Children and Sleep

Children can suffer from sleep disorders. It is estimated that 25-30% of visits to the pediatrician are related to a problem linked to sleep, and parents can do a lot to help their children get the deep restorative sleep they need to develop, live healthy lives, and stay awake during the day.

Whatever nighttime problems encountered with young children, such as getting children to go or stay in bed, they are common in many homes. Parasomnias, separation anxiety, insomnia caused by bad habits, stress, illnesses, medications, or overexcitement are sufficient to cause sleep changes that can occur in any family at any time.

Insomnia in children

Since before birth, children have brain neurons with the ability to function as a “biological clock”. The control of sleep and wakefulness is determined by this biological clock, which allows the child to sleep at certain times and be awake at others. However, the operation of this biological clock is also influenced by environmental conditions of light-dark, so that in conditions of darkness, our brain secretes a hormone called melatonin, which facilitates sleep as this hormone is inhibited by external brightness. Starting from approximately 3 months, children learn to synchronize these two pieces of information so that they can start to match the sleep-wake cycle with the day-night cycle.

How many hours do children need to sleep?

A newborn sleeps up to 16 hours per day, in 6-8 episodes of sleep of 4 hours each, with intervening periods of wakefulness. Hence the newborn does not respect the night, waking up once or several times throughout it.
From 1 month until 3-6 months, the length of the nighttime awakenings diminishes and the child starts to sleep continuously, practically all night. However, in nearly a third of preschool-age children these nighttime awakenings persist, resulting from improper consolidation of the nocturnal sleep period. Between ages 3 and 5 they sleep 10-13 hours through the night in addition to two regular naps. From three years of age, the “need” to sleep during the day diminishes, until it practically disappears before the age of six. Between the ages 6-12, children should get between 9 and 12 hours of sleep, and between the ages 13-18, teenagers should get 8-10 hours of sleep.

Between ages 5 and 10, sleep reaches a degree of maturity sufficient to allow comparison with adults. Although there are important individual variations, the number of hours of sleep tends to be 2.5 times higher than in adults, and the proportion of REM sleep is similar to adults.

After the age of 7, it is not common that children need to nap. If it happens, chances are that they are sleeping less than they need to at night or are suffering a problem during the night, preventing rest.

Starting in adolescence, the number of hours slept will decrease to an average of 8 to 10 hours, which may be insufficient since there is an increase in daytime sleepiness, which has led to the idea that the total need for sleep does not decrease but rather increases during adolescence.

When should we suspect a sleep problem in a child?

Sleep needs vary considerably. There is no uniform sleeping pattern and what one child needs may not be applicable to another. However, if a child regularly has trouble falling asleep or staying asleep through the night or if he or she is tired and sleepy during the day, a sleep problem, or the habits that lead to one, should be suspected.

Some behavioral and psychological causes of children’s sleep problems.

Bad habits:

Like adults, children can have difficulty initiating or maintaining sleep, though they rarely complain of this problem and are usually happy to stay awake.

Sleep initiation requires a complex coordination of biological circumstances and learned behaviors: on one hand, the organism must be physiologically ready for sleep. On the other hand, the activities that precede bedtime become ritual facilitators of sleep that, when they are missing, prevent falling asleep.

Rituals for falling asleep are also necessary in children, and often the problem of child insomnia is not waking up at night, but returning to sleep, since the stimuli associated with the onset of sleep are not present in the middle of the night when they wake up (mum or dad, light, story…).

Stress:

Due to irregular hours, overtiredness, family problems, fears and separation anxiety

Children need routine as it provides security. When this security is threatened, children react by showing their anxiety through crying, behavioral changes, and resistance to sleep at night. They behave the same way when, after an exciting day, they are told that they have to go to bed since sleep implies a change from the activity they are currently enjoying. Sometimes, the problem may come from the existence of exceedingly irregular family schedules.

Another frequent cause of difficulty falling asleep is taking long naps in the afternoon. For this reason, with an insomnia problem in children, one of the first measures to be considered will be the reduction or even elimination of daytime sleeping (naps).

A child can have difficulties separating at night from the rest of the world or may pick up subtle changes in the family environment and cause problems at bedtime. Even in the safety of a happy home, children may be afraid of the dark or imaginary creatures in the shadows of the bedroom.

Whatever the case, the response of the parents always has to be supportive. They must talk with the child about their fears.

In children over three years old, positive reinforcement techniques, such as prizes, can be used if their behavior is appropriate.

Pediatric insomnia: Some medical causes of insomnia in children

Some medical problems that should be ruled out for a child with insomnia:

