Chapter 14
Battling the Midnight Blues: Pediatric Sleep Disorders
In This Chapter
Figuring out why your child won’t sleep
Determining whether your child has a sleeping disorder
Looking at pediatric sleeping disorders and treatments
Even first-time parents aren’t surprised about having to wake up every night to care for their newborn baby. Sleep deprivation goes with the territory when you have an infant. But how long should that sleep deprivation last? If your child is 4 or 5 years old, or older, and still waking you up every night, is that normal? If that’s the case, you’re not only chronically tired, you’re probably also feeling exasperated and confused. Aren’t kids supposed to sleep through the night starting at age 3 months or so?
Yes, they are, but many children suffer from a sleep disorder that keeps them from sleeping soundly. Other kids have developed poor sleep habits because their parents, instead of modeling healthy sleep habits, all unknowingly, have trained them that temper tantrums at bedtime get attention.
If you think that you can’t use sleep disorders and children together in the same sentence, you’re wrong. The problem is so widespread that some pediatricians have become sleep specialists who treat children with sleep problems exclusively. You may not have thought about your child having a sleep disorder, but when your child can’t sleep, you aren’t getting much shuteye, either. You’re too busy trying to comfort your little one and soothe her back to sleep to pay much attention to your own needs for a good night’s rest. The end result? Everyone is cranky, and no one is having any fun.
Think about all the problems that can beset a child trying to sleep — bedwetting, nightmares, sleepwalking, teeth grinding, sleep talking, sleep starts, and monsters lurking under the bed or in the closet. All these conditions (most of them parasomnias introduced in Chapters 11 and 12) can keep a child wide-awake and in a state of discomfort and even terror. Do any of these sound familiar? If you’re a parent of a small child, probably some of them do. Furthermore, many children snore loudly or suffer from nocturnal cough, earaches, indigestion, or some other condition that disturbs their sleep. All these situations may indicate or contribute to poor sleep quality in children.
In this chapter, we look at children’s bedtime habits and also examine the world of pediatric sleep disorders. We offer savvy tips to help you get your child to sleep without a nightly bedtime battle and also provide guidelines to help you assess if your child may have a pediatric sleep disorder. We review the symptoms of the most common childhood sleep disorders and walk you through the diagnostic process and typical treatments.
After you get your kids to sleep comfortably through the night, your slumber will become much more peaceful and restorative as well.
Grappling with Why Your Child Won’t Go to Bed
We can think of tons of reasons why children balk and resist going to sleep when bedtime rolls around. However, the simplest and most common reason is that you’ve taught them to behave that way. Wait, wait, wait! Before you pitch this book into the trash, take ten deep breaths and let us explain.
Raising baby
When it comes to child-rearing practices, conviction and emotions run high. Developmental practices concerning sleep are no exception. In some respects, child-raising is a social and even political issue; therefore, parents must decide for themselves what approach best suits their family. Parents should be keenly sensitive to their child’s level of distress.
In some respects, it all boils down to control. That is, who controls sleep practices — the parents or the child. Different and strongly opposite schools of thought exist on the subject. One school of thought is that the parents should set the timetable and ground rules. The opposite approach is more permissive and cedes some control to the infant or child and recognizes biologically driven factors. These two approaches clash head-on when you ask, “When should a child begin sleeping alone in his own bed?”
One school of thought answers, “If and when your child is ready.” The other school replies, “Anytime after 3 months when the parents are ready.” Each position has its pros and cons, but push really comes to shove over the issue of whether or not to let a baby cry (see the nearby sidebar “To cry or not to cry”).
To cry or not to cry?
