Excessive crying beyond 3 months may herald other features of multiple regulatory problems

OBJECTIVE: To assess duration of excessive crying and its relation to sleep and eating disturbances in a population sample of infants. DESIGN: Cross-sectional study. SETTING: Random digit-dialing survey, enrolling birth cohorts between 1999 and 2003, in Germany. PARTICIPANTS: Children aged 4 years and younger. MAIN EXPOSURES: Excessive crying, retrospectively ascertained according to modified Wessel's criteria, and duration of excessive crying. MAIN OUTCOME MEASURES: Severe eating or sleeping problems at interview. RESULTS: The participation rate in the random digit-dialing survey was 62%. The analysis was confined to 1865 children with complete data. The observed prevalence for excessive crying ever was 16.3% (95% confidence interval [CI], 14.7-18.1), beyond 3 months 5.8% (95% CI, 4.8-6.9), and beyond 6 months 2.5% (95% CI, 1.9-3.3). Excessive crying only in the first 3 months did not increase the prevalence of sleep or eating disturbances whereas crying beyond 6 months did; prevalence of eating disorders was 19.1% (95% CI, 9.1-33.3) and prevalence of sleeping disorders was 12.8% (95% CI, 4.8-25.7) compared with 2.7% (95% CI, 1.9-3.6) and 3.6% (95% CI, 2.7-4.6), respectively, in children without excessive crying. CONCLUSIONS: Persistence of crying beyond the first 6 months heralded a higher prevalence of eating or sleeping difficulties in children with excessive crying than in children without excessive crying. These parents should be offered support and counseling over a broader spectrum of features related to multiple regulatory problems.     

Tic disorders and arousal dysfunction: clinical evaluation of 49 children and adolescents

AIM: Tourette Syndrome (TS) shows a significant comorbidity with obsessive-compulsive disorders, behavioral problems (i.e. attention-deficit/hyperactivity disorders) and sleep disturbances. Several studies showed that sleep problems are common in TS patients affecting 12% to 62% of patients. Aim of this study was to evaluate the relationships between tics, sleep disorders and behavioral disturbances. METHODS: Fourty-nine consecutive children and adolescents with tics have been studied by the following procedure: a) the Yale Global Tic Severity Scale (YGTSS) was administered in order to establish the severity of tics; b) the Child Behavior Checklist (CBCL) was used to evaluate behavioural disturbances; c) the Sleep Disturbance Scale for Children (SDSC) was filled out in order to assess the presence of sleep disorders. An age-matched control group was used for comparison. RESULTS: All patients (either TS or non-TS) showed a higher prevalence of sleep disturbances versus the control group. Sleep-wake transition disorders (SWTD) were the most frequent sleep disturbances found in our sample, followed by disorders of initiating and maintaining sleep (DIMS). These latter sleep disturbances were highly correlated with the severity of tics. Internalization problems, anxiety/depression and attention and thinking problems were very frequent in our sample. Correlation analysis showed a positive relationship between internalization problems and DIMS and also between aggressive behaviour and respiratory disturbances during sleep (RDS). CONCLUSION: The results obtained seem to confirm the literature reports on the strict relationship between tics and sleep disturbances, mainly SWTD, and further support the hypothesis of a dysfunction of arousal mechanism in TS.     

Parents'reports of disturbed sleep in 5—7-year-old Swedish children

Parents’reports on 1844 five to seven year olds from the general population were used to provide a detailed update about prevalence and correlates of sleep disturbances in children. Five different sleep disturbances were focused on: difficulty falling asleep, reported in 5.6% of the children; night waking in 15.5%; snoring in 7.7%; nightmares in 3.1%, and bedwetting in 5.3% of the children. Coexisting sleep disturbances were frequent in children with difficulties falling asleep, night waking and nightmares, but bedwetting usually emerged as a singular sleep disturbance. Nightmares were associated with serious health problems or handicaps, sleep problems in conjunction with life events, and female gender. Snoring as well as bedwetting were associated with reports of “very active” children. In 6.7% of the total sample, parents had previously consulted the healthcare services for a sleep problem in their child. These children had reports of colic during infancy, eczema, serious health problems or handicaps, current snoring and current nightmares. Only 1.1% (n = 21) of the children were said to have a present need to remedy sleep problems. The reports on these children included coexisting sleep disturbances, previous consultations for sleeping problems, parents’perceptions of “very active” children, diagnoses of attention deficit hyperactivity disorder, and major life events which had triggered sleep problems. In conclusion, although sleep disturbances are common in 5—7-y-old children, parents seldom express a need to remedy sleep problems in their children of this age. □ Children, parents, sleep behaviour, sleep disturbances, survey     

