The association between perinatal factors and later night waking

Treatment of Sleep Disorders in Children with Developmental Disabilities

Sleep disorders in children with developmental disabilities are a common and frequently disruptive behavioral concern. In the present study, four children with developmental disabilities (two of the children exhibited frequent night wakings and two had bedtime disturbances) were treated using a multiple baseline across subjects design. Sleep diaries were used to monitor changes in each child's sleep throughout treatment. Establishment of a consistent bedtime routine combined with a graduated extinction procedure for nighttime behavior problems resulted in a decrease in night wakings for two children (a 7-year-old girl and an 11-year-old boy) and a decrease in bedtime disturbances for two children (a 2-year-old girl and a 12-year-old boy). This series of interventions highlights the heterogeneity of maintaining variables in sleep disorders and the effectiveness of relatively simple behavioral interventions for the treatment of night wakings and bedtime disturbances in children with autism and other developmental disabilities.

Parent Management of Sleep Difficulties in Young Children

Difficulties in settling children to sleep and night waking are common problems faced by parents with young children. The effectiveness of parent-managed behavioural intervention is examined in this study of four children which employs a multiple-baseline-design across subjects. Components of the intervention included: establishing regular bedtime routines; paying attention to the children before bed in the living areas and staying with the children only briefly when settling them in bed; adopting procedures for ignoring disruptive bedtime behaviour and night waking; and giving praise for appropriate behaviour. Complete success in settling the three children who were difficult at bedtime was achieved in five to fourteen days. Persistent night waking in all four children was eliminated in five to thirteen nights.

Handling Parents' Concerns Regarding the Behavioural Treatment of Infant Sleep Disturbance

Infant sleep disturbance (ISD) is widespread and troublesome. Although effective management techniques have been established, some lay and professional authors have expressed concern about these interventions. These concerns are sometimes shared by parents who seek professional advice while feeling ambivalent about undertaking treatment. These concerns include (a) that ISD is normal and inevitable, (b) that it results from unnatural or artificial cultural practices, (c) the belief that ISD expresses a need state, and (d) the belief that the use of extinction is harmful. These concerns are examined and the management of ISD by extinction and its alternatives are considered in the light of the ethics of professional practice. It is concluded that these concerns are best answered within the context of a professional relationship based on a partnership and the sharing of expertise with parents.

Prevalence, patterns, and persistence of sleep problems in the first 3 years of life

OBJECTIVE

Examine the prevalence, patterns, and persistence of parent-reported sleep problems during the first 3 years of life.

METHODS

Three hundred fifty-nine mother/child pairs participated in a prospective birth cohort study. Sleep questionnaires were administered to mothers when children were 6, 12, 24, and 36 months old. Sleep variables included parent response to a nonspecific query about the presence/absence of a sleep problem and 8 specific sleep outcome domains: sleep onset latency, sleep maintenance, 24-hour sleep duration, daytime sleep/naps, sleep location, restlessness/vocalization, nightmares/night terrors, and snoring.

RESULTS

Prevalence of a parent-reported sleep problem was 10% at all assessment intervals. Night wakings and shorter sleep duration were associated with a parent-reported sleep problem during infancy and early toddlerhood (6-24 months), whereas nightmares and restless sleep emerged as associations with report of a sleep problem in later developmental periods (24-36 months). Prolonged sleep latency was associated with parent report of a sleep problem throughout the study period. In contrast, napping, sleep location, and snoring were not associated with parent-reported sleep problems. Twenty-one percent of children with sleep problems in infancy (compared with 6% of those without) had sleep problems in the third year of life.

CONCLUSIONS

Ten percent of children are reported to have a sleep problem at any given point during early childhood, and these problems persist in a significant minority of children throughout early development. Parent response to a single-item nonspecific sleep query may overlook relevant sleep behaviors and symptoms associated with clinical morbidity.

Night waking in Thai infants at 3 months of age: Association between parental practices and infant sleep

BACKGROUND AND PURPOSE

Night waking is common among infants and can create sleep deficit in both parents and infants. Sleep practices are influenced by cultural variations which may affect the prevalence and associated factors of frequent night waking. Our objective was to determine whether differences in parental practices related to infant sleep are associated with frequent night waking in Thai infants.

METHODS

A cross-sectional survey based on interviews with parents of infants aged three months, birth weight greater than 2500 g, conducted under the Prospective Cohort study of Thai Children (PCTC).

