Sleep Ponderings from Me: Questions for You

If your child fits into the 25% of children with sleep problems you may want to ask yourself a list of questions:

• Does your child get the appropriate amount of sleep for their age?
• What is your bedtime routine? Is it comforting?
• Do your evening activities include no TV or nonviolent programs, nonviolent computer games, reading, and a bath?
• Does your child have bedtime refusal, stalling, and/or difficulty falling asleep?
• Does your child have any sleep issues after going to sleep: confusional arousals, sleep terrors, nightmares? How many night wakings a week?
  
• Do they have any symptoms of obstructive sleep apnea (snoring, gasping, breathing pauses, restless sleep)?
• Do your kids participate in weekday, night, or weekend activities that take away from adequate sleep? What activities do they participate in?
• Does your child take a nap? When? How long?
• When does your child eat? Do they take medications? How much caffeine do they consume and when?
• What signs of sleepiness do they show? Anything abnormal (falling asleep at inappropriate times, hyperactivity, irritability, behavior problems)?
• Is there any stress within your family?

If you are left perplexed and don't feel like you are ready to deal with your child's sleep issues alone please contact a physician, sleep center, or me.

Article Review Day 12: Summary of the Study

You may think, "Hmm, my kids don't get that much sleep but I don't think they are tired. They don't yawn much, or fall asleep in the car or at school. And they have so much energy at night! How could they be tired?"

Well, according to the Sleep in Infants article by Davis, Parker, and Montgomery and my observations, "children often manifest symptoms that are paradoxical to sleepiness such as irritability, hyperactivity, short attention span, and low tolerance for frustration." Now, you may be thinking, "That sounds like my child." Let's remember that 1 in 4 children has some sort of sleep problem. "These indicators are often overlooked because children may have a long history of these symptoms or they may be mild in nature."

As parents, educators, people in contact with parents and children, we need to advocate for the importance and necessity of sleep. "Considerable clinical and anecdotal evidence supports an association between sleep loss and resultant cognitive and behavioral changes. Children's emotional and behavioral problems often significantly improve when underlying sleep problems are identified and rectified resulting in the attainment of adequate amounts of sleep. Furthermore, several studies have found a link between typical symptoms of inadequate sleep in children and symptoms characteristic of attention deficit/hyperactivity disorder (ADHD)."

So, think again before thinking "Sleep, Shmeep". This is serious stuff- just increasing the amount of sleep our children receive could change our child's behavior, performance at school, emotional well-being, decrease kids accidents and injuries, and even answer some of the unanswerable questions regarding ADHD.

Article Review Day 11: Rythmic Movement Disorder

Rythmic Movement Disorder is dyssomnia.

I am just going to tell you what the article states on this issue. It is beyond me.

"Rhythmic movement disorder involves the rhythmic movement of large muscle groups, such as the head and neck, and occurs when the child is drowsy, attempting to fall asleep, and can continue into stage 1 sleep. The first incidence usually occurs before the second birthday; headbanging and body-rocking are the most common types seen in practice. Polysomnographic monitoring during an episode can rule out a medical cause such as seizure activity. The disorder is usually transient and self-limited and seldom requires treatment."

Article Review Day 10: Sleep Terrors vs. Nightmares

My oldest daughter has nightmares every once and awhile. She wakes up upset and tells me about the nightmare or "bad dream" as we call them. They are usually about something that she has heard about or seen the day before. I am already very cautious about what my children watch on television, but I am extra cautious about what my daughter watches since she is very sensitive. I am also cautious about the conversations my husband and I have around her and the other kids- I don't want my children to be burdened with undue stress that they don't understand.

Nightmares occur in 25% to 50% of children ages 3 to 6. Both boys and girls struggle with these. "Occasional nightmares are not worrisome, but recurrent nightmares or those with disturbing content may indicate excessive daytime stress. You should gently question children regarding their daytime experiences such as tv shows or encounters with other children to try to determine possible frightening content or situations." After you figure out why your child is having these nightmares you should do whatever you can to "eliminate or reduce the child's exposure" to whatever is causing the nightmares.

