Please check out the new pages on the Sleepy Kidz website. I am so excited to finally announce that Sleepy Kidz is offering Pediatric Behavioral Sleep Medicine Services. The first intake session is usually about one and half hours and either conducted in your home or at my office. The remainder of the sessions are typically conducted by email and/or phone for support, problem-solving, and follow-up. A customized sleep package will be created with you during the initial intake session based on your family’s needs. Sleepy Kidz works with infants through adolescents to treat a variety of behavioral sleep problems including night wakings, behavioral insomnia of childhood, bedtime refusal/struggles, insomnia, and any other problems negatively impacting the amount of sleep your baby, toddler, child, or adolescent is getting. Looking forward to helping you and your little one get a better night’s sleep!
Sleepy Kidz is Excited to Now Be Offering Pediatric Behavioral Sleep Medicine Services!
Bed time
Many parents ask what is the best bedtime for their child? The answer is: it depends. Let’s start with infants and toddlers. The natural bedtime for them is between 6 and 8PM. If they miss their natural bedtime, they can become overtired. An overtired child of any age does not always look sleepy – they can also be hyperactive, impulsive, and inattentive. You know that time when they bounce off the walls right before bed? Yes, that is how children often act when they are tired. An overtired infant or child is much harder to get to sleep than a well-rested one. They also sleep shorter amounts of time and less soundly. For example, many parents believe that if they keep their infant/child up later at night, he/she will sleep in later in the morning. This is a common misconception and it is actually counter-intuitive. The earlier a child goes to bed (within reason of course), the later they will sleep. This is because the child is well-rested and not overtired. Many parents are scared to put their child down for bed at 6:30PM in fear the child will then wake up at 4AM. In the families I have worked with, this has never been the case. The child typically sleeps until 6-6:30AM for a full nights sleep. Same goes for infants/toddlers that miss their naps in hopes for a better nights sleep. It does not work this way – the more time they spend napping means more well-rested little ones and a better and longer night’s sleep. Overtired infants or children are also much more difficult to get to fall asleep as they are cranky and disregulated as they have missed their natural bedtime.
Many parents also do not put little ones down for bed between 6 and 8PM as this is typically the only time a working parent or parents get to spend with the little ones. They therefore keep the child up in order to spend time with him/her. It is obviously up to the family as to what works best for them and if the child is sleeping well, then there is no problem.
As far as older children (I generally think school age and up), bedtime is best determined by starting with what time they need to wake up in the morning for school and how many hours of sleep they need to be getting. Count backwards from the time they need to be up as far as how many hours of sleep they need and I would set bedtime about 30 minutes before this. That gives some time for the child to fall asleep and ensure he/she is getting a full nights rest. For example, if the child needs to be awake (or naturally wakes up at 7AM) and needs 10 hours of sleep per night, I would aim for a bedtime of 8:30PM.
Sleep Associations
What does your child associate with falling asleep? Depending on the age of the child it could be a binky, a blankie, a bottle, a stuffed animal, watching TV or even Mom or Dad laying down next to him. A sleep association is anything a child has linked to falling asleep and needs in order to fall asleep (at bedtime or during the night after a nightwaking).
A positive sleep association would be one that a child can re-create on his own without adult assistance. This would include such things as a binky, blankie, stuffed animal, white noise machine, etc. If a child wakes in the middle of the night (like we all do naturally), he would be able to recreate the situation he needs to go back to sleep independently. The object associated with sleep should also be limited to sleep as it will trigger to the child’s body it is time to sleep. A good recommendation is to leave it in bed during the day.
A negative sleep association would be one that a child requires adult assistance to re-create in order to fall back asleep. This would include being rocked to sleep, watching TV, needing Mom or Dad to lay down next to him, a bottle/breastfeeding, etc. When children with negative sleep associations wake in the middle of the night, they are unable to recreate the situation they need to fall asleep and therefore, require adult assistance.
Negative sleep associations are the basis for a very common sleep disorder found in about 25% of children: Behavioral Insomnia of Childhood: Sleep Onset Association Type. These children are unable to self-soothe and require parental intervention after a brief arousal that normally occurs at the end of a 60-90 minute sleep cycle. One way to prevent this problem is to put an infant in bed while he is still awake, but drowsy. Thus, preventing the creation of an association between being held or rocked and falling asleep. For a child that has already developed a negative sleep association, it is important to replace the negative association with a positive one – this may involve a lot of coaching with the child (talking them through it/preparing them for it) and possibly some crying from the child as he learns to self-soothe (a critical developmental milestone).
