Prim Care Clin Office Pract 35 (2008) xi–xiii Preface Edgar V Lerma, MD, FACP, FASN, FAHA Guest Editor Chronic kidney disease (CKD) is a major public health problem According to the National Health and Nutrition Examination Survey (NHANES) 1999–2004, approximately 20 million Americans are diagnosed with CKD; that is, out of adults in the US satisfy the criteria for the diagnosis of CKD Another 20 million are estimated to be at risk This projection points to the fact that patients with CKD will soon far outnumber trained nephrologists in the US This dilemma can be solved only by a collaborative approach between primary care providers and nephrologists We, as nephrologists, are well aware that the primary care providers occupy a unique and vital role in this team approach (Table 1) Primary care providers are at the forefront of this war against CKD They are in a position to be the first to identify and screen patients at risk for CKD, eg, those with diabetes, hypertension, etc They also are providers of long-term care and management of these patients Nephrologists and nephrology teams contribute to this collaborative process by being involved in the earlier stages of CKD, perhaps at the time of diagnosis, and also by providing assessments of patientsÕ conditions and strategic guides to overall management [1] An example of this is the administration of erythropoietin, a proven and effective treatment strategy that is not available in many primary care establishments [1] To be effective, however, our ultimate goal, as primary care providers and nephrologists alike, is to be able to educate and empower patients so that they will be able to take charge of their disease 0095-4543/08/$ - see front matter Ó 2008 Elsevier Inc All rights reserved doi:10.1016/j.pop.2008.06.005 primarycare.theclinics.com xii PREFACE Table Team approach to the role of primary care physician and nephrologist in chronic kidney disease What the primary care physician does What the nephrologist does Identifies and screens for risk factors of CKD, including:  Diabetes  Cardiovascular disease  Anemia Provides ongoing management of patients with CKD Provides role-specific patient education Diagnoses and assesses patient Assists in developing strategic guidance Recommends and implements patient care Provides role-specific patient education Abbreviation: CKD, chronic kidney disease Data from BeActive slide deck Ortho Biotech, Bridgewater, NJ As guest editor of two issues on ‘‘Kidney Diseases and Hypertension,’’ I feel privileged with a unique opportunity to contribute to this goal I have carefully chosen the different topics that I feel are of great interest to our colleagues involved in primary care practice The first issue deals with the typical topics faced by primary care providers, such as common fluid and electrolyte disorders, as well as acid-base problems These articles discuss the diseases with predominant involvement of renal pathophysiology, such as glomerular and tubulointerstitial diseases, and common systemic diseases, such as diabetic nephropathy, systemic lupus erythematosus, congestive heart failure, etc The various treatment modalities and approaches are also rendered towards the end of each article An article discussing the new classification of chronic kidney disease and the various complications that may arise secondary to it is also included The last two articles deal with common upper and lower urinary tract problems, such as infections and stones The second issue focuses on the various treatment strategies, namely renal replacement therapy or dialysis and renal transplantation Hypertension, a common problem encountered in the outpatient setting and also the second most common cause of CKD, is discussed in greater detail Over the past decades, with so many advances in technology, as shown by our new understanding of the various disease processes and pathophysiologies, there has been a very noticeable increase in representation of the geriatric population in those afflicted by renal disease processes, the so-called ‘‘gerontologizing of nephrology.’’ I believe that a discussion on this new trend is appropriate, and so it is presented in the last article I would like to take this opportunity to thank my fellow authors who collaborated with me on this project All of the authors were asked to give a specific discussion related to kidney diseases and hypertension, while taking into consideration that our target audience would be the primary care providers whom we collaborate with on a regular basis PREFACE xiii I am hopeful that primary care providers will find the information provided in this text quite useful in their practice of daily medicine As medicine is ever-changing and developing, future studies will be published that may either differ or provide updates to the recommendations presented herein I encourage readers to stay updated with the medical literature and to use it in their practices as they deliver healthcare Edgar V Lerma, MD, FACP, FASN, FAHA Section of Nephrology Department of Medicine University of Illinois at Chicago College of Medicine 820 S Wood Street Chicago, IL 60612-4325 Associates in Nephrology, SC 210 South Desplaines Street Chicago, IL 60661 E-mail address: edgarvlermamd@pol.net Reference [1] Schoolwerth A The Scope of the cardio-CKD-anemia triad Taking control of chronic kidney disease: beyond the kidney Presented at the ANNA Meeting Orlando, May 25, 2002 Prim Care Clin Office Pract 35 (2008) 407–432 Treatment Options for End Stage Renal Disease Paul W Crawford, MD, FACPa,b,*, Edgar V Lerma, MD, FACP, FASN, FAHAc,d a Feinberg School of Medicine, Northwestern University, Chicago, IL, USA b Evergreen Park Dialysis Unit, 9730 S Western Avenue, Suite 326, Evergreen Park, IL 60805, USA c Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine, 820 S Wood Street, Chicago, IL 60612-4325, USA d Associates in Nephrology, SC, 210 South Desplaines Street, Chicago, IL 60661, USA Currently, more than 480,000 United States citizens are receiving dialysis [1] More than 314,000 