Whatever Gets You Through The Night: All About Sleep Disorders by Dr. JJ Levenstein (MD, FAAP)

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Imagine being a 4th year medical student, with a new baby screaming and wailing incessantly at night. Fast forward to the pediatrician’s office the next day. Conclusion: nothing is wrong. Night after night of mad screaming every three hours. Then it stops. And picks up again months later. Fast forward two years when your child is verbal and screaming and crying as if he is going down on a crashing plane. Imagine the horror of not being able to console him or wake him. Then it clicks. My child has night terrors. Holy shit! He is not possessed. I am not a bad mother (but rather a mother with a tainted history of sleep walking and a legendary history of brushing my teeth with my underwear at age five). So that history behind me, here’s how to possibly sort out those rough nights, with perfect days (as your little ones don’t remember shit, but we remember everything). Here come the hard facts or as I call them, the “Parasomnia Stories." How common are sleep disorders in children?

Sleep disorders, or parasomnias, occur in an estimated 35-45% of children aged 2-18 years.  The most common disorders brought to us in practice include nightmares, night terrors & sleepwalking/sleeptalking.

Sleep is divided into 2 distinct states - REM (rapid eye movement) or “light sleep” and non-REM “deep sleep.” These states alternate every 90-100 minutes through the night.

REM is more of a “wakeful pattern” and constitutes about 25% of the night.

  • Only 90-120 minutes total –
    • 4-5 periods all night
    • gradually lengthen as the night goes on
    • newborns spend about 80% of time in REM
    • aids processing of creativity
    • if REM-deprived, higher risk of depression

Non-REM is present 75% of the night

  • SWS (slow wave sleep) is part of non-REM…also known as “deep sleep”
    • Young children typically enter this phase of deep sleep within 15 minutes of going to bed (thus making it easy to move them)
    • During SWS, growth hormone is made
    • The phase in which the brain recovers from daytime activities
    • Memory processing takes place

NIGHTMARES – occur during REM sleep (the “wakeful” state)

Nightmares are common in younger kids- 30% regularly, but 75% of kids experience a nightmare, at least once. They are defined as recurrent episodes of awakening from sleep with recall of intensely disturbing dream content (typically involve fear, anxiety, anger, sadness, disgust or other negative emotions).

  • Usually occur in the second half of the night when REM states start to lengthen
  • Frightening for the child and the family
  • Prevalence declines in school age and adolescence due to progressive maturing of the brain
  • EYES ARE TYPICALLY CLOSED:  On waking, child is: Alert, easy to arouse; Able to recall the dream in detail;If pre-verbal, able to fall asleep quickly after comforting from parent or caregiver; Able to recall the event the next morning
  • Can impair daily function due to loss of sleep

WHAT TO DO IF YOUR CHILD HAS NIGHTMARES

  • Identify triggers, if any: Child getting “second hand news” – young children frightened by overheard conversations, violence, or misinterpreting news
  • Reduction and editing of media
  • Sleep hygiene – good naps and good bedtime
  • Wake your child if distressed – should be responsive, alert and easily consoled; talk briefly about his/her nightmare, let them disclose content and reassure just a nightmare and then tuck back to sleep

NIGHT TERRORS

  • Also known as sleep terrors
  • Affects 1-6% kids
  • Defined as episodes of extreme panic and confusion associated with vocalization, movement, and autonomic discharge (dilate pupils, gooseflesh, panic, excessive movement, agitation) – eyes are open, child appears awake but is NON-RESPONSIVE to comforting
  • Occur during non-REM sleep (deep sleep) – thus difficult to arouse and console
  • Occur in first third of the night – when non-REM sleep is in greater proportion
  • Child has NO recall of dream or nightmare the next day
  • On waking, child is: Confused, disoriented

WHAT TO DO IF YOUR CHILD HAS NIGHT TERRORS

PREVENTION: Look at triggers:  lots of new activities (onset of school, camp, lots of social events), loss of naps, illness, medications, disruption of usual routine are typical

