Community Paediatric Review Vol 15 No 3

COMMUNITY PAEDIATRIC REVIEW 5

Community Pædiatric Review

A NATIONAL PUBLICATION FOR COMMUNITY CHILD HEALTH NURSES AND OTHER PROFESSIONALS

VOL 15 NO 3 SEPTEMBER 2006

An initiative of the

Centre for Community

Child Health,

Royal Children’s

Hospital, Melbourne

EXECUTIVE INDEX

Sleep and Settling 1

Development in

Infants

Fluid Intake in Infants 5

and Young Children

Sleep and Settling Development in Infants

CENTRE FOR COMMUNITY CHILD HEALTH, THE ROYAL CHILDREN’S HOSPITAL, MELBOURNE

SUPPORTED BY AN

EDUCATIONAL GRANT FROM

It is widely known that an unsettled infant can

be a major cause of stress for some parents.

Not surprisingly infant sleep and settling is a

major component for health professionals

working with families. Of interest is the debate

about what techniques are appropriate for

parents and children. Some organisations have

questioned some settling techniques that could

be detrimental to an infant’s mental health

and/or parent-infant attachment.

When considering sleep and settling

development, it is important to understand the

parameters of sleep to be able to support the

family and plan an appropriate course of

action, if any, for the parent to follow. The

majority of parents already have an idea about

the importance of sleep; however it is the

understanding of the child’s ability to self

regulate that makes the process more difficult

for some parents.

It is important to keep in mind that a parent’s

expectations of sleep patterns may not reflect

the developmental ability of the infant to

regulate themselves. To “sleep through the

night from the day they are born” is an

unrealistic expectation in most cases.

What is sleep?

Sleep is a physical and mental resting state in

which a person becomes relatively inactive and

unaware of their environment. It is worth

remembering however, that infant sleep is as

individual as the infant themselves.

Sleep serves as a restorative function for our

bodies and minds and is very necessary for

normal functioning during the day.

Sleep can be divided into 2 distinct stages.

1) Non-rapid eye movement (REM) sleep –

quiet sleep

It is during this stage that we lie quietly with a

regular heart rate and breathing pattern.There is

very little dreaming happening in this stage and

it is where the most restorative functions occur.

It is in the earliest months of life that the non-

REM sleep divides itself into four stages. It is

these stages that identify progress through

sleep, from drowsiness to a very deep sleep.

Stage I: This is a state of drowsiness, and is a

similar experience to what you might feel as

you are drifting off in a lecture or in front of the

TV. You nod off and may miss some of the

TEL 1800 55 2229

www.rch.org.au/ccch

Editors

Professor Frank Oberklaid

Sharon Foster

Michele Meehan

Dr Jane Redden-Hoare

Vicki Attenborough

Carolyn Briggs

Jenny Donovan

Libby Dawson

Production Editor

Raelene McNaughton

Community Pædiatric Review

SUPPORTED BY AN EDUCATIONAL GRANT FROM

CENTRE FOR COMMUNITY CHILD

HEALTH

THE ROYAL CHILDREN’S HOSPITAL,

MELBOURNE

For further information contact the Centre for Community Child Health, The Royal Children’s Hospital, Melbourne. Phone 03 9345 6150 or Fax 03 9347 2688 www.rch.org.au/ccch

© COPYRIGHT 2006. THIS PUBLICATION IS COPYRIGHT. APART FROM ANY FAIR DEALING FOR THE PURPOSE OF PRIVATE STUDY, RESEARCH, CRITICISM OR REVIEW AS PERMITTED UNDER THE COPYRIGHT ACT, NO PART MAY BE REPRODUCED BY ANY

PROCESS OR PLACED IN COMPUTER MEMORY WITHOUT WRITTEN PERMISSION. ENQUIRIES SHOULD BE MADE TO THE PRODUCTION EDITOR.

TEL 1800 55 2229

Why water is important

Water has many important roles in the body. It helps

transport nutrients, maintains blood volume, regulates

body temperature and removes waste products.

Infants and young children:

• Have a higher metabolic rate which increases heat

production, waste products and fluid requirements.

• Have immature kidneys and do not concentrate urine

as well as adults.

• May not be able to verbalise that they are thirsty and

unlikely to have independent access to beverages.

All these factors contribute to an increased risk of

dehydration in infants and young children.

Dehydration can be life threatening. Symptoms to be

aware of include sunken eyes, decreased urine output,

irritability and dry skin, mouth and eyes. Dehydration can

also contribute to constipation as the colonic contents

become dry and hard, making stools more difficult to

pass.

Fluid requirements

The daily fluid intake for children 0 – 12 months old

should be around 150ml/kg. After 6 months, a portion of

this fluid is provided by solids and it is normal for fluid

intake to decrease.

Children 1 – 5 years old should drink at least one litre

each day. This includes water, milk on cereal and juice.

Best fluid choices are described below.

Best fluid choices

Breast milk is the best fluid for infants under 12 months.

For the first 6 months, it provides all the nutrition the

infant needs. Infant formula should be used for those

infants who are not breast fed. Cow’s milk should not be

introduced as a beverage until the infant is 1 year old,

however, small amounts of cow’s milk may be used in

food (i.e. on breakfast cereal) after 6 months of age.

Tap water is the best drink for children. Water should be

offered to all children over 6 months to supplement fluid

intake and can be offered in a cup from this time. If

children are consuming spring or rain water, a fluoride

supplement may be necessary but this should be

discussed with the child’s dentist.

Milk or milk products are essential for ensuring young

children (over 12 months) have an adequate intake of key

nutrients such as calcium and zinc. However, too much

milk may contribute to nutrient deficiencies as the child

will easily fill up on milk at the detriment of other foods.

Limit milk to 600ml/day and encourage children to eat a

varied diet. Cow’s milk should be offered in a cup, avoid

offering it in a bottle, as this promotes tooth decay and

excessive intake of milk.

What our children are drinking

According to the 1995 National Nutrition Survey, juice

was a popular beverage choice, with 85% of boys, aged

between 2-3 year old, drinking juice (fruit or vegetable) on

the day of the survey compared to 79% who consumed

water. The average intake of juice in this age group was

388ml per day, far above the daily recommendation.

Fruit juice contains the vitamins from fruit but it lacks the

fibre and variety children would be getting if they ate

fresh fruit. If children are drinking juice, it should be

limited to one small glass per day, preferably with a meal.

The percentage of children drinking soft drink was also

alarming, with 26% of all 2-3 year olds and 33% of 4-7

year olds, consuming soft drink on the day of the survey.

