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Daily Dose

Back to Sleep Ads

1:30 to read

I am concerned that I have been seeing on line ads promoting “new” baby products in which an infant is shown sleeping on their tummy. In other words….not following AAP guidelines that all infants are placed on their back to fall asleep.  Their should be a “law” that you cannot shoot a picture for any product being advertised for an infant in which the baby is shown sleeping in the prone position. Seeing this photo may only confuse parents about correct sleep position for their baby, especially when many of the advertisements are for sleep related products. 

 

The “back to sleep” campaign which started in 1994 has served to reduce the incidence of SIDS by over 50%. I have been fortunate in that I have not had a patient of mine die from SIDS since the recommendations for sleep position were changed. Unfortunately, when looking at data, 30% of SIDS cases report that the baby was found in the prone (tummy) position.  

 

So, if a sleep deprived new parent is surfing the net for products related to infant sleep, and then sees a baby on their tummy, they may think “maybe that is the trick “ to get my baby to sleep, never realizing the huge risk they are taking. Many a parent has come in to my office and said “ I think my baby sleeps better on their tummy”, which immediately puts a look of horror on my face!! “WHAT…I thought we had discussed that your baby must sleep on their back until they are rolling over on their own.” Some of the parents do reply, “my ……told me it was okay.” In this case do not listen to anyone about tummy sleeping!!! Discuss car seats, high chairs, pacifier options or whatever else instead….and choose which works for you. Sleep position is non negotiable. 

 

With that being said, I realize that between 4 - 7 months many babies will roll over during sleep even when placed on their backs. It is a developmental milestone for babies to roll and you cannot put a brick on them. I would “guesstimate” that about 25% of the babies I see will ultimately prefer to sleep on their tummies, but they are all out of their swaddle and then roll over after being put down on their back. I also get many videos showing me a baby in their crib who is in the act of rolling over, with a nervous parent running in turning them back over, only to have the child roll right back to their tummy. You could spend the entire night “flipping the baby” over!

 

Remember, back sleeping only, in a crib with just baby and no bumpers or toys….you will have plenty of time for other stuff in the crib when they are bigger.

Daily Dose

Crib Deaths

1:15 to read

Crib bumpers may cause deaths and should never be used!  A recent study in The Journal Pediatrics looked at the incidence of crib bumper related deaths from 1985- 2012.  The authors reviewed data from the U.S. Consumer Product Safety Commission (CPSC) and found that there were 3 times more bumper deaths reported in the last 7 years than the 3 previous time periods that had been reviewed. Bumper pads caused 48 suffocations of which “ 67% were due to the bumper alone and not clutter in the crib, and 33% of the deaths were due to wedgings between a bumper and another object in the crib”.  An additional 146 infants had sustained injuries from the bumpers, which included choking on the bumper ties or near suffocation.  

The study also looked at the number of CPSC reported deaths compared with those from the National Center for the Review and Prevention of Child Deaths, 2008- 2011. When using that data the total number of deaths increased to 77. 

While bumpers had been marketed to prevent a baby from falling out of a crib or to keep a baby’s arms or legs from getting stuck between the crib rails, in reality they cause injury and death.  In 2012 a national standard was revised which required that crib bumpers must be 2 inches in thickness or less.  At that time the thought was that “thinner bumpers” would be less likely to cause suffocation. But the recent study found that 3 of the deaths occurred in cribs that had thinner bumpers.   

According to Dr. N.J. Scheers, the lead author in the study, “these deaths are entirely preventable” if bumpers were not used and were not widely available.  But when flipping through a baby store catalog, or even shopping for cribs, parents  and grandparents) see beautiful cribs that are adorned with bumper pads!!  So, if they cause death why are they being sold?  Mixed messages are very hard for parents to understand. Concrete recommendations and guidelines save lives.  

Several cities and states have already banned the sale of crib bumpers and the CPSC is currently in the process of publishing new recommendations on how crib bumpers should be regulated. 

I don’t see the need for any more studies to show that bumper pads may cause deaths and injuries.  Clear guidelines from the AAP state, “bare cribs are the best”  and “all infants should be put to sleep on their backs”.  Save your money and your baby’s life…no bumpers.

