Your Child's Sleep Habits and You

Last Editorial Review: 10/1/2004

WebMD Live Events Transcript

The National Sleep Foundation's seventh annual Sleep in America poll is the first to examine children's sleep habits. How are your children sleeping? How is it affecting their health and your sleep? Sleep specialist Judith Owens, MD, MPH, joined us to discuss the poll results and what you can do to improve sleep for the whole family.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Welcome to WebMD Live, Dr. Owens. The National Sleep Foundation has released the results of its latest annual survey, this one focusing on children. What did they find out about the sleep habits of American children?

I think one of the most striking findings is that sleep problems appear to be more prevalent of this age group than we had previously expected. The poll shows about 70% of parents and caregivers report that their child has some type of sleep problem.

An additional finding is that it appears as though children in all age groups are not meeting the expert recommendations, in terms of sleep amounts, and even toddlers and preschoolers, according to the poll results, are not getting the amount of sleep we would recommend children in that age group obtain. It looks like the sleep deprivation that we know exists for adults and for adolescents is now trickling down into the younger age group, as well.

What age range did the study focus on?

The study looked at children up to 10 years old. These were mainly babies, toddlers, and preschoolers, as well as elementary school children.

What effect does this chronic sleep deprivation have on the developing brain, particularly in those toddlers and preschoolers?

We know that younger children, in particular, require an extraordinary amount of sleep. When you think about it, the average newborn sleeps for about 16 to 20 hours in a 24-hour day. We can conclude from that, that sleep is vitally important to brain development and although we don't know what the exact mechanisms are, we do think that sleep has very important impact on the development of memory.

We also know that sleep is very important for:

  • Attention
  • Creativity
  • Higher level organizational functioning

So there are all sorts of cognitive problems that could result from inadequate sleep in young children.

What is the leading cause of sleep problems?

I think a common medical condition that can cause significant sleep problems in children is obstructive sleep apnea. This is a condition characterized by loud snoring, breathing pauses, and there may be choking or gasping sounds during the night. Many of these children have enlarged tonsils and adenoids, which are the cause of blockage that occurs during breathing. Other risk factors emerging are being overweight and obese.

The consequences of the sleep fragmentation caused by obstructive sleep apnea may include:

  • Mood changes, such as irritability
  • Attentional problems
  • Behavioral problems
  • Academic impairment (as a consequence of the above)

It's an important condition to identify. This is something parents can bring to their child's physician. One of the things we know from the NSF poll is that physicians don't always ask parents about children's sleep habits, so it's very important that parents be aware of potential problems and volunteer that information.

I think another very important cause of sleep problems in children is not getting adequate sleep. The poll results really suggest that this is a pervasive problem, and that many parents are uncertain about how much sleep their children need, and don't always know the best way to ensure their child gets adequate sleep.

"Children need a psychological preparation to approach bedtime. Parents can assist in the process by having a regular series of activities that culminate in bedtime and lights out, so that it becomes a regular- routine-every-night kind of proposition."

If my child sleeps in another room how can I tell if he has sleep apnea?

Most of the time the type of snoring that is associated with sleep apnea is quite loud. I would suggest that if you, as a parent, have concerns that you make an opportunity to observe your child sleeping. Red flags might include:
  • Children who have allergies or asthma
  • Children who have a history of enlarged tonsils
  • Children who tend to be mouth breathers
  • A family history of obstructive sleep apnea or loud snoring

These are indicators that you might be more vigilant in observing your child's sleep and observing him for obstructive sleep apnea.

Do you have any data on possible sleep differences in children in daycare centers vs. home care?

There has been some data from looking at children of working mothers, and that particular study did not find any differences between children whose mothers were employed outside the home and those who were not, in terms of their sleep habits and sleep amounts.

I think that one of the issues with daycare that's very important is that of napping. It's critical that parents make sure that there's adequate time and facilities made available for napping in those children in this age range, namely up until about 5 years of age, who may still require a nap during the day.

How many hours of sleep for what ages are recommended, especially for babies? My son is going on 8 months.

Remember, this recommended amount is over a 24-hour period, so it includes daytime naps in the younger children.