The original hard-line approach to letting baby “cry it out” has become less rigid over the years. Some parents find letting their child cry impossible to do; their child’s continued wailing so distresses them that they have to go to him, pick him up, and comfort him. The distress the child’s crying causes likely has a biological basis, and certainly the crying is a signal to the parent. In many cultures, the baby sleeps in or near the parents’ bed. The concept of cosleeping, while not widely accepted in the United States, has a long cultural tradition in other parts of the world. In the past several decades, advocates for cosleeping have questioned the “each child in his own bed approach,” especially for very young children. Devices are available that attach to the parents’ bed so that the child can safely be in the bed for nursing. For more information about cosleeping, visit www.visi.com/~jlb/thesis/cosleep.html or www.unhinderedliving.com/sids.html.
Of course, other reasons exist why a parent, often the father, wants the baby out of the bed. Nonetheless, at this point, if and when the child is moved to his own bed (and bedroom) does the issue of control come into play. Sometimes there is no problem, and the transition happens smoothly. But at other times, the child wants to stay and protests by crying.
The “cry it out” approach establishes bedtime and location control, which isn’t suitable for some children. However, it often succeeds in getting a child to sleep alone in his own bed. Try and find a balance between having your child cry uncontrollably and having him depend on your presence to fall asleep. Comforting a crying child is a biologically driven practice, but if you pick up and cuddle your child every time she whimpers, you’re helping to perpetuate behaviors you may want to extinguish. Cosleeping renders the issue moot.
If you do need to attend to your baby, for example for a wet diaper, don’t turn on the lights, talk to him, or play with him while you’re working. If you do, you’re rewarding him for waking you up and not instructing him to associate nighttime with quiet time and sleeping. If your goal is to have the child sleep alone and you can steel yourself to live through the crying, you can gradually withdraw yourself as the child’s sleep-onset object. It may take several days or a week (sometimes longer if your baby is particularly determined), but your child will figure out that he can fall asleep on his own, and you’ll have your uninterrupted nights back. Remember, this approach isn’t for every parent or every child. Nonetheless, try and use it. It can be effective in most cases to have your child sleep in her own bed rather than the parents’ bed.
For information on a method pioneered by children’s sleep specialist Dr. Richard Ferber that allows your child (age 6 months or older) to discover how to sleep without you being present, visit www.keepkidshealthy.com/welcome/treatmentguides/sleep.html. If you follow Ferber’s program consistently, you can, in most cases, rapidly overcome the association between sleep initiation and your presence. In fact, the technique works so well that it was successfully demonstrated over a three-day period on television.
Raising a baby in our busy, stressful, modern world is hard work. Frequently, both parents have jobs, which means that you often have to stick to rigid schedules. In contrast, newborns come into this world with no schedules. Additionally, many of them have very irregular sleep-wake patterns (having developed in a dark environment). Exhausted parents quickly figure out what to do so they can catch a few winks here and there, squeezing catnaps into the all-too-brief intervals when baby is sleeping.
So when your baby starts screaming at 1 a.m., bringing her into your bed and just nursing her there may seem like the easiest and most logical thing to do. You rock her, sing to her, pat her back, and do whatever it takes to soothe her back to sleep. The faster baby falls asleep again, the faster you can get back to sleep, too.
By the time babies finally start sleeping through the night around 3 months of age, most parents are down to their last reserve of endurance. In fact, they may be stumbling around like zombies. So when three months come and go and your baby is still waking up every night, often more than once, parents get desperate and may even go a little crazy, not even realizing that their established routine has trained their baby and is actually contributing to what’s making their baby cry out every night. What they’ve taught their baby is that she needs mommy (or daddy) to fall asleep again. In technical terms, you have become the sleep-onset association object. Good for baby, maybe not so good for mommy and daddy.
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After about ten minutes of the calming activity, tuck your child into bed with his favorite animal or blanket. Sit with him for a few more minutes, and say prayers, sing a lullaby, or do whatever helps your child settle down comfortably in anticipation of sleep. If darkness is a problem, keep a small night light on nearby or buy him a small bedside lamp. Give him a gentle hug and kiss, say goodnight, and leave the room.
