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Sleep Q & A

Dr. Harris, Missouri’s most experience pediatrician, answers questions regarding sleep.

Q-  Someone told me that there is a lot of new research about sleep that can help solve sleep problems in my child.  It this true?

A-  Yes. We know much more about sleep than we did even a few years ago.  In order to understand sleep problems one must know some of this information.

1. One does not sleep in a constant sleep state but in cycles of light and deep sleep.  The light sleep cycles are called REM (rapid eye motion) cycles.  This is a light restless type of sleep characterized by more movement and dreaming.
2. Deep sleep cycles (non-REM) are totally relaxed, more effective type of sleep.  People who have more deep sleep cycles tend to require less sleep.
3. There are natural wakings that occur during the light (REM) sleep cycle.  Most adults easily go back to sleep from thew “wake-up times” but usually, because of parent interference, many children have trouble.  It is important to remember that waking up is a normal part of light sleep cycle.
4. In man, as in lower animals, the establishment of a natural “biological rhythm” seems to be important.  The natural rhythm for most people seems to eat and be awake during the daylight hours and to sleep and not eat during the dark hours.
5. Dreaming occurs at regular intervals during sleep.

Q-  When can I expect a baby to be able to sleep through the night?

A-  During the first month of life sleep is disorganized with alternating periods of sleeping and eating extending over the 24 hours.  From 3 to 6 months, sleep is organized into longer periods at night.  By 4 to 6 months, sleeping through the night occurs in many babies.

Q-  How about daytime napping, when does it become regular?

A-  As nighttime sleeping becomes organized at 4-6 months of age, then daytime napping also begins.  By 6 months of age a baby may be taking a regular nap for 1-2 hours both in the morning and afternoon.  These usually continue into the second year of life at which time a child may take a nap only once a day.  This nap may continue until he is about 5-5 years of age.   It may become shorter and some children give it up sooner.

Q-  I rock my 9 month old daughter to sleep in my arms, put her in bed and she sleeps for about 3 hours, then wakes up requiring me to rock her back to sleep again.  This happens 2-3 times nightly.  I have to get up and go to work everyday and I am exhausted.  She definitely has a sleep problem.  What can I do?

A-  You are right.  A sleep disturbance only becomes a problem when it is a problem for the family.  In your case, because you have to be up every day and working, you are being deprived of normal sleep.  Your daughter is experiencing one of the most common sleep problems in our culture called the sleep association problem.  When she is put to sleep in your arms and then transferred to the bed, when experiences the normal waking during the night, she demands the same thing that put her to sleep at bedtime.  If she does not go back to sleep with the same rocking she would be more likely to have some other cause for her waking.  To solve this problem you need to start doing the following:

You may rock her but try not to let her go to sleep in your arms.  Put her in the bed while she is awake, hug her, go out of the room as wait 5 minutes.  If she is still crying and you feel guilty, go back into the room briefly and pat her on the back, go out of the room and this time wait 10 minutes.  If she is still crying go back into the room, make sure she is all right and leave the room.  You gradually increase the time out of the room until she goes to sleep.  Then, during the waking periods in the night, you do the same thing.  Wait 5 minutes, check her but avoid picking her up, rocking her or doing any other manipulation.  She will learn to go back to sleep for the normal waking periods just like she did at bedtime.  Soon, you will just put her into bed awake and she will go to sleep without a lot of fuss.  You will then get to sleep when she learns to go back to sleep during the normal nighttime waking.  Remember, if you have been rocking her to sleep at bedtime and during the night for 8 months, it may take a few nights to change old habits.

Q-  My 9 month old son awakens and breast feeds 3-4 times nightly.  I am exhausted.  What can I do?

A-  This is another type of sleep association problem.  He associates going to sleep at bedtime and going back to sleep at the normal nighttime waking with breast feedings.  Also the feedings may be disrupting his normal biological rhythm.  His most natural biological rhythm would be to not eat at night.  To solve this problem, try to increase the interval between his daytime breast feedings thus helping him also to go longer periods without eating at night.  Try to schedule his last feeding approximately 1 hour before he usually goes to sleep at night.  Then follow the same procedure as previously outlined for sleep association problems.  However, it may be necessary to gradually stop the nighttime feedings rather than completely stop in a day.

Q-  We have much trouble getting our 4 year old son to bed a t night.  He is up and out of his room several times wanting a drink or something to eat.  Sometimes he  says he is scared to sleep in his room.  It’s a real problem.  What is your advice?

