Friday, May 29, 2015

Night Terrors




Night terrors rank up there with things that are pretty horrible for parents, but ultimately usually not dangerous. If you want to practice your latin, they are also known as Pavor Nocturnus. These are not your typical nightmares. Your child might wake up screaming and thrashing. They may be sweating, wide eyed and terrified. Their hearts are racing. They seem frantic but you can't calm them down. No one is going to sleep through this. Except your child. They seem awake, but they won't remember a bit of this.

Your job is simple. Keep them safe until this passes. If your child is small, I have found that it is helpful to try to swaddle them with a big sheet. Think straight jacket! Hold the sheet wide and try to wrap around the thrashing arms until they are snuggled tightly. Sing quietly until they are calm. If you can't manage that, just make sure they don't hurt themselves until it is over. These rarely last longer than 20 minutes. Bigger kids might get even wilder if they feel restrained so see if you can put a comforting hand on them, but mostly you are just being present. If your child is toilet trained, see if you can manage to walk them to the bathroom and have them pee. Believe it or not, that might settle them down.

Pediatric night terrors happen to between 1-6% of kids. The typical age range is 3-12 years of age. There seems to be a genetic component. If you put your parents through this yourself, it is payback time. I think I may have had a few younger patients over the years that had bouts of these, but with really young infants, a sudden wake up is more likely from gas pains or something illness related.

These tend to happen in intervals and you may have days or weeks with frequent episodes and then they go away. It is worth trying to figure out if there is some extra stress or changes going on. Are they on any new medications? Any change in their diet? Lots of extra sugar perhaps? Are they overtired? Have they been watching any over-stimulating videos, movies or games (if they are in the room when an adult is playing or watching something, that counts)? If night terrors are happening on a routine basis and there is no obvious cause it is worth having them checked out by their physician. Some kids who are plagued with these for an extended period might have sleep apnea at the root of the problem.

Unlike dreams or nightmares, night terrors do not occur during the REM sleep. They usually occur during a phase of the sleep cycle that comes about 2-3 hours after falling asleep. If you are going through a stretch where you dealing with them nightly, some experts suggest breaking the cycle by waking your child about 15 minutes before they routinely occur (this would be a fine time to walk them to the bathroom for a "dream pee.") This assumes that you are on a regular bedtime routine and the terrors are happening roughly at the same time nightly.

Take comfort in knowing that extensive studies have found absolutely no correlation between
kids with night terrors and an increase in occurrence of psychiatric disorders.

Friday, May 22, 2015

Sleep part 3/ leaving the crib behind




You are sound asleep but suddenly sense that something is amiss. Sure enough you look over to the side of your bed to see one of your children inches away quietly staring at you. Sound familiar? Once your little one is no longer confined to the crib, nocturnal visits can be a nightly affair if you don’t nip this habit in the bud.

There are a variety of signals that will alert you that it is time to move the kids out of their crib. At some point every parent is going to have to deal with this transition. My daughter Lauren learned to climb out of hers at a fairly young age. The day she proudly called me into her room to show me how she could balance on the crib rails was my signal that her crib days were gone. She wasn’t even two. Alana would have stayed in her crib forever, but she eventually got big enough that it was just silly.

It is important that the new bed be low and safe. There are all sorts of toddler rail options that can keep kids from falling out. Some folks keep the mattress on the floor for the first couple of weeks. Once your kids are out of the confines of the crib there is always a normal  bit of an adjustment. The main issue though is not falling out of bed, it is new found freedom to wander out of the bedroom. Even if they used to be a good sleeper, many kids may need a little help learning to stay put. If your child discovers that they need to show up in your bedroom several times a night, it can get exhausting.

Once you have the marvelous luxury of getting an uninterrupted night’s sleep, it doesn’t take long to forget how disruptive it can be to be woken frequently throughout the night. If you make a plan and stick to it, you can get through this transition with minimal disruption.  As noted earlier, both of my kids had the unnerving habit of silently entering  my room, coming to my side of the bed and just staring at me until I work up. It didn’t usually take long until I was jolted out of a deep sleep. (Interestingly, my dog would do the same thing if she needed a middle of the night pee.) Children  have a myriad of reasons for getting out of bed.….scary shadows, strange sounds, they are thirsty, they can’t sleep and so on and so forth. Let them know right from the start that except for an emergency, they need to stay in bed. Be consistent with your expectations. Be present as needed but say nothing other than “shhh, it’s night time.” If they get out of bed, just keep taking them back. SHHHH, night time! For the first week you may find yourself doing this dozens of times. Say nothing else. “Shhh night time.”

