Behavior and Sleep Disorders and the Visually Impaired

Originally presented March 19, 2020

by Dr. Spandana Nallapati, MD

A quick review of how circadian rhythm affects sleep cycles and how this functions in children with visual impairment. A review of evidence-based treatment options and sleep hygiene education.

Transcript

Sheila

All right, thank you everyone for joining the Lighthouse Guild tele-presentations. We are so fortunate tonight to have Dr. Nallapati, who currently works as a Developmental Behavioral Pediatrician at Children’s Specialized Hospital in Jersey City. She graduated from Ross University Medical School in 2012, and completed her pediatric residency in Brookdale Hospital in Brooklyn, New York. While relatively new to the industry, she is quickly finding that being an advocate for patients and their families is one of her greatest passions, especially those from inner-city neighborhoods. In her time outside of work, she shares a love of scuba diving, gaming, hiking, traveling and food with her husband. Thank you so much for joining us tonight. I’ll turn it over to you.

Dr. Nallapati 

Thank you so much, Sheila. And thank you, Linda, for this. And thank you to all you parents for inviting me. And coming on at a time where I’m pretty sure, learning more about sleep disorders isn’t quite exactly on the top of your to-do list tonight. Between figuring out how to homeschool, and also being your kids PT, OT, speech therapist, homeroom teacher, feeding instructor, sleep-time manager, etc, etc. I think that we will soon learn why we need to pay our teachers more really, really quickly. And thank you so much, truly I do mean it. It’s an important topic, but it’s a stressful time. And I know that this is truly still relevant in this time of stress, and I hope that we shed some light on things. So what I’m going to do is I’m going to jump right in. And as Sheila did a wonderful introduction of me, you know, I am a developmental pediatrician. I am from New York, I work in Jersey, but I live in New York City. So just to give you sort of where I’m based off of.

Let us jump in, I’m going to share my screen, then I’m going to go on to my PowerPoint. And please let me know if you cannot see my PowerPoint presentation for whatever reason. And the only thing I would request is that you mute yourself.

The reason that I mentioned that I’m from New York City is that we speak fast. And I guarantee you that I’m going to finish pretty quickly. I’m going to leave plenty of time for questions. But while we do the lecture, if everybody wouldn’t mind just muting, muting their microphones, that would be fantastic against any feedback that we hear. So let’s get started. 

So tonight, we’re going to be talking about the very exciting topic of sleep. And I call it exciting in the same way that maybe a polar plunge in Antarctica is exciting as in it’s super, super stressful, and it’s really not funny when it actually happens to you. So, we’re going to be talking about sleep disorders, and all of us have sleep issues, there are nights that we can’t fall asleep. There isn’t anybody I’ve met as a teenager, and as somebody who went through medical school, I’m well-versed in being sleep deprived.

But what we’re talking about today, is children with what is usually referred to as NDD, which is neurodevelopmental disabilities, which really covers the full gamut of disabilities. Whether it’s visual impairment, whether they have autism, whether you have cerebral palsy, or you have a combination of a lot of these things- most of the time, children with visual impairment, rarely have just that. They usually have something else they come with, for example, a syndrome, or ADHD, or autism or some sort of an issue. And all of these put together we call them neurodevelopmental disabilities, but no two are alike. And each parent struggles with a different set of struggles. And each child, in the same way, has a different set of strengths that we have to empower them with.

The prevalence of sleep disorders in these children that have NDD can be as high as 80%. And that just shows you that basically, if you have a developmental disability, you’re going to have an issue with sleep at some point in your life or another. It could be anywhere from, he never fell asleep through the night when he was a baby to he’s gone… I had a mom yesterday that she called feeling absolutely crazy because it had been the fifth day that her child hadn’t slept. And she was going to lose her mind, and she had tried everything. It can be just that, it can drive you literally crazy. 

What is the most important thing when it comes to sleep? And it’s ocular light exposure. That’s a very, very fancy way of saying light. And the light that we see through our eyes. Even the majority of people who are legally blind, actually retain some degree of light perception. And I think that’s a big, big misunderstanding that a lot of people have, when it comes to children with visual impairment is that they say, well, you can’t see. What you can see doesn’t exactly mean what you perceive and what your brain can take in. Just because you can’t talk, the voice is not the only way to communicate, there is sign language. And there’s other things and there’s expressive and receptive parts of language. It’s the same with sleep.