RESULTS

Of the total sample, 82.9% (3172 of 3826) of parents provided completed night waking information. The mean number (+/-standard deviation [SD]) of awakenings per night was 2.7+/-1.1, 47.3% awoke 1-2 times per night, and 46.9% awoke 3-4 times per night. The group of frequent night wakers (more than 14 night wakings per week, n=1634) was compared with the group of infrequent night wakers (n=1538). Significant and independent associations were present between frequent night waking and male gender (odds ratio [OR] of 1.5; 95% confidence interval [CI], 1.3-1.8), more than three naps per day (OR, 1.3; CI, 1.1-1.5), use of a swinging or rocking cradle (OR, 1.5; CI, 1.2-1.98), falling asleep while feeding (OR, 1.3; CI, 1.1-1.5), and breastfeeding only (OR, 1.2; CI, 1.1-1.4). No significant association was noted between frequent night waking and parental age, education, occupation, household income, type of parental response to infant's nighttime crying, or type of diaper.

CONCLUSION

An association with frequent night waking was demonstrated with various factors of parental practice related to infant sleep, such as number of naps, use of a swinging or rocking cradle, breastfeeding only, and falling asleep while feeding. Further documentation of these associations may be clinically important. Implementing preventive interventions may be able to reduce frequent night waking in early infancy.

Prenatal Cocaine Exposure and Infant Sleep at 7 Months of age: The Influence of the Caregiving Environment

The primary goal of this study was to examine sleep problems in a sample of cocaine-exposed 7-month-old infants and to determine if maternal psychopathology mediated any existing association between substance exposure and sleep behaviors. We also examined the differences in sleep behaviors of cocaine-exposed infants in parental custody and cocaine-exposed infants in nonparental custody. Participants were 65 cocaine-exposed and 53 nonexposed infants and their primary caregivers who were recruited at delivery and assessed at 7 months of infant age. As expected, women who used cocaine during pregnancy had more psychiatric symptoms than nonusers. Prenatal exposure to heavier amounts of cocaine was significantly related to more severe sleep difficulties, and maternal anxiety mediated this association. Approximately 28% of cocaine mothers lost custody of their infants by 7 months of age. Nonmaternal caregivers had significantly fewer symptoms of psychopathology than the cocaine-using women who retained custody of their children. Infants who were in nonparental care at 7 months of age also had less severe sleep problems than did infants who remained in parental care.

Treatment of young children's bedtime refusal and nighttime wakings: a comparison of "standard" and graduated ignoring procedures

Young children with sleep problems received either "standard" or graduated ignoring treatment. Both brief treatments were superior to a wait-list control condition and resulted in comparable improvements in bedtime and nighttime sleep problems. At bedtime, the treatments did not differ with respect to maternal compliance and stress. For nighttime wakings, mothers in the graduated ignoring group reported higher rates of compliance and less treatment-related stress. Maternal characteristics predicted treatment outcome in the standard ignoring condition. Following treatment, only positive side effects were observed. When compared to the wait-list group, mothers in the standard ignoring group reported less verbose discipline and decreased stress in parenting, while mothers in the graduated ignoring group reported improved parent-child relationships. Treatment gains were maintained over a 2-month follow-up period.

Aetiological factors and development in subjects with obstructive sleep apnoea

OBJECTIVE

To examine whether maternal pregnancy complications, adverse birth events, respiratory illnesses, or developmental difficulty were increased in neurologically normal children with obstructive sleep apnoea (OSA) and whether severity of OSA adversely affects the child's development and temperament.

METHODOLOGY

Maternal report of perinatal events, respiratory illness and developmental difficulty in 37 children with OSA was contrasted with a comparison group (n = 67). Children with OSA were assessed developmentally (Griffiths Scales), had a parental rating of temperament (Australian Temperament Scale) and attended an overnight polysomnographic sleep study.

RESULTS

Children with OSA had an increased prevalence of adverse maternal pregnancy and perinatal events, respiratory disease and developmental concerns. Limited associations were found between the severity of OSA and development or temperament difficulty.

CONCLUSIONS

This study suggests a relationship between OSA, though not its severity, and pre/perinatal adversity and child development. Polysomnographic and detailed developmental assessment of community-based samples of children with OSA and control children are necessary to confirm these findings.

The sleep patterns of normal children

OBJECTIVES

To determine the range of sleep behaviour of normal children to age 38 months and to ascertain the level of parents' problems associated with their child's sleep behaviour.