A-  I think your son has a problem with inconsistent limit setting at bedtime.  Start a bedtime ritual to prepare him for sleep and make sure his bedtime is appropriate.  A bedtime ritual consists of a bath, a story and tucking in for the night.  Then parents should be consistent in their approach.  Once the bedtime ritual is finished he should understand if he gets out of bed after the bedtime ritual he will be put back in bed and the door to his room shut and the opened only after he has gone to sleep.  Using the firm consistent approach will usually solve this sleep problem.

Q-  My 3 year old daughter takes one short nap of 1 hour early each afternoon.  She then falls asleep shortly after supper and gets up at 5 a.m. each morning ready to go.  Is there anyway to change this?

A-  Yes.  Your daughter has a sleep phase problem which is apparently not convenient for your family.  She is sleeping the normal number of hours but it is  “out of phase”.  You need to mover her nap time 1 hour later in the afternoon and each night keep her awake 15 minutes later which should delay her waking time in the mornings until a suitable waking time is reached in the morning.  Moving the afternoon nap somewhat later will help her to stay awake later in the evening.  This problem may have started because her natural biological rhythm is to go to bed early and get up early.  If left without intervention this would be her natural tendency.  These individuals are sometimes referred to as “larks”.  Her biological clock is set differently.

Q-  My 5 year old son likes to stay up very late and then would sleep all morning.  My wife and I would like to have some private time with each other in the evenings.  Do you have any suggestions?

A-  Your child has a different setting on his biological clock.  His natural rhythm seems to be staying up late and sleeping late.  These individuals are referred to as “owls”.  Obviously this creates a sleep problem for your family.  The easiest way to begin to solve it is get him up 30 minutes earlier each morning and his natural tendency will be to get sleepy 30 minutes earlier each night.  This should be continued until the desired bedtime is reached.

Q-  My 8 year old daughter sometimes comes into our bedroom in the middle of the night crying and tells us she had a bad dream.  She appears very frightened.  What causes bad dreams and how can we help her?

A-  You must understand that dreams occur every night.  They happen during light (EM) sleep.  Some dreams are good and some are bad.  Bad dreams are also called nightmares.  After a nightmare the child may be completely awake, rational and often will be able to describe the nightmare however may have trouble returning to sleep.  An occasional nightmare probably represents some type of stress or conflict the child may be experiencing during waking hours.  The stress may be the usual types of tings that happen to children as they grow.  Examples might include toilet training, starting school, or problems with a playmate.  Nightmares can also be related to more serious daytime stress such as divorce, death or abuse.  Other frightening events, such as watching horror movies, may precipitate nightmares.  In general, the more frequent the nightmares, the more likely there is serious stress in the child’s life causing them.

Immediately following the nightmare, try to physically comfort the child by hugging and holding her.  Giver her comforting words and stay with her while she goes back to sleep.  With the infrequent nightmare try to determine what kind of daytime stress may be bothering her and try to help her deal with it.  Get her to talk to you during the daytime not only about her nightmares but also about her feelings in regard to other things going on in her life.  Do not allow her to view frightening movies or television programs.  If frequent nightmares are occurring it may be necessary for for the child to see a child psychologist, or a physician specializing in emotional or mental disorders of children (child psychiatrist).

Q-  The other night my 5 year old son awakened screaming with his eyes wide open, looking at me but he didn’t respond to my questions.  When I tried to hold him, he started hitting me and pulling away.  I talked to his doctor about this and he told me this was anight terror.  What can you tell me about this?

A-  I think your doctor was right.  A night terror is characterized by unusual behavior and although the child may have his eyes open he will not respond to your questions and resist your efforts to comfort him.

Night terrors occur when a child has been in the deep sleep cycle and has only been able to make a partial arousal from this deep sleep cycle.  He has become partially “trapped” in this cycle rather than going from a deep to a light sleep cycle as is usually the case.  This is most likely to happen when he has become fatigued during the daytime and as he falls asleep, goes rapidly into the deep sleep cycle but has trouble leaving the deep cycle.

Sleep walking and sleep talking are other examples of this type of sleep problem.  Treatment of these include helping the child avoid fatigue, and making sure he is getting an adequate amount of sleep on a regular sleep schedule.  It may mean re-instituting a daytime nap.  Recently success with this sleep problem has been achieved by the parent keeping a sleep diary to determine if these night terrors occur at the same time every night.  It may be found that these occur 2-4 hours after going to sleep.  Then by awakening the child about 15 minutes before the night terror usually occurs and keeping him awake for 5 minutes before he returns to sleep, the terror can be avoided.  This may help him to establish a new sleep cycle and avoid the partial arousal from the deep sleep state.  It is not useful to hold or try to comfort the child during the terror.  It actually may prolong it.  Most of the night terrors last from 10 to 30 minutes.  With sleepwalking it is important to arrange furniture and doors so the child is not hurt.