are receiving hemodialysis, more than 25,000 are receiving peritoneal dialysis, and another 143,000 have had transplants [1] Significantly, 16.8% of the population has chronic kidney disease (CKD) [2] The latest National Health and Nutrition Study revealed an increasing incidence of kidney disease among aging baby boomers, as the incidence of diabetes mellitus and hypertension rises Because of this trend, a greater proportion of a primary care physician’s practice will involve patients with CKD, and consequently, end stage renal disease (ESRD) or CKD patients receiving dialysis [3] Unfortunately, far too many of these CKD patients are referred to a nephrologist very late More often than not, the opportunity for secondary preventive intervention, with the goal of avoiding renal replacement therapy, is lost [4] When should a patient with CKD be referred to a nephrologist? The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend a referral to a nephrologist when the glomerular filtration rate (GFR) is less than 30 mL per minute per 1.73 m2 [5] A more aggressive approach is to encourage referral when the * Corresponding author Evergreen Park Dialysis Unit, 9730 S Western Ave., Suite 326, Evergreen Park, IL 60805 E-mail address: pwcmd@yahoo.com (P.W Crawford) 0095-4543/08/$ - see front matter Ó 2008 Elsevier Inc All rights reserved doi:10.1016/j.pop.2008.05.003 primarycare.theclinics.com 408 CRAWFORD & LERMA GFR is less than 60 mL per minute per 1.73 m2 As a cautionary note, a consultation when the GFR is greater than 60 is warranted in the presence of rapidly declining GFR with or without hematuria or proteinuria Late referral to the nephrologist is considered by most clinicians to be ‘‘when management pf patients with chronic kidney disease could have been significantly improved by earlier contact with the nephrology team,’’ and surprisingly, it is extremely common in the United States In most cases, it is when one is referred within months or less before start of dialysis therapy [6] With an early referral, the patient and family are given the advantage of participating in educational classes concerning CKD, as well as of receiving oneon-one counseling with a multidisciplinary kidney care team, including a nurse practitioner, physician, dietitian, and social worker These team interventions (informed selection of dialysis modality, timely placement of appropriate dialysis access, as well as preemptive transplant) are paramount in helping the patient and family overcome many of the fears and myths associated with dialysis, as well as to arm them with skills needed to cope with the CKD, its complications, or ESRD diagnosis and treatment [7] Similarly, other benefits associated with early referral include nonemergent initiation of dialysis, lower morbidity and improved rehabilitation, less frequent and shorter hospital stays, lower cost, and improved survival [8] Moreover, many CKD patients are able to remain stable (within the same CKD stage), or improve CKD stage with aggressive intervention The National Kidney Foundation classifies CKD stages into stages through 5, as illustrated in Table Unfortunately, many patients with ESRD have been threatened with dialysis by primary care providers or family members Though well intentioned, the use of the threat of dialysis as a tool for motivating compliance with prescribed treatments and medications ultimately results in a patient who fears the treatment (dialysis) more than the disease (ESRD), with all the accompanying complications All too often, this leads to patients with CKD Stage refusing renal replacement therapy for a prolonged time (more than a year in some cases) or even never consenting to this life-saving treatment Table National Kidney Foundation stages of chronic kidney disease Stage Description GFR (mL/min/1.73 m2) Kidney damage with normal or [ GFR Kidney damage with mild Y GFR Moderate Y GFR Severe Y GFR Kidney failure R 90 60–89 30–59 15–29 !15 (or dialysis) Chronic kidney disease is defined as either kidney damage or GFR less than 60 mL per minute per 1.73 m2 for greater than or equal to months Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies From National Kidney Foundation KDOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification Am J Kidney Dis 2002;39(2 Suppl 1):S46; with permission TREATMENT OPTIONS FOR END STAGE RENAL DISEASE 409 It is ironic that, given our current armamentarium, our success in managing comorbidities associated with CKD Stage 5, such as anemia, hypertension, metabolic acidosis, and secondary hyperparathyroidism with hyperphosphatemia leads our patients to question whether dialysis can improve their quality of life With diligent management of these comorbidities, patients no longer need suffer from symptoms of fatigue, weakness, loss of mental alertness, lethargy, severe pruritus, recurrent chronic heart failure, shortness of breath, and inability to perform activities of daily living (ADLs) Instead, they are able to work, walk miles on a treadmill, golf, bowl, swim, dance and perform all ADLs without difficulty, despite having a GFR of less than 15 mL per minute Indications for renal replacement therapy ESRD is always a diagnosis of exclusion; it is only after all exams have ruled out all reversible causes for renal failure that a diagnosis of ESRD should be made No assumptions can be made in the work-up A comprehensive, meticulous work-up includes an extensive history and physical, laboratory exams, renal ultrasound, chest X-Ray, and CT scan and MRI when indicated Previous medical records must be reviewed The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines define CKD as: Kidney damage for greater than or equal to months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR and manifest by either: Pathologic abnormalities; or Markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests GFR less than 60 mL per minute per 1.73 m2 for greater than or equal to months, with or without kidney damage (Table 2) [9] Table KDOQI criteria for initiation of renal replacement