  • simplify life- cancel some activities, restore a more restful mellow routine
  • insure that young children nap
  • no media before bedtime and don’t let kids stay up late
  • keep a diary of awakenings, typically they’ll be about the same time each night
    • once that is known, actually wake your child gently about 30 minutes before the anticipated terror, tuck back to sleep
    • do this for 7-10 nights; this approach often aborts the cycle

Listen in: Make sure no obstructive sleep apnea symptoms – irregular snoring, thrashing – this may require medical intervention

Provide: Safe sleep environment to prevent harm 

IF YOUR CHILD IS IN A TERROR:

  • Empty bladder before bedtime, and during the terror quietly walk child to the toilet to see if he/she can void
  • DON’T attempt to wake your child
  • KEEP LIGHTS AND STIMULATION to a minimum
  • DON’T PANIC – as some terrors are terrifying to parents
  • Wrap child in your arms or in a blanket, rock and shush until their body tone relaxes, then get them back in bed.
  • A new device called  Lully, when placed under the mattress and paired with its app, can help parents by providing a gentle stimulus around the time of a night terror, and pull a child out of the unhealthy phase of sleep that leads to a terror. www.lullysleep.com

SLEEPWALKING & SLEEPTALKING

  • Occurs in 1-15% of the general population
  • most prevalent in children – usually disappears by adolescence – peaks 4-8 years, again at 11-12 years, then dissipates

Defined as recurrent episodes of incomplete awakening from sleep, usually without the terrifying feeling of the night terror.

  • Occurs typically in the first 1/3 of the night – slow wave non-REM, deep sleep
  • Rises from bed and walks about and can perform activities that are usually performed in full consciousness – sitting up in bed, cooking, driving, cleaning, and even violent gestures
  • May see lipsmacking, pulling at clothing or chewing are observed
  • Eyes open but blank, staring face, relative unresponsiveness to efforts at communication
  • little or no memory of event
  • lasts 30 seconds to 30 minutes
  • can be inherited – runs in families and identical twins - 45% chance in child if one parent affected, 60% if 2 parents with history
  • Triggers: sleep deprivation, fever, excessive tiredness, medications, stress
  • More often seen in children with enuresis (bedwetting), restless leg syndrome and sleep disordered breathing (obstructive sleep apnea)

What to do:

  • provide safe sleep environment – lock doors and windows, dangerous objects put away
  • avoid sleep deprivation – regular bedtime and regular naps
  • divided opinion on whether to wake – most advise guide sleepwalker back to bed
  • tend to illness, stress
  • keep a diary of sleep walking/talking, typically they’ll be about the same time each night
  • once that is known, actually wake your child gently about 30 minutes before the anticipated event, tuck back to sleep
  • do this for 7-10 nights – may take more repetitions than night terrors
  • this approach often aborts the cycle
  • LISTEN IN: if irregular snoring, thrashing, see your doctor to evaluate for obstructive symptoms

JJ3BIO: Dr. JJ Levenstein has spent the last 30 years caring for children. She received her undergraduate degree from UC Berkeley, graduated summa cum laude with a second undergraduate degree from Duke University, and completed training as a Physician Assistant with a specialty in Pediatrics at Norwalk Hospital/Yale University. After serving as a Pediatric PA for 5 years, she was accepted at the Keck School of Medicine at USC and completed her internship and residency at Children's Hospital of Los Angeles. There she was acknowledged as the outstanding pediatric intern, and was also recognized as one of the top three graduating residents in her class. While in private practice, she was voted one of the Best Doctors in America® 2004 through her retirement in 2012 and recognized as one of the top pediatricians in her community.

Dr. JJ continues as a fellow of the American Academy of Pediatrics and continues to be committed to promoting infant and child health by serving as an educational and media speaker and is also a regular contributor to several parenting websites. Since 2013 she has appeared as a regular medical expert on Hallmark Channel’s Home & Family television show, and leads the Food Allergy Awareness Committee for the National Peanut Board.