DESIGN AND SETTING

A cross-sectional survey by questionnaire of parents presenting with their children for routine well-child checks at child health centres, mobile clinics, flying doctor clinics and home visits throughout Queensland. Of 3383 questionnaires distributed 3269 (96.5%) were returned.

MAIN OUTCOME MEASURES

1. Sleep frequency and duration, settling procedures, time taken to settle at night, age when child first slept through the night and number of night-time wakenings requiring parental intervention. 2. Parents' problems with their child's sleep behaviour.

RESULTS

There is a wide range of normal childhood sleep behaviour. Circadian rhythm is not well established until four months of age. Daytime sleep becomes less regular with increasing age. Frequent night-time wakening is common from four to 12 months. Night-time settling requires more parental input from 18 months. A large proportion of parents (28.6%) have a problem with their child's sleep behaviour.

CONCLUSIONS

Parents require information from health care providers about the wide range of normal childhood sleep patterns. This information can help prevent misdiagnosis, inappropriate medication use, child abuse and parental depression when children's sleep patterns are a problem.

Sleep problems in childhood

Sleep, like eating and toileting, is an individual physical requirement that changes with time as the child matures. Although much about a child's sleep is biologically determined, extrinsic factors, usually through the parents, also mold the child's sleep behavior. Normal sleep for a child is restful to the child and not excessively disruptive to others. Sleep problems interfere with the quality of the child's sleep and frustrate or frighten caretakers. Several sleep problems have their origins in normal sleep behavior from an earlier age. Some, the parasomnias, are caused by self-limited biologic diatheses. Many sleep problems have psychosocial triggers. Sleep disorders only rarely are a primary medical problem that is adequately treated with medication (e.g., narcolepsy). Good history-taking, often accompanied by diary-keeping, will usually identify the problem--the first step in effective treatment. Treatment of a sleep disorder in the pediatrician's office can start with educating caretakers about normative sleep for the age of the child and providing information regarding the cause and natural course of the problem. Treatment also may involve behavioral or psychological intervention or both, but medication is generally not indicated. When needed for short-term treatment, mild sedatives such as antihistamines are used most often. More serious sleep or behavioral problems should be acknowledged by the primary care pediatrician, followed by referral to an appropriate specialist. Inquiry into a child's sleep habits at each well-child visit, coupled with appropriate anticipatory guidance, could make an important contribution to the child and family by preventing problems with sleep and identifying sleep problems early in their evolution. Pediatricians and parents can work together to help children develop good sleep habits that fulfill the child's evolving sleep requirements within the context of the family's needs and expectations.

Does phenobarbital used for febrile seizures cause sleep disturbances?

The effect of phenobarbital on total sleep time, night awakenings, and lengthy awakenings was examined as part of a randomized trial of children with febrile seizures; information about sleep patterns was gathered by parental observation. Children were between ages 8-36 months at enrollment and were examined subsequently for 2 1/2 years. Night awakenings were not more common in children assigned to phenobarbital except for those who were poor sleepers at the beginning of the study. Total sleep time was no different in children assigned to phenobarbital than in those assigned to placebo. It is concluded that sleep problems reported in most young children with febrile seizures treated with phenobarbital did not exceed those reported in children treated with placebo, but a subset of predisposed children did experience an increase in night awakenings.

The effects of illness on sleep behaviour in infants

For the purpose of evaluating the association between health problems and sleep disturbances as part of a community survey of sleep patterns in childhood, a questionnaire was administered to 752 mothers of children between the ages of 4 months and 4 years, and to the nurses at their regular baby clinics. The questionnaire covered the areas of past and present sleep and settling behaviour, as well as health history and demographic data. The study group consisted of 66 (8.9%) children who had either chronic medical problems, or history of an illness requiring hospitalisation. Regular night waking was reported in 35% and 34% of the group with and without history of illness, respectively. The mean number of interrupted nights per week was similar in both groups and so were the sleep problems perceived by the mothers. We conclude that in this age group the results do not support an association between health problems and prolonged sleep disturbances.

Sleep disorders in early childhood: association with insecure maternal attachment

Psychological, family, and social characteristics relating to attachment relationships were measured in mothers of 20 sleep-disordered toddlers, comparing them with 21 mothers of toddlers without sleep problems. The groups were matched on measures of socioeconomic status, child and maternal age, maternal education, marital status, and family size. Results showed that 100% of mothers of sleep-disordered children were classified as insecure with respect to attachment, as assessed by the Adult Attachment Interview, compared with 57% of control group mothers (p less than 0.002). There were no group differences on measures of maternal defensiveness, self-esteem, marital satisfaction, and social support. These results suggest that maternal current perspectives on their relationship history, rather than general psychosocial adjustment, are crucial contributors to the onset and perpetuation of sleep disorders in early childhood.