therapy Criteria for initiation of renal replacement therapy Prior approach Diabetics Nondiabetics Transplant Current approach All patients Patients with symptomatic severe left ventricular dysfunction, symptomatic uremia, uncontrollable hyperkalemia or metabolic acidosis Transplant GFR !15 mL/min !10 mL/min Not candidate until on dialysis GFR !15 mL/min 15–20 mL/min !20 mL/min 410 CRAWFORD & LERMA According to KDOQI guidelines, hemodialysis is also indicated when the GFR has not yet decreased to or below 15 mL per minute per 1.73 m2, in the presence of [9]: Intractable extracellular fluid volume overload Hyperkalemia Hyperphosphatemia Hypercalcemia or hypocalcemia Metabolic acidosis Anemia Neurologic dysfunction (eg, neuropathy, encephalopathy) Pleuritis or pericarditis Otherwise unexplained decline in functioning or wellbeing Gastrointestinal dysfunction (eg, nausea, vomiting, gastroduodenitis) Weight loss or other evidence of malnutrition Hypertension diarrhea, After the diagnosis of ESRD is determined, a decision concerning the most appropriate mode of renal replacement for the patient must be made The various modes of dialysis must be very carefully discussed with patients and families as a life saving treatment for those with ESRD who, without this opportunity to receive treatment, will die prematurely of uremic complications If the primary care provider is unable to dedicate the time for this often very lengthy, emotional discussion, then it is best left to the nephrology team Options for renal replacement therapy for ESRD Kidney Transplantation a Deceased donor b Living donor Peritoneal Dialysis a Continuous ambulatory peritoneal dialysis (CAPD) b Continuous cycler peritoneal dialysis (CCPD) c Nocturnal intermittent peritoneal dialysis (NIPD) d NIPD-wet day e Tidal peritoneal dialysis Hemodialysis (HD) a Conventional: to hours, times per week i In-center HD ii Home HD iii Nocturnal home HD iv Nocturnal in-center HD (not widely available) b Daily home HD (day or nocturnal) c Day or nocturnal 8–10 hour HD TREATMENT OPTIONS FOR END STAGE RENAL DISEASE 411 Variations of the above referenced renal replacement therapies are being attempted in an effort to improve outcomes, such as reduction of morbidity, mortality, and hospitalization days, in accordance with current ongoing demonstration projects Goals of renal replacement therapy include: Prolongation of life Reversal of symptoms of uremia Return the patient to their prior lifestyle/activities of daily living Maintenance of a positive nitrogen balance and an adequate energy intake Minimization of patient inconvenience Maximization of quality of life Selection of renal replacement therapy mode The nephrologist has great influence over the patient’s selection of peritoneal versus hemodialysis The nephrologist’s preferences are greatly dependent upon their training, orientation, and practice location A significant percentage of Nephrology Fellows come into practice with no prior experience in peritoneal dialysis Subsequently, these nephrologists are much less likely influence a patient to choose peritoneal dialysis because of a lack of confidence in their ability to successfully manage peritoneal dialysis patients and staff Lack of experienced and adequately trained staff can be, and often is, a major deterrent to a nephrologist recommending CAPD, even when they believe this to be the best option for the patient Fear of insecure, inexperienced staff can also make an already apprehensive and fearful new ESRD patient even more anxious and reluctant to take on the responsibility of self-care (Table 3) Table Considerations when determining mode of renal replacement therapy Consideration Access Hemo CAPD Desired: arteriovenous Tenckhoff catheter; no (AV) fistula AV access Alternate: catheter Frequency/duration times per week/4 hrs Four exchanges daily per session Patient manual Not a factor Partner is dexterity recommended Patient intellectual Not a factor Partner is capacity recommended Family support An advantage Necessary CCPD Tenckhoff catheter; no AV access Cycler at night Partner is recommended Partner is recommended Necessary 412 CRAWFORD & LERMA Hemodialysis History Georg Haas performed the first human hemodialysis in 1924 in Giessen, Germany Using collodian tubes arranged in parallel cylinders, blood came in contact with exchange fluid Since that time, there have been numerous breakthroughs with various membranes, including cellophane, cellulose acetate, and cupraphane, all in the search for more biocompatible dialysis membranes and ultimately, disposable kidneys In 1946, Gordon Murray created a dialyzerda coil design on steel framed and used his invention on a patient in acute renal failure, performing the first successful dialysis in North America Many patients start dialysis with the perception that their kidneys are going to recover and that dialysis is ‘‘only temporary.’’ This is despite counseling to the contrary by multiple care providers that their kidney disease is irreversible and that they will need renal replacement therapy for the rest of their life Such denial is common in patients starting renal replacement therapy and is to be expected for the first to 12 months of dialysis This is true even for the patient who has received early, in depth education about the need for renal replacement therapy Contraindications to hemodialysis Hemodialysis contraindications include hemodynamic instability, hypotension, unstable cardiac rhythm and patient refusal Vascular access Vascular access has been called the Achilles heel of dialysis Without adequate access to the circulation, it is impossible to achieve adequate dialysis results Blood flow of between 200 mL to 500 mL per minute is required for adults, depending on their size For patients needing chronic hemodialysis, creation of an arteriovenous (AV) fistula (connecting an artery to a vein using a surgical anastomosis of the native vessels) in an upper extremity is imperative Early identification of patients requiring AV access Patients in CKD Stage