Sleep

0-3 months

• Normal is 14 hours per day with 5-6 sleep periods; infants demonstrate both REM (active sleep involving body activity, closed eye movements, irregular respiration, and sudden movements) and non-REM (quiet sleep involving limited activity, no eye or sudden movements, regular respiration). Advise parents that it is generally not necessary to awaken a healthy baby to feed at night. (See Sleep at 0-3 months pt)

4-7 months

• Sleep for 8 hours at a time, mostly at night. (See Sleep at 4-7 months pt)

8-11 months

• Early in infancy, nighttime waking is quite common.
• By approximately 8 months, most infants have developed self-soothing capacities, reducing the need for parental intervention. (See Sleep at 8-11 months pt)

12 months or later

• For older babies and toddlers, nighttime difficulties are more likely to arise from separation. (See Sleep at 12 months and older pt)

Variation

Problems

Disorders- Dyssomnias

Key Points

• Some infants do not spontaneously adhere to the daylight clock and begin sleeping longest during the day.
• Circadian rhythms are set by the timing of light exposure, feedings and interaction.
• New parents may not understand infant sleep patterns and their ability to change them.
• Mothers who are depressed may make complaints about sleep more ardently and need their depression to be addressed. (See: Post-Partum Depression)

Trigger Questions (see Difficulty Falling Asleep clinical guides algorithm)

• When is his longest stretch of sleep? How long is it?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• How has all this been for you?
• How bad are your blues?

Management (see Difficulty Falling Asleep clinical guides algorithm)

• Address bedtime routines (See Good sleep habits for infants or Older Children pt)
• Keep handling and interaction to a minimum during nighttime feedings and keep the lights off or low. In the morning, keep lights bright and encourage social interaction.
• The bath may soothe some infants or arouse others and should be shifted accordingly.
• Awaken infant if he/she sleeps more than 3 hours during the day.
• Help parents understand their role in their infant's physiological regulation (See Being in Sync with your Child pt).

Key Points

• Definition of Settling: 5 hours of sleep after midnight for 4 weeks
• 70% of infants have settled at 3 months of age
  • 83% at 6 months
  • 90% at 9 months
  • 90% at 12 months
• Delays in settling occur more commonly in breast fed infants.
• Parents may be unrealistic about expected ages for settling, especially if a prior child settled early.
• Infants who, by temperament, are easily aroused and are sensitive to sound tend to settle later.
• Premature infants settle around the time expected for their adjusted gestational age.^[note]
• Infants with frank neurological impairment may not only be delayed in settling but also have other severe sleep problems that can be difficult to treat.
• State regulation problems are more common in infants with prenatal risk factors or mild neurodevelopmental dysfunction.^[note]

Trigger Questions

• How do you think he is sleeping compared with other infants his age?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• How has all this been for you?

Management

• Address ways bottle or breast fed infants can be helped to settle. (See Good sleep habits for infants pt).
• Emphasize that starting solids has not been shown to influence age of settling. (See When to Start Solid Foods pt).

Key Points

A habit of falling asleep with a person or object. It may begin in the first two months and persist for years making difficulties falling asleep independently and causing night wakings.

• Sleep associations consist of habits that occur at sleep onset and assist in falling asleep such as sucking on the breast or pacifier, twirling mother's hair or a lovie or favorite toy.
• Sleep associations help the child feel safe. Safety is essential to falling asleep in all species.
• Sleep associations can interfere with sleep when the child cannot reestablish them on their own when they awaken at night, which most people do. Instead the child needs adult assistance in reestablishing sleep. The child has to become more aroused to signal the adult and the adult has to wake up!
• Sleep associations can produce night waking in this way as well as trouble falling asleep. The child will usually fall asleep without difficulty when the habit pattern is restored e.g. put back on the breast.
• Children may develop sleep associations at either naps or nighttime or both.
• Sleep associations often occur along with other sleep problems that also need management simultaneously.
• Sleep associations of falling asleep with the TV or radio may also occur and create problems in older children.
• Contributing factors include:
  • Interaction factors
    • Parenting style^[note]
    • Attachment/continuity of caregiving^[note]
    • Parent "in love" with child who wants to spend time with child at bedtime.
  • Environment factors
    • Caregiver reaction to stress^[note]
    • Marital discord^[note]
  • Parental disagreement over management may create this problem.
    • Sleep association (See Sleep Associations pt)
      • Management

Trigger Questions

• Tell me exactly what you do at bedtime.
• Where/with whom does he sleep?
• How does he fall asleep for naps?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• What does your spouse/partner think about this?
• Is he already asleep then you put him in the crib/bed?
• What works to resettle him?
• How is that for you?

