The Sleepless Child - Interview with Gary L. Montgomery, M.D.

Gary L. Montgomery, M.D.
Georgia Pediatric Pulmonology Associates, P.C.
Diplomate, American Board of Pediatrics
Diplomate, American Board of Sleep Medicine
Fellow, American Academy of Pediatrics
Atlanta, GA

Listen to this interview now (mp3)

Conducted by Dan Rutz

DAN RUTZ: Any new parent finds out right off the bat that the first thing they're going to lose, for a while at least, is sleep because of an infant's needs. At what point though would we identify a sleep problem in a child, a child's sleeplessness is out of the ordinary?

GARY MONTGOMERY: The simple answer is that I consider it a sleep problem when the parents identify it as a problem. In other words, when the parents realize that they're not getting enough sleep or when their child is crying too much at night. Basically, when they call me and say, I have a problem. The problem with that is that parents often wait much too long to call.

They'll let this go on for weeks or months before they realize hey, things are just too hectic at my house. My child's not sleeping. Then they realize to call somebody and ask for help. One reason they wait so long is because, they don't realize what's out there to help. They don't think there's any help out there.

DAN RUTZ: But still, certainly there is a period of time where a child is not going to be able to sleep through the night because of physical reasons and that's normal.

GARY MONTGOMERY: Sure. Sure.

DAN RUTZ: Help me please to fine tune a little bit more about when you really have cause for concern.

GARY MONTGOMERY: Yeah, babies start to develop a circadian rhythm or a real good day-night sleep pattern as they get into about three or four months of age. Then you start really seeing a difference between the daytime sleep and the nighttime sleep. Nighttime sleep duration increases, daytime sleep decreases. After six to eight months of age, then you get into those discreet two daytime naps and a long sleep period at night.

DAN RUTZ: Can an anxious parent inadvertently aggravate a child's sleep pattern? I mean, can you pick up a baby too much and slow down the habitualization of a sleep pattern?

GARY MONTGOMERY: Yeah, we certainly can. And that's the trigger for most sleep problems is that parents think their doing something good with cuddling their baby, attending to them too fast when they're fussing or crying or not going down easily for sleep at night or during naps. And giving them too much attention at those times then results in irregular sleep patterns and the baby doesn't learn to fall asleep by his or herself.

DAN RUTZ: So, sometimes it's better perhaps to let a child cry it out?

GARY MONTGOMERY: That's right. It is. There's some variations in that theme but that's often the basic tenet to the different things that I teach.

DAN RUTZ: That's awfully tough for a new mom.

GARY MONTGOMERY: It sure is. And that's why I customize it for each family to make sure I do it in a way that will fit in with them. Sometimes it's some gradual withdrawal of the parent from the crib. And sometimes it's more what I call a cold turkey approach. But I really need to customize it and individualize it for each family.

DAN RUTZ: So, it sounds like the first step is really parent education in diagnosing a sleep problem with a baby. But then it can go to another step if you find out in fact there is something going on here beyond a little nervousness or anxiety.

GARY MONTGOMERY: That's right. Education and prevention, of course, is the best thing to start with. But then it goes further and those simple educational things or advice don't work, then we need to be tougher with our intervention.

DAN RUTZ: What kinds of problems are you on the lookout for?

GARY MONTGOMERY: The most common problem would be the baby who has trouble settling at night, the baby that cries a lot when the parents put him or her in the crib. And often when they cry a lot at bedtime then during the night when they have normal arousals, then they'll cry and they need intervention. They can't fall back asleep by themselves.

DAN RUTZ: What's the first thing you would look for? And then after that's ruled out, take me through the steps please.

GARY MONTGOMERY: Well, the parents will present to me with the complaint or problem that the child won't sleep so I need to go through several things. I need to look for medical problems to make sure there's not a physical reason why the baby won't sleep. That's often things that can cause pain, like fever, ear infections, colic, gastro esophageal reflux, which is spitting up and heartburn, acid.

Sometimes there'll be other medical problems like obstructive apnea where the baby is actually having trouble breathing during sleep and that causes him or her to not fall asleep and wake up a lot. So, that's the first thing, is I will rule out those medical problems. The next thing is I find out through talking to the parents what they're doing with their patterns or their routines at night causing difficulties in the baby to fall asleep by him or herself. I call these the behavioral problems, you know, the development problems, the problems that they can fix by just changing their routine.

So I listen for hints of that as the parents are describing a typical night to me. And then the third thing is what we call circadian rhythm problems. And we all have circadian rhythms, times when we're definitely sleepy and times when we're wide awake. Well babies and toddlers will have circadian rhythms too. So I need to make sure the parents aren't trying to put the baby to sleep when the baby really isn't tired.

