If your kids have been running on summertime time, staying up late, sleeping in, living a little loose with the schedule, I want you to know you are not alone. I gave my own kids a grace period. About 30 minutes, which is short for most families, but I have a sleep background and it is hard for me to let it slide further than that.

My guest for this one is someone I had been quietly fangirling over for a while before I finally met him at SLEEP 2026. Dr. Sujay Kansagra is a pediatric neurologist and sleep medicine specialist at Duke, he runs the “That Sleep Doc” accounts across Instagram, TikTok, and everywhere else, and he invented a smart crib mattress called Lullabee. More on that at the end, because it is clever. But first, the reset.

How much sleep kids actually need

Sujay puts it plainly. Sleep is not one of the pillars of good health. It is the foundation the rest is built on top of.

The need is age-based, and the younger you are the more you need. Around one year of age, the average is roughly 14 hours over a 24-hour period, with a wide range around that. Preschoolers, about 3 to 5 years, land somewhere between 10 and 13 hours. School-age kids, 6 to 12, sit around 9 to 12. Teenagers need eight to eight and a half, and some up to ten. By the time we are adults, we are back to 7 to 9.

Worth knowing your child’s ballpark before school starts, so you can see how far the summer has pulled you from it.

Is the summer drift actually bad?

Mostly, no, and the reason is body clocks.

Teenagers are natural night owls. Their circadian rhythm is shifted late, so when they stay up and sleep in, they are following what their biology is asking for. Toddlers are the opposite, wired as morning people, which is why an early bedtime works for them, since they are going to be up at dawn regardless.

So a little drift over summer is fine, as long as the quality and the quantity are there and they are sleeping at the time their body clock actually wants. The trouble is not the drift itself. It is that school is about to demand a hard reset, and that is where the two problem cases show up: the toddler who fights bedtime and the teenager whose clock has slid hours off schedule.

The toddler who will not stay in bed

Toddlers are, as Sujay says, amazing experimenters. They are testing what they can do to delay bedtime, and there is real FOMO involved, a genuine not wanting to miss whatever is happening in the house without them.

But there are two very different things that look the same from the hallway. One is limit testing. The other is anxiety. You have to sort out which one you are dealing with before you pick a strategy, because they need opposite responses.

If it is pure limit testing turning into a nightly battle, the foundation is ordinary sleep hygiene. A calm nighttime routine, a dark and comfortable room, watching caffeine during the day (yes, even in little kids, who sneak sips of a parent’s coffee more than you would think), and a consistent wake-up time. And critically, putting them down when they are actually sleepy, not an hour before, because that guarantees a fight.

Then you hold the line. Sujay calls it a robotic return to bed. No emotion, no coaxing, no negotiation. Timmy gets out, you walk him back, you tell him calmly that the routine is done and it is time for sleep, and you leave. He follows you out. You do it again. Same words, same flat affect, same result.

How persistent do you have to be? He told me he once returned his own toddler to bed 213 times in a single night.

That number is the whole point. The consistency has to outlast the testing, and the testing goes further than most parents expect.

The caveat rides along the whole time: this is for the limit-testing child, not the anxious one. Anxiety at this age usually shows up as separation anxiety larger than you would expect. Brutal daycare drop-offs. Rigid need for routine. Asking the same questions over and over even after you have reassured them. And sometimes it hides, surfacing as irritability or behavior problems when the core issue is worry. If any of that sounds familiar, that is a conversation with your pediatrician, not a robotic return to bed.

The teenager whose clock has slid

This is the hard one, and I see it constantly.

By nature teenagers cannot feel sleepy until late. Sujay’s analogy is perfect: telling a teenager to fall asleep at 9 is like telling a typical adult to go to bed at 7 p.m. It is not where their body clock is. So the nightly fight, where the parent says you can’t sleep because you’re on your phone and the kid yells back that they can’t sleep, has a little truth on both sides.

You cannot fix a multi-hour shift overnight. If a kid has been going to bed at midnight and waking at 10, and school is about to demand a 6 a.m. wake-up, that is a four-hour move, and it has to be gradual. Plan for about 10 to 15 minutes a day.

The levers, all pushed together:

Wake up 10 to 15 minutes earlier each day. Get lots of bright light immediately on waking. Move bedtime earlier by the same 10 to 15 minutes. Keep the lights dim for the 20 to 30 minutes before bed. And shift mealtimes earlier too, because food timing feeds into circadian physiology.

On melatonin, Sujay was careful and so am I. This is one of the few places in sleep medicine where we actually have data for it, used not as a sedative but as a clock-shifting agent. The catch is that most people use it wrong: it works at low doses taken much earlier than expected, often 2 to 6 hours before the current bedtime, not 30 minutes before lights-out hoping for magic. Neither of us is telling you to go buy gummies. Do not reach for monster doses, and talk to your provider about timing first, because the timing is the part that is easy to get wrong.

And do not wait until the night before school to start. This is a two-week project, not a one-night one.

The weekend catch-up question

Once school is running, everyone wants to sleep in on Saturday to recover. Here is the reframe that changed how I think about it.

The single most important scheduling lever is a consistent wake-up time, more than a consistent bedtime. Sleepiness fluctuates night to night, but the wake-up is what anchors the whole system, because it is the morning light at a steady hour that keeps the circadian clock locked to 24 hours. We know this from studies where people lived in caves for months and their rhythm drifted slightly longer than 24 hours. Morning light is what pulls us back in line each day.

So instead of letting a sleep-deprived teenager sleep until noon on the weekend, keep the wake-up close to the school-day time, get them into morning light within about an hour, and then let them take a nap midday if they need to catch up.

I had never recommended a full-cycle nap before, and Sujay’s version made sense to me: aim for either 20 to 30 minutes, short enough to avoid the deep stages, or a full 90 minutes to complete a whole sleep cycle. The danger zone is in between, where you wake mid-deep-sleep, feel awful, get a headache, and conclude the nap made things worse, when what you actually hit was sleep inertia.

One honest caveat I added, because it is my life: this is for the healthy sleeper who is simply sleep-deprived and time-crunched. For those of us with chronic insomnia, napping is often the worst thing we can do, and I would end up fragmenting my night into two broken cycles. Sujay agreed. Teenagers are usually good sleepers who just are not getting the hours, and for them a nap is a reasonable tool. Know which camp you are in.

The bigger fight: standard time and school start times

We could not talk about teenage sleep without getting into the two structural problems stacked on top of it.

Sujay’s case against permanent daylight saving time comes down to morning light. In the winter, permanent DST means the sun rises far later than most of us wake up across much of the country. No light signal in the morning, too much light in the evening, and since our clocks already run a touch longer than 24 hours, everyone drifts toward being a night owl while society still demands an 8 a.m. start. The result is a nationwide squeeze on sleep opportunity, everyone a little more deprived and a little less healthy.

His biggest concern is safety for kids walking to school in the dark, the exact issue that sank this experiment when the country tried it in the 1970s. Dark, colder, an hour deeper into the night, with weather hazards on the roads before sunrise and no daylight to deal with any of it. This is why the push is for permanent standard time, not permanent DST, ideally with a bit of built-in flexibility for people who want it.

Layer early school start times on top, and you have a genuine setup for failure. Teenage biology already runs late, permanent DST would delay it further, and then we ask those developing brains to show up in the dark before dawn. Sleep-deprived kids learn worse, get injured more in sports, and make worse decisions, because everyone makes worse decisions when they are not sleeping. In an ideal world, as Sujay put it, we would give people the sleep they need and adjust our societal expectations to match. His words: maybe our teenagers would be a little less cranky if we actually let them sleep.

Full disclosure on where I stand: I have been to Hill Day three times advocating on this, I have a related conversation with Dr. Beth Malow out this week, and I have a meeting with Senator Kim’s team coming up. So this one is close to my heart.

The invention: Lullabee

Sujay is a clinician and researcher by training, and Lullabee came out of a frustration. He had an idea years ago that mapped directly onto what we know about infant sleep science: support the baby when they need it, then wean them into being an independent sleeper. He kept waiting for someone to build it, and noticed that the products actually reaching the market often ran opposite to the science, because they were made by people good at marketing rather than by sleep doctors. There is also a darker motivation underneath it, from his years covering child neurology in the hospital and seeing what happens when infants are not in a safe sleep location, or when exhausted parents reach the end of their rope. So he built it himself.

Lullabee looks like an ordinary crib mattress with sensors inside. When the baby is awake and crying, it produces a gentle sound and vibration from within the mattress to help settle them, increasing the intensity in steps, level one through ten, all of it still gentle, until the child falls asleep, then ramping back down to nothing. At baseline it does nothing at all. It just waits.

The clever part is that it learns. It tracks the child’s historical sleep patterns and, when the data shows the child is ready, it automatically starts weaning the amount of help it gives with each awakening. If sleep regresses later, teething, learning to sit up, it kicks back in. A temporary technology solution aimed at lasting behavioral change, which is exactly what technology for sleep should do: wean you off of itself.

It keeps the baby in the crib, the safest sleep location, which is bare and firm and can make sleep harder for a young infant, so giving them a little help to sleep there safely is the whole idea. And yes, it lets exhausted parents get some rest instead of running in at every wake-up. It will not feed a hungry baby or change a diaper. Not yet, anyway. We joked about smell sensors for a future model.

Sujay suspects the earlier you start the more effective it is long term. Their oldest user began around 18 months and it helped that family transition out of bed-sharing and into the crib. He announced it in March, so it is only a few months old, which is why my first reaction was: where was this when my kids were little.

What I want you to take from this

You do not have to fix everything the night before school starts. Pick the child in front of you, name whether you are dealing with limit testing or anxiety or a slid clock, and move in 10 to 15 minute steps with morning light doing most of the work.

Great days start the night before. Sleep well, and I will see you next time.

You can watch or listen to the full conversation with Dr. Sujay Kansagra here:

Find him at @ThatSleepDoc on Instagram, TikTok, and YouTube to learn more.

Sweet dreams and happy listening.

The Sleep Is My Waking Passion podcast is for entertainment and educational purposes only and does not constitute medical advice. Always consult your healthcare provider for personalized guidance.

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Adam invited me onto his podcast to talk about something I bring up in my office almost every week, and I said yes before he finished asking.

He has lived with chronic daily headaches for as long as he can remember. Years ago a neurologist sent him for a sleep study, and he came back with moderate obstructive sleep apnea he had no idea he had. He had spent years assuming his daytime sleepiness was just the headaches wearing him down. He has been on CPAP ever since.

Here is the part I want you to sit with. For Adam, CPAP did not fix the headaches. His sleep quality improved enormously, from interruptions in the high twenties down to low single digits, but the headaches stayed. He is honest about that on the show, and I appreciated it, because the real story here is more complicated than a clean before and after.

For a lot of other people, it is the fix. Those are both true at once.

The three buckets

I do not speak in absolutes. We live in the real world and life is imperfect. But when I think about what makes up optimal sleep health, I am looking at three things.

Consistency, meaning a routine schedule. Duration, meaning sufficient sleep for you and your physiologic needs, which varies from person to person. And quality.

Most people assume the answer is duration. Just get more sleep and the headaches will settle. There is data supporting that, and for most of us the number lands somewhere around 7 to 9 hours. Very few people actually need less.

But the data points more strongly at quality. So once you have the duration handled and you are still getting headaches, the question becomes whether we can improve how well you are sleeping during those hours. Sometimes that is behavioral. The TV on all night giving you little wakeups you never fully register. A bed partner who makes noise, and by bed partner I mean human or non-human, because I have plenty of patients who sleep with their pets. It is the worst. I also know I am not going to change them.

You are not your own best observer

This is the line I most wanted people to take away.

We are not our own best observers of our sleep. If you have a bed partner, or you go on a trip and somebody says something to you about how you sound at night, take the witness account seriously. You genuinely have no idea what is happening in your own bedroom for eight hours.

The clues are often small. Getting up to use the bathroom several times a night. Waking up feeling anxious without knowing why. Waking up and simply not feeling rested, without being able to point at the reason.

Before you spend money on a specialist consult, there are things you can do at home. Judicious use of a sleep tracker, and I mean judicious. If your Apple Watch flags that your oxygen levels dip, that is worth getting checked. If an app tells you your sleep is fragmented, that is a signal worth following. These trackers were never designed to be perfect and they are not replacing sleep testing. Please do not get obsessed with the data. But they can flag that something is amiss. Even a free app that records snoring will tell you whether you are making funky noises at night when nobody is there to hear it.

Having a low threshold to get your sleep assessed is low-hanging fruit. Think about what we actually do. I am not putting you through an invasive procedure. Most of the time I am not even drawing blood. A sleep test can be as simple as monitoring you in your own bed at home.

What the numbers actually say

Roughly a third of patients with obstructive sleep apnea will complain of headaches.

Sleep-related bruxism is worth knowing about too, and most people learn they have it from their dentist rather than from me. Grinding your teeth at night is an activation of the sympathetic nervous system. Depending on how you ask the question, up to 80% or more of people with sleep-related bruxism may have obstructive sleep apnea. About a third of sleep apnea patients also grind. The direct link between grinding and headaches is less conclusive, but the association with sleep disordered breathing is strong enough that I bring it up.

Other sleep disorders raise your headache risk as well. Chronic insomnia, which I have had for over twenty years myself, tends to fragment your night into chunks. Four hours here, awake for two, then trying to nap before work just to function. Those people may be more prone to headaches. Restless legs is common in our population, and while most patients notice the symptoms before they fall asleep, the movements can continue once they are asleep without their awareness.

Then it runs the other direction. Headaches disrupt sleep, because going to bed in pain makes sleeping harder. It becomes this vicious swirl. You do not sleep well, that aggravates the headache, which makes it harder to sleep, which aggravates the headache.

And the number that made Adam sit up: the literature points to up to 80% of people having their headaches resolve once they are on CPAP therapy, with the majority resolving within about 72 hours. It looks different if you have had headaches for a very long time, or if you have significant migraines. But addressing the underlying sleep disorder often improves at least the frequency, even when it does not make things perfect.

What is actually happening in your airway

This is the explanation I give patients in the office, so you are getting the office version.

Right now, reading this, you are not snoring. Your airway is open, there is no airway resistance, and all of that musculature is engaged. When we go to sleep, our muscles naturally relax. In REM sleep those muscles are quite literally paralyzed. Your heart is beating and your diaphragm is working, so you are alive, but the size of your airway once those muscles are paralyzed is what you have got.

With obstructive sleep apnea you get complete or near complete closure of that upper airway. Some people have smaller airways to begin with. Jaw shape matters, neck size matters, and whether you can breathe through your nose matters, because sinus congestion adds upper airway resistance before you have even fallen asleep.

So now you are breathing against a closed airway. It is like someone put a plastic bag over your head and duct taped it on. That is a powerful analogy and I use it on purpose, because that is functionally what is happening.

Your oxygen goes down. That lovely parasympathetic state you are supposed to be in, low heart rate and low blood pressure, gets interrupted, because your body senses it has no airway and activates the sympathetic nervous system. Heart rate blips up. Blood pressure blips up. You get a small arousal from sleep to reopen the airway.

The connection to your head is blood flow. Blood flow shifts depending on what your oxygen is doing, and you get an increase not only in systemic blood pressure but in intracranial pressure, which comes down to how your blood vessels respond to a low oxygen state. Probably other mechanisms too, some still being worked out. What it comes down to is that your brain registers that increased pressure, and that can show up as a headache.

Why CPAP works, and why the fear is fair

I cannot go in and place a physical stent in your airway. It is all musculature and it is all dynamic. So we use air as a pneumatic stent, pushing the tissue open until we hit what we call the critical opening airway pressure. Then the airway is stented open and normal breathing is restored.

Everyone needs a different amount. Your report may show a P95, meaning the pressure you spend 95% of your time at. Twelve is a fairly average number. And size does not predict it the way people expect. I have had someone over 300 pounds need a pressure of 8, and a tiny Asian woman who needed 15 to keep her airway open. Predicting who needs more is one of the ongoing challenges in sleep medicine.

I also want to speak to the people who find the whole idea of CPAP frightening. I see you in my office every day. That fear is real and I take it seriously.

You have options. It does not have to be one size fits all, and that is part of why I love practicing sleep medicine right now in 2026. We may even have a pill by 2027. So if you know something is going on and you have been burying your head in the sand because you have exhausted every other headache treatment and this one scares you, please do not write it off. Get the information.

About the testing itself

Adam described his in-lab study as kind of a racket, and honestly, the experience he had is one a lot of people recognize. Arriving in the evening, getting covered in electrodes and leads, then trying to sleep in an uncomfortable bed knowing it is somebody’s literal job to watch you.

Home sleep apnea testing has made this much easier. The classic setup involves a band around the chest and something resembling a nasal cannula, with a probe on your finger for oxygen. Newer options look like a ring, or a wristwatch, and one device a colleague at UCLA told me about simply sticks to the chest.

The caveat, and it matters: right now in 2026 most insurance plans only pay for one night. Sleep apnea can wax and wane. I have seen patients who test mild one night and moderate another. The latest data suggests that tracking sleep longitudinally, maybe a few snapshots over a month, would give us a much better sense of what is real. So a negative home test does not always mean no sleep apnea. It can mean we missed it.

If your test is negative and suspicion remains high, if multiple people are telling you something funky is going on with your breathing, if your watch keeps flagging oxygen drops, you do not pass go. You go to the polysomnogram, the in-lab study. It is more labor intensive, but it gives us leg leads, more sophisticated cardiac monitoring, position data, and your true sleep architecture for that night. The tradeoff is that we get one shot, and if the first night effect kicks in and you cannot sleep, I am working with limited data.

What I want you to take from this

Your headaches may be related to your sleep. So address the sleep, and prioritize it if you struggle to do so.

I have spent a career in pulmonary and critical care alongside sleep medicine. I watched a lot of people die during COVID. The perspective that stuck with me, the one I cannot shake, is how fragile life is. Health is our true wealth. Very little else matters without it.

If sleep is the thing standing between you and a more headache-controlled life, do not be afraid of us. I promise we do not bite. We are here to help you.

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You can hear the full conversation here:

If you have questions I did not answer, send them to me. Adam offered to pass along anything his listeners wanted to ask, and the offer stands here too. The people who show up with “wait, you didn’t talk about this” are usually asking the best questions.

Sweet dreams.

The Sleep Is My Waking Passion podcast is for entertainment and educational purposes only and does not constitute medical advice. Always consult your healthcare provider for personalized guidance.

I sat down to jot a quick list and realized the question is like sleep itself: simple on the surface, complicated underneath. The usual suspects —screens, stress, etc — matter, but if you’re reading this you already know the basics. I had to go deeper. And what struck me is that the ten biggest threats I see aren’t habits at all. They’re the things people believe about sleep before they ever walk through my door.

