Children’s Sleep
Normal Sleep
Wide natural variations are found in the daily sleep lengths of children within all age groups. For example, in week-old babies the mean daily sleep length is 16 hours (sd = 2 h). Thus, in a group of about 25, one will be sleeping almost twice the length of another. After a year the daily mean falls to about 12 hours sleep (also with large natural variations), partly because sleep is more consolidated into the night. Short sleep is not a sign of a higher IQ. Most infants will wake up least once per night, and with the exception of (usually breast-fed) babies, should return to sleep by themselves.
By about 18 months, sleep patterns are more stable, and daytime naps remain part of the total daily requirement; the more a child sleeps in the day, the less it will sleep at night. It is for this reason that daytime sleep, especially for the baby (from around 3 months of age), should always be in the light, not in a darkened ‘hushed’ room, and with the usual daytime noises – this helps to concentrate sleep into the night. Too much daytime sleep can add to difficulties in going to sleep at night (see below). Regular daytime naps tend to disappear by five years of age, when the average child will sleep about 10-11 hours a night. From around 7 -10 years the amount is approximately 10 hours a night. These figures are for the time asleep, and exclude the period from ‘lights out’ to the onset of sustained sleep, which for 5-11 year olds changes little, and averages about 20 minutes.
Because of these individual differences one cannot really prescribe an ideal amount of daily sleep for a particular age group. Nevertheless, many older children nowadays do not get enough sleep, usually because they stay up too late. The acid test of insufficient sleep in the child is difficulty in arising in the morning, with unscheduled dozes throughout much of the day. For many children persistent sleep loss also causes irritability, inability to concentrate, and they continually seek stimulation and attention. In fact many cases of mild attention deficit hyperactivity disorder (ADHD) are solely due to chronically insufficient sleep, which can include obstructive sleep apnoea (OSA – very heavy snoring) often due to enlarged tonsils in normal weight children. Sleep problems are not the cause of ADHD in those children with more severe levels of ADHD, although the sleep problems can further aggravate it.
Difficulty in going to Sleep
The usual recipe for successful sleep in infants and children is a standard, unremitting pre-sleep routine, only broken exceptionally. This period should be a time of progressive settling down, with the bedroom being seen by all concerned as primarily a place for peace and sleep rather than for excitement. After the child is tucked up for sleep, the parent should retire from the bedroom and not be open to persuasion to stay by delaying tactics. Whereas very young babies have to be almost asleep before being put successfully in the crib, by around six months they should be used to being put in their cribs awake, and encouraged to self-soothe. To continue with the practice of waiting for the infant to fall asleep in one’s arms beforehand is inviting future trouble. Many children are unable to entertain themselves to sleep and need an adult to be present until sleep onset. Often, the parent is conditioned by the child into enacting various time-consuming bed-time rituals, that in effect keep the child awake. This area presents one of the most common sleep problems encountered in infants and children, and causes much parental frustration and anguish.
Sleeping tablets/elixirs are seldom indicated, and at best should not be given for more than a day or two. Behavioural approaches are generally more successful in solving most sleep problems, although it is essential that parents first reassure themselves that the disturbance is not due to genuine causes such as colic, milk intolerance, real fears of sleep or nightmares, which require different approaches. Probably the most effective behavioural technique is ‘systematic ignoring’. Providing that the child has plenty of tender loving care during wakefulness, and knows this, then the method has much to recommend it. After tucking up the child at bedtime, and maybe having warned the neighbours, the parent leaves the bedroom, and resolves not to go back until the child is asleep, come what may. When the child awakes at night, the parent ignores this, or failing that, briefly enters the bedroom for reassurance that the child has no physical complaint, and leaves immediately. The first night is traumatic for all concerned, maybe the second night also, but thereafter success is usually obvious and progressive. The distress and poor sleep for the parents during the first few nights can be tempered by their realistic anticipation of a fairly rapid and dramatic improvement in the sleep of all concerned. Half-way measures, such as the parents allowing the child to cry for twenty minutes and then intervening, are counter-productive as the child just learns to cry for this time, in anticipation of the parent’s arrival. There is also the rather less traumatic, ‘protracted withdrawal technique’ whereby, over what can turn out to be many nights, the parent gradually withdraws physically and temporarily from the scene, this may take around six weeks compared with “systematic ignoring”, which produced comparable reductions within one to two weeks. For the child who wakes up in the night and demands that a parent accompany him/her back to sleep, then there is another approach, of ‘scheduled awakenings’. This relies on the tendency for most of these children to wake at constant times. Here, the parent gently arouses the child about 30 minutes before the typical spontaneous awakening, gives a hug for a minute, and allows the child to fall back to sleep again. The usual awakening is forestalled, and the routine continues for only a few nights until all the spontaneous awakenings have disappeared, with the awakenings under the control of the parent rather than the child. The final step is gradually to eliminate these scheduled awakenings until the child no longer wakens and cries at night.
