A 6-month-old male came to clinic for his health supervision visit. He was growing well and was making good developmental milestones. The parents were complaining that he didn’t sleep well though. A detailed history found that he was always breast or bottle fed, then rocked to sleep before putting him in a crib at the beginning of a nap or nighttime. Occasionally the parents would also sleep with him on a couch or in their bed. When he would awaken they would go into his room, pick him up and again usually feed him to sleep. He slept about 2-4 hours at a time. The past medical history was negative. The pertinent physical exam showed a smiling male infant with growth parameters in the 75% to >95% for age. His examination was negative.
The diagnosis of trained night wakenings was made. The pediatrician discussed sleep hygiene issues with the family. He recommended to talk about the issue during the day when the parents were tired and decide exactly how they were going to implement the sleep hygiene. He also recommended that the family start doing the training during the day for naps as the parents could then figure out what techniques were working and what wasn’t and make changes when they were less tired. He reiterated that continued breastfeeding was encouraged and that normally children who are breastfed will awaken more frequently but they can learn self-regulation to easily put themselves back to sleep after feeding. At his 9 month visit his mother reported that the past two weeks he had been sleeping better after he weaned himself to formula feeding. He still needed to feed to go to sleep though.
Poor sleep has been associated with a variety of poor health outcomes, accidents, and learning and memory problems in adults. In children, sleep problems have been associated with emotional/behavioral problems and poorer cognition.
Newborn infants sleep about 16 hours/day, 6 months olds sleep about 14.5 hours/day and 9 month olds sleep 13.5 hours/day. Nighttime sleep is generally consolidated (6-8 hours) by around 4 months of age. Nighttime wakening is normal – 84% of 9 month olds awaken at least 1 time/night. Most children self-soothe themselves to sleep.
Breastfeeding infants have physiological needs to feed frequently (~2-4 hours). An Australian study found that breastfed infants had more night wakenings and often did not sleep alone but did not have other abnormal behaviors, i.e. breastfeeding infants awoke to feed, but once fed went back to sleep appropriately. Breastfeeding infants may also lengthen out the time between feedings as they age. A longitudinal study of maternal sleep settling strategies in the first few weeks of life such as active movement (e.g. pushing stroller), active comforting (e.g. cuddle/rocking, stroking) and parental presence (e.g. lying next to child on sofa, co-sleeping) were evaluated. Infants whose mothers did more of these active strategies had more sleep disturbances and the sleep disturbances persisted at 12, 18 months and 5 years.
Nighttime wakenings and resistance to sleep are also common occurring in about 20-30% of children. Nighttime wakenings have been associated with prematurity and perinatal problems, breastfeeding as noted above, temperament (e.g. less adaptable infant), family stress, maternal depression and co-sleeping.
Parents themselves really are losing sleep. Researchers in a longitudinal study found that parents of minor children average 13 fewer minutes of sleep/night with children < 2 years, 9 fewer minutes/night with children 2-5 years, and 4 minutes with children 6-18 years. They estimated that a parent loses 645 hours of sleep during a child's birth to age 18 years. Parents with children were also more likely to be short-duration sleepers (41%, defined as < 7 hours of sleep) than adults without children (33%). Because of the study methods this is probably an underestimate of the problem.
Sleep onset problems for infants and older children can also be challenging as the parent will often teaches poor sleep hygiene and the child expects the parent will be present whenever the child is going to sleep. When the child awakens at night, they cry until the parent comes and this inadvertently reinforces that their presence is needed to fall asleep. The child expects to go to sleep each time with the parent present. This is called trained night wakenings. Parents need to put their children to bed when they are sleepy but awake. Children should be put into their own bed with no co-sleeping. In this way, the child knows the location and surroundings of where they will fall asleep, and when they awaken they are in the same circumstances and can self-regulate themselves to put themselves back to sleep. Parents also need to understand that sleep is physiological and they cannot control when the child will sleep, but they can control the surroundings and circumstances. Families with a consistent sleep routine have fewer struggles with infant and child autonomy issues as the child has some control over the routine and knows what is expected and what will happen next. Parents should have clear rules about the routine – parents put the child to bed, the child puts themselves to sleep. There should be no eating, television/computer, or getting out of bed. A favorite object can help address separation issues and be comforting when the child awakens at night.
Questions for Further Discussion
1. When do children start to have normal REM/non-REM cycling during sleep?
2. What is the definition of insomnia?
3. What other sleep advice could be offered to parents?
- Symptom/Presentation: Sleep Disturbance
- Age: Infant
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Zuckerman B. Sleep Problems in Behavioral and Developmental Pediatrics. Parker and Zuckerman eds. Little Brown and Company, Boston, MA. 1995;289-93.
Hagen EW, Mirer AG, Palta M, Peppard PE. The sleep-time cost of parenting: sleep duration and sleepiness among employed parents in the Wisconsin Sleep Cohort Study. Am J Epidemiol. 2013 Mar 1;177(5):394-401.
Sheridan A, Murray L, Cooper PJ, Evangeli M, Byram V, Halligan SL. A longitudinal study of child sleep in high and low risk families: relationship to early maternal settling strategies and child psychological functioning. Sleep Med. 2013 Mar;14(3):266-73.
Galbally M, Lewis AJ, McEgan K, Scalzo K, Islam FA. Breastfeeding and infant sleep patterns: an Australian population study. J Paediatr Child Health. 2013 Feb;49(2):E147-52.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital