Healthy Sleep Habits, Happy Child

by Marc Weissbluth, M. D.

  Some families have found it difficult to establish naps because their bedrooms are too bright or noisy during the day. One family I know was fortunate enough to have a large walk-in closet, which they furnished like a little bedroom and which was used only for naps. Other families have problems because they live in a one-bedroom apartment and it is difficult for anyone to sleep well when a child shares a bedroom with the parents. Such parents sometimes relocate to the living room and turn the bedroom over to the child so that the entire family can stay well rested. If you do not want to have a family bed, expect it to become difficult for your child to sleep well in your room. Plan ahead, before the family becomes overtired.

  PRACTICAL POINT

  As long as your child retains the expectation that she can convince you to play during nap time, she won't nap well. If she thinks she can outlast you, she won't give up her protesting.

  Brief Sleep Durations

  If your child is on an apparently normal sleep schedule and napping well, you might presume she is getting enough sleep. Overall, she doesn't look tired. But what if around ten, eleven, or twelve months she starts waking at night? What's happening? Many times, physical and mental activity increases around nine months. The child is now moving around more, exploring more, becoming more active and independent.

  If the customary bedtime hour had been around 8:00 or 9:00 P.M. before the onset of night waking, the problem will often disappear when bedtime is shifted to an earlier hour. Most families find that if they gradually shift the bedtime earlier in twenty-minute increments, they reach a time when night wakings melt away. Usually this change is easy for the baby; sometimes it is hard for the parent who returns home late from work to accept. But small changes in sleep patterns often make big differences in sleep quality. Even a change as small as twenty minutes’ more sleep at the front end of the night can cause a big change in your child's behavior during the day.

  Early Awakenings

  Most children five to twelve months of age should go to bed between 6:00 and 8:00 P.M. and wake up between 6:00 and 7:00 A.M. Some also get up once around the midnight hour for a brief feeding. This pattern is very common, but many parents don't like the idea of starting the day so early! In this age range, though, it seems that the wake-up part of our brain is like a neurological alarm clock.

  For well-rested children, this neurological alarm clock is fairly regular, and I don't think we can ignore crying around 6:00 A.M. simply because we don't want to get up so early. Because they are well rested, having slept overnight, it seems unreasonable to expect children to go back to sleep without any kind of response. Instead, I would suggest a prompt, brief, soothing response so that perhaps both child and parent can return to sleep. If responding before 6:00 A.M. turns out to be more stimulating than soothing, then I would suggest not going in until 6:00 A.M. The reason is that children who get too much attention too early in the morning fight sleep to get up earlier and earlier for the pleasure of their parents’ company. Increasingly, it makes it difficult to stay up to catch the first midmorning nap around 9:00 A.M., SO the whole day gets thrown off balance. Sometimes overtired children develop new patterns, such as waking up at 4:00 A.M. and not returning to sleep after a prompt, soothing parental response. These kids are really up and want to play, yet they are often not well rested. When the parents put these children to bed earlier, they get more sleep at the front end and they sleep later in the morning because they are more rested and are thus able to sleep better. Even though this is counterintuitive, it is true.

  This means that when your child has disturbed sleep and an abnormally late wake-up time, you might decide to control his schedule by waking him up earlier so that the naps and bedtime hour all occur earlier. If your child has disturbed sleep and an abnormally early wake-up time, shorten the intervals of wakefulness before naps and make the bedtime hour earlier. When your child is well rested and has no disturbed sleep, an early wake-up hour may be inconvenient but not necessarily changeable.

  METHODS THAT USUALLY FAIL TO PREVENT

  EARLY AWAKENINGS

  Keeping your child up later at bedtime

  Waking him for a feeding when you go to sleep

  Giving solid foods late at night

  If your child is near his first birthday, you might consider some of the items discussed in the section on older children.

