Managing Sleep Problems in Children and Adolescents: Q&A with Dr. Maida Chen
Dr. Maida Chen, director of Seattle Children’s Pediatric Sleep Disorders Center, addresses questions about sleep in children of all ages.
Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.
Q. At what point is “cry-it-out” (CIO) safe for babies?
A. It’s controversial. Cry-it-out needs to happen when a baby is mature enough to understand cause and effect – in this case, “If I cry, you pick me up,” compared to “If I cry, you don’t pick me up, so I’ll go back to sleep.” That maturity usually occurs between 4 and 6 months of age. It’s not clear if it’s psychologically safe at an earlier age or if it’s just ineffective.
Studies have found that babies who have learned to sleep on their own at an early age, commonly through CIO methods, may be little better adjusted and a little more independent than kids who still require parental involvement for establishing sleep.1
CIO may involve a few nights of pain, but it’s probably worth it if everyone gets more sleep for the next few years. However, CIO methods may not be the best fit for every family, and other methods may be effective as well.
Q. What is the most common mistake parents make with toddlers who wake up?
A. If a toddler wakes up frequently, the most common mistake for parents is to respond inconsistently. A toddler who gets mixed messages will have unpredictable responses.
Q. What health concerns in infants and toddlers do you see that we may miss?
A. The most commonly missed concern in infants is probably snoring. Recent studies have shown that obstructive sleep apnea (OSA) is way more common in infants than you might expect. We now know that OSA has long-term neurocognitive effects, including lower cognitive scores on the Bayley Scales of Infant and Toddler Development.2
Q. Could you discuss the use of melatonin or Benadryl? How can these medications be used to phase-shift a child who has a hard time falling asleep?
A. When I’m asked about melatonin or Benadryl, the main thing I ask is why the parent or provider wants to give the child a sleep medication. It’s important to understand the underlying issue, and it may be time for a sleep clinic referral or a behavioral assessment.
What is needed depends on the child. A classic example is the 7- or 8-year-old who can’t sleep due to evolving anxiety. Benadryl and melatonin shouldn’t be used as a crutch for children with anxiety. Children with autism have different reasons for not falling asleep, and a provider or specialist with knowledge of autism should supervise treatment.
Melatonin is better than Benadryl for phase-shifting. However, to be successful, it’s important to do a careful assessment of what’s happening in the home. Pay attention to caffeine intake, timing of naps and exposure to light, including media use before bedtime. Giving melatonin at the wrong times may result in a phase shift in the undesired direction.
It’s important to work with a child’s biology instead of against it; a child won’t fall asleep if they are given a medication at a time when they are physiologically very awake.
Q. Do you recommend drawing a ferritin level on children who seem restless at night? If you start a child with a ferritin under 50 on iron, how often would you repeat a ferritin test?
A. It’s reasonable to draw a ferritin level. It’s done a lot in clinical practice based on evidence within the restless legs syndrome literature, although there’s no evidence within a general pediatrics population. We are actually starting an observational study to look at the effect of iron on children with low ferritin levels and restless sleep to explore this topic.
If ferritin is less than 50, we treat with 3 mg/kg per day of elemental iron, and we usually recheck ferritin levels in three to six months. If the child’s restlessness doesn’t improve with iron, then I’d recommend referring to sleep medicine.
Q. What signs and symptoms should prompt a referral for a sleep evaluation?
A. In general, an evaluation is important if a parent notices that a child:
- Does not feel refreshed in the morning, or has daytime sleepiness
- Is snoring
- Has open-mouth breathing
- Has many position changes
- Is bed-wetting after being potty-trained
For particular ages, additional symptoms may warrant a referral:
- For toddlers through school-age children: Hyperactivity, impulsivity and lack of focus
- For adolescents: Waking up without feeling refreshed and manifesting sleepiness during the day
It’s not as useful to ask if a school-age child (up to age 10) is falling asleep in school to screen for sleep problems because children tend not to manifest overt sleepiness.
If there’s a question about sleep and the cause is not clear, then it’s important to make a follow-up appointment to talk about sleep or make a referral to sleep medicine.
Q. What long-term health concerns are associated with sleep problems?
A. While more is known in adults, there is plenty of research in pediatrics that highlights the long-term impact of disordered sleep, including:
- Cognitive deficits2,3 – poorer academic performance and executive function
- Behavioral concerns2,3 – more mood swings, depression, oppositional outbursts and difficulty with peer interactions
- Medical concerns4 – higher blood pressure and cardiac dysfunction in children, poor growth
In adults, there is also evidence of an impact on cardiovascular health (heart attacks, strokes, increased blood pressure), glucose intolerance and diabetes, obesity and cancer. Studies looking at these effects on children are underway.
- Owens JA and Mindell JA. Pediatric Insomnia. Pediatr Clin N Am, 2011. 58; 555-569.
- Piteo AM, Lushington, K, Roberts RM et al. Parental-reported snoring from the first month of life and cognitive development at 12 months of age. Sleep Medicine. 12 (2011) 975-980.
- Beebe DW. Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review. SLEEP 2006;29 (9):1115-1134.
- Witmans M, Young R. Update on pediatric sleep-disordered breathing. Pediatr Clin N Am, 2011. 58; 571-589.
Change to ACIP Recommendations for Meningococcal Conjugate Vaccine in Certain High-Risk Children
The Advisory Committee for Immunization Practices (ACIP) has recommended that children with certain high-risk conditions receive a four-dose series of the meningococcal conjugate vaccine MenHibrix or Menveo at 2, 4, 6 and 12 through 15 months of age. These high-risk conditions include anatomic or functional asplenia (sickle cell disease) and persistent complement deficiency.
