Sleeping problems for infants and toddlers

Newborn infants have irregular sleep cycles, which take about 6 months to mature. While newborns sleep an average of 16 to 20 hours per day, they may only sleep 1 or 2 hours at a time. As children get older, the total number of hours they need for sleep decreases. However, different children have different needs. It is normal even for a 6 month old to wake up briefly during the night, but these awakenings should only last a few minutes and children should be able to go back to sleep on their own. For specific concerns regarding your child’s sleep patterns, always consult with your pediatrician.

Before delving into the many problems that parents deal with on this subject, we have to discuss the hugely controversial topic of “bed-sharing’ or “co-sleeping.” No article about sleep is complete without addressing this important topic. So here we go:

Bed sharing is very common in many cultures and as pediatrician we are aware and respectful that things may be done differently in various cultures. There are some benefits to bed sharing, but we believe that the risks and hazards of bed sharing outweigh its benefits.

The American Academy of Pediatrics (AAP) has an official statement and discourages bed sharing. However, THIS DOES NOT mean that once you move the baby into a crib you need to “kick him” out of your bedroom. It is very important that mother and baby sleep within reach of each other, just not in the same bed. Have the crib or bassinette right next to your bed so when it is feeding time, all you have to do is sit up and reach your baby, you don’t even have to walk to the crib.

Here is the most important reason why we advise against bed sharing:

Most parents are ready to sacrifice their life for the well being of their baby. What most parents don’t realize is the huge impact of sleep deprivation, not only on their own health, but also its effect on the health of their loved ones including their baby, their spouse and other children.

Over the last few decades there has been growing evidence to suggest that too little sleep is associated with adverse health outcomes in adults, including total mortality, cardiovascular disease, type 2 diabetes, hypertension, respiratory disorders, obesity in both children and adults, and poor self-rated health. It has also been demonstrated that lack of sleep affects mood and anxiety levels. The prime example is your toddler who has not slept well the night before and fusses about everything the next day.

No one can deny that when your child sleeps with you, the quality of your sleep is negatively affected. I recollect more than a few occasions when I woke up with my daughter’s big toe in my right nostril (yes, I admit, she has snuck into our bed more than just a few nights!!). When this poor quality sleep is carried on for a few weeks, even if you are superman and superwoman, the resulting increased stress and anxiety levels eventually negatively impact you and your relationship with your spouse, your co-workers, and MOST IMPORTANTLY your own baby!!!! So whether you think it is easier having the baby sleep in your bed, you enjoy the cuddling, feel you are nurturing beyond what is expected, or this is a custom you grew up with, bed sharing negatively impacts your health and the health of your loved ones.

Here you have it…..the most important reason we advise against bed sharing.

Anatomy of a Child’s Sleep

Newborns can sleep 16 to 20 hours in a 24-hour period, broken up into 1- to 4-hour sleep periods, followed by 1- to 2-hour awake periods. Newborns cycle through rapid eye movement (REM) and nonREM sleep every 50 minutes, which is a much shorter cycle than the 90 to 110 minutes that older children and adults use to cycle through. Although it is normal to have an arousal at the end of every cycle, such arousals are not always true awakenings. Many parents, however, mistake this behavior as a true awakening. Although most newborns return immediately to sleep, some parents see the arousal and immediately pick up the baby, creating a true awakening. In addition to these normal arousals, REM sleep (also called active sleep in the newborn period) is associated with movements such as smiling, frowning, sucking, limb twitching and occasional “pushing” noises. Because REM sleep can occupy up to 50% of sleep time in newborns, parents may believe mistakenly that their baby never gets any restful sleep.

By 2 months of age, babies already have begun to distinguish between day and night.

By 4 months of age infants generally sleep about 14 to 15 hours in a 24-hour period and many babies begin sleeping through the night (or at least SHOULD begin to do so!!!). Nighttime arousals still occur, normally while cycling through sleep, with cycles now occurring every 90 to 120 minutes. Babies should have the ability to self-soothe through the arousals and return immediately to sleep.