Daily Dose

Bedtime!

1:30 to read

Bedtime….an important word for parents and for children. A recent study in Pediatrics just reinforces how important bedtimes for children may be.  The research shows that preschool children who had an earlier bedtime were less likely to become obese in their teenage years. 

The study involved nearly 1,000 children who were born in 1991 and whose parents recorded their bedtimes when they were 4.5 years old.  The researchers then looked at the growth data (height/weight) for these children when they were 15 years of age.

Interestingly, the pre-school children who were in bed by 8:00 p.m. had half the risk of becoming obese as a teenager compared to those children who went to bed after 9 pm. Specifically, of the children who went to bed by 8 pm, only 10 percent were obese as teens, while 16 percent of those who went to bed between 8 and 9 pm developed obesity, and 23 percent of those children   who had bedtimes after 9 pm developed teenage obesity. 

While there has been much research surrounding sleep and obesity (as well as behavior), this study provides even more evidence to the possible “protective effect” of early bedtime and bedtime routines for young children.  If getting to bed on time and earlier can in some way help stem the obesity tide, it would seem like an easy recommendation for many parents to follow.  

As a mother I was always a “fan” of schedules and bedtimes…and actually putting your child to bed at night is such a wonderful time of day. The routine of a bath, snuggles, some books ( with wishes for just one more) and more hugs and kisses is such a wonderful memory I have of my own 3 boys. It just seemed that everyone was happier (and I guess healthier) when we had early bedtimes. I remember I had a friend who always had her 3 young children fed, bathed and in bed by 7:00 p.m. every night..and in those pre cell phone days we did not dare call her house after that time!!  

I also think bedtime routines are important for younger children year round. While it is more difficult to have regular bedtimes for older children during the summer months, children under elementary school age (and maybe even older) really do benefit from continuing on the same bedtime schedule during the summer months.  I think if you told your middle school or teenager this “rule” there  might be mutiny….but I know as well as a working parent, it is much easier to have a routine even when the kids are out of school…they would totally disagree!

I am excited about this study and using it as another resource when discussing sleep habits and bedtime routines with my patients.  

Daily Dose

Treatment Strategies for Bedwetting

1.15 to read

I receive quite a few emails daily and many have to do with bedwetting. The best way to attack the problem of bedwetting begins when you and your child have had a discussion about their feelings related to bedwetting. This often happens as they get older and continue to have problems with bedwetting and they are anxious or embarrassed. If you bring up the subject and they would rather just wear a pull up at night, and go back to playing outside rather than discuss strategies for staying dry, it is not time to tackle the issue. Timing is everything! As you start to discuss strategies to stop bedwetting, begin with having your child keep a calendar of their dry nights. This gets them involved and gives you an idea of their level of commitment. Then start setting their alarm clock to awake them in the morning and see if they can get up on their own. If the alarm doesn’t wake them up for school it is probably not going to awaken them in the middle of the night. Remind them to recognize their need to go to the bathroom during the day too, and have them go every several hours to feel the sensation of their bladder filling throughout the day. Many of these kids are infrequent voiders during the day and have actually stretched their bladder wall and hypertrophied the bladder muscle. Lastly, make sure that they are not constipated and put them on something like Miralax to ensure that they do not have stool that also compresses the bladder (the colon sits right above the bladder and can push on the bladder). Talk about a reward system that they would like to use while working on the problem. It doesn’t have to be a major reward, small things work equally well. I think the rewards should be given by the week, rather than the day. I also give rewards for effort, not just for dry nights. Trying is the whole idea. Sometimes the brain and bladder are just not ready and you do not want your child to feel defeated even though they have tried their hardest. If all of this is successful it is then time to set up a “bedwetting alarm system” (numerous ones available over the internet). The alarms consist of a bell and pad. The alarm sounds when the pad senses moisture. The alarms that actually buzz are more effective than those that only vibrate. Remember, your child is already hard to arouse and vibration alone will probably not work. Once you begin using the alarm and you hear the alarm go off, you will need to go into their rooms and call their name or shake them too, to actually get them awake and to the bathroom. In the beginning it may almost be like sleep walking them to the bathroom. Then rinse off the pad and reset the alarm and put them back to bed. Over time they should arouse more easily and the time spent awake and going to the bathroom should shorten. As you can see this is disruptive to everyone’s sleep so best done over the summer or a long winter break. It often takes at least a month for bedwetting to stop and the alarm system should really be used for several more months to reinforce the process. There is also a drug call DDAVP that works on the kidneys to reduce the flow of urine. This medication works when given but does not “cure” the problem. I often use this for children who are worried about a camp or overnight experience, before they have started the alarm system regimen. It has not been shown to be as effective as the alarm system, but in difficult cases I have used it in conjunction with the alarm system. You might want to discuss the pros and cons of this drug with your pediatrician. Remember this takes time, motivation and determination on both the parent and child’s part. Remain positive and optimistic throughout the training process. It is not a sprint but a longer race, and don’t expect overnight success. Remind them of their other childhood accomplishments and that with time and determination they will be successful with bedwetting too. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