So Chris, this one’s for you. Here’s my honest answer, from the exam room, not the algorithm — counting up to the one I think matters most.

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1. Sleepmaxxing culture

Somewhere along the way, sleep stopped being something you do and became something you optimize. Mouth tape, magnesium stacks, cooling mattress pads, red light, a score to beat every morning. I’ve watched patients turn their bedrooms into laboratories and their nights into performance reviews.

Here’s the irony: the anxiety of chasing perfect sleep is itself a threat to sleep. There’s even a name for it in the medical literature now, “orthosomnia,” coined for patients whose pursuit of ideal tracker data was actually making their sleep worse (Baron et al., 2017). The goal was never perfect sleep. The goal is understanding your body and getting the right support.

2. The confidence of people who speak in absolutes

Sleep is nuanced. It’s so complex that the honest truth is we haven’t figured it all out yet, and I say that as someone who does this for a living. And yet open any social media app and you’ll find someone declaring, with total certainty, that there is one supplement, one wake time, one trick.

When someone speaks in absolutes about sleep, that’s not expertise. That’s marketing. Real sleep medicine sounds more like “it depends, tell me more about you,” which, I’ll admit, makes for a lousy 15-second video. But it does make for good care. Absolutism is dangerous because it convinces people they’ve already found the answer before anyone has asked the right questions. I’ve said it before and I’ll say it again: the future of sleep is personalized!

3. The sleep-industrial complex

Think about it. I’m convinced that almost every source of information you turn to — your search engine, the radio, the TV, social media, literally everyone — is ultimately trying to sell you something. The latest elixir, sleep app, or gadget that promises to solve all your sleep problems, for everyone, every time. And once the algorithm learns you’re tired, the rabbit hole opens: you can hemorrhage real money on meaningless garbage while the actual cause of your exhaustion goes completely unaddressed.

Some of those exhausted people scrolling the sleep aisle at 2 a.m. don’t need a $400 gadget. They have a sleep disorder that needs real treatment. Nearly a billion adults worldwide are estimated to have obstructive sleep apnea, and the vast majority are undiagnosed (Benjafield et al., 2019). No pillow spray fixes that.

4. Being afraid of the sleep doctor

I understand this fear more than you might expect. But avoiding the evaluation doesn’t make the problem go away. It just means you carry it longer, unexamined, while it quietly affects your heart, your mood, your metabolism, your relationships, and more.

You are allowed to ask for help. You are also allowed to be evaluated and told everything is fine. That happens too, and it’s wonderful. Sleep should not be the last thing you mention to your doctor, because it may be the thing explaining everything else.

5. Arriving with the story already written

This one is subtle, and I see it constantly. A patient comes in having already diagnosed themselves, already decided what they will and won’t accept, and then, consciously or not, edits their history to fit that story.

I’ve even been told (just last week!) that taking a history feels invasive for “just a sleep study.” But your history is the sleep study, or at least half of it. Sleep data means very little without the person attached to it. When you’re not honest with me about your medications, your alcohol, your naps, your 3 a.m. scrolling, your fears, you’re not protecting yourself. You’re tying my hands. I’m not here to judge you. I’m here to figure this out with you, and I can only work with what you give me.

6. Dr. Google and Dr. ChatGPT

Let me be clear about what I’m not saying. I’m not saying don’t read, don’t research, don’t come with questions. Please do. An informed patient is my favorite kind of patient.

But I practice medicine. I’ve been a board-certified attending for nearly twenty years. I’ve had patients rely on me in critical situations to make the right call, then deliver that treatment with compassion, using every tool available to me. Dr. Google can’t do that for you. And AI? AI is only as good as the inputs you give it, and when you’re the one describing your own symptoms, you are, by definition, working from an incomplete picture. You can’t see your own sleep. That’s rather the point.

7. Fearing the diagnosis because you don’t understand the treatments

So many people avoid testing because they’ve already decided the treatment will be unbearable. Usually it comes down to one thing: they’re picturing a CPAP machine from 1997.

Sleep medicine has options. Modern PAP therapy is quieter and smarter than what you’re imagining, and it isn’t the only tool we have. Oral appliances, positional therapy, weight-focused approaches, surgical options, newer medications — treatment is personalized, and it’s a conversation, not a sentence. Refusing to learn your diagnosis because you fear one treatment is like refusing to open a letter because you’ve already decided what it says.

8. Reaching for a pill before you’ve tried the gold standard

If you have chronic insomnia (trouble falling and/or staying asleep more than three nights a week for more than three months) and you’ve never done cognitive behavioral therapy for insomnia (CBT-I), then you haven’t yet tried the treatment with the best evidence behind it. Not my opinion. Fact. The American College of Physicians recommends CBT-I as the first-line treatment for chronic insomnia in adults (Qaseem et al., 2016).

Medications have a role. I prescribe them. But a sleeping pill without addressing the underlying drivers is a bandage on a leak. CBT-I retrains the system itself, and its results last after the treatment ends. That’s a claim no pill bottle can make.

9. Believing sleep is a nighttime-only activity

Yes, you sleep at night. But the time you invest in rest shows up everywhere: your health, your productivity, your mental health, your relationships, your recovery from workouts, illness, and hard seasons of life. Both chronically short and chronically long sleep are associated with a higher risk of death — sleep duration is a genuine signal for your long-term health, not just a measure of how you’ll feel tomorrow (Cappuccio et al., 2010).

Sleep is not a luxury. It is not the thing you do once everything else is finished. It’s the foundation your body needs to hold up every other part of your life, and it’s built by what you do across all 24 hours, not just the last seven.

10. Treating sleep as if it lives in a vacuum

And the flip side of number nine: don’t assume you only have to fix your sleep to improve your life. Sleep, nutrition, and physical activity are not three separate self-improvement projects. They’re one system. What you eat influences your sleep architecture that very night (St-Onge et al., 2016), and regular physical activity is one of the most reliable non-drug tools we have for better sleep (Kredlow et al., 2015). Dial in all three. They rise and fall together.

One final thought, and this one stems from a conversation I had with a non-medical guest, Justin Hai. Above all else, make sure you have fun. You need whimsy in your life. As a mom of two girls who are quickly turning into young women, there has been no greater gift to my life than the privilege of learning from them. Every day they make time to play, run, invent games, fight, hug, cuddle, laugh. And as someone who spent her entire youth being told that cartoons are for babies and to prioritize the next goal above all else, I’m reminded daily that life is very short. You only get this one ride in human form, so make the most of it. With fun comes friendship, laughter, and joy — the stuff that, in the end, is what really matters.

Thank you, Chris Winter, for asking a question that made me sit still long enough to answer it.

If any item on this list stung a little, that’s worth paying attention to. Your body is trying to tell you something, and you are allowed to ask what.

Come find me:

• Follow me here on Substack — Diary of a Sleep Doctor

• Ask The Sleep MD — askthesleepmd.com · @askthesleepmd

• The Sleep Is My Waking Passion™ (SIMWP) podcast — askthesleepmd.com/simwp, on Apple, Spotify, and YouTube

Wake up to better tomorrows.

Now its lights out for me.

— Alison Kole, MD, MPH, FCCP, FAASM

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References

1. Baron KG, Abbott S, Jao N, Manalo N, Mullen R. Orthosomnia: Are Some Patients Taking the Quantified Self Too Far? J Clin Sleep Med. 2017;13(2):351–354. PMID: 27855740

2. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med. 2019;7(8):687–698. PMID: 31300334

3. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125–133. PMID: 27136449

4. Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):585–592. PMID: 20469800

5. St-Onge MP, Roberts A, Shechter A, Choudhury AR. Fiber and Saturated Fat Are Associated with Sleep Arousals and Slow Wave Sleep. J Clin Sleep Med. 2016;12(1):19–24. PMID: 26156950

6. Kredlow MA, Capozzoli MC, Hearon BA, Calkins AW, Otto MW. The effects of physical activity on sleep: a meta-analytic review. J Behav Med. 2015;38(3):427–449. PMID: 25596964

When was the last time you felt at home in your body and actually slept at night?

I see this constantly in the clinic. Smart, accomplished women doing everything correctly. Eating well. Exercising. Watching the waistline expand anyway. And underneath it all, sleep that has quietly stopped working, for reasons nobody has adequately explained.

There is an explanation. It runs through your gut.

I brought Marissa Sharkey back on the show to walk through it. She is a registered dietitian who specializes in gastrointestinal health and women’s nutrition. She and I met in the intensive care unit, where she was the person I called the moment a patient could tolerate feeding. Neither of us is in the ICU anymore. She now helps women, and especially nurses and other clinicians, eat well inside lives that were not built for it.

The bacteria that handle your estrogen

Start here, because this is the piece I had not fully appreciated.

You have a collection of gut bacteria whose job is to metabolize estrogen and recycle it back into your bloodstream. It has a name. The estrobolome.

When hormone levels swing during perimenopause, that system gets disrupted, and the disruption makes symptoms worse. It also runs the other direction. A more diverse gut microbiome may support a healthier estrobolome, which may help your body hold onto and regulate estrogen and progesterone more effectively.

So gut health is not a side quest running parallel to hormone health. It is the same machinery. Marissa put it plainly: perimenopause and GI go hand in hand. Some women get their first IBS diagnosis in their forties and never connect it to their hormones.

And sleep sits downstream of both

Here is where my world and hers meet.

Estradiol, the dominant estrogen, is quietly doing a great deal of work. It supports lean muscle mass. It helps regulate blood sugar. It plays a role in appetite. When it starts fluctuating, all of that destabilizes, and unstable blood sugar and appetite are not conditions under which anyone sleeps well.

Then there is the mechanical part, which Marissa was direct about. When there is food in your stomach, your body prioritizes digestion, and digestion keeps you awake. Lie down too soon after eating and reflux finishes the job. If you already have a history of reflux, this is the whole ballgame.

Which is why the timing of your last meal is not a fussy detail. It is one of the few levers you can pull tonight.

The nighttime snack, done properly

This is the question I get most, so I will be concrete.

A small snack before bed can genuinely help, particularly if you have diabetes and are prone to overnight lows. Eat it about two hours before you lie down. Keep it small. Pair a carbohydrate with a protein or a fat.

A cheese stick with whole grain crackers. Greek yogurt with a little granola and fresh berries.

No large meal. Nothing right before you get into bed. The goal is stable blood sugar and a stomach that is not still working while your brain is trying to power down.

There are foods that help you more than others. Protein is where you get tryptophan, and tryptophan supports sleep. Turkey, chicken, fish, eggs, and cheese all qualify. Eggs are also rich in melatonin. Plant sources work just as well: edamame, tofu, peanuts, quinoa, pumpkin seeds. And no, you do not need to fear soy. The research does not link it to cancer risk, and it may help with hot flashes while supporting bone, heart, and brain health.

The single most effective change, though, is subtraction. Less alcohol. Marissa loves an espresso martini and said so. But alcohol provides no meaningful nutrition, worsens mood, disrupts sleep architecture, is linked to several cancers, harms heart health, reduces nutrient absorption, and contributes to weight gain. If you change one thing this month, make it that one.

Puberty in reverse

Marissa gave me a phrase I have not been able to shake. She calls this stage of life puberty in reverse.

That is exactly it. You are learning a brand new body. Meanwhile, life is doing its own thing around you, with kids leaving, careers shifting, parents needing care. It is a lot, and it is mentally hard in a way people rarely say out loud.

Some vocabulary, because it matters. Perimenopause is not menopause. Perimenopause is the runway, the years when your cycle changes and symptoms start, and it can last anywhere from two to ten years. Menopause itself is a single day. It is the twelve-month anniversary of your last period. The next morning, you are postmenopausal. As Marissa put it, no party, just biology.

The symptoms are stranger and wider than most women are warned about. Brain fog. Joint pain. Frozen shoulder. Anxiety that arrives without an obvious cause.

One more hormone, and one correction

As estrogen declines, the liver makes less sex hormone-binding globulin. Less binding protein means relatively more circulating androgens, testosterone among them, which contributes to visceral fat, the kind stored around your organs and linked to chronic disease.

Marissa stopped me here to make a point worth repeating.

There is no such thing as a male hormone or a female hormone. Testosterone is produced in the ovaries and the adrenal glands. Women have it, women need it, and it supports muscle mass, bone density, and libido. It stays controversial in women’s care partly because many providers will not prescribe it, and partly because female-appropriate doses are genuinely hard to source, since most formulations are built for men.

I will be transparent. I recently started menopausal hormone therapy with my own primary care physician. What I noticed first was not the weight or the sleep. My brain fog lifted a little. The delayed onset muscle soreness that used to flatten me for a week after a hard session finally eased. I squatted a hundred pounds and was not destroyed by it.

Note the terminology. Marissa does not say hormone replacement therapy. She says menopausal hormone therapy, because nothing is being replaced. You are supplementing what your body has stopped producing. Think of perimenopause as an estrogen deficiency, the way you would think about a vitamin D deficiency. You cannot eat your way to more estrogen, so the conversation with your clinician is worth having.

She is emphatic about this. Poorly interpreted science from the early 2000s frightened an entire generation of women away from hormone therapy. As she said, this is a hill she will die on.

Can we please stop demonizing carbs?

Some of the new dietary guidance is good. Fewer ultra-processed foods, more protein, less added sugar. I have my own views on how it came together, and I will leave that where it is.

But the treatment of carbohydrates makes no sense. Fiber is barely emphasized. Your brain runs on carbohydrates. Fiber is a carbohydrate, and in menopause, it is doing enormous work: managing cholesterol, stabilizing blood sugar, feeding your gut, improving satiety, keeping digestion regular, and lowering cancer risk. Cutting out whole food groups, fruit included, is not a strategy. It is deprivation with better marketing.

A few other quarrels. Pushing full-fat dairy exclusively makes it very hard to stay under the recommended ten percent of calories from saturated fat, which matters when many women in this stage are already watching their cholesterol drift. Artificial sweeteners, in moderation, are safe, and the data do not support the cancer scare. Marissa is not giving up her Cherry Coke Zero.

And while we are here: please consume pasteurized dairy. Pasteurization does not destroy the nutrition. It keeps you alive. Both of us have watched what foodborne illness does to a liver.

Marissa also made the case for omega-3s, particularly from fatty fish like salmon, sardines, mackerel, and herring. They are anti-inflammatory, and perimenopause is an inflammatory phase of life. They support healthy cholesterol and feed short-chain fatty acid production in the colon, which strengthens your gut barrier. If fish is not for you, flax, chia, hemp, and walnuts work, though the body converts them less efficiently.

Her framing throughout was consistency, not perfection. Not everyone can afford organic groceries, which she notes are not nutritionally superior anyway. Time, budget, and preference are real constraints, not moral failures.

Where GLP-1s fit

We spent a while here, and her position was more nuanced than the internet’s.

Her sequence is to consider menopausal hormone therapy first. If the underlying problem is an estrogen deficiency, addressing the root cause makes sense, and the benefits can be maintained long-term.

GLP-1s are a legitimate tool for the right person. Someone who has been consistent with lifestyle change and is not seeing results. Someone who is not a candidate for hormone therapy. Someone with type 2 diabetes, PCOS, or obstructive sleep apnea, which is now an approved indication for Zepbound.

But lifestyle does not become optional once you are on one. Without attention to nutrition and movement, you may lose weight and lose muscle with it, and muscle is what protects you from frailty as you age. Rapid weight loss carries real costs: the facial changes people call “Ozempic face,” vitamin deficiencies, hair loss, sarcopenia, and bone loss. The medications are expensive and often need to be continued indefinitely.

She was firm on one point. If you have a difficult relationship with food, if you struggle with body image, if you experience food noise, work with a qualified mental health provider and a registered dietitian before starting a GLP-1. These medications are contraindicated in active eating disorders. If the underlying issues go unaddressed and the medication stops, the weight tends to return.

What I keep thinking about

I asked Marissa my closing question. One sentence she wishes every woman would replace in her internal script about aging.

She said that aging is a profound privilege and that menopause is a new beginning, where, despite your genetic blueprint, your daily self-care becomes the power that keeps you visible and thriving.

Your gut, your hormones, and your sleep are having one conversation, not three. In midlife, all of them change at once, which is why nothing you tried in your thirties is working now. That is not a failure of discipline. It is a different body, asking for different things.

Start with protein at every meal. Start with less alcohol. Start with a small snack two hours before bed instead of a large one at ten.

Then go have the conversation with your clinician that nobody offered you.

🎧 Listen to the full conversation with Marissa Sharkey, RD, on Sleep Is My Waking Passion.

Find Marissa on Instagram at @thegutsy_dietitian, grab her free meal prep guide for busy adults through her bio link, or reach her at marissa-sharkeynutrition.com. She is based in New Jersey, provides telehealth across a number of states, and takes most major medical insurance. If you are not sure whether she can see you, just ask her.

Sweet dreams, and happy listening. — Dr. Alison Kole

Sleep Is My Waking Passion is for educational purposes and is not a substitute for personalized medical advice. Always consult your own clinician before starting or stopping any medication, supplement, or hormone therapy.

Almost nobody describes the night.

That gap has always bothered me. I see patients who manage their daytime sleepiness reasonably well and who still dread going to bed, because bedtime is where the real trouble lives. They have nightmares. Not the occasional unsettling dream that fades by breakfast, but long, detailed, emotionally punishing ones that arrive most weeks of their lives.

I asked Dr. Jennifer Mundt onto the podcast because she is one of very few researchers taking this seriously. She is a clinical psychologist and a board-certified specialist in behavioral sleep medicine, now an associate professor at the University of Utah, and her work sits exactly where I wish more sleep research would sit: on a symptom patients bring up quietly, if at all.

The number that stopped me

Roughly 5% of adults have frequent nightmares, meaning at least one a week. In narcolepsy, that figure climbs to something like 30 to 40%.

Dr. Mundt was clear about why this matters. A nightmare is not a silly bad dream. People wake up with their hearts pounding. The images follow them into the next day and surface as flashbacks while they are trying to work. And many of them feel a low, persistent embarrassment about it, some version of it was only a dream, why can’t I let it go. So they never mention it. Not to their partner, not to their neurologist, not to me.

Which means the symptom stays invisible, and invisible symptoms do not get treated.

Why these dreams behave differently

What makes nightmares in narcolepsy their own category is that they rarely show up alone. They tangle with the other REM phenomena that define the disorder.

Sleep paralysis and hypnagogic hallucinations can pick up where the dream leaves off, so a person surfaces from a nightmare into a body that will not move, or into a room where the dream imagery is still hanging in the air. Some people physically act out their dreams, a pattern we call narcolepsy-related REM sleep behavior disorder, though Dr. Mundt notes it tends to be less violent than the isolated form we see in other patients. And people with narcolepsy are unusually likely to be lucid dreamers, aware inside the dream that they are dreaming.

