Hi, it’s Linda Szmulewitz, owner of Sleep Tight Consultants. Thanks for tuning in to today’s episode of the Sleepy Qs podcast. Today, we’re going to be speaking about medical issues that interfere with your child’s sleep. Before we get started. I just wanted to remind you that if you’ve enjoyed this podcast, and if you have found our episodes helpful, please write your five star reviews so that we can continue to provide this very helpful information to other families for many, many more episodes to come.
So in this episode about how to handle medical issues that interfere with your child’s sleep, we’re going to be talking about why medical issues need to be resolved before the behavioral sleep issues can be addressed, what medical issues can be problems for your child’s sleep, and how to handle your child’s sleep when they inevitably get sick.
Medical issues can interfere with your child’s sleep even when they are the best of sleepers, it is understandable and necessary that when your child isn’t feeling well, that you are going to need to do all sorts of things in order to help your child sleep. That may mean that that’s a time where they end up co-sleeping with you. It may mean that you end up holding your child for their sleep more often than you might otherwise. All of these things are things that are understandable, as I said, to help your child be able to sleep because when you don’t feel well, it’s hard to sleep well.
Important to resolve medical issues before addressing the behavioral
When you’re starting to think though about changing your child’s sleep behavior, this is where any medical issues that are complicating, your child’s sleep really need to be resolved before you can deal with the sleep issue. This is for two very, very important reasons. One is because if there’s something that’s making your child uncomfortable, that it’s going to be hard for them to sleep. You’ve already figured this out. You’ve already seen that they don’t. Well, when they aren’t feeling well, they have a bad night. And the other big piece of why this is so important is because when you’re changing sleep behavior, it’s very important to be consistent. Please go back and listen to the episode from a couple of weeks ago about intermittent reinforcement.
We have to do all sorts of things in order to help our children sleep when they aren’t feeling well. And if you feel like you can’t be consistent, and consistency is the key to changing sleep behavior. If you feel like you can’t be consistent, it’s going to be very, very hard to make any sort of changes in your child’s sleep behavior. It’s essential. And so that’s why you want to really make sure that you rule out as much of this as possible before you say, okay, now we’re going to help you learn how to become a better sleeper.
Check in with your pediatrician or specialist
First and foremost, before you start any sort of sleep training, and especially if there’s an underlying medical issue, it’s really important that you speak with your pediatrician, or if you have a specialist that you’re working with, that’s treating whatever the issue is that you speak with that provider to make sure that your child is cleared for sleep training. That may mean that your pediatrician has some concerns that need to be addressed before you can work on these issues. It may mean that that specialist says no, I would rather that you hold off and that’s going to really take precedence. I know parents are tired. You want to just jump right in there and help everybody get more sleep. But these things are really, really important before you start to make any more significant changes.
So, what are those medical issues that I find that most complicate children’s sleep? There are a few, and I’m going to go through each of those here. I’m going to list them out. And then I’m going to go through each individual one so that you can get a better sense of why these things can cause sleep issues and why it’s important to get them resolved first
Most common sleep challengers
I find that the things that really complicate sleep most are: reflux, eczema, allergies, obstructive sleep apnea, which I’ll explain what that is and talk more about it, restless leg syndrome, and when kids are being treated for more serious medical issues. So , I’ve worked with a few kids who are being treated for childhood leukemia. Those are kids that are taking steroids in many cases as part of their treatment. This can absolutely complicate your child’s sleep.
Reflux
So starting with reflux. Reflux is normal in a lot of babies. Newborns are often born with reflux because their GI system isn’t totally developed yet. To keep food and liquids moving in the right direction. Your esophagus has muscles called sphincter muscles that holds your food down for babies. With reflux. Often those muscles aren’t either fully developed yet, or just aren’t strong enough in order to keep their food down. So food and acid comes back up, burning their esophagus and makes eating very uncomfortable for babies with acid reflux.