Whoever is counselling the parents about these techniques, must ensure they understand that none of the methods, although effective, is easy.
Night-time feeding
This is a controversial area – one key factor is whether an infant is breast or bottle fed, as there is good evidence that breast-fed babies sleep through the night at a later age than those bottle-fed, especially if they suckle mainly for comfort, many times a day. Nevertheless, by around 6-9 months a full-term infant should be able to obtain all of its food during the daytime only. An infant over six months, waking several times a night (eg more than 3-4 occasions) and requiring substantive feeds, is probably ‘abnormal’, whereas an infant waking up once or twice for a short suck would not be. Large night-time feeds can create or compound the problem, leading to wet nappies (diapers), discomfort and awakenings, as well as reduced food intake during the day. These feeds should be minimised or stopped. Probably the best method is for this to be done gradually over, say two weeks, by decreasing the milk available (or breast feeding time), and increasing the acceptable time between feeds. Success is usually marked, and parents are often surprised by how quickly the infant adapts.
Nightmares
For most children dreams are pleasant experiences of everyday events. Whilst nightmares are usually infrequent, often very real, and soon forgotten, for some children they are very disturbing, particularly if frequent or the child dwells on them for several days. That is: repetitive acting out of the nightmare with toys; a dread of sleep; struggling to stay awake etc. The impact of nightmares should be weighed up with the effect these have on the child’s life in general. Often, of course, the reverse is true, or there is a two-way interaction, with frequent nightmares being a sign of an unhappy mind or home. Nightmares tend to become a more serious problem when parents fail to confront and deal with their child’s worries. Don’t bother to try and analyse the content of the nightmare. It is important when comforting a child who has a nightmare, to try and get the child to go over what happened, but not to dwell on the emotional side of it. Ask the child to go over it again (and maybe again) and try and downplay the emotion. This process divorces the contents from the emotion and the child will be able to become more ‘matter of fact’, even laugh about the nightmare. When this happens the nightmare is unlikely to return. Some nightmares are not always what they seem and may turn out to be night-terrors (see below), or, if (and unlikely) accompanied by repetitive stereotyped body movements, often of short duration, followed by confusion, then form of epilepsy could be suspected and advice sought (most of these will disappear when the child gets older).
Sleepwalking
This happens in deep non-dreaming sleep, when children are particularly difficult to arouse. It is common in childhood and tends have some hereditary basis. Sleepwalking peaks in adolescence, but declines rapidly by the late teens. Episodes are often triggered by anxiety; in susceptible children, the worry can be trivial – the loss of a favourite toy, or just a frustrating day. Only in serious cases, when sleepwalking occurs most nights, might there be severe distress and underlying emotional conflict, requiring intervention. One of the best treatments for children is simply to reassure the parents, as the more worried they become, the more this will be sensed by the child, the more anxious he or she gets, and the more sleepwalking will happen. If the child is given greater parental support, then the episodes often resolve themselves.
It is difficult to wake up a sleepwalking child, and is unwise to do so, as distress or a wild and emotional outburst may set in. It is best to guide or carry them back to bed. The mind of a sleepwalker is unresponsive to what is going on around and seems steeped in thought. The sleepwalker behaves like an automaton with a limited repertoire of behaviour. There is no memory of the nocturnal activities the next day. Episodes can last up to 30 minutes, but usually average 5-15 minutes. Typically, in a sleepwalking episode the child will sit up quietly, get out of bed and move about in a confused and clumsy manner. Although behaviour becomes more coordinated, the sleepwalker tends to remain in the bedroom, often preoccupied by searching for something in drawers, cupboards or under the bed. It is almost impossible to attract their attention; however, if left alone they normally go back to bed. Navigation is done mostly by memory of the layout of the room and house; the eyes are unseeing and usually it is dark. Difficulties and sometimes injuries occur to sleep-walkers at night if they think they are somewhere else, when walls, doors, staircases and windows are not where they should be.