Fluid Intake in Infants and Young Children

Problems with too many sweet drinks

Sweet drinks such as cordial, soft drink, sports drinks and

fruit juices are not necessary for children and excess

consumption can contribute to common nutritional

problems.

• Toddler Diarrhoea

Juices and soft drinks are especially concentrated and

some children may find it difficult to digest such large

loads of sucrose or fructose. Managing toddler

diarrhoea may be as simple as removing fruit juice.

• Dental caries

Regular consumption of sweet beverages contributes

to tooth decay and poor oral health. Putting babies or

young children to bed with a bottle also increases the

risk of decay.

• Fussy eating

Always ask what type and volumes of fluids children

are drinking. Children may fill up on sweet drinks or

milk and be less inclined to eat a variety of food.

• Weight gain

Recent research shows soft drinks can contribute to

obesity and industry data suggests that soft drink

intake is increasing. Habits are formed at a young age

and we should be encouraging our children to be

drinking less soft drink and other sweet beverages.

Situations requiring increased fluid requirements

Hot/humid weather and activity

Children playing outdoors or in a car on a warm day can

lose high volumes of fluid and are very susceptible to

dehydration and heat stress. Thirst is not always the best

indicator of hydration and children should be offered fluid

more regularly in the warmer weather, particularly if they

are active.

In hot weather, babies will usually naturally demand more

fluids and it is acceptable to give formula fed babies small

amounts of cool boiled water after the bottle if they seem

extra thirsty. Breast fed babies may need extra breast

feeds and mother should maintain her hydration. It is not

usually necessary to offer water; however, occasionally

this may be needed.

Illness/Fever

When children are unwell they may not feel like drinking

or eating despite an increased need for fluids. This is an

appropriate time to offer flavoured beverages such as

watered down juice or flat and diluted soft drink to

encourage fluid intake and provide some energy

(kilojoules).

Gastroenteritis/Diarrhoea

Maintaining hydration is critical in children with

diarrhoea/gastroenteritis. The principle of fluid

replacement is offering small amounts frequently. Clear

fluids familiar to the child will be accepted but must be

diluted to ensure a glucose solution of about 2%. An Oral

Rehydration Solution (ORS) available from pharmacies

over the counter, may be used. ORS helps to more

effectively restore fluid by replenishing electrolyte

balance. Be mindful that children may refuse some of

these because of the taste. If a child is breast fed then

this should continue during the period of illness.

Author:

Tanya Lewis, Dietitian Children

Youth and Women’s Health Service, South Australia

Reflection Questions

1. During hot weather do you regularly

discuss with parents the increased fluid

needs of their infants and children?

2. Have you recently reviewed your

knowledge of the clinical signs of

dehydration in infants and children?

3. Do you currently discuss with parents the

range of problems that are associated

with sweet drinks?

What milk is best?

Full fat dairy products are recommended for children

under two years of age, skim milk and reduced fat

milks should not be used for this age group.

Between the age of 2 and 5 years, children do not

usually need the extra fat from milk and milk

products, therefore, reduced fat milks are appropriate

from 2 years of age. Skim milk should not be used for

children less than 5 years of age.

Children with allergies or intolerance to cow’s milk

should find a suitable high calcium replacement. Soy

milk is appropriate after 12 months if the child is

eating a varied diet.

Practice Resources

NEW

Professionals now have ready access to evidence-based information on a range of early childhood

concerns as a result of the Centre for Community Child Health’s new online Practice Resources

series. The series is designed to bridge the gap between research and practice, translating

evidence into easily understood, practical information. The topics covered in these resources are:

• Settling and sleep • Language • Smoking

• Behaviour • Literacy • Overweight and obesity

• Breastfeeding • Injury • Eating behaviour

Practice Resources can be downloaded from www.rch.org.au/ccch

2 COMMUNITY PAEDIATRIC REVIEW

COMMUNITY PAEDIATRIC REVIEW 3

conversation. You can wake instantly. This is termed

hypnagogic (the art of falling asleep).

Stage II: As you transition through the drowsiness into

deeper sleep you may experience jerking of the whole

body. This is known as the “Hypnagogic startle” and is

quite normal. You can be woken easily in this stage.

Stage III and IV: At these stages you fall into a deeper

sleep state. Your breathing becomes more stable and

some people sweat profusely and are difficult to wake. If

woken, you have difficulty thinking clearly and wonder

where you are.

2) Rapid eye movement (REM) sleep – an active state

After one or two cycles in non-REM sleep, you will enter

REM sleep. This is a different stage all together. Your

temperature will be impaired, so that you will neither

sweat nor shiver. You are very relaxed and your muscle

tone is also relaxed. This is an active stage and the mind

is alert and dreaming occurs. Your body does not react to

the outside world, only to what is happening in your own

body. You will have rapid eye movements in bursts,

which parallel increased heart rates and blood flow.

Arousal is normal between stages, however it is the

inability to fall back into sleep that can cause problems

for some infants and adults. Infants spend 60% of their

sleep in REM sleep. As they get older than 12 months of

age, this falls to 30% of total sleep.

Cycles of sleep

A newborn can enter REM sleep immediately after falling

asleep. At about 3 months of age a baby will enter non-

REM sleep first and they will do this for the rest of their

life.

During an arousal state from stage IV of non-REM sleep

to REM sleep, the child may call out, sit up, speak

unintelligibly and then return to sleep. Arousal can occur

every 30-40 minutes followed by a REM sleep for 5-10

minutes.

The previous diagram is the author’s version of the sleep

cycle which parents may find useful.

Environmental factors

There are environmental concerns that affect sleep such

as:

• Noisy chaotic home

• Cold or too hot environment

• Inability to be allowed time to sleep

• Parents high expectations of how much sleep is

necessary

• Constant checking of the infant

• No routine

• Stimulated to get to sleep (sleep associations).

Another problem that may exist is between the parent’s

expectations of infant sleep and crying patterns and the

actual crying behaviour of an infant. It is important to

work through this problem so that you can assist the

family to move forward if they’re feeling concerned with

the sleep pattern of their infant.

Sleep regulation

A sleep problem is defined in children of one year as

being a sleep onset problem, associated with fussing that

lasts longer than 30 minutes on a regular basis, or night

waking episodes that occur at least 4 nights a week and

require parental intervention. Whilst this is the definition

of a sleep problem, the practitioner should understand

that if a parent is raising a concern, then this needs to be

addressed regardless of the definition.

