In this week’s post, I’m talking a little bit about creating a successful bedtime. Specifically, creating a bedtime that is predictable, linear, goal directed, and brief (e.g. less than 30–40 minutes). I would also love to hear what has worked for you and what has not? What are the rituals at night which you hate to miss? What has not worked for bedtime in your home?
In the last several days, multiple parents have asked me about Enterovirus D68 infection which has received of press coverage. In the last week a few cases have been reported here in Connecticut, including one here at Yale New Haven.
First, some background: enteroviruses are a common group of viruses which can cause cold and stomach symptoms. In all likelihood, your child has had enterovirus infections in the past and you have not even known in. This particular strain of the virus is unique in that it has not previously been commonly seen in the US. In the Midwest, there have been clusters of children with severe respiratory illness. [Note that many children with mild symptoms may go undiagnosed so this virus may be more common than the data suggests]. Children with asthma seem to be particularly vulnerable, and those without asthma may present with asthma like symptoms of cough, shortness of breath, and difficulty breathing. Unlike bacterial infection, antibiotics will not help with these infections but they will run their course with supportive care. Interestingly, many of these children do not seem to have fevers at the time of presentation, which is different from other viral syndromes like influenza. At Yale New Haven we are able to test for the virus.
All parents should be on the the look-out for symptoms of cough, runny nose, and difficulty breathing. Hand washing is critical for preventing the spread of this disorder. In my practice I take care of children who are vulnerable to respiratory illness. It is especially critical for the parents of these children to make sure that their children are taking their breathing medications and doing their treatment regimens so that they are in the best possible shape if they have a viral illness, with EV-D68 or any other virus. Specifically:
- Children with asthma who are on controller medications should have started their prescribed controllers with a spacer if they have slacked off over the summer (we did with my four year old). Also make sure there you have an adequate supply of albuterol.
- Children with cystic fibrosis should be doing airway clearance treatments and taking aerosolized treatments regularly as prescribed.
- Children with neuromuscular disorders such as Duchenne muscular dystrophy, spinal muscular atrophy, and other disorders should be using cough assist regularly, or at least their parents should verify that all treatment equipment (oximeters, cough assist devices, VESTs) are in good working order.
I’m a parent and a physician and always get concerned when I hear about a new virus in the news. I think that with preparation your child will be in good shape and will do well if they are exposed to EV-D68. If you are worried about your child, please call your physician and bring him or her to be seen.
Centers for Disease Control Information Page for enterovirus D68
Enterovirus D68: What Parents Need to Know via Web MD
12 states confirm Enterovirus D68 cases via CNN
What You Need to Know About Enterovirus d68 via Boston.com
EV-D68 in KC via KC Kids Doc
I often find that parents who see me in clinic have tried and failed to sleep train their children. (Obviously, the ones who had an easy time don’t need an appointment). As I work with families to come up with plan to help their children fall asleep and stay asleep on their own, bedtime fading is one of the most useful tools that I use. In a nutshell, this involves moving their child’s bedtime later with the goal of having them be more sleepy at bedtime. In this video, I talk about how families can use bedtime fading to successfully sleep train their child. If you are interested, there is some interesting research that was published by Dr. Monique LeBourgeois which shows that children who have difficulty settling at night are frequently put to bed too early.
As stated in the video, the keys to successful bedtime fading include:
- Avoiding “sneaky sleep” in the later afternoon.
- Not allowing your child to sleep much later in the mornings, unless they are getting up at an uncomfortably early hour.
Have you tried moving your child’s bedtime with the goal of leading to a better night of sleep? How did that work for you?
Let’s perform a thought experiment for a moment:
if you knew that in your child’s school there was a toxic substance that reduced the capacity to learn, increased chances of a car crash and made it likely that 20 years from now he would be obese and suffer from hypertension, you’d do everything possible to get rid of that substance and not worry about cost.
What would you do if you were worried about your child’s safety in school? In a nutshell, anything and everything it takes to resolve the situation. This quote, from Dr. Judith Owens, is not discussing a chemical; she is describing early school start times. We know that insufficient sleep caused by excessively early school start times:
- Makes children irritable and obese
- Causes insulin resistance analogous to a prediabetic state
- Lowers standardized test scores
- Increases the risk of accidents on the roads for all drivers in a community
- Can lead to mood disorders, substance abuse, and school drop outs.
