Child Health Part 1 Flashcards
1
Q
What is a life course approach to health?
A
- A persons physical and mental health and wellbeing are influenced by the wider determinants of health. A Life course approach to health considers all of these factors and their contribution to health and wellbeing throughout an individuals life, not at just one point in time.
- Right from pre-conception, to the early years of life, to childhood, adolescence, adulthood, later life and end of life these factors influence out health.
- In looking at health from a life course perspective, rather than a ‘disease-focussed’ approach, we approach health more holistically and can take a more proactive role in promoting and restoring health and wellbeing at different stages of an individuals life and in turn prevent ill health in the future
2
Q
Why are the early years of life so critical?
A
Marmot review:
The foundations for virtually every aspect of human development, physical, intellectual and emotional,
are laid in early childhood.
3
Q
Which aspects of health and wellbeing are affected during early years?
A
obesity, heart disease and mental health to educational
achievement and economic status.
4
Q
What can inadequate foetal nutrition lead to?
A
irreversible delayed cognitive or motor development in the child.
5
Q
What plays a role in the weight of a child in childhood as well as adulthood and in the risk of type 2 diabetes?
A
Foetal nutrition and maternal physical activity levels during pregnancy
6
Q
What term describes lifestyle factors being inherited influencing an individuals future health before even born?
A
intergenerational relationship
7
Q
During the first two years of life, What factors influence the foundations of behaviour formed during this time such as cognitive, physical, social and emotional development?
A
diet, physical activity, relationships, sleep, stress and socioeconomic status.
8
Q
Which interventions are crucially important in getting a healthy start to life? What group is uptake of these interventions lower in?
A
- breast feeding and vaccinations
- uptake of these interventions is lower amongst more deprived groups in society.
9
Q
Define school readiness.
A
a marker linked to educational attainment, life chances and even involvement in crime.
- Modifiable factors in early years influence this
10
Q
Why is it imperative for children to get a healthy start?
A
- to reap a double dividend of better health now,
- but also in reducing health inequalities across the life course.
11
Q
What is the most reported disturbing trend amongst school children in the UK?
A
epidemic of childhood obesity
12
Q
What is the umbrella term for obesity and overweight
A
Unhealthy weight
13
Q
Whats one way unhealthy weight can be managed?
A
lifestyle interventions.
14
Q
What does current data show in terms of childhood unhealthy weight.
A
- one in five children entering reception class, that’s as young as four and five years old, are already overweight or obese.
- Overweight infants are five times more likely to be obese in later childhood, adolescence and adulthood.
15
Q
Other than unhealthy weight, which other conditions are increasingly being observed in children?
A
conditions associated with lifestyle such as Type two diabetes, fatty liver disease and arteriosclerosis
16
Q
Why is intervention at the early stage crucial?
A
Behaviour in childhood lays the foundations for behaviour in adolescence and adulthood.
17
Q
Why are those who are physically active in childhood much more likely to be physically active as adults.
A
Behaviour in childhood lays the foundations for behaviour in adolescence and adulthood.
18
Q
Describe physical activity patterns of children in the UK.
A
- Today’s children are the least active generation that has ever been.
- only 23 percent of boys and 20 percent of girls currently meeting age specific recommendations for physical activity.
- Across the population levels of physical activity reach a lifetime peak at the age of school entry, and this typically declines with age, declining even further during the school holidays, more markedly amongst those living in deprived areas.
19
Q
Is inactivity or activity a more persistent behaviour?
A
inactivity - so important interventions occur before this behaviour becomes habituated.
20
Q
Define physical literacy.
A
- physical literacy = the motivation, confidence, physical competence, knowledge and understanding to value physical activity throughout their life course.
21
Q
Describe how physical literacy is developed.
A
- When children engage in inclusive, positive, meaningful physical activity that place equal value on both the physical and psychological benefits to health and well-being, children develop physical literacy
22
Q
What does physical activity in children and young people contribute to?
A
- improved cardiovascular fitness, improved sleep and contributes to healthy weight.
- There’s strong evidence for improved learning, better academic achievement and higher executive functioning.
- Active children are happier, more resilient, report higher levels of self-esteem, confidence and are more trusting of others.
- They show reduced feelings of anxiety, stress and depression all fundamental when looking to improve children and young people’s mental and physical health.
23
Q
At what age are lifelong Health behaviours established and why?