How To Prevents SIDS

1:15 to read

A new study on swaddling and sudden infant death (SIDS) was just published this week in the journal Pediatrics. Not surprisingly, it found that infants who were swaddled and placed on their sides or stomach had a higher incidence of SIDS. It has been routinely recommended for more than 15 years that all babies sleep on their backs and since that time the incidence of SIDS has been dramatically reduced.  Unfortunately not everyone follows the AAP recommendation. 

While it has been known that tummy sleeping has been associated with SIDS this meta analysis looked at data which was gathered over two decades and from 3 different global sites. The review found that infants who were swaddled and placed on their sides were almost twice as likely to experience SIDS and the risk of SIDS did double in those babies who were swaddled and placed on their stomachs.  

I discuss swaddling with all of my patients as there are so many different swaddle blankets available.  Actually, one of the first things a newborn nurse seems to teach a new parent is how to swaddle their baby.  While swaddling has been promoted to aid in calming a newborn as well as to help their sleep, the recommendation that the baby be placed on their back in their crib continues..  Many a baby looks like a little burrito….. rolled up in the swaddle and then being placed on their back in the crib.

But is seems from this study that some babies were being swaddled and then placed on their side to sleep. Unfortunately, even a newborn may squirm enough that they then move from their side into the prone position.  Older infants who are swaddled may actually roll from their back to their tummies, even while swaddled. While the association between swaddling and SIDS remains unclear, I think this is a good reason to start getting a baby out of a swaddle once they are rolling. So around the 3 month mark I start having parents loosen the swaddle and try to just lay the baby on their back without being swaddled.

Let me re-iterate, this article does not confirm an association between swaddling and SIDS.  I do think it is a good reminder for putting a baby, “back to sleep” and once they are rolling “ditching” the swaddle seems to make even more sense. Once less thing to worry about, right?

 

Daily Dose

Get Your Baby to Sleep!

1:30 to read

How many times can you discuss newborns and getting them to sleep? It doesn’t matter how many babies you have, the biggest issue for new parents is ”when is my baby going to sleep through the night?”.  This statement is often followed by, “I have read every book and none of it seems to be working”. “What’s the trick?”  

Over the years I have realized that there is “NOT” one way or method that makes that newborn sleep through the night.  While some babies seem to lull themselves to sleep fairly easily and are sleeping in the first 4-6 weeks, most infants still awaken during the night for the first 8-12 weeks. There are also the “difficult” infants who don’t sleep through the night until 4- 6 months. But all in all...it just takes time, patience and a bit of prayer.

So, with all of this knowledge and remembering how I longed for my own babies to sleep 8-10 hours at night, I found a new article in The Archives of Diseases and Children quite interesting and thought provoking.  

Physicians have long known that it takes some time for circadian rhythm (biological sleep patterns distinguishing day and night) to develop in babies and a study done in the UK actually looked at infant’s sleep patterns between 6-18 weeks of age. They analyzed data including the infants’ body temperature throughout the night,  length of sleep a d urine samples collected am and pm to look at cortisol and melatonin levels. They also looked at the babies’ cheek swabs for circadian gene expression.  All in all a lot of data.