Management

• Address sleep rituals. (See Good sleep habits for infants or Older Children pt)
  • Put the child in bed at least a little bit awake for both nights and naps. Some fussing is to be expected.
  • if the child falls asleep at the breast or with a bottle, wake them up enough so they have to return to sleep on their own.
  • Avoid pacifiers and bottles in bed.
  • Placing a shirt the mother has worn^[note] under the crib sheet can encourage sleep for children who are used to having mother hold them.
• Ease off sleep aides and associations. (See Sleep associations in infancy pt)
  • Substitute a habit the child can control. For example, provide 50 pacifiers so the child can find one, substitute a lovie or blanket, or assist the infant in finding his or her thumb to suck on. Some of these will be more acceptable to parents than others.
  • if a sleep association is strong, the child may need the parent to sit beside him/her for successive nights in decreasing amounts of time.
  • Negotiate with the teen-ager or older child by making radio and/or TV at bedtime contingent upon a successful morning routine (i.e. no struggle getting up).
• Address parental resistance to change.
  • if one parent can't tolerate the child when the child is upset, this may need to be further explored to solve the problem. Consider vulnerable child syndrome or overprotection (See Parents who worry too much pt).
  • Recommend special time for parents who allow their child to fall asleep in their arms because they want to spend more "quality time" with their child. (See Special Time pt).
  • if parents disagree about making changes, have the parent who is open to change handle bedtime for three weeks.
  • Discuss the marital relationship and explore the possibility that sleep problems are an excuse to avoid the spouse. (See Marital stress pt).
• It usually takes one week or less to end a sleep association when consistently managed with these suggestions.

Key Points

• Many children rock themselves or bang their heads at times of stress, boredom, or while falling asleep.
• This can be quite vigorous and break the crib or damage the wall.
• Children with more intense temperament rock and bang more than others.
• These habits may begin with head rolling at 6 months of age and persist into adulthood in some.
• Pathological reasons for rocking and banging include: autism, mental retardation, sensory deficits, seizures, child abuse or neglect, and pain e.g. from otitis, migraine, post head trauma.
• Parents and relatives may present with this as a complaint because of fears of any of the above.

Management

• Rule out the pathological causes with a careful physical exam and developmental screening. Manage any pathology found.
• Assess temperament either by history or a standard tool (link to: temperament questionnaire)
• Be sure to assess for abuse or neglect by sitters as well as parents as this can be enough to stimulate rocking.
• If no pathology is found (the usual finding), educate about temperament and advise increased holding and vigorous rocking at bedtime.
• Suggest bolting the crib to the wall to reduce household damage.
• Be sure the child is not being put to bed too early and is awake and bored in the crib or bed for a prolonged period. See Circadian rhythm disorders. Collect a sleep diary if unsure.
• In severe cases a short course of po hydroxyzine can be helpful.
• Reassure parents who may be worried with information (See Self-rocking, head-banging pt)

Key Points

• Children resist bedtime when they are not tired. Make sure that the child is not excessively napping or sleeping after 4 pm.^[note] Consider Circadian Rhythm Disorder.
• Total sleep time including naps is typically 11 one half - 13 hours for a child between 2 and 4 years old. Expected sleep schedule should be compared with this total. (See Sleep Table)
• Domestic discord or violence should be considered as a potential reason for children avoiding bedtime after which time they can hear their parents fighting.
• The child may be charming in pleading for one more story, game, or glass of water, or be tearful. Parental guilt and love can make this into a habit.
• Children who are noncompliant generally often test at bedtime. It is a good place to start to set limits. Other behavior problems will need to be addressed.
• The child who is no longer sleeping in the crib may come out after being put to bed (Named Curtain Calls).
• Discuss the marital relationship and the potential tendency to avoid the spouse. Parental disagreement over management may create this problem.
• Parental depression can interfere with limit setting at bedtime and other times.

Trigger Questions

• What is your bedtime routine?
• What is he doing just before bedtime?
• How does he act at bedtime?
• How did his sleep problems start?
• Were there other changes in his life happening around that time?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• What does your spouse/partner think about this?

To the child:

• What do you think about before you go to sleep?
• What do your parents think about this?
• What do you think your parents should do about this?

