Toddler Sleep Strategies

Sleep

• Nightmares occur during REM sleep
• 75% of children have nightmares in the last third of the night

Toddler Sleep Refusal

• Parent Education/Prevention: Bedtime routine of 4-5 consistent, quiet activities lasting 20-30 minutes. Use a mantra such as "good night, I love you" before leaving the room.
• Extinction: A bedtime routine of 4-5 consistent, quiet activities lasting 20-30 minutes. Use a mantra such as "good night, I love you" before leaving the room.
• Cry it Out: Takes about 4-7 days for the process to have a consistent result.
• Graduated Extinction: Gradually increasing the time between checks and reassurances.
• Positive Routines/Faded Bedtime: Use rewards for desired behaviors. Substitute physical presence with positive associations.
• Leaving the Room (and Retucking): Parents exit the room before the child falls asleep. If the child leaves the room, parents should return the child to the crib and tuck them in.
• Avoid Arguing: No talking while the child is crying.
• No Sleeping with Parents: Children should not sleep with their parents in this instance
• Associated with sleep environments:
  • Not placing the infant on their back to sleep.
  • Using items other than the standard bedding set on the crib.
  • Placing blankets on an infant.

Sudden Unexpected Infant Death (SUID)

• Possible causes associated with sleep environment
  • Infants not placed on their backs to sleep
  • Using an unsuitable mattress in the crib
  • Placing blankets in cribs

Nutrition & Food Scarcity

• The appropriate age to introduce complementary foods in infancy is 6 months of age. Ideally, complementary foods should not be introduced any earlier than 4 months to decrease risk of allergies.
• Do not introduce one particular food group first. Focus on all food groups for the best outcomes.
• Introduce one new food at a time with a minimum of 3 days in between each new food. Monitor for allergic reactions.
• Food groups with potential risk such as peanuts, nuts, eggs, shellfish should be introduced one at a time
  • No specific food group needs to be introduced first.
• Introduce ONE new food at a a time for at least 3 days. Monitor for allergic reactions

Vitamin D Intake

• Infants: 400 IU per day
• Children (1-3 years old): 600 IU per day
• Children (4-8 years old): 600 IU per day

Iron Deficiency

• Common Ages: Infants 9-24 months old
• Risk Factors: Premature babies; low birth weight; babies given cow or goat milk before the age of 1; breastfed babies not given complementary foods containing iron after 6 months
• Dietary Sources: Red meats, poultry, and fatty fish

Food Insecurity

• Defined: Limited or uncertain access to nutritionally adequate and safe food.
• Risk Factors: Low income, unemployment, race/ethnicity and disabilities.
• Associated Risks: Cardiovascular disease, hyperlipidemia, diabetes, low levels of vitamins D, calcium, and iron

Elevated BMI in Children

• Adverse health outcomes associated include Type II diabetes, fatty liver disease, dyslipidemia, sleep apnea, and hypertension.

Social Determinants and Obesity

• Education access and quality
• Healthcare access and quality
• Neighborhood
• Built environment
• Social and community context
• Enough money to purchase enough food
• Adequate health insurance for preventing obesity
• Sufficient health insurance coverage to receive necessary preventative care

Pediatric BMI Concerns

• Patient centeredness: Maintaining a patient's well-being and self-esteem is important

Recommended Screening for 10+ Year Olds with BMI of 95% or Higher

• Every two years: Fasting blood glucose/HgA1c; fasting lipid panel (consider non-fasting if not feasible), ALT, AST, and GGT; 25OH Vitamin D; sleep study; liver ultrasound; uric acid; fasting serum insulin and urine microalbumin/creatinine (urine protein to creatinine); C-peptide; hs-CRP

Tooth Enamel Defects

• Factors associated with increased incidence: Lower socioeconomic status (SES); Premature births; Genetic disorders; Cerebral palsy

First Dentist Visit

• AAP Recommendations: Children should have a first visit to a dentist within 6 months of their first teeth erupting. It should ideally happen by 12 months of age. This establishes a base for risk assessment, assessment of dental health, and education for parents.

