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Compiled by Carol Aloysius

Why do we need to sleep?

by Sampath Nanayakkara (Family Physician)

The complicated mechanism of sleep still remains a mystery. You may think that going to sleep is just like turning off a switch, but it is not so; it is a very active process where the brain cells produce certain chemical changes which cause one to fall asleep.

All living beings have a 'Biological clock'. It is an internal mechanism to regulate the cyclic events of the body. One such event is "wake-sleep cycle".

This works on a rhythmic pattern, within its own time frames. Sleep occurs in cycles of 2 different characteristics; one cycle lasts for about 1 1/2 hrs and at the end changes to the other form. The light sleep period is called Rapid Eye Movement Sleep (REM SLEEP), which lasts for about 1 1/2 hrs and then changes into deep sleep pattern, which also has four distinct stages of its own. This is why some infants awaken and cry every 1 1/2 to 2 hrs, when they approach the light sleep cycle from the deep sleep cycle.

Why sleep is important?

Sleep enhances the activity of the immune system of your body. Perhaps that may be the reason why when you are sick you tend to sleep more. Sleep is believed to organise newly learned skills in your brain during the day, especially in small children. Most of the physical growth of children occurs during sleep. During sleep we convert our short term memories into long term ones. Therefore sleep is obviously helpful to our health and wellbeing.

How much of sleep should one have? This is a common question of parents of small children. A newly born baby sleeps about 16 hrs a day. As the baby gets older he/she sleeps less and at the age of 2 yrs the child needs about 10-12 hrs of sleep at night and an afternoon nap. By the time the child is 12 yrs 10 hrs of sleep is adequate.

Most babies in their early months sleep from one feed to the other, whereas a few are unusually wakeful right from the beginning. Some children require a lot of sleep, others very little. Parents do not need to worry about a child not getting enough sleep.

Every baby gets as much sleep, as he/she needs. If he/she decides to achieve that in the mid part of the day, then he/she stays happily awake at night. That can definitely become a problem to his/her sleep deprived parents. A child's sleep may also be disturbed by loneliness; fear of being left alone, fear of the dark, fear due to nightmares, bed wetting and excitement from the past experiences.

It is very important to let babies sleep on their own beds without company, by the time they are 5 months old. This is one way of preventing sleep problems telling on. A baby who expects the mother to hold and rock him/her before he/she goes to sleep may want such comforts for years. Even, when he/she awakens in the middle of the night, he/she may want his mother to rock him/her to sleep.

Rituals

You should not try to force a child to go to sleep, but you can get him go to bed and rest. He/she may on his own choose to read quietly or to sing a song until he/she false asleep.

Sleep is essential for all human beings. Most of us, develop symptoms of tiredness after 16 to 20 hrs without sleep. However, the body can readjust itself. So even after 24 to 30 hrs without sleeping, some people still feel quite wide awake. After 36 hrs however, the body begins to feel the effects of sleeplessness.

Beyond 48 hrs, i.e. foregoing sleep for 2 nights in a row, can make it increasingly difficult to think clearly and rationally. By 60 hrs, collapse is usually imminent, and those who have managed to stay awake longer usually find that they are developing false perceptions called Hallucinations.

People develop different types of sleep problems. Some of them are directly due to physical disorders of the body. Others are "sleep disorders". Inability to fall asleep is called Insomnia, which is very common.

It is usually related to worry, excitement or anxiety. But it may be symptoms of major psychiatric disorders. Depression is one of them. A person who is depressed may fall asleep as soon as he/she goes to bed but wake up at very early hours and keep up until dawn.

Treating these disorders with 'sleeping pills' is not an answer. The most important thing is to find out the cause and treat the cause appropriately. Most sleeping pills are 'habit forming', and are not suitable for elderly patients and are dangerous when combined with alcohol.

Some children resist going to bed, and this reluctance in most cases, starts off with an irritable cry. These are the problems with sleep onset associations. This is due to a habit, forming on the part of a baby who wants more attention. Some babies go to sleep very comfortably, but develop the habit of waking in the middle of the night.

Sometimes this may be due to some pain, e.g. an ear infection. Sometimes wakefulness may be due to teething. A few babies may wake up to demand not just the company of the mother, but to be carried or rocked on her lap, and will resist being put back to bed by crying incessantly. The treatment is simple. Mother should not go to the baby at all. The baby may cry for twenty minutes the first night, ten minutes the second night, not at all the 3rd.

