Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Kids don't get any respect.
- Mary Fay (21 January 2000)
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Do not discard proper drug treatments in young children
- Salvador Vale (22 January 2000)
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When to treat sleeping problems
- Dieter Wolke (22 January 2000)
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Ignoring Biology
- Zan Buckner (22 January 2000)
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Quality Ratings of Behavioural Trials
- Dieter Wolke (23 January 2000)
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Treatments for settling problems and night waking in young children
- Malcolm Cooper (25 January 2000)
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Some children have "regulatory disturbances"
- Martin Maldonado-Duran (30 January 2000)
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A natural treatment.
- J W Tankel, R S Tankel (4 February 2000)
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The prevention of infant sleep disturbance
- Brian Symon (21 February 2000)
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Mary Fay, general pediatrics
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I am disappointed to see that once again children with sleep disorders are being lumped into a homogenous group of "behavioral" problems, then "studied" without using polysomnography. I think it's presumptuous and dangerous of us to think every child who has trouble sleeping is a behavioral problem. Few physicians are aware that breathing difficulty can cause night waking and bedtime resistance, and it is due to studies like this. Doctors don't look for sleep disorders properly, don't know much about them, and are told over and over again that behavioral treatments are the way to go. This is wrong unless we can guarantee these are behavioral problems. When you consider that a study looking at obese children using polysomnography diagnosed unsuspected OSA in 75% of the children studied - meaning the physicians examining the children only picked up 1 in 4 cases - it seems a big leap of faith to not be doing polys more often. Why couldn't some of these night waking kids or bedtime resisters be those with UARS where this is also a problem? Most doctors can barely take a proper history for sleep disorders, let alone diagnose a subtle case of UARS causing repeated night waking or bedtime resistance. Studies like this certainly don't help because they take the emphasis off of finding a "real physiologic" problem and stress behavioal modification. Before we continue to send physicians our to behaviorally modify breathing difficulties or other subtle causes of sleep disorders that can mimic behavioral problems, we need to do polysomnography on these children. I think it's just good experimental technique that I'm advising. Don't bother comparing the different types of treatment available until you know what you are treating. |
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Salvador Vale, Psychiatrist Researcher Antiguo Hospital Concepcion Beistegui, Regina 7, CP 06080, Mexico DF
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The recent review in the journal (1) gives the impression that behavioural interventions are the best option in the management of settling to sleep and night walking in young children. However, several considerations are appropriate before total acceptance of this statement. 1) Behavioural treatments may help families to cope actively with their child’s disorders and make the necessary life accommodations to optimise family functioning. Because of those reasons, parent’s opinions may be biased toward behavioural interventions. Nevertheless, behavioural management has a high cost and in consequence it should be prescribed only in the most disturbed patients. 2) It is important to consider the possibility to obtain the greatest benefits for these young children using both drug and behavioural treatments. For example, these benefits has been reported for the combined management in the attention-deficit / hyperactivity disorder in childhood (2) in which multimodal treatment has yielded significant low medication doses and modest superiority in overall results. 3) Drug treatment for any child disturbances, needs to be a carefully skilled decision. The controlled trials reviewed in the article, report bad long-term results with general sedative drugs (antihistamines) or benzodiazepines, which are not the best options for the management of the present puzzle. The problems of difficulties in functional settling to sleep and night walking are chronic but tend to disappear with the time. In consequence the short-term benefit of some psychotropic drugs like tricyclic antidepressants and others can be exploited for the benefit of the patients. May I suggest that until further randomised controlled trials discard the value of drug treatments in this problem, patients may be considered to receive combined behavioural and drug treatments whenever possible ? 1.- Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of treatments for settling problems and night waking in young children. BMJ 2000 ;320 : 209 - 213 2.- The MTA Cooperative Group. Moderators and mediators of treatment response for children with Attention-Deficit / Hyperactivity Disorder. Arch Gen Psychiatry 1999 ; 56 : 1088 - 1096 |
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Dieter Wolke, Professor of Psychology University of Hertfordshire, Department of Psychology, DWRU, College Lane, Hatfield, AL10 9AB, UK
