Solve Your Child's Sleep Problems

Part II

The Sleepless Child

Chapter 8

Colic and Other Medical Causes of Poor Sleep

Illnesses of various kinds can disrupt a child’s sleep. Unless the illness is chronic, this disruption is usually temporary; a child in discomfort or running a fever might sleep fitfully at night and nap intermittently during the day until the illness resolves. Teething pain, for instance, can cause a young child to sleep poorly for several nights, but it will not interfere with his sleep for weeks on end, as parents sometimes suppose. In young children, even chronic medical conditions rarely cause sleep disturbances that continue for months or years. Still, if your child has consistently poor sleep and you have ruled out the more common causes—or, of course, if you know that your child has a significant medical problem—then you may have to consider a medical cause.

Colic

In the early months, probably the most common cause of significant sleep disturbances is colic, a condition in which a baby has frequent spells of intense crying and is difficult to soothe. The episodes begin to appear in the first weeks after birth; they usually occur in the late afternoon or evening and can go on for several hours. If your baby is colicky, you may find you can help only by walking around with him for hours or by placing him over your legs while you rub his back. Often, nothing you do may seem to help.

A colicky baby often has a distended stomach; his legs will likely be pulled up toward his chest, and he may seem to feel relief when he passes gas or has a bowel movement. For these reasons, it is commonly assumed that colic is caused by intestinal pain. Whether that is true (or always true) remains uncertain, but in very severe cases of colic a pediatrician may prescribe medication to relax the bowels and ease the apparent discomfort. On the other hand, it’s possible that the distention, the gas, and at least some of the apparent discomfort may actually be caused by air swallowed during long periods of vigorous crying. The initial reason why the baby started crying, or cries so long and so hard, may be something else entirely.

Another possible contributing factor is sensory overstimulation. Colicky infants often seem to be unusually sensitive to events happening around them or to excessive handling and other stimulation, or at least they behave as if that is the case. Many professionals have concluded that these children see, hear, and feel the world about them as an unpleasant and disorganized barrage of sensations. This chaotic input would be difficult for an infant to handle; the child could become upset and build up so much tension throughout the day that his coping abilities become overloaded. He would need to discharge this accumulated tension at the end of the day. Whether or not this explanation is true, colicky babies do act as if they have a need to cry and seem to do better when allowed to do so for a while.

If your baby seems to have colic, you should first try to comfort him; you might try rocking him gently, feeding him, or giving him a pacifier. If you find he cannot easily be comforted, allow him to cry for fifteen minutes while held calmly or alone in his crib. If he has not settled by then, try again to console him. Be calm and speak softly; try not to become frantic, and don’t do anything too vigorous, such as bouncing him or running around the room with him. If he still isn’t comforted, try again every fifteen minutes or so. Remember, since colicky babies seem to benefit from a period of crying, you are actually responding to his needs by letting him cry for a while. If you try too hard to stop the crying, you might just over-stimulate him and make things worse. If he needed to be held, nursed, or rocked, or just wanted to use a pacifier, then those interventions would have calmed him down.

A child’s colic often improves if he is allowed to cry undisturbed for just two or three consecutive colicky periods. His crying spells may get shorter and less intense in a day or two, and, if they do, he will probably sleep better as well. Babies hospitalized for severe colic often seem to be “cured” just by being in the hospital, probably because nurses are more likely than parents to allow an infant periods to cry by himself if he does not accept comforting.

Colic is discussed in all books on baby care, and if your baby suffers from it, you should also talk it over with your pediatrician. In almost all cases, the symptoms completely disappear by the time the child reaches three months of age. However, although colic is not in and of itself a sleep disorder, colicky infants often do develop long-standing sleep problems. These ongoing problems may look the same as those the baby suffered from during the colicky months, but they are not.

What happens is that the habits formed when your child was colicky can persist after the colic has disappeared. You may have spent a great deal of time walking, rocking, and holding him and otherwise trying to comfort him to help him get to sleep. Once the colic is gone, your child may still demand these rituals, not because he is in distress (despite his crying), but because he has come to expect them. If that happens, you will have to help him learn new, more appropriate associations with falling asleep, as discussed in Chapter 4.

The biggest difficulty here is deciding when the colic is gone. It goes away gradually, not overnight, so it may not be obvious to you when the time has come to change your responses. Keep in mind that colic is usually gone by the age of three months, and that it occurs during the day, not just during normal sleep hours. In fact, colic tends to be most severe in the evening, suggesting an interaction with underlying circadian rhythms, although it is not known which hormones or bodily functions may be involved. A colicky baby appears to be genuinely distressed, as if he is in pain and not merely hungry, frustrated, or angry, and it is difficult to ease a colicky baby’s suffering. So it is unlikely that colic is (still) the problem if your baby cries mainly at bedtime and during the night; if, despite the crying, he does not appear to be in pain; if the crying stops promptly when you pat his back, rock him, give him a pacifier, or feed him; and if you can get him to return to sleep quickly when he does wake. Once you have realized that, you can go on to identify the real cause of the persisting sleep problem and take steps to correct it. If you don’t, it may continue for months or even years.

Chronic Illness

Chronic medical conditions can contribute to ongoing sleep disturbances in a variety of ways. A child’s illness may cause pain or discomfort: skin irritation causes annoying itching; migraines cause nighttime headaches and nausea; asthma makes breathing difficult. His sleep may be disrupted by the specific symptoms of his disease or disorder: perhaps he wakes feeling jittery or needing to urinate because of poorly controlled diabetes, or his sleep may be broken by epileptic seizures. The indirect consequences of a medical disorder can also cause trouble: for example, certain medications have side effects that interfere with sleep; an orthopedic brace can cause discomfort or limit a child’s ability to move; and even a child’s anxieties about his condition can keep him awake.

If your child suffers from a chronic medical problem, you’re probably well aware of it. The difficulty lies in sorting out which factors related to the illness—if any—are disrupting his sleep. Several factors may be contributing at once. This can be a very complex problem, possibly too difficult for you to solve alone. Ask your pediatrician or specialist for help.

Several conditions do merit special discussion here.

Nocturnal Pain

When pain at night affects sleep, it is the pain, not the sleep itself, that must be treated. In most cases—for example, when a child is up at night after sustaining an injury or while teething—it is clear what is happening, and the solution is as simple as relieving the pain with medications or other treatments. Fortunately, most causes of pain are easy to recognize and resolve quickly. However, there are two especially common ones that often go unrecognized for long periods of time: middle-ear disease and gastroesophageal reflux.

Nighttime pain from these or other causes often wakes children at unpredictable times during the night (not at a regular time, say, always an hour after the child falls asleep). If your child has awakened in pain, he will probably be crying and unhappy, and there will be no easy way to stop it. It makes little difference where he is. If he usually stops crying quickly and seems fine once you pick him up or allow him something he wants, then he’s probably not in pain. Similarly, if he cries every night in his own bed but always sleeps soundly when you let him sleep in your bed, look for an explanation other than pain (he could not be suffering from reflux or middle-ear disease only when in his own bed, after all).

Middle-Ear Disease

Once identified, chronic middle-ear disease is usually easy to treat. In this condition, fluid collects in the middle-ear cavity behind the eardrum and does not drain satisfactorily. This fluid can become infected, but even if it doesn’t, the fluid buildup alone can lead to a temporary loss of hearing, and if the fluid remains there long enough, it can permanently damage the bones of the middle ear.