The findings were interesting showing that increasing cortisol secretion at night occurred around 8.2 weeks of age, followed in the next week or two by increased melatonin at night....both integral to establishing circadian rhythm.

When they analyzed body temperature, a drop in core temperature at the beginning of sleep (again maturational) they found that this occurred around 10-11 weeks.  Lastly, mature circadian gene expression was found at about 11 weeks.

So, no matter what book you read, or what your pediatrician, best friend or your own mother tells you, it is all about those hormones starting to “wake up” and regulate sleep. 

At least you know your baby is “normal”, even when everyone on Facebook “SWEARS” that their baby slept all night in the first 2 weeks. They probably either have totally forgotten or just made it up...it is all about science after all.

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Daily Dose

Kids & Bedtimes

1.30 to read

As the summer winds down, my office is bust with back to school check-ups.  During these exams, I find myself asking a lot of questions related to a child’s sleep routines. Over the years I have always asked about sleep, and for so many  parents it is one of their main concerns.  

But what I have noticed is it seems children are going to bed later and later. I know the summer months are less scheduled for many families and children tend to get out of routines, but never the less, when I routinely ask, “during the school year what time does your child go to bed at night?” I am surprised by some of the answers.  And I am not talking about teens either, this is mainly the 5-13 year old set. (I do think teens need bedtime guidelines as well, that is a different discussion). 

As a working parent I totally understand and empathize with how busy the evenings are. I tell new parents that the evening hours between 6-9 pm are often the “witching hours” for newborns but I also see these same “crazy hours”  for most families once their children get to be school aged. (is this why cocktail hour was invented?)  It is the time of day for after school activities, homework to be done, dinners to be cooked and children to be bathed. Add in bedtime stories and/or reading by your child and it is CRAZY....but even so children need to have bedtimes appropriate for their ages.

Hearing that 5 year olds go to bed at 9 pm or that 10 year olds are up until 10 or 11 pm not only makes me tired but worries me as well that these children are not getting enough sleep. And the statement from frazzled parents, “they just won’t go to bed” makes me know just how important early good sleep habits are. Bedtime is a statement not a question!

While some children are just natural sleepers, others can be more difficult, but I am convinced that early good sleep habits help all children to be better and more independent sleepers.  Self soothing begins in infancy, but self calming and sleeping in your own bed is an important milestone as well. A child who awakens every night and ends up sleeping in their parents bed is disrupting both their sleep and their parents, which leads to irritable, unfocused and tired children and adults.

So, this seems to be a good time to re-look at bedtimes and adjust accordingly for your child’s age.  Once you get a good routine going, good habits are easy to continue.  

 

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Sleep

Get Your Kids to Sleep!

Your Baby

Updated Safety Guidelines for Infant Sleeping

2:00

Elaborate beddings and plush accessories may look stylish and cute in a newborn nursery however, pediatricians know that these things should never be part of a baby’s sleeping environment. Getting new parents to understand why this type of bedding can be dangerous for babies is one of the reasons that the American Academy of Pediatrics (AAP) has updated and issued new safety guidelines.

Nineteen evidence-based recommendations aimed at protecting infants up to 1 year of age are featured in SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment, an AAP policy statement and technical report from the Task Force on Sudden Infant Death Syndrome.

Safe sleep recommendations include placing infants on their backs to sleep; using a firm sleep surface; room sharing without bed sharing; avoiding exposure to smoke, alcohol and illicit drugs; breastfeeding; routine immunization; and using a pacifier.

Every year, about 3,500 infants die from sleep-related deaths. Soon after the “Back to Sleep” campaign debuted in 1994, the SIDS rate declined, but it has leveled off in recent years. Ninety percent of cases occur before an infant turns 6 months of age, with peak incidence between 1 and 4 months.

Most parents know the importance of placing babies on their backs to sleep; the focus now is on the total sleep environment.