A critical sleep reorganisation period is at 8-12 weeks,

which is the establishment of the diurnal cycle. Sleep

regulation and consolidation (settling and sleeping

through the night) is seen as a developmental milestone

by many child health professionals. This consolidation

refers to the ability of infants to sustain sleep in a

continuous fashion for their age – for an appropriate

period of time before fully awaking.

From the wider reading it is evident that up until the

infant is 3 months of age they do not have the ability to

regulate their patterns and have an immature involuntary

response, so that settling techniques may not be hugely

successful prior to 3 months of age.

At 3 months of age, the research tells us that crying

becomes more organised and co-ordinated with visual

regard and gestures. Infants are also able to be soothed

by their parent’s voices at this age.

It is important to keep sleep problems in perspective and

parents need to be reassured that crying is a normal

development for an infant and 70% of infants can self

regulate back to sleep at 3 months and 90% infants do

this regularly at 9 months. So we can see that by 12

months of age, the majority of infants have regulated

themselves and are self soothing and perhaps sleeping

for long periods at night. Remember, there will be some

parents still experiencing difficulty with their child’s sleep

at this stage.

Settling techniques

Settling techniques can be best explained by considering

these techniques as being cognitive management and

behaviour management.

• Cognitive approach

The cognitive approach to settling allows the parent to be

in tune with their infant and understand what is age

appropriate for them.

The main cognitive approach suggested is to allow the

infant (1-3 months of age) to fall asleep on their own at

bed time. This strategy works in 70% of infants by three

months of age; and this then increases to 90% by nine

months of age.

If an infant is put into bed awake they are more likely to

be self soothers compared to those babies who are put to

bed asleep. Infants that require a lot of parental

assistance to go to sleep at night are also more likely to

require further intervention to fall back to sleep during a

wakeful period in the night.

Many parents, (if they accentuate day/night differences),

can assist the infant to learn to regulate sleep and

waking behaviour according to environmental cues. This

may involve a focal feed settling them in a darkened

environment or minimising interaction during the night,

and/or trying not to rock, hold or feed the baby to sleep.

At around 3-6 month of age, parents can regulate the

infant by:

• Moving the infant out of the family bedroom

• Not racing to comfort the infant the moment they

make a sound

• Infants are given greater opportunity to self sooth

• Feeds start to distance themselves apart

• Some may start solid food at 6 months of age

• Nighttime feeds become less interactive

Other techniques to encourage sleep are:

• Identification of a child’s unique tired signs and acting

on these as soon as possible.

• Monitoring the baby’s crying by listening and getting

to know their own infant’s crying and acting

accordingly.

• Reassuring parents that short crying periods at

settling times are normal and it may take 10 minutes

of crying and grizzling to allow the infant to self settle

to sleep.

In most cases these small/subtle settling techniques can

be enough of a signal for the infant to relax into a sleep.

• Behaviour modification ideas

Behaviour modification strategies tend to come into play

when cognitive techniques are in place and the infant and

family are continuing to struggle to find a balance in their

routine.

There has been much discussion on the different types of

behaviour modification strategies, particularly the

controlled crying / comfort settling / extinction methods.

From the evidence, it is paramount when considering

using a behaviour modification technique that the health

professional completes a full assessment of the situation

and assesses whether a technique such as this should be

recommended.

It is important not to recommend a controlled crying

technique unless you are able to support and closely

follow up while parents are using the technique.

It is also advisable that behaviour extinction methods not

be used for an infant who is aged less than 6-8 months

of age.

Another cautionary note would be that the parents need

to listen to their infant’s need and cries and monitor how

they are managing when using a technique such as

controlled crying / extinction.

Food for thought

From literature reviews and meta-analyses, it is evident

that there needs to be many questions clarified in relation

to the technique for sleep and settling. It is important that

we consider all opportunities to gather evidence and

research, to develop and review current best practice.

Some questions that need to be answered are:

• What are different cultural theories and expectations

on sleep for infants?

• What is an accepted level/length of crying?

• How does the use of behavioural modification

techniques affect maternal attachment and the ability

to respond to their infant? And visa versa.

Author:

Megan Leuenberger

Families First Project Officer/

Parenting Co-ordinator, NSW

Useful websites for parent information on sleep and

settling:

• Raising Children Network – raisingchildren.net.au

• Child and Youth Health – www.cyh.com

Reflection Questions

1. How informed are you about infant tired

signs? Can you confidently explain these

to parents?

2. How do you personally feel about

behaviour modification techniques?

Would you use or recommend them to

parents? Would your decision be based

on evidence or personal feelings?

3. Consider the demographic and cultural

characteristics of the parents attending

your services. What are their

expectations on sleep for infants?

Are these realistic?

Infant Sleep Cycle

Newborns go into REM sleep immediately (10 min)

2 COMMUNITY PAEDIATRIC REVIEW

COMMUNITY PAEDIATRIC REVIEW 3

conversation. You can wake instantly. This is termed

hypnagogic (the art of falling asleep).

Stage II: As you transition through the drowsiness into

deeper sleep you may experience jerking of the whole

body. This is known as the “Hypnagogic startle” and is

quite normal. You can be woken easily in this stage.

Stage III and IV: At these stages you fall into a deeper

sleep state. Your breathing becomes more stable and

some people sweat profusely and are difficult to wake. If

woken, you have difficulty thinking clearly and wonder

where you are.

2) Rapid eye movement (REM) sleep – an active state

After one or two cycles in non-REM sleep, you will enter

REM sleep. This is a different stage all together. Your

temperature will be impaired, so that you will neither

sweat nor shiver. You are very relaxed and your muscle

tone is also relaxed. This is an active stage and the mind

is alert and dreaming occurs. Your body does not react to

the outside world, only to what is happening in your own

body. You will have rapid eye movements in bursts,

which parallel increased heart rates and blood flow.

Arousal is normal between stages, however it is the

inability to fall back into sleep that can cause problems

for some infants and adults. Infants spend 60% of their

sleep in REM sleep. As they get older than 12 months of

age, this falls to 30% of total sleep.

Cycles of sleep

A newborn can enter REM sleep immediately after falling

asleep. At about 3 months of age a baby will enter non-

REM sleep first and they will do this for the rest of their

life.

During an arousal state from stage IV of non-REM sleep

to REM sleep, the child may call out, sit up, speak

unintelligibly and then return to sleep. Arousal can occur

every 30-40 minutes followed by a REM sleep for 5-10

minutes.

The previous diagram is the author’s version of the sleep

cycle which parents may find useful.