DAN RUTZ: Is diet ever a factor here? I suppose with an infant, there's not a whole lot going in them. But as a child gets older, or perhaps even with an infant, there's a lactose intolerance. Are there issues here that you need to explore?

GARY MONTGOMERY: There are a few. The most common one on infants would be the feeding schedule that is mixed up and the baby's feeding too much at night and not enough during the day. After four to six months of age, babies don't need any night feedings. So if the baby is waking up hungry, again, it's probably either due to a habit of learning that he or she wants a feeding at night or it's due to the parents just assuming that when the baby's awake, the baby's hungry. So you shift things... Two other things in a diet that can cause problems. One is caffeine, especially in the older children. Some of them are getting a lot of caffeine at night and the evening like cola drinks and things and the parents don't realize it.

DAN RUTZ: With an infant, if a mother, a nursing mother is taking in too much caffeine, can that influence an infant's sleep pattern? Can it get into the breast milk?

GARY MONTGOMERY: That can too, so that caffeine and other things in a mother's diet can affect the sleep problems, so I evaluate that too.

DAN RUTZ: Sometimes people use the term that a baby's got its nights and days mixed up. Is there any validity to that simplistic expression?

GARY MONTGOMERY: There is some. The parents can pattern the sleeping of the infant so that the days and nights truly are mixed up and they sleep longer during the day and less at night. The baby has learned that pattern so we can change it and get the baby to learn a different pattern.

DAN RUTZ: This takes a bit of patience and some time. It's not going to happen over night, is it?

GARY MONTGOMERY: No, definitely not. Definitely a few nights and sometimes a few weeks. I prepare the parents for that.

DAN RUTZ: And again, that's going to be where you might want to turn the stereo up when the baby's crying and just let it go for a few minutes longer.

GARY MONTGOMERY: Right. Sometimes when you do that. Exposure to sunlight during the day really helps train our circadian rhythms too so sometimes I'll have the parents do some other simple things, like take the baby, put the baby in a stroller and go for a walk in the morning. That helps change them from the sleep pattern to the awake pattern during the day.

DAN RUTZ: Lately there's been a great deal of emphasis on the positioning of the infant in the crib - on his back for the minimizing the risk of SIDS. Does sleep position have any effect on sleep quality in a young child?

GARY MONTGOMERY: No it doesn't. The position that the baby is comfortable in is sufficient. And babies are comfortable when they're on their back. So we do agree with the back to sleep position.

DAN RUTZ: What about as children begin to get a little bit older and they may be crawling out of the crib at that point, wanting to come in mom and dad's bed. Generally, ill advised or do you have an opinion on that kind of behavior?

GARY MONTGOMERY: Generally ill advised. Those problems, of course, are much tougher. It's a lot easier to take care of it when they're in the crib. It's kind of a jail cell in their crib and they can't crawl out. But I consider it a problem when they are older, when it does disrupt the family.

For instance, the baby or the toddler will move around a lot during the sleep and if they're in their parents bed, then they'll disrupt the parents' sleep a lot. So it usually does cause a problem in the family, although I need to say that in some families, co-sleeping like that is what they prefer and if it doesn't cause a problem for them, then I don't make it a problem. But often they come to me because both the parents and the child have trouble sleeping.

DAN RUTZ: Sure. Is there a problem here with the child becoming too insecure when it's alone if it's with the parents too much? Do you need to be concerned about that?

GARY MONTGOMERY: Yes, that's my main concern. And that's what I often see with co-sleeping arrangements. Eventually the parents decide that it's time to get the child back to their bed. And then it's very difficult because the child is so used to sleeping with the parents. They're not used to sleeping alone.

DAN RUTZ: As a new parent, when there's enough going on, when you're anxious, having the newborn's crib maybe too close to you, you hear every little thing. Perhaps that interferes with the quality of the parent's sleep.

GARY MONTGOMERY: It sure does. Babies make a lot of noises through the night, even when they are sleeping well. So, I prefer to have the crib in a different room so the parents don't see all those little noises here and there.

DAN RUTZ: What about a light in the room? Again, as a child gets older - realize we're bouncing back and forth between newborn and toddler hood - is it wise to make a big deal about a night-light?

GARY MONTGOMERY: A night-light is okay if it's dim. I mentioned bright light during the day that helps keep you awake. Well, bright light at night will keep you awake too. So, if there's going to be any light, it should be dim. It's perfectly safe to have no light in the room and probably even healthier for sleep for it to be completely dark. So I'd prefer it to be completely dark, but a real dim nightlight is okay.

DAN RUTZ: Is there any pathology around the notion of a child being overtly afraid of the dark?