Then there is the one I keep turning over in my head. Dream-reality confusion. The dreams are vivid enough that the brain files them as real events. You wake up certain that you had a fight with your sister, or that you sent the email, or that something terrible happened to someone you love. One study put this at more than 80% of people with narcolepsy, against roughly 15% of people without it.

Sit with that for a moment. It means carrying real grief, or real guilt, through an entire day over an event that only ever occurred during REM sleep. That is not a curiosity. That is a burden.

The part where this gets hopeful

Here is what I most want people to take away: nightmares are treatable, and the treatment is behavioral.

The older name for it is imagery rehearsal therapy. The more standardized version, which researchers including Dr. Kristi Pruiksma have worked to formalize, is cognitive behavioral therapy for nightmares, or CBT-N. It runs about six sessions.

Part of the work happens before sleep. There is a theory called mood matching, the idea that the emotional state you carry into bed shapes what your brain builds while you are in there. Go to sleep tense and braced, and the dream tends to follow. So the therapy makes room for a genuine wind-down: relaxation, slow breathing, some space between the day and the pillow.

The center of it, though, is the rewrite. You take the nightmare, the recurring one, the one you know by heart, and you write it again. You change whatever makes it frightening. You can change the ending, the setting, who is there, what happens. Then you rehearse the new version in your mind at bedtime.

What I find remarkable is what patients report back. They usually do not say they started dreaming the rewritten dream. They say the nightmare stopped coming. Or that it still turns up now and then, and it no longer scares them. The brain seems to get unstuck from the track it was looping.

Adapting it for the people who need it

Dr. Mundt’s contribution is to ask what this therapy should look like when the patient has narcolepsy.

In her pilot work she added a technique that uses the lucid dreaming ability many of these patients already have, helping them rescript the dream while it is happening. Her early findings pointed toward less anxiety and shame around sleep, with sleep paralysis and hallucinations easing for some participants.

She also thought carefully about a problem that seems obvious once you hear it. How do you ask someone with profound daytime sleepiness to lie down, close their eyes, and visualize for ten minutes at bedtime, and expect them to still be awake at the end of it?

The answer is to bend the protocol around the person. Move the rehearsal earlier in the day, when they are more alert. Let them keep their eyes open. Have them write the new dream out, or draw it. Small, humane adjustments, made so the therapy is something a patient can actually finish.

That is good clinical thinking, and it is the kind that tends to come from people who spend real time with real patients.

If you live with narcolepsy, read this part

Dr. Mundt is now running a larger trial, and it is open to participants anywhere in the United States. Narcolepsy is rare, and the treatment is delivered entirely over video, so there is no weekly drive to a university clinic.

It is called the DAWN Study, for Decreasing Nightmares in Adults with Narcolepsy. If you have narcolepsy, type 1 or type 2, and you have nightmares, you can write to the team directly at dawnstudy@utah.edu. Dr. Mundt keeps a current list of her trials at jenmundt.com.

Patient advocacy groups are also a good way to find studies like this one. Wake Up Narcolepsy, Narcolepsy Network, and the Hypersomnia Foundation all keep an eye on recruiting research.

What I keep coming back to

I have spent my career telling people that sleep is not a luxury. This conversation gave me a sharper version of that.

For a person with narcolepsy, sleep is not simply broken in its timing. It can be a place they are afraid to go. And we have spent decades treating the clock and almost none of it treating the fear.

The brain that learned the nightmare can learn its way out again. Somebody just has to ask the patient about it first.

🎧 Listen to the full conversation with Dr. Jennifer Mundt on Sleep Is My Waking Passion. If it lands with you, pass it along to someone whose nights have been harder than they have let on.

Sweet dreams, and happy listening. — Dr. Alison Kole

Sleep Is My Waking Passion is for educational purposes and is not a substitute for personalized medical advice. Always consult your own clinician.

But what about the people for whom that scene comes back? Night after night, week after week, sometimes for years. For them, the bad dream is not a one-off. It is a pattern, and it is stealing their sleep.

I had a specific patient in mind when I recorded this week’s episode of Sleep Is My Waking Passion™. I knew I would be seeing her soon, and I knew I wanted to bring her something better than my usual reassurance. So I called in an expert.

Dr. Courtney Worley, PhD, is board-certified in clinical psychology and a diplomate of behavioral sleep medicine. She coauthored The Nightmare and Sleep Disorder Toolkit, a workbook built around imagery rehearsal therapy and other evidence-based approaches. She has led national training initiatives in the U.S. Department of Veterans Affairs for trauma therapies, and she now teaches clinicians here and internationally. As someone who trained at the VA, that work holds a special place in my heart. What she does is not easy, and it matters enormously.

Here is what I learned, and what I want you to know.

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When a bad dream becomes a disorder

Almost everyone has the occasional nightmare. As Dr. Worley put it, “about 85% of U.S. adults have had a nightmare in the last year, but certainly not that many have a nightmare disorder.”

So where is the line? She walked me through an acronym her colleagues coined to capture the features that move nightmares from common to clinical: disturbing or dysphoric dreams, awakenings, recalled content, and clinical distress or impairment. In other words, it is not just that the dream is upsetting. It is whether it wakes you up, whether you remember it, and whether it is starting to bleed into your daily life.

That last piece is the one I keep coming back to, because sleep is a 24-hour process. What happens during the day shapes the night, and what happens at night shapes the next day. Nightmares sit right in the middle of that loop.

Roughly 2 to 5% of the population would meet criteria for nightmare disorder, and in some groups the number climbs higher. Nightmares are more common in women; they can increase around perimenopause and menopause, and they show up at higher rates in people who have lived through trauma.

It is not only about trauma

When most of us hear the word “nightmares,” we think trauma. And trauma-related nightmares are very real and very common. But Dr. Worley was clear that this is only part of the story. Nightmares are what she calls a transdiagnostic symptom, meaning they show up across many conditions: depression, anxiety, narcolepsy, REM sleep behavior disorder, and as a consequence of certain medical issues, medications, and substances that affect sleep.

And sometimes nothing else is going on at all. Stress and disrupted sleep alone can bring nightmares on. For some people, they fade in and out. For others, they settle in and stay.

REM, non-REM, and why the timing matters

This is the part that fascinated me as a physician. I have always thought of nightmares as a REM phenomenon, and the screaming, partial-recall episodes some of my patients describe as something else entirely. It turns out I was mostly right, but not completely.

Most nightmares do come out of REM sleep, which makes sense. REM is when the brain is hard at work on fear extinction and on processing memories and emotions. But not all nightmares are REM events. In patients with PTSD, Dr. Worley noted, about 40% have nightmares outside of REM.

Timing is a useful clue. Distress in the first half of the night, especially without recalled content, points more toward a non-REM event like a sleep terror. Vivid, remembered dreams in the second half of the night point more toward REM-related nightmares. It is not a perfect rule, but it helps.

The good news: this is treatable

Here is the headline I most want you to hear. Nightmares are treatable, and the leading treatment is not a medication.

The American Academy of Sleep Medicine lists imagery rehearsal therapy, or IRT, as the front-line treatment for nightmare disorder. It has more empirical support than the medication options, and yet most people are never offered it. For many patients, it is a brief course of care, typically 4 to 6 sessions, with results that tend to last.

So what is IRT, actually? The idea is that recurring nightmares become scripts. When the same nightmare plays again and again, the brain keeps pulling the same well-worn imagery that matches the distress. IRT works by writing a new script. You carefully craft a new dream you would like to have, rich with detail, the sights and sounds and smells and thoughts and feelings, and then you rehearse it in your imagination while you are awake, on a specific practice schedule. Over time, that gives the brain a new path to take at night instead of the old one.

I love this, because it is neuroplasticity in action. We are using the brain’s own ability to rewire itself. And it works at any age. As Dr. Worley pointed out, even older adults who have had the same nightmare for decades can change it. The biggest hurdle is often belief, because it sounds a little too good to be true. But in her words, “it’s one of those things that works if you work it.” More practice and more consistency lead to faster change.

More than one tool in the kit

IRT is the most researched option, but it is not the only one.

Cognitive behavioral therapy for insomnia, or CBT-I, can double as a nightmare treatment. By improving sleep quality and continuity, and by easing the anxiety around falling asleep, it can reduce nightmare awakenings.

For trauma-related nightmares, there is Exposure, Relaxation, and Rescripting Therapy (ERRT), which is IRT with an added exposure component. Rather than writing an unrelated dream from scratch, you start from the stem of the actual nightmare, find the moment it becomes intense, and rewrite it from that point forward.

And then there is lucid dreaming therapy, which is exactly as remarkable as it sounds. Lucidity is being aware that you are dreaming while you are dreaming. Some people do it naturally, and the rest can be taught. Once you can recognize the dream, you can learn to change it from the inside. As Dr. Worley put it, you can “change the dream within the dream.” For people whose nightmares come in shifting variations rather than one fixed script, that flexibility can be a real gift.

When a nightmare is a red flag

Not every nighttime awakening is a nightmare, and this is where my world and Dr. Worley’s overlap.

Some people wake gasping, with a sense of panic and shortness of breath, but no recalled dream content. That pattern makes me think about obstructive sleep apnea, which co-occurs with nightmares more often than people realize. Behavioral therapy will not fix apnea. That is a medical condition, and it needs to be evaluated and treated as one. Nightmares alongside symptoms of narcolepsy or REM sleep behavior disorder also call for a full medical workup, because those require additional tools.

This is exactly why I am so passionate about team-based care. Sleep touches everything: our mood, our memory, our hearts, our metabolism, our relationships. No single specialty owns it. Dr. Worley said it best when I asked how she thinks about all of these overlapping fields. “Interdisciplinary care is best.” I could not agree more. I am not interested in staying in my lane. I would rather we all work together and get the patient where they need to be.

If you take one thing from this

You do not have to just live with your nightmares. So many people never mention them to a clinician because they assume nothing can be done. That assumption is wrong, and it is costing people real rest.

If your nightmares are disturbing, waking you up, staying with you in the morning, or affecting your days, please bring them up with your healthcare provider. And if you want a place to start on your own, Dr. Worley’s workbook is a generous, practical resource.

Sleep well,
Dr. Alison Kole

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Resources from this episode

The Nightmare and Sleep Disorder Toolkit, by Dr. Courtney Worley, PhD, and Dr. Michael R. Nadorff, PhD: https://www.amazon.com/Nightmare-Sleep-Disorder-Toolkit-Evidence-Based/dp/1648485812/

The book is published by New Harbinger Press, where you will also find free bonus chapters and downloadable recordings for breathing retraining and imagery rehearsal, whether or not you buy the book there.

To find a behavioral sleep medicine provider near you, you can search the Society of Behavioral Sleep Medicine website.

Connect with Dr. Courtney Worley:
LinkedIn: https://www.linkedin.com/in/drcourtneyworley/
Instagram: https://www.instagram.com/drworleyconsult/

Watch or listen to the full episode

A middle-aged man. Overweight. Loud snoring. Falling asleep during the day.

But according to one of the most respected voices in sleep medicine, that picture is exactly why so many women are still being missed.

On a recent episode of Sleep Is My Waking Passion™, I sat down with Dr. Nancy Collop, former president of the American Academy of Sleep Medicine, former editor-in-chief of the Journal of Clinical Sleep Medicine, and director of the Emory Sleep Center, to talk about one of the biggest blind spots in modern healthcare: sleep apnea in women.

And honestly, I think this conversation explains why so many women spend years feeling exhausted while being told their symptoms are “just stress,” “just aging,” or “just hormones.”

The symptoms women report often do not sound like sleep apnea

Dr. Collop explained that women frequently present very differently than men.

Instead of classic daytime sleepiness, women are more likely to report:

• fatigue

• insomnia

• frequent awakenings

• night sweats

• morning headaches

• restless sleep

• feeling “wired but tired”

• waking up exhausted despite being in bed for hours

The problem is that these symptoms are incredibly easy to dismiss.

“They often get attributed to menopause or thyroid disease or all different kinds of things,” she explained.

And because the presentation feels vague or nonspecific, many women spend years cycling through other explanations before anyone even considers sleep apnea.

I see this constantly in clinic.

Women often come to me after years of trying to figure out why they feel awful. They have already explored hormone replacement therapy, thyroid testing, anxiety, burnout, stress, depression, or “mom exhaustion.” By the time they finally arrive in a sleep clinic, their quality of life has often declined significantly.

And yet their sleep apnea numbers may technically look “mild.”

“Mild” sleep apnea may not actually feel mild

This is one of the most important parts of the conversation.

Sleep apnea severity is usually categorized by something called the apnea-hypopnea index (AHI), which measures how many breathing disruptions occur per hour during sleep.

On paper, an AHI between 5 and 15 is considered “mild.”

But Dr. Collop made an important point: those numbers do not always correlate with how impaired someone actually feels.

“I’ve had patients who have mild sleep apnea by our definition and are extremely impaired by it,” she said.

That matters because many women are told their sleep apnea is “not bad enough” to explain their symptoms.

Meanwhile, they are struggling to function.

They are waking up repeatedly during the night. Their sleep is fragmented. Their blood pressure is climbing. Their headaches are worsening. Their concentration is declining. Their mood changes. Their energy disappears.

And because the sleep study report says “mild,” they are sometimes dismissed.

The reality is much more nuanced than that.

REM sleep may be where the real problem is hiding

One of the reasons women can appear “mild” overall while still feeling terrible is something called REM-related sleep apnea.

REM sleep is the stage of sleep associated with vivid dreaming. During REM, the muscles in the body become deeply relaxed, including the muscles that help keep the airway open.

According to Dr. Collop, women are particularly vulnerable to breathing disruptions during this stage of sleep.

What makes this important is that REM sleep tends to occur more heavily in the second half of the night. So women may sleep relatively normally early on, only to experience repeated airway collapse later in the night when REM periods become longer.

This can lead to:

• oxygen drops

• repeated arousals from sleep

• surges in blood pressure

• sympathetic nervous system activation

• fragmented sleep architecture

Dr. Collop also explained that women lose some of their normal protective mechanisms during REM sleep, making the airway more likely to collapse.

And the consequences are not just about feeling tired.

REM-related sleep apnea has been associated with:

• hypertension

• cardiovascular disease

• loss of normal nighttime blood pressure “dipping”

• increased stroke risk

In other words, these breathing events may be happening during the exact stage of sleep where the cardiovascular system becomes especially vulnerable.

Menopause changes the equation

One of the clearest trends in sleep medicine is what happens after menopause.

Before menopause, sleep apnea is somewhat more common in men. After menopause, the prevalence in women rises dramatically.

Dr. Collop described menopause as a major “triggering factor” for the development of sleep apnea in women.

As estrogen and progesterone levels decline, airway stability changes. Muscle tone decreases. Sleep itself often becomes more fragmented. Weight changes can also contribute.

The result is that many women suddenly begin developing sleep apnea symptoms in their 40s and 50s without realizing what is happening.

And because those symptoms overlap heavily with menopause itself, sleep apnea often gets overlooked entirely.

Sleep apnea in women is not just about snoring

One of the things I appreciated most about this conversation was Dr. Collop’s emphasis that women do not always fit the stereotype.

Some women snore loudly. Some do not.

Some women are overweight. Others are not.

Some are profoundly sleepy. Others mainly feel exhausted, anxious, or chronically unrested.

That is why relying solely on stereotypes causes people to slip through the cracks.

As Dr. Collop put it, “sleep apnea should always be on the differential.”

What should women actually look out for?

If your sleep has felt “off” for a long time, it may be worth asking deeper questions.

Some major red flags include:

• waking unrefreshed despite enough time in bed

• insomnia or frequent awakenings

• morning headaches

• snoring or witnessed pauses in breathing

• waking with a racing heart

• resistant high blood pressure

• daytime fatigue that does not improve

• worsening symptoms after menopause

• diabetes, atrial fibrillation, or cardiovascular disease combined with poor sleep

One thing Dr. Collop emphasized is that many people do not realize they have sleep apnea because it happens while they are asleep.

“You don’t know you have it,” she said.

That is part of why bed partners, wearable technology, and sleep testing matter so much.

The future of sleep medicine is changing quickly

One of the most encouraging parts of the discussion was hearing how rapidly the field is evolving.

Dr. Collop spoke about the rise of wearable sleep technology, better home diagnostics, multi-night testing, new treatments for sleep apnea, and increasing public awareness around sleep health.

And honestly, I agree with her.

People are finally beginning to understand that sleep is not optional maintenance. It is foundational physiology.

You cannot separate sleep from cardiovascular health, hormonal health, metabolic health, mood, cognition, or longevity.

Sleep touches all of it.

What I want women to take away from this

If your body has been telling you something is wrong, listen to it.

If your sleep is fragmented, your energy has changed, your blood pressure is rising, your headaches are worsening, or you constantly feel exhausted despite “doing everything right,” please do not automatically assume it is just stress or aging.

And if you are a healthcare provider reading this, I would echo one of the most important points from our conversation:

If a patient takes the time to bring up their sleep, they have probably been thinking about it for a long time already.

That conversation matters.

Watch the full episode

This conversation with Dr. Nancy Collop goes much deeper into:

• sex and gender differences in sleep disorders

• REM-related sleep apnea

• cardiovascular risk in women

• menopause and sleep

• future sleep technology

• why sleep medicine still has a long way to go

🎧 Watch the full episode of Sleep Is My Waking Passion™ on YouTube:

And if you are struggling with your sleep and wondering whether something deeper may be going on, you can learn more or schedule a consultation at: askthesleepmd.com

Sweet dreams,

Dr. Alison Kole
Sleep Is My Waking Passion™

To talk about why, I sat down with one of the smartest people I know on this topic: Dr. Joyce Lee-Iannotti, professor of neurology, director of the Sleep Center, and interim director of the Petznick Stroke Center at Barrow Neurological Institute in Arizona. She also chairs the Dean’s Faculty Advisory Council at the University of Arizona College of Medicine, serves as vice chair of the sleep section of the American Academy of Neurology, chairs the Sleep Medicine Fellowship Directors Council at the American Thoracic Society, and is a director on the American Academy of Sleep Medicine Foundation Board.

Her site is also one of the participating sites in the Sleep SMART trial — the Sleep for Stroke Management And Recovery Trial — a national study looking at whether treating obstructive sleep apnea after a stroke improves recovery and prevents the next one.

If that résumé doesn’t tell you she knows her stuff, nothing will. Here is what we covered.

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What a stroke actually is — and why every second matters

When I asked Dr. Lee-Iannotti to describe a stroke for someone who has never had one in the family, she didn’t soften it.

“Stroke is a scary episode of acute neurologic symptoms,” she said.

The textbook signs she wants every reader to memorize: facial drooping, weakness on one side of the body, numbness or tingling on one side, inability to talk, difficulty swallowing, visual problems, and falling. Sometimes there are warning signs in the days or weeks before — what we call transient ischemic attacks, or TIAs — but very often there are not.

