Ask the Pediatrician: Dr. Molly

Category: Sleep

Sleep solutions for school-aged kids

How much sleep do kids need? About a third of our lives are spent asleep and the amount and quality of that sleep is essential to a sense of well being, immune system function and school and sports performance.

Whenever I do a checkup I talk about sleep. There are lots of barriers to good sleep including homework, TV, texting, chatting, after school and evening activities and video games. Others kids have difficulty falling asleep, snoring, frequent night waking and lack of a nighttime routine with a consistent bedtime.

Kids aged 6-9 need about 10 hours of sleep, children 10-12 need on average a little more than nine hours each night and teenagers need about eight-nine and a half hours of good quality sleep to ensure a sharp mind and healthy body. Not all kids fit these guidelines but most do and it is a good place to start.

Children and teens who routinely get fewer hours of sleep than they need may appear unfocused or hyper, have difficulty focusing in school and/or have periods of excessive sleepiness during the day. Many kids who aren't getting enough sleep will have more illnesses than their healthy sleeping peers and are more likely to be overweight because sleep deprivation results in carbohydrate cravings. So there are many good reasons to encourage healthy sleep.

Here are strategies to help your child get the sleep he needs:

Make sure all media (TVs, phones, computers, iPods, etc.) are off about a half hour before bedtime. Try to have the same bedtime each night with minor variations when needed and keep the wakeup times about the same, too, which will create a rhythm in the body to ready it for sleep naturally. Some kids benefit from light reading or listening to instrumental music as they wind down to go to sleep. Even relaxation techniques can be helpful. Recent data suggests online cognitive behavioral therapy when used in adults can work almost as well as medication at improving symptoms of insomnia.

Some kids will still have trouble falling asleep at an appropriate time despite these things and as such may benefit from a natural product called melatonin. Prepubertal kids can take 1-3 mg and while teenagers will need the whole 3 mg. Melatonin is great because it is natural and doesn't act the way a sleeping pill would. It merely sends the message to the brain that it is time to release the hormone that quiets the body and brain and readies it for sleep. It cannot be addictive nor can you develop a dependency on it. It doesn't change your sleep cycles and as such you wake as refreshed as you always would.

Some kids don't have trouble falling asleep, but have trouble staying asleep either because they are snoring and having intermittent waking as a result, are over-caffeinated or are having emotional issues that are impairing sleep. When snoring is the cause, seeing an Ear, Nose and Throat specialist for evaluation is very important. Removing tonsils and adenoids when needed can result in dramatic changes in behavior, school performance and even eliminate bed wetting for some kids. For those kids with frequent waking due to stress, depression or emotional challenges, addressing these head-on can often have significant improvements in sleep quality relatively quickly.

It may be that with some minor adjustments the eight or more hours of sleep your child needs is within your grasp.

Category: Sleep

Night terrors frightening for parents, but common and managable

Your little angel finally went to sleep at 8 o'clock after a long and busy day. Then a few hours later as you are dragging yourself up the stairs to bed you hear your child moaning and wailing. You rush to the crib or bedside and find your child wide-eyed, often sweating and utterly inconsolable. The older the child is, the more words the moaning and wailing will have in it. Your child is thrashing and upset and even when you turn on the lights and speak loudly you cannot seem to stop this "bad dream." The episode lasts 10-20 minutes, then ends with a whimper and your child returns to sleep. You are worried and exhausted and lay awake for an hour or so before you are able to relax and fall asleep.

This child has had a night terror. Night terrors are different than nightmares. Night terrors occur in the first few hours after the child has fallen asleep whereas nightmares usually occur after midnight. Night terrors are not remembered in the morning and the child seems completely normal the next day, whereas nightmares can often leave the child apparently poorly rested and perhaps a bit anxious.

Night terrors occur as a result of disordered sleep. Sleep usually happens in a very predictable way, progressing from stage 1 to REM sleep in a very orderly fashion. When this goes awry, sleep walking, sleep talking or night terrors can occur. Because kids are so unresponsive to consoling or waking during these episodes while they are thrashing about, sweating, wide-eyed, screaming, moaning or talking incoherently, parents often worry that the child is having a seizure. Luckily this is not the case!

Children often have night terrors (or sleep walk or sleep talk) when they are overtired. One way to manage them if this is occurring frequently is to make sure your child gets more sleep. Because this is disordered sleep, when you are overtired, your brain tries to fast forward through some of the early stages to get to the restful stages. In doing so, sometimes the transitions don't go smoothly and this odd combo of being apparently awake while asleep occurs.