Night time is not the best time to reinvent your bedtime routine. Creating an improvement plan with your child as a key member of the team has to take place earlier in the day when they have your attention. Talk about how important sleep is. Read bedtime books. The library is full of great ones. Tell stories about other children who are learning to have good sleep habits. I like telling stories about the “cooperative” and the “not so cooperative” child. The troublesome child gets into all sorts of trouble and everyone is grumpy. The positive role model figures out a way to stay in bed. Everyone is proud. yada yada yada….. Make the stories nice and silly to keep them engaged. Problem solve with them ahead of time for ways to manage their issue without getting up.

Thirsty? Let’s have a little sippy cup of water next to the bed. Lonely? This is the perfect time for a special new stuffed animal or favorite blanket. Alana not only had several special blankets, but she started sleeping with an old soft green sweater of mine. That sweater stayed in her bed for years. Scary shadow? Lets turn on and off the light and figure out exactly what it is that is making that shape. Creaking noise? Let’s identify what is making that sound. Is it a bird? Maybe it is a branch scratching against the window.
Thinking about monsters? Do NOT look under the bed to make sure the coast is clear,  that would lead them to believe that a monster lurking in the room is a possibility. Tell them that really smart kids have amazing brains and good imaginations. Try to do some exercises using that power. Draw the scariest monster that you can think of, then add a pair of polka dotted underwear on the scary monsters head. Now put a lollipop in their hands; there, they turned them from scary to silly.


For kids 3 and older who are going through a phase of getting out of bed a lot you might consider doing a one week exercise. Once again, find the moment when they are receptive (not bedtime) and talk about the fact that bedtime routines needs to be better.
Have them help you pick out 14 little (don’t need to be expensive) age appropriate toys or treats. Wrap them up like presents. Every night your child has 2 passes. If they need you for anything, they need to turn in one of the passes every time they get out of bed. Any unused pass can be redeemed in the morning for one of the prizes. (Of course, for older kids, a trip to the bathroom that does not require your assistance doesn’t use a pass.) At the end of the week, any unclaimed prizes are given to another child who needs a treat, or put away for a later time.  It is important to know that in the immediate time frame they are missing out on any prizes that they didn’t earn. I have seen this work well for kids who are old enough to reason. Be clear that the earning prizes for staying in bed has a firm expiration date. One week only.

If you don’t want to fuss with prizes and passes, that is fine. Focus on appropriate rewards and consequences.

Reward: if you get a good night's sleep, plan a special activity. Make sure you give lots of positive attention. “You let me sleep and only got out of bed once. I am proud of you. We are all rested, lets do something fun.” Some kids do well with a sticker chart.

Consequence: You kept waking me up during the night. I am tired and grumpy. I don’t want to do a special activity.

There are some very creative toddler clocks that will help your child know when it is okay to get up and when they need to stay in bed. Just google “toddler clocks” to see some of the varieties.

As I noted in last week’s post, you may want to have a chime on the door that alerts you that you may have a wanderer.

Friday, May 15, 2015

Sleep tidbits part two/ Shifting nap times and bedtime routines

   
Here is a quick reference for the average sleep needs by age group per day:

Age 1-2       13-14 hours (includes 1 or 2 naps)
Age 2-3       13 hours (1 nap)
Age 3          12-13 hours (1 nap)
4-5 years     11-12 hours (hopefully 1 nap)

Sleep requirements vary from person to person. Hopefully by the time your baby is one, they have a reasonable nap schedule and the entire family has been routinely getting a good night's sleep. Ah, but time passes, kids grow and solid routines start to shift.

Kids need naps. If they don't get them, they get overtired and actually don't end up sleeping as well at night. Generally a good napper is a good sleeper. Someone who is overtired from missing naps has an even harder time with bedtime. I know it is counter intuitive, but sleep begets sleep.

