Difficulties in the Management of Sleep and Eating Disorders

REVIEW ARTICLE

Difficulties in the management of sleep and eating disorders

Isabel R. Madeira,1 Leda A. Aquino2

Abstract Objective: To update the knowledge about anorexia and insomnia in childhood. Sources: Search of Medline database, including articles from1997 to 2002. The key words anorexia, feeding disorders, insomnia, sleep disorders and childhood were used. Some textbooks were also included. Summary of the findings: Definition, main types and causes, diagnosis and treatment of anorexia and insomnia are presented. Conclusions: Anorexia and insomnia are prevalent in childhood. The former is a much more frequent complaint in pediatric visits. The diagnosis is almost always based solely on a good history. Both conditions are generally behavioral and reflect the family dynamics. They are preventable and treated at the primary care level, based upon simple strategies, although sometimes not easily accepted by the patients.

J Pediatr (Rio J) 2003;79 Suppl 1:S43-S54: Childhood, anorexia, feeding disorders, insomnia, sleep disorders.

Introduction Eating and sleep disorders are quite common in Pediatrics Anorexia, difficulty in falling asleep, and night wakings and may be a natural part of developmental stages in are usually behavioral disorders, provoked by family children. dynamics,1,2,4,7 which are amenable to prevention and The “my-child-won’t- eat” complaint is nearly constant treatment at the primary care level. in appointments with a pediatrician. On the other hand, The approach, although simple, is not easy to adopt sleeplessness complaints are not so frequent as expected, as when a more severe disorder has already developed, since far as the prevalence of sleep disorders is concerned; more it implicates changes in behavior and in family dynamics.4-10 often than not, this occurs because the topic is seldom approached by pediatricians.1-7 “My child won’t eat” This complaint is quite frequent in the pediatrician’s office.10 Those mothers who are too anxious expect 1. MD, Assistant Professor, Universidade do Estado do Rio de Janeiro. 2. MD, Pediatrician, Hospital Municipal Jesus - Rio de Janeiro. rapid solutions and prescription of powerful drugs or

S43 S44 Jornal de Pediatria - Vol.79, Supl.1, 2003 Management of sleep and eating disorders - Madeira IR et alii miraculous techniques that produce the desired results.3 From the sixth month of life, it is necessary to supplement Due to the multiplicity and complexity of the issues breastfeeding with other types of food, which should be involved, the problem cannot be easily approached, and introduced slowly and gradually. Some authors say that it is therefore necessary that the pediatrician know exactly infants can determine the adequate amount of food intake what to do and be sensitive when choosing a suitable according to their needs, and establish the interval between management.1 meals. The meal size will be proportional to the time Although eating disorders are commonplace in the interval between the meals. routine of outpatient clinics, they were included in the Around the ninth month, when a new demand for American Psychiatric Association’s Diagnostic Statistical autonomy arises, infants may refuse to eat and also have fits Manual of Mental Disorders, Fourth Edition (DSM-IV,) of anger.14 only in 1994, when well-defined criteria were established At the end of the first year of life and during the second for diagnosis. Up to now, some studies were conducted one, the child shows less appetite, known as physiological by authors who described different problems related to anorexia, because his/her growth slows down. In addition, child nutrition, by using a wide variety of poorly specified the interest in food is easily replaced with the innumerable terms and definitions, which does not allow them to be discoveries the child makes around himself/herself. compared between themselves.2 In addition, other authors approached childhood eating disorders as failure to thrive, At 15 months, the child associates food with play. The which actually is the description of a problem - children child wants to touch and squeeze foods as if they were toys. younger than three years who do not develop At around 17 to 20 months, the child begins to select normally.11,12 foods and wants to eat by himself/herself. It is when he/she Chatoor et al. presented criteria for the diagnosis of wants to participate in the adults’ world. It is important to infantile anorexia in 1998 and showed a strong relationship understand and accept the child’s necessity for autonomy in between eating disorders and several problems involving relation to food so that he/she can develop normally within mother-child interaction, as cited by other authors.2 the family and social context. In spite of the fact that nutrition contemplates survival, At the age of three, the child begins to value the it is basically a way of individuals relating with the world. appearance, color, shape and consistency of foods. Marked The relationship an individual will establish with nutrition preferences and pickiness predominate. This phase should during his/her life reflects the dynamics of his/her first be respected, but the introduction of different foods should relation, as a baby, with the mother, family and the not be neglected. environment.1-3,13 At four, the child feels like helping to prepare foods, For the baby, feeding is the moment of emotional setting the table, and joining the family at the table. The contact with the mother. Hence, the importance of greatest difficulty at mealtime is that the child is quite evaluating the mother-infant interaction and all factors talkative and cannot settle down. that might determine or interfere with this relationship.2 At the age of five, appetite improves, and will be Feeding is essential to infants not only for their growth enhanced by the age of eight.3,8 and development, but also as a source of psychological experience and sociocultural conditioning. Therefore, Anorexia in children solutions are not usually that simple, because mothers are not willing to recognize or get involved with problems Appetite means desire for food, which stems not only related to the mother-infant interaction in the family from the necessity of the body, but also from pleasant context.1,3 sensations associated with eating. Hunger is characterized by the organic, physical and “urgent” desire for food. Taking all these aspects into consideration, the Hunger does not distinguish between types of food. Appetite problems related to child nutrition could be avoided or makes people keep on eating even if they are not hungry, even minimized from the very first moment of life if which not uncommonly leads to obesity. Actually, appetite pediatricians were attentive to the breastfeeding process is plenty of behavior-related events and may considered a and to the establishment of mother-infant interaction. mediator between physiological impulses and/or signs and psychosocial ecological factors. Development-related eating behavior in infants Anorexia or lack of appetite is when the child does not In the first year of life, the infant establishes an oral spontaneously eat the amount of food necessary for his/her relationship with the environment. Feeding represents normal growth and development, that is, there is some affection between him/her and the mother. During exclusive imbalance between satisfying psychological and organic breastfeeding it is the infant who determines breastfeeding needs, which leads to malnutrition in some cases.9,10 time and intervals. This practice is now beginning to be Thus, when mothers complain that their children do not better understood by parents. eat, the pediatrician should observe the child’s weight. Management of sleep and eating disorders - Madeira IR et alii Jornal de Pediatria - Vol.79, Supl.1 , 2003 S45