Early school start times have effects like this the children in your community and in mine. [In my town, the two middle schools start at 8 AM and 7:50 AM, and the high school starts at 7:25 AM]. The arguments marshaled against changing school start times have nothing to do with the welfare of children, and only reference inconvenience and monetary expense. Importantly, communities that have changed school start times have found that the inconvenience and expense is actually less than anticipated, and the benefits are considerable. I’ve written before about the difficulties the teenagers have excessive homework and early school start times, and unfortunately there is a physiologic limit on how much teens can compensate for this, as their biological clock pushes them to stay up later as school start times get earlier.
This week, the American Academy of Pediatrics has added its voice to the chorus advocating for our children by recommending the school start times for middle schoolers in high school age children be no earlier than 8:30 AM. If you are a parent, and educator, or concerned citizen who cares about the welfare of your community, I would urge you to reach out to the school board and superintendent of schools of your community and to advocate for this change. Nothing will change unless you make it. There is a lot of inertia against changing the status quo. One good place to start in Start School Later, a national organization which has many local chapters working on precisely this issue. Here are some links which provides an extra information on this topic:
• “Let Them Sleep: AAP Recommends Delaying School Start Times of Middle and High Schools to Combat Teen Sleep Deprivation”. Here is the complete report: “School Start Times for Adolescents”, by the Adolescent Sleep Working Group and Committee on Adolescence, and Council School Health.
• “Let Them Sleep, Start School Later”, from Seattle Mama Doc
I’m going to try something a little bit different today. I have put together a brief video on the “camping out” sleep training method which is a gentler but still evidence based method of sleep training.
Here is the pyramid from the video, courtesy of Ruth Fidino. I like this way of representing the process because the pyramid narrows as the distance from your child increases.
Please let me know if you think the video is helpful and if there are other topics that may benefit from this approach. Inspired by my colleagues Wendy Sue Swanson and Howard Luks, who are really good at making short videos.
As a sleep doctor, I hear a lot of creative excuses that children come up with as the try to extend their bedtime. In the business, we call these “curtain calls” and are a key feature of behavioral insomnia of the limit setting type. My niece used to yell, “Julia’s hurt!” until her family came to check (she wasn’t). One mother in clinic told me how she pulled out four loose teeth on one occasion when her mother was having a friend over. I have heard children ask for:
- Glasses of water
- Another story
- Going to the bathroom (multiple times)
- For parents to check the closet/under the bed/ in the toy chest for monsters
- The pacifier that he or she just threw on the floor.I was listening to NPR today and heard about a little boy named Noah Shaw who surpassed all of these other children. Noah was born with a cancer of the eye called retinoblastoma (you can read about more about Noah, whose diagnosis led his father to develop a way to detect this tumor in baby photos). As a result, he wears a prosthetic eye in his right eye socket. Some nights, after his parents, would put him to bed:
. . . he used to play this little game with his mom and dad. They’d put him down for bed, then they’d leave the room. And a few minutes later, Noah would take his eye out and throw it on the ground. It sounded like an M&M hitting the hardwood floor. And then of course, Mom and Dad would go rushing back into the room, which would make Noah terribly happy. Read the full story here.
I have to hand it to this little boy for creativity. Most parents would have a hard time not going into that room. What are the most creative delaying tactics that your children have come up with?
Note that this article is republished from last summer.
Summer, sadly, is coming to an end. It’s been great for us. Long, lazy days at the beach. Dripping ice cream cones. Bike rides. Long days and lazy mornings. Well guess what, campers? That is coming to an end. (Many school districts now start in the last week of August). To me, professionally, what this means is that it is time for a sleep tune-up. I usually schedule my patients with sleep disorders, especially body clock or circadian problems, to make sure that they are on the right trajectory to re-enter school successfully. I would advise parents to think about the sleep habits of their children, and how they may need to be readjusted prior to restarting school.
- For elementary school age children, their schedule tends not to deviate too much during the summer. (Even if you want them to when you are on vacation, they don’t sleep in). As with other major developmental steps, a little of night time sleep disturbance is common but should resolve rapidly.
- Teenagers are a bit more problematic. Teenagers have a natural predisposition to go to bed later and stay up later. If they have time shifted later by more than an hour, you can anticipate some difficulty in the first week of school. This is due to their natural body clock predisposition to stay up later and go to bed later, which can become exaggerated over the summer.
I have a couple of thoughts about the best way to gently help an older child ease back into the fall routine.
- Roll the clock back, slowly. You can only move the schedule back by about 15 minutes a day. So if your teenager is sleeping from 1-10 AM and your target sleep period is 10 PM-7AM, you will need about 12 days to make the move.
- Open those blinds. Early morning exposure to light will help to shift your child’s sleep schedule earlier. Conversely, late night light light exposure (usually from TVs, iPads, phones, gaming consoles) will move your child’s sleep schedule later.
