Aaah, is there any sight more beautiful than a
sleeping child? Their perfect features in innocent repose, their mouths open with the rhythmic flow of their sweet breath, their every pore radiating vulnerability and promise.
And, let's not forget, their blessed unconsciousness and immobility, so they can't bug us for a while with their incessant demands and needs. A mother once told me: "It's a good thing, Dr. P, that my baby didn't come equipped with an on/off switch or he'd be sleeping a whole lot more than he does now."
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That's one good reason to nix
sleeping medications for kids: the irresistible temptation to drug kids into unconsciousness to suit parental convenience. After all, we have competing agendas: kids want to stay awake, adults want them to fall asleep. Using drugs makes it an unfair fight, just too easy to activate the off switch. Furthermore, where do you draw the line? What about the 4-month old who doesn't sleep well? Or a 2- year old?
Even more worrisome: we don't know the long-term side effects of sleep medications on kids. This is especially problematic as most physical growth and the consolidation of long-term memories occur during sleep.
On the other hand, there are many new studies demonstrating how insufficient sleep is wreaking havoc on
children's behavior and development. Children, we are told, need their 8-10 hours or else. The problem is no one knows how to coax kids into sleeping more. So let me ask the unaskable: if they were known to be safe, why not use drugs to that end?
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Before you answer, let's complicate the issue.
There are some developmental disorders (like
ADHD and
autism) in which the lack of sleep clearly has a negative impact on children's behavior and development. It's a clinical issue I frequently face, so I was relieved to see a new study* that examined the effectiveness of melatonin - a natural hormone made by our glands when we sleep - on 107 poorly sleeping, autistic kids.
With a dose of about 1-6 mg, 25% of their parents said the sleep problem had been solved and 60% said it had improved. Better still, only three families reported mild side effects (morning sleepiness, bedwetting).
Maybe you'll agree with me that medications can be a good idea for autistic or ADHD children with sleep problems. Certainly I prescribe them for that reason all the time, often with gratifying results for parent and child. But what about using drugs in 'typical' kids who don't sleep well. Shouldn't they and their parents be allowed the benefits of a full night's rest, especially when there appears to be a 'natural' drug that is both safe and effective?
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Consider this scenario. Let's assume you have a healthy nine year old child, Beckett, who goes to bed at 8, but doesn't fall asleep until midnight. In the morning it's impossible to awaken Beckett and he is wicked cranky to get off to school. Let's assume that you've instituted good 'sleep hygiene' measures (no TV in the room, a consistent bedtime, a consistent bedtime ritual of reading a story, winding down with a bath before falling asleep, etc.). And let's assume Beckett doesn't snore or have signs of disturbed sleep or obstructive sleep apnea.
This was exactly the challenge I recently faced in my practice. Beckett's desperate, bleary-eyed parents wanted me to OK a medication to improve the duration and quality of his sleep. I told them no because of the concerns I already discussed. Am I being appropriately cautious or just a Luddite (i.e., reflexively anti-progress) wimp?
As I later learned, Beckett's parents judged me to be the latter. When I saw them recently (for another reason), his mom looked at me somewhat accusingly and told me that, despite my cautions, they were giving Beckett melatonin and...success! He was falling asleep much earlier and he seemed to be more rested and even-tempered during the day, as were his parents, so whatdoyouthinkofthat Dr. P???
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I know, I know: many of you and many of your kids are just soooo tired. Everyone in the family needs relief. Will you - should you - then choose to give your sleepless in Cheboygan child this 'natural' substance (or the next one that rolls around) that promises to fix the problem without apparent side effects, perchance to dream?
译文:
让宝宝服药入睡，是否是聪明之举？
哇噢，还有什么能比睡着的孩子更美的？他们睡着时天真无邪的完美的样子，他们有节奏地呼吸着，小嘴也随着微张，他们每一个毛孔都散发着稚嫩和希望。
然而，别忘了此时他们是无意识的，静止的，所以他们暂时不会用不断的需求来打扰我们。曾经有个母亲告诉我说：“P医生，要是我的宝宝睡觉不用哄，起床不用叫，或者比现在睡得更久就好了。”
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一个拒绝给孩子服用安眠药的有力理由就是：将孩子麻醉到无意识状态好给父母提供便利，是个不可抵挡的诱惑。毕竟我们有对抗的计划：孩子们想要醒着，大人想要他们睡着。使用药物着实让这场战斗变得不公平，孩子们太容易睡着了，无法刺激“睡着“这个开关。此外，你划定的界线在哪里？是睡得不好的四个月大的宝宝？还是2岁大的？
更加令人不安的是：我们不知道安眠药对孩子有长期的副作用。特别是当睡着的时候发生大多数的生理生长和长期的记忆合并时，问题就更大了。
另一方面，有很多新的研究，论证了睡眠不足对孩子的行为发展有重大破坏作用。我们都知道，孩子需要8-10小时的睡眠时间，或者更多。问题在于没有人知道怎样才能哄孩子多睡会儿。所以让我来问问这个不该问的问题：如果药物是安全的，最后为什么不用药呢？
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回答之前，让我们来看看这个问题的复杂性。
一些发展性紊乱（如多动症和孤独症）体现了睡眠不足对孩子的行为和发展有明显的消极影响。这是我经常面临的临床案例，所以我当我看到一项对107个睡眠质量差，有孤独症的儿童进行的关于褪黑激素——我们睡着时腺自然分泌的一种荷尔蒙——效力的最新研究时，我就放心了。
通过注射一剂量，大约1-6毫克，25%的父母称孩子的睡眠问题解决了，60%的父母称孩子的睡眠质量提高了。更好的消息，只有2个家庭表示有轻微的副作用（如早困，尿床）。
也许你会同意我说的，药物对有睡眠困难的孤独症和多动症孩子是个福音。我确实是因为这个原因，才一直这样开方子，通常也得到了父母和孩子满意的成效。但是，要是给那些睡眠质量不太好的“典型”孩子用药，会怎么样呢？特别是有这样一种既安全又有效的“自然”药物的时候，他们和他们的父母难道不该睡个安稳觉吗？
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考虑一下这样的情形。假设你有一个9岁大的健康宝宝，Beckett，他8点上床，却半夜才睡着。早上把Beckett叫醒几乎不可能，他淘气又暴躁地出发去学校上课。假设你已经建立了一个良好的“睡眠卫生”措施（房间里没有电视机，固定的睡觉时间，睡前要讲故事，睡前冲个凉等等）。假设Beckett不打鼾，也没有任何打扰睡眠或阻碍性的睡眠呼吸暂停的征兆。
这确实是我最近在实践中面对的挑战。绝望的、筋疲力尽的Beckett父母希望我开一剂可以延长睡眠时间，提高睡眠质量的药给他。基于我上述的观点，我拒绝了她们。我是不是开始慢慢谨慎起来，还是我只是个胆小的勒德分子（阻碍自己前进的人）？
后来我知道，Beckett的父母把我认定为后者。当我最近（因为其他原因）见到他们时，他母亲用责难的眼光看着我，告诉我说，虽然我很谨慎，不过她们还是给Beckett吃褪黑激素，而且……成功了！他比以前睡得早，白天看上去休息得更好更镇定了，他的父母也是这样。那P医生你怎么看这件事呢？
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我知道，我知道：你们和你们的孩子大多数都只是太太太累了。家庭中的每个人都需要缓解。你会不会——你应不应该——选择给你失眠的孩子吃这种没有明显副作用，保证解决问题的“自然的”物质（或者是下一种循环的物质），听上去像是在做梦？