Sleep problems in children
I wish to comment on the recent article by Hannan and Hiscock (AFP December 2015).1 I am grateful that the topic of sleep problems in children has been discussed as, unfortunately, current general practice training programs fail to address this common issue despite the frequency and social impact of the problem.
As a general practitioner (GP), I can confirm that the topic is fraught with anecdotal opinion rather than evidence in both the nursing and medical fraternity. The wider public is confused by the plethora of advice options.
The article was refreshingly objective and informative. I was surprised to see that the extinction method was not discussed. It was listed in the study that Meltzer2 details and which Hannan and Hiscock cited as support for the two management options described in the article (‘controlled comforting’ and ‘camping out’). Meltzer’s results support both the effectiveness of extinction for sleep and behavioural improvement in the infant–toddler age groups. Granted, Meltzer admits ‘parents can find it uncomfortable’, but with the proper teaching/background information and explanation parents do well and as a result so too do the children. The randomised controlled study by Symon et al3 supports this. Their study found that a brief nurse-led session on sleep principles in a population of infants led to a significant increase in daily sleep time in the intervention arm.
Ramchandani et al4 also examined the utility of extinction and graduated extinction methods in a systematic review of randomised controlled trials of interventions for settling problems and night waking in young children. Both methods were found to produce benefit for settling problems and night wakings, compared with no treatment. Extinction also achieved these clinically useful effects more quickly and were maintained at six weeks follow-up.
While the challenging nature of the extinction method must be acknowledged, and it is unlikely all parents would be willing or able to adopt these techniques, the researched and real-world results speak for themselves. I would suggest graduated extinction (‘controlled comforting’) as plan B for parents who are unable to comply with the strict instructions. In my opinion, GPs should be aware of the extinction method’s utility and efficacy.
Erin Oliver-Landry BMBS, CCFP, FRACGP
Adelaide, SA
Reply
We thank Dr Oliver-Landry for her comments, and for raising the important question of whether ‘extinction’ should be recommended to manage infant sleep problems.
While we agree that there is a body of evidence demonstrating the effectiveness of the extinction method (also known as ‘crying-it-out’ method), this approach has some limitations. First, as outlined in multiple reviews of sleep management strategies,5–7 adherence to pure extinction is often poor as many parents find this technique distressing. Further, there are limited data on medium-term outcomes in child behaviour associated with its use,8 and an absence of long-term data on the child, parents and parent–child relationship outcomes. This is in contrast to the use of graduated extinction, which has been shown in follow-up from a large, randomised, controlled trial to have no harmful effects on child and parent mental health or parent–child relationship outcomes at five years post-intervention.9 For these reasons, we chose to include the more widely practised and evidence-based graduated extinction technique.
The pure extinction method is an available option; however, clinicians need to be mindful of its deficiencies, including lack of long-term data examining child and parental outcomes, and poorer acceptability to parents.
Dr Katrina Hannan, Paediatric Trainee and Honorary Research Fellow Centre for Community Child Health, Royal Children’s Hospital, Parkville, VIC Murdoch Childrens Research Institute, Parkville, VIC.
A/Prof Harriet Hiscock, Paediatrician and Senior Research Fellow Centre for Community Child Health, The Royal Children’s Hospital, Parkville, VIC Murdoch Childrens Research Institute, Parkville, VIC Department of Paediatrics, University of Melbourne, Parkville, VIC
References
- France KG, Blampied NM, Henderson JM. Infant sleep disturbance. Curr Paediatr 2003;13:241–46.
- Meltzer LJ. Clinical management of behavioral insomnia of childhood: Treatment of bedtime problems and night wakings in young children. Behav Sleep Med 2010;8(3):172–89.
- Thomas JH, Moore M, Mindell J. Controversies in behavioral treatment of sleep problems in young children. Sleep Med Clin 2014;9:251–59.
- France KG. Behavior characteristics and security in sleep-disturbed infants treated with extinction. J Pediatr Psychol 1992;17(4):467–75.
- Price AM, Wake M, Ukoumunne OC, Hiscock H. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomized trial. Pediatrics 2012;130(4):643–51.
Higher education in New South Wales for permanent wheelchair users
Higher education is acknowledged worldwide as a public good by governments of all persuasions. It is particularly important for those who become permanent wheelchair users early in life from spinal cord injury or other diseases/disorders. For those with this major disability, a university degree significantly enhances employment prospects and all the benefits that come from this.
In 2000, SpineCare Foundation (a charity registered in New South Wales that is now a division of Northcott) established scholarships for wheelchair users to assist them in obtaining higher education; these are also available for postgraduate and overseas studies. An award is made for one year in the first instance.
The scholarships have been privately funded in succession, initially by the Cecilia Kilkeary Foundation, then by the late Miss Joyce Fardell, and more recently in the name of Gregory and Dolores Farrell. In 2015, four scholarships of $5000 were offered. The conditions for the awards are detailed on Northcott’s website (www.northcott.com.au/tertiary-scholarships). An award cannot be used to pay Higher Education Contributions Scheme (HECS) fees.
A review of the results for the first 35 recipients has been carried out; 33 successfully completed the year for which they received funding. One student discontinued his studies due to complications of his quadriplegic state and one other withdrew for psychosocial reasons.
The drop-out (attrition) rate of 6% for this small cohort compares favourably with that of 20%, or thereabouts, which is generally considered to be the drop-out rate of first year students across all faculties in any given tertiary institution. Universities do not publish these data.
The determination and perseverance of these students are more than admirable and auger well for their futures. It is to be acknowledged that most universities are not at all wheelchair friendly. Transport to and from the campus is a major expenditure.
Since these scholarships were started, there have been three or four worthy applicants for each award. Funding enabling access to education provides opportunities for later employment, with all the associated personal and social benefits and is, by any measure, a sound investment.
Thomas K F Taylor Emeritus Professor of Orthopaedics and Traumatic Surgery University of Sydney Former Chairman, SpineCare Foundation
Erratum/corrigendum
Loton D, Lubman DI. Just one more level: Identifying and addressing internet gaming disorder within primary care. Aust Fam Physician 2016;45(1–2):48–52.
On page 51, the text, ‘In a world where “screen time” is becoming simply “time”, our policies must evolve or become obsolete. The public needs to know that the Academy’s advice is science-driven, not based merely on the precautionary principle,’ is a direct quote from Brown A, Shifrin DL, Hill DL. Beyond ‘turn it off’: How to advise families on media use. AAP News 2015,36(10):1–2. Due to a production error, an attribution to Brown et al was not included. The attribution has been added to the HTML and PDF versions of the article. At the request of Drs Loton and Lubman, the second sentence of the quote has been deleted.
We apologise for this error and any confusion this may have caused our readers.
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