- Enlist your child. If there is one thing I have earned as a sleep doctor is that a parent’s (or doctor’s) best laid plans are doomed to fail if the child is not on board. Discuss your concerns with your child in terms that they get.
- Recognize when things are a bit out of control. Some teens with a condition called delayed sleep phase syndrome may have a severe, marked delay where their day/night schedules become reversed.
- If your kid is already in school and having trouble sleeping all is not lost. It is key to continue to observe good sleep hygiene, including nap avoidance and avoidance of excessive weekend sleep (e.g. past 10 AM) will ensure habituation to the school schedule.
I also want to share some related links:
- This interactive graphic at the Harvard Healthy Sleep website explains the interaction between body clock and sleep drive very clearly.
- Here is an article in the Washington Post from a while ago in which I was interviewed on this topic.
- Two of the child psychiatrists at MGH, Drs. Gene Beresin and Steve Schlozman provide some great advice in Back to School Psychology 101: Tips for Parents.
I remember having marked difficulty sleeping before the first day of school as long as I can remember, perhaps due to my undiagnosed restless leg syndrome. Finally, I’d love to close by ask if any parents have any useful tips (or horror stories) about the back to school transition for their children.
We just back from vacation. I thought that I would reshare some tips that have been helpful to me.
There have been a lot of great recent articles on summer related for children and families; many have been thoughtfully gathered by Dr. Heidi Roman in her Summer Safety article . I also really like this article from the New York Times on how not to ruin your own vacation. (In a nutshell, cut the virtual umbilical as much as you can– something I have struggled to do as you can see from my recent volleys of tweets).
We are having a great time here but are dealing with a bit of sleep disruption from the wee ones. Witness the usual view from the foot of my bed at approximately sunrise all week-long. Thus, clearly, I don’t have the secrets of perfect child sleep on vacation. However, I’ve gleaned a few lessons:
- Respect the routine: When we go on vacation we try really hard to maintain our kids’ bedtimes and nap times. Of course, we bend the rules for special occasions like fireworks. (I wish we had seen the display in San Diego where all the fireworks went off at once; all the excitement and home early for bedtime.) Also, some “sneaky sleep” may be unavoidable as the kids will be pretty tuckered out.
- Go to bed early: We were vacationing with cousins, and all the kids got up earlier than normal. If you want to catch up on your sleep, your best chance is by going to bed earlier than normal.
- Make the room dark: Don’t hesitate to hang towels over the windows if you need to– that can make a huge difference in when your child gets up.
- Get creative with the sleeping arrangements: We were staying with several cousins at a vacation home. Our older son shared a “room” (which was a walk in closet) with his 6 year cousin. That way they did not have to get up with their younger siblings (and tired parents) the next day. Of course, this is not perfect; my niece got up at 5:15 AM on the first day and awoken our son as well. Sharing rooms can be a bit tricky for children used to having their own room; older children should be instructed to let others sleep if they wake up early. They may also be a bit chatty at bedtime, but that is part of the fun.
- Jet lag can be tricky: Jet lag occurs when travelling across time zones east or west. You can prepare a bit by putting your kids to bed later for a few days before travelling west or getting them up a bit earlier before travelling east. Children tend to adapt quickly if they have natural light exposure. For more on this topic there are some good articles here and here.
- Be realistic: Remember long relaxing reading sessions by the pool and sleeping on the beach? Yeah, me neither.
- Have fun: Although vacation with little ones may not exactly be restful, we had a ton of fun digging holes in the sand, looking at snails, riding bikes, and having lots of family meals.
Any crazy vacation sleeping stories out there? Please share.
There are lots of reasons that parents fail at sleep training their children. One of the most often overlooked is timing. If you pick the wrong time to start, you are doomed to failure. You really want to allow yourself about two weeks of time without any major changes in routine to maximize your chance of success. Some examples of when NOT to sleep train:
- Before age 4–6 months of age.
- When your mother-in-law is visiting
- Right before a vacation
- When your child is suffering from a cold/teething/working on another developmental task such as potty training or learning to walk
- Immediately before or after a new sibling is born
- Around the time of a big work deadline
I think of starting sleep training as analogous to quitting smoking. One of the important smokers are counseled to do when planning to quit is selecting a quit date. If you think of sleep training as quitting bad sleep, you want to pick a date for starting for sleep training as well. If you have selected your date for starting sleep training, I would recommend:
- Marking it on your calendar
- Telling family and friends (who are supportive) of your plans
- If you have been unsuccessful in the past, reflect on what worked and what didn’t
- Making a plan in advance of starting using proven strategies for sleep training
If you have any sleep training horror stories, please share them below. Do you think that timing may have been a factor?