Cases of children with appropriate-for-age weight and, Diagnosis sometimes, overweight, are a frequent finding. If the It essential that organic causes be immediately ruled out, pediatrician’s observation shows a weight-for-height ratio since an adequate treatment may lead to cure in most cases that is lower than expected on growth curves, it is doubtlessly (Figure 1).2,9,13 Among the organic causes, the most difficult a case of true anorexia, as identified by some authors. If the to treat are those that involve central nervous system child’s growth and development are normal, it is a case of disorders, such as encephalopathies and some genetic false anorexia, which represents the excessive concern of syndromes, and chronic diseases such as AIDS, cancer and the family with overfeeding the child. congenital metabolic disorders. The etiology of infantile anorexia or true anorexia may The anamnesis should be rigorous and detailed, in order be organic or behavioral (Table 1.) to investigate all past histories of the child in every sense. False anorexia is the situation in which the child eats The eating history should include the following questions: too little (in the family’s opinion), but grows and develops What foods are offered,? How are they offered,? How long normally. This situation should be immediately noted by is the interval between meals,? Who feeds the child,? What the pediatrician, so that it will not turn into true anorexia. was breastfeeding and weaning like,? When and how was Pseudo-anorexia is attributed to unwillingness to eat the problem first noticed.? caused by chewing and/or swallowing disorders, presence The clinical examination is based on the verification of of aphthae, cleft palate, stomatitis or other conditions signs on epithelial tissues, such as skin, eyes, hair and the that provoke pain or suffering.9,13 oral mucosa, which are related to adequate nutrition. Examples of these signs include gingival bleeding, gingivitis and brittle and thin hair. Apathy and oversleeping may also result from nutritional deficit. The anthropometric evaluation of the nutritional status Table 1 - Etiology of anorexia9,10,13 is based on weight and height, in addition to head, chest, arm and abdominal circumferences, but measurements Organic causes of subcutaneous fat and muscle mass can also be used. –Infections of different etiologies and in different locations The three most widely used anthropometric indices are – Digestive disorders (vomiting, diarrhea, GER, food intolerance, weight for age, height for age and weight for height, etc.) – Intestinal parasitosis always compared with NCHS (US National Center for – Central nervous system disorders Health Statistics) reference standards. This evaluation – Congenital metabolic disorders should be dynamic, by means of the construction of – Lack of vitamins and mineral salts (anemia, rachitism, etc.) growth curves.15 – Malnutrition The detection of specific clinical findings will lead to Behavioral causes diagnostic suspicion of pathologies that trigger off anorexia. 8-10 Psychological Sometimes, lab exams are necessary for clarification. – Disorders of intra-family dynamic (alterations of mother-child Behavioral causes are the most frequent and the most bonds, family tension, food blackmailing, parents’ difficulties to difficult to be treated, as they usually include concepts and establish limits, routine changes, parents’ divorce, death of a conducts that are misunderstood by parents. This occurs family member, new caretaker, birth of a sibling) due to the lack of knowledge about children’s actual – Infantile emotional disorder (adaptation problems, negative nutritional needs according to their ages, and also due to the behavior, search for attention, satisfaction of desires) – Inappropriate weaning lack of information about the stages of emotional and – Introduction to the use of spoon and complementary food in an behavioral development in children. Nutritional problems inappropriate manner begin when the child seeks autonomy and when new practices – Parents’ lack of knowledge about children’s behavior regarding are implemented, as the use of spoons. food at different ages, which can lead to wrong transitional interpretations that will determine food refusal Many parents establish arbitrary amounts of food without taking the child’s appetite into account. Some Dietary causes think that to have good appetite means “eat up the food.” – Liquid meals If for some children the amount is excessive, for others – Food monotony it is scarce, but parents often do not listen to and meet – Unpleasant characteristics regarding flavor, appearance, smell their demands.2,8-10 and temperature Appetite may be less pronounced at the end of the Other causes first year of life due to delayed growth. A viral respiratory – Unpleasant environmental physical conditions process or any process commonly found in this age group – Mismatching between sleep time and eating time may determine a temporary loss of appetite. Anxious – Mismatching between school time and eating time parents exaggeratedly insist and “coerce” their children into eating, turning meals into a “battlefield,” thus taking S46 Jornal de Pediatria - Vol.79, Supl.1, 2003 Management of sleep and eating disorders - Madeira IR et alii

