help them to understand, and they they often will come into my clinic going. What is the medication? You can give us to stop this happening and they walk out at my clinic going, Oh, we don't need a medication for this. We're really fine. And that's that's a win for my, uh and that's that's so I just kind of jumping in there, Uh, just jumping on that, come up with that absolutely right. And I suppose, again, try to put yourself in the shoes of a family. You know that this is happening regularly. They're tired. They get anxious. They're trying to hold down busy jobs. They you know, everybody wants a quick fix, but actually tearing, tearing them, grinding them in this sense that this this is how it work, works. And this is how we get better. And look, there's nothing to fear. And you said the words because often like it's I want the quick fix tablet. Uh, invariably patient's will leave my GP surgery with a handout on the URL. Not a prescription. Um, so thank you. Excellent. Excellent. Very, very, very interesting. Again, in the interest of trying to to answer people's questions, I'm gonna I'm gonna divert away from from the next question that we planned and try just to explore this for just a minute or two. Um, I'm curious if there's any thoughts on the relationship between neuro diverse individuals and sleep disorders. So the likes of developmental autism a d h d is there any link has been described there at all? Perhaps, Mike, it's about 50% of the work of our clinic. Um, So thank you, Caitlin. And thank you more than anything for using the phrase neuro diverse rather than the kind of the older fashioned term, which would be new disability. Um, And for me, that's actually a fundamental point about this. Um, there are lots of differences in all of us. There are lots of differences in sleep. Um, and I think we have to be really careful when we're talking about people who have differences not to use language that actually stigmatizes. So thank you very much for that. I really, really appreciate this. I was having this conversation with a very senior colleague yesterday who was describing a different group of young people as being new, uh, with the phrase your disability and I bristled quite strongly at that. Um is there a link? Absolutely. Um, sleep as Jerry said earlier, is a complex function of a typically functioning brain. Okay, as soon as you have a brain that is working in a different way, it is not a particular surprise that sleep is one of the things that is going to be affected. Um, so the vast majority of people with neuro diversity are more vulnerable to differences in sleep. Now is their sleep better or worse? That's a bit like asking, you know, is autism really actually better or worse than your typical? And And the answer is often. Often it's a little bit more complicated. You get the severe ends of difference of those conditions, particularly autism. But just being different in itself is not necessarily about the problem. Is um, for this as a general comment is that society is set up to function to support those who are the majo pretty, which is what would tend to be called neurotypical. So if you have a difference in the way that your brain works, life often becomes very difficult not because you are better or worse, but just because you are then a square peg trying to fit into a round hole, and that's really difficult. But it's particularly true for Children and teenagers. Because school is rigid, there is no capacity really to change that. Whereas as a neuro diverse adult, you may choose to work in a way that suits the way your brain works. But many neuro diverse Children young people don't get that ability. So that's the general background. What are the differences? So, um, as I said, about 50% of the workload of our clinic is supporting young people and their families where the young person has, uh, diversity and I included in that are a number of kids with rarer genetic conditions that the impact development because of that little play, um, the autism made actually, by far the top of the list. In general, kids with autism and kids with a D H D are likely to sleep less, on average. Compared to their peers, they are more likely to have what we would call disruptive night waking where they wake up and everybody knows about it compared to their peers, um, and sleep is often likely to be more vulnerable. Uh, in many ways, not everybody safe as anything, and some kids, some artistic, could sleep beautifully in some kids with PhDs sleep beautifully. A D H d is a really good example. A D H D is a 24 hour condition affects the brain over on the clock If you are diagnosed with a d. H D. The most common treatment strategy if you get the medication, would be using medications like the long acting uh, methylphenidate, which last for about 8 10 hours. Which is great if you're trying to, uh, manage the symptoms of your a d h d at school or university or work. But they were off, and then you've got untreated a D H D symptoms in the evening, and it means that sleep onset is often a really struggle for young people with a D h d as well. Um, lots of things you can do about that for Children with developmental delay in general again, people are often looking for the magic quick fix all the evidence tells us that actually, for these kids, it's even more important to get all the basics right. Uh, the routines, the habits, the behavioral interventions, and that is the foundation of everything. If you have a d h. D, you can do all of that, but it might not be enough and actually get into a D. H D. Medical treatment right is often really