Go Back to Sleep! Advice from Dr. JJ Levenstein

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Take Back the Night - A Guide to Getting Your Toddler Back to Sleep! From the moment our first babies are born, we respond to every cry and squawk with parental love and attention, because it’s in us. Face it. And babies NEED us.

But when our angels start to manipulate us, especially at night, it’s sheer exhaustion.

So essentially from day one, our babies become the boss of us. Why does that happen? Out of necessity we must 100% meet our babies needs in those first few months. By 4-6 months they are intelligent enough to know how to use their cries very specifically when they need us – and they do, brilliantly.

It’s no wonder that they push back when we start to put up boundaries to protect them, say no, and all of a sudden have to become the boss of them! It’s the reason why toddlers sometimes cry and protest excessively – these rules, gates, boundaries and no’s weren’t asked for…..but are necessary to help structure their days and keep them safe.

And as those little tots get a little bigger and bolder, they pull out their old bag of tricks and start MANIPULATING to get their way. During daylight hours we can usually handle it and re-direct their attention…but at night, it’s brutal.

I certainly experienced this with my son Max. I was a resident in the hospital 16 hours a day, barely saw him in the light of day, and when he showed up standing on the side of my bed every night at 2 am breathing in my face, waiting for an invite, I said yes. I didn’t have the energy to sleep train him when I had to get up in four hours.

So how do we break this cycle with our little tykes?

Based on years of doing this here’s what works best.

  • Make sure your little one is healthy--no ear infections, etc.
  • Make a PLAN, stick to it and share the plan – alternate who gets the duty each night to walk your angel back to bed.
    1. Make sure your child naps every day, without fail. A toddler who doesn’t nap goes into sleep overtired, overly wired, and fails to enter deeper phases of sleep.
    2. Don’t keep your toddler up too late. Since most kids are up at the crack of dawn, a 7pm bedtime is very appropriate – even if one parent isn’t home.
    3. Start dinner earlier, and after meal a soothing bath. NO MEDIA--quiet play dials down that active brain.
    4. As you are starting your bedtime routine, tell your toddler what is going to happen – you are going to have dinner, a bath, a book, two kisses and lights off. You might be a little sad when we leave the room, but we’ll kiss you awake in the morning. If you get out of bed when it is dark, one of us will walk you back to bed and tuck you in.
    5. Under NO CIRCUMSTANCES give in to wishes for attention, milk, more books, water, playing, videos, etc. That secondary gain is the reason night waking often happens. Walk your tot back to bed without saying anything, tuck him in and walk out.
    6. Repeat.
  • Don’t give in.
    1. Make a big deal the next morning if he was successful. Point out how happy everyone is when they slept well! Encourage him for the next night…and stick to your plan.
    2. If your child wants his book to be an encyclopedia, don’t give in either. Get a small hourglass that counts down to 5 minutes – tell your tot when all the sand is at the bottom, it’s time for two kisses and lights out. It’s a concrete and sure way to end the routine.
    3. Hang in…he loves you so much and doesn’t realize the toll this takes on you…so you and your partner have to take back bedtime and take back the night.
 

JJ3BIO: Dr. JJ Levenstein has spent the last 30 years caring for children. She received her undergraduate degree from UC Berkeley, graduated summa cum laude with a second undergraduate degree from Duke University, and completed training as a Physician Assistant with a specialty in Pediatrics at Norwalk Hospital/Yale University. After serving as a Pediatric PA for 5 years, she was accepted at the Keck School of Medicine at USC and completed her internship and residency at Children's Hospital of Los Angeles. There she was acknowledged as the outstanding pediatric intern, and was also recognized as one of the top three graduating residents in her class. While in private practice, she was voted one of the Best Doctors in America® 2004 through her retirement in 2012 and recognized as one of the top pediatricians in her community.

