Does Napping After Age 2 “Spoil Sleep”? Not So Fast

This week, a study was published with the innocuous title of “Napping, development and health from 0 to 5 years: a systematic review”. The authors carefully reviewed multiple studies on the effects of napping on development and health in early childhood. They looked at 785 published articles, narrowed the articles down to 26 which met rigorous criteria, and came up with several conclusions:

1. The study designs were variable but mostly observational. They involved children of various ages and had different measures of interest. Thus, it was very difficulty to synthesize these results. Some studied habitual nappers; others studied children who napped sometimes but not other times. Here is a sample sentence
2. The most consistent finding was between napping and later sleep onset, shorter periods of night sleep, and worse sleep at night after age 2.
2a. A few of the studies reviewed suggested that non-habitual napping may precede a night of short/poor sleep, as opposed to occurring after a night of short sleep.

Today, headlines have trumped how napping after age 2 could ruin your child’s sleep. Here’s an example from Today.

PANIC NOW!

PANIC NOW!

However, the lead author, Karen Thorpe, noted in a statement released by her institution:

There is consistent high quality data that indicates napping beyond the age of two lengthens the amount of time it takes for a child to fall asleep. The evidence for napping and its impact on behaviour, health and development of a child is less clear.

How Napping Evolves Through Childhood

Some of the most widely cited information about how much children sleep over time is derived from information gathered from Swiss children. The whole article is worth a read, but here are their findings about napping:

This shows the frequency and of napping in the first seven years. Most kids have transitioned from multiple to one nap by 18 months (pink arrow) and half have given up napping by age three (blue arrow). Iglowstein, I., Jenni, O. G., Molinari, L., & Largo, R. H. (2003). Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics, 111(2), 302–307.

This shows the frequency and of napping in the first seven years. Most kids have transitioned from multiple to one nap by 18 months (pink arrow) and half have given up napping by age three (blue arrow). Iglowstein, I., Jenni, O. G., Molinari, L., & Largo, R. H. (2003). Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics, 111(2), 302–307.

Essentially, most children transition from multiple (2–3 naps) to one nap by 18 months of age.  By age 3 half will have given up napping, with most children not napping by the time they enter kindergarten.

Why Napping Can Affect Nighttime Sleep

In prior posts, I have talked about the homeostatic sleep drive. In a nutshell, the longer you are awake, the more tired you are. If you nap, especially for prolonged periods or in the late afternoon, you may be less tired and have a harder time falling asleep. Here’s a graph to refresh your memory:

Napping can reduce your need for sleep at bedtime.

Napping can reduce your need for sleep at bedtime.

Why These Results Matter, and May Matter to You

Although there is limited research on the topic, many child care centers and preschools have one size fit all nap policies which do not necessarily fit every child. Hopefully this may lead to more flexibility in this domain.

Additionally, napping needs clearly vary from child to child. Some healthy children easily give up napping around age 2 (and I guarantee that their parents are pretty bummed). Others, (like my older son), may happily take a three-hour nap in until five PM every day then go to bed without a complaint.

Clearly, there is a lot of variability in nap requirements in children. Here are some good rules of thumb:
1. If your child routinely naps past four PM, and struggles to fall asleep at bedtime, you may want to think about shortening his or her nap by an hour.
2. If naps are brief and difficult to obtain, and your child is older than age two, try playing with skipping them for a few days and see if bedtime and night-time sleep goes more smoothly.
2. If you are working on sleep issues, it is also important to avoid unplanned napping. My friend Dr. Wendy Ross calls this “sneaky sleep”– sleep obtained in the car or the stroller, say on the way home from day care. If it is just you and your child in the car, your options for avoiding this may be limited. However, if you have an older child, they will likely be MORE THAN HAPPY to keep their younger or brother sister happy by yelling at them, singing songs, or poking them.

Why These Results May Not Matter To You

If your child is happily napping every day, going to bed without difficulty, and is less than five, enjoy and don’t worry. There is no evidence in this study that you need to change. The worst thing you could do for your child (and your sanity) is to make a change when things are going well.

I find this study to be a great addition to the limited literature on napping in childhood, and that the authors acknowledge the limitation of the available information. For more information about this study, I suggest this article from the Huffington Post, specifically Lisa Meltzer’s take on this.
I’m curious about your take on these results. Please answer the poll below or leave a comment.

