The world of childhood sleep
By Charles Downey

Healthy child development requires sufficient slumber. So, when a young child fails to fall asleep at an appropriate hour, both parents and child suffer.

Ideally, it starts with a yawn and maybe a story somewhere in the early evening. But all too often, it progresses through successive glasses of water, a cracker or other small snack, perhaps another story, some prayers, more kisses for mom, dad, grandmother, grandfather, and even the pets. Yet more water and two or three suddenly remembered anecdotes from a busy day.

Bedside lamps, night-lights, and hallway lights are turned off and on so much they blink like Christmas tree decorations. The bedroom is alternately too hot, too cold, too stuffy and too filled with scary monsters lurking in closets and under beds. The bedroom door is opened and shut more times than an exit door on a rush-hour bus.

Around 10 p.m. or 10:30 or even 11:00, tempers of busy working parents start to fray, and anger becomes apparent. Adult voices rise while tears well up in little eyes.

It's bedtime for young children
Many paediatricians report the number one complaint among parents and caretakers of five-year-old children is bedtime and its associated rigors. Yet you really can't blame the kids’ life is new and exciting and young children just don't want to face sleep.

Experts say five-year-olds are at their manipulative, pleading best when finding ways to stay up late, past their normal bedtimes.

In one case, a five-year-old created an elaborate bedtime ritual that involved a ride on a lake in a motorboat. The child would only fall asleep amidst the roar of the speeding boat and was then carried back onto the dock, into the family bus, back home, out of the car and, finally, into his own bed and deeper into the land of nod.

Why fight it? Is sleep that important?
However they get them, Sleep is absolutely necessary for healthy young development.

One recent study of sleep-deprived persons revealed that the body's immune defences reduce after lost sleep. The good news is that a sound night's sleep restores those cells to their former levels of effectiveness.

Researchers think that sleep, like fever, may represent a basic defence mechanism in our bodies. Alice Carskadon, PhD, a sleep researcher nd professor at Brown University in Providence, Rhode Island, studied 39 slumbering children. She found that kids with poor sleep quality had higher levels of depression, hopelessness, and low self-esteem.

Other sleep researchers have linked a lack of sleep in young children to a whole host of daytime woes, including hyperactivity, behaviour problems, learning difficulties, and that dreaded condition feared by all parents: the cranky child.

Because many parents work and the whole household rise early, bedtime is more important than ever. "To get kids to go to bed on time, the caregiver must be consistent," says Arthur Maron, MD, paediatrician and chairman of graduate medical education at St. Barnabas Medical Centre in Livingston, New Jersey. "Children must know that tonight, and tomorrow night, and the night after that, bedtime is always 8:00 p.m."

Make use of transitional time
Experts recommend using "transitional time." Quiet, low-key activities such as bedtime stories, prayers, singing, warm baths, cuddling, and quiet talk make for good transitional time. Many children have a favourite teddy bear or toy they associate with bedtime each night. Wrestling and other roughhousing, exciting videos or shoot-'em-up television shows just before bed should be discouraged.
"Too often, children think of a parent as a 'sleep assistant,'" says Donald Shifrin, MD, associate clinical professor of paediatrics at the University of Washington in Seattle, Washington. "If you develop a bad habit like lying down with the child to get him to sleep, it will be a requirement from then on. Every time that child wakes, he expects to see mom or dad there with him."

Instead, parents should think of themselves as "drowsy assistants" who help set the mood for a good night's sleep. The American Academy of Paediatrics recommends waiting several moments when a child calls out from bed. The idea? Give the child a chance to fall asleep on her own each time she calls out. Then, stop farther from the child's bed every time you go to her room. Soon, you can just answer from an adjoining room.

Other items that can interfere with childhood sleep are a new sibling, a new teacher or school, fights between parents, or a divorce or a death in the family. The average five-year-old needs about 11 hours of sleep daily, several hours of which can be spent napping.