It is estimated that 25% to 50% of 6- to 12-month-olds have problematic night wakings and about 50% have sleep onset or self-soothing difficulties at 12 months of age. So our job is to teach you how to infuse self-soothing habits into your infant and hopefully, minimize those problematic night awakenings.

Some milestones can also disrupt sleep, for example rolling over and pulling to stand. The increased ability to “do things” and move around may make a baby less willing to lie down and go to sleep. By six months of age, separation anxiety or the baby’s desire to continue socializing and be with you may complicate getting a baby to sleep. That is why you see the resistance to go to bed as your child is growing.

Toddlers (12-36 months) sleep about 12 hours in a 24-hour period. Most give up a second nap by 12-18 month and generally nap 1.5 to 3.5 hours once a day. The peak of separation anxiety at 9 to 18 months is often associated with increased night wakings.

Preschoolers (3-5 years) should sleep about 11-12 hours per night. Most of them give up napping by 5 years old.

Common Sleep Problems Parents Encounter

Day Night Reversal: is usually something parents encounter the first few weeks of their infant’s life. Here are some general tips:

1. Feed more frequently during the day and don’t let the interval between a feeding be longer during the day that it is at night.
2. In contrast, at night, if your baby is healthy and your pediatrician tells you it is acceptable to let the baby wake you for feeds at night (rather that you waking the baby every 2-3 hours), it is alright to allow the baby to sleep up to 4-6 hours.
3. When the baby is awake during the day expose her to bright indirect light (7am-3pm)
4. Allow baby to fall asleep in “active/noisy” part of the house during the day. Don’t worry about background noises such as talking, telephones, or music during daylight hours.
5. In contrast, try to make your nighttime interactions calm and quiet
6. Take a more focused approach to your nighttime interactions—limiting them to feeding, burping, changing, and gentle soothing when necessary.

Sleep Onset Association Disorder: Many babies associate certain conditions or objects with falling asleep. For example, a baby may go to sleep in his mother’s arms, while breast/bottle feeding or with his back being rubbed or with a certain degree of light in the room. If that baby’s particular “requirement” is not present during subsequent arousals or awakenings, the baby may be unable to go back to sleep, even if the arousal is one of the normal arousals that occurs through the night. Often, the physical presence of a parent is a baby’s sleep onset association, which can lead to an array of unsatisfactory situations, such as the baby crying until a parent returns, a baby never letting the parent leave the room without crying, the parent beginning to sleep in the baby’s room, or the baby needing to fall asleep in the parent’s bed. It is important in those first few postnatal months to teach the baby self soothing habits.

Difficulty Self-soothing: This is often the most common problem parents encounter and is responsible for many sleepless nights for mom and dad. So, extra time will be spent to cover this topic.

Teaching the infant to fall asleep on her own (self soothing) is a very important behavior that needs to be taught to the infant as soon as possible. The timing of when that needs to happen, however, is slightly controversial as mentioned above. It is traditionally recommended after 4-6 month of age by allowing her to “cry it out” or various other methods. However, a recent study published in the Journal of Pediatrics in July 2010 stated that the sooner (less than 4 months) babies learn self-soothing habits the faster they will master the behavior. This article did not recommend a specific age to start this self-soothing. In my humble opinion the sooner you start, ideally after 4 week of age in a healthy baby who is gaining weight, the easier it is. That does not mean that you should let your 6 weeks old infant cry until he turns blue!!

The following is one method to help infants ease into sleeping a little longer at night starting at 4 weeks of age, published in the Journal of Pediatrics in 1993:

Although you are asked to feed on demand the first few day and weeks of life, start by trying to schedule a feeding between 10pm to midnight. Try to not hold, rock or nurse the baby into sleep. Once you put her down make sure to not pick her up until she is really complaining (crying versus whimpering). The idea is to lengthen the time between the feeding in the middle of night (between midnight and 5am). Once the baby wakes up after the 10pm-midnight feed, if not crying try not to feed her. Most babies move a lot and grumble when asleep or when just awakened. But of course she will eventually start crying and instead of feeding right away try alternative ways to calm the baby like reswaddling, patting, diapering, or even walking the infant instead of feeding. If after these interventions the baby continues to cry then go ahead and feed. The goal is to “stretch” nighttime feeding intervals by breaking the association between awakening at night and being fed. In this 1993 study most of the babies who followed this routine slept through the night by 8 weeks of age. (12am-5am was the definition of sleeping through the night in that study).