Sleep As A Drug of Choice: Dr. Maida Chen Ends Her #YearofNoSleep

Dr. Maida Chen provides this reflection from the lovely city of Seattle, where she is the director of the Pediatric Sleep Disorders Center at Seattle Children’s Hospital. I think that it is a great way to close our month (albeit a few days after the 31st). Currently, she is working tirelessly [insert sleep joke here] to start school later in Seattle.

New Year’s resolutions. Mine have been the same for the last several years — lose a little weight, eat a little healthier, exercise a little more. But for me, sleep hasn’t been on the list because sleep had always been my drug of choice — until this past year. In the past, when deadlines were swirling and patients were knocking, I would do the absolute minimum before bed, and then go to sleep, knowing I would be way more efficient at tackling the problem the next day after recharging. And when there were temporary reprieves in work-life demands — others celebrated with a night out or a late night up watching TV, but I rewarded myself with sleep. It was my cure-all, and sleep medicine was my perfect calling.

But this past year, it all fell apart. Why? Because I got sucked into the ubiquitous #NoTimeToSleep mentality. The work couldn’t wait until tomorrow, because tomorrow there was even more work to be done. Coffee became a life essential, not just a morning pick me up. The smartphone feeds could not wait, and sat plugged in next to my head all night, constantly daring me to check. The nights dedicated to fun couldn’t be wasted on staying home. I knew it was wrong, but I believed it was excusable, even forgivable — I am a busy mom and doctor, so the rules of getting sleep somehow didn’t apply to me anymore because, well, I was too busy for the rules. There was NO WAY that i could carve time out of my crammed life for anything extra, especially sleep. I thought I was being ultra-efficient.

And then came Holiday Season 2014, the apex of #TheYearOfNoSleep. Everything felt frenetic and frantic. I drowned in a vortex of inefficiency. Everything took forever, and nothing got done. Rock bottom was hit. Reality set in of just how awful I felt. The quality of my life in every aspect imaginable had plummeted. Epic fail. How could a sleep doc let this happen?

So I went back to my old ways a few weeks before the New Year. This resolution couldn’t wait until January 1. I resumed my previous drug of choice, sleep. And it has been wonderful, leaving me pondering why I thought I could live with less. So when Dr. Canapari’s pledge to get 30 minutes more sleep per day was posted after the New Year, it was a perfect way for me to reflect on my changes, and quantify time saved during the day by sleeping more at night. None of these are “scientific”, but rather my life experiences:

  1. I am nicer, so save ~15 minutes by not provoking arguments/oppositional behavior because I’m not constantly yelling at my kids and husband. It’s amazing, the kids are more likely to get dressed and the trash more likely to get taken out when I ask in a friendly, polite way.
  2. My memory and organization are better, so save at least 5 minutes by not looking for my keys or various other ill-placed items while trying to get myself and 3 young children out the door in the morning.
  3. My energy level is higher, so I tend take the stairs up to my office, instead of waiting for the elevator, and spend 2 less minutes waiting. (and burn calories to boot!)
  4. I am more reasonable and level-headed, so save 15 minutes by not obsessing over somebody else’s (probably sleep deprived) snarky e-mail comments that I would have previously perceived to be a personal attack. I hadn’t even realized just how much time I would perseverate over a single e-mail — usually scattered through the day but totaling 15 minutes.
  5. Along the more reasonable and level-headed vein, I save at least 15 minutes by being off my phone. Sleep has allowed me to realize that checking Facebook and e-mail every 2 minutes is neither necessary nor beneficial.
  6. (this one is not a joke). I save 2 minutes in the cafeteria. I can make smart, quick decisions about healthy foods and not sit and stare at the potato chip section trying to talk myself out of a ridiculous carb craving which was omnipresent in #TheYearOfNoSleep.
  7. I now need minimal caffeine, so I save at least 10 minutes a day by not waiting in the Starbucks line with the rest of the world.
  8. I am able to do both mundane and challenging tasks faster and better. The hard stuff at work honestly takes a little less time and is less difficult when I have slept. The chores at home take much less time because I’m focused. That’s harder to quantify, but there is probably a lot of time saved — from laundry to dissertations.

