Sleeping through the night

From Dr. P's Message Board

Dr. P: My 3-week-old is awake all night and sleeps only for a few hours at a time during the day. I'm exhausted! Is there anything I can do to make her sleep longer,

especially during the night?

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I feel for you. Caring for any infant is a ton of work, but it's even harder when you are sleep deprived and exhausted.

What's going on
It would be nice if falling asleep was as simple as flipping an "off" switch in the brain. (It would be even nicer if an "on/off" switch was affixed to the outside of every baby's body!). Alas, it's not that simple.

In fact, the processes that regulate sleep patterns are quite complex. They involve the brain responding to various hormones in the body and to environmental stimulation. Plus, different parts of the brain must be turned on and turned off in a coordinated fashion. Only when the brain is mature enough to regulate all of these processes does a regular sleep pattern and the ability to sleep through the night emerge.

(An ex-boss used to say that, like all department chairmen, "I sleep like a baby. I wake up every three hours and cry.")

The good news / bad news is that the ability to sleep through the night typically occurs around 4-6 months of age. Until that time, it's unrealistic (and unfair) to expect your baby to be a great sleeper or for you to be able to do much about it.

The average newborn sleeps around 15-16 hours or so, but that sleep may occur unpredictably, at any time, and for just a few hours at a time. As the brain matures over the first months, you'll thankfully begin to see a pattern emerge: longer periods of sleep (hopefully at night); more activity in the day, less at night; more sleep during growth spurts (much of growth occurs during sleep).

What does this mean?
Have realistic expectations. Every baby is different and you could luck out, but for most the first months will likely be no picnic when it comes to your baby's (and, therefore your) sleep.

Since it takes 3-6 months for a baby's brain to mature enough to establish a regular pattern and to sleep through the night, it usually doesn't make sense to let them "cry it out" or use other methods to try to teach them to sleep through the night at an earlier age.

But that doesn't mean you can't set the stage for good sleep patterns to emerge when the time is right. Here's how:

1. Help to regulate her day-night sleep cycle.
• During daylight hours, keep things stimulating and active.


• Play with her a lot when she is awake.


• Try to keep her awake after feedings (often a losing battle!).




2. When it's dark, become a more 'low key' parent.
• Feed her in a semi-darkened room.


• Cut down on all stimulation e.g., keep light and noise soft and low.


• Keep life boring. Hopefully, she'll come to learn that daytime is fun time and night time is boring, so I might as well sleep when it's dark outside.




3. Begin to teach your baby to fall asleep on her own, without getting used to (and then becoming dependent on) being held, rocked, fed, etc. The goal will be that when she awakens in the middle of the night at 9 months of age (as most babies do), she will be able to get herself back to sleep without the need for you to come in and rock, feed, or soothe her.
   

• After a few weeks (when everyone is not so sleep-deprived and things are settling down) begin to try to put your baby to bed awake and drowsy whenever you can, so she can learn to fall asleep on her own. Remember that teaching an infant to fall asleep on her own is learned over months. Your goal should be try to put your infant to bed when awake and drowsy if at all possible (which it often may not be). But, if you are reasonably consistent, over a few months she still will get the message.
  
• And keep in mind, that promoting such independence in falling asleep is for the good of the family and for your own sleep. Your infant will do fine and get plenty of sleep no matter what you do or don't do. If you are not worried about your baby's eventual ability to fall asleep on her own, feel free to skip all of this "sleep hygiene" advice!
  
  

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"There never was a child so lovely, but that his mother was glad to get him asleep."
Ralph Waldo Emerson (American philosopher, 1803-1882)

Related Topics: Why a Good Night's Sleep is Important for Children, WebMD Video: Is Your Child Sleep-Deprived?

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Cleanliness and asthma

Dr. P's Pediatric Journal Club

The study
These Dutch researchers measured levels of dust and bacterial and fungal toxins (potential "allergens") on the living room floors of 700 three-year-olds with allergic moms.

• They classified exposure to these allergens as low, moderate, or high.
• They then followed the kids for 4 years, looking for the development of doctor-diagnosed asthma and allergies.