And that is the very first thing that we look at, which is light, and that is controlled by our eyes. So that is what takes in the light. And this is a quick little visual, I promise, I’m not going to get too crazy into neuroanatomy or anything. But I do think that one thing that families aren’t given a chance to do when they’re explained this in the office, is that they’re not given a chance to fully understand all the different parts that could be affecting their child’s sleep. I always believe the more information the better when it comes to any issue with your child. I think the more you know, the better you feel and the calmer you feel when things go wrong.

So, if we look at the diagram, you see, the light comes in at number one. And that is where your receptors are, don’t worry about the fancy words and everything, but just take a look at this- this is how your brain and your eyes work together in order to perceive light. And what is the most important thing when it comes to sleep? It’s the circadian rhythm. So sleep/wake cycles, alertness and performance patterns, core body temperature rhythms, and the production of hormones such as melatonin and cortisol are all regulated by an endogenous (and the word endogenous just means inside the body), near 24-hour oscillatory index, we’re just gonna call it SCN of the anterior hypothalamus. So lots of big words there. And the basic idea is that basically, you take in light, and there’s a certain part of your brain that is called the pineal gland that produces a hormone called melatonin. And there’s another part of your brain that creates something called cortisol. And both of these things act together in order to help you set your sleep rhythm. And out of those two, the very much more important mechanism and hormone that’s in control of your sleep is melatonin.

So, let’s spend a minute on melatonin because you hear about it all over the place. And it’s going to be one of the things we talk about to take when you have sleep issues. And I know a lot of families will probably already have some experience using melatonin and it may have helped, it may not have helped, and you’re unsure of what it actually did. But a lot of people will say, well, it has no side effects, and it’s super safe, but nobody quite explains why it’s super safe.

One of the main things about melatonin is the major biochemical correlate of the light/dark cycle, and it’s provided by the pineal melatonin rhythm. What that means is that under normal light/dark conditions, melatonin is produced only during the night, and it produces an internal representation of the environmental photoperiods. Like what does that mean? Melatonin tells your body when to sleep. It means that when melatonin is produced, it’s supposed to be nighttime. And that’s a huge thing in our children who don’t have a good perception of light because they can’t tell when it’s nighttime. And if you can’t tell when it’s nighttime, then your body can’t produce melatonin at the right time, which means that your body doesn’t know that it’s dark.

Nighttime levels are roughly 10 times higher than daytime, and levels fall sharply before daylight and are barely detectable in daylight hours. What does that mean? That means that your body is telling you when to sleep through melatonin. And it’s also telling you, as importantly, when to wake up. So when doctors, like me, are kind of pushing you parents to use melatonin first before any other prescription medication., it’s because we’re trying to explain to the body through melatonin that, hey, this is when you need to sleep. And this is when you need to wake up, because you can’t figure it out yourself because you don’t have normal photo and light perceptions. 

Now, let’s talk just a second about why we need sleep. Why do we make such a big deal of sleep? And here, it’s a very busy slide, but I’ve written a few small things. There have been books written about this on all the things that happen when you don’t get enough sleep. Impaired sleep not only predisposes children to mood, behavioral and cognitive impairments, but also has an impact on physical health, which in turn may further dispose them to sleep difficulty. So, it’s a cycle. It’s such a vicious cycle. And we see this in our children every day, they don’t sleep well, they’re cranky.

If you have a child with autism, it makes all of their behaviors worse, if you have a child with ADHD, it makes them crankier and it’s harder for them to focus. They don’t learn as well, they don’t retain information as well. These effects may be even more pronounced in children with underlying neurodevelopmental vulnerabilities. That’s all of our children. There is clear evidence that insufficient or inefficient, (so insufficient, not enough and inefficient is good quality) sleep adversely affects learning, memory, cognitive flexibility, verbal creativity, attention, abstract reasoning and other executive functions that are related to the prefrontal cortex. So that’s the front part of the brain that’s involved in executive function, it means that it’s the front part of your brain that helps you organize. It’s the front part of your brain that helps you think before you speak, and be organized in your life, and make executive decisions.