Q-  Are there illnesses that cause nighttime wakings?

A-  Yes.  Most common cause is earache from an infection in the middle ear.  Sometimes abdominal pain from various causes will cause sudden wakings or failure to sleep.  If the usual measures we have discussed do not help the child to sleep, an illness or injury cause may be present.

Q-  My wife and I are getting a divorce.  My son’s grandmother recently died.  He has been refusing to sleep in his room but wants to sleep with me.  What should I do?

A-  Major stress in a family causes major sleep problems in children.  Until he can deal with this stress or he can get help in dealing with it, do whatever gets the both of you the most sleep.  Let him sleep in your bed.

References:  Schmitt, B.D., Lozoff, B.  Sleep Problems in Children:  Pediatric update, Vol. 10 no. 8(1990)

Lask, B. Novel and Non-Toxic Treatments for Night Terrors.  British Medical Journal 297:595(1998)

Dr. Harris’ advice on the 18-24 month old

Imagine if you had been helping parents manage two year olds since the Johnson presidency… Missouri’s longest practicing pediatrician shares his advice for managing common problems in the toddler age.

Dr. Harris’ instructions for parents at the 18 MONTH / 2 YEAR check up.

This information is designed to help you with some problems that may be encountered at this time which are unique to this particular age group.

During the second year of life, both children and parents realize that there must be controls on their behavior.  As a result of controls on their behavior, many children react in a negative manner with so called “TEMPER TANTRUMS”.  These are characterized by screaming, banging the head, or repeatedly acting in a negative manner.   Usually if the parents are able to ignore these episodes or repeatedly acting in a negative manner.  Usually if the parents are able to ignore these episodes and if the child does not gain anything from them over a period of time, they will disappear.  Discipline for the child during the second year of life should be consistent - that is everyone responsible for disciplining the child should discipline him the same way.  Discipline should also be reserved forthose things which are disruptive to the whole family or dangerous to the child.  If a parent constantly says no to everything the child does, then this becomes entirely ineffective.  However, if the parent reserves discipline for those important things which are disruptive to the family or dangerous to the child, he quickly begins to distinguish between acceptable and unacceptable behavior.  The “isolation” method appears to be effective when discipline is needed.  This is carried out by immediately taking the child away from the center of the room and center of attention to a room and making him sit for a short period of time in a chair away from the rest of the house.  If this is done in a firm manner and reserved for important things, it is probably more effective than any kind of physical punishment such as spanking.

Toilet training is an individual occurrence with children.  The real signal when a child is ready for toilet training is when he comes to the parents and indicates that he has had a bowel movement and wants to be changed – then he is aware that he is having bowl movement but more importantly, he wants to do something about it.  At this point, set a small potty chair where he can see it and get used to it and not be afraid of it.  When he gives you some indication that he might want to have a bowel movement or he comes to you and lets you know that he wants to use the potty chair, take him and let him try, if he doesn’t mind or doesn’t rebel.

The approach should be a LOW KEY, LOW PRESSURE approach.

Reward him if he does, show positive behavior by praise.  However, do not exert undue pressure on him or let other well meaning relatives exert pressure because he will react in his usual negative type manner.

Teeth brushing is most important to start at this age, and you may start this by brushing the child’s teeth with a tooth brush, brushing up on the lower front teeth and down on the upper front teeth and over all surfaces of any molars that he may have.  Also, give him a tooth brush and a little tooth paste and let him try to use it at the time the other family members are brushing their teeth.  If the tooth paste contains fluoride, us just a small amount.

I hope this information will help you with some of the behavior and problems that might be encountered with this particular age group

Dr. Harris on Infuenza

In this post, Dr. Harris, Missouri’s most experienced pediatrician discusses a common, and commonly misunderstood infection, influenza.  Despite the CDC’s recommendation to vaccinate all children for this viral infection, influenza is still one of the leading causes of pediatric deaths.

