• My Child Can't Sleep

    Introduction

    Sleep is a precious thing. Its value to your child can be measured by his or her smiling face, happy nature, and natural energy. A child who doesn't sleep well can turn an entire family's life into a bad dream. Your tired child may experience development or behavior problems and in turn, you and the other members of your family may suffer unnecessary stress.

    Whether your child sleeps alone, shares a room with other siblings or parents, or sleeps in the same bed with someone, it is important to establish a pattern that promotes quality sleep at night, and during daytime naps. Any of these arrangements for sleeping can work. What's most important is recognizing problems in your child's sleep so that you can start to solve them.

    Children's sleep is a subject that puzzles many parents. You may not know, for example, how long your child should sleep at night or during naps. Did you know that s early as six months of age; a child can learn to sleep at least nine hours at night -without interruption? Some children sleep different lengths of time-shorter or longer-but most have the potential to sleep through the night regardless of the exact number of hours they sleep. This is just one example of a sleep issue that parents should be aware of and discuss their child's pediatrician. We hope this booklet will help you pinpoint your child's sleep problems and take the first steps toward correcting those problems.

    Signs of a Problem with your Child's Sleep

    • You spend too much time "helping" your child fall asleep
    • Your child wakes up repeatedly throughout the night
    • Your child's behavior and mood are affected by poor sleep
    • You lose sleep as a result of your child's nighttime patterns
    • Poor sleep causes your parent-child relationship to suffer

    A child's most common sleep problems can be corrected quickly once they are identified and treated. Usually, a little guidance and some common sense can solve the problem. Sometimes talking with other parents or your pediatrician will provide some useful tips. Occasionally, consulting with a sleep specialist is recommended.

    Bedtime Routine

    Preparing your child for bed may mean separating him or her from you, and this can be a source of anxiety for both of you. Parents naturally want to comfort their children. Yet, bedtime routines can be one of the richest ways for you and your children to spend time together.

    When you plan a bedtime routine, it is important to set aside 10 to 30 minutes to do something special with your child before he or she goes to sleep, The activity should not be over-exciting (avoid jumping, running, or wrestling), nor should you tell scary stories. Your child needs to know the time limits of this special time and that you will not exceed them. Giving in to requests for extra juice or for another story will teach your child that bedtime can always be put off. Without established routines, the evening is more likely to be filled with tension, anxiety, and arguments.

    Three Common Sleep Problems in Young Children

    1. Sleep-onset association

    All of us wake up briefly a number of times during the night, especially during dream sleep (known as REM, or rapid eye movement, sleep). We are usually not aware of these awakenings and return to sleep quickly.

    Yet, young children respond differently. They may cry or fell great insecurity during awakenings. Parents naturally attempt to comfort the young child who appears anxious and calls for their attention. They may feel they need to "help" their child return to sleep by feeding, rocking, holding, or lying down with him or her. But by doing so often, they teach their child that this "help" pattern will occur regularly. Many young children who experience this become unable to fall asleep without their parent's' help, instead of learning to comfort themselves or connect with, and find security in, objects in the crib or bed, such a favorite blanket or stuffed animal. If this or the following descriptions apply to your child, he or she is probably experiencing a problem with sleep-onset association.

    "I'm exhausted. I have to rock my child to sleep every night and for every nap. If she wakes up during the night, she won't fall asleep again until I rock her again."

    This child is probably connecting the action of falling asleep with something else (such as being rocked, nursed, and/or held while falling asleep). When that other action, person, or object is missing, your child is unable to fall asleep.

    "The only place my child can nap is in the car. I drive around town after he has fallen asleep for an hour or two, because if I bring him inside he will not be able to sleep."When a child cannot sleep in his or her own crib, but for some reason can sleep perfectly in a moving vehicle, stroller, or baby swing, the child has learned to associate falling asleep with some sort of movement.

    How Do I Correct This Sleep Problem?

    First of all, parents should be aware that a baby can learn to fall asleep without their help. Once an infant or young child begins to associate falling asleep with being rocked or held, she does not have any idea how to return to sleep on her own so she starts to cry once she's awake. If she is picked up readily every time she cries and falls back to sleep in a parent's arms, the association of being held while falling asleep is only strengthened, and it will be for the child to learn how to do it alone. This can create stress for the parents, who naturally want to comfort their baby, but also want him or learn to learn to sleep well. It is important for parents to know that children can and will learn to fall asleep on their own once they are given the chance to do so.

    We are not suggesting that you ignore your baby's cries. You must always make sure your child is safe and not hungry, sick, or wearing a soiled diaper. The technique described below will help your child learn to fall asleep more easily and naturally without feeling abandoned or alarmed.

    To correct your child's sleep problem, you must teach him or her to fall asleep during all sleep periods-naptime, nighttime, and after awakenings at night-with a new set of associations that do not require a response from you. It is best to begin the relearning process at night, but some parents choose to do it during naptime

    During the relearning process you should expect your child to cry a t first. However, you must keep in mind that you are not abandoning your child. With an organized process of encouragement and reassurance, your child can learn to fall asleep without your help. If you choose to use a pacifier to comfort your child, keep in mind that using it as an object of association is discouraged after five to six months of age because it is sure to fall out repeatedly during the night. The use of a blanket or stuffed animal usually does not create a major problem, as these items should still be in the crib or bed when the child wakes up.