important. And we often go for medications that work 24 hours. So, uh, you probably, uh Well, it's kind of small print ready H d. Anyway. But things that atomoxetine guanfacine which work around the clock rather than the methylphenidate, are often better kids with autism. Uh, my colleague Paul Greengrass was involved in a study a few years ago that led to was done with the drug company to produce a version of melatonin called Sliney Toe, which is a tiny tablet that can actually swallowed by kids in your diversity, which is the big difference. Uh, and he was able to show that if you use melatonin appropriately in these kids, you improve their ability to get to sleep and stay asleep, which makes a massive difference. Their families. Usually, when we're looking at the sleep of these kids, the kids themselves are fine. They sleep the way that they like. They do what they do. It's the poor families that are actually on your knees a lot of the time. So is there a relationship? Absolutely. Can I talk about that for hours on end? Absolutely. I hope that kind of covers the basics of it, but more than have to take more questions than that if anyone's got here. Thank you so much, Doctor. Bakwa, Just another question from the audience addressing to Doctor, uh, doctor calmly would be Has it been found that bad sleep can cause or worsen illnesses? Um, really Good question. And one, I think we should raise the profile off more with ourselves as healthcare, professional students and the wider society. Um, I I know I know some around adults, and I'm going to be asking Mike to make sure they are probably still with the bottom line is yes. Um, you know, So if you take adults, yes, it can affect not only your mental health, but your physical health increase obesity, um, and and even things like accidents. You know, it's it's a real important thing. Um, but for sure, it it is not just a a thing that you pass off. It actually has, uh, you know, real impact on your mortality. Morbidity? Um uh, so it is so important to to really value sleep uh, as an individual. Suppose as a society and actually just reacting to to to to what you had said, Mike, there about, uh, you know, Children with neuro diverse, um, conditions that Yeah, I got my heart goes out to the family, you know, they're trying to work within the constraints society, that this is where we all gravitate to. This is the norms. This is the way the world is set up. We start work at nine. We finish it at, uh, you know, whatever time, um, there's rigidity within those structures, but actually, on a more societal level, we can try to improve in that. I think what I've seen with some parents, and if you seem more working from home, allow some more flexibility, uh, to to allow gravitating to to your child's cycles to the time of the day. You know, if you think how hard it takes to get yourself up in the morning, but then adding a routine of getting a child that you have to work with them in so many ways. Um, just try to feel that experience. It's it's hard. But if we can make any difference in that, would be really important. So getting back to the impact on health, you know, it's around. If we, you know, if we can help, uh, you know, uh, allow some changes where we can to help individuals have a routine that works for them. Um, there, there, there are benefits for your health. Um, you know, I I think the public start to hear that would be more of a and I cry on that. We do need to, you know, kids need to maybe start school a little bit later. Um, maybe those early morning meetings that sometimes people do, actually hold on, that's interrupting our sleep time. Uh, you know, So it's trying to advocate on that. I'm going off on a tangent. Might. But for for kids agreed. So I think a few things to come back from from not come back on to agree with you. The point about parental sleep deprivation is actually one of the most important ones in our clinic. You know, a lot of the time the kids themselves that, you know, if you make them sleep a bit more, they might give, you know, uh, we're open to learning progressing and things that day, but actually, a lot of times they they're fine. Parents are often literally on their knees. Um, used to have a clinic, a box of tissues. When I still to face to these appointments, I go through one a week, I think, with parents crying in my clinic, um, as a parent of a child with complex difficulties, you are very bad at prioritizing yourself. Uh, and you feel that if you have to do something that you think is not the right thing to do for your child, that you failed One of the real challenges for many of the families that come to our clinic, which is a stupidly high referral threshold, Um, is they've been told all the basics. They've done them all. They're not not doing them. They're just not enough for that child. And they've got complex difficulties. But they often meet professionals, you say, Well, if your child still have sleep problems, it must be that you're not doing something right. Probably following the advice properly are you and that just makes them feel 10 times where it's interesting. They come to my clinic and I can go. No, I'm not surprised. they're still not sleeping because look at them bouncing off the walls of my clinic. Um, and for those kids, we often do think about using sedatives now. The threshold these and sedatives and sleep medicine in general is phenomenal. High is very much high in Children, but for some families, it's the right thing to do. And usually the deciding factor is not the child directly. It's the fact that if we don't use