Children who snore and have many of those problems associated with poor breathing during sleep often have abnormal X-rays of the neck when viewed from the side. The most common abnormality is enlargement of the adenoids or tonsils. A simple X-ray might tell the entire story. But some children who snore might have normal X-rays and will require studies designed to document airway obstruction; it is important to pursue this before clinical problems develop.
Studies that have been used to document obstructive breathing problems during sleep include actual measurements of respiratory flow through the nose, skin oxygen levels, and the carbon dioxide concentration in the air exhaled during sleep. Another type of sleep study, using fluoroscopy, may visualize the level of obstruction. CT scans during sleep also have been used to measure the cross-sectional area at different levels of the airway to determine the anatomical location of the airway narrowing.
Electrocardiograms are useful because, in severe instances, the right side of the heart shows signs of strain. This strain can lead to pulmonary hypertension in long-standing cases.
Pulmonary hypertension also occurs with massive obesity, as in Pickwickian syndrome. This is named after Dickens's The Pickwick Papers, in which an extremely fat boy is pictured as standing motionless, barely awake, and feebly snoring. Massive obesity itself apparently causes difficulty breathing.
Finding the Answers
If the tonsils or adenoids are causing significant airway obstruction, they should be removed. Sometimes a surgical procedure to correct an abnormal nasal septum solves the airway problem. Tracheostomy, or creating a breathing hole in the neck, is occasionally needed when the obstruction is due to airway closure or narrowing not caused by enlarged adenoids or tonsils. During the day, the hole is closed and covered by a collar. Oral devices are now available that keep the tongue from flopping backward, when that's the major problem.
OBSTRUCTIVE SLEEP APNEA
SNORING, DIFFICULT BREATHING, OR
MOUTH-BREATHING WHEN ASLEEP
DISTURBED SLEEP
ABNORMAL SLEEP SCHEDULE
BRIEF SLEEP DURATIONS
SLEEP FRAGMENTATION (PROTECTIVE AROUSALS)
NAP DEPRIVATION
PROLONGED LATENCY TO SLEEP
BEHAVIORAL, DEVELOPMENTAL,
AND ACADEMIC PROBLEMS
REVERSIBLE
FIGURE 8: POOR-QUALITY BREATHING CAUSES PROBLEMS
Weight reduction to correct obesity and management of allergies may be crucial nonsurgical treatments in some children. The management of allergies might include a trial of a diet without cow's milk, making the bedroom dust-free by using efficient air purifiers, reducing the level of mold spores in the air by using dehumidifiers, or getting rid of pets. Nightly administration of decongestants or antihistamines are sometimes needed to reduce the allergy symptoms. Often, intranasal steroid sprays are used to keep the nasal airway open; this treatment avoids the side effects of oral decongestants. A “snore ball,” which is a small glass marble or half of a small rubber ball sewn to the pajamas or attached with a Velcro strap in the midback region, will prevent a back snorer from sleeping on his back.
Enjoying the Cure
When treatment restores normal breathing during sleep, the loud snoring, daytime sleepiness, morning headaches, and other problems either disappear or are greatly reduced. Sleep patterns return to normal, and electrocardiogram abnormalities disappear. These changes are rapid and dramatic. For example, in one report, a thirteen-month-old boy was assessed as having the developmental level of an eleven-month-old baby before surgery, but five months after surgery, his developmental level had jumped past his real age, to the level of a twenty-month-old!
Remember, sleep deficits may directly cause behavioral, developmental, or academic problems. These problems are reversible when the sleep deficits are corrected (see Figure 8).
One word of caution: If the problem has been long-standing, then once children are cured of their snoring or their allergies are under control, bad social or academic habits or chronic stresses in the family or school will still require the continuous attention of professionals, such as psychologists, tutors, or family therapists. The treated child is now a more rested child, however, and is in a better position to respond to this extra effort.
