TOW #47: Sleep problems

This week we are continuing a theme of addressing sleep and broadening the topic for sleep problems beyond the newborn period.


Take-home points for pediatric sleep problems:

  1. Epidemiology: In community surveys, 25% to 50% of preschoolers and up to 40% of adolescents experience sleep-related problems. These are common problems so it pays to know them well!
  2. Sleep duration varies by age: There is substantial variation in need for sleep, but generally, newborns sleep 16-20 hours and most can sleep through the night by 3-6 months. Infants sleep 13 to 15 hours, 2 to 5 year olds sleep 11 to 12 hours, school-age kids sleep 10 to 11 hours, and adolescents ideally 9 hours.
  3. Educate parents about normal sleep patterns, consistency in sleep routines, and appropriate sleep environment to prevent sleep problems. The natural rhythm of sleep follows a 70-100 minute cycle through deep sleep/REM/arousal. For many children, transitioning between sleep stages leads to a wakeful state. This can be a problem when combined with the developmental phase of separation anxiety and lead to increased nighttime demand for the parent. Appropriate parental response (through gradual removal of parent role) will lead to improved sleep habits. Sleep routines: key is consistent schedule and the 4 Bs: (Bath), Brush, Book, Bed. (In our house we add "Ballads" and do nighttime songs. 🙂 Environment: quiet, low nightlight, cool, and definitely no TV or other devices in the bedroom.
  4. Screening: Ask about BEARS: Bedtime problems, Excessive sleepiness, Awakenings at night, Regularity and duration, and Snoring. If you can only do one, ask about snoring to screen for obstructive sleep apnea (OSA). See articles for diagnostic criteria of specific disorders.
  5. Referral and resources: When concern for OSA, or other sleep disorder that is interfering with function, consult with a sleep specialist. Our own SCH sleep clinic experts provide handouts and info here.

Wishing you a happy Memorial Day weekend and time to remember all those who have served.

TOW #46: Infant sleep

Infant sleep is among the highest priority areas that we address in the early months, both from a safety and a quality of life standpoint. Those who have experienced a difficult sleeper can empathize with how incredibly challenging this is. The recommendation for Back to Sleep is unquestioned, but some other infant sleep guidance is less clearcut. It's helpful for us to be familiar with various sleep recommendations and how we help families navigate these.

Materials this week:

Take-home points to review on infant sleep:

  1. Epidemiology of SIDS: Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant less than 1 year of age which remains unexplained after autopsy & review of death. Reducing SIDS through the Back to Sleep campaign has been a great success in pediatrics, as SIDS rates decreased by half since implementation in 1992. It is considered one of the top 7 research achievements in pediatrics: SIDS is uncommon before 1 month of age (~10% of SIDS deaths), peaks between 1 and 6 months of age, and is rare after 8 months.
  2. What are some risk factors for SIDS? SIDS involves convergence of 3 factors – environmental factors, a critical period of development, and intrinsic vulnerability (i.e., dysfunctional or immature cardiorespiratory systems). Environmental risks include prone sleep position, sleeping on a soft surface, bed sharing, young maternal age, overheating, multiple births, and multiple siblings. Intrinsic vulnerabillity includes preterm birth, low birth weight, male sex, maternal smoking during pregnancy, previous stillbirths, African-American or American Indian race, as well as URI infections.
  3. How should we discuss infant sleep? Our role is to support families with accurate information and explore their beliefs. In a 2012 study, <1/2 of internet resources (43.5%) contained accurate information about infant sleep. Ask open-ended questions about where baby is sleeping and in what position. Safest sleep for babies is on their backs in their own sleeping unit without extra blankets or stuffed animals. Co-sleeping/ bed-sharing is the highest cause of death under 3 months- it is especially dangerous if parents smoke or drink alcohol. Review evidence and encourage room-sharing rather than bed sharing.
  4. What if a baby has difficulty sleeping? There are a number of resources out there and variable recs on strategies: 1) swaddle or not, 2) swaddle with arms or legs in or not, 3) pacifiers or not & for how long, 4) graduated extinction "cry it out"/"Ferberizing" or not, etc. It can be tough for parents to navigate all of this, so we need to be able discuss what we think may work (based on research, experience, family preferences, etc). Personally I liked reading the Baby 411 chapter on sleep – a helpful summary of different strategies. I also liked Dr. Richard Ferber's book Solve Your Child's Sleep Problems (which covers much more than graduated extinction – see great dialogue where he demystifies some of the interpretations of his work).
  5. Refer to specialists when the family/infant are struggling. In Seattle, we are lucky to have some great sleep experts at Seattle Children's. When all else fails, time is on the side of the parents. Some of the best pediatricians I know who've had infants with sleep challenges tried everything without much success until their infant grew and eventually became a good sleeper. There is hope!