A
Adolescence - Between the ages of 10 and 24 years old
- individuals experience a range of changes in lifestyle with associated behavioural, emotional and social changes.
24
Q
When is the best opportunity to intervene and promote positive health behaviour?
A
Adolescence - Children, young people start to become more independent with their behaviours,
25
Why is early intervention in positI've health behaviour so important?
- It is far easier to establish positive, healthy behaviour early in life than to change behaviour at a later stage when habit and inertia become more powerful.
- It is more cost effective, too. With earlier intervention giving greater returns to society, than later interventions.
26
Which individuals help form a child's expectation of themselves and those around them?
Parents, families and caregivers are, of course, crucial for shaping childhood behaviour.
27
What is the single biggest risk factor for childhood obesity.
parental obesity - Lifestyle behaviours are often entirely dependent on caregivers initially, and children mirror the lifestyle behaviours of parents, for example, mirroring eating habits. - Genetic, environmental and social factors also contribute
28
Why is a family approach important?
It's crucial to understand that when thinking about lifestyle interventions in children, we take a whole family approach to empower the family to make changes,
29
Which practise is crucial for self-regulation and internalisation of healthy behaviours amongst children.
autonomy supporting parenting practises
30
Outline our duty of care as physicians
- involves promoting healthy lifestyles and practising lifestyle medicine with children and their families.
- For the population - have a role in advocating to reduce and mitigate health inequalities from the beginning of the life course. It's our moral duty as professionals.
31
What does giving every child the best start in life enable
- enables individuals to thrive and reach their potential,
| - reducing health inequalities, preventing chronic disease and improving health and well-being.
32
How does encouraging a life course approach, starting early and enabling positive health behaviours benefit the society?
Making people fitter, improving employment levels, increasing tax revenues, and reducing pressure on health systems.
33
What did Royal College of Paediatrics and Child find?
good quality, cheap food and drink, exercise and hobbies were identified as children's priorities for staying healthy, happy and well.
34
What are dental carries?
- when oral bacteria metabolise sugar and produce acid that demineralises enamel and dentin from the hard coating of the tooth
35
How do dental carries impact quality of life
Severe caries can cause pain and infection and can even lead to sepsis and death. Dental caries are a common cause of school and work absenteeism and impact on quality of life and wellbeing.
36
Describe the dental carries global impact
They are major public health problem and the most common non-communicable disease globally. Children and adolescents are most at risk of developing dental caries; in 2015 a quarter five-year olds experienced dental caries in England and between 2015-2016 it was the most common reason for hospital admission in children aged 5-9 years old.
37
Why is management of dental carries limited?
Management may need to involve tooth extraction – both extremely expensive, time consuming and widely unavailable in low income countries. The average cost of a tooth extraction admission for a child between 2015-2016 was £836!
38
Describe sugar intake, Dental carries and obesity in terms of social deprivation.
- associated with excessive intake of sugar.
- often occurs with obesity occur together,
- affecting disadvantaged populations.
39
How can we prevent dental carries
- sugar reduction in the diet and maintaining good oral hygiene.
- Reducing free sugar intake to less than 10% of energy intake
- Population-wide approaches can include water fluoridation, fluoride varnish programmes and sugar-reduction programmes.
40
What are the key social determinants and lifestyle behaviours identified in this referral letter that would be important to address when taking a holistic approach to this child’s health?
- Behavioural problems noticed at school
- ADHD – currently awaiting review from
community paediatrician
• Childhood obesity
• UTD immunisations – did not have annual flu immunisation as was moving house.
– recent course of antibiotics to treat dental abscess (amoxicillin 500mg TDS for 7/7)
- Moved from Wales to London 6 months ago
- Lives with mother and 3 siblings (18 months, 7 and
10).
- Mothers family nearby for support
- Safeguarding - Currently on Child in Need plan (Previous Domestic violence in home involving mothers ex-partner- no Longer in contact). No immediate concerns.
Family History
• Mother Previous Depression/anxiety – well managed.
• 10 year old brother ADHD under CAMHS
- severe early dental caries affecting upper and lower molars and canines
- pain causing to disturb sleep, has led to a loss of appetite and avoidance of certain foods and may be contributing to behavioural problems at school.
- school absenteeism
- diet that is high in sugar and consumes sugary drinks. difficult to encourage him to try different foods
- overweight
- compliant with brushing his teeth daily, though did suggest sometimes she does not
always check he has brushed his teeth as caring for four children so daily life can be chaotic.