What the study found

• Children with high exposure to dust and mold at 3 months were significantly less likely to have developed persistent wheezing by four years of age.
• Children with high exposure at 3 months were less likely to wheeze occasionally, but this outcome was not as pronounced (and not statistically significant).
• Children with high exposure at 3 months had lower allergic antibodies (IgE) to one of the fungi.
  

Dr. P comments.
Why do farmers' kids have fewer allergies and asthma? Why has the prevalence of allergies and asthma increased, even as we conquer ever more infectious diseases? This study adds to the mounting evidence that the exposure early in life to a very clean environment (low on dust and various bacterial and fungal toxins) may play a role.

Here's the theory: The newborn immune system is tolerant and non-allergic to most anything (which is why it sometimes does such a lousy job of fighting off infection). When it is exposed to the usual allergy-causing antigens (such as dust and mold and dogs and cats), the immune system and allergens become lifelong buddies: a long-lasting acceptance and tolerance between them develops.

On the other hand, when an allergy-prone infant is raised in a very clean - almost sterile - environment, the immune system remains unfamiliar with these allergens. Then, when exposed later on, it reacts to them as it would to any alien invader, triggering allergies and/or asthma.

What does this mean?
Sloppy parents of the world stand tall! Your kids may have fewer allergies than will those of your hyper-sanitary peers!

Even if there is a family history of allergies and/or asthma, I think it's too early to actually recommend a little extra dust and mold in your baby's bedroom. But I do hope this information will help parents to overcome their messiness/germ phobia and free you to lighten up on obsessively trying to 'sterilize' your infant's world from all germs and dirt and crud.

Hey, life is messy. This study suggests that maybe that's not such a bad thing after all!

A caveat from Dr. P: It may be true that early exposure to mold and dust and cats, for example, will prevent allergies to them later on (in an already susceptible child). However, once that allergy has been established, the horse is out of the barn: cleanliness and even catlessness, etc. are then very important to prevent significant symptoms.

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Article cited
"Does early indoor microbial exposure reduce the risk of asthma?
The Prevention and Incidence of Asthma and Mite Allergy birth cohort study"
Douwes J, et al. Journal of Allergy and Clinical Immunology, April 2006.

Related Topics: New Clue to Development of Asthma, WebMD Video: Pets & Allergies

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Welcome, Pediatric Grand Rounds!

Pediatric Grand Rounds is a collection of the week's postings from pediatricians and related medical professionals on the internet. You can read all of this week's submissions on Dr. Clark Bartram's blog this week, including my post on fever phobia.

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Snoring and your child's behavior and learning

Dr. P's Pediatric Journal Club

The study --

• 78 children, ages 5-13, who were scheduled to have their tonsils and adenoids removed due to "sleep disordered breathing" were compared to 22 children (the "control group") having other minor surgery.
• Testing prior to surgery included a "sleep study", parents' description of the child's behavior, cognitive testing, any psychiatric diagnoses, and sleepiness during the day.

What the study found --

• Only half of the children with "sleep disordered breathing" turned out to have obstructive sleep apnea on sleep tests.
• Children who had their tonsils and adenoids out were more likely to be hyperactive, inattentive, diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), and sleepy.
• One year later, the groups did not differ on these measures, suggesting that in some children removing the tonsils and adenoids improved their hyperactive and inattentive behaviors.

Dr. P comments

Since the link between disordered sleep and children's behavior and learning is new, it's hard to know what to make of it. The returns are by no means all in. Still, as of April 2006, here's what we think we know:

• Children with severe "obstructive sleep apnea" (i.e., who snore and who have episodes lasting longer than 15 seconds in which they can't move air in or out) are at risk for high blood pressure, poor growth, heart problems.
• Children with less severe symptoms seem to have more behavioral problems (such as ADHD) and more learning challenges (such as poor attention).
• Children who snore loudly but don't have apnea may have similar behavioral and learning risks, although this is as yet unclear.
• This study suggests (but does not prove) that taking the adenoids out in such kids may improve these problems in some of them.
  