INFLUENZA

This is a severe, usually wintertime virus, associated with fever of 101 degrees or above, 4-5 days associated with headache, nose congestion, eye pain (in older children), cough and occasional vomiting.  After 4-5 days fever subsides, though the nose congestion & severe cough usually persist for 7-10 days.  This is a virus, not a bacterial infection, therefore antibiotics are not given unless a secondary infection such as ear infection, bronchitis, or pneumonia develop.  If the infection is caught in the first 48 hours, your physician may decide to treat the infection with an antiviral like Tamiflu.  Though this drug does not cure the infection, it makes the illness less severe.

Signs to indicate perhaps a secondary infection and need for additional antibiotic therapy would include:

1. Earache (ear infection)
2. Fever 101 degrees or above lasting longer than 5 days especially if associated with worsening cough (bronchitis or pneumonia)
3. Secondary fever–if fever 101 or above disappears for 24-48 hours then reappears, this could indicate secondary infection.

Persistent vomiting with change in mental status (confusion, excessive drowsiness, combativeness, irrational behavior) can indicate a sever complication called Reye’s Syndrome.  This is a medical emergency but can be treated if detected early.

Treatment for uncomplicated influenza would include:

1. Rest
2. Increased fluids containing sugar and water (flat 7up or sprite, juice diluted 1:1 with water, jello)
3. No aspirin should be given with this illness
4. Some fever probably helps to fight the illness but for high fever or discomfort you may give Acetaminophen (Tylenol)
5. Some cough helps keep congestion out of the chest but for older children 5 years and up, you may use Robitussin DM or a like cough syrup every 4 hours for cough disturbing sleep.

Dr. Harris on Strep Throat

STREP THROAT

With more than 50 years in practice, Dr. Robert Harris is Missouri’s most experienced pediatrician.  This is the first in a series of posts in which Dr. Harris shares his advice on common pediatric problems.  Dr. Harris continues to see a full schedule of patients in the practice he help found in the 1960′s.  For appointments with Dr. Harris or the other pediatricians at Tiger Pediatrics call 573-777-ROAR.

What is a Strep Throat Infection?

It is a common infection of the throat due to a group of bacteria called streptococcal bacteria.  These bacteria have been divided by testing into different groups.  Not all of them cause disease in man.  The group causing disease in man are referred to as Group A Streptococcal Bacteria.

What are the symptoms of Strep Throat?  How are they different from other throat infections?

The symptoms of a Strep throat infection are usually the same as the symptoms of any throat infection.  One is usually unable to distinguish a Strep throat infection from other throat infections on the basis of the symptoms.  The most common symptoms are fever and sore throat.  However, some children, especially younger ones, may not complain of sore throat and merely have fever.  Occasionally a child may have intestinal symptoms associated with fever, such as abdominal pain and vomiting.  Some older children may only complain of sore throat without significant fever.

What is Scarlet Fever?  Is it caused by a Strep Throat infection?

The easiest way to define scarlet fever is that is usually a Strep infection with a skin rash.  The particular Strep bacteria causing the infection releases a substance referred to by the medical term of toxin.  This substance causes a red, round, itching skin rash to spread over most of the body.  The skin rash is so typical that it is easily recognized.  The Strep infection causing the infection is usually located in the throat but can also start from skin sores caused by streptococcal bacteria.

Is there a typical appearance of a Strep Throat infection that will allow the Doctor to make the diagnosis?

There is a typical appearance of Strep Throat but unfortunately, it does not occur all the time.  In its typical appearance the back of the throat is very red and the piece of tissue hanging down in the back of the throat (called the Uvula) is red and swollen.  The tongue may be coated, resembling a white covered strawberry.  When all these findings are present, there is a very good possibility that a streptococcal infection is present.  However all the above mentioned findings may be absent, and the Strep Throat infection can still be present with the child usually just having a fever and sore throat of the previously mentioned associated symptoms.

If the signs and symptoms are not always typical, what is the best way of making a diagnosis?

A swab of material from the throat area, called a throat culture, remains the most reliable method of diagnosing a Strep Throat infection.  There now is a reliable rapid throat culture test which takes about 10 minutes.  In addition, there is still the old “over night” throat culture test.

How is a Strep Throat infection treated?

Penicillin remains the first choice in treating Strep Throat.  Penicillin can be given by mouth for 10 days, if the family understands that all of the medicine must be given and not discontinued as soon as the patient feels better.  If the situation regarding treatment is unreliable, a long-acting Penicillin injection can be given.  This injection proves to be very painful and potentially more allergic, so I tend to avoid it if I can.

If the child is allergic to Penicillin, what antibiotic can be used?

Azithromycin can be used if the patient has a penicillin allergy, however the dose that is used is not the typical dose.