When a child’s middle ear is acutely infected, pressure in the middle-ear cavity increases, the eardrum bulges, and the child likely experiences pain. When the fluid does not become infected, children usually don’t complain of pain, but their sleep may nonetheless be disrupted—it is not clear how or why. It may be that when the child is lying down the middle ear drains less effectively than at other times, more fluid collects, pressure increases to a degree, and the child feels enough discomfort to interrupt his sleep. Whatever the cause, children with persistent fluid behind the eardrum sometimes have significant sleep disturbances that cannot be explained any other way. It is striking that when these children are treated with proper medication, or, if necessary, by having drainage tubes inserted through the eardrums, not only are their middle-ear problems cured but often the sleep disturbances disappear as well.

Caroline was an eighteen-month-old girl who had a long history of frequent wakings at night despite the fact that she went to bed easily. On waking she usually cried. She calmed down somewhat if her parents picked her up, but she had a hard time getting back to sleep, no matter what her parents did. Even when they walked with her or rocked her she usually whimpered for ten or fifteen minutes before finally going back to sleep. Nothing they tried seemed to help at all. Caroline’s history did not suggest an obvious cause for her sleep disturbance, but her parents did report that Caroline had had three or four ear infections over the past year.

When I see a child with sleep problems like Caroline’s—frequent unhappy nighttime wakings, with difficulty returning to sleep regardless of anything the parents do—I always take a careful look at the child’s eardrums before deciding on a diagnosis and plan of therapy. In Caroline’s case, I found that she still had a buildup of fluid behind her eardrums. Not only were her ears better treated with drainage tubes, but her sleep problems went away, and we avoided a series of behavioral treatments that, in her case, would not have worked.

Gastroesophageal Reflux

Another cause of nighttime pain is gastroesophageal reflux, what we commonly call heartburn. Ordinarily, food passes down from the mouth through the esophagus and then through a valve that keeps food in the stomach and prevents it from coming back up. This valve often functions imperfectly in early infancy (which is why spitting up is so common). Other problems with the normal passage of food out of the stomach into the intestines can complicate the problem further.

Occasional spitting up in itself is no more than an annoyance, and most reflux material is cleared fairly rapidly from the esophagus by swallowing. But if stomach contents (which are very acidic) are repeatedly regurgitated into the esophagus and remain there too long, they can burn and even scar it. Occasionally some acid even spills over into the trachea (windpipe) and possibly down into the lungs, causing coughing, gagging, and occasionally pneumonia. Pediatricians and gastroenterologists have good techniques for evaluating these symptoms and many effective medicines to treat the problem. You should not hesitate to consult them.

When a young child is frequently up at night crying inconsolably, pain from reflux is one of the causes we must consider. Reflux occurs more often when a child is active than during sleep; most episodes of reflux at night are actually caused by movement and crying, not vice versa. Children with reflux generally also show symptoms during the day: they spit up frequently and perhaps gag and choke. If your child has no such symptoms during the day, then it is unlikely that he is experiencing much reflux at night.

When a child’s symptoms suggest reflux as a possibility, further evaluation may be indicated, possibly including x-ray studies or direct monitoring of the level of acid in the esophagus. Occasionally we simultaneously monitor a child’s sleep and reflux patterns overnight in the sleep laboratory to see if reflux is actually causing discomfort and wakefulness. Treatment is generally by antacid or anti-reflux medication, sometimes started on a trial basis to help make the diagnosis. Surgery is only rarely indicated.

Medication

Sleep medication is very frequently misused. In recent years doctors have begun to appreciate that sleeping pills have caused far more sleep disorders in adults than they have ever cured. That is equally true with youngsters. A child receiving sleep medication regularly may reach a point where without the medication he cannot sleep, yet his sleep on the medication is of poor quality. When a child is not sleeping well and nothing seems to help, the family feels frustrated and hopeless, and they often beg the doctor for help. Often the doctor will prescribe some sort of sleep medication. The ones most commonly used are the antihistamines, such as diphenhydramine (Benadryl); certain medicines for high blood pressure, such as clonidine (Catapres); and certain drugs used to treat depression, such as trazodone (Desyrel). All of these drugs cause sleepiness as a side effect. Major sedatives, such as chloral hydrate, and even major tranquilizers, such as those related to diazepam (Valium), are often tried as well.

