Bledidoc Advice

Objectives:

1. After reading this script, parents will develop a better idea about sleep physiology and the intrinsic and extrinsic causes of sleep problems in young children.
2. Parents will have better understanding of bedtime routines and their application in order to teach the child good sleeping habits.
3. Introduction to sleep training of young children by using cry-it-out and the Ferber sleep training methods.

Introduction:

Sleep is crucial for the brain development of young children. Sleep stimulates their growth(1). It plays a crucial role in their cognitive development(2), promotes their immune defense mechanisms(3) and affects how well they manage everyday life. Without regular sleep, young children become bad tempered and have difficulties concentrating. Their appetite is affected and their immune system becomes weak and more susceptible to infections. The prevalence of sleep problems in young children varies according to genetic, environmental and cultural factors. In general, 20-66% of them experience some type of sleep problems, which can be managed properly by teaching the child and his parent strategies of good sleeping habit(2).

Physiology of Sleep

During sleep, the brain progresses through several sleep cycles each consisting of non-rapid eye movement and rapid eye movement (REM) stages. During the REM stage, the brain becomes active, dreams occur and the eyes move rapidly. Newborns have twice as much REM sleep compared to adults. During REM sleep, the child’s face twitches and eyelids flicker. At this stage, the sleeping child processes and stores the new information collected during his waking hours(4).

On the other hand, sleep is controlled by two physiologic mechanisms. The sleep homeostasis mechanism, which tells us that a need for sleep is accumulating and that it is time to sleep, and the biologic Circadian clock mechanism, which regulates rhythmicity of our sleep drive throughout the day. The Circadian clock is influenced by environmental cues such as light and promotes alertness across the day. The strongest sleep drive in adults occurs between 2:00-4:00 am and in the afternoon between 1:00-3:00 pm. Naptime in toddlers is a rhythmicity issue that has to do with the timing of the Circadian clock(5).

How Much Sleep Do Young Children Need?

Newborns sleep most of the time because they are physically growing at a higher rate and cells multiply faster during sleep. Duration of sleep decreases as the child gets older to reach 7-9 hours/ day in adulthood(6).

Assessment of Sleep Problem

Assessment of any sleep problem starts with sleep history. Parents should be prepared to answer the following questions when they consult their pediatrician about their child’s sleep problem.

1- Timing of the sleep problem

• At what part of the day does the sleep problem occur?
• At what time does the child go to bed? Is there a fixed bedtime or not?
• Is his/her sleep irregular at daytime/ nighttime?
• How long does it take the child to sleep when he/she is put in bed?
• How does he/she feel when he/she wakes up in the morning? Is he/she energetic or tired?
• What are his/her daytime routine activities? What does he/she do during a regular day?
• At what time of the day does the child nap and for how long?
• Is there any difference in activities and sleep patterns between weekdays and weekends?
• What are the possible causes of the problem from the parents’ point of view?

2- Rhythmicity of Sleep.

Inquire about child related sleep factors and environment related factors that affect rhythmicity of sleep.

3- Activities Associated with Bedtime.

• Bedtime Routine: The aim of the bedtime routine is to help the child relax and prepare to sleep. The activity should be reassuring and relaxing to the child, e.g. giving a bath, dress the baby in different comfortable clothes (for more details see below…)
• Environment Safety Issues: A safe environment is the place which is familiar to the child in routine and schedule and provides the child with protection from danger, meets his basic needs of food, water and shelter, and is non-stimulating (e.g. clean bed, calm room with dim lights).
• Are there any factors that make the child sleep better or worse at nighttime or at daytime e.g. sleeping with/ or in his parents’ bed or with a certain toy? etc...
• Family social determinants of health i.e. parents/family characteristics e.g. busy parents barely have time to stay with the child, child is put in to sleep in bed by maternal helper etc….
• Assesment of the child’s basic health needs of play, nutrition, affection, screen time play and physical activity and their relation to bedtime.

Principles of Good Sleep Habit

1- Set a fixed time for sleeping and waking up. Just like adults, children need to follow bedtime routines, which help them learn what to expect when they are placed in bed. 

