- The parents of a 3 month old infant are exhausted because their baby gets up approximately 3 times at night for feedings. They would like to know how they can get their baby to sleep through the night. What would you recommend to them?
ANS: It is not until the age of 4 to 6 months that babies will sleep through the night. One can therefore expect a 3 month old to get up often at night regardless of what the parents do.
- You are seeing a 9 month old baby girl in your clinic and the mother complains that she has not been getting enough sleep at night. While her baby goes to sleep quite easily, she gets up every 2 or 3 hours throughout the night, crying and fussing. The baby usually falls asleep around 9PM in the mother’s arms while she rocks her; then she is put in her crib shortly afterwards, only to wake up a couple of hours later. The mother picks her up, soothes and rocks her, and she is back to sleep once again. Yet, two hours later, the baby wakes up crying again. What do you think is happening? What guidance would you give the mother?
ANS: This is a sleep association problem [refer to sleep stage progression]. The baby has gotten used to the condition of being rocked in her mother’s arms to fall asleep. Unfortunately, when she gets up from Stage IV sleep, her surroundings have totally changed and she is understandably distressed. She must be conditioned to fall asleep in the surroundings she will be in for the rest of the night, and only then will she not get up on a regular basis. General considerations as the child grows older: consistent schedule, never use bed as place of play/punishment, calming bed routine, put child in bed awake, avoid stimulating activities just before bed
- A 2 year old child is brought to your clinic because the parents are frightened by his nightmares. Recently, he has started getting up a few hours after falling asleep, thrashing about and sometimes screaming. During these episodes, he is sweating profusely, and the father, who is a paramedic, notes that his pupils are dilated and his heart is racing. The parents try their best to wake him up, but to no avail. About ten to twenty minutes later, he falls asleep again, and the parents wake him up to make sure he is all right. At that point he does wake up, seems completely fine, and in fact, does not go back to sleep so easily. What do you think is the problem, and how would you guide the parents?
ANS: These are sleep or night terrors. They occur during the first third/half of the night, and are partial awakenings from Stage IV deep non-REM sleep; kind of a simultaneous “awake” and “deep sleep” state, or a poor transition between the deep sleep states. However, sleep association is not the problem and neither is any particularly troubling anxiety; in fact the child never really wakes up fully, and when he does in the morning, he will probably seem normal. Keeping a distance, making sure he is safe, and not waking him up afterwards may help. Sleep terrors may signal excessive anxiety or stress in children older than 6 – consider psychological counseling in these cases. Note the differences between nightmares and sleep terrors below; pay special attention to what time of night they occur, along with the other characteristics. In general, exploring and stressful frightening daytime occurrences may be helpful in elucidating an etiology. Comforting and reassurance is usually all that’s necessary, although if they are persistent and causing significant disturbances, don’t forget to think about some major traumas that are happening at home, like DV or child abuse.
Night terrors Nightmares
Age > 18 mos (4-12 y = peak) all ages (3-6 y = peak)
Sleep state NREM REM
Time of night First 1/3 Last half
Autonomic d/c Yes No
Movement Active Little
Alert or consolable No Yes (after waking)
Remembers? No Yes
Can go back to sleep? Yes No
- You are seeing a two week old child in your clinic for the first time. During your intake, you find out that a distant cousin on the paternal side died of SIDS three years ago. The mother also states that she co-sleeps with her baby every night, because she finds it easier to nurse her in this way. What other information do you want to know? How would you counsel her with regards to co-sleeping?
Ans: The AAP Task Force on SIDS recently published recommendations that discouraged bed-sharing (or co-sleeping). They do encourage room-sharing with the crib next to the parents’ bed. It turns out that there are many experts who are disputing this universal recommendation and would like to see it revert back to counseling parents on how to co-sleep safely if they decide to do so (i.e., to take a neutral/more harm-reduction based approach and focus on more definitive risk factors for SIDS like smoking). This conflict is based more or less upon differing perspectives regarding how much data do you need to have and how accurate and reliable must it be before you can establish a “definite” association and therefore a universal recommendation. In addition, we have to be cognizant of cultural and social factors in tailoring our health promotional messages so that we take into account commonly accepted practices of the communities we take care of. When counseling parents about co-sleeping, keep these in mind (i.e., need to inquire in this case):
- Discourage smoking. Smoking is a definitive independent risk factor for SIDS that has often thought to be the confounder that accounts for the risk of co-sleeping with SIDS, although that is now being debated.
- Discourage use of alcohol or drugs, as well as any soft bedding, such as water beds, because they have been associated with increases in overlying.
- Also, higher risks have been noted with co-sleeping on couches
In addition, this baby’s risk of SIDS is the same as that of the general population, and home monitoring is not recommended because it has not been proven to have any benefit. This is true even if the relative who died of SIDS was a sibling.
- On a routine well child care visit of a 5 year old girl, the parents state that she snores every night and appears to stop breathing occasionally while asleep (not every night). She doesn’t take any naps during the day and doesn’t have any daytime sleepiness. What other questions would you ask and how should you proceed?
Ans: Snoring may be the sign of obstructive sleep apnea syndrome or sleep-disordered breathing, which is a failure to maintain airway patency during sleep. This occurs because of airway narrowing (congenital or acquired) and poor contraction of the dilator muscles of the airway (neurologic or muscular). These dilator muscles are important because they counterbalance the negative pressure generated intraluminally during inspiration. Adenotonsillar hypertrophy is commonly thought to be a major factor in the pathophysiology as its growing size between the ages of 2 and 5 compromises the airway lumen. Hypoxemia and hypercapnea result, especially during REM sleep (which happens in the latter half of the night)when muscle tone is at its lowest. Risk factors for OSAS include obesity (although most children with OSAS have failure to thrive) and neuromuscular disorders, like Down’s Syndrome, micrognathia, cerebral palsy, and hypothyroidism. Common symptoms include: mouth breathing, snoring, nighttime apneas, hyperextended neck position. The nighttime sleep arousals occur because of hypoxia and hypercapnea which stimulate respiratory drive. These arousals as well as the hypoxia can lead to behavioral disturbances, daytime sleepiness, poor school performance, and failure to thrive. In severe cases, there can be secondary enuresis, right-sided heart failure, pulmonary hypertension.
Snoring is the most common symptom and the most confusing, as there are many children who have primary snoring and who do not have sleep disordered breathing. Asking about the above symptoms can help distinguish OSAS from primary snoring, but the best test is polysomnography. In mild cases of OSAS, nasal steroids have been shown to reverse symptoms and signs, so this is one option.
In moderate to severe cases, or if nasal steroids do not show improvement in 3 to 4 weeks, then a referral to ENT should be considered as a tonsillectomy/adenoidectomy may need to be performed – adenotonsillectomy has been shown to have a 75 to 100% cure rate for OSAS. If symptoms and signs persist, CPAP has been used with some success.