These steps may seem too simple to be effective, but trust us, routines usually work. When you visit a house where children seem calm and go right to bed without a fuss, you can bet that the parents have a good bedtime routine in place. But when you visit a house where the kids are spinning around like tops, crying and rebelling against the very idea of going to bed, you can also bet that these parents have no bedtime routine, and the parents are resigned to the nightly bedtime battles.
Showing your child good sleep habits
One part of your job as a parent is to establish schedules and routines for your baby. One such routine is the bedtime routine that involves activities you repeat every night to reinforce to your child that it’s time to settle down and go to sleep. You want this time to be a warm, loving, and comforting routine, including the same activities performed in the same order every night to build a sense of reliable routine and confidence. The process is actually developing a “winding-down ritual.” Rituals are very effective for increasing and decreasing nervous system arousal. Some rituals are designed to whip you into a frenzy and others to relax your mind and body. At bedtime, you’re striving for the latter.
For a baby, your routine may include a feeding, taking a bath, changing the diaper, putting jammies on, singing a lullaby, saying a prayer, going quietly to bed with a favorite blanket or stuffed animal, and maybe having his back patted gently for a minute or two. For older children, the routine can include taking a bath, putting pajamas on, reading a bedtime story, saying prayers, having a brief, quiet conversation with mom or dad, singing a lullaby, and perhaps even putting their stuffed animals to bed, but nothing scary or too stimulating.
A routine naturally is ritualized. You may read the same bedtime story every night. And your child won’t allow you to skip any pages because, after all, it’s her ritual. And right at the end of this process, if you listen carefully, you may notice a ritualized verbal exchange between you and your child, where you both speak the same words, in the same order. The child then assumes the sleeping position and falls right to sleep.
Unfortunately in some families that have no nightly routine, bedtime turns into a regular round of tears, screaming, threatening, cajoling, bribery, and maybe even physical force. Not a pretty picture. And worse yet, you’re conditioning your children to associate distress with the idea of going to sleep. You’re helping them to believe that bedtime is a frightening time when you abandon them to the dark and leave them to face their fears and sorrows all alone.
On the other hand, in some families without nightly routines the children just “run out of gas” and go to bed. That is, they don’t need the control or guidance from the parent.
Putting your baby to bed sans bottle
Putting your baby in bed every night with a bottle full of milk or juice may result in a condition called nursing bottle mouth or bottle rot. When sugary liquids coat the teeth all night long, they promote rampant tooth decay. As a result, this bad habit can ruin your child’s teeth. In severe cases, the child loses every single tooth and may even suffer abscessed teeth and severe infection. It also leads to a higher incidence of decay in the permanent teeth. The treatment required to remedy nursing bottle mouth is painful and very expensive, but the condition is 100 percent preventable if parents just remember not to give bottles of milk, juice, or other sweetened liquids at bedtime.
You’re also demonstrating to your child that a bedtime tantrum or showdown is a good way to get the spotlight of parental attention shining full force on them. A child who has been in daycare, with a sitter, or at school all day may crave your attention so deeply that she will do anything to get it, including pitching nightly fits that register 9.9 on the Richter scale. After all, in the child’s mind, negative parental attention is better than no attention at all.
A better idea is to establish good bedtime rituals so that your child becomes self-reliant and falls asleep on her own. Instruct her to associate the idea of going to bed with positive feelings, and empower her with good habits to get to sleep (or get back to sleep) all by herself.
You can instill good sleep habits in your children with a few simple and consistent routines. Would you be willing to spend a half-hour of quality time with your child every night before putting him to bed if you knew that it would help both of you enjoy a peaceful night of uninterrupted sleep? If so, read on. If not, skip directly to Chapter 2, because everyone in your family is going to need it.
Building a bedtime routine
To be effective, a good bedtime routine has to meet everyone’s needs, work with your family’s schedule, and make your child feel good about going to sleep. Children hate to be interrupted when they’re doing something they like, and that can cause problems at bedtime when they don’t want to stop playing their game, reading their book, or watching their movie. But if you have an enjoyable bedtime routine in place that your child looks forward to as a special time with mom and/or dad every night, initiating the first step of that routine can quickly and almost automatically get your child to stop whatever she’s doing and start to focus on going to bed.
