October  15,  2015     Dear  school  officials,  public  officials,  parents,  teachers,  coaches,  and  students:     I   am   a   Pediatrician   and   Sports   Medicine   trained   physician,   parent   of   two   middle   school   athletes,   and   strong  supporter  of  youth  activity  and  movement  in  order  to  maintain  health.    Remembering  that  sports   is  a  means  of  learning  about  life,  society,  and  yourself,  I  am  always  hopeful  our  communities  can  find   ways  for  everyone  to  be  active  and  engage  in  physical  movement.    It  is  this  overall  view  of  healthy  living   through   sports   that   leads   me   to   strongly   believe   we   should   start   school   later   for   our   middle   and   high   school  students.     The   American   Academy   of   Pediatrics   has   been   clear   in   recommending   starting   school   no   earlier   than   8:30am   for   all   middle   and   high   school   children.     This   is   re-­‐enforced   with   similar   endorsements   by   the   American   Academy   of   Child   and   Adolescent   Psychiatry,   American   Thoracic   Society,   and   the   CDC.     Teenagers  are  not  little  adults,  nor  are  they  physiologically  children  anymore.    We  all  know  puberty  is  a   time  of  great  change  physically  and  emotionally,  but  what  many  are  not  aware  of  is  the  shift  in  circadian   rhythms   (our   internal   clock)   occurring   simultaneously.     Teenagers   of   many   animal   species   are   programmed   to   go   sleep   later,   BUT   they   still   require   more   sleep,   approximately   9   hours   per   night.     With   the  hectic  schedules  our  society  has  created  for  teens,  many  of  them  cannot  achieve  this  needed  goal.     In   2010,   one   study   found   only   8%   of   high   school   students   slept   close   to   9   hours   per   night,   while   33%   were  sleeping  6  hours  or  less.    Very  quickly  these  children  fall  into  a  sleep  deprived  state!     Many   others   will   speak   to   the   general   effect   of   sleep   deprivation   on   mood,   behavior,   academic   performance,  and  cognition.    In  this  letter,  I  will  focus  on  athletics  and  how  starting  school  later  can  help   our  young  active  teenagers,  and  possibly  open  the  discussion  on  how  to  get  ALL  teenagers  to  become   more  active.     Regardless  of  their  sport,  athletes  want  to  continuously  improve  their  performance.    More  and  more  of   our   young   athletes   are   training   year-­‐round   for   one   sport   with   many   of   them   overlapping   with   other   sports  throughout  the  year.    Top  that  off  with  work,  academics,  and  a  social  life  and  there  is  not  much   time   left   for   sleep.    But   sleep   is   critical!     In   2012,   one   study   found   teens   sleeping   at   least   8   hours   per   night   had   a   68%   LOWER   risk   of   being   injured   than   those   sleeping   less   than   8   hours.     Those   sleep   deprived  correlate  directly  with  athletes  suffering  overuse  and  fatigue  related  injuries  (stress  fractures,   tendinopathies,  myofascial  pain).     Why   is   sleep   important   to   an   athlete?     When   we   sleep,   our   bodies   cycle   through   REM   and   NonREM   stages   in   order   to   allow   memory   repair   and   consolidation,   rebalancing   of   hormones,   and   recovery   of   tissue   damage   from   normal   use   and   injury   all   of   which   are   critical   for   normal   growth,   learning,   and   remaining  healthy.    With  sleep  deprivation,  our  stress  hormone  (cortisol)  is  elevated,  our  restoration  of   glycogen  (stored  fuel)  is  decreased,  and  the  ability  to  metabolize  glucose  is  diminished  by  30-­‐40%.    This   leads  to  less  fuel  for  the  brain,  decreased  immune  function  to  fight  off  illness,  and  an  increased  risk  of   obesity.    Living  in  this  chronic  fatigue  state  will  increase  the  athlete’s  risk  of  injury  and  possibly  evolve   into  overtraining  syndrome,  where  the  body  just  can’t  physically  perform  to  its  capacity  anymore.       Athletes  develop  new  skills  and  abilities  by  pushing  their  bodies  and  minds  beyond  what  they  think  they   can  do,  let  it  recover  and  adapt  to  this  new  norm,  and  then  push  it  once  again.    This  is  how  strength,   endurance,  and  accuracy  improve.    Those  with  adequate  sleep  have  been  found  to  have  increased  free   throw   accuracy,   faster   sprint   and   reaction   times,   and   better   mood.     Those   with   inadequate   sleep   function   with   decreased   focus,   cognitive   slowing,   memory   impairment,   diminished   attention   and   poor   vigilance,  all  having  a  negative  impact  on  performance.    