Yet such medications rarely solve the sleep problems of a child who is otherwise normal and healthy. A child may even have a so-called paradoxical response to the medication, becoming “hyper” and unable to sit still or sleep. In some conditions, such as sleep apnea (see Chapter 17), certain medications can be very dangerous. Even if your child sleeps well on medication, he will be far better off if you can determine the cause of the disturbance and help him learn to sleep well without drugs. Sometimes medication improves a child’s sleep for several nights, even for a few weeks, but usually the old pattern returns. Besides, the stronger medications often affect a child’s daytime mood and level of functioning: he may become overactive or clingy, cranky, and babyish. Only occasionally will a short (one- to two-week) course of drug treatment break the cycle of a poor sleep pattern and allow a good one to emerge so that normal sleep persists after the medication is stopped. If this treatment succeeds, the medication probably did no harm, but proper behavioral approaches would probably also have been successful. If you are able to correct your child’s sleep without medicine, you will avoid the nagging anxiety that he has an underlying medical or neurological problem that keeps him from sleeping well, and you will feel more confident in dealing with any problems that may emerge in the future without feeling that you have to head immediately for the medicine cabinet.

In my practice, I see far too many young children who have been given powerful medications in an attempt to relieve sleep disorders that could be corrected by other means. In many cases, whatever the child’s problem, the medication only makes matters worse. Also, the child’s daytime behavior and his ability to concentrate and learn may well be compromised. This was the case with Joshua.

Joshua was a four-year-old boy described by his family as tense and irritable. His parents said he had great difficulty sleeping at night and wasn’t very happy during the day. Because of the boy’s repeated nighttime wakings and his behavioral difficulties during the day (which were probably the result of his poor sleep), his parents had sought medical advice. Joshua ended up on three medications: a long-acting stimulant taken in the morning, a drug to induce sleep at bedtime, and an even stronger sleeping pill to be taken if he didn’t fall asleep quickly or woke again later in the night. He had been on these medications for ten months.

Joshua was so clearly an unhappy and irritable child that I was quite concerned. He interacted poorly with adults and peers, and I felt that a complete psychological evaluation would likely be needed. But first, to get a clearer picture of the situation and to establish a baseline for making further decisions, I had the family gradually stop Joshua’s medications altogether. We also discussed changes to his sleep schedule and bedtime routines and ways for his parents to set limits. Joshua agreed to cooperate in exchange for stickers and prizes. When I saw the family several weeks later, Joshua’s parents were already vastly relieved. After a few difficult nights in the beginning, Joshua had begun going to bed easily and sleeping through the night for the first time in a year. In addition, he was much happier in the daytime and his parents had begun to enjoy his company again. When I saw him in my office, Joshua was smiling, obviously happy, and good-natured in our conversation. In short, he was a delightfully normal four-year-old. His good sleep pattern and normal daytime behavior have continued, and there has been no need for further intervention.

I almost never recommend medication for a child with difficulty falling or staying asleep, and when I begin to treat a child who has been taking medication just for his sleep, I usually try to arrange for a trial period off of the medication before doing anything else, as I did with Joshua. If your child is on medication just to help him sleep, you may want to speak with your doctor about doing the same.

Your child, of course, may have to take medications to treat other medical conditions. Phenobarbital and other drugs with sedative properties are often used in the treatment of epilepsy. Theophylline (Slo-Phyllin, Slo-Bid), aminophylline (Phyllocontin, Truphylline), metaproterenol (Alupent), albuterol (Ventolin, Proventil), terbutaline (Brethine, Bricanyl), and other similar medications with stimulant properties are used to treat asthma. Other stimulant drugs, such as the amphetamines (Dexedrine, Adderall) or methylphenidate (Ritalin, Concerta), may be used to treat Attention Deficit Hyperactivity Disorder (ADHD). Some children need antibiotics on an ongoing basis as protection against recurrent infections. These and many other medications can interfere with proper sleep. Again, the various effects of the underlying medical disorder, the medication, and other causes of sleep problems have to be sorted out—not always an easy task. The dilemma can be further complicated if your child has had many hospitalizations and has become fearful at night, or if you (understandably) find it hard to set firm limits for your child because of his illness.