Routines can last anywhere from 15 to 30 minutes. Create an individual routine for each child and spend that special time with him. Let your child make suggestions for what he wants to have included in his particular routine.
Consider the following factors when developing a routine.
Filling out a pediatric sleep questionnaire
When you go to a doctor to discuss your child’s sleeping patterns, your doctor will ask you to fill out a pediatric sleep questionnaire. See Chapter 2 for information on keeping a sleep diary, and maintain one for your child for two consecutive weeks before the doctor visit. Be sure to bring the sleep diary to show the doctor. You can use the information you gather for the diary to help fill out the questionnaire. If your child attends school, her teacher can give you the answer for Question 11. The information you provide on this questionnaire gives your doctor many valuable clues that will help him determine whether your child has a sleep disorder and what disorder it may be.
Here’s a typical pediatric sleep questionnaire:
1. Who puts the child to bed?
2. Where does the child fall asleep?
3. When does the child fall asleep?
4. Does the child need a bottle, pacifier, or one particular object like a blanket or toy to fall asleep?
5. Is the child awake or asleep when you put him to bed?
6. Do you have a bedtime routine for your child? If so, please describe it.
7. Does your child take a medication to assist sleep?
8. Describe your child’s evening activities and behavior from dinnertime to bedtime.
9. During the night, does your child:
Ask for a drink
Awaken screaming in terror but not really fully alert or responsive
Awaken with vividly recalled nightmares
Bang or rock his head
Grind his teeth
Have seizures or convulsions
Jerk his arms or legs
Move into the parents’ bedroom
Need a diaper change or use the bathroom
Seem to stop breathing
Snore
Talk
Wet the bed
10. Upon waking, does your child:
Look tired
Seem irritable and uncooperative
Not want to get up
11. During the day or at school, does your child:
Appear drowsy
Fall asleep at inappropriate times
Nap
Have episodes of muscular weakness triggered by laughter, anger, or crying
Make sure the bedroom is comfortable
Enlist your child’s help to make sure he feels comfortable and secure in his bedroom. Does he like the decor and the room’s colors? Is it too hot or cold? Are his covers adequate? Is the floor clear or cluttered? Does he like his mattress or think it’s too hard or too soft? Is there a lamp or night light available within easy reach to guide him if he needs to use the bathroom?
By making sure your child is happy with his bedroom and his sleeping arrangements, you go a long way toward eliminating bedtime problems.
Set a regular bedtime
Think about your child’s age and level of activity, and your family’s work and school schedules, and then select a regular bedtime. Do your best to stick to this schedule because it will help your child to sleep better and reduce the opportunity for problems at bedtime.
Take the child’s age and sleep requirements into account as you plan. Although it makes sense to establish an 8:30 p.m. bedtime for a 6-year-old, good luck getting a teenager to toddle willingly off to bed at that hour. Be aware that as children get older, homework and extracurricular activities may cut into the amount of sleep they get. Be flexible, but also monitor your older children to make sure they’re getting at least the minimum recommended amount of sleep most nights.
If teenagers had their druthers, most would party all night and sleep all day. That’s just how they’re wired to respond to the environment and their hormones. Unfortunately, many school districts have pushed high school start times to an extremely early hour, 7 a.m. or even earlier. Research shows that younger children, who tend to bound out of bed at the crack of dawn, would do better with these earlier start times while older kids would do better with later start times. But, the fact is that many school districts have planned their schedules to be the opposite of research recommendations, sending older children to school earlier and letting them out earlier for athletic practice and after-school jobs, while younger children may not start school until almost 9 a.m.
Table 14-1 lists the average amounts of sleep required by children of various ages.
| Child’s Age | Amount of Sleep Required |
|---|---|
| Newborn | 16 to 19 hours a day |
| 3 to 6 months | 13 to 15 hours a day |
| 6 to 12 months | 12 to 14 hours a day |
| 1 to 6 years | 10 to 12 hours a day |
| 6 to 12 years | 10 hours a day |
| 13 to 19 years | 9 to 10 hours a day |
| 19 plus years | 8 to 9 hours a day |
Take a bath
Most families prefer to bathe small children at night after supper, just to avoid the hassle of morning baths when time is tight, and mom, dad, and older children are likely to be in the shower for a while.
As you bathe your child, talk quietly and listen to what she has to say. Keep bath time peaceful and short, about 5 to 10 minutes.
Put on pajamas
After the bath, dress your child in comfortable nightclothes, either pajamas or a nightgown, whichever she prefers. Let her help you chose what she wants to wear and lay it out before the bath so she can get right into it after she is dry.
Choose a favorite calming activity
Whether your child likes reading, singing lullabies, coloring, or listening to soft music, these quiet activities signal that it’s the end of the day and time to start winding down. Spend about 5 to 10 minutes with your child, fully focused on this activity. (Don’t rush! Your child will sense your impatience and balk!) Then go to the next step in the routine.
And no, a rousing game of Monkey in the Middle isn’t a calming activity. If you roughhouse, play sports or violent video games, or argue or talk loudly, how can you really expect your excited child to calm down enough to sleep?
Analyzing Your Child’s Possible Sleep Disorder
If you’ve established a good bedtime routine and your child still balks at going to bed, wakes up every night, or if he seems sleepy and out of sorts during the day, your child may have a sleep disorder. Just like adults, children can suffer from the effects of chronic sleep deprivation. It can impact every area of their lives, from their academic and athletic performance to overall health and personal safety. Plus it can make them pretty hard to be around.
So how do you know if your child has a sleep disorder? The same way you’d know if you had chronic problems sleeping — you take him to your family doctor to discuss the problem.
Many different sleep disorders could be affecting your child. Your doctor will ask you to complete a pediatric sleep questionnaire to start the diagnostic process. (See the nearby sidebar “Filling out a pediatric sleep questionnaire” for details.)
Identifying Pediatric Sleep Disorders
Many pediatric sleep disorders are similar to disorders that adults suffer, but a few, like Sudden Infant Death Syndrome (SIDS), are exclusive to children. In this section, we look at the most common pediatric sleep disorders, discuss their symptoms, and review treatment options.
Most of the disorders that affect children are classified as parasomnias, that is, sleep disorders that interfere with sleep-stage transitions.
Infant and childhood sleep apnea
No matter what the age of the sufferer, apnea is a potentially life-threatening condition that demands immediate medical attention. It’s one of the most frightening situations a parent can face; every time your child stops breathing, his life may be endangered.
When an adult has an episode of apnea, he usually arouses and starts breathing again. Many babies don’t arouse as quickly. Furthermore, babies breath faster than adults in order to get enough oxygen. Thus, when breathing stops, babies have less oxygen reserve, and each second has a bigger impact than in an adult. If a baby with apnea can’t get his breathing going again quickly, it can become an apparent life-threatening event (ALTE), a medical emergency!
Apnea occurs when breathing completely stops and lasts for a period of at least 10 seconds (6–8 seconds in infants). In obstructive apnea, the upper airway is blocked. In central apnea, the effort to breathe actually stops.
In babies age 9 months or younger, most episodes of apnea are related to the immaturity of their systems that control breathing. As children grow and develop, this type of apnea resolves on its own.
