91. Sleep Solutions for New Parents, Sleep Training Babies & Sleep's Effect on Overall Health | Jade Wu, PhD

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Okay, welcome back to the Medicine Redefined podcast. You are all in for a treat today. Now if you've been a listener for a while, you may remember our guest, Dr. Jade Wu. She featured an episode 47, and if you haven't been here that long, I highly recommend checking out that episode possibly first before this one because in episode 47, Dr. Wu does an extensive job in terms of explaining how sleep works. The foundations of sleep, talking about quantity and quality, as well as going over the common misconceptions when it comes to insomnia versus sleep deprivation and how to think about sleep hygiene so that we can all hit our bed with maximal relaxation and making sure that we wake up less gruggier than we usually do. So if you don't know Jade Wu, she is wearing many different hats. She is a researcher. She's got a PhD. She's board certified behavioral sleep medicine psychologist. She is now an author. She's a podcaster, and she's also a mother of two children. So why does all that matter? Because as you're going to see in this episode, she is an absolute excellent communicator. So throughout this episode, we're going to start out by recapping insomnia versus sleep deprivation. Obviously, sleep is getting a lot of attention right now and deservedly so. I tend to see a lot of people use the terminology wrong, especially when they are trying to explain data. So Dr. Wu is going to recap a little bit about the terminology. We're then going to touch on how sleep affects different lifestyle factors, our cognitive ability, our cardio metabolic health, for example. And then we're going to deep dive into perinatal time period. So what should pregnant mothers do to improve their sleep? How should partners be sleeping? How do we sleep trained children? How do we think about postpartum depression? What is the link between depression and sleep? So we're going to have all those questions answered for you in this episode. I don't want to delay you any farther. There's so much high yield education in this episode. So let's get to it. All right. Welcome back, Jade. Second time here on this show on medicine redefine. Thank you so much for coming back. Oh, thanks so much for having me again. This I was honored to get the request. Yeah, absolutely. So I'll let the listeners know right now the first episode, that was episode 47 and a lot of that we talked about sleep hygiene and also the link between insomnia, anxiety and sleep deprivation. So I think before they, I mean, they could listen to this as well because we're going to go through kind of special populations. But I think that episode is also phenomenal in terms of having a good foundation of understanding sleep and kind of going through the quality and quantity and what's important. But I'm, yeah, truly excited for this episode talking about special populations and what not. I think it is important to just recap insomnia briefly, especially now since you have a book out about it. But why don't you take us a little bit between insomnia and sleep deprivation because I will say Twitter has been popping off a lot about sleep and I'm seeing a lot of people write the terminology but may not understand exactly the context of what it should be. So take us through a little bit about insomnia for sleep deprivation. Sure. This is one of my favorite things to debunk actually because I think often we use insomnia, sleep deprivation, sleep disruption, all of these terms interchangeably as if they were the same thing. But actually they're really different and I'll say why in just a moment. But sleep deprivation is when you don't get enough opportunity for good quality sleep. So think of, you know, single mom working three jobs, college students sing up all night to either study your party, this is sleep deprivation. This is not even giving your sleep a chance to do with thing. Whereas insomnia is when you have the opportunity, but for some reason your brain just does not want to sleep or doesn't want to sleep the way that you expect it to. So there, I think of it kind of as a vent diagram with some overlap in the middle where, you know, sleep deprivation is over here, people who don't get enough opportunity sleep. And insomnia is over here where, you know, opportunity, yes, but just can't sleep anyway. And in the middle are people who, usually it's people who have sleep apnea, PTSD, other types of sleep disorders, something that makes it so that you have insomnia and you're not getting enough sleep. But that's the minority of people. Most people either have sleep deprivation and not insomnia or insomnia and not sleep deprivation. The reason it's really important to tease those two apart is because your treatment for those two things are completely opposite. Like if a patient came to me and he was like, oh, I just like can't motivate myself to go to sleep on time, you know, I'm up all night like trading crypto or whatever. What I do with this person would be completely different than someone who's like, I try really hard to go to bed at 9 p.m. or 10 p.m. And I try so hard to fall asleep and I just can't and I've done all the meditations and I take melatonin and just nothing works. That's opposite treatments for two very different people. Yeah, no, thank you for that beautiful explanation. So in your kind of practice of what you've been seeing based on today's environment, do you see more, would you say there's a higher percentage of people with insomnia or that are going through sleep deprivation? That's a great question because whom I see, that's all people with insomnia because people who are sleep deprived are not going to the doctor about it. So it's in a way, it's a tricky public health messaging problem, right, because I think I believe there are many, many more people who are sleep deprived or not taking, not prioritizing sleep and not getting enough quality sleep than people who have insomnia. And there are a lot of people that have insomnia, I mean, about 25 million adults in the US, right, about 10% of the adult population. But I think there are more people who don't get enough sleep. So it's really tricky for, you know, those of us who want to help people with their health, with podcasts and blogs and whatnot and writing books and whatnot, it's hard for us to just put a headline out there to say, oh, you should be prioritizing sleep, you should be sleeping more or taking it more seriously. Because there's 10% of people who will hear that and get even more anxious about their sleep and, you know, have even more insomnia. So it's a really tricky balance to find. Yeah, last time we spoke a little bit about how, because the conversation on sleep health has really increased over the last maybe two years or so and there have been bestseller books out there and more and more people and, you know, media outlets taking that messaging. You know, I, again, I personally have mentioned this before. I was in that camp where it was becoming more detrimental than helpful, like the sleep trackers and all that kind of stuff. You did mention that, you know, people who have sleep or sleep deprived aren't necessarily going, I do think there are some cases though, right, where, so, okay, let me just backtrack. So I was recently listening to a podcast with Matthew Walker on Tim Ferriss and Matthew Walker was kind of highlighting the different types of insomnia, previously we talked about this as well, right? You mainly people characterized in sleep onset insomnia where you're kind of laying in bed difficulty falling asleep and then you have the sleep maintenance insomnia, right, where people who have frequent awakenings, although we know that night time awakenings are natural part of healthy sleep, but just too many of them. He also mentioned, which I hadn't heard about before, that there's a different type of insomnia where people sleep what seemingly seems appropriate, seven to nine hours, whatever you call it. And they never seem to feel refreshed that following day. Is there a term for that one? Do we have terminology for that type of insomnia? Well, okay, so he's not wrong. He's not wrong, but I think when we take a, when we take a step back and look at insomnia and the etiology, like where it comes from, how it works, all of these types of insomnia are actually pretty much the same thing. I think it's a little bit of an arbitrary division between sleep initiation versus sleep. Maintenance sleep, you know, paradoxical insomnia, primary insomnia, secondary insomnia, all of these types of insomnia actually boil down to the same mechanisms. It just so happens that for some people, depending on their chronotype, depending on their lifestyle, depending on their circumstances or physical surroundings, are having more trouble at the beginning of the night, or they're waking up frequently, or they're staying awake for a long time. Those are the two main types, you know, you mentioned there. And then the people who don't wake up feeling refreshed, that, that may or may not be insomnia. So that could either be insomnia where someone has trouble falling or staying asleep on some nights, but not on other nights. So a lot of my patients will say, oh, I'll have two, three nights in a row where, where I hardly get any sleep and it's just awful. And then I crash on that third or fourth night and I sleep for nine or 10 hours, but I still wake up feeling not refreshed and groggy, almost worse than I felt when I went to bed. You know, it could be that kind of situation, or it might be someone who doesn't have insomnia, but has sleep apnea or has periodic limb movement disorder or some other type of sleep disorder, where their sleep quality is not good. You know, their sleep is interrupted very frequently, but so briefly that they don't actually remember waking up. So, you know, sleep apnea is someone's waking up every two minutes to breathe, but so briefly that you don't remember any of those awakenings, they're never hitting deep sleep. So of course they're waking up feeling groggy and unrefreshed. So that particular presentation, I would have to do a little more assessment to figure out, is this insomnia? Is this something else? What's going on? But yeah, that would be a fun puzzle to tease apart. Yeah, and I think it's a challenging puzzle for sure, right? I'm glad you brought up the sleep quality piece of it, and before you mentioned how anxiety and stress can certainly contribute to that, I also find that, again, that individual, that 30-year-old, trading crypto at the middle of the night, or just the executive highly functioning individuals, medical students, ourselves, who tend to have a lot of anxiety, which can be beneficial in many of the things that make us very, very good at jobs. It's also hard to turn that off, right? And you might hit the sack and feel like you slept well, but really that sleep quality was so poor that the next day you find yourself honestly, bingeing on caffeine, right? People just joke that, oh, I just need an IV caffeine in medical school, is it? Well, the darsha is one of one of one million who didn't do that, so we'll exclude him from this case study here. But most medical students, residents and stuff, are in that camp. And then, you know, understanding the half-life of caffeine, if