Wishing you all some restful sleep this week!

TOW #45: Adoption

Our next TOW is adoption medicine. A big thanks to Dr. Julie Bledsoe, one of the national experts on adoption medicine and founder of the Center for Adoption Medicine for her input on this topic.

Materials for this week:

Take-home points for adoption:

  1. How many children are adopted – from where and to whom? Overall 2% of children in the US are adopted. Each year >100,000 children are adopted, of which about 22,000 are international adoptions. In a 2013 statement, the AAP supported civil marriage rights for all parents and ‘willing and capable foster and adoptive parents, regardless of [their] sexual orientation.’ As of 2015 Florida was the only state banning adoption by LGBT individuals.
  2. What are some of the health issues for adopted children? Many children entering foster care or adopted domestically or internationally have special health care needs including physical, developmental, and mental health concerns. Risk factors include poverty, limited prenatal care, malnutrition, neglect, and perinatal and postnatal exposure to toxins, especially drugs and alcohol. Children who have been adopted internationally may have unknown or misdiagnosed neurologic, hematologic, cardiac, and metabolic disorders, and medical records from other countries (if available) may be limited or unreliable.
  3. What is the pediatrician's role after adoption? An initial comprehensive pediatric evaluation after adoption should be done to evaluate existing medical diagnoses, assess for unrecognized medical issues, discuss development and behavior concerns, and make appropriate referrals. This evaluation can take place over multiple visits, including physical exam, which may be more difficult because of children's prior trauma. Children should be screened for infectious diseases based on what is endemic in their country of origin. Have a low threshold for referral to specialists when problems are identified.
  4. What are the priorities for physical exam? Our exams should assess for growth parameters, micro- or macronutrient deficiencies, congenital disorders (i.e., fetal alcohol syndrome, genetic abnormalities), genital abnormalities, and abuse. WHO growth charts are recommended under age 5 and CDC charts for 5 and above. Carefully assess skin, nails, eyes, and hair for protein or vitamin deficiencies, as well as for scarring. Age-appropriate vision, dental, and hearing screening are needed.
  5. How can pediatricians help families adjust? Children being adopted are by nature experiencing some trauma as they adjust. Parents can help transitions by providing 1) supportive and responsive care, 2) routines and regular schedule, 3) time and patience for healing from trauma and loss, 4) physical contact (hugs, holding), regular conversation, and reading, music, and toys. Parents also feel a range of emotions including regret, despair, isolation and disillusionment as they face challenges and should be encouraged to seek out support and counseling, too.

TOW #44: Discipline

This week’s topic comes courtesy of the expertise of our own wonderful Dr. McPhillips. We have certainly been the beneficiary of her sage advice in our household.

Materials for this week:

Take-home points for discipline:

  1. Definition: Discipline means “to teach” and should not be confused with “punishment.” Fundamentally, we want children to know that we love them and care about them, and that’s why we set age-appropriate limits. We promote “positive discipline” in pediatrics: having a loving relationship, teaching and modeling what we want them to do (and setting up their environment for them to be successful), and reinforcing limits by decreasing unwanted behaviors without shaming or corporal punishment.
  2. Extremes in discipline are a problem: Authoritarian parenting tends to be overly restrictive, demanding, and “doing it because I say so.” Permissive parenting is too loose and sets few limits, allowing a child too much leeway in deciding the rules. The best outcomes are with an authoritative approach: being firm AND loving, setting limits and knowing it’s okay, providing boundaries and opportunities to make decisions within those boundaries.  
  3. Spanking is not recommended. While spanking may still be used by a lot of parents, it has many negative associations including increased aggression, emotional distress, and escalating to abuse, and is less effective at older ages. Direct families to more effective strategies.
  4. Time-outs are one strategy; if used, know some pitfalls. Time-outs are one strategy used to remove children from a situation where they may be harming themselves or others and to reinforce calming themselves down before re-joining activity. These have become more controversial among discipline experts and alternatives are offered, especially parent time-outs! Those who advocate child time-outs remind us they should not be viewed as punishment, and are especially preferred to physical punishment. To be effective, time-outs need to be consistent, kept short, and clear. Parents need to be calm and use few words and to not convey that they are leaving/abandoning their child.
  5. Help parents recognize triggers and build positive connections. We want to help parents recognize their child's needs, especially for love and connection, and know their child's triggers for negative behavior. One great trigger acronym I've learned from my husband (a clinical psychologist) is HALT: Hungry, Angry, Lonely, Tired. These triggers are true for all of us but especially for young children. Recognizing meltdowns/ misbehavior as a sign of unmet need in a little one can help us be more empathic and calm in our responses as adults.