Healthy Sleep Habits, Happy Child

by Marc Weissbluth, M. D.

  PRACTICAL POINT

  A constant small deficit in sleep produces a cumulative reduction in daytime alertness.

  As the child develops, the relationship between disturbed sleep and problems of mood and performance becomes less clear because of the increasing complexity of psychological and intellectual function. It is even possible that chronically disturbed sleep causes children to grow up experiencing excessive daytime sleepiness, low self-esteem, or mild depression. In one study, about 13 percent of teenagers with disturbed sleep were reported to be like this. They usually took longer than forty-five minutes to fall asleep or woke frequently at night. Some of these teenagers may simply have never learned self-soothing skills to fall asleep easily when they were much younger. As adults, they are described as insomniacs.

  One theory of adult insomnia is that it is characterized by an internalization of emotions associated with a heightened or constant state of emotional arousal plus physiological activation, which causes disturbed sleep. But distinct differences exist between adult insomniacs whose insomnia started in childhood and those whose insomnia started in adulthood. The childhood-onset insomniacs took longer to fall asleep and slept less than the adult-onset insomniacs. I think this kind of data tends to support the notion that the failure to establish good sleeping habits in infancy or early childhood may have long-term harmful effects, such as adult insomnia. And among psychologically unhealthy adults, the more severe the sleep difficulty, the more severe the degree of mental illness.

  Let's now review some of the most common sleep problems that can disrupt our children's sleep and their solutions.

  When you consider solutions for your child's sleep problems, it is important to think of healthy sleep as a collection or group of five related elements, described in Chapter 2, grouped together to form a “package.”

  FIVE ELEMENTS OF HEALTHY SLEEP

  Sleep duration: night and day sleep

  Naps

  Sleep consolidation

  Sleep schedule

  Sleep regularity

  All five elements must be present to ensure good-quality or healthy sleep. In the following discussions, I might emphasize one part of the “package” as being especially important for solving a problem, but keep in mind that the solution might fail if other elements of healthy sleep are absent. Also, some sleep problems occur at specific ages. Here, I will provide a brief outline of the solution and I will refer you to the chapter appropriate for your child's age for more detailed instructions. It is best to first read here and then read the appropriate chapter for your child based on his age. Reading the preceding and following age-appropriate chapters will also help.

  For any particular problem, there may be more than one cause or solution. Your child's age and temperament might influence which solution you will want to try first. Also, not all solutions are practical for all families. So please read the entire section for any particular problem before trying to help your child. Also, because many of these problems are interrelated, it might be worthwhile to browse through this entire chapter; you might discover some additional solutions. One important principle for solving sleep problems is to execute a schedule or behavioral change for several days to determine whether the change helps before making another change in routine. Be patient and keep a sleep log.

  Sleep Log

  A sleep log is a series of bar graphs showing on each day when your child was awake, asleep, quiet in bed or crib, and crying in bed or crib. On the horizontal axis, show the day of the week and on the vertical axis, the time of day. Each bar represents a twenty-four-hour snapshot of a day and the graphic view of all the bars allows you to see trends in sleeping patterns. A detailed diary makes it hard to see the forest for the trees.

  REMEMBER, SLEEP BEGETS SLEEP

  The more rested you are, the easier it is to fall asleep and stay asleep. The more tired you are, the harder it is.

  Excessive Daytime Sleepiness

  Superficially, we tend to think of being either awake or asleep. But just as there are gradations between light sleep and deep sleep, there are gradations of wakefulness. Task performance, attentiveness, vigilance, and mood may be influenced by the degree of daytime wakefulness. When we do not feel very awake during the day, we say that we feel “sleepy.” Excessive daytime sleepiness or impaired daytime alertness is a result of disturbed sleep.

  The Stanford Sleepiness Scale is a self-rating instrument developed at Stanford University to describe the different states or levels of daytime sleepiness. Obviously, children who are depressed or irritable due to sleep deprivation will have high numerical ratings.