should have vein mapping with ultrasound After mapping has identified that the patient has adequate size vessels for the creation of a native AV fistula, a surgical referral for creation of an AV fistula should be made Only a native AV fistula should be placed The decision to place any other form of access should be reviewed with the nephrology team, patient, and family Some surgeons believe an AV graft using artificial veins (PTFE) are also fistulas However, the nephrologists must not relegate the decision of appropriate AV access placement to the vascular surgeon 566 ST JAMES-ROBERTS [78] Ramchandani P, Wiggs L, Webb V, et al A systematic review of treatments for settling problems and night waking in young children BMJ 2000;320(7229):209–13 [79] France K, Blampied N Services and programs proven to be effective in managing pediatric sleep disturbances and disorders, and their impact on the social and emotional development of young children In: Encyclopedia on early childhood development Available at: http://www.excellence-earlychildhood.ca/documents/France-BlampiedANGxp.pdf Accessed March 8, 2007 [80] Stores G, Wiggs L, editors Sleep disturbance in children and adolescents with disorders of development: its significance and management London: MacKeith PressdCambridge University Press; 2001 No 155 [81] Papousˇ ek M, Wurmser H, von Hofacker N Clinical perspectives 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Lubitz L, et al Clinical predictors of pathological gasto-oesophageal reflux in infants with persistent distress J Paediatr Child Health 2006;42(3):134–9 INFANT CRYING AND SLEEPING 567 [98] Barr RG, St James-Roberts I, Keefe M, editors New evidence on unexplained early infant crying: its origins, nature and management Johnson & Johnson Pediatric Round Table Series Skillman (NJ): Johnson & Johnson Pediatric Institute; 2001 [99] van den Boom CD Behavioral management of early infant crying in irritable babies In: Barr RG, St James-Roberts I, Keefe M, editors New evidence on unexplained early infant crying: its origins, nature and management Skillman (NJ): Johnson & Johnson Pediatric Institute; 2001 p 209–28 Prim Care Clin Office Pract 35 (2008) 569–581 Bedtime Problems and Night Wakings in Children Melisa Moore, PhDa, Lisa J Meltzer, PhDa, Jodi A Mindell, PhDa,b,* a CHOP Sleep Center, 34th Street and Civic Center Blvd., Philadelphia, PA 19104, USA b Department of Psychology, Saint Joseph’s University, Philadelphia, PA 19131, USA Bedtime problems and night wakings in children are common complaints heard by general pediatricians and sleep specialists, affecting 20% to 30% of young children [1–7] Bedtime problems and night wakings in children can significantly impact daytime functioning for both children and their parents, including daytime sleepiness, increased behavior problems, decreased neurocognitive functioning, and family stress [8–10] In most cases, behavioral sleep problems not resolve on their own [11,12], highlighting the need for preventive education, early identification, and intervention Previous research has found behavioral treatments for bedtime problems and night wakings to be highly effective [13], improving not only sleep quality and sleep quantity, but also impacting other important parentand child-related outcomes, such as mood and behavior This article reviews the presentation of bedtime problems and night wakings, empirically validated interventions, and challenges to treatment in both typically developing and special populations of children Presentation of bedtime problems, night wakings, and nighttime fears Bedtime problems Bedtime problems include both bedtime refusal (eg, refusing to participate in aspects of the bedtime routine, to get into bed, or to stay in bed) and bedtime stalling (eg, attempting to delay bedtime with repeated requests for hugs, food or drink, stories, and so forth) [7] Bedtime problems typically A version of this article originally appeared in Sleep Medicine Clinics, volume 2, issue * Corresponding author Department of Psychology, Saint Joseph’s University, Philadelphia, PA 19131 E-mail address: jmindell@sju.edu (J.A Mindell) 0095-4543/08/$ - see front matter Ó 2007 Elsevier Inc All rights reserved doi:10.1016/j.pop.2008.06.002 primarycare.theclinics.com 570 MOORE et al begin with the developing independence of toddlers, but can continue or develop in preschoolers and school-aged children Often children test the limits to determine boundaries and gain independence, both at night and during the day, which in most cases is developmentally normal At bedtime, however, these behaviors can be more difficult for parents to deal with and can result in inconsistent bedtime routines or rules that change with the child’s requests If this occurs, bedtime problems may worsen With regular sleep routines and appropriate bedtime limits, children can learn to fall asleep quickly and independently Night wakings Night wakings are most common in infants and toddlers, but can also occur in older children Typically, night wakings are caused by negative sleep associations, although physiologic causes must be ruled out (eg, reflux, obstructive sleep apnea) Sleep associations develop when children learn to fall asleep under certain conditions (eg, parent present, being rocked) or with certain objects (eg, bottle, blanket) [14] When the condition or object is not present the child may have difficulty falling asleep, at bedtime and following normal nighttime arousals Although some associations may be positive and promote independent sleep (eg, stuffed animal or pacifier), negative associations (eg, lying with or rocking a child) that require the presence of another person, most often a parent, are problematic [14] Normative night wakings occur throughout the night [15], but a child who has a negative sleep association at bedtime needs this same association to return to sleep following each night waking [16] Bedtime problems and night wakings co-occur if a negative sleep association develops in response to inconsistent limits For example, a