A frantic mother brings an 18-month-old with complaints of her child getting up frequently in the night for feeds and then had to be rocked to sleep. Also, she was distressed that it took at least one hour to put the baby to sleep. She was worried about the child getting inadequate sleep and she herself was sleep-deprived. So, the questions that she raised were –

Doc, is it normal for a child of this age to awaken so many times in the night?

I am even feeding the child in the night and why is my child not sleeping?

Is this a sleep problem?

Is my child getting adequate rest?

If this is not normal how do we treat it?

It is important for us to understand that sleep is an important and integral part of our life and is required for rejuvenation, restoration, cognition, and memory. Altered or insufficient sleep can result in mood changes, poor concentration and memory, obesity, diabetes, and poor immunity. Sleep is a dynamic process that changes with age, disease states, and medications. To understand what is abnormal, we need to know what is normal.

Babies do not have a day-night rhythm until 3-5 months of age. By the age of 4-6 months, babies can sleep uninterrupted for 4 to 8 hours, and above 6 months of age up to 8 hours. But in order that children sleep uninterrupted, we need to develop good sleep hygiene.

SLEEP STAGES:

Sleep is divided into the Awake stage, Non-Rapid Eye movement (NREM – Stage 2, 3 & 4), and Rapid Eye movement stage (REM – Stage 5). In adults, REM sleep comprises 25% of total sleep whereas in infants it is 50% of total sleep. REM sleep is accompanied by arousals which make children whimper in sleep.

SIGNALERS V/S SELF SOOTHERS:

Whimpers or arousals during sleep are mistaken as an awakening by most parents and they respond by feeding, rocking, or walking up and down with the baby. This then becomes ‘Props’ for the baby to go back to sleep. We call such babies ‘Signalers’ but what we need to develop is a baby who can sleep by himself i.e. ‘Self-Soothers’.

STEPS TO HEALTHY SLEEP:

Do not respond to small arousals with props after the age of 6 months

Good sleep hygiene develops good sleep habits in children of all ages

Parents also need to have a good sleep schedule for children to follow

The following are the steps to develop good sleep hygiene

WHEN TO SEEK MEDICAL ADVICE:

Babies who do not settle down with all the steps above or are failing to gain weight and develop normal milestones need to be evaluated.

Disorders like colic, reflux, allergies, sleep apneas, developmental delays, etc. prevent healthy sleep.

Older children and Adolescents:

These children have deterrents to sleep apart from sleep hygiene issues.

Screen time due to mobile phones, television, and electronic gadgets.

Watching adult-oriented shows like news, violent TV shows, etc. near bedtime

Normal delay (by 1-2 hours) in the initiation of sleep in adolescents

STEPS TO HEALTHY SLEEP:

Avoid/reduce screen time especially if it is not educative or interactive. The American Academy of Pediatrics recommends zero screen time for children below the age of 2 years.

Avoid watching adult-oriented TV shows, news, violent or exciting games closer to bedtime.

Adolescents physiologically have a delayed onset of sleep than regular bedtime but they also require more sleep (about 8-9 hours). So, setting a schedule for adolescents by setting sleep and wake up times is important. This is easier said than done as teenagers have a lot to catch up on social networking, academic, and peer pressures. Increasing physical activities helps. An allowance will have to be given for weekends but with the condition that the wake-up time is not delayed beyond 30 mins to 1 hour of the regular time.

WHEN TO SEEK MEDICAL ADVICE:

Sleep disorders that affect breathing during sleep causing low oxygenation and fragmentation of sleep require medical help.

Children with snoring, awakenings with gasping breathing, abnormal postures and movements during sleep, bed wetting, and also daytime excessive sleepiness or hyperactivity.

Other not so serious conditions include crying in sleep, nightmares, sleepwalking, teeth grinding, etc. This may require medical attention, if frequent and disturbing to the parents and the child.

Pain or uncomfortable sensations in the legs during sleep is called Restless leg syndrome which may need some medications to resolve.

In summary, sleep is important as we spend at least 1/3rd of our lives sleeping. What matters for normal development is both a good quantity and quality of sleep. Medical disorders related to sleep go undiagnosed beyond infancy as most of the time children are sleeping in their own bedrooms. Like all good habits, good sleep hygiene should begin in early infancy and continued till adulthood. Be mindful of symptoms mentioned above for sleep disorders and seek early medical advice.