Sleep-wake cycles in obese children with and without binge-eating episodes

AIM: The aim of the study was to assess binge-eating episodes and to characterise sleep-wake cycles among obese children. METHOD: The obese group consisted of 36 children. All participants received a diagnosis of primary obesity. The obese group was subdivided into two groups: obese with binge eating and without binge eating. A normal-weight control group was comprised of 25 normal-weight children. Sleep-wake patterns were monitored for 1 week, using mini-actigraphs and self-report questionnaires. RESULTS: Thirty-seven per cent of the obese children reported uncontrolled binge-eating episodes. Actigraphic monitoring revealed significant differences in sleep quality between all three groups. Self-report questionnaires presented significantly more sleep disturbances in the obese group with binge eating and obese group without binge eating than in the normal-weight group. CONCLUSION: Sleep disruption in obese children with binge eating is significantly more severe than in both obese non-binge-eating children and normal-weight controls.     

Sleep disturbance and rage attacks in opsoclonus-myoclonus syndrome: response to trazodone

OBJECTIVES: Parents of children with opsoclonus-myoclonus syndrome (OMS) frequently describe poor sleep and rage attacks. We hypothesized that these manifestations are related and could result from underlying monoaminergic dysfunction. STUDY DESIGN: We clinically characterized the sleep and behavioral characteristics of 51 young children with OMS; 19 of those with the most disruptive sleep patterns were treated with trazodone, a soporific serotonergic agent. RESULTS: Sleep disturbances, including prolonged sleep latency, fragmented sleep, reduced quantity of sleep, snoring, and non-restorative sleep, were reported in 32 children, and frequent rage attacks were reported in 25. In 59% of the poor sleepers, parents felt that the problem was severe enough to warrant treatment. Children sleeping <10 hours/night had a higher rage frequency than those who slept more. Of the children who required trazodone, 84% were receiving corticosteroids or adrenocorticotropic hormone (corticotrophin), compared with 37% in the subgroup with normal sleep. Trazodone (3.0 +/- 0.4 mg/kg/day) improved sleep and behavior in 95% of the children, significantly increasing total sleep time by 72%, decreasing the number of awakenings by 76%, and reducing rage attacks by 33%. CONCLUSIONS: Children with OMS exhibited multiple types of sleep disturbances, which contributed to rage attacks. Trazodone was effective in improving sleep and decreasing rage attacks and was well tolerated, even in toddlers.     

Sleep habits and disturbances in Malaysian children with epilepsy

Aims: To compare sleep habits and disturbances between Malaysian children with epilepsy and their siblings (age range 4–18 years) and to determine the factors associated with greater sleep disturbance. Methods: The Sleep Disturbance Scale for Children (SDSC) questionnaire was completed by the primary caregiver for 92 epileptic children (mean age 11.1 years, 50 male, 42 females) and their healthy siblings (mean age 11.1 years, 47 males, 45 females). Details of sleep arrangements and illness severity were obtained. Multiple regression analysis was used to determine factors associated with high Total SDSC scores in epileptic patients. Results: Compared with their siblings, epileptic children had significantly higher total SDSC score (difference between means 8.7, 95% confidence interval (CI) 6.4–11.1) and subscale scores in disorders of initiating and maintaining sleep (3.9, 95% CI 2.8–5.2), sleep–wake transition disorders (2.1, 95% CI 1.3–2.9), sleep‐disordered breathing (0.7, 95% CI 0.3–1.1) and disorders of excessive sleepiness (1.5, 95% CI 0.6–2.4). Epileptic children had a higher prevalence of co‐sleeping (73.7% vs 31.5%) and on more nights per week (difference between means 3, 95% CI 2.0–3.9) than their siblings. Higher Epilepsy Illness Severity scores were associated with higher total SDSC scores (P= 0.02). Conclusion: Co‐sleeping was highly prevalent in children with epilepsy, who also had more sleep disturbances (especially problems with initiating and maintaining sleep and sleep–wake transition disorders) than their siblings. Epilepsy severity contributed to the sleep disturbances. Evaluation of sleep problems should form part of the comprehensive care of children with severe epilepsy.     