child may make repeated requests for attention at bedtime, with the parent eventually staying with the child until he or she is asleep, forming a negative sleep association The child becomes unable to fall asleep or return to sleep without the parent’s presence, and during normative night wakings, the parent must return to the child’s room to lie with him or her for the child to return to sleep Nighttime fears Most children experience nighttime fears (73.3% of children ages 4–12), but these are considered to be normal features of development [17,18] Cognitive development in young children, primarily increased creativity, imagination, and an awareness that bad things can happen, contributes to these fears The presence of a parent or older sibling at bedtime typically alleviates children’s fears at night, but also may result in a negative sleep association It is important to discuss these fears with the child during the day, but it is also important to maintain consistency with regard to bedtime routines to promote a developmentally appropriate level of independence and prevent more serious bedtime problems BEDTIME PROBLEMS AND NIGHT WAKINGS IN CHILDREN 571 Classification and prevalence Most empiric research on behavioral sleep problems and interventions has not been conducted using strict diagnostic definitions Rather, studies have used a multitude of definitions to designate bedtime problems and night wakings, from parental identification of their child experiencing a sleep problem to more empirically based definitions, such as a child waking three or more nights a week No studies have classified children according to the designation of the recent International Classification of Sleep Disorders, 2nd edition [19], which has included difficulty falling asleep independently or frequent night wakings to be primary symptoms in behavioral insomnia of childhood (BIC) The International Classification of Sleep Disorders, 2nd edition [19] defines three subtypes of BIC based on the behavioral etiology of the bedtime problem or night waking: (1) BIC sleep-onset association type, (2) BIC limit-setting type, and (3) BIC combined type BIC sleep-onset association type is most often seen in infants and toddlers (ages months–3 years), although it can occur at any point during childhood or adolescence [19] Negative sleep associations contribute to prolonged sleep onset or frequent night wakings In contrast to sleep-onset association type, children with BIC limit-setting type are often described by their caregivers as refusing to go to bed or attempting to delay bedtime with repeated requests [14,19] BIC limit-setting type occurs most commonly in toddlers, preschoolers, and school-aged children [20] If bedtime routines and rules are not clear and consistent, and parents have difficulty enforcing limits, BIC limit-setting type can occur BIC combined type typically occurs when a negative sleep association develops in response to nonexistent or inconsistent limits Because bedtime problems and night wakings often coexist, many prevalence studies not treat them as separate disorders and the prevalence of each specific problem is difficult to ascertain In cross-sectional studies, 20% to 30% of young children are reported to have bedtime problems or frequent night wakings [1–3,6] In addition, frequent night wakings are one of the most common sleep concerns in children over months, with 25% to 50% of children waking at night [7,21] As stated, with regard to specific diagnoses, BIC limit-setting type occurs primarily in toddlers and preschoolers (10%–30%) and school-aged children (15%) [20] Assessment A comprehensive assessment of both sleep patterns and daytime functioning is needed to evaluate bedtime problems and night wakings [16] One approach is to guide a family through a ‘‘typical’’ 24-hour period to assess factors that may impact both nighttime sleep and daytime sleepiness This provides information about the child’s sleep schedule (eg, bedtime and wake time on weekdays and weekends); bedtime routines (nighttime activities, 572 MOORE et al bedtime stalling or refusal, sleep-onset latency); parental responses to child behaviors at bedtime and following night wakings (limit setting, reinforcement); parental knowledge and beliefs about sleep (eg, keeping the child awake longer leads to sleeping through the night); social and environmental context (eg, cosleeping, parental presence at bedtime); symptoms of physiologic sleep disorders (eg, snoring, sleep terrors); and daytime functioning (eg, sleepiness, napping schedule, irritability) Additional questions about the impact of the child’s sleep problems on the family and a discussion of the type and duration of strategies previously used is helpful in treatment planning Finally, psychosocial information about significant life events is needed (eg, birth of a sibling, marital conflict) because these events may impact sleep and result in the development of sleep problems Along with information provided by parents in a history, additional information may be collected using sleep diaries that track bedtime; sleep-onset latency; frequency and duration of night wakings; morning wake time; and naps (frequency, duration, and timing) It is recommended that a 2-week baseline diary be completed to provide sufficient information about sleep patterns [22] Objective information about sleep patterns may be provided by actigraphy Actigraphs are electronic activity monitors that are typically worn on the child’s wrist, providing measures of sleep patterns for an extended period of time (eg, days–2 weeks) In addition to providing a picture of the child’s sleep patterns, actigraphy provides valid estimates of total sleep time, sleep interruptions, and times of sleep onset and offset [23–25] Behavioral treatments for bedtime problems and night wakings Behavioral interventions have been empirically validated for the treatment of bedtime problems and night wakings A recent American Academy of Sleep Medicine review of 52 studies investigating behavioral interventions