Environmental factors

There are environmental concerns that affect sleep such

as:

• Noisy chaotic home

• Cold or too hot environment

• Inability to be allowed time to sleep

• Parents high expectations of how much sleep is

necessary

• Constant checking of the infant

• No routine

• Stimulated to get to sleep (sleep associations).

Another problem that may exist is between the parent’s

expectations of infant sleep and crying patterns and the

actual crying behaviour of an infant. It is important to

work through this problem so that you can assist the

family to move forward if they’re feeling concerned with

the sleep pattern of their infant.

Sleep regulation

A sleep problem is defined in children of one year as

being a sleep onset problem, associated with fussing that

lasts longer than 30 minutes on a regular basis, or night

waking episodes that occur at least 4 nights a week and

require parental intervention. Whilst this is the definition

of a sleep problem, the practitioner should understand

that if a parent is raising a concern, then this needs to be

addressed regardless of the definition.

A critical sleep reorganisation period is at 8-12 weeks,

which is the establishment of the diurnal cycle. Sleep

regulation and consolidation (settling and sleeping

through the night) is seen as a developmental milestone

by many child health professionals. This consolidation

refers to the ability of infants to sustain sleep in a

continuous fashion for their age – for an appropriate

period of time before fully awaking.

From the wider reading it is evident that up until the

infant is 3 months of age they do not have the ability to

regulate their patterns and have an immature involuntary

response, so that settling techniques may not be hugely

successful prior to 3 months of age.

At 3 months of age, the research tells us that crying

becomes more organised and co-ordinated with visual

regard and gestures. Infants are also able to be soothed

by their parent’s voices at this age.

It is important to keep sleep problems in perspective and

parents need to be reassured that crying is a normal

development for an infant and 70% of infants can self

regulate back to sleep at 3 months and 90% infants do

this regularly at 9 months. So we can see that by 12

months of age, the majority of infants have regulated

themselves and are self soothing and perhaps sleeping

for long periods at night. Remember, there will be some

parents still experiencing difficulty with their child’s sleep

at this stage.

Settling techniques

Settling techniques can be best explained by considering

these techniques as being cognitive management and

behaviour management.

• Cognitive approach

The cognitive approach to settling allows the parent to be

in tune with their infant and understand what is age

appropriate for them.

The main cognitive approach suggested is to allow the

infant (1-3 months of age) to fall asleep on their own at

bed time. This strategy works in 70% of infants by three

months of age; and this then increases to 90% by nine

months of age.

If an infant is put into bed awake they are more likely to

be self soothers compared to those babies who are put to

bed asleep. Infants that require a lot of parental

assistance to go to sleep at night are also more likely to

require further intervention to fall back to sleep during a

wakeful period in the night.

Many parents, (if they accentuate day/night differences),

can assist the infant to learn to regulate sleep and

waking behaviour according to environmental cues. This

may involve a focal feed settling them in a darkened

environment or minimising interaction during the night,

and/or trying not to rock, hold or feed the baby to sleep.

At around 3-6 month of age, parents can regulate the

infant by:

• Moving the infant out of the family bedroom

• Not racing to comfort the infant the moment they

make a sound

• Infants are given greater opportunity to self sooth

• Feeds start to distance themselves apart

• Some may start solid food at 6 months of age

• Nighttime feeds become less interactive

Other techniques to encourage sleep are:

• Identification of a child’s unique tired signs and acting

on these as soon as possible.

• Monitoring the baby’s crying by listening and getting

to know their own infant’s crying and acting

accordingly.

• Reassuring parents that short crying periods at

settling times are normal and it may take 10 minutes

of crying and grizzling to allow the infant to self settle

to sleep.

In most cases these small/subtle settling techniques can

be enough of a signal for the infant to relax into a sleep.

• Behaviour modification ideas

Behaviour modification strategies tend to come into play

when cognitive techniques are in place and the infant and

family are continuing to struggle to find a balance in their

routine.

There has been much discussion on the different types of

behaviour modification strategies, particularly the

controlled crying / comfort settling / extinction methods.

From the evidence, it is paramount when considering

using a behaviour modification technique that the health

professional completes a full assessment of the situation

and assesses whether a technique such as this should be

recommended.

It is important not to recommend a controlled crying

technique unless you are able to support and closely

follow up while parents are using the technique.

It is also advisable that behaviour extinction methods not

be used for an infant who is aged less than 6-8 months

of age.

Another cautionary note would be that the parents need

to listen to their infant’s need and cries and monitor how

they are managing when using a technique such as

controlled crying / extinction.

Food for thought

From literature reviews and meta-analyses, it is evident

that there needs to be many questions clarified in relation

to the technique for sleep and settling. It is important that

we consider all opportunities to gather evidence and

research, to develop and review current best practice.

Some questions that need to be answered are:

• What are different cultural theories and expectations

on sleep for infants?

• What is an accepted level/length of crying?

• How does the use of behavioural modification

techniques affect maternal attachment and the ability

to respond to their infant? And visa versa.

Author:

Megan Leuenberger

Families First Project Officer/

Parenting Co-ordinator, NSW

Useful websites for parent information on sleep and

settling:

• Raising Children Network – raisingchildren.net.au

• Child and Youth Health – www.cyh.com

Reflection Questions

1. How informed are you about infant tired

signs? Can you confidently explain these

to parents?

2. How do you personally feel about

behaviour modification techniques?

Would you use or recommend them to

parents? Would your decision be based

on evidence or personal feelings?

3. Consider the demographic and cultural

characteristics of the parents attending

your services. What are their

expectations on sleep for infants?

Are these realistic?

Infant Sleep Cycle

Newborns go into REM sleep immediately (10 min)

2 COMMUNITY PAEDIATRIC REVIEW

COMMUNITY PAEDIATRIC REVIEW 3

conversation. You can wake instantly. This is termed

hypnagogic (the art of falling asleep).

Stage II: As you transition through the drowsiness into

deeper sleep you may experience jerking of the whole

body. This is known as the “Hypnagogic startle” and is

quite normal. You can be woken easily in this stage.

Stage III and IV: At these stages you fall into a deeper

sleep state. Your breathing becomes more stable and

some people sweat profusely and are difficult to wake. If

woken, you have difficulty thinking clearly and wonder

where you are.

2) Rapid eye movement (REM) sleep – an active state

After one or two cycles in non-REM sleep, you will enter

REM sleep. This is a different stage all together. Your

temperature will be impaired, so that you will neither

sweat nor shiver. You are very relaxed and your muscle

tone is also relaxed. This is an active stage and the mind

is alert and dreaming occurs. Your body does not react to

the outside world, only to what is happening in your own

body. You will have rapid eye movements in bursts,

which parallel increased heart rates and blood flow.