Babies with acid reflux will often cry when they spit up or often cry in anticipation of it being uncomfortable when they spit up. They arch their back. They kind of writh around. They wake up very frequently. So reflux is very disruptive to children’s sleep. And this is something that I have seen when it’s untreated, especially can persist into toddlerhood or as children get older, it can continue. So it’s really important that you work with your pediatrician about this. That might mean also speaking with the GI doctor and making sure that this has resolved. It can cause long-term problems with feeding for many children. Babies start to associate feeding with being uncomfortable. They’re super smart. They know that if it’s uncomfortable to eat, they don’t want to do it. So then you can start to have a lot of negative associations with feeding. There can be weight, gain issues, both because of that negative association and also if they’re spitting up a lot, now they’re not able to keep it enough calories. And so when you start to think about sleep training, if your child is going to be maybe eating less overnight, and there’s a weight gain issue, this can be a problem. Also sleep training often involves some level of crying. And when babies with reflux start crying more, they take in more air. They can be more likely to spit up more. I’ve often found for babies with reflux that the more they’re eating in the middle of the night, the more they may be refluxing. So if you’ve ever had reflux before, you know that if you eat and you lay down, that’s where you start to feel really uncomfortable. And so sometimes even with younger babies, if there isn’t a weight gain issue, I’m a little bit more inclined to start to remove feeding just because it can actually help significantly with their comfort overnight.
Also what babies with reflux tend to be more comfortable when they sleep on their bellies, because it puts the contents of their stomachs farther down. When your child can roll themselves from their back onto their belly, it is safe for them to sleep in that position. There is often a period of time before they can roll from their back to their belly, where they may get stuck on their bellies, but it is safe for them to stay in that position for sleeping if your child has put themselves there. So for babies with reflux, once they can roll themselves onto their bellies, they are often more comfortable sleeping like that due to the fact that the contents of their stomach, as I said, are lower down at that point.
Eczema
Eczema can be very problematic for sleep. I’ve actually had several families that I’ve worked with recently whose children have had pretty severe eczema. Eczema is the itch that rashes so for some, it’s actually more of a problem when the weather gets cold and the air is drier, but some children can have it just in general all the time. Your child could be itchy before the rash shows up. Eczema, in general, can inflame your child’s whole body and can make them really uncomfortable even if it’s not because they’re itchy in a particular spot. I really strongly recommend that you work with your doctor to figure out what you can do to control this so that your child can be more comfortable. This might mean seeing a specialist. Sometimes the dermatologist can be helpful. I find it’s helpful to see if you can get to the cause of what’s causing the eczema. In many cases, this actually can be related to allergies. This could be underlying allergies that are environmental or even food allergies. So I have had some families work with allergists, to deal with the allergy that was causing the eczema. And then once that resolves now, the sleep piece is much easier. Incidentally, there is often a connection between children who have peanut allergies and egg allergies, and then also have eczema. So that is something to check for if you see an allergist. If you’ve learned that your child has peanut and egg allergies, that can often be an explanation for the eczema as well.
Allergies
Allergies also can cause children to really struggle with sleep. Again, it inflames their body. It makes it hard to sleep. This can cause all sorts of inflammation in their airway, which we’re going to talk a little bit more about when we talk about sleep apnea in just a minute, and this is something that can be a problem.
I’ve also worked with a number of families who their child is older maybe by the time we work together and they tell me that when they were younger, you know, under a year old maybe they had a dairy allergy or a soy allergy that wasn’t detected for a very long time. And their sleep was horrible. And once that was discovered, and once they were able to really remove that from their child’s diet, the sleep did improve significantly.
Obstructive sleep apnea
Obstructive sleep apnea can also be very problematic for children’s sleep. So what this means is that when your child is sleeping, their airway shuts. This may mean that they startle awake. Certainly their oxygen level drops and they’re going to wake up frequently and not be sleeping. Well, I have seen many children, not the families that I’ve worked with, but just known people in general where their child has sleep apnea and they’ve actually been a pretty good sleeper or to the point where the parents didn’t realize it until some of the symptoms showed up. But the sleep was actually pretty good. The families that I work with it’s really because their children are not sleeping well in addition to the sleep apnea. And so the symptoms that I am really on the lookout for are things like snoring, especially. Snoring is the number one symptom of sleep apnea in children. And this is something that to me, whenever I see this marked off on a history form, I start asking a lot of questions because children really shouldn’t snore. I’ve had people that are like, “Oh yeah, she snores like a lumberjack. It’s kind of cute.” It may seem cute, but it actually could be more of a problem.
