Sleep behaviors are culturally determined, and problems tend to be defined as behaviors that vary from accepted customs or norms. In cultures where children sleep separately from their parents in the same house, sleep problems are among the most common that parents and children face.
The supine sleep position is recommended for every sleep period for all infants to reduce the risk of sudden infant death syndrome (SIDS). Prone or side sleep positions place infants at high risk of SIDS, particularly for those who are placed on their side and found on their stomach. See also Prevention of SIDS.
Co-sleeping is when parent and infant sleep in close proximity (on the same surface or different surfaces) so as to be able to see, hear, and/or touch each other. Co-sleeping arrangements can include
Bed-sharing (the infant sleeps on the same surface as the parent)
Room-sharing (the infant sleeps in the same room as the parent in close proximity)
Parent–infant bed-sharing is common but controversial. There are often cultural and personal reasons why parents choose to bed-share, including convenience for feeding, bonding, believing their own vigilance is the only way to keep their infant safe, and believing that bed-sharing allows them to maintain vigilance even while sleeping. However, bed-sharing has been associated with an increased risk of SIDS as well as infant injury or death resulting from suffocation, strangulation, and entrapment.
Room-sharing without bed-sharing allows for close proximity to the infant and for the facilitation of feeding, comforting, and monitoring; is safer than bed-sharing or solitary sleeping (the infant sleeps in a separate room); and is associated with a decreased risk of SIDS. For these reasons, room-sharing without bed-sharing is the recommended sleeping arrangement for parents and infants in the first few months of life.
Infants usually adapt to a day-night sleep schedule between 4 months and 6 months of age. Sleep problems beyond this range take many forms, including difficulty falling asleep at night, frequent nighttime awakening, atypical daytime napping, and dependence on feeding or on being held before being able to go to sleep. These problems are related to parental expectations, the child’s temperament and biologic rhythms, and child–parent interactions.
Factors that influence sleep patterns vary by age. For infants, inborn biologic patterns are central. At 9 months and again around 18 months, sleep disturbances become common because
Separation anxiety develops.
Children can move independently and control their environment.
They may take long late-afternoon naps.
They may become overstimulated while playing before bedtime.
Nightmares tend to become more common.
Partial arousals from sleep are common among all age groups. Infants who are always held and rocked or driven in a car to help them fall asleep will not learn to fall asleep on their own in their typical sleep environment and may develop problems with frequent night awakenings. These problems can be avoided by always placing infants in their crib or bassinet when drowsy but still awake and allowing them to fall asleep on their own. In toddlers and older children, emotional factors and established habits become more important. Stressful events (eg, moving, illness) may cause acute sleep problems in older children.
Evaluation
History
History is focused on the child’s sleeping environment, consistency of bedtime, bedtime routines, and parental expectations. A detailed description of the child’s average day can be useful. The history should probe for stressors in the child’s life, such as difficulties in day care or school, as well as exposure to unsettling television programs and caffeinated beverages (eg, sodas). Reports of inconsistent bedtimes, a noisy or chaotic environment, or frequent attempts by the child to manipulate parents by using sleep behaviors suggest the need for lifestyle changes. Extreme parental frustration suggests tension within the family or parents who are having difficulty being consistent and firm.
A sleep diary compiled over several nights may help identify unusual sleep patterns and sleep disorders (eg, sleepwalking, night terrors).
Careful questioning of older children and adolescents about school, friends, anxieties, depressive symptoms, and overall state of mind often reveals a source of a sleep problem.
Physical examination and testing
Examination and diagnostic testing generally yield little useful information.
Treatment
Options for parents
Measures to help children fall asleep on their own
The clinician’s role in treatment is to present explanations and options to parents, who must implement changes to get the child on an acceptable sleep schedule. Approaches vary with age and circumstances. Infants are often comforted by swaddling, ambient noise, and movement. However, always rocking infants to sleep does not allow them to learn how to fall asleep on their own, which is an important developmental task. As a substitute for rocking, the parent can sit quietly by the crib until the infant falls asleep; the infant eventually learns to be comforted and to fall asleep without being held.
All children awaken during the night, but children who have been taught to fall asleep by themselves usually settle themselves back to sleep. When children cannot get back to sleep, parents can check on them to make sure they are safe and to reassure them, but children should then be allowed to settle themselves back to sleep.
In older children, a period of winding down with quiet activities such as reading at bedtime facilitates sleep. A consistent bedtime is important, and a fixed ritual is helpful for young children. Asking fully verbal children to recount the events of the day often eliminates nightmares and waking. Encouraging exercise in the daytime, avoiding scary television programs and movies, and refusing to allow bedtime to become an element of manipulation can also help prevent sleep problems.
If stressful events are the cause, reassurance and encouragement are always ultimately effective. Allowing children to sleep in their parents’ bed in such instances almost always prolongs rather than resolves the problem.