you take that in later hours of the day, and other interesting things I recently learned, is that it tends to excise your deep sleep, which we get in the first few hours of the night, right? So it perpetuates this vicious cycle where your sleep quality is poor, you're drinking more caffeine later in the day, you have poor sleep quality, you keep going back and forth. But it begs a question also from this archetype of person who has high stress, high anxiety. Could you talk a little bit about, because you imagine you see these people all the time, just the correlation of stress, anxiety and sleep quality, a little bit deeper than what I just mentioned? Yeah, I'm so glad you brought that up because there is, I think, a very special animal. This very high functioning person who, you know, if it weren't for the sleep thing, they would have everything, all of their stuff together, right? And they're going through life, doing just fine, except they're just tired and wired all the time. I'm glad you brought up caffeine, because the tricky thing about caffeine is that it actually makes you more tired, because it's false fuel, right? It's not real energy, not like food, not like actual sleep. It forces your body into running on empty. It's like scraping the bottom of the barrel in terms of what actual fuel you have in your body, so that when you do crash, when you withdraw from caffeine, it really hits your heart and it can make you feel, you know, you are truly exhausted. And so even if you do finish drinking caffeine early enough the day for, you know, because caffeine can have a long half-life depending on who you are. Even if you do that early enough for caffeine to leave your system, the withdrawal symptoms can also mess with your sleep. So you're exactly right that there's a vicious cycle where when you get onto the caffeine treadmill, it's kind of hard to get off. But let's go back to what you said about stress and anxiety too, because that's hyperarousal. Insomnia is a disorder of 24-7 hyperarousal. In fact, sometimes I don't even think of insomnia as a sleep disorder, because it just so happens that people notice the nighttime symptoms and complain about those when they come to the doctor, but it's actually a 24-7 disorder, right? During the day you're tired but wired, during the night you're wired and tired, but you're not really sleeping that well. So it's like this, you know, our biology is designed such that we have our 24-hour rhythms and ideally our rhythms have high peaks and low troughs. So big contrast between day and night. We should be very energetic during the day and very restful at night. But what's happening when we have 24-7 hyperarousal is that kind of everything gets blunted. Like we're not super energetic during the day, but we're not really restful at night either. So we're just kind of in this constant low simmer of hyperarousal kind of low-level fight or flight all the time. When you're experiencing that, I mean really what our body, what message we're sending our bodies is that there must be a saber-to-tiger on our tail, because otherwise why would we be kind of just like this and like nervous 24-7, right? And if there's a tiger on your tail, of course you're not going to sleep well. Like that would be fatal, right? So it's kind of a, it's actually a protective thing that your body is doing for you by keeping you hyper-visual at night when you don't have enough time to rest during the day. Yeah, thank you for that overview. You know, you mentioned the tired boat wired and I think I shared in episode 47 that my father had in Somia and like he would always ask me, what should I be doing? And you know, I need to take naps, but I can and then you'd be wired at night and he's going to be listening to this and I was going to be like, yes, I got over it. But it's pretty interesting because I remember him telling all the sleep hygiene and then in 47 you kind of debunk that saying, you know, actually these patients don't need the sleep hygiene, but more of the CBT or the psychotherapy in a way, talking about narrowing the window and then adjusting the times. But one of the things, you know, in correlation with anxiety is also like a cognitive aspect to to to pour sleep, right? And I think obviously the reason sleep has become more and more talked about is that we're seeing this bi-directional relationship with physical activity and, you know, emotional regulation and cognition being one of them. So we know that when you're sleeping at night, the brain is going through a process of kind of getting rid of metabolic waste, recharging kind of refueling. When people complain of poor cognition and not being able to focus and concentrate, is do we truly understand exactly why that's happening? Like what it is with force sleep that's causing people to kind of have that brain fog? That's a great question. It is a bit of a mystery actually. And just to give you an example of how complicated this question actually is, you know, there are studies looking at, you know, let's say 20 people and putting them through sleep deprivation and then testing them on different types of tasks. So you may not be surprised to hear that some people are more resilient than others. Some people get sleep deprived and they're just like, okay, no problem. Let me just do these things and breeze through them. So, you know, there might be that colleague or, you know, co-worker, whoever, who says, you know, I just need four or five hours of sleep. Maybe they're not wrong, at least not on a short term, right? But some people struggle a lot more. They're a lot more sensitive to sleep deprivation. But people can have, but people can be differentially sensitive to different types of tasks. For example, you might completely fall apart at a reaction time task after sleep deprivation, but be totally fine with decision making or working memory, for example. So it's really hard to actually trace what is going on because we don't even have our handle on whether and when and to whom it happens. You know, Jay, the other interesting about the resilience piece of it, I also find that that resilience diminishes over years, right? And I don't mean substantially like over 30 or 40 years. I think about when I was an undergrad, 19, 20, 21 years old, I'm studying for whatever test comes up, organic chemistry over two weeks or any physics or something. My preferred mode of studying was pulling on lighters three nights before, like many of them. And I did, you know, I did okay. Now, if I go two nights without sleep, I honestly feel like, you know, my brain has aged 30 years and I'm not that much older far from undergrad. And so, you know, what could potentially explain that? I do know, right? I mean, this concept of chronic sleep debt has been debunked, right? I don't believe that, or at least the data doesn't suggest that 13 years later, I guess, I don't know, maybe 12 years later from undergrad, I am updating myself that I have that chronic sleep debt from that time. But at the same time, you know, just this is just subjective. I don't think I am as resilient as I was. Do you have any thoughts on to that? So I think you're totally right. I'm experiencing that as well. I'm in my early, maybe mid 30s at this point. And I feel so bad after not sleeping well. Whereas I could party and study and do whatever in my 20s and it seemed perfectly fine. So there are a couple of things going on here, I think. One is that remember that you have a lot more going on now than before. Even though it seemed like when you were young, you felt like there was a lot going on now, your parents, your professional, you've got a podcast, you know, you've got your a partner, you've got all sorts of things going on, all sorts of more responsibilities and fewer opportunities to recharge during the day. So how you feel during the day is not just based on how well you slept last night. It's also, you know, are you having pockets of time to really just be by yourself and be calm? Are there times when you are refueling with things that fulfill your soul and, you know, your your emotional needs? And hopefully we all have some of that, but I bet we have less of that than we did in in college and physical activity, by the way. In college, at least you had to walk a couple minutes between each class, right? So every hour you got up and stretch your legs. Nowadays, how often do you spend a whole day just kind of sitting at your desk or or maybe y'all are on your feet for your job? But I know that I sit a lot, right? So I think that's part of it is our lifestyles are actually contributing to how tired we feel or how not resilient we are after bad sleep. Another thing is perception. So there actually is research showing that objectively, if you test younger adults versus older adults after a night of sleep deprivation, everybody does a little bit worse than when they're not sleep deprived. That's not surprising. But what was interesting and kind of funny was that the young adults were really cocky about it. They were overconfident. They thought they were performing just fine because they were asked, how do you how well do you think you did on this test for how confident are you about your answers? And they were like, fine, I don't feel bad. I'm good. Whereas the older adults were more anxious and they actually underestimated their performance. So I'm not sure why that is, but for some reason, younger adults are feel like they're more resilient to sleep deprivation, but they're not actually. Yeah, that one's really interesting. You know, I have some theories, but but I'll hold on to that myself. I do want to follow up on the physical health piece of it. I really love that you brought that up. And I certainly agree. I think in terms of just neat, right, non-exercise activity thermosynthesis, it's it's far lower as you get older, your basal metabolic rate doesn't necessarily slow down significantly or the data which suggests maybe not at all, but just the activity level. We do become more sedatory. And then the bandwidth piece, I mean, that that totally makes sense, right? We do spread and you have so many other things that are responsibilities for a lack of better word. The physical health piece is interesting because again, bi-directional and stars mention, you know, if you don't get enough physical activity, both planned and unplanned throughout the day, then you might not be able to quote unquote optimize your sleep quality. And we have good data to suggest that exercise as long as it's not very intense and too close to bed does help improve our sleep. And if I am remembering correctly, then particularly deep sleep more so. And that that makes sense because that's where a lot of the physical recoveries happen. Is that correct? Yeah. Exactly. Correct. And good news, there's actually updated research. I believe a systematic review. So, you know, we're pretty confident about it showing that even moderate to vigorous exercise within two hours of bedtime is okay. Yeah. Awesome. Yeah. So I love that because now I can tell people literally exercise anytime because between your responsibilities and lack of motivation and rainy days, like just whenever you can squeeze it in, squeeze it in, even if it's right before bedtime. Yeah. Some exercise is better, you know, or some exercise at the less than opportune time is better than no exercise at all, right? So yeah, I love