Another way to manage night terrors is to try to reset the sleep cycles by actually awakening the child about 45-90 minutes after falling asleep. In doing so, you short circuit this rapid progression through the sleep cycles and the night terrors are much less likely to occur.

However frightening to witness, night terrors are harmless but do indicate the child is in need of more sleep. Adjust his bedtime or awaken him soon after falling asleep and night terrors can largely be avoided.

Category: Sleep

Change summer sleep routines before school starts

Most children and teenagers have a more relaxed schedule in the summer, getting to stay up and wake up a bit later, but in general still get the nine-10 hours of sleep every school-aged child and adolescent needs. Some teens are staying up routinely until 1 a.m., but try to get those same kids out of bed by 10 a.m. and you are in trouble! How then do you help kids get ready for the very early mornings to come just after Labor Day?

Step 1: Start now! Starting well before the first day of school will allow your child or teen to re-establish the pattern of earlier to bed and earlier to rise and make up for any sleep deprivation that will occur during the transition. It will take a week or so to make the switch.

Step 2: Start waking up your child at the target time for school. In other words, no matter what time your child goes to sleep, make sure that if he needs to be up by 6:30 a.m. to get ready for school next week you start getting him up at 6:30 now.

Step 3: Don't allow your child or teenager to nap during the day! By waking them up earlier and not allowing them to nap, they will develop a sleep debt (and some crankiness, too!) and that will encourage early sleep times in the evening.

Step 4: After about four-five days of earlier mornings, set the school bedtime again and make sure lights are out and all TV, games, texting, computer time and even intense reading ends at least 30-60 minutes before this bedtime.

Sounds easy, huh? In reality, you will have to put up with the arguments, crankiness and complaining from your child as you implement the plan.

Even if you stick to your guns, some kids will still have a hard time making the switch. For these kids, a couple of other things can be tried. First, make sure you have a routine that leads up to bedtime. This is easier with younger school-aged kids. For teenagers, have all electronics off an hour ahead of bedtime, encourage a shower or bath to calm and ready the body for sleep and if this still isn't enough, relaxation techniques like progressive relaxation and toe tensing can help.

Teenagers present special challenges when it comes to switching the sleep schedule. It is no coincidence teens stay up really late and prefer to sleep in. Their bodies are designed to do this during the adolescent years in part because of a delay in the release of melatonin in their bodies. Melatonin is a substance that relaxes the body and prepares the mind for sleep. The good news is that melatonin is available as a natural supplement and when given to teenagers about 30 minutes before the desired sleep time works quite well to allow them to fall asleep easily.

Between changing wakeup times, discouraging naps, encouraging healthy bedtimes and sometimes using relaxation techniques or melatonin, all kids can be bright eyed and bushy tailed for the first day of school.

Category: Sleep

Get your baby to sleep through the night

I get asked every single day about babies who don't sleep well. Some won't fall asleep without their parents holding them, others wake up several times per night wanting to eat, have their pacifiers replaced or be held again to fall asleep.

Of course, because the wakings occur at the time of day when we are least patient, parents often do whatever it takes to get their child back to sleep quickly so they can return to bed, too.

These parents seem like they are just striving to meet their child's needs when in many ways, they are meeting their need to return to sleep quickly and not hear their child cry. Some parents may do these same things when their child awakens during the night, but it is part of an overall approach called attachment parenting whereby the child's needs are primary and met. As a part of this approach, if infants have difficulty sleeping independently, parents would hold, rock or sleep with the baby.

Parents need to approach sleep as they would other challenges, by understanding their own style (e.g., routinized vs. on-demand feeding, traditional vs. attachment parenting) and by doing so, parents will have a better sense of which of many "right" approaches work for them.

Here are some approaches to encourage good sleep for more traditional parenting:

Understanding normal sleep in infants along with normal developmental changes can help parents know what to expect, anticipate changes in sleep due to normal developmental stages and respond in a way that will encourage good sleep for their baby.

Infants need a ton of sleep to grow and develop normally. If babies are deprived of normal sleep, they may gain weight more slowly and may not achieve the normal developmental milestones on time. Through the first six months of life, infants need 14.5-16 hours of sleep per 24-hour cycle. What changes the most during this time is the distribution of sleep between night and day. As every parent knows, newborns sleep all day and are awake all night, but by a month or so, babies are about 50-50 when it comes to daytime and nighttime sleep. By two months, most babies can sleep one five- to six-hour stretch at night and will add an hour to that stretch about every month until they are sleeping through the night.

