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How much sleep children need at each stage of their lives has been a subject of great debate among parents and pediatricians alike. A study in the January 2013 issue of the journal JAMA Pediatrics hopes to put that question to bed.
Using time-diary data from a national sample of American families, researchers from UCLA and the University of Washington estimated percentiles of sleep for weekdays, weekends and overall in children from birth to age nineteen. The information is largely unsurprising. Babies nap. Older kids don’t. Teenagers sleep longer on the weekends. There were no significant differences found among various racial-ethnic groups or over the study’s ten-year period. The CDC’s recommendations for hours of sleep needed by children (12 to 14 hours for kids 1 to 3 years of age, 11 to 13 for 3 to 5-year-olds, 10 to 11 hours a night for the 5 to 10 year old set and 8.5 to 9.5 hours for teens) well mirrors the results of this latest study.
This new information is all well and good, but the specific needs of each individual child needs to be considered. Some kids just need more sleep than others and, unfortunately for their parents, others function very well on much less sleep than the norms presented here.
Parental questions and concerns about children’s sleep are an everyday occurrence in pediatric offices. Sleep issues range from problems falling asleep to difficulties staying asleep. The former is the most common by far, especially in toddlers and pre-schoolers. Typical is the 3-year-old who makes numerous “curtain calls” after being put to bed with requests for another drink of water, one more story, or a second or third trip to the bathroom. A predictable bedtime routine that involves quiet activities like reading and storytelling can prepare young children for sleep. But if the curtain calls continue, parents may consider giving the child one pass or ticket where they are granted one additional request. After that, all requests are met with a firm back-to-bed order.
It’s also important to make sure kids aren’t taking naps that are too long or too late in the afternoon so they’re just not tired at bedtime. And kids shouldn’t be drinking coffee of course, but there is also caffeine in sweet drinks and chocolate, so this is important to think about and minimize in the child with sleep difficulties.
Generally, once these children go to sleep, they tend to stay asleep. Frequent night wakenings is more common in infants and can be frustrating and exhausting for parents. While the total number of hours newborns sleep varies greatly, most babies generally establish a typical day/night sleep cycle and are ready to sleep through the night by 4-6 months of age. After this time, the problem I generally see in the office is the baby who falls asleep being nursed or rocked and placed into his crib sound asleep. These children associate sleep with the breast or their parents arms and simply do not know how to put themselves to sleep, which is problematic because we all normally have several periods of arousal a night. At these times, most of us simply roll over and go back to sleep. But if a baby is nursed or rocked to sleep, every time she rouses, guess what? She needs to be nursed or rocked back to sleep… or at least she thinks she does. What parents of these babies need to do is to teach them how to fall asleep independently. One excellent way to do this is by putting infants into their cribs when they are drowsy but not quite asleep. This gives them the experience of falling asleep in their own cribs and associating the crib with a place to fall asleep, not just a place from which to call for someone to come in and help them back to sleep.
In addressing both kinds of sleep issues—falling asleep and staying asleep—consistency is key. Giving in and rocking the baby or capitulating to that one more drink or book, even if it occurs only every fourth or fifth night, only incentivizes kids to hold out for a parent to come nurse them or read to them.
When parents have tried multiple techniques to coax their children to sleep and nothing seems to work, I am invariably asked, “Should I just let her cry?” Well, there is no right or wrong answer to the “let them cry it out” dilemma. For some parents this just isn’t an option. They either cannot bear to listen to their children cry or one or both parents needs to get up in the morning and needs sleep. Some families live in close quarters with others and are concerned about keeping up other family members or the neighbors. But for those parents who want to give this so-called extinction method a try, an October 2012 study in the journal Pediatrics may give them reason to persevere with the approach. The Australian study acknowledged that the extinction intervention was effective in teaching infants to sleep through the night and reducing the incidence of associated maternal depression. The question the study sought to answer was: are children being harmed by this approach in the long run? Through questionnaires completed by the study’s families, they found that, at least in the first six years of life, the answer was a definite no.
So I will continue to discuss the cry-it-out option with families. I generally talk about a co-called modified extinction method where rather than let kids cry it out in their rooms alone, parents can opt to stay in the room with the crying child or check on them and reassure them at regular intervals until they fall asleep. But for families interested in going cold turkey, I now have good evidence that they, like us doctors, are following the cardinal rule of “first do no harm.”
The American Academy of Pediatrics has long recommended
against corporal punishment. Children who are hit can become hitters
themselves, bullying other children or eventually hitting their own kids. They may
never learn more appropriate forms of discipline or self-control if spanking is
all they experience. What is conveyed to them is that discipline is
reactionary, not thought-through or purposeful.
I’ve stated in a previous column that we are always teaching our children, whether we are
intending to or not and what we teach children when we punish them physically
is that violence is an acceptable way to deal with anger, frustration or
disappointment in another person. If we hit instead of articulating to our kids
our expectations of them, we rob them of the opportunity to learn better
communication skills. Hitting also impedes the development of a sense of trust,
safety and security. Another obvious consequence might be actual physical harm
to the child, as our emotions can so easily get away from us.