that. But the other interesting thing, you know, when we when we flip it and you probably see this a lot, right, when people are coming to you and they're not getting good sleep quality. Again, they're not sleep deprived. Maybe it's more insomnia. And the struggle is, well, if I'm not getting enough sleep quality, I don't know if I have time to exercise. Shouldn't I be spending that time working on my sleep, right? In fact, if there were times when again, I was sleep deprived through our residency and stuff. And I would have this struggle if I had a bad call or multiple bad calls or an intern year where I might have gotten less than five hours sleep on consecutive days. And the question was, do I go to the gym? Do I get some exercise in or do I skip it and do I just, you know, try to quote unquote catch up on sleep? And I'm wondering what your thoughts are and just kind of that conundrum. That's a very good question. I definitely do people do see patients who struggle with that exact same problem. I would say sleep opportunity is more important than exercise opportunity. When we're talking about like you're going on multiple nights without enough sleep, you know, it's my hierarchy is like oxygen, water, food, sleep, and everything else after that. So sleep is pretty high up there for me because I think if you don't have enough opportunity to sleep, you're really not going to do anything else really well. So even if you end up hitting the gym, you know, your workout is not going to be that great. And, you know, your next day's functioning is not going to be that great. And you're not going to be able to get as much out of the sort of me time that you're spending by going to the gym. Whereas if you use that extra hour or two to give yourself more opportunity to catch up on sleep, then it's much easier to kind of get back on track with your exercise routine after that. However, if you have insomnia and you've always had plenty of opportunity to sleep and the issue is just that you're having trouble falling or staying asleep and you're not lacking opportunity, then absolutely go to the gym because, you know, going to bed an hour earlier is just going to backfire. So again, opposite advice depending on the situation. Yeah, I love that. I put you on the spot there a little bit, but I think you nailed it. I think for me, my thoughts have developed into, as you suggested right there, context really matters, right? What kind of problem are dealing with it? And then the other piece of it, let's just take the lack of opportunity in the sleep deprived individual, which is what we were, which is what we're going to talk about for new parents, something that's been an interest of both of ours personally. And, you know, for that, it's really an art, right? And so what I, and I'll just, it's not about me, but what I would just say when I talk to other people is it doesn't necessarily have to be, the exercise doesn't necessarily have to be the same workout regimen that was planned before, right? We could just do any type of movement or maybe a mobility workout or just move, right? We know that the benefits of exercise, again, are just, you have a myriad of benefits in terms of cognition, physical health, metabolic health, which is also the case for sleep, right? Speaking of metabolic health, we, you know, we have studies of how just a couple of nights of sleep deprivation can significantly disrupt your endocrine hormones to decades later than there should be, right? To testosterone, estrogen, specifically, same thing with insulin regulation or dysregulation, right? People are far more insulin resistant after a couple of nights of sleep deprivation. And it doesn't stop at that, right? When we're talking about the perinatal period, I mean, poor sleep is related to hypertension, gestational diabetes, pre-term birth, even C-sections all these kinds of things that are going to matter a little bit further in the conversation. And considering the epidemic of obesity, which is one of the things that has perpetuated for a long time, we've said you just need to move more, exercise more. And I think a lot of people who do exercise, do it for a couple of reasons, but one of them is, you know, they want to feel good, they want to look good, right? So combat that obesity. And if you're doing that, but you're not getting your sleep in order, understanding everything that we do, and I haven't even talked about the piece of dysregulation of your emotions and binging and cravings and all that piece of it, it's going to be very, very challenging to accomplish your goals of good health, good function, really, whatever it is. So I think that that is really, really piece. I like the hierarchal thing that you said. And especially the context thing, I think that's clutch. Mm hmm. Yeah, I so agree. I mean, I'm no expert in metabolic health and and all of that, but I think in any domain of health, if you're trying to improve your health, but your sleep is not in order, I mean, that's kind of like, you know, paddling down river with like a broken ore. I mean, you can paddle as hard as you want, but it's just not going to be efficient, not effective, not sustainable in a long run. So yeah, I very much agree with that. Awesome. So let's talk about combating sleep deficit or disruption in times of high stress. Again, we're not necessarily talking about insomnia. We're talking about the lack of opportunity now. And you know, I couldn't wait to get back on with you because at the last time, when we ended the recording, you mentioned developing interests of yours, or I'm not sure, you know, if that was ongoing for a long time, or if that was a recent thing, but perinatal sleep, you were very interested in this. And at the time, I probably had a three or four-month-old, I can't remember exactly when we were recording. Slow, there was no sleep to be had for me, and I wanted to get the recording on immediately. And since then, you've had another one, congratulations of your own, right? You said it's almost one year old. So I am interested in learning all about the perinatal period. And then also, we could translate a lot of those lessons to other professions, other areas in life where people don't have enough opportunity for sleep, right? Military, medicine, other healthcare professionals, et cetera, et cetera. But before we do that, let's take a step back. Let's just define what that term perinatal sleep means. And I'm even interested, like, where did that interest come from? Well, research is me search, right? As soon as I got pregnant and started to lose my mind from all the sleep problems I was having, I was like, oh, I need to look into this. Because turns out, even when you're a bore certified sleep specialist, they don't really teach you about perinatal sleep. You have to really dig and really dig to learn what you need to know. So fortunately, things with my second child, so much better now that I kind of knew what I was doing. So if it was that hard for me, I imagine it's very hard for people in general. So I really, really do have a strong personal interest in helping especially moms, but also dads, you know, all parents to sleep better during this period. So perinatal just means the time around when a birth happens, right? So that's like pregnancy. And I would even extend that a little earlier into the trying to conceive period, because a lot of folks are, you know, doing IVF, IUIs, and those times can also really be challenging for sleep. So that whole time period before the birth, and of course postpartum, and into the first year or so, I would say, is a very vulnerable time for sleep for parents. So I'm really interested in that two-year-ish window and longer depending on how long someone has tried to conceive. Sorry, did that answer your question? I kind of forgot what you asked. No, you nailed it. Thank you. Okay. That was good. So one thing I was curious about was the physiology of sleep, right? Is there anything that changes once a woman becomes pregnant that either disrupts their sleep or tries to help their sleep? So much, so much changes. So let's start with hormones, right? So you're probably very aware that there are several hormones that increase dramatically in a woman's body when she conceives, even within the first few weeks, you know, HCG, progesterone estrogen are like doubling every couple of days, and it's just mind-boggling how much hormone we change in our bodies. So, you know, these hormones are making us more sleepy during the day. And at the same time, making sleep more interrupted at night. So progesterone is a real culprit on this one. And estrogen makes you have more nasal congestion. So if you had sleep apnea before, it's going to be worse now. If you didn't snore or have apnea before, it's very possible that you'll start snoring. And in fact, pregnancy onset snoring is related to some bad outcomes. I mean, it's not certain, but the correlation is strong enough that I would be very concerned if you suddenly start snoring loudly during pregnancy. And so estrogen makes you have more congested. It makes you have nightmares. It messes with your body temperature. Well, progesterone is the one that messes with your body temperature. So all sorts of hormones are messing with sleep directly. And also causing other body symptoms that are making sleep more difficult. So hotter body, more frequent urination, joint pain, breast pain, you name it. So just bearing uncomfortable. There's also anatomical changes. Of course, there's rapid weight gain. There is doubling of the blood volume. And, you know, the pelvis is loosening up. Things are just changing, you know, shifting around. And so that causes a lot of pain and discomfort. There's also a lot of psychological changes and emotional changes. Because preparing for a child's arrival, I mean, think about what that felt like for you. Now multiply that by 10 for your wife. There's just a biological drive that kicks in, that nesting instinct, that, you know, hypervigilance instinct. It all kicks in. So there's just a lot more anxiety. And that's part of why there tend to be more nightmares too. And insomnia during pregnancy. So I mean, I could go on, but basically everything changes physically, emotionally, hormonally, you know, so yeah, a lot can mess up sleep during pregnancy. Yeah, I know the emotional part is particularly interesting and challenging to deal with. Because I think we just don't talk about it enough, you know, depending on the statistics anywhere from one in four to one in three women have a miscarriage at some point, right? At least in this country, I think something that's just not well known. I mean, I only recently learned about that. And you brought up the IVF, other fertility issues that people have. So you have all that anxiety. And, you know, whereas for the male partner, father, it might just be a lot of excitement because you're ready, you're planning, you're thinking about the future. But I think for, you know, for the mom, until you get to that 12 week mark, but really, really after that, far after that, until the baby gets there and even beyond, you just have that anxiety. If you've been in that camp where you've had a miscarriage before or you had a process that was prolonged and fertility issues and stuff, it's really hard to enjoy. And then you've got all the physiological things that you're talking about. Again, and then