GARY MONTGOMERY: There can be pathology if the parents make pathology from being afraid of the dark. And that can occur when there's thoughts of monsters or parents' separation or fear that the parents will leave the next day. So, what the parents tell the children about monsters, etc. can make them afraid of the dark.

DAN RUTZ: So, horror stories at bedtime are not probably a good idea?

GARY MONTGOMERY: That's right. I don't like horror stories at bedtime. And I don't like parents who somehow give the kids the notion that monsters are real. We need to make sure that they know that anything they see on T.V. that has to do with monsters isn't real. If you go into a child's closet and check for monsters because the child calls you in the room because there's monsters in my closet, if you say, no, no monsters there, then you're going to leave the room and the child's reassured for only about five minutes because they're going to say, we, there's no monsters in my closet but maybe they're under my bed, so mom, mom. There's a monster under my bed. And it perpetuates.

DAN RUTZ: And this really can become quite a problem, can't it?

GARY MONTGOMERY: It sure does. And children can really be afraid of things like that. So I call those true fears. And we have to teach them that there are no monsters.

DAN RUTZ: I guess sometimes really we have to put ourselves in the mind of a child to try to view the world through their eyes and how the world can be a scary place when you're alone.

GARY MONTGOMERY: That's right. And I use that technique a lot with parents to try to have them look at the world through their child's eyes. And it gives them a totally different perspective.

DAN RUTZ: It sounds like a recurring word here is common sense and really discipline to some extent that are involved in coming about with a healthy and workable sleep routine. Bedtime, is that an important issue?

GARY MONTGOMERY: Bedtime is important. Bedtime for a child needs to be what I call a secure, loving, yet firm interaction time. It's a security and loving time where the parents can really spend some special time with their children. It's firm because they have to go through a certain bedtime routine that the child is used to. And the end of that routine means that the lights are off and you are in your bed alone and you fall asleep. All of that can be a really secure, special time if you make it that way.

DAN RUTZ: What about the child who begs successfully to stay up later?

GARY MONTGOMERY: The key for the parents is to not let the child be successful with that. The parents have to discuss what the bedtime routine is and the bedtime during the day so that the child knows what to expect at night and then stick with it each night. If the kids know what to expect, then they'll do okay with it.

DAN RUTZ: As kids get older, they're going to negotiate from a different perspective. The tactics become different but really the goal is often the same - to have control over that bedtime. This could become an issue I suppose when school starts and a child really needs to be well rested. How much sleep would you say a child really needs to be able to optimally function?

GARY MONTGOMERY: That's a common question I get regarding how much sleep a child needs. And it's difficult to answer in the terms of hours because it's different, of course, for each child, even at a certain age. For the school-aged child, they still need somewhere between 9 and 12 hours of sleep at night. The parents have to find out for their child how much sleep they need.

What I tell parents is that the right amount of sleep is where at the child's bedtime they can fall asleep within 15 to 30 minutes, when it's wake-up time, they can wake up easily. They don't need to keep bugging their child to wake up. And during the day, their child is awake and alert all day. They don't need, when it's school-aged, they don't need a nap during the day. So, if the child can go to bed, fall asleep easily, wake up easily, and not be tired during the day, then they're getting enough sleep.

DAN RUTZ: Do you have an opinion on toys in bed?

GARY MONTGOMERY: For young infants, there shouldn't be any toys in bed because they can get too close to their nose and cause some obstruction and suffocation. So the bed needs to be clear of toys for early infants. For toddlers and older children, it's good to have some transitional objects, something secure to hold on to. And it could be one relatively soft toy or it could be a blanket. Sometimes it's a book.

DAN RUTZ: But as far as the bed becoming a play place?

GARY MONTGOMERY: Right. That's a different story. I don't want the bed to become a play place. I want it to be a place to fall asleep. So, just one object, or one toy to help fall asleep is okay. I don't want a lot of toys there to disrupt the child so they start playing when they need to fall asleep.

DAN RUTZ: Let's talk a little bit now about bedwetting and the point at which that becomes more than a nuisance. Obviously it takes a while for a child to become continent, but there becomes a point when they are and it usually sticks but not always.

GARY MONTGOMERY: If a child has been continent for a while and then starts wetting the bed again then the parents need to make sure they talk to the child's doctor because that could indicate a bladder infection or something. But for the child who's never quite become dry at night and they're getting into the school age years, like for boys into the eight, nine, or ten, for girls, six, seven, or eight and it's still probably normal and they're still going to get better soon. But sometimes parents want some help or some advice on trying to help their children get dry at night faster.

DAN RUTZ: Well, it can be a source of great frustration and embarrassment for the older child I'm sure. Do you consider this first of all to be a sleep disorder? Is it in that family of things?

GARY MONTGOMERY: Yes it is. It's a sleep disorder because it's something occurring at night that causes some havoc or problems in the family. So we deal with this quite a bit too.