  LEVEL DESCRIPTION

  Feeling active and vital; alert; wide awake

  Functioning at a high level, but not at peak; still able to concentrate

  Relaxed; awake; not at full alertness; responsive

  A little foggy; not at peak; let down

  Fogginess; beginning to lose interest in remaining awake; slowed down

  Sleepiness; preferring to be lying down; fighting sleep; woozy

  Almost in reverie; sleep onset soon; lost struggle to remain awake

  Morning Wake-up Time Is Too Early

  Make sure that the bedroom is dark and quiet in the morning. Window-darkening shades and a white noise machine or noise from a humidifier will help reduce the startling effect of street noises. Keep a sleep log to help find the best bedtime.

  The most common cause for waking up too early before four months of age is extreme fussiness/colic (see Chapter 4). The most common cause, after four months, is a too-late bedtime.

  If you suspect the bedtime is too late, slowly make the bedtime earlier. Try twenty minutes earlier for four nights to see whether your child will fall asleep at the earlier time and sleep in later. Do everything you currently are doing at bedtime but simply start the bedtime ritual at an earlier time. If this seems to help a little, repeat the process with an additional twenty-minute earlier bedtime for four more nights. You can again repeat this process until it is clear that you have reached a too-early bedtime because your child no longer easily and promptly falls asleep. Now you might want to return to the last step and let your child stay up an additional twenty minutes. This gradual shift in bedtime may produce no protest crying.

  If you think the bedtime is too late because your child appears tired much earlier, then move the bedtime much earlier right away. The abrupt shift may or may not produce protest crying. For young children, at night, use Ignoring, discussed on page 211; Partial Ignoring, discussed on page 214; or Check and Console, discussed on page 215. For older children, use Sleep Rules, discussed on page 325 and 353, or Silent Return to Sleep, discussed on page 320. Ignoring your child until 6:00 to 7:00 A.M. will probably be needed. For younger children, the option of bringing them to your bed for soothing may produce extra ZZZs in the morning.

  Sometimes, after four months, a child is already going to bed very early, around 5:30 or 6:00 P.M. The entire schedule becomes shifted: too early a wake-up time causes too-early or poorly timed naps and a very tired child in the late afternoon who goes to sleep easily very early in the evening. For young children, it should help to simultaneously move their bedtime a little later, maybe twenty to thirty minutes every four nights, and ignoring them until about 6:00 A.M. For older children, use the fifth Sleep Rule, discussed on page 353, with a clock radio to tell them when they can leave their room. If you move the bedtime too late, your child might become so overtired that the wake-up time does not become later, instead he simply wakes up more overtired. However, for some older, persistent children, I have temporarily pushed the bedtime to a very late hour and it caused them to sleep in later. They receive lavish praise and token rewards (such as a small treat, stickers, or stars) for sleeping in later. Then the bedtime is slowly and gradually moved to an earlier time but the later wake-up time is preserved because the child continues to receive the praise and rewards.

  Finding the bedtime that is just right for your child migh
t require some back-and-forth adjustments; make one change and then wait four days to see whether it helps. And be patient.

  Morning Nap Is Absent, Too Short,

  Too Long, or at the Wrong Time

  The morning nap develops at three to four months of age in 80 percent of children and a few months later in 20 percent of children who had colic. Correcting a too-early wake-up time or a too-late bedtime might be needed.

  Sometimes the morning nap is short because that is all the sleep your child can get at that time—that is, your child is a short napper. About 20 percent of children between about six and twenty-one months always have short naps in the morning and afternoon, no matter what parents do. Between six and nine months of age, they may appear to be too short because the child requires many short naps, or “snaps,” throughout the day and often appears tired. As long as the bedtime is early, by nine or twelve months, most of these children are taking fewer and longer naps and no longer appear tired. I think that most of these short nappers are those who had colic when younger.