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The timely systematic review on the treatment of sleeping problems in young children (1) reported that behavioural treatments are effective. There are a number of behavioural methods that allow for interventions that are suitable to different families. The review will inform practice but omitted three issues that are important for practitioners to note. First, at what age can we expect infants and toddlers to sleep through the night and should commence treatment? It is of concern that two of the nine identified studies included infants as young as 1 month of age in their treatments (1). Infants are not born with the ability to sleep through the night but the sleep architecture develops to be roughly identical to the adult during the first 6 months of life and sleep patterns are entrained by environmental cues (2). Waking at night in the early months of life is adaptive to secure frequent feeding and to allow for rapid weight gain and brain growth. Sleeping through the night in the early weeks of life and a lack of waking for feeds is likely to put vulnerable infants (e.g. preterm infants, SGA infants, poor feeders) at risk for poor appetite development and sub optimal growth (3,4). While provision of information on appropriate bed and nighttime routines in early infancy is encouraged, behavioural treatments for night waking should not commence before 6 months of age, a time when night waking is not anymore necessary for appropriate growth. Secondly, infants who are breastfed do sleep less during 24 hours (5) and are more likely to wake at night than bottlefed infants (3). It is important to inform parents about this and to reassure them that breastfeeding does not impede the learning to sleep through the night (3). The establishment of early routines, avoidance of feeding the infant into "submission" and the use of focal feeds (6) help to reduce the stress of nighttime breast feeding and prevent premature change to bottle feeding. Thirdly, sleeping problems, both in the community or clinical practice often co-occur with other behavioural problems such as excessive crying or feeding difficulties (7, 8). Parents with infants with multiple difficulties are more likely to seek help from health professionals. We do not know from the review whether the young children had other behavioural difficulties. Effectiveness studies (treatment evaluation in the field) are thus needed to establish that behavioural interventions are still effective with infants with multiple problems. Considering that behavioural interventions are also successful with crying (9) and feeding problems (10) it is most likely that they are effective in multiple problem groups. Finally, the behavioural methods detailed in the review have been developed with one aim in mind, to help the child to learn to fall asleep unaided both in the evening and at night (11). Children who have never learned to fall asleep by themselves have no strategies when they awake at night other than to call for or go to their parents. Behavioural management helps the child to self regulate: "Yes I can fall asleep by myself". 1. Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of treatments for settling problems and night waking in young children. British Medical Journal 2000;320:209-213. 2. Wolke D. Feeding and sleeping across the lifespan. In: Rutter M, Hay D, editors. Development through life: a handbook for clinicians. Oxford: Blackwell Scientific Publications, 1994:517-557. 3. Wolke D, Söhne B, Riegel K, Ohrt B, Österlund K. An epidemiological study of sleeping problems and feeding experience of preterm and fullterm children in South Finland: Comparison to a South German population sample. Journal of Pediatrics 1998;133:224-231. 4. Skuse D, Reilly S, Wolke D. Psychological adversity and growth during infancy. European Journal of Clinical Nutrition 1994;48:113-130. 5. Lucas A, St James-Roberts I. Crying, fussing and colic behaviour in breast- and bottle-fed infants. Early Human Development 1998;53:9-18. 6. Pinilla T, Birch LL. Help me make it through the night: behavioral entrainment of breast-fed infants' sleep patterns. Pediatrics 1993;91:436- 444. 7. Wolke D, Meyer R, Ohrt B, Riegel K. Co-Morbidity of crying and feeding problems with sleeping problems in infancy: Concurrent and predictive associations. Early Development and Parenting 1995;4:191-207. 8. Wolke D, Gray P, Meyer R. Excessive infant crying: a controlled study of mothers helping mothers. Pediatrics 1994;94:322-332. 9. Lucassen PLBJ, Assendelft WJJ, Gubbels JW, van Eijk JTM, van Gelfrop WJ, Knuistingh Neven A. Effectiveness of treatments for infantile colic: systematic review. British Medical Journal 1998a;316:1563-1569. 10. Wolke D, Skuse D. The management of infant feeding problems. In: Cooper PJ, Stein A, editors. Feeding problems and eating disorders in children and adolescents. Chur: Harwood Academic Publishers, 1992:27-59. 11. Wolke D. Die Entwicklung und Behandlung von Schlafproblemen und exzessivem Schreien im Vorschulalter. In: Petermann F, editor. Kinder- Verhaltens-therapie: Grundlagen und Anwendungen. Baltmannsweiler: Schneider-Verl. Hohengehren, 1997:154-203. |
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Zan Buckner, breastfeeding counselor Attachment Parenting International, La Leche League International