sedatives to improve the child's sleep, the parents are going to break down literally. And if the parents break down, then the child's life gets a lot worse. So it's an indirect, benefits the child. So I think that's a really important point, the more general point about sleep and health. So as I kind of said earlier, there are a few things that I think are absolutely essential for health and well being. And I think sleep is absolutely at the bottom of that foundation, you know, it's the thing that underpins everything. Obviously, I'm side advised. Um, we know that when you are sleep deprived, um, it has lots of consequences. You are all about to enter a phase of your lives where your choice of profession is going to significantly screw up your sleep. Congratulations. Um, you are all going to have to work. I was trying to hold back and get it out of the bag. Um, you're all gonna have to work around the clock. It's really bad. A lot of the evidence for just how bad sleep deprivation is for your health comes from shift workers. Um, and I'm more than happy. I can send him, like, I've written people years ago now about how to support sleep for people who have to work around the clock. And it was working, in a sense, because it's really important to be you get right. But a lot of the evidence that we have for the impact on health of sleep deprivation comes from shift workers, and it's not insignificant, and it increases your mobility. It probably increases your mortality, uh, in terms of doing that, and it impacts every single aspect of your function when I'm talking about sleep. One of the first slides I usually use is a picture of a car in a garage, and I say to people that the way to think about sleep, lots of ways to think about sleep. The simplest way to think about sleep If you think about car occurring into regular repair and maintenance, uh, to be able to keep working, if you skip the repair and maintenance, the car will probably keep going. But it will start making funny noises and clunking, and eventually it gets a point where it doesn't work. It will probably cost you a lot more money to repair the car than if you just done the regular repair maintenance. The first place sleep. Is that regular repair and maintenance your mot if you like, um, for your brain and body every single night of your life. And if you are skimping on sleep, the consequences that will accrue over time. Um, and we know, As you said, there's lots of evidence now that tells us just how much it affects it. The other way to think about that is you're going to spend a significant part of your professional careers, no matter what part of medicine you go into looking after people with chronic health problems. Um, if you are someone who has epilepsy and you then become sleep deprived, you're much more likely to have a seizure. If you are a type one diabetic and you are sleep deprived, your control of your HBA one C is likely to be less skewed. Um, if you are, uh, sleep deprived, you're much money to have high BP. You're much money to have cardiovascular disease. You're much more likely to develop some types of cancer. You much might develop mental health problems. And then the real problem is that almost all of those things are also just probably is likely to negatively impact on sleep itself. So then you get into this horrible, vicious spiral where everything gets worse and thinking about sleep and improving. It is often a really important part of that, and again because we don't talk enough about sleeping medical school curriculum. It's not something that many healthcare professionals think about as a thing that is manipulate able to both that word, uh, to to improve health outcomes. Um, so yes, is the short answer to the question. Very, very interesting stuff I'm looking with with one eye on the clock and and the other I greatly interested in everything that that we're discussing here. It's absolutely brilliant. Why do you wear to finish Bangles. I don't mind running over slightly as as long as people don't mind. But if you if you have to finish in time, that's fine. But I mean, that is absolutely fine with us. But look, 11 question that I think we do want to kind of get get get answered is, um for you make And it is what, actually so pediatric sleep medicine. How did you get into pediatric sleep medicine? It is, uh, like we're I see the head and hand there. I see the head. It's clean. Explain that there's two bits that question. All right, so I'll do the bit that's less directly related. Sleep quicker. So the reason I'm a pediatrician, I think if you talk to many pediatricians, actually, um, one of the reasons that many of us become become interested in child health and pediatrics is because we had a family member who was sick on your booking. Um, um, my sister was normally sick. At one point in my childhood, she got acute. Typical tightest, twice, actually, which is quite unlucky even before vaccinations. Um, and nearly died. Um, and she literally arrested in e. D. waiting room. Uh, once we got there was in intensive care for a while, was saved by a team of professionals who, you know, just different death story to Sorry. Right. And I was about 9 10 at the time, and I thought, Well, that's quite cool. So I decided I want to see a doctor after that and a pediatrician in particular, and that that never shifted. Um, so that's the pediatric bit of it. Um, and as I said earlier, there are lots, you know? So that's the kind of what got me interested. But actually, why would you want to be anything other than a pediatrician? Um, so much more fun. Um, kids keep you