In the latest episode of the ConnectSafely podcast, CEO Larry Magid speaks with Dr. Anil Rama, founder of Sleep and Brain and adjunct assistant clinical professor at the Stanford Center for Sleep Sciences and Medicine. Dr. Rama shares his insights into how sleep impacts general and mental health, especially among children and adolescents.
Listen to their conversation below or on Apple Podcasts, Spotify or wherever you get your podcasts.
Listen to “Unlocking Sound Sleep for Children” on Spreaker.Transcript
Larry: I’m excited to be speaking with Dr. Anil Rama, who is the founder of Sleep and Brain and serves as an adjunct assistant clinical professor at the Stanford Center for Sleep Sciences and Medicine.
He’s the recipient of the 2021 Stanford Distinguished Service Award, awarded to one clinical faculty member per year. He’s the former medical director of Kaiser Permanente’s Tertiary Sleep Medicine Laboratory. Dr. Rama, may I call you Anil?
Anil: Yes, of course. Thank you, Larry.
Larry: Well, I’m really excited to be talking to you because sleep is really important. Everybody I think should know that by now. I guess everybody sleeps to some extent, but it is an issue for people of all ages.
And I want to focus mainly today on children and adolescents, but we can certainly talk to and about adult issues as well. But let’s start by talking about the relationship between sleep and general health and mental health and how it impacts young people.
Anil: I think as we know there’s no other period in your life like being a child.
60 percent of your face develops by age 4. 90 percent of your face develops by age 12. The largest growth increments, you double in size in a couple of years, in life, the largest growth increments occur. In those first, 10 to 18 years of life and you can imagine anything, we know the sleep helps restore.
We know help helps the immune system. We know it helps develop memories and process information and all the other rejuvenated effects. And so you can imagine that for kids and adolescents that are growing rapidly. That sleep takes on a more, exaggerated role in their general well being. And, for that reason, I think It’s something we should definitely focus on more to optimize so they can develop properly.
Larry: Now, I happen to have a grandchild, a one year old, and she seems to sleep just fine. At what age does sleep actually start become an issue for kids?
Anil: I believe sleep is becoming an issue at a very early age. I’d even argue sometimes before they even leave the hospital, they may become an issue.
one thing in this podcast, I want to differentiate is that, you can always Google sleep and adolescent sleep and childhood and sleep in adults and find out. You know all the usual hygiene things, but one thing that’s highly correlated to sleep is how you breathe if you don’t breathe, well, you’re not going to sleep Well, and I am seeing more allergies in kids than I’ve ever seen in my entire life. I’m seeing them start at an extremely young age, and it’s causing the turbinates in their nose to be inflamed.
It’s causing their tonsils to be inflamed, and all of that restricts breathing, and it restricts daytime breathing. And when your daytime breathing is bad, at night when you lie recumbent, the breathing gets even worse.
But apart from that it’s fragmenting the sleep. It’s causing arousals. It’s not allowing for the deeper levels of sleep. And so it’s not just how much the person sleeps. To answer your question, yeah, they should be worried because most likely They’re probably inflamed and no one ever even thinks to look at these early ages.
Larry: Are you suggesting that children should routinely be seen by an allergist to screen for this?
Anil: We should really examine the environment that the child is in, like, is the bedding, like, are there, like, are the beddings surrounded, encased with dust mite proof covers?
Is the pillow dust mite proof? Is the duvet dust mite proof? Is the duvet covered dust mite proof? You can make sure in the room there’s no rugs, no carpets no fabric furniture no stuffed animals.
Larry: Wow.
Anil: You can make sure there’s adequate ventilation if you need to get a like one of those HEPA filters, get a HEPA filter, right?
Make sure you change the filters in the house routinely. I mean things that no one really thinks about right? Yeah
Larry: the other thing you mentioned about breathing, so just full disclosure I, as of course, I have seen you professionally and you gave me some advice.
And one of the things that you advise me to do is to breathe through my nose, which frankly I spent most of my life not thinking about. And that seems to be something that we could be teaching kids at a young age. Is that something you recommend for all ages or just people like me?
Anil: Absolutely. Proper oral posture.