the lack of discussion, the lack of awareness, lack of knowledge, that just, you know, just kind of compounds how difficult that that process can become. So I think that that's hard as well. Yeah, absolutely. You know, I trained during, during residency at the Duke Fertility Center, just for a part-time rotation. And that was just a really eye-opening experience for me. I mean, I had no idea how any of that worked before. And none of my patients were sleeping well. You know, I was there providing emotional support, psychological treatment. And I mean, there's only so much you can do when someone is dealing with something so existentially. I don't even know how to describe it, but it's it's all, you know, at the same time I was rotating through the cancer center. And let me tell you, the cancer patients had an easier time emotionally than the infertility patients. Just because, you know, you're on a monthly rollercoaster of, you know, excitement, dread, and then disappointment, and then all over again. And you're just on tender hooks all the time, you know, you're grieving and working really hard and going through hormonal treatments all at the same time. It nobody was sleeping well. Yeah, and I do think that that's kind of like the support piece of it too, right? At least a small part. And I'm just kind of taking a stab at it and I'm not qualified to speak on this at all. But, you know, for cancer awareness, we, for a lack of better word, we celebrate the awareness, right? We try to recognize we've got a whole month dedicated to breast cancer awareness, et cetera, et cetera. Like we have all these five Ks, all that kind of stuff. And so people do feel supported, right? It's still hard. Don't get me wrong. I've got family members dealing with that stuff. And it's impossible. It's very, very challenging. Yet people in those fertility clinics, they almost feel ashamed. They feel inadequate, right? And so that's not something that is discussed as much. And when it's not that you don't really have support. And, you know, I think this phrase suffering and silence comes to mind for a lot of women when it comes to that. And that's, that's a difficult place to be. So I can, I can totally see that. Yeah, it's extremely isolating. And it's just really heartbreaking. Because, you know, people, even family and friends try to be supportive, but the way they do it is often well-intentioned, but it really misses the mark. So it makes people feel even more isolated than they didn't have family to talk to you at all sometimes. So yeah, it's very challenging. Totally. So I wanted to hold off on strategies till the very end. But I think now that we're talking about this, I think kind of temporally in terms of that period up here, it makes a little bit more sense, particularly because you brought up body temperature and, you know, I use an uller. Darshoes is an eight sleep because we're both hot sleepers. And it has been revolutionizing. For me, Darshoes, I don't want to speak for you. You can tell us your experience afterwards. But I'm wondering, what are some, some strategies that you employ with new mom, or not new moms yet? Well, I guess technically new moms, but in the, in the prenatal period, right? And when they're going through the physiological changes, hot sleep and rapid waking, all that kind of stuff, more pain, that kind of stuff, daytime fatigue. Can you talk about some tools tactics? Yes, absolutely. So let's work outside in because, you know, you, you want to hit this at every level that you can. Sure. So environmentally speaking, yes, if you can have cooler, more, you know, breathable sheets and like a mattress that works well for you, something that keeps you cool and comfortable, body pillow, you know, just make your partner get you all the most comfortable stuff and just like pamper you. And this might be a good time to sleep, sleep separately. And I know that's stigmatizing. I know people don't like the idea of couples sleeping separately. But truly, if, if there's ever a time to do it, pregnancies are really good time to do it because believe me, you're going to want to starfish, you're going to need to move. You're, you're going to not want to worry about waking up your partner. You just need that freedom and space to feel physically comfortable and to be able to deal with your sleep changes on your own terms. I also think that it's great to, if you have the resources and the ability, add these people onto your team, a therapist before you think you need one, a physical therapist before you think you need one. With my second child, I want to see a prenatal physical therapist and it made all the difference from my body, from my mental health. It was just like, she's worth her weight and gold. And, you know, be, I'm sure people are already engaged in their prenatal care. But, you know, speak to, speak to people who have experience specifically with sleep. And I know that's a tall order because there are very, very few people who specialize in prenatal sleep. But real quick plug here, goodnightmama.com. I'm launching this new thing, hopefully this year. And I want this to be a resource for all moms out there, pregnant, trying postpartum, you know, 10 years out, everybody. And so look for resources like that because sometimes even just a little hint of something can really make a big difference. So get your resources lined up. Working more in words. So there, first of all, we need to accept that there are some things we cannot control. Like our hormones, they're there for good reason, you know, our bodies are changing, we're growing a human. So we have to accept that, that the being hot, being congested, all of that is just, we can't really change that. But what we can change is our relationship with sleep if we feel that that's starting to get rocky. So what I mean is we want to be extra flexible. We don't want to be rigid because things are changing so rapidly during pregnancy that what works for you one week, maybe totally off base next week. So don't hold too tight and fast to the eight hour rule or the seven hour rule or the, you know, I go to bed at 10. I'm a 10 p.m. bedtime person. You may not be. You may need to go to bed at nine. You may need to go bed to bed at midnight. So listen to your body. Hold down some bumpers, like try to get up at about the same time every day, give or take an hour, but let yourself really fluctuate on the evening end because you may find that you are so sleepy during first trimester before you're even showing yet that you need, you know, 10 hours of sleep and that's totally fine. That's normal. Another really good thing to experiment with is napping. So napping may be your savior because that's the thing that's going to allow you to catch up on sleep and give you that extra sleep that your body now needs without throwing off your circadian rhythm. So instead of sleeping in by two hours, you know, on a Saturday morning, still get up at the same time, but take an hour long nap or even two hours long nap, you know, a lot of the conventional rules about, you know, you know, keep your nap 30 minutes or shorter. That does not apply during pregnancy. Sleep as long as you want, as long as you keep your circadian rhythm straight. And that brings me to the most important point, which is your circadian rhythm, your body clock is way more important than you think because you're sleep quality and how you feel during the day and everything else about your health depends on a robust circadian rhythm. And a robust rhythm means it runs every 24 hours and there's a big contrast between day and night. So in order to keep that, get up at the same time, like I said before, get lots of sunlight during the day. And if you can't physically go outside and get sunlight a lot of the time, at least try to sit by a bright window or have a, you know, a light box at your desk move during the day, your body, your body and your baby will appreciate that too. And eat regular meals. Don't, you know, skip meals or get haphazard about that. All of this keeps your circadian rhythm steady. And guess what that's going to be good for as a bonus, which is that postpartum, you're going to be sleeping better because your baby's going to be sleeping better. Babies take about a month to three months to establish their own circadian rhythm. When they first come out, they have no idea what's day versus night. They just don't have that concept. But you want them to establish their own circadian rhythm as soon as possible because the sooner they do that, the sooner everybody is sleeping at night. And one of the ways you can help your body baby to establish that earlier is by keeping a really good robust circadian rhythm while you're pregnant because your baby is listening to those cues too. So I mean, I could go on forever, but I feel like those are some good starting points. Yeah, ultimately, you want to ask, I was going to ask about supplements. I mean, that was the perfect segue Jade and to go into postnatal, but I do want to ask about supplements because I know, you know, there's other podcasters out there who talk about it. A lot of people are looking into supplements, but being in pregnancy, you know, obviously a lot of families might be more hesitant to starting any supplements or any type of medication. Is there anything that you have found or is there anything that is safe maybe to take from a prescription standpoint or a supplements standpoint? So I'm not a prescriber. So disclaimer that all I say is evidence-based, but not in the context of being a medical doctor. So definitely review your medications, including your over-the-counter stuff with your doctor because you never know there might be something in there that is actually interfering with your sleep. For example, Unisom is often prescribed for pregnant women because this is one of the ones that's deemed safer for taking during this time, but Unisom will exacerbate restless legs, which is very common during pregnancy, particularly for people who are pregnant with not their first child. So with every subsequent pregnancy, you're more likely to have RLS. By the time you're on your third pregnancy, you're more likely to have it than you're not. And RLS can really mess with your sleep quality and just be really annoying and make it hard to fall asleep and give you insomnia. And Unisom actually exacerbates this. So that's not a direct answer to your question because I don't really know any supplements that is actively good, but I just want to warn people to be cognizant of Unisom. And also, I know we talked about caffeine already, but did you know that during pregnancy, the half-life of caffeine can be as high as three to five times longer. Oh, wow. Especially during the whole day. Yeah, exactly. So if before you were stopping your coffee by noon and you thought, well, that was perfect. That worked perfectly well for me. I'm going to keep doing that. That may very well not be okay anymore. So I know that's a really hard pill to swallow for people who really love their coffee, but if you're in your third trimester and you're not sleeping well, there are probably many reasons, but let's, you know, examine coffee as one potential one. Do we do we know why the caffeine metabolism slows down? I do not know. That is not my area of expertise, but it is this is evidence-based. And I was shocked to hear it. Yeah, me too. I never have to get