Going back to those different symptoms of sleep apnea in children. The list includes snoring, mouth breathing, especially if your child’s mouth breathing during the day, you’re noticing that as they’re playing, they’re, they’re breathing through their mouth, their mouth is sort of like in an ‘O’ shape when they’re, when they’re playing. Sweating in their sleep. For some children, they get really sweaty when they’re not breathing properly, waking up with a soaking wet diaper when your child is no longer eating in the middle of the night anymore. For older children, this may mean that they really struggled to stay dry at night, even when they’re potty trained during the day beyond what you would expect to be normal.
Other things like sleeping in really funny positions, doing things to help their airway be open a bit more. Children who have perpetual early rising, that just is not resolved by any sort of behavioral intervention, general struggle to sleep but even with consistent sleep training still, that’s not resolving because of the underlying discomfort.
And also just kids who are sick all the time. And sometimes this can happen if your child’s in daycare and they’re just being exposed to a lot of germs, especially in the first year. But I’ve seen some kids who have never been in any sort of group childcare and are sick constantly. And that’s often a red flag for me. These are families that I am referring out to ear, nose and throat doctors for they’re the ones that evaluate those. Often what’s going on is that your child’s tonsils or adenoids are enlarged. And if you ever go to your pediatrician and say, I’m not sure if my child might have sleep apnea, can you check their tonsils and adenoids. If your pediatrician ever says, “Oh yeah, their adenoids look fine.” No, I would take them to an ear, nose and throat doctor, otherwise known as an ENT. Your adenoids are not externally visible. Only the tonsils are. Here in Chicago when I send families to Lurie Children’s Hospital for this evaluation, most often they do an x-ray. They don’t usually put the scope up their nose and down their throat. It’s a really uncomfortable procedure. I’ve had it done myself. I do not recommend it and certainly not for children. But they’re great at the things that they do there so if there’s any place that you’re going to take your child for care, I usually do recommend them, especially for this sort of an evaluation. But usually they do an x-ray and through that, they’re able to see their adenoids in most cases to determine if they’re enlarged.
I’ve had it happen where it comes out that yeah, they look a little bit enlarged and they end up having them removed. And the ENT gets in there and I was like, “Whoa!, they were blocking 90% of their airway.” So they can sometimes actually not even look as severe on x-ray as they do in reality. There are instances where an ENT or even a sleep medicine doctor will recommend a sleep study in order to determine if the child is breathing properly throughout the night.
Generally the way that this is resolved is by having the tonsils or adenoids removed, and then the problem resolves itself, and they start sleeping significantly better. I’ve worked with a lot of families who this has been detected in our work together, or who have had their tonsils or adenoids out, and now are still struggling with sleep, which I will explain in just a minute, why that’s the case.
Restless leg syndrome
Another medical issue that I come across with, not as frequently, but it does come up is what’s known as restless leg syndrome. This is where it’s really hard to keep your legs still. This is actually something that happens to many moms when they’re pregnant. And so if you’ve ever experienced before, you know, that it is really, really uncomfortable and it makes it hard for children to sleep and stay asleep. This is often related to low ferritin levels or iron levels in your child’s blood. I often refer families back to their pediatrician to have their ferritin checked and make sure that it’s at the correct level. Sometimes even when it is within normal limits, they still need extra ferritin added into their diet or as a supplement in order to make sure this really stays at bay. So definitely something to pay attention to.
More serious medical issues
And then lastly, less common, but definitely something that I have seen: I’ve worked with a number of families whose children have been treated for leukemia. Part of that treatment process, which can go on for several years is that periodically children are put on steroids. And when you’re on steroids, you can be extra, extra hungry. And so these are children who will wake up in the middle of the night and need food and legitimately be hungry. And so I’ve worked with them on making sure that we are getting past that treatment, or at least we have a plan for how to handle the times where they’re in the middle of that steroid treatment so that they can now get back on track once they’re, once they’re not quite as hungry in the middle of the night.
If your child has had any of these medical issues that I’ve just described and their sleep has really been pretty poor during that time and now the medical issue is resolved. So maybe it means that the reflux is under control. Maybe it means that they’ve had their tonsils or adenoids out, but now you think to yourself, well, This is resolved. So now they should sleep better. Unfortunately, that’s often not the case, so it can get a little bit better, but sometimes it’s not fully resolved. And the reason for that is because when children are sick, we do all sorts of things in order to help them be able to sleep better. And this is understandable, you know, we’re all just trying to survive while just trying to get from one day to the next and we’ll do whatever we have to do in order to help our child sleep. This may mean that that child has been held for a lot of their sleep when they weren’t feeling well, it could mean that they were co-sleeping.
