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Sleep Problems

by Stephen Brian Sulkes, MD

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

Normal sleep

Most children sleep for a stretch of at least 5 h by age 3 mo but then experience periods of night waking later in the first years of life, often associated with illness. With maturation, the amount of rapid eye movement (REM) sleep increases, with increasingly complex transitions between sleep stages. For most people, non-REM sleep predominates early in the night, with increasing REM as the night progresses. Thus, non-REM phenomena cluster early in the night, and REM-related phenomena occur later. Differentiating between true sleep (REM or non-REM)–related phenomena and awake behaviors can help to direct treatment.

It is important to determine whether parents view the child sleeping with them as a problem, because there is much cultural variation among sleep habits.

Nightmares

Nightmares are frightening dreams that occur during REM sleep. A child having a nightmare can awaken fully and 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 even when the child has seen a movie or television program containing frightening 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 non-REM episodes of incomplete awakening with extreme anxiety shortly after falling asleep; they are most common between the ages of 3 and 8. The child screams and appears frightened, with a rapid heart rate and rapid breathing. The child seems unaware of the parents’ presence, may thrash around violently, and does not respond to comforting. The child may talk but is 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 episodes. About one third of children with night terrors also sleepwalk (the act of 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 almost always stop on their own, although occasional episodes may occur for years. Usually, no treatment is needed, but if a disorder persists into adolescence or adulthood and is severe, treatment may be necessary. In children who need treatment, night terrors may sometimes respond to a sedative or certain antidepressants. There is some evidence that disrupted sleep associated with periodic leg movements often responds to iron supplementation, even in the absence of anemia. If children snore and thrash, evaluation for obstructive sleep apnea also should be considered.

Resistance to going to bed

Children, particularly between the ages of 1 and 2, often resist going to bed due to separation anxiety, whereas older children may be attempting to control more aspects of their environment. Young children often cry when left alone in bed, or they climb out and seek their parents. Another common cause of bedtime resistance is delayed sleep onset 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 onset time. It can be difficult to move bedtime earlier, but brief treatment with an OTC 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 sleep-onset 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) often is helpful. A small night-light, white noise, or both also can be comforting.

If the child is accustomed to falling asleep while in physical contact with a parent, the first step in establishing a different bedtime routine is to gradually lessen the contact from full body to a hand touching the child to a parent sitting next to the child's bed. Once the child is regularly falling asleep with a parent next to the bed, the parent can leave the room for increasing durations.

Awakening during the night

Everyone awakens multiple times each night. Most people, however, usually fall back to sleep with no intervention. Children often experience repeated 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.

Allowing the child to sleep with the parents because of the night awakening reinforces the behavior. Also counterproductive are playing with or feeding the child during the night, spanking, and scolding. 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 > 3) is often helpful. To prevent arousal, it is important that the conditions under which the child awakens during the night are the same as those under which the child falls asleep. 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 diminishes the night awakening. Extended crying is counterproductive, however, because parents then may feel the need to revert to a routine of close contact. Gentle reassurance while keeping the child in bed is usually effective.

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