  • Infants aged 3 months and over: Somewhere around 14 to 15 hours
  • Toddlers: 12 to 14 hours
  • Preschoolers: 11 to 13 hours
  • School age: 10 to 11 hours

What is one of the major factors affecting toddler sleep habits?

With toddlers, many of the sleep-related issues are developmental issues. For example, toddlers often have separation anxiety, which means they have difficulty separating from their primary caregiver, so this can result in bedtime resistance, with the child being reluctant to part with their beloved caregiver at bedtime. Also night wakings are an issue.

That's why the importance of a bedtime routine becomes so critical at this age. Children need a psychological preparation to approach bedtime. Parents can assist in the process by having a regular series of activities that culminate in bedtime and lights out, so that it becomes a regular- routine-every-night kind of proposition.

Toddlers are also asserting their independence and discovering limits, so bedtime struggles can oftentimes be the result of that developmental process. Parents need to be very consistent with bedtime and very firm about setting limits around the bedtime hour.

In general, we recommend that parents teach their young children to fall asleep independently. So it's important to introduce transitional objects such as a blanket or a stuffed toy that provides some reassurance and comfort to the child, while allowing them to learn to soothe themselves to sleep.

"Rest does not equal sleep, and rest will not yield the same benefits that actual sleep does."

Is resting time/down time, but not actual sleep helpful? Sometimes my 7 month old skips naps, but I try to do some quiet time at least.

Rest does not equal sleep, and rest will not yield the same benefits that actual sleep does. Rest provides an opportunity for quiet interaction with the caregiver, and can remove some overstimulation in the environment, so from that standpoint it certainly can be beneficial, but it does not substitute for sleep.

Sleep occurs in very specific stages, which are determined by different levels of activity in the brain. There are also certain physiologic processes that occur during specific sleep stages, as well. So if you don't actually sleep, your brain and your body don't get the full benefits of those particular sleep stages.

Is there ever a time when you should wake a child? I have a 7-month-old son; should I just allow him to sleep when he wants or is it important to get him on a schedule?

In general, we recommend that sleep patterns be established along a regular schedule guideline. Establishing a regular bedtime and wake time, as well as a naptime, helps to reinforce the body's normal circadian rhythms. Circadian rhythms are the time course across the 24-hours of the day, primarily for sleep and wake patterns, but for many other physiologic processes, as well. So the more set and established and the circadian rhythms are, the better the body functions. Think about how you feel when you have jet lag, for example. It makes you feel physically out of kilter, as well as mentally.

So it is important to have as much of a regular schedule for sleep and wake patterns. This also helps ensure a child gets adequate sleep over a 24-hour period, rather than taking five minute catnaps here and there.

Should a naptime routine resemble the bedtime routine?

Children become very conditioned to sleep and falling asleep in a certain way. In general, it's usually easier to get a child down for a nap if you use a shortened version of a bedtime routine. That might be just reading a page in a storybook or singing a song and having a transitional object, such as a stuffed animal.

Most babies up until about 18 months or so will take a morning and afternoon nap. By a year to 18 months most will have given up the morning nap and begin napping once a day. It's very variable when children give up napping. Some give up napping between 3 and 3.5 years old; some continue requiring a nap up to age 5. There are some interesting data to suggest that in certain ethnic and racial groups napping may continue well into the elementary school age years.

So I think the key to looking at napping is to look at that 24-hour sleep period, and to look at the child's behavior and mood when they habitually nap. Most children will show signs they need a nap by becoming irritable; they may become overactive; they may be more aggressive or behaviorally disruptive. If that's the case, those are indications that the child continues to need that nap period during the day.

Any suggestions for when babies are refusing naps? Do you agree with letting them cry it out? At what age, if so?

Make sure that the environment is conducive to napping, such as the room is dark and quiet. It's also important to time the nap appropriately. Remember those circadian rhythms we mentioned earlier. There tends to be a dip in alertness around midafternoon and that's often a time when you can take advantage of that dip to put a child down for a nap.

If a young baby who still needs a nap is refusing to nap, it's important to look at how they're falling asleep at bedtime. If a baby needs to be rocked or held to fall asleep at bedtime, they're going to need the same conditions at bedtime, as well.