Here's the dilemma: everyone is in agreement that true "obstructive sleep apnea" often requires surgery for medical reasons. And, as more data comes in, we'll better know how often this also results in improved behavior and academic functioning in kids.

But what about the child who snores but has no apnea, and who is having behavioral or learning problems? Lots of normal kids snore and there is no "cure" for snoring (except perhaps treating allergies at night). Should he also have his adenoids lopped out to see if it would help? I think the prudent answer for now is no, but stay tuned as new scientific studies come in.

Dr. P's Bottom Line
Practically, here's what I suggest if your child is a major league snorer:
Watch him/her to see if there are periods at night in which his chest moves but the snoring stops and all is silent because air is not flowing in or out. Time how long it lasts. Make a tape recording or video to show your pedi. If obstructive sleep apnea is suggested, get a sleep study done to confirm the diagnosis.

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Article cited:
Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy Chervin R, et al. Pediatrics. April, 2006

Related Topics: Snoring May Run in Families, Kids Who Snore Could Be Hyperactive Later

Technorati Tags: tonsils, sleepdisorders, snoring, ADHD

Health, Not Food = Love

"Eat! Eat! How often do I see you?"
Dr. P's grandma

"Food is love"
As a child I would visit my immigrant grandma and, just for me, she would have made her famous oily fried chicken and her lethal-dose mayonnaise potato salad and, of course, a generous supply of her might-as-well-just-directly-paste-them-onto-your-butt creamy cookies, "just like in the old country ".

Yum! I can still taste them to this day - a glorious childhood memory. And if I didn't ask for seconds (at least) or eat a dozen cookies, she was all over it, insisting, "Eat! Eat! How often do I see you?"

The truth is: food really is love.

A baby learns to associate the divine smell and taste of milk with warmth and cuddling and soft skin and gentle words and human interaction and nurturing and cozy love - a multi-sensory emotional feast.

Plus, our brains are wired to love the taste of food (alas, the more fat and the more sugar the better!). How can we not then appreciate and love the vehicles who generously put it in our eager mouths? What better way to promote child-parent attachment? (When I collaborated with Dr. Spock and he recommended a milk-free diet, I was horrified by the thought of a childhood without ice cream!) As George Bernard Shaw, the Irish dramatist, wrote, "There is no love sincerer than the love of food."

So too does food = love for parents. A woman's first official act and most solemn responsibility as a new parent is to nourish her infant. A "fat baby is a healthy baby" has long been a universal truism. A fat child is a sign of high social status in many cultures. We may not have nearly as much control of our kids' lives as we might want, but we can feed them 3 squares a day. It's an easy, "can't miss" way to demonstrate our love.

So where's the problem?
Am I just another killjoy puritan (defined by the American humorist H.L. Mencken as a person with "the desperate fear that someone, somewhere might be having a good time.")?

As I have written in a few previous blogs, the epidemic of childhood obesity - showing up at earlier and earlier ages - is a major 21st century health concern. And I've been honest in sharing my frustration as a pediatrician in successfully helping my patients and families deal with their overweight child.

Recently I've been thinking a lot about why I can't seem to get anywhere with this problem, why parents' eyes lid over as they politely tune out my lecture about decreasing animal fat and junk food, why they show up in my office a few months later with a hangdog look on their face and a child with 5 new pounds of body weight.

For some reason, this old saw kept echoing in my brain: food is love, food is love. Remember that controversial and excruciating case a few years ago of the young, morbidly obese child who was taken away from her Latino parents on the grounds that continuing to feed her was a form of 'child abuse'?

For many parents of overweight children, asking them to cut down on calories, to deprive their child of one of his/her favorite things in life, to diminish this pure message of parental love and regard -- is simply asking too much, especially to prevent health concerns (like diabetes, heart disease, hypertension) that are not likely to show up for decades.

How can I do a better job helping overweight kids and their families?