One of the things you will be faced with is that between 12-18 months many kids start dropping their second nap.  Hold onto it as along as you can but it is going to go the way of all things. When you realize it is inevitable, try to delay the morning nap as long as possible. Ideally, when they are down to the one nap, it is best timed for early afternoon. Do your best to avoid the late afternoon crash that wreaks havoc with bedtime. Try to be firm about at least one nap a day in their crib/bed. I realize that if you have more than one child, the baby might be doing more naps while out and about. It is what it is; do the best you can.

Assuming you have the luxury of a schedule that allows for a firm nap time, be consistent. Have a brief routine leading up to the nap, make the room dim, consider having a little quiet music play list that you can set for a certain amount of time (there are great bedtime play lists that you can find online.) For the kids old enough to get it, they can be taught that it is naptime/quiet time in bed until the music stops. Toddler clocks can also be set so they know when it is time to get up. When they are older and claim not to be tired, continue to insist on the quiet time even if they don't fall asleep. It is really common for some kids to nap way better for a nanny or at daycare than they do with the more inconsistent parents. Kids can follow rules fairly well as long as they know what they are.

With any sleep training, including naps, your job is to be very clear and follow through. First step is to enforce that your child will be in be in their bed/crib for naptime for a certain amount of time on a reasonably regular schedule. If your child is really resisting, it may be that initially you need to sit there, gradually move your chair further and further away until you don't need to be in the room. Do a quiet activity to keep yourself occupied while you are in there.
For the record, I would like to think that I have a lot more knowledge and experience now than I did then, but I personally  failed 'Naps 101'. My first time around I somehow couldn't allow myself to simply place my daughter in her crib and have a little "down time" for myself. My older daughter Lauren made the rules. Naps would be in my bed with me.  She had tight hold of my hair, and as part of this routine, I had hold of her foot. I wasn't going anywhere.
If you are able to take a nap with your child, enjoy. I actually loved it. The important thing is that you figure out what works for you. Just don't ignore the importance of naps.

*Safety tip: If you are both sleeping and your child is not in a crib, make sure you have a bell or alarm on door so you will be woken if your child gets up and starts to wander.

For night time our ultimate goal is to have your child be able to drift off with minimal intervention and sleep well until the morning. If possible, start winding down at least 30 minutes before the nighttime ritual starts. Don't give anything with sugar or caffeine. Avoid roughhousing, or stimulating screen time. It is important to find a bedtime that works for your family and accounts for your child's sleep needs. I know it can be challenging with working parents. Many folks want to spend precious time with their kids at the end of the day, but it is important to start the routine before your child is already overtired. Forty five minutes is good length of time from the start of the bedtime ritual until sleep. Keep this time consistent except for special occasion exceptions.

My husband was the bedtime enforcer. One night when he was out of town, even though it was a school night, I kept the girls out late at some friends' house. They started getting crabby as our evening was wrapping up. I said, "Hey look, I let you stay up late as a special treat, so you need to stop being grouchy." They both essentially responded "We are grumpy because we are tired and you should have made us go home. Mommy should know better."  Betrayed!!!

Create a ritual that your child will look forward to. This might include reading a book or telling a story. Have a set number of books you will read, or a set limit to story time and STICK TO IT! Once you go down the slippery slope of "just one more" you are stuck.
(Coming soon will be a post with  details on how to make a special bedtime ritual book.)

Perhaps talk a little about the day or a pleasant upcoming event  that you are anticipating.
A few minutes of massage are a lovely way to end the day. Hands, feet and earlobes have relaxation points (find the reflexology maps online.) Make sure the environment is a safe and soothing one. Use light to your advantage and get the room dimmer and dimmer throughout the bedtime activities. Some families like white noise in the room, such as a HEPA filter or fan. It may create a habit, but so what. It is not something that I have issue with. Just as I suggest for naps, there are also lots of lovely lullaby CD's available that set a nice ambiance for the bedtime ritual that you are creating.

Some children sleep better with a special blanket or stuffed animal. Once they are over a year I am fine with these, although I would still avoid things that are super cushy until they are two.

Next week I will address issues that surface as you make the crib to bed transition.

Friday, May 8, 2015

Sleep tidbits part one/infants




I spend a lot of time talking to parents about sleep. Most folks have told me that they have had at least some measure of success from the following tips. For the tough cases there are some great sleep consultants out there in the community, but you may as well start here. This post will not cost you the $$$ that the sleep specialists charge. Happy Mother’s Day!

