I initially became interested in sleep problems in children as a young general pediatrician when my daughter was born and developed colic. Almost 30 years later, I still remember how stressful that time was; I also remember receiving a handout from our pediatrician that indicated that we were supposed to “prevent later sleep problems.“ As I think back on that time, my major focus was on maintaining my own sanity, and not on preventing problem sleep habits in my daughter. So, I suppose that it is not too surprising that my daughter later had trouble falling asleep on her own. As physicians, I think it is critical that we maintain our patient- and family-centered focus when addressing common problems. When I help families manage the initial symptoms of a colicky baby, I always tell them that they should focus on what works for them and that together we will address any future sleep issues.
With that last sentence in mind, the article “Sleep Disorders in Children” in this month’s Pediatrics in Review is really helpful for all of us. I think this article should be required reading for those in residency training as part of an expanded curriculum on common problems seen in pediatrics. The authors do a really nice job of providing both the scientific background as well as very practical advice that we can provide for our patients and families. As a generalist, some of the most common concerns I hear from caregivers are that their young infants or children don’t want to go to sleep or stay in bed. The authors describe these problems as sleep onset association disorder (SOAD), and limit-setting sleep disorder (LSSD). Essentially, SOAD is often seen in infants and young children who have developed an association with a person or an activity with being able to go to sleep. This association could be the presence of a caregiver in their bed, rocking a child until they are asleep, or some other similar activity. This type of sleep concern is often seen in children who had colic as young infants. The primary solution suggested by the authors is to put the child into bed while the child is still slightly drowsy so the child can learn to put themselves to sleep. This is not always easy to do but is crucial to developing good sleep habits. Providing this advice at all well-visits is an important thing that we as clinicians can do to support parents and caregivers.
LSSD is often seen in older children who don’t want to stay in bed and keep coming out of their rooms. My daughter also had this issue, this time as a toddler, and we implemented a system similar to what the authors describe, using bedtime passes. This worked really well for us, and my daughter adapted pretty quickly. As a parent, I found that instituting the bedtime pass resulted in less stress and conflict.
As we address sleep problems in practice, I would again say that providing family-centered advice is critical. Over the years, I have cared for many families who cannot let their child “cry it out” for a variety of reasons. Sometimes they live in an apartment with walls that allow sound to penetrate another apartment. Other times families have other young children who awaken easily when one child is awake and crying. Aligning our recommendations with the needs of the family can help us be more successful in altering behavior. Also, acknowledging the challenges of raising children is important even for these relatively “simple“ problems. Lastly, while this article focuses on scientific literature, clinicians should become familiar with some of the common books and resources designed for children or for caregivers that address sleep problems at different ages. After reviewing some of these resources, clinicians can make appropriate recommendations to families who could benefit from them.
One of the other key insights that I gained from this article was the authors’ statement that polysomnogram-confirmed resolution of obstructive apnea occurs in up to 50% of children without any intervention. I didn’t realize that this was so likely, and as a result I am reminded of the old adage, “Don’t just do something. Stand there!“ The challenge for us is knowing when to send a child for further intervention, which understandably has led to a lot of practice variation. The authors note that the Pediatric Adenotonsillectomy Trial for Snoring (PATS) trial is underway; we hope we will soon have results to help us make more evidence-based recommendations for our patients.
Sleep problems are common in our practice, and even in our own home. This article is an easy read and relevant to our patients. I hope you will take the time to read it and share it with your learners and colleagues.