Sleep is as important to humans as breathing, eating and drinking. Yet for patients and families dealing with eczema, sleep often comes in short bursts between itching and scratching cycles. As a doctor, I want to help you better understand why sleep is so challenging when eczema is in the picture and offer tips for how to get a better night’s rest.
Waking during the night is normal
We go through different stages of sleep. The first part of the night is spent in our deepest sleep and the last part of the night in dreaming (rapid eye movement or REM) sleep, with the rest of the night spent in lighter stages of sleep.
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In children, sleep cycles are about an hour. In adults, they are 90 minutes to 2 hours. At the end of every sleep cycle, we have a short arousal where our brain wakes up briefly and then returns to sleep.
Most people are not aware of the fact that they wake at least two to six times a night. In terms of eczema, this is important for two reasons. First, during these brief arousals, the itch sensation may kick in and the reflex of scratching begins.
Unfortunately, the reflexive scratching will often result in increased itching/scratching and may even result in bleeding. Remember that a sleep cycle is shorter in children, so it may appear as if your child is scratching in their sleep every hour on the hour.
The other reason it is important to understand that we all wake multiple times per night is related to how we fall asleep. We all have favorite ways of falling asleep: a teddy bear, a fan, or some type of white noise.
For me, it is pillows. I put my head on these two pillows and fall asleep easily at bedtime. But when I wake in the middle of the night and find my pillows on the floor I can’t go back to sleep. The pillows falling off the bed did not wake me, but when I had a normal arousal, I couldn’t go back to sleep without my pillows. I scoop my pillows up, put my head on them and return to sleep.
The moral of the story is if you help your child fall asleep at bedtime by lying with him, he will then need you to return to sleep following normal nighttime arousals. All that said, if you need to monitor your child for health reasons (such as to keep them from scratching), then you need to share a bed or room with them.
However, if medical supervision is not necessary, then you may want to consider the benefits of teaching them to fall asleep independently at bedtime (i.e., no more helicopter kicks in the middle of the night!). Over time, they will learn to return to sleep in the middle of the night on their own.
Our internal clock is ticking
Our internal clock, or circadian rhythm, is a strong factor in helping us sleep. The funny thing about our circadian rhythm is that it runs on a clock that is slightly more than 24 hours. That means we can adapt when we cross time zones or at the start/end of daylight saving time.
Our internal clock is regulated by light and dark, as darkness is a cue for our brains to produce the hormone melatonin. Naturally produced melatonin doesn’t make us sleepy at the onset of darkness, but instead prepares our body for sleeping by doing things like cooling our core body temperature.
However, this means that in the hour or two before bedtime, heat escapes our body through the periphery, in particular extremities and skin. This is believed to be one factor that contributes to increased itchiness right before bed.
In fact, studies have shown that children with eczema sleep soundest between 2 and 4 a.m., when they reach their coolest body temperatures, both internal and external. This is contrary to what we know about sleep physiology, as our deepest (and soundest) sleep occurs in the first part of the night, usually at a time when we find many children with eczema to be the most restless.
What can I do to improve sleep?
We find that once eczema improves, so does sleep. But that is pretty obvious and not necessarily the answer you are looking for. So here are some other suggestions to ensure healthy sleep practices for every member of your family.
- Go to bed and wake up at the same time every day. Easier said than done, I know. But if you’ve never tried it, get yourself (and your children) on a consistent sleep schedule. You will find it is easier to fall asleep and wake up every day. Of course, this means not staying up late or sleeping in on weekends. But having more energy to enjoy the day is usually worth the trade-off.
- Create a consistent bedtime routine. Bedtime routines are not just for young children. In order to fall asleep, you must be calm and relaxed. While our technology turns off with the touch of a switch, our brains have a dimmer switch that takes a little while to shut down. Set 15-30 minutes aside before bed to have the same quiet routine every night (e.g., snack, brush teeth, read, lights out).
- Make bedrooms a place for sleeping. Bedrooms should be cool, dark and comfortable. It is also really important that they be technology-free. Children and adolescents with technology in their bedrooms sleep on average 30 minutes less per night, and it only takes a small amount of sleep loss to cause problems with learning, attention and behavior. Also, the light that comes from these devices is enough to prevent the release of melatonin, making it difficult to fall asleep. Set a bedtime for everyone’s devices and tuck them in to charge in a central location (i.e., kitchen). It is best if devices are shut down 30-60 minutes before bedtime. If you or your child uses an electronic reader, make sure that the screen is on night mode and that there are no other options (e.g., internet, apps) that could be distracting. If you keep your phone by your bedside for emergencies, make sure it is on night mode, alerting you only when a child is calling or there is a true emergency.
- Limit caffeine intake after lunch. Four to six hours after you consume caffeine, it is usually still buzzing in your brain (unless you have a really high tolerance for caffeine!). Caffeine consumed after school or at dinner can interfere with falling asleep. In general, children should not be consuming caffeine. Be aware caffeine comes in many different products, including the obvious (e.g., Coke, Pepsi, Mountain Dew, coffee, iced tea, etc.), the less obvious (e.g., Sunkist orange soda, Barq’s root beer, A&W cream soda), and the surprising (e.g., certain gums, candy, maple syrup and even bagels!).
Although some of these recommendations can be difficult to follow when eczema is flaring, stick to them as much as possible, in both good and bad times, to increase your family’s chances for better sleep quality and longer sleep duration.
Dr. Lisa Meltzer is an associate professor of pediatrics at National Jewish Health in Denver. She is board certified in behavioral sleep medicine by the American Board of Sleep Medicine and directs the Pediatric Behavioral Sleep Clinic at National Jewish Health. Visit www.nationaljewish.org/doctorsdepartments/providers/physicians/lisa-j-meltzer for more information.