- recent abscess and symptoms disrupting daily life.
- age
- area
41
What are adverse childhood experiences. Give examples.
ACES are stressful events that occur in childhood. They include, but are not limited to:
Experiencing abuse: Physical, sexual, psychological or neglect.
Witnessing domestic abuse
Having a close family member or caregiver who misused drugs or alcohol
Having a close family member or caregiver with mental health problems
Having a close family member or caregiver who served time in prison
Experiencing parental separation or divorce on account of relationship breakdown.
42
Summarise Study about ACEs
https://www.sciencedirect.com/science/article/pii/S2468266717301184
- ACEs often cluster in children's lives and a growing body of research is identifying cumulative relations between multiple ACEs and poor health.(1990s.)
- multiple ACEs affect health-harming behaviours and development of health conditions, including non-communicable diseases.
- individuals with at least four ACEs were at increased risk of all outcomes examined
- Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two), moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three),
- strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven)
- This systematic review and meta-analysis highlights the pervasive harms that ACEs place on health throughout the life-course and the importance of addressing the various stressors that can occur in children's lives, rather than limiting attention to any one type
- strong relations between multiple ACEs and poor health suggest that a reduction in ACEs and building of resilience to enable those affected to avoid their harmful effects could have a major effect on health.
43
Effect of ACEs on following health outcomes:
1. Physical inactivity, overweight or obesity and diabetes
2. Smoking, heavy alcohol use, heart disease, respiratory disease, cancer and poor self-rated health
3. Mental ill health, sexual risk taking, problematic alcohol use
4. Problematic drug use and interpersonal and self directed violence
1. Weak or modest
2. Moderate
3. Strong
4. Very Strong
44
How do you think trauma experienced by a caregiver affects both the developing baby or child?
Mother release cortisol - baby absorbs cortisol through placenta - It can impact Baby's:
HPA axis, central nervous system, limbic system, autonomous nervous system.
If a caregiver struggles to regulate, the attachment relationship between caregiver and child may be strained. It can impact the Childs: development of a core sense of self, ability to integrate experiences, Epi-genetic expressions.
This trauma can make the child more prone to PTSD of the trauma, struggle to repair after conflict, struggle with relationships, unintentionally bring out negative behaviours in others, be emotionally detached, And be more prone to dissociate.
This can become a cycle impacting future generations
45
specific tips for lifestyle consultations with children and
| families
- be opportunistic (make time in consultation to talk about it)
- Be Sensitive
- non judgemental approach (some people may not be aware of potential health concern)
- Strength based approach - focus on positives (children respond well to positive reinforcement from healthy behaviours from both clinicians and family) (make children and families identify their own healthy behaviours and reinforce these)
- Focus on barriers of particular importance to the child (link the health benefit to current things/problems in their life)
- Encourage children with long term conditions to be active and thrive (moving medicine)
- Relate to other children
- Engage parents and families (Parents want to do the best for their children, and evidence strongly now suggests that autonomy, supporting parenting practises and behaviours are crucial for the development of healthy behaviour in children.)
- Identify barriers in seeking Health behaviours and address these first (eg. if cost is barrier - can advise on healthy start vouchers)
- specific and short term goals
- Daily routine (eg. walking to school)
46
LEAP CRITERIA
For social prescribing:
```
LOCAL
ENJOYABLE
AND
PRACTICAL
make participation more likely.
```
47
What is the National Child Measurement Programme
The NCMP measures height and weight of children in reception, ages 4 and 5, and in year six, ages 10 and 11. It assesses changes and trends over time in the population.
48
How is BMI categorised in children
- Defining children as overweight or obese is a complex process.
- Children of different ages and sex grow and develop at different rates. Therefore, BMI is characterised differently than in adults.
- It's calculated by dividing their weight in kilograms by the square of their height in metres.
- over the age of 4 - compared to reference measurements collected in 1990.
- These take into account age and sex of the child. Based on the BMI centile, the child will be considered as underweight, healthy weight, overweight or obese or a subcategory of obesity, severely obese.
49
Outline Tier 1 BMI services.
Access to health care services is tiered, based largely on these clinical cut-offs. And while services vary depending on the local area, the principal of each tier remain broadly similar.
Tier one services are universal and do not only target children who are overweight or obese.
