Sleep Issues
Restful and adequate sleep is equally important for children and parents alike. In infants, it is important for proper development of their nervous system. In toddlers and older children, it is necessary for impulse control, optimal school performance, positive mood, normal socialization, and stable emotional state. In adolescents and adults, poor sleep has been associated with obesity, difficulty loosing excess weight, high blood pressure, and depression. And good sleep, as I am sure you will agree, is essential for optimal parenting. Well rested parents enjoy their children more, spend better quality time with them, and in general function as more effective parents.
Yet, sleep problems of various degrees are extremely common among children of all ages (up to 30 percent during some time in childhood). Frequently, one type of a sleep problem is replaced by a different one as the child grows. It is easier to prevent the development of poor sleep habits rather than break the established ones.
Below you will find some useful information that may be discussed during the health supervision or "well" visits. It is intended to provide general guidelines for establishing healthy sleep patterns in children, starting at a young age. Of course, individual variations apply.
Expected Average Amount of Sleep at Different Ages
- Newborn – 16-20 hours a day , with rather evenly spaced naps after every feed, and little variation between day and night schedule
- 3-4 months – 16 hours a day, including 3 naps; many will sleep through the night without feeding*, or have an early morning feeding only
- 6 months – 16 hours, with 2 naps (late morning and afternoon)
- 9 months – 14-15 hours, with 2 naps as above
- 1 year – 13-14 hours, with 1-2 naps
- 2 years – 13 hours**
- 3 years – 12 hours**
- 4 years – 11 hours **
* Through the night at this age is defined as about 12 midnight to 5:00 a.m.
** 2-5 year olds may or may not have a nap during midday, but some quiet downtime is beneficial.
Prevention of Sleep Problems
The hallmarks of prevention are nap time and nighttime routines, designed to gently guide babies and encourage them to learn soothing themselves to sleep and develop positive and convenient sleep associations.
Newborn behavior often seems erratic in the first few weeks, but frequently by the age of 1 month (and, definitely, by 2 or 3 months) parents can predict their baby's needs and interpret their unspoken language. Observe your baby and write down the times when you think she/he is sleepy, hungry, or ready to play. Note that signs of sleepiness in babies may be quite subtle, and include fussing, whining, crying without another reason, "spaced out" facial expression, sudden loss of attention or interest in a just enjoyed activity, eye rubbing, repeated yawning, falling down, or letting go of held objects. When signs are present, the child needs to be put to sleep very promptly. Also, note that full feedings as opposed to short snacking are encouraged in order to achieve a functional daily schedule. To help the baby stay awake for the full feeding, feed them as soon as they wake up from their nap.
The suggestions below should work for a lot of babies. Adopt more and more steps as the baby grows.
- Starting soon after birth, whenever possible, put the baby down to sleep in a drowsy but awake state. If she begins to cry, pick her up, reintroduce breast/bottle/pacifier/holding/ rocking etc. for a few minutes, and then put her back down while she is still awake. Repeat these steps as necessary until your baby falls asleep.
- It is normal for the baby to briefly open her eyes, look around, and go back to sleep. Noises during sleep such as very brief crying, fussing, or screeching, are also normal. Do not pick the baby up unless the crying or fussing is sustained or escalating. The exception is a 1-3 week old newborn who needs to be breastfed at their first cue.
- Help babies learn to distinguish day from night. Allow daytime naps in a better lit louder area of the house, in a bassinette/carriage etc. . Night sleep is best initiated in a crib or co-sleeper, in a dark quiet environment. The night feeding sessions should be duller, without playing/singing/ diaper changes (unless significant diaper rash, or a very soiled diaper). Ensure a full tummy before nighttime sleep. Tight swaddling is always encouraged.
- Minimize long daytime naps and evening naps.
- By 5-7 months, develop about 20-30 minute long nighttime routine involving feeding, bath, massage, a book/ song. Have a shorter daytime nap routine. Whenever possible, enforce same sequence of events, same timing, same sleeping arrangement, even same words and phrases for each routine.
- Encourage early nighttime for babies – 6:30-7:30 pm is reasonable. Put your baby to sleep before she is overtired. Later bedtime does NOT usually equal later awakening in the morning.
- Initiate gradual shortening of nighttime feedings. After about 3 months, if the baby is not crying a lot for the nighttime feed, try to calm her down with gentle patting/ pacifier/ 1 oz of water instead of formula. If breastfeeding, in order to avoid possible unwanted early weaning, still nurse, but make the sessions shorter (offer one breast only, or cut the time) . Again, always ensure that the baby is not going to bed hungry.
Solutions for Established Nighttime Sleep Problems
Frequent nighttime waking with inability to self-soothe back to sleep, gratuitous night feedings, resisting naptime etc. in the face of parental frustration qualify as sleep problems. The typical age for a child with these issues is about 6 months to 2 years. It is most effective to tackle the nap time and nighttime problems simultaneously. No matter which method described below is used, it is VERY helpful to have consistent daytime schedules, routines, and nap times. Below are the two major types of approach suggested by the sleep experts:
- "Crying out". The modified version involves putting the fed drowsy baby in the crib, leaving the room, letting him cry, and checking on him at the regular but gradually increasing time intervals. Please, refer to Dr. Richard Ferber's book "Solve Your Child's Sleep Problems", or Dana Obleman's "The Sleep Sense Program" for all the details. The unmodified version involves putting the baby in his crib and seeing him next time in the morning (provided the safety assurance). Both versions can be used on children at least 4 months of age, both are well known to work quickly (about 1-2 week) and effectively with lasting results. Both could often be hard on the parents and babies during the training process, but the modified version much less so. I definitely recommend the modified version to those parents choosing the "crying out" approach. The baby should not be sick with anything (even a mild cold) during the training. I also recommend that you don't take any overnight trips anywhere in the couple of weeks after the training time to allow the new skill to "mature."
- The "cry-less" approach – involves a very gradual re-developing of new sleep associations and healthy naptime and nighttime routines. This quiet method takes much longer to work (often, many weeks), and is successful in fewer cases compared to the "crying out" approach. Please, refer to "The No-Cry Sleep Solutions" by Elizabeth Pantley.
Preschoolers' and Older Children's Sleep Problems
These are most due to poor limit setting, delayed internal clock, snoring and disordered breathing during sleep (sleep apnea), and bedtime anxiety. The result of any one of these problems is sleep deprivation, which can manifest itself as daytime sleepiness, irritability, poor school performance, emotional lability, poor impulse control, and other behavioral problems.
When to See a Doctor
- If you are not certain whether or not your child has a sleep problem
- If your preschooler or a school-aged child has any problems listed above
- If your frequent nighttime feeder is not gaining weight
- If you are planning to have your baby "cry it out" before the age of 4 months
- If you would like to discuss any other questions about your child's sleep
Some Useful Books on the Topic
Dr. Richard Ferber "Solve Your Child's Sleep Problem"
Elizabeth Pantley "The No-Cry Sleep Solution"
Marc Weissbluth "Healthy Sleep Habits Happy Child"
Dana Obleman "The Sleep Sense Program"