Sleep loss is known to result in increased irritability, depression, poor affect modulation, impulsivity, hyperactivity, and aggressiveness. Health outcomes of inadequate sleep in children include potential deleterious effects on their cardiovascular, immune, and various metabolic systems, including glucose metabolism, and endocrine functions, as well as coordination and an increase in accidental injuries. And to sort of break that down, you get sick more often, you have more of a chance of having heart issues as you’re growing up, you can have issues with weight loss, or weight gain, because you’re not getting enough sleep. And we’ve all seen it, we’re a little bit more clumsy when we don’t get enough sleep. And now imagine it in a child, though, that already has neurodevelopmental disabilities, such as visual impairment, or, you know, autism, or ADHD, or a combination of anything. 

This is a further education on all the different words that are thrown around. I wanted to put this in there, but again, I apologize if it’s a little too much sciency. But I just wanted you to know the different terminologies that doctors will use and what they might mean. So, insomnia is the inability to stay asleep, or fall asleep. So, that’s a really important thing that we’re going to talk about later is that a lot of parents will say, my kid can’t fall asleep, but once he falls asleep, he can stay asleep. Okay, my kid can fall asleep, but they keep waking up in the middle of the night over and over again. 

Hypersomnia causes the person to be excessively sleepy. People with hypersomnia may fall asleep at times that are inconvenient or even dangerous, such as work or while driving or at school or standing at the edge of a train station, etc. 

Sleep related breathing disorders, obstructive sleep apnea is a really common issue that becomes even more prominent with weight gain. These days with our children’s increasing obesity issue, this is a big problem that children have and it usually starts with something as simple as snoring and inability to sleep, and it can really get out of control. 

Circadian sleep disorder- this is the most common disorder that we see in children with visual impairment. It’s a condition in which the sleep times are out of alignment. A patient with one of these disorders does not follow the normal sleep time at night. More than 70% of people who are totally blind have something called non-24 sleep wake disorder.

Parasomnias are unwanted events or experiences that occur while you’re falling asleep, sleeping or waking up. 

Sleep movement disorders are conditions that cause movement during or prior to sleep. These disorders can make it difficult to fall asleep, or stay asleep, or to get restful sleep.

 And this is a quick explanation of what non-24 hours sleep wake disorder and sometimes it’s shortened to N24 or non-24. A lot of you may have seen this in your children’s diagnosis, just because of how common it is. But basically, instead of sleeping at roughly the same time, every day, someone with N24 will typically find their sleep time gradually delayed by minutes, or hours every day. And they sleep at later and later clock times until their sleep periods go all the way around the clock. I don’t know if that’s something that some of you struggle with your children, but we could definitely talk about it in a minute.

So, everybody talks about sleep hygiene, and I’m sure it’s the first thing that your doctors have told you when you’ve said my kid isn’t sleeping well. We mean well as doctors, but we sort of have a script, right? We all start with asking the same questions and you sort of look at them and go, you don’t think that I tried that? But sleep is still important,

Man

Yeah, quick question. So, this is very, very informative. I just wanted to clarify, you earlier said that melatonin is totally safe and does not have any side effects. So, the first question is that, at what age a child could have melatonin, and how much? And the second question is about cortisol? So, you said that melatonin and cortisol work together to do this? And how do they work together? Thank you.

Dr. Nallpati

No problem. Those are two really good questions. The first question we’re going to handle in about two or three slides, we are going to talk about all the different medicines that we can try for the sleep issues, and melatonin is the first one we’re going to tackle. So, I will answer that question at that time.

To do a quick description of how cortisol works. Basically, melatonin and cortisol work in distinction as cortisol. So, what is cortisol? Just to give you an idea, cortisol is a stress hormone. When someone asks you a question out of nowhere, and you sort of freeze and you don’t know what to say, we call that the cortisol freeze. When we were medical students, we knew that very well. You all of a sudden can’t even remember your name. It’s your stress hormone. It is the hormone that when you are under stress, you can’t sleep.

In a very basic way, and I would love to get into this in another lecture, but basically, cortisol is also released in sort of a rhythmic fashion during the day and during the night. And it’s pattern matching with melatonin’s pattern is how you get a good night’s sleep. When those two mismatch is when you don’t get a good night’s sleep. And to sort of bring that to a more practical, sort of what you can picture it. Basically, if you’re stressed out, if you have a lot of anxiety, that means that you have high cortisol running through your system, and you’re not going to have a good night’s sleep, you may fall asleep, but you may have a lot of nightmares, and you may have a lot of issues.