“What differentiates strokes from other neurologic disorders is it often happens in a split second,” she said. “People are blindsided and they don’t know what to do. And that’s where education really comes into play.”

Her core message, which I want you to write on your fridge: Time is brain.

If you or someone near you develops those symptoms, call 911 immediately. Within a 4.5-hour window, there are real, life-altering treatments — clot-busting medication and catheterization to physically remove a clot — that can potentially reverse the symptoms completely, with no long-term debilitating effects. Wait too long, and that window closes for good.

The two types of stroke — and why an aspirin can be the wrong move

About 85% of the strokes that show up in the emergency department are ischemic, meaning a clot has stopped blood flow inside the brain. That clot can come from the arteries inside the brain, from the carotid arteries in the neck, from the heart, or even from a clot in the legs that has traveled up through the heart. When blood flow stops, brain tissue starts dying, and acute neurologic symptoms follow. These strokes are tightly linked to diabetes, high blood pressure, and high cholesterol.

The remaining 15 to 20% are hemorrhagic strokes, where an artery actually bursts and bleeds into or around the brain. Aneurysms fall into this category as subarachnoid hemorrhages.

Here is the part most people don’t know: if you reach for an aspirin thinking you are being proactive, you may make a hemorrhagic stroke significantly worse.

“The last thing we want is for patients to delay coming to the emergency department or taking an aspirin, which can actually make things worse,” Dr. Lee-Iannotti said.

Don’t self-medicate. Get to the ER.

The numbers nobody wants to hear

The reality of stroke in 2025:

• Over 700,000 people in the U.S. have a stroke every year.

• Approximately 150,000 of them die.

• Stroke is a leading cause of death worldwide.

• It is one of the leading causes of long-term disability in the United States.

• And we are seeing strokes in younger and younger people — men, women, every ethnicity, every body type.

That last point is what really concerns Dr. Lee-Iannotti, and it brings us to one of the most interesting things she said in our entire conversation.

Why young people are having strokes — and the energy drink problem nobody is talking about

When I asked her why we are seeing strokes in people in their 20s and 30s, she didn’t just point to obesity and metabolic disease, although that is certainly part of it. She pointed to something else.

“My other theory is we see a lot of young people, even in their 20s and 30s with atrial fibrillation,” she said. “And usually when you do a deep dive, Alison, it’s related to energy drinks.”

Atrial fibrillation is a serious abnormal heart rhythm that significantly increases stroke risk. And Dr. Lee-Iannotti is seeing patients — young, otherwise healthy patients — walking in with new-onset AFib because they are drinking three or four energy drinks a day to get through full-time jobs, night school, and family obligations.

“This is an epidemic that we need to stop right away,” she told me. “I’ve never seen so many people go into atrial fibrillation, especially during an in-lab study. And when you dig really deep, it’s energy drinks. It’s not because they’ve had a heart attack before that’s caused an electrical problem with their heart rhythm. It is all related to energy drinks and too much caffeine.”

People are caffeinating themselves into cardiac arrhythmias because they are not sleeping. Which is exactly where we go next.

The link between sleep and stroke

This is the part I want you to read twice.

Obstructive sleep apnea is an independent risk factor for stroke — just like high blood pressure, just like diabetes, just like smoking.

Even without any of those other risk factors, untreated obstructive sleep apnea alone has been shown to increase the risk of stroke by up to three times.

“That is a clear association. No brainer. There’s no question about it,” Dr. Lee-Iannotti said.

And the mechanism is brutally simple. Dr. Lee-Iannotti put it about as plainly as anyone has ever put it on this podcast:

“Obstructive sleep apnea is suffocating your brain at night.”

Whether you are six, twenty, fifty, or seventy — when you lay your head on your pillow for the night, your brain is not getting enough oxygen. Your heart is not getting enough oxygen. Your major organs are running on low fuel, and your body sits in fight-or-flight mode all night long. That is why people who have sleep apnea wake up feeling like they only got two hours of sleep after eight hours in bed. That is why they have morning headaches. That is why their bed partners say things like, “you were gasping and choking for air at night, and your snoring is really awful.”

The consequences aren’t subtle. In the sleep lab, Dr. Lee-Iannotti has watched blood pressure jump from 120 to 230 in response to apneic events. She has watched heart rate spike from the 70s into the 120s. She has watched atrial fibrillation start in real time — right after a patient stopped breathing. The longest apneic event she has ever personally counted in the sleep lab was 32 seconds.

“I can’t even hold my breath when I’m awake for 32 seconds,” she said.

Now imagine that happening to your brain dozens — sometimes hundreds — of times a night, every night, for years. As she put it: “Obstructive sleep apnea is the root of all evil.”

Can treating sleep apnea actually prevent stroke?

The short answer: yes, especially after a first stroke.

Longitudinal research — most notably work coming out of Spain from Dr. Martínez-García — has followed stroke patients for five to ten years. Patients who had sleep apnea and consistently treated it with CPAP saw their risk of a second stroke stabilize. Patients who did not use their CPAP kept having strokes over that same window.

This is what we call secondary prevention in medicine — preventing the next stroke after a first one — and the data here is clear.

The picture for primary prevention — preventing a first stroke in someone with sleep apnea — is messier. Some randomized controlled trials have shown mixed results. But Dr. Lee-Iannotti walked through exactly why those trials are limited: they excluded the most severe patients, they enrolled people who were barely using their CPAP for an hour or two a night (which is essentially no treatment at all), and U.S. researchers face ethical constraints that make it nearly impossible to run a proper randomized trial on a therapy we already know works for sick patients.

“Those studies, I think, are useless,” she said. “And we need to do better studies.”

What she has seen with her own eyes is more compelling than any flawed trial. She told me about a patient with severe sleep apnea who developed atrial fibrillation right there on the monitor in the sleep lab. They titrated him onto CPAP that same night. The AFib disappeared.

“Coincidence?” she said. “I don’t think so.”

Her own story — and her father’s

This is the part of the conversation that has stayed with me, and I want you to hear it the way she told it.

After her second child, Dr. Lee-Iannotti gained weight. Her husband told her he was moving to the guestroom because her snoring had become unbearable. She was 44 years old. She took a home sleep study — and then, like any health professional in deep denial, she repeated it four more times. The numbers kept coming back worse and worse.

Her oxygen was dropping to 70% at night. She was spending over 45 minutes per night below 88% oxygen saturation.

She finally accepted what she already knew: she had obstructive sleep apnea.

It took her six weeks and thirteen masks to find what she calls her “Cinderella shoe” — a nasal mask that finally worked. She used to drink five cups of coffee a day to function. Now she barely touches coffee. And three months into consistent CPAP use, her chronic daily migraines completely disappeared.

But the part that gutted me was her father.

He had obstructive sleep apnea too. She tried to talk to him about it. She tried to talk to her mother and her siblings. The response she got, especially from her Korean family, was the response so many sleep specialists hear from the people we love most:

“Oh, Joyce, come on. You’re just not sleeping enough. You’re working too hard. You just need to sleep more.”

A pooh-poohing of it, she called it. Like it wasn’t real.

He died two years ago of cardiac complications.

“I truly believe that if I had pushed it, maybe he’d still be alive today,” she said. “I was the pushover daughter who didn’t want to pressure him to get tested or use a CPAP, because I didn’t want to be that hovering helicopter daughter.”

This is why we keep talking about this on the podcast. This is why I keep showing up to your inbox. The cost of not asking the hard questions about sleep with the people you love is too high.

The cultural piece nobody wants to address

Dr. Lee-Iannotti and I are both Korean — she is full Korean, I am half — and there is a cultural reality I cannot let this post end without naming.

Asian Americans are at higher risk for obstructive sleep apnea than our Caucasian counterparts, even though we are very unlikely to look like the “obvious” sleep apnea patient. Anatomically, we have smaller airways, flatter facial structure, and smaller jaws — a perfect setup for airway collapse during sleep. And yet we are consistently underdiagnosed because we do not fit the body type that primary care providers have been trained to flag.

I have personally seen patients who were 90 pounds soaking wet walk into my office with very significant sleep apnea — patients who almost never got tested because nobody thought to test them.

And in many Asian cultures, including Korean culture, there is still a saying: sleep is for the dead. You can sleep when you’re older and you’ve accomplished a lot.

The same gap exists in Native American, Latino, and many other communities of color. We have a lot of work to do.

What I want you to take from this conversation

Three things.

1. Know the signs of a stroke and act fast. Facial drooping. One-sided weakness or numbness. Slurred or absent speech. Sudden vision changes. Difficulty swallowing. A sudden fall. Call 911 immediately. Don’t take an aspirin. Don’t wait it out. Time is brain.

2. Take sleep apnea seriously — and get tested if you have any symptoms. Loud snoring, witnessed gasping or choking, waking unrefreshed, morning headaches, daytime fatigue, the feeling that you are still tired after eight hours in bed. Sleep apnea is an independent stroke risk factor. Treatment works. And CPAP is no longer the only tool in the toolbox — there are oral appliances, hypoglossal nerve stimulators, weight management approaches, and other options that didn’t exist twenty years ago.

3. Talk to the people you love. If someone in your family snores, gasps, or sleeps poorly, please don’t let it go. Dr. Lee-Iannotti’s regret about her father is one I never want any of you to carry.

As I said to her during our conversation: longevity isn’t just about the number of hours that you’re on the planet. It is about your quality of life.

Watch the full episode

This conversation went places I wasn’t expecting, and there are stories, science, and moments in the full episode that I couldn’t fit into a single post. If this resonated with you, please go listen.

🎧 Watch Stroke & Sleep Apnea: What You’re Missing Could Cost You Everything on YouTube:

And if you have been wondering whether your own sleep could be putting your brain health at risk, I would love to help. I see patients in New Jersey, New York, California, and Georgia, with more states coming soon. You can schedule a free ten-minute review of services to find out which visit is right for you at: https://www.askthesleepmd.com

If you found this post valuable, please share it with one person in your life who needs to hear it — especially the partner, parent, or friend you have been quietly worried about.

Sweet dreams,

Dr. Alison Kole Sleep Is My Waking Passion™

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George knows this story personally.

For years, he lived with sleep apnea. He felt isolated. He struggled with treatments that did not work for him. He even convinced himself he was fine after surgery, despite still falling asleep at the wheel.

Then came the moment he could no longer deny it.

He fell asleep while driving with his daughter and grandchild in the car.

That was the wake-up call.

“I always felt isolated.”

George said something during our conversation that I think many sleep apnea patients will recognize:

“I always felt isolated. I never realized that I was one of a billion people out there suffering with sleep apnea.”

That is one of the cruelest parts of this condition.

You can be surrounded by family, coworkers, doctors, and friends, yet still feel completely alone in your exhaustion.

You may not even realize how much sleep apnea is affecting you because it happens while you are unconscious. You wake up tired, foggy, irritable, or emotionally flat, and over time, that starts to feel normal.

But it is not normal.

And it is not harmless.

Obstructive sleep apnea can affect your memory, mood, blood pressure, heart health, driving safety, relationships, work performance, and quality of life. In severe cases, untreated sleep apnea can contribute to life-threatening outcomes.

Why

Out of Breath matters

George did not make a film full of charts and medical explanations.

He made an experience.

As he explained:

“The film is an experience. It takes you through the journey of what it’s like to be living with sleep apnea in the home, within the family, within the community.”

Four people from different backgrounds, ages, and communities documented their own sleep apnea journeys using their cell phones over a two-year period.

What they captured was something no outside camera crew could have manufactured.

The middle-of-the-night fear.
The marital strain.
The parent who cannot stay awake for her children.
The surgeries that did not work.
The caretaker who is exhausted too.
The spouse listening in the dark, afraid their loved one might die.

That is the part of sleep apnea we do not talk about enough.

It does not only affect the patient.

It affects the family.

Sleep apnea is not just snoring

Snoring can be a clue, but sleep apnea is much bigger than snoring.

It can show up as:

• chronic exhaustion

• brain fog

• falling asleep while driving

• morning headaches

• depression or anxiety symptoms

• irritability

• poor concentration

• high blood pressure

• waking up gasping

• waking up to urinate frequently

• relationship stress

• feeling like you are losing yourself

And because people often blame stress, aging, parenting, work, or “just being tired,” sleep apnea can go undiagnosed or undertreated for years.

George’s journey took decades.

He had been diagnosed, but not properly treated. CPAP felt difficult at the time. Dental appliances were more primitive years ago. Surgery did not solve it. Denial became part of the story.

That is not uncommon.

Many patients are not refusing care because they do not care about their health. They are scared, overwhelmed, uncomfortable, financially strained, or discouraged by treatments that did not work the first time.

Treatment is not one-size-fits-all

One of the most important messages from this episode is that sleep apnea treatment should not be reduced to, “Here is a mask. Good luck.”

As I said in the episode:

“I’m not here to yell at you to put your mask on, otherwise you’re a horrible human being.”

That is not sleep medicine.

The goal is not shame.

The goal is better sleep.

The goal is to make sleep restorative again, to help people wake up feeling better in the morning, and to find a treatment approach that actually works for the person in front of us.

For some patients, that may be CPAP.
For others, it may be an oral appliance.
For others, it may involve weight loss, airway evaluation, positional therapy, surgery, newer devices, or a combination of approaches.

The field is changing. Treatment options are expanding. But access, cost, insurance coverage, and provider training remain real barriers.

“Your life is a lot more valuable.”

George spoke honestly about the cost of treatment, especially oral appliance therapy.

Yes, treatment can be expensive. Yes, insurance can be frustrating. Yes, many patients are stuck navigating high-deductible plans, limited coverage, and a shortage of providers trained in sleep.

But George said something worth sitting with:

“Your life is a lot more valuable than those short term costs.”

That is not meant to dismiss the real financial burden.

It is a reminder that untreated sleep apnea has costs too.

Falling asleep at the wheel.
Losing a job.
Straining a marriage.
Missing years of presence with your children.
Living in a fog.
Putting your cardiovascular health at risk.

Those costs are harder to measure, but they are real.

Why stories change people

As physicians, we often rely on numbers.

Apnea-hypopnea index.
Oxygen levels.
CPAP compliance.
Blood pressure.
Risk ratios.

Those numbers matter.

But stories reach a different part of the brain.

A statistic can inform you.
A story can move you.

That is what Out of Breath does so well. It gives people a way to see themselves, their spouse, their parent, their friend, or their patient in the experience of sleep apnea.

George hopes the film will open conversations that would not have happened otherwise.

A daughter watching with her father.
A spouse finally understanding the fear they have been carrying.
A patient realizing, “That’s why I’m tired all the time.”
A doctor or dentist seeing the human cost of what gets missed.

That is the kind of medical education we need more of.

If this sounds familiar, please do not ignore it

If you or someone you love is constantly tired, falling asleep during the day, snoring loudly, gasping at night, waking up with headaches, struggling with memory, or feeling like life is passing by in a fog, please consider asking about sleep apnea.

You do not have to wait until something dangerous happens.

You do not have to fit the stereotype.

You do not have to be “bad enough” to deserve help.

Start with a conversation.

Ask your doctor:

“Could sleep apnea be part of what’s going on?”
“Should I have a sleep study?”
“What treatment options are available if CPAP is not the right fit for me?”
“Can you refer me to a sleep specialist?”

That one conversation could change the direction of your life.

Where to watch

Out of Breath

You can learn more about the documentary at:

sleepapneafilm.com

George also shared that PBS has expressed interest in broadcasting the film nationally, and fundraising is underway to help make that possible.

Final thought

Near the end of our conversation, I asked George what a healthy night of sleep would sound like if he could capture it the way he has captured music and dance in his other films.

His answer was beautiful.

It would sound like a gospel singer belting out a note.

Open.
Full.
Breath moving freely.

That is the hope.

Not just silence.

Not just fewer snores.

But breath. Restoration. Presence. Life.

And for many people living with untreated sleep apnea, that hope may be closer than they think.

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If you’re a parent, chances are you’ve had at least one night where you stood outside your child’s bedroom door and thought:

Why are they still awake?
Why are they tossing around so much?
Why do they snore like that?
Why are mornings so hard?

A lot of parents get reassured with some version of:
“They’ll grow out of it.”
“Some kids are just bad sleepers.”
“It’s probably nothing.”

Sometimes that is true.

But sometimes it is not.

In a recent episode of Sleep Is My Waking Passion™, I sat down with pediatric neurologist and double board-certified sleep medicine physician Sleep Doctor Chris to talk about something that deserves far more attention than it gets: sleep-disordered breathing in children, especially pediatric obstructive sleep apnea.

This matters because poor sleep in children does not always look like sleepiness. Sometimes it looks like hyperactivity. Sometimes it looks like behavioral issues. Sometimes it looks like inattention, emotional volatility, or a child who just seems to be struggling more than they should.

And sometimes the first clue is snoring.

Snoring in children is not always harmless

Let’s start here, because this is often the symptom parents notice first.

A child who snores is not automatically a child with sleep apnea. Plenty of children snore intermittently, especially when they are congested or recovering from an illness.

But habitual snoring should not be brushed off.

As Dr. Chris put it in the episode:
“Snoring. Does that mean they have a sleep disorder? No, but it starts to ask those other questions.”

That is exactly the right framework.

Snoring is not the diagnosis. It is the doorway to the conversation.

If a child snores regularly, especially when it is paired with restless sleep, mouth breathing, difficulty waking in the morning, falling asleep in the car, or unusual sleep positions, that is the point where parents should become more curious, not less.

What pediatric sleep apnea actually is

Obstructive sleep apnea happens when the upper airway becomes partially or completely blocked during sleep.

In children, the most common reason is often anatomical. Small airways plus enlarged tonsils and adenoids can create enough resistance that the child has repeated breathing disruptions overnight.

Unlike adults, children are still in the middle of rapid brain and body development. That means sleep quality is not just about feeling rested the next day. It is tied to learning, mood regulation, growth, memory consolidation, and behavior.

Dr. Chris said it well:
“Those are the formative years. Not only are you growing and you’re learning, you need that restoration for it to happen.”

That is why pediatric sleep apnea matters so much.

It is not just about snoring. It is about what fragmented sleep does to a growing child.

Why this gets missed so often

One of the most important parts of our conversation was this: children with sleep disorders do not always present the way adults do.

Adults with sleep apnea often complain of fatigue, daytime sleepiness, or waking up feeling unrefreshed.

Children can show those symptoms too, but they may also look wired instead of tired.

That is where things can get tricky.

A child with sleep apnea may seem:

• hyperactive

• inattentive

• emotionally dysregulated

• harder to wake in the morning

• prone to bedtime resistance

• unusually sleepy during passive moments, like car rides

This overlap is one reason pediatric sleep disorders can be confused with ADHD or behavioral concerns.

As Dr. Chris explained:
“There’s a lot of people where they think, ‘Oh no, my child might have ADHD,’ but then ultimately, no, just a sleep disorder like obstructive sleep apnea.”

