Pediatric Primary Care Case Studies (43 page)

A complete physical examination should be performed, but probably will not yield much information unless the baby’s history points to organic or functional disease. However, the provider needs to identify signs of illness or areas of discomfort that may be interfering with the child’s ability to get appropriate levels of sleep. Most experts agree that the clinician should focus on the respiratory and nervous systems for clues to sleep disturbances (Nativio, 2002; Pohl & Renwick, 2002).

Physical Examination

In this particular case, the infant is alert, active, and smiling while sitting in her mother’s lap. She has good eye contact with you. The rest of the examination is unremarkable.

During the physical examination, you need to observe the child’s behavior (she was smiling) and the parent–child interaction (handed her off to grandma). This can provide clues as to the nature of the maternal–child bond as well as the family dynamics.

Cultural and Ethnic Aspects of Sleep

How might the family’s beliefs and expectations affect their perceptions of sleep problems and how they should be managed?

What other cultural influences in this family may affect the baby’s sleep behavior as well as the decision to seek medical care?

The family’s ethnicity is Hispanic American. An understanding of some of the traditional health beliefs and practices within the Hispanic culture can be helpful in assessing and understanding the concerns presented here. Many families in the Hispanic culture will seek the help of other family resources such as a
señora/abuela
(grandmother),
yerbew
(herbalist),
sobador
(massage therapist), or
portera
(midwife who also treats children) (Kemp, 2005). Family involvement in health care is common among Hispanics, and it is common for a female relative such as a grandmother to accompany mothers to healthcare visits. In the Hispanic culture, childrearing is primarily the woman’s responsibility, but the decision-making is left to the man. It is also important to note that traditionally, neither disease prevention nor health promotion visits are valued (Kemp). According to Schachter et al. (1989), there is an increased incidence of all-night co-sleeping (sharing a bed) in Hispanic American children versus white children. Hispanic children are 8 times more likely to share a parental bedroom and 3.5 times more likely to co-sleep than their white cohorts. Schachter found that multiple families sharing a house and crowding, which are more common factors in the Hispanic culture as compared to whites, may be a factor in families’ healthcare practices.

In addition, differences noted in family values may play an important role in the sleep habits of the Hispanic culture. There is a greater emphasis on family interdependence and intimacy in Hispanic cultures as compared to white cultures, where the emphasis is on independence and individualism (Schachter et al., 1989).

In this case, several cultural factors may be affecting the sleep habits of this family. As with all families, healthcare providers must be respectful of cultural differences and consider these differences when developing and communicating a plan of care with the family. Thus, the plan of care must be driven by evidence-based practice and the values and preferences of the family.

Making the Diagnosis

Based on your detailed history and physical examination, infection and disease states are ruled out. This case study is a fairly classic presentation of the normal developmental level of an 8-month-old and normal sleep physiology and how the factors of family and environment interact and impact sleep hygiene. The familial expectations of what are normal sleep and feeding patterns may also be factors in this sleep arousal disorder. The history and physical examination are consistent with the diagnosis of: 1) sleep arousal with the development of sleep-onset association disorder, 2) family stress, 3) inappropriate expectations regarding sleep, and 4) a trained night feeder.

Management

How do you plan to treat the child’s sleep disturbance?

Therapeutic Plan

The plan of care must address the four sleep problems that you have identified:

•   Sleep-arousal disorder

•   Sleep-onset association disorder

•   Family stress

•   Inappropriate sleep expectations

To address these issues, you review some of the main points you want to make in your counseling. You also are aware that sleep patterns are very family and culture dependent. For example, some families keep infants and children in the same bed or bedroom with parents until they are several years old. Feeding children in the night may be the norm. Letting infants cry rather than consoling them immediately may vary, too. And, there are issues around generational differences in the ways that sleep and other child-rearing issues are managed. In this case, Grandma must also be integrated into the plan for it to be successful. Parents must define what is problematic for sleep in their infants. In most cases, the infant is happy and rested. It is the parents and household that have the problem. Given these values, you decide that you will want to do the following:

•   Counsel and discuss physical findings with Mom and Grandma.

•   Counsel regarding normal developmental tasks of the 8- to 12-month-old, including separation anxiety and object permanence.

•   Counsel regarding appropriate nutrition for an infant 6 to 12 months old.

•   Counsel regarding the lack of nutritional need for a nighttime feeding.

•   Counsel on changing the learned behavior of sleep-onset association including use of a transitional sleep object.

