Sleep: How much and how

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Sleep: How much and how

How much sleep children need at each stage of their lives has been a subject of great debate among parents and pediatricians alike. A study in the January 2013 issue of the journal JAMA Pediatrics hopes to put that question to bed.

Using time-diary data from a national sample of American families, researchers from UCLA and the University of Washington estimated percentiles of sleep for weekdays, weekends and overall in children from birth to age nineteen. The information is largely unsurprising. Babies nap. Older kids don’t. Teenagers sleep longer on the weekends. There were no significant differences found among various racial-ethnic groups or over the study’s ten-year period. The CDC’s recommendations for hours of sleep needed by children (12 to 14 hours for kids 1 to 3 years of age, 11 to 13 for 3 to 5-year-olds, 10 to 11 hours a night for the 5 to 10 year old set and 8.5 to 9.5 hours for teens) well mirrors the results of this latest study.

This new information is all well and good, but the specific needs of each individual child needs to be considered. Some kids just need more sleep than others and, unfortunately for their parents, others function very well on much less sleep than the norms presented here.

Parental questions and concerns about children’s sleep are an everyday occurrence in pediatric offices. Sleep issues range from problems falling asleep to difficulties staying asleep. The former is the most common by far, especially in toddlers and pre-schoolers. Typical is the 3-year-old who makes numerous “curtain calls” after being put to bed with requests for another drink of water, one more story, or a second or third trip to the bathroom. A predictable bedtime routine that involves quiet activities like reading and storytelling can prepare young children for sleep. But if the curtain calls continue, parents may consider giving the child one pass or ticket where they are granted one additional request. After that, all requests are met with a firm back-to-bed order.

It’s also important to make sure kids aren’t taking naps that are too long or too late in the afternoon so they’re just not tired at bedtime. And kids shouldn’t be drinking coffee of course, but there is also caffeine in sweet drinks and chocolate, so this is important to think about and minimize in the child with sleep difficulties.

Generally, once these children go to sleep, they tend to stay asleep. Frequent night wakenings is more common in infants and can be frustrating and exhausting for parents. While the total number of hours newborns sleep varies greatly, most babies generally establish a typical day/night sleep cycle and are ready to sleep through the night by 4-6 months of age. After this time, the problem I generally see in the office is the baby who falls asleep being nursed or rocked and placed into his crib sound asleep. These children associate sleep with the breast or their parents arms and simply do not know how to put themselves to sleep, which is problematic because we all normally have several periods of arousal a night. At these times, most of us simply roll over and go back to sleep. But if a baby is nursed or rocked to sleep, every time she rouses, guess what? She needs to be nursed or rocked back to sleep… or at least she thinks she does. What parents of these babies need to do is to teach them how to fall asleep independently. One excellent way to do this is by putting infants into their cribs when they are drowsy but not quite asleep. This gives them the experience of falling asleep in their own cribs and associating the crib with a place to fall asleep, not just a place from which to call for someone to come in and help them back to sleep.

In addressing both kinds of sleep issues—falling asleep and staying asleep—consistency is key. Giving in and rocking the baby or capitulating to that one more drink or book, even if it occurs only every fourth or fifth night,  only incentivizes kids to hold out for a parent to come nurse them or read to them.

When parents have tried multiple techniques to coax their children to sleep and nothing seems to work, I am invariably asked, “Should I just let her cry?” Well, there is no right or wrong answer to the “let them cry it out” dilemma. For some parents this just isn’t an option. They either cannot bear to listen to their children cry or one or both parents needs to get up in the morning and needs sleep. Some families live in close quarters with others and are concerned about keeping up other family members or the neighbors. But for those parents who want to give this so-called extinction method a try, an October 2012 study in the journal Pediatrics may give them reason to persevere with the approach. The Australian study acknowledged that the extinction intervention was effective in teaching infants to sleep through the night and reducing the incidence of associated maternal depression. The question the study sought to answer was: are children being harmed by this approach in the long run? Through questionnaires completed by the study’s families, they found that, at least in the first six years of life, the answer was a definite no.

So I will continue to discuss the cry-it-out option with families. I generally talk about a co-called modified extinction method where rather than let kids cry it out in their rooms alone, parents can opt to stay in the room with the crying child or check on them and reassure them at regular intervals until they fall asleep. But for families interested in going cold turkey, I now have good evidence that they, like us doctors, are following the cardinal rule of “first do no harm.”