That does not mean every child with ADHD symptoms actually has sleep apnea. It does mean that sleep should be part of the evaluation, especially when the history includes snoring, restless sleep, or unusual nighttime breathing.

What parents should actually look for

If you are wondering whether your child’s sleep deserves a closer look, here are some of the biggest red flags we discussed:

Nighttime signs

• habitual snoring

• sleeping with the mouth open

• neck extended backward while sleeping

• tossing and turning constantly

• unusual sleep positions

• pauses in breathing

• gasping, choking, or labored breathing during sleep

• frequent awakenings

Daytime signs

• hard to wake in the morning

• falling asleep easily in the car

• hyperactivity

• irritability

• trouble focusing

• behavior concerns

• school struggles

• seeming tired but not necessarily saying “I’m sleepy”

A child does not need every single one of these to warrant a conversation. Even a few of them, especially when snoring is part of the picture, can be enough to justify raising the issue with a pediatrician.

You are allowed to push if something feels off

I really appreciated Dr. Chris’ directness on this point, because parents often sense something is wrong long before anyone gives it a name.

He said:
“You are an advocate for your child.”

I want every parent reading this to hear that clearly.

If your child snores, pauses in breathing, struggles with sleep, or seems disproportionately tired or dysregulated during the day, and you feel your concern is being minimized, it is okay to keep asking questions.

It is okay to say:

• “I’m still concerned.”

• “Can we document this?”

• “Can we evaluate this further?”

• “Can we refer to sleep medicine or ENT?”

That is not overreacting. That is parenting.

What a pediatric sleep study looks like

Another reason families hesitate is fear. A sleep study can sound intimidating if you have never seen one.

Most children with suspected sleep apnea are evaluated with an in-lab sleep study, not a home study.

That means spending the night in a sleep lab, which usually looks more like a bedroom than a hospital room.

During the study, the child may have:

• belts around the chest and abdomen to track breathing effort

• sensors under the nose to measure airflow

• an oxygen monitor

• leg sensors to look for movement

• EEG leads on the scalp to determine sleep stage

It can look like a lot. But the goal is simple: to understand whether the child is breathing normally during sleep and whether their sleep architecture is being disrupted.

This is one reason Dr. Chris wrote his children’s book Sweet Dreams. He wanted children and parents to have a gentler, more familiar way to understand what a sleep study is and why it matters.

The numbers are different for kids than they are for adults

This is one of the most important medical points in the entire episode.

In adults, 5 breathing events per hour can qualify as mild obstructive sleep apnea.

In children, 1 event per hour can qualify as mild obstructive sleep apnea.

Yes, one.

That difference shocks many families, especially if an adult in the household also has sleep apnea and is used to hearing very different thresholds.

Why are pediatric criteria stricter?

Because children are more vulnerable to the developmental consequences of repeated sleep disruption and oxygen instability. They do not need as many events as adults to be significantly affected.

In children, a sleep study may also look beyond the apnea-hypopnea index and consider other factors, including carbon dioxide retention, oxygen drops, and the child’s overall symptom picture.

So if your child’s report sounds “mild,” that does not necessarily mean it is insignificant.

How pediatric sleep apnea is treated

This is where the conversation often gets more hopeful.

Children have several potential treatment options, and the right one depends on the anatomy, the severity of the sleep apnea, the symptoms, and the family’s overall situation.

1. Tonsil and adenoid removal

For many children, enlarged tonsils and adenoids are a major part of the problem. Removing them can significantly improve or even resolve the sleep apnea.

This is often the most common first-line treatment when the anatomy supports it.

2. Nasal steroid sprays

In some cases, especially when families are waiting to see ENT or when symptoms are milder, nasal steroid sprays may help reduce tissue swelling and improve airflow.

This is not the answer for every child, but it can be a useful bridge or adjunct.

3. Orthodontic approaches

We also talked about rapid maxillary expansion, which can help widen the upper jaw and create more airway space in growing children.

This is a different conversation than adult oral appliances. In the pediatric world, the goal can sometimes be to guide development while the airway is still changing.

4. CPAP therapy

CPAP is absolutely used in children when needed.

If the airway needs to be held open and surgery is not the right option, or if sleep apnea persists even after tonsils and adenoids are removed, CPAP can be effective.

It is not always easy, but children can adapt beautifully with the right support.

5. Follow-up testing

One of the most practical pearls from Dr. Chris was this: if a child gets treated, do not assume the sleep apnea is automatically gone.

Sometimes families are told, “We took the tonsils out, so it’s fixed.”

Maybe. But maybe not.

If a child had meaningful sleep apnea beforehand, it is reasonable to ask whether repeat evaluation is needed, especially if symptoms linger.

That is not being difficult. That is making sure the treatment actually worked.

Why timing matters

One of the hardest realities in pediatric sleep medicine is that diagnosis can take time.

There may be a wait for the sleep study.
Then a wait for the sleep specialist.
Then a wait for ENT.
Then a wait for treatment.

That timeline is frustrating for families, especially when the child is clearly not sleeping well.

But this is exactly why awareness matters.

The earlier parents spot the signs, the sooner that process can begin.

And that matters because we are not talking about a minor inconvenience. We are talking about sleep quality during years that shape cognition, behavior, learning, and emotional regulation.

Bedtime starts before bedtime

I also want to include one of the most practical parenting reminders from the episode, because it is useful whether or not your child has a diagnosed sleep disorder.

Dr. Chris said:
“Bedtime doesn’t start at bedtime. Bedtime starts one to two hours before.”

That is true.

The transition into sleep begins well before lights out. Children often do better with a predictable wind-down period that lowers stimulation and helps the nervous system shift toward sleep.

That might include:

• dimmer lighting

• less screen exposure

• a consistent routine

• quieter activities

• predictable timing

• emotional calm instead of chaos

A strong bedtime routine will not cure obstructive sleep apnea. But it can absolutely improve sleep quality, reduce bedtime resistance, and make it easier to notice what is behavioral versus what may be physiological.

The bigger takeaway

If your child snores, do not panic.

But do pay attention.

Watch how they sleep.
Watch how they wake.
Watch how they function during the day.

And if your gut says something is off, trust that instinct enough to ask more questions.

The truth is, many children with sleep disorders do not look obviously sick. They just look like kids who are struggling. That is why these conversations matter so much.

Sleep problems in children are common.
They are treatable.
And they are worth taking seriously.

Because sometimes better sleep does not just improve the night.

It changes the whole child.

Want to learn more?

If you are interested in more sleep topics that affect children, adults, and families, check out my podcast Sleep Is My Waking Passion™, where I talk with experts about the science of sleep in a way that is practical, compassionate, and useful in real life.

And if this article helped you think differently about your child’s sleep, consider subscribing to Diary of a Sleep Doctor for more evidence-based writing on sleep, health, and the human side of medicine.

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April is World Autism Acceptance Month, and it’s a good time to talk about something that affects millions of families, but rarely gets enough attention.

Sleep.

When most people think about autism, they think about communication differences, sensory sensitivities, or repetitive behaviors.

What they don’t often think about is what happens at night.

But for many families raising children on the autism spectrum, nighttime can be one of the hardest parts of the day.

Children who can’t fall asleep.
Children who wake repeatedly in the night.
Parents who are exhausted before the next day even begins.

Sleep struggles in autism are incredibly common—and when they happen, they affect the entire household.

That’s why I wanted to revisit one of the most important conversations I’ve had on Sleep Is My Waking Passion™: my discussion with Dr. Beth Ann Malow, a leading expert on autism and sleep.

Dr. Malow is Professor of Neurology and Pediatrics at Vanderbilt University, Director of the Vanderbilt Sleep Division, and one of the most respected researchers studying sleep in autism.

She is also the mother of two sons on the autism spectrum.

That perspective matters.

Because when she talks about sleep in autism, she understands both the science and the lived experience.

And both are essential.

Autism Is a Spectrum—And Every Experience Is Different

One of the most important things Dr. Malow emphasized is that autism is exactly what the name suggests: a spectrum.

People on the autism spectrum experience the world in many different ways.

Some individuals have limited spoken language.
Others communicate fluently but struggle with subtle social cues.

Some develop intense interests in specific topics.
Others experience sensory sensitivities or behavioral patterns that help them regulate their environment.

Autism has traditionally been referred to as autism spectrum disorder, but many people prefer the term simply autism spectrum condition or neurodivergence.

Why?

Because autism is not simply a deficit.

For many individuals, it is also a different way of experiencing and interacting with the world.

At the same time, some individuals do experience significant challenges that require support.

The goal isn’t to label people.

The goal is to help individuals reach their potential while supporting the areas that create difficulty.

Autism Is Being Diagnosed More Often

Another striking statistic Dr. Malow shared is how dramatically autism prevalence has changed over time.

According to the CDC, 1 in 36 children in the United States is now identified as being on the autism spectrum.

When Dr. Malow’s son was diagnosed in the early 2000s, the estimate was closer to:

1 in 198 children.

Why the increase?

Experts believe the change reflects a combination of factors:

• Greater awareness
• Improved screening and diagnosis
• A broader definition of the spectrum
• Possible environmental or genetic influences

In many ways, increased recognition is positive.

Earlier identification allows children and families to access support sooner—which can significantly improve long-term outcomes.

Sleep Problems Are Extremely Common in Autism

One of the most consistent findings in research is that sleep problems occur much more frequently in individuals with autism.

Studies suggest that 50–80% of children on the spectrum experience sleep difficulties.

The most common issues include:

• Difficulty falling asleep
• Difficulty staying asleep
• Frequent night wakings

In other words: insomnia.

But insomnia in autism is rarely caused by a single factor.

Instead, sleep disruption often comes from a combination of biological, behavioral, and environmental influences.

Possible contributors include:

• Anxiety or an overactive mind
• Differences in circadian rhythm
• Sensory sensitivities
• Medical conditions like seizures or gastrointestinal discomfort
• Medication side effects
• Screen exposure before bedtime
• Difficulty transitioning from daytime activities to sleep

For many families, sleep challenges develop slowly and then become deeply entrenched.

And when sleep breaks down, everything else becomes harder.

Nighttime Behaviors Can Be Confusing

Sleep disruption in autism isn’t limited to insomnia.

Some children also experience parasomnias, which are unusual behaviors during sleep.

These can include:

• Sleepwalking
• Nightmares
• Sleep terrors
• Talking or movement during sleep

Sometimes it can be difficult to distinguish these behaviors from anxiety, night wakings, or even seizures.

Children with autism can also experience other sleep disorders seen in the general population, including:

• Sleep apnea
• Restless legs syndrome

Even when these conditions aren’t unique to autism, identifying and treating them can make a dramatic difference in daytime functioning.

Better sleep can improve:

• concentration
• emotional regulation
• school performance
• family wellbeing

When a Child Doesn’t Sleep, the Whole Family Feels It

One of the most powerful insights Dr. Malow shared had nothing to do with a laboratory or research paper.

It came from being a parent.

When a child wakes repeatedly at night, the parents lose sleep too.

And sleep deprivation affects everything.

Parents become exhausted.
Stress levels rise.
Patience becomes harder to maintain.

And children are remarkably sensitive to parental stress.

Dr. Malow described the moment she realized something profound:

On the days when she was most stressed and sleep deprived, her children often struggled more too.

Not because she was doing something wrong.

But because stress within a household is contagious.

Helping parents sleep better is not selfish.

It often helps children feel calmer and more supported as well.

Melatonin Can Help—But Quality Matters

Melatonin frequently comes up in conversations about autism and sleep.

Research suggests that melatonin supplements can help some children with autism:

• fall asleep faster
• reduce nighttime awakenings
• regulate circadian rhythms

Scientists are still studying why melatonin appears especially helpful in autism.

Some research suggests that certain individuals on the spectrum may have differences in melatonin production or regulation.

But Dr. Malow emphasized an important caution:

Not all melatonin supplements are created equal.

Because melatonin is sold as a dietary supplement rather than a prescription medication, the amount in the bottle does not always match what the label claims.

Some products have even been found to contain additional substances.

One practical tip she recommends is looking for USP verification, which indicates that a supplement has undergone independent quality testing.

When it comes to dosing, her approach is simple:

Start low.

Often around 1 mg, increasing gradually if needed.

More is not always better.

Behavioral Strategies Are Still the Foundation of Good Sleep

Even when melatonin is helpful, behavioral approaches remain essential.

Some of the most effective strategies include:

Adjust bedtime timing

Sometimes children simply aren’t tired yet. A slightly later bedtime can help build enough sleep pressure to make falling asleep easier.

Reduce screens before bed

Light and stimulation from phones, tablets, and video games can interfere with natural sleep signals.

Create a calming bedtime routine

Bathing, reading, music, or quiet play can help the brain transition from daytime activity into nighttime rest.

Encourage daytime movement

Exercise during the day helps promote healthy sleep.

Limit caffeine

Even drinks like iced tea, soda, or chocolate can disrupt sleep.

None of these strategies are dramatic.

But they are powerful.

And they apply to many adults as well.

Acceptance and Support Belong Together

World Autism Acceptance Month is an important reminder that neurodiversity should be understood and respected.

But acceptance doesn’t mean ignoring challenges that can be improved.

Sleep is one of the most powerful ways we can support individuals on the autism spectrum and their families.

Better sleep can improve learning, behavior, emotional regulation, and family wellbeing.

Sometimes it can transform an entire household.

That’s why conversations like the one I had with Dr. Beth Ann Malow matter so much.

They remind us that compassion, science, and practical tools can work together.

And when they do, families benefit.

If you’d like to hear the full conversation with Dr. Beth Ann Malow, you can find it on the podcast:

And if you’re interested in more reflections on sleep medicine, patient care, and the science of better rest, consider subscribing here on Substack to Diary of a Sleep Doctor.

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Have you ever wondered what it is actually like to sleep in space?

In our heads, astronauts zip into sleeping bags, float in zero gravity, and drift off to the hum of the spacecraft—like a high-budget weighted blanket commercial.

In reality, they face cramped cabins, constant noise, 16 daily sunrises, a packed timeline, and average just six hours of sleep per night, often for months.

As a sleep doc, I look at that and see what it really is: a fatigue management problem in the most unforgiving workplace humans have ever built.

This first piece in the series is Space Sleep 101: how astronauts actually sleep in orbit, what the data say, and why NASA now considers sleep and circadian disruption a mission-critical risk—not a lifestyle issue.

The strangest bedroom you can imagine

Start with the environment.

On the International Space Station (ISS), the crew orbits Earth roughly every 90 minutes. That means about 16 sunrises and 16 sunsets every 24 hours. Your brain, however, is expecting one.

So astronauts live in a world where:

• The “outside” light cycle is changing constantly.

• The “inside” light is whatever the program decides—overhead fixtures, laptops, tablets, windows.

• There’s always some noise: fans, pumps, equipment, clicking, beeping. Silence doesn’t really exist in a sealed metal can.

They don’t flop into a bed. They slide into a sleeping bag tethered to the wall, ceiling, or a small personal crew quarter. There is no “lying down” in microgravity; your body has no idea what “in bed” means anymore, which matters more than we think because posture and pressure changes are quiet signals to the brain about state (wake vs rest).

Astronauts do all the things we tell our patients to do:

• Eye masks, earplugs.

• Darkening the small sleeping cubby.

• Consistent pre-sleep routine when possible.

And yet, even with pretty decent sleep hygiene, they are routinely and measurably sleep deprived. That tells you how powerful the operational and circadian pressures are.

The numbers: astronauts are tired before they leave the ground

NASA has actually studied this in detail. Not with vibes, but with actigraphy—wristworn devices that estimate sleep and wake based on movement—and sleep logs spanning thousands of nights.

Here’s the short version of one of the largest data sets we have:

• In the three months before launch, during intensive training and travel, astronauts averaged a little over 6 hours of sleep per night.

• In the 11 days leading up to launch, as stress and workload ramped up, their sleep dropped to around 6 hours or less.

• During Shuttle and ISS missions, they continued to average about 6 hours a night.

• Only after returning to Earth did their sleep rebound closer to 7 hours.

So they’re not going into space “topped off.” They’re launching with sleep debt already on board.

When you zoom in on thresholds, it gets even more stark:

• On nearly half the nights in Shuttle missions, and more than 40% of nights on ISS, astronauts slept for less than 6 hours.

• Before some of the most critical, high-risk tasks—spacewalks (EVAs)—more than half of the nights still had less than 6 hours of sleep. Only a small fraction hit 8 hours.

If this were an ICU schedule, we’d call it brutal. In orbit, we’ve historically called it “normal.”

“But don’t their circadian rhythms just…break?”

Not exactly.

The master clock in the brain—the suprachiasmatic nucleus (SCN)—doesn’t suddenly forget how to keep time in microgravity. It still runs at roughly 24 hours.

What changes is the alignment and the strength of that rhythm.

Think of the circadian system as an orchestra that wants a predictable conductor (light–dark cycle, regular sleep/wake schedule, consistent meals and activity). In space, the conductor is drunk and occasionally leaves the stage.

Some of the things that scramble the signal:

• Light timing: The station barrels through sunrise and sunset 16 times a day. If an astronaut is working near a window or staring at a bright screen at “night,” the circadian system gets mixed messages.

• Shifted schedules: Dockings (when vehicles connect), undockings (when they separate), visiting vehicles, EVAs (spacewalks)—these often demand “slam shifts,” where sleep and wake times are abruptly moved by several hours.

• Workload and stress: High cognitive load, time pressure, and stress hormones are not particularly friendly to either sleep onset or circadian stability.

• Microgravity and activity patterns: You don’t have the usual posture, gravitational loading, and movement cues that help the brain distinguish “day” from “night.”

The result: the rhythms in core body temperature, hormones like cortisol, and subjective sleepiness can become blunted and shifted. Sleep shows up at odd phases, is more fragmented, and is often shorter than the schedule would theoretically allow.

Importantly, it’s not that “space makes sleep impossible.” It’s that we are pushing human physiology to operate near its limits, chronically, and the circadian system is constantly playing catch-up.

So how do they sleep up there?

Despite the chaos, there is a plan. Crews follow a mission timeline tied to a 24-hour “day” referenced to a ground time standard (e.g., Greenwich Mean Time on ISS).

A typical day includes:

• Scheduled wake time.

• Blocks for work, exercise, meals, and experiments.

• A defined sleep period—on paper, often 8.5 hours of “protected” sleep.

The key phrase is “on paper.” Just because you block 8.5 hours doesn’t mean anyone gets 8.5 hours:

• They may need that time to wind down from high-stress tasks.

• They may be awakened by equipment, alarms, or other crew activity.

• Presleep routines and basic hygiene still have to fit in there.

Actigraphy makes it clear that a scheduled opportunity does not equal actual sleep. Astronauts often use a substantial chunk of their “protected” period trying to fall asleep or waking up intermittently.

