27 AUG 2020 by Bob Floro, MS, RRT
Quality Sleep is Essential in Children
“Behavioral insomnia is highly prevalent, affecting approximately 25% of children. It involves difficulties initiating and maintaining sleep and frequently results in inadequate sleep, leading to an array of negative effects for both the child and the child’s family.” – Jennifer Vriend & Penn Corkum, National Center for Biotechnology Information, U.S. National Library of Medicine
Sleeping habits have considerable impact on the child including their physical health, cognitive development, and emotional well-being. Long-term insomnia can also cause issues to the entire family’s well-being and emotional state. When an infant or child is unable to sleep, the parents’ sleep cycles are likely affected as well , as they’re either comforting the child, caring for their needs until the child is soothed back to sleep, but then the parents may often find it difficult to return to a deep sleep themselves. Sleep deprivation for the parents can increase the risk of postpartum depression, obesity, and lack of focus that can result in even more dangerous results.
“An estimated seven percent of all motor vehicle crashes in the U.S. and 16 percent of fatal crashes involve driver drowsiness.” – Science Daily
Over time parents who are exposed to significant sleep deprivation (termed sleep debt) will have difficulty staying focused during normal everyday activities in the home, at work, caring for the children and even driving. There are also serious consequences to a sleep-deprived infant or child. If quality sleep cannot be achieved the night before, the child is more apt to display symptoms of inattention, irritability, hyperactivity, impulse control problems, and behavioral issues at home, daycare, or school.
Some common pediatric sleep disorders are listed below:
Obstructive Sleep Apnea
- Central Sleep Apnea
- GER-related Apnea
- Periodic Limb Movement Disorder
- Restless Leg Syndrome
- Narcolepsy
- Idiopathic Hypersomnolence
- Kleine-Levin Syndrome
Some rare, yet significant pediatric sleep disorders follow:
- Nocturnal Seizures
- Circadian Rhythm Disturbances
- Delayed Sleep Phase
- Advanced Sleep Phase
- Non-24 Hour Rhythm
So, with that understanding the potential negative consequences for parents and children, let us discuss some methods to improve sleep quality for infants and small children.
Crying Out
The first step to improving the sleep quality and bedtime habits of our children is parent education. Why?
“Parents who understand the various stages of child sleep development will be more in-tune to the duration, timing, and frequency of their children’s sleep requirements allowing them to prevent sleep issues from forming.” – Alaska Sleep
One such philosophy that parents have debated for decades is ‘should you let your baby or toddler cry it out’? One study by the American Academy of Pediatrics (AAP) examined different types of sleeping training. The AAP defined a sleep training process as “graduated extinction.” This refers to a ‘graduation’ in the number of times a parent lets their baby cry before going in to soothe them.
When it comes to graduated extinction sleep training, you must first consider the child’s age. Newborns until about six months of age do not have regular sleep patterns, possibly sleeping 1 to 2 hours at a time, but totaling up to 15-16 hours per day. therefore, the beginning the training process after six months will be more beneficial since the child is beginning to develop routine sleep patterns.
Graduated Extinction Sleep Training may be seen as harsh by some parents, but the time they are allowed to cry should be short. During the first night of training, the child may be allowed to cry for 2 minutes before intervening. Follow a process of gradually increasing the times between interventions subsequent nights (consider increasing by 2 minutes each night) until the child is able to sleep for long stretches.
The goal which is often realized for this type of sleep training is that the child will learn to self-soothe rather than requiring sleep-onset treatments such as excessive nursing, rocking, and cuddling by the parents. The term” extinction” in this method refers to the procedure whereby the parents have completely removed themselves from the room while the child falls asleep. The results show that that babies allowed to ‘cry it out’ slept twenty minutes longer on average, according to the AAP study.
Does the graduated extinction method cause undue stress on the child?
“Australian researchers found that babies who are allowed to ‘cry it out’ were no more stressed than babies who had their parents respond to every cry.” – Today Show
How to Improve Sleep Hygiene for Infants and Toddlers
What is sleep hygiene?
“Sleep hygiene is a variety of different practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.”