Some initial thoughts:

• Try to help parents change their awareness to "health, not food = love." Even if your child won't really appreciate it until much later, as a parent you can best show your love by having a healthy child. (And then launch into my usual healthy diet and exercise mantra.)
• "Feed everyone much smaller portions." In 1760, a portly Benjamin Franklin wrote, "In general, mankind, since the improvement of cookery, eats twice as much as nature requires." Why are the French (and their kids) skinny? It's not a mystery. Portion size. (Plus they don't snack between meals). A typical French meal is perhaps 1/2 the size of a stick-to-your-ribs supersized American meal. They even feed their babies less milk to avoid excessive baby fat (which I'm not recommending until more is known).
• Admittedly, this is a tough sell in our culture, but "smaller portions have their advantages." There is not much deprivation in the type and wonderful variety and tastes of food you can eat. A nice small dessert is allowed. I'm convinced we have been programmed in childood not to be satisfied unless we are very full, instead of just a little hungry (or at least not stuffed) when we leave the table.
• "There are other ways to show your love." In the shorter time it takes to eat smaller meals, you can be with your child, do fun things together, interact in great ways. Yes, I'm talking about some extra quantity of quality time together as a way to supplant food as the best way to express your love.

As you can see, this is a work-in-progess I'm sharing with you. I'm getting desperate to figure out ways to inspire parents to follow sound nutritional advice. And I'm hoping to use my Blog to improve and refine my ability to improve outcomes for overweight kids and their families.

Help me (and my patients) out here, team. I'd love to hear from you! Tips, thoughts, suggestions...?

Related Topics: Quiz: How Healthy Is Your Diet?, Fast Food Choices

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Parenting your autistic child

Let's not sugarcoat it: it's tough to have an autistic child.

Some have likened it to unexpectedly ending up in Holland on vacation when you thought you were going to Italy. Really it's more like ending up in Slobovia where there is little accommodation to tourists, where you don't speak the language, where the roads are rocky and the sightseeing isn't always very pretty.

Like all parents, you never expected this to happen. It's incredibly disappointing on many levels and you wonder if you are up to the task. The good news is that, in my experience, most parents adapt in a very healthy and constructive way, and end up doing the best for their kids, themselves and their family. Many parents' and family's lives are even enriched by the experience -- learning new meanings of love and caring, and an appreciation of life that has been hard won by keeping your balance on a bumpy road.

"All politics is local" said my ex-congressman Tip O'Neil. I've found his pronouncement true for most situations, including parenting an autistic child. Just as every autistic child is different -- with different challenges, different strengths -- so too are all parents different in how and where they find support and comfort and happiness. There is no one magic answer to parenting an autistic child; you'll have to find your own balance, your own way. All politics is local.

Nevertheless, I'm going to share with you some things I've learned along the way that may ease the road or at least minimize some traps I've seen parents inadvertently fall into.

