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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 usually 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 on being held before being able to go to sleep. These problems are related to parental expectations, the child's temperament and biologic rhythms, and child-parent interactions.
Factors that influence sleep patterns vary by age. For infants, inborn biologic patterns are central. At 9 mo and again around 18 mo, sleep disturbances become common for these reasons:
In toddlers and older children, emotional factors and established habits become more important. Stressful events (eg, moving, illness) may cause acute sleep problems in older children.
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—see Sleep and Wakefulness Disorders: Parasomnias). 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 infants to sleep does not allow them to learn how to fall asleep on their 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; 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 usually settle themselves back to sleep. When children cannot get back to sleep, parents can check on them to make sure they are safe and to reassure them, but children should then be allowed to settle themselves 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 fully verbal children 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 can also help prevent sleep problems.
If stressful events are the cause, reassurance and encouragement are always ultimately effective. Allowing children to sleep in their parents' bed in such instances almost always prolongs rather than resolves the problem.
Last full review/revision February 2010 by Eve R. Colson, MD; Rachel L. Chapman, MD; Melissa R. Held, MD
Content last modified February 2010
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