Management

• Address bedtime routines. (See Good sleep habits for older children pt, Bedtime issues pt)
  • Establishing daily bedtime routines of less than 1/2 hour.
  • Limit bedtime routines to a defined set of activities and end the routine on time.
  • Strategies include preparing for the transition to bedtime, maintaining a bedtime routine, putting the child down somewhat awake to facilitate self-soothing, cuddle objects, soft music, gentle baths, or other soothing activities, making sure naps aren't interfering with nighttime sleep (toddlers should be awake by 3 PM), and using a nightlight for toddlers afraid of the dark.
  • Have parents establish a daily schedule and bedtime routine for 7 days per week.
  • Have the routine include close interaction between parent and child, not television or videos at the end of the routine.
• For the child who is getting out of bed or calling out try the behavioral methods below.^[note] (See Toddler sleep problems pt)
• The parent should lead the child back to bed without talking to them as many times as necessary.
  • Parent should notify the child that they will not respond to further requests.
  • Having the parent promise to "check" the child in 5 minutes may also be reassuring.
• The child may be rewarded for staying in bed without calling out by two stories the next night - only one if they came out. Alternatively, the parent may offer the child a choice of having the door opened or closed and the light on or off. Inform the child that the door will be closed and the light turned off if the child comes out or calls out. If the child comes out or calls out, the consequence is done for a few seconds before opening the door and giving the child a second chance.
• Try a "bedtime ticket": a paper certificate that can be redeemed for "one more thing" only.
  • Having the parent promise to "check" the child in 5 minutes may also be reassuring.
• Toddlers who come out may need the doorway gated if they are not mature enough to respond to the above measures.
  • Have parent(s) spend "special time" with child every day to reassure child and relieve parental guilt. (See Special Time pt).
  • Evaluate whether prolonged routines are a way for parents to avoid each other. If so, suggest marriage counseling. (See Marital stress pt).
  • Rule out a phase shift problem. (See Bedtime issues pt).
  • Assess for a phase shift problem, i.e., ask about excessive or late day napping. (See Sleep Table for total sleep time for toddlers and pre-school children).
  • Advise parent how to get child on a normal sleep schedule (See Adolescent sleep shift pt; See also phase shift problem dtw)
• Bedtime should be first conducted at the time the child is tired for several days until there is no more resistance and then advanced by 10 minutes per night until it is an acceptable hour.
• Morning wake up should be consistently at the target hour from the beginning of the intervention.
  • Stress importance of firm limit setting. (See Limit setting at bedtime pt; See also Principals of Limit Setting pt). Parents may need coaching on limit setting or referral if discipline is a general problem.

Key Points

• Bedtime fears are developmentally appropriate for young children and generally related to their daily stresses.
• A common stress is having out of control behavior so that adults are unhappy with the child and the child is then worried about his relationship with them (this is subtle).
• Exposure to violent or frightening media or videogames can result in fears even if the child appears to like them.
• Other stresses can cause bedtime fears.^[note]
• Sexual issues may result in fears if the child is over stimulated by home nudity, co-bathing, or lack of limits on physical intimacy with adults.
• Consider sexual molestation.^[note]

Trigger Questions

• How did his sleep problems start?
• Were there other changes in his life happening around that time?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• What is the room like where he sleeps?
• What is he doing right before bedtime?
• What routines do you use to put him to bed?
• What does your spouse/partner think about this?
• What are some of his fears?
• What works to resettle him?
• How is that for you?
• What does he watch on television? What types of video games does he play?

To the child:

• What do you think about before you go to sleep?
• How do you feel when you wake up in the night?
• What are you afraid of?
• How do you feel about this sleeping problem?
• What do you think your parents should do about this?

Management

• Suggest a soothing bedtime routine as the best preventive for night fears at any age (See See Good sleep habits for older children pt).
• Evaluate fear(s).
  • Identify the stresses for the child.^[note] (See Stress affects sleep pt).
  • Exposure to violent or frightening media or video games should be eliminated.
  • If the child is over stimulated by home nudity, co-bathing, or lack of limits on physical intimacy with adults, these should be discontinued.
• Encourage parents to give child sympathy and concrete reassurances for unfounded fears (See Giving concrete reassurance pt)
  • The parent should give sympathy for the fearful emotion.^[note]
  • A ritual of the adult "spraying away monsters" (with room deodorizer) may be helpful.
  • Have the child buy a special flashlight to use to check out the room at night.^[note]
  • A nightlight may help a child as long as it does not interfere with sleep once it is achieved.
  • Older children benefit from relaxation exercises^[note] and empowerment stories^[note] at bedtime.
• Educate parent in setting appropriate limits during the day and if necessary suggest a behavior management plan. (See Limit setting at bedtime pt; See also Principals of Limit Setting pt)

Key Points

• The most common difficulty with falling asleep is a sleep phase shift or circadian rhythm disturbance.
• The natural circadian cycle is about 25 hours.^[note]
• A circadian disorder may be differentiated from an oppositional disorder by the lack of resistance to going to bed but the inability to fall asleep.
• In late phase shift the child is difficult to arouse and does not feel rested in the morning.
• In early phase shift (usually in infants and toddlers) the child falls asleep early but then awakens early in the morning.
• Adolescents become accustomed to a late bedtime.^[note]
• Child's daily activities (school, work and social activities) may bring on a phase shift with sleeping late on the weekends to "catch-up".
• Family or school avoidance.^[note]

Trigger Questions

• What time is he put to bed?
• What time is he asleep?
• What times does he wake up?
• What time is he up for the day?
• Is the schedule the same for the weekends or does he sleep in?
• What does it take for him to wake up in the morning?
• When you wake him up does he seem rested/cheerful?
• Does he fall asleep during the day? When, where, and for how long?

