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Sleep Problems in Children

REM sleep is dream sleep, and patients generally have some loss of muscle activity. Be aware that you donít necessarily lose all muscle tone. Kids can twitch a little bit during REM. They are not perfectly motionless, but they generally donít get up and move around. Itís an active physiologic state. Their heart rate is up, their respiratory rate is up, those are the EEG findings. Infants actually spend about 50% of their time in REM sleep, whereas those of us as adults spend about 25% of time. So the older you get, the more REM sleep develops. The key thing we will talk about with sleep disorders is most of REM sleep occurs in the second half of the night. You go through stage IV sleep for the first three to four hours, then you pop up into brief REM, drop down to stage IV, pop back up and as you keep popping up your REM stages get longer and longer.

Normal sleep patterns. Newborns sleep up to 16 hours per day. Average adolescent is down to 8-9 hours per day, and that gives you some of the range. The longest sleep period; by two-months-of -age, children start to sleep longest at night. Remember, as pediatricians we all know, in the first couple of weeks of life they are up more during the night than they are during the day. Generally at two-months-of-age there is about a 4-6 hour stretch.

In terms of naps, naps generally beyond about four months thereís usually about three naps; thereís usually an early morning nap, an early afternoon nap and one right around dinner time, or before dinner. At 15-months-of-age half the kids are only taking one nap, and half are taking two naps. By two-years-of-age almost all kids - or most kids - are down to one nap.

Okay, letís talk about some sleep problems. Night awakening in infants. Learned sleep associations. These are the kids who wake up at night and canít put themselves back to sleep. They canít handle the normal arousals from REM sleep. And why does that occur? Because you as the good parent are trying to help them go back to sleep and you are doing something that they have become dependent on. So either they need to nurse at the breast, or they need to suck at a bottle, or they need to be held. Those are the cues that they need to fall asleep.

What do we do with it? There are a couple of approaches. Ignoring is basically the cold-turkey approach. You know, heíll grow out of it, give him a few days. Very few parents can do that. But it does work. Graduated extinction is the fancy way of describing the Ferber technique that I think most of you guys are familiar with. The idea of; let them cry for a few minutes, go in, try to calm him down very briefly for maybe a minute. Wait another five or ten minutes.

Scheduled awakenings is something you guys may not have heard about. This is an interesting approach. What you basically do is you go in, if your child always wakes you up at three in the morning, then you wake up at 2:45 and go in and wake the child up. And you get your revenge. And you get him to where heís awake and you keep him awake for.

Separation anxiety or fear. This is why kids who are sleeping at six-months-of-age start waking again at nine or ten-months-of-age because at nine or ten-months-of-age they wake up and now instead of just rolling over, they have the ability to climb and get up to the crib rail and, "Oh, man, momís not here" so now they are scared. So that can happen, and illness and pain.

Preschoolers; we all know why preschoolers donít want to go to bed, right? They are afraid they are going to miss out on something fun. They hear you out there with the TV or the older children having fun and they know they are missing out on it. What are things that you need to know about it? Environmental problems. Is there a night light? Is there too much light? Is there too much noise? Are they hearing the TV? Are they hearing the other kids? Inconsistent bedtime.

Inappropriately timed naps; when you take a good sleep history and you are trying to find out why this child not going to sleep at 8 oíclock when I put him down. You need to ask, "What time do you put him down, what time does he eventually fall asleep? What time does he wake in the middle of the night? What do you do to put him back to sleep?

Problems with limit setting; this is the typical, "Daddy, I need some water. Daddy Iím cold. Daddy I want to give you another hug" and it goes on and on for an hour or two.

Delayed sleep phase; this is a real easy one to pick up on. These are kids whose clock is just off compared to mom and dad. So mom wants him to go to sleep at eight but he really doesnít fall asleep until about nine or nine-thirty, and yet when mom tries to wake him up at eight in the morning heís really hard to get out of bed. Because he has shifted. The key to the diagnosis is, if you keep doing whatever your child keeps wanting you to do - you give him extra water and you go in and give him a hug and all that stuff - what time does he always fall asleep? Does he always fall asleep at 9 oíclock regardless of what you do? Do you have trouble waking him up in the morning? That means that heís shifted and thatís how you make that diagnosis.

Nighttime fears can certainly be a problem, and then some kids just donít need to sleep as long as others. You canít force a kid to sleep.

Real quickly with delayed sleep phase. If they ask you about treatment, how do you change that? If youíve got a child who wants to go to sleep at 9 oíclock and sleep late, what can you do? Well, you canít make a child sleep but you can wake him up. So what you do is start waking him up 15 minutes earlier every day. And after a few days he is going to get a little tired. Instead of falling asleep at 9 or 9:30, heíll fall asleep at 8:45. A few days later, 8:30 and you can gradually get them back. The flip side is you have to be willing to have a child waking up a little earlier in the morning.

Okay, night terrors and nightmares. They will probably ask you a question on this. Itís easy to test and itís pretty easy for you guys to answer it. It should be a gimme. Night terrors occur as partial arousals during non-REM sleep. So they occur in the first two to three to four hours after you fall asleep. They donít occur in the middle of the night.

Anything that kind of wears the child down will precipitate the terrors. So if your child didnít get a nap that day, he might have a night terror that night. If the child is a little bit sick, if the child is stressed out for some reason. Thereís a lot of different things you can do. Most of the time we tell the parents to just watch the child to make sure they are okay. Sit in the corner of the room, donít try to wake them up and they will fall back asleep. Most of them last about 10-20 minutes and then the kid falls back to sleep. They can be associated with sleepwalking.

Sleepwalking, somnambulism, occurs during the same stage. This is during non-REM sleep. Itís part of a partial wakening. You are not fully awake when you are sleep walking. It begins in about four to eight-years-of-age. This actually often goes on for a long, long period of time. Most night terrors kind of go away by about five or six-years-of-age, but sleepwalking often goes on. And you can walk out of the room, you can do semi-purposeful activities, you can eat, you can get food out of the refrigerator.

Sleep talking. A lot of you guys may do this, itís normal. It can occur at any stage of sleep. Itís real common in five or six-year-olds. Itís not always coherent. You donít always really understand what they are saying. The key thing is you may see sleep talking during night terrors or confusional arousal. Those kids will sometimes vocalize in the connection and that can actually make it more frightening for the parents.

Grinding the teeth. This is not just a little bit. This is the type that wakes you up and makes you go sleep in the other room. We are talking about big-time teeth grinding. It runs in families. Any stage of sleep, and pretty much the dentist is the one that deals with this depending on the amount of wear and tear on the teeth. Like most other parasomnias itís increased with stress as well.

Sleep starts. These are the little jerks that you do as you start to fall asleep. I remember being in a lecture hall in medical school, and you jerk and there goes your pen. It rolls all the way down to the front of the room. Everybody looks at you and knows that you fell asleep. It occurs in the transition from awake to asleep, and adults and actually older kids sometimes get the sensation of falling or bright light.

Rhythmic movement disorder. These can really freak parents out. This is the head-banging, the rolling, the thumping. Kids do this at the time they are transitioning from awake to asleep. Sometimes they will hum while they are sitting there rocking back and forth and it really freaks the parents out.