Hyperactive Behavior
Educators and parents have used different terms to describe children with hyperactive behavior, but the current popular diagnosis is attention deficit hyperactivity disorder, commonly called “hyperactivity.” Hyperactivity in children is not usually thought to be related to snoring or severe allergies, although children suffering from ADHD, snoring problems, or allergies all have similar academic problems and characteristically poor sleep patterns.
Yet restless sleep, or increased amounts of movement during sleep, has been documented in hyperactive children. Could these turned-on school-age children be cranked up from chronically poor sleep habits that started in infancy?
I studied a group of boys whose ages were between four and eight months. Only boys were included, because most hyperactive school-age children are boys. The infant boys in my study also had active sleep patterns—they moved throughout the night in a restless fashion, with many small movements of the hands, feet, or eyes. They also had difficult to manage temperaments: They were irregular and withdrawing, had high intensity, were slow to adapt, and were moody. This temperamental cluster is thought to be common among hyperactive children as well. The results of my study showed that infant boys with more difficult temperaments and active sleep patterns also had briefer attention spans. Perhaps their motors were racing so fast, day and night, that they couldn't sleep quietly at night or concentrate for prolonged periods when awake during the day.
Another study I did involved preschool children at age three. It also showed that children who had increased motor activity when awake had a physically active sleep pattern. A child with active sleep patterns was more likely to be described in the following terms, taken from a questionnaire used to help diagnose hyperactivity:
Restless or overactive
Excitable, impulsive
Disturbs other children
Fails to finish things he starts—short attention span
Constantly fidgeting
Inattentive, easily distracted
Demands must be met immediately—easily frustrated
Cries often and easily
Mood changes quickly and drastically
Temper outbursts, explosive and unpredictable behavior
Figure 9 summarizes my research suggesting how a transformation could take place from an extremely fussy/colicky/difficult temperament baby with brief sleep durations to a hyperactive school-age child. The upward-pointing arrows before certain terms mean that high ratings for rhythmicity signify irregularity and high ratings for persistence signify short attention spans. These infant traits are replaced by hyperactivity and increased intensity as the child becomes more fatigued. As an infant, the child would have been negative in mood and less easily adaptable due to brief sleep durations, and would have remained so at three years.
Such children never learned how to fall asleep unassisted and had accumulated a chronic sleep loss, which caused chronic fatigue. As discussed in Chapter 3, this long-lasting fatigue turned such children “on,” making them more active night and day, and interfered with learning.
Learning may suffer, then, in kids who do not sleep well because they breathe poorly during sleep or sleep too little, and who in turn suffer from chronic fatigue that causes hyperactivity. Figure 10 summarizes this entire cycle. It shows how crying and sleeping problems present at birth can trigger parental mismanagement. Parental mismanagement or breathing problems during sleep can in turn cause disturbed sleep, elevated levels of neurotransmitters, and a more aroused, alert, wakeful, irritable child. This turned-on state directly causes even more disturbed sleep because of heightened arousal levels. It also may indirectly cause parents to misperceive their child as not needing muc
h sleep: “Johnny just won't quit—he certainly doesn't seem to be running out of gas.”
All of these factors in combination—the fatigued child who is too alert to sleep well, plus irregular, inconsistent parents who also are tired and anxious—conspire to produce a child who may find it difficult to concentrate, may seem hyperactive, or may have behavioral problems that make him difficult to manage. These school and behavioral problems make the parents even more anxious, and the cycle continues on and on. Of course, there may be other causes for school problems or hyper activity, but disturbed sleep appears to be one that is both preventable and treatable.