The next several weeks will all be sleep related:
* just starting out/the first year
* toddler/preschool sleep tips
*Transition from crib to bed
*Bed time book
* Insomnia/ general sleep tips for teens and adults

For the most part I am a big believer that decisions involving sleep are very personal choices made by each family figuring out what fits their own unique situation. Most families do some sort of co-sleeping for the first couple of weeks. Some folks are happy keeping a family bed. Others move the baby out to a separate room fairly soon. Each family has a different tolerance level for how much crying they are comfortable with. Everyone needs to figure out what works best for their family (and hopefully both parents have been able to discuss this and be comfortable with their decision.)


I tend to fall somewhere in between the attachment parenting and the cry it out methods. I do NOT worry that your baby will have future psychological damage or attachment issues from a bit of  crying at night. That is a lucky thing, because I also have found that even with the best routines, and watching for sleep cues, it is the rare infant who learns how to fall asleep without some fussing.


There are many books out there on the subject and many of them make good points.

Dr. Ferber (who tends to be one of the “cry it out” guys) says something that really resonated with me. We ALL have sleep cycles and may have periods during the night where we are semi awake. You might fluff your pillow, go to the bathroom or have a sip of water and then go back to sleep. But if you woke up and your pillow was missing, you wouldn’t simply turn over and go back to sleep. You would be up!! Where the heck is your pillow?


Guess what. If you are nursing your baby, they fall asleep and you sneak them into their bed, it is no surprise that when they come to a light sleep cycle they become fully awake. Hey, where is that breast, bottle, pacifier, rocking body?


As much as our instincts lead us to PUTTING the baby to sleep, we are better off letting them soothe themselves down with a minimum of assistance. It is certainly okay to pat them or put a firm loving hand against their forehead or chest. Go ahead and surround them with gentle shushing noises. Of course it’s fine for your baby to fall asleep during a feeding, but every time you are able to put your baby down while they are still drowsy, you are a giant step closer to getting a baby who can sleep through the night. Don’t sneak them into bed. Let them be aware of how they get there. Watch for little cues that they are getting sleepy. Rubbing the eyes is a classic one. Believe it or not it is much easier to get a baby to go to sleep if you catch them before they are over-tired.


Feeding at night

Young infants need to eat around the clock. but I really want them to start learning the difference between day and night as soon as possible. I would encourage you to feed every 2 ½ -3 hours during the day. Don’t let any nap go longer than 2 ½ hours. I fully acknowledge that not everyone agrees with me about that. Some people would claim that it feels criminal to wake a sleeping baby. Listen, if they are taking a super long nap and you are in heaven with a bit of free time, go ahead and let them sleep. Once your baby is over 3 months of age and at least 11 pounds, they can start giving you a longer stretch without eating. We want that stretch to be at night.


Watch their pattern. Once they have shown you that they can go 4 or 5 hours at night, try not to backslide. It is okay to comfort them if they wake up, but I would do my best to avoid falling into the “feeding because it is easy” trap. Their little bodies have a lot of growing to do while they are sleeping.


Eventually we want your baby’s nighttime to be food free. There are plenty of books by experts who say that an 11 pound baby can give you 11 hours. If they naturally do it, fabulous; enjoy. But don’t worry if they don’t. I don’t usually start to really focus on dropping 100% of the night feedings until they have started solids, and you are sure they are getting adequate calories during the day. But if your 11 pounder is not giving you at least a four hour stretch, you need to take some action.

There are lots of lessons that must be taught in the quest for your child to sleep through the night. First is learning to fall asleep on their own. Second is learning the difference between day and night. Finally when they have started solids, it is time for the all important lesson. Nighttime is NOT the time for a meal. One of the things I like to say is to imagine if you were up in the middle of the night and having a hard time getting back to sleep. Someone is trying to help you. They might rub your back or stroke your hair. They might offer you a sip of water. They would likely not offer you a turkey sandwich.

