It happened to be a busy afternoon in late winter and there had been a great deal of illness in the community. Looking at the schedule I noticed half an hour had been blocked out for seven-year-old Amy, coming in for "sleep problems". Entering the room I couldn't help but wonder what issues might be going on with this child.
Sitting there in her school uniform Amy was doing her homework with mom's help. When I walked in mom said, "Let's put this away for now. You can finish it when we get home." Amy was a charming first grader who always greeted me with a big smile and a pleasant hello, and today was no exception. Glancing at her chart I noticed that she did not have a fever. The chief complaint was, in fact, "problems with sleep". This perked my interest.
Amy's mom told me that for the past two and a half weeks she went to bed at her usual time without any problems. She fell right to sleep within fifteen minutes, just as she always had done. But for some reason, between midnight and two o'clock in the morning, Amy was wide-awake. This happened at least five out of seven nights. The first time it happened mom was awakened by a noise coming from her room. When she looked Amy was sitting at her desk doing homework. She was fully awake and alert, and said that she just couldn't sleep. She felt fine, did not have a fever, nor did she have a bad dream. Mom thought that this was a bit odd, but got her to go back to sleep without any problem. She forgot about it the next day until around midnight when the same thing happened.
The next night mom let the child stay up half an hour later so that she would be good and tired when going to bed. Amy fell right to sleep. Checking on her periodically mom finally went to sleep at one o'clock in the morning...just to be awakened by Amy at 1:30 who informed her that she was awake again.
Mom was about to make an appointment but Amy had two good nights sleep in a row. Thinking that all of this might be related to a growth spurt, perhaps the problem had resolved itself. Over the next week Amy was up four out of the seven nights. This is what prompted mom to make the appointment.
In obtaining the history I found Amy to be a healthy, well-adjusted child doing well in school and in the extra-curricular activities. She had solid friendships and was getting along well with her peers. There were no external stressors that they could think of. Amy told me that she falls asleep without any problem, but simply wakes up and feels wide awake. There was no pain or discomfort, nor did she have nightmares.
Mom asked if we could talk alone, so I had the nurse take Amy out to check her blood pressure. It was a relief when mom assured me that there was nothing going on in the child's life that was of concern. Quite the contrary. I asked if Amy could be getting an inordinate amount of caffeine, either in soft drinks or tea. But this was not even a possibility. Then mom got serious and asked if Amy should be seen by a psychologist. Could there be some underlying issues that we needed to sort out?
As I thought about it, this did not seem like a psychological or physiological problem. Then I told mom that I thought she might have pinworms. Mom gave me a blank stare. "What?" she asked. "Did you say pinworms?"
I explained to her that pinworms are one of the most common parasites in the world. In some schools and pre-schools it occurs in epidemic proportions. But it is relatively harmless and easy to treat. The worm is tiny, colored white or brown-gray, and measures from an eighth to a quarter of an inch. People inadvertently ingest the eggs that pass into the stomach and hatch into the adult form. The adult worm travels to the large intestine where it lives, rarely causing any problems. At night, usually well after the host has fallen asleep, the adult female worm crawls out onto the peri-anal area to deposit her eggs. Then she crawls back into the rectum. The next day the host may experience a little peri-anal itchiness and scratches her bottom...thus picking up the eggs on her fingers. The eggs are readily passed on to some unsuspecting subject who shares contaminated food or toys. With this life cycle, it is no wonder how it easily spreads among children and toddlers.
At nighttime, when the adult female crawls out to deposit her eggs, a child may wake out of a sound sleep and cry as if she were having a night error. It is not painful, but it is described as a strange sensation. If the child is in a deep REM sleep she can wake up screaming hysterically. I think that in Amy's case the sensation was just enough to awaken her.
Other problems that can occur as a result of the pinworms are intense peri-anal itching. In female patients the worm may migrate towards the vaginal area and may cause irritation and discomfort (vaginitis). In some cases the worms have been known to be the cause of a bladder infection.
The best way to diagnose pinworms is to have the child go to bed at the usual time. One-to-two hours after she has fallen asleep, the parent should use a bright flashlight and inspect the peri-anal area looking for the actual worm. The child can get in the knee-chest position, or lay on her side. If the parent is looking closely for the worms, they are usually easy to see. But you have to be looking for them. A cursory glance will often miss seeing them. I explained all of this to Amy's mom who was a bit repulsed by the whole notion, but was willing to give it a try. I told her to give it at least three nights of looking for the worms. If nothing panned out we could do a special test that we send to the lab.
Amy's mom called me first thing the next morning to inform me that Amy did in fact have pinworms in no uncertain terms. Then she asked, "Now what? Do my husband and I have to worry about getting them? What about her eight-year-old brother?" I told her that the treatment was simple. I would phone in a prescription for eight tablets to treat the family. Each family member was to take a chewable tablet that day followed by another seven days later. The first tablet kills all of the adult worms, and the second one kills the eggs that have hatched after the first dose. Mom was to wash Amy's underwear, wash cloths and towels, and bathing suits in hot water after the first dose was given.
A week later Amy's mom called to tell me that since the first tablet her little girl had slept through the night without even a whimper. She also went on to tell me how relieved she was that it was something so simple. "I was afraid that we were looking at deep-seated psychological issues, or perhaps some abuse had been going on that I didn't know about," she went on. "I guess I never would have thought that I'd be relieved to know that my daughter had a parasite!"