FIGURE 9: TRANSFORMATION OF TEMPERAMENT CHARACTERISTICS ASSOCIATED WITH BRIEF SLEEP DURATIONS
FIGURE 10: DISTURBED SLEEP
Seasonal Affective Disorder
Seasonal affective disorder (SAD) is commonly known as winter depression. Symptoms of depression include feeling blue or sad; decreased interest or pleasure in activities; dramatic weight gain or weight loss, or failure to gain weight normally; sleeping too little or too much; behaving very restlessly or in a very slowed-down manner; fatigue or loss of energy; feelings of worthlessness; indecisiveness or difficulty in concentrating; and recurrent thoughts of death or suicide. Not all of these symptoms need to be present, but when many occur daily for extended periods of time, the diagnosis of depression has to be considered. When these symptoms tend to occur only or mainly during the months of October and November, then seasonal affective disorder may be the problem.
The reduced amount of daylight during winter, with its short days and long nights, seems to cause the depressive symptoms, and treatment may include using a bank of special fluorescent lamps behind a plastic diffusing screen. The intensity of light needed, the duration of the light treatment, and the risks bright-light treatment may pose for the eyes are currently being investigated. Light therapy has been shown to be effective in children, but it's not like taking penicillin for a strep throat, so if you think your child might have SAD, your best bet is to contact a sleep disorders center for evaluation and treatment.
Survey studies have shown that between 2 and 5 percent of children between the ages of nine and nineteen fulfill diagnostic criteria for SAD. More symptoms appear in northern regions, where days are significantly shorter in winter, compared to southern regions. So if you have an older child who seems not to be doing well after the first few months of the school year, consider the possibility that it is not the teacher, the coach, or the increased homework load, but winter depression.
Bed-wetting
Bed-wetting during sleep occurs in about 20 percent of children at age four and 10 percent at age five. By the age often, it occurs in about 5 percent of children. The exact cause of bed-wetting is not known. It is not caused by emotional problems. It tends to occur more often in boys and has a tendency to be inherited. Pediatricians or pediatric urologists may offer bladder-training strategies or other treatments, but it is difficult to prove that one treatment works best, as most children outgrow the problem. Restricting fluids before bedtime does not work.
I find that moisture alarms are an effective treatment for bed-wetting. These alarms wake the child as he begins to urinate. This seems to disturb the sleeping brain, and so to prevent such an abrupt arousal from the alarm in the future, the brain controls the bladder better and prevents urination.
Sometimes the alarm does not rouse the child, so the parent has to be able to hear the alarm in order to wake the child. The reason the child might sleep through the alarm is that bed-wetters appear to have very deep sleep. Even though older research suggests that bed-wetters are not more difficult to awaken than children who are not bed-wetters, this deep sleep may be a major part of the problem for some children.
In my experience, some children with too-late bedtimes or severe allergies causing difficulty breathing through the nose appear to be overtired during the day and wet at night. When they are helped to sleep better, they often appear to be better rested during the day and drier at night. The most dramatic “cures” of bed-wetting sometimes occur when enlarged adenoids or tonsils are removed. Now the child breathes easier during sleep, sleeps better, and becomes drier.
Special Events and Concerns
As if growing up were not hard enough, there are inevitable events that might significantly disrupt your child's healthy sleep habits. Other special concerns, such as frequent injuries, may well be the result of unhealthy sleep habits. Here are some examples:
Changes with Daylight Savings Time
When you move the clock time an hour earlier or later, continue to sleep your child according to the new time. If her bedtime has been about 6:30 P.M., and you moved the clock forward an hour so her old 6:30 is now 7:30 P.M., still put her down to sleep at the new clock time of 6:30 P.M. The reason you can ignore the time change is because a lot of social cues in the family such as active or quiet times, meals, bathing, outdoor play time is adjusted with the time change, and these social cues help regulate your child's sleep schedule.
New Sibling
If you are expecting another child, it is best to maintain as much regularity as possible during the pregnancy and not move your young child to a bed until the new baby is about four months old, if then. Toward the end of the pregnancy, the mother is more tired and the older child becomes aware that her mother has less energy or patience. Receiving less attention or not as prompt a response is something that she will have to get used to. So don't kill yourself putting forth a heroic effort; it will only delay your older child's learning to adapt to the inevitable: a decrease in parental attention. When the newborn is about four months old, the developing biological rhythms in the baby permit a new and stable social rhythm in the household. The older child now knows that there are approximate times when her mother is feeding the baby or putting it to sleep. The stability of these events makes the older child feel more secure.