Juice Intake for Infants and Toddlers

• Infants (<12 months): Avoid giving fruit juice as it does not provide nutritional benefit at this age.
• Toddlers (1-3 years): Limit fruit juice to 4 ounces maximum per day.
• Children (4-6 years old): Limit fruit juice to 4-6 ounces or 1/2 to 1/4 cup per day
• Older Children (7-18 years): Limit fruit juice to 1 cup or 8 ounces per day.

Fluoride Supplements

• Optimal level: 0.7 ppm in water
• Consideration: Optimally fluoridated water is recommended for oral health.

Injury Prevention

• Newborns*: Highest risk is falls, SIDS, and unintentional injuries. Constant supervision is crucial. Safe sleep environment with proximity to the infant. Back to sleep/safe sleep.
• Toddlers*: Most common injuries include drowning, falls, ingestion, choking, motor vehicle accidents, and injuries from pets. High supervision required.
• School-age children*: Supervision, and knowing where the child is at all times. Safe water access is critical. No running unsupervised in areas with no supervision.
• Pre-adolescents*: Understanding and responding to peer pressure, influence of social media. Addressing the possibility of the use of alcohol and recreational drugs is also important.

Preventing Drowning

• Swimming lessons: For children 1 and older to build proficiency.
• Recognizing high-risk situations: Rips, currents, extreme temperatures for water safety.
• Knowledge of water safety devices: Devices like life preservers give safety to swimmers so they do not lose their lives in the water.
• Identify swimmers in distress: Recognizing and responding to others who are in need.
• Environmental barriers: Use gates, fencing and lifeguards for pools and other water environments.

Unintentional Firearm Injuries in Minors

• High rates: States with easy access to firearms have higher rates of unintentional and intentional injuries.
• Home environment: Having a gun in the home increases risks

Social Determinants Associated with Gun Violence

• Income inequality
• Residential economic and racial segregation
• Intergenerational social mobility

Toilet Training

• Cross-cultural differences: Some cultures begin toilet training in infancy, others later.
• Infancy perceived benefits: Hygiene and reduced illnesses.
• Older toddler perceived benefits: Pre-school readiness and independence
• Practices for family struggling with toilet training: Show techniques; observe the process, let the child learn and develop the process on their own terms.

Constipation in Children

• Red flags: Passage of meconium after 48 hours of birth in infants, constipation starting within the first year, family history Hirschsprung's disease, ribbon-like stools, blood in stool without anal fissures, Failure to thrive, bilious vomiting, severe abdominal distention, abnormal thyroid gland, abnormal anal position, decreased cremasteric reflex, tuft of hair on spine, gluteal cleft deviation, and anal scares, extreme fear during rectal examinations.
• Initial evaluation: Assess bowel patterns; consider changes in diet; assess medications; assess for diarrhea; consider encopresis.

Sleep Apnea Syndrome

• Obstructive Sleep Apnea Syndrome: In this obstructive sleep disorder, episodes of apnea occur that affect bladder function and control.
• Diagnosis: Stress-related enuresis and behavioral changes are symptoms that need to be closely monitored.
• Enuresis red flags: Weight loss, decreased linear growth, nausea, increased thirst, elevated urine glucose, difficulty voiding, etc. This warrants a diagnosis in conjunction with a complete physical assessment

Hearing and Speech

• Cooing: 2-4 months
• Babbling: 6 months
• Hearing tests: Otoacoustic emissions (OAE), Auditory Brainstem Response (ABR)

Hearing Loss Risk Factors

• Family history: A crucial factor in identifying children at risk for hearing loss.
• Prematurity: Infants who spend a considerable amount of time (greater than 5 days) in the NICU are monitored more closely after leaving the NICU

This quiz explores various strategies and routines to help toddlers with sleep refusal issues. Learn about techniques like 'cry it out,' graduated extinction, and the importance of a consistent bedtime routine. Assess your knowledge on improving children's sleep habits for better nights.