Dr. JJ continues as a fellow of the American Academy of Pediatrics and continues to be committed to promoting infant and child health by serving as an educational and media speaker and is also a regular contributor to several parenting websites. Since 2013 she has appeared as a regular medical expert on Hallmark Channel’s Home & Family television show, and leads the Food Allergy Awareness Committee for the National Peanut Board.

We Could All Use More Sleep! Advice from Dr. JJ Levenstein

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For the next three Wednesdays, Dr. JJ Levenstein will be taking over my blog, offering tips about that thing we all need more of. That thing our little ones don't really give a shit about, but we desperately need them to. That thing that makes every mom happier. And when mom is happy, everyone is happy. I'm talking about sleep! Trust me, you will want to read below and check back the next two Wednesdays for some incredible information I wish I had when my toddler was going through these various sleep transitions! You can also subscribe below and get each new post sent directly to your inbox. Then you don't have to worry about mom brain and missing out! Top 10 sleep tips to help babies and parents sleep through the night:

  1. Very early on, establish a minimal number of sleeping environments for your child. Whether it is just a bassinet, or a crib or co-sleeper, try to consistently put baby there for naps and sleep.  If a baby sleeps in innumerable locations, she will become confused as to what she is supposed to do.  From the first breath, babies develop associations quickly – if the expectation is sleep, the locale is consistent, and the baby is tired, a baby will know what to do.
  1. Learn to recognize signs of sleepiness in your baby. Typically, young infants will become fussy and difficult to console if they have been up for 2-3 hours (and if their bellies are full and bottoms are dry, this is generally a sure sign they need to sleep). Older infants will also be fussy, and may combine that behavior with yawning, eye rubbing, banging their faces on your shoulder, or just dozing off. Learning to recognize these signs and seizing the moment (carpe diem) will allow a parent to get a baby down before she gains a second wind and is so tired she becomes wired.  A crawling/cruising/walking baby typically becomes cranky, less active, and seeks the solace of bed often by pointing, or calming once she is near her sleeping place.

  1. Embrace the concept that naps, however long or short, are essential for good nighttime sleep. Newborns nap many times during the day--infants 3-4 times daily, and older babies generally 2-3 times daily. If a baby has a chance to rest her brain during the day by napping, ironically she will sleep better at night (as she can go deeper into sleep and stay there, being well rested). Make it a priority, early on, that napping is part of your routine.
  1. A baby will learn to sleep if we ENABLE her to be successful. If we DISABLE a baby by using too many external assists, a baby will be unable to self soothe. Developmentally a young infant can’t self soothe effectively, so swaddling her after she feeds may be necessary until she can suck her fingers at 4 months – gradually lowering her swaddle will enable her to find a comfortable position on her own. Abandon the concept that swings and strollers, or rocking, shushing and walking the halls, or worse yet, driving around, are helpful to induce sleep – once a baby becomes dependent on these external devices and behaviors to sleep, it is VERY hard to break those habits. I still feel the best advice for starting early in enabling a baby to sleep is to carve out a few moments between feeding and landing on her mattress so that she learns not to expect a nipple in order to go to sleep. Eating, then having a brief diaper change or change into pjs, followed by the remainder of her soothing routine will eventually pay off with a baby who doesn’t expect to eat in order to fall back to sleep.
  1. Establish a bedtime and a bedtime routine despite the expected awakenings that will happen for the first few months. 7-8pm should be the latest bedtime for baby, no matter what her age. That being said, then a bedtime routine of breast/bottle, bath, putting on pajamas, perhaps a little more feeding, a book and bed should start 30-40 minutes in advance of that time. Believe it or not, babies respond to fairly regular/rigid routines, and if done in the same order, she will know what comes next……….that she is expected to sleep.
  1. Once babies sleep mostly through the night, putting them to bed later will NOT result in a later morning awakening. So dialing BACK the bedtime to earlier in the evening will result in MORE sleep, not less. Unfortunately, most babies love to rise at 5:30 or 6, so often a quick feed is necessary at that time to get baby back to bed for a few precious hours.
  1. For baby’s safety, always use an approved crib or bassinet (babies are too big and active in bassinets after 3-4 months), or a co-sleeper if you want baby “in” your bed. Placing a baby between parents or on the edge of a bed adjacent to a wall asks for a rollover suffocation risk, or equally dangerous, a baby who ends up wedged between bed and wall. Always place baby on her back and never have pillows, fluffy quilts, blankets with long fringe (due to strangulation risk), stuffed animals or other non-breathable objects near her. Keep her sleeping space zen-like – a firm mattress, sheet and baby are all that is necessary for safe sleep (and pajamas of course for warm nights, a light blanket/swaddler/sleep sac and more clothing layers for cold nights).
  1. Keep the temperature of baby’s room a little on the cooler side. Remember crib mattresses don’t breathe due to their plastic cover, so your baby’s bed is warmer than you think.  Cooler temperatures stimulate respiratory drive, especially in young infants. It’s OK to have the AC on when it is hot, and if you are concerned about it blowing on baby, change the location of her crib.  When it is cold, several thin layers (a onesie, thermal pajamas, and a sleep sac) are usually sufficient to keep most babies comfortably warm. Her room at night can be in the high 60’s as long as her body is appropriately dressed.
  1. Babies are active and often loud during sleep. I like to envision them as having super-hero baby dreams as their development progresses.  For this reason, they will often cry out, make peeping noises, or become physically active at night……and yet be asleep. Desperate for our own survival, we often snatch up a baby at the first peep and actually WAKE THEM, when they weren’t ready. Forcing yourself to count to 30 will give your baby a chance to move through the scene of her dream (if she is asleep) or to more fully convince you she is awake.
  1. Once your baby is sleeping 4-5 hours at a stretch, put her in her own room (if she has one). If her room is close to yours, keep both sets of doors open and put away the nursery monitor.  If she needs you her cry will wake you. Being in her room at this point will allow HER to not be awakened by YOUR noises, and her little utterances and peeps will not wake YOU.

