Healthy Mama: Your FAQ’s about common childhood sleep issues

Dr. Dimitry Fomin specializes in neurology and sleep medicine at Mercy Health System’s Sleep Disorders Center. We narrowed down the most frequently-asked-questions about sleep issues and Dr. Fomin agreed to answer them here for us. He even answered one that keeps some of us women up way too many nights: the s-n-o-r-i-n-g husband.

Q: Does playing video games or watching television before going to bed affect sleep quality for kids or adults?

A: Yes. There are a couple of reasons for this. The first reason is a straight-forward one. Assuming that a television show one is watching before sleep is not something from the realm of “The latest discoveries in the world of trigonometry”, the content of the programs we choose to watch or the games we play are highly psychologically stimulating. This stimulation makes it harder for us to relax to fall asleep. The second reason is a bit more technical. You see, modern TV screens and computer monitors emit a kind of light that is very similar in its physical characteristics to natural daylight. Biologically, we humans are programmed to wake up when exposed to daylight. This has to do with a hormone that our brain produces, called melatonin. Melatonin is important in regulating our sleep and wake cycle. It contributes to a deep and sustained sleep. However, our brain will not produce melatonin unless we are in a dim light for an hour or two during our regular sleep time.

Q: What are the common sleep disorders in children?

A: Believe it or not, the most common sleep disorder in children has nothing to do with health. Statistically, nowadays the most common sleep-related problem in children is insufficient amount of sleep and/or poor sleep hygiene. Sleep hygiene has to do with our behaviors related to sleep initiation, sleep maintenance and awakening. Poor sleep hygiene leads to such common behavioral sleep-related problems such as:

• Bedtime resistance (seen in 10-30% of toddlers and preschoolers)
• Inappropriate night awakenings (25-50% of 6- to 12-month-olds, 30% of 1-year-olds, and 15-20% of 1-3-year-olds).

Of true sleep disorders, common ones are sleep-walking (most common in children of 4 to 8 years of age), insomnia and delayed phase circadian rhythm disorder in adolescents.

Q: Are there sleep-related disorders linked to pregnancy?

A: There are two in particular: Restless Limbs Syndrome and sleep-related breathing abnormalities. These are commonly undiagnosed and untreated because of the notion on both a patient’s and a health care provider’s part that since pregnancy is a transient state, so are sleep-related problems that emerge during this state. However, for many women these problems could have a significant impact on their well-being. Given the fact that these two conditions can be easily diagnosed and treated in most cases, there is no need to ignore them.

Q: What are night terrors and what should we do if our child is having them?

A: It is proper to call these sleep terrors, as opposed to night terrors, since they can occur during daytime naps as well. Sleep terrors is a disorder of sleep that is a sibling to sleepwalking. They belong to a family of sleep disorder we call partial arousal parasomnias that are episodic in their occurrence and share a common underlying pathophysiology and have a number of overlapping clinical features.

The common theme of this class of disorders is that they share characteristics of both the waking and deep sleep states, and involve autonomic and skeletal muscle manifestations, autonomic behaviors, and disorientation. They occur almost exclusively during the deepest stage of sleep, called slow-wave sleep, and, therefore, do not involve dreaming. Since the majority of slow-wave sleep takes place in the first half of our sleep period, both sleepwalking and sleep terror episodes occur within one or two hours of sleep onset.

Sleep terrors are dramatic events accompanied by autonomic and behavioral manifestations of intense fear and, as such, can be distressing to parents. As disturbing and frightening as these events appear to the observer, the child is totally unaware of his or her behavior. Paradoxically, sleep terrors are much worse to watch than to experience, and much less traumatic to the child than a nightmare or bad dream. Most children stop having sleepwalking episodes or sleep terrors by adolescence. In the interim parents need to ensure the child has a safe sleep environment, triggering and/or exacerbating factors are eliminated, and proper sleep hygiene is followed.