More adventurous activities may occur, such as dressing, going to the fridge for food or walking outdoors. But if the behaviour is more complex, with the individual seemingly alert and organised and, for example, able to get dressed, get on a bike and pedal off down the road, then this is not sleepwalking as such, but probably a confused, waking, amnesic state that can last for several hours.
If the sleepwalking happens at the same time of night several times a week, and the child is otherwise quite a happy soul, then pre-emptive awakening can be tried to break the habit. Initially, over a week or so, a record is kept of the exact time the sleepwalking occurs, which is often around two hours into sleep and fairly constant. So, gently arouse the child about 20 minutes before the typical sleepwalking starts, give a hug for a few minutes to ensure they are awake (but not too much awake), and allow the child to fall back to sleep again. This should be continued for about 3-4 nights – worth a try.
Night Terrors
These are another phenomenon of deep sleep and are sometimes associated with sleep-walking, and distinct from the visually vivid, prolonged nightmare, and are not just bad dreams, but sudden and horrifying sensations accompanying fleeting mental images that shock the sleeper into immediate wakefulness. Night-terrors are also more common in older children. Typically, the child sits abruptly up in bed, screams and appears to be staring wide-eyed at some imaginary object – maybe “a monster”. When this part of the episode passes the child appears to awaken somewhat but is confused and disoriented. They may well remain like this for many minutes until sleep returns, having little or no recollection of the event next morning. The terrified child may run around the house in an inconsolable and incommunicable state for many minutes; half an hour or more is not uncommon. Again, morning recollection is fragmentary at best.
If the child is otherwise untroubled, then night terrors are seldom a matter for serious concern. If these are fairly frequent and p, then pre-emptive awakening can be tried (as above). The likelihood of a night terror occurring on these nights is reduced and, with the pattern having been broken, it is claimed that the night-terrors are less likely to return on the following nights when the child sleeps through the night without interruption. However, all that may happen is for the night-terror to re-schedule itself elsewhere in sleep.
Bedwetting
In general, children should have full control over their bladders by the age of 4. Bedwetting occurs to what seems to be an abnormal degree in around 15% of children aged 5-6 years, with this level falling by about 2-3 % per year thereafter. Whilst bedwetting is commonly thought to have an emotional basis, this is usually not the case, unless it disappears for say, 6-12 months and then reappears in association with clear emotional upset. Often the emotion displayed by a bedwetting child is a reasonable response to the bedwetting itself. Unusually, bedwetting can be a sign of urinary tract infection, diabetes, epilepsy and even sleep apnoea; disorders that should be eliminated initially.
Sleep-enuretic children can have one or more of the following: a small bladder capacity; a weak external urethral sphincter; have not learned to recognise the signals from a distended bladder that should arouse the child. Psychological factors can be important, such as inappropriate toilet training, excessive teasing about the problem by siblings, or parents who inadvertently reinforce bladder immaturity by continuing to keep an older child in a nappy (diaper) at night. Treatment should be symptomatic, for example: bladder and/or sphincter training exercises; conditioning by the “pad and buzzer” technique to enable the sleeping child to recognise a full bladder; star charts for dry nights. Medication is seldom the answer but could be an occasional adjunct during the treatment period (which can last several weeks) to give the child reassurance if sleeping away from home, for example.
Sleeptalking
This is a minor mental event of sleep, having no real content. It occurs in light sleep, and seldom has anything to do with dreaming.
Toothgrinding
This ‘bruxism’ is usually found in light sleep, and has a tendency to be related to anxiety and/or stressing days. It can occur in children soon after the first dentition has erupted and may lead to tooth damage and misalignment. For this reason a night-time rubber mouthguard is often used. If anxiety is indicated, then relaxation treatments can be successful.
Conclusions
Often, sleep problems in children are not of child but of the parents, who may have unwittingly created the problem in the first place, or worry unduly about a relatively minor matter that is inflated out of all proportion, or transmit their anxiety to the child whose sleep perturbation is exacerbated into a real problem. In these cases, it may be the parents rather than the child who really need the treatment (i.e. advice and reassurance). On the other hand, there are more serious sleep disorders that can all-too easily be dismissed by the parents as “nightmares” or “snoring”, for example. Most of these problems can, with the appropriate medical advice, can be resolved fairly easily.