Another cause for sleep problems in a child is Separation Anxiety. Such a child is feeling worried about being left alone.

Nightmares and Night Terrors are also causes to be concerned. All children begin to have bad dreams when they are 3-6 yrs. Even in adults 70 per cent of all dreams have a disturbing emotional tone. Dreaming seems to trigger our deepest fears more easily than our deepest joys.

Nightmares may indicate some stress in the child's world. When your child awakens from a nightmare crying and screaming, you should comfort the child by telling him that everything is alright and that it was a dream and that dreams are not real. Continue to reassure him that it was only a dream and stay with the child until she/he falls back to sleep.

On the following day you should discuss with the child what dreams are, why they don't hurt you, and how everyone has dreams. Medical Hypnosis is accepted as a treatment for nightmares and night terrors. By this treatment nightmares are converted into lucid dreams.

Sleep Walking - is not very common. These are due to temporary disturbances in the nervous system during deep sleep. Some times this tends to run in families, but the majority of cases usually disappears as the child grows.

Children never remember sleep walking. Some walk outdoors and may even get into life threatening situations. As a precaution what you must do is to alert the child when she/he is sleep walking by keeping a wet rug near the door or secure the door from outside. For this too hypnotherapy has been tried with very good results.

Acupuncture and pain management

The article 'The pain in your brain', by Sharmila Jiffrey, which appeared in the Sunday Observer of October 31, 2004 was quite enlightening, but prompts more enlightenment. It is only now that modern science is able to discern some of the many bio-chemical mysteries of the human body.

Developing medical technology has enabled the scientist to delve deep into such mysteries. The discovery of the neuro transmitters serotonin and endorphin as mentioned in the article and the impact of such neuro transmitters on pain management was inevitable, with a progressive medical technology.

However, long before the era of the microscopes and test tubes, acupuncture was resorted to in order to induce the secretion of such neuro transmitters and was used extensively for pain management! And this was in circa 4000 years back!! Of course the acupuncturist of that time never knew about serotonin and endorphin but he knew that a bio-chemical process could be initiated by acupuncture to control or eliminate pain.

Acupuncture produces six different effects: analgesic (pain relieving), sedation, homeostatic (regulatory), immune enhancing, psychological and motor recovery (from paralysis). Of these the best known is the analgesic, as pain is a chief characteristic in most disorders.

Pain is basically nature's way of telling us that there is something wrong. It is an early warning defense mechanism. For example, if not for the mechanism of pain initiated naturally, a person with an acute appendix about to rupture will feel no sensations of pain to warn him about the potential danger of a rupture and subsequent peritonitis. Similarly, a person with nascent stage osteoarthritis of the knees would be denied of prior warning by bouts of pain till such time be becomes totally disabled one fine day.

Experiments have shown that a rabbit given acupuncture experiences an increase in the pain threshold. The cerebrospinal fluid of the punctured rabbit is then circulated into a non-punctured rabbit and the threshold of pain of the second rabbit was also found to rise. This demonstrates that chemical transmitters are definitely involved in the mechanism of acupuncture induced analgesia.

Besides the analgesia produced by chemical transmitters, a popular neurological explanation is that of Melzack and Wall (1965) called the 'Gate Control Theory Of Pain'. This theory says that our perceptions of pain are modulated by a 'gate' within the Central Nervous System (CNS).

This gate within the CNS is normally open and enables pain impulses to pass through using small diameter fibres. When acupuncture (needling) is effected, a flow of nonpainful impulses are initiated at the site of the pucture, which use large diameter fibres. These impulses bring about a jamming effect at the 'gate' and subsequent closure of the gate.

Thus, a pain impulse coursing through a small diameter fibre is not relayed appropriately to its destination and, therefore, pain is not felt. Yet again, the humble acupuncturist of 4000 years back never knew of such intricate relays of pain impulses but faithfully used acupuncture to control or eliminate pain.

Scientific research into acupuncture and its effects has proved beyond all doubt that acupuncture triggers the release of neurotransmitters and influences hormonal and neural mechanisms. Acupuncture has come a long way and has now come to stay.

