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Children often have sleep problems during the first year of life, including trouble getting to sleep, waking up in the middle of the night and having irregular sleep patterns. Remember that there are no definite right or wrong ways to put your child to sleep and that if you and your baby are happy with your current routine then you should stick to it.
However, it is not good if it is a struggle to put your child to bed, if he gets overly frustrated in the process, strongly resists being put to bed or if he is waking up so much that he or other family members end up not getting adequate sleep.
Newborns have irregular sleep patterns, but by two to three months of age, your child should be on a more regular schedule. It is important to provide a consistent routine for your child, including a bedtime routine, which consists of all of the things that you do to help get them ready for bed, and can include quite playtime, a last feeding, reading a book, taking a bath, changing their diaper, etc.
This should also include developing good sleep associations, which are the things that your child associates with falling asleep, including falling asleep alone in their crib. It should not include falling asleep while nursing or drinking a bottle, sucking on a pacifier or being rocked, since if your child wakes up in the night, he will need those same conditions to go back to sleep.
By three months, the majority of babies are able to sleep for most of the night, but may wake up again in the middle of the night. The babies that have developed good sleep associations are able to go right back to sleep, while the ones with the wrong associations cry out. The best way to develop healthy sleeping habits is to have a good bedtime routine and to put your child into their crib while they are drowsy, but still awake, with conditions that they can re-establish for themselves if they wake up in the middle of the night.
To make this easier you may give your child a special stuffed animal, toy or blanket, or help them find their fingers to suck on when you put them to bed. Try to incorporate this 'transitional object' into the bedtime routine (for example, have them hold their blanket while you are reading to them before bed). Avoid letting your child fall asleep with a bottle, since the milk or juice will coat their teeth all night and promote cavities or using a pacifier at bedtime, since if it falls out while they are sleeping, when they wake up they will cry out until it is replaced. The biggest mistake that most parents make is allowing themselves to become the 'transitional object' with which child has learned to fall asleep.
If your baby has not learned the proper sleep associations by the time he is five to six months old and he is waking up one or more times during the night, there are ways to help your child learn to sleep through the night. The most popular method is that taught by Dr. Richard Ferber, which advocates that at bedtime you put your child in his bed while they are drowsy, but still awake, and help them learn how to fall asleep on their own.
It is recommended that you start the training at a time when you can afford to lose some sleep for up to a week and that you be consistent during this time. If at any time during the training you give in and let your child fall asleep in your bed or while drinking a bottle, then you may have to start all over. Most children show improvement in a few days, and will be sleeping through the night in a week or two.
To begin, you will need to develop a bedtime routine that will end with you placing your child in his bed to fall asleep on his own (with his transition object). The Ferber method is a 'progressive approach' in which you allow your child to 'cry for gradually longer periods of time before returning to him briefly.' The first night, after placing your child in bed to fall asleep alone, you should leave the room and allow him to cry for about five minutes.
If he is still crying after that time, you can return to his room to reassure him that you are still there. You can speak to him briefly and pat his back a few times, but avoid picking up or rocking your child. After two or three minutes you are to leave the room again (even if he is still crying). If your child continues to cry now for ten minutes, you can again return to his room briefly for reassurance, but be sure to leave after two or three minutes. If she is still crying after fifteen minutes you can return again, and the rest of the night wait for a maximum of fifteen minutes. Your child will probably fall asleep during one of these fifteen-minute periods.
If your child wakes up again during that first night, you can use the same method of letting him cry for five, ten, and then fifteen minutes. The next night you will start off by waiting for ten minutes and increasing by five-minute intervals to a maximum of twenty minutes. Each night, you will increase the 'First Wait' by five minutes. For example:
First Wait
Second Wait
Third Wait
Subsequent Waits
It is important to realize that you are not hurting your child by letting him cry and that this method is much easier on him than a 'cold turkey' method. The first few nights may be difficult, but your child will eventually learn that it isn't worth crying for twenty to thirty minutes if the only reward is that you are coming in for a few minutes. He will quickly learn to fall asleep on his own, which is an important step in his development.
Preschool Children
Preschool age children may have sleep problems, including trouble getting to sleep, frequent night waking in the middle of the night and having irregular sleep patterns. Remember that there are no definite right or wrong ways to put your child to sleep and that if you and your child are happy with your current routine then you should stick to it. However, it is not good if it is a struggle to put your child to bed, if she gets overly frustrated in the process, strongly resists being put to bed or if she is waking up so much that she or other family members end up not getting adequate sleep.
To help prevent problems at bedtime you should develop a bedtime routine that you follow closely each night. This routine can include taking a bath, brushing her teeth, saying prayers, talking, and reading a book. A good way to end the routine is to read a book or story after your child is tucked into bed. You can warn her that bedtime is near after the story is finished and then end the routine by turning the light off and saying goodnight. Remind her that she is not allowed to leave her bed until morning. Ignore any further requests or questions.
Once your child has been put to bed, you should be strict about the rule of not leaving the bedroom. If she does get up and comes out, quickly return her to her room and remind her that she has to sleep in her own bed. Ignore all protests or requests and keep your interactions with her to a minimum (no bedtime hug or kiss this time). If she continues to leave the room you can warn her that you will have to close the door.
You should follow up on this warning if she keeps leaving the room. You can stand outside the door and let her know that you will open the door again if she gets back in bed and stays there. You should also consider closing the bedroom door if she continues to cry or protest going back to bed. Again, let her know that you will open it again if she quietly goes back to bed. You may need to lock the door if she is able to open the door and continues to come out. This is a necessary step to make sure that your child does not hurt herself while she is awake and able to wander around the house.
While the first few nights of this treatment may be difficult and your child will probably cry and protest, she will quickly learn how to fall asleep on her own and sleep through the night. Other steps you can take to help with this process is to cut back on daytime sleeping and consider a later bedtime, since your child is less likely to protest or repeatedly wake up if she is very tired. And remember to praise your child when she does sleep through the night, stays in her own room or goes to bed without protesting.
You should not feel guilty about letting your child cry or locking their bedroom door. Children usually have bedtime problems because they are trying to test your limits or because of poor sleep habits. Rarely are these problems caused by real fears, but you should comfort and reassure your child if she is truly afraid.
School Age Children
Sleep problems at this age usually involve having a late sleep phase. School age children will sometimes stay up very late on the weekends and then sleep in the next day, sometimes until noon. This carries over into the school week and can causes difficulty falling asleep at a proper time on school nights. One way to prevent this is to encourage a routine of falling asleep and waking up at about the same time each day.
Treatment of a late sleep phase, it is sometimes necessary to allow your child to stay up until the time that she commonly falls asleep and insisting on a regular morning wake up time to get ready for school. After a few weeks, you can gradually make the time that she goes to sleep a little earlier. You can gradually move her to a more regular sleep cycle.
Other Sleep Problems
Like adults, children have dreams when they are in REM sleep. This occurs 4-5 times each night, and while most dreams aren't remembered, some are frightening enough to wake the child and make them summon their parents. Nightmares usually begin when a child is about three years old, they are most common between the ages of three and eight (when their fantasy life is more active) and they are most likely to occur later in the night. Unlike night terrors, your child will be wide-awake and responsive after the nightmare and she may be able to recall the details of the nightmare the next morning.
While an occasional nightmare is normal, an increase in the number of nightmares can be a response to stress or your child being anxious about something. Other triggers can be a change in her normal routine, like moving, starting a new school, or a death in the family. Or the nightmares may be a response to a violent or scary movie, television show or story.
When your child has an occasional nightmare, you should reassure her that it was just a dream and isn't real. Give her lots of hugs and be supportive. You may need to search her room with her to reassure her that their aren't any monsters or whatever the nightmare was about. It is probably best to wait until the next morning to really talk about the details of the dream, at which time she should be calmer. And try to figure out if there was a specific event or stressor that may have triggered the nightmares. Did she see a television show or movie or read a story in which this may have occurred? Have you recently moved or had another big change in your home situation? Is she on any new medications that may be affecting her sleep?
Tips to decrease nightmares include:
Decreasing stress in her life.
Avoid television at least an hour before bedtime.
Avoid telling her scary bedtime stories.
Let her sleep with a night light.
Talk about the nightmare the next day. Suggest that she draw a picture of the dream to help her talk about it.
While an occasional nightmare is normal, you should seek professional help if the nightmares are also associated with changes in her daytime personality or behavior. If she is under a lot of stress or seems very anxious and the nightmares are increasing, then she may need professional counseling. Otherwise, with a lot of reassurance, she should outgrow them.
Night Terrors
Night terrors are more frightening for parents, but can also be normal. They usually occur a few hours after your child has gone to sleep, at which time you may wake up to your child's crying or screaming. When you go to him, he will NOT be alert and won't recognize you, even though he may seem like he is awake. He will usually seem like he is terrified and may have a rapid heart beat and rapid breathing. Night terrors occur as your child moves through different stages of sleep and they represent a partial awakening. Since your child isn't really awake, there is nothing that you can do to reassure him. You should see that he is safe and do not try to wake him up. He will usually settle himself down after a few minutes.
Sleepwalking is similar to night terrors, in that they represent a partial awakening. They also occur a few hours after your child goes to sleep. Although your child may be walking around the house, he is not awake and isn't aware of what he is doing. It is not necessary to wake a child up that is sleepwalking. Instead, you should just make sure that he can't hurt himself and maybe return him to bed. If sleepwalking occurs often and you are worried about your child's safety, you can try and wake him up yourself, before the time that he typically wakes up. This treatment can disrupt the cycle and decrease his sleepwalking.
Some children grind or clench their teeth while sleeping. This is called bruxism and is usually not a concern, unless it is leading to damage of his teeth. Children with bruxism should be evaluated by a pediatric dentist, who may recommend a plastic mouth guard to prevent damage.
"Common Sleep Problems" is adapted from materials © 2001 by KeepKidsHealthy, LLC and Dr. Vincent Ianelli, and is reprinted here by permission of the author. Dr. Ianelli's health website, KeepKidsHealthy.com offers information about all aspects of health for children from newborns to adolescents. For information on pediatric health issues, visit www.keepkidshealthy.com .
Vincent R. Iannelli, MD, FAAP is a board certified Pediatrician in Dallas, Texas. He is a member of the Dallas County Medical Society, Texas Medical Association and is a Fellow of the American Academy of Pediatrics. In addition to having a Pediatrics practice in a suburb of Dallas, he is currently an Associate Professor of Pediatrics at the UT Southwestern Medical School. Dr. Iannelli's current practice is located at:
Lake Ray Hubbard Pediatrics 6900 Scenic Drive Suite #102 Rowlett, Texas 75088.