My daughter uses a stuffed animal as a transitional object. Should I send it to daycare and her grandmother's, where she is cared for on some days?

I would suggest the same transitional object be used in the other settings as well. I believe the transitional object will make the sleep transition a lot easier when she's not in her normal environment.

What are some solutions for frequent night wakings in toddlers?

The key to understanding night wakings is to know they are normal. Throughout the night all of us sleep in cycles, and at the end of a cycle, which in young children is about 60 to 90 minutes, there is a brief arousal or awakening. Most of us just roll over and go back to sleep. The problem comes when a child has developed those conditioned associations at bedtime that they need in order to fall asleep. If those same conditions are not present during night wakings, then they're going to have trouble falling back asleep.

If night wakings are a problem, look at how the child is falling asleep at bedtime. If they need you to be there, they need to be held or rocked or patted, then they're going to need those same conditions to fall back to sleep at night, as well. So the trick is to teach the child to fall sleep on his or her own without needing those conditions present. That's where putting a child to bed after the bedtime routine drowsy, but still awake, is key, because then they are not actually falling asleep while being held or rocked, etc.

How can you institute a routine in an older child (5-6) who has never had one? Can you use cry it out this late in the game?

I would keep it simple and I would use activities as part of the bedtime routine that the child enjoys, but that are not stimulating. So for example, television should not be part of the bedtime routine. I think it's important, first of all, to establish a set bedtime and then to make those 30 minutes or so prior to bedtime kind of a calm down period. That might consist of reading or listening to music or even talking quietly, as long as it's consistent, soothing, and not stimulating.

With older children you can also use reward systems, as well, which is an advantage because you can use positive reinforcement. You could use a sticker or star chart, for example, to reward a child for going to bed without protest, or for going to bed within a certain period of time, or going to bed and not getting up again after lights out.

So you establish the routine, make it pleasant, and also build in rewards if you're meeting resistance about establishing a routine.

"Make a good night's sleep high on the list of health habits. Think about getting sleep as a health habit, like good nutrition, wearing a seat belt, getting exercise, and all those important things we do for ourselves and our children."

How can you tell if your child has a sleep disorder, and is not just refusing sleep?

The most important thing to look at first when you have a child with bedtime resistance is to make sure they're getting an adequate amount of sleep. That's the first priority or measure when looking at the child's sleep.

Then look at whether the child is difficult to wake in the morning. A child who jumps out of bed in a great mood ready to start the day, probably is getting enough sleep, if that's a consistent behavior. If the child has to be called three or four times, is grumpy and irritable, that suggests they're not getting enough sleep and the bedtime issue is a problem. This is an important consideration, because sometimes parents try to put their children to bed too early, and that can be one reason for bedtime resistance.

Another common reason is there are some children who are really more night owls, even at a relatively young age. They may have more difficulty going to sleep at an earlier time. You can help a little bit with that by making sure the room they're sleeping in is dark. Darkness is important because it regulates the body's production of a hormone called melatonin. Darkness helps the body to turn melatonin on, and bright light shuts it off. So light and darkness can really help to set bedtime and wake time.

Another common cause of bedtime resistance is inconsistency on the part or parents in terms of bedtime, meaning not having a regular bedtime, not having a regular bedtime routine, and not having a window of time before bedtime where the child can get relaxed and ready for sleep.

We are almost out of time, Dr. Owens. What recommendations has the National Sleep Foundation come up with following the study of children's sleep habits?

No. 1, sleep needs to be a priority for the whole family. Parents are excellent role models for their children, and they need to pay attention to their sleep habits, as well as their children's. Make a good night's sleep high on the list of health habits. Think about getting sleep as a health habit, like good nutrition, wearing a seat belt, getting exercise, and all those important things we do for ourselves and our children. Sleep needs to be up there.

Second are good sleep habits include:
  • A regular bedtime
  • A bedtime routine
  • Putting babies to sleep drowsy or awake
  • Not having a TV or a computer in the bedroom
  • Avoiding caffeine during the day

Third, parents should recognize potential sleep problems in their children, such as snoring or having difficulty waking in the morning, and bring those concerns up with their child's doctor.

Thanks to Judith Owens, MD, for sharing her expertise with us today.

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