Food refusal

No Presence of clinical findings Yes To discard organic disease

Evidence of delayed To discard neurologic disorder No Yes development and eating disorder due to mother-child bond problems

History of parents´ To discard eating disorder due to No Yes negligence mother-child bond problems

History of disorder of To discard post trauma No Yes oropharyngeal and eating disorder gastrointestinal tract

Food refusal for < 1 month, To discard eating disorder No beginning during the transition Yes due to adaptation process to spoon feeding

To discard eating disorder Parents´concern regarding No Yes due to mother-child bond problems low food intake

To discard eating disorder Parents/child conflict, chat and No Yes due to mother-child bond problems distraction during meals

FALSE ANOREXIA No Acute or chronic malnutrition Yes

INFANTILE ANOREXIA

Figure 1- Decision tree for the diagnosis of infantile anorexia, according to Chatoor et al.2

away the pleasure of eating. Some children when forced food. In fact, parents think young children do not have to eat develop a refusal mechanism, which is initially preferences and aversion to certain kinds of food and when characterized by refusal to eat, but later on represented children refuse to eat, they attempt to make them eat by a strong reaction to such imposition, such as the anyway, or else they try to compensate the refusal for other conditioned reflex of vomiting every time the food is foods that have nothing to do with their children’s nutritional mentioned or presented.9 needs, but which make children feel satisfied (e.g.: bottle- Offering the same kind of food over and over causes feeding and cookies.) This practice makes parents think that monotonousness and lack of interest. Liquidized soups in “their children do not eat anything, just anything,” when in which all foods are blended do not allow the child to see the reality, a careful anamnesis will show that things are not as colors of each one, neither the flavor that distinguishes one they seem and that the child is offered some kind of food all food from another. The child gets used to not chewing the the time.9,16-18 Management of sleep and eating disorders - Madeira IR et alii Jornal de Pediatria - Vol.79, Supl.1 , 2003 S47

