Ahmed’s mom states that he cannot fall asleep without nursing or being held.
When parents place him in his crib awake and drowsy, which is what they have read to do, he just screams, and does not seem to stop for what they deem ‘a very long time’ though they have never actually timed this period.
- Ahmed has a sleep onset association disorder, in which he requires parental presence and nursing in order to fall asleep. He has learned to fall asleep only in these circumstances.
- Families often undergo significant stress when this occurs, with heightened parental anxiety which then escalates their sensitivity to the infant’s distress and often leads to strife between parents.
Ahmed’s mom states that he also does not nap well at daycare, though he does fall asleep quickly in the carseat on the way home from daycare.
- Remember that Excessive Daytime Sleepiness in younger children frequently does not present with only overt sleepiness during the day, but rather with more subtle findings such as irritability, fussiness, mood lability, poor behavior, etc.
- Difficulty napping in children with Insomnia may result from being overtired and an inability to focus enough on self-soothing for sleep onset, as well as sleep onset associations that carry over from nighttime sleep at home to daytime sleep in a different environment.
Ahmed’s mom states that he will awaken every 1-2 hours throughout the night, with the exception of the first part of the night when he will sleep solidly for 3 hours once he falls asleep.
- Timing of awakenings at night can help distinguish between pathologic and physiologic awakenings, both of which may manifest with difficulty falling back asleep unassisted. Awakenings that occur every 90-120 minutes are likely physiologic arousals between ultradian sleep cycles, with the first uninterrupted portion of sleep being delta sleep. Children who alert caregivers during those arousals when they cannot fall back asleep then become behaviorally more aroused when they cannot be rapidly soothed back into sleep, typically with their needed associations. Children who are able to self-soothe will arouse during those same sleep stage transitions, but be able to fall back asleep quickly and independently, not signaling an acute need for parental presence. Those who cannot self-soothe at the beginning of the night usually cannot self-soothe after nocturnal arousals.
Ahmed’s mom states that these sleep problems occur nightly. Ahmed has rarely slept through the night and definitely not since he was 6 months old.
Ahmed’s mom states he awakens at least 4 times a night, mostly between midnight and 6AM. Awakenings last anywhere from a few minutes to close to an hour.
- The frequency and duration of awakenings helps to seal a diagnosis of chronic insomnia, which requires episodes 3 nights a week for at least 3 months.
- The chronicity of these issues also suggest that Ahmed has developed long standing sleep onset associations that became more pronounced after a combination of repeated illnesses and mom returning to work. In addition, a resurgence of night wakings is common between 9-12 months of age when children are able to physically accomplish much more during those transient physiologic awakenings (e.g., able to crawl, pull to stand) contributing to heightened arousal during those times.
Ahmed’s mom states that Ahmed does not snore. He has had isolated nights of congested nasal breathing during colds and ear infections, but not persistently.
- Determining the difference between obstructive sleep apnea and habitual (or even occasional) snoring is difficult by parent report alone. Lack of witnessed apneic episodes or gasping unfortunately does not rule out more significant sleep disordered breathing.
- The role of infant obstructive sleep apnea on later childhood development and behavior is only beginning to be explored, but early studies suggest that the presence of snoring or OSA in early infancy may be associated with later childhood difficulties with behavior and cognitive performance.