  • Allergies: affected children sleep in a fragmented and interrupted manner.
  • Pain: Ear infections and cramps are very common in children. Any situation that produces pain, discomfort or fever will interrupt sleep at night. If the situation has become chronic, bad sleep habits have usually become conditioned over time so they may persist despite the disappearance of pain, probably due to mismatches in the rhythm of sleep and the acquisition of bad habits.
  • Enuresis: It is likely that enuresis is the most stressful of sleep disorders for the child, since it is not only a source of lost sleep, but also of shame. Enuresis is considered to exist when there is still control over the sphincter of the bladder at five years of age. Enuresis affects 15% of boys and 10% of girls. Although most of them get better as they get older, one should go to the doctor to find a solution and accelerate the process.
  • Chronic diseases: In principle, any chronic disease is able to cause persistent sleep disturbances. Disorders such as headaches, asthma, diabetes mellitus, gastroesophageal reflux or epileptic seizures can alter sleep in those who suffer from it. Insomnia can be a direct result of the problem, the treatment, or the anxiety generated by the disease. For all these reasons, it is advisable that, as a first step, children see their pediatrician for a medical examination as complete as possible..
  • Medications: Medications can alter sleep. Relatively safe drugs that are prescribed to treat acute or chronic diseases can disrupt sleep (e.g., antibiotics, bronchodilators, etc.)
  • Once the problem is identified (by a temporal association between the onset of treatment and the sleep disorder), treatment should be discontinued whenever this is possible. If it is not, one should try changing the time the medication is taken, modifying its dosage, using another similar medication, keeping the same drug but using a different preparation, or varying its route of administration. Other medical causes that should be taken into account are dental, gastrointestinal problems, allergies, and sleep apnea. It is also helpful to rule out the presence of parasites.

Sleep in children with infantile hyperactivity

These are children who are usually restless and find it difficult to stay and complete the tasks they perform, are distracted and often annoy other children at school, cry easily, and have mood swings. They frequently show hyperactivity and restlessness. They get frustrated easily and may have destructive behavior. During sleep, the most characteristic symptom is the presence of frequent awakenings and restless sleep.

Sleep-related problems are common in these children, with 16.5% presenting initiation of sleep difficulties and 39% presenting nocturnal awakenings. Early diagnosis and treatment is important since the hyperactivity disorder worsens sleep, and vice versa i.e., a hyperactive child tends to have sleep problems, and at the same time, lack of sleep causes hyperactivity and attention-deficit during the day.

The parasomnias, anxiety caused by separation and insomnia caused by bad habits, stress, illness, some medications or overexcitation are sufficient causes to alter sleep, which can occur in any family at any time.

What to do? Treatment plan for insomnia in children: the Ferber method

At the end of the 1970s, American pediatrician Richard Ferber published a behavioral method for childhood insomnia management ( https://en.wikipedia.org/wiki/Ferber_method), which became popular around the world. The basis of this method is the extinction of crying over a brief period. But this method is not for everyone. For this reason, other variations based more on physical attachment have been developed (Elizabeth Pantley: The No Cry Sleep Solution http://elizabethpantley.com/no-cry/sleep/At the Sleep Institute, we recognize that there is not a universal method for the treatment of all types of childhood insomnia, and that strategies must be adapted to each individual family’s circumstances.

In very general terms, the recommendations can be made: If the cause is thought to be medical, go to the specialist with the child to solve the problem.

If the cause may be learned bad sleep habits or behavioral problems, then the parents may consider consulting a psychologist or doctor specializing in these problems if results are not seen within a week of trying to implement healthy sleep habits that help the child learn to make the transition between wakefulness and sleep without the participation of the parents.

The child must learn to sleep alone, under conditions that are reproducible when he or she wakes up in the middle of the night. In some cases, deterioration will occur during the first two or three days, so it is advisable to start the treatment plan during the weekend so if the parents don’t sleep the first few nights, they can do so the next day.

  • Place the child in bed or a cradle with only his or her favorite objects that can remain next to him or her during the night so he or she becomes accustomed to sleeping next to these objects and associates them with sleep. Thus, if the child wakes up in the middle of the night, he or she can fall back asleep without anyone.
  • The room must be dark, quiet and a comfortable temperature.
  • Parents can reassure and comfort the child until he or she is lying quietly in bed. Once the child is quiet in the bed or cradle, the mother/father must leave the room.
  • If the child starts to cry, do not go to them immediately. After a few minutes (at least 2 minutes) the mother or father may return to the room to comfort the child, who should not move from the bed, until he or she is quiet (though awake).
  • Then the parent should leave the room. If the child begins to cry again, the parent will wait a slightly longer time (for example, 2 to 5 minutes) before entering and repeating the previous step.
  • The process must be repeated (with a waiting time of no more than 2 to 5 minutes on the first night) until the child is asleep.

It must be kept in mind that during this first night, the cry-answer process can last several hours until the child falls asleep. The plan will succeed only if parents are persistent and consistent with the “treatment” and do not give in to the temptation to take the child from his or her bed. It should involve everyone who takes care of the child to ensure consistency in the implementation of the plan.

The following nights will progressively extend the wait times before reassuring the child if he or she cries. Wait times are usually proportional to the age of the children (with older children, the wait time should be longer).

  • Interventions of parents should be supportive. The child should know that they are close and understand the child.
  • Parents should never externalize anger or frustration. They must not allow these emotions increase as the night progresses.
  • Improvement is generally seen after the third night. The nighttime awakenings tend to be shorter, and crying is weak and brief. The child learns to fall asleep alone without the help of their parents.

It is advisable that throughout the treatment parents fill out a sleep diary to document progress. This will serve both the parents and the doctor overseeing the process. Once the child has learned to sleep alone, he or she will continue to do so in the future. However, it is possible that a slight deterioration may occur at times when regular hours are changed, such as during holidays, birthdays, etc. The persistence of these relapses will depend on the way the parents respond. If the response occurs according to the stated plan, relapses will be resolved alone and the child will continue sleeping well.