Another trick is to distract the child’s attention while the The Ministry of Health elaborated the document “10 food is being offered, increasing his/her interest in the steps to Healthy Nutrition for Brazilian Children under the surrounding environment, thus reducing interest in food. Age of Two Years” (Table 2).20 The attitude of parents towards the problem should be The treatment of infantile anorexia should take into carefully observed during the medical appointment, as well consideration the etiology of the problem. The detected as the type of relationship they maintain with the child. organic causes will be treated according to pediatric In addition to these issues, it should be underscored that routines.2,9,10 Parents should be informed that appetite many parents transfer their emotional problems, such comes gradually and that any force-feeding attempt will relationship difficulties, anxiety, feelings of guilt, and produce a refusal mechanism.16-18 2 problems with mother-infant interaction, to mealtime. Substances known as “appetite stimulants” are usually requested by the family as a way to quickly solve Management of children “who won’t eat” unwillingness to eat or anorexia. Quite often, these drugs act as tranquilizers for an anxious mother, improving her Eating disorders should be prevented already in the relationship with the child, by increasing the child’s appetite. rooming-in facilities.10 Rooming-in facilities allow mothers However, this action is transitory, since the major causes to be with their babies from the very moment of birth, thus persist. Different vitamin supplements whose action is not strengthening the mother-infant interaction and favoring yet proven are also used. Antihistamines and serotonin breastfeeding, since mothers perceive their babies’ desires inhibitors, such as cyproheptadine, act on nervous centers, right away. The pediatrician should be alert to any difficulties possibly causing hypoglycemia and increasing appetite; the at this moment, as to both breastfeeding and problems American Academy of Pediatrics Committee on Drugs related to the mother-baby interaction (interaction/rejection) confirmed their efficacy,10 although placebo effects cannot that might be occurring, and he/she should intervene as soon be disregarded.11 Conversely, the deficiency of some as possible.2 Counseling is crucial so that the mother feels vitamins such as B1, vitamin C, vitamin B12, folic acid, safe enough to face any difficulties that might arise. In the iron, zinc, copper and magnesium, may lead to loss of case of exclusive breastfeeding, it is recommendable that appetite. The pediatrician should be attentive to this the time be chosen freely. Within a few months a time that evaluation.8,9 is good for both mother and infant will be established. With the normal development of mother-infant interaction in With regard to behavioral anorexia, the treatment terms of nutrition everything is easier. basically consists in restoring the child’s pleasure of

Table 2 - Ten steps of healthy eating habits for Brazilian children younger than two years20

Step 1 - Up to six months diet should be restricted to breastfeeding. Do not offer water, tea or any other kind of food. Step 2 - After six months, gradually offer other kinds of food and keep breastfeeding up to two years or longer. Step 3 - After six months, give complementary food (cereal, tubercles, meat, fruits and vegetables) three times a day if the child is still being breastfed, and five times a day if not. Step 4 - Complementary food should be offered without strict schedule, so that the child’s appetite is always respected. Step 5 - Complementary food should be thick since the beginning of spoon use; it should be introduced with pasty consistency (mushes/mashed potatoes) and, gradually, thickened till the child can eat the same food as the whole family. Step 6 - Offer different kinds of food to the child every day. Varied food is colorful food. Step 7 - Encourage daily intake of fruits and vegetables during meals. Step 8 - Avoid sugar, coffee, canned food, fried food, soft drinks, candies, salty snacks, and ther junk food in the first years of life. Use moderate amounts of salt. Step 9 - Be careful regarding the hygiene while preparing and handling food; make sure food is appropriately stored. Step 10 - Encourage sick children to eat by offering his/her usual and favorite food, but do not force the them to eat. S48 Jornal de Pediatria - Vol.79, Supl.1, 2003 Management of sleep and eating disorders - Madeira IR et alii eating, in addition to improving the nutritional status. Among sleep disorders, protodyssomnias usually affect Therefore, it is important to counsel the family properly children between one and three years of life.6 The prevalence on the child’s nutritional requirements, and eating in young children ranges from 14 to 50%,18-22 but it is behavior to be followed (Table 3.) In extreme situations, negligible in older children.5,22-26 such as serious problems with family dynamics or severe Curiously enough, albeit common, sleep disorders are emotional disorders of the child, the patient should be not usually mentioned in pediatric appointments, because 3,9,13 referred to a psychotherapist. parents do not regard them as a medical issue or because they lack knowledge about normal sleep behaviors.5,7,22 “My child won’t sleep” With regard to this topic, physicians have some Insomnia, or difficulty in falling or staying asleep, may responsibility for bringing it up. Even in the United occur in healthy children or as a result of some kind of States, studies conducted in the 1990s by the National disease.4 Center on Sleep Disorders Research revealed that sleep disorders are underdiagnosed in medical appointments, Sleep disorders, a topic that has been discussed in a which is explained by the poor qualification of students previous review published in this journal,4 may be in this field of medicine.25,28 classified into dyssomnias, parasomnias and sleep disorders secondary to other conditions.5 Dyssomnia, Sleep disorders are telltale signs of family problems, 7 which is defined as the difficulty in falling or staying either with emotions or interaction, and are used as an asleep, according to the American Psychiatric example of the wide range of pathologies involving 27 Association’s Diagnostic Statistical Manual of Mental relationships. Disorders, Fourth Edition (DSM-IV,) cannot be correctly The prevention and treatment of these disorders should applied to young children, as far as the criteria for this be as early as possible. When such prevention does not classification are concerned. Thus, for infants and occur, the problem may persist for some years,6,7 although preschool children, the correct term is protodyssomnia, they are transient and self-limited in most cases.22 based on the context of the child as a developing being. Likewise, protodyssomnia cannot be diagnosed before Children’s normal sleep pattern one year of age because sleep-wake patterns, the attitudes of parents and infants and the environmental factors are Some concerns of parents with their children’s sleep still under development.6 Parasomnias are an abnormal behavior may originate from the lack of information on behavior that occurs during sleep, such as confusional what is normal for each age. Therefore, a complaint of arousal, night terror and nightmares.5 All these issues sleeplessness might not correspond to a diagnosis. may be encompassed by the “my-child-won’t-sleep” Circadian rhythms are established in the perinatal complaint. period.4