- These interventions involve frontline health care professionals such as yourselves using brief advice or interventions to make healthy changes to lifestyle, along with local or regional population health approaches.
50
Outline Tier 2 BMI services
Tier two services are for children at or above the 91st centile for weight. Interventions are typically with community based teams and are time specific.
For instance, a 12 week intensive course for families and children addressing nutrition, lifestyle and behaviour change.
Typically, these interventions revolve around enabling the children to grow into a healthy weight rather than focussing on weight loss depending on their stage of growth.
51
Outline Tier 3 specialist BMI services.
Tier three services are appropriate for children at or above the 99.6th centile, or above the 91st centile with comorbidities or complex needs.
- These are typically longer term clinics involving specialist multidisciplinary teams with a specialist clinician, specialists nurses, dieticians, psychologists, physiotherapists and psychiatrists working with the child and the family with a longer term follow up.
52
Outline Tier 4 specialist BMI services
Tier 4 services don't really apply in children, but in adults, this might involve something like a surgical intervention, such as bariatric surgery.
53
Why is developing clinical practise in which discussing improving health behaviours with
children and families crucial in improving children's health.
- This tiered system highlights that whilst clinical services are directed at those most in need,
you can see how a large proportion of children, even though they're in the overweight category by definition, do not meet criteria for referral or access to specialist services.
- Therefore, all children and families, regardless of their weight status, should be able to access lifestyle advice and intervention from frontline health care professionals to help support them, make healthy changes and ideally prevent gaining excess weight.
54
Give an example of a public health approach in improving child health.
Sugar tax - fiscal measure in action
55
Giving every child the best start in life not only enables individuals to thrive and reach their potential, it also:
- Reduces health inequalities
- Prevents chronic disease
- Improves health and wellbeing
- Increases employment
- Increase tax revenue
- Reduces pressure on the health system
- All of the above
Correct! The benefits are far-reaching. Correct answer: All of the above The early years of life are a critical time for health. Here’s what The Marmot Review said about the early years: "The foundations for virtually every aspect of human development – physical, intellectual and emotional are laid in early childhood. What happens during these early years, starting in the womb, has lifelong effects on many aspects of health and wellbeing – from obesity, heart disease and mental health, to educational achievement and economic status. Later interventions, although important, are considerably less effective where good early foundations are lacking". Further reading (optional): The Marmot Review 2010 The Marmot Review – 10 years on
56
Physical literacy occurs when and individual has the motivation, confidence, physical competence, knowledge and understanding to value physical activity throughout their lifecourse. This can be developed when a child:
- When children engage in inclusive, positive, meaningful physical activity experiences that place value on the physical benefits to health and wellbeing
- When children engage in inclusive, positive, meaningful physical activity experiences that place equal value on the psychological benefits to health and wellbeing
- When children engage in inclusive, positive, meaningful physical activity experiences that place equal value on both the physical and psychological benefits to health and wellbeing
Correct! When children engage in inclusive, positive, meaningful physical activity experiences that place equal value on both the physical and psychological benefits to health and wellbeing. This is important as behaviour in childhood lays the foundation for behaviour in adolescence and adulthood. Inactivity is a far more persistent behaviour than activity, and it is easier, more cost effective and better for health and wellbeing of individuals to stay active from a young age. By focussing on either physical or psychological benefits of physical activity, benefits to individuals can be underestimated.
57
Embedding healthy behaviours into a daily routine is likely to make behaviour change more effective. However, if a family wishes to participate in something new like an activity, the LEAP criteria makes participation and perpetuation of the behaviour more likely.
What does LEAP in this context stand for?
- Local, Easy, and Price-appropriate
- Local, Enjoyable and Practical
- Local: Enabling Active Participation
LOCAL, ENJOYABLE AND PRACTICAL
| Correct! If these criteria are met, families are much more likely to keep participating in the long-term.
58
How should we open the conversation about weight with our patients?
if start off bad - can put families off and doctors off from speaking about it again.
- choose the right opener (would it be ok if i ask about your family diet/physical activity levels)
- addressing importance (how important is it to address family health right now?)
- ask about feelings (How do you feel about families household diet or lifestyle at the moment)
3 above approaches avoid passing any judgement
59
What are some of the challenges for clinicians around having conversations about weight with patients?
- Family have agenda of their own ( Where is that family currently on journey to healthy lifestyle)
- do not make assumptions
- use the openers asking permission and about feelings
60
How should we move from starting the consultation around weight to motivating patients to actually make change?