Sleep stations help—especially on ISS, where crew now have individual small cabins that cut noise and light exposure—but they don’t fully overcome the combination of circadian misalignment, workload, and a racing brain.

The hidden risk: we’ve normalized six hours

If you’ve ever worked in medicine, aviation, or emergency services, six hours of sleep probably sounds…aspirational.

That’s exactly the problem.

We normalize chronic partial sleep restriction and then ask people to do high-stakes cognitive and technical work as if the brain is magically immune.

Decades of data say otherwise:

• Reaction time slows.

• Attention lapses become more frequent and longer.

• Decision-making gets more impulsive and error-prone.

• Insight into your own impairment declines—you feel “okay” while performing measurably worse.

In most jobs, this leads to minor mistakes and irritability. In orbit, there is no “minor” mistake if it involves breaking the station, the vehicle, or the crew.

NASA’s own language has caught up to this reality. Sleep loss and circadian disruption are now categorized as a major human-system risk—on par with other medical and engineering hazards that can threaten mission success.

That’s a huge conceptual shift: sleep is no longer a wellness perk for astronauts; it’s an operational parameter you have to manage.

Why I care (and why you should too)

From a sleep medicine lens, space is the ultimate extreme case study in shift work and circadian stress:

• The environment is maximally disruptive.

• The workload is high-stakes.

• The participants are highly selected, highly trained, and incredibly motivated.

If they can’t “tough it out” without measurable performance costs, what makes us think our residents, nurses, pilots, or first responders can?

We tend to dismiss our own chronic sleep loss because the consequences aren’t as visually dramatic as a spacecraft malfunction. But the brain doesn’t know the difference between a control panel in orbit and a ventilator in an ICU. It only knows how much sleep it has had and where the circadian clock is set.

The good news is that NASA has started treating sleep as something to be engineered and protected, not squeezed. They’re redesigning schedules, using smarter lighting, and trying to reduce the reliance on hypnotics as a band-aid.

In Part 2, we’ll go deeper into that: the “pillo talk” in orbit (yes, astronauts take a lot of sleeping pills), what we’ve learned about light and circadian misalignment in space, and how those strategies are evolving.

For now, the takeaway is this:

Space didn’t change the rules of human physiology. It just made it impossible to ignore them.

And if six hours a night isn’t enough for a person flying a spacecraft at 17,500 mph, it’s probably not enough for the rest of us either.

Interested in more sleep topics like this?

If you enjoy exploring the science, stories, and real-world implications of sleep, check out my podcast Sleep Is My Waking Passion™.

On the show, I sit down with researchers, clinicians, and experts across medicine, science, and human performance to unpack the many ways sleep shapes our health, our decisions, and our lives.

You can listen here or wherever you get your podcasts.

If you’ve ever been told your CPAP data looks great, but you still feel awful, this is for you.

One of the most humbling parts of practicing sleep medicine is sitting across from a patient who has done everything “right.” They got diagnosed. They started treatment. They use the machine. Their numbers look better. Their breathing events are down.

And yet they look at you and say, “I still feel terrible.”

That moment matters.

Because if we stop at the download report, we can miss the most important part of the story: how the patient actually feels.

That is exactly why I wanted to sit down with Dr. Fariha Abbasi-Feinberg for this episode of Sleep Is My Waking Passion™. She is a powerhouse in sleep medicine, a nationally respected leader within the American Academy of Sleep Medicine, and someone who has been deeply involved in creating something our field has needed for a very long time: a better way to ask better questions after a patient starts treatment for obstructive sleep apnea.

The tool is called PLATO, short for the Patient-Reported Longitudinal Assessment Tool for OSA.

And while that name may sound a little academic, the idea behind it is actually very simple.

We need to stop acting like sleep apnea treatment success is only about whether the machine is being used.

We need to start asking whether the person is actually getting better.

The problem with “your numbers look fine”

In sleep medicine, we love data. I do too.

I love showing patients how often they stopped breathing on their original sleep study compared to what their treatment is doing now. I love pulling up the numbers and showing concrete progress. Patients often love that too. It helps them see that something real is happening.

But numbers can only take us so far.

A patient can have beautiful CPAP compliance, a dramatically improved apnea-hypopnea index, and still feel exhausted, irritable, foggy, headachy, or just plain unwell.

And if our follow-up conversation begins and ends with, “Looks great, see you next year,” we have failed them.

That is one of the most important ideas Dr. Abbasi-Feinberg raised in our conversation. We have to focus in on what the patient feels. We have to narrow down what “I feel terrible” actually means.

Is the patient still sleepy?

Are they tired but not sleepy?

Are they waking up with headaches?

Are they still snoring?

Are they sleeping through the night, or are they waking up repeatedly?

Do they feel that their sleep quality is still poor, even if the breathing events are technically better?

Those distinctions matter. They shape what we do next.

Why the Epworth Sleepiness Scale is not enough

If you’ve ever been evaluated for sleep apnea, there’s a good chance you’ve seen the Epworth Sleepiness Scale.

It is one of the most commonly used questionnaires in sleep medicine. It asks how likely you are to doze off in different situations, like reading, watching TV, or sitting quietly after lunch.

It has value. I use it. Most sleep specialists do.

But here is the problem: it mainly measures one thing. Sleepiness.

And sleep apnea is not always that simple.

Some patients, especially women, do not come in saying, “I fall asleep everywhere.”

Instead, they say things like:

“I’m exhausted all the time.”

“I wake up feeling terrible.”

“I’m irritable.”

“I have headaches.”

“I don’t feel like myself.”

“I’m functioning, but I feel awful.”

That is a very different clinical picture.

A patient can score low on the Epworth and still be struggling significantly. That is one of the reasons PLATO is so important. It expands the conversation beyond whether someone is likely to nod off during the day.

It asks broader, more meaningful questions about how life actually feels.

So what is PLATO?

PLATO is an 11-question patient-reported tool designed to help sleep clinicians better understand how patients with obstructive sleep apnea are doing over time.

Not just whether they are using treatment.

Not just whether the machine download looks pretty.

But whether symptoms are improving in a way that matters to the person living with the condition.

The questions were built around what patients themselves reported as important. That part matters to me deeply.

This was not a bunch of people in a room making assumptions about what patients should care about.

This work began by listening.

According to Dr. Abbasi-Feinberg, the process involved talking to people with sleep apnea, understanding their complaints and improvements, and then carefully refining the tool over several years until it became something practical enough to use in real-world clinics.

The final result is brief, readable, and clinically useful.

It looks at symptoms across several areas, including:

• daytime sleepiness

• fatigue and exhaustion

• irritability

• morning headaches

• nighttime sleep disruption

• snoring

• overall sleep quality

It sounds simple, but do not underestimate what that kind of structured listening can do.

Sometimes the right question opens the right door.

Why this matters so much now

The truth is, sleep medicine is changing.

For years, the public perception of sleep apnea treatment has been incredibly narrow. Most people hear “sleep apnea” and think one thing: a mask.

And yes, positive airway pressure therapy remains a highly effective treatment for many patients. It can be life-changing.

But it is not the only treatment.

And more importantly, it is not enough to just hand someone a machine, tweak the mask, and hope for the best.

That old model is part of why some patients avoid getting evaluated in the first place. They assume the whole process leads to one option and one option only.

But today we have more tools, more treatment pathways, and hopefully, more opportunity to personalize care.

That includes:

• CPAP and other PAP therapies

• oral appliance therapy

• implantable options

• behavioral strategies

• better phenotyping of patients

• and, in the near future, likely medication-based options for some forms of sleep-disordered breathing

To choose the right next step, we need better conversations.

That is where PLATO comes in.

Better sleep care is not just good for patients. It is good for the healthcare system.

One of the most striking points Dr. Abbasi-Feinberg made is that sleep health is not just an individual issue. It is a population health issue.

When sleep disorders are properly treated, people use fewer medications. They have fewer ER visits. They have fewer hospitalizations.

That means better quality of life for patients and better outcomes for healthcare systems.

I have said it before and I will keep saying it: sleep health is population health.

This is one reason I think tools like PLATO matter beyond sleep clinics. They help us move toward a future where we can show not just that a treatment reduced breathing events, but that it improved meaningful outcomes.

That kind of data is powerful.

It matters to patients. It matters to clinicians. And yes, it matters to the people making coverage decisions too.

The future of sleep medicine is personal

One of my favorite parts of the conversation was talking about where sleep medicine may be headed next.

I truly believe the future of this field is personalization.

Right now, we still do a lot of educated guessing. We know many things about our patients. We look at anatomy, symptom patterns, severity, sleep study findings, comorbid conditions, and tolerance for different therapies.

But I would love for us to get to a place where we can say with much more certainty:

“Based on your biology, your symptoms, and your specific data, these are the treatment options most likely to help you.”

We are not fully there yet, but I think we are moving in that direction.

That is exciting.

Because the future should not be one-size-fits-all sleep medicine.

The future should be smarter, more human, more precise care.

The real question is not “Are you compliant?”

The real question is: Are you better?

That is what I hope both patients and clinicians take away from this conversation.

If you are a patient with sleep apnea and you are using treatment but still do not feel well, please know this:

You are not imagining it.

You are not being difficult.

And you are not asking for too much by wanting your doctor to go deeper.

If you are a clinician, I think this is our reminder to resist the urge to let the machine report become the whole visit.

The machine gives us data.

The patient gives us meaning.

We need both.

Final thoughts

What Dr. Abbasi-Feinberg and her colleagues have built is more than a questionnaire.

It is a signal.

A signal that sleep medicine is continuing to grow up. A signal that outcomes matter. A signal that listening better may actually be one of the most evidence-based things we can do.

Because sometimes the missing data is not hidden in the machine.

Sometimes it is sitting right in front of us, waiting to be asked the right question.

If that resonates with you, I hope you’ll subscribe.

This Substack is where I keep exploring the space where sleep science, real life, and honest clinical conversations meet. And if you know someone who has ever said, “My CPAP says I’m fine, but I still feel awful,” send this to them.

They may need better questions too.

Listen to the full episode:

“Better Questions, Better Sleep: Why Smarter OSA Conversations Could Be the Data We’re Missing” featuring Dr. Fariha Abbasi-Feinberg

In the video I was texted that night, you can literally hear the moment “loud snoring” turns into choking, gasping, and long, terrifying pauses that only a sleep specialist would instantly recognize as an impending medical emergency.

If you—or someone you love—use kratom or other “natural” sleep aids, watch this clip to learn what’s really happening. Subscribe to access the full story and video breakdown. By subscribing, you’ll help: 50% of every subscription will be donated to The Herren Project in Xavier’s honor to support families and individuals affected by substance use disorder.

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Twice a year, most of us go through the same ritual.

We change the clocks.

We complain about being tired.

Then we move on.

But what if the way we currently handle Daylight Saving Time is doing more than disrupting our routines? What if it is quietly affecting our health?

Sleep scientists have been talking about this for years. Yet the policy conversation happening right now may be heading in the wrong direction.

In this flashback of Season 1 Episode 4 of Sleep Is My Waking Passion, I sat down with sleep physician Dr. Karin Johnson to talk about the science behind Daylight Saving Time and why many sleep experts believe it is time to stop changing the clock.

Just not in the way most people expect.

Why This Conversation Is Happening Now

You may have heard about the Sunshine Protection Act, which proposes ending the twice-yearly clock changes.

At first glance, the idea sounds great. Most Americans say they are tired of adjusting the clocks every spring and fall. The shift disrupts sleep, throws off routines, and leaves people feeling foggy for days.

But here is the detail that rarely gets discussed.

The proposal would make Daylight Saving Time permanent.

Many sleep scientists believe that is the wrong approach. Instead, the healthier option would be permanent standard time.

That distinction might sound minor. In reality, it matters quite a bit for how our biology works.

What Happens Right After the Clock Change

Most people notice something feels off after the spring shift.

That lost hour of sleep has real consequences. Studies show that in the days following the change to Daylight Saving Time, there are increases in car accidents, workplace injuries, heart attacks, strokes, and episodes of depression.

Part of the problem is sleep deprivation. Losing an hour matters. But there is another issue happening at the same time. Our internal clocks suddenly become misaligned with the environment.

The body relies on precise timing to regulate sleep, hormones, metabolism, and mood. When that timing is abruptly shifted, the effects ripple through the system.

Those short-term consequences are only part of the story.

The Longer-Term Effects Most People Miss

What many people do not realize is that Daylight Saving Time can influence sleep throughout the entire season, not just during the transition.

When the clocks move forward, sunrise and sunset both occur an hour later. That change feels pleasant in the evening, but biologically it creates a challenge.

Morning light is one of the strongest signals that resets our internal clock. When sunrise happens later, that signal becomes weaker.

People tend to fall asleep later, but they still need to wake up at the same time for work or school. Over time this leads to a gradual loss of sleep.

Research suggests that when sunrise and sunset are delayed by an hour, people lose an average of about nineteen minutes of sleep per night. For those with early schedules, the loss can approach thirty minutes.

Those minutes accumulate over weeks and months.

Why Our Bodies Follow the Sun

In sleep medicine we often talk about circadian rhythm, the internal timing system that regulates the sleep-wake cycle.

Inside the brain is a structure that functions as a master clock. It coordinates many biological processes including sleep, hormone release, body temperature, and metabolism.

The most powerful signal that resets this clock each day is light.

When light enters the eyes in the morning, it sends a signal to the brain that suppresses melatonin and promotes alertness. This process helps align our internal clock with the outside world.

Morning light plays a crucial role in maintaining healthy sleep patterns.

When the clock is shifted later, that morning signal arrives later as well. Our bodies may still be operating according to solar time even though our social schedules have changed.

This mismatch can affect sleep quality, mood, cognitive performance, and cardiovascular health.

A Lesson From History

This debate is not new. The United States has already experimented with permanent Daylight Saving Time.

It happened once during World War II and again during the energy crisis of the 1970s.

Both experiments were eventually abandoned.

The main problem was winter mornings. In some regions sunrise did not occur until after nine in the morning. Children were waiting for school buses in darkness, and many adults were commuting before daylight.

Public support faded quickly.

Who Feels the Impact Most

Circadian disruption affects everyone, but certain groups experience stronger effects.

Teenagers are a good example. During adolescence, the body’s internal clock naturally shifts later. Teenagers tend to fall asleep later and prefer waking later.

Daylight Saving Time pushes their schedule even further away from early school start times. The result can be chronic sleep deprivation, worse academic performance, and higher rates of mood problems.

Lower-income families may also be affected more strongly. Fixed early work schedules and long commutes can limit flexibility in sleep timing. When sunrise occurs later, opportunities for adequate rest shrink.

The Appeal of Long Summer Evenings

Many people say they prefer Daylight Saving Time because they enjoy longer evenings.

It is an understandable preference, but it is important to remember that the clock change does not actually create more daylight.

The length of the day is determined by the Earth’s orbit and tilt. Summer days will grow longer as we approach June regardless of what time the clock says.

Daylight Saving Time simply shifts the label attached to those hours.

Weather and temperature often play a bigger role in how much time people spend outdoors. Warm evenings encourage activity whether or not the clock has been adjusted.

Places like Arizona and Hawaii do not observe Daylight Saving Time at all, and people there still enjoy long summer days.

Why the Issue Often Gets Overlooked

Sleep tends to be undervalued in public policy discussions.

During a recent television segment about Daylight Saving Time, one commentator asked whether people really cared about the issue.

At first glance it might seem trivial. But sleep influences nearly every system in the body. Even small changes in sleep duration or circadian alignment can affect safety, mental health, and chronic disease risk.

The science suggests that timing matters more than many people realize.

A Simpler Approach

If the goal is to eliminate clock changes, the research points toward a clear solution.

Permanent standard time aligns more closely with human circadian biology. It provides earlier morning light and better synchronization between our internal clocks and our daily schedules.

Many countries already operate on permanent standard time.

The concept is not radical. It simply recognizes how closely our physiology is tied to natural light.

A Final Thought

Decisions about time policy may sound abstract, but they influence something very real: how well we sleep and how well our bodies function.

Our schedules may run on digital clocks and calendar alerts.

Our biology still runs on sunlight.

And in the end, the sun remains the most powerful clock we have.

Not fainting.

Not falling asleep.

But suddenly losing control of your muscles while remaining fully awake and aware of everything happening around you.

That is the reality for some people living with Narcolepsy Type 1 with cataplexy, a neurological sleep disorder where strong emotions can trigger sudden loss of muscle control.

In the newest episode of Sleep Is My Waking Passion™, I spoke with patient advocate, writer, and artist Solomon Briggs about what this experience actually feels like.

Solomon described the moment laughter began to change for him:

“I was internally laughing really hard, but my facial muscle control would melt.”

Within weeks, the episodes escalated.

“I would go down to the ground for 30 seconds, be fully paralyzed… fully conscious. I can hear, I can see.”

Cataplexy is one of the most misunderstood symptoms in sleep medicine.

And hearing directly from people who live with it every day helps us understand something that textbooks alone cannot explain.

Want more conversations like this?

If you care about sleep health, patient stories, and the science behind sleep disorders, consider subscribing.

This newsletter shares new essays and episodes from Sleep Is My Waking Passion™, exploring the real experiences behind sleep medicine.

Watch the full episode

What Is Cataplexy?

Cataplexy occurs in people with Narcolepsy Type 1, a central disorder of hypersomnia caused by loss of neurons that produce orexin, a neurochemical responsible for stabilizing wakefulness and regulating REM sleep.

Without orexin, the boundary between sleep and wakefulness becomes unstable.

REM sleep features — including muscle paralysis — can intrude into waking life.

During cataplexy, the body temporarily enters a state similar to REM sleep muscle paralysis.

But unlike sleep, the person remains fully conscious and aware.

As Solomon explained:

“My whole body would go down… but I could hear everything happening around me.”

Episodes can range from subtle facial weakness to complete collapse.

At its worst, Solomon experienced these episodes 5 to 20 times per week.

The Early Signs Began in Childhood

Looking back, Solomon now recognizes that the symptoms began much earlier.

As a child, he noticed strange moments during playful interactions.

Tickling games with friends or family would suddenly leave him unable to keep his arms raised.

“I could laugh… I could try to tickle back… but my arms would just barely move.”

At the time, there was no language for what was happening.

Like many people with narcolepsy, he lived with symptoms for years without understanding their cause.

The Long Road to Diagnosis

It wasn’t until age 28 that Solomon encountered the term cataplexy.

He found it through a Google search:

“laughter and paralysis.”

The description immediately resonated.

“I was like, wow… that fits like a glove.”

But the diagnosis process was complex.

Sleep specialists rely on several diagnostic tools, including overnight sleep studies and the Multiple Sleep Latency Test (MSLT).

Solomon’s case was further complicated by other sleep disorders, including idiopathic central sleep apnea and delayed sleep phase disorder.