pregnant. Very challenging. So let's shift over to, let's, let's fast forward. Let's hope that, you know, all through trimesters, we had a smooth delivery, happy baby, happy mom. Let's talk about the postnatal period. And this is where, you know, selfishly, we can jump in and we can talk about partner fatigue as well, very much so. Yes. And because you did mention you work with parents, not just, not just moms, you know, what are, what are common things that you tend to see challenging periods? Talk a little bit about the postnatal period, frequent awakenings, all that kind of stuff. Yeah, so the postnatal period is very challenging for sleep. I mean, that's the honest bad news that I think people should be aware of before they get there. And it's hard for both the birthgiving person and partners, caregivers, but obviously most, most so for the person giving birth, because again, there are hormonal changes, there are physical changes, there's pain, recovery, lactation for many people, some people are recovering from major surgery if they had C-section. So there's just a lot of factors going on, not to mention the fact now, you have a baby, a baby who does not have a circadian rhythm and can and needs to eat about everyone and half to two hours at first, or even more often in those newborn weeks. So the major challenges are lack of a circadian rhythm for caregivers of this baby, lack of sleep continuity, and poor quality sleep due to many factors, including hypervigilance. So I don't know if you had this experience of being the dad, but I know that I am just very, very sensitive to noises that sound even remotely like a baby crying. Like I have chickens in the backyard, if a chicken squawks, I'm like, is the baby awake? So you did not have that experience? No, it's funny that you say that. I do think, I mean, my wife is just hyper aware of it and I'm not. And interestingly, I am an incredibly light sleeper. Well, to light, I'm very, very sensitive to light, but not necessarily to sound. But yeah, every single night now, especially that our daughter is sleeping in her own room down the hall. I never hear her when she cries, but my wife every single night, you know, hears her. And it's so much so that I've had to beg her to like, please wake me up so I can go. But, you know, being the angel that she is, she never does that. So I've had to be like, please, please, it's my turn. I don't know what to do. I don't know how to get around that, but I don't know if that's biology. I don't know what that is, but luckily or unlikely. It must be. It must be biology, because I hear this from everybody. And for same sex couples, like two moms, the birthgiving mom will be more hyper vigilant than the partner. So that makes me think that it's not so much a gender or a sex thing, but rather a birthgiving, like, hormonal biological change thing. Yeah. And it's also interesting, you know, after that happens and how like social media, your feet start turning into just postnatal experience and parent and toddler and all that kind of stuff. And there are some really funny videos, I don't know if they're TikTok or Instagram, but like where the mom's coming over and like moving the dad over to the dad side of the bed and says, this is the side that you don't hear the baby crying on. And so I'm going to sleep on this side tonight. I've seen that one. Yeah, I find that to be pretty funny as well. All right, so let's talk a little bit about since you brought it up, right? You know, of course the challenge has, well, actually, I want to backtrack. You mentioned that, is it three months or so that the baby starts developing their own sleep? One to three months. So that begs a question, right? I mean, so this concept of prototype that we've talked about before that you brought up before and for those who are not familiar, it's like, you know, night owls, morning larks, that kind of stuff. Is that like a nature versus nurture thing, right? So that one, we know that kids as they're developing in children, they're, they're malleable in terms of, you know, their beliefs, everything, the, what they're learning languages, et cetera, et cetera. And I'm wondering if we can kind of influence and shape their circadian rhythms as well? Or are they genetically hardwired to be their night owls later through the night, morning larks, that kind of stuff? So all babies are morning people. I am so sad about this because I am not a morning person and goodness gracious, I have tried to make my kids into more of a night person to be more like me so that we can all, you know, be aligned. But I had to make myself a morning person. I was telling Darsha this before we started a recording that I use blue walking glasses at night. I use bright light in the morning. I do all these things to force myself to become more of a morning person because my kids will not budge. They will magically wake up at 6.30 no matter what happens. Sometimes 5.30. So kids are just biologically hardwired to be morning people and they will remain morning people until about 14, 14, 15 like post puberty. When, once they're an adolescent, especially into their late teens, they will become a night person and college too. And then mid 20s they'll start to like mellow out a bit to be more of a conventional chronotype. And then from there on, people kind of branch off into what they're going to be. But pretty universally as young kids like the younger you are, the more likely you are to just be hardwired to be whatever you are for that stage of life. Why is that the case though? Because society clearly favors morning larks, right? I mean, in fact, night owls have been a significant disadvantage throughout their professional careers. And I remember my roommate, I might have mentioned this before in medical school where he felt like his best hop to study was between 10 p.m. and 2.30 am. And I remember the mornings when we had 7.30 exams, it was like, I was dragging this kid out and he was like half asleep literally and I was like, my god, I don't know how this is going to go for you. It doesn't look like you're barely awake. I had to slap him around and be like, let's go, we haven't test. Oh my gosh. And I felt terrible for him, but also a lot of other people. But if we all start off that way where 5.30 is go time, why do some people tend to transition through their adolescent ears to being more night owls? Is it just more exposure through the night? I mean, do we even know why? It's a few things. One is just biology. We are just hardwired with genes with, you know, with whatever it is that makes us night owls or morning larks. We are hardwired to a large extent. And then in adolescence, I think it's a particularly stormy period for chronotype because not only are they already biologically hardwired to be night owls, they also have their, you know, social media and like light exposure and the demands of school and homework. And I mean, you talk to a typical high schooler and it's like, well, of course they're not sleeping until 2 am. They've got homework to do. They've got practice. They've got to catch up with their friends. They're on TikTok for like 2 hours. You know, it's just, so it's behavior as well. So, you know, during adolescence it's kind of a perfect storm. College, yes, as well. I mean, there are just so many things happening at night. You know, I used to start getting ready to go out at 10 or 11 pm. Now I'm like, hopefully sleeping by then, you know. So it's just lifestyle, your peers, your environment, everything. That is so true. I mean, I remember a college going out. You wouldn't get to a club until it was like 11, 30 pm. And now I can't even, I know. Like we be pre-gaming at that point. And now I'm like, oh god, 9 pm, can I please go back? Yeah, absolutely. I did, I did want to ask about chronotypes. I know I forget who founded the term and the survey, but is that a validated survey? I know there's like a 40 question one. There's also like a mini quiz. But then also, I feel like a lot of those questions might be influenced by what you just kind of coined, you know, as the perfect storm of social media and things. So do we know if that's validated? I don't know which survey you're talking about. Is it the morning this evening this questionnaire or is it something else? It's the, it's it's like a specific chronotype like that you're either a wolf or a dolphin. Oh, the sleep animals thing. Yeah, I think that's what it's called. I don't think that's validated because there is actually no such thing as like five different types like qualitatively different types of chronotypes. It's a spectrum. I mean, it's just it's like a bell curve like anything else. But I guess you can make it into categories if you like want to, you know, and you know, some people would say like, oh, you know, you can be like a morning larp, but you need a nap and whatnot. But that's just that just depends on your upbringing and your culture. Like if you live in Greece, like, yeah, you're going to nap. So, you know, so going back to your point, you know, it's some of it is biological, some of it is environmental and social and cultural. Okay, so let's bring it back to to that time where let's just say a couple of weeks after, right? So mom and hopefully safe delivery, she's recovering, right? There's that new transition, particularly the first time parents where you're trying to figure out, I mean, it's just especially new dads are just in a world of hurt, right? We're trying to figure out diapers, you're trying to figure out breastfeeding. If that's the the route that you're going to go down, you're trying to figure out whether or not your babies liking the formula, different types of formulas. We got formula shortages. We got collic. We've got all these factors that just not, there's no blueprint, right? And I saw a really funny skid. I was on one of the late night shows. At least I forget who who is on it. But anyways, he was talking about how everybody, when you're pregnant or before you get pregnant, they're just talking about, oh my god, congratulations. You know, it's like magic. It's like heaven. This is a great time. And as soon as the baby gets it, they're like, oh, welcome to hell. You're never going to sleep again. And I found that to be so funny because I do think there's a little bit of truth in that. And you know, I share that not because it adds anything to the question, but just because it was funny. But um, but it does beg the question is, you know, that challenging time where you're trying to figure out all these things, but at the same time, you're still trying to care for yourself, right? We've talked about the first half of this discussion of how important sleep is. But now you have no opportunity because literally, there is this life form that is 100% dependent on you and it is your responsibility to take care of this, right, person. And how do we navigate that situation? How do you work with parents, moms, dads to navigate that situation? What are some tools, tricks, tactics that we can talk about that can make that transition a little bit easier to not only survive, but maybe even thrive? Yeah, yes. I love that question because I think often we just throw in a towel and say, well, that's just how it is. Welcome to hell, you know, but there are actually some things we can do. So let's start with sleeping arrangements. So the American Pediatric Association, I