If sleep problems loom large, it’s at least in part because sleep is such an important part of early development. A new baby sleeps 16 to 18 hours a day, and by the age of five will have spent half her life in bed while still managing to interrupt the sleep of both parents numerous times. Some of the sleep problems of children are simply habits that fail to mesh with those of the rest of the family. By five to seven months, most children are sleeping through the night, and if night-time awakenings develop again several months later, they can become a source of growing frustration on both sides.
Doctors point out that children adapt quickly to associations that are present during the transition from wakefulness to sleep. If a child becomes dependent on being held, rocked or fed while falling asleep, she will expect the same treatment should she wake up in the middle of the night. Using a pacifier is clearly a more convenient sleep association for the parent than having to drive the child around the block.
Sleep-Onset Associations
If night-time awakenings begin to trouble the parent, the solution is to help the child learn to make the transition to sleep without help. This may mean letting the baby cry for gradually longer periods. Feeding a child too much during the evening can also contribute to the problem by conditioning a hunger response and increasing the number of wet diapers at night. Again, a gradual decrease in the frequency and quantity of night-time feedings is recommended.
Colic is not a sleep problem but a persistent fussiness probably caused by abdominal pain. The crying usually occurs at about the same time every day–often in the late afternoon and evening. The distress may be a reaction to the formula being used or, if the baby is nursing, to something in the mother’s diet. It may also be related to intestinal gas or an immature digestive or neurological system. Otherwise, the child is happy and healthy, and the episodes will eventually stop. Strategies to calm the child–such as holding and rocking–may be helpful, but they may also lead to sleep-onset associations, which must be dealt with later.
For a child who resists going to bed and has a hard time getting to sleep, doctors usually recommend a consistent bedtime and a nightly ritual–such as a bath, a story, a song and a bedtime kiss. Rowdy games, TV viewing and computer games in the evening are more likely to stimulate the toddler.
Problems such as night terrors, sleep-walking and bed wetting usually trigger a doctor’s visit. In most cases, however, these are not signs of any serious physical or mental abnormality but are probably related to delayed maturation in the central nervous system and glitches that take place in the transition between sleep stages. All of these problems tend to run in families.
A night terror, usually occurring in the first two or three hours of sleep, may prompt a child to sit bolt upright and scream non-stop for up to half an hour, hardly noticing the parent’s attempt to comfort him. Then he’ll relax and go back to sleep, without remembering the event. A night terror may be more likely to occur when the child is tired or under stress.
Nightmares, which may also be associated with stress or fatigue, are frightening dreams that take place later in the night and are nearly always remembered. The child needs comforting and reassurance–at the time and later. Sleep talking and sleep walking are arousal disorders similar to night terrors and should not be thought of as a symptom of a psychiatric disorder. One young adolescent had a sleep walking incident at summer camp and another at home that left him on his front porch in the middle of the night, locked out of the house. The specialist who treated him was less concerned about the behavior than the potential for physical danger. The parents shifted the boy to a bedroom on the main floor of the house and added safety locks on his windows and the outside door.
Bedwetting is one of the most common night-time problems and one of the most troubling for both parent and child. It requires patience and understanding rather than firm discipline. Practical strategies include limiting the intake of fluids in the evening and waking the child to use the bathroom before the parents go to bed. If these fail, bed-wetting alarms have been found superior to medication in terms of effectiveness and lack of side effects. Doctors may also recommend one of several types of continence training.
A sleep problem may also be linked to a breathing disorder such as sleep apnea, repeated interruption of breathing in brief episodes during sleep. Newborns, especially premature babies, may have central sleep apnea, linked to functional immaturity of brainstem cells. This could be a life-threatening condition but can be treated through use of a sleep apnea monitor.
Apnea in older children is more likely to be caused by an obstruction, such as a congenital malformation of the breathing passages or enlarged tonsils and adenoids. As with adults, obesity can also be a factor. Treatment for obstructive sleep apnea usually involves either removal of the tonsils and adenoids or use of a mask during sleep to provide continuous positive airway pressure (CPAP).
One recent study of 1,129 children found that children who snored (usually an indication of obstructive sleep apnea) were more likely than other children to do poorly in school. Another study found snorers more likely to have behavior problems such as inattention and hyperactivity.
Poor sleep, whatever the cause, is a frequent cause of problem behavior, poor performance in school and even illness and injury. It’s important for parents to address problems early and seek help when needed.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director, Richmond Apothecaries, Inc.