honest, which is is is great with all the There are lots of good things about being a doctor, I promise you, but you are coming into the NHS. It's quite a tricky time in the NHS existence. The thing that keeps me saying is talking to kids most days, which is otherwise after my, um so pediatrics? Yes. Um why am I asleep? Physician. So this is a few years later when I would have been about 13 or 14. I started to have these experiences where in the middle of the night I would get this sensation. I felt like I had woken up. I couldn't move. I was paralyzed. I had a heavy, crushing weight on my chest. And I thought there was horrible things in my room that we're trying to attack and kill me. Um, and they were quite frightening. And, you know, I didn't die. And also, I wake up the next morning and go, What the hell was that? Um, I eventually went to see my GP, and, uh, my GP was a lovely guy, but had no idea about sleep because again, people talk about this thing, so he didn't really know what they were. He kind of went. He kind of looked me over exam and went, I don't think you're dying. I don't think it's a seizure in like that. I think you'll be fine, but I don't know what they are. And then I was one of those annoying kids that aren't right, right? What is this? And this is pre internet. So I had to go to the library and do old school research. Uh, eventually, I find out what these were so. These are things called hypnagogic hallucinations and sleep paralysis, which are relatively common. Most people will have that experience at least once in their life. I'm unlucky enough to still have them very frequently. Um, and they come about their their another one of those gearshift changes. Um, they come about when the brain is shifting between being awake and being in dream sleep rather than deep sleep and wake, which the partial rise of parasomnias do. Um, as you dream at night, you're all paralyzed. The tone and all your muscles drops down to virtually nothing. Your voluntary muscles when you dream. And that's because when you dream, your brain actually looks very similar. If you look at the IgI traces as if you're awake. So all those amazing dreams you're having you're having adventures. Climbing mountains find pirates, ballet dancing, whatever it is you're doing, your brain would think that was normal, and it would get your body to act out all those things that you're doing again from an evolutionary perspective. Zocor caveman again and you are sound asleep and your ballot dancing, pirouetting your way out to the cave into the mouths of the nearest sabertooth tiger. Then there are no more babies, oaks and human rights that's out, and that's very sad. So to stop that happening, we evolve this protective mechanism where we're paralyzed during dream sleep, to stop us acting out your dreams in sleep, paralysis and hypnagogic hallucinations. What happens is that you get a gear shift change error where you get stuck between dream, sleep and wake. And the key difference here is that with the partial arousal parasomnias, you are more asleep than you are awake. With these episodes, you are more awake than you are asleep. So basically you're awake with some elements of dream sleep intruding into your waking state, and that includes the paralysis of voluntary musculature, which is why you get that feeling of not being able to move. The reason you get a feeling of a heavy crushing weight or constricting band is because although your diaphragm is involuntary and it's working absolutely fine, your voluntary muscles of respiration, the accessory muscles, respiration are paralyzed. And when you get a fright, one of the natural things you do is try and take a big breath in, because you might have to try and fight. But if your voluntary muscles of, uh, respiration of paralyze you can't do that, so you try and take a big breath in you can't. Your brain tells stories your brain tries to imagine. What if you can't do that? Why is that? So your brain imagines it constructs a reason why you can't take the breath. And that is then perceived as this pressure or constricting band that goes along with that. And the hallucination element is just the kind of persistence of scary dream military into the weekend state. I thought that was quite cool. I did some research. I discovered that every society, every culture in history has a legend or a myth of a monster that comes in the night and tries and attacks you. So, uh, in Christian mythology, it was in Q bye and suck You buy. Uh, that would come and sit on people's chest and trying to sort of things that, in fact, um, but no matter which culture you look at, there is a Dhiman or something that comes in the night. Um, the Russians talk about old heart attacks, where they it's procedures. All the rest of it I think they explained most alien abduction stories. If you talk to people who talk about what an alien abductions like it sounds to me like regarding hallucinations, sleep, paralysis, event. But in the you know, the Middle Ages, where the cultural filter for these experiences was religion and medieval thinking in 20th 21st century, it's more science, fi. So we have alien abductions instead of demons. Sometimes you get both. Um, anyway, I thought that was already cool. Uh, so then I got interested. Sleep. And then I read the Sandman Daniel game in, which is amazing around about a few years later, which is all about sleep and the brilliance of that. And I just got really interested, and I I'm a very, very stubborn person. So despite the fact that all the way through my career, I was told there is no way to be