I hope this list helps you realize how valuable that 30 minute investment of extra sleep night after night (starting tonight!) will be. Sleep has returned as my drug of choice, and I intend to keep it in good use. Happy Sleeping!

I’ve had a lot of fun reflecting on my own sleep needs this month and it has been a terrific honor to have all of these great writers on my humble little blog. Next week we will return to our routine posting schedule. Did reading these posts change your behavior around sleep?

Early Morning Awakenings: What To Do About Them

As part of my “30 More Minutes of Sleep in 2015″ series, I have updated this post, one of my first from when I started this blog in 2012. In fact, this was originally a guest post over at Seattle Mama Doc which you should go check out. As I describe below, this was a really touch issue for us when our old son was less than a year old. In terms of parental quality of life, teaching your kids to get up a bit later is pretty high yield. 

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When I meet other parents socially, there is one question I get asked more than any other. “Why does my child get up so early in the morning?And, more pressingly, “What can I do about it?” I’m going to talk about toddlers and preschoolers here (1-5 years of age).  [Most parents of teens have the opposite problem, as school start times and excessive homework has resulted in less than 10% of teens getting enough sleep at night. ]

When assessing this concern, I always see if the parents have realistic expectations. Most little children are morning people, which is a real challenge if you are a night owl like me.  To expect your toddler to sleep past 6:30 AM is usually unrealistic. Some children naturally wake up between 5:30-6:30 AM. Other children may have developed a habit of waking up early because of sleep onset associations but are not actually ready to get up, and tend to be quite cranky. I have a couple of suggestions to try if you want to try to get your little one to sleep later:

  • Minimize ambient light. Those black out shades are expensive but they may be worth it. Most kids are really light sensitive. This spring, my kids were getting up earlier and earlier with the longer days. This was getting a bit painful until daylight savings time bailed us out and magically made 5:30 into 6:30 AM.
  • White noise via a sound machine may be useful if a parent needs to get ready for work before the appointed hour, or if one child tends to wake another. We use this one, which appears to be indestructible. Some concerns have been raised about the possibility of these machines affecting children’s hearing. Based on my own very unscientific research, I suspect that this is pretty safe for most children.
  • Adjust the sleep schedule. Children 1-3 years old will sleep between 11-13 hours a day, with 9.5-10.5 hours at night. If your child is going to bed before 7-7:30 PM I would move the bedtime 30-60 minutes later, although it may take a week or two for this strategy to bear fruit. 
  • Avoid switching your child from a crib to a bed until they are three or four, unless they are jumping out of the crib. Changing from a crib to a bed is often a “Hail Mary” move for desperate parents, but in my experience it often backfires.
  • Check sleep associations: In other posts, I’ve talked about sleep onset associations and  This means that if your child requires a certain set of conditions to fall asleep, they will need them again whenever they wake in the night. Early morning awakenings can be a version of this.  When a child is brought into the parents’ bed when he/she wakes very early ( before 5 AM), they will soon start to wake up anticipating this comfort. We went though a month with my son at six months of age where I was lying on the floor with him with a pillow and blanket every day at 4:30 AM (pathetic, I know). I was essentially trying to have my cake and eat it too– get to sleep some more but avoid a sleep association. It didn’t work. The next step was ignoring him until a later and later time until he got to 6 AM. So we got up with him at 4:40 AM, then 4:50 AM, then 5 AM and so on, until he slept until a more reasonable time. I felt comfortable with this strategy as he clearly was not ready to be up at 4:30 AM. Was this painful? Yes. But it was worth it.
  • Wake up clock: This may work with older toddlers or preschoolers. Set up a timer with a light or just try out one of these OK to Wake Clocks . Our older son tends to rush out of bed if he hears his brother stirring or me getting ready for work. He likes his new clock and will wait for it to turn green. The key in being successful with this is going slowly and being realistic. That is to say, buying one of these clocks will not make your two year old sleep until 9 AM on the weekends. I would recommend picking a time about ten minutes later than your child’s current wake time, then moving it later by ten minutes every day or two until you reach your target wake time. This maximizes your chance of success and your child’s sense of mastery.
  • Other positive reinforcement: sticker chart can be helpful in this context, or even (!) an M&M or jelly bean every time your child gets up when you wish them to.
  • Negotiate. When I first wrote this post my boys were four and one; now they are seven and four. This has made mornings much better. My older son understands time very well and will actually take his brother downstairs or read him stories if we ask him to. This is simply lovely. On the weekends we ask them not to get us before 7:30 AM and, unbelievably, they have complied. Once your children are old enough that they do not require direct supervision, I don’t have a problem with parents turning on a show for their kids for 30 extra minutes of sleep on the weekend.