 

I don’t know of ANY sleep training that doesn’t involve some fussing, but my method is relatively gentle. I tend to start with fairly low expectations. If a baby is getting adequate milk during the day, no one should need to eat more often than every 3 hours during the night (let’s consider nighttime as soon as you go to bed and until the sun comes up.) If they wake up sooner than 3 hours, someone can check on them (better to not be the mom who is nursing) but food is simply not an option until the magic 3 hour mark. After a few days stretch it to 3 ½ hours and so on. You can certainly check on them, change the diaper, even offer ½ ounce of water. If you think they might be teething go ahead and try some homeopathic teething gel. You are present for them, just not offering food (think turkey sandwich.)  If you want to sit next to the crib and sing, that is up to you. The main lesson is that nighttime isn’t meal time.

Liore, one of my reader/moms shared an even better analogy. If you woke up and someone offered you a lovely warm chocolate chip cookie, of course you would accept it. That doesn't mean you need it!


The Ferber method involves going in to check on them and trying to settle them in increasingly longer increments. First time might be 5 minutes, then waiting 10, then waiting 15…etc.


I have actually found that some babies tend to get much madder if you go in at all and  many parents just leave them awake and crying until the next feeding opportunity has come. You guys need to figure out what works best for you.


If you absolutely can’t bear the thought of letting them cry, you can do the “pick up/put down” method. If they are in a full scream, pick them up and jiggle and shoosh until they are calm. If they were really furious, this might take a while. Don’t say much. The minute they are calm. Place them back into the bed. Yes I know, they will immediately go back into fury mode. Once again pick them up until they quiet, and then put them down. This method takes a tremendous amount of patience and takes much longer than the simple let them cry strategy.

 

No one can dispute the clear message you are giving. “I am here. If you are crying I will calm you. It is time for you to be in bed. It is not time to eat.”  Sometimes your job as a parent involves saying “NO”. I am the parent. I need to show you the rules.

Night time feedings should always be dark, quiet, and business like. Once babies learn to fall asleep on their own and don’t expect to eat at night, you will be headed in the right direction. I understand that it is really wrenching to let your baby cry. In my case I had to remind myself often of what we were doing and why we were doing it. It also helped that my husband accepted the responsibility of being the primary sleep “trainer.”


Here are some of the factors that convinced me that it had to happen:

·         Many people are lousy sleepers their entire lives. If you can potentially give your child the tools that it takes to be a good sleeper, and it only costs a week or two of crying, it is worth it, and you are giving them a gift for life.

·         You have to “put your own oxygen mask on first”. Sleep deprivation is an awful thing. In order to be the best parent that you can possibly be, you need to be rested.


Take shifts.

If you are lucky enough to be in a two parent household, there is no reason for both of you to be up all night. Figure out a way for each parent to get a three or four hour shift of being off duty. Once you have spread out the feeding expectations, this will get easier to figure out. It is amazing how wonderful that little stretch of being off duty feels. No guilt. You each get a turn.

Even the best sleeper will need a tune up once in a while. Traveling babies almost always need an adjustment but these little tweaks are much easier than that first round of sleep training.

If you suspect that your baby may be ill, in my opinion, that is not a good time for ‘crying it out’. I often get folks into the office for a quick visit with their doctor so that we can make sure they are well (sometimes ear infections can cause sleep disruption.)

Common questions:

Pacifiers, good or bad? I would rather have a baby be in charge of their environment but some folks find that pacifiers make falling asleep much easier. Unfortunately some parents end up being woken up every hour or so to replace the pacifier. That sucks (sorry I couldn’t resist.) Some of my parents end up putting dozens of pacifiers in the crib with the hope that the baby will be able to reach one and manage to replace it on their own. Personally I would either keep them out of the crib completely or let them fall asleep with it but then let them figure out how to self soothe once it falls out.

Swaddle: what to do when they grow out of it? At some point every baby is going to have that transition. There are current swaddle blankets that can work with larger babies than there used to be. I also just learned about something called the Merlin suit from one of the dads in my last class. He called it a miracle suit. Do make sure you do daily tummy time. The sooner your baby can master rolling in both directions, the easier it is for them to deal with the post swaddle.

Turning over: They are finally out of the swaddle and turning onto their tummy.

http://nursejudynvp.blogspot.com/2013/07/crib-safety.html

 

Worried about disturbing your neighbors with night time noise? Sometimes a proactive bottle of wine, some ear plugs and little note explaining that you are sleep training goes a long way.

May the force be with you. You will get through this.
Good night.



