January 2008

In Search of a Good Night’s Sleep

By Dana Thompson

Sleep.

For parents, especially parents of young children, that one word can be loaded.
Usually it’s a case of not enough. Whether it’s a newborn waking through the night, a toddler resisting bedtime, or a school-age child up too late and needing to wake early for school, children’s sleep issues can affect the whole family.

All children (and adults) need adequate rest. Sleep is an anabolic process – a building time when our body and mind rejuvenates, rests and become ready for the next day. Growth hormone is also excreted during sleep, and is essential for growth and tissue repair.

According to Dr. Thomas R. Monk, a Bainbridge Island pediatrician, 20 to 30 percent of children ages 1 to 5 are identified by their parents as having a sleep problem, and approximately a third of the children he sees beyond age 6 will struggle with sleep at some point in their development. Most are transitory issues, such as teething, temporary illness, poor sleep habits or normal developmental stages. In other cases, the child may have an actual sleep disorder that needs to be medically addressed.

“Every parent discusses sleep at some point,” says Monk. “Issues vary from a child having a hard time going to sleep or staying asleep to getting up and coming into the parents’ room. Often, whether (a sleep issue) is a problem depends upon the tolerance of the parents … if the parents don’t mind, it’s generally not seen as a problem.”

In most cases, with a normally-developing and healthy child, occasional mild sleep disturbance is normal. Just like adults, children pass through all stages of sleep – starting with a light sleep and then shifting into a deeper REM sleep. It’s not uncommon to awaken slightly between stages, but whereas most adults will simply glance at their watches or roll over, some children may have difficulty making that transition. That’s often when a child will cry out or pad into her parents’ room.

“However, parents need their sleep, too,” says Monk, “and if either parent is really annoyed, the issues need to be addressed for both the child’s sake and the entire family’s.”

Fostering Good Sleep Habits

Most sleep problems, at all ages, can be solved by planning a basic, common-sense sleep routine.

In today’s busy, over-achieving, sensory-overloaded environment, providing a good night’s rest can be hard to accomplish. Many parents do not realize just how much

sleep a child needs at each age:

· Infants 0 to 3 months require approximately 14-20 hours a day, with a four to five hour stretch constituting “sleeping through the night.”

· From 3 to 6 months, 12 hours of sleep is recommended, with night wakening considered normal.

· From 6 months to 6 years, children need 10-12 hours a night, with night time wakening and naps gradually easing off by 6 years old in most cases.

· Most school-age children from 6 to adolescence function well with an average of 10-11 hours per night.

· Teens should still be getting about nine hours of sleep. In adolescence, the advent of puberty and the fluctuation of hormones often shifts a kid’s sleep cycle – hence a teenager’s going to bed late and sleeping in late – which becomes a problem due to early school start times.

One of the best things parents can do is to establish a consistent bedtime that they stick to throughout the week, including weekends.

The next step is to provide a consistent, relaxing routine leading up to lights out. This could include teeth-brushing, a warm bath, stories, quiet music, saying goodnight to all the toys, cuddling with a favorite stuffed animal or a goodnight prayer – whatever helps to settle the child and cue him that it is time for bed and sleep.

“Children love consistency,” says Monk, “so really anything works. Just remember, though, you may be doing it for a long time, so unless you want to tap dance and perform a Broadway musical each night, you should create a routine that works for you.”

Activities parents should not include are television or computer games. Studies show that children (and adults) are unable to mentally shut off the images even after they’ve stopped viewing TV or a computer. These activities stimulate the brain and make it much harder to calm down. Ideally, children should avoid these activities for at least two hours prior to bedtime.

Avoiding stimulants, such as sugar, chocolate or sodas which contain caffeine, is also important. Exercise and time outside during the day are very helpful for night-time tiredness, but any activity needs to be done early in the day. The calmer the few hours prior to bedtime are, the better chance a child can go to bed easily and stay asleep. Special time with a caregiver is also important in soothing the child towards sleep.

Donna Kee, an Everett mother of three, credits a very strict bedtime routine with helping her two sons, ages 7 and 4 – both of whom have been diagnosed with Autism Spectrum Disorder – to successfully make the transition to sleep. “We’ve made sleep into a little protected time,” says Kee.

The Kees have modified their sons’ bedroom so that it is only a sleeping room. There are books and stuffed animals, but no other toys to distract them from the business of sleeping. “We’ve tried to make it easier for them (and for us) by providing them with a consistent routine. We’ve made the decision for them and there’s no confusion. They can clear their minds and say, “This is what I’m doing now – I’m sleeping.”

Should You Be Worried About Poor Sleep?

The difficulty for parents is recognizing when a child’s sleep problem is more serious than either a transitory disruption or a lack of good sleep habits.

If a consistent routine and bedtime is followed and the child is still having trouble going to sleep or staying asleep, or is wetting the bed, having nightmares or night terrors or sleep-walking, then his sleep should be evaluated, even though many of these conditions, called “parasomnias,” are still considered normal in young children. Restless sleep with fitful movements, as well as snoring, teeth-grinding and leg cramps, can also indicate poor sleep quality.

