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Tuesday, March 11, 2014
Baby Getting Agitated While Sleeping
My 10 weeks old baby started to move arms and legs during her sleep at night, touching her face like something is bothering her. She gets very agitated while sleeping and ends up crying and waking up. She has never had problems sleeping at night until now. She started with this a week ago, one week after her immunizations. When she was 1 week old she had some vomiting events and was very congested. Her doctor told us to drop saline before feeding and to suck her nose regularly. She had a projectile vomit once and for the last 2 weeks hasn`t spit up. She had trouble breathing for 2 weeks due to being congested (no illness related) but now she is ok. She still seems congested even though we have been using saline drops every time she eats. It seems like she has something ion her throat, that never goes away. She coughs and sometimes after a feeding she would cough like she would choke, but then she gets better. She also started to pull back from the breast while eating quite often and wants more 5 seconds later. I exclusively breastfeed her. Her doctor now prescribed zanac as she thinks it might be acid reflux. Her condition hasn`t improved so far. Please help. What else should I do? She seems to be very tired during the day. Thank you!!
My initial thought is that your infants sleep is being interrupted by painful events. Gastroesophageal reflux seems like the likely candidate, given the history of vomiting, pulling away from the breast, and the "congestion" that accompanies her feeding. A clue might be if the infant is crying excessively during the daytime suggesting pain. I suspect the issues more that she is lying flat, probably shortly after feeding, rather than that she's sleeping.
Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus (the tube connecting the mouth to the stomach) and is a normal physiologic process that occurs in all age groups. A pediatric practice base survey estimated that vomiting, a common symptom of GER is noted in 50% of infant's in the first 3 months of life, and in 5% of 12-month-old infants. Gastroesophageal reflux disease (GERD) is associated with symptoms that include feeding difficulties, failure to thrive, recurrent respiratory symptoms, and sleep disturbance. During sleep after feeding when lying flat, children with GERD are at risk to develop esophageal pain (similar to “heartburn” in adults) and sleep disturbances. Sleep appears to be a vulnerable time for children with GERD due to changes in the ability to clear stomach contents from the esophagus, and this may predispose patients to complications such as esophagitis. Sleep-related GERD may also lead to respiratory symptoms such is stridor (high pitched noises during inhalation), chronic cough, and recurrent wheezing. Children appear to awaken less easily during sleep than adults, making it less likely for children with GERD to have sleep disturbances as significant as those seen in adults.
In practice, I find that only about 1/2 of infants seem to respond well to zantac. The wide range of dosing guidelines means that many infants may be under treated when zantac is the first line agent. It would be reasonable to talk with your infant’s doctor about either adjusting the acid suppression by using either a higher zantac dose (depending on where she is dosed in the range for weight) or switching to a different class of drugs called proton pump inhibitors. I would also recommend the use of blocks under one side of her crib or a rolled towel under the mattress to give a slight elevation to the head of her bed. Although it is not practical in the middle of the night, keeping her elevated at least for a short time after feeding may also help her problems.
While prone positioning (lying on the belly) is sometimes tried, it is important to remember that supine (on the back) position is associated with the lowest risk for sudden infant death syndrome for children less than 12 months of age and is recommended by the American Academy of Pediatrics. Please talk with your child’s doctor to determine if more testing is necessary before changes in your infant’s treatment
Mark Splaingard, MD
Clinical Professor of Pediatrics
College of Medicine
The Ohio State University