To the child:

• Do you still feel sleepy in the morning?
• How do you feel about this sleeping problem?
• Do you ever fall asleep during the day?
• What do you think your parents should do about this?

Management

• Shift child's sleep phase. (See Bedtime issues pt).
  • Simultaneously shift naps, bedtime, waking time and meals to a desired schedule that matches the child's sleep needs.
  • Adolescents must stick to a schedule of bedtime and waking 7 days per week matching their school needs and avoid napping to readjust.^[note] (See Adolescent sleep shift pt)

Key Points

• Primary insomnia is unusual in children and occurs only rarely in adolescents as a diagnosis of exclusion.
• Primary insomnia must last at least one month, interfere significantly with functioning or cause significant distress, and not be part of another sleep or mental disorder to be diagnosed.
• Impaired concentration, vigilance, or attention, low energy, increased fatigue and bad mood may be associated symptoms.
• Children with Attention Deficit Hyperactivity Disorder often have sleep onset problems.
• Excessive exercise, smoking or caffeine beverages close to bedtime can make sleep onset difficult.
• Daytime naps can make sleep onset very difficult in the child over 4 years old.
• Breathing Related Sleep Disorders, asthma and Restless Legs Syndrome may set up negative associations with falling asleep of which the child is unaware.
• Circadian Rhythm Disorder is the more common reason for difficulty falling asleep.
• Sleep associations to television or music at bedtime may delay sleep onset.
• Anxiety at bedtime, often in combination with a phase shift, is a much more common reason for insomnia than primary insomnia.
• Consider past sexual abuse, especially if it occurred in the bed, as a reason for bedtime anxiety.

Trigger Questions

• Do you exercise, smoke or take caffeine beverages before bedtime?
• What time do you go to bed?
• What time do you finally fall asleep?
• What do you think about while you are in bed? Do you worry?
• Do you read or watch television in bed?
• What time do you go to bed on weeknights? Weekends?
• What have you tried to get to sleep?
• Do you feel worried or scared at bedtime?
• Do you ever take a nap during the day?

Management

• Rule out other disorders and manage risk factors.
  • Children with Attention Deficit Hyperactivity Disorder often have sleep onset problems.
  • Breathing Related Sleep Disorders, asthma and Restless Legs Syndrome may set up negative associations with falling asleep of which the child is unaware.
  • Circadian Rhythm Disorder is the most common reason for difficulty falling asleep.
• Address bedtime routines. (See See Good sleep habits for older children pt).
  • Establish a soothing routine such as reading in bed- do not allow television in bed.
  • Children of all ages may benefit from parental presence and guidance at bedtime even though some children think they are too old for it.
• Tell parent to break up cognitive reminders of insomnia (See Change the sleep environment pt).
  • Move the furniture around in the room to split up associations of the bedroom with sleeplessness.
  • Have the child turn the alarm clock so that it can't be seen or have someone designated to awaken them so that the clock can be removed to reduce attention to how late it is.
• Reestablish appropriate bedtime (See Bedtime issues pt)
  • Start bedtime at a time the child has actually been falling asleep until sleep onset is within 10 minutes of laying down then push it earlier by 15 minutes per night keeping morning wake up at the expected (early) hour for school or work.
  • Alternatively, if the child is not asleep in 10 minutes, have the child stay up another hour then try again. Repeat this as needed all night. Assure that the child is up for the day at the correct time and stays awake all day.
• Temporary use of medication may be needed along with the above but prolonged use is not effective (e.g. Ambien, Clonidine).

Key Points

• Chaotic or noisy households may interfere with sleep onset^[note]
• Sleep deprivation may result in an overly tired child having difficulty falling asleep.
• Dyssomnias, NOS can be used to describe other situations of insomnia that do not meet disorder criteria^[note]
• Restless legs syndrome had been noted in children old enough to report discomfort usually at bedtime but also often awakening the child from sleep.

Trigger Questions

• How did his sleep problems start?
• What is the room like where he sleeps?
• What routines do you use to put him to bed?
• Tell me exactly what you do at bedtime.
• Does he do anything in his sleep?
• When you wake him up does he seem rested/cheerful?

To the child:

• What do you think about before you go to sleep?
• Do you still feel sleepy in the morning?
• How do you feel about this sleeping problem?