believe recommends six months of co-rooming with your baby, but not co-sleeping in the same bed, at least not during the newborn period. So this presents a challenge for a lot of families, because think about you and your partner sleeping in a bed and then right over there is a baby that wakes up all the time, or even if the baby is not fully awake, she's making noise, she's gurgling, she's like startling, she's doing all these weird things and you as a new parent, you're like, what is that? Is she okay? Is she awake? Does she need something? So there's no need for both of you to be going through that. Now, birthgiving mom is going to be more hyper vigilant and non-birthgiving parent probably less so. So here's what I recommend. Both a spatial and temporal strategy to make it so that at least a birthgiving mom is getting as much recovery sleep as possible. So here's what I mean. Set up your schedule so that you have a, what would you call this? Like a two shifts that overlap. So for example, mom might go to bed at 9 pm and she is completely off-duty, like unless there's a fire alarm going off, she is not responsible for anything. And she is sleeping in a dark quiet room by herself. Nobody else is there. Until maybe, let's say, I don't know, 11 or 12, at which point, you know, dad or partner goes to bed. And then at that point, dad or partner is still on duty so that if the baby cries, dad or partner is watching the monitor or listening for the baby or sleeping in the same room with the baby away from mom. And then that shift switches at let's say 1 am or 2 am. And then mom is now on duty. So you're both still sleeping, but she's the one watching the monitor. She's the one getting up. And then she gets up early to get the baby up at whatever 5 am, 6 am while the dad or partner is continuing to sleep undisturbed in a room by him or herself herself. So this way, you get the advantage of both partners have at least 2 or 3 hours of undisturbed like throwing the towel completely know that there's nothing that's going to disturb them kind of sleep. Because a lot of what keeps us in light sleep is just like back of our mind knowing that we might become responsible for something. Like if you ever needed to catch an early flight and you set like three alarms, but you still keep waking up during the night, that's what's happening to parents all the time. There's constantly a flight they need to catch like six times a night, right? So just take that burden off of one parent at a time for at least a couple hours at a time. Have mom go first because the first two, three hours, as you said before, that's when deep sleep happens. We want mom to get as much uninterrupted deep sleep as possible. So have mom do whatever she needs to pump nurse or if using formula, then it doesn't matter. Do whatever she needs to right before her bedtime so that she earns, you know, as long of a stretch as possible where she's definitely not needed. Pumping versus nursing is a little bit of a tricky issue because surprisingly, breastfeeding actually extends the amount of sleep that you get. I'm not sure exactly how, but my guess is that pumping and feeding a bottle actually ends up taking more time and effort and like wakes you up more and gives you less of that oxytocin than breastfeeding at night. So with my first baby, I tried to, I pumped so that I could give, so that my husband could give a bottle and I thought that was me being strategic and smart. But that did not actually work out very well. For second baby, I just nursed. I just nursed. So even during my husband's shift, if the baby needed to eat, he would wake me up briefly for me to nurse and then he would take away the baby to change her and blah, blah, blah. And that actually gave me more sleep and better sleep because prolactin gives you more deep sleep percentage, like a lot more, like it doubles your deep sleep. So if you are breastfeeding, lactating prolactin, like keep doing that because that is actually good for your sleep quality. So that's the temporal part. The spatial part is, yes, the baby is recommended to sleep in the same room as one of the parents. Great, but not everybody has to sleep in the same room because we want maximum oxygen for everybody. We want there to be less noise and light disturbance for everybody. So only one parent should be monitoring the monitor or being in the same room with the baby at a time. And then once the baby and, okay, so here's the thing. The official recommendation is six months co-roaming. But multiple pediatricians have told me this and multiple sleep experts, pediatric sleep experts have told me this. It's okay to not co-room. Once the baby is past a newborn stage. If you don't smoke, if you don't drink excessively, you know, if you, if you're baby and you are not at particularly high risk for a sids, it's okay to not co-room. So we're, you know, kind of, talk to your pediatrician, do what works for your family. I think a lot of the public health messaging airs on the side of conservative, but it doesn't, not everybody needs to follow it exactly to the letter. Yeah. Jay, I noticed that you have emphasized the importance of deep sleep a couple of times, especially for the mom. And I remember at some point, I don't, I don't know whether or not this is a valid fact or not, that the ability to emotion, regulate our emotions better is, is directly correlated with the amount of REM sleep. I total sleep for sure, but also REM sleep. Is there any truth to that? Oh, yeah. Yeah. REM sleep is, is the emotion regulation, you know, is oversimplifying it a little bit, but yeah, that's when emotion regulation happens. Yeah. So let's say knowing that, would it be better for the mom to get the second sleep shift? So, or, or, is it that no matter what time you're sleeping, your first couple hours are, and you're going to go through the phase of deep sleep before you go to REM, right? Yeah. You're going to do deep sleep before you do REM sleep. And I would generally, unless the mom is like such a severe night owl, that it just doesn't make sense for her to, to do the first sleep shift, you know, like so, for example, if dad is a total morning person, and mom is a total night owl, then you would reverse what I just said. Like have, dad go to bed first, mom stays up, you know, but generally speaking, I would totally recommend mom go first, because there's a reason your brain does deep sleep before REM sleep, because deep sleep is just more important. So if you are physically recovering from giving birth or C section, if you are producing milk for your baby, or even if you're not, you're still taking care of a baby, and that's very energy expensive, right? So just everything that your body and mind need to do, I mean, emotion regulation is great and all, but you can't regulate emotions if you're like dead, you know, if you're like physically not functioning. And also don't worry, like you will get REM sleep too. I would be, I would rather have sort of more protected uninterrupted deep sleep bouts, and let REM sleep just happen whenever it does or can, rather than the other way around. Jade, I do want to ask about postpartum depression, right? Something that I just hear that is so common, and you know, as we talked about earlier, there's not really this vocal group that's coming out and really kind of talking about, I mean, there is more awareness happening, but do you find that with that strategy of that spatial and temporal spacing that women, primarily the moms are having less episodes or less anxiety? So I'm so glad you brought that up. Postpartum depression and anxiety, super common, as you said, and very, very related to sleep. So and very, very related to circadian rhythm functioning. So getting enough sleep, getting sleep at approximately the right times, which means primarily at night with naps during the day as needed, go a long way to helping prevent postpartum depression. We know that from cross-sectional research, longitudinal research, we know that if your sleep during pregnancy is better, you are less likely to have postpartum depression. So every which way you slice or dice it, sleep at any time is going to be important for preventing postpartum depression. And you know, an interesting fact, so for a long time, pediatricians and, you know, and everybody else thought that infant temperament was the main driver, or at least one of the main drivers of postpartum depression. So if you had a colloquy baby, then the mom was more likely to have depression. Well, yeah, that makes sense. But it turns out newer research has found that if we factor in sleep, like the mom's sleep, then we know that that's what's driving the relationship. So if we statistically take sleep, you know, take sleep into account, then that infant temperament to postpartum depression link disappears. Because it's really, it's kind of like the way we would interpret that is, sure, babies can be more colloquy or less, but your resilience to colloquy and difficult temperament is how well you slept. So if you slept while having a more difficult baby is, you know, you're still protected. But if you didn't sleep well, even a moderately difficult baby might make you feel more depressed. So sleep is really, really important. And at what point do we tend to say, what's the earliest that you might see it present? Oh, like immediately. Yeah, it can really be quite early on. And in those cases, it's likely that somebody already had mental health problems to begin with or depression anxiety during pregnancy. And in part, I think, I mean, to bring it back to sleep again, I don't know what your and your wife's experience was like in the hospital, assuming you gave birth in the hospital. Yeah, I did as well for both my kids. It is not a good environment for postpartum sleep. I mean, those first 72 hours are really crucial for recovery, right? Because during labor, I mean, first time moms especially are laboring like 24 plus hours, that's a lot of time that you may not be getting much sleep at all. So then, you know, if it's so in the hospital 24 seven, there are people coming in, poking you, prodding you, turning the light on, making noise. So people do not sleep well in the hospital, including in a maternal ward. So so by the time you get home, you're going on like four days of not getting much sleep. And so you just had major surgery or you just had, you know, you just like gave birth. And you haven't slept well for four days. And you're like, now I have a baby, I need to figure out what to do with it. Like what's happening? And your milk is coming in, hopefully, or maybe not, or you're having trouble with that. There's just too much going on. The very least we can do for people is help them to sleep better in those first few days. Because in my experience, those first few days actually really can't, I don't want to say make or break, but they, they have an outsized impact on how things go from, you know, from there. Yeah, it's critical. This, yeah, I'm starting to think I spend way too much time on social media because there is another video of just talking about OB nurses that will just come in and check on mom and check on baby like every 10 minutes and then be dropping a clipboard to be like, why don't you get some sleep? I'm just going to check on the baby in the back 10 minutes later, 10 minutes later. I found that to be very funny because all these