Arousal is normal between stages, however it is the

inability to fall back into sleep that can cause problems

for some infants and adults. Infants spend 60% of their

sleep in REM sleep. As they get older than 12 months of

age, this falls to 30% of total sleep.

Cycles of sleep

A newborn can enter REM sleep immediately after falling

asleep. At about 3 months of age a baby will enter non-

REM sleep first and they will do this for the rest of their

life.

During an arousal state from stage IV of non-REM sleep

to REM sleep, the child may call out, sit up, speak

unintelligibly and then return to sleep. Arousal can occur

every 30-40 minutes followed by a REM sleep for 5-10

minutes.

The previous diagram is the author’s version of the sleep

cycle which parents may find useful.

Environmental factors

There are environmental concerns that affect sleep such

as:

• Noisy chaotic home

• Cold or too hot environment

• Inability to be allowed time to sleep

• Parents high expectations of how much sleep is

necessary

• Constant checking of the infant

• No routine

• Stimulated to get to sleep (sleep associations).

Another problem that may exist is between the parent’s

expectations of infant sleep and crying patterns and the

actual crying behaviour of an infant. It is important to

work through this problem so that you can assist the

family to move forward if they’re feeling concerned with

the sleep pattern of their infant.

Sleep regulation

A sleep problem is defined in children of one year as

being a sleep onset problem, associated with fussing that

lasts longer than 30 minutes on a regular basis, or night

waking episodes that occur at least 4 nights a week and

require parental intervention. Whilst this is the definition

of a sleep problem, the practitioner should understand

that if a parent is raising a concern, then this needs to be

addressed regardless of the definition.

A critical sleep reorganisation period is at 8-12 weeks,

which is the establishment of the diurnal cycle. Sleep

regulation and consolidation (settling and sleeping

through the night) is seen as a developmental milestone

by many child health professionals. This consolidation

refers to the ability of infants to sustain sleep in a

continuous fashion for their age – for an appropriate

period of time before fully awaking.

From the wider reading it is evident that up until the

infant is 3 months of age they do not have the ability to

regulate their patterns and have an immature involuntary

response, so that settling techniques may not be hugely

successful prior to 3 months of age.

At 3 months of age, the research tells us that crying

becomes more organised and co-ordinated with visual

regard and gestures. Infants are also able to be soothed

by their parent’s voices at this age.

It is important to keep sleep problems in perspective and

parents need to be reassured that crying is a normal

development for an infant and 70% of infants can self

regulate back to sleep at 3 months and 90% infants do

this regularly at 9 months. So we can see that by 12

months of age, the majority of infants have regulated

themselves and are self soothing and perhaps sleeping

for long periods at night. Remember, there will be some

parents still experiencing difficulty with their child’s sleep

at this stage.

Settling techniques

Settling techniques can be best explained by considering

these techniques as being cognitive management and

behaviour management.

• Cognitive approach

The cognitive approach to settling allows the parent to be

in tune with their infant and understand what is age

appropriate for them.

The main cognitive approach suggested is to allow the

infant (1-3 months of age) to fall asleep on their own at

bed time. This strategy works in 70% of infants by three

months of age; and this then increases to 90% by nine

months of age.

If an infant is put into bed awake they are more likely to

be self soothers compared to those babies who are put to

bed asleep. Infants that require a lot of parental

assistance to go to sleep at night are also more likely to

require further intervention to fall back to sleep during a

wakeful period in the night.

Many parents, (if they accentuate day/night differences),

can assist the infant to learn to regulate sleep and

waking behaviour according to environmental cues. This

may involve a focal feed settling them in a darkened

environment or minimising interaction during the night,

and/or trying not to rock, hold or feed the baby to sleep.

At around 3-6 month of age, parents can regulate the

infant by:

• Moving the infant out of the family bedroom

• Not racing to comfort the infant the moment they

make a sound

• Infants are given greater opportunity to self sooth

• Feeds start to distance themselves apart

• Some may start solid food at 6 months of age

• Nighttime feeds become less interactive

Other techniques to encourage sleep are:

• Identification of a child’s unique tired signs and acting

on these as soon as possible.

• Monitoring the baby’s crying by listening and getting

to know their own infant’s crying and acting

accordingly.

• Reassuring parents that short crying periods at

settling times are normal and it may take 10 minutes

of crying and grizzling to allow the infant to self settle

to sleep.

In most cases these small/subtle settling techniques can

be enough of a signal for the infant to relax into a sleep.

• Behaviour modification ideas

Behaviour modification strategies tend to come into play

when cognitive techniques are in place and the infant and

family are continuing to struggle to find a balance in their

routine.

There has been much discussion on the different types of

behaviour modification strategies, particularly the

controlled crying / comfort settling / extinction methods.

From the evidence, it is paramount when considering

using a behaviour modification technique that the health

professional completes a full assessment of the situation

and assesses whether a technique such as this should be

recommended.

It is important not to recommend a controlled crying

technique unless you are able to support and closely

follow up while parents are using the technique.

It is also advisable that behaviour extinction methods not

be used for an infant who is aged less than 6-8 months

of age.

Another cautionary note would be that the parents need

to listen to their infant’s need and cries and monitor how

they are managing when using a technique such as

controlled crying / extinction.

Food for thought

From literature reviews and meta-analyses, it is evident

that there needs to be many questions clarified in relation

to the technique for sleep and settling. It is important that

we consider all opportunities to gather evidence and

research, to develop and review current best practice.

Some questions that need to be answered are:

• What are different cultural theories and expectations

on sleep for infants?

• What is an accepted level/length of crying?

• How does the use of behavioural modification

techniques affect maternal attachment and the ability

to respond to their infant? And visa versa.

Author:

Megan Leuenberger

Families First Project Officer/

Parenting Co-ordinator, NSW

Useful websites for parent information on sleep and

settling:

• Raising Children Network – raisingchildren.net.au

• Child and Youth Health – www.cyh.com

Reflection Questions

1. How informed are you about infant tired

signs? Can you confidently explain these

to parents?

2. How do you personally feel about

behaviour modification techniques?

Would you use or recommend them to

parents? Would your decision be based

on evidence or personal feelings?

3. Consider the demographic and cultural

characteristics of the parents attending

your services. What are their

expectations on sleep for infants?

Are these realistic?