It is important to create positive sleep associations from an early age and there are a variety of options to select from. Just be sure not to use blankies, stuffed animals, etc. until your child is old enough (see American Academy of Pediatrics recent recommendations for Safe Sleep).
Sleep in the News
I am way overdue for a post. It has been a long 2 weeks and I definitely have sleep debt I am still catching up on. I promise to post tomorrow, but in the mean time here are some interesting articles in the news recently:
More Kids Sleep with TV, Study Finds, Wall Street Journal.
Such a great idea for the toddlers and preschoolers that wake up too early and can understand! The Good Nite Lite is a patented behavioral modification device designed to promote a child’s ability to get the rest that is critical for healthy development.
Sleep-Deprived Families Make Adjustments During the Day to Have a Restful Night, South Florida Parenting.
This shows why the need for awareness is so great! Many Pediatricians Overlook Sleep, The Sleep Doctor, Michael Breus, PhD, The Insomnia Blog.
I wonder why sleep paralysis is more common in college students? I have this all of the time! Sleep Paralysis More Common in Students, The Body Odd on MCNBC.
Sleep-deprived teens engage in more risky and unhealthy behaviors. Sleep-Deprived Teens: Risky Business, WebMD.
How are you and your little ones adjusting to the time change? I really wanted to do a post about how to prepare kids for the time change, but work got crazy. One to come in the future. I know my body thinks it is later!
Bedtime Resistance
Bedtime resistance is known in the sleep disorders world as Behavioral Insomnia of Childhood and has two different subtypes: Sleep Onset Association and Limit Setting. Sleep Onset Association means that a child needs something to go to sleep (a sleep association) that he cannot recreate on their own. For example, a child that needs to be rocked to sleep or needs a parent to lay next to him. Limit Setting is when parents do not set appropriate limits that allow the child to stay up later and therefore, not get enough sleep. For example, a child that asks for one more book, one more drink of water, or a child that continuously gets out of bed. Bedtime resistance is most common in children ages 2 through 5 and either means the child never developed healthy sleep habits or is testing limits with his parents.
The important thing is that either type is a learned behavior. When teaching a child to learn a new habit, it is the same as any other habit – if you give in once, the child will protest even longer the next time because he has learned there is some chance you will give in. You will therefore make it harder on your child if you give in. It is important to remind yourself you are allowing your child to cry, not making your child cry. It is the same as allowing your child to fall when learning to walk, as learning to sleep is just as big of a developmental milestone. If your child wanted to eat chocolate for every meal and threw a tantrum at every meal, would you give in? It is the same with sleep. Sleep is just as important and the effects of not sleeping enough are detrimental to a child’s development.
I spent a month with a 2.5 year old this summer and immediately realized he had never learned how to go to sleep on his own – he needed someone to lay with him (at naps, bedtime, and nightly awakenings). This meant sometimes I would lay with him and he would fall asleep in 5 minutes and other times closer to 1.5-2 hours. I decided this was not in his best interest nor mine, as he needed to develop the ability to fall asleep on his own. Not to mention, he was not sleeping enough due to this behavior (sometimes as little as 8 hours per night). Here are some tips when dealing with bedtime resistance:
- Keep the bedtime routine consistent (and follow the recommended guidelines in the Bedtime Routine post).
- Bedtime should be between 6 and 8PM. If it is currently later, I would slowly move it to the desired time. If your child is taking 1 hour to fall asleep, bedtime should be 1 hour before the desired bedtime until they can fall asleep quicker (i.e. if you want him to go to bed at 7, but he is currently taking an hour to fall asleep, put him in bed at 6).
- Explain to your child what the routine will be and that it will end with you saying “Goodnight” and leaving the room. Tell him your expectation that he remain in bed and go to sleep. You can talk about ways to help him fall asleep, such as relaxation.
- Go through the routine and do as you said you will – tell your child goodnight, turn off the lights, and leave the room. Do not delay nor allow your child to continue conversation with you to keep you in the room.
- If your child comes out of the room or gets out of bed, walk him back to bed and return him to bed. Do not engage in conversation and do not hug or cuddle him. Say “Goodnight” or “Goodnight, I love you” and leave the room again. Do not engage in any further conversation or give your child any further attention. This is what he wants. The child I worked with this summer tried everything to get me to engage with him, saying things such as “I want to hit you,” “I need to go to the bathroom,” and “I’m hungry.”
- Your child’s behavior may be worse at first. This is what we refer to as the “extinction burst.” He will try harder to get you to give in before giving up and realizing you will not give in. This burst will be even bigger if you do give in at all. Also, remember, the longer you put this off or the more you give in and delay the sleep training, the older your child will be and the longer/harder he will protest.