  Different Sleep Patterns: No Problem—Temporarily

  Sleep patterns are as varied as children themselves, family sizes, and parental lifestyles. One five-month-old always awoke briefly at 6:00 A.M. and then promptly returned to sleep until 10:00 A.M. A long midday nap occurred from noon to 3:00 P.M. and a brief nap from 5:00 to 5:45 P.M. Between 7:30 and 8:00 P.M. the child went to sleep for the night, until about 6:00 the following morning. This child was well rested, and the midday nap coincided with his older brother's single nap. For the time being, this pattern met both children's sleep needs. By six or seven months, this child developed the more common pattern of a midmorning nap and an early afternoon nap.

  However, other children begin to accumulate a sleep deficit that grows, often slowly, over time. Eventually, daytime mood or behavior problems develop, as do sleep disturbances at night.

  PRACTICAL POINT

  A temporary disturbance or mild variation in sleep schedules, nap patterns, amount of sleep, or early awakenings may not be changeworthy. But if chronic or severe problems cause your child to become tired, then try to help your baby become more rested. Watch your child's behavior, not some inflexible schedule.

  Night Wakings

  In this age range, night wakings are typically the complete arousals from sleep associated with disturbed sleep in postcolic babies (see Chapter 4), partial airway obstruction during sleep (see Chapter 10), general disorganization of sleep with chronic fatigue (see Chapter 2), or parent reinforcement of such wakings.

  Two separate groups of infants between four and eight months of age seem especially prone to night waking.

  The first and larger group—about 20 percent of infants—includes those infants who had colic when they were younger. These infants not only awaken more often, their total sleep time is less. Although boys and girls in this group awaken the same number of times, parents are more likely to state that it is their sons who have a night-waking problem. In fact, boys are handled in a more irregular way than girls when they awaken at night. This was shown in studies using videotapes in dim light in the children's own bedrooms at home. Even when the colic has been successfully treated with a drug during the first few months, by four months of age the children still were reported frequently awakening at night.

  My conclusion is that some biological disturbances in infants can cause an overaroused, too wakeful, hyperalert, irregular state full of crying, especially in the late afternoon or early evening. This is commonly called “colic.” In the past, the crying part of colic has been thought to be the major problem. But while this evening crying diminished at about three to four months, the wakeful, not sleeping, state may continue and thus be more serious and harmful in the long run.

  This is because the parents have the correct impression that regular and consistent parenting does not much affect the colic, and, unfortunately, they give up the effort permanently. They do not know that after four months of age, regular and consistent attention to bedtimes and nap times really does help the older infant sleep better. The parents’ failure to develop and maintain healthy sleep patterns in these older postcolic babies then leads to prolonged fussiness driven by chronic fatigue. (This is discussed in more detail in Chapter 4.)

  The second group of frequent night wakers in the four-to eight-month-old age group includes the 10 percent of infants who snore or breathe through their mouths during sleep. This difficulty in breathing during sleep might be due to allergies (see page 382). These infants awaken as frequently as do those with postcolic night waking, but their parents do not label this night waking as a problem. Probably the parents had not worried about ni
ght waking because the infants had not suffered from colic. Those infants who snored also had shorter sleep durations than other infants. As in many sleep disturbances, when one element of healthy sleep is disrupted, other elements are disturbed. (I will discuss why snoring is more than an acoustical annoyance in Chapter 10.)

  A third frequent cause of night waking in this age group is sometimes associated with abnormal sleep schedules. Going to bed too late and getting up too late seems to set the stage for frequent night waking. Sleeping out of phase with biological rhythms produces an overtired and hyperaroused child. One child I cared for took two to two and a half hours of soothing, rocking, or holding before she would go to sleep, and then would usually awaken three to four times each night, sometimes as often as ten times. This prolonged period to put a child to sleep is called “increased latency.” It's also called a waste of parents’ time because the off/on twilight sleep for the child during the rocking, walking, and hugging represents lost good-quality sleep.

