Jennifer Seidenberg, MD

The mother of a 4-month-old-patient is concerned that her son is not yet sleeping through the night. This is not uncommon for a young baby, the mother needs to return to work soon and is worried about being able to do her job effectively. He is on a regular feeding schedule at this point, but wakes up several times throughout the night, and sometimes it is difficult to get him back to sleep. She is wondering if there is something else she should be doing to help him sleep more consistently through the night. She has been reading about different methods of sleep training, and would like your input on which, if any, might be the most effective.

Getting enough sleep each day is critical to children’s health. The National Sleep Foundation maintains that babies, children, and teenagers need more sleep per day than adults to support mental and physical growth.

 Sleep deprivation has been shown to result in increased weight, restricted cognitive and motor development, slowed growth, affected cardiometabolic health, increased sedentary behavior, and more injuries.

 Rather than address all of these connections to sleep deprivation, this article focuses solely on the negative effects of insufficient sleep on behavioral and emotional regulation in children and teenagers. Despite the potential severity of sleep deprivation, parents as well as practitioners are nonetheless unsure of the amount of sleep children need.

The American Academy of Sleep Medicine (AASM) published pediatric sleep recommendations in 2016, and the American Academy of Pediatrics (AAP) endorsed these guidelines.

 The AASM recommends that in a 24-hour period, including naps, infants aged 4 to 12 months should sleep 12 to 16 hours; children aged 1 to 2 years should sleep 11 to 14 hours; those aged 3 to 5 years, 10 to 13 hours; those aged 6 to 12 years, 9 to 12 hours; and teenagers aged 13 to 18 years, 8 to 10 hours.

 The National Sleep Foundation makes similar recommendations, which are summarized in Table 1.

Despite clear guidelines for sleep duration in children, most children get 30 to 90 minutes less sleep than recommended in a 24-hour period.

 Conditions that can interfere with adequate sleep in children include mental health conditions, such as attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression. Separation anxiety, nighttime fears, and nightmares can interfere with sleep in younger children. Additionally, restless leg syndrome, insomnia, and sleep apnea are conditions which may affect sleep quality and quantity in children as well.

Media use can also lead to decreased duration and quality of sleep. A meta-analysis of 20 studies around the world, including a total of 125,198 children, found a correlation between media use near bedtime and decreased number of hours of sleep.

 The risk of not getting enough sleep was twice that in children and adolescents using media prior to bedtime compared with those not using media before bedtime. Interestingly, having access to a media device in bedrooms is associated with inadequate sleep even if the device is not in active use.

 Research results shows that 72% of children aged 6 to 17 years have at least 1 electronic device that is left in their bedroom overnight, and 39% report leaving a television on all night.

Other risk factors for insufficient sleep include female gender, non-White race, disadvantaged socioeconomic status, and doing homework in the morning hours prior to school.

 A lack of a consistent bedtime routine in all ages can lead to insufficient sleep, and many families of preschoolers fail to adhere to their stated bedtime routines.

 Table 2 illustrates contributive factors related to insufficient sleep.

Outcomes of insufficient sleep can include attention, behavior, and learning disorders.

 A study of Head Start children aged younger than 5 years revealed that over 20% of these children slept less than the recommended minimum of 10 hours of sleep per night. Disrupted and insufficient sleep was linked to aggression, hyperactivity, and lower social scores.

 Overtired children may not slow down, as adults tend to do, but may instead become more active and impulsive.

Insufficient sleep in teenagers is even more common than in younger children, with some estimates indicating that less than 25% of teens obtain the minimum recommended amount of 8 hours of sleep at night. This sleep debt can result in self-harm, suicidal ideation, and suicidality. Sleep loss affects brain regions thought to be involved in mood and emotional regulation, and may make it more difficult to redirect negative thoughts.10 Indeed, a shorter sleep duration increases the odds of a mood disorder by 55%. Conversely, delaying school start times by 45 minutes in one study led to increased sleep duration by 20 minutes in 9th and 10th graders, and fewer disciplinary issues.

 Additional measures that help accommodate adolescents’ circadian rhythms include ensuring that classrooms are brightly lit, and scheduling more classes that may be challenging, such as math or science for late morning or afternoon.

The problem of insufficient sleep in children and adolescents is likely best addressed in a multifactorial manner. Although adjusting school start times has been an effective social intervention, educating caregivers and health care providers also is necessary. Children whose parents enforce sleep-related rules, such as having a specified bedtime and limiting electronics and caffeine use, sleep on average 0.6 to 1.1 hours longer than children in homes where these rules are not present or enforced.

