TOW #42: Sleep disorders

This week we broaden the topic for sleep problems beyond the newborn period. There are plenty of sleep-challenged toddlers through teens out there!

Materials:

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 and by person: There is individual variation in need for sleep, but generally, newborns sleep 16-20 hours and most can sleep longer stretches (4-6+ hour stretches) 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. Most children drop their naps before age 4 (give or take). Remember, sleep duration includes both daytime and nighttime sleep added together. After babies are about 6 months old, the natural rhythm of sleep follows a 70-100 minute cycle through deep sleep/REM/arousal.
  3. What are common sleep problems at different ages? One of the most common for toddlers is nighttime waking. For many young children, transitioning between sleep stages leads to a fully awake state. Combined with the developmental phase of separation anxiety and fear of the dark, this can increase nighttime demand for the parent. Gradual removal of the parent role in returning to sleep will lead to improved sleep habits. For teenagers, their circadian rhythm shifts and can shift their natural bedtime, often about 2 hours later –  a common problem is disrupting sleep drive with light stimulus from phones and devices. Sometimes teens compensate with long afternoon naps that diminish their sleep drive at night. Strategies include removing devices an hour before bed, not taking naps, avoiding caffeine in afternoon/evening, and trying to stick to a regular bedtime and wake-up within an hour of usual time.
  4. Sleep routines and sleep environment help with regular sleep: A consistent schedule is one of the most important parts of sleep routine. Dr. Canapari recommends keeping it simple enough that one parent can do alone. Use the 3 or 4 “Bs for bedtime”: (Bath), Brush, Book, Bed. (In our house, we added “Ballads” and include nighttime songs.) Environment: quiet, low nightlight, cool, and definitely no TV or other devices. Consider a fan or white noise machine, which can help with sounds in the house or outside (especially in our urban environment!).
  5. What are important issues we screen for? Ask about Bedtime “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). The articles above review diagnostic criteria of specific disorders. 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.

TOW #41: Hearing screening

This week’s topic is on hearing screening and common hearing disorders. I love the quote included in this week’s case discussion from Helen Keller: “Everything has its wonders, even darkness and silence, and I learn whatever state I am in, there in to be content.” Such a powerful reminder for us as we journey through whatever life brings.

Materials:

Take-away points about hearing screening:

  1. How many children are affected by congenital hearing disorders? 1 to 3 per 1,000 well newborns and 2-4 of every 100 NICU patients are affected by hearing loss. Prior to mandated hearing screening (now in all 50 states), the average time of diagnosis for congenital hearing loss was as late as 14 months. We should pay close attention to any family history of hearing loss as there are strong genetic factors.
  2. What are the key timelines in early recognition? Early Hearing Detection and Intervention (EDHI) programs have created guidance to help us with early identification of children who are deaf and hearing-impaired. Early detection allows children to develop language skills and academic performance that is similar to their hearing 41peers. EDHI follows a 1-3-6 month guidance for screening, diagnosis, and intervention. By 1 month, we want all babies to have a hearing screen (this now happens in the hospital in most places, but if they need a 2nd screening, this should happen before 1 month). By 3 months, we want to confirm diagnosis. By 6 months, we want to intervene for the best outcomes.
  3. What are the types of hearing loss? There are conductive, sensorineural, mixed, and central types. Conductive hearing loss (CHL) is far more common in kids and results from problems in the mechanical transmission of sound through the external and middle ear-this is caused most often by congenital malformation of the ear structures or infections such as otitis media. Sensorineural hearing loss (SNHL) is a problem with the transmission of vibrations into neural impulses within the cochlea or down the vestibulo-cochlear nerve. SNHL causes include in utero infections (CMV, MMR-V, and syphilis are biggies), family history, severe hyperbilirubinemia, respiratory distress, prolonged mechanical ventilation, as well as childhood infections or trauma.
  4. What are the types of newborn hearing screening? Otoacoustic emissions (OAE) and auditory brainstem response (ABR) [also known as brainstem auditory evoked response (BAER)] are the most common newborn hearing tests. OAE tests the reflex response of the hair cell in the cochlea to sound and detects hearing loss up to and including cochlear function. ABR tests the auditory CNS response to sound and detects hearing loss through the entire conductive, sensory, and neural pathway. OAE is faster and is not affected by motion artifact, but is affected by debris in the canal and has a higher rate of referral than ABR. ABR/BAER is sensitive to motion artifact and requires the child be asleep when tested. False positives are common – only 2 to 7% of those who fail screening ultimately are found to have sensorineural hearing loss. After newborn age, we have a gap until age 4 when it can be difficult to detect hearing problems. Always refer for any language development issues.
  5. How do we interpret hearing tests? Hearing in the range of 0-15 dB is normal, 15-25 dB represents upper range of normal to minimal hearing loss, and 25-40 dB indicates mild hearing loss. We should refer if consistently at 25 dB or above on screening. When in doubt, refer to audiology!