Eventually, specialists at Mayo Clinic diagnosed him with probable Narcolepsy Type 1 with definitive cataplexy.

The Hidden Cost of Cataplexy

When cataplexy is severe, it can reshape everyday life.

Solomon described how emotional triggers — especially laughter or joy — forced him to rethink social interactions.

“It robbed my ability to experience joy and pleasure.”

At one point, he tried suppressing emotion altogether.

“There was a phase where I was being very non-emotive… trying to block humor and block laughter.”

But suppressing emotion did not prevent cataplexy.

Instead, it created new psychological challenges.

Learning to Live With Narcolepsy

Over time, Solomon began making major lifestyle adjustments.

Many medications caused unwanted side effects for him, so he focused on understanding his triggers and setting boundaries.

For some people, cataplexy is triggered by stress or frustration.

For Solomon, the triggers were often positive emotions:

• laughter

• compliments

• moments of connection

“Being smiled at… being complimented… telling a joke.”

Recognizing these triggers helped him navigate daily life.

Why Cataplexy Is Often Misunderstood

Cataplexy is frequently described simply as “muscle weakness.”

But that phrase may not fully capture the experience.

As Solomon explained:

“Cataplexy is a physiological neurologic event where you have a physical reaction.”

Language matters.

How we describe symptoms shapes how patients understand their experiences — and whether clinicians recognize the condition.

Creativity as Advocacy

Today, Solomon channels his experiences into creative advocacy.

He writes, creates photography, and is developing a graphic narrative project titled Leo’s Daily Normal, which follows a teenager learning to live with a sleep disorder.

Creative storytelling helps communicate something clinical descriptions often miss: the lived experience of neurological sleep disorders.

Bridging Science and Human Experience

Sleep medicine has made significant advances, particularly with the discovery of orexin deficiency and the development of emerging treatments.

But Solomon believes something essential must remain central:

“There hasn’t always been enough focus on the human experience.”

Improving sleep medicine requires collaboration between clinicians, researchers, and patient advocates.

And it requires listening.

Key Takeaways

• Cataplexy is a sudden loss of muscle tone triggered by emotion.

• People remain fully conscious during episodes.

• Narcolepsy Type 1 is linked to orexin deficiency in the brain.

• Many patients live with symptoms for years before diagnosis.

• Patient experiences provide critical insight into sleep disorders.

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Sleep disorders affect millions of people, yet many go years without answers.

Through Sleep Is My Waking Passion™, we aim to bring together science, patient experience, and practical insight into the world of sleep health.

But there’s one risk factor that rarely makes the front page.

Sleep.

Your heart does not go off duty when you go to bed. In fact, for many people, nighttime is when the greatest strain occurs.

Each year in the United States, hundreds of thousands of people experience cardiac arrest. Most events are fatal. Many occur at home. A significant proportion happen during sleep — when we are most vulnerable and least likely to get help quickly.

Sleep is not separate from heart health.

Sleep is heart health.

Heart Attack vs. Cardiac Arrest: Why the Difference Matters

One of the most important distinctions we discussed in this special Heart Month episode is the difference between a heart attack and cardiac arrest.

They are not the same thing.

A heart attack is typically a plumbing problem — a blocked coronary artery.

Cardiac arrest is an electrical problem — the heart falls into a deadly rhythm like ventricular tachycardia or ventricular fibrillation and stops pumping effectively.

Many people believe heart attacks always present with crushing chest pain.

They don’t.

Especially in women over 65, symptoms may be:

• Fatigue

• Shortness of breath

• Indigestion

• Anxiety

• Nausea

In fact, only about half of heart attack patients report chest pain.

Cardiac arrest often represents the electrical consequence of untreated or progressive heart disease. And during sleep, when oxygen drops and stress hormones surge, the risk of dangerous arrhythmias increases.

Why Sleep Disorders Stress the Heart

We often think of sleep problems as nuisances — annoying, inconvenient, exhausting.

But physiologically, they are far more than that.

Let’s break it down.

Obstructive Sleep Apnea (OSA): The “Poster Child”

In obstructive sleep apnea, the airway repeatedly collapses during sleep.

Each collapse triggers:

• Oxygen drops

• Adrenaline surges

• Heart rate spikes

• Blood pressure rises

Imagine being jolted into fight-or-flight dozens or hundreds of times per night.

Over time, this leads to:

• Hypertension

• Atrial fibrillation

• Ventricular arrhythmias

• Heart failure

• Increased risk of cardiac arrest

Inflammation increases. Oxidative stress increases. The heart works harder.

And here’s the critical point:

Most apnea events occur in the second half of the night — during REM sleep, when muscle tone is lowest.

If someone uses CPAP for only 3–4 hours and removes it halfway through the night, they may be missing the most dangerous portion.

Duration matters.

Insomnia & Short Sleep: Not Harmless

Obstructive sleep apnea is not the only disorder that affects the heart.

Chronic insomnia and short sleep duration are associated with:

• Higher systemic inflammation

• Increased sympathetic activation

• Elevated cortisol

• Poor metabolic regulation

Consistently sleeping less than six hours per night has been associated with:

• ~55% higher likelihood of obesity

• ~21% increased risk of hypertension

• ~33% increased risk of diabetes

All of these are major cardiovascular risk factors.

Sleep quality and quantity matter.

Too little sleep increases risk.

Too much sleep (over nine hours regularly) is also associated with adverse outcomes.

For most adults, 7–8 hours appears to be the “sweet spot.”

The Reciprocal Relationship: Heart Failure & Sleep Apnea

There is also a dangerous feedback loop.

Untreated sleep apnea can weaken the heart over time.

But once heart failure develops, abnormal breathing patterns at night can worsen — including periodic breathing and central apnea patterns.

If we treat heart failure but ignore sleep apnea, it’s like “giving someone medication while they’re drowning.”

The airway obstruction must be addressed.

Cardiology, pulmonary medicine, sleep medicine, and dental sleep specialists must work together. Patients deserve coordinated care.

Warning Signs You Shouldn’t Ignore

If you or someone you love experiences:

• Loud snoring

• Gasping or choking at night

• Morning headaches

• Excessive daytime sleepiness

• Waking multiple times to urinate

• Restless or jerking legs at night

• Difficulty falling or staying asleep

These are not trivial complaints.

They may be signs of a sleep disorder with cardiovascular consequences.

And here’s the most important truth:

You don’t have to “feel” sleep apnea to have it.

Many patients are unaware.

Many are not overweight.

Many are atypical.

When in doubt, get tested.

Even if the first study is negative — especially if you didn’t sleep well — that does not necessarily mean you don’t have a disorder.

Advocate for yourself.

For Providers: We Cannot Miss This

If you are a healthcare professional reading this, know that sleep disorders are not fringe issues.

They are central to cardiovascular prevention.

If you are treating:

• Hypertension

• Atrial fibrillation

• Heart failure

• Resistant arrhythmias

• Metabolic syndrome

Sleep should be part of your differential.

This is not siloed medicine.

This is systems medicine.

Your Nights Are Not Separate From Your Heart

When you go to bed, you are not “off.”

Your nervous system, your airway, your oxygen levels, your heart rhythm — all remain active.

Sleep is a biologic stress test that repeats every night.

Caring for your sleep is caring for your heart.

This American Heart Month, my hope is simple:

Recognize the warning signs.

Understand the physiology.

Advocate for evaluation and treatment.

Work collaboratively across specialties.

Because prevention does not stop at diet and exercise.

It continues when the lights go out.

Your nights are not separate from your heart.

Remember that.

—

If you’d like to watch the full Heart Month special featuring Dr. Lee Surkin and Dr. Paul Nguyen, you can find it here:

If you suspect a sleep disorder or need a second opinion, you can learn more at AskTheSleepMD.com.

Sweet dreams — and take care of your heart.

Long before she became known to history as Harriet Tubman, she was Araminta “Minty” Ross, born around 1822 in Dorchester County, Maryland, under the brutal conditions of slavery. From an early age, she witnessed and endured violence that left deep physical and emotional scars, yet out of that suffering she cultivated an unshakable faith that would carry her toward freedom and transform her into one of history’s great liberators.

As a young girl, she suffered a traumatic head injury when an overseer threw a heavy weight—aimed at another enslaved person—that struck her on the head. After this injury, she began to experience lifelong headaches, sudden episodes of sleep or loss of consciousness, and vivid dreams and visions. Today, neurologists and sleep physicians might see these as symptoms compatible with posttraumatic narcolepsy, epilepsy, or other neurologic conditions affecting sleep and wakefulness, though no definitive diagnosis can be made from historical records.

What is most extraordinary is how Tubman understood these episodes. She believed her dreams and visions were messages from God—sacred guidance that showed her when to move, when to wait, and which paths were safe. She trusted what came to her in these altered states, using them to guide her as she made roughly 13 journeys back into the South, helping about 70 enslaved people—mostly family and friends—escape to freedom along the Underground Railroad.

It is striking that a woman who lived with a condition that disrupted her wakefulness became a symbol of being profoundly “awake” to injustice, morality, and the call to liberation. Tubman reminds us that perceived limitations do not define what we are capable of; instead, they can reveal unexpected forms of strength and clarity. Her experiences—what many would now call a disability—shaped her destiny, helping her envision freedom and hope in the darkest times.

This Black History Month, Tubman’s story invites us to rethink what we mean by “disability.” Rather than seeing disability only as deficit, her life pushes us to recognize purpose, resilience, and wisdom in bodies and brains that do not fit narrow definitions of “normal.” It also reminds us that the harm of oppression includes not only physical chains, but the ways people are denied care, dismissed, or disbelieved when they describe their own symptoms.

For those of us in medicine—and especially those dedicated to sleep health—her life underscores the importance of recognizing the full humanity of every person who walks into our clinics, no matter their diagnosis or circumstance. Many people seeking sleep care have been tired for years, told that their struggles are “just stress,” or made to feel that their bodies are a burden rather than a story that deserves to be heard. Tubman’s example calls us to listen differently: to approach each symptom with curiosity, respect, and an awareness that what looks like limitation may also be a source of insight and courage.

Our mission, as a team, is to help close that gap—to ensure that every person who seeks help for their sleep, regardless of race, background, or circumstance, is met with compassion, expertise, and partnership. In a world where Black communities have long faced disproportionate barriers to diagnosis, treatment, and trust in the healthcare system, this work is inseparable from the work of equity.

This Black History Month, as we honor Harriet Tubman, we honor not only the conductor of the Underground Railroad, but also a Black woman who lived with the enduring effects of a traumatic brain injury and still changed the course of history. Her dreams were not just the visions of one person; they were a map toward liberation. In her story lies a truth that guides our work every day: that rest, healing, and the freedom to dream belong to everyone.

Sources

Balmuth EA, Scammell TE. Harriet Tubman’s Hypersomnia: Insights from Historical and Medical Perspectives. J Gen Intern Med. 2023 Dec;38(16):3621-3627. doi: 10.1007/s11606-023-08414-x.

Larson, K. C. (2004). Bound for the Promised Land: Harriet Tubman: Portrait of an American Hero. Ballantine Books.

So you assume this is just part of pregnancy.

But what if I told you that what you’re experiencing could be obstructive sleep apnea—a treatable medical condition that significantly increases your risk of life-threatening pregnancy complications?

This is the conversation that should be happening in every OB office, at every prenatal visit. But it’s not. And that silence is costing us—in maternal health outcomes, in preventable complications, and in long-term risks that extend far beyond pregnancy.

Let’s talk about what every pregnant woman deserves to know about sleep, breathing, and the hidden condition affecting up to one-third of expectant mothers.

When Pregnancy Fatigue Becomes Something More Serious

Pregnancy fatigue is real. First-trimester exhaustion from hormonal surges, third-trimester discomfort from a growing belly—these are expected parts of the journey. But there’s a line between normal pregnancy tiredness and a medical condition that demands attention.

That line is obstructive sleep apnea.

OSA occurs when your airway repeatedly collapses during sleep, causing you to stop breathing for seconds to minutes at a time. Your brain jolts you awake—often so briefly you don’t consciously register it—just enough to restart breathing. Then the cycle repeats. Over and over. All night long.

The result? Fragmented sleep. Oxygen drops. Stress hormone surges. Inflammation. And a cascade of downstream effects on both you and your developing baby.

Research shows that between 8% and 32% of pregnancies are complicated by OSA, depending on risk factors like obesity and pre-existing health conditions. Yet despite how common it is, most pregnant women have never heard of it. Most obstetricians don’t routinely screen for it. And most insurance plans make testing and treatment frustratingly difficult to access.

When researchers first started systematically asking pregnant women about sleep symptoms, they found something striking: approximately one in three pregnant women snore loudly and frequently—a hallmark symptom of sleep-disordered breathing.

That’s not normal. That’s not “just pregnancy.” That’s a red flag that deserves medical evaluation.

The Warning Signs You Shouldn’t Ignore

Here’s what you need to watch for:

Loud, frequent snoring: Not occasional light snoring when you have a cold—we’re talking about snoring loud enough that your partner can hear it from outside the bedroom, happening most nights of the week.

Gasping or choking awake: If you wake up suddenly feeling like you can’t breathe or you’re choking, that’s a clear sign your airway is collapsing during sleep.

Witnessed breathing pauses: If your partner tells you that you stop breathing during sleep—even for a few seconds—that’s the textbook sign of apnea (which literally means “without breath”).

Excessive daytime sleepiness: Yes, pregnant women are tired. But if you’re struggling to stay awake while driving, nodding off in meetings, or feeling like you could fall asleep the moment you sit down, that goes beyond normal pregnancy fatigue.

Morning headaches: Waking up with a headache that goes away after an hour or two can signal that your oxygen levels dropped too low overnight.

Difficulty concentrating: Brain fog, memory issues, and trouble focusing can result from fragmented sleep and intermittent oxygen drops.

If you’re experiencing any of these symptoms, especially multiple ones, it’s time to have a conversation with your healthcare provider. Don’t let anyone dismiss these symptoms as “normal pregnancy stuff.” They’re not.

Why Pregnancy Creates the Perfect Storm for Airway Collapse

Your body performs miracles during pregnancy. But some of those same miraculous changes inadvertently set the stage for sleep-disordered breathing. Understanding why helps you recognize that this isn’t your fault—it’s physiology.

Weight gain happens in all the wrong places for breathing. You gain weight throughout pregnancy (which is healthy and necessary), but much of that weight accumulates centrally around your abdomen. This elevates your diaphragm—the main muscle you use to breathe—making it work harder and reducing your lung capacity, especially when lying down.

Fluid retention affects more than your ankles. You’ve probably noticed swollen hands and feet. But that fluid doesn’t stay put. At night, when you lie down, gravity redistributes fluid from your legs and extremities throughout your body—including into the soft tissues of your upper airway. Just like your rings don’t fit anymore, your airway space narrows. Imagine trying to breathe through a straw that’s gradually getting smaller. That’s what’s happening.

Your protein levels drop, making fluid shifts worse. Pregnancy decreases the protein concentration in your blood (specifically albumin), which normally helps keep fluid inside blood vessels. With less protein, fluid leaks more easily into surrounding tissues, including the tissues around your breathing passages.

Hormones reshape your airway. Progesterone and estrogen—both dramatically elevated during pregnancy—affect your airway in complex ways. Estrogen causes blood vessels in your nasal passages to dilate and swell, contributing to that “pregnancy rhinitis” many women experience. Progesterone increases your respiratory drive but can also increase airway collapsibility. The result: you’re working harder to breathe through a more compromised airway.

Nasal congestion becomes chronic. Hormonal changes cause persistent nasal stuffiness in many pregnant women. When you can’t breathe easily through your nose, you’re forced to breathe through your mouth. Mouth breathing during sleep increases the likelihood that your tongue and soft palate will collapse backward, obstructing your airway.

Inflammation increases system-wide. Pregnancy is a pro-inflammatory state—necessary for supporting fetal development and preparing for delivery. But this systemic inflammation also contributes to swelling in your airway tissues, further narrowing the space available for breathing.

These changes don’t happen all at once. They accumulate across the trimesters. That’s why some women develop OSA symptoms only in the second or third trimester, even if they had no sleep issues earlier in pregnancy or before conception.

The Complications No One Talks About

This is where the conversation gets serious. Because untreated obstructive sleep apnea during pregnancy isn’t just about being tired or snoring loudly. It fundamentally alters the physiological environment of your pregnancy in ways that increase serious complications for both you and your baby.

What OSA Does to Your Health

Preeclampsia risk more than doubles. Study after study shows that pregnant women with OSA are 2.2 to 2.35 times more likely to develop preeclampsia—a dangerous condition characterized by high blood pressure and organ damage. The mechanism is clear: every time your airway collapses and you stop breathing, your oxygen level drops. This triggers a cascade of inflammatory responses, activates your sympathetic nervous system (your body’s “fight or flight” mode), and damages the lining of your blood vessels. The result is elevated blood pressure, impaired kidney function, and the systemic inflammation that defines preeclampsia.

Preeclampsia isn’t just uncomfortable—it’s one of the leading causes of maternal death worldwide. It can cause seizures (eclampsia), stroke, liver rupture, and kidney failure. It necessitates early delivery to save both mother and baby. And once you’ve had preeclampsia, your long-term cardiovascular disease risk is permanently elevated.

Gestational diabetes becomes 1.5 to nearly 2 times more likely. OSA increases your risk of developing gestational diabetes (GDM) by 55% to 89%, depending on severity. Here’s why: the repeated oxygen drops from apneas trigger stress hormone release—cortisol, adrenaline, inflammatory molecules. Sleep fragmentation elevates cortisol even further. These hormonal disruptions directly impair how your cells respond to insulin and how effectively your body processes glucose.

Research shows that pregnant women with OSA sleep about 1.5 hours less per night than women without OSA (6 hours versus 7.7 hours), and sleep duration under 6.25 hours dramatically increases GDM risk. Gestational diabetes isn’t just about managing blood sugar during pregnancy—it triples your risk of developing type 2 diabetes later in life and increases your baby’s risk of obesity and metabolic problems.

Your heart takes a beating—literally. This complication gets far less attention than it deserves, but it may be one of the most serious. Pregnant women with OSA have a ninefold increased risk of developing peripartum cardiomyopathy—a form of heart failure.

Here’s the mechanism: every time your airway collapses during sleep, you generate enormous negative pressure in your chest trying to suck air past the obstruction. This forces your heart to pump against higher resistance. Add in the elevated blood pressure from OSA-related inflammation, add in the metabolic stress from diabetes, add in the normal fluid overload of pregnancy—and your heart becomes dangerously overworked. For some women, the heart muscle weakens to the point of failure.

Pulmonary edema (fluid in the lungs) and heart failure aren’t theoretical risks in research papers. They’re real outcomes documented in pregnant women with untreated OSA.