Establishing good sleep hygiene should start in the early infancy, as many infants 4 months of age and older can self-soothe and sleep through the night without a feeding. Research findings supports behavioral interventions for decreasing bedtime resistance and night awakenings. Investigators have studied various methods, such as unmodified extinction (ie, crying it out), graduated extinction (intermittent soothing without picking the child up), faded bedtime (starting bedtime when the child is sleepy then gradually making bedtime earlier), and scheduled awakenings, but there is no clear consensus as to which is the most effective. The goal of all sleep training is to enable the child to self-soothe, and sleep independently, and provide them with positive sleep associations. Positive sleep associations such as holding a stuffed animal or a blanket, help a child fall asleep independently of a caregiver. Negative sleep associations are actions a caregiver takes to help the child fall asleep, and should be avoided. These can include rocking, singing, bouncing, or feeding, and do not teach the infant to self-soothe. External sleep associations consist of the sleep environment itself, such as ambient room temperature, white noise, darkness, and so on, and caregivers should modify them to promote sleep.

Consistent routines are important throughout childhood, and should be implemented at bedtime to promote healthy sleep behaviors.

 In young children, a simple bedtime routine could include brushing their teeth, reading a book, then going to bed (with or without a bath).

 Such a routine provides structure for children, as well as bonding time with caregivers. Children should not have media in their bedrooms during sleep hours and caregivers should restrict its use, focusing on unplugged time with family an hour prior to bedtime.

 Children should avoid active play and exercise near bedtime, and omit or limit caffeine.

All well-child visits should include sleep-habit discussions, as well as visits when patients present with concerns such as fatigue, inattention, or psychological or behavioral issues. Difficulty waking in the morning, napping for longer intervals or unplanned napping, irritability, depressed mood, inattention, and difficulties at school may indicate insufficient sleep.

 Afternoon naps longer than 20 minutes can signal inadequate sleep and may delay bedtime, which can contribute to abnormal regulation of the circadian rhythm.

 Keeping a diary of sleep habits may identify clues to potential causes of insufficient sleep. Practitioners can consider a sleep study if there are ongoing concerns, but the majority of sleep concerns can be addressed with a thorough history and physical.

In the earlier scenario with the mother of the 4-month old infant, it is important to look at the baby’s growth charts and ask about the feeding schedule. If he is growing appropriately, and nighttime nursings are brief, encourage sleep training. Sleep training at this age can set a baby up for successful sleeping as he ages, and help his mother have adequate sleep as well.

According to a recent survey done by the AASM, more than half of parents (57%) with school-aged children say they have a child or teenager who does not get enough sleep on school nights.

 For children of all ages, ensuring adequate sleep hygiene is necessary for maintaining their health and well-being, especially behavioral and emotional health. The importance of sleep quality and quantity in children and adolescents in behavioral and emotional regulation is well documented. Educating caregivers regarding the importance of sleep training and bedtime routines in infants and young children can help to establish healthy sleep patterns at an early age. For adolescents, good sleep hygiene practices and later school start times can help improve mood and emotional regulation, and decrease disciplinary issues.

National Sleep Foundation. How Much Sleep Do Babies and Kids Need? Accessed April 2, 2020. 

Chaput JP, Gray CE, Poitras VJ, et al. Systematic review of the relationship between sleep duration and health indicators in the early years (0-4 years). 

Paruthi S, Brooks L, D’Ambrosio C, et al. Recommended amount of sleep for pediatric populations: A consensus statement of the American Academy of Sleep Medicine. 

American Academy of Pediatrics. American Academy of Pediatrics Supports Childhood Sleep Guidelines. Accessed April 2, 2020. 

Carter B, Rees P, Hale L, Bhattacharjee D, Paradkar MS. Association between portable screen-based media device access of use and sleep outcome: a systematic review and meta-analysis. 

Widome R, Berger AT, Lenk, KM et al. Correlates of short sleep duration among adolescents. 

doi.org/10.1016/j.adolescence.2019.10.011

Thacher PV, Onyper SV. Longitudinal outcomes of start time delay on sleep, behavior, and achievement in high school. 

Schlieber M, Han J. The sleeping patterns of Head Start children and their influence on developmental outcomes. 