Management

• Establish bedtime routine. (See See Good sleep habits for older children pt, Bedtime issues pt).
  • Emphasize need for adequate sleep and make routine changes as needed.
  • Reduce household noisiness until the child is asleep. If this is not possible, move the child to a quieter bedroom or use a white noise machine to drown out household sounds.
• Rule out restless leg syndrome. If present, some medications may help. (See What is Restless Leg Syndrome? pt).

Variations

Problems

Disorders

Trigger Questions

• How much sleep does s/he get on weekdays? On weekends?
• Does s/he snore or seem to have trouble breathing during the night?
• Doe s/he ever fall asleep during the day? Can s/he stop from falling asleep?
• Does s/he have any behavior problems?

Management

• Rule out other causes of hypersomnia.
  • Rule out sleep debt.
  • Rule out serious organic causes.
  • Ask if hypersomnia is correlated with timing of menses and/or cyclic hypersexuality in girls to consider menstruation related hypersomnia.
  • Consider depression as a reason for excessive sleep. Also feigned sleepiness may be used as a way to avoid socializing.
• Be sure that adolescents are not driving while sleepy and have a designated driver arrangement.
• Emphasize need to schedule time for appropriately large amounts of sleep.

Key Points

• Cataplexy, sleep paralysis, and hypnogenic hallucinations are highly associated with narcolepsy.
• 90-100% of patients with narcolepsy have the HLA DQB 1*0602 gene.^[note]
• Absence of HLA DQB 1*0602 effectively excludes the diagnosis of narcolepsy.
• Occurs in 0.04 - 0.07% of the population.
• Narcolepsy rarely has onset before puberty.^[note]
• Sleep paralysis.^[note]
• Sleep paralysis is highly familial.
• Cataplexy.^[note]
• Hypnogogic hallucinations.^[note]

Trigger Questions (for child)

• Do you ever fall asleep during the day?
• Can you stop from falling asleep?
• Do you have scary dreams while falling asleep or waking up in the morning?
• Do you ever have a sudden attack of weakness and fall down?
• Do you ever feel like you can't move while falling asleep or waking up?
• Does anyone else in your family have trouble falling asleep during the day?

Management

• Rule out other disorders.
  • Diagnosis can be aided by polysomnography.^[note]
  • Differential diagnosis includes hydrocephalus, post viral or trauma state, or the rare idiopathic CNS hypersomnia.
  • Depression is often a concomitant disorder. If suspected, give referral for evaluation and treatment.
• Assess usefulness of medication.
  • Daytime stimulants such as methylphenidate.
  • Antidepressants, such as Clomipramine 10-20 mg/day in divided doses, can also help eliminate cataplexy.
  • Monoamine oxidase inhibitors can reduce sleep paralysis, hallucinations and cataplexy.
• Stress need for regular and adequate sleep.
  • Child may need 2-3 planned one half hour daytime naps.
  • Have parent time activities during the child's best hours.
• Extend social support network.
  • Refer child or parent to local support groups.
  • Help parent educate teachers, friends and family members about disorder.
  • If school work is affected, work with parent and school to ensure adequate educational accommodations for child.

Variations

Problems

Disorders

Key Points

• Central apnea in the premature infant rarely has any sequelae other than parental over concern.
• Episodes may occur 200-300 times per night.^[note]
• In toddlers this can even result in failure to thrive.^[note]
• Obstructive sleep apnea occurs in 0.7 - 1.1% of children.^[note]
• Snoring occurs in 75% of children with obstructive sleep apnea.
• Profuse sweating during sleep, hyperextension posturing, very restless sleep, and distress upon waking from obstructive episodes may all be clues.
• Because of hypoxia, these episodes can result in concurrent negative mood; aggression; hyperactivity; poor attention, memory, visuomotor performance, and school success; and, in the long term, high blood pressure, corpulmonale, increased risk of cardiovascular accidents, and death.
• Adenotonsillar hypertrophy is the major cause of obstructive sleep apnea in children.^[note]
• Sleep apnea is made worse by alcohol consumption.

Trigger Questions

• Does he do anything in his sleep?
• Does he snore or seem to stop breathing during the night?
• When you wake him, does he seem rested/cheerful?
• Does he fall asleep during the day? When, where, and for how long?

To the child:

• How are your concentration and grades at school?

Management

• Assess and make referral.
  • A sleep study is often needed to make the diagnosis.^[note]
  • For children who have adenotonsillar hypertrophy as the cause for the disorder, adenotonsillectomy is the treatment and usually successful.
• Suggest behavioral interventions.
  • Sleeping on one's side helps - try sewing a tennis ball into the back of pajamas.
  • Symptoms improve with the relief of the obstruction.

