Pediatric Primary Care Case Studies (42 page)

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Current comments: Report on growth in young wrestlers
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Landry, G. L. (2007). Female athletes: Menstrual problems and the risk of osteopenia. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. F. Stanton (Eds.),
Nelson textbook of pediatrics
(18th ed., p. 2865). Philadelphia: Elsevier/Saunders.

Landry, G. L., &, Logan, K. (2007). Sports medicine. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. F. Stanton (Eds.),
Nelson textbook of pediatrics
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Postconcussive syndrome
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Loud, K. J., Gordon, C. M., Micheli, L. J., & Field, A. E. (2005). Correlates of stress fractures among preadolescent and adolescent girls.
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McCarthy,V. (2006). Getting to the big game: Keys to performing an efficient sports physical.
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Stevenson, K., & Adelson, P. (2003). Pediatric sports-related head injuries. In J. DeLee, D. Drez Jr., & M. Miller (Eds.),
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(Vol. 2, 2nd ed., p. 781). Philadelphia: Elsevier/WB Saunders.

Chapter 11

The Infant Not Sleeping Through the Night

Lynne Henry

Sleep, or lack of it, is often not discussed at routine health maintenance visits and is typically not discussed at all until the child’s sleep disturbs the parents’ sleep. The quality of an infant’s sleep can affect an entire family’s well-being, resulting in parental fatigue and mood disturbances, which lead to less effective parenting. Furthermore, studies have shown that infant sleep problems can reoccur or persist into early childhood (Chamness, 2008). Many concerns regarding sleep disturbances are related to the infant’s or child’s developmental level, whereas other sleep-related concerns are associated with habits or behaviors that parents unintentionally support.

Assessment of sleep habits should be addressed at every well child and health maintenance visit. In order to avoid common sleep disturbances, it is important to establish healthy sleep patterns as early as infancy. A sleep assessment should begin with an understanding of normal sleep physiology and knowledge of how the child’s developmental stage affects sleep physiology.

Educational Objectives

1.   Understand the normal physiology of sleep.

2.   Apply developmental factors of the child to the physiology of sleep.

3.   Understand the parental role in sleep disturbances.

4.   Apply the cultural factors that may influence the normal physiology and management of sleep hygiene issues in the family

   Case Presentation and Discussion

Natalia Fernandez is an 8-month-old female who presents today at your rural health clinic with her mother and her paternal grandmother. Mom is concerned because Natalia, who had been sleeping through the night, is now awakening at around 2 a.m. and crying as though something is wrong. This has been going on for about 4 weeks. Mom worries that Natalia may have an ear infection because she pulls at her ears while she is crying. Mom also notes that when she gets Natalia out of the crib, she stops crying and seems to want to play. When this happens, Mom gives Natalia a bottle of formula to calm her down but
she drinks only 1–2 ounces. Mom admits that her baby’s night waking really frustrates her, and she becomes very irritable with Natalia in these early morning hours.

Assessment

What questions will you need to ask the family related to the presenting complaints?

A thorough history can often elicit the underlying issue. As you assess this concern of the mother, there are some detailed questions you should ask. These include:

•   A description, from the parent’s perspective, of the disturbing behavior

•   The baby’s usual sleep and feeding patterns

•   The length of time the child stays and sleeps in bed relative to the entire day

•   The time the parent puts the baby to bed throughout the day

•   The parent’s expectations of when, where, and how long the baby should sleep

•   Exact details of the manner in which the parent puts the baby to bed

•   What the parent has tried to do to help stop the sleep disturbance

•   How the parent usually responds to the sleep disturbance

•   Baby’s temperament

•   Household routines (who is the primary caregiver)

•   Changes in the household (stressors, e.g., new job)

•   Family history of sleep problems

•   Family history of depression

Obtaining a thorough and accurate history is the key to delineating the problem and developing a differential diagnosis of likely causes.

Upon further review of Natalia’s chart and additional questioning of her mom, you learn that Natalia was born via spontaneous vaginal delivery at 40 weeks gestation to Nicole, age 22 years, and Roberto, a 22-year-old Hispanic man. They have no other children. Roberto works full time at a car dealership and Nicole recently returned to work at Starbucks 12 to 15 hours per week. Natalia was diagnosed with GERD (gastroesophageal reflux disease), but the spitting up never interrupted her sleep. In fact, the symptoms of reflux dissipated after she began eating solids by spoon. Natalia’s mother is the primary caretaker and usually gives Natalia a bottle about 1 hour before she puts her in her crib at around 8:00 p.m. every night, practicing the “Back to Sleep” recommendations. Natalia uses a silk blanket, called her “meese,” to help soothe herself to sleep and usually falls to sleep around 8:15 p.m. or so. Natalia’s mother gets her up around 8:30 a.m. when Dad is leaving for work. She began sleeping all night at around 4 months of age. She naps twice a day, 1 hour in the morning around 10:00 a.m. and approximately 2 hours in the afternoon, around 2:00 p.m.