If your body’s cortisol system is releasing cortisol at the wrong time, let’s say a two o’clock in the morning, instead of four or five o’clock in the morning, which is usually when it releases it along with growth hormone, then you wake up early, and you’re having trouble sleeping, because all of a sudden you have this stress hormone running through your system when it’s not supposed to be released. So that’s a little bit, and I apologize it’s a little bit of a basic way to explain how those two work together, but basically, it is what modulates stress. We will get back to the melatonin question, I promise.

So, as I said, sleep hygiene. So all doctors, we love to sort of harp on it and parents sometimes get frustrated because they say I know all of this, I do all of this, but I believe that a lot of of families have tried most things. And most doctors mean well and they start to explain this to you because they say okay, did you try everything? And sometimes when you’re, you know I had a parent today, they were talking to me about something and they said, oh my gosh, when I said it out loud I just came up with the solution myself. And sometimes it helps to talk these things through with your doctor to say, “Oh, I didn’t think of that. Let me try that.” 

So what is sleep hygiene? It’s a set of sleep related behaviors that expose persons to activities and cues that prepare them for, and promote appropriately timed and effective sleep. So, the there are four parts to sleep hygiene. One is basic, optimal environment, which includes temperature, light, noise level, etc. The next is scheduling. The next is sleep practice. And the last is physiologic sleep promoting factors. And we’re gonna touch on all of them a little bit now. 

Environment and we’re gonna go a little bit into light, but it could be anything. It could be the choice of mattress, pillow, blanket, that may be very important. For example, is it a comfortable mattress? Is it a comfortable pillow? Is it a weighted blanket? Some children really do feel much more comfortable with a weighted blanket than a light blanket. Is it too hot? Is it too sweaty? Are the sheets on the bed making them sweat. Exposure to even low levels of light inhibits melatonin secretion by the pineal gland disrupting the circadian mediated sleep onset. Children with Cortical Visual Impairment tend to stare into a light source for self stimulation, and this light gazing can keep them in an alert state.

So, what do those two things mean? It means that for our children with visual impairments, it’s extremely important that we look at the light sources in their room. Now some children don’t sleep, if the room is absolutely dark, we understand that, but at the same time, we have to realize that if there is even one light source, then some children will just stare at it even if they don’t really even mean to. It’s just that it’s the only thing that they can perceive because they already have a low perception of light, so their gaze kind of goes towards it. It’s kind of like being in a forest and all of a sudden you see something move, you’re going to look at it, and so you can’t see much, but you can see this little shiny thing in the corner of your eye, you’re gonna keep looking at it, and that’s going to affect their sleep. So, having a very dark environment that has no light source coming out of it is extremely important. 

Encouraging physical activity during the daylight hours. So during the daylight hours, if you encourage physical activities, it may help children with NDD sleep better at night, because bright daylight aids the nocturnal melatonin rise and may promote better sleep and mood. And I absolutely know between wintertime and these crazy viruses, it’s extremely hard to get kids out and active. But the important part of this point is less the activity, and more the light hours. So, it’s all about getting a little bit of sunlight. And for them to feel that sunlight, because then they’ll have an idea that oh, this time is really, really bright. And so when you take away all the light source, then their brain can really shut down and say, oh, okay, so compared to where I was all day, this is really, really dark.

Now, if you can’t leave the house, another good thing is that they do sell these lights that mimic daylight. And those are things that you can find on Amazon, and I find that some parents use those when their kids are stuck in the wintertime, they’re stuck in the house all day. They make the house much, much brighter, so that when it’s time for bed, they make it absolutely dark with dark, dark curtains and there’s no light streaming from the bottom of the door and everything, then true darkness is even more effective because in the daylight time they were exposed to a ton of light. 

So, the next is scheduling. Although regular bedtimes and wake up times should be enforced for all children the institution of a consistent sleep wake schedule may be particularly important with children with MDDs because they’re uniquely vulnerable to both sleep and circadian rhythm disruptions. And this is really important and this is a really tough one. There should not be more than one hour difference between the bedtime and awake times during the week and weekends. We all want to sleep in, and I completely understand that. But for children, especially with visual impairment, and in addition, any other disabilities, routine is really important. Schedules are really important. And letting them sleep till 11am or letting them stay up till 2am. It really does disrupt their timings and for my patients I go as far as telling the families that a month before school starts I ask them to start implementing this again. Because in between extended school years and that recommendation, basically the child is on the schedule all year round. That can be a bit of a torture for families, and I understand that and I respect that. It’s just that when this routine is broken, putting the routine back is so very difficult.