Persistence of sleep disturbances in preschool children

The purpose of our study was to determine if common sleep disturbances in young children, such as night waking and bedtime struggle, tend to persist; if they are related to environmental stress factors and are accompanied by other behavior problems; and if their persistence is related to other factors. Sixty children aged 15 to 48 months (mean age 26.4 months) were studied by interviewing their mothers initially and after 3 years. Children with and without sleep disturbances were compared, with the latter serving as the control group. Twenty-five (42%: night waking, 22%; bedtime struggle, 13%; both night waking and bedtime struggle, 7%) of 60 children had sleep disturbances at the initial interview, and of these 25 children, 21 (84%) had persistence of sleep disturbances after 3 years, persistent sleep disturbances had a significant relationship with increased frequency of stress factors in the environment (P less than 0.01). Other generalized behavior difficulties were present in 30% of sleep-disturbed and 19% of non-sleep-disturbed children (P = NS). Co-sleeping (sleeping with a parent or sibling) was noted more frequently in sleep-disturbed (34%) than in non-sleep-disturbed (16%) children. Twenty percent of the mothers at initial interview and 30% at 3-year follow-up perceived their child's sleep disturbances as stressful to them and to their family life. Early identification of the child with sleep disturbances and timely intervention would help both the child and the family.     

Short-term prospective study of sleep disturbances in 5-8-year-old children

The course and psychological correlates of disturbed sleep during middle childhood were investigated using parents' responses to questionnaires. Five specified sleep disturbances were explored in 614 5-8-y-old children, at baseline and at follow-up, 14 +/- 3 mo later. Difficulties falling asleep, in 6.2% of the children at baseline, persisted in 47.4% of the cases at follow-up; night-waking, in 18.6% at baseline, persisted in 45.5%; snoring, in 9.4% at baseline, persisted in 60%; nightmares, in 4.4% at baseline, persisted in 29.6%, and bedwetting, in 6% at baseline, persisted in 46%. Moreover, children with difficulties falling asleep at baseline frequently displayed bedtime resistance and shorter sleep at follow-up, while night-waking at baseline was related to co-sleeping at follow-up. Snoring at baseline was associated with a trend towards restless sleep at follow-up. Nightmares at baseline were related to several other sleep complaints as well as to behavioural difficulties during daytime at follow-up. Bedwetting at baseline was associated with tendencies towards hyperactivity at follow-up. Separate analyses of cases of persisting sleep disturbances showed that persisting difficulties falling asleep were associated with a need to remedy sleep problems, while persisting nightmares were strongly related to reports suggesting behavioural and emotional problems. Conclusion: During middle childhood, difficulties falling asleep, night-waking, snoring, nightmares or bedwetting commonly persist over the course of a year. Persistent nightmares frequently indicate significant psychological problems in affected children.     

Treating infant sleep disturbance: Does maternal mood impact upon effectiveness?