Proper oral posture is lips closed, teeth together, tongue flush on the roof of your mouth. If you do that, the most important bone in your body is the maxilla. The maxilla is the upper jaw, and it’s the most important bone because you breathe through it.
The most important muscle in the body is the tongue, and that’s because the tongue shapes the maxilla. The roof of your mouth is the floor of your nose. So, your nose is basically in the maxilla. So if you have your lips closed, teeth together, tongue flush on the roof of your mouth, you are adding a constant pressure on the roof of your mouth, spreading the maxilla, widening the base of the triangle.
if your mouth is open, your tongue is now in a lower position. It’s no longer at the roof of your mouth. And now all the other muscles, the bucconators, lateral pterygoid, medial pterygoid, whatever, all the other muscles are now exhibiting an inward force on your face that’s going to collapse your maxilla.
You’ll be basically breathing through a smaller triangle, a triangle with a smaller base for the rest of your life.
Larry: So what you’re saying sounds very daunting, but if you’re a parent of a young child, does this become something, a habit that’s easy to teach at a younger age? Cause it, it seems daunting to me.
Anil: Well, it’s natural. It’s natural to breathe through your nose.
Larry: Fascinating. I’ve spoken to a number of people who advertise themselves as sleep experts, read lots of books about it, but this is the first I’m hearing about this connection between breathing and sleeping. I hear a lot about things like blue light.
In fact, I want to talk to you about that, about the tech angle. This is after all, are we doing tech, right? I hear a lot about the issue of tech, but I’ve heard very little about the breathing issues what can people do in their own homes and their own lives? What can parents do with their own kids to try to counteract some of these things?
Anil: Well, I think you gotta take it piece by piece.
Okay, what can you do for the brain? A 15 minute walk versus staring at your iPhone for 15 minutes is a huge difference, right? In how alert the brain becomes.
So you want to, I’m not sure what the word is, wild your kid. Get them out. Send them to camp. Go outside. Go play. Go ride your bike. Go visit the neighbors. Go talk to people. Interact. Meet with them. And then in terms of breathingyou want to reduce anything that causes inflammation,
you want to make sure you air out the room. Make sure the environment is very allergy friendly, so to speak, right? that part of it is what you eat too, like that will also, like I said, try not to eat things that are in packages. And then the third thing is to optimize the sleep and you can do all the things you can google how to improve sleep and you can do all those simple things, right?
But what are some other things that you could do that could potentially improve sleep? You can make sure that they’re the oral like we know oral muscle strength is linked to sleep. And so you can make sure that they have strong oral muscles. And once again, everything is tied into everything.
Make sure they eat an apple a day. Make sure they don’t need a smoothie. Give them the actual fruits and vegetables. Make them use their jaws more.
Larry: What about playing a wind instrument? We have a mutual friend, Philippe Kahn, who happens to be an inventor, but he’s also a wonderful musician, plays flute and clarinet.
And based on his advice, I’ve actually started picking it up again. Is that a help?
Anil: Absolutely. So in addition to improving oral muscle strength, which we know improves sleep expiratory muscle strength, expiratory respiratory muscle strength, which is blowing, which a lot of wind instruments are, you, the clarinet, the flute, whatever you’re blowing, right?
That will improve sleep. In fact, that’s been shown to improve breathing, but also inspiratory respiratory muscle strength training helps. And that’s been shown. in the studies to help more sleep quality and daytime sleepiness.
Larry: I’m just thinking about, you’re talking about getting kids involved in doing things other than, messing around with their technology, which is okay too, but music is certainly one of them.
Anil: But you’re right. Playing a musical instrument. Hey, maybe it’s developing the brain, but maybe it’s developing the respiratory system. So you breathe better and you sleep better. No one ever thinks of that, but it is.
Larry: What are some of the other, like, things that you do? Like in your practice, you have a lot of measuring tools. you scan people, you scan their brains, you scan their necks. I mean, what is about these kinds of diagnostic tools?
And I know they’re not commonly used by your typical physician, but some of the things that you’ve done are quite unique, it strikes me.
Anil: Yeah, well, we do a brain map and that tells us it’s a function test. How are they doing? the kid could be literally sitting there seemingly wide awake, but the brain could be completely sleepy.
This could be a kid who’s getting straight A’s, right? Yeah, it could be a kid getting straight A’s, or it could be the kid that’s literally jumping from chair to chair in the office too. So sometimes sleepiness comes out as yawning and fatigue, sometimes it comes out as lack of initiative and kind of like motivation, and sometimes it comes off as hyperactivity.
So the brain map, it’s quick. It takes, 5 minutes to actually record, but maybe 10 minutes to set up. it gives us a window in how they’re functioning. And then the other test we use is Rhinomanometry.
It’s just a test that looks at daytime breathing, just a few breaths through each nostril. And we can kind of tell what their nasal resistance and nasal airflow is like through each nose. And we know what the normative numbers are. And we just want to compare where they’re at with the normative numbers.
Larry: I mean, sometimes some of these kids were there at 5 percent of normal, and they have no idea. Because you only, like, if I asked you, how do you breathe? Do you think you breathe fine? The reality is if you don’t know anything better, you don’t know anything better. And so that’s a helpful test.
A lot of us during the pandemic bought what do they call those things you put on your finger?
Anil: Like an oximeter.
Larry: Yeah. Pulse oximeter. I think most people are aware that we need to have oxygen and you want to have a number somewhere close to a hundred on this device and you can buy these almost anywhere. But what about CO2? That’s something that until I came into your office, I had never measured my CO2.
Why is that important? And how does it, how, what, what affects it?
Anil: Yeah, I didn’t want to go too far off the reservation because people come to our office and they don’t understand what the heck we’re testing because they don’t get any of these tests anywhere else. But we measure CO2 routinely on people.
Normal CO2 is 35 to 45. So, you breathe in oxygen, you breathe out CO2. there’s a nice balance. when you’re in that range, taking enough air and blowing out enough bad air is optimal cellular respiration. Your body functions the best. It’s the most ideal scenario.
It’s very happy in that state. So if you’re not breathing enough, like let’s say you have ALS or, some type of, dystrophy, then maybe your CO2 levels are high. And if you’re breathing too much, you’re panting. Even though it doesn’t look like it, you look like you’re just perfectly still sitting there, but you’re over breathing.
Your CO2 will be too low because you’re breathing it all out. your body’s respiration system doesn’t. Respond to O2. It responds to CO2 to carbon dioxide. Carbon dioxide dictates how your body, when your body breathes and how much and whatnot.
So what’s happening is I think these kids are stuffed up. I think they’re like they’re they’re just not, they have high nasal resistance. They have low flow. They’re stressed out like they’re panicking in a subconscious level and they compensate for that high resistance and low flow by overbreathing the problem with overbreathing is Try blowing a balloon five times.
You’re gonna get light headed dizzy. What happens when you overbreathe your body says? Hey, I got too much air so It starts vasoconstricting. It starts constricting all the vessels in your body. It constricts the vessels in your prefrontal cortex, so you lose attention, focus, concentration, ADD type symptoms.
In adults, you can constrict the vessels. It can elevate your blood pressure. It can cause brain fog. And in kids, like I said, it can cause brain fogs too, and just it would come out in different ways. It can cause anxiety. So one of the main, if you overbreathe it, it’s stressful. You’re in a fight or flight response.
And so, and then finally, Bohr’s principle, when you overbreathe, oxygen binds tighter to hemoglobin. So not only is less blood flow being delivered to the entire body and brain, Less oxygen is being let go by the hemoglobin once it gets there. So it’s a double whammy. And so we measure it routinely. And the interesting thing is that’s a learned phenomenon.
Usually low CO2 levels from over breathing is learned and you have to unlearn it. The good news is that kids can unlearn it quickly. within a month, if they’re taught to properly breathe with CO2 monitoring, they can restore normal levels, and hopefully they’re calmer, more focused, and happier kids.
Larry: Interesting. Well, let’s briefly at least go through the things that we hear about, for example, screens at night. Is that a problem? I mean, it’s pretty hard to avoid screens, but at what point should we put them away before bedtime?
Anil: I mean, the thing is, you just want to think, what do the hunters and gatherers do? The sun would go down and they’d go to bed. The sun would come up and they’d wake up, right? And they’d sleep outside, with a thin blanket at most on, a pretty flat ground.