DAN RUTZ: Is there an easy answer for it?

GARY MONTGOMERY: No there's not. Like a lot of these problems, there's not an easy answer. But a few things we need to remember is that it's not the child's fault. They're going through developmental maturation. They're learning how to recognize during their sleep that their bladder is full and to be able to actually wake up from sleep to go to the bathroom. And that's really something that we learn. When we're babies and toddlers when our bladder's full at night, it doesn't trigger us to wake up. You know, we just wet in our diaper. So, children truly have to learn that from a neurologic standpoint.

So that my main message to parents is it's not the child's fault and therefore we need to take the punishment out of wetting the bed, make sure the child isn't punished for it. The child can take some responsibility for it, though. And that means that the older children can change into some dry clothes, even at night, when they wake up with it, if they do. After they wet, they can change into some dry clothes. The next day they can take their sheets off and put their sheets and their pajamas in the laundry. Things like that are just responsibility items, not punishment items.

DAN RUTZ: So it tends, perhaps, to reinforce to the child that they have a role in this?

GARY MONTGOMERY: That's right. They're a little bit more responsible for their actions. And it gives them a little bit more incentive to try to stay dry at night.

DAN RUTZ: What about the idea of gold stars on the refrigerator and rewards for a clean week, that kind of thing? That's positive bribery, I suppose, but is there a role for that kind of reinforcement?

GARY MONTGOMERY: That can help some but we have to make sure we don't stress it too much or too early before the child is really able to be dry at night. And again we look at that developmental progression when their bodies physiologically are ready to be dry.

DAN RUTZ: For most kids that's going to be around...

GARY MONTGOMERY: For being dry at night it's more toward the four, five, six year for most kids to be dry at night. They are dry during the day much earlier of course.

DAN RUTZ: Is there an optimal bedtime? Not just how many hours of sleep a child needs but when should they be getting put down?

GARY MONTGOMERY: There actually is an optimal bedtime. The parents need to have the insight to identify it in that child and it's that time in the evening when their child really is starting to slow down and getting physiologically tired, looking like they're slowing down, getting sleepy. That's the time that they should get their bedtime routine done and get the child into bed. If they wait beyond that then the child becomes more sleep deprived and the child's actually trying hard to stay awake. And that's when they get that second wind that all of us as parents know about where they get even more difficult to discipline and handle and they don't make as much sense to the parents and harder to fall asleep.

DAN RUTZ: That's interesting that parents may be really missing the first window where bedtime would be less of an ordeal for them. And waiting until that second wave of energy comes on where it becomes perhaps a real struggle for them to accomplish it.

GARY MONTGOMERY: That's right. And that's a good way to put it. It's a window of opportunity that the parents need to look for, take advantage of, that's the time that the child will fall asleep.

DAN RUTZ: Kids compare notes and when a child hears, well, so and so gets to stay up, why can't I? I mean, every child has pulled that at some point. Sometimes it's hard to win with some kids.

GARY MONTGOMERY: It is. That's certainly a tactic that all the kids know so that they can try to use on their parents and make their parents feel guilty. What I advise parents is to let their child know that they're different than everybody else. Every child is different and this is your bedtime. Johnny's bedtime may be different but this is your bedtime. And I make sure the parents tell them that they're doing that because this is healthy. You'll feel better during the day if you sleep well at night.

DAN RUTZ: Rather than to imply that this is a punishment for the child, that you have to go to bed. Although that's something that people will often threaten a child with, if you don't behave, I'm going to put you to bed. Is that not a good idea, do you think?

GARY MONTGOMERY: It's definitely not. I wish I could throw away all those threats of bedtime because I want bedtime not to be threatening. I want the kids to enjoy it. I want...we can actually teach kids that bedtime can be enjoyable, just like us as adults. We love bedtime, we want to fall asleep. And kids can like bedtime if the parents do make it a special time, some one-on-one time with their child, you know, a story, tucking in, maybe a final drink, and some hugs. And then they'll fall asleep easily.

DAN RUTZ: What about snacks?

GARY MONTGOMERY: One snack before bed is okay. That can be part of the bedtime routine. When the child keeps asking for more and more snacks then they're just trying to pull the chain of the parents and get more attention.

DAN RUTZ: Anything that they should not have for snacks? I mean, is it a good idea to give someone a Twinkie right before they go to bed?

GARY MONTGOMERY: The sugar actually probably doesn't make any difference. But things like caffeine, which can be in some of the drinks, and also in chocolate, things like that, needs to be avoided. I recommend no T.V.s in the bedroom. That's another distraction where it's not easy to fall asleep with the T.V. on, so no T.V. in the bedroom.