But nightmares in most young children do not seem to be associated with any specific emotional or personality problems. However, two recent reports in children, one for five to eight years of age, and the other for six to ten years of age, concluded that anxiety issues or other psychological problems are associated with nightmares. Analysis—guesswork, really—of dream content in disturbed children who have been referred to psychologists or psychiatrists should not be generalized to normal populations of children with the assumption that normal anxieties or fears represent a mental or emotional problem. We really do not know the exact value or limitations of dream interpretation. If you think your child is having a nightmare, shower him with hugs and kisses and try to awaken him.
What do you do if the child comes into the parents’ room, sometimes several times a night, complaining of nightmares? If you strongly suspect that your child is not feigning nightmares just to get extra attention at night, consider consulting with a child psychologist or psychiatrist.
Head Banging and Body Rocking
My third son banged his head against the crib every night after we moved into a new house. Actually, he struck his shoulder blades more than his head against the headboard of his crib. My solution was to use soft cushions to pad both ends and both sides completely. Now when he banged away there was no racket, no pain, and no parental attention. After a few days he stopped. Other parents are not so lucky.
About 5 to 10 percent of children will bang or roll their heads before falling asleep during their first few years. This usually starts at about eight months of age. Boys behave this way more than girls. No behavioral or emotional problems are seen in these children as they develop, and they certainly have no neurological problems. Body rocking before falling asleep also occurs in normal children.
All this rhythmic behavior usually stops before the fourth year if there are no underlying neurological diseases. Your pediatrician can diagnose these uncommon conditions if they are present.
Bruxism
Teeth grinding, or bruxism, during sleep is common in children. At the Laboratory School at the University of Chicago, about 15 percent of the students were reported by their parents to have a history of bruxism. In the age range of three to seven years, the percentage of bruxists was about 11 percent; between eight and twelve years, it was 6 percent, and between thirteen and seventeen years, the percentage dropped to about 2 percent.
Teeth grinding does not occur during dreams or nightmares. Furthermore, there is no association between emotional or personality disturbances and teeth grinding. No treatment is needed for bruxism in children.
Narcolepsy
The major characteristic of narcolepsy is excessive abnormal sleepiness. It appears as if the child has a sudden sleep attack while engaged in ordinary activities such as reading or watching television. The child with a mild form of narcolepsy may drift into a state of excessive drowsiness; the child with a more severe form might fall stone asleep in the middle of a conversation.
Narcolepsy is less common under the age of ten. When it begins in older children it may be mistaken for lack of concentration or inattentiveness.
Other features of narcolepsy seen in older children are cataplexy, a muscular weakness triggered by emotional stress; sleep paralysis, a passing sensation of inability to move when drifting off to sleep; and hypnagogic hallucinations, visual or auditory experiences that occur as sleep begins.
Poor-Quality Breathing
(Allergies and Snoring)
If you've ever suffered through a head cold, I'm sure you'll agree that when you can't breathe easily during sleep, you can't sleep easily either. In turn, this makes you sleepy during the day, which can affect your mood and performance. When the cold finally disappears, you feel like your old self again, and your mood improves, as does your performance. Some children experience the same type of disrupted sleep every night because of allergies or snoring. Let's look at them both.
Allergies
Allergies frequently are suggested as a cause of the typical signs and symptoms characterizing snorers. Here's a list of symptoms from one study of children with difficulty breathing during sleep, conducted at the Children's Memorial Hospital in Chicago.
Snoring
Difficulty breathing during sleep
Stopping breathing during sleep
Restless sleep
Chronic runny nose
Breathing through mouth when awake
Frequent common colds
Frequent nausea/vomiting
Difficulty swallowing
Sweating when asleep
Hearing problem
Excessive daytime sleepiness
Poor appetite
Recurrent middle-ear disease
Perhaps the “chronic runny nose” and the “frequent common colds” are due to allergies.
Allergists have long associated food sensitivities or sensitivity to environmental allergens with behavioral problems, such as poor ability to concentrate, hyperactivity, tension, or irritability. Terms such as “tension-fatigue” syndrome or “allergic-irritability” syndrome are used by allergists to describe children who exhibit nasal or respiratory allergies, food allergies, and behavioral problems. It is possible that allergy causes behavioral problems in children by producing swollen respiratory membranes, large adenoids, or large tonsils, which partially obstruct breathing during sleep. The difficulty these children experience in breathing during sleep causes them to lose sleep and thus directly causes fatigue, irritability, and tension.
Also perhaps due to allergies, large adenoids or tonsils can partially or completely obstruct breathing during sleep as well as cause hearing problems or recurrent ear infections. So, either because of the actual enlargement of the tonsils or because of the underlying allergies that cause swelling of the membranes in the nose and throat, these children suffer from frequent “colds”—runny nose, sneezing, coughing, and ear problems.