a pediatric sleep doctor, go away, go and be something else. Instead, I didn't listen, and now I am one. I I think that is. I think we have asked that question on a number of occasions as to why someone got into a particular specialty, and I honestly think I can say without doubt that that may trump every other story we've heard. What do you think brought? Normally, I I think that's going to be hard to knock off the top of the pedestal. It is absolutely fascinating. And I think, you know, very inspirational. Like I have to say, even for me. I'm thinking of a career change. You're very welcome. Uh, we certainly more people thinking, actually, I ask a quick question. Uh, so I I so in Northern Ireland, and I know that you know Dara Donahue, and you do some great work with Dara, And I suppose what? I'm trying to get a sense from our view of Northern Ireland to what's like in the UK. So, um, as far as I'm aware for adults, we have very, very limited services for anybody with the sleep disorder. Uh, if if, if at all, Um and yet it is a really common problem. Uh, it's a it's a It's a disorder that transcends everything. You know. We can impact on diabetes and vice versa, and all the other, But yet we don't You know, we're not just grasping this, you know, on on a on a healthcare front. So I just wondered, What's it like in in London? Is their sleep clinics or the GPS is special interests. What's it be like? They're just give us a kind of a bigger view of what's happened. The rest of UK, the annoying thing about London. Um, and I say this as a Scott on Saint Andrews day, uh, London tends to suck everything into it. And then so I literally the only place I can work in the UK is where I work. Uh, pretty much, um because it just doesn't exist anywhere else. So my job doesn't exist in Scotland, for example. Uh, um, so London is always a bit of an unrealistic bubble when we look at what's available compared to what's available elsewhere within London. Uh, there is actually quite good sleep stuff, and we all try to extend beyond the M 25 as much as we can, which is why I'm very, very happy to always do things like this. Um, there are good adult services. The adult sleep clinic, as that's part of our trust, is the oldest sleep clinic in the UK. Uh, is one of the biggest in Europe uh, and serves not just the population of London, but a good distance beyond even pure metrics. There are a number of diagnostic sleep labs in London, so Darius Team in Belfast do amazing work with diagnostic sleep studies. But they do it by sheer determination to pull together the resources that there are to make something that works for the kids that need it. In London, we've got the luxury of two of the biggest sleep labs in the country in ourselves and Great Ormond Street, plus a number of other smaller labs doctor in the city. And that's just for kids alone for adults. Um, we've very much try and make sure that we, um, reach out beyond, and we all I think all of us who are involved in sleep medicine do a lot of teaching and talking, and the message that we are giving is almost always most people with the sleep problem don't need something like me. They need something like you who's who's interested, who's applying the the fundamentals of good sleep and good sleep medicine practice to everyday care, and we, and to see the real tip of the iceberg, where you know the problems are so difficult or so rare or so refractory to treatment that we need to get involved, that most people don't. Um I think you know. So we've been pushing for a long time to get more about sleeping medical school curriculums. Um, you know, I don't think we'll get a third of your curriculum on sleep. You'd probably find that a bit challenging, but, um, for the first time in 10 years of being a consultant here, I gave a lecture to our second year medical students a month ago, and that's the first time I've managed to get that in. I have managed to get in a lecture to our medical students for a lot longer than that. Uh, not all of them, unfortunately, ones that would take through our hospitals all get a lecture from me about how to sort out their sleep for being a shift worker, which, actually, I think is something that also should be never. Medical school curriculum, uh, one of the bits of work I'm proudest of over the last 10 years, uh, psychology colleague and I worked with the psh, the association, which is the association that sets the curriculum recommendations for personal social health and economic. It's called these days, I think what you say called social education when I was a kid, Um, and we built into that for the English curriculum, which is like a noise move any for the English curriculum. We built lessons about sleep into every key stage, so that's now they are available as a resource. Uh, so we're always trying to do that and get these points across. And, you know, if you if you ever come across me again, it'll probably be me trying to do something about that in some way, shape or form. But it's difficult. And, you know, the challenges is Jay. When you and I were medical students, the amount of knowledge that we had to emphasize in five years is a fraction of what these guys are having to learn. Now, Um, so coming up and saying, Well, you need to get my extra speciality stuff in as well. My counter to that counter is Well, you know that sleep is really fundamental. And it's, you know, everything else is better when you see it. Yeah. No, I I couldn't I mean, actually really inspirational Mike, and I think you're You're right. It's about how we can how we can elevate this in, because