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The basic assumption that very young children should settle down to sleep away from their parents, and not be seen or heard from again until morning, is flawed. In many non-Western societies, this type of sleep patern would be seen as an aberation. Antropolgogist Carol Wortham of Emory University in Atlanta uncovered a variety of sleep patterns in ten traditional, hunter-gather societies, none of which coincides with our sociey's current ideal of sleeping alone without waking for the entire night. (Worthman, C.M., and M.K. Melby. In press. Toward a comparative developmental ecology of human sleep. In Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, M. A. Carskadon, ed. New York: Cambridge University Press.) Perhaps some amount of night waking in children and their desire for comforting by parents is both natural and healthful. Our difficulty in combating this behavior may be because we are struggling against nature and basic human biology. We must be careful not to confuse that which is desirable for health and well-being with that which is merely a current preference and expectation of our society. |
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Dieter Wolke, Professor of Psychology University of Hertfordshire, Department of Psychology, DWRU, GB-Hatfield, Herts AL10 9AB
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The systematic review of treatments for sleeping problems in young children (1) and a recent review of treatment of colic (2) provided evidence for the efficacy of behavioural treatments. This, despite the generally lower quality ratings that behavioural trials received compared to drug or dietary trials. It is worrisome that quality criteria derived from drug trials are used as "off the shelf" gold standards (3) to judge the quality of behavioural treatments in recent reviews in the BMJ. Double blinding is used in trials to guard against performance bias, i.e. systematic differences in the care provided apart from the intervention being evaluated (4). Double blinding is not possible in behavioural or many other medical treatment studies. Imagine the therapist or surgeon who does not know why or what s/he is doing with this patient? Thus a range of safe guards have been proposed and tested to guard against performance bias such as the investigation of generalised placebo effects, e.g. comparison of a treatment to a different treatment and a no-treatment group. The difference between a different (placebo) treatment and no treatment indicates generalised placebo effects (e.g. how just attention leads to improvements) (5). Randomisation is applied to exclude selection bias. However, in small samples (e.g. < 30) effect sizes may become inflated due to outliers and thus checking for a range of pre-treatment differences may be as important than randomisation itself (6). The reviewed drug or dietary trials (1,2) were mostly small sample studies. It should be remembered that the aim of quality ratings is to judge how optimal the internal validity of a trial is (i.e. the confidence that the cause of any observed differences is due to the treatment conditions) rather than to apply a set of criteria that are "off the shelf" and were developed without behavioural treatments in mind. 1. Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of treatments for settling problems and night waking in young children. British Medical Journal 2000;320:209-213. 2. Lucassen PLBJ, Assendelft WJJ, Gubbels JW, van Eijk JTM, van Gelfrop WJ, Knuistingh Neven A. Effectiveness of treatments for infantile colic: systematic review. British Medical Journal 1998;316:1563-1569. 3. Jaddad AR, Moore RA, Carroll D, Jenkinson C, Reynolds JM, Gavaghan DJ, et al. Assessing the quality of randomized clinical trials: is blinding necessary? Controlled Clinical Trials 1996;17:1-12. 4. Cook TD, Campbell DT. Quasi-experimentation: Design and analysis for field settings. Chicago: Rand McNally, 1979. 5. Howard KI, Moras K, Brill PL, Martinovich Z, Lutz W. Evaluation of Psychotherapy. American Psychologist 1996;51:1059-1064. 6. Lipsey MW, Wilson DB. The efficacy of psychological, educational, and behavioral treatment. American Psychologist 1993;48:1181-1209. |
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Malcolm Cooper
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As a community pharmacist I was interested in the paper submitted by Paul Ramchandani, Luci Wiggs, Vicky Webb and Gregory Stores,1 I am often approached by parents requesting a sedative for their young children. Many are aware that liquid preparations of some antihistamines e.g. Promethazine (Phenergan) can be bought over the counter without the need to 'bother the doctor'. While their use may be justified in some cases for short term use for children over two years old I am very reluctant to supply these products without carefully questioning the requester first. From experience I have found that a simple dose of a proprietary children's gripe water before settling the child down often does the trick and I believe that the child's sleep disturbance may sometimes be caused by hyperacidity in the stomach. Has any research been carried out in this area? It is always satisfying to use a simple remedy where possible. Malcolm Cooper BPharm MRPharmS 1. Ramchandani P,Wiggs L,Webb V,Stores G. A Systematic review of treatments for settling problems and night waking in young children. BMJ 2000;320: 209-213. |
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Martin Maldonado-Duran, Investigator,Child and Family Center Menninger Clinic, PO Box 820. Topeka, Kansas USA 66601
