back again for help 2

[kayasmama]

I have a 4 mo old spirited lo who has been having napping issues for the past 2 months (maybe more, I've lost track). I popped over to the NW board, but I am back here because her naps are the source of her issue (and maybe her A time?)She can't get through the 45 minute transition, and it is leading to lots of NW and EW. I was holding through the jolts for the past month, and was making some progress a couple of weeks ago. She was starting to need less help and was getting good 1 1/2 to 2 hour naps with minimal interruption. We even had one night where she slept through the night! After that one night, it was worse than ever with 4-5 night wakings and taking 1-1/2 hours to go back to sleep. She is also waking from naps at 30 or 45 minutes even with HTTJ and usually needs to be taken out of her crib and pat back to sleep, she gets so worked up. She just cannot seem to settle. She usually does great going down for naps and can go to sleep on her own when I put her in her crib sleepy after 5 minutes of sitting with her. It may take her 10 minutes of "talking" to herself, but she can do it. She even did it once at night- but only once. Her room is dark, she is swaddled (although it is getting harder to swaddle her and she breaks out of it several times a night- even the miracle blanket!), and we use white noise. She does not use a pacifier because she won't take it. She has a consistent naptime and bedtime routine and she is usually yawning by the time we sit in the chair. We give her time to try to settle herself when she wakes from naps and at night, but isn't able to do it on her own. Her A time is 1 hr 25-30 min depending on how long it takes her to fall asleep, and we start wind down at 1 hr 10 min. She was waking at 600, which was bad enough, but now it is 530, and this morning it was 515! I can sometimes get her back to sleep if I feed her, but again it may take 30 min. At night,. she is not waking from hunger. I may feed her once (usually if it is 3 hour since last feed) but she never eats very well, and then does not wat well for her first feed of the day. She is a big girl (16 lbs!) and I have a huge milk supply so I think she is getting enough during the day. Any help would be great! We are at the end of our rope and are absolutely exhausted. To add to it, I am starting work next week so all of this will pretty much be out of my control. She will have to eat at 6am and I am able to feed her at 12 noon due to my schedule, but now when I feed her at 600, she usually just falls asleep. hmmm..... Any ideas? Here is an average day....sometimes it can start at 600, sometimes at 700 if I get her back to sleep when she wakes at 515/530.

Wake 515, can feed a little and maybe go back to sleep…
E 630
A 645-800 (start wind down at 740)
S 800-930/945 if I can get her through 45 min mark, but usually wakes
E 945
A 945-1115, wind down at 1055
S 1115-1245 (same as above)
E 1245
A 1245-215
S 215-345: this is where she has been waking most at 30 minutes.
E 345
A 345-515/530 depending on when she is tired and how long it takes her to go to sleep
S 530-600- this one used to be 45 min and is now 30 min
Bath 615
E 630 and eats until 715/730 when she goes to bed
Df 1030

She has been waking at 1145 and is up for 30 min-1 hour, 130- I feed her but she is sometimes still up for 1 hour-1 1/2 hrs, then usually sleeps until 515/530. I can feed her a little and she sometimes will go back to sleep. The closer it is to 600, the less likely she will go back to sleep. This is an improvement as last week she was also waking at 1230 and 330. She does not have a pain cry, and sometimes is just up, awake and talking to herself and just won't go to sleep. We have been trying to leave her until she cries. Patting in her crib doesn't work so we pick her up and sit with her, sometimes patting until she is drowsy. She will fall asleep when we put her in her crib, sleep briefly and then she will wake up again since she just can't settle into deep sleep.

Sorry this is so long, but I am trying to give as many details as possible. Thanks so much for the help- it's a lifesaver!!!!


 

[becky1969]

Hey girl! I've notified the other mods to see if anyone else has some different ideas than the ones I've offered.

I've got to tell you that since we've been working so hard on this, and you also got input from the NW board, and yet no real improvement I'm REALLY wondering if the reflux is truly helped.  She's behaving like an unmedicated reflux baby.  I know you say the spit up has been reduced and that the crying doesn't seem to abate when held upright, but that's the only thing I can think of! She's not responding to the techniques that typically work in these cases.    I don't know what to offer! Reflux is a tricky problem; my son had silent reflux so NEVER spit up.  In fact, i used a burp cloth twice his whole little life!    The lack of improvement when held upright seems to say reflux is better, but she's so freaking OT that it's hard to say whether that may be a contributing factor to the crying.  What medicine are you guys on right now?

[kayasmama]

She's on zantac now and we just increased it again. I think it still could be causing the nap isssues, and maybe the NW and EW are due to OT? At night she is waking but not crying much- just awake. Thanks so much for your dedication in helping us!

