Is your child getting enough sleep?


If your child wakes up fairly happy in the morning and remains engaged throughout the day, you can be almost certain he or she has probably had a good night’s sleep. Higher sleep quality enhances neural connections, enabling better memory consolidation and information processing1. Hence poor sleep is thought to negatively impact children’s learning and early academic achievement (AA2).Children of the age bracket 6-13 could easily minimise behavioural problems and cognitive deficits with 9-11 hours of sleep however in reality only 23% of school children are getting less than 8 hours of sleep where 2% sleep 7 hours or less3. The effect of good sleep on academic achievement among children with lower effortful control (EC4, is a dimension of temperament related to the self-regulation of emotional reactivity and behaviour) has been established recently5.

There are many reasons for the lack of sleep among children and the side effects of poor sleep pattern. Interestingly, parental insomnia symptoms have an impact on children’s sleep as evident by in-home sleep- electoencephalaograpgy6. Another major cause of sleep deprivation among children includes anxiety disorder7 where many children are being referred to mental health services. Most common sleep problems associated with anxiety include difficulty in initiating/maintaining sleep, refusal to sleep independently and nightmares8. Research studies also link children’s sleep problems, parental sleep and daily functioning9. Several reports have demonstrated a link between children’s sleep problems and parental sleep difficulties in healthy population. ADHD and autism also have big influence on the quality of sleep in children and their parents as well10, 11.

Many studies also indicate the relationship between sleep duration and childhood obesity12, which is one of the hugest healthcare burdens for the NHS. Lack of sleep can influence the development of obesity by certain biological pathways13, 14, 15 like increased energy intake (unhealthy dietary patterns); decreased energy expenditure (diminished physical activities, increased screen time).

Srini

Fig 1. Potential mechanism12 by which sleep deprivation predisposing obesity. ↑ – short sleep duration leads to the increase of the affected factors; ↓-short sleep duration leads to the affected factors; (?) sufficient evidence not available.

Other potential mediators are hormonal (leptin, insulin, ghrelin) changes evoked by sleep deprivation16, 17, and 18. Many reviews focused on paediatric populations have established a clear link between short sleep and obesity12 and some studies have investigated the association between sleep duration and dietary habits where a 5-day duration sleep restriction resulted in the consumption of higher glycaemic index foods leading to obesity19. Decreased sleep duration also increase the tendency of external eating (Eating in response to the sight or smell of food20. Studies also revealed that short sleepers tend to consume higher energy foods, more added sugar and high sugar beverages compared to long sleepers21.

Large multicentre study (Australia, Brazil, Canada China, India, Colombia, Finland, Kenya, Portugal, South Africa, UK, and USA) concluded low MVPA (medium to vigorous physical activity), short sleep duration and high TV viewing are the important correlates of childhood obesity22.

Here are some of the recommended tips23 – mostly a focus for children but many of the strategies apply to all age groups. The easiest thing parents can do is to make sleep a priority in their children’s lives. At times, avoid scheduling activities (music lessons, sports, social events, etc.) that would delay bedtime. This can be more challenging with older children dealing with heavy homework loads and relatively early school start times but with sufficient organisation and prioritisation of activities, it can be done.

It is easier for kids to wind down if there is a predictable bedtime routine to follow. For example, the four B’s of bedtime: bathing, brushing teeth, books, and bedtime. It can also be helpful for kids maintain sleep and wake times roughly the same (within an hour or so) each day, even on weekends.

It is highly recommended for children to get at least an hour of exercise every day. While daytime exercise can contribute to sleeping better at night, vigorous exercise too close to bedtime may keep kids awake, so try to plan your child’s physical activity accordingly.

Avoid keeping computers or TVs in your child’s bedroom, and keep portable devices (phones, tablets, handheld games) out of reach. A helpful tip is to have a central charging station where all of the family’s electronics spend the night.

Exciting or violent programming in particular can make it difficult for children to fall asleep and bright screens (or brightly lit rooms) can consequently delay melatonin release and, as a result, the onset of sleep.