for bedtime problems and night wakings reported that 94% of studies demonstrated clinically significant effects [13] Empirical evidence from controlled group studies using Sackett criteria for evidence-based treatment provided strong support for unmodified extinction and preventive parent education, and additional support for graduated extinction, bedtime fading and positive routines, and scheduled awakenings [13,26] These treatments are based on principles of learning and behavior, including reinforcement Such interventions rely on parent training to impact changes in the parent’s behavior, which facilitate changes in the child’s behavior [13] The primary goal of behavioral strategies is for children to develop positive sleep-related associations and self-soothing skills to fall asleep at bedtime and return to sleep following night wakings independently Although the treatment strategies are straightforward, implementation is affected by multiple factors One crucial element of behaviorally based treatments is parental consistency Because these treatments can be stressful for parents, interventions should be tailored to the specific family and when BEDTIME PROBLEMS AND NIGHT WAKINGS IN CHILDREN 573 possible, ongoing support should be provided to maximize the chances of successful follow through [27] Extinction Extinction or ‘‘crying it out’’ is one of the earliest behavioral interventions studied for bedtime problems and night wakings, and continues to be recommended today [13,28] Extinction involves putting the child to bed at a consistent time and ignoring the child’s negative behaviors (while monitoring for safety and illness), until a designated wake-up time Negative behaviors that should be ignored include yelling, crying, and tantrums The first known study of unmodified extinction (also called systematic ignoring) for bedtime problems and night wakings was conducted by Williams [28] with a toddler whose duration of crying decreased after consistent ignoring by her parents Since that time, three randomized, controlled studies [27,29,30] and several smaller studies and case reports [27,31,32] have been conducted, providing strong empirical support for extinction One randomized, controlled study found that extinction was more effective at reducing parental report of night wakings than a control group and worked faster than scheduled awakenings [29] Another similar study compared an intervention delivered by a therapist (including a consistent bedtime, bedtime routine, and extinction) with a written information–only group and a wait-list control group [27] Both intervention groups (written information and therapist support) demonstrated improvements over the control group; however, no differences were found between the intervention groups Finally, extinction alone has been compared with extinction plus sleep-enhancing medication (trimeprazine) and extinction plus placebo [30] Results showed that extinction was effective in all groups, with those in the extinction plus medication group showing the fastest response When compared with untreated controls, significant improvements were maintained at and 30 months for the intervention groups [30] Parental consistency is essential for success, yet most parents find their child’s prolonged crying to be stressful; the standard approach to extinction may be difficult for some parents If parents respond to yelling and crying after a period of time, the child’s negative behavior is reinforced with attention, increasing the likelihood of the behavior continuing Parents should be advised about the likelihood of an ‘‘extinction burst’’ or brief reemergence or worsening of negative behaviors at some later date Although this is a normative part of the extinction process, parents may perceive this as evidence that the intervention is not working Graduated extinction As an alternative to unmodified extinction or the ‘‘cry it out’’ method, graduated extinction was developed Graduated extinction involves ignoring the child’s negative behaviors (eg, crying and yelling) for a specified duration 574 MOORE et al before briefly checking on the child The time between checks should be based on parental tolerance of the child’s crying, and the child’s age and temperament The period of time between checks can be fixed (every minutes); can increase on a given night (3 minutes, then minutes, then 10 minutes); or can increase over a week (3 minutes Monday, minutes Tuesday, 10 minutes Wednesday) Following the ignoring period, the parent briefly checks on the child and provides reassurance but minimizes attention Both randomized, controlled studies of graduated extinction [33,34] and case reports and within-subjects studies have supported graduated extinction [7,31,35,36] Adams and Rickert [33] compared graduated extinction with positive bedtimes and with a control group In the graduated extinction group, parents were told to keep their child’s established bedtime and ignore negative behaviors (eg, tantrums) for a set amount of time (based on the child’s age and the length of time the parents believed they could ignore the child) After the ignoring period, parents were told to comfort their child for a maximum of 15 seconds In this study both graduated extinction and positive bedtime routines were significantly more effective at reducing bedtime tantrums than controls There were no significant differences between the intervention groups A recent randomized, controlled study of to year olds evaluating the use of the bedtime pass [34] found this to be an effective modification of graduated extinction In this study, children were given a card (bedtime pass), which could be traded in for a visit from a caregiver or one trip from their room After the bedtime pass was used, caregivers were instructed to ignore negative, attention-seeking behaviors from the child Results demonstrated less frequent calling and crying out and shorter time to quiet in the intervention group compared with controls These gains were maintained at months, and parent satisfaction was