Aim:   To explore whether mild-to-moderate maternal depression affects the effectiveness of a behavioural approach to treating infant sleep disturbance (ISD).
Methods:   The health records of 90 mothers attending an inpatient parenting service for management of their 5–12-month-old infant's sleep difficulties were examined. These records contained detailed, nurse-completed, 24-hour behaviour charts of infant sleeping and crying. Participants were allocated to the depression group based on Edinburgh Depression Scale score and/or review of mental health assessment notes.
Results:   There were no differences between infants of mothers with ( n = 39) or without ( n = 51) depression on either (i) the severity of their initial sleeping difficulty, or (ii) their response to behavioural treatment. Both groups showed significant improvements over the 5-day stay on all sleep variables observed, including number of night wakings, time to fall asleep, time spent crying at night and total time slept at night.
Conclusions:   Mild-to-moderate maternal depression does not appear to attenuate ISD behavioural treatment outcomes. Given ISD treatment has been shown to improve maternal mood, the results of this study argue against recommendations initially to address maternal mood in isolation when managing ISD.     

The bedtime pass: an approach to bedtime crying and leaving the room.

OBJECTIVE: To evaluate a novel intervention for bedtime problems. DESIGN: We used an ABAB withdrawal-type experimental design. SETTING: The intervention was prescribed in an outpatient primary health care context and evaluated in the home setting. PARTICIPANTS: Two normally developing boys aged 3 and 10 years were the primary participants. Twenty parents and 23 practicing pediatricians rated the acceptability of the intervention. INTERVENTION: A bedtime pass, exchangeable for 1 excused departure from the bedroom after bedtime. MAIN OUTCOME MEASURES: For both primary participants, instances of crying and/or coming out from the bedroom after bedtime; for the 20 parents and 23 pediatricians, comparative ratings of acceptability for the pass and 2 other commonly used approaches to bedtime problems (ignoring crying and letting children sleep with their parents). RESULTS: Crying and coming out from the bedroom reduced to zero rates in both children. Pediatricians rated using the pass as significantly more acceptable than letting children sleep with parents and equivalent to ignoring. Parents rated the pass as more acceptable than either alternative. CONCLUSION: The bedtime pass provides pediatricians with a readily usable, potentially effective, and highly acceptable novel intervention for bedtime problems, one of the most common complaints in outpatient pediatrics.     

The price of pruritus: sleep disturbance and cosleeping in atopic dermatitis

BACKGROUND: Atopic dermatitis is a common skin disorder that most often begins in infancy. Sleep disturbances in children with atopic dermatitis are likely due to itching and scratching and not only impact the afflicted child but may also affect the entire family. Sleep characteristics in young children with atopic dermatitis and their families have not been thoroughly investigated. OBJECTIVE: To evaluate sleep disturbance and cosleeping in young children with atopic dermatitis and evaluate the association between sleep characteristics and features of the disease. DESIGN AND METHODS: Parents of 300 children ranging in age from birth to 6 years with atopic dermatitis responded to 4 questions about sleep characteristics of their child and family. Analyses determined the prevalence of reported sleep disturbance and cosleeping, and their association with features of the patients and disease severity. RESULTS: Sleep disturbance attributed to atopic dermatitis was common; most parents (> 60%) reported that the dermatitis affected how well they or their child slept. Cosleeping because of the skin condition was reported by 30% of families, and most of these parents (66%) were bothered by the cosleeping. Sleep disturbance and cosleeping were directly associated with severity of atopic dermatitis and with the degree to which parents reported that the atopic dermatitis affected the child and family's happiness. CONCLUSIONS: Sleep disturbances were more common in children with atopic dermatitis than have been reported in children overall. These results demonstrate important sequelae of a very common childhood condition that warrant further investigation and the development of intervention strategies.     

Pädiatrie und Kinder- und Jugendpsychiatrie

The spectrum of diseases in childhood has changed in the last two decades. The prevalence of disease patterns characterized by behavior disorders and/or distinctive psychosocial aspects has significantly increased. These disorders include regulatory disturbances in infancy, such as excessive crying and early-childhood eating problems; attention-deficit hyperactivity disorder in school-age children; eating disorders such as obesity and anorexia; and an increased rate of depression and delinquency in adolescence. Furthermore, chronic diseases have increased, including bronchial asthma, diabetes mellitus, and chronic infectious intestinal diseases, which can have a negative impact on the psychosocial development of the child and the whole family system. Regarding the roles of pediatrician on the one hand and child psychiatrist on the other hand, the former has a special key role as “gatekeeper.” Pediatrics, social pediatrics, and child psychiatry should work more closely together to guarantee optimal care for these children. At the same time, research on the etiopathogenesis of the above-mentioned diseases is needed.     

Subjective daytime sleepiness and its predictors in Finnish adolescents in an interview study

The purpose of this study is to evaluate the predictors of subjective daytime sleepiness (SDS) and its chronicity in adolescents. Two groups of adolescents (107 with SDS and 107 without SDS) from our first questionnaire study were invited to an interview after 3 y. A follow-up questionnaire had been sent to them one year earlier. The interview included questions about sleep, daytime sleepiness, living habits, physical and mental health, and progress at school. The adolescents were also examined clinically. Interviews were conducted with 66 out of 107 subjects with SDS and 64 out of 107 without SDS (age range 12 to 19 y). In this interview 42 out of the 130 adolescents had SDS. A total of 20 adolescents reported SDS in both questionnaire studies and in the interview (chronic SDS). In a multivariate analysis (logistic regression) sleep disorders, frequent medication and depressive emotions were significantly associated with SDS. Chronic SDS was connected in a bivariate analysis (Pearson's chi-square) with excessive night waking, difficulty in falling asleep, dreaming, frequent medication, frequent alcohol drinking, and irregular breakfast eating, and in our previous studies also with delayed sleep rhythm.
Conclusion: Sleep disorders and health problems were more common causes of SDS than undesirable living habits. However, alcohol drinking and delayed sleep rhythm were associated with chronic SDS in addition to sleep disorders and medication.     

Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress

BACKGROUND: Gastro-oesophageal reflux (GOR) is common in infants with persistent crying. Empirical treatment with antireflux medications is common practice, although on clinical grounds it may be difficult to determine whether GOR is abnormal. AIMS: To examine the diagnostic accuracy of clinical predictors of pathological GOR in infants with persistent crying. METHODS: One hundred and fifty-one infants (82 male; median age 2.5 months, range 0.5-8.2 months) with persistent crying were prospectively studied. Crying and fussing were charted for 24 h, and parents completed a validated questionnaire on reflux symptoms. All infants underwent oesophageal 24-h pH monitoring. RESULTS: Twenty-seven (17.9%) infants had pathological GOR with a fractional reflux time (FRT) >10%. There was no significant association between total crying duration per 24 and FRT (P = 0.84) or the number of reflux episodes (P = 0.68). Pathological GOR was more common in infants under 3 months, compared to older infants (P = 0.04). Feeding difficulties were significantly associated with pathological GOR (P = 0.02). Backarching was not increased in infants with GOR (P = 0.30). Pathological GOR was significantly associated with the frequency of regurgitation (P = 0.04), but not with vomitus volume (P = 0.62). Regurgitation more than 5 times daily was the most specific reflux symptom (specificity 70.9%), but was a poor predictor of pathological GOR (positive predictive value 22.2%). In the absence of frequent regurgitation or feeding difficulties, pathological GOR was unlikely (negative predictive value 87-90%). CONCLUSIONS: Investigation and treatment of GOR in infants with persistent crying should be primarily directed at infants presenting with frequent regurgitation or feeding difficulties.     

Prevalence of obesity, binge eating, and night eating in a cross-sectional field survey of 6-year-old children and their parents in a German urban population