Symptoms
Whether your child is still an infant or older, the most prominent symptom of apnea is a complete cessation of breathing. When the baby is sleeping, breathing between apnea episodes may sound very noisy and seem labored if there is airway resistance or partial blockage. In addition, babies may be
Pale and clammy, with a bluish tinge around the mouth and fingernails
Limp and unresponsive
In older children, symptoms may also include (in order from most common to least common):
Excessive daytime sleepiness (EDS)
Frequent episodes of obstructed breathing while asleep
Raspy snoring (caused by swollen tissues or soft tissue collapse)
Heavy nighttime sweating
Nightmares
Breathing through the mouth while sleeping
Complaints of headache upon arising in the morning
Crankiness, mood swings
Bedwetting
Obesity
Learning and developmental problems; failure to thrive
Frequent upper-respiratory infections
Heart problems, high blood pressure
If the doctor suspects that your child has sleep apnea, he will schedule a sleep test, also called polysomnography. This test, conducted overnight in a sleep lab, can show if your child has sleep apnea and determine the apnea’s severity. (For more information on polysomnography, see Chapter 3.)
Treatment
In some children, surgically removing the tonsils and/or adenoids is all that’s needed to restore proper breathing and eliminate the sleep apnea. If surgery doesn’t fix the problem, your child needs a machine to help him breathe properly while he sleeps. CPAP or continuous positive airway pressure machines keep the breathing passages open with a steady stream of cool air blown in through the nose while your child sleeps. Some children may require a bi-level machine that blows air in at a higher pressure during inhalation and a lower pressure during exhalation.
The equipment may require a bit of getting used to, but with time and patience, most children adapt well to their CPAP machines.
Sudden Infant Death Syndrome
Sudden Infant Death Syndrome (SIDS) claims the lives of 8,000 to 10,000 children annually in the United States. Even after thousands of hours and millions of dollars invested in research, no one yet can say with any degree of certainty what causes an apparently healthy baby to die in his sleep. The fact that no definitive cause of death can be pinpointed at autopsy only makes SIDS more frustrating to parents and researchers alike. But at least researchers now have some clues as to what triggers SIDS. Also, you can buy easy-to-use, in-home equipment to monitor “at-risk” babies that sounds an alarm to alert parents when their infant is experiencing breathing problems.
Symptoms
Unfortunately, babies display no readily apparent symptoms of SIDS. Some at-risk babies can be identified in families that have already lost one or more babies to SIDS, and among premature and low birthweight babies. Other babies are identified when they suffer a near-miss episode of SIDS, such as when the baby was going into respiratory distress or cardiac arrest but the parents found him in time and revived him.
Treatment
Although no specific treatment for SIDS exists, parents can monitor at-risk babies at home with special equipment. If your baby is at risk, get training in infant CPR and keep emergency supplies in the nursery.
In addition, the American Academy of Pediatrics now recommends that all babies be put to sleep on their backs, in what is known as the supine position. A study published in Pediatrics in March 2000 showed that babies put to sleep on their stomachs have an almost 13 times greater risk of death from SIDS than babies put to sleep on their backs.
Sleepwalking and sleep talking
No one is quite sure what causes a child who is sound asleep to get up out of bed and wander around the house, or jabber nonsensically about nothing, but that’s what sleepwalkers and sleep talkers do — they walk the walk and talk the talk, all while they’re asleep. And when you wake them up, they have little or no recollection of what they’ve just said or done.
Remember “To be or not to be? That is the question.” That’s one of the most famous soliloquies ever written. In fact, Shakespeare wrote a lot of soliloquies, but no somniloquies that we know of. That’s probably because somniloquy is what a person who’s sound asleep says. Most of them make very little sense, and even fewer of them are ever written down because after sleep talkers wake up, they can’t remember that they were talking in their sleep or what they said.
Sleepwalking (somnambulism) and sleep talking are both parasomnias. Parasomnias are disorders that cause full or partial awakening. They usually occur during sleep-stage transitions. Parasomnias cause some sort of physical activity or behavior, like walking or talking, that people don’t normally associate with sleep. Sleepwalking occurs in about 18 percent of the population and is far more common in children than in teens or adults. Most sleepwalkers outgrow their tendency to wander at night, but people who talk in their sleep may keep jabbering well into adulthood. Sleepwalking usually occurs during a very deep sleep called slow wave sleep (SWS). Children have a large amount of SWS, which begins to decrease in late adolescence and continues to decrease from adulthood to old age. By contrast, sleep talking can occur in any stage of sleep, which may help explain age-related diminishing of sleepwalking compared to persistence of sleep talking.