And so, in terms of tech, light makes you go to bed later. That’s just normal circadian rhythm, like treatment. You can make someone go to bed later. By exposing them to light you can make someone go to bed earlier by exposing them to light first thing in the morning So one of the strongest Zeitgebers is light and you can use it to your advantage or disadvantage if you’re not using it properly when you expose yourself to any kind of light like computers or ipads and iphones and things like that you’re going to basically delay the person’s bedtime So if you’re going to have your kids use tech, Have them wake up take a walk outside and stare at their phone at that point then at least they’ll go to bed earlier that same night.
They’re more likely to write so You can incorporate the things, like, that they want to do, but maybe just time it differently. Maybe set limits on them in that way. Hey, why don’t you wake up and look at your phone for an hour, if you’re going to look at it for an hour, right?
And then, melatonin is, when the sun goes down, that’s when your pineal gland makes melatonin, but if you stare at light, are retarding that process?
Do you recommend people take melatonin? I mean, obviously you can buy it at any drugstore. They’ve done studies and I think there was just an article that just came out recently saying that the actual melatonin between different brands and even in the same brands can vary wildly in a tablet with a certain amount. So you don’t know what you’re getting.
I actually like melatonin, but I think it’s when it is used. I think the Dosages are too high. Your body makes about 300 micrograms or so of melatonin per night that’s the dosage I give to patients. If I say, Hey, if you need melatonin, I tell them, take 300 micrograms,
that’s point three milligrams. Most people take three milligrams, five milligrams, 10 milligrams, 20 milligrams, some people, right? But that’s 10 to 30 X what your body naturally makes. So I say, take 300 micrograms. You can buy on Amazon. There’s different brands. And then I say, take it at sunset. Why sunset?
Okay. Because that’s when your body would naturally start making it. So, in the winter you could be taking it as early as 4 30 p. m. 5 p. m.
Larry: When if ever do you recommend sleep medication?
Anil: In my opinion look, when you’re born, your sleep is quite fragmented.
You take naps, wake up, take naps. You don’t really have a sleep wake cycle per se, right? And then as neurodegeneration, look, we’re all programmed to die. And our brains, like, just like our skeletal, musculoskeletal system, we hit a peak. And then things start to fall apart, right?
We can maintain it for as long as we want But there is degeneration and sleep is just you know, it’s pervasive throughout the brain So when your brain degenerates your sleep is going to degenerate. So I personally believe there is a role for medication and I think if we can reduce the EEG at night, I think if we Increase deep sleep or delta sleep.
I always tell people you want alpha during the day and you want Delta at night. And if you can increase the Delta sleep, decrease the arousals, increase the sleep consolidation and not worsen breathing, I think that’s a win.
Larry: Yeah. Well, it’s interesting because, one of the things I’ve learned working with you and working with other sleep doctors is there are things at any age you can do, even my age, And certainly young people, have a much easier time, I think, adapting to new techniques. So I think it’s really useful.
Your website does have some great advice, even for people who aren’t fortunate enough to be able to come into your office. Tell us how we can access that website.
Anil: Oh well, it’s www. sleepand, the and is spelled out, brain. com, sleepandbrain. com. But what’s nice about the website is I’m pretty transparent.
I show all the diagnostic testing that we do and all the, at least the main treatments that we do. I put all the normative data for the different tests that we do on there. So if your viewership is from around the world and they can find a doctor locally that does these tests, they can just go on the website and see what the normative test data are for, their male, female, adult, kids, and whatnot, and then compare it.
I see our role as curating. There’s a lot of stuff that’s out there for sleep. There’s always things coming out. It seems like on a weekly, if not daily basis, and we try to curate it. We try to test it and see if number one, if it’s real and number two, if the treatment makes the person better.
And so if you see it on the website, you can assume we’ve had success with it.
Larry: Any other points that you’d like to bring up
Anil: I think that’s it. I hope that macro points come across to your viewership. I’ll look forward to more discussions.Pleasure to be on your show.
Larry: Dr. Anil Rama, the founder and chief, of the Sleep and Brain Clinic in Northern California. Thank you so much for taking the time.