“I think the back-to-sleep message has gotten out loud and clear,” said Rachel Y. Moon, M.D., FAAP, lead author of the statements and chair of the task force. “When you ask parents, almost every parent knows — whether they are doing it or not is a different thing. We have been less successful at getting people to not sleep with their babies … and much less successful in getting the soft bedding away from babies.”

The dangers of bed-sharing and soft bedding are two problems that Moon says are often misunderstood.

“For the soft bedding, everybody thinks if it’s soft, then it can’t hurt the baby. But soft bedding is actually really a problem because it’s so soft they sink into it. People will often use pillows to ‘cushion’ the babies, and babies sink into them. …That’s very dangerous.”

It’s similar with bed-sharing, she said. “Some parents also think if baby is right next to them, they can tell if there is a problem … and protect the baby,” Moon noted.

A simple ABC formula can help remind new parents and caregivers of safe sleeping actions.

Michael H. Goldstein, M.D., FAAP, a neonatologist and task force member, lays out the “ABCs”:

 A for the baby sleeping alone

for back sleeping

C for sleeping in an uncluttered crib (or play-yard or bassinet)

“Outside of these, one of the biggest things I would really like to see people take away from the updated recommendations is that no matter what, babies should never sleep on a couch, especially with another person,” Dr. Goldstein said. Babies can get wedged between the adult and the cushions.

Other messages in the guidelines deal with sleeping with an infant, swaddling, breastfeeding and pacifiers.

Breastfeeding, along with the use of a pacifier after breastfeeding is established, also is a key recommendation. “We don’t know if people realize that (by breastfeeding) you reduce the risk of SIDS about 50%,” Dr. Goldstein said.

Parents also are advised to be vigilant about environments out of the home. A study in the November issue of Pediatrics found out-of-home settings are more likely to have certain risk factors for sleep-related deaths, including level placement for sleep and location in a stroller or car seat instead of a crib or bassinet

One of the most important milestones for parents and caregivers is when baby sleeps through the night However, it’s normal and appropriate for newborns to wake up a couple of times during the night, especially if breastfeeding, said Dr. Goldstein. Babies will eventually sleep through the night, but not till their little bodies are ready.

Below are the 2016 infant sleep recommendations for parents, caregivers, researchers, pediatricians and media outlets:

1. Place infants on their back to sleep for every sleep period until they are 1 year old. This position does not increase the risk of choking and aspiration.

2. Use a firm sleep surface.

3. Breastfeeding is recommended.

4. Infants should sleep in the parents’ room, close to the parents’ bed but on a separate surface designed for infants, ideally for the first year, but at least for the first six months.

5. Keep soft objects and loose bedding out of the infant’s sleep area.

6. Consider offering a pacifier at naptime and bedtime.

7. Avoid smoke exposures during pregnancy and after birth.

8. Avoid alcohol and illicit drug use during pregnancy and after birth.

9. Avoid overheating and head covering in infants.

10. Pregnant women should obtain regular prenatal care.

11. Infants should be immunized according to the recommended schedule.

12. Avoid using commercial devices that are inconsistent with safe sleep recommendations, such as wedges and positioners.

13. Don’t use home cardiorespiratory monitors as a strategy to reduce SIDS risk. 

14. Supervised tummy time while the infant is awake can help development and minimize positional Plagiocephal (flat head syndrome).

15. There is no evidence to recommend swaddling to reduce the risk of SIDS.

16. Health care professionals and staff in newborn nurseries and neonatal intensive care units as well as child-care providers should endorse and model recommendations to reduce SIDS risk.

17. Media and manufacturers should follow safe sleep guidelines in messaging and advertising.

18. Continue the Safe to Sleep campaign, focusing on ways to further reduce sleep-related deaths.

19. Research and surveillance should continue on all risk factors.

Parents and caregivers can find more information about the “Safe to Sleep” program at: http://www.healthychildcare.org/pdf/sidsparentsafesleep.pdf

Story source: Alyson Sulaski Wyckoff, http://www.aappublications.org/news/2016/10/24/SIDS102416

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