For unknown reasons, boys sleepwalk more frequently than girls.
Symptoms
The most obvious symptoms of sleepwalking and sleep talking are . . . drum roll, please . . . sleepwalking and sleep talking. Some children just sleepwalk, others just sleep talk, but some children sleepwalk and talk in their sleep at the same time. You may well see some other unusual behaviors, including
Your child may urinate in an unlikely location, more than likely because he believes he’s in the bathroom.
A sleepwalker’s eyes may be wide open with a glassy, staring appearance, but this doesn’t mean he’s awake or aware.
Your child may scream or use foul language that you’d never hear if he were truly awake and aware of his behavior.
If you try to intervene with the episode for safety reasons, your child may resist you or be very hard to arouse.
Your child may deny that he was sleepwalking and act embarrassed, anxious, angry, confused, or ashamed when you try to discuss the problem.
Treatment
Sleepwalking generally isn’t a cause for concern. Make sure the child’s bedroom is uncluttered to minimize the chance of falls and injuries, and also make sure your child can’t open a door or window to get outside. Dangers increase exponentially if your child gets outside your house in the middle of the night.
You can buy special motion sensor mats to put by your child’s door that sound an alarm if he tries to leave his room. You can also purchase motion sensor devices for windows that alert you if he’s trying to open a window and get out.
You can minimize sleepwalking episodes if you make your child get adequate sleep. Sleep deprivation and excessive tiredness can trigger sleepwalking episodes. Limit liquids close to bedtime, because a full bladder can also make a child sleepwalk.
In severe cases where the sleepwalking occurs almost nightly, or the child suffers injuries from falls or accidents during a sleepwalking episode, your doctor may prescribe diazepam, clonazepam, or lorazepam. They’re members of a class of sleep aids called hypnotics. (See Chapter 4 for more information on hypnotics.) Drug therapy can either completely eliminate sleepwalking episodes or greatly reduce them. If the sleepwalking is frequent and persistent, an overnight study in a sleep lab (see Chapter 3) may be helpful to rule out whether nocturnal seizures are triggering these episodes.
Doctors normally don’t order any treatment for sleep talking. If your child’s talking bothers you or another child sleeping in the same room, try using earplugs to block the sound.
Sleep terrors and nightmares
Sleep or night terrors and nightmares are two distinct sleep problems that can occur together or independently. If they occur occasionally and no other problems result, they don’t require treatment. However, if your child is experiencing nightmares or sleep terrors frequently, or has injured himself during an episode, a doctor should evaluate the problem.
Symptoms
During a sleep terror, a child wakes up suddenly from a deep sleep, screaming or crying loudly, his heart pounding, in an abject state of terror. But when you rush to his side to comfort him, he resists your efforts. He can’t tell you exactly what he was thinking or what was frightening him because he remembers very little about the event.
By contrast, nightmares are frightening dreams that awaken a child from a sound sleep. They’re distinct from sleep terrors because the child can remember every terrifying detail of the bad dream. When a child wakes up, he is fully alert and doesn’t display any of the confusion or disorientation that a child awakened from a sleep terror has. After a bit of comforting from a parent, the child is able to go right back to sleep.
For unknown reasons, sleep terrors and nightmares seem to affect boys more frequently than girls.
Treatment
Unless episodes of sleep terrors or nightmares become so frequent that they interfere with your child’s sleep quality, no treatment is required other than offering love, support, and comfort at the time of each nightmare or sleep terror event. Sleep terrors and nightmares usually stop on their own when the child reaches adolescence. If the sleep terrors or nightmares are frequent and persistent, an overnight study in a sleep lab may be helpful to rule out that nocturnal seizures are triggering these episodes. In some cases, sleep terrors and/or nightmares have been linked to sexual abuse or other traumatic experiences.