- communication approaches - people don't like being told what to do so avoid telling people the answers
- use motivational interviewing ( use families ideas and work off them)
- short brief intervention
- help make families focus and build on their ideas
- Signposting (asking families what support they need)
- leave the door open (build on initial conversation at later date)
- Explore family goals (SMART goals)
61
How should we manage patients expectations and help support patients set realistic, specific goals regarding their weight?
- Develop conversation over time
- find out families expectations
- reflection (how feasible is goal)
- Shape patients expectations by breaking it down
-
62
When is the right time to health coaching conversations with a parent and their child?
- Pitch public health approaches where relevant into presenting complaint
63
What else can doctors do to create a culture where talking to families about healthy weight is effective?
- Team working
- Normalise conversations.
- offering support in community where available
64
IF whole family has weight problems, not just the child. How is it best to address this?
- Non judgemental approach
- undo psychological damage from years gone by
- General household approach non specific to family member
- Broad healthy approaches
65
What is the effect of junk food advertising?
- impacts what we buy and crave subconsciously
66
What impacts our food choices
- advertising
- price of food relative to what we can afford
- food insecurity (disruption of food intake or eating patterns due to lack of money)
- financial insecurity ( manifestation of a self worth problem - following a spike in money you feel low because you know you are not secure in your funds)
67
5 eatwell food groups
- fruit and vegetables.
- potatoes, bread, rice, pasta and other starchy carbohydrates.
- beans, pulses, fish, eggs, meat and other proteins.
- dairy and alternatives.
- oils and spreads.
68
Rank 5 eatwell food groups from most to least expensive per 1000KCAL
1. Fruit and Vegetabales
2. Milk and Dairy food
3. Meat, fish, eggs, beans, other sources of non dairy protein
4. Food and drinks high in fat and sugar
5. Breads, rice, potatoes and pasta
Fruit and vegetables are the most expensive food group per 1000 calories on the “Eatwell Guide”. Conversely, macronutrient dense and micronutrient poor foods much cheaper per 1000 calories.
69
Describe the proportion of disposable income used up of the cost of the eatwell guide was spent by all households, by income decile.
Data from the Family Resource survey in 2016 found that those in the poorest 10% of UK households would need to spend 76% of their disposable income (after housing costs) on food to meet “Eatwell Guide” costs. Whilst the wealthiest 10% would be spending just 6% of their disposable income to meet the “Eatwell Guide”.
70
Who has the greatest burden of malnutrition (undernourished, hidden hunger and obesity) according to UNICEF STUDY
found in children and adolescents from the poorest communities throughout the world including in high income countries like the UK.
71
Define the concept "hidden hunger"
-over consumption of calories derived from cheaper, unhealthy, processed foods, which lack nutrients that are key to growth, brain development and immunity. Sleep, physical activity, mental wellbeing and concentration are also affected by malnutrition.
72
Describe the scale of the physical inactivity challenge in British children.
Less than half of all children in England between the ages of five and sixteen achieved the recommended 60 Minutes, a day of moderate to intense physical activity.
In Wales, Less than 20 per cent of adolescents between the ages of eleven, six 16 years old get enough physical activity.
- And across all across all countries, physical activity declines quite sharply as as children get older and into adolescence.
- We can see that boys are more active than girls at every age group during school life.
- There is a real inequality there where Asian and minority ethnic children are much less likely to be physically active and meet those physical activity guidelines.
- And equally children from low income households are much less likely to be physically active and meet those activity guidelines.
There's a real gap and there's a real problem in all children. But we can see that there are certain groups within society where they really struggle to meet those those guidelines.
73
Benefits of Physical activity for children
- physical health.
- socio-emotional mental wellbeing.
- positive impacts on children's attainment and educational outcomes the more active they are.
74
How can non profit organisations get children to undertake more physical activity?
4 key domains
1. Research and insights
2. Public affairs and Policy
3. Strategic Projects and campaigns
4. Membership
- key pillars and themes
- children, young people and families
- workplace health
- active ageing and long term conditions
real focus across all of those is inclusion, infrastructure, digital and learning development
75
Describe how organisations can use research and insights to work with public health and policy to get children to be more active
Use research and insight and a member consultation to inform policy positioning.
-lobbying and policy work to look at ways in which we can unlock opportunities for children, young people and their families to be more active, whether that's in community environments, home environments, or school environments.