•   Counsel on how to establish a routine for a healthy sleep pattern in children. (See
Box 11-1
.)

Box 11–1   Developing a Routine Should Begin Around Two Months of Age

•   Consider feeding baby ahead of bedtime rather than just before bedtime.

•   Get into a regular routine at bedtime, such as a bath and quiet time approximately 1 hour before bedtime.

•   Put baby to bed drowsy, but not asleep.

•   Distinguish nighttime from daytime—use a soft voice to talk to baby when putting her to bed at night.

•   Never put a baby in bed with a bottle of milk, juice, or any liquid.

•   Make sure the sleeping environment is quiet, dark, and not too hot or cold.

•   Put infants on their backs to sleep.

•   Expect crying; do not reward the baby for awakening (i.e., do not pick up).

From a nutritional standpoint, normal term infants do not need a nighttime feeding after 4 to 6 months of age. Being rocked or fed teaches the baby to associate that activity with going to sleep. This learned behavior occurs in as many as 40% of 6- to 24-month-olds (Nativio, 2002). The last waking memory the baby has needs to be of the crib, not the bottle.

The Ferber method (2006) is a progressive approach in which the parent allows the baby to cry for gradually longer periods of time before returning to him or her briefly. This method recommends putting your infant, after 6 months of age, in the crib drowsy, but still awake. This will help the baby fall asleep on his or her own. You decide to present this plan as an option the family might want to consider, knowing that it might not fit with the family’s beliefs about management of infants.

The plan begins with a routine that ends with the baby placed in the crib with her transitional object, in this case, Natalia’s “meese.” The parent should then leave the room. If the baby cries, wait 5 minutes before re-entering the room. The parent can speak to the baby briefly and touch her stomach, but avoid picking her up or rocking her. After 2 to 3 minutes, the parent should leave and not return until 10 minutes have passed; then they can repeat the reassurance. The next interval should be about 15 minutes, with 15-minute intervals for the rest of the night. Natalia should be awakened at the routine time the next morning. The next night, the first wait increases by 5 minutes, to 10 minutes. Each night the first wait increases by another 5 minutes. She eventually will learn that it is not worth crying for 20 to 30 minutes if the gain is just a few minutes of attention. Falling to sleep on her own is an important developmental task to learn.

Implementing the Plan

You proceed with your plan. First, you reassure this mother that there are no signs of illness (e.g., ear infection). You continue on to say that although many experts agree that GERD is a medical problem that can interfere with sleep (Chamness, 2008; Pohl & Renwick, 2002), Natalia’s GERD symptoms seem to have resolved at around 6 months of age. Therefore, GERD, or any other disease state, does not appear to be a factor in this child’s sleep arousal issues.

Next, you tell Mom and Grandma about the normal developmental tasks that Natalia is trying to accomplish. You begin by asking whether the crying begins when she leaves the room or if, when others like Grandma try to hold her now, does this seem to upset Natalia? Mom replies that Natalia seems to cry when she leaves the room and she will look around for Mom, even when held by someone else. You explain that these are indicators that Natalia is beginning to experience some separation anxiety, which is normal. Natalia has learned that Mom is someone special and misses her when she is not within sight.

Experts agree that one way to help babies with separation anxiety is to offer a transitional object like a blanket, doll, or other favorite thing as baby begins to sleep (National Sleep Foundation, 2009; Pohl & Renwick, 2002; Schmitt, 1992; Schultz, 2001).
In this case, Natalia uses a silky blanket called her “meese.” Mom may want to also give Natalia something that smells like Mom or Dad to ease this separation. This should help her to return to sleep and comfort her.

What Grandma unknowingly did was to add a transitional object, the bottle. You need to develop a plan to discontinue the bottle as a transitional object. In addition, she and Mom may have trained Natalia to be a nighttime feeder.

You also consider the family’s stressful situation and the changed sleep environment as you further develop the plan of care. The fact that the baby’s crib has been moved into the parent’s room may be a factor in the sleep arousal of this infant. Children appear to be more distracted by environmental disruptions than are adults (Pohl & Renwick, 2002). However, parents who are accepting of co-sleeping report less sleep problems compared to those who are not. It is known also that families living under stress have babies and children less likely to sleep through the night. Finally, maternal depression may be playing a role in this child’s nighttime awakening. Research does not show that mom’s depression causes sleep problems, only that children with moms who are depressed have more night waking (National Sleep Foundation, 2009).