Setting the stage for good sleep is an important habit that can make a difference in your child’s future health. If you have concerns, talk to a paediatrician, or check out health guide to better sleep by mental health foundation24 and NHS choices25

Blog by Srini Natarajan

 

Advertisements

The butterfly effect: Combinations of immunotherapy and radiotherapy to amplify the abscopal effect in metastatic disease.


Combination therapies are known to be effective in treating cancer, and there have been many advances with the use of two or more therapies that have either an additive or a synergistic effect upon treating disease. Often, the use of a combination therapeutic will reduce the overall toxic effects of chemotherapeutics on healthy tissue, which has a huge clinical benefit. A lot of combination therapies are used in conjunction with chemotherapy, but there are also combination therapies that are being researched that can positively impact the “abscopal effect” of radiotherapy.

A recent article in Nature Reviews Cancer has outlined the developments in research that have provided evidence that the abscopal effect can be boosted with a combination of radiotherapy and immunotherapy1.

The abscopal effect (from the Latin for “away from target”, ab scopus), was first described in a paper in 1953 in which metastatic cancer sites were found to regress away from the site where radiotherapy was administered2.  This beneficial off-target impact is known to be driven by the immune system, but is a rare event because in the tumour microenvironment, weakened immune responses may restrict the development of an abscopal response. However, there is growing evidence to support the idea that using a combination of radiotherapy and immunotherapy may boost the abscopal effect.

Whilst the exact mechanism of the abscopal response is not completely understood, there are multiple studies that have highlighted how combining an immunotherapeutic with radiotherapy can boost its effect. Upon injury through radiation, a tumour can release tumour-specific antigens, which are presented by antigen-presenting cells to CD8+ T cells. These T-cells can then identify both the tumour that has been irradiated and also areas of metastatic disease to be targeted for attack by the adaptive immune system3 (Fig. 1). Damage-associated molecular patterns (DAMPs) and cytokines may also be expressed by the irradiated tumour cells to further feed into the inflammatory cascade that leads to the ultimate cellular elimination by CD8+ T-cells 4.

Will Pearce 1

Fig.1 The inflammatory cascade involved in the abscopal effect1

However, the rarity of the abscopal effect suggests that the immunosuppressive microenvironment of tumours inhibits the ability of primed CD8+ T-cells to identify tumour cells and target them for elimination. This is possibly due to immunosuppressive cytokines such as TGF-β and surface receptors such as CTLA4, which can inhibit T-cell function4. Therefore, methods to overcome the immunosuppressive microenvironment of tumours have been explored to assess whether overcoming immunosuppression by inhibiting Treg cells using anti-CTLA4 and PDL-1  (programmed cell death protein 1) blockade can lead to increased CD8+ T-cells:Treg cell ratios. In theory, this would make the tumours more sensitive to CD8+ T-cells and lead to adaptive immune responses aimed at the tumour and metastases, which would boost abscopal responses.

Other methods of overcoming immunotherapy include direct injection of IL-2 (a proinflammatory cytokine) or dendritic cells (DC) into the irradiated tumour. Boosting DC numbers in the irradiated tumour will lead to an increase in tumour-specific antigen presentation and therefore a larger adaptive immune response. Injection with IL-2 leads to inflammation and therefore a boost in the abscopal effect. All of these methods are aimed at overcoming immunosuppression and therefore better targeting of the tumour and metastases by the immune system.

There are many examples in which combinations of radiotherapy and immunotherapy could be used to boost abscopal effects and therefore treat metastatic disease, which is known to account for most of the fatality associated with cancer. It is therefore an important area of research and an interesting approach to combination therapy in cancer.

Blog written by Will Pearce

  1. Ngwa, Wilfred et al., Nat. Rev. Cancer., 2018, Vol.18., 313-322
  2. Mole, R.H., BR J Radiol., 1953, Vol.26, 234-241
  3. Grass, G.D. et al., Curr. Probl. Cancer., 2016, Vol. 40., 10-24
  4. Vatner, R.E., et al., Front Oncol., 2014, Vol. 4., 325