Another technique is to set your baby to a consistent schedule as you begin this process starting at about 6-8 weeks of age. For example, if your goal is to try to get your child to sleep at 10pm, try to start a schedule where every night at 9 pm you do the same 2-3 things in the same sequence (e.g. give a bath, read a book, sing a song) then feed your child. As your child gets to the end of the feed and starts to get drowsy, this is the time to put him in the crib and see if he will fall asleep on his own. He will probably cry as he is most likely used to being held, however try to let him cry for 5-10 minutes to see if he is tired enough to fall asleep on his own. If he is still crying after 10 minutes, by all means soothe him and try again with the same schedule the next night. Every time your child DOES fall asleep, he will learn that he is capable and it will be easier the next time. Studies show that by adhering to the same schedule, many babies start to expect the routine and will improve their sleeping patterns.

Others recommend to begin teaching self-soothing habits as soon as the infant remains awake at the end of the last feeding 2 to 3 nights in a row, typically at about 3 months of age:

As soon as the baby’s eyes begin to get “heavy,” lay her in the crib. You can talk to her, sing, or massage her calmly until she is relaxed but not asleep. Then leave the room for 60 seconds, while the infant typically begins to fuss. On return, massage the baby some more, then leave the room for another 60 seconds. This progression continues (2 or 3 times) until the baby “loses it,” at which time you can pick her up and put her to sleep by rocking her or whatever else that works for her. This completes a single “training session.” For the next sleeping cycle you do the same exact thing again but lengthen the time between visits on each successive nights until hopefully after a few weeks (4 to 6 weeks sometimes!), the baby eventually “gets it,” and she falls asleep on her own. Realize we never said this is an easy process, not at all. As a matter of fact it can be very trying. But look at it as an investment. This small investment of time and energy that you are putting into this now will hopefully lay the foundation for successful sleeping habits for years to come. This almost gentler and longer method works best by 6 months of age. After 6 months, it can still be tried, but Doctor Ferber’s original method of allowing infants to cry for progressively longer periods over successive nights (1-2 weeks) is best at that point.

One important warning to mention at this stage is that you need to be PERSISTANT and consistent. Mom and dad (and grandparents/aunties if involved) need to all be on the same page, mentally prepared to do this, and ready to stay with plan until the baby is properly trained. If you give up in the middle after letting your child cry for a while and decide to stop, the next training session will be longer and more difficult. Your baby’s perception will be “ok… the next time, I will need to cry for 18 minutes and beg longer before mammy gives up and picks me up!!!” But once she knows that you mean business and will not give up, she will give in and learn the desired behavior.

Trained Night Feeder: From birth to 2 months of age, most babies normally awaken twice a night for feedings. Between 2 and 3 months, some need a middle- of-the-night feeding. By 4 months of age, about 90% of infants can sleep more than eight consecutive hours without feeding. Here are some tips for those frequent nighttime feeders:

1. Try to increase the daytime feeding intervals to 3 to 4 hours. Nighttime feeding intervals cannot be extended if the daytime intervals remain short. The baby’s stomach is conditioned to expect frequent feedings and complains if they are delayed. Gradually postpone feeding times until they are more normal for the child’s age. Your goal is four meals per day (every 3-4 hours) by 4 months of age. During the day, the infant’s demands for unnecessary feedings can be met with extra holding, attention or a pacifier, although if your baby really seems to be hungry, go ahead and feed him. Feed your child at bedtime, but don’t let him hold or keep the bottle. If he has increased sucking needs offer him a pacifier or help him find his thumb. Discontinue any bottle in bed immediately.
2. Phase out night feedings. Keep in mind that most babies over 4 months old do not need any calories during the night. Once the daytime intervals are more appropriately spaced, nighttime awakening will probably decrease or disappear spontaneously. In the meantime, when your child awakens at night and appears hungry, feed him but leave him slightly hungry. For bottle-fed babies, the amount can be decreased by one ounce every few nights until your infant no longer has a craving for food at night. For breast fed babies, feed him on just one side or decrease latching by 1min every few nights.
3. Start Early. It is never going to be easy and there is no shortcut and “easier” time. The longer you wait to stop night feedings after 4 months of age, the harder it is going to change this habit (and yes, realize it is just a habit!!). With these measures, improvement should occur in about two weeks.