Infant Sleep Cycle

Newborns go into REM sleep immediately (10 min)

COMMUNITY PAEDIATRIC REVIEW 5

Community Pædiatric Review

A NATIONAL PUBLICATION FOR COMMUNITY CHILD HEALTH NURSES AND OTHER PROFESSIONALS

VOL 15 NO 3 SEPTEMBER 2006

An initiative of the

Centre for Community

Child Health,

Royal Children’s

Hospital, Melbourne

EXECUTIVE INDEX

Sleep and Settling 1

Development in

Infants

Fluid Intake in Infants 5

and Young Children

Sleep and Settling Development in Infants

CENTRE FOR COMMUNITY CHILD HEALTH, THE ROYAL CHILDREN’S HOSPITAL, MELBOURNE

SUPPORTED BY AN

EDUCATIONAL GRANT FROM

It is widely known that an unsettled infant can

be a major cause of stress for some parents.

Not surprisingly infant sleep and settling is a

major component for health professionals

working with families. Of interest is the debate

about what techniques are appropriate for

parents and children. Some organisations have

questioned some settling techniques that could

be detrimental to an infant’s mental health

and/or parent-infant attachment.

When considering sleep and settling

development, it is important to understand the

parameters of sleep to be able to support the

family and plan an appropriate course of

action, if any, for the parent to follow. The

majority of parents already have an idea about

the importance of sleep; however it is the

understanding of the child’s ability to self

regulate that makes the process more difficult

for some parents.

It is important to keep in mind that a parent’s

expectations of sleep patterns may not reflect

the developmental ability of the infant to

regulate themselves. To “sleep through the

night from the day they are born” is an

unrealistic expectation in most cases.

What is sleep?

Sleep is a physical and mental resting state in

which a person becomes relatively inactive and

unaware of their environment. It is worth

remembering however, that infant sleep is as

individual as the infant themselves.

Sleep serves as a restorative function for our

bodies and minds and is very necessary for

normal functioning during the day.

Sleep can be divided into 2 distinct stages.

1) Non-rapid eye movement (REM) sleep –

quiet sleep

It is during this stage that we lie quietly with a

regular heart rate and breathing pattern.There is

very little dreaming happening in this stage and

it is where the most restorative functions occur.

It is in the earliest months of life that the non-

REM sleep divides itself into four stages. It is

these stages that identify progress through

sleep, from drowsiness to a very deep sleep.

Stage I: This is a state of drowsiness, and is a

similar experience to what you might feel as

you are drifting off in a lecture or in front of the

TV. You nod off and may miss some of the

TEL 1800 55 2229

www.rch.org.au/ccch

Editors

Professor Frank Oberklaid

Sharon Foster

Michele Meehan

Dr Jane Redden-Hoare

Vicki Attenborough

Carolyn Briggs

Jenny Donovan

Libby Dawson

Production Editor

Raelene McNaughton

Community Pædiatric Review

SUPPORTED BY AN EDUCATIONAL GRANT FROM

CENTRE FOR COMMUNITY CHILD

HEALTH

THE ROYAL CHILDREN’S HOSPITAL,

MELBOURNE

For further information contact the Centre for Community Child Health, The Royal Children’s Hospital, Melbourne. Phone 03 9345 6150 or Fax 03 9347 2688 www.rch.org.au/ccch

PROCESS OR PLACED IN COMPUTER MEMORY WITHOUT WRITTEN PERMISSION. ENQUIRIES SHOULD BE MADE TO THE PRODUCTION EDITOR.

TEL 1800 55 2229

Why water is important

Water has many important roles in the body. It helps

transport nutrients, maintains blood volume, regulates

body temperature and removes waste products.

Infants and young children:

• Have a higher metabolic rate which increases heat

production, waste products and fluid requirements.

• Have immature kidneys and do not concentrate urine

as well as adults.

• May not be able to verbalise that they are thirsty and

unlikely to have independent access to beverages.

All these factors contribute to an increased risk of

dehydration in infants and young children.

Dehydration can be life threatening. Symptoms to be

aware of include sunken eyes, decreased urine output,

irritability and dry skin, mouth and eyes. Dehydration can

also contribute to constipation as the colonic contents

become dry and hard, making stools more difficult to

pass.

Fluid requirements

The daily fluid intake for children 0 – 12 months old

should be around 150ml/kg. After 6 months, a portion of

this fluid is provided by solids and it is normal for fluid

intake to decrease.

Children 1 – 5 years old should drink at least one litre

each day. This includes water, milk on cereal and juice.

Best fluid choices are described below.

Best fluid choices

Breast milk is the best fluid for infants under 12 months.

For the first 6 months, it provides all the nutrition the

infant needs. Infant formula should be used for those

infants who are not breast fed. Cow’s milk should not be

introduced as a beverage until the infant is 1 year old,

however, small amounts of cow’s milk may be used in

food (i.e. on breakfast cereal) after 6 months of age.

Tap water is the best drink for children. Water should be

offered to all children over 6 months to supplement fluid

intake and can be offered in a cup from this time. If

children are consuming spring or rain water, a fluoride

supplement may be necessary but this should be

discussed with the child’s dentist.

Milk or milk products are essential for ensuring young

children (over 12 months) have an adequate intake of key

nutrients such as calcium and zinc. However, too much

milk may contribute to nutrient deficiencies as the child

will easily fill up on milk at the detriment of other foods.

Limit milk to 600ml/day and encourage children to eat a

varied diet. Cow’s milk should be offered in a cup, avoid

offering it in a bottle, as this promotes tooth decay and

excessive intake of milk.

What our children are drinking

According to the 1995 National Nutrition Survey, juice

was a popular beverage choice, with 85% of boys, aged

between 2-3 year old, drinking juice (fruit or vegetable) on

the day of the survey compared to 79% who consumed

water. The average intake of juice in this age group was

388ml per day, far above the daily recommendation.

Fruit juice contains the vitamins from fruit but it lacks the

fibre and variety children would be getting if they ate

fresh fruit. If children are drinking juice, it should be

limited to one small glass per day, preferably with a meal.

The percentage of children drinking soft drink was also

alarming, with 26% of all 2-3 year olds and 33% of 4-7

year olds, consuming soft drink on the day of the survey.

Fluid Intake in Infants and Young Children

Problems with too many sweet drinks

Sweet drinks such as cordial, soft drink, sports drinks and

fruit juices are not necessary for children and excess

consumption can contribute to common nutritional

problems.

• Toddler Diarrhoea

Juices and soft drinks are especially concentrated and

some children may find it difficult to digest such large

loads of sucrose or fructose. Managing toddler

diarrhoea may be as simple as removing fruit juice.

• Dental caries

Regular consumption of sweet beverages contributes

to tooth decay and poor oral health. Putting babies or

young children to bed with a bottle also increases the

risk of decay.