Preterm birth and cesarean delivery rates climb. Women with OSA are 36% to 62% more likely to deliver preterm (before 37 weeks) and 42% to 99% more likely to require cesarean delivery. The reasons span multiple pathways: inflammation triggers early labor; maternal complications like preeclampsia necessitate early delivery; larger babies from gestational diabetes make vaginal delivery more difficult; and surgical complications from OSA during anesthesia may prompt C-section decisions.

Your mental health suffers. Pregnant women at high risk for OSA have three to four times higher odds of experiencing depression, generalized anxiety, and post-traumatic stress disorder symptoms. The connection is bidirectional and multifaceted. Sleep disruption and intermittent oxygen drops preferentially damage the prefrontal cortex—the brain region responsible for emotional regulation. Inflammatory molecules released during apneas (like IL-6 and TNF-alpha) directly affect mood-regulating neurotransmitters. Cortisol dysregulation from fragmented sleep impairs stress response systems.

Depression and anxiety during pregnancy aren’t just emotionally difficult—they’re associated with poor prenatal care adherence, substance use, preterm birth, and postpartum complications.

Maternal mortality risk increases 4 to 5 times. Multiple large studies document that pregnant and postpartum women with OSA have four to five times higher in-hospital mortality compared to those without OSA. Let that sink in. The conditions we’ve already discussed—preeclampsia, heart failure, blood clots, complications during anesthesia—all converge to create genuinely life-threatening risk.

What OSA Does to Your Baby

The intrauterine environment your baby develops in is profoundly shaped by your oxygenation, your metabolic health, and your placental function. When OSA disrupts all three, fetal development suffers.

Growth restriction becomes more common. Babies born to mothers with OSA are at increased risk of intrauterine growth restriction (IUGR) and being small for gestational age—nearly three times higher risk in some studies. The mechanism is clear: intermittent drops in maternal oxygen mean intermittent drops in oxygen delivery to the placenta. Chronic inflammation impairs placental blood vessel development. The result is a placenta that can’t adequately nourish the growing fetus.

Preterm birth and low birth weight. OSA increases the likelihood that your baby will be born too early (36% to 94% increased risk) and weigh too little at birth. Preterm babies face immediate complications—respiratory distress, feeding difficulties, temperature instability—and long-term developmental challenges.

Gene expression changes before birth. Perhaps most concerning, research has identified dysregulation of over 3,200 genes in fetal cells from pregnancies complicated by maternal OSA. These genes control critical developmental processes: cell growth, metabolism, stress response, immune function. We don’t yet fully understand the long-term implications of these epigenetic changes, but the evidence suggests that intrauterine exposure to maternal OSA fundamentally alters fetal programming.

Neurodevelopmental effects may persist. Babies born to mothers with OSA show shorter telomere length in cord blood—a marker of cellular aging and stress—and potentially altered neurodevelopmental trajectories. While long-term cognitive and behavioral outcomes are still being studied, the intermittent hypoxia and inflammatory milieu that babies experience in utero raise real concerns about lasting effects.

Lower Apgar scores and higher perinatal complications. OSA is associated with lower Apgar scores (the immediate assessment of newborn wellbeing) and higher rates of NICU admission. These aren’t subtle statistical findings buried in research papers—these are observable clinical outcomes affecting real babies.

The Treatment That Actually Works

Now for the part that gives me hope: unlike many pregnancy complications, obstructive sleep apnea is treatable. And treatment genuinely reduces complications.

CPAP therapy (continuous positive airway pressure) is the gold standard treatment. It’s a machine that delivers pressurized air through a mask you wear during sleep. The air pressure acts like a splint, holding your airway open so it can’t collapse. No apneas, no oxygen drops, no sleep fragmentation.

I know what you’re thinking: “A mask on my face all night while I’m already uncomfortable being pregnant? No thank you.”

I hear you. But let me share what the research shows about women who use CPAP during pregnancy:

Preeclampsia rates drop from 19% to 7%—that’s a nearly 65% reduction in one of the most dangerous pregnancy complications.

Gestational diabetes drops from 31% to 10%—a 68% reduction in diabetes risk.

Blood pressure stabilizes. Women using CPAP show significant reductions in both daytime and nighttime blood pressure, reducing hypertensive complications.

Babies are born at healthier weights. CPAP therapy improves placental blood flow and fetal oxygenation, leading to better fetal growth and fewer low-birth-weight infants.

Preterm delivery risk decreases. With better management of maternal complications and improved fetal wellbeing, fewer pregnancies require early delivery.

These aren’t marginal improvements. These are dramatic, clinically meaningful reductions in serious complications.

The Reality of CPAP Use During Pregnancy

I won’t sugarcoat it: CPAP adherence during pregnancy is challenging. Studies show that only 33% to 50% of pregnant women use their CPAP consistently enough to get full benefit. Why?

• Mask fit issues: As your face swells from pregnancy fluid retention, masks that fit initially may become uncomfortable or leak air.

• Physical discomfort: Adding one more thing to manage when you’re already dealing with heartburn, back pain, frequent urination, and general discomfort feels overwhelming.

• Appearance concerns: Some women feel self-conscious about wearing a mask, especially if they’re concerned about their partner’s reaction.

• Claustrophobia: The sensation of pressurized air and having something on your face can trigger anxiety in some women.

But here’s the thing: these barriers are surmountable. Sleep medicine has evolved. Modern CPAP masks are lighter, smaller, and more comfortable than older models. Nasal pillows (small prongs that sit just inside your nostrils) work for many women and feel far less intrusive than full-face masks. Humidification features reduce dryness and irritation. And most importantly, sleep specialists can work with you to troubleshoot problems and find solutions that work.

The benefits to your health and your baby’s health are worth the adjustment period.

The Screening Gap We Need to Close

Here’s the frustrating part: we have the tools to identify OSA in pregnancy. We have effective treatment. Yet systematic screening still isn’t standard practice in most obstetric care.

Why not?

Partially, it’s a knowledge gap. Many obstetricians weren’t trained to think about sleep-disordered breathing during their residency. Partially, it’s a time constraint—prenatal visits are already packed with screenings, measurements, education, and questions. And partially, it’s an insurance and access problem—not all plans cover sleep testing during pregnancy, and for women on Medicaid or without insurance, the cost can be prohibitive.

But the solution doesn’t have to be complicated.

A single screening question at each trimester could dramatically improve detection: “Do you snore loudly? How often?” If the answer is “yes” and “frequently,” combined with any risk factors, referral for sleep testing should follow.

High-risk women should be screened automatically, including those with:

• Pre-pregnancy obesity (BMI ≥30)

• Chronic hypertension or development of high blood pressure during pregnancy

• Prior gestational diabetes or a new diagnosis of gestational diabetes

• Prior preeclampsia in a previous pregnancy

• Persistent loud snoring reported by a partner

Home sleep testing has made evaluation more accessible. You don’t need to spend a night in a sleep lab with electrodes glued to your head. Home sleep tests involve wearing a small device overnight that monitors your breathing, oxygen levels, and heart rate. The data downloads to a computer, and a sleep specialist interprets the results. It’s non-invasive, done in the comfort of your own bed, and far less expensive than in-lab testing.

Screening at multiple points matters. A woman who doesn’t have OSA in the first trimester may develop it in the third trimester as weight gain and fluid retention peak. Screening only once early in pregnancy misses women who develop symptoms later.

The evidence-based recommendation is to screen at the beginning of each trimester—early pregnancy, mid-pregnancy, and early third trimester. This catches both pre-existing OSA and new-onset cases while still leaving time to implement treatment before delivery.

What Happens After You Give Birth?

This is a critically underappreciated question: does OSA go away after pregnancy?

The answer: sometimes, but not always.

Research shows that while OSA improves in most women after delivery (as weight decreases and fluid resolves), it only completely resolves in about half of postpartum women. The other half continue to have sleep-disordered breathing that requires ongoing management.

Who’s likely to still have OSA postpartum?

• Women who had more severe OSA during pregnancy

• Women who had OSA before they got pregnant

• Women who don’t lose pregnancy weight in the months following delivery

• Women with persistent metabolic issues (diabetes, hypertension)

Yet here’s the problem: most women diagnosed with OSA during pregnancy receive no follow-up after delivery. No repeat sleep study. No reassessment of symptoms. They’re left wondering whether they still need CPAP or whether the problem resolved.

This is a massive gap in postpartum care.

Here’s why it matters: OSA is associated with long-term cardiovascular disease, metabolic syndrome, cognitive decline, and increased all-cause mortality. Women who continue to have untreated OSA after pregnancy face these risks for decades. But if we identify that OSA persists and continue treatment, we can protect long-term health.

The ideal postpartum management looks like this:

• Continue CPAP therapy initially after delivery (because sleep is more precious than ever with a newborn, and every hour of quality sleep matters)

• Follow-up visit 4 to 6 months postpartum with a sleep specialist

• Reassessment of symptoms: Are you still snoring? Still experiencing daytime sleepiness? How’s your weight and metabolic health?

• Repeat sleep testing if symptoms persist or if you had moderate to severe OSA during pregnancy

• Ongoing treatment if OSA is confirmed, with counseling about long-term cardiovascular risk and lifestyle modifications

This isn’t happening routinely. But it should be.

The Inequity We Can’t Ignore

One more uncomfortable truth: access to OSA screening and treatment during pregnancy is profoundly unequal.

The populations at highest risk for OSA—pregnant women with obesity, Black women (who have higher OSA prevalence and severity), and women of lower socioeconomic status—face the greatest barriers to diagnosis and treatment.

Insurance coverage varies dramatically by state. Some states provide comprehensive pregnancy coverage through Medicaid that includes sleep testing and CPAP therapy. Others don’t cover chronic conditions that weren’t addressed before pregnancy. Private insurance generally covers it, but even then, high deductibles and copays can make treatment financially out of reach.

Access to sleep specialists is geographically uneven. If you live in a major metropolitan area, finding a sleep medicine physician or clinic is relatively easy. If you live in a rural area or a medically underserved community, you may need to travel hours for an appointment—a significant barrier for a pregnant woman who may not have reliable transportation or paid time off work.

Implicit bias affects who gets screened and referred. Research consistently shows that Black women and other women of color receive less comprehensive prenatal care and are less likely to have symptoms taken seriously by healthcare providers. This extends to OSA screening. If providers don’t ask about snoring, and if women’s reported symptoms are dismissed as “normal pregnancy,” diagnosis never happens.

The cost of CPAP equipment remains a barrier even when testing is covered. A CPAP machine, mask, tubing, and supplies can cost $800 to $3,000. Even with insurance, out-of-pocket expenses can be hundreds of dollars—prohibitive for many families.

This is a solvable problem, but it requires systemic change:

• Insurance policy reform to ensure equitable coverage

• Expansion of home sleep testing programs (lower cost, higher accessibility)

• Training for obstetric providers on OSA screening and referral

• CPAP equipment assistance programs for low-income pregnant women

• Community health worker outreach to underserved populations

Until we address these inequities, the women most vulnerable to OSA complications will continue to have the least access to the care that could protect them.

What You Can Do Right Now

If you’re pregnant or planning to become pregnant, here’s your action plan:

Know the warning signs. Loud frequent snoring, gasping or choking awake, witnessed breathing pauses, excessive daytime sleepiness—these aren’t normal. They deserve medical evaluation.

Know your risk factors. If you have obesity, hypertension, diabetes, or had preeclampsia or gestational diabetes in a prior pregnancy, you’re at higher risk. Bring this up proactively with your provider.

Advocate for screening. At your first prenatal visit, ask: “Given my risk factors, should I be screened for obstructive sleep apnea?” If you develop symptoms during pregnancy, don’t accept dismissal as “just pregnancy.” Push for referral to a sleep specialist.

Prioritize sleep hygiene even beyond OSA. Good sleep habits benefit every pregnancy:

• Keep consistent sleep and wake times (yes, even on weekends)

• Create a cool, dark, quiet sleep environment

• Limit screen time for at least an hour before bed

• Sleep on your left side (improves blood flow to the placenta and reduces airway collapse risk)

• Use pregnancy pillows to support your belly and keep your airway aligned

• Avoid eating large meals or drinking excessive fluids right before bed

If diagnosed with OSA, engage with treatment. Yes, CPAP takes adjustment. Yes, it’s one more thing to manage. But the stakes—your health, your baby’s health, your long-term wellbeing—are too high to dismiss it. Work with your sleep specialist to find a mask and settings that work for you. Give yourself time to adapt. The benefits are worth it.

Demand postpartum follow-up. Before you deliver, establish a plan with your provider: “I was diagnosed with OSA during pregnancy. When should I follow up after delivery? Do I continue CPAP? When should I be retested?” Don’t let this fall through the cracks.

Share information. If you learned something from this article that could help another pregnant woman, share it. Talk about it in your prenatal groups, on social media, with your friends who are planning pregnancy. The more women know about OSA in pregnancy, the more we can shift the culture of prenatal care to include this critical screening.

Why This Matters

Every pregnancy ends with a procedure. Either you deliver vaginally or you have a cesarean section. Either way, knowing whether you have OSA matters for anesthesia planning, monitoring during high-risk deliveries, and postpartum care decisions.

But more fundamentally, your sleep during pregnancy isn’t a luxury or a minor inconvenience to tolerate. It’s foundational to your health and your baby’s health.

When you breathe well at night, your blood pressure stabilizes. Your glucose metabolism improves. Your placenta functions optimally. Your baby receives consistent oxygen and nutrients. Your mental health benefits from restorative sleep. Your body can do what it’s designed to do: grow a healthy baby while maintaining your own wellbeing.

When you don’t breathe well at night—when your airway collapses repeatedly, when your oxygen drops, when your sleep is shattered into fragments—everything becomes harder. Complications cascade. Risks multiply. Outcomes worsen.

The good news is that we can change this. We can screen. We can diagnose. We can treat. We can protect maternal and fetal health in ways that weren’t possible a generation ago.

But it starts with awareness. With asking the right questions. With refusing to accept that crushing fatigue and loud snoring are just “part of pregnancy.”

You deserve better. Your baby deserves better. And the evidence is clear: when we identify and treat obstructive sleep apnea during pregnancy, outcomes improve dramatically.

So if you’re snoring, gasping, or exhausted beyond normal pregnancy fatigue, please: talk to your doctor. Advocate for testing. Engage with treatment if diagnosed.

Your sleep matters. Your health matters. And this conversation—the one about OSA in pregnancy—needs to happen in every prenatal office, at every visit, for every woman.

Because when we prioritize maternal sleep health, everyone benefits.

To learn more about this profoundly important topic, please listen to my interview with Dr. Ghada Bourjeily, MD, a leading sleep researcher with a focus on sleep during pregnancy.

Research participation:

We need diverse voices in sleep medicine research. If you’re a pregnant woman (particularly if you’re Black, Latina, or from a community historically underrepresented in medical research) and interested in participating in studies that examine sleep health during pregnancy, researchers are seeking participants. Your involvement helps ensure that findings are relevant to all women, not just a narrow demographic. Find out more: http://redcap.lifespan.org/redcap/surveys/?s=LN83K89N7FAPNRXF

References

Dhamelia P, et al. Obstructive Sleep Apnea in Pregnancy and its Impact on Maternal-Fetal Health. Open Respir Med J. 2025.

Liu L, et al. The prevalence of obstructive sleep apnea and its association with pregnancy-related health outcomes: a systematic review and meta-analysis. Sleep Breath. 2019.

Bourjeily G, et al. Obstructive sleep apnea in pregnancy: emerging insights. Curr Opin Pulm Med. 2024.

O’Brien LM, et al. Sleep apnea and pregnancy: epidemiology and management. J Clin Sleep Med. 2014.

Izci B, et al. Sleep-disordered breathing and upper airway changes in pregnancy. Sleep Med Rev. 2014.

Antony KM, et al. Obstructive Sleep Apnea in Pregnancy: Physiologic Mechanisms. WMJ. 2021.

Pamidi S, et al. Maternal sleep-disordered breathing and adverse pregnancy outcomes. Am J Obstet Gynecol. 2014.

Ding XX, et al. Maternal sleep, snoring, and pregnancy outcomes. Sleep Med Rev. 2018.

Reutrakul S, et al. Obstructive Sleep Apnea, Glucose Tolerance, and Insulin Secretion in Pregnancy. J Clin Endocrinol Metab. 2013.

Louis JM, et al. Obstructive sleep apnea and severe maternal-infant morbidity/mortality. Am J Obstet Gynecol. 2014.

Rubio DM, et al. Poor Sleep Quality and Obstructive Sleep Apnea as Risk Factors for Perinatal Psychiatric Disorders. Sleep Health. 2022.

Okun ML, et al. Sleep-disordered breathing and depression during pregnancy. J Women’s Health. 2018.

Louis J, et al. Maternal and neonatal morbidities associated with obstructive sleep apnea. Obstet Gynecol. 2018.

Guilleminault C, et al. Nasal CPAP reduces sleep-induced blood pressure increments in preeclampsia. Am J Respir Crit Care Med. 2000.

Edwards N, et al. Continuous positive airway pressure treatment in pregnancy and maternal cardiovascular outcomes. J Clin Sleep Med. 2016.

Blyton DM, et al. Treatment of sleep disordered breathing reverses low fetal activity levels. Sleep. 2013.

Facco FL, et al. CPAP adherence in pregnancy. J Clin Sleep Med. 2017.

Bourjeily G, et al. Natural history of obstructive sleep apnea in pregnancy. Sleep Med. 2020.

Chen YH, et al. Racial disparities in obstructive sleep apnea during pregnancy. Sleep Health. 2021.

Louis JM, et al. Racial and ethnic disparities in maternal sleep-disordered breathing. Sleep Med Rev. 2019.

After weeks of staying up late and sleeping in during winter break, returning to your college schedule can feel brutal. The good news? With the right approach, you can reset your sleep-wake pattern within one to two weeks—and the benefits extend far beyond just feeling less groggy in the morning.

Why Sleep Should Be Your Academic Priority

Sleep isn’t just about avoiding exhaustion. Research demonstrates that sleep quality, duration, and consistency account for nearly 25% of the variance in academic performance—more than you might expect. Students who maintain regular sleep schedules perform significantly better than those with irregular patterns, regardless of their total sleep time.​

Each hour of sleep lost corresponds to a 0.07 decrease in end-of-term GPA. More concerning, students getting less than six hours per night experience a pronounced decline in academic performance, with massive accumulation of sleep debt that impairs both health and study habits. Sleep deprivation doesn’t just affect your grades—it impacts memory consolidation, attention, decision-making, and information processing.​

The effects extend beyond academics. With every additional night of insufficient sleep, your risk of experiencing mental health symptoms increases by more than 20%, including depressed mood (21% increase), anxiety (25% increase), and hopelessness (24% increase). The relationship between sleep and mental health is bidirectional: poor sleep contributes to mood problems, which in turn make it harder to sleep well.​

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