From a simple folk medicine practised by humble physicians thousands of years ago in rustic villages in Asia to a scientifically established neuro-humoral mechanism - it has indeed come a long way and verily deserves to stay for the benefit of mankind.

by. Dr. Mass R. Usuf

Pros and Cons eating fish

by Dr. D. P. Atukorale

Fish has an important role in our diet and its consumption should be strongly encouraged. Fish is a reliable source of protein, iron, selenium and iodine. The livers of lean white fish are a particularly good source of vitamin A and D.

The flesh of oil rich fish such as herring and mackerel is an important source of the long chain n - 3 polyunsaturated fatty acid (PUFA) including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) due to large amounts of fatty acids in marine algae upon which the fish feed. However the fat composition of fish is very susceptible to various factors such as the time of the year and type of feed available.

Processing and cooking methods may also result in alteration of nutritional composition of fish. A very popular form of oil rich fish available in Sri Lanka is tuna ("Balaya", "Kelawalla") fish. In canned tuna fish, precooking operation drastically reduces the EPA and DHA content.

A low incidence of coronary heart disease (CHD) in the Inuit (Eskimos) and Japanese has been associated with consumption of large amounts of oil - rich fish. Eating 200-300g of fish per week has a beneficial effect on many physiological factors involved in CHD. Eating oil rich fish regularly appears to reduce the death after a heart attack rather than preventing the heart attack itself. Possible mechanism of these effects include the beneficial role the long chain n -3 PUFA might exert on:

1) the balance of eicosanoids which promote the tendency of the blood to clot;

2) high levels of plasma lipids;

3) irregularity of the heart beat;

4) high blood pressure.

Fish oils when combined with recognised drug therapies can alleviate some of the symptoms associated with skin disorders e.g. psoriasis. Increased fish oil consumption is also associated with a reduction in the use of pain - relieving drugs taken for various immune disorders.

DHA found in oil rich fish is essential for the development of the foetal brain and retina and a deficiency of DHA in the maternal diet might have serious consequences in infant development. Therefore it is wise to ensure that there is sufficient DHA in the main source of nutrients of developing infant, be it human milk or infant milk products.

Consumption of oil rich fish such as mackeral, herring, salmon pilchards, and sardines and other oil rich fish should be increased to about two portions per week. Intake of fruits, vegetables and wholegram cereals should be increased to provide antioxidant substances which protect the vulnerable polyunsaturated fatty acid in fish oils from oxidation.

The American Heart Association (AHA) and American Dietetic Association (ADA) advise people to eat plenty of fish. Two seafood servings per week provide a low fat source of protein that could prevent heart disease, cancer and many other illnesses.

However, a report of the Journal of American Medical Association (JAMA) has warned that consuming fish tainted with mercury can be dangerous to pregnant women and children.

According to a study of AMA mercury enters the environment naturally through industrial pollution. Power plants that burn fossil fuels such as coal, and waste incinerators, pulp, paper manufacturing and other processes generate the most mercury emissions. Once mercury falls into rivers and streams and sea, fish and other creatures such as prawns and crabs convert it to methyl-mercury which is a potent neurotoxin.

By eating such contaminated fish and shellfish people are exposed to methyl-mercury which is dangerous for women of childbearing age because the chemical can damage the brain and kidney of developing foetus according to a study.

Mercury builds up as it passes up the food chain, so longer lived predatory fish such as shark, sword fish ("Talapath"), Tuna ("Balaya and Kelawalla") and others which contain the highest amounts of mercury are the biggest health threat.

Currently the Food and Drug Administration (FDA) recommend pregnant women and those who could become pregnant to avoid eating shark, sword fish, king mackeral and tile fish, all predatory fish known to contain elevated levels of methyl-mercury.

However, you can still obtain the benefits of fish by staying away from predatory fish and instead consuming fish low in methyl-mercury such as haddock, tilapia, salmon, cod, pollock, sole and other small fish.

As far as I am aware the mercury levels of Sri Lankan sea fish and Sri Lankans who regularly consume fish have not yet been investigated. As mercury affects the visual cortex and responsible for controlling complex movements and maintaining balance; it is high time that our scientists do research to find out the blood mercury levels of commonly consumed predatory fish such as tuna, sword fish and shark and also measure blood mercury levels of Sri Lankan fish consumers especially those regular fish and crayfish consumers.