Table 3 - Some guidelines for management of behavioral anorexia3,8,9,13,16-20

– Respect the child’s eating preferences. If the child refuses to eat, replace the refused food for another one from the same nutritional group. – Understand that after one year of life the growth pace decreases, and, as a consequence, appetite diminishes. – Do not exchange attention and care by food. – Do not blackmail the child to force him/her to eat; do not reward or threat the child. – Avoid using tricks to encourage food intake, such as “pretending that the spoon is an airplane”, TV, “disguising food”. Avoid walking around the child or performing tasks that may distract him/her. Meal time should be a peaceful moment. – Offer the child small amounts of food so that he/she can ask for more. – Establish regular schedules for meals and snacks. – Establish, at least, two or three-hour gaps between meals. – Do not offer anything between meals. Management of sleep and eating disorders - Madeira IR et alii Jornal de Pediatria - Vol.79, Supl.1 , 2003 S49

Newborns sleep longer than older children, with Difficulty falling asleep fragmented sleep periods throughout the day, which This is the most frequent complaint of parents of school- gradually consolidate into a single period (night’s sleep.) aged children. In infants, it is often a problem of sleep Newborns and infants sleep 16 to 18 hours a day, 50% patterns. In older children, it is usually caused by lack of in REM (rapid eye movement.). They alternate sleep and limits. In adolescents, the major causes are problems with wake every three to four hours, evenly distributed between the circadian rhythm provoked by lifestyle.6 day and night. Inappropriate routines include the environment, bedtime At around six months, the infant sleeps up to six hours or inadequate activities carried out before bedtime.4 in a row, and two long sleep periods with a brief arousal Inappropriate routines also include sleep associations, such usually occur. as taking the infant to bed when he/she is already asleep, At approximately six months, sleep patterns are just like lulling him/her to sleep by establishing physical contact, those of an adult - non-REM sleep with four stages, followed either on the lap or in the parent’s bed, or through the use of by REM sleep. Stages 1 and 2 of non-REM sleep are pacifiers or baby bottle; these infants associate the initial superficial and stages 3 and 4 are deep. sleep stage with some kind of intervention by the parents and become unable to fall sleep by themselves. In older At the end of the first year of life, the infant sleeps about children and adolescents, television and radio are harmful 12 hours, but sleep is restricted to two moments: an afternoon associations.33-35 Depressed mothers, hyperresponsive nap and a long night’s sleep. parents, vulnerable child syndrome or inability of parents to Over preschool years, sleeping hours progressively participate in their child’s life during the day are not decrease from 15 to 12. Naps are not usual anymore until the uncommon. In adolescents, the lack of limits is quite frequent. age of five. During school years, sleep lasts around eight to As far as circadian rhythm disorders are concerned, 10 hours.28,29 there may be delayed sleep, when the circadian rhythm for Sleep architecture models itself and improves over sleeping and waking has been switched to a later time; months and years. The good quality of sleep depends on the another cause is the afternoon nap. Children with an advanced structural and functional integrity of neural structures, on sleep stage fall asleep and wake up early, thus requiring the general health status of the child and on his/her parent’s some attention; this behavior is common in infants older 30 or own capacity to properly discipline the sleep process. than eight months.4,5,7,31 The child’s behavior towards sleep should be analyzed The lack of limits in the preschool period is also related in the context of development and its stages, through which to the absence of bedtime routines; infants refuse to sleep at the infant is able to achieve maturity. This process is the time set by their parents, they often get up and ask for a determined by changes in the neuropsychological patterns glass of water or another bedtime story. These children may of the child and modeled by interpersonal, social and also have behavioral disorders during the day. Usually, 31 cultural practices of the family. parents meet all of their child’s demands before bedtime and, not uncommonly, we find parents who feel guilty about Difficulty in falling asleep and night wakings their children. There is a paucity of literature reports that objectively Another cause for not falling asleep in infants might be establish the limits between sleep disturbance, considered hunger, especially when the last meal took place several a normal stage of development, and childhood sleep hours before bedtime, or also when infants did not have disorders. enough calorie intake during the day. Gaylor et al.6 put forward criteria for defining these Food allergy, whose onset typically occurs in the first disturbances and stratify them according to their severity. year of life due to the association with the introduction of Difficulty in falling asleep is considered if a child older than cow’s milk protein in the diet, may result in difficulty falling 12 months takes more than 30 minutes to start sleeping, or asleep or in frequent night wakings. if parents have to stay with the child until he/she sleeps; this Cough and dyspnea also interfere with falling asleep, in symptom should occur once a week for more than one addition to causing night wakings at all ages. Some month. Night waking is diagnosed when a child older than medications used for the treatment of cough and dyspnea, 12 months awakes at least twice in the middle of the night such as methylxanthines, may contribute as well.32,36 and always needs the presence of his/her parents and/or Colics in infants cause crying, irritability and do not when parents have to take the child to their bed; this allow them to sleep, in addition to arousing them from sleep. symptom should occur at least once a week in the last three Colics may last for hours. Normally, they develop between months; for children older than 24 months, one episode per the second and