Remember the motorboat boy? It's a perfect scenario of what not to do. Eventually, a kindly paediatrician showed the wind-blown parents a better way.
"Establish a bedtime routine when the child is an infant and stick to it," says Dr. Shifrin. "It's far easier to deal with a little fussiness now than a power tantrum later. And, don't use television as a transitional device. For young children, T.V. should be a daytime thing."

Jimmy wants to sleep with us. Is that okay?
Another destroyer of restful childhood sleep is something scientists refer to as "co-sleeping." That's when young children make a habit of crawling into bed with mom and dad in the wee hours.

One study has approved of an occasional (once a month or so) session of bed sharing. But children who get into the habit of sleeping with their parents may suffer chronic sleep problems and attendant daytime woes. The Co-sleeping study of 303 families was first reported in 1990 at the University of Massachusetts Medical School in Worcester, Massachusetts. Young children who routinely slept with their parents more than once a week proved 10 times more likely to dislike sleeping alone and up to four times more likely to resist going to bed. The study suggests that habitual bed sharing makes it more difficult for a child to get a full night's sleep.
"Co-sleeping is a hard habit to break once parents start," says Deborah Madansky, MD, paediatrician and study co-author. "Many children who sleep with their parents are restless and tired during the day."

Is my child's snoring normal?
To get children to sleep solo, experts say to offer a morning reward when the child spends the night in his or her own bed. Once a child does sleep alone, caregivers should hear no snoring or other wheezing sounds at night.

"Too many people believe snoring is normal," says Dr. Rafael Pelayo, MD, head of the Paediatric Sleep Disorders Clinic at Stanford University Hospital in Stanford, California. "Actually, snoring is a problem of blocked breathing and can be cured by removing the child's tonsils and adenoids."

If a child is not breathing properly, he or she will tend to be underweight and may have behaviour problems during the day. "When I find a five-year-old with night breathing problems, it's because the parents have brought the child in due to misbehaviour problems at school," says Dr. Pelayo. "A child who does not get enough sleep will spend his days fidgeting, doodling, teasing other children and not paying attention in school. Sometimes these children are mislabelled with attention deficit disorder problems."

Many snoring children are also bed-wetters. Nights become dryer, though, when the snoring is stilled. Snoring youngsters may also sweat profusely at night and be underweight because the breathing obstructions force them to expend far more calories. They usually gain weight after the tonsillectomy. Moreover, a child's growth hormone is secreted at night, so anything that disrupts sleep also interferes with proper growth.

Keep a sleep diary
If you think your child may have a sleep problem, the American Academy of Paediatrics recommends keeping a sleep diary. Adds Ray Coleman, MD, a Washington, D.C. expert on child sleep: "Record for the doctor where the child sleeps, what time he was put to bed, how long it takes him to fall asleep, the time he gets up in the morning, the time and length of naps, if he woke up at night, what you did to comfort him, changes or stressful events in the home and even the time the caretakers went to bed."

Also, consider what happens during the day. Does the child get a lot of daytime sleep? Is he over stimulated by watching too much television or playing too many video games?

With over stimulation and other factors in check, bedtime does not have to be the day's most difficult event. And there's certainly no need to rush out and buy a speedboat to lull a young child to sleep.

Resources
"Co-sleeping in a Community Sample of Two and Three Year Old Children," by D. Madansky, et al. al. Pediatrics, Vol. 86, No. 2, August, 1990, pp. 197-203.

"Naps in Children: Six months to Seven Years," by Marc Weissbluth. An excerpt from Sleep: The American Sleep Disorders Association and Sleep Research Society. To order reprints, contact Marc Weissbluth, MD, 680 North Lake Shore Drive, Suite 123, Chicago, IL 60611.

"Sleep Problems in Children: Guidelines for Parents" is a brochure available from the American Academy of Pediatrics, Division of Publications, 141 Northwest Point Blvd., P.O. Box 927, Elk Grove, IL 60009-0927.

"Parent/Child Sleep Guide" and "Sleep Tips for Teens" brochures are available by sending a self-addressed stamped envelope to The Better Sleep Council, PO Box 1953, Alexandria, VA 22320-0534.

The National Sleep Foundation
American Academy of Pediatrics