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Children's sleep
What's normal and what's not?
BY Manisha B. Witmans, MD and Rochelle
Young, RN
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Issues related to children's sleep are often
troubling, stressful and frustrating for the entire family. Be it
perceived as inadequate, disrupted or elusive sleep, the whole household
may be affected. While parents are frequently faced with these concerns,
they may not mention their worries during a visit to the doctor's
office. The root of the trouble can be a genuine sleep problem or
lie in inappropriate expectations on the side of the parents regarding
the child's needs and behaviours.
Disrupted or inadequate sleep impacts a child's
health and well-being with respect to mood, academic and social
performance, behaviour and quality of life.1,2
While the effect of sleep deprivation in adults is well documented,
the impact in children has received less attention. Both adults
and children who sleep poorly show a higher rate of accidental injuries,
and sleep loss has been seen to produce potential impacts on the
cardiovascular, immune and metabolic systems.3,4
Sleep is as much a health priority in children as it is in adults
and should be addressed as such. It's important that healthcare
professionals help parents understand the sleep needs of their kids,
so that they can guide their offspring into healthy habits and attitudes.
What's
normal in the newborn?
In the newborn stage, one can expect an infant to sleep approximately
16-20 hours per day. This is broken up into periods lasting 1-4
hours, followed by 1-2 hour wake periods. The sleep-wake cycles
of the newborn are largely driven by hunger and satiety with no
nocturnal/diurnal patterns in the first few weeks. The baby's sleep
will likely be evenly distributed through both the day and night.5
During this period, parental expectations are the most prevalent
"sleep problem," as they don't always align with what's developmentally
appropriate (see
Table 1). It's unrealistic to expect that infants will sleep
through the night at this age. Safety is another concern for the
newborn. Studies have shown that sleeping on the back reduces the
risk of sudden infant death syndrome (SIDS).
How
much should infants sleep?
For infants, sleep is the primary activity of the brain in
the first year of life -- accordingly, they spend up to 15 hours
a day doing just that.2 They sleep
between 9 and 12 hours at night and spend 2-4.5 hours napping in
divided episodes, typically in the morning and afternoon. The nighttime
periods of rest usually last 3-4 hours during the first 3 months
and then lengthen to 6-8 hours when the child is 4-6 months old.
Sleep consolidation occurs during the later part of infancy, and
70-80% of babies sleep through the night by 9 months.2
At this age, sleep behaviours begin to be
shaped by attachment issues and social interaction. According to
Mindell and Owens,5 the patterns
and conduct of infants in respect to sleep should be perceived in
the context of the relationship between child and parent/caregiver,
which impacts on the quality and quantity of rest. Achievement of
developmental milestones may also temporarily disrupt sleep, such
as increased mobility (pulling up on crib rails and rolling over).
What
about the nighttime ritual?
A considerable issue for infants -- and their parents --
is sleep onset associations. Problems occur when the conditions
that are present at the time of sleep onset, such as rocking, feeding
and/or being held, aren't repeated during normal nighttime arousals.
These arousals follow the rhythm of 45-60 minute sleep cycles, and
all infants and children wake briefly at least 6 times a night.
The key to avoiding prolonged arousals is to put the baby to bed
awake but drowsy. This enables the child to learn to "self-soothe"
or to do so with the aid of a transitional object, e.g. pacifier,
blanket or music.
Once established, sleep habits and associations
can be remedied but require a great deal of patience on the part
of the parent. There are no medications for these concerns. Treatment
includes empirically proven behavioural strategies that alter the
parent's response to nighttime arousals. Some parents may not be
comfortable with certain practices -- such as allowing the infant
to "cry it out" -- so the approach must be individually tailored
to the specific infant and family.5
In regards to separation anxiety and bedtime resistance, it's been
found that soothing objects become more important as infancy progresses.
Other sleep concerns include rhythmic movement
disorders, head banging, body rocking and rolling, which occur primarily
during sleep-wake transitions. Children engage in these activities
in order to soothe themselves to sleep. They can occur when going
back to sleep following normal night arousals or after awakenings
associated with nightmares. While the actions may be distressing
to parents, they're largely benign and injury is rare as long as
child safety is properly addressed.5
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