Key Points

• 50% of infants can go 8 hours without a feeding at 1.3 months of age. Premature infants need night feedings to an older age. A premature infant that does not wake for a feeding generally should be gratefully allowed to sleep if they are healthy otherwise.
• 95% of full term infants do not need a 2 A.M. feeding by 4 months of age.
• Infants who arouse and are fed develop a changed sleep cycle (learned hunger) and the infant will consume a full feeding.
• Infants may persist in feeding at night if given a feeding during normal night time arousals even if they don't really need it. They may become overweight as a result.
• Parents who have few strategies for consoling their fussing babies ( See Calming Your Infant pt) often resort to feeding during the day as well as at night especially if they do not recognize different cues well. (See: Reading Baby's Cues, Recognizing Feeding Cues)
• Babies with feeding as a sleep association are likely to wake at night and return to sleep only with feeding. One clue to this is that the infant usually drinks a very small amount before falling back to sleep.
• Night feeding can cause excess weight gain, caries, and bronchitis as well as sleep associations.
• Trained night feeding should not be diagnosed before 4 months post term because of the frequent continued need for a feeding during the night prior to this age or in premature infants.
• Infants who were sleeping all night and begin waking inconsolable except by feeding are probably ready for solids or increased volumes of feeds during the day.
• Over-responsive parents will go to feed the infant when he stirs even though he may have been able to resettle given the chance.
• Parents not providing a late night feeding may have infants waking to feed who could sleep through if fed around 10-11 pm.
• Trained night feeding can occur at older ages as well and even in school aged children who get up and eat at night. These situations often reflect parent-child pathology of nurturance or a serious sleep disorder.

Trigger Questions

• Do you have any concerns about his sleeping?
• How do you think he is sleeping compared to other infants his age?
• How did his sleep problems start?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• How has all this been for you?
• What time does he wake up?
• What are you afraid of?
• What works to resettle him?

Management

• Educate parent on how to console a fussy infant. (See Calming Your Infant pt)
• Trained night feeding can best be prevented through appropriate parent education to teach ways to recognize and console a fussy infant by other means than feeding during the day.
• Clarify expectations of the appropriate need for a late night feed for infants older than 4 months post term.
• Suggest behavioral retraining. (See Night feedings pt).
  • Daytime feeding intervals can be gradually lengthened and any sleep associations retrained simultaneously. (See Good sleep habits for infants pt).
  • In the middle of the night, infant can then be allowed to cry at least one minute to try to resettle himself.
  • If infant does not settle, try feeding 1 oz. less or spend 1 minute less at the breast each night than the night before until night feedings are eliminated. This should resolve trained night feeding in about a week.

Key Points

• Trained night waking can be caused by sleep schedule disruptions.^[note]
• Household environment.^[note]
• A parent who works during the day may look forward to and reinforce night waking with play.
• Trained night waking is more common in infants with a difficult temperament.
• Trained night waking is twice as frequent in infants with depressed mothers.
• Brief sedation should only rarely be needed to change this habit.

Trigger Questions

• Do you have any concerns about his sleeping?
• How do you think he is sleeping compared to other infants his age?
• How did his sleep problems start?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• Who else has something to say about his sleeping?
• How has all this been for you?
• What is the room like where he sleeps?
• What routines do you use to put him to bed?
• Tell me exactly what you do at bedtime.
• Is he already asleep when you put him in the crib/bed?
• What time does he wake up?
• What are you afraid of?
• What works to resettle him?

Management

• Work with parent(s) to manage precipitant pain or stresses.^[note]
• Establish bedtime routine. (See Good sleep habits for infants pt).
  • The infant should be put to bed awake.
  • Consider using a transitional object like a lovie or a smelly shirt from the mother.
  • Limit naps to 2 hours to consolidate the longest sleeping period at night.
• Suggest behavioral retraining. (See Trained night waking pt)
  • When the infant awakes at night, allow 5 minutes of crying before checking on him then check every 10 minutes. Do not feed the infant.
  • May require the more nervous parent to take a shower, turn up music, go out of the house or otherwise distract himself or herself for this to be successful.

Key Points

• Children cue on the face of anxious parents and begin waking at night for reassurance.
• This is very common because after an illness parents are both more likely to check sleeping children and appear anxious when they do so.

Management

• Ask about recent illness or stress and educate parents about how easily their facial expressions can cause the child to sleep lightly and wake up for comfort. It is also reinforcing to get to see the parent. (See Waking up after a recent illness pt).
• Have parents verbalize how concerned they are about the recent stress.
• If one parent is more able to look calm than the other, the calm one should put the child to bed.
• If the child wakes up, wait 5 minutes to allow the child to settle before going to comfort briefly.
• Avoid feeding or picking up the child and keep interaction to a minimum.
• This type of waking handled well disappears in less than one week.