- You may have to return your child to bed MANY times the first few nights until he learns. This can be exhausting and hard to see your child so distraught. It may help to remind yourself that you are teaching your child a crucial habit in his development and that a couple of rough nights will lead to peaceful nights from there on out. It may seem like he will never learn, but I promise he eventually will!
- This is also true for the child that wakes up in the middle of night and joins you in bed or wants attention. Do the same as above… return him to bed with minimal attention and leave the room.
- The most important thing is consistency! You are the parent and you are responsible for shaping your child’s healthy sleep habits.
- Lastly, if the child is old enough to understand, Reward Charts are great. Come up with a reward that the child really wants and give a sticker for every night that he goes to bed on his own and sleeps through the night in his own bed.
After many nights of returning the child to bed this summer (over 30 times a couple of nights) and hours of crying, he began falling asleep on his own and sleeping 12 hours at night, with no awakenings. Needless to say, although the mother was resistant at first to allowing her child to cry, she stuck it out and all are enjoying more peaceful and restful nights.
New Safe Sleep Recommendations
The American Academy of Pediatrics released new safe sleep recommendations to reduce the risk of Sudden Infant Death Syndrome (SIDS). The AAP recommends no bumpers in the crib, immunizations and breast feeding to reduce the risk of SIDS. While bumpers are definitely cute and inviting, they do not reduce the risk of injury and do increase the chances of suffocation and strangulation. Therefore, pediatricians say bumpers do not belong in the crib (even the breathable ones). They recommend a firm mattress and fitted sheet, with no gaps between the mattress and crib. In addition, no stuffed animals, wedges, sleep positioners, or blankets in the crib. Further, they recommend that babies sleep in the crib regularly and not in car seats or other sitting devices (swings, bouncy seats, etc.). As far as immunizations, which I know have become a controversy among some parents (due to the media coverage of the possibility of them causing Autism – the research shows this is not true), they say that the risk of SIDS is reduced by 50% when infants are immunized. 
Other safe sleep recommendations include using a pacifier at nap and bed time (I would recommend taking away by 3-4 months when the child is developmentally able to self-soothe). Also, to place babies on their backs for every sleep time. Finally, they recommend supervised, awake tummy time to facilitate development and minimize
the occurrence of flat head.
With these new recommendations, do you think parents will stop putting bumpers in cribs?
Bedtime Routines
Most parents will agree that bedtime is the most chaotic time at home (particularly if they have more than one child). Many times I have been asked to babysit just at bedtime to be an extra set of hands. Kids are tired and cranky, parents are exhausted too, making it hard for bedtime to be a smooth, relaxing process. However, this is just what it should be. Most importantly, the bedtime routine should be fairly consistent and always start at the same time. Predictability helps kids to feel less anxious as they know what to expect. Did you know that one of the top predictors of mental health problems in children is inconsistent parenting? It is impossible to be consistent 100% of the time, but the more the better. How do you feel if you do not know what is expected of you or what your routine will be? It makes kids and adults alike feel anxious. Ok, back to the bedtime routine.
You want to prepare your child for the bedtime routine by giving them a ten minute warning and let them know what the bedtime routine will include (most importantly that it will conclude with them going to sleep!). You want to have a period of winding down before bed, with calming activities in low light. Examples of such activities include doing a puzzle, playing a board game, going outside and looking at the stars, taking a bath, drawing a picture, listening to calm music, or reading a book. You want to avoid stimulating activities and light exposure (TV, computer, video games, cell phones, etc.). The dark signals to our body to release melatonin, so when a child or adult is exposed to bright lights, this can interfere with the production of the sleep-promoting hormone, melatonin.
Additionally, the bedtime routine signals to children’s brains it is time to start winding down. When their brain gets this message, it tells their body to produce melatonin. The activity right before bed should stay the same as this will be the final signal to the brain that it is time for sleep. This can include a light snack, saying goodnite to pets, brushing teeth, reading a book, etc. It is recommended to go to bed neither starving nor stuffed. Great bedtime snacks include yogurt, toast with peanut butter, a piece of fruit or a small bowl of cereal.
Do your children have a bedtime routine? What is it like? It is never too late to introduce one!
How much do you know about your child’s sleep?
Test your knowledge of pediatric sleep by answering the following true or false questions:
- While snoring is a common problem among children and adolescents, it occurs most often among males?
- Snoring is a matter of concern and should always be brought to the attention of a doctor?
- It is always a good idea for children to sleep in on the weekends to “catch-up” from not getting enough sleep during the week.
- Children sleep longer at night if they do not take a nap.
