To Your Health! Community Health Resource Center Newsletter, Summer 2007

Sleep is probably the number one topic that I discuss with parents. It affects all of us from newborns (and their tired parents) to teenagers, whose parents increasingly report are up all night and exhausted during the day. Parents often wonder how much sleep their children need, and how to know if they are sleeping enough.

Each of us has different requirements for sleep. In general, we should all be sleeping enough that we feel rested when we awaken, and appropriately tired when we go to bed at night. Infants up to 1 year of age should be getting at least 14 hours of sleep (including naps). Toddlers and preschoolers should be getting 11 to 14 hours. School-aged kids should be sleeping 11 to 12 hours per night. Teenagers need 9 to10 hours, but they are unlikely to be getting the sleep that they need.

Inadequate sleep can cause problems ranging from daytime sleepiness, difficulty with concentration, irritability, depression, hyperactivity (sometimes mimicking ADHD), and even delay in recovery from illness. To make matters worse, children who are overtired will often have greater difficulty falling asleep and staying asleep than children who are well rested. Many parents are familiar with the scenario of an obviously exhausted toddler, who is rubbing her eyes as she screams "I’m not tired!" Children who are chronically sleep deprived will become increasingly irritable, hyperactive, and paradoxically, will have ever greater difficulty settling down and falling asleep.

• Infants and Toddlers
• Preschool and School-Age Children
• Teenagers

Infants and Toddlers

Infants and toddlers accomplish sleep through daily naps as well as nighttime sleep. For most of us beyond the toddler age, sleep occurs at night. All of us have an internal biological clock that regulates when we feel awake and when we feel sleepy. People of all ages sleep best when their schedule and their biological clock are well connected. It is best to go to sleep at the same time every night, and awaken at the same time every morning. This predictable pattern cues the brain that it is bedtime, and allows us to fall asleep more quickly and easily. Children who nap should also nap at the same time every day. Even for newborns, it helps to begin to regulate their sleep cycles by using external stimuli to signal the difference between awake time and sleepy time. In the morning, opening the blinds and enjoying bright natural light, with lots of busy daytime sounds signals the brain that it is daytime. And at night, preferably an hour or so before bedtime, darkening the room, turning down the volume of voices, and avoiding stimulating activities signals the brain that sleep is near.

Newborns sleep most of the day, usually waking up just enough to feed, with just a few short blocks of quiet alert time during the day and night. From the beginning, it is helpful to take note of the baby's own circadian rhythm, and learn his or hear signs of sleep readiness. By the age of 3 to 4 months, most babies will begin to establish a fairly predictable pattern. As soon as the baby begins to appear sleepy, he or she should be put down to sleep. It is best to put your baby down drowsy, but not completely asleep. Babies, like all of us, wake many times in the middle of the night. A baby who has fallen asleep in a parent's arms and then awakens in a crib will cry, seeking the familiarity of the setting in which he or she fell asleep. A baby who learns to fall asleep in the crib will find it much easier to fall back asleep quickly after all of the brief nighttime awakenings.

In order to decrease the chance of sudden infant death syndrome (SIDS), babies should be put down for sleep on their backs, and on a firm mattress in a safety
approved crib, bassinet, or co-sleeper. Ensure there are no pillows, stuffed animals, fluffy blankets, or other soft items in bed. Do not expose your baby to secondhand tobacco smoke. These safety guidelines are critical to follow both for naps and nighttime sleep, and for all of the baby's caregivers to understand and follow carefully.
Around 3 to 4 months of age, it is useful to begin establishing a bedtime routine. Most babies this age will naturally do best when they go to sleep early, around 7 or 7:30 pm. The routine (bath, book, quiet music, and breastfeeding, for example) should begin about an hour before bedtime to give baby a chance to wind down. Many babies whose parents try to keep them awake to "wear them out" actually end up with overtired babies who sleep less. Babies who are put to sleep early, usually by 7:30 pm, will often have less night awakenings and sleep later into the morning than babies who are kept up too late.

By six months of age, night feedings are usually unnecessary (consult your pediatrician for guidance on your child), and most babies whose parents have already helped them to establish a good sleep routine and have been put down while still awake will drop night time feedings gradually. For those who still need a little help sleeping through the night, focus on routine and try putting baby to bed using white noise such as a bathroom fan, soft music, or music with sounds from nature. If baby wakes up briefly and calls out, try to wait for a few minutes before rushing in. Sometimes babies, if given the opportunity, will be able to put themselves back to sleep rather quickly, especially if they have already learned to fall asleep in the crib.