things have some truth to them. It's so true. I actually tell people one crucial item to pack in your hospital bag is a sign that says, please do not disturb unless absolutely necessary because mom is recovering. And I say recovering and or sleeping, because sleeping, I don't know, people don't take that very seriously, but when you say recovering, it sounds more serious. So I have people literally plaster that on the outside of their door and like, maybe post, you know, like grandma can come and like post up by the door and be play bouncer and just like send people away unless it's absolutely necessary. I work for the nurses that they have to do. Ah, not all the time. No, but you know, my birthing center was actually quite good about it. They, I talked to them ahead of time and I had my sign and they were like, totally, there are sometimes when we do have to come in to make sure everything's okay with baby, but we'll do our best to, you know, like to cluster so that like three of us will come in and do all three things at the same time. Instead of us coming, it's like every 20 minutes to like disturb your whole hour. And, you know, I ask them like point me to every single light switch in this room or just like shut them all off for me because there's like 15 different lights in the hospital room and some are hidden like behind the head. Yeah, like just know, just tell people that you prioritize sleep in a super important to you and like make them prioritize it on your behalf as well. All right, so let's come back to a little bit later in that postpartum period. So you said kind of co-rooming according to the AP. It's about six months after that. Let's just say some parents will start transitioning the kids, their children to their own room. And that is hit with another challenge usually. Maybe, you know, that's a time for some milestones. The prevailing theory is that at least during some milestones, people have regressions. I'd love to hear you. I know you've talked about this before. Some might be myths, others might not be. If I like my daughter had a lot of sleep regressions, still continues to. So I don't know how much merit there is to that. So I'd be curious to hear your thoughts on that. But then also strategies of how we can deal with those type regressions. But also that attachment that is kind of being severed, right? They're going to a different room. They're starting to recognize who mom and dad are, the mom and dad aren't around anymore. So what can you say about that stuff? Oh, yeah. This is a very interesting and a little bit of a controversial area we're waiting into because there are just very strong feelings on both sides of the sleep training, whether to do it, when to do it, does it harm attachment, you know, and all of that. So, okay, so first I'm going to say that there is not one right answer for every family. That's just, you know, that's not, that just doesn't work. So I respect people's decisions to sleep train, not sleep train somewhere in between. Although I will say the term sleep training, I think gets a bad reputation because really, really sleep training is the whole process of helping your baby to sleep well. So I think what the thing that people have a problem with is cry it out or this extinction based sleep training. So there are, so let me say that there are many things you can do to help your baby sleep well long before you get to the question of whether you cry it out or not. So from, you know, taking care of your own circadian rhythm while you're pregnant, you know, from that early of a stage, you can be helping your baby sleep. And in the newborn weeks, you know, just helping your baby sleep as much as possible, like no matter what, like as much holding contact naps, you know, skin to skin, wearing your baby in the in the wrap in the sling, just whatever you need to do to get the baby to sleep as much as possible. That will actually teach the baby to sleep better later on. So helping the baby to establish their circadian rhythm, establishing good bedtime routine, having a really good sleep environment. That's a very different context from waking environment to teach baby the difference between sleeping and waking, getting on a really good schedule. Well, schedule is not the right word. It's more like getting on a good rhythm, knowing your baby's sleepy cues, following them and starting to gently encourage more of a pattern so that you end up with a nice, you know, 4-nap schedule, 3-nap schedule, your baby's not getting overtired. You know, all of these things are extremely important for helping your baby to sleep well. And then you get to three-ish, four, maybe closer to four-ish months, where babies go through a really big milestone, which you mentioned, which is that they start to learn that once you leave the room, you're still there. And they are wondering why the heck are you not still holding me? And they're starting to be more aware of their environment. They're both stimulated by your presence and also unable to sleep without your presence. So they're at a conundrum, where sometimes the more you hold them and soothe them, the more mad they get. But also, you know, they don't know how to soothe themselves yet. And this is the time where they're starting to roll over, so you need to stop swaddling for safety reasons. So just so much is happening for the baby that sleep, you almost certainly will go through sleep regression as three-ish, four-ish months. And sleep regressions are real. I mean, the term is not really accurate in that it's more of a cognitive progression. Your baby is learning a lot of new stuff, is developing, is learning new skills, all good things. But it just so happens that sleep takes a little bit of a hit, because I mean, imagine for yourself, like if you suddenly learn to fly, I mean, would you be sleeping very well, right? Or would you be super excited being like, oh my god, I know how to fly, right? So that's what's happening to babies when they learn to roll, when they don't to sit and, you know, babble and talk and walk and all that stuff. So we really shouldn't hold it against them for having sleep regressions. Okay, so now I'm like beating around the bush with the cryo-dial thing. Okay, so we're going to be a real evidence-based and very compassionate at the same time, okay? So evidence base is that extinction-based sleep training is perfectly healthy. It is good for baby sleep, is good for parent sleep, is perfectly fine for attachment, perfectly fine for babies, emotional, cognitive, you know, social well-being. And there are short-term studies, there are long-term studies. There are studies that follow these kids into childhood, adolescence, adulthood, fine. Like nobody is like being damaged from cryo-dial. Another myth about cryo-dial, I want to bust off the bat, is that it's not like forever, you know, I think sometimes people think you just like you put the baby in the room, you leave and you don't come back till morning and then you just do that until the baby grows up. But really like it's really more like three to five days. Both of my baby sleep training three days, maybe four for Finn. Sometimes you have to redo it, you know, after regression, but it's never going to be as bad as the first round. So really, it's not a matter of, am I going to let my baby cry or not? It's a matter of, do I let my baby cry a lot for a short period or a little for a long period? Because there's no magic baby that's going to never cry, you know, at night or at bedtime. They're protesting because they don't like the fact that you're walking away. And this is a really good evolutionary mechanism, by the way, because back in the day when we were living, you know, on the savannah, you know, a baby should never be left alone because that baby will immediately become a snack for predator, but we're not dealing with that anymore. So even though our evolutionarily built in traits are still, you know, manifesting, that doesn't mean we have to always answer those want because they're not necessarily needs. Of course, that's based on the premise that you take care of your baby's needs, feed, clean, you know, burp, all of that. And if your baby's sick, obviously don't, don't, you know, don't do it, go answer them. But extinction-based sleep training is not damaging, it is effective, and it's like ripping off the bandaid real quick. And then everybody sleeps better after that. And that's actually good for everybody's mental health and good for preparing child bonding because if you're in a better mood, you can bond better with your child. Agreed. Understanding that it is individualized from family to family, what's an appropriate time to do the first round of that training? What months? Yeah, usually I would say somewhere between three and six months. We don't want to do that, yeah, we don't want to do that earlier than that because, well, occasionally it is appropriate to do it earlier, but usually let's say like the middle, you know, majority of the bell curve would be like three to six months. Because before that, likely your baby still needs to eat during the night or has other needs or just, you know, it just isn't quite capable of sleeping through through the night yet. But we also don't want to wait too long because the longer you wait, the more cognitively advanced your baby is, the more physically mobile your baby is, and the harder it is going to be on them to do cry it out. Because think of your 14 month old. I mean, if you were doing cry it out for the first time now, how difficult would that be? She would be like, why is this happening? Like, you know, she would be like saying words to you about how bad this is. Like, that's not helpful for anybody. And also another reason is they're like, if you're already going to go through a sleep regression at four months, you kind of might as well just do it all on one go. Like, unswaddle, sleep regression, cry it out kind of all at the same time. And another reason is because sometimes your baby will ask for it. Like, both of my babies, they got to the point at three and a half months, four months, where they were just like, you're pissing me off more by holding me right now. Like, this is not working for me. They would just get so pissed that I like just out of respect for them because they were flailing and kicking so hard that I would just put them, have to put them down. And then they were, they were so crying, but they were happier or like less mad. And so some babies will actually tell you when they need their own space to just figure it out and learn to self-soothe. And if your babies telling you, well, listen to them, you know, some babies won't tell you. So then at that point, like you and your partner just have to have a conversation and get emotionally ready and and do it. Awesome. Well, thank you for that. I do want to keep this applicable to all people. I know we talked a lot about special populations, but I want to bring it back to times of high stress for other individuals. And I know you're in a perfect position because you are a mother of two, you're a clinician, you're a researcher, you're a scientist, you're an author. So you wear a lot of hats and clearly you're a busy person, your speaker, right, your podcaster. And, you know, with it so much on your plate, I'm wondering how or what have the lessons that things that you're speaking about that kind of