- direct interface with national devolved and local governments - looking at ways in which we can get children more active at school. eg. unlock opportunities for children to travel to school in an active way but that's safe and accessible for all children
76
Describe how organisations can use strategic projects and campaigns to get children to be more active
-use strategic projects and campaigns as platforms to enable our members on the ground that are working in communities, working in schools, having that direct connection with families to operate safely, operate effectively, and with an evidence base behind them so that they can make that really important impact on the ground with those children that we're targeting to be more active.
77
Describe how organisations can be a part of membership bodies to get children to be more active?
-membership body which enables work with large networks of organisations and individuals across the country that are trying to get more people physically active.
78
most effective way to get UK children more active?
- individual interventions which are sustainable
- common values
eg. active mile schemes in schools
- inclusive and accessible
- very little equipment
- very little cost or often no cost to participants
- ease of access
above make physical activity interventions successful
apply values in community and home environments
79
What is an overriding hallmark of successful interventions?
- adopt a very whole systems approach.
eg. Active mile schemes work in schools when they are adopted in the context of a whole school approach, working with all stakeholders within that school, making sure that children are brought into it, making sure that the teachers and other staff in the school environment are brought into it, making sure that the senior leadership team are brought into it - embedded into school life.
80
as well as increasing physical activity, what do organisations also want to promote.
- increase children's enjoyment of physical activity as well, because children's enjoyment of physical activity is often an indicator for them to go on and participate in activity in a Long-Term Way
81
What are the roles of different skateholders in this approach to increase physical activity in childten?
- joined up approach
- connection across skate-holders
- information sharing, best practice and learning through research and insights
- wider and diverse network
- ability to engage skate-holders
connection between schools, community sports and physical activity offers.
eg. when schools close
- multi-skate-holder networks - Works with local stakeholders on the ground. So people, the groups that deliver physical activities, local nutritionists and public health experts on the ground to create these really safe, fun, energising, inclusive environments for children and their families to come into and get that physical activity and healthy food during a time in which they might not get it.
82
biggest barriers are to children of becoming active?
- accessibility
- low vs high socioeconomic groups
- poorest children
solution - government action plans and strategies need proper implementation and investments in vulnerable groups, need time and patience
- need deep skate-holder engagement
- common values and hallmarks of successful interventions to be transferred
- all communities are different - relevant skate-holders
- commitment
- Tackle this inequality gap between those children from different ends of the socioeconomic spectrum.
83
How as doctors and future doctors, can we do our part in getting UK children active?
- advocacy - top line knowledge of the physical activity guidelines for children and young people actively promoting those (so understanding how many minutes a day of moderate to intense physical activity young people should get)
- understanding preventative virtues of physical activity and the benefits of physical activity from a prevention perspective
- patient centred approach - individual approach
(understanding what's in that local environment from a physical activity perspective)
- confidence in communication
- signposting and social prescribing
84
Describe the 2 process model of sleep.
Humans are “hard-wired” for sleeping during the night and being active during the day. Researchers explain that sleep regulation has two components:19-21
Build-up of homeostatic sleep drive
Circadian rhythms
These two components interact to determine the time when we go to sleep and the time when we wake up, as well as the stability of waking neurocognitive functions (e.g., how well we feel when we are awake).
85
Negative impacts of non optimal sleep on health and wellbeing.
- obesity
- heart disease
- high blood pressure
- diabetes
86
How much sleep does an averaage adult need to maintain optimal health?
7-8 hours (national guidelines)
87
Does every need the same amount of sleep.
No - How much sleep you need to adequately function is driven by your genetics and dependent on the stage of life that you're in.
88
Describe Short sleep sleepers
A small proportion of people, around one percent, are naturally short sleepers and will function perfectly well on as little as four hours sleep.
- It has been suggested that this is driven by genetic mutations, which affect the production of orexin, also known as hypercretin, increased orexin leads to increased wakefulness. It's also been suggested that genetic, familial short sleepers have a higher tolerance for stress, implying that these changes aren't necessarily sleep specific, but also impact daytime behaviours.
89
are people genetically disposed to need more sleep?
It's theorised that there are some people who genetically need more sleep, although the mechanisms for this are still to be elucidated.
90
Describe the relationship between age and sleep
Age also affects the amount of sleep we need. And when the optimal time to sleep is.
graph shows total sleep time changing with age. Newborns and infants require the most sleep between 12 to 17 hours for every 24.