Trained Night Cryer: If your baby does not awaken for food, but still has nighttime crying, respond briefly or not at all. Crying is not harmful and some infants cannot get over this problem without some crying. When your baby awakens and cries, wait at least five minutes before going into the room. Infants should be taught to use their own resources to get back to sleep. If the crying continues, you can go in, but don’t stay long. Act sleepy, whisper “Ssh, be quiet, everyone’s sleeping,” add a few reassuring comments and give some gentle pats. Do not turn the lights on or remove him from the crib. Absolutely avoid rocking or playing with the baby, bringing him to your bed or staying in the room for more than a minute or two. Most young infants will cry for 30-60 minutes and then fall asleep. If the crying persists, you may want to check your baby briefly every 15-20 minutes if you feel it is necessary.

Night Terrors/Night Mares: Occur most frequently in children between 2 to 6 years of age, but can be seen in younger and older children. They are most likely to happen during periods of illness, stress and sleep deprivation, but they can also happen with out any associated stress or any specific reason. The AAP has a great patient handout, which we have placed in our Patient Education section

Sometimes even if parents do everything right, babies still cry at bedtime and wake up sporadically. You should try to be patient and consistent as babies go through bedtime resistance. Babies learn very quickly how to control a situation by crying, and if successful, such learned behaviors are even more difficult to extinguish. Here are some general tips that may help your baby (and you) sleep better at night:

1. Be consistent. Be consistent. Be consistent. It’s extremely important. Make bedtime the same time every night. This helps your child know what to expect and helps him establish healthy sleep patterns.
2. Worsening of the crying behavior is usually seen at the beginning of the treatment. You have to hang in there, be patient and very persistent.
3. Put an Infant to bed when Awake. Many trained night feeders and criers are rarely if ever placed in their cribs awake. If your baby goes to sleep in your arms occasionally, that’s fine, but try to place him in the crib awake for bed- time and all naps. His last memory should be of the crib, not of you or the bottle.
4. Eliminate long and late daytime naps. If your baby has napped for more than 4 hours, awaken him. Ideally, do not allow naps after 6pm, or at least not long ones.
5. Set up a quiet routine before bedtime to help your child understand that it will soon be time to go to sleep. Use this time to read him a story, listen to quiet music, or give him a bath. It may be tempting to play with your child before bed. However, active play may make your child too excited to sleep. Older children should not watch TV, play on the computer or with videogames or handheld devices 1-2 hours before bedtime.
6. Allow your child to take a favorite thing to bed each night. It’s okay to let your child sleep with a teddy bear, special blanket, or some other favorite toy. These often help children fall asleep—especially if they wake up during the night. Make sure the object is safe. Look for ribbons, buttons, or other parts that may be choking hazards. Stuffing or pellets inside stuffed toys can also be dangerous.
7. Make sure your child is comfortable. He may like to have a drink of water, a light left on, or the door left slightly open. Try to handle your child’s needs before bedtime so that he doesn’t use them to avoid going to sleep.
8. Do not return to your child’s room every time he complains or calls out. Instead, try the following:
   • Wait several seconds before answering and make your response time longer each time he calls. This will give him a chance to fall asleep on his own.
   • Reassure your child that you are there. If you need to go into the room, do not turn on the light, play with him, or stay too long.
   • Move farther from your child’s bed every time you go in, until you can reassure him verbally without entering his room.
   • Remind him each time he calls that it’s time to go to sleep.
9. Give it time. Helping your child develop good sleep habits can be a challenge and it is normal to get upset when a child keeps you awake at night. Try to be understanding. A negative response by a parent can sometimes make a sleep problem worse.