Once medical issues is resolved, now work on behavior
Once you resolve that medical issue, now they still have all the same expectations. Your child, isn’t going to understand why they’re not being held to sleep or why they can’t sleep in your bed anymore. And so that’s where some sleep training is probably going to come into play. And so that’s where you’re going to help them learn: okay- now you’re feeling better. Now, those things that were bothering you before are not happening, but now we have to help you have a different behavioral expectation for what’s going to happen when you’re going to sleep or what’s going to be happening anytime you wake up. And this is where their sleep will start to improve.
How to manage sleep when kids get sick
The other issue that often comes up with families, as it relates to illness is what do you do when your child has been sleep trained, is sleeping well, and now they get sick. How do you handle this? Families often are really concerned about, you know, how to handle this when it comes up and how to not lose all of the great progress that they’ve made with helping their child become a great sleeper.
I will tell you that as a parent, one of my least favorite things to happen is when my kids get sick. It’s miserable for them. It’s miserable for me. It’s really, it’s just not fun. In terms of how to handle sleep, when this sort of thing comes up, some of it has to do with how seriously sick your child is. So do they just have a cold where their noses a little bit stuffy and they’re kind of sniffily? Do they have a fever? Are they throwing up? Or is it something really more significant? Like they have hand foot and mouth, or they have, you know, like a really serious GI bug. That’s just relentless and goes on for days and they’re on the verge of dehydration. I mean, so the, the severity really does matter in terms of 1 how much it’s going to disrupt their sleep and also how much you’re going to need to be able to do in order to help your child in that circumstance.
Ensure your child is still going down awake at bedtime
So, first and foremost, I always have parents still really try to make sure that they’re putting their child down awake at bedtime, fully awake when they’re not feeling well. If it’s possible to do this, you’re always going to end up in a better spot in the middle of the night. If in the middle of the night, now you need to do more to help your child go back to sleep. Fine. Again, as I was saying before, those are things that you may have to do because your child isn’t feeling well and it’s going to be uncomfortable for them to sleep. Maybe they’re super stuffy, maybe they’re congested and laying flat now makes them really uncomfortable and you end up holding them for some period of time at night. If your child has a fever and they wake up warm and feverish, does giving them some Tylenol or some Motrin help? I have seen children who wake up when they have a fever, their parents give them some Tylenol or some fever, reducing medication. And then after it starts to kick in about 20 minutes or so later, they actually want to go back into their sleeping space because that’s the comfortable space for them to sleep in at that point. So that can be the case and it’s always fine to stay there and be present until your child is feeling better and until the medication has really helped.
One thing to keep in mind though, is that if it’s really serious, if you can’t continue to put them down a wake at bedtime and you have to do all sorts of things in the middle of the night in order to help them go back to sleep, then that’s okay. But just know that you’re going to have more work to do to sort of dig yourself out of the hole when your child is feeling better.
Your child does not know why you were doing all of those things to help him or her sleep when they’re not feeling well. They just know that those are things that might happen. And so once your child is feeling better, now you have to get back on track. You have to go back to the things that you were doing before. And it may get worse before it gets better, because again, your child has experienced holding and rocking and maybe co-sleeping and all of those things were totally fine. You did all of those things for a very good reason, but now you got to get back on track and that’s going to be hard because your child doesn’t understand: we did those things before when you weren’t feeling well. Now these are the things that we do as our normal, everyday regular routine.
May have to revisit sleep training
So I usually recommend, if you can, going back to whatever sleep training method you used, when you helped your child learn how to sleep better before. In particular, if you’ve used a behavioral fading approach where you’ve stayed in the room with your child and gradually worked your way out, I find that this is a great way to get back on track and you don’t usually have to go through the whole process all over again. If you’ve been in a spot for three days as you’ve gone along as you’ve moved, you may only need to do one day in each spot before you’re back on track. And maybe not even that much, because they do remember that they’ve done this before. So it doesn’t have to be a big disaster. Once kids are sick, you can resolve it, but you do really want to make sure, as soon as possible, without too much time in between resolving the illness and getting back on track that you’re really working on it again, because you can end up in a pretty big regression if the response that you made to your child when they were sick now becomes the new normal it’s going to become a problem. And you’re going to end up with sleep issues again.
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