Sleeping

Sleeping

Sleep behaviors are culturally determined, and problems tend to be defined as behaviors that vary from accepted customs or norms. In cultures where children sleep separately from their parents in the same house, sleep problems are among the most common that parents and children face. Infants generally adapt to a day-night sleep schedule between 4 and 6 mo. Sleep problems beyond these ages take many forms, including difficulty falling asleep at night, frequent nighttime awakening, atypical daytime napping, and dependence on feeding or being held for sleep. These problems are related to parental expectations, the child's temperament and biologic rhythms, and child-parent interactions. Inborn biologic patterns are central to an infant's sleep patterns, whereas emotional factors and established habits become more important in the toddler and older child. In addition, sleep disturbances become common at 9 mo and again around 18 mo, when separation anxiety, increasing ability of the child to move independently and control his environment, long late-afternoon naps, overstimulating play before bedtime, and nightmares tend to become more common.

Evaluation


History: History focuses on the child's sleeping environment, consistency of bedtime, bedtime routines, and parental expectations. A detailed description of the child's average day can be useful. The history should probe for stressors in the child's life, such as difficulties in school, as well as exposure to unsettling television programs and caffeinated beverages (eg, sodas). Reports of inconsistent bedtimes, a noisy or chaotic environment, or frequent attempts by the child to manipulate parents by using sleep behaviors suggest the need for lifestyle changes. Extreme parental frustration suggests tension within the family or parents who are having difficulty being consistent and firm.

A sleep diary compiled over several nights may help identify unusual sleep patterns and sleep disorders (eg, sleepwalking, night terrors). Careful questioning of older children and adolescents about school, friends, anxieties, depressive symptoms, and overall state of mind often reveals a source for a sleep problem.

Physical examination and testing: Examination and diagnostic testing generally yield little useful information.

Treatment



The clinician's role in treatment is to present explanations and options to parents, who must implement changes to get the child on an acceptable sleep schedule. Approaches vary with age and circumstances. Infants are often comforted by swaddling, ambient noise, and movement. However, always rocking the infant to sleep does not allow the infant to learn how to fall asleep on his own, which is an important developmental task. As a substitute for rocking, the parent can sit quietly by the crib until the infant falls asleep, and the infant eventually learns to be comforted and to fall asleep without being held. All children awaken during the night, but children who have been taught to fall asleep by themselves will usually settle themselves back to sleep. When a child is unable to get back to sleep, parents can check on the child to reassure themselves of the child's safety and to reassure the child, but the child should then be allowed to settle himself back to sleep.

In older children, a period of “winding down” with quiet activities such as reading at bedtime facilitates sleep. A consistent bedtime is important, and a fixed ritual is helpful for young children. Asking a fully verbal child to recount the events of the day often eliminates nightmares and waking. Encouraging exercise in the daytime, avoiding scary television programs and movies, and refusing to allow bedtime to become an element of manipulation also help prevent sleep problems. Stressful events (eg, moving, illness) may cause acute sleep problems in older children; reassurance and encouragement are always ultimately effective. Allowing the child to sleep in the parents' bed in such instances almost always prolongs rather than resolves the problem.