Safety measures include use of gates (doorways, top of staircases), locking of outside doors and windows, lighting of hallways, eliminating floor clutter in the sleep environment. Parents can use door/window alarms or a bell attached to the bedroom door. Ensure adequate sleep, maintain regular sleep-wake schedule. Avoid awakenings as attempts to awaken a child during a parasonmia will typically increase agitation and prolong the event. Guide the child back to bed to encourage return to normal sleep. Avoid interfering as this can prolong the event. The normal response of parents is to try and comfort their child during one of these episodes, which may increase agitation. Avoid next-day discussions, as this I likely to worry the child and may lead to bedtime resistance. Medication therapy is needed very rarely, but may be indicated in cases of frequent or severe episodes, high risk of injury, violent behavior, or serious disruption to the family.

For more info on sleep terrors, click the icon on the right to watch a short video podcast of Dr. Fomin explaining the difference between a sleep terror and a more common nightmare.

Q: What can I do if my spouse snores and I can’t sleep?

There are times when snoring is just noise and represents no underlying illness. In such cases the least invasive intervention is to have the snoring person sleep alone in the environment where the noise does not disturb anyone else. Other techniques for minimizing snoring is to have the snoring spouse avoid sleeping on his or her back, avoid alcohol consumption before sleep, avoid sleep deprivation, and maintaining healthy body weight. Alternatively, there are dental appliances and surgical interventions available to minimize snoring.

Unfortunately, for most people snoring is not “just noise”, but a symptom of a medical disorder called Obstructive Sleep Apnea (OSA) syndrome. This condition is a serious and potentially lethal disorder that has been shown to contribute to the development of coronary artery disease, cardiac arrhythmia, systemic and pulmonary hypertension. Untreated OSA has been implicated as a contributing factor to heart attacks and strokes and creates a major risk for vehicular and industrial accidents. It has also been thought to contribute to the development of obesity and suppression of immune system.

Early diagnosis and proper treatment have been shown to prevent most of the negative effects to one’s health from an untreated OSA. So, talk to your doctor about having you or your spouse evaluated for presence of this condition. Treating OSA will not only improve snoring and the health of the person who is snoring, but also the quality of sleep of the spouse who has to listen to that awful noise on nightly basis.

Q: Any advice on how to get a child to go to sleep on his own? (Rather than a parent having to stay in the room until they fall asleep?)

The question of whether a child should sleep alone or with the parents (either in the same room or in the same bed) is as ancient as the human race itself. There is no scientific basis that can clearly support one side of the argument over the other. This decision is made on individual family basis and has more to do with the cultural and socioeconomic reasons than with medical ones. However, no matter which sleeping arrangement the parents choose, one important issue is to make sure the environment in which the child initiates sleep remains constant throughout the entire sleep period. In other words, if the parent is present during the time the child is falling asleep, the parent will have to remain by the child’s side during the entire sleep period. If the child falls asleep with the light on, the light should remain on during the entire sleep period. If the child falls asleep with some background noise or music, this should continue for the duration of sleep. If this rule is not followed, than sleep-related behavioral abnormalities are likely to occur. For parents who choose to have the child sleep alone the following are general guidelines:

• Institute a sleep schedule that ensures adequate sleep. A bedtime should be set that is appropriate for the child’s age and that provides adequate sleep at night.
• Establish a consistent bedtime routine that is approximately 20-45 minutes and includes three to four soothing activities (e.g. bath, pajamas, stories)
• Maintain daytime naps at least through the age of 3 to 3.5 years, as sleep deprivation in a young child will increase nighttime arousals and thus increase sleep problems.
• Use transition objects such as a blanket, doll, or stuffed animal.
• Do not respond immediately to a baby’s movements or sounds to allow the baby a chance to return to sleep independently.
• Often a parent’s response will contribute to a prolonged arousal. The key to a successful transition from relying on parental intervention to self-soothing to fall asleep is to have the child put to bed drowsy but awake at bedtime. This will encourage the development of self-soothing skills, which will generalize to self-soothing back to sleep following normal nighttime arousals.
• Discontinue nighttime feedings in a baby older than 6 months. Extinction, graduated extinction and fading of adult intervention are three behavioral strategies that can be used to transition a child to independent sleep. Extinction (“crying it out”) involves putting the child to bed at a designated bedtime and then systematically ignoring the child until a set time the next morning. Graduated extinction involves putting the child to bed drowsy but awake and waiting progressively longer period of time, usually in 5-minute increments, before checking on the child. On each subsequent night, the initial waiting period before checking is increase by 5 minutes. When parents check on the child, they should reassure the child but keep contact brief (1-2 minutes) and neutral (e.g. pat on shoulder rather than pick up and cuddle). The success of graduated extinction is usually based on the parents’ ability to be consistent and follow through.
• Finally, fading of adult intervention is appropriate for families who are unable to tolerate the above extinction approaches or consider them to be unacceptable. A plan should be developed that gradually fades adult intervention. In order to develop such a strategy, the end goal should be identified (e.g. falling asleep independently at bedtime) and successive steps to achieving that goal specifically outlined (e.g. 3 days of establishing a bedtime routine and setting bedtime; 3 nights of parent sitting with the baby while the baby falls asleep in the crib; 3 nights of parents sitting 3 feet from the crib while the baby falls asleep; 3 nights of sitting in the doorway; 3 nights of sitting outside the doorway; and so forth).
• Parents can start with instituting treatment at bedtime only and responding to their child in their usual manner throughout the night. However, some parent may decide to respond to their child’s night wakings in the exact same manner as at bedtime to provide a consistent response at all sleep times.