  The most common cause of an absent or a too-short morning nap is an interval of wakefulness that is too long between the wake-up time and the beginning of the nap. For the child under four months of age, sometimes starting the morning nap after only one hour of wakefulness allows the child to be soothed back to sleep before she becomes overtired. In an older child, starting the nap at the wrong biological time may either shorten the nap or make it less restorative; either too early or too late, it messes up the rest of the day. Use the morning nap rhythm that is well developed, 9:00 to 10:00 A.M., as an aid to help the child sleep. If needed, stretch the interval of wakefulness using 9:00 A.M. as your target time. You might only get to 8:30 or 8:45 A.M. because your child is becoming overtired. It's a balancing act: You want to start the nap when the biological nap time begins, but you also want to avoid the overtired state. You are willing to allow the child to become a little overtired but not become so wigged-out that he has great difficulty falling asleep.

  Sometimes an older brother or sister has a scheduled activity that interferes with the morning nap. Some options are to try to get relatives or a neighbor to watch your younger child at home while you drive your older child to the activity, or try to carpool to reduce the number of days per week your younger child misses out on a good morning nap. Often the young child might fall asleep in the car seat during the drive and the parent allows the child to continue to nap in the car seat, either in the car or when the car seat is placed in the crib. It looks awkward to us, but many young children appear to sleep well in the cozy car seat.

  Sometimes the wake-up time is too late because the bedtime is too late and the child cannot fall asleep at 9:00 or 10:00 A.M. “Control the Wake-up Time” simply means waking your child around 7:00 A.M. in order to get a good-quality nap to begin around 9:00 A.M. TO avoid an overtired child, the bedtime will have to be moved earlier. Parents or a parent may not like this solution because they like to play with their child late at night and/or they like to sleep in later in the morning.

  If the morning nap is too long or too late in the morning, it may interfere with your child's ability to fall asleep easily around 12:00 to 2:00 P.M. for the second nap, and the result is an overtired child by late afternoon. The reason the morning nap is too long or too late is usually because the bedtime is too late. Limiting the morning nap to one to two hours by waking your child is necessary because it is important to protect the second nap. At the same time, moving the bedtime earlier will cause your child to awaken in the morning better rested, and this will then automatically shorten the morning nap.

  NAP HINTS

  Before the morning or afternoon nap, go outside to, briefly but intensely, stimulate your child with physical activity at the park or in the sandbox; expose your child to light, wind, clouds, voices, music, traffic sounds; go for rides in the jogger or stroller. Then tone it down as you get near nap time. Now spend an extra long time soothing; include a bath if it is soothing in the nap time routine. Make the room dark and quiet.

  Afternoon Nap Is Absent, Too Short, Too Long, or at the Wrong Time

  The afternoon nap usually lasts until about three years of age and gradually disappears after the third birthday. If the afternoon nap disappears too soon, your child may become overtired in the late afternoon and have difficulty falling asleep at night. Either reestablishing the afternoon nap (if your child is substantially under age three) or moving the bedtime earlier (if your child is substantially over age three) should help. If the afternoon nap persists in much older children the bedtime might progressively get later and later, causing bedtime battles to develop. Eliminating the afternoon nap will permit an earlier bedtime and help erase bedtime battles.

  Bad timing is a common cause of problems associated with the afternoon nap. If the afternoon nap is too early, way before noon, because of a too-short morning nap, it will not be as restorative and your child might be way overtired by late afternoon. One mother said her son was a “French fry” by the end of the day because he was crispy. Under nine months of age, this might lead to a late or long third nap that causes the bedtime to become too late. If the afternoon nap is too late, way after 2:00 P.M., it may interfere with an early bedtime.

  Sometimes the afternoon nap conflicts with scheduled activities, such as preschool for the child or scheduled activities for the older brothers and sisters. Try to minimize these conflicts regarding the older children by using baby-sitters, car pools, or skipping some, but not all, of the classes for your infant. An earlier bedtime might be essential when the afternoon nap is shortened or skipped.

  Day care may be associated with poor-quality naps because there is bad timing, too much noise, not enough help for long soothing, or crying from other children. The morning nap usually goes easier in day care because the child is already better rested in the morning from the previous night's sleep. Sometimes there are no alternatives available to the family in their choice of day care, and although it is especially hard on these families, an earlier bedtime will help these children.