Then gradually decreases and stabilises at around 20 years of age.
As we age, sleep tends to become more fragmented and the type of sleep we get changes.
You can see in the graph here how the amount of each sleep stage changes over time.
91
Discuss how the circadian rhythm changes from childhood to adulthood and how this affects our sleep
The timing of our sleep also changes. We've discussed circadian rhythms before, an adult's physiological processes cycle round once every 24 hours at birth.
- Babies have what we call ultradian rhythms. These are cycles that repeat within a 24 hour period.
- The circadian system does not develop until about two months of age, and it's been suggested that breastfeeding may facilitate the development of a circadian system as melatonin is passed on by a mother's milk.
- During adolescence, the circadian system delays, so that teenagers want to stay up later and therefore sleep in later, meaning that they are often sleep deprived. NO KNOWN MECHANISM
apart from some tentative data demonstrating an interaction between the suprachiasmatic nuclei (the SCN) and the gonadal hormones.
- This circadian shift is accompanied by an increase in sensitivity to light. This could mean adolescents are more likely to experience sleep disruption in response to excess screen time.
Now, the extent to which screen time impacts the circadian system during adolescence is unknown, but an association between late night screen time,
sleep disruption, caffeine use and obesity has been demonstrated repeatedly in the published literature during adolescence. these relationships maintain independently to diet and activity.
92
Describe effect of caffeine on sleep in adolescence
The recommended upper limit for caffeine is around 400 milligrams per day. The half life caffeine is around five hours. If you have too much caffeine close to bed time, it will fragment your sleep. This will then create cravings for caffeine the next day. This, of course, then becomes cyclical and is intensified by changes to the sleep
homeostat, which builds sleep pressure more slowly in adolescence.
This means that adolescents are less sensitive to the impacts of prolonged wakefulness. All of this serves to highlight the vulnerability of sleep during adolescence and the importance of protecting it. Bearing in mind the relationship between sleep and health, not to mention the relationship between sleep and interpersonal functioning and impulse control, all of which are particularly pertinent for adolescents.
93
Describe sleep post adolescence
- circadian system starts to advance post adolescence so that we want to sleep earlier and get up earlier. (mechanisms for this aren't fully understood. But are driven by genetics, changes in neuropeptide expression and lifestyle.
For example, elderly people in care homes may be less active and get less daylight.
Ageing is associated with yellowing of the lens and so may decrease the amount of light that enters the system. The production of melatonin has also been shown to slow in old age, but interestingly, not in those that have maintained good health into their elderly years.
94
Describe sleep conditions and responses across lifespan
As well as sleep duration and sleep timing changes, vulnerability to different sleep disorders also change across the lifespan.
In adults,
- the most common sleep disorder is insomnia, followed by obstructive sleep apnoea.
in childhood
- rise in the cases of childhood obstructive sleep apnoea in response to rising childhood unhealthy weight.
- Typically in childhood and early adolescence, things like sleepwalking, night terrors, sleep paralysis, nocturnal enuresis are fairly common and tend to resolve over time.
Certain disorders will appear as we age and in response to lifestyle changes.
Insomnia is a normal response to stress and often resolves as the stress dissipates.
Pregnant women may experience restless leg syndrome as their iron levels are depleted.
It's important to keep in mind the role that sleep plays in general health.
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Why is achieving optimal sleep important?
- too much sleep or too little sleep is associated with negative health outcomes.
- Sleep has a key role to play, and the prevention of many non-communicable disease. It is therefore important that we understand how sleep need and
- timing changes across the lifespan so that we know how best to protect and to identify when it has become disordered.
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How would you expect sleep deprivation to present in children and adolescents?
The impacts of sleep deprivation in children are similar to adults (impacts on mood, cognitive functioning, overall physical health), however the way this manifests might be different.
Nocturnal enuresis (bed-wetting) is common in children. This can be a result of sleep deprivation as sleep deprivation leads to a rebound in REM sleep which prevents the urge to be from creating an arousal from sleep. Changes in sleep architecture may be one way through which stress and anxiety also associate with bed-wetting.
Other indications of sleep deprivation in childhood are hyperactivity, behavioural problems at school and an inability to focus. You might also see increases in interpersonal conflict, as well as more impulsive behaviours and more labile mood.
This can present with difficulties at school.