I know parents that also struggle with sleep terrors. You may wonder what the difference is? Both are just being scared during sleep, right?

Well, sleep terrors usually begin after 18 months old, where nightmares usually begin between 36 and 72 months old. Sleep terrors usually occur during the first third of the night, where nightmares occur during the last half of the night. Sleep terrors occur during NREM (non-rapid eye movement, stages 1 to 4) and nightmares occur during REM sleep (stage 5). With sleep terrors the child appears extremely agitated- screaming, increased heart rate, and dialated pupils could occur. With nightmares the child is sometimes agitated but to a much lesser extent. The child does not wake up during sleep terrors even though they may seem awake and they don't usually remember in the morning; the child does wake up with a nightmare and can remember details and often still remembers in the morning. The child does return to sleep easily with sleep terrors and it is suggested that you gently guide them back to their bed. The child does not return to sleep easily with nightmares.

"Children with more violent, prolonged, or unusual episodes should be evaluated at a pediatric sleep disorders center. Although sleep terrors are often very disturbing to parents, they can be reassured that sleep terrors are a developmentatl phenomenon and are not a sign of underlying issues."

Please share your experiences with sleep terrors and nightmares.

And another resource from a recent article from the National Sleep Foundation: nightmares

Article Review Day 9: Sleepwalking

I'm sure everyone has heard stories of someone who sleepwalks... people eating in their sleep, walking through the house, or??? Please feel free to share a sleepwalking story.

"Sleepwalking is common, occurring in 1%- 15% of children, and usually begins when the child is between the ages of 4 and 8 years." So, what does it really mean to sleepwalk? "A sleep walking episode consists of minor actions such as sitting up in bed, walking around the room or house, or other activities... Sleepwalking can persist into late adolescence and adulthood."

What should you be wary of if you have a child who sleepwalks? Take precautions to guard doors, windows, and stairs. "The sleepwalker does not meaningfully interact with people and is often easily agitated. Arousal is difficult and, if successful, the child will appear confused. Recollection of the event is rare."

So, what should you do? Gently direct your child back to bed without waking them up. You should intervene to avoid an injury. You may want to come up with a creative solution that will inform you if your child is leaving their room, for example, a bell on the bedroom door, or? Please share anything you have found to be helpful.

Article Review Day 8: Confusional Arousals

Confusional Arousals is a parasomnia.

Have you ever heard your child have minor episodes of mumbling or grimacing, disorientation, or inappropriate behaviors during sleep? I have not experienced these with my children, but some parents have. "Confusional arousal occurs in the first 3 hours after sleep onset when the child experiences an abrupt transition from the deepest phases of NREM sleep" to lighter sleep stages. Sometimes parents don't even know this occurs because the child stays asleep during the episode and doesn't remember the next day.

If you do notice such an episode with your child, it is good to know:

• "Most episodes are brief, averaging 2 to 10 minutes in duration, and end when the child re-enters deep sleep."
• "Predisposing factors include obstructive sleep apnea, overtiredness, sleep deprivation, and irregular wake/sleep schedules..."
• "These episodes are harmless and you should not awaken the child."
• "Confusional arousals diminish as the child matures."
• If your child also has one of the predisposing factors you need to look into altering their sleep schedule so they can get the appropriate amount of sleep.

Article Review Day 7: Obstructive Sleep Apnea Syndrome

Obstructive Sleep Apnea Syndrome is a dyssomnia.

Who: 2-3%, the highest prevalence is in preschool-aged children

What: It is "a disorder of breathing characterized by partial or complete upper airway obstruction during sleep. The obstruction can be intermittent or protracted and interferes with normal ventilation and normal sleep patterns."

When: During sleep.

Where: In bed.

What: "Symptoms include nightly snoring frequently accompanied by sporadic pauses, gasping, choking, disrupted sleep, and daytime attentional and/or behavioral problems. Associated problems include chronic rhinitis, nasal congestion, mouth breathing, otitis media, sore throats, halitosis, and frequent upper respiratory infections. Frequent complications include attention and behavioral difficulties, restless sleep, and growth impairment."