• Fussy eating

Always ask what type and volumes of fluids children

are drinking. Children may fill up on sweet drinks or

milk and be less inclined to eat a variety of food.

• Weight gain

Recent research shows soft drinks can contribute to

obesity and industry data suggests that soft drink

intake is increasing. Habits are formed at a young age

and we should be encouraging our children to be

drinking less soft drink and other sweet beverages.

Situations requiring increased fluid requirements

Hot/humid weather and activity

Children playing outdoors or in a car on a warm day can

lose high volumes of fluid and are very susceptible to

dehydration and heat stress. Thirst is not always the best

indicator of hydration and children should be offered fluid

more regularly in the warmer weather, particularly if they

are active.

In hot weather, babies will usually naturally demand more

fluids and it is acceptable to give formula fed babies small

amounts of cool boiled water after the bottle if they seem

extra thirsty. Breast fed babies may need extra breast

feeds and mother should maintain her hydration. It is not

usually necessary to offer water; however, occasionally

this may be needed.

Illness/Fever

When children are unwell they may not feel like drinking

or eating despite an increased need for fluids. This is an

appropriate time to offer flavoured beverages such as

watered down juice or flat and diluted soft drink to

encourage fluid intake and provide some energy

(kilojoules).

Gastroenteritis/Diarrhoea

Maintaining hydration is critical in children with

diarrhoea/gastroenteritis. The principle of fluid

replacement is offering small amounts frequently. Clear

fluids familiar to the child will be accepted but must be

diluted to ensure a glucose solution of about 2%. An Oral

Rehydration Solution (ORS) available from pharmacies

over the counter, may be used. ORS helps to more

effectively restore fluid by replenishing electrolyte

balance. Be mindful that children may refuse some of

these because of the taste. If a child is breast fed then

this should continue during the period of illness.

Author:

Tanya Lewis, Dietitian Children

Youth and Women’s Health Service, South Australia

Reflection Questions

1. During hot weather do you regularly

discuss with parents the increased fluid

needs of their infants and children?

2. Have you recently reviewed your

knowledge of the clinical signs of

dehydration in infants and children?

3. Do you currently discuss with parents the

range of problems that are associated

with sweet drinks?

What milk is best?

Full fat dairy products are recommended for children

under two years of age, skim milk and reduced fat

milks should not be used for this age group.

Between the age of 2 and 5 years, children do not

usually need the extra fat from milk and milk

products, therefore, reduced fat milks are appropriate

from 2 years of age. Skim milk should not be used for

children less than 5 years of age.

Children with allergies or intolerance to cow’s milk

should find a suitable high calcium replacement. Soy

milk is appropriate after 12 months if the child is

eating a varied diet.

Practice Resources

NEW

Professionals now have ready access to evidence-based information on a range of early childhood

concerns as a result of the Centre for Community Child Health’s new online Practice Resources

series. The series is designed to bridge the gap between research and practice, translating

evidence into easily understood, practical information. The topics covered in these resources are:

• Settling and sleep • Language • Smoking

• Behaviour • Literacy • Overweight and obesity

• Breastfeeding • Injury • Eating behaviour

Practice Resources can be downloaded from www.rch.org.au/ccch

COMMUNITY PAEDIATRIC REVIEW 5

Community Pædiatric Review

A NATIONAL PUBLICATION FOR COMMUNITY CHILD HEALTH NURSES AND OTHER PROFESSIONALS

VOL 15 NO 3 SEPTEMBER 2006

An initiative of the

Centre for Community

Child Health,

Royal Children’s

Hospital, Melbourne

EXECUTIVE INDEX

Sleep and Settling 1

Development in

Infants

Fluid Intake in Infants 5

and Young Children

Sleep and Settling Development in Infants

CENTRE FOR COMMUNITY CHILD HEALTH, THE ROYAL CHILDREN’S HOSPITAL, MELBOURNE

SUPPORTED BY AN

EDUCATIONAL GRANT FROM

It is widely known that an unsettled infant can

be a major cause of stress for some parents.

Not surprisingly infant sleep and settling is a

major component for health professionals

working with families. Of interest is the debate

about what techniques are appropriate for

parents and children. Some organisations have

questioned some settling techniques that could

be detrimental to an infant’s mental health

and/or parent-infant attachment.

When considering sleep and settling

development, it is important to understand the

parameters of sleep to be able to support the

family and plan an appropriate course of

action, if any, for the parent to follow. The

majority of parents already have an idea about

the importance of sleep; however it is the

understanding of the child’s ability to self

regulate that makes the process more difficult

for some parents.

It is important to keep in mind that a parent’s

expectations of sleep patterns may not reflect

the developmental ability of the infant to

regulate themselves. To “sleep through the

night from the day they are born” is an

unrealistic expectation in most cases.

What is sleep?

Sleep is a physical and mental resting state in

which a person becomes relatively inactive and

unaware of their environment. It is worth

remembering however, that infant sleep is as

individual as the infant themselves.

Sleep serves as a restorative function for our

bodies and minds and is very necessary for

normal functioning during the day.

Sleep can be divided into 2 distinct stages.

1) Non-rapid eye movement (REM) sleep –

quiet sleep

It is during this stage that we lie quietly with a

regular heart rate and breathing pattern.There is

very little dreaming happening in this stage and

it is where the most restorative functions occur.

It is in the earliest months of life that the non-

REM sleep divides itself into four stages. It is

these stages that identify progress through

sleep, from drowsiness to a very deep sleep.

Stage I: This is a state of drowsiness, and is a

similar experience to what you might feel as

you are drifting off in a lecture or in front of the

TV. You nod off and may miss some of the

TEL 1800 55 2229

www.rch.org.au/ccch

Editors

Professor Frank Oberklaid

Sharon Foster

Michele Meehan

Dr Jane Redden-Hoare

Vicki Attenborough

Carolyn Briggs

Jenny Donovan

Libby Dawson

Production Editor

Raelene McNaughton

Community Pædiatric Review

SUPPORTED BY AN EDUCATIONAL GRANT FROM

CENTRE FOR COMMUNITY CHILD

HEALTH

THE ROYAL CHILDREN’S HOSPITAL,

MELBOURNE

For further information contact the Centre for Community Child Health, The Royal Children’s Hospital, Melbourne. Phone 03 9345 6150 or Fax 03 9347 2688 www.rch.org.au/ccch

PROCESS OR PLACED IN COMPUTER MEMORY WITHOUT WRITTEN PERMISSION. ENQUIRIES SHOULD BE MADE TO THE PRODUCTION EDITOR.

