To die, to sleep;
To sleep: perchance to dream: ay, there's the rub;
For in that sleep of death what dreams may come,
When we have shuffled off this mortal coil . . .
William Shakespeare (1564–1616), Hamlet III.1
The Greeks recognised the healing powers. ‘Sleep's the only medicine that gives ease’, wrote Sophocles (496 bc–406 bc) in Philoctetes (p. 766). In Greek mythology, Hypnos was the personification of sleep. The Roman equivalent was called Somnus. His twin was Thanatos (death), and their mother was the goddess Nyx (night). The Romans, too, were interested in sleep. In his Aeneid, Virgil (70 bc–19 bc) draws the same comparison as Shakespeare between deep sleep and death: ‘That sweet, deep sleep, so close to tranquil death’. Ovid gave the name Morpheus to Hypnos’ son, from the Greek word morphe for form, because he gave form to airy nothings. Morpheus was the god of dreams and appeared in the dreams of kings, with his brothers Phobetor (phobias) and Phantasos (phantasy or fantasy). Hypnos gives us hypnotic, Somnus gives somnolence and Morpheus gives morphia or morphine. Sigmund Freud believed that dreams are a product of the unconscious mind trying to tackle unresolved conflicts from the previous day, and, when he developed psychoanalysis, the therapy included the interpretation of dreams.
What links paediatricians and sleep? Paediatricians are blooded on sleep deprivation during training, and many continue to experience it for most of their working lives. Sleep deprivation is, of course, used in war for torture. For many parents of children with chronic conditions, sleep deprivation may be the last straw, determining whether or not the family can cope. When I am taking a long case history in the clinical examination, I always ask how the child and the parents are sleeping.
Sleeping sickness (human African trypanosomiasis) has not much to do with sleep, but I am an infectious disease physician so you will have to humour me. It is a neglected disease that affects 300 000–500 000 people in sub-Saharan Africa and kills over 66 000 a year. The disease is caused by trypanosomes, protozoan parasites transmitted by the bite of the tsetse fly, and comes in two forms, East African and West African. There is no vaccine, the four main drugs are all toxic (melarsoprol, the only drug effective for both types of central nervous system disease, kills 5% of patients who receive it) and vector control is difficult. Although mainly a disease of adults, children can be affected even before they are 2 years old.1 There is an early, haemolymphatic stage and a late, encephalitic stage, when the parasites cross the blood–brain barrier and cause encephalitis lethargica, a relapsing disease that can cause death or permanent intellectual disability. In our refugee clinic, we recently saw a Ugandan boy with severe global developmental delay as a result of sleeping sickness.
If you Google ‘sleep and paediatrician’, most hits are for obstructive sleep apnoea. Obstructive sleep apnoea is a growth industry, and adult sleep specialists outnumber their paediatric colleagues several fold. What about ‘normal children’ with sleep problems? If children are not sleeping well, can medications help them sleep without putting them in danger of obstruction or apnoea? Many parents and paediatricians believe that ‘sedating anti-histamines’ are a useful short-term hypnotic, but the evidence is weak. In a randomised controlled trial, poignantly called the TIRED study, diphenhydramine was no more effective than placebo in reducing night-time awakening for infants or in improving overall parental happiness with sleep.2
In common with a number of my paediatric colleagues, I sometimes suffer from insomnia. The only advantage of insomnia is that you are less likely to die in your sleep.
[ Connor Quagliotto (photo by his mother, Dr Meryta May). ]