Dr Scott Blundell
Sleeping problems in infants and young children are a common presentation to both general practitioners and paediatricians. More than one third of children have sleep difficulties either with bedtime problems or with unwanted awakenings. While sleep is important for us all, adequate sleep is vital for the emotional development of a child. Poor sleep is associated with restlessness, inattentiveness, irritability and oppositionality. In short, children who don't sleep well are more likely to behave poorly and are less effective learners. The flow on effect to the family is also significant with much higher rates of maternal depression in mothers whose children are poor sleepers.
The amount of sleep required declines from infancy until adolescence with most young infants requiring approximately 15 hours sleep per day and most adolescents requiring approximately 9 hours. Young infants typically have three daytime naps with this reducing to two per day by the time that they are twelve months old. The morning nap is usually excluded by 18 months and the afternoon nap by five years. By 3-4 months of age approximately two thirds of infants "sleep through" the night.
Sleep difficulties in children often go unreported by parents who do not realise that their child’s sleeping pattern is out of the ordinary or that solutions are available. A simple screening tool for sleep difficulties is the BEARS acronym. Asking about Bedtime problems and Excessive daytime sleepiness, enquiring about Awakenings during the night, the Regularity and duration of sleep and whether or not the child Snores. It is worthwhile considering the impact a child's medical condition may have on their sleep. For example, children with eczema may be kept awake by itching, children with asthma may be woken by coughing and children with ADHD may find it difficult to switch off.
THE FREQUENT WAKER
The majority of paediatric sleep conditions are behavioural. One such condition is Behavioural Insomnia of Childhood: Sleep Onset Subtype (International Classification of Sleep Disorders). This describes the young child or infant who wakes frequently overnight and demands to be put back to sleep. The child has learnt to go to sleep under certain conditions or with certain associations. This may be sucking on a dummy, being rocked or patted to sleep or having a parent lie down with them. Children go through sleep wake cycles which last 45 to 60 minutes with partial arousals at the end of each cycle at which point the child must get themselves back to sleep. If their conditions are not met, they demand their parents meet them. Like any behavioural problem the principles of management are to identify and eliminate any trigger factors, extinguish unwanted behaviours and to reinforce wanted behaviours. The solution may be as simple as swapping the dummy for a transition object such as a teddy bear or blankie, or the elimination of night-time feeds. Incentives and praise should be used to encourage the child not to call out or to stay in their room. For the child over six months who requires a parent to settle them back to sleep "Controlled Crying" and its variants such as "Checking In" are both safe and effective. A large randomised controlled trial of controlled crying versus no intervention in children over 6 months demonstrated improved sleep patterns in the controlled crying group with additional improved parental sleep patterns, maternal mental health and child parent interactions. There were no differences between the two groups on any measures at follow up at 6 years of age.
A study recently published in Pediatrics re-affirmed these findings with infants treated with graduated extinction (a form of controlled crying) getting to sleep faster and waking less often compared to a control group. The salivary cortisol (a marker of stress) of the infants in the graduated extinction group was mild to moderately lower than the control group, suggesting that these infants were no more stressed than their peers, and at 12 months there was no difference between the two groups on measures of emotional attachment.
Finally "Camping Out" and "Parental Presence" are two techniques quite similar to each other which some parents may find more palatable than controlled crying. Over a two to three week period the parent gradually reduces the amount of intervention required to settle the child to sleep until no intervention at all is required. Social interaction such as talking and eye contact should be kept to a minimum whilst performing these techniques.
THE BEDTIME STALLER
Another common bedtime problem is Behavioural Insomnia of Childhood: Limit Setting Type. This describes the young child who either stalls or refuses to go to bed. It often arises from a parents’ inability or unwillingness to set consistent limits and manage behaviours pertaining to bedtime rules. Again as with any behavioural problem triggers must be identified and avoided, wanted behaviours should be reinforced and unwanted behaviours“extinguished”. Management centres around employing a good bedtime routine and sleep hygiene, and setting and enforcing appropriate boundaries. Giving attention to unwanted behaviours usually serves to reinforce them. As such stalling behaviours should either be simply ignored or met with a firm direction to return to bed. Realistic goals, such as the child simply staying in their room, should be set and incentive schemes such as star charts put in place. As the child achieves their goal, new challenges such as staying in their bed are set.
Delayed Sleep Phase Syndrome describes the child, most commonly an adolescent who typically goes to bed quite late and if left to their own device sleeps until late morning. The child’s body clock is essentially out of sync with the rest of society. It is often associated with anxiety and depression. Strategies include employing a good bedtime routine and sleep hygiene, creeping the bedtime forward by 15 minutes per week until an appropriate bedtime is reached and bright light therapy (going out into the sunlight as soon as they wake in the morning). Melatonin may be useful in this instance. Bedrooms should be dark, quiet and devoid of TVs, phones and computers.
Good sleep hygiene is essential in the management of all behavioural sleep problems. The child should have a bedtime routine where the half hour to hour before bed is spent preparing for bed. Three to four soothing activities such as a bath, changing into pyjamas or reading should be undertaken. Stimulating activities such as TV, phones and other screens should be avoided.
There are a number of excellent resources on the internet for behavioural sleep problems (www.purplecrying.info, www.raisingchildren.net.au, www.sleephealthfoundation.com.au). A day stay sleep training school is available through the local child health network and the Ellen Barron Family Centre at the Prince Charles Hospital in Brisbane offers week long admissions for sleep settling. Pindara Private Hospital offers a Sleep School.