The keys to success are being consistent every time, having realistic expectations, and keeping your child’s room dark. If you have persistent early AM awakenings (e.g. 4-5 AM or earlier) it is worth discussing with your pediatrician, especially if your child seems really cranky and tired during the day.

Have you struggled with too early mornings with your child? What has worked for you? What hasn’t?

How Reading At Night Can Help You Cope With Nocturnal Awakenings

I’ve learned a lot from Dr. Lynelle Schneeberg. She is a clinical psychologist boarded in Sleep Medicine. She is the director of Behavioral Sleep Medicine at Gaylord Sleep Medicine, which is soon to become the Yale Sleep Medicine Program. I have sent her some of my most challenging cases and she has been incredibly helpful. I’m really glad she agreed to help with advice on how to get 30 more minutes of sleep at night. She writes here on what to do when you wake up at night and just can’t get back to sleep:

The acorn falling
(“The acorn falls” by Liza. Click the photo to go to the original)

Should you ever read in bed in the middle of the night if you have a long awakening?

Actually, yes! Another method of getting 30 more minutes of sleep each night would be to keep nocturnal awakenings short. All of us, of course, hope to obtain the most possible sleep each night between the time our heads hit the pillow and the time our alarms ring in the morning. But many people struggle with nocturnal awakenings and sometimes these awakenings are fairly lengthy.

Most people think that the smartest approach is to lie in bed waiting for sleep to return. “At least I’m relaxing!” they’ll say, or “If I sit up or get up, I’ll never get back to sleep.” However, this is often not true. Lying in bed awake is often rather stressful and frustrating. We all tend to think about the things in our lives that have gone wrong, that might go wrong, that are currently going wrong…you get the picture! We also begin worrying about all of the sleep we are losing. These thoughts often result in longer and longer awakenings and the bed becomes a place where some people are awake more than they are asleep.

Moreover, “trying to sleep” is not often very successful. In fact, there was a very interesting study in which some subjects were told there would be a cash prize for the first person who fell asleep while other subjects were simply asked to fall asleep in their normal fashion. What happened? As you might guess, the subjects who were offered the cash took three times as long to fall asleep.

So, what should you do if you awaken at night and can’t fall back to sleep? The best option is simply to sit up in bed and read a book. Try using a soft reading light or, if you use an electronic reader such as an iPad, read your book on the night setting to keep screen light exposure to a minimum. Reading allows drowsiness to “sneak up” on you by engaging your busy mind on something else and by allowing you to relax. Reading in bed is also likely to be much less disruptive to your bed partner than tossing and turning. This technique is called “stimulus control” and it is used to make sure that your bed remains a “stimulus” only for sleep, not for long periods of wake. Try not to use your bed for anything else besides reading or sleeping, though. Keep those electronics out of the bedroom but keep that book on your bedside table and don’t be afraid to crack it open at 2am!

I find stimulus control to be one of the most important interventions for patients with insomnia, but all of us can benefit. When I was taught about this, I learned that you are supposed to actually get out of bed, so I asked Lynelle about this. Her reply was informative:

Classic stimulus control as developed by Bootzin does absolutely say to get out of bed include but  Dr. Gregg Jacobs, a well-known expert on insomnia treatment and author of Say Good Night to Insomnia, has modified the practice of stimulus control to allow sitting UP in bed (which is a  different behavioral “state” than lying down in bed) as long as the person doesn’t read for more than an hour.  (And we are posting this in the winter which I know from long experience is a difficult time to ask people to leave their beds.)

I do find that my patients (kids and teens) may still benefit from more clear instruction.  For this group, I recommend that they do a low light, low stimulation activity. For kids that don’t like to read, I recommend coloring books or jigsaw puzzles.