JJ3

BIO: Dr. JJ Levenstein has spent the last 30 years caring for children. She received her undergraduate degree from UC Berkeley, graduated summa cum laude with a second undergraduate degree from Duke University, and completed training as a Physician Assistant with a specialty in Pediatrics at Norwalk Hospital/Yale University. After serving as a Pediatric PA for 5 years, she was accepted at the Keck School of Medicine at USC and completed her internship and residency at Children's Hospital of Los Angeles. There she was acknowledged as the outstanding pediatric intern, and was also recognized as one of the top three graduating residents in her class. While in private practice, she was voted one of the Best Doctors in America® 2004 through her retirement in 2012 and recognized as one of the top pediatricians in her community. Dr. JJ continues as a fellow of the American Academy of Pediatrics and continues to be committed to promoting infant and child health by serving as an educational and media speaker and is also a regular contributor to several parenting websites. Since 2013 she has appeared as a regular medical expert on Hallmark Channel’s Home & Family television show, and leads the Food Allergy Awareness Committee for the National Peanut Board.

Stay the Fuck Asleep…

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As I write this I am in complete and utter shock. Disbelief. Amazement. It’s 8 o’clock in the morning and Mason is still asleep. He stayed the fuck asleep! This has never happened before. Well, it’s never happened to his mommy and daddy.  Let me start at the beginning—when Mason was a super tiny human, fresh out of the womb. Before Mason was born, we hired a night nurse. Night nurses are like popular wedding venues. They book up at least a year in advance. So when I was three months pregnant, my husband and I met with and hired Nurse Jackie, after her promise that most of her babies successfully sleep through the night by two months. I know what you’re thinking. I was duped. What baby actually sleeps from seven to seven at two months? Silly new mom-to-be. Just wait until that baby is actually here.