– National Sleep Foundation
There may be various factors that contribute to impaired sleep quality in children, including environmental disturbances, poor sleep hygiene and/or various health issues. Every parent understands the value of a happy, sleeping child but some have inadvertently become part of the problem.
“There are two main reasons kids have trouble sleeping at home: their parents stay with them for too long during the sleep process, and they return for ‘extra requests’ when the bedtime routine is supposed to be over. Schneeberg describes these things as sleep crutches.”
– Dr. Lynelle Schneeberg, PsyD, * Connecticut Children’s Hospital
(*Dr. Schneebergy is the author of Becoming Your Child’s Sleep Coach: The Bedtime Doctor’s 5-Step Guide. She is also a distinguished lecturer at AAST’s 2019 Annual Meeting, which takes place September 6-8 in St. Louis.)
Some suggestions for parents to improve sleep hygiene include:
- Create a relaxing bedtime routine such as a soothing bath, brushing teeth, calm and familiar bedtime story, a good night kiss but without parents taking too long or becoming ‘sleep crutches’ for their children.
- Ensure the child gets plenty of light and exercise during the day, with routine playtimes and social interaction.
- Schedule meals a few hours before bedtime and discourage snacks and caffeinated beverages before bed.
- Schedule pre-bedtime activities and bedtime for the same time each night and strictly adhere to the routine, including weekends and during travel.
- Make sure the child’s bedroom is cool, dark and quiet to ensure less distractions, noise and sleep disturbances.
- If middle-of-the-night feedings are required, keep the room as dark as possible, speak in low comforting tones and keep the child’s environment quiet and soothing.
Sleep Test Recommendations
Parents/caregivers should consult with physicians specializing in neonatal and pediatric sleep medicine when recommended interventions have proven unsuccessful. These referrals are generally made by the family physician and/or pediatrician. The sleep physician may also be able to recognize other disorders that may be associated with and/or manifested by the child’s sleep deprivation. Examples of these complex sleep disorders may include:
obstructive sleep apnea- significant insomnia of unknown etiology (idiopathic)
- excessive daytime somnolence
- excessive night terrors
- nightmares
- sleepwalking
- bedwetting
- confusion
- anxiety
- periodic limb movement (restless leg syndrome – although rare in children)
- seizures
- miscellaneous psychological or behavioral disorders.
A sleep test will diagnose most significant sleep problems, as well as determine recommendations and treatments to improve sleep quality. Sensors are placed on their head, chin, legs, face and around their chest and stomach. The sensors will check the child’s eye movements, heart rate, breathing patterns, brain waves, blood oxygen level, carbon dioxide levels, snoring, body movements and sleep positions.
Sleep Technologists are skilled in creating environments that mimic the child’s sleep environment at home. Generally, parents /caregivers will stay overnight in the room with the child. Parents should plan to assist their child’s comfort during the sleep study by bringing soft, comfortable pajamas, a favorite pillow, stuffed animals, books, blankets – virtually any item that will make the session more comfortable for the patient. It is imperative that professionals and parents alike attempt minimize the child’s anxiety, and not attempt to force the child to sleep during a sleep study. These pediatric patients must have sufficient time to adjust to the foreign, and somewhat intimidating environment of the lab.
“That feeling of anxiety can transfer into the sleep lab, too. Pediatric patients don’t always understand what a sleep study is. The equipment used in a sleep lab can look scary to a child, too, which only adds to anxiety about their sleep habits. Dr. Schneeberg (quoted above) says any sleep center should have tools to help children feel more comfortable and at ease.” – AAST blog
Concerned parents should always discuss any irregular sleep habits with their pediatrician first. Keeping a sleep diary prior to the appointment is highly useful, enabling the physician to analyze occurrences such as questions about specific bedtime, time of sleep-onset, duration of sleep and occurrence of awakenings.
For further information and continuing education courses in pediatric sleep, please visit www.AACSM.org and click on the “courses” tab.
The information contained in this article is offered for educational purposes. The views and opinions expressed are those of the authors and do not necessarily reflect the official policy or position of The American Academy of Cardiovascular Sleep Medicine.”