    A Technique That Works

    This technique will help a six-month- to three-year-old child learn to sleep without a parent's help. The child should be placed awake or drowsy in the crib or bed after a quiet bedtime routine. Say "goodnight" and leave the room, making sure to allow a little light into the room. If your child is still crying after two minutes, return to the room. Don't turn on lights or lift your child from the crib or bed, and don't hug your child or give in to new requests (for juice, another story, or for you to lie down next to him). You can comfort your child with words and/or by placing your hand on his or her back to show that he or she is safe. Leave promptly; don't stay in the room longer than one or two minutes.

    If your child continues to call out or cry, begin to wait a little longer before returning to the room. Counting the minutes while a child cries can be heart wrenching and nerve-wracking to parents. In fact, this process is likely to be far more trying for you than it is for your child. It is the key, however, to helping your child relearn a healthy sleep pattern. By not removing your child from the crib or bed, you are helping him or her learn to fall asleep alone.

    When this plan is followed consistently, significant improvement is usually seen after three nights. If improvement is not seen after five nights of this routine, you should consider the possibility that the instructions are not being followed consistently by both parents (or other caretakers). It is also possible that your child just needs more time to fully adjust to the change and that persistence will pay off.

    This last possibility is very frustrating and anxiety producing for the parent. Rather than listening to child "suffer," many will be tempted to rock or comfort the child somehow, or perhaps "give in" to the pacifier. This will delay the relearning process, however, and keep your child from learning to fall asleep alone.

    Techniques for Older Children: Desensitization

    Sometimes older children have trouble sleeping because they become frightened. If you have been lying down next to your child to help him or her fall asleep and have decided that it is now time that your child learns to fall asleep on his or her own, the following technique typically works well. This method, called desensitization, should also be used consistently prior to naps and awakenings during the night.

    Explain to your child that you will sit in a chair near the bed (rather than in or on the bed) until he or she falls asleep. After several nights of your child falling asleep with you sitting next to the bed, move the chair farther away from the bed and closer to the door. Gradually (over the course of several nights) move the chair closer and closer to the door. Eventually the chair should be moved out of the room. The door may be left open for a child who does not get out of bed, but a door-closing technique will probably be needed for a child who does.

    Depending on the child and how log the previous routine was followed, this relearning may take one to three weeks. For the older child, a positive reinforcement program using rewards such as star charts or small prizes, may speed up the relearning process. As it is often the goal to have your child sleep alone, it is helpful to praise him or her for excellent behavior.

    2. Nighttime eating/drinking disorder 

    "My child is hungry during the night. I feel like she eats/drinks all night long. I'm exhausted."

    This complaint signals excessive nighttime feeding. This is often a problem for infants and young children. "Excessive" can mean several feedings during the night when the child is a few months old, or even one nightly feeding after age six to seven months.

    Children who become hungry during the night can wake up often and are unable to fall asleep or return to sleep without being fed. A child who is used to being fed several times during the night may therefore feel hungry at those times without actually needing nourishment, and the parent's task may be teaching the child to feel hungry at more appropriate times of the day.

    A child at least five to six months old who drinks more than eight ounces of fluid during the night is probably taking in more fluid than necessary. This is also true of a child who nurses more than once or twice, or for longer than two or three minutes at a time. A quick way to tell if your child is taking in more fluid than necessary is to check his or her diaper. If your child has a soaked diaper when he or she awakes during the night, he or she could have a nighttime eating/drinking disorder.

    To eliminate the habit of nighttime feedings, start by gradually reducing the number and frequency of feedings. This technique is better than suddenly stopping nursing at night. For an infant feeding every hour and a half at night, the parent should wait a minimum of two hours between feedings the first night, then two and a half hours the second night, increasing the between-feeding times gradually until all nighttime feedings are eliminated. This process may take one to two weeks. IF your child is bottle-fed, you can also try decreasing the quantity offered at each feeding by one ounce per night.

    3. Limit-setting problems

    Limit-setting problems usually begin after age two. When your child refuses to go to bed, stalls, or makes it difficult for you to leave the bedside he or she probably has a limit setting problem. Limit-setting problems can occur at bedtime, naptime, or when your child wakes up during the night.

    Parents must appreciate that it is their responsibility to know when it is time for bed, even if the child disagrees and seems active and alert. Children can get very creative with their requests-for one more hug, a tissue, a drink of water, to have the light turned off or no, to "tell you something important," and it can be hard to know what is real and what is simply a delay tactic. A firm and consistent approach to these delays will help avoid strengthening those behaviors. Parents need to give their children well-defined limits.

    For an older child who sleeps in a bed instead of a crib, the sleep problem may involve the child getting out of bed repeatedly (rather than crying for the parent). In this case, a gate can be placed in the doorway or the door can be closed until you are sure your child is staying in the room. You can tell your child that you will gladly open the door again when he or she stops trying to leave the bedroom.

    For a child who has learned to climb over a gate, the parents should consider using a better gate, two gates, or the bedroom door. The gate or door should be kept closed all night. You should avoid going into the room to comfort your child bit should stand on the other side of the gate, or outside the closed door, and speak to your child at regular intervals in a clam voice. The intervals should become progressively longer. I f you are using a gate, you should be out of sight of your child. A child will sometimes fall asleep on the floor near the gate or door during this relearning process.

    Gates are preferable until your child is too big. For older children, a warning that you will close the door may motivate him or her to stay in bed, provided you follow through with your warning. When using the door method, the intervals are shorter; just a few seconds at the beginning progressing slowly up to one to three minutes. The purpose of this technique is to teach your child a new technique to fall asleep, not to scare him or her.
    It is important for parents to believe and understand the important of limit setting during the day or night. A gate or the door-closing technique should be used for a child who won't stay in bed. A reward system may also help. It is also important to discuss bedtime routine with babysitters and other caregivers, so that the established routine remains in place consistently.

    Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

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