[kayasmama]

So yesterday's naps were 45 min except for 1 2hr nap I APOP. Last night wasn't too bad. She woke at 2 and I fed her- didn't need to eat, I think. Then she woke at 530. I left her in her crib talking until 6, then tried to feed her but she wouldn't go back to sleep. Again she wasn't super hungry. I'm thinking about APOP 20 naps due to 530 wake but am not sure if it will create new problems. We don't know what to keep trying for her short naps and 530 wake

[becky1969]

Zantac is kind of the first medicine they try.  For some babies it just doesn't do the job.  It didn't for us.  Prevacid is the next one they typically try.  The thing about Zantac is it often works in the beginning, but then doesn't seem to work as well over time.  I *might* consider talking to the doctor about trying Prevacid.  The napping thing isn't getting better with all the usual methods, and so it leaves me to wonder if there is an underlying medical problem interfering with her ability to stay asleep.

One mama I know had a doctor who left her DD on Zantac for the 2 weeks it takes Prevacid to work.  I don't know if that is a common protocol or not.  Might be worth asking about? Reflux is a tricky illness and it's very hard to tell how comfortable your child is! In fact, NOW with 20/20 hindsight, I can see that we took my son off the meds too soon and that he was in pretty bad discomfort for 2 full months until the reflux started getting better on it's own.  We're actually having a scope and biopsy done for him in another week to see if the reflux is still going on, amongst other things.  It's an awful disease!

[kayasmama]

I will definitely ask her md. In the meantime, should I keep httj? I am not sure what else to do and getting very tired of spending all day in her room, but if there is still a chance it will work, I'll keep at it.

[becky1969]

If she is'nt going back to sleep with httj, then ditch it.  I think nap #1 is too late, though.  With her waking at 5:15, it's unclear whether she's going back to sleep.  I think I'd try for a nap at 7.

[becky1969]

So maybe our problem is you're counting A time from when you stop nap extention instead of when she wakes up? That could make a big difference! Oooh, I'm getting excited here!    If she only sleeps 45 minutes, and you spend 30 trying to get her back to sleep, you still count A time as starting the moment her eyes opened after that 45 min nap.  Make sense?

[kayasmama]

If she doesn't go back to sleep, then I do count it in her a time. But what if she sleeps only 20-30 min more after trying to settle her for 15-20 min? Maybe that's the issue?

[kayasmama]

If I don't do httj, then I just resettle her for every nap? And what should her A time be now that she is 4 months?

[becky1969]

A time at 4 months is somewhere between 1h45 and 2 hours. 

Here's what I'm thinking: put down for nap.  If she stirs, then try to resettle using shush pat, or just gentle pressure, or whatever she seems to respond to best.  Give that a go for 20 minutes.  If it doesn't work, then get her up.  If she sleeps for 20-30 min more, usually you'd start A time when she wakes from that sleep.  But if that's what you're doing, it's not working!

Looking at your routine, I think 1st nap may be too late, but 2nd nap too early?  It's hard to say because her sleeping is so erratic.  Not sure she's ready for 1h45, but you sure can try it!! Why don't you give 1h45 a try and see how she reacts.  It's possible she's UT for her her naps at 1h30 (which is about what you're doing, right?)

[kayasmama]

Do I go for the 1 hour 45 min all at once or gradually. She is yawning usually by 1hr 15, but maybe it's because she's used to it. If she still wakes do I go back to original A time?

[becky1969]

Are you at 1h30 now? If you're at 1h30, adding 15 minutes isn't out of the question.  But follow her cues! If it's just a STRUGGLE to keep her awake until 1h30, then that may all she can handle and in fact it may mean that even 1h30 is too much for her.  If you do low key activities in her room and she can stay awake, then go ahead and push her abit. 

[Canwi]

Hi.  The girls asked me to have a boo at things and see if I could see anywhere where you might be able to make some adjustments to help your DD sleep better.
After reading through all of your threads http://babywhispererforums.com/index.php?topic=146765.0 and http://babywhispererforums.com/index.php?topic=149094.0 here’s a few sentences that jump out at me …

Shh/pat doesn’t work and pu/pd definitely doesn't work since it just wakes her up more.

PU/PD causes the acidic stomach contents to “slosh” up and down and causes discomfort hence it doesn’t work.  Shh/pat can also cause sloshing, but not as bad as PU/PD

She is over 95th percentile for height and weight (13lbs at 3 mos) so I don't think she really needs the feedings.

Some refluxers will drink for comfort.  Think of it in this way, if you have a sore throat drinking a soothing liquid eases the pain … but only temporarily.  So you need to drink more … and more … and more.  Even though you aren’t thirsty.  You do it because it eases the discomfort. 

HTJ is definitely not working. She wakes up regardless and just screams at me. I have to pick her up and pat her. Then she won't let me put her back down-starts screaming again. The past 2 days her sleep seems so restless and she just yells when she wakes.

Not wanting to lie down makes me suspicious that it’s not a nice place to be … maybe because of discomfort from reflux.

