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Sleep Problems in Children

by Stephen Brian Sulkes, MD

Most children sleep for a stretch of at least 5 hours by age 3 months but then have periods of night waking later in the first years of life, often when they have an illness. As they get older, the amount of rapid eye movement (REM) sleep increases, and it is during this phase of the sleep cycle when dreams, including nightmares, occur. Families vary in their attitudes about children sleeping with parents and other sleep habits. It is important that parents be open with each other about their preferences to avoid stress and avoid sending mixed messages to their children.

For most children, sleep problems are intermittent or temporary and often do not need treatment.

Nightmares

Nightmares are frightening dreams that occur during REM sleep. A child having a nightmare can awaken fully and can vividly recall the details of the dream. Nightmares are not a cause for alarm, unless they occur very often. They can occur more often during times of stress, or after a child has seen a movie or television program containing frightening or aggressive content. If nightmares occur often, parents can keep a diary to see whether they can identify the cause.

Night Terrors and Sleepwalking

Night terrors are episodes of incomplete awakening with extreme anxiety shortly after falling asleep. They occur in non-REM sleep and are most common between the ages of 3 and 8. The child screams and appears frightened, with a rapid heart rate, sweating, and rapid breathing. The child seems to be unaware of the parents' presence, may thrash around violently and does not respond to comforting, and may talk but be unable to answer questions. Usually, the child returns to sleep after a few minutes. Unlike with nightmares, the child cannot recall these episodes. Night terrors are dramatic because the child screams and is inconsolable during the episode. About one third of children with night terrors also sleepwalk (rising from bed and walking around while apparently asleep, also called somnambulism). About 15% of children between the ages of 5 and 12 have at least one episode of sleepwalking.

Night terrors and sleepwalking (see Parasomnias) almost always stop without treatment, but occasional episodes may occur for years. Usually, no treatment is needed, but if these disorders continue into adolescence or adulthood and are severe, treatment may be necessary. Children who need treatment for night terrors, sometimes respond to a sedative or certain antidepressants. However, these drugs are potent and can have side effects.

Resistance to Going to Bed

Children, particularly between the ages of 1 and 2, often resist going to bed due to separation anxiety (see Growth and Development:Infants), whereas older children may be attempting to control more aspects of their environment. Young children often cry when left alone in their crib, or they climb out and seek their parents. Another common cause of bedtime resistance is delayed sleep start time. These situations arise when children are allowed to stay up later and sleep later than usual for enough nights to reset their internal clock to a later sleep start time. It can be difficult to move bedtime earlier, but brief treatment with an over-the-counter antihistamine or melatonin can help children reset their clock.

Resistance to going to bed is not helped if parents stay in the room at length to provide comfort or let children get out of bed. In fact, these responses reinforce night waking, in which children attempt to reproduce the conditions under which they fell asleep. To avoid these problems, a parent may have to sit quietly in the hallway in sight of the child and make sure the child stays in bed. The child then establishes a routine of falling asleep alone and learns that getting out of bed is discouraged. The child also learns that the parents are available but will not provide more stories or play. Eventually, the child settles down and goes to sleep. Providing the child with an attachment object (like a teddy bear) is often helpful. A small night light, white noise, or both also can be comforting.

Awakening During the Night

Everyone awakens multiple times each night. Most people, however, usually fall back to sleep on their own. Children often have repeated episodes of night awakening after a move, an illness, or another stressful event. Sleeping problems may be worsened when children take long naps late in the afternoon or are overstimulated by playing before bedtime. Sleep sometimes is disrupted by restless legs syndrome (see Periodic Limb Movement Disorder and Restless Legs Syndrome), and a few children, particularly those who thrash and snore, may have obstructive sleep apnea (see Sleep Apnea). A doctor may recommend iron supplements for children with restless legs syndrome, even if they do not have iron-deficiency anemia, and may suggest an evaluation for sleep apnea for children who thrash and snore.

Allowing the child to sleep with the parents because of the night awakening reinforces the behavior. Playing with or feeding the child during the night, spanking, and scolding also are counterproductive measures. Returning the child to bed with simple reassurance is usually more effective. A bedtime routine that includes reading a brief story, offering a favorite doll or blanket, and using a small night-light (for children who are older than 3) is often helpful. To decrease the likelihood of the child awakening, it is important that the conditions and location under which the child awakens during the night are the same as those under which the child falls asleep. Thus, although a child may be allowed to settle down in another location (for example, in another room with the parents), the child should not be fully asleep when placed in the crib or bed. Parents and other caregivers should try to keep to a routine each night, so that the child learns what is expected. If children are physically healthy, allowing them to cry for a few minutes often allows them to settle down by themselves, which will diminish the night awakenings.