By Stephen Tarnoczy, BS, RRT, RPSGT, Clinical Specialist/ Education, Gaylord Hospital Sleep Services

A child’s sleep is wondrous, often enviable. How many adults have relished the chance to say, “Oh, how I slept like a baby last night.” Sleep comes naturally to small children, but their sleeping habits are greatly determined by the patterns established at an early age. A steady dose of good sleep results in a happy, thriving child. A child who doesn’t get a restful night’s sleep can turn a household’s evening into a nightmare! An ill-rested child may experience problems in normal child development and exhibit behavior that can place undo stress on family members.

A child’s sleep can be very puzzling to many parents, especially new ones. Many question how long a child should sleep at night, during naps, or whether they should wake their child at a scheduled time or on her own. The fact is that a child as young as six months can learn to sleep through the night for at least 9 hours. Every child is unique, but most have the potential to sleep throughout the night

Sleeping arrangements vary. Some children sleep by themselves, others share a room with a sibling or parent, and some share a bed for a while. Still, it is important to establish a good sleep pattern that encourages quality sleep for naps and a full night’s rest. While these arrangements can work, a parent needs to recognize problems in you’re a child’s sleep before the problems become difficult habits to break.

Is There a Problem?

Children with sleep problems tend to share one or more of the following signs:

1. An unusual amount of time spent helping the child fall asleep.
2. Repeated awakenings occurring throughout the night.
3. Child’s behavior and mood are affected by poor sleep.
4. Parents lose sleep because of a child’s disrupted pattern(s).
5. Poor sleep interferes with the parent-child relationship.

Fortunately, most of these issues can be resolved swiftly once identified and treated with a dose of common sense and a little guidance. Sometimes comparing notes with other parents or consulting with a pediatrician may help. In other instances, consulting with a sleep disorders specialist might be recommended.

Time For Bed

A relaxing bedtime ritual can be one of the richest moments shared between a child and a parent. Yet getting a child ready for bed almost always initiates a feeling of separation anxiety between children and their parents. This is a normal. Parents naturally want to comfort their children. Waffling on requests, however, for “just one more story” or “another glass of juice” will inadvertently teach the child that bedtime can be extended and manipulated. Without established sleep routines, bedtime can be filled with tension, arguments and anxiety. A good bedtime routine starts with setting aside 10 to 30 minutes to do something special with the child. Choose something soothing and relaxing, like reading. Bedtime is not the time for overly stimulating activities such as wrestling, running, ghost stories, or scary movies. Quiet, happy activity is best.

EARLY CHILDHOOD SLEEPING DISORDERS

Sleep-onset Association Disorder

“I’m completely exhausted. My child wakes up during the night, and I end up rocking her. It’s the only way I can get her to sleep.”

Does this sound familiar? Some children learn to associate the act of falling asleep with a specific action such as being rocked or patted on the back. When the action is removed, the child is unable to fall asleep. This is sleep-onset association disorder.

Most people wake up briefly a number of times during the night, especially during dream sleep—or rapid eye movement (REM) sleep. These brief awakenings usually go unnoticed and people return to sleep rather quickly. Parents, however, may feel obligated to help the child return to sleep. The child quickly associates the helping activity with sleep and will soon be unable to fall asleep without assistance. The sleepy child starts to cry when awake, and a vicious cycle begins.

What is an equally sleepy, frustrated parent to do? Parents need to know that a child can—and will—fall asleep on his own if he has the opportunity and when the reinforcing behavior is removed.

Learning How to Sleep

No one suggests that parents ignore their baby’s cries. Adults must always make sure the child is safe, not hungry, sick or wearing a soiled diaper. To correct the baby’s sleep problem, parents must teach the child to fall asleep at bedtime, naptime, and after awakenings with a new set of associations that do not require a response from the parent. It’s best to start this relearning process at night, but naptime is fine too.

The following technique will help the child learn to fall asleep more easily without evoking feelings of anxiety, alarm or abandonment.

1. Expect the child to cry. Remember, you are not abandoning the child. With encouragement and reinforcement, the child can learn to fall asleep by herself.Pacifiers may be used as a comfort measure, but their use is discouraged after the child is six months old because they tend to fall out repeatedly during the night. Cuddle toys such as blankets or stuffed animals usually don’t create a major problem, as these items should still be in the crib or bed when the child wakes up.

2. To help a child six months to three years old learn to sleep on his own, place the child while awake or drowsy into the crib or bed after a quiet bedtime routine. Say goodnight and leave the room. Make sure a little light shines into the room. If the child is still crying after two minutes, return to the room. Don’t turn on the lights. Don’t hug the child or lift him from the crib. Don’t give in to any new requests. Comfort the child with words or gently touch him to show him that he isn’t being abandoned. Leave again promptly and don’t stay in the room longer than a minute or two.

