Sleep management is crucial for infants and young children

Renée Shellhaas, MD, MS, FAAP

Sarah Morsbach Honaker, PhD, CBSM

Sleep has important implications for health and development in children. Therefore, it is essential that pediatricians know the features of normal, safe, and healthy sleep, ask about children’s sleep habits, and provide guidance to address existing problems.

At the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida, Renée Shellhaas, MD, MS, FAAP, discussed the risks associated with abnormal sleep, safe sleep policies, and the detection and management of common sleep issues in infants and young children. The informative session titled “Rock-a-bye baby: Basic sleep management” took place on November 3.

“Sleep is a topic that is not well covered in most residency training programs,” says Shellhaas, clinical associate professor of Pediatrics, University of Michigan, Ann Arbor, Michigan, “but being knowledgeable about sleep is important for pediatricians because it will enable the discovery and management of sleep problems. In our practices, we need to ask about sleep and to teach parents about safe and healthy sleep.”

Sleep affects children’s health

Shellhaas reviewed research showing that sleep problems have deleterious consequences for children of all ages. Studies in premature infants show that sleep-wake cycling is a marker of brain function, and that babies with normal sleep-wake cycling have better development than those with abnormal sleep physiology.

Other research demonstrates that infants with parent-reported snoring are likely to have worse cognitive and behavioral scores later in life compared with infants who are not snorers. Frequent awakening during the night among infants and toddlers also has been shown to be associated with lower development scores. In young children, short sleep duration is associated with increased risk for obesity, Shellhaas points out.

In her session, Shellhaas also highlighted that abnormal sleep is particularly common and potentially even more negatively impactful in children with certain diagnoses. For example, trisomy 21, cerebral palsy, and myelomeningocele all are associated with an increased risk for sleep-disordered breathing.

“In children with these disorders, pediatricians can uncover an important health problem by asking a few simple questions about sleep,” she says. “Make it routine during the well-child exam to ask about snoring and pauses in breathing, and if these problems are present, refer the child for a sleep study.”

Safe sleep for babies

Shellhaas also reviewed current recommendations regarding safe sleep for babies that advocate placing children alone in a crib in a supine position. She notes, however, that the AAP recommendation that babies should sleep in the same room as the parents for the first months of life can jeopardize adherence to these recommendations because infants who sleep in the same room as their parents are more likely to end up bedsharing.

“Furthermore, it is known that sleep consolidation is poorer when infants do not sleep alone in a separate room,” Shellhaas says.

Although it is important to counsel all families about safe sleep, pediatricians should know that racial/ethnic minorities and people with a lower education level are less likely to follow safe sleep guidelines.

“There are also some interesting data showing that parents are more likely to position their baby prone-on the belly-if the child was positioned on his or her side when laid to sleep by staff in the hospital after birth. It is important that safe sleep be modelled to parents from the beginning,” Shellhaas says.

Pediatricians are well positioned to advise families about behavioral sleep interventions for infants and young children. Serving in this role, it is important that clinicians know there is evidence-based research showing that “cry it out” and graduated extinction methods are effective and do not have long-term adverse psychologic consequences for the child.

“Familiarity with the available data in this area will allow pediatricians to talk confidently and accurately with families about sleep behavior training,” Shellhaas says.

Commentary

Evidence clearly shows that normal and sufficient sleep is critical for healthy child development and family well-being. Considering the importance of safe and healthy sleep, information presented by Dr. Renée Shellhaas in the session “Rocka-bye baby: Basic sleep management” has great value for pediatricians.

Shellhaas covered a range of important topics. Her review of safe sleep recommendations included helpful insights on families who might be targeted for more intensive counseling to achieve adherence with current guidelines. Discussion of strategies to promote evidence-based detection and management of common sleep difficulties also was included. As frontline providers, pediatricians have an essential role identifying affected children and providing intervention or referral as appropriate.

Although many pediatricians generally ask about sleep duration and habits, other areas are less frequently addressed. Obstructive sleep apnea, presenting in an estimated 2% to 3% of children, is often underidentified. The AAP’s “Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome” recommends that screening be included in all routine health maintenance visits.¹

Shellhaas also discussed problematic night wakings in older infants and toddlers, a common concern for parents of young children. In counseling parents on behavioral sleep interventions, it is important for clinicians to be aware of a variety of diverse approaches that can be used to help children fall asleep independently and return to sleep after night wakings. Offering parents choices is empowering, and the likelihood of successful intervention is increased when parents are allowed to select a method they think best fits the baby’s temperament and their personal preferences and values.

Reference

1. Marcus CL, Brooks LJ, Draper KA, et al. Clinical Practice Guideline: Diagnosis and management of childhood obstructive sleep syndrome. Pediatrics. 2012;130(3):576-584. Available at: http://pediatrics.aappublications.org/content/130/3/576.long. Accessed October 29, 2018.

Sarah Morsbach Honaker, PhD, CBSM, is assistant professor of Pediatrics, Indiana University School of Medicine, and director, Behavioral Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana.