Paediatrics

Dr Linda Calabresi
Clinical Articles iconClinical Articles

New study findings confirm what many parents already believe, introducing solids early helps babies sleep through the night. The UK randomised trial, published in JAMA Pediatrics showed the early introduction of solids into an infant’s diet (from three months of age) was associated with longer sleep duration, less frequent waking at night and a reduction in parents reporting major sleep problems in their child. Researchers analysed data collected as part of the Enquiring About Tolerance study, which included on-going parent-reported assessments on over 1300 infants from England and Wales who were exclusively breastfed to three months of age. At baseline, there were no significant differences in sleeping patterns between those infants who were then introduced to solids early and those who remained exclusively breastfed to six months, as per the World Health Organisation recommendation. However, at six months the difference between was significant. “At age six months,..[those babies who had started solids] were sleeping 17 minutes longer at night, equating to two hours of extra sleep per week, and were waking two fewer times at night per week,” the study authors said. “Most significantly, at this point, [early introduction group] families were reporting half the rate of very serious sleep problems,” they added, saying the results confirm the link between poor infant sleep and parental quality of life. And the findings contradict previous claims that a baby’s poor sleep habits and frequent waking has nothing to do with hunger. The study found that those babies with the highest weight gain between birth and three months (when they were enrolled in the study) were the most likely to be waking at night. “This is consistent with the idea that their rapid weight gain was leading to an enhanced caloric and nutritional requirement, resulting in hunger and disrupted sleep,” they said. Overall, it seems that the study has simply proved what many parents had already suspected. The study authors referred to previous research that showed that, despite WHO and British guidelines recommending babies be exclusively breastfed to six months, three quarters of British mothers introduce solids before five months and 26% report night waking as influencing this decision. Interestingly, recent evidence with regard reducing the risk of allergy and atopy has seen some organisations including our own Australian Society of Clinical Immunology and Allergy, recommending infants be introduced to solids earlier than six months. The authors of this study suggest that parents following these newer guidelines might find they get the added benefit of more sleep. “With recent guidelines advocating introducing solids from age four to six months in some or all infants, our results suggest that improved sleep may be a concomitant benefit,” they concluded. Ref: JAMA Pediatr. doi:10.1001/jamapediatrics.2018.0739

Dr Linda Calabresi
Clinical Articles iconClinical Articles

It seemed such a godsend, didn’t it? Omeprazole for severe infant reflux. A massive improvement on the previous advice to elevate the head of the cot and nurse upright. But since it first appeared in guidelines, there have been studies, reports and opinions cautioning against the overuse of PPIs citing everything from them being ineffectual to their potential to predispose the child to allergy. Now it looks like there is yet another reason why we need to think again before prescribing a PPI for the distressed infant with reflux and their exhausted parents. According to an article recently appearing in a JAMA network publication, recent study findings cast more doubt on the safety of this treatment option, suggesting that giving PPIs to infants less than six months of age is associated with a higher risk of bone fractures later in childhood. The US researchers analysed data, including pharmacy outpatient data from over 850,000 children born within the Military Health Care System over a 12 year period. According to findings presented at a Pediatric Academic Societies Meeting earlier this year, children given a PPI in the first six months of their life had a 22% increased risk of fracture in the following 5-6 years. And if, for some reason they were also given a H2 blocker the risk jumped to 31%. Interestingly if they only received the H2 blocker there was no significant increase in fracture risk. The study also showed the longer the duration of PPI use the greater the risk of fracture. It is thought that the mechanism behind the increased fracture risk relates to the PPI-induced decrease in gastric acid causing a reduction in calcium absorption. While the study is still going through the process of peer-review and is yet to be published, the study’s lead author, US Air Force Capt Laura Malchodi (MD) said the findings suggest increased caution should be exercised with regard these drugs. “Our study adds to the growing body of evidence suggesting [acid-reducing] medications are not safe for children, especially very young children,” she told delegates. “[PPIs] should only be prescribed to treat confirmed serious cases of more severe, symptomatic, gastroesophageal reflux disease (GERD), and for the shortest length of time needed.” Ref: JAMA published online Sept 29, 2017. Doi:10.1001/jama.2017.12160

Prof Wendy Hall
Clinical Articles iconClinical Articles

How much sleep, and what type of sleep, do our children need to thrive? In parenting, there aren’t often straightforward answers, and sleep tends to be contentious. There are questions about whether we are overstating children’s sleep problems. Yet we all know from experience how much better we feel, and how much more ready we are to take on the day, when we have had an adequate amount of good quality sleep. I was one of a panel of experts at the American Academy of Sleep Medicine to review over 800 academic papers examining relationships between children’s sleep duration and outcomes. Our findings suggested optimal sleep durations to promote children’s health. These are the optimal hours (including naps) that children should sleep in every 24-hour cycle. And yet these types of sleep recommendations are still controversial. Many of us have friends or acquaintances who say that they can function perfectly on four hours of sleep, when it is recommended that adults get seven to nine hours per night.

Optimal sleep hours: The science

We look for science to support our recommendations. Yet we cannot deprive young children of sleep for prolonged periods to see whether they have more problems than those sleeping the recommended amounts. Some experiments have been conducted with teenagers when they have agreed to short periods of sleep deprivation followed by regular sleep durations. In one example, teenagers who got inadequate sleep time had worse moods and more difficulty controlling negative emotions. Those findings are important because children and adolescents need to learn how to regulate their attention and manage their negative emotions and behaviour. Being able to self-regulate can enhance school adjustment and achievement. With younger children, our studies have had to rely on examining relationships between their sleep duration and quality of their sleep and negative health outcomes. For example, when researchers have followed the same children over time, behavioural sleep problems in infancy have been associated with greater difficulty regulating emotions at two to three years of age. Persistent sleep problems also predicted increased difficulty for the same children, followed at two to three years of age, to control their negative emotions from birth to six or seven years and for eight- to nine-year-old children to focus their attention.

Optimal sleep quality: The science

Not only has the duration of children’s sleep been demonstrated to be important but also the quality of their sleep. Poor sleep quality involves problems with starting and maintaining sleep. It also involves low satisfaction with sleep and feelings of being rested. It has been linked to poorer school performance. Kindergarten children with poor sleep quality (those who take a long time to fall asleep and who wake in the night) demonstrated more aggressive behaviour and were represented more negatively by their parents. Infants’ night waking was associated with more difficulties regulating attention and difficulty with behavioural control at three and four years of age.

From diabetes to self-harm

The Consensus Statement of the American Academy of Sleep Medicine suggested that children need enough sleep on a regular basis to promote optimal health. The expert panel linked inadequate sleep duration to children’s attention and learning problems and to increased risk for accidents, injuries, hypertension, obesity, diabetes and depression. Insufficient sleep in teenagers has also been related to increased risk of self-harm, suicidal thoughts and suicide attempts.

Parent behaviours

Children’s self-regulation skills can be developed through self-soothing to sleep at settling time and back to sleep after any night waking. Evidence has consistently pointed to the importance of parents’ behaviours not only in assisting children to achieve adequate sleep duration but also good sleep quality. Parents can introduce techniques such as sleep routines and consistent sleep schedules that promote healthy sleep. They can also monitor children to ensure that bedtime is actually lights out without electronic devices in their room. The ConversationIn summary, there are recommended hours of sleep that are associated with better outcomes for children at all ages and stages of development. High sleep quality is also linked to children’s abilities to control their negative behaviour and focus their attention — both important skills for success at school and in social interactions. Wendy Hall, Professor, Associate Director Graduate Programs, UBC School of Nursing, University of British Columbia This article was originally published on The Conversation. Read the original article.
Dr Robyn Littlewood
Monographs iconMonographs

This article discusses the proper identification and management of overweight and obese children in general practice.