high with this treatment Positive routines and faded bedtime Positive routines with a faded bedtime is an alternative to extinction for the treatment of bedtime problems and frequent night wakings [33,37] Proponents of positive routines suggest that although extinction eliminates negative behaviors, it does not provide positive behaviors to take their place [33] Positive routines involves collaborating with parents to determine the child’s bedtime, based on when they would naturally fall asleep Parents then create a bedtime routine involving a few quiet activities lasting 20 minutes in total [13,33] Delaying bedtime is used to ensure a rapid sleep-onset latency that is paired with a positive association with bedtime Once the association between the positive routine and rapid sleep association is in place, the child’s bedtime is moved 10 to 15 minutes earlier every few nights until the desired bedtime is reached The linking of positive bedtime activities with bedtime and sleep onset is believed to eliminate bedtime problems, helping the child to develop self-soothing skills and fall asleep independently BEDTIME PROBLEMS AND NIGHT WAKINGS IN CHILDREN 575 Although less extensive than the literature on extinction and graduated extinction, at least three studies have found positive routines to be beneficial in the treatment of bedtime problems or frequent night wakings [33,37,38] In the only study of positive routines to include a control group, Adams and Rickert [33] compared positive routines with graduated extinction and with a control group in 36 toddlers and preschoolers Positive routines involved moving the child’s bedtime to a time the child would more naturally fall asleep Before bedtime, the parent and child would complete four to seven calm, pleasurable activities together If the child began to tantrum, the parent was to end the activities and tell the child that it was time for bed Additionally, the child’s bedtime was gradually moved earlier until it reached the desired bedtime In this study, both positive routines and graduated extinction were significantly more effective than the control group; however, they were not significantly different from each other Scheduled awakenings If children wake during the night at predictable times, scheduled awakenings can be an effective treatment option This interventions involves parents recording the time and number of spontaneous night wakings to determine a baseline [39,40] The next step is for parents to wake their child and provide their typical response to night wakings (feeding, rocking, patting on the back) until the child returns to sleep at predetermined times during the night The length of time between scheduled awakenings is gradually increased, which is thought to increase the length of time between spontaneous night wakings [13] At least four studies have been conducted with scheduled awakenings [39–41], including one study with a control group [29] Rickert and Johnson [29] found that scheduled awakenings were significantly more effective than a control group and as effective as extinction, although extinction worked more quickly Although results may be seen in days with extinction, scheduled awakenings may take several weeks [13] Additionally, scheduled awakenings may be more complex to implement, because parents consistently have to wake their child at least once every night Further, this intervention is not applicable to children with bedtime struggles Parent education and prevention Before the development of bedtime problems and night wakings, parental education and prevention has been shown to be an effective intervention [13,35,42] Through written material or in-person education (individual or group), parents are taught how to help their child develop self-soothing skills Prevention and education efforts have also focused on positive sleep habits, including a consistent sleep schedule, appropriate bedtime routine, and responses to normal developmental changes 576 MOORE et al Studies of parent education demonstrate that compared with controls, infants whose parents were part of a sleep intervention obtained more nighttime sleep and had less frequent night wakings [13] Multiple studies have been conducted showing that short interventions (one to four sessions) greatly impact infant sleep [42–46], although longer-term outcomes from such studies are not available Wolfson and colleagues [46] randomly assigned first-time parents in child birthing classes to a sleep education group (two classes before childbirth and two classes after childbirth) or a control group According to parent diary, 72% of 3-week-old infants ‘‘slept through the night’’ as compared with 48% in the control group A study by Pinilla and Birch [43] found that by weeks, 100% of infants in a parent education intervention slept through the night as compared with 23% of controls Fewer sessions may be effective, as demonstrated by Adair and coworkers [45], who incorporated written sleep information into two routine well-child visits St James-Roberts and coworkers [44] found less robust effects than Pinilla and Birch [43] when using a written format; however, the difference in numbers of infants who slept through the night was still 10% more than those in the control group These findings suggest that face-to-face contact may be an important element of parent education interventions Nighttime fears interventions A recent review of the treatment literature for nighttime fears found that most studies used cognitive behavioral techniques, such as desensitization, positive self-talk, positive imagery, reinforcement, relaxation, and desensitization [17] Although it is difficult to determine the efficacy of any specific component because most studies used a combination of techniques, most of the 29 studies demonstrated a reduction of nighttime fears after a few sessions One key component of cognitive behavioral interventions, as found in a small study by Ollendick and colleagues [47], is behavioral reinforcement When children were rewarded for making