Sleep deprivation is accumulated, so when a child is not sleeping well, it will show up in her daytime behaviors, including oversleeping, trouble waking easily and daytime sleepiness. Many behavioral and health problems are often a result of poor quality or inadequate sleep, according to Dr. Yemiserach Kifle, medical director for the Pediatric Sleep Disorder Program at Children’s Hospital and Regional Medical Center in Seattle. These include poor concentration and performance in school; increased irritability, hyperactivity and restlessness; poor coordination and slow reaction time; and, sometimes, increased sensitivity to noise and stimulus.

In some cases, sleep deprivation can actually lead to a misdiagnosis of developmental disorders or ADD/ADHD, and thus be further aggravated by medical stimulants, such as Ritalin, used to treat these disorders.

Sleep issues, unfortunately, are often compounded for children with serious neurological disorders such as Down Syndrome or Autism Spectrum Disorders, as well as many developmental delays and learning disabilities. Many of these children have an increased resistance to going to sleep, staying asleep, sleeping well through all the normal sleep cycles, and waking refreshed. Some problems are due to physiological differences, such as lower muscle tone, which affect the actual mechanism of breathing while asleep. Other problems are due to increased sensitivity and anxiety that interfere with a child’s ability to settle down and fall or stay asleep. Regardless of a child’s specific circumstances, a lack of adequate rest will only aggravate his challenges.

In extreme cases, serious medical issues, such as seizures and heart problems, can be related to a lack of sleep. A recent report by the American Academy of Sleep Medicine finds a link between sleep loss and disorders and the rise in the rate of diabetes. Lack of sleep appears to interfere with glucose metabolism.

Diagnosis and Treatment of Sleep Problems

One of the most under-diagnosed serious sleep problems in children (and adults) is obstructive sleep apnea, according to Kifle. Apnea is a pause in breathing, usually caused by a partial or fully obstructed airway during sleep. People with sleep apnea need to wake frequently to re-start their breathing. However, children have a higher arousal threshold than adults, and will go longer without oxygen, resulting in low blood oxygen levels by the end of the night. Left untreated over time, sleep apnea can lead to cardiovascular problems, as well as mood disturbances, failure to thrive and many cognitive and behavioral problems.

Approximately 2 percent of children of healthy, normally developing children with no underlying medical conditions develop some form of sleep apnea, most commonly between the ages of 3 and 6, and it is not something they out-grow. Children with special needs may develop it at a higher rate – more than 50 percent of children with Down Syndrome are affected. “I really want the news to be out there that sleep apnea is a big problem in children,” says Kifle, “and treating it can make a big difference in their health.”

According to Kifle, doctors are seeing an increase in sleep apneas in children. This is partly due to increased awareness – although obstructive sleep apnea is still under-diagnosed – while some of it is due to the increase in childhood obesity. Anything that causes a narrowing of a person’s airway, including extra weight, can lead to sleep apnea.

Snoring is one of the best night-time indicators of possible sleep apnea, and per the guide recommended by the American Academy of Pediatrics, all children should be screened if they snore at night, have shallow breathing, choke or gasp, move a lot into different positions, sweat, wet the bed, breathe through their mouths or commonly flip over onto their tummies when sleeping. There often are no breathing difficulties during the day, and so parents may have no idea their kids struggle at night.

Daytime symptoms of sleep apnea are similar to those of sleep deprivation, including hyperactivity, restlessness, poor concentration, distractibility, irritability, aggressiveness, anxiety, depression and generally poor functioning. “Parents need to be an advocate for their child,” says Kifle. “If your child snores, he should be screened for apnea.”

A diagnosis is made from a child’s clinical history and a physical examination and an overnight sleep study where a child’s brain waves are studied, along with his blood oxygen levels. The sleep study usually ranges in cost from $500 to $2,000 and is covered by most insurance companies.

While very serious, sleep apnea is also treatable. In 80 percent of otherwise healthy kids, removing their tonsils and adenoids will take care of it, although some may develop apnea again as adults. Sometimes a sleep mask is prescribed to exert consistent pressure to a child’s airways.

Other serious childhood sleep disorders include extreme parasomnias – such as sleepwalking or night terrors – if the child poses danger to herself or others. Clinical depression can also manifest itself in poor sleep quality, and in some children, especially adolescents, their circadian (natural sleep) rhythm may shift, so that they stay awake late and sleep late in the morning and may need help to re-regulate their cycle. Congenital cardiovascular problems, narcolepsy, insomnia and restless leg syndrome can all manifest themselves in children’s sleep patterns.

Kifle encourages parents to have their child evaluated if they have any concerns. “Sleep is so essential to their health,” says Kifle, “and good health is what we want for all our kids.”

Although understandably tempting for exhausted parents, there are no recommended medications for use with children to help with sleep. “There are no good pharmaceutical sleep studies for children,” says Monk, “and many commonly used sleep aids in adults show a higher incidence of seizures in children.” Even natural substances like melatonin are not recommended for the same reason. However, grandma’s old favorite, a warm cup of milk or chamomile tea, actually does help.

Sleep, while an inherent drive, is not always a given.

“There are many different factors that lead to sleep, and if you have a child that sleeps well, you are really lucky,” says Monk. “Don’t brag about it to your neighbors!”

For families struggling with sleep issues, what should be a sweet time of renewal can instead lead to frustration and despair, often having negative impacts on the ability of the child, and all family members, to function well. As parents, we owe it to our kids and ourselves to put a priority on getting a good night’s sleep.

Dana Thompson is a frequently sleep deprived freelance writer and mother of two, living on Bainbridge Island.

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