BACKGROUND: To assess the prevalence of obesity, obesity-related binge eating, non-obesity-related binge eating, and night eating in five- to six-year-old children and to examine the impact of parental eating disturbances. METHODS: When 2020 children attended their obligatory health exam prior to school entry in the city of Aachen, Germany, 1979 parents (97.9%) filled out a questionnaire on their child's eating habits and weight development in a cross-sectional survey. Anthropometric measurements were collected for all children in a standardized form. RESULTS: Episodes of binge eating were found in 2.0% of the children surveyed and night eating in 1.1%. There was a significant relationship between binge eating and obesity but not between night eating and the child's weight. Children's binge eating and night eating were strongly associated with eating disturbances on the part of their mothers (adjusted odds ratios [95% confidence intervals]: 6.1 [2.7-13.5] and 7.8 [2.1-29.4], respectively) and with a non-German native language (adjusted odds ratios [95% confidence intervals]: 2.6 [1.2-5.5] and 11.6 [3.5-38.7], respectively). CONCLUSIONS: In concurrence with studies on adulthood, binge eating is linked to obesity already in early childhood. Children of mothers with eating disorders and children of mothers with a non-German native language are at increased risk of developing eating disorders themselves. Future studies should focus on obesity and eating disorders in early childhood; prevention programs should seek to target young children at risk as early as possible.     

Prediction of early outcome in resolving chronic lung disease of prematurity after discharge from hospital

Interview data from parents of 201 children under age 7 years with severe feeding and eating difficulties were analysed to describe features in the child's and parents' experiences that may have contributed to the development of the eating problem. Prematurity and low birth weight, distress during feeding in the first six months of life, and regular or frequent vomiting were common findings in the histories of the children. Aversive experiences during feeding may be the basis for early childhood eating difficulties.     

Sleep Problems in Children of Affectively Ill Mothers

The objective of the study was to determine whether the frequency and severity of sleep problems were greater in children of affectively ill mothers than in children of control mothers. Sleep problems were studied in children of mothers with a diagnosis of unipolar ( N = 38) and bipolar ( N = 23) affective illness and children of mothers with no current or past psychiatric diagnosis ( N = 24). Mothers' reports on the Child Behavior Checklist (CBCL) were obtained three times, 4 years apart, on sibling pairs (ages 1.5–3.5 and 5–8 years, respectively, at first assessment). In addition, on the third assessment, the Diagnostic Interview for Children and Adolescents was filled out by mothers and children. In both siblings, sleep problems, as assessed through the CBCL, were more frequent and severe in children of affectively ill mothers. In younger siblings, the persistence of sleep problems was more frequent in children of affectively ill mothers. Co-occurrence of sleep problems among siblings was more frequent in children of affectively ill mothers than in those of control mothers.     

Baby Business: a randomised controlled trial of a universal parenting program that aims to prevent early infant sleep and cry problems and associated parental depression

Background  

Infant crying and sleep problems (e.g. frequent night waking, difficulties settling to sleep) each affect up to 30% of infants and often co-exist. They are costly to manage and associated with adverse outcomes including postnatal depression symptoms, early weaning from breast milk, and later child behaviour problems. Preventing such problems could improve these adverse outcomes and reduce costs to families and the health care system. Anticipatory guidance-i.e. providing parents with information about normal infant sleep and cry patterns, ways to encourage self-settling in infants, and ways to develop feeding and settling routines before the onset of problems-could prevent such problems. This paper outlines the protocol for our study which aims to test an anticipatory guidance approach.     

Obstructive sleep apnea syndrome in children: the responsibility of pediatricians

Although obstructive sleep apnea syndrome (OSAS) in children is a frequent and potentially serious respiratory disorder, it has a reliable diagnosis and treatment is highly effective. OSAS is a respiratory sleep-related disorder that forms part of sleep apnea-hypoapnea syndrome. The syndrome affects between 1 % and 3 % of children. In addition to its cardiopulmonary complications, it can retard growth and increase the risk of hyperactivity and learning difficulties. It has also been associated with attention deficit disorder and hyperactivity. When OSAS is suspected, up-to-date nocturnal polysomnography is the gold standard for the diagnosis and quantification of severity of childhood OSAS. In most children the treatment of choice is adenotonsillectomy, which has a success rate of more than 85 %. We provide an up-to-date review of the evidence on the clinical features, etiology, complications and treatment of OSAS in children. The main objective of this review is to alert pediatricians to their essential role in the early detection of this syndrome, especially among children who snore, and to provide a clinical practice guideline for the diagnosis and definitive treatment of these children.