Bedwetting
Bedwetting, also called sleep enuresis, can be a source of acute concern for parents and children alike. Kids are embarrassed by wetting their beds, and parents get exasperated having to get up every night and change sheets and pajamas, not to mention the mountain of laundry that bedwetting produces.
Although some children with profound disabilities never achieve bladder control, remember that every child who doesn’t have a severe underlying medical or emotional condition becomes dry eventually. You don’t really need any treatment or a doctor visit unless the child has reached school age without achieving nighttime dryness.
Support your child if he’s still wetting the bed, and help him to feel better about the situation. Don’t make fun of him, don’t humiliate, and, above all, don’t take out your anger on him. Children don’t wet the bed because they want to; they wet the bed because their bladder control is immature, and they sleep more deeply than other children. Their bodies don’t respond to the full bladder signals that wake up older children and adults to urinate in the middle of the night.
Symptoms
The primary symptom of bedwetting is the child’s inability to stay dry through the night. In addition, the child may display emotional symptoms of embarrassment or shame if anyone discusses the bedwetting during the day.
Bedwetting is more common in boys than girls.
Treatment
If your child has been wetting the bed since he was a toddler, he doesn’t require any treatment; all that he needs is patience and love to help him through what can be a very difficult period in his life. But in the meantime, while you’re waiting for the bedwetting to resolve, restrict fluid intake in the evening, eliminate caffeine, and use absorbent pads or diapers to make cleanup easier.
Additionally, have your doctor check out secondary enuresis, or bedwetting that starts suddenly after a child has been dry for a while. Your child may have a urinary tract infection or some other medical or emotional problem that is causing the bedwetting. Sometimes secondary bedwetting begins when a sibling is born and the child wants to be a baby again and get mommy and daddy’s attention.
Rhythmic movement disorders
Rhythmic movement disorder is a blanket term that covers a range of repetitive large muscle movements that start right before the onset of sleep and continue into light sleep. Like sleepwalking and sleep talking, rhythmic movement disorder is a parasomnia. Some doctors believe that children use these movements to calm and comfort themselves as they settle down to sleep. Even though the movement starts as a voluntary act during wakefulness, it continues as an involuntary act after the child falls asleep. As children mature, the movements stop.
Symptoms
Rhythmic disorders may include one or more of the following types of movement:
Headbanging: The child either lifts his head and slaps it down onto the mattress repeatedly, or literally bangs his head into a solid object like the headboard.
Headrolling: While lying on his back, the child rolls his head back and forth from side to side.
Bodyrocking: While supported on his hands and knees, the child rocks his whole body back and forth.
Bodyrolling: While lying on his back, the child rolls his whole body back and forth from side to side.
Treatment
Unless your child is rocking so violently that he injures himself, treatment isn’t required for rhythmic movement disorders. Nonetheless, make sure that your child’s bed or crib is padded and no sharp objects are nearby. If headbanging is occurring, a helmet to protect the head may be prudent. If you feel like the problem is getting out of hand or that your child may hurt himself, ask your doctor for help. Your child may need an overnight sleep study to determine if a previously undetected nocturnal seizure is provoking the movements. For more information about sleep studies, see Chapter 3.
Teeth grinding
Some children grind their teeth so loudly at night that people sleeping in other rooms can hear them. Nocturnal teeth grinding, or bruxism, is a problem you shouldn’t ignore because your child can damage her teeth by grinding them every night.
Symptoms
In addition to the tooth grinding, which is the most obvious symptom, your child may also complain of jaw soreness, show significant wear on her teeth, and suffer from daytime sleepiness, as the clenching and unclenching of the jaw muscles that accompany teeth grinding prevent the child from reaching the deepest and most restorative phases of sleep.
Treatment
Like many other childhood parasomnias, most children outgrow teeth grinding by adolescence. If the problem is causing significant damage to the teeth, or if your child is suffering from significant daytime sleepiness that interferes with school performance, your family dentist can make a bite plate or other dental device that can keep your child from grinding her teeth at night.