3. If the child continues to call out or cry, you should extend the amount of time that goes by before you re-enter the room. Waiting can be difficult for parents. A crying child often tugs at the heartstrings. The retraining process is actually tougher on the parents than it is on the child. Sticking to this regimen is important to transition the child successfully.

Parents usually notice a significant difference after three nights, when following the guidelines consistently. Those who don’t see any improvement after five nights should review how religiously they followed the guidelines. Keep in mind that it may take some children longer to adapt to the change in sleep routine. Even so, it is vital that both parents stick to the same regimen and don’t bend the rules. Any deviation will delay the relearning process.

Desensitizing the Older Child

Sometimes an older child may have difficulty falling asleep after becoming frightened. The following technique works well and is a desensitization method that should be used for all naps and nighttime awakenings.

1. Tell the child that you will be near the bed, but not in the bed, while the child falls asleep.

2. After several nights of his falling asleep with you sitting near the bed, move your chair progressively farther away from the bed over the next several nights until you are outside the room.

3. The door could be left open for a child who does not get out of bed, but you may need to close the door completely for the child who does.

4. Depending on the child and how long this routine has been followed, desensitization may take from one to three weeks. For an older child, a reward program could be used to speed up the relearning process. Small prizes or a star chart on the refrigerator are excellent methods. If you want your child to sleep alone, be sure to praise the child for excellent behavior.

Nighttime Eating/Drinking Disorder

“My child is hungry during the night and eats or drinks all night long. I’m exhausted.”

This complaint is a sign of excessive nighttime feeding disorder, which is more common among young children and infants. Excessive is a relative term, and can mean several feedings through the night for a baby who is a few months old. A child of six to seven months who requires an extra feeding may also fit this description. Kids can be hungry during the night, then wake up and be unable to fall asleep without being fed. A child who is accustomed to being fed several times during the night may be awakening out of habit, not hunger. The parent’s role may be to teach the child to be hungry at more appropriate times during the day.

A child of five to six months who drinks greater than eight ounces of liquid during the night is probably drinking more than he or she needs. This can also be said for a child who nurses more than once or twice, or for longer than two to three minutes at a time. If the child’s diaper is soaked whenever he awakens during the night, he might be experiencing a nighttime eating/drinking disorder.

To eliminate the nighttime feeding habit, gradually reduce the frequency and number of feedings. Nursing mothers should gradually wean babies away from nighttime feedings. For an infant who feeds at night about every hour and a half, the parent should wait at least two hours between feedings the first night, and then increase the time span to two and a half hours the second night. Increase the interval between feedings until all nighttime feedings are eliminated. This can take from one to two weeks to complete. If your child is bottle-fed, try decreasing the amount of food offered at each feeding by an ounce each night.

Limit Setting Problems

When a child refuses to go to bed, stalls for time, or makes it difficult for a parent to leave the bedside, limit-setting problems may be at work. Limit setting problems (which tend to show up after two years of age) can occur at bedtime, napping, or during nighttime awakenings. Parents must keep a firm bedtime routine despite a child’s pleas. As seasoned parents know, children can come up with an endless stream of delay tactics. Parents need to set limits and be consistent to reinforce these behaviors.

Older children may get in and out of bed repeatedly during the night. Try placing a gate in the child’s doorway or—if everyone is comfortable with it—close the door until the child successfully stays in the room all night. Let the child know that the door will remain open when she stops trying to leave the bedroom.

For those who climb over the gate, consider using a taller gate, two gates, or closing the bedroom door all night. Avoid going into the bedroom to comfort the child, but you could stand on the opposite side of the door or gate to talk to the child in a calm, soothing voice. Gradually extend the time between your visits. If you use a gate, remain out of sight from the child. A child can sometimes fall asleep near the gate or the door during this relearning process.

Gates are preferred until the child gets too big. For older kids, a warning that you may close the door may motivate them into staying in bed. Make sure you carry through on your warnings. When using the closed-door method, the intervals are much shorter, from a few seconds to just a few minutes. The idea is to teach the child a new way to fall asleep—not scare them to sleep.

Rules For Helping Your Child Sleep Better

A successful nighttime routine can usher y our child into peaceful dreamland. Here are some general guidelines to get you and your child on the way:

1. Be consistent in your routine.
2. Avoid caffeine (chocolate, soda, tea, etc.).
3. Make a relaxed setting just prior to bedtime.
4. Screen viewing material and games for age appropriateness.
5. Don’t rock the child to sleep while he or she is drinking a bottle.
6. Don’t substitute TV for parent-child interaction at bedtime.

For more information on sleep and sleep disorders, check out the National Sleep Foundation's Web Site at www.sleepfoundation.org