Snoring
Two of the world's leading sleep researchers, Dr. Christian Guilleminault and Dr. William C. Dement, published a landmark paper in 1976 that was the first careful study of how impaired breathing during sleep destroys good-quality sleep in children. At Stanford University School of Medicine, they studied eight children (seven boys and one girl, ages five to fourteen years), all of whom snored. All eight children snored loudly every night, and snoring had been present for several years. Snoring started in one child at six months, and while the snoring in most children was originally intermittent, it eventually became continuous. Here's how their symptoms were described.
Daytime drowsiness: Five of the eight children experienced excessive daytime sleepiness. The report noted that “the children, particularly at school, tried desperately to fight it off, usually with success. To avoid falling asleep, the children tended to move about and gave the appearance of hyperactivity.”
Bed-wetting: All the children had been completely toilet trained, but seven started to wet their beds again.
Decreased school performance: Only five of the eight children had learning difficulties, but all the teachers reported lack of attention, hyperactivity, and a general decrease in intellectual performance, particularly in the older children.
Morning headaches: Five of the eight children had headaches only when they awoke in the morning; the headaches lessened or disappeared completely by late morning.
Mood and personality changes: Half the children had received professional counseling or family psychotherapy for “emotional” problems. The report noted that “three children were particularly disturbed at bedtime; they consistently avoided going to bed, fighting desperately against sleepiness. They refused to be left alone in their rooms while falling asleep and, if allowed, would go to sleep on the floor in the living room.”
Weight problems: Five of the children were underweight, and two were overweight.
Overall, we have a picture here of impaired mood and school performance, which deteriorated as the children grew older
or as the snoring became more continuous or severe. Sleep is definitely not bliss for these children!
But was this a new discovery? Not really. As I will discuss further, most snoring children have enlarged adenoids, which medical texts written as early as 1914 acknowledged can disrupt sleep and cause behavior problems. As one early textbook noted:
Restlessness during the night is a prominent symptom; the patient often throws the covers off during the unconscious rolling and tossing which is so characteristic. … Daytime restlessness is also a characteristic sign. The child is fretful and peevish, or is inclined to turn from one amusement to another … the mental faculties are often much impaired … difficult attention is very often present. The child is listless and has difficulty in applying himself continuously to his play, studies, or other tasks, of which he soon tires. He has fits of abstraction.
Interestingly, increased motor activity or physical restlessness during sleep, distractibility, and reduced attention span are also characteristic features of children who have been diagnosed as “hyperactive.”
Another study, this one done in 1925, showed enlarged adenoids and tonsils as a physical cause of poor sleep. Even a major pediatric professional journal cited “difficulty in breathing, such as seen with extreme enlargement of the adenoids” as a common cause of “infantile insomnia” as far back as 1951. In truly severe cases of enlarged adenoids and tonsils, affected children appear to be mentally retarded, have impaired growth, and suffer from heart disease.
In one study of children who had documented difficulty breathing during sleep, the following problems were observed in addition to snoring:
“Breath holding,” “stopping breathing” during sleep
Frequent nighttime awakening
Breathing through an open mouth
Sleeping sitting up
Excessive daytime sleepiness
Difficulty concentrating
Bed-wetting
Decreased energy, poor eating, weight loss
Morning headaches
Hyperactivity
Some parents have also described to me their child's apparent “forgetting to breathe” during sleep. Their child's chest is heaving, but during those moments of complete airway obstruction airflow is stopped. These periods are called “apnea.” With only partial airway obstruction, though, excessively loud snoring throughout the night is the result. In either case, it's the poor-quality sleeping that's the culprit, causing daytime sleepiness, difficulties in concentration, school and behavioral problems, decreased energy, and hyperactivity … even though the total sleep time may be normal!
Why, then, has kids’ snoring particularly been ignored? Are there more snorers around today? Perhaps yes, because although surgical removal of tonsils and adenoids is much less common today, it was for years a very popular procedure for recurrent throat infections; it also happened to “cure” snoring in children. And perhaps yes, because the air we breathe is increasingly polluted and our processed foods increasingly allergenic; this may cause reactive enlargement of adenoids or tonsils in more children.
Whatever the causes of snoring, we've seen so far that children who snore aren't getting the best-quality sleep. Now we see that generally they aren't getting the best quantity either. One study of snorers at Children's Memorial Hospital in Chicago also showed that children with documented obstruction of breathing generally slept less than normal children. At about age four, average night-sleep duration was only eight and a half hours in affected children, compared to ten and a quarter hours in normal children.