TOW #40: Toilet training

With the April showers bringing spring flowers, we can talk about a topic of toddler “blooming,” so to speak… toilet training! I’m grateful those days are long behind us at our house… in the process of going through it with our daughters, I learned how different approaches work for different children, as described below. Attached are the case and discussion, thanks to our own fabulous Dr. Heather McPhillips, and several summary articles.

Materials for this week:

Take home points on toilet training:

  1. Age of toilet training changing: Toilet training in the US has moved later in toddler years (combination of factors including availability of better disposable diaper options and children in child care settings). Average age at which toilet training begins has increased from earlier than 18 months to between 21 and 36 months. Some believe there is little benefit of intensive training before 27 months of age. Only 40 to 60 percent of children now complete toilet training by 36 months of age; the average age is 37 months.
  2. Earlier start is associated with longer time to potty train, but earlier completion: Generally the earlier that children start, the longer it may take to fully potty train. Earlier start has also been associated with earlier completion of toilet training. Girls usually begin and complete toilet training about 2-3 months before boys.
  3. Child-centered toilet-training approach: this is the most commonly used approach now in the US. As described by Dr. Barry Brazelton and recommended by the AAP, this approach suggests that children are more likely to be developmentally ready after 24 months. This approach follows the child’s lead, looks for developmental readiness cues and provides positive encouragement for attempts at toilet training but avoids forcing / coercing or any negative comments.
  4. “Train in a day” type approach: as described by Azrin and Foxx, this potty training “bootcamp” is often done in a dedicated day/weekend using an operant conditioning model with positive reinforcement and negative reinforcement for accidents. One element we found helpful at our house was to set a “potty timer” to remind when to go make an attempt-about every 30-60 minutes to avoid accidents (can start with more frequent then gradually spread them out).
  5. Different approaches work: both of the most common approaches have been shown to work in practice to effectively teach typically developing children how to potty train. Different approaches are used around the world and can all be effective in context. In countries with more limited resources, there is much more use of elimination communication (EC), in which parents potty train children as early as 6 months based on parent use of watching infant cues and minimal to no use of diapers. Pediatricians who have experience with EC are now advocating for more broad discussion and adoption of this approach as well. We can help explore with families what they are comfortable with trying in their home.

TOW #39: Adolescent sexuality

One of the joys of general pediatrics is the opportunity to see children across the lifespan. After some recent infant-focused TOW’s, it’s time to shift gears to adolescents and review an important topic to them: sexuality! We have the privilege to help teens and their parents navigate through an incredibly important (albeit challenging) phase in life. So, here are some materials to get us comfortable with the sex talks.

Materials for this week:

Key take-away points on adolescent sexuality:

  1. Importance of discussing conditional confidentiality: When meeting with adolescents, we need to review why we are having these conversations and that our discussions are confidential except for situations of abuse or self-harm (when we are mandated reporters). Some helpful wording: “I need to ask you some personal questions that I ask all of my patients so that I can the best take care of your health. When we talk our conversation is confidential. This means that what we talk about is between you and me, and I won’t tell other people, such as your parents, unless you want them to know. One exception to this is if I am concerned someone has abused or hurt you. Another exception is if I am concerned you are at risk of hurting yourself or someone else.” It’s also good to specify that patients do not have to answer any question that they don’t want to answer.
  2. How to broach the subject of sexuality/sexual orientation: we want to normalize the conversation as much as possible and put our patients at ease. “Many teens your age have romantic interests and develop attraction to other people. Have you been attracted to anyone? Do you find yourself attracted to guys, girls, both?” This can be followed by more specific questions about sexual activity. Remember, sexual attractions can be evolving throughout adolescence so you should continue to ask as this may not be a fixed preference.
  3. Asking about sexuality activity: Some prefer to start by asking what questions the teen may have: “What questions do you have about sex that you’ve never really had the chance to ask?” Others prefer to start by asking directly about types of sexual activity. Dr. Shafii reminds us we will not find out unless we ask, and we have to ask direct questions to find out about different behaviors and STI risks. “There are different ways people have sex like oral, vaginal, and anal sex. Have you ever had any of these types of sex?” and “Now or in the past have you had sex with males, females, or both?”
  4. Screen for unwanted sexual activity: As mandated reporters, we need to ask about a history of sexual abuse with a question like: “Has anyone touched you in a way you didn’t want to be touched?” “Have you ever felt forced or pressured into having sex with anyone?”
  5. Counsel on contraception: Discussing contraception and pregnancy prevention is so important for us to do: in one US study, 46% of males and 33% of females did not receive formal education about contraception before their sexual debuts. Contraception should be discussed with both males and females regardless of whether they have started having sex. Helpful wording includes “What are you doing to protect yourself from pregnancy?” or “What are you doing to protect yourself from sexually transmitted infections?”