• Address your grief. All parents with an autistic child grieve: for the "normal" child they didn't have and for the challenges of they one they did. Grief is expected, grief is "normal", grief is even healing. Problems arise when the grief is never experienced and therefore never addressed and therefore never resolved. I've seen stoic parents stuck in grief's early stages: denying there is a problem, angry at the world, depressed at the unfairness of it all. All parents have these emotions, of course, but for some this is as far as their grieving gets. You can imagine how such unresolved grief might get in the way of their accommodating to their child's condition, to working with the outside world, to their (and their family's) happiness and well-being.
• Don't be guilt-ridden. "Never underestimate the parental capacity to feel guilty about anything that befalls their child!" (I said that). Nothing you did (or did not do) caused your child's autism. Period. Yet I've seen parents endlessly beat themselves up, convinced it was that glass of wine in the second trimester. Aside from being unjustified, guilt can be overwhelming and depressing and incapacitating.
• Find support. For some of you that will mean talking to other parents at your local Autism Support Center. Or joining a chat group on the internet. Or just baring your soul to a good friend. Whatever works for you. Don't go it alone.
• Make an alliance with a trusted professional. Whom can you trust? There is so much noise out there about autism. Everyone has a pet theory, a pet treatment. It is a truly bewildering landscape. Find a professional you trust and like (often one who was involved in making the diagnosis) who can serve as a guide and as a support over the long haul.
• Learn about autism. The more you know about your child's condition, the better you will understand him and the better you can help to craft a world that is responsive to his needs. (I like The Autism Source Book by Karen Siff-Exkorn as a helpful guide. Reliable information also can be found on the Autism Society of America's web site) .
• Organize! Suddenly life may be full of appointments and meetings and therapy sessions and chaos and who-knows-what else. Many parents, as an example, find it helpful to keep a loose-leaf binder that contains all the important information, dates of appointments, etc in one place.
• Learn how to be an effective advocate. Sorry to say, at some point most parents have to make some noise out there to get the services their child needs. There is no more effective advocate for a child than a persistent parent who knows how to work the system.
• Don't neglect your other kids. It's so easy to focus all of your limited energy on your disabled child. Many parents then make the mistake of thinking their "normal" kids don't need them nearly as much. The good news is that having a disabled sibling can be a very positive experience as kids learn about sensitivity to children who are different, who are challenged in many ways, who need the help of others. In fact, some of the most empathic, terrific kids I've met have been siblings of disabled kids. But that only happens when she doesn't feel neglected and undervalued by parents who don't remember that "normal" kids have emotional needs also.
• Don't neglect your adult relationships. 1/3 of marital relationships are unchanged by having a disabled child in the family, 1/3 are strengthened, and 1/3 go down the tubes. All relationships take care and work and open communication and sensitivity to each others' needs, but never more so than when raising a challenging child together. Don't forget your important relationships, just like your child, needs TLC if they are to thrive.
• Don't neglect yourself. The best parent of an autistic child is one who is happy and fulfilled in his/her life. If that means "selfishly" spending time doing what you love, so be it. If it means devoting most of yourself to your child, fine. You'll need to find your own way to balance your needs with that of your family.
• Be your child's parent more than his teacher. It's hard to know how much time to devote to your child's "therapies". When in doubt, be his loving parent, not his relentless teacher. He'll have plenty of educational experiences but only you can provide the kind of nurturing relationship that only comes from a parent.

Of course, I've just scratched the surface. I'd love to hear from parents and what they have found that helped them to accommodate and appreciate their trip to Slobovia.

Related topics: Video: Laughter Heals, New Intensity to Debate Over Autism Cause

Technorati Tags: parenting, autism, special needs, living with autism

Too fat for a car seat?

Dr. P's Pediatric Journal Club

The study
The authors looked at growth data on U.S. children ages 1-6 years from the 1999-2000 National Health and Nutrition Examination Survey (N-HANES) and compared it to the maximal weight recommended for child safety seats.

What the study found

• About 283,000 children in the U.S. are at risk for not finding an appropriate child safety seat due to obesity.
• Of these, the majority (183,000) were 3 year olds weighing more than 40 pounds. (This works out to about one in every twenty 3 year olds.)
• There were only 4 oversized models of car seats made to accommodate wide load toddlers and these all cost about $250.

Dr. P comments
As we say in the trade: oy vay!

I've blogged and harangued you before about the stunning increase in childhood obesity, about the long-term risks of diabetes, heart disease, and hypertension, about the wisdom of feeding your family a low animal fat, minimal junk food diet, and about the need for everyone to get sufficient exercise.

But most of my warnings about obesity were of consequences some time off in the future. These clever authors have identified a risk that can affect a child's safety today, especially in those families who can't afford or don't think it's neccessary or don't think to buy a specially enlarged, expensive car seat for their big guy or gal.

Improper restraint in the car is especially worrisome because:

• More than 1.5 million kids/year are involved in a car accident.
• Car accidents are the leading cause of death in children. For example, they account for almost 1/3 of all preschooler deaths.
• Car seats reduce the risk of a fatal injury by 71% in infants using rear-facing seats and 54% in toddlers secured in forward facing seats. [Editorial comment: Keep your infants in a rear-facing car seat as long as you can, preferably until they are married!]
• Forward facing seats are not meant to be used by a child weighing more than 40 pounds. Why not? As explained in http://www.carseat.org/: "Children who are under 4 years old or who are very active may not stay put without a 5 point harness system that holds them in place. Booster seats do not work well for those children because vehicle shoulder belts do not prevent them from leaning forward or placing the shoulder belt behind the back or under the arm."
  