Key Points

• Sleep-wake transition disorders are especially common in preschoolers because of their initial NREM states.
• Rhythmic movement disorders include head banging, sleep starts and body rocking.
• Some rhythmic activity at bedtime occurs in 58% of 9 month olds, decreasing to 33% at 18 months and 22% at 2 years.
• Head banging is very common.^[note]
• Head banging is typically monotonous.^[note]
• More common in children with intense temperament.
• CNS injury, headache, ear pathology, sensory deprivation including visual or hearing impairment, neglect or abuse may result in head banging.

Trigger Questions

• Do you have any concerns about his sleeping?
• How did his sleep problems start?
• What ideas have you had about the problem?
• What have others told you about this problem?
• How has all this been for you?
• Does he do anything in his sleep?
• What are you afraid of?

Management

• Instruct parent that head banging can often be reduced by kinesthetic stimulation during the evening and holding the child as part of the bedtime routine.
• Consider medication such as Imipramine or hydroxyzine. Both are effective but rarely needed.
• Reassure parent(s) that the child is not autistic or retarded since rhythmic movement is common in these conditions. (See Self-rocking, head-banging pt)

Key Points

• Bruxism occurs in 50% of normal infants at the time of tooth eruption.
• Stress can cause bruxism in older children, e.g., 10-20 years old.
• Dental malocclusion and some neurological conditions can cause bruxism.

Trigger Questions

• How did his sleep problems start?
• Were there other changes in his life happening around that time?
• What ideas have you had about this problem?
• What is the room like where he sleeps?

To the child:

• How do you feel when you wake up in the night?
• How do you feel about this sleeping problem?

Management

• Obtain a dental consult or referral.
  • Tooth guards can protect the teeth and reduce potential damage to the temporomandibular joint.
  • If possible, have dentist treat the dental condition(s) causing the bruxism.
• Emphasize that relaxation exercises at bedtime can be helpful. (See Relaxation exercises pt).

Key Points

• Starting around 8 months infants have a convergence of developmental abilities that can result in night waking. These include: stranger anxiety, object permanence, and motor restlessness. Often the night waking with fearful expression begins when waking to a sitter but then continues nightly. The child is easily consoled by the parent, which differentiates this from night terrors.
• Developmental night waking represents fear about separation^[note] and therefore, it is a common sleep problem whenever separation difficulties are present, generally up to age 4 years, with the same solution applicable.^[note]

Trigger Questions

• Do you have any concerns about his sleeping?
• How do you think he is sleeping compared to other infants his age?
• How did his sleep problems start?
• What have you tried to solve this problem?
• What ideas have you had about this problem?
• What have others told you about this problem?
• Who else has something to say about his sleeping?
• How has all this been for you?
• What is the room like where he sleeps?
• What routines do you use to put him to bed?
• Tell me exactly what you do at bedtime.
• Is he already asleep when you put him in the crib/bed?
• What time does he wake up?
• What are you afraid of?
• What works to resettle him?

Management

• Educate parent about the developmental forces behind the night waking. (See Separation Anxiety pt).
• Advocate for a bedtime routine that includes a transitional object and a dim night-light. (See Good sleep habits for infants pt and older children pt).
• Suggest a behavioral retraining plan. (See Developmental night waking pt)
  • When the infant awakens, allow him to cry at least two minutes to give him a chance to self-console.
  • If crying continues, one parent can go to the child, reassure him briefly without touching or feeding, and settle down within sight to sleep the rest of the night without talking to the child.
  • For children no longer constrained to a crib, the parents must require the child to stay out of body contact giving him the alternative that the parent will leave the room to avoid establishing a sleep association instead.
  • If vomiting occurs, clean up should be postponed to morning to avoid reinforcement.
  • Within average of 4 nights, the child will no longer awaken during the night, presumably because of increased trust in the availability of the parent.

Key Points

• Nightmares are extremely common parasomnias occurring during REM sleep, and therefore, typically present in the last 1/3 of sleep.
• The dream content is often recalled as frightening and reflects daytime stresses.
• Nightmares are most common between 3 and 6 years.^[note]
• When nightmares are frequent, the same concerns listed under Bedtime Fears should be addressed^[note] (See: Anxiety DTW)
• Withdrawal of REM suppressing medications.^[note]

Trigger Questions

• Do you have any concerns about his sleeping?
• How did his sleep problems start?
• Were there other changes in his life happening around that time?
• What is the room like where he sleeps?
• Does he take any medications?
• What routines do you use to put him to bed?
• Tell me exactly what you do at bedtime?
• What time does he wake up?
• What does he look like/do when he wakes up?
• What are you afraid of?
• What works to resettle him?
• How is that for you?
• Does he remember what happened during the night?
• Has he ever been given any medications for sleep? What? How did it work?