If it seems possible that medication may be causing the sleep problem, you should raise the issue with your doctor and discuss the several approaches that may be helpful. You may be able to change your child’s dosage or the time of day when he takes the drugs, or your doctor may be able to suggest alternative drugs—even a temporary change will help you determine whether the original medicine was causing the sleep problem. Asthma medications taken by mouth may also be available as an inhalant, with fewer side effects. Antibiotics themselves are unlikely to cause much of a sleep problem, but the additives in the liquid preparations may; switching to pills, or even to a different brand of liquid, may be helpful.

In any case, these changes will take time and require a certain amount of trial and error. But do not make any changes before you talk to your child’s specialist. With his or her help, significant improvements may well be possible.

Abnormal Brain Function
and a True Inability to Sleep Well

On occasion I see children who appear to sleep poorly because of some impairment in the brain mechanisms that control one aspect or another of sleep. Most of these children show general impairments significant enough to be obvious. Usually they are mentally retarded; they may suffer from spasticity and seizures; and they may be blind or deaf.

When such a neurological disorder is accompanied by a sleep disorder, we have to consider all the possibilities very carefully. For example, the child could have any of the sleep problems described in this book apart from his illness, and those problems can be solved in much the same way as for any other child. If your child has a neurological disorder or sensory impairment, it may be especially difficult for you to be firm at night—enforcing new patterns and setting new limits—but often the only way to solve his sleep problem is to accept that there will be some crying as, for example, you help him learn new associations with falling asleep (see Chapter 4). Although it may seem harsh, it is in your child’s best interest. You may just have to proceed more slowly than you would in the absence of the disorder. Instead of setting an initial goal of being out of the room while he falls asleep, say, you might simply work on helping him learn to fall asleep when you are out of his bed, even if initially you remain in the same room. Correcting an inappropriate sleep schedule is easier, and it is especially important for children with visual handicaps who have an impaired ability to rely on daylight to control their body rhythms (see Chapters 9 through 12). As described above, medications that your child is taking for his disorder could also be a source of his sleep problems. Finally, your child’s neurological impairments could be directly responsible for his inability to sleep—that is, the brain systems that control sleep may not be working properly.

When I treat a child who is neurologically impaired, I first try to identify and treat factors apart from the brain damage, such as medication, inappropriate sleep associations, or schedule problems. More often than not, this approach leads to a successful outcome, and the child’s sleep problem is resolved in spite of the neurological disorder. Only after all other factors are eliminated do I conclude that the child is sleeping poorly as a direct result of the brain damage.

Sarah was a six-year-old girl with muscular dystrophy, which left her severely compromised. She was largely confined to bed, although she spent part of the day in a wheelchair. She took one medication, to help keep her muscles relaxed. Though she could not speak, she understood much of what went on around her. Her parents were devoted to her. They did not, however, like the fact that Sarah slept only about five hours each night, usually from midnight to 5:00 A.M. If she was put to bed early, she made noise until her parents came and stayed with her or brought her into the other room with them. Neither behavioral changes nor sleep-inducing medication seemed to help. The family had been told that the problem was part of Sarah’s illness and that there was little that could be done.

However, when I met Sarah I discovered that, although she slept little at night, she usually slept about four hours during the day. She spent much of the daytime in bed, and when she was alone she often fell asleep for up to three hours at a time. This was due mainly to habit, not to the sedating effects of her muscle relaxant medication (since her sleep pattern changed little when the medication was temporarily discontinued). It was clear to me that, despite her neurological illness, Sarah had a normal sleep requirement; the problem was that too much of her sleep took place in the daytime.