Do you struggle with middle of the night insomnia? If so, have you tried stimulus control?

We are at the end of January and a few snow days have put my a bit behind schedule. I have a few more entries which I will be running next week. Thanks for following!

How Children and Adults With Chronic Pain Can Get More Sleep

I first met Dr. Valerie Crabtree several years ago at the Sleep Meeting in Boston after going to a great talk which she gave. Since then she has been a great help to me as I try to learn more about behavioral sleep medicine. Like Dr. Honaker, she is a psychologist. She is knowledgeable about all aspects of behavioral sleep medicine, but her special expertise in helping children with pain, especially pain related to cancer at St. Jude’s. She also has two school aged kids and is constantly finding ways to extend her own sleep (Me too!) I asked her to provide some guidance for both children and adults regarding our goal this month of finding ways to get 30 more minutes of sleep per night in 2015.

09/04 - Worst. Bed. EVAR!
(“09/04 – Worst. Bed. EVAR!” by Erik Ogan on Flickr. Click the photo to go to the original)

People with chronic pain often find it hard to fall asleep. Or, if they fall asleep, they may wake up repeatedly during the night and find it hard to get back to sleep. Research shows that poor sleep actually makes pain worse the next day. In fact, newer research is beginning to show that sleep may affect pain MORE than pain interferes with sleep. Finding ways to protect your sleep can actually make your pain better too! [Bold is mine–CC] Wanting to get better sleep? Try this:

  1. Get physical activity. If you are in pain during the day, you may want to lie in bed because it is more comfortable. This can actually have the opposite effect, though, causing pain, fatigue, and sleep to get worse. For many people with chronic pain, following a physical activity program (as prescribed by their doctor or physical therapist) can improve pain, function, AND sleep. Here is a great post on seven ways to exercise with chronic pain.
  2. Rest somewhere other than your bed. If you DO need to rest because of your pain, try to lie on the couch or a reclining chair and reserve your bed just for sleep. This helps your body learn that your bed is only for sleeping, not just for resting.
  3. Try not to nap. When you are resting, try to stay awake. Napping (especially for a long time) during the day can make it very hard to fall asleep or stay asleep at night.
  4. Plan the timing of your pain medication. If your pain medication makes you sleepy, take advantage of this at night. Take sedating medications just before sleep and ask your doctor for other medication options during the day–those that don’t make you feel like you need to nap.
  5. Use non-medicine treatments to improve pain. These techniques can include progressive muscle relaxation, breathing exercises, and guided imagery. What is nice about these strategies is that they can improve both pain and sleep simultaneously.

Here are some links which may be helpful:
Tips for patients with fibromyalgia
Healthshare tips for getting more sleep with chronic pain

Above I highlighted the critical point– bad sleep makes pain worse, just as pain can worsen sleep. Do you struggle with chronic pain? If not, do you have a child or other family member who does? Please share your advice about what has worked and what has not below.

Terra Ziporyn Snider on Building a Sleep Friendly Community

One of the best parts of writing this blog has been getting to know many people who, like myself, are passionate about the importance of sleep. One of the best champions for healthy sleep in teenagers is Terra Ziporyn Snider. Terra is a mother of three and a successful author. She is a former associated editor of the Journal of the American Medical Association and co-author of The Harvard Guide to Women’s Health.Terra is also one of the founders of Start School Later, a non-profit dedicated to improving the sleep of teenagers.