Friday, May 1, 2015

A rash of rashes/when do you need to worry

Please see the updated post September 2017
    
There are all kinds of rashes making the rounds recently so I figured that this is a good time to update this old post. Not only do we get calls about rashes, but these days we get emailed photos. I recall one day while I was with my daughter Lauren, I checked the emails on my phone. She looked over at a screen shot of a nasty looking rashy butt and said "OMG why would someone send  you a picture of that!?"

You can't imagine the emails we get. Rashes can be spotty, blotchy, hivey, oozy. They can be caused by allergies, virus, bacteria, fungus. They can be on only one body part or cover the entire body. They can be part of a chronic condition that comes and goes, or something acute.

Once in a while I can actually look at a photo of a rash and know exactly what I am dealing with, but more often things aren't completely clear cut. The most important thing really comes down to one very important and basic question: "Do we need to be worried about this rash?"

I divide rashes into two categories - Am I curious or concerned?

Rashes that I am curious about

If your child  is acting fine but has a random rash, ask yourself the following questions:

-Are there any new medications?
-Are there any new foods?
-Are there any new soaps, detergents, bubble baths?
-Have you used a new sunscreen or lotion of any sort?
-Has there been an exposure to a new animal?
-Has your child been in a hot tub?
-Is the weather very warm?
-Has your child been laying in the grass or sand?
-Have they been in a hot tub?
-Has there been any recent travel?
-Any recent hiking?
-Have you checked the mattress and area around the bed to see if there are any spiders or insects hanging around?

If your detective work has lead you to an answer, make the common sense adjustments.

My first attempt at clearing up many a rash is with several basic staples that are worth keeping on hand:

*Cetaphil cleanser (no water  needed, apply and wipe off)
*Aquaphor
*Over the counter Hydro cortisone cream/ointment for itchy areas
*Over the counter Neosporin or prescription Mupiricin for any open areas
*Over the counter anti-fungal cream/ointment for any possible yeast rashes.
*oatmeal bath (don't clog your drain with real oatmeal, there are special products used for this)
*You all know that I love adding a splash of apple cider vinegar to the tub for all sorts of rashes

If a rash is persistent and your best attempts at clearing it with a variety of OTC creams isn't helping, it is worth having someone take a look. If the docs are baffled, the next step may be the dermatologist.

If you had a mystery fever and then a rash comes out once the fever is gone, I am NOT as concerned about it. There are quite a few viral syndromes that wave goodbye with a rash. Feel free to call the advice nurse for help trouble shooting.    
Rashes that I am worried about

Any purple rash needs to be evaluated. These rashes don't lighten up when you press on them. If you have a child who has a purple rash and also has a fever and looks ill, they need to get to an emergency room immediately to rule out meningitis. A stiff neck, vomiting and headache would make me even more concerned. These kids look SICK.
Any rash that comes along with a fever at the same time is probably worth being seen. Strep throat can do this. We have still not ever seen an actual case of measles in the office, but that also would present with a rash and fever at the same time. The patient will look sick.

Other viral syndromes that may have the rash and fever at the same time are Slap Cheek and Hand Foot Mouth. We don't have anything other than suggestions for symptom relief for those. You simply will need to ride them out

If the rash is oozy and crusty it might be bacterial. Impetigo is fairly common.
If your child has had it in the past and you already have Mupiricin, you can try to treat a small area. If it isn't clearly taking care of things, an appointment is warranted. Sometimes oral antibiotics are indicated.

If a rash seems to have fluid filled centers, it could be chicken pox!

If the rash seems very painful or itchy certainly try Zyrtec or Benedryl, but if your child is uncomfortable let's get them seen to see if we can help. Some itchy rashes like poison oak may need oral steroids.

Hives are scary because most people associate them with a severe allergic reaction. It is true that if your child has hives along with any facial swelling or difficulty breathing, they need immediate attention. If they have a history of severe allergy to something, you should have an epi-pen or AuviQ on hand. Even after you use it, it is worth having your child checked out.

What most people don't realize is that most of the time hives are not always a big deal. They are a signal that the body is reacting to something, but often they come along with a virus. I have recently had a bunch of patients with mystery hives that have been cycling on and off for several weeks.

Any painful rash that is only on one side of the body and doesn't cross the midline could be shingles. It is rare for children to get this, but it can happen.