Q: They’re not sleep/night terrors – my child is afraid to start the night out in his own room. Any advice?

Nighttime fears are common, and typically both normal and benign. Most children experience bedtime or middle of the night fears at some point during childhood, and these are usually considered a normal aspect of development. These fears characteristically begin to occur during preschool years as children develop the cognitive capacity to understand that they can get hurt or be harmed. Parents must maintain a balance between reassuring the child and avoiding reinforcement of the fears. If a child is reassured too much, the parents may be subtly providing positive attention for the fearful behavior, thus increasing the likelihood that it will reoccur. In addition, some children may interpret their parents’ concern about the fears as tacit proof that the fears are well founded.

Suggestion for way parents can respond to their child’s nighttime fears include reassuring and communicating the idea of safety, such as having parents repeatedly tell the child that he or she is safe and that the parents are always nearby and will make sure that noting bad happens (e.g. “Mommy and Daddy are right downstairs and we’ll always make sure that you are safe.”). Teach the child developmentally appropriate coping skills and discuss alternative ways to respond to nighttime fears, such as “being brave” and making positive self-statements (e.g. “Monsters are just pretend.”) Another strategy is to provide examples of coping role models by reading stories about children who are afraid and conquer their fears. Develop creative solutions, such as the use of “monster spray” (parent fills a spray bottle with water and sprays the child’s room and closet at bedtime). Having a pet as a nighttime companion or having siblings share a bedroom are alternative strategies that work for some families. Whenever possible, the child should be actively involved in generating solution to foster a sense of mastery and control. Encourage the use of security objects, as they can be comforting to the child. Use a night light to decrease a child’s fear of the dark or monsters. Leave the bedroom door open, so that a child does not feel isolated. Avoid television shows and movies that may be frightening or overstimulating, particularly just before bedtime. Teach the child relaxation strategies, such as deep breathing or visual imagery (e.g. imagining a beach or other favorite scene), which can help a child relax at bedtime and fall asleep more easily. Discuss the child’s fears and alternative ways to respond to the fears during the day rather than in the evening, as this is less likely to provoke anxiety. Set appropriate, firm, and consistent limits on bedtime behavior to avoid reinforcing the child’s “being scared.” For example, a parent might say, “Remember, no crying and no calling at bedtime.” Institute a “checking system” at bedtime to provide the child with a predictable schedule (e.g. every 10 minutes) of parental reassurance. This has the benefit of making parental contact non-contingent on the child’s behavior (e.g. calling out). Encourage the child to remain in bed or in the bedroom , so that he or she does not become conditioned to avoid the bedroom. If parental presence is temporarily required to alleviate the child’s fears, it is generally better for parents to stay in the child’s room rather than to have the child join the parents in their room. Develop a reward system for appropriate bedtime behavior (stickers for being a “big boy”) rather than reinforcing (with attention) the learned fearful behavior.

Dr. Fomin most recently served as European Regional Medical Command Consultant for Neurology and Department of Medicine Chief at Landstuhl Regional Medical Center in Germany. The Mercy Sleep Disorders Center, located at 2708 Rife Medical Lane in Rogers, can be reached at 479-338-3571. Fore more information, go to www.Mercy4U.com.