  IMPORTANT POINT

  If the morning or afternoon nap is sometimes way too short or skipped, try to keep the child up and go to the next scheduled sleep time, but move it a little earlier. Protect the sleep schedule.

  Third Nap Is Absent, Too Short,

  Too Long, or at the Wrong Time

  The third nap, around 3:00 to 5:00 P.M., is variable: It may be short, long, or absent. It usually disappears by nine months of age. If it is a long nap, your child might be able to go to bed later at night. But if it is too long, the very late bedtime might become associated with bedtime battles because your child is way past his biological time for evening sleep. So either shorten (if your child is way under nine months) or eliminate (if your child is nine months or older) the third nap. Even a brief, baby power nap lasting twenty to forty minutes late in the afternoon or early in the evening might interfere with an early bedtime. So if you are struggling with bedtimes, consider eliminating this third mininap and try for an earlier bedtime.

  Sometimes, around nine to twelve months of age, a child falls asleep around 5:30 P.M. and is up around 7:30 or 8:00 P.M., then is up playing with parents for a few hours until 10:00 P.M., and finally goes back to sleep but does not sleep well at night. The parents think the child is taking a third nap at 5:30 P.M. But in reality the child needs a very early bedtime, maybe around 6:00 P.M., and no playing between 7:30 and 10:00 P.M.

  REAL LIFE

  Special events often result in skipped or shortened naps for children. Do not become a slave to your child's nap schedule. The more you protect the sleep routine for regular days, the less disruptive those special days will be.

  Needs Two but Can Get Only One

  The bedtime might be too late and/or the wake-up time too early, causing your child to be very tired in the morning. This morning fatigue causes him to take a meganap in the morning that interferes with his ability to take an afternoon nap. As a resu
lt, he is not well rested in the late afternoon or early evening. Or, scheduled morning activities might conflict with a nap around 9:00 to 10:00 A.M., resulting in a very late morning nap around 10:30 or 11:00 A.M. Even if this is a brief nap, it may recharge your child's battery and interfere with a long afternoon nap. During the transition between two naps and one nap, roughly twelve to twenty-one months, there may be some days when one nap works well and other days when your child takes two naps. This transition time, however, might be associated with an inability to get in two naps when he clearly needs them. The solution here is a twenty-or thirty-minute earlier bedtime.

  Needs a Nap but Refuses to Nap

  Holidays, trips, illnesses, or other changes in routine might cause your two-to three-year-old child to give up napping and be very tired during the day. Another common cause of no napping occurs when the child drops the morning nap but the parents do not make the bedtime a little earlier. Over many weeks or months, your child develops “cumulative sleepiness” until he hits a wall and becomes way overtired. In this state, it is difficult for him to nap because his body is geared up to fight the fatigue. When you try to reestablish the nap, he either just plays in his crib, or cries, or a combination of both.

  If your child is substantially under three years old, try a temporarily super-early bedtime to help him wake up better rested. In other words, for four or five nights, put him to sleep when he is drowsy at 5:00 or 5:30 P.M. This might backfire and cause him to wake up too early. If this happens, for those four or five mornings, ignore him until 6:00 A.M. Often, the early bedtime will help erase his sleep debt so he is more able to relax and take a nap. To help reestablish the nap habit, you might want to have intense morning stimulation and an extra long and soothing nap time ritual. Leaving him alone in his crib for no more than one hour, even if he cries, often will allow the nap to occur because he is tired and not receiving any stimulation from his parents. Or, you might have to lie down with him in your bed to help induce sleep. If successful, then you would very slowly and gradually transition him back to his crib. (See page 177 for transitioning children from parent's bed to child's crib.) Once the nap has been reestablished, the bedtime can be made a little later. Children who slip in and out of good sleeping patterns are usually the ones who are always going to bed slightly too late. They don't usually have major problems, but they are always on the edge of becoming overtired and they easily and quickly become overtired whenever there is a disruption of sleep routines.