Why: The abnormal body functions that accompany this particular syndrome are an inadequate supply of oxygen to the tissues resulting from apneas (suspension of external breathing) and leads to numerous arousals from sleep.

How: How does a parent deal with this? First, if any of these symptoms seem familiar, you need to pay careful attention to your child's sleep. "Children with suspected OSAS symptoms should be referred to a pediatric otolaryngologist for evaluation, and a sleep study should be considered."

Article Review Day 6: Insufficient Sleep Syndrome

You struggled with your baby's sleep; you struggled with your toddler's sleep; you continue to struggle with your preschoolers sleep. "Insufficient sleep syndrome arises when a child regularly fails to get an adequate amount of sleep to maintain appropriate wakefulness during the day. The child's usual sleep period is shorter than predicted by age-based norms, and the child may experience daytime sleepiness or other behaviors indicative of sleep loss in child (e.g. problems with attention and concentration, irritability, and hyperactivity). Hmmm, could this have been the problem with some of my students all those years?

Besides the guidelines on the number of hours of sleep children need I often give which I find to be pretty accurate, (In general newborns should nap after 1-2 hours of being awake and then sleep for a large amount of time with a feeding or two mixed in. Infants will then transition to a three or maybe straight to a two nap a day schedule through 12-18 months. They should get 14-15 hours of sleep. Toddlers will have an afternoon nap and should get about 12-14 hours of sleep per day. Preschoolers may or may not have an afternoon nap and will continue with 11-13 hours of sleep per day. School age children should get 10-11 hours per day.) a few questions to consider in checking if your child is getting enough sleep are:

• Can he/she fall asleep easily at night (in less than 20 minutes)?
• Can he/she wake up easily at his/her normal wake time?
• Does he/she require a daytime nap? (if a nap is age appropriate please make sure they nap)

Some Tips for Addressing Insufficient Sleep Syndrome:

• Take inventory of your busy life- what can you cut out to allow for your child to get their needed sleep? What activities do you need to cut out or limit in your child's schedule?
  
• Check out your child's sleep environment- can something be changed to make it a more suitable sleep environment?
• Are you too tired to enforce bedtimes? What can you do to fix this problem?
• Do you need to subscribe to Lullaby Luna to stay up on sleep ideas? Do you need to read a sleep book? Do you need to come up with a consistent discipline plan with your children? Are you educated on the "importance of sleep to a child's health and well-being?"

"Many adults do not realize the pervasive and profound effects that even a small amount of sleep loss can have on a child's cognition and behavior."

Article Review Day 5: Inadequate Sleep Hygiene

Sleep hygiene? Yes, we try to work on our kids dental hygiene as much as they will cooperate, but sleep hygiene? Really?

We all want to create good dental habits in our children to maintain the integrity of their teeth, in the same way to want to create "habits and activities that promote the initiation and maintenance of effective sleep." Poor dental hygiene creates cavities that need fillings. Poor sleep hygiene creates habits that "enhance wakefulness and interrupt the sleep period, which can lead to a decrease in the quality and quantity of sleep and excessive daytime sleepiness."

Examples of Poor Sleep Hygiene:

• "engaging in stimulating activities near bedtime"- you should probably skip the before bedtime basketball game
  
• "using the bed for non-sleep-related-activities" (e.g. playing, watching tv, time out)
• "routine consumption of caffeine near bedtime" (Note: chocolate has caffeine. I recently read that it takes a child up to 6 hours for caffeine to completely leave their body)
• "allowing the bedroom to be uncomfortable to the sleeper (too cold, too hot, too noisy, too bright, etc.)"
• "inconsistent bedtimes and wake times with or without inappropriate napping"

Ways to Change Sleep Hygiene and Create Good Habits:

• "develop a consistent, calming bedtime routine" (bath and storytime are good items to have in your routine)
• "activities such as reading and singing lullabies also can foster sleep onset"
• be educated on poor sleep hygiene and avoid
• work with a sleep specialist/doctor or sleep consultant to create a plan that works with the family's schedule and lifestyle and gets the child the sleep they need.
  