My child has had Strep Throat 2X in a row.  Both times he received penicillin for 10 days, but as soon as he finished treatment, the infection came back.  Is this very common and what causes it?

The situation you described is very common, but we are not certain what causes it.  It has been proposed tat there is another bacteria in the throat not making the child ill, but producing a substance called penicillinase which renders the Penicillin ineffective in treating the infection.  I also believe that occasionally the infection can be very deep-seated in the tonsil tissue and 10 days of Penicillin fails to get rid of it.  Occasionally, there will be a carrier of Strep in the family or at school which results in re-infection of the child.  By carrier, we mean someone that has a strep germ in their throat not making them ill, but capable of passing the Strep to someone who can become ill.

When Penicillin fails to clear the infection and if it keeps coming back, we can use a group of antibiotics called cephalosporins.  Examples of such antibiotics would include Keflex, Ceclor or Duricef.  These antibiotics are capable of eliminating the throat bacteria producing the penicillinase, and they also may penetrate tonsil tissue better than penicillin.

Family members may be carriers of Strep so then it is useful to do throat cultures on all the family when 1 person in the family experiences repeated episodes of Strep Throat.  Remember also to do throat cultures on the family cat or dog as they may also be carriers of the Strep.  If a carrier of Strep is found, they should be treated with antibiotics.

Are the tonsils ever removed to cure repeated Strep Throat infections?

Sometimes even when Strep infections are adequately treated and a possible carrier are treated, repeated frequent Strep Throat infections still occur.  This usually indicates the tonsils are chronically infected and their removal may improve things.  At this point, I think the tonsils acting like an “infected sponge”, soaking up infection without completely getting rid of it.  You must remember that the removal of tonsils (tonsillectomy) is a MAJOR operation, carrying definite risks of complications, and should be undertaken when more conservative treatment with medication has failed.

Is there a relationship between Rheumatic Fever and Strep infections?

Years ago, an occasional episode of untreated or inadequately treated Strep infections would precede the development of Rheumatic Fever.  Today, Rheumatic Fever is a forgotten disease, only very rarely occurring.  I have not diagnosed a case in many years.  The reason for this remains a mystery.  Perhaps the streptococcal bacteria have changed over the years and no longer possess the characteristics to predispose a child to Rheumatic Fever.  Perhaps a greater awareness of streptococcal infections with early diagnosis, adequate treatment and careful follow up by both the patient and the medical profession have played a role in reducing the threat of rheumatic fever after a streptococcal infection.

 

 

4 to 6 months

Activity has begun!  Most kids learn to roll over sometime during this period.  We frequently see head injuries during this period as kids learn to roll over before the parents are expecting it.  Keep a close eye on your 4 month old!  Kids do tend to learn to roll over somewhat later than they used to, likely due to the fact that most kids sleep on their back (to prevent SIDS).  The old standard that kids learn to roll from front to back at 3 months and back to front at 4 months has been replaced by children learning to roll both front to back and back to front about the same time at 4-5 months.

Most parents start their children on solid foods during this phase as well.  Until 6 months of age breast milk and formula both provide all the vitamins and minerals that a child needs (except Vitamin D, which is nearly absent in breast milk and should be supplemented from age 2 weeks).  After 6 months, however, breast fed kids may run low on folic acid and will run low on iron if they do not receive some in the diet.  Rice cereal (which is very high in iron) is typically the first food in the US.  It is naturally hypoallergenic, though it tastes pretty bland.  Dr. Wheeler recommends mixing rice cereal with breast milk or water to a thin pudding consistency and feeding it on a spoon, once or twice a day starting at 4 or 5 months of age.  Fruits and Vegetables are traditionally started at 6 months.  Pureed meats will probably become the new standard food to be introduced after 6 months, as they are a better source of iron, folic acid and protein than fruits and veggies.  Breast fed kids older than 6 months need at least one serving of rice cereal daily as long as mom is breast feeding (for iron).

We don’t recommend putting rice cereal in the bottle except in a few special cases.  Research shows that it does not make kids sleep any better or any longer and may be associated with adult obesity.

Dr. Harris’ mission trip to Southern Missouri

Dr. Harris is receiving some publicity for his recent trip to Southern Missouri.  Dr. Harris believes that the state has numerous “pockets of poverty” that cause the state to have a less than impressive child mortality ranking.  Adding to his four decades of fighting childhood diseases in mid-Missouri, Dr. Harris traveled to one such “pocket of poverty” to help local health care providers in their battle in rural Missouri.