2- Follow a simple bedtime routine such as a bedtime bath, good night kiss, lights out before putting the child in bed to go to sleep alone. Parents may choose other bedtime routines that are suitable for them and for their child. The chosen item/s should be relaxing for the child and inviting to sleep. Examples of bedtime routines include:

• Give the child a bath before bedtime.
• Dress them in different comfortable clothes different from one she was wearing during the day.
• Feed them in the room where they sleep prior to bedtime. Once the child is of age, dinner should be in the kitchen or dining room but not in front of television. Always insist on milk before sleep as it contains an ingredient called Tryptophan and is a natural aid for sleep and anxiety related disturbance(7). Your child’s milk should always be adapted to his age up to 6 years, before moving to adult milk.
• Cuddle the child then put him/her in bed.
• Put the baby or the child in bed while he is still awake. This is important for him/her to recognize essential cues for falling asleep on his own. A child who has already fallen asleep when put in bed may feel anxious if he wakes up because he will not immediately know where he/she is.
• Read a story for him while he/she is still awake in bed.
• Sing or play soft music.
• Provide the baby with a soft cloth of familiar smell at bedtime. Some babies are comforted with familiar smell. At a later stage your child might have a teddy bear or a doll to comfort him.
• Provide the baby with a pacifier if needed.

The whole process of bedtime routine should not take more than 45 minutes from bath to sleep in bed. While it is fine to let the baby sleep outside his bed during the first few weeks, you should avoid letting this become a habit.

3- Mindell et al., found that following more bedtime routines during the week is associated with: Decrease time to sleep onset from >25 minutes to

4- Bedtime routines should not be stimulating. Examples of stimulating routines include watching television or video games and playing with the child at bedtime. Similarly, sleeping out of bed and sleeping outside the child’s room imply environment change and should be avoided as much as possible.

5- Support rhythmicity intrinsic and extrinsic factors of the sleep process by:

1. Making sure that the child is tired and he wants to sleep before placing him in bed to sleep. You can make the child tired by having:

• Enough waking hours during the day i.e wake up early, appropriate napping, and stay up until bedtime.
• Spending energy during the day both physical and cognitive.
• Avoid stimulants like video games and TV near bedtime.
• Management of existing hyperactivity and fears.

      b. Setting a regular daily sleep and wake-up schedule.

• At what time the child wakes up, at what time he naps and at what time he goes to bed.

      c. Make sure that the sleeping place is safe and familiar to the child (put the child to sleep in the proper place at the proper time and            while he is still awake).

      d. Get the child ready to sleep by setting his regular bedtime and environment routines prior to putting him in bed. (e.g. Bright light            during the day and dim light at sleep time).

6- Mark the day by using daily living activities e.g. mealtime, playtime, naptime, outings and bedtime.

7- Upon the doctor’s recommendation, medicine may be used for short period of time in some cases with advanced time to sleep until the child gets used to the new sleeping habit.

Sleep training:

Sleep problem is a form of separation and to sleep smoothly the child has to train himself to separate effectively and to sleep smoothly by depending on himself. Two methods of sleep training were found to be effective in that respect:

1. Cry-it-out Method (Extinction)
2. The Ferber Method (Gradual extinction)

Cry-it-out Method (Extinction)

It consists of placing the child in bed while he is still awake at a constant time daily, after the regular bedtime routine. Parents say good night and leave the room. Child is allowed to cry and exhaust himself until he gets asleep. Child is aroused next morning at the usual wake-up time(6).

Advantage: Training is performed in a safe child environment. The child learns to soothe himself.

Disadvantage: Parents ignores the negative behavior of their child (tantrums, crying, and yelling).

The Ferber Method (Graduated extinction)

This method allows the child to cry it out but in shorter increments. It consists of placing the child in the bed while he is still awake at constant time daily after his regular bedtime routine. Parents say good night and leave the room. Child is allowed to cry following a schedule i.e. for 3 minutes the first night. Parents return briefly to comfort and pat the child but do not engage by picking up the child from bed, feeding him or turning on the light. Parents will leave the room again then come back after 5 minutes and repeat comforting the child smoothly and continue by extending the time period each time until the child falls asleep. If the child wakes up in the middle of the night, repeat this process to help them go back to sleep.

The idea is that after a few days of slowly increasing the waiting time, most babies will eventually learn to fall asleep on their own, knowing that their Mom or Dad is not going to pick them up when they cry(6).

Advantage: Less crying compared to the cry-it-out method. Training is performed in a safe child environment. The child learns to soothe himself gradually.

Disadvantage: It needs more effort from the parents. It may take longer time compared to the cry-it-out method.

Summary:

1. Sleep problems in toddlers can be managed safely by teaching the toddler and his parents the principles of good sleeping habits.
2. Pediatricians should screen their patients for sleep problems even with a single question.
3. Good sleep habits consist of setting an appropriate bedtime for age in the right place, the right time, the right state of mind, the right signs, consistent bedtime routine, consistent sleep schedule, and providing the child with the ability to self-soothe.

Dr. Mohamad ITANI

Pediatrician

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