The plan was for Jackie to come three nights a week for four weeks. Jackie came after we had been home from the hospital for three days. Obviously those three nights were hell and Mason barely slept. The only place he would sleep was in that Fisher Price Rock and Play monkey chair. We had a beautiful bassinet that my mom insisted on buying us and Mason hated it. He would scream the minute we put him down in it.  I should also mention that by three, I was well into the beginnings of postpartum depression. The perfect snapshot of parenthood at our house consisted of me asleep in a pool of my own tears and my husband asleep with his arm hanging off the bed from rocking mason in the “monkey chair” until they both fell asleep.

When Jackie arrived on that third day, life well night-life changed for the better. She took Mason, bathed him, and put him to bed in his crib. In his crib!  We had never planned to sleep him anywhere other than his crib, but we obviously sucked at accomplishing this by ourselves. My husband and I became so spoiled by Jackie’s presence. What started as three nights for four weeks turned into seven nights for two months. Jackie and her aunt switched off as Mason’s night nurses. Of course Jackie needed some time with her own family. Although at that point, I would have resorted drugs or prostitution to be able to pay her to move in with us.

When the two months were up, Mason was sleeping through the night, from seven to seven. I know you want to punch me in the face right now. I should make it clear that I had always planned to supplement breastfeeding with formula at night. Since breastfeeding all other times of the day didn’t work out so well, Mason quickly became an exclusively formula fed baby. I think his champion sleep habits are largely a result of that. Not having to breastfeed or pump at night also meant I could sleep while Jackie was there. And as I was suffering from severe postpartum depression, sleep was about the only thing I could successfully do on most days.

So here was Mason, our champion sleeper. While my husband and I faced other challenges, we were very spoiled in the sleep department. I could definitely handle a child who woke up between 7 and 7:30 in the morning, even with postpartum depression.

We switched Mason to a big boy bed at two years old and he slept even better than in the crib. Some mornings he would sleep to 7:45. Again, I know you want to punch me in the face. If he got up early, he would look through books in his room or play with a toy until I came to get him ready for the day. This also meant I could take my sweet-ass time getting out of bed.

Please hold your punches though. Even though Mason can sleep past seven, we have had plenty of sleepless nights where he has woken up screaming. Rarely he falls right back to sleep. Most times he gets out of bed and it takes at least three rounds of multiple books and trips to the potty before he even agrees to lie back down to fall asleep. And parents know better than anyone that having to wake up in the middle of the night fucks up everything for the following day.

Recently, Mason has started falling asleep later (and we still put him in bed between 7:30 and 8pm) and waking up between 6 and 6:30 am, which really doesn’t work for me. If I go to sleep later, I can usually sleep later. Unfortunately for me, my toddler does not possess this skill. I am so used to his rockstar sleep habits that this has been such a shock to the system and I walk around as a zombie most days. I know you don’t feel bad for me at all. I’m comfortable with that.

What makes it even worse, is that when he sleeps for anyone other than his mommy and daddy, he sleeps until almost 8 am. If he sleeps at his Zayde’s house, he wakes up close to 8. Or he wakes up earlier and then decides to go back to sleep. Or Zayde gets him and brings him in his bed to watch cartoons and then he falls back to sleep there. Last week, his Aunt came to stay with him and in the morning she walked into his room at 8 and he said, “More sleep,” and that little fucker fell back to sleep until 8:45.

So WTF dude? I carried you for nine months! I gave up alcohol, sushi and turkey and brie sandwiches for you. I gained over 50 pounds that I am still trying to lose for you. My stomach was sliced open to allow you to come into this world. Why can’t you stay the fuck asleep…for the number one woman in your life, the girl you love the most, your best friend until you leave me for hopefully a nice, not bitchy Jewish girl one day. You have excreted every kind of bodily fluid on me. You have ripped my hair our, scratched my face, head-butted me in the nose, and pinched my boobs until I cried out.

Some nights, I can’t fall asleep until it’s really late because I’m too busy worrying about you, praying nothing bad ever happens to you and hoping I don’t screw you up too much, which means I could really use that extra hour in the morning. Motherhood is no joke. This shit is hard. So I’m asking, begging you, please stay the fuck asleep!