Article Review Day 4: Limit-Setting Sleep Disorder

Limit-Setting Sleep Disorder is a dysommnia.
Does anyone have a demanding preschooler? Does anyone has a preschooler who resists bedtime? Does anyone give into their preschooler? We all give into our kids at times- even the best parents have weak moments... consistent inconsitency can lead to this disorder.

The most common form of Limit-Setting Sleep Disorder is the preschooler who makes excessive (some requests may be normal but excessive is key) demands at bedtime to delay sleep. It looks pretty much the same in all homes: another story and another, water, potty again, another show, a parent going to sleep with the child or laying with them while they fall asleep. Whatever the demands may be, they make bedtime later, sleep time shorter, and bedtime and bedtime routine become inconsistent (ew! inconsistent).

"Bedtime resistance often leads to delayed sleep onset, which is classified as requiring longer than 20 minutes to fall asleep after going to bed. The degree of sleep loss depends on the actual length of time children require to fall asleep but is often enough to result in behavior and learning problems during the day."

How do I combat Limit-Setting Sleep Disorder you ask?:
-set up an appropriate bedtime where they get enough sleep. Figure out that appropriate bedtime based on how much your child's age needs.
-make sure your child is getting the needed amount of day sleep if that is appropriate for their age.
-create a bedtime routine. It may consist of: bath, book, PJs, teeth... What does your routine look like? I like to encourage a simple routine.
-help your child feel safe and secure in their sleep environment. You may also want to spend some fun time in their room during the day. You may also want to give children the chance to help arrange and decorate their own room. These things will help them feel comfortable being alone in their room.
-parental firmness- set limits and expectations and be consistent in them- both day and night.

Article Review Day 3: Sleep-Onset Association Disorder

Sleep-Onset Association Disorder is a dyssomnia (remember last Thursdays post?).

Night wakings are normal in infants and preschool children. They may wake up as many as 5 to 8 times a night. You may be thinking, my child sleeps all night (or at least most of the time). Or, you may be thinking, yep, they wake up about 5 to 8 times a night. Well, according to this article (I have been reviewing over the past few Thursdays) "the difference between children who are 'good sleepers' and sleep through the night and those who are 'poor sleepers' and wake frequently is their ability to self-soothe after awakening." So, even if you have a good sleeper that doesn't wake up they are probably just waking up and soothing themselves back to sleep. Self-soothing is wonderful and necessary. It sometimes means letting a child cry for a short period of time to discover how they will self-soothe. Many children are never given the opportunity to learn how to self-soothe. What does your child do to soothe themselves back to sleep? Do you soothe them back to sleep?

You may wonder why it is necessary for children to learn this skill. Well, if you soothe your child to sleep at bedtime with rocking or nursing or bottle feeding (this doesn't mean you skip a nighttime routine or if they fall asleep nursing they are going to be poor sleepers) they may learn to expect these as the way to go back to sleep when they wake during the night, and then you do these things to soothe them back to sleep during the night. "These children are unintentionally trained by their parents to expect these conditions and can experience many disruptions in their nighttime sleep leading to sleep loss. Parents also experience stress and a profound sleep deficit themselves because of night waking, resulting in potential for a negative impact on overall family functioning."

So, what do you do if your child has Sleep-Onset Association Disorder:
-Keep reading Lullaby Luna- informing yourself as a parent is a great way to help your kids get a new sleep routine.
-As a parent, you need to learn how "to help your children fall asleep in their cribs or beds and return to sleep during the night with minimal parental intervention."
-You may try "crying it out" or "graduated extinction" where you check on the child during episodes of nighttime crying- you make scheduled checks on the child and slowly increase the time between the checks. "During the checks, the parent should not hold or rock the child, as this will reinforce the crying and the need for parental intervention to return to sleep. By simply checking on the child, the child is reassured that his parents are still present but learns self-soothing techniques and often will accept that he is safe, his parents are near, and that he can fall asleep without the help from his parents."
Note: In my experience, crying will be part of this training, this training is necessary to create good sleepers, the younger the better (I like to do this by 5-6 months old), if your child is older it will take longer and probably be more difficult- not impossible, just more difficult.
-If you struggle to do this on your own or feel overwhelmed hire a sleep consultant.