third weeks of life, in totally healthy infants. night is enough for characterizing the disturbance. At night, paroxysms are more common before midnight. Difficulty in falling asleep and night waking may have They usually resolve spontaneously until the fourth month different etiologies. The most common etiologies are of life. If the infant still has such difficulty after this age, the described below. reason might be the inappropriate sleep management by the S50 Jornal de Pediatria - Vol.79, Supl.1, 2003 Management of sleep and eating disorders - Madeira IR et alii parents after episodes of colic. In this sense, there are when they have to go back to sleeping. School-aged children studies showing that infants with colics have normal results insist on watching television and listening to the radio at on polysomnography, both during and after episodes of night; the presence of a TV set and radio in the bedroom colic, which rules out the possibility of parasomnia.37 encourages this kind of behavior. The unfortunate effect of other types of pain on sleep is Night feeding, no longer necessary in most infants after also known. Acute diseases such as acute otitis media and the sixth month of life, if it should be maintained, makes the chronic diseases such as juvenile rheumatoid arthritis are infant wake up in order to be fed, which can later cause sleep typical examples. Chronic diseases may cause important associations. sleep disturbances for a prolonged time.32 Gastroesophageal reflux usually wakes infants up due to Blind children may have the sleep-wake transition pain, often after a three hours’ sleep, and the pain is relieved disorders, that is, cycles not distributed within 24 hours. In when the infant is removed from the cradle. There is an this syndrome, periods of extreme inability to sleep at night association between sleep apnea and gastroesophageal and remarkable drowsiness during the day are alternated reflux,38-40 and the coexistence of these two events during with normal sleep periods. On other occasions the wake sleep could contribute to night waking. periods may extend, followed by long sleep periods.32 Development-related night wakings occur in infants Fear of sleeping in preschool children is part of their older than eight months and are the result of maturity, due magical thinking. In preschoolers and school-aged children, to the development of separation anxiety. This becomes exposure to violence on TV and videogames may be persistent and disruptive when the infant learns to deal with important factors. These fears may also be caused by that on his/her own, feeling calm every time he/she wakes everyday life stress, triggered by problems in day care up normally, requiring permanent intervention of parents at facilities, schools, aggressive schoolmates, learning night.31 disorders, problems related to toilet pressure, separation of parents, physical punishment, domestic violence, presence On this occasion there is a new demand for autonomy, of siblings or a loss experience. Exposure to sex may be a which may coincide with the onset of unwillingness to eat. source of fear at these times, especially if the child suffered Problems previously solved with feeding and sleep return sexual abuse in his/her own bed, at night.7 and should be seen as a result of progress in the development towards autonomy, and nonregression. Several psychoses are associated with dyssomnia, such as autism and schizophrenia. Daytime symptoms are always Nightmares are extremely common parasomnias that present and there may be intercalation with hypersomnia.32 occur during the REM sleep, in the wee small hours. The infant usually reports his/her dreams in a frightened way. Anxiety at bedtime is more frequent in school-aged Dreams often reflect daytime stress. They are more frequent children than in adolescents, and is also related to everyday among preschool children,7 also common in school-aged life activities. children and sporadic in adolescents.41 In cases in which In some school-aged children and adolescents, some the infant has terrible and frequent nightmares, posttraumatic drugs and medications such as caffeine, tobacco, alcohol, stress disorder should be suspected. bronchodilators, antidepressants and stimulants may Arousal disorders are rarer types of parasomnias. Classic interfere with sleep behavior. Alcohol may cause night examples are night terror, which affects 3% of infants, and waking.32 sleepwalking, which is found at least once in 15% of children.7 They are characterized by disorderly arousals in Night waking deep sleep stages, thus occurring at the beginning of the Most children wake up during the night; those who night. Both can actually wake up the infant. Fatigue, stress, cannot ease down and fall asleep by themselves are a full bladder and noises may trigger these episodes. considered to have sleep disorders. Obstructive sleep apnea occurs in 0.7 to 11% of children.7 In the first month of life, night wakings may originate Its main characteristic is snoring, but not all children who from changes in the day-night cycle and necessity to feed; snore will have this diagnosis. The most common cause of At this time, the infant has the longest sleep periods during obstructive sleep apnea is hypertrophy of tonsils and the day and stays awake at night. It is common to find adenoids, but is also frequently found in children with maternal depression or difficulty of parents in taking care of Down’s syndrome,42 achondroplasia43 and newborn infants.7 myelomeningocele,44 obesity, mucopolysaccharidosis, 7 Sleep associations cause difficulty in night waking just craniofacial malformations and neuromuscular disorders. as they do with falling asleep, because all stages required by Mood disorders (depression) may cause insomnia in the child for sleeping are repeated in arousals. The infant adolescents, although they are more common in adults. In cannot ease himself/herself down and becomes restless and addition to night wakings, they also cause difficulty in cries until his/her demands are met. Preschool children get falling asleep. Sleep disorders are always proportional in up from bed, go to their parent’s bedroom and complain severity to the level of depression.32 Management of sleep and eating disorders - Madeira IR et alii Jornal de Pediatria - Vol.79, Supl.1 , 2003 S51