I’ve been living and breathing this issue on both a personal and professional front for years. However, after working futilely to change the 7:17 a.m. high school start times in my local school system, I came to see that even when schools want to change, they often can’t: politics, money, and myth often trump research, common sense, and the best interests of the kids. I also saw that local efforts alone were largely doomed to repeating failed history if left to fight this battle in isolation. The whole idea of Start School Later, a nonprofit organization dedicated to ensuring safe, healthy school hours, is that we can address this issue more effectively by joining forces among health professionals, educators, policymakers, and community advocates working to raise awareness at local, state, and national levels.
For most of us, even us “sleep evangelists,” sleep often gets bumped to bottom of the priority list. This is partly because we live in a culture that equates sleep with laziness, weakness, and apathy. It is also because sleep itself makes us feel vulnerable and takes us out of the action. But simply reminding ourselves that sleep is not a luxury, but a necessity as vital as eating and breathing, is a great way to bump sleep up on anyone’s list of priorities.
That said, it’s equally important to remember that many of us cannot get close to enough sleep no many how hard we try. This is because not all health matters are under personal control. For example, many people work jobs that conflict with their sleep needs and patterns. Even more troubling are the many adolescents whose school clocks require waking before sunrise. Many middle and high schools today start the day in the 7 am hour, with buses starting as early as 5:15 a.m. – hours that require 16-year-olds to be sound asleep by 8 or 9 p.m. to get the 9 or so hours of sleep that most of their growing brains and bodies need. Even teenagers with impeccable sleep hygiene cannot possibly get close to enough sleep with these hours.
If we want our children – and teenagers are still children – to get the sleep they need for optimal health and learning, we can’t just work on ourselves. We also need to work on our communities to get them to set sleep-friendly, developmentally appropriate school hours. Families should certainly resolve to ensure reasonable bedtimes. But their resolutions will mean little until communities resolve to ensure reasonable wake times.

I would challenge you to think about how can you change the culture in your community to make sleep a priority, and not an afterthought. If you are a manager, make sure that you have sleep friendly policies for your employees. Model good sleep behaviors (like getting 30 more minutes of sleep every night) for your friends and your family, especially your children. I would love to hear your ideas on how to make sleep a priority in your community, and in our culture.

Manage Your Mornings: Sarah Honaker on Maximizing Sleep

Breakfast Propulsion
(“Breakfast Propulsion” by Stéfan. Click the photo to go to the original)

I’m really excited that Dr. Sarah Honaker has agreed to provide some great advice on how to get 30 more minutes of sleep every day in 2015. I met Sarah last summer at the AASM meeting in Minneapolis. She was the course director for a terrific section on behavioral sleep medicine in pediatrics, and I furiously took notes during her lecture. She is a clinical psychologist at Riley Children’s in Indianapolis where she has behavioral sleep clinics. She also the mother of two girls age three and six, which is an important part of any sleep doctor’s training. Her post is on the importance of morning planning in getting enough sleep at night.

Although a lot of sleep advice tends to focus on getting to bed earlier, it’s sometimes easier to control the time that we wake in the morning, assuming we don’t have early rising little ones at home. This is particularly true for adolescents and young adults, who tend to operate on a delayed sleep phase (meaning that biologically they are prone to go to bed later and sleep later). Here are some tips for extending your morning sleep:
Limit morning activities to whatever is absolutely necessary. You might shower in the evening, prepare the clothing and items you will need the night before, and eat a simple breakfast.
Don’t “snooze.” Get out of the habit of setting your alarm for earlier than you actually need to wake up. The sleep you obtain in the seven minutes between alarms is generally light sleep.
Encourage younger children to be independent in the morning, when developmentally appropriate. The OK to Wake alarm can be used to teach younger children who cannot tell time when they are allowed to get up for the day. Before the alarm turns “green,” they can read books in bed or play quietly in their room, which means that mom or dad can sleep a little longer.
Take your kids to school, especially middle and high-schoolers. Long bus rides mean even earlier wake times for kids. If you can drive them or arrange a car pool, those extra thirty minutes can make a big difference.
Advocate for later school start times. Research over the last decade has consistently found that teens sleep more and function better when schools start later.
One caveat: be wary of too much weekend oversleeping. While some weekend oversleep (1–2 hours) may be restorative, particularly for those who have to wake extremely early during the week, sleeping too late on weekends usually results in less sleep during the week.

Personally, I have to leave for my clinic in Norwalk at 6:30 AM on Monday mornings. I have found that preparing the night before really helps me get out the door. Specifically, I shower, prepare the coffeemaker and breakfast, put out my clothes, and lay out everything I will need to take with me. If I don’t do this, it takes me about 15–20 minutes to get out the door, as I am blearily looking for the coffee grinder or (on more than one occasion) pouring orange juice into my granola. A carefully planned morning routine helps me minimize friction and decision fatigue before I start my day.

Do you plot your mornings to maximize your sleep? If so, what has worked for you in the past?