Despite recommendations to the contrary, many parents still use corporal punishment to
discipline their children. In a 2005 poll conducted in the United States, 72%
of adults reported that it was “OK to spank a child.”
Well, now, pediatricians and other professionals have some new data to carry in their
armamentarium of advice against spanking. A new study in the journal Pediatrics out this summer concluded that harsh physical punishment—defined as hitting, slapping, shoving or grabbing—is associated with mood disorders, anxiety as well as substance abuse and dependence in later life. These results came from face-to-face interviews by US census workers of nearly 35,000 non-institutionalized adults over the age of 20. The response to the survey was an impressive 86.7%. All results were in the absence of more severe child maltreatment. Socioeconomic variables and a family history of dysfunction were adjusted for. One surprising result of this study (for me as well as for the authors) was the finding that as education and household income increased, the incidence of harsh physical punishment actually also increased. The authors of the study concluded, importantly, that some mental
health disorders could be decreased by 2-7% if harsh physical punishment of
children were to stop tomorrow.
So how will this study change my practice? I will certainly continue to advocate for
non-physical methods of discipline. But now I have something more to talk to
parents about than just the benefits of time-outs as the preferred method of
discipline, or the AAP’s positions. Now I can point to real down-the-line
consequences if corporal punishment is the go-to modus operandi in a family.
1. Caring for your
Baby and Young Child (Copyright American Academy of Pediatrics 2005.)
2. “Physical Punishment and Mental Disorders: Results from a
Nationally Representative US Sample. Afifi,TO et al. Pediatrics Vol. 130 No.2 August 1, 2012.
I get asked a lot of questions about well water in the office. That’s not surprising since 15-20% of US households get their water from private wells. Unlike municipal water supplies,
private wells are not bound by federal regulations. And aside from initial
inspections during drilling, state regulation of private wells is minimal. It
is up to the owners of the wells to have their water tested and it is up to us
as pediatricians to make specific recommendations. Let me give you an idea of
Groundwater collects under the topsoil and above the bedrock forming what
is called an aquifer. The water table, or the depth at which the aquifer is
saturated with water, varies according to the seasons. Aquifers are replenished
with rain water and run-off and the water is filtered naturally on its journey
underground. Wells take advantage of this naturally-occurring water in the
earth by different methods. Old-fashioned dug wells were nothing more than
shallow, lined holes with a pump at the spigot. They were easily contaminated.
Drilled wells, on the other hand, reach the bedrock some 100 to 400 feet below
the earth’s surface. They have an electric pump at the bottom of the well. In
positioning wells, home-owners should strive to keep them as far as possible
from septic fields and from areas which house livestock or store fertilizers or
Well water can be contaminated by both micro-organisms and by organic
and inorganic chemicals. These contaminants vary regionally (for example,
contamination from crop fertilizers in the mid-west vs. sea salt contamination
in coastal communities. Arsenic is a fairly common contaminant of well water. A
recent study from the US Geological Survey found that 13% of some 2000 wells tested in New England exceeded federal safety standards for public drinking water. While no arsenic poisonings from well
water have been reported from well water in this country, arsenic is a known
cause of bladder, skin and lung cancer.
Uranium contamination occurs mostly in the mountainous western US
although areas with much granite are also at risk. Radon, another naturally
occurring radioactive gas similar to uranium can also contaminate well water.
Radon can be consumed directly by drinking, but exposure can also occur
showering and cleaning with contaminated water. Perchlorate is a
naturally-occurring chemical used in rocket fuel and fireworks that can also
contaminate well water. Importantly, perchlorate can interfere with thyroid function.
Nitrates are one of the most common contaminants of well water. They can
come from either sewage or fertilizers. If well water testing detects nitrates,
further testing for coliform bacteria should be done. If no coliforms are
detected, the source of the contamination is likely fertilizer. Nitrates with
coliforms suggests contamination from either livestock or human sewage. Water
with > 10mg/L of nitrate should not be given to children younger than age
Speaking of micro-organisms, not only bacteria but also parasites,
funguses and even viruses can contaminate well water. Testing for these
organisms can be confusing because not all organisms found necessarily cause
disease. Also, the absence of coliforms on a well water test does not necessarily
mean that fecal contamination is not present. Families can learn where to have
their well water tested by contacting their local Department of Public Health
or US Environmental Protection Agency. Testing can be expensive and the American Academy of Pediatrics encourages
states and municipalities to provide free or low-cost testing to families who
cannot afford it.
If contaminants are found in a family’s well water, there is plenty that
can be done to eliminate the contaminants or lessen their toxic effects. If
bacteria are found, the well should first be inspected to look for damage or
defects and any structural problems repaired. In consultation with local health
departments, water can be treated with high concentrations of chlorine then
flushed out of the system and re-tested. Carafe-style and faucet-mounted
filters can reduce lead, sediment, some organic materials as well as Giardia and Cryptosporidium cysts.
But they are designed for use with municipal
water and should not be counted on to filter contaminated well water.
Ultraviolet light, ozone or hydrogen peroxide can remove or kill many
micro-organisms. Reverse-osmosis filtration systems can remove many kinds of
contamination but are expensive.