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I read the interesting article on settling problems and would like to add two points. 1)Many children who experience difficulties settling to sleep have " regulatory disturbances". One of the features of this group of problems is trouble making transitions, for instance from being awake to falling asleep. This is not taken into consideration by the article. There may be a 5 to 10% of children who have those regulatory difficulties. These children even in the "best" families who have bedtime routines, soothe the child, and devote time to settle him or her to bed, are sensitive, reassure,etc. may find that the the child has much trouble setting to sleep. He or she may " toss and turn", talk, think about many things and simply struggle to fall asleep. The usual " sleep hygiene" techniques do not work with these children. These children should be properly identified as special behavioral techniques are necessary to help them, and sometimes at least for the short term, medications. 2) The advice for parents to ignore their child crying may be inadequate for many families. Many parents struggle with problems in being sensitive to their child's anxieties, fears and difficulties. advicing them to ignore the child's cry only because this " works " may be counterproductive in terms of the whole parent-child relationship. That is, even if ignoring " works" parents may not want to convey to their child that his/her distress is ignored and the child has to figure on his/her own that there is no help, and he willjust have to go to sleep or " cry himself to sleep". I would worry that parents would worry that physicians or other health professionals might convey the message that the child's distress should be ignored. |
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J W Tankel, GP principal Lance Burn Health Centre, Salford M6 5QX, R S Tankel
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The paper by Ramchandran et al misses two important points. Firstly, children often rouse during the night and if there is subsequent disharmony then perhaps this indicates that the problem belongs to the parents and not the child. After all if the child were to receive the attention it appears to need in order to pacify him or her all will be well - although the parents will be somewhat disturbed. Secondly, I would commend a treatment about which he makes no mention and which is almost guaranteed to succeed within 30 seconds. Breastfeeding!! There are no side effects and an excellent safety record. It has certainly been a huge success in our household. |
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Brian Symon
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Ramchandani et al [1] in their systematic review of treatments for established infant sleep problems show that behavioural interventions improve sleep patterns. The authors reference the frequency of sleep disorders as 20% in children aged one to three years, the tendency for these problems to be persistent and their associations with behavioural difficulties and family disharmony. Other authors quote the frequency of sleep disturbance to be as high as 35%.[2]. Armstrong [3] reported 60% of parents still rising from their beds when their child was 12 months old, and half of them were rising three times per night or more. We tested the impact of a short-behavioural intervention in normal neonates in a randomised trial (submitted for publication). In all, 269 families with normal newborn singletons were recruited within the first three weeks of life and were randomly allocated to intervention or control groups. Intervention families received a single 45-minute tutorial from a research nurse. Points of emphasis in the tutorial were that in children who were healthy and gaining weight satisfactorily, that sleep achievement should be regarded as a 'learned skill' influenced by environmental factors or 'cues of sleep'. Parents were encouraged to avoid fatigue in their infants by not overhandling and to establish cues of sleep independent of the parent. Outcomes were measured through a sleep diary at six weeks of age. All aspects of sleep performance were significantly improved in the intervention group. Total sleep increased by almost nine hours per week at six weeks (p< 0.0001). The proportion of infants achieving 15-hrs sleep per day was 61% in the intervention group and 28% among controls (p < 0.0001). 78% of sleep cycles in the intervention group achieved > 8.0 hrs of night sleep, compared to 61% of controls (p < 0.0001). While the technique emphasised minimising parental handling at sleep time there was no difference in the amount of crying in either group. (p = 0.2). Follow up at three months of age showed that improvements were maintained. Our findings therefore support, and add to, those reported in the systematic review. Despite doing a well designed systematic review, our unpublished work was not identified, and it would be unreasonable to expect it to have been. This experience therefore supports the calls for a register of planned and on-going randomised trials [4], and also demonstrates the importance of regularly updating systematic reviews through the Cochrane Collaboration, as new evidence becomes available. 1. Paul Ramchandani, et al., A systematic review of treatments for settling problems and night waking in young children. BMJ, 2000(320): p. 209-213. 2. Johnson, M.C., Infant and toddler sleep. A telephone survey of parents in one community. Developmental and Behavioural Pediatrics, 1991(12:2): p. 108-114. 3. Armstrong, K.L., R.A. Quinn, and M.R. Dadds, The sleep patterns of normal children. The Medical Journal of Australia, 1994(161): p. 202-206. 4. Horton R and S. R., Time to register randomised trials. 1999(319): p. 865-866. Dr Brian Symon.
Dr James Martin
Professor John Marley
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