Diagnosis Table 5 - Sleep hygiene The diagnosis is most times established from a detailed Environment history (Table 4.) – Dark Very rarely, an electroencephalogram is necessary – Clean for the differential diagnosis with complex partial – Calm seizures, or even a polysomnography when there is – Colder temperature – Bed appropriate to age suspicion of obstructive sleep apnea, gastroesophageal – Few blankets reflux or abnormal movements as causes for the arousal.4,45 Time – Regularity to wake up and to go to bed – Regular time, frequency and duration of naps

Activities Table 4 - Guide to create questions for the diagnosis of – Avoid watching TV or listening to the radio one hour before insomnia, according to Howard and Wong7 going to bed – Avoid tough physical activities one hour before going to bed – Child’s age and problem onset. – Do not use the bed as a place for playing – Problem occurrence. – Establish a routine: warm bath, followed by the last meal, teeth brushing, dressing pijamas, going to the bathroom, story telling – Bed time routine and child’s reaction to this routine (time the – Transition object (diaper, soft toy) child goes to bed; schedule regularity; where he/she falls asleep; period of time between the last meal and bed time; period of time he/she takes to fall asleep after being taken to bed; the child needs to have physical contact with someone else , uses a milk bottle or a pacifier, or needs the TV set or the radio on to fall asleep; naps routine; total daily sleeping time). If the infant wakes up in the middle of the night and – First time the child wakes up at night. gets restless, parents should not intervene immediately, – Parents’ behavior when the child wakes up and becomes restless so that a possible arousal state during sleep will not turn (he/she eats, needs physical contact). into a state of complete alertness. After some minutes, if – The child seems sleepy during the day, he/she presents other the infant is still restless, parents should try to spot any behavioral, health or developmental disorders. discomfort. Hunger is not usually the cause in infants – Use of medication, beverages with caffeine, alcohol, cigarettes older than six months, unless the infant has taken to and drugs. feeding during the night.45 If parents need to get near the infant to check this, they should not remove him/her from bed or play with him/her. They should only show that they are there and that everything is fine. Otherwise, they will be awarding inadequate behaviors with positive reinforcements. Management of children who “won’t sleep” In circadian rhythm disorders, the strategy is to change The management initially consists of measures that aim bedtime towards the desired time five to 10 minutes at regulating sleep behavior and model sleep architecture every week.5 according to the circadian rhythms. For children with fear of sleeping, parents may sit down When these measures are implemented from the very in their bedroom until they sleep, but they should not talk to first days of life, they can prevent most sleep disorders. them about their fears at this moment; such discussions When sleep disorders are already present, these measures should be conducted during the day. As the child learns to are still highly efficient, but are not always easily applied by sleep without fear, parents should move their chair away parents and accepted by the child. from the cradle a little bit farther every day until they do not First and foremost, good sleep hygiene should be obtained have to stay there. A lampshade light left on may be helpful (Table 5). under these circumstances. Inadequate sleep associations, such as physical contact, There are several strategies for night wakings (Table 6.) bottle-feeding, pacifiers, television and radio, should be When nightmares occur, the child should be calmed avoided so that children will not associate the beginning of down when he/she wakes up; at this time, parents should not sleep with some intervention by their parents, thus becoming talk about the nightmare, since this could make the child feel unable to fall asleep by themselves. more anxious; they should do it the following day. Stories As the infant approaches the sixth month, the intervals in which children overcome difficult situations, in addition between night feedings grow wider and wider until they are to relaxing exercises, may help older children with recurrent discontinued.4,7,22 nightmares. S52 Jornal de Pediatria - Vol.79, Supl.1, 2003 Management of sleep and eating disorders - Madeira IR et alii