In adolescence sleep deprivation has also been associated with more negative thinking and increased catastrophising.
Therefore addressing sleep deprivation is an important consideration when thinking holistically about child and adolescent health.
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lifestyle causing child health issues
```
• Foetal nutrition +
maternal physical
activity →
determines child
weight
• 1/5 young children
(aged 4/5) are
already
overweight/obese
• Physical activity in
children → improved
cardiovascular
fitness/sleep/weight
```
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Behaviour causing child health issues
Inadequate foetal nutrition → irreversible delayed cognitive/motor development
If more physically active in childhood → more likely as adult
Children are less active than ever now
Physical activity in children → improved learning/academic achievement/ executive functioning
Physical activity in children → reduced anxiety/stress/ depression
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Social causing child health issues
- Diet/physical activity/relationships/sleep/stress/socio-economic status → school readiness
- If children engage in inclusive + positive + meaningful physical activity → develop physical literacy
- Physical activity in children → improved happiness/resilience/self-esteem/ confidence/trust of others
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environmental causing child health issues
Early interactions with parents/ caregivers → heavy influence on lifestyle behaviours
Parental obesity = biggest risk factor for childhood obesity
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Define ACE and what it includes
ACE = adverse childhood experience
Includes
Experiencing abuse: Physical, sexual, psychological or neglect
Witnessing domestic abuse
Having a close family member or caregiver who misused drugs or alcohol
Having a close family member or caregiver with mental health problems
Having a close family member or caregiver who served time in prison
Experiencing parental separation or divorce on account of relationship breakdown
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Evidence behind impact of ACEs on child health
- Strong associations with sexual risk taking, mental ill health, problematic alcohol use
Strongest associations with problematic drug use, violence
- Toxic stress: Excessive chronic activation of stress response → system dysregulation
- Childhood experiences affect epigenetics and gene expression (temporarily/permanently)
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summary on lifestyle medicine consultation practices
Normally focuses on nutrition + physical activity
• Be opportunistic
• Be sensitive
• Non-judgemental approach
• many parents find it difficult to know if their child is growing healthily
• Strengths-based approach (positive affirmations)
• Focus on barriers that are particularly important to the child
• E.g. benefits of physical activity on learning
• Encourage children with long term conditions to be active (Moving Medicine)
• Relate to other children
• ‘Do you mind if I share some ideas with you that helped other people your age?’
• Engage parents and families
• Look at their strengths, needs, challenges and priorities
• Specific, short term goals
• Daily routine – more effective goals
• LEAP criteria activities (Local, Enjoyable And Practical)
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BMI consultation referral criterion
```
Tier 1 - none
offers:
•Universal prevention
•Consultation with frontline health professionals
•Public health approaches
Tier 2 ≥ 91st centile
offers:
•Intensive + community based
•Time-specific
•Public health approaches
Tier 3 ≥ 99.6th centile
Or ≥ 91st centile + co-morbidities/complex needs
offers:
•Specialist MDT
•Weight management clinics
•Longer term follow up
Tier 4 - Not available in children
offers:
•Surgical options
```
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Effect of orexin on sleep
Orexin – effects (higher levels in those who don’t need much sleep)
- Arousal state! (cerebral cortex activation + involves LC neurons)
- Autonomic function
- Food intake
- Hormonal changes
- Glucose control
- Energy expenditure + metabolic rate
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Effect of age on sleep
-Sleep time decreases
-Becomes more fragmented
-Changes in type
From 2 months = circadian sleep (cycles every 24 hrs), infants = ultradian sleep (cycles within 24hrs)
Circadian rhythm delays in adolescents (stay up later and sleep in later)
Accompanied by increased light sensitivity (increased impact of screen time etc.)
Post adolescence – circadian system advances (genetics, neuropeptide expression, lifestyle)
Slowed melatonin production in elderly (unless remained in good health)
Sleep disorders: insomnia and OSA most common
In adolescence – sleep walking, night terrors, sleep paralysis, nocturnal enuresis
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key points
a. Lifestyle, behaviour, social circumstances and the environment impact a child’s health
from before conception and have both short and long-term effects throughout their life.
b. Children can experience various stressful events termed “adverse childhood
experiences” (ACEs), which have health impacts across the life course
c. Lifestyle medicine approaches play a key role in consultations with children and
families to improve individual and population health, as demonstrated by the tiered
services for weight management.