Don't be surprised by setbacks – even babies who had been sleeping through the night will frequently start waking up some nights between ages 9 months to twelve months, as separation anxiety begins, and as they learn to crawl and pull to stand. Many babies will get "stuck" standing up in their crib until they learn how to sit back down. Of course, babies will frequently experience night wakening with teething and illness. These setbacks are normal, and once the inciting factor is gone, it is important to return to the established routine as quickly as possible.

As babies enter the toddler years, they may experience new sleep challenges. Toddlers frequently need some help winding down after a busy day, and they need a consistent bedtime. An hour or so before bedtime, dim the lights, use quiet voices, put on soothing music, and stick with a routine. The last part of the routine (usually reading books) should take place in the toddler's room, to establish a sense of security in the room. Reading to children is a perfect way to end the bedtime routine. It is relaxing for both the parent and child, and provides a loving end to what sometimes can become a stressful bedtime battle. In addition, a love of reading is a beautiful gift to share with your child from the very beginning.

Parents frequently wonder about the right time to transition from a crib into a big kid bed. The solution is different for each family, but in general it is helpful to keep children in the crib until at least two, if possible. At the point when the child is able to climb out of the crib unassisted, it is time to switch to a big kid bed. This may be anything from a toddler bed to a mattress on the floor. Often, the transition to a big bed, along with its newfound freedom, brings new concerns. Toddlers can escape from the bed, and the room, at will. Some parents find it useful to put a baby gate in the child's doorway, to prevent escape.
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Preschool and School-Age Children

Some preschool-age children are masters at finding excuses at bedtime. They will overwhelm parents with requests, from one more drink of water, to five trips to the potty. For these children, a ticket strategy can be useful. The child is given three "get out of room" tickets at the beginning of the night, and can trade them in for coming out of the room for whatever reasons they have. Once the tickets are gone, the child must stay in the room. Many children are so reluctant to give up the cherished tickets that they fall asleep still clutching them in their hands.

Nightmares are common for preschool and school-age children. Parents should monitor the content of any movies, TV shows, or books carefully. Even stories that seem non-threatening to adults can be scary to children. In addition, daily naps should be part of the routine for toddlers. Toddlers who miss naps or who have inconsistent naptimes will become overtired by bedtime. They often have more difficulty falling and staying asleep.

School-age children also require a consistent bedtime and consistent bedtime routine. The bedroom should be a quiet, peaceful place, and around bedtime should be kept dark and at a comfortable temperature. Some people find that cooler temperatures will aid sleep. It is best to keep all electronic media, such as TVs, stereos, computers, and video games out of kids’ rooms. These are over-stimulating, and many kids cannot resist the temptation for one last video game when they need to be sleeping. It is important to avoid caffeine in the diet, which can sneak in in the form of soda, chocolate, energy drinks, and frothy coffee drinks. Any significant caffeine intake, even if early in the day, can have dramatic impact on sleep. Exercise is a great way to wear out the body physically and clear the brain, and can help with sleep problems. However, exercise in the couple of hours before bedtime can be too stimulating and should be avoided.
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Teenagers

Teenagers are some of the most sleep-deprived members of our population. The consequences of inadequate sleep in this age group are serious, and include academic problems, depression, and risk of involvement in motor vehicle accidents. For teenagers, many times busy schedules get in the way of consistent bedtimes. In addition, teenagers experience a normal change in circadian rhythm that makes them prone to being night owls. They often stay up late, are tired during the week, and sleep in on weekends. It is important for them to understand that they need to get to bed at a reasonable time in order to get up for school the following day, and to get up no more than 2 hours later on weekends than they do on weekdays. For most kids, this means getting up at 8 or 9 am on weekends. Many schools are concerned about the issue of sleep deprivation in teenagers, and school schedules that do not match most teenagers’ natural circadian rhythms. Some schools are even experimenting with the idea of 1 to 2 hour later high school starting times.

Many teenagers consume large amounts of caffeine, in the form of energy drinks, coffee drinks, and soda. This gives them a temporary burst of energy during the day, but can further impair their ability to fall asleep at night. This will lead to further sleep deprivation, fatigue, and a perceived need for more caffeine. It is best to avoid or limit caffeine intake, and to use bright natural light and exercise early in the day to improve both daytime energy level and aid in falling asleep at night.

While most children's sleep problems can be fixed with careful attention to routine and avoidance of triggers that make sleep worse, there are some warning signs for more severe problems. You should call your child's doctor if he or she exhibits frequent loud snoring, periods where he or she stops breathing during sleep, excessive daytime sleepiness, mood or behavioral problems that seem to be related to poor sleep, or any signs of systemic illness.
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