Pretty sure- she is barely spitting up at all. When she cries at night and we put her upright, her crying doesn't change

Not all reflux babies have an instant change in crying when held upright.  Another “rule” that some MD’s use is that ‘all reflux babies can’t stand laying flat at all” – not true.  DS2 didn’t have an issue with laying flat on the change table, but wouldn’t sleep worth a dollar.

She will fall asleep when we put her in her crib, sleep briefly and then she will wake up again since she just can't settle into deep sleep.

She can’t settle into a deep sleep as every time her body relaxes, her esophagus relaxes too and more acidic stuff floats back up from her stomach and irritates her esophagus.

If your DD is on Zantac there’s a chance she has developed a tolerance to it.  Here’s some info from the MARCI website on H2-blockers (the family of medications that Zantac is from):
What are H2 blockers?
H2 blockers are histamine2-receptor antagonists that prevent stomach acid production from taking place.
How do H2 blockers work?
H2 blockers block the message that tells stomach acid production to begin. Acid is produced by parietal cells located in the stomach lining. These cells don’t secrete acid until they receive a signal to begin. That signal is delivered by a messenger hormone called histamine. Histamine communicates with the cell by attaching to contact points located on the cell surface called receptors. The H2 blocker works by occupying the receptors so that histamine cannot bind and communicate to the parietal cell to start producing acid.
A final word on H2 blockers
Tolerance to H2 blockers can occur with prolonged administration; that is, the medication will no longer inhibit acid production, even if the dose is increased. Although your child may feel better at first, the symptoms will often return within one or two weeks, even after increasing the dosage.
H2 blockers inhibit only one stimulus of acid production. For example, H2 won't block production stimulated by the nervous system (stress-induced acid production).
Simply put tolerance occurs when the body tells the stomach to grow some more receptor sites as there aren’t any messages getting through.  So if you started off with say 100 receptors and your Zantac dose fills up all those 100 receptors, the drug works.  Then the body makes another 25 receptors, unless you increase the Zantac dose, you now have 25 receptors to send "make acid" messages.  Then the body says, "Not enough acid yet", so it makes another say 25 receptors and on it goes.  Eventually you are back to square one in terms of signs and symptoms from your LO, but in actuality their system now has say 200 receptors with 100 of them 'deactivated'.  Does that make sense?

Becky is right about the next medication family that is tried after Zantac.  It doesn’t necessarily have to be Prevacid, but it is usually a PPI that is tried if the Zantac isn’t working so well. 
More info from MARCI:
Proton pump inhibitors (PPIs) are chemical compounds that irreversibly inactivate the pumps that produce stomach acid.
How do PPIs work?
PPIs work within the parietal cells of the stomach, the site of acid secretion by way of proton pumps on the cell surface. PPIs reach the parietal cells via the bloodstream and react with the pumps. This reaction completely inactivates the pumps, stopping acid secretion.
Unlike H2 blockers, PPIs can stop acid production regardless of the source of the stimulus because they work against the pump itself rather than on the receptors involved in triggering acid production. The only way for more acid to be produced is for the body to make more acid pumps.
There’s a stack more info on PPI’s if you follow this link http://www.marci-kids.com/medications.html#ppis

I would seriously consider taking your LO back to the MD and ask to try a PPI.  Prevacid seems to be the most commonly used, but Omeprazole (aka Losec, aka Prilosec, aka Zegerid) is also a common one.  A referral to a pediatric gastrointestinal doc wouldn’t go amiss either.  Reflux is their specialty and they will know what is reasonable and what isn’t.

In the meantime, try elevating the head of her crib with blocks of wood or books under the legs at the head of the bed.  Put a towel/sheet across the bed so that her bottom rests against it so that she doesn’t slide down the bed.  Swaddle her, lay her on her left side and prop her that way.  There is some medical evidence that lying on the left side is using the natural anatomy of how the esophagus joins to the stomach to help ease the pain/irritation and “sloshing”.  If she is too mobile, then you may have to look at a sling/wrap that holds the baby stable on the mattress so they can’t ‘scoot’ down/around the bed eg http://www.tuckersling.com/
If you have more questions etc, come over to the http://babywhispererforums.com/index.php?board=13.0 board.  There’s a bunch more mothers who have experience with reflux and it’s insidious effects on baby’s sleep.

As for the Naps, NW and EW, I would APOP for now until you are 100% certain that you have dealt with the reflux.  My DS2 only had 30-45 minute naps until he was nearly 7 months old and was waking 2-5 times a night to feed – and I had a 2 yr old as well to deal with.   So I know mind-numbing the sleep deprivation is and how soul-destroying the frustration is also.
Hope there is some kernel of help in this epistle (wasn’t meant to be this long, but I can’t see any info that I can leave out )

[kayasmama]

Thanks so much for the info. It's very helpful.