If you need to move the older child from a crib to a bed, consider leaving the crib up and empty for a while before the younger child is shifted to it. The parents’ understanding is that she is graduating to a “big kid's” bed, but the child might not have the same opinion. Prepare yourself for the possibility that, either because of fearfulness in the big bed or because the child now realizes she can easily get out of bed to explore the house, you might have to return her to the crib. Sometimes a crib tent is necessary because your child is curious about the new baby at night but you do not have the energy to repeatedly do the silent return to sleep (see Chapter 7). Don't be inhibited because of a fear that you are causing a “regression” or sense of failure in your child. Under these circumstances, the baby might have to go to a portable crib, another crib if the children are close together in age, or maybe some temporary larger substitute for the bassinet.
Twins, Triplets, and More
Let's face it: Having a baby is a blessing and a bother. With two or three babies at the same time, the blessings are two-or threefold, but the bother is about ten or twenty times as great! The reason why the bother is so much greater is that you can't clone yourself. When one child is awake and wants to play but the other needs to be put to bed, or when one baby needs to be fed at the same time as the other needs to be changed, you've got a problem. Not everyone has family members or hired help to give them a break, and even if you are lucky in this regard, there are still times when both the mother and father are exhausted from not getting enough sleep. However, if you plan ahead and if the father is actively involved, as described in the story of Caleb and Ezra, then the duration of your sleep-starved state will be shorter.
CALEB AND EZRA
As much as it gave us great joy, the news that we were having twins shocked us as well. We hadn't had children yet, so how our lives would work with one baby was a big question, but two seemed to raise to an unimaginable degree the level of responsibility and the sheer amount of labor we anticipated. Eventually the shock faded, giving way to excitement tempered by trepidation, and we began facing
the many tasks we had to do.
We had our share of endless nights, during which someone was up every hour with one fussy fellow or another—or both didn't fall back to sleep without being walked back and forth. In a sleep-starved daze, we both covered many miles during those nights. To keep track of who fed whom, Jen and I drew two clock faces, one for each boy, on which we would record the time we retrieved either Ezra or Caleb, how many ounces of formula he consumed, and what time he went back down. To maintain our sanity—or as a record of its fragility during these sleep-drained hours—we would amuse each other with humorous notations on the clocks.
During the day the boys would sleep with regularity; up for an hour or so and down for several. One thing we experienced in full force, when the boys were around six weeks old, was heart-wrenching, inconsolable, nonstop crying at the end of the day, starting around 6:00 P.M. and sometimes lasting until as late as 10:00 P.M. before the exhausted babies would relent and drift off to sleep. During their fifth and sixth months, they began to sleep through the night. On the rare occasion when we did hear one of them cry or yell out during the night, we would resist the urge to react, and within a few minutes the baby would soothe himself back to sleep. We took advantage of their ability to soothe themselves to catch up on our sleep, too—even with the rest, two babies are a lot of work and we need all the energy we can muster.
One of our concerns, specific to having twins who sleep in the same room, has been about one baby waking the other. When our boys were about seven and a half months old, Ezra was waking Caleb up consistently. We consulted with Dr. Weissbluth, who instructed us to keep a twenty-four-hour chart for each baby over the course of a week. We recorded, in half-hour increments, whether the boys were asleep, awake and crying, or awake and happy. With this information, Dr. Weissbluth was able to tell us that we should put Ezra and Caleb down for naps at 9:00 A.M. and 1:00 P.M., and that it was time to eliminate their third nap of the day. This approach smoothed out their sleep pattern.
Healthy Sleep Habits, Happy Child Page 41