Sleep practices, so children may be easily overstimulated because their brains have difficulties processing extra information, so it results in an overload state. Clinical experience suggests that stimulation occurs in response to new and unexpected events like anxiety, excessive noise, cold or heat, vigorous exercise, hunger, large meals at the same time, pain, seizures, and certain drugs. Alternatively, calming activities include, well-structured routine behaviors, like quiet baths, listening to stories, lullabies, prayers, small snacks, the presence of a small toy or familiar blanket, a comfortable bed with the secure and quiet environment.

Rhythmic, repetitive, low-frequency movements, quiet sounds, soft music and gentle touching seems to have a calming influence on all young children. Playing tapes of heartbeats can also be calming to small infants. Regular daily routines and structure assist in reinforcing circadian rhythms. I love this word, and I put it into all my sleep lectures, it’s called zeitgebers, and I may be saying that wrong, for any Germans in the chat, but they’re basically time cues. The time cues are basically when you have a pattern, your brain starts to understand what that pattern means. Which means if bath time every day is 8pm. And your brain starts to realize that bath time is always followed by story time, followed by sleep, your brain, when it starts to take the shower at night, starts to cue itself down, and to understand then after the next two steps, you’re going to sleep.

Children with those time cues every night, sleep better because they understand the structure and routine. Although having meals before bedtime may disrupt sleep maintenance, and thus should be avoided, a light bedtime snack consisting of carbohydrates is useful, because hunger is one of the causes of impaired sleep in children. 

Other potentially sleep interfering behaviors such as television, viewing in close proximity to bedtime, consumption of beverages containing caffeine, and vigorous physical exercise within a few hours of sleep onset should be avoided, should be curtailed. 

Okay, so, that was a lot. But let’s talk about what happens when your child has an issue. What do you do? So first, you talk to your pediatrician, or your developmental pediatrician, or your specialist, or whoever you see regularly. But, before you walk into the office, at least a week before, and in this one, I say two to four weeks. Before you go in, the minute you start to realize that this is something that you want to talk to your doctor about, keep a sleep diary, talk about their sleep patterns, talk about all of this, so that we don’t bother you. Use this as a guide. Tell us what their environment looks like. Tell us what their schedule is. Tell us what your sleep practices are. Tell us how you promote their sleep, so that we already know where we’re starting from. If we know that you already did all the stuff we’re about to tell you to do, hopefully a good physician listens and doesn’t make you do that all over again. 

These days, we have all kinds of technology. There’s Fitbit, and there’s things that promote your sleep. And if you’re lucky enough to have one of those things, record it. There are certain types of Fitbits that measure your sleep. Record it and bring it with you. The doctors would love to see that. They would love to get an insight on your child’s sleep. You don’t need to. A sleep diary is just as good, but if you’ve got it, use it. 

So sleep tests, which are also called polysomnographic evaluations, are rarely done as routine and should only be done once your doctor checks and sees. Maybe your child has really big tonsils, and they think you’ve told them that they snore. Maybe your child is overweight, and maybe that’s a reason they’re snoring. Maybe they’re having obstructive sleep apnea, but allow the pediatrician to make that call. You don’t need to get that done before you go and speak with the doctor.

The next thing you’re going to tell them is, and every doctor is going to ask you is, does your child have trouble falling asleep? Staying asleep? Or both? Because it depends on what the problem is, for us to think about what the answer is. And first is behavioral management, and that is sleep hygiene. I apologize, I don’t think I finished my sentence and thought there. But basically, having a good plan to improve sleep hygiene. Whatever the sleep hygiene is, as good as you thought it was, it can always be better. So talk with your pediatrician, talk with your specialist and say, these are the things that I’m doing. Do you see anything in here that I could do better? Maybe I need to get a sound machine, maybe I need to get a humidifier, maybe I need to get those very thick curtains that block out light, maybe there’s a thin seam at the bottom of the door that’s letting some light in. Maybe there’s a ticking clock in the room that’s keeping my child up. Something. So always have that discussion first. We always want behavioral management first before we go to medication. 