Berger AT, Wahlstrom KL, Widome R. Relationships between sleep duration and adolescent depression: a conceptual replication. 

Sheldon, Stephen H. Sleep education in schools: Where do we stand? 

Lewin DS, Wolfson AR, Bixler EO, Carskadon, MA. Duration isn’t everything. Healthy sleep in children and teens: Duration, individual need and timing. 

American Academy of Sleep Medicine. AASM Sleep Prioritzation Survey. July 17-20, 2020. Accessed September 14, 2020. 

https://aasm.org/wp-content/uploads/2020/08/sleep-prioritization-survey-2020-amount-of-sleep-school-nights-results.pdf

Articles

Getting enough sleep each day is critical to children’s health. It supports mental and physical growth.

Effects of insufficient sleep on behavior and emotional regulation in children

A 9-year-old girl presents with a painful blistering patch on her right leg noted when her mother picked her up from school following an after-school ski club trip.

When the mother helped the girl remove her boot to check the leg, she noticed a bright erythematous patch with blistering to the lateral distal lower extremity that had been covered by her sock. Her mother noticed that the girl had a disposable toe warmer in her sock, next to her bare skin. The girl had activated the toe warmer and placed it inside of her sock near her toes prior to putting on her boots and skis. She did not experience any pain until after she was done skiing, about 2 hours later.

On exam, the patient was in no acute distress and her vital signs were normal. She described her pain level in the right leg as 5 out of 10. The right, lateral distal lower extremity had an area of mild erythema with a central, intact, round 1.5-cm bulla and grouped, smaller adjacent vesicles proximal to the lateral malleolus. The area of erythema was blanching and minimally tender. She had full range of motion of the right ankle and foot, and her gait was intact.

The patient was diagnosed with a second-degree burn triggered by the disposable toe warmer in her sock.

Disposable chemical hand or foot warmers generally are composed of iron, activated carbon, salt, and vermiculite. When the iron is exposed to oxygen, it begins to oxidize and produce heat. Salt helps catalyze the reaction; the activated charcoal helps disperse the heat; and the vermiculite helps insulate the heat. These warmers can reach temperatures as high as 165°F if exposed to an oxygen-rich environment, such as shoes with ventilator holes.

Precautions for the warmers advise that they should not be exposed to free-flowing air, applied directly to bare skin, and used in shoes for vigorous activity such as running, or burns may occur. Supervision is advised for use in children or the elderly, who have relatively thin skin and may not apply them properly.

In spite of these precautions, hand and foot warmers are useful tools for protecting hands and feet from cold injury and are generally regarded as safe. There are few references in the medical literature regarding injuries related to disposable chemical hand or foot warmers. One case report notes burns sustained by a diver using foot warmers while using nitrox as a breathing gas.

 Another series of reports involve ingestion of chemical disposable warmers by 4 elderly patients.

 These patients did not experience any serious consequences from the ingestion. However, no case reports were identified involving a pediatric injury from one of these warmers.

The patient in this case had apparently placed the warmer inside her sock next to the plantar surface of her foot, and it subsequently migrated to the thinner skin along the lower leg. Burns can be classified as superficial (first degree), partial thickness (second degree), or full thickness (third degree). Burns are also classified as minor, moderate, or severe. A minor burn in a pediatric patient is a superficial or partial thickness burn that involves less than 5% of the total body surface area (TBSA) in a patient aged younger than 10 years; is an isolated injury; does not involve the face, hands, perineum or feet; is not circumferential; and does not cross a major joint line.

This patient had a minor burn and was a good candidate for outpatient care. Silvadene cream (silver sulfadiazine) was applied and the area was bandaged. The burn healed gradually without complications.

1. Littlehottieswarmers.com. (2019). Precautions : Little Hotties Warmers. [online] Available at: 

https://www.littlehottieswarmers.com/precautions

2. Anderson, GP. Skin Burns as a Result of using Commercial Hand Warmers in a Dry Suit Using Nitrox as a breathing gas. A Case Report. 

3. Tam AY, Chan YC, Lau FL. A case series of accidental ingestion of hand warmer. 

A 9-year-old girl presents with a painful blistering patch on her right leg noted when her mother picked her up from school following an after-school ski club trip. What's the diagnosis? 

Jennifer Seidenberg, MD

Articles

Effects of insufficient sleep on behavior and emotional regulation in children

Girl’s leg blisters after school ski trip