To the child:

• What do you think about before you go to sleep?
• How do you feel when you wake up in the night?
• How do you feel about this sleeping problem?
• What do you think your parents should do about this?

Management

• Educate parents about nightmares and night terrors (See Nightmares and night terrors in toddlers pt)
• Implement behavioral interventions. (See Relaxation exercises pt).
  • Nightmares deserve comforting.^[note]
  • Children with chronic nightmares have been shown to improve with targeted relaxation exercises and stories in which the child masters the situation.
  • Children can prepare to have good dreams through rehearsal and imaging at bedtime.
• Consider medication. Severe nightmares may respond to bedtime diphenhydramine, trazadone, or cyproheptadine, although counseling is mandatory if the condition is of this severity.

Key Points

• Sleep Terror Disorder, Sleepwalking Disorder, and Confusional arousals are all related episodic behaviors often occurring in the same child and family because of genetic predisposition.
• Children show automatic behaviors and lack of awareness of others.
• Children are difficult to arouse, have little or no recall of dreams at the time but instead are confused, and have no recall of the arousal later.
• Disorders of arousal are most likely to occur in the first 3 hours of sleep because the deepest stage IV sleep is in the first cycles of the night.
• Sleep talking and nocturnal leg cramps are part of normal developmental variation.

Confusional Arousals

Sleep Terrors, Age 3 and Older

Sleepwalking Disorder18 months and older

Restless-Leg Syndrome (Nocturnal Arousals Problem V40.3) (Adolescents but mostly adults)

Violent Behavior During Sleep (Parasomnia NOS 307.47)

Sleep Behavior Disorder (DC: 0-3R and Associated CHADIS Criteria)

Normal text is quoted directly from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; Zero to Three, 2005). Italicized text conveys information about the CHADIS items assessing the DC: 0-3R criteria.

General Information (p. 34) Sleep problems are common during the first year of life. They are associated with a variety of conditions and medical problems. The clinician should not use this diagnosis when a young child's sleep problem is primarily due to disorders of affect, transient adjustment problems, Posttraumatic Stress Disorder, or a relationship disorder.

The classification of Sleep Behavior Disorder is reserved for two types of conditions that occur after 12 months of age, when stable sleep patterns typically emerge (within CHADIS, sleep problems and variations may be classified as young as 3 months):

Sleep-Onset Disorder (pp. 35) Sleep-onset problems are reflected in the time it takes a child to fall asleep, the child's need for the parent to stay in the room until she falls asleep, and/or the child's need for reunions with the parent (i.e., the parent leaves the room and comes back in response to bids from the child).

CHADIS requires one or more of the following:

• Once your child is in bed for the night, how long does it take him/her to fall asleep? (For children 24 months and less: Greater than 30 minutes; For children older than 24 months: Greater than 20 minutes)
• At bedtime, do you have to stay in the room with your child to get him/her to fall asleep? (Yes)
• At bedtime, how often do you usually have to go back to your child to get him/her to go to sleep? (For children 24 months and less: Three times or more; For children older than 24 months: Twice or more)

The diagnosis of Sleep-Onset Disorder requires that there be significant difficulty falling asleep for AT LEAST 4 WEEKS, with five to seven episodes per week.

CHADIS requires both of the following:

• How long has your child had difficulty getting to sleep? (A month or more)
• You said that your child takes a long time to get to sleep or that you have to be in the room for him/her to get to sleep. How often does this happen?(Five or more times per week)

Night-Waking Disorder (pp. 35) Night-waking problems are reflected in awakenings that require parental intervention and/or removal to the parental bed.

CHADIS requires all of the following:

• How many times does your child usually wake up during the night? (For children 24 months and less: Three or more; For children older than 24 months: One or more)
• When you child wakes in the night, which of the following is true? (Easy to quiet by holding; Doesn't settle even by holding; He/she settles by being fed 1 ounce or less, or by 1 minute of nursing or less; He/she only settles by being fed more than 2 ounces or more than 2 minutes of nursing; He/she only settles if the pacifier is replaced in his/her mouth; or He/she only settles if sucking)
• You said that your child typically wakes during the night. How much total time does he/she usually spend awake during the night? (For children 24 months and less: Greater than 30 minutes; For children older than 24 months: Greater than 20 minutes)

A diagnosis of Night-Waking Disorder requires that significant difficulty in nighttime awakenings be present for AT LEAST 4 WEEKS and involve five to seven episodes per week.

CHADIS requires both of the following:

• How long has your child been waking up at night and needing you to be there to go back to sleep? (A month or more)
• You said that your child wakes up at night and needs you to be there for him/her to go back to sleep. How often does this happen? (Five or more times per week)