Sleep problems in children are some of the most common concerns which parents have, but frequently pediatricians (and other clinicians) may not have great information about how to fix these problems. I asked my good friend Dr. Valerie Crabtree, who works at St. Jude Children’s Research Hospital and studies sleep disorders in children with chronic pain and cancer. She previously wrote a post on how kids and grown-ups with chronic pain can sleep better). She and Dr. Lisa Meltzer just published a terrific book called Pediatric Sleep Problems: A Clinician’s Guide to Behavioral Interventions(affiliate link). It has a lot of great information as well as very useful handouts that clinicians can use in their office. I asked her to tell me what issues she thinks are commonly misunderstood by pediatricians and other caregivers when counseling parents about sleep. Here is her list of the top fallacies shared when advising parents about sleep problems in children:
- You can start sleep training as soon as you feel ready. Sleep training is a very effective approach to helping infants learn to put themselves to sleep and return themselves to sleep without the help of their parents. This is VERY important for exhausted parents who are desperate to have longer stretches of sleep, themselves. It is also very important to teach infants how to soothe themselves so that they can develop a self-regulation skill that can be generalized throughout their day. Young infants, however, NEED to awaken frequently to eat and do not have the physiological and emotional maturity to accomplish this skill, which will lead to great frustration on the part of the baby and the parent if started too early. Sleep training should not begin until around 6 months of age and when the infant is nutritionally stable enough to sleep throughout the night without eating. This helps start babies and parents off in the right direction for healthy sleep. [Here is my article on sleep training mistakes and pitfalls, which includes starting too early -CC]
- You have to stay consistent in ignoring the crying at bedtime and throughout the night. Most sleep training can be very effective if carried out only at bedtime. If a parent continues to then try to ignore crying later in the night, both the parent and infant can become very frustrated. We all know that we can tolerate frustration better when well-rested at 8:00 pm than when awakened from a cold sleep at 3:00 in the morning. So, parents can be given permission to work on sleep training before they go to bed and then give it up for the rest of the night. Parents should be cautioned, though, that the child will typically continue to have nighttime awakenings for the first few weeks of sleep training. Typically, if an infant or toddler learns to settle at bedtime, this skill will eventually generalize to nighttime awakenings as well. If nighttime awakenings continue for 2-3 weeks after the child is settling himself at the beginning of the night, sleep training can begin during nighttime awakenings at that point. [Here is my comprehensive sleep training techniques article -CC].
- Try some melatonin. Melatonin can be a very helpful supplement in certain circumstances. However, it is a much more powerful chronobiotic than hypnotic. This means that it is going to be far more effective when used in children with a circadian rhythm sleep disturbance than in children with sleep onset difficulties caused by insomnia or behavioral difficulties. To be effective, melatonin must be timed and dosed effectively. In particular, when used as a hypnotic, it should be given 30-60 minutes before bedtime, at the same time each night, and the child should GO TO BED after taking it. For a chronobiotic, it should be given 3-6 hours before bedtime at much smaller doses than when used as a hypnotic. Whether used as a hypnotic or a chronobiotic, melatonin should always be given in the lowest dose possible to achieve its goal. For any child whose sleep onset difficulties appear to be related to causes other than a circadian rhythm sleep disorder, behavioral strategies should be the first line intervention. [I totally agree that melatonin is overused, and have a comprehensive guide for parents on melatonin -CC]
- If she isn’t falling asleep at night, just have her skip her nap. This is excellent advice for older children and teenagers; however, for younger children this can be counterproductive. In the infancy, toddler, and preschool periods, sleep begets sleep. That is, the healthier and more structured the daytime sleep, the better the nighttime sleep will be. As children begin to outgrow naps (typically around 4-6 years of age), this can become trickier. If a child takes a nap, she may need a later bedtime, but if she skips a nap, she may be a nightmare for her parents from 5-7 pm. Often, parents need to make the decision about which is more tolerable to them. In children prior to this age, however, it is strongly advised that the parent/childcare provider maintain a regular, quiet, darkened nap opportunity at the same time each day. If it is a sleep-conducive environment, most young children will eventually sleep. [There is some controversy about the optimal time to stop naps: here is more information on when to stop napping -CC]
- He’ll outgrow his bedwetting. OR Just don’t let him drink before bed. OR We don’t know how to treat bedwetting. In fact, behavioral treatments for bedwetting are some of the oldest and most established behavioral interventions we have to offer. Previously known as the bell and pad, bedwetting alarms have been used effectively in the treatment of nocturnal enuresis since the 1930s. Current models are lightweight, easy to use, and offer options such as remote receivers in the parents’ room and both vibrate and auditory modes. Several options are available for online purchase, such as http://bedwettingstore.com/ or amazon.com(affiliate link). Most alarms cost between $50 and $150 and are less expensive with fewer side effects than medication.
I found Dr. Crabtree’s advice to be really useful. Obviously, sleep problems in children are a common cause for trips to the pediatrician. I know that I received very little education about sleep issues in my medical school (about two hours!) and little more in residency. Tell me about advice you’ve received (good AND bad) as you tried to address your child’s sleep problem).