Even though Sarah had had this problem for years, it was fairly easy to fix. I simply asked her parents to keep her awake all day. They needed to get her out of bed more often, and at first someone had to be with her almost all the time to be sure she did not doze. I also changed the dosage and timing of her daily medication. Once Sarah was no longer allowed to sleep so much during the day, she started sleeping more at night. Within two weeks she was sleeping from 9:00 P.M. to 6:00 A.M. and never took more than a one-hour nap.

Although Sarah had a severe neurological illness, it was not the illness or even her medication that (directly) caused her sleep problem but her sleep schedule. The solution was an adjustment to her hours of sleep, not more medication.

Nicholas was a four-year-old boy who was moderately retarded because of a birth injury. He had always been a poor sleeper and was now falling asleep no earlier than ten o’clock in the evening (albeit fairly easily) and waking at about four o’clock in the morning, after which he would stay awake for several hours or even the rest of the night. On waking he would call out, throw toys around the room, and bang his head against the wall. During the day Nicholas sometimes napped for about thirty minutes, rarely longer. Nicholas’s parents wanted very much to keep him at home instead of placing him in a residential treatment program, but getting up with him every night was a tremendous strain, and some of Nicholas’s behavior posed dangers to him.

We began Nicholas’s treatment by changing all of the possible behavioral factors we could identify, including how his parents handled his bedtime routines and responded to his nighttime wakings, but he showed only slight improvement over a period of several months. Eventually, I had to conclude that behavioral intervention would not work and that he had a true inability to get the sleep he needed. The only other explanation, which seemed unlikely, was that he simply didn’t need very much sleep (although even if that were the case, we had to do something since he could not continue to live at home if he slept so little).

In an extreme case like Nicholas’s, when I know that brain function has been impaired and I’m convinced that the impairment is responsible for the sleep disturbance, I will consider the use of medication. Sedatives are sometimes effective. There have been a few reports suggesting that melatonin (a hormone, sold in health food sections, that is normally secreted during nighttime sleep periods; see Chapters 9 and 10) can help children like Nicholas, and as far as we know at this writing it is probably a relatively benign drug (we do not yet know for sure what side effects it may have, especially when it is used for a long time); however, I have not found it particularly helpful. Usually we must resort to stronger medications. There is no single medication that is helpful to all children like Nicholas, and not all children respond best to the same drug. While I greatly prefer not to use such drugs, they do help children like Nicholas to go to sleep more easily and, more important, to sleep long enough for them and their families to get sufficient rest.

With the help of medication, Nicholas began sleeping from 9:30 P.M. to 6:00 A.M. While he was still getting less sleep than the normal amount for his age, this was a major improvement and it made life much easier for his parents. In addition, as is typical of children with neurological impairment, Nicholas seemed to show no lingering drug effects in the morning, and his teachers said he seemed more alert.

Results like these suggest that children such as Nicholas are not sleeping poorly just because their sleep requirements are short. It is also interesting that such children may continue to sleep well even when they are prescribed medication for extended periods, whereas in a normal child the same medications usually become less effective over time and eventually create new sleep problems. When I must recommend medication, I continue to monitor the child carefully, and at intervals we decrease the dosage or stop the medication altogether to see if it is still needed.

Most of these drugs require prescriptions and can only be managed under the care of a doctor. My experience shows that when neurologically impaired children require medication to help them sleep, they often need a fairly powerful drug, and in substantial doses. If a child shows improvement on a mild medication such as an antihistamine, then I am convinced that he can get the same improvement without drugs.

If your child is neurologically impaired and not sleeping well, you may consider discussing a trial of medication with your doctor. But before you decide to give your child a strong sleep medication, do try to identify other possible causes and to regulate his sleep patterns according to the methods outlined in this book. The behavioral approach has been successful with many neurologically impaired children, and it just might be all that your child needs.