  PRACTICAL POINT

  Fatigue causes increased arousal. Therefore, the more tired your child the harder it is for him to fall asleep, stay asleep, or both.

  One consequence of increased arousal is that disturbed sleep produces more wakeful, irritable, and active behaviors in children. Also, these children often have increased physical activity when asleep. Although all babies can have gross movements involving the entire body or localized movements or twitches involving only one limb, these are brief motions lasting only a second or less. But chronically fatigued babies who are overly aroused move around more in a restless, squirmy, crawly fashion when sleeping. It seems that their motor is always running at a higher speed, awake or asleep. I will explain how you can reduce your child's idle speed by making sure he gets the sleep he needs.

  What is disturbed sleep?

  Abnormal sleep schedules (going to bed too late, sleeping too late in the morning, napping at the wrong times)

  Brief sleep durations (not enough sleep overall)

  Sleep fragmentation (waking up too often)

  Nap deprivation (no naps or brief naps)

  Prolonged latency to sleep (taking a long time to fall asleep)

  Too active sleep (lots of tossing and turning)

  Difficulty breathing during sleep

  Night waking is not caused by:

  Too much sugar in diet

  Hypoglycemia at night

  Zinc deficiencies

  Pinworms

  Gastroesophageal reflux

  Teething, contrary to popular belief, does not cause night waking. If you ask parents what happens when teething occurs, the answer is: everything! All illnesses, fevers, and ear infections that happen to occur around the time a tooth erupts are blamed on teething. Throughout medical history, doctors used the diagnosis “teething problems” as a smokescreen to hide their ignorance. In fact, at the turn of the twentieth century, 5 percent of deaths in children in England were attributed to teething.

  A proper study of problems caused by eruption of teeth was performed in Finland. Based on daily visits and the testing of 233 children between the ages of four and thirty months, it concluded that teething does not cause fevers, elevated white blood cell counts, or inflammation. And most important, teething did not cause night waking.

  Night waking between the ages of six and eighteen months is more likely due to nap deprivation, overstimulation, or abnormal sleep schedules—not teething.

  PRACTICAL POINT

  Putting your baby to bed, allowing die child to hold a bottle of milk or juice, or resting the bottle on a pillow, will cause “baby-bottle cavities.” Protect your child's teeth. Hold your baby in your arms when you give a bottle.

  Growing pains also do not cause night waking. One study examined 2,178 children between six and nineteen years of age and found that 16 percent complained of severe pain localized deep in the arms or legs. Usually the pain was deep in the thighs, behind the knees, or in the calves. The pain usually occurred late in the afternoon or in the evenings.

  But when the growth rates of these affected children were compared to children without pain, there was no difference. In other words, growing pains do not occur during periods of rapid growth! Blaming night waking on growing pains is a handy excuse. But the rubbing, massaging, hot-water bottles, or other forms of parent soothing at night are really serving the emotional needs of the parent or child and not reducing organic pain.

  Night waking may be caused by:

  Fever

  Painful ear infections

  Atopic dermatitis, eczema

  PRACTICAL POINT

  Do not attempt to correct unhealthy sleep habits unless you see a clear period ahead when you will be in control. Don't trust most relatives or baby-sitters to do as good a job as you can to correct unhealthy sleep habits. Also, if your child's sleep improves during a retraining period but suddenly he becomes worse, appears ill, or seems to be in pain, let your pediatrician examine him for the possibility of an ear or throat infection.

  Let's consider the child who naps well, has a reasonably normal sleep schedule, does not appear overly tired, but simply gets up too often and/or stays up too long in the middle of the night. We want to help this child learn how to soothe herself to sleep unassisted when she wakes up. This skill also will help her fall asleep at bedtime, so the two strategies outlined here can be used when a child fights going to bed, too. The first technique, called “fading,” is a more gradual approach, while the second, called “extinction,” is an abrupt, cold-turkey solution. Let's look at how each works, and their pluses and minuses.