Maternal, environmental, and temperamental characteristics of toddlers with and toddlers without sleep problems

Sleep problems of young children are a common behavioral concern of parents. Thirty parents of toddlers with sleep problems (SP) and 30 parents of toddlers without sleep problems (WSP) were studied to ascertain differences in maternal, environmental, and temperamental characteristics. The Sleep Behavior Inventory and The Toddler Temperament Scale provided data identifying certain environmental and temperamental characteristics that may influence the development and/or maintenance of sleep problems. Implications of these findings for anticipatory guidance and counseling are discussed.

Behavior management of infant sleep disturbance

Using a nonconcurrent multiple baseline design, we evaluated the effects of extinction and stimulus control on nighttime sleep disturbances exhibited by 7 infants. Results showed that frequency and duration of night wakings decreased for all subjects, with corresponding improvements reflected through changes in responses to the sleep behavior scale. Observed improvements maintained at 3 and 24 months posttreatment.

Sleep patterns of infants in the first year of life

A prospective study of 132 infants aged from 1 month to 1 year found that infants who were breast fed or breast plus bottle fed were significantly more likely to wake at night throughout the first year. Social class of the family, parity of the mother, and the weight gain of the infant had no consistent effects. This increased waking was not due to mothers of wakeful infants prolonging breast feeding to soothe their infants.

Controlled trial of trimeprazine tartrate for night waking

Mild hypnotics are often recommended for young children with sleep problems. This study assesses the efficacy of trimeprazine tartrate in 1 to 3 year old children with persistent and severe night waking in a double blind crossover trial with placebo. Children on treatment with trimeprazine had significantly fewer wakings, less time awake at night, and more night time sleep compared with those on treatment with placebo. There were no differences in these sleep variables when the first and last (fourth) week of treatment with drugs were compared. Follow up observations showed no significant difference in any sleep variables from baseline measures. The results are consistent with the idea that trimeprazine tartrate may be a useful short term treatment for night waking in young children.

A developmental approach to the management of children with sleep disturbances in the first three years of life

A developmental approach to the management of sleep disturbances was successful in 85% (44/52) of the children (aged 2-36 months) within 2-6 weeks. No drugs were used. The approach was based on the following two principles: taking into account the characteristics of sleep behavior in infants and young children by setting up seven rules of normal sleep behavior, and dealing with the expectations and anxieties of the parents by means of a sleep chart.

Night waking in 4- to 8-month-old infants

Parental reports of night waking and sleep patterns were obtained for 141 normal 4- to 8-month-old infants from middle-class families. A group of infants was identified who had a past history of colic and who were perceived to have a current night waking "problem." These infants awoke more often than other infants and also had significantly briefer total sleep duration. Night waking was described as a problem in infant boys more often than in infant girls. A second group of infants who awoke frequently was reported to snore or mouth breathe when asleep. This group of infants did not have a past history of colic, was not perceived to have a night waking problem, and was not overly represented by boys. Ordinal position, father's education level, gender, and method of feeding did not affect reported sleep patterns.

Behavioural management of sleep problems

The outcome of 19 consecutive children referred with sleep disorders and managed by behavioural methods is described. An 84% success rate is reported, which was maintained at 6 months' follow up. Successful outcome was associated with absence of marital discord and attendance of both parents at treatment sessions.

Sleep behavior of preterm children at three years of age

Caregivers of 50 preterm children completed a questionnaire relating to their child's sleep behavior at three years of age. Assessments of the children's EEGs at term and three months, medical status at birth and at four, nine and 24 months, caregiver-child interaction at one, eight and 24 months, the Bayley Scales at 25 months and the Stanford-Binet at five years of age were also obtained. Sleep disturbances were frequently noted at three years of age. However, by five years of age, the number of reported sleep-problem children was greatly reduced, and they were not the same children with sleep problems at three years. Surprisingly, children with the greatest difficulty falling asleep at night at three years were likely to have had fewer medical problems, higher scores on the Bayley scales, and more positive social interactions with their caregivers in the first two years. The relationships among early physical, psychological and social development and sleep behavior are discussed.