The researchers should arrange to do tests to assess mental functions such as learning attention, memory, accuracy, manual speed and dexterity blood levels of mercury.

Fixing mistakes in the blood

An upsurge in the number of patients with kidney problems is a cause of concern to health authorities. Dr. P. Ravichandran, Chief Nephrologist, Miot Hospital, Chennai, discusses some recent treatments for malfunctioning kidneys.

Q: There seems to be an increase in kidney problems today. Why is this?

A: There is very little understanding about the kidney among the general public. We must understand that Kidney is just not an organ to remove waste through urine but it is a complex recycling unit designed to maintain not only the correct salt balance in the body but also to maintain the blood pressure, haemoglobin, keep the cellular functions of the body by maintaining the pH and to neutralise the excess acidity.

Unlike in the past, man in the name of urbanisation and industrialisation has mastered the art of distributing refined salt (Sodium), refined sugar and refined oil and we are in a situation that can be comparable to a fresh water fish trying to live in seawater. In that our kidney and body is conserving salt, sugar and oil and we are drowning into diseases called High Blood Pressure (Salt induced) diabetes (sugar Induced) and Hypercholesterolemia (fat Induced). This is why kidney failure is on the rise today.

Q: Which way can we prevent kidney related problems?

A: Simply follow the basics. Asian culture is most ancient and always gives useful tips as how to lead a healthy life. If you deviate from your traditional food habits and practices you are prone to diseases. Western lifestyle is commercial oriented. Fast foods are based on sodium salt, which is the cheapest available salt. Our Asian food on the other hand, is Calcium and Magnesium based which is important for bones and metabolism.

Q: Nephrology is a fairly recent speciality. What is the role of the Nephrologist in controlling the speed of and managing kidney problems?

A: Nephrologists are doctors who treat people who have problems in the kidney and this also refers to fixing mistakes in the blood. Until 1975 this was a very new subject but now it is slowly taking shape into a major speciality.

Q: What do you mean by fixing mistakes in the blood?

A: Simple. If the kidney cannot function as a recycling unit the blood becomes impure. 'Mistakes' in blood can be categorised as excess of salt, excess of water, excess of waste materials like urea, uric acid, excess of cholesterol, excess of antibody, excess in bile acids, presence of virus like HIV, hepatitis B and hepatitis C.

Nephrologists are the best qualified to remove the blood from the body and put it back in after fixing the problems in the blood that might arise due to the reasons explained above.

Q: What is this treatment called?

A: Dialysis is removing of waste from blood using membrane technology and washing it with 120 litres of ultra pure water with predetermined salt concentrate. Now Citrate dialysis is catching up where citrate from a fruit source is used to prevent the blood from clotting instead of heparin, which has complications like bleeding.

Instead of cleaning the blood the latest technique is called rheopheresis or blood purification technology where instead of one filter more than one is used to separate the blood into its water, fat and cell component and tackle the mistake wherever it is present.

Q: What is Rheopheresis

A: Rheopheresis is blood purification technique first started in Japan in 1980 but still not practiced in Asia due to lack of training. Rheopheresis can be used to remove cholesterol, remove antibody, especially in transplantation (where kidney from different unmatched persons can also be transplanted). Other uses are in cancers, blindness, stroke, peripheral vascular diseases, auto immune diseases.

Q: I understand that you have developed some new techniques in Dialysis. In what way are they different from the Dialysis techniques now used?

A: I have designed a triple dialysis system called Diarheopheresis where we have combined dialysis and rheopheresis together.

It is a useful procedure to remove cholesterol and also for performing transplantation with very little chance of rejection. Additionally, I have been advocating the concept of Herbal Dialysis going on the basis that our body contains 45 per cent water.

Here we use dialysis technology to replace our body water into herbal water by infusing herbal extracts. By doing so we found that viruses like hepatitis B and C are unable to survive in this environment.

There is wide scope for research in this field especially in Sri Lanka where the traditional herbal medicine awareness is high. Funding and exchange of knowledge is all that is needed to put this technology into big use, which has a potential to cure HIV and many other degenerative diseases in a simple natural way that is very cost effective.

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