Medication. So, there are two important things we need to realize when we’re talking about medication. One is the fact that these are children, and not adults. And for adults, there’s a huge plethora, and those are called hypnotics. Those are medications like Ambien and Zolpidem. Those are medications that will, in some form, knock you out. Even Benadryl is like that, you know, you take Benadryl you get sleepy, you fall asleep. It isn’t a natural way to fall asleep. And that is, if at all, the very last thing that we do. No hypnotics are recommended for children.

The very first thing that we recommend for children when they’re having sleep issues, whether it’s falling asleep, staying asleep, or both, is melatonin. Now just to clarify, melatonin helps more with children that are having trouble falling asleep than staying asleep. Melatonin helps more with sleep initiation. But as we discussed earlier, melatonin is overall a hormone that needs to be regulated anyway. So, if your child is having any kind of sleep issues, we’re going to want to fix their sleep schedule first, naturally, which means giving them melatonin.

And to answer your question from earlier, I have very, very young children, children as young as three or four, on melatonin. Because it is an over-the-counter box, you can just go to Walgreens or CVS or Rite Aid. You can pick it up in gummy bear form, in liquid form, in pill form. And right on the box that will tell you how much you can give depending on the child. And there are some guidelines- roughly from three to five years old, they would like you to start with one milligram. And then you can try to go up a little bit. I would always discuss any medication management, exact dosing with your pediatrician or your specialist.

But, basically, the idea is you start with the absolute lowest dose possible and wait, and give it every single night, and also put into effect the sleep hygiene behavioral management that you spoke about with your family physician, it could be, or your pediatrician or your specialist. After you’ve given it a few weeks, at least, then you speak with them again and say you know what? I tried it at this milligram, can I go up on it? And you go and you increase the medication as per your pediatrician’s advice. Yes, you started by following the directions on the box. But a lot of our children with visual impairment and other developmental disabilities you know, I like to call them stubborn. They don’t like listening to medication, something that would knock me out cold for two days, I have had my patients just kind of laugh at it and they fight it. So, I’ve learned my lesson to take children very seriously when it comes to their sleep issues. You may need to go up higher than you feel comfortable with, or what it says on the box, but you should always do it with the help of your doctor. 

The next thing is Clonidine. Clonidine, just to give you an idea, is originally a medication, is still used as a medication for blood pressure management in adults. But at extremely low doses, starting usually from 0.1 milligram, it is used in children, especially with neurodevelopmental disabilities for sleep. Now Clonidine helps more with staying asleep, than falling asleep. So, when I hear a child is waking up over, and over, and over again at night, and if I’ve tried melatonin already, then I go to Clonidine. Rarely, I even put them together, but only, and absolutely, and please do not go home and try this on your own without talking to your doctor, that is an absolute biggest disclaimer for this. But having said that, Clonidine also comes in two flavors. So, Clonidine also comes in liquid. So, clonidine itself is short acting, and it should last through the night. But for some children, they use it up. They metabolize it so quickly, and in that case, there is a longer acting version of it that children can take. It goes from 0.1 milligram to .4 milligram, and usually, that’s it. So those are four dose increases you have before you run out of options for Clonidine.

As I said, we do not give hypnotics to children. It has been a one in a million case when I’ve told a parent that maybe just for one night, they can try Benadryl, because if not, I think somebody would have gone crazy. It’s just not a natural way to sleep, it’s not a long-term solution. We want to fix this, not just for one night, but we want to fix it for the long term. 

Earlier we talked about a specific circadian rhythm syndrome called N24. And recently, there’s been an FDA approved medication for it, which I put all the way at the end. But by the time we get to hypnotics, you are absolutely now being sent to a sleep specialist. Your pediatrician or your developmental pediatrician isn’t really going to go past Clonidine. There are some antidepressants, anti-anxiety medicines, for example, Trazodone. Some use something called Remeron or Mirtazapine, which some of your families might have used. And if anybody has a question about it, I can go into those deeply. But as I said, when we’re getting to those big guns for sleep issues, then now we’re getting psychiatrists, sleep specialists involved, we’re going the next step. So, hopefully, we get the sleep issues controlled by the time we hit Clonidine. 

Okay, and I know that that was a lot. I understand that and I hope that everybody’s still awake. And please feel free to bombard me with questions, and I’ll answer as many as I can, to the fullest extent I can. If I don’t know something, I will look it up and I will get back to you.