In another study I performed, also at Children's Memorial, the affected snoring children were somewhat older, about six years of age, and their total sleep duration was about half an hour less than that of normal kids. They also had night wakings that lasted longer, went to bed later, and took longer to fall asleep after going to bed. These affected children exhibited snoring, difficult or labored breathing, or mouth-breathing when asleep. Parents described problems such as overactivity, hyperactivity, a short attention span, an inability to sit still, learning disabilities, or other academic difficulties in their snoring children. And as we have seen, a chronic sleep deficit of only half an hour per night might cause impaired intellectual development.
Even in infants, snoring might be a problem. I studied a group of 141 normal infants between four and eight months of age. In these infants, 12 percent exhibited snoring and 10 percent exhibited mouth-breathing when asleep. These snoring infants slept one and a half hours less and awoke twice as often as infants who did not snore.
In another study of infants about four months of age, cow's milk allergy was thought to be the cause of brief night-sleep durations and frequent awakenings. Other studies have suggested that an allergy to cow's milk protein can cause respiratory congestion.
PRACTICAL POINT
Although snoring reflects difficulty breathing during sleep, it is not related to sudden infant death syndrome (“crib death”).
The night waking in these snoring infants and the restless light sleep in older children probably represent protective arousals from sleep. As we learned earlier, these arousals mean that the child awakens or sleeps lightly in order to breathe better. When awake, the child breathes well, but the brain's control over breathing is blunted during sleep stages. So, to prevent asphyxiation, the child awakens frequently, cries out at night, and has trouble maintaining prolonged, consolidated deep-sleep states. Here, the crying and waking at night and resistance to falling asleep are caused by a valid medical problem, not a behavioral problem, not nightmares, not a parenting problem.
Not all children who snore a lot have all of the problems listed above. Differences among snorers can probably be explained by differences in severity and duration of the underlying problems. Also, I have encountered many monster snorers with minimal problems because they habitually take very long naps or have been able to go to bed much earlier than their peers. In other words, there are snorers and there are snorers! Some, like myself, have never been studied, and except for occasional nightmares—like the ones of asphyxiation, drowning, or strangulation I have when sleeping on my back—do not suffer adversely from snoring. Other snorers are not so fortunate because their snoring is more severe, a result of enlarged adenoids or tonsils.
PRACTICAL POINT
All children snore a little, and frequent colds or a bad hay fever season might cause more snoring, which usually does no harm. Consider snoring a problem when it gets progressively worse, is chronic or continuous, disrupts your child's sleep, and affects daytime mood or performance. About 10 to 20 percent of children snore frequently.
The reason attention has been focused on the problem of enlarged adenoids and tonsils is that sleep researchers have proven that breathing is actually disordered during sleep. This is an important point, because when the child opens his mouth, the tonsils do not necessarily look enlarged. In fact, the adenoids and tonsils may cause partial airway obstruction in some children during sleep only because the neck muscles naturally relax and the airway thus narrows. In other words, the real problem in some children might not be enlarged adenoids or tonsils, but rather too much relaxation in the neck region during sleep. This relaxation of the muscles in the neck may permit enlarged tonsils or adenoids to swing toward the midline, causing a partial or complete blockage of the flow of air. If snoring appears to be disrupting your child's sleep, consult with your physician. Your child's doctor may have to do some tests to determine how serious the problem really is.
The term “sleep-related breathing disorders,” or SRBDs, was coined to describe those children who had snoring or heavy or loud breathing while sleeping, or who appear to have trouble struggling to breathe while sleeping, or who make a snorting sound and wake up. One research study conducted in 1997 directly connected SRBDs to attention deficit hyperactivity disorder (ADHD). They calculated that about 25 percent of children with ADHD would have their symptoms eliminated by correcting their habitual snoring or SRBD.
In 1998, two studies showed that SRBD was associated with extremely poor academic performance in first grade (improvement occurred upon removal of tonsils and adenoids) and also that SRBD was associated with difficulties with behavioral sleep disorders such as fighting sleep at night or bedtime battles. By 2002, the terminology had changed to “sleep-disordered breathing,” or SDB, but the message was the same. Inattention, hyperactivity, behavioral, and emotional difficulties are more common in children with SDB. Again, surgical intervention helped these children.
Locating the Problem
Try to suck through a wet paper soda straw. You can't; it collapses. When we inhale, active neuromuscular forces keep our neck from collapsing like a wet straw. Sometimes things don't work well during sleep and the neck muscles lose their tone. Sometimes the major problem involves the tongue, which may not stay in its proper position during sleep and flops backward, causing upper-airway obstruction.
Think of this as a neurological problem involving the brain's control over our muscles while we sleep. The result is that the airway is not kept open during sleep. If it's a neurological problem, then consider the possibility that there are other associated problems involving the brain: difficulty concentrating, poor school performance, excessive daytime sleepiness, or hyperactivity. If the major problem involves the tongue or neck muscles, removing the tonsils or adenoids might not help. So it is obviously important to determine the cause of the problem before considering surgery.
Healthy Sleep Habits, Happy Child Page 40