- The main reason students fall asleep in class is because they have bad school-work habits and/or are lazy.
- While there is some variability in the amount of sleep children need, overall, most require the same amount as their age peers.
- Sleeping more (naps or at night) makes people feel more tired.
- Insomnia is solely characterized by difficulty falling asleep.
- Daytime sleepiness always means a child is not sleeping long enough at night.
- Medication is the always the best treatment for sleep problems.
- It is recommended for children/adolescents to watch TV to help them wind down and become sleepy.
- Health problems such as obesity, diabetes, hypertension, and depression are unrelated to the amount and quality of a person’s sleep.
Answers:
- False
- True
- False; Our sleep-wake cycle is regulated by a “circadian clock” in our brain and the body’s need to balance both sleep time and wake time. A regular waking time in the morning strengthens the circadian function and can help with sleep onset at night. That is also why it is important to keep a regular bedtime and wake-time, even on the weekends when there is the temptation to sleep-in.
- False. When a child (or adult) is over-tired, they do not sleep as well, it is actually the opposite of what most would assume. The less a child sleeps the more difficult it is for them. Most parents know how difficult it can be to get an over-tired child to sleep.
- False. Excessive day-time sleepiness is the primary symptom of a sleep disorder in children.
- True. See previous post on how much sleep children really need.
- False. See #4.
- False. Insomnia can be difficulty falling asleep, waking up at night, or early morning wakings. In children it is considered “behavioral insomnia” as they engage in behaviors that prevent them from sleeping enough.
- False. It can mean a variety of things, including the child is experiencing parasomnias (sleep walking, sleep talking, etc.) or a variety of other factors that are effecting the quality of the child’s sleep.
- False. Behavioral interventions are shown to be extremely effective (typically more effective and more acceptable by parents) for most pediatric sleep problems.
- False. I will discuss this in the next post on healthy sleep hygiene.
- False. These are all related to sleep.
How did you do? Did you know we spend 1/3 of our lives sleeping? Stay tuned for healthy sleep hygiene for kids.
Relying on Motion for Sleep
As I am getting ready to fly to NYC tomorrow, I am reminded of a common mistake parents make. It is easy to soothe babies using motion – we all do it, including swings, strollers, car rides, rocking, etc. Often these are last resorts for getting a baby to sleep and a tired parent will do whatever it takes! However, “if the child is always sleeping in motion – in strollers or cars – he probably doesn’t get the deep, more restorative sleep due to the stimulation of motion,” says Marc Weissbluth. He relates motion-induced sleep to the type of sleep an adult might get while flying on an airplane (not restorative!). 
Using motion to soothe a cranky baby is not a bad thing. Motion can also be used as part of a bedtime routine or to help a child become sleepy, but be careful not to rely too much on motion. Once the child has fallen asleep, just be sure to turn the swing off or park the stroller. Also, you want to be sure the child can recreate whatever it is that helps him fall asleep on his own, so that when he wakes up he can put himself back to bed. If he needs to be rocked in order to completely fall asleep, he is also going to need to be rocked to fall asleep each time he awakes at night (will talk more about this on another day!).
So remember… use the motion to calm your baby, not for him or her to fall asleep. This will allow your child the opportunity to have some deeper, high-quality sleep, and he’ll be more likely to stay asleep longer and generally be more rested.
Does sleep REALLY matter?
Most people, including parents and medical and mental health professionals, do not realize how important sleep is. I am often told that “He’s never been a good sleeper” or “She doesn’t seem to need as much sleep.” It is true that there is some variability in how much sleep everyone needs, but not that much. While many parents believe that it is not a big deal that their child is not a “good sleeper,” they are often unaware of the detrimental effects of sleep deprivation on children.
Not only does sleep impact an infant’s and child’s ability to meet developmental milestones, but it also impacts their cognitive abilities, behavior, mood/affect, learning, and health. The symptoms of sleep disorders are most often misdiagnosed as ADHD, Learning Disabilities, and Depression, when in fact the problem is insufficient sleep due to a variety of reasons. In very basic terms, basically anything that prevents an infant or child from getting enough sleep is considered a sleep disorder. This can include delaying bedtime (one more book, one more drink of water, etc.), nighttime wakings, early morning wakings, or a variety of nighttime disturbances (night terrors, sleep walking, etc.). Most interventions to help children (and as a result parents) sleep more involve parent training as parents are the ones who shape a child’s sleep habits. It is unbelievable that approximately 40% of children have a sleep disorder… so if this includes your child, you are not alone! Stay tuned for more information on prevention, interventions and basic facts about sleep for kids.
Sleepy Kidz 