it just transcends so many arenas, uh, in how you will provide care. And of course, we've got We've got pharmacists here. We've got nurses on the call as well. Everybody has their role, Uh, in in in in, well, being We talk about the five steps of well being, but actually sleep sleep transcends all of those. And by the way, not they're gonna plug. You did a wonderful paper about night shifts. And BMJ was it? Uh, yeah, yeah, yeah. So I I share that with the final year students in their preparation for practice. Uh, yeah. So it, um So your your reaches going beyond and really, really appreciative of that of that. Like Tim, I think, uh, so I think we're sort of getting to the end, Aarti, I think so as well. I think in the in the interest of time, I think in a similar way to being sleep deprived, I think, if you are, if you spend much more than 60 minutes talking about something, um, I think it's it's it's a good idea to to stop while the ball is rolling as such. And and then we will take something valuable away. So I'm gonna I'm gonna hand over the house now just to present our last closing question, which is how we close all of our dear colleague sessions. So, uh, the last question for this evening would be, um What would be the one piece of advice you would give future healthcare professionals working with patient struggling personally with sleep or with pediatric sleep issues? Do you want to go first year? You Will. I go first? I well, I go 1st. 1st of all, I think you've just got a recruitment camp Mike for everybody. Want to be the next thing consultant? Basically, let us in general practice. Um, no. Look, I again, it's it's really we have a duty. And perhaps you might be advocates of increasing the noise, increasing awareness around important to sleep on how we can make that sort of omnipresent in your in your professional being but probably your own personal well being, particularly when you're looking at the ships coming down your way in a year's time or so. But it's it's it's, um Yeah, it's good. I think it's at societal level. We need to. We need to push it up there and your great advocates because people listen to you as healthcare professionals. That's not really a well formatted answer, but might over to you for something entirely mind to be very similar. It's I think the one thing I would advise you all to try to appreciate is the value of sleep as simple as that. I think it's something that we all underestimate the importance of. Um, I think if we get it right for ourselves and our patient's, then actually it makes a real big difference. And that means to him not being in the library at two o'clock in the morning unless you absolutely have to be, um, so it's about, you know that is that you know, it's that horrible appreciate moment. Be kind to yourself. But actually, the thing about cliches is a degree of truth in them. That's why they got to be tha is the first one, um, practical tips. I'll send it in the paper to circulate the thing that I think you know when you are doing night shift, learn how to power nap, Um, learn how to be able to take a 15 to 20 minute nap during the night shift, break and recharge your batteries So important for lots of reasons, not least because it reduces the risk of you having an accident driving home after, which is the reason I started doing that piece of work. So learn how to power it up. You can learn how to do it. And it's a really useful skill to have as a junior doctor or in your professional work around the club and that, actually it actually happens. A colleague of mine. So I they you know. So by the way, Tim and all the students, Mike, And when you get to our age, we can say back in part I But the the shifts were terrible. I mean, 48 hours, no sleep, and one of my colleagues scratched a car. Nobody home. Uh, that should never happen. Um, so, yeah, I think that's a very valuable piece of advice. And I know hustle and I are both final years. Um, I do spot some find your colleagues on the call, but for for everyone in any profession in that aspect. A power nap carries a lot of power behind it. I think its power because it's quickly but power, because it is very efficient as well. That's something I'm going to work on. I promise something, something to work on. But, folks, look, it's my absolute pleasure just to close things off this evening. Um, by thanking, um, first of all, prof Gormley, um, for giving up his time once again to join us. Um, it's been a busy day in surgery, and he he's been been scoffing dinner in the background there as well because because time goes on and thank you so much, um, and two to make to make far quart. Mike, Um, I think having you on has just been absolutely, incredibly interesting. I have been entertained here above all else, and and there's some absolutely brilliant points to take away their and I hope that resonates with the rest of the audience. Also, um, folks keep an eye out on our social media for upcoming events. What I'm gonna do is I'm going to pop the feedback form into the chat. Um, and when you have completed the feedback form, there will be, uh, an automatically generated attendance certificate for you. Um, we will also put this recording up on the event page so it will be available if you had to nip away from the computer for any reason or if any of your colleagues are particularly interested in in the event. Please do share the word about them. The recordings will be there to view. Um, so folks were just about 10 minutes after time what we hope to be, but I want to say thank you all for coming, and we will see at our next session.