  Fading

  A gradual approach to reduce the number of night wakings until the baby can return to sleep independently is called “fading.” Over a period of time you gradually reduce your efforts at night, so that your child takes over for himself and falls asleep or returns to sleep by himself. This is like teaching an older child how to ride a bike. You first provide balance and support and then gradually withdraw as the child gains confidence and skill. Here is an example of a fade sequence to eliminate night wakings.

  Respond promptly, spend as much time as needed

  Father gives bottle or mother doesn't nurse

  Change from milk to juice

  Dilute juice to only water

  No bottle

  No picking up

  No singing, talking, verbal communication

  Minimal contact, patting, or hand-holding

  No eye contact; sober, unresponsive face

  No physical contact; sit next to child

  Move chair away from crib toward door, slowly over several days

  Reduce time with child

  Delay response

  This has been called the “chair method” when done with an older child in a bed because you are basically slowly moving the chair farther from your child until you are just outside the door.

  The apparent advantage of gradually weaning the child from prolonged, complex contact is its seeming gentleness. A disadvantage is that it takes several days or weeks, during which many brief crying spells may occur. The major reasons why this approach usually only partially succeeds, or fails completely, are (a) unpredictable, real-life events interfere with parents’ best plans and schedules, (b) parents do not appreciate the enormous power of intermittent positive reinforcement to maintain a behavior (“I'll just nurse him this one time”), and (c) parents’ resolve weakens from their own fatigue and sometimes from impatience. Here is an account of one mother's attempt to use a gradual approach.

  EXHAUSTION WINS OUT OVER PATIENCE

  Lauren was eight months old when I finally sought help from the doctor; her sleep schedule could only be described as unbearable.

  When we brought her home from the hospital after her birth, she would have a very long, wakeful period in the evenings from about 8:00 P.M. to 1:00 A.M. We can't say that she was colicky, as she was really quite pleasant most of the time. Only about once a week did she have an extended crying spel
l during which she would be inconsolable.

  At around seven months or so, we decided to try nursing Lauren and putting her back in her own bed consistently. That's when the trouble really began! Lauren would wake up every few hours, and it would take one and a half to two hours to get her back to sleep. By now she had learned how to stand up, and I think that made it even more difficult for her to settle down.

  The other thing Lauren did was to fall asleep easily at about 9:00 P.M. and wake up a half hour later, inconsolable. Eventually (after nursing, rocking, and so on), she would perk up and become very pleasant and often stay up and play happily for anywhere from two to four hours. At the same time, naps were totally irregular and unpredictable. She would usually sleep twenty minutes, but sometimes it was two hours.

  When I saw the doctor, I explained that I was one of those people who didn't think I could let my baby cry herself to sleep. The doctor recommended a plan of action that involved a gradual withdrawal process that would stretch out over seven to ten days. The response to Lauren's waking was supposed to be consistently prompt, but there was to be less handling of the baby at each step of the plan.

  I put Lauren in her crib, kissed her good night, walked out, and closed the door. She screamed for forty-five minutes and finally went to sleep. They were the longest forty-five minutes of my life—longer than labor! But it worked!

  A few nights after our first success, we decided to leave her alone when she woke up at 9:30. Well, that crying session lasted for about thirty-five minutes. The next night Lauren went to bed about 9:00 P.M. and got up at 7:30 A.M.! I kept thinking that it must be horribly frightening for a baby, who is unable to communicate except through crying, to be left alone in a room to cry. What helped to convince me, however (in addition to utter and complete exhaustion), was the realization that as long as I stayed in Lauren's room she screamed anyway. Walking, rocking, singing—none of these quieted her anymore. The only thing that calmed her was endless, nonstop nursing! I finally came to the conclusion that as long as Lauren was going to be miserable crying anyway, she might as well be learning something positive from it—learning to go to sleep. Even now, if I stay in her room after I put her in bed, she stands up and cries, but as soon as I kiss her good night, walk out, and close the door, she lies down and goes to sleep.