Table 6 - Strategies to be used when the child wakes up at night

Behavioral technique of gradual stopping Ignore when the child wakes up or cries for periods of time that gradually become longer and longer. After the waiting time is over, get into the bedroom and make the child to calm down, leaving the room as soon as possible.

Systematic ignoring technique Get into the bedroom when the child starts crying to check if everything is alright, and leave the room ignoring the rest of the crying episode. It is also possible to stay in the child’s bedroom without interacting with him/her.

Modified stopping technique Ignore the crying for 20 minutes, then get into the child’s bedroom to check if there is a problem, without interacting with him/her, and after that take at least 20 more minutes to go back again.

Scheduled waking technique Wake up the child 15 to 60 minutes before the usual time he/she wakes up, and allow the child to fall asleep spontaneously afterwards4,5,7

With regard to night terror and sleepwalking, it is interfere with sleep; when behavioral measures fail, important that parents be well-informed about these clonidine, which has an 80% efficiency, may be used.7 phenomena, so that they do not worsen the situation In night terror, when arousals are too violent and the when they get stressed or try to wake the child up, since child is at risk of injuring himself/herself, benzodiazepines this is not easy, and may prolong the episode and make or tricyclic antidepressants may be used. These the child even more anxious. The child should ideally medications are given at bedtime and, according to some keep sleeping. It is advisable that parents see about authors, three to six weeks of treatment often prevent protection against traumas in both situations. In case of relapses.4 According to some other authors, paroxysms sleepwalking, a bell on the child’s bedroom door may return after weaning, when tolerance7 and rebound5 warn parents about the episode; extra locks should be phenomena are also common, which restrains the effect installed on doors so that the child will not get out of the of this approach. The same medications may be used house. Waking up the child 30 minutes before the habitual against sleepwalking, with the same restrictions. time of paroxysm, every day, for one week, may interrupt Nightmares may improve with the use of the episodes. A quiet and dark environment and voiding diphenhydramine, trazadone or cyproheptadine, indicated of the bladder before bedtime also have a good effect.7 for severe cases, which require more careful evaluation.7 Drug treatment against insomnia has been widely Drug therapy against infantile insomnia, unrelated to studied in the last few years, but is reserved for exceptional parasomnias, behavioral or neurological disorders, is cases. even more restrictive and should always follow behavioral The use of melatonin in children with neurological techniques, which should not be discontinued. The drugs developmental disorders has yielded good results, but of choice are antihistamines and, in severe cases, deterioration of existing convulsive crises may occur as benzodiazepines and chloral hydrate. They should be 7,46 a side effect. used for a short time, always for less than three weeks. Children with attention deficit /hyperactivity disorder There are few studies about the use of melatonin as an have insomnia and the drugs used for its treatment may also alternative treatment.4 Management of sleep and eating disorders - Madeira IR et alii Jornal de Pediatria - Vol.79, Supl.1 , 2003 S53

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