The only good news in these stunning numbers is that car seat manufacturers will likely seize the opportunity and begin to make more "hefty" models to meet the demand of an ever-widening population of preschoolers. Then, if good old American capitalism and competition do their magic, prices will drop and more families will be able to afford them.

For more information on the proper use of car seats, go to http://www.aap.org/family/carseatguide.htm

Related Topics: 10 Ways to Raise Food-Smart Kids, Calculate your Child's BMI

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Autism: Making the diagnosis

I have been evaluating kids for autism in my Developmental Assessment Clinic for a long time. Here are some important aspects about the diagnostic process that are rarely mentioned.

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Autism is an easy diagnosis to make in children.
When a child is very affected, he has little to no language or communication skills, he rarely (if ever) makes eye contact with other people, he likes to do the same thing over and over, he is fascinated with looking at parts of objects, he never points for what he wants nor looks to where his parents point, he never brings toys to his parents to share with them, and he basically seems "lost in his own world". Few would disagree that a child with those behaviors is likely autistic.

Autism is a difficult diagnosis to make in children.
Often, however, the story is not nearly so straightforward. The diagnosis of "autism" encompasses a huge range of behavioral and developmental challenges, from the moderately or severely autistic child I just described, to a child with so-called "high functioning autism" who makes pretty good eye contact (although not the same as a 'typical' child), who is interested in and emotionally related to people (again, not the same as a 'typical' child), who has decent (albeit unusual or somewhat delayed) language skills, who has no obsessive interests or unusual body movements, etc.

In such a child (especially if younger than 4 years), it's not always clear where the line that separates the autism spectrum from a "quirky", but non-autistic child (or adult) should be drawn. For this reason, a professional who admits his/her uncertainty about the diagnosis may be demonstrating sophistication and expertise, not indecision and a lack of competence. In such cases, competent professionals may honestly disagree. Here are some reasons why...

Dr. P's Pearl #1
There is no specific test that clinches the diagnosis of Autism Spectrum Disorder. The diagnosis is only made by observing and testing the child's behavior and development, and by being sure that these behaviors are what other important people in the child's world (parents, teachers) are seeing. Then it's the professional's job to put all of this information together and decide on a diagnosis.

Dr. P's Pearl #2
Especially when the diagnosis is uncertain, parents should be aware that some clinicians are "lumpers": they like to give a single, unifying label to things. Faced with a number of ambiguous behaviors, they are more likely to call them due to the diagnosis of autism.

Other professionals are "splitters". In the face of uncertainty, they label and address each of the child's behaviors separately (e.g., "developmental language disorder" + "sensory issues" + "social skills delays") without lumping together into a single diagnosis, such as autism.

[FYI, I tend to be more of a splitter. Since every child has unique constellation of challenges and strengths, when a diagnosis of autism is questionable, I tell parents he has "(The name of the child)'s Syndrome."]

Dr. P's Pearl #3
If you are confused by the labels we use, it's because you should be. You will hear the terms "Autism", "Autism Spectrum Disorder", "Pervasive Developmental Disorder (PDD)", and "Asperger Syndrome". These terms are intended to describe the severity of the autistic symptoms. Because there are often questions on who fits into what label, I prefer to use the term "Autism Spectrum Disorder" for all kids, as the words imply the expected differences in how autistic children look and function.

Dr. P's Final Pearl
I don't need to tell you that a diagnosis of autism is serious stuff. If you are concerned about a child, given how difficult it can be to make the diagnosis, you want to find an experienced clinician to do the evaluation. It really doesn't matter if s/he is a developmental pediatrician, child neurologist, or child psychologist.

What does matter is that s/he has sufficient experience and knowledge to put together all the information into an informed, sophisticated diagnosis, and that you trust him/her to be a reliable guide and support no matter what the future may hold.

Related Topics: Autism Advances: WebMD Special Report, On the Cutting Edge of Autism Treatment

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