At this point, Natalia begins to fuss and you observe her mother’s attempts to comfort her. Mom appears frustrated and hands her off to her paternal grandmother.

Observing this interaction, you ask if there have been any changes in the family’s routine at home or any new or different stressors, good or bad, that the family is currently experiencing. Natalia’s mother admits that approximately 1 month ago, Natalia’s dad’s company downsized and he suffered a decrease in his pay. These events required the family to move into the paternal grandmother’s home. Grandma interjects that when Natalia cries at night, she goes to her and gives her a bottle, then rocks her back to sleep. Natalia’s mother says that a week ago they moved Natalia into their bedroom to avoid waking the grandmother.

The Normal Physiology of Sleep

In order to develop a plan of care for this family, it is important to understand the sleep cycle. There are two sleep states: nonrapid eye movement (NREM) and rapid eye movement (REM). NREM sleep cycles predominate during the first third to half of nighttime sleep, and are divided into four stages (Pohl & Renwick, 2002). In stage 1, the sleeper is drowsy, but responsive, but by stages 3 and 4, it is difficult to arouse the sleeper. The sleeper may be very confused if aroused during this time. Stages 3 and 4 are when the sleeper may experience sleep terrors and sleepwalking, behaviors characterized by dramatic body movements with no awareness of the environment (Pohl & Renwick). During NREM sleep, blood supply to the muscles is increased, energy is restored, tissue growth and repair occur, and growth hormone is released for growth and development (National Sleep Foundation, 2009).

REM sleep cycles predominate in the latter half or third of the night (Pohl & Renwick, 2002). In this stage, muscle tone is inhibited in all systems except the ocular and respiratory systems, and there is loss of ability to regulate body temperature. The sleeper has episodic bursts of eye movement, irregular pulse, and tachypnea but no movement of the extremities. During this cycle, sleepers usually dream and can be easily awakened (Nativio, 2002).

The human body cycles between these NREM and REM phases all through the night. Furthermore, there are very brief arousal periods with transitions from one phase to another (Chamness, 2008). Newborns sleep 16 to 17 of 24 hours a day, with approximately 50% REM cycles, and have one to two cycles per sleep period (Nativio, 2002). Term newborns have four to six evenly distributed sleep-wake periods daily with consolidation of daily sleep into the nighttime period occurring by about 6 weeks of age (Pohl & Renwick, 2002). At approximately 3 months of age, a baby averages about 5 hours of sleep during the day and 10 hours at night, with brief interruptions. About 90% of babies this age sleep through the night (KidsHealth, 2007). Sleep time decreases to about 13 hours per day by 2 years of age, 11 hours per day by 5 years, 10 hours per day by 10 years, and 9 hours per day during adolescence.
By about 3 to 5 years of age, children move to a more adult-like sleep cycle. In addition, daytime sleep decreases to three naps a day by about 6 months, two naps per day between 6 and 12 months, and no naps by 3 to 5 years of age (Pohl & Renwick).

Normal Infant Development

Several major developmental tasks are occurring during infancy that can affect sleep patterns. According to Erikson, by about 2 to 4 months, infants accomplish the emotional developmental task of basic trust (Boynton, Dunn, & Stephens, 1994). With the security of trust, the baby is now aware that differences exist in people and certain people are more important to him or her than others (i.e., primary caretaker). Therefore, infants can experience stranger anxiety by about six months. The infant can feel anxiety if he or she awakens and mother is not there, or comfort if she is there. Infants who have more body contact during the day sleep better at night (Schultz, 2001). It is important to understand that separation anxiety is a normal developmental task for all children, and bedtime is a time of separation. According to Piaget, infants at around 6 months of age accomplish the intellectual task of memory or object permanence (Boynton, Dunn, & Stephens). Thus, the baby may awaken as a normal part of sleep, remember mother, and experience separation anxiety (Nativio, 2002). This developmental process can interfere with sleep for a period of weeks. Thus, between 6 and 12 months of age, separation anxiety can become a major sleep disturbance issue. This is due to the cognitive development of object permanence. Natalia is in this developmental age range.

What about the theory of a trained night feeder?

Baby wakes between sleep cycles and needs to learn to put him- or herself back into the next sleep cycle. If fed, he or she learns that food is the way to self-soothe and get back to sleep.

Is a complete physical examination necessary?