Regardless of the kind of contamination—chemical or bacterial—the source
of the contaminant should be located and corrected. Homeowners can seek help in
testing and treating their water by contacting NSF International, a non-profit,
non-governmental agency that tests and certifies consumer products.
Well water can be safely consumed by families, but vigilance, regular
testing and, if needed, treating is necessary.
1. “Drinking Water from Private
Wells and Risks to Children.” Pediatrics. Vol 123, No. 6 June 2009.
“Troubling Findings in Some N.E. Wells.” Boston Globe. June 28, 2012.
In a previous Pediatric Points column I wrote a few years ago, I made
the case for offering the (then new) HPV Vaccine against Human Papilloma Virus (HPV) to girls. HPV is the most common sexually transmitted infection. Within two years of first having sex, nearly 40% of young women are infected with one or more types of these viruses. Younger women are more susceptible to infection with HPV for several reasons including a lack of adequate cervical mucus production and incomplete immune systems.
The good news is that they will very often clear these viruses on their own. But for those young women in whom infection persists, the risks of eventually developing cervical cancer increases. Cervical cancer is the second leading cause of cancer deaths among women worldwide. Over 1/4 of a million women die from this disease each year. 70% of all cases of these cancers are caused by two especially high risk types of HPV numbered 16 and 18. Gardasil is the name of the shot that protects against these two HPV types as well as against types 6 and 11 which are responsible for 90% of genital warts. These kinds of warts affect both men and women. The Food and Drug Administration approved HPV vaccine for boys in 2009. The Advisory Committee on Immunization Practices voted in October 2011 to
recommend the routine vaccination of boys between the ages of 11 and 21.
Although women are affected in larger numbers by HPV-related cancer (approximately 15,000 HPV 16- and 18-associated cancers each year) men are also affected by this sexually-transmitted virus. Approximately 7,000 cases of HPV-associated cancers, including anal, penile and oropharyngeal, occur each year in men. The HPV vaccine has been found to be very effective in males. In studies of men not previously infected who received all three shots, efficacy for prevention of HPV-related genital warts approached 90%. HPV vaccine for girls, in my opinion, is essentially a vaccine against cancer and I recommend it whole-heartedly to my patients. If I had girls of my own, I would vaccinate them in a heartbeat. But currently fewer than 50% of girls have completed the three-dose series.
Many pediatricians I have spoken to are reluctant to tackle this new recommendation for boys when we haven’t yet been successful with the population many of us feel would benefit enormously from vaccination. Some of us are skeptical that the vaccine for boys is truly cost-effective. Some also point to the Australian experience where mandatory vaccination of girls led to a decrease in genital warts in both men and women, suggesting successful herd immunity.
Also, we pediatricians are spending increasingly more of our time
defending proven, effective, life-saving vaccines to nay-sayers, reluctant
parents, and media pressure. To quote Dr. Stacey Humphries from a recent issue
of Consultant for Pediatricians, “To add controversial vaccination of boys to the mix with limited data available may only further taint vaccine acceptance.” So for now, while Dr. Moran and I will certainly give the HPV vaccine to any boy whose family requests it, for now, we’re now going to be pushing this one.
There’s always something to worry about as a parent. It begins the
moment we discover we’re pregnant. We start worrying about everything we put
into our bodies and how it will affect our unborn children. From that point on,
every developmental stage of childhood comes with a worry (or two, or three.)
Crib death looms in infancy. Drowning hovers over toddlerhood. Abduction fears
mark the school-age years. The teens usher in fears of drugs, drinking and
driving. Having children makes the world more joy-filled and more fear-filled
at the same time.
But it doesn’t end there. I wish I could tell you that once they’re out
of the house, college graduates, young adults with stable jobs and apartments
of their own, that everything’s fine and the worrying can end. It doesn’t. My
oldest just announced he’s taking up hang-gliding. See? It’s always something.
Just this morning as I cleaned lint from my clothes-dryer I wondered if I had
taught my boys to do this. And there it is: another worry. Dryer fires.
Nine years ago, my youngest son, then a teenager, was hit by a drunk
hit-and-run driver while walking his girlfriend home after a study date. She
did not survive her injuries. He carries his with him to this day in the form
of a traumatic brain injury. We helped our son during those early days in
intensive care, then through months of physical therapy. He took
anti-depressants for years and sees a therapist still. He worked hard at his recovery
and made impressive gains. He is currently in a graduate program for math
education in a nearby state.
But there’s always something to worry about. My husband and I mine our
conversations with our son for signs of depression or anxiety, residuals from
the accident. He recently told me that he went to the school’s Disabilities
Office seeking extra test-taking time and a distraction-free testing
environment. I immediately worried that he was overwhelmed and struggling. But
he assured me he was just trying to utilize available services and avoid a
stressful end to the semester.
And what more can a parent ask for? Seeing our children independent,
following their dreams, seeking the help they need to get there. It’s what
we’ve prepared them for since the day they were born. I guess I just thought
the days of worrying would someday come to an end. But as far as I can see,
worrying and parenting go hand-in-hand. Forever.