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?
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).
Establishing a routine will help change the learned behavior of having a bottle as a transitional object. First, all family members need to be committed to this plan. Families need to be prepared, because the first night without a bottle is usually the most difficult. The family should realize that Natalia will continue to cry until she unlearns the old pattern of the parent and bottle putting her to sleep. Grandma should be committed to the plan and agree not to intervene. You need to reinforce that all children, especially babies, cry when their schedule and environment change. Crying is their only way to communicate before they are able to talk (Pediatric Advisor, 2008a; Pediatric Advisor, 2008b). Crying for brief periods is not harmful. Furthermore, increasing touch, physical contact, and affection during the day can help Natalia adjust to this new task.
You recommend that Nicole offer Natalia a bottle approximately 1 hour before bedtime. It is important to establish a nightly routine that Natalia can count on. This can include a bath, then bottle, then being read a book, and then laying her in the crib under the same conditions that she will wake up to in the nighttime.
One challenging factor with this family is the fact that the parents and baby share a bedroom. Hanging a blanket on the side of the crib that faces the parents’ bed can be helpful with separation, because then Natalia cannot see her parents upon awakening. You should remind this family that Natalia may open her eyes and make other movements during the partial awakenings that occur as she cycles through the phases of sleep. This is normal and not a signal to intervene. These awakenings are especially common in children 6 to 12 months of age (Pediatric Advisor, 2008b; Pohl & Renwick, 2002).
The most important fact that needs to be impressed on the family is that Natalia’s sleep behaviors may take several nights to weeks to change. Also, this new plan should be started at a time when one or the entire family can afford to lose some sleep for about a week. This helps with consistency with the plan.
You make these recommendations and the mother agrees that the plan is worth trying. Grandma agrees and they leave, saying they are hopeful that it will work as planned.
When should you see this family again?
You ask the family to return in about 2 to 3 weeks. You reassure them that when following a consistent plan, most infants show improvement in a few days and will be sleeping through the night in 1 to 2 weeks.
What complications might occur?
The family should be encouraged to return sooner if:
• They feel that the sleep disturbance is due to a physical cause.
• Someone in the family cannot tolerate the crying at night.
• The steps outlined do not improve the baby’s sleep habits within 2 weeks.
• Any other questions or concerns arise.
At follow-up in 2 weeks, Dad accompanies Nicole and Natalia. He does not have any questions and relays to you that the first few nights were fairly sleepless. But, the couple continued with the plan and put a blanket on the side of the crib so Natalia could not see them. They admit to continuing to be awakened by Natalia’s movements and verbalizations through the night. They feel certain their movements may also disturb Natalia. They have discussed this with the paternal grandmother and are currently converting a room for Natalia. Mom is aware that this will change Natalia’s sleeping environment once again and is taking steps to place familiar items and materials in that room to help with this transition. She also acknowledges that she may have to start back at the beginning to help re-establish good sleep hygiene in Natalia.
Key Points from the Case
1. Sleep assessment should be a part of every well-child visit. The healthcare provider should ask the caregiver if he or she is satisfied with their child’s current sleep pattern and follow up on any concern that is expressed (Nativio, 2002).
2. Sleep problems are common in children.
3. Counseling families with anticipatory guidance regarding what is a normal sleep pattern as their child grows can give parents the tools they need to intervene as situations arise with their children.
4. Education about the effect on sleep of temperamental style, developmental stages, and changes in the environment will empower parents and enhance the parent–child relationship.
5. Families need to decide if the plan is workable for them and adapt it as necessary.
REFERENCES
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Ferber, R. (2006). Solve your child’s sleep problems. New York: Simon & Schuster.
Kemp, C. (2005). Mexican & Mexican-Americans: Health beliefs and practices. Retrieved April 14, 2009, from http://bearspace.baylor.edu/Charles_Kemp/www/hispanic_health.htm
KidsHealth. (2007). All about sleep. Retrieved July 7, 2008, from http://kidshealth.org/PageManager.jsp?dn=KidsHealth&lic=1&ps=107&cat_id=190&article_set=10233
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Schultz, J. R. (2001). Sleep and bedtime behaviors. In R. C. Baker (Ed.), Pediatric primary care: Well-child care (pp. 283–290). Philadelphia, PA: Lippincott Williams & Wilkins.