It  appears  athletes  can  power  through  a  single,   high  intensity  test  when  tired,  but  without  adequate  sleep,  they  fatigue  easily  on  sub-­‐maximal,  repeated   efforts,   which   most   sports   require.     They   don’t   have   the   energy   reserve   to   keep   up   to   their   normal   level   of  performance.     We  all  want  to  do  what  is  right  for  our  children.    In  this  case,  biology  is  telling  us  9  hours  of  sleep  per   night   is   what   our   teens   need.     If   I   offered   a   medicine   that   would   decrease   the   risk   of   injury,   improve   academic   and   sports   performance,   and   allow   maximal   normal   growth   to   occur   with   the   side   effects   of   a   lower  risk  of  obesity  and  improved  mood  in  your  teen  all  for  FREE,  who  wouldn’t  come  get  that  pill!    We   have  access  to  that  medicine  right  now,  adequate  sleep  for  teens!    Shifting  school  start  times  will  likely   affect   the   timing   of   after-­‐school   activities.     In   regards   to   athletics,   this   can   be   done   collaboratively   amongst   school   districts   and   still   allow   the   approximately   20   minutes   required   of   “pre-­‐game   warm-­‐ups”   and  full  completion  of  the  game.     Thank  you  for  your  consideration  of  this  critical  change  to  our  school  systems.  A  healthier  starting  time   will  help  the  most  important  people  in  that  system,  our  teens.     Sincerely,       Lucien  Ouellette,  MD,  FAAP   Pediatrics  &  Sports  Medicine  Physician  OA  Centers  for  Orthopaedics Division  of  Spectrum  Medical  Group   (Portland,  Saco,  Windham  and  Brunswick)     This  letter  has  been  reviewed  and  endorsed  b y  the  following  board  certified  Sports  Medicine,  Pediatric   and  Family  Medicine  physicians  caring  for  teen  athletes  in  York  &  Cumberland  counties:     OA  Centers  for  Orthopaedics   Regional  Sports  Medicine  Physicians     Doug  Brown,  MD,   James  Findlay,  DO   William  Heinz,  MD   Benjamin  H.  Huffard,  MD   Alison  Lee,  DO   D.  Scott  Marr,  MD,  FACSM     Michael  D.  Pleacher,  MD,  FAAP,  FACSM   Margaret  Bordeau,  DO,  MPH  –  Southern  Maine  Health  Care  Pediatrics   William  Dexter,  MD  –  Maine  Medical  Center  Sports  Medicine   Allyson  Howe,  MD  –  InterMed  Sports  Medicine   Philip  M.  Kowash,  MD  –  Southern  Maine  Healthcare  Family  Medicine   Timothy  B .  McAteer,  MD  –  Martin’s  Point  Sports  Medicine   Joan  Pelletier,  DO  –  Southern  Maine  Health  Care  Pediatrics   Bradford  Wagner,  MD  –  InterMed  Sports  Medicine                  RECOMMEDATIONS  FOR  NORMAL  SLEEP  HYGIENE     You   can   change   your   sleep   hygiene.     Pick   1   or   2   things   from   the   list   above,   which   seem   most   likely   to   be   changed.     Once   successful,   then   move   onto   items   which   seem   more   challenging   for   you.     Expectation   would  be  for  improved  sleep  within  a  couple  of  weeks  if  these  changes  were  applied  consistently!     1. Try  to  go  to  bed  and  get  up  at  the  same  time  each  day.    Deepest  sleep  occurs  between  9:30PM   and  11:00PM,  so  try  to  gradually  pull  your  bedtime  back  to  this  range.    A  change  of  15  minutes   each  night  is  often  tolerable  so  don’t  try  to  change  too  drastically.   2. Use  bed  for  sleep  only.    No  reading,  hanging  out,  or  watching  TV  in  bed  as  these  activities  train   your  body  to  be  awake  in  your  sleeping  spot.    If  you  must  do  these  activities  in  the  bedroom,  use  a   small  chair  and  sit-­‐up  until  you  are  ready  to  actually  lie  down  and  go  to  sleep.   3. Get  10-­‐30  minutes  of  early  morning  sun.    Sun  sets  your  sleep-­‐wake  cycle.    Waking  up  with   sunshine  will  set  your  circadian  rhythm  to  sleep  later  in  the  evening.   4. Exercise.    Mild  to  moderate  exercise  daily  help  to  regulate  the  sleep-­‐wake  cycle.    A  walk  at  lunch   or  after  dinner  is  often  enough.   5. Avoid  napping.    If  you  must  take  a  nap,  limit  it  to  45  minutes  or  less.    Napping  interferes  with   deep  sleeping  at  night.   6. Avoid  large  meals  or  drinks  in  the  last  hour  before  bed.    Foods  with  tryptophan  in  them  can  help   induce  sleep  (turkey,  warm  milk).   7. Avoid  caffeine  in  all  forms  after  4PM.    Coffee,  tea,  soda,  chocolate.   8. Avoid  tossing/turning  in  bed.    If  you  are  still  awake  after  20  minutes  in  bed,  get  up  and  read  a   boring  book  (phone  book).    Go  back  to  bed  when  you  begin  to  feel  tired.    Avoid  TV,  computer,  or   interesting  books.   9. Relax  before  bed.    Take  a  warm  shower  or  bath.    It’s  easier  to  fall  asleep  if  your  body  temperature   is  dropping.   10. Learn  relaxation  exercises.    Deep  breathing,  muscle  relaxation,  meditation,  or  imagery  before  bed   each  night  will  signal  to  your  body  it  is  time  for  bed.