perianatal period postpartum strategies, tactics, things that you mentioned, how have they helped you in other avenues of your life? And what are some lessons that those who are not necessarily parents at this time, but do live those high stress lives, maybe that 30 year old we talked about trading crypto, who is not giving themselves sleep opportunity, can employ, or maybe even the resident or the medical student or somebody to take an optimizer's quality. Yeah, great question. I think there are a lot of lessons that are generalizable to other populations. The first one I'll mention is about circadian rhythms again, but I say this knowing that a lot of people in the medical field just don't have the luxury of keeping, you know, regular conventional daytime hours because you'll have a shift work, right? A lot of people, medical professionals, you know, emergency services professionals, and a lot of our essential workers during COVID did shift work. So that is really difficult. So I want to acknowledge that upfront that I think, you know, as much as we do want to talk about individual strategies that we can employ, sleep is a societal thing too. It's a systemic thing. And this is especially important because some populations are more prone to the societal disruptors on sleep than others. So like shift workers are much more likely to be black and brown. For example, you know, you know, many people who are less wealthy and less privileged are living and working in conditions that are less conducive to sleep. So there are many things that we can do as individuals and then there are many things that are kind of up to a bigger changes that we may not just we can't just we can't cover that on this podcast, but I think it is really important to remember. So that being said, if you are able to swing it like, you know, a decently length maternity leave or if you're not a mom, you know, if you can, try to stabilize your circadian rhythm as much as possible. Because this is such an underappreciated aspect of sleep and every other aspect of health that you will be really shocked, I think, to how much better you feel once you get your clock on track. So just to give a personal example, with my first child, my goal was to maximize my number of hours of sleep. I was just like snatching sleep left and right whenever I could sleep when the baby sleeps, you know, like my husband and I had totally offset sleep schedule so that like he could take care of the baby all night while I was sleeping and he was like sleeping during the day and it was that turned out to be not a very good plan. For my second baby, I prioritized my circadian health. So I was like, no, I am going to live my normal life and try to try my best to, you know, protect sleep when I can and nap when appropriate instead of turning my entire schedule upside down around this baby. And I mean, honestly, it was much easier to do that with baby number two because my toddler kept me in line because he gets up at 630 and he goes to bed at this time. So I needed to wrangle him between those hours. So by doing that, I actually ended up getting more sleep, better quality sleep, having less postpartum depression and having just generally more successful functioning and parenting than the first time around. And just better mental health overall. So I think this can be applied to people who, you know, are students who maybe work around the clock, have high stress jobs, you know, there are times when you can't help but do those things that you need to do. But when you can help it, really try to stabilize your circadian rhythm, get up at the same time every day, including weekends with a one hour-ish, you know, leeway, and then nap strategically to catch up on lost sleep and get lots of light during the day, activity levels moving your body when you can during the day really teach your body the difference between day and night because that will go a really long way. Oh, I've had Jade. This is super, super, super helpful and it's so nice to have all these high-yield points here just in, you know, an hour 25 minutes where people can just come to and learn all of this. Honestly, I think, I mean, ultimately you can correct me, but I'm sure it's pretty hard to find all this information. I mean, a lot of times you have to go scatter to different websites and things. So I'm super excited to send this episode out to some family that I know is going to be expecting and that hopefully me and my wife will be revisiting in a couple of years or so. But hey, you have a book coming out February 7th and that's the day this will be published, so this episode. Yeah. Tell us about Hello Sleep. Well, thank you so much for bringing that up. So Hello Sleep is my third baby. I wrote it while pregnant with baby number two. And so yeah, I'm really excited. This is my sort of me trying to speak to all the insomniacs of the world because there are just not enough insomnia specialists out here and I know many of y'all are suffering through nights feeling so isolated, so alone, so frustrated, feeling like there's something wrong with you. There's nothing wrong with you. You know, your sleep, believe it or not, can be good. You know how to sleep. Your brain wants to sleep and knows how to sleep. We just need to figure out what are the things getting in the way. Take those barriers out and allow your body to get back to doing what it does best. So yeah, the subtitle of Hello Sleep is The Science and Art of Overcoming Insomnia without medications. And I think I put both science and art in there because well, one, you know, it's it's very evidence-based. This is cognitive behavioral therapy and other behavioral sleep medicine tidbits that are very well backed by research. But I also wanted to emphasize that this is not just a like sleep hygiene list. This is not just a checklist where you go, you know, if I mechanically walk through these steps, my sleep will be better because there is a relationship building here. You need to rekindle your love for sleep and invite sleep to be your friend again. Because by the time you have chronic insomnia, you've probably developed a strained relationship with sleep that plays a probably a much bigger role in your insomnia than you know. So my goal is to help people romance their sleep, have a beautiful lifelong relationship and be able to sort of roll with the punches that life frames and still have good sleep. So yeah, I'm really excited to put it out there. Amazing. Yeah, no, that's going to be super super helpful for everyone out there. We'll definitely put the link to Amazon. Is that the only Amazon anywhere else? Can they get that in the bookstores or anywhere? Yeah, lots of bookstore.org, your local bookstore shelves, Barnes and Noble. And you can go to my website, which has kind of a link to all the different sources and you can choose your favorite place to buy your book. But yeah, thank you. Awesome. So we'll definitely put, yeah, we'll put all the links down there in the show notes. Jade, where else can our listeners find you? What else are you up to? So my personal website is drjboo.com where the doctor is dr. So drmyname.com and I also invite you to check out goodnightmama.com. Currently it's not quite ready yet, but stay tuned, sign up for the newsletter, put it on your RSS feed because this is what I'm working on next. This is really like going to be my fourth baby because I really, really want to help, especially moms, but all parents to, you know, like you said, not just survive, but thrive. And I think a crucial ingredient for that is sleep and it's just so hard to find information on that. Even I, you know, like I do this, I do sleep stuff for living and I had no idea for my first baby, so I figure it must be hard for other people too. So I really wanted to create a resource and a community for parents to be able to go there, know that it's all scientifically sound, you know, evidence-based stuff, but also know that they can find a very compassionate voice because there's nothing, like there's nothing worse than feeling judged when you're trying your best, right? So as a mom myself, I really, really want to put that compassion and help out there. Well Jade props to you. I am here just dragging through life because every day my toddler is up one and I'm down negative something, but here you are talking about having a third of four babies. So that's awesome. I want to thank you so much for coming on, for educating us, for educating me. There's so much that I took away from the selfishly that I can implement immediately and certainly in the future and I think a lot of other people are going to find the same. We asked you last time and we'll ask you again, but this one is going to be sleep edition only and it's essentially the kind of tagline mission of the show you might remember. It's, you know, how do people add the health back to healthcare with the sleep edition? Yeah, I remember loving this question last time and I still do. So let me say a little different from last time since we talked so much about parianatal and parenting and children's sleep. I think healthcare should be social. It should be, you know, family systems. It should be community. We should take into account the fact that health doesn't happen in a vacuum. There's so much relationship involved, right? I mean, we talked about just the setup of who's and what room to sleep together makes a big difference for everybody's sleep quality and we should really know about that and counsel patients about that and just have that be part of the, the ingredients for helping people to restore their health. Fantastic. Thanks so much, Jane. Thanks, Jane. Thank you. Yeah, thanks so much for having me. Thank you so much for tuning in. As you can tell, Altamash and I learned a ton and it's because even though we're physicians, we don't get taught this stuff in medicine, you know, it's really hard information to find. And as Altamash alluded to in the episode, a lot of the times for this information, we have to scramble to different sites and different sources and we hear different things. So it's truly nice to have Jane who come on and have a single place where we can now understand how we should be sleeping and different strategies that come to sleep, especially around that perinatal period. Now, I don't have kids yet. Altamash does, so he's obviously going to use some of those techniques, but I have family members who are expecting and I have friends and family who have little ones and they're going to greatly benefit from this episode and I'm sure you guys all know people who are in that stage. So please be sure to send them this episode so that they can catch up on their sleep and feel better and avoid the postpartum depression and avoid the struggles that maybe you may have gone through if you do have kids. So truly appreciate you guys listening in. Don't forget to subscribe. Listen to the other episodes. Episode 47 is also a gem from Dr. Jade Wu on this podcast. Medical disclaimer, everything in this podcast is for educational purposes only. It is not constituted by medicine and we are not providing medical advice. No physician, patient, patient, laser, informed, anything discussed in this podcast, not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues. And lastly, I'd like to thank our team, Yaman Bershiri, Harita Yapuri, and Ethan Zhu. We'll see you next Tuesday.