TEL 1800 55 2229

Why water is important

Water has many important roles in the body. It helps

transport nutrients, maintains blood volume, regulates

body temperature and removes waste products.

Infants and young children:

• Have a higher metabolic rate which increases heat

production, waste products and fluid requirements.

• Have immature kidneys and do not concentrate urine

as well as adults.

• May not be able to verbalise that they are thirsty and

unlikely to have independent access to beverages.

All these factors contribute to an increased risk of

dehydration in infants and young children.

Dehydration can be life threatening. Symptoms to be

aware of include sunken eyes, decreased urine output,

irritability and dry skin, mouth and eyes. Dehydration can

also contribute to constipation as the colonic contents

become dry and hard, making stools more difficult to

pass.

Fluid requirements

The daily fluid intake for children 0 – 12 months old

should be around 150ml/kg. After 6 months, a portion of

this fluid is provided by solids and it is normal for fluid

intake to decrease.

Children 1 – 5 years old should drink at least one litre

each day. This includes water, milk on cereal and juice.

Best fluid choices are described below.

Best fluid choices

Breast milk is the best fluid for infants under 12 months.

For the first 6 months, it provides all the nutrition the

infant needs. Infant formula should be used for those

infants who are not breast fed. Cow’s milk should not be

introduced as a beverage until the infant is 1 year old,

however, small amounts of cow’s milk may be used in

food (i.e. on breakfast cereal) after 6 months of age.

Tap water is the best drink for children. Water should be

offered to all children over 6 months to supplement fluid

intake and can be offered in a cup from this time. If

children are consuming spring or rain water, a fluoride

supplement may be necessary but this should be

discussed with the child’s dentist.

Milk or milk products are essential for ensuring young

children (over 12 months) have an adequate intake of key

nutrients such as calcium and zinc. However, too much

milk may contribute to nutrient deficiencies as the child

will easily fill up on milk at the detriment of other foods.

Limit milk to 600ml/day and encourage children to eat a

varied diet. Cow’s milk should be offered in a cup, avoid

offering it in a bottle, as this promotes tooth decay and

excessive intake of milk.

What our children are drinking

According to the 1995 National Nutrition Survey, juice

was a popular beverage choice, with 85% of boys, aged

between 2-3 year old, drinking juice (fruit or vegetable) on

the day of the survey compared to 79% who consumed

water. The average intake of juice in this age group was

388ml per day, far above the daily recommendation.

Fruit juice contains the vitamins from fruit but it lacks the

fibre and variety children would be getting if they ate

fresh fruit. If children are drinking juice, it should be

limited to one small glass per day, preferably with a meal.

The percentage of children drinking soft drink was also

alarming, with 26% of all 2-3 year olds and 33% of 4-7

year olds, consuming soft drink on the day of the survey.

Fluid Intake in Infants and Young Children

Problems with too many sweet drinks

Sweet drinks such as cordial, soft drink, sports drinks and

fruit juices are not necessary for children and excess

consumption can contribute to common nutritional

problems.

• Toddler Diarrhoea

Juices and soft drinks are especially concentrated and

some children may find it difficult to digest such large

loads of sucrose or fructose. Managing toddler

diarrhoea may be as simple as removing fruit juice.

• Dental caries

Regular consumption of sweet beverages contributes

to tooth decay and poor oral health. Putting babies or

young children to bed with a bottle also increases the

risk of decay.

• Fussy eating

Always ask what type and volumes of fluids children

are drinking. Children may fill up on sweet drinks or

milk and be less inclined to eat a variety of food.

• Weight gain

Recent research shows soft drinks can contribute to

obesity and industry data suggests that soft drink

intake is increasing. Habits are formed at a young age

and we should be encouraging our children to be

drinking less soft drink and other sweet beverages.

Situations requiring increased fluid requirements

Hot/humid weather and activity

Children playing outdoors or in a car on a warm day can

lose high volumes of fluid and are very susceptible to

dehydration and heat stress. Thirst is not always the best

indicator of hydration and children should be offered fluid

more regularly in the warmer weather, particularly if they

are active.

In hot weather, babies will usually naturally demand more

fluids and it is acceptable to give formula fed babies small

amounts of cool boiled water after the bottle if they seem

extra thirsty. Breast fed babies may need extra breast

feeds and mother should maintain her hydration. It is not

usually necessary to offer water; however, occasionally

this may be needed.

Illness/Fever

When children are unwell they may not feel like drinking

or eating despite an increased need for fluids. This is an

appropriate time to offer flavoured beverages such as

watered down juice or flat and diluted soft drink to

encourage fluid intake and provide some energy

(kilojoules).

Gastroenteritis/Diarrhoea

Maintaining hydration is critical in children with

diarrhoea/gastroenteritis. The principle of fluid

replacement is offering small amounts frequently. Clear

fluids familiar to the child will be accepted but must be

diluted to ensure a glucose solution of about 2%. An Oral

Rehydration Solution (ORS) available from pharmacies

over the counter, may be used. ORS helps to more

effectively restore fluid by replenishing electrolyte

balance. Be mindful that children may refuse some of

these because of the taste. If a child is breast fed then

this should continue during the period of illness.

Author:

Tanya Lewis, Dietitian Children

Youth and Women’s Health Service, South Australia

Reflection Questions

1. During hot weather do you regularly

discuss with parents the increased fluid

needs of their infants and children?

2. Have you recently reviewed your

knowledge of the clinical signs of

dehydration in infants and children?

3. Do you currently discuss with parents the

range of problems that are associated

with sweet drinks?

What milk is best?

Full fat dairy products are recommended for children

under two years of age, skim milk and reduced fat

milks should not be used for this age group.

Between the age of 2 and 5 years, children do not

usually need the extra fat from milk and milk

products, therefore, reduced fat milks are appropriate

from 2 years of age. Skim milk should not be used for

children less than 5 years of age.

Children with allergies or intolerance to cow’s milk

should find a suitable high calcium replacement. Soy

milk is appropriate after 12 months if the child is

eating a varied diet.

Practice Resources

NEW

Professionals now have ready access to evidence-based information on a range of early childhood

concerns as a result of the Centre for Community Child Health’s new online Practice Resources

series. The series is designed to bridge the gap between research and practice, translating

evidence into easily understood, practical information. The topics covered in these resources are:

• Settling and sleep • Language • Smoking

• Behaviour • Literacy • Overweight and obesity

• Breastfeeding • Injury • Eating behaviour

Practice Resources can be downloaded from www.rch.org.au/ccch