This vaccine was formerly recommended for children with these high-risk conditions down to 2 years of age.
“There is no change in risk; the age range has been expanded because these newer vaccines are now licensed for use in infants,” says Dr. Janet Englund, infectious diseases specialist and ACIP liaison member for the Pediatric Infectious Diseases Society.
Adolescents should continue to receive this vaccine starting at 11 years of age, with a booster dose at age 16.
From 2005 to 2011, there were an estimated 800 to 1,200 cases of meningococcal disease each year in the United States; the case-fatality ratio ranges from 10% to 15%, and 11% to 19% of survivors have serious long-term sequelae such as neurologic disability, limb or digit loss or hearing loss (Centers for Disease Control and Prevention. Prevention and Control of Meningococcal Disease. MMWR, 2013;62, No. 2. 1-28).
The 2014 immunization schedule doesn’t have any major changes that affect pediatric practice, although the dosing schedule for human papillomavirus vaccine has been clarified, and there is a recommendation for booster doses of Tdap after 10 years of age.
Speech and Language Assessments Available with Wait Times Under 10 Days
Seattle Children’s offers speech and language assessments with wait times of 10 days or less. Appointments for standard evaluations can be made within one to two days of receiving a referral; evaluations with specialists who have specific areas of expertise may be made in one week to 10 days.
Speech-language pathologists have expertise to provide services for patients with needs related to:
- Autism spectrum and social communication disorders
- Augmentative and alternative communication
- Receptive and expressive language disorders
- Articulation and phonological disorders
- Bilingual language development
- Motor speech disorders
- Velopharyngeal dysfunction
- Paradoxical vocal fold motion
- Acquired brain injury/cognitive communication
- Swallowing (videofluoroscopic swallow studies and clinical swallow studies)
Speech and Language Services offers in-depth diagnostic evaluations that can inform ongoing care provided at schools and private practices.
“We provide differential diagnoses that may not be available in other settings,” explains Sharon Lindsey, manager of Speech and Language Services. “For example, we can determine if a child who is stuttering at 3 years of age has a disorder that requires treatment or a temporary difficulty that will be outgrown. Ongoing care is often best provided right in a child’s school or local community.”
For more information, see the clinic referral information (PDF).
First Two Relapsed Leukemia Patients in Remission After Cellular Immunotherapy Trial
Two patients with poor-prognosis relapsed acute lymphoblastic leukemia (ALL) are now in remission after receiving a new therapy that could eventually replace radiation and chemotherapy. The new therapy involves drawing blood from the patient, reprogramming their T cells to find and destroy cancer cells and infusing the blood back into their body.
The reprogrammed T cells are genetically modified to attack cancer cells in the same way they would respond to a viral infection, resulting in an effective, targeted therapy with fewer side effects.
At Children’s, 86.9% of patients who are diagnosed with ALL for the first time survive – which is a higher survival rate than the national average of 85%. But if a patient goes through treatment and the cancer comes back, less than 20% survive.
“The success of the therapy in our first two patients in this phase I trial gives us hope that many more patients will be able to benefit in the future,” says Dr. Rebecca Gardner, lead clinical researcher.
In addition to this trial, which is open to patients ages 1 to 26, the research team recently received approval from the Food and Drug Administration to conduct a second trial for patients who have experienced relapsed ALL after a bone marrow transplant.
Seattle Children’s is one of only a few institutions in the country conducting this type of clinical trial, which involves using a specialized high-tech facility to “manufacture” the personalized therapy using each patient’s blood.
For questions about these trials, contact Seattle Children’s Cancer and Blood Disorders Center at 206-987-2106 or, toll-free, 866-987-2000.
You can also read about the two patients in remission, Lynsie Conradi and Milton Wright, on Seattle Children’s news blog.
Grand Rounds for March 2014 (CME Credit Available)
Upcoming Grand Rounds
- Competency in Pediatric Procedural Skills: Getting It, Keeping It, March 6
- The First 1,000 Days: The Importance of Early Brain and Child Development, March 13
- Foster Care: Improving Outcomes for a Challenging Population, March 20
- Antimicrobial Stewardship at Seattle Children’s Hospital: Progress in Protecting Patients, March 27
- See all upcoming Grand Rounds
Watch Past Grand Rounds Online
- Fluoride: An Evidence-Based Counteroffensive
- Using the Hospital Experience to Advance Our Clinical Knowledge of CSF Shunt Infection
- Disturbances in Cardiorespiratory Coupling Implications for SIDS, RETT Syndrome and Familial Dysautomia
- See all online Grand Rounds
New Medical Staff and Allied Health Professionals, March 2014
New Medical Staff
Katherine Banker, MD, Seattle Children's, Critical Care Medicine
Carole Jenny, MD, MBA, Harborview Medical Center, Pediatrics
Jeremy Kassebaum, MD, Richmond Pediatric Clinic, Pediatrics
Viral Patel, MB BS, University of Washington, Orthopedics and Sports Medicine
Colin Pritchard, MD, PhD, University of Washington, Laboratory Medicine
Mary Rebagliati, MD, Group Health Central Hospital & Clinics, Hospital Medicine
New Allied Health Professionals
Julia Chan, ARNP, Seattle Children's, Developmental Medicine
Genevieve Dennis, ARNP, DNP, Seattle Children's, Neonatology
Kristy Liu, ARNP, Seattle Children's, Neonatology
Sophie Lu, ARNP, Seattle Children's, Anesthesiology and Pain Medicine
Alexandra Nienhuis, ARNP, Seattle Children's, Anesthesiology and Pain Medicine
Lara Sabourin, ARNP, Seattle Children's, Cardiology