Article Review Day 2: Normal Sleep and Sleep Problems

Definitions:
Normal Sleep-"After the newborn period, normal sleep can be defined as the quantity and quality of nonrapid eye movement (NREM) and REM slee necessary to refresh the child."
Sleep Problem- "A sleep problem is any sleep pattern that interferes with the refreshing nature of sleep or that appreciably disrupts the sleep of others."

Courtney interjected thought: I think that too many children do not receive "normal sleep". We need to make sure as parents that we make the strides necessary to get our children the sleep they need- that may mean cutting errands short, hiring a babysitter, staying in more often, saying no to your child as they try to temper tantrum their way out of bedtime. PLEASE make sure they get the sleep they need!!

Sleep Problem Examples:
-"Any sleep problem that interferes with the child obtaining the optimal amount of sleep required for normal growth and development, emotional and psychological health, and proper immune function."
-Minor sleep problems: awakening a parent for a drink every night or to go the bathroom or waking up at the crack of dawn(if this is a behavior the parent wants to stop) or if this is inhibiting the quality of the child's sleep or making it so the child does not get enough sleep

Types of Sleep Problems:
-Dysomnias "are problems in which the child has trouble falling or staying asleep at night, or experiences excessive sleepiness during the day."
*They are the major cause of "disturbed nighttime sleep and daytime sleepiness..." Most common of these problems include: sleep-onset association disorder, limit-setting sleep disorder, inadequate sleep hygiene, insufficient sleep syndrome, and obstructive sleep apnea syndrome.

-Parasomnias "involve behaviors or physiologic events that interrupt sleep after sleep onset, and include disorders of arousal, partial arousal, or with transition between the stages of sleep."
*They are frequently between the ages of 3 to 8 years old, "and children who experience one of these problems are likely to experience symptoms of another sleep problem. They are typically a developmental phenomenon and tend to subside as the child matures. In general, parasomnias are exacerbated by poor sleep schedules and inadequate sleep."
**"Parental education regarding proper sleep hygiene is essential for these children." (Great start visiting Lullaby Luna)
Examples of parasomnias: confusional arousal, sleepwalking, sleep terrors, nightmares, and rhythmic movement disorders.

Article Review Day 1: Sleep Problems

I just read an interesting article in an online medical journal. The article was written by Katherine Finn Davis, Kathy P. Parker, and Gary L. Montgomery.

They have found that "approximately 25% of children younger than 5 years experience some type of sleep problem. Whether the problem is acute or chronic, significant disruption to the child's sleep can occur and have a negative impact on the child and family."

As I have become more interested in sleep, I have reflected back on my teaching years... specific student's issues, SST meetings (Student Study Team), parent concerns and issues at home, etc. I think that amount of sleep, and really over all care, need to be a part of the process that schools go through as they work to identify and deal with a student's issue(s). I also think that doctors need to make sure that they are aware of a child's sleep as they work with a patient or diagnose a problem.

This article also states that "Pediatric health care providers are not well prepared in the basic aspects of pediatric sleep. Children with sleep problems who are seen in general pediatric clinics rarely have problems addressed, diagnosed, or treated, even when providers ask about sleep issues during the visit. Failure to recognize sleep patters can be attributed to parental lack of knowledge, lack of clinician expertise, or hurried discussions regarding the child's sleep behaviors." Because of this large percentage of children with some type of sleep problem, teachers, doctors, nurses, and social workers need to help parents in identifying and addressing sleep problems that really could change a child- their behavior, their attention span, their academic progress, their health... sleep is so important and necessary.

In the coming Thursdays, I will be looking at the different sleep problems highlighted in this study.