steps toward sleeping independently and confronting their fears, much larger treatment gains were made Nightmares may also contribute to the development of nighttime fears [48] To help a child learn that they are objectively safe, it is important to promote appropriate coping skills, including sleeping independently Following a nightmare, parents should return their child to bed and provide reassurance that the dream was not real It is important for parents to model calm behavior and to provide reassurance with limited attention at night A more in-depth discussion of the nightmare can be deferred until the next day [16] To reduce the potential for future nightmares, sufficient sleep and avoidance of frightening books, movies, and television are recommended Many parents are concerned that nighttime fears are a symptom of a more serious psychologic problem Typically, when more severe anxiety disorders (posttraumatic stress disorder, generalized anxiety disorder, phobias, or separation anxiety) are present, symptoms are also seen during the daytime When nighttime fears BEDTIME PROBLEMS AND NIGHT WAKINGS IN CHILDREN 577 persist or cause significant distress to the child and family, psychologic assessment and intervention are recommended Treatment challenges Although behavioral treatments for bedtime problems and night wakings are effective, there are a number of barriers that may result in nonadherence to treatment recommendations Behavioral treatments, such as extinction and graduated extinction, rely on behavioral principles, including schedules of reinforcement Parent inconsistency results in an interval or unpredictable reinforcement schedule, which in turn maintains the unwanted behavior When parents report that ‘‘they have tried everything,’’ it is important to assess for how long they tried each treatment approach Unlike medications, behavioral interventions take several days to several weeks to implement, and parents may give up prematurely if not apprised of this factor While monitoring for safety, it is crucial that parents select an approach (in collaboration with a clinician) and systematically adhere to that approach for several weeks To improve consistency, it is important that parents understand the rationale for the behavioral intervention and the specifics of implementation One factor that may improve adherence to behavioral treatments is determining the appropriate timing for sleep training, so it does not coincide with any life stressors Individualizing the treatment plan also helps to prevent the inconsistencies that can lead to poor outcomes Furthermore, family and environmental issues can contribute to difficulties in treatment implementation Parental mental health challenges and limitations in basic parenting skills can result in an inability to develop and implement treatment strategies Other children in the home or parents who are shift workers can make it difficult for families to follow through on any strategies that may result in sleep disruption to others Furthermore, home environment issues can be challenging, such as child needing to share a bed or bedroom with other family members Special populations of children Developmental disorders Children with developmental conditions, such as autism spectrum disorders (ASDs), may be at increased risk for bedtime problems and night wakings compared with typically developing children In fact, 44% to 83% of children diagnosed with ASDs have a sleep problem as determined by actigraphy or parent report [49–51] The most common problems reported are difficulty falling asleep, inability to sleep independently, frequent and lengthy night wakings, early morning wakings, and less total sleep time [51–54] Although research in this area is limited, sleep problems in children 578 MOORE et al with ASDs have been shown to relate to more energetic, excited, and problematic daytime behaviors [50] Moreover, in this population total sleep time has been shown to be related to both social skills and stereotypic behaviors [55] Although the implementation of behavioral interventions may be challenging, studies have shown that parents of children with ASDs prefer behavioral approaches to sleep-enhancing medications, although pharmacologic interventions are offered more frequently than behavioral interventions [54,56,57] A recent survey of various behavioral approaches found that at least 50% of parents perceived most interventions as helpful [58] The same study demonstrated that between subgroups of children with ASDs (mentally retarded versus not mentally retarded), the effectiveness of each behavioral intervention might differ [58] Attention-deficit–hyperactivity disorder Children with attention-deficit–hyperactivity disorder (ADHD) have been reported to have more bedtime problems (eg, longer time to sleep onset and bedtime resistance) than children without ADHD; however, this remains a controversial issue [22,59] Although parents of children with ADHD may report more bedtime problems [60–64], recent reviews of objective evidence have not demonstrated increased bedtime resistance or time to sleep onset in children with ADHD [65,66] One potential explanation is that longer time to sleep onset is related to medications for ADHD [67] In addition, sleep problems may be caused by a comorbid psychiatric disorder (eg, oppositional defiant disorder) rather than the ADHD Furthermore, it is possible that parents may overreport the severity of both daytime and sleep-related behavior problems in a negative halo effect [61] Behavioral interventions for bedtime problems and nightwakings in children with ADHD are promising, with at least one case series [68] and one small study [69] showing feasibility and parent satisfaction Early implementation of behavioral treatment is critical, because sleep disturbance can exacerbate symptoms of ADHD [70,71] Summary Bedtime problems and night wakings in children are extremely common, and the treatment literature demonstrates strong empiric support 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