During these first six months, parents have the opportunity to help their baby develop good sleep habits. Schedules are a good thing for infants. Scheduling feedings every three hours or so throughout the day helps a baby organize her eat-sleep cycles and encourages earlier prolonged nighttime sleep. Some infants will sleep easily and without much assistance from day one but most will need to learn how to fall asleep on their own. The first couple of months are difficult enough for baby and parents that I usually tell parents to do what feels right to them, especially if it is their first child.

At the 2-month well visit, if an infant is still up multiple times during the night to eat, I encourage parents to recognize that feeding that often shouldn't be needed at this age and let the baby drop one of those feedings to encourage the five-six hour stretch she is capable of at night. The parents inevitably ask how to go about dropping the feeding? My answer: let the baby cry through the feeding and go back to sleep on her own. How long to let her cry? My answer is always the same: as long as it takes her to fall asleep or until the next feeding. Stunned, parents will ask, "Won't this harm her, cause her not to trust or have psychological damage?" Because infants' needs are met and are loved and interacted with throughout the day, letting the baby cry through a feeding to learn to sleep longer will not harm the child.

No one likes to have their child uncomfortable, but there are times when this is necessary. When the crying or discomfort is needed to encourage normal developmental progress, it is acceptable. When the crying is not going to result in any good as it were, tending immediately to the infant's needs is paramount. With loving support and consistency in meeting an infant's needs, no harm will be done by allowing him to cry - and there is data to support that.

Between 6 and 12 months old, babies start consolidating their short cat naps into two longer daytime naps. They have often just started sleeping through the night for the last month or two. Even though their daytime sleep gets better, often their nighttime sleep gets worse again.

Babies this age are undergoing many changes They are teething, learning to sit alone, crawl and sometimes even pull to stand. They are learning to communicate with sounds and nonverbal cues. They are getting wary of strangers and beginning to understand that just because you can't be seen, that you do exist. At the same time, their diets are broadening to include much more solid foods. All of these changes can disrupt sleep.

All of us awaken several times each night and successfully put ourselves back to sleep. Infants awaken, too, and often will miss you in the middle of the night. The first night or two you won't know whether your baby is sick or hurt, so you naturally go in to check on him. If your baby is fine throughout the day, these night wakings are not due to teething or hunger and you should ignore these wakings as much as possible. Don't feed or pick up your baby or even go in the room and your child will in two or three nights return to sleeping through the night.

By knowing what to expect, you can avoid having your child awaken several times each night needing your attention, allow your child to get the long stretches of sleep needed for normal growth and development - and even get a good night's sleep yourself. It's not easy to listen to your child cry, but it is short-term pain for long-term gain - for parent and child alike.

Category: Sleep

With infant deaths up sharply, know good co-sleeping habits

Rates of sudden infant death from suffocation or strangulation have increased four-fold over the past 20 years, most apparently from parents sleeping with their babies, a recent study by the Centers for Disease Control and Prevention found.

Parents are often reluctant to tell their doctors they are sharing a bed with their children. I get that. Most doctors will discuss the risks with you and a few will even give you a little lecture about the potential harm. Some will even go so far as to try to scare the living daylights out of you and tell you that your child will never be independent and you are not only spoiling your child but harming him, too.

I don't agree. Each family needs to make decisions about sleeping with their children that reflect their needs and values. Of course, understanding the risks and ways to diminish them is essential in making the decision. I am not necessarily advocating co-sleeping, but I feel strongly that if families are opting to do it occasionally, often or always, it is important for your pediatrician to know so you can have the information and support you need to decide if this is right for you and do it safely.

Some families are co-sleeping by default: perhaps a habit began when a child was sick and parents don't know how to undo it. In that situation, pediatricians have a lot of different strategies to offer to help families make the transition back to sleeping independently. Some families are co-sleeping by design and they need support and information, too. So here's the information:

Many of the deaths in the CDC study were related to co-sleeping. Because most parents will sleep with an infant or young child at least once during their life as a parent, reviewing how to do it with the least amount of risk is timely. Next time your colicky newborn is up all night breast feeding, make sure you don't have your fluffy down comforter and pillows near the baby. Next time your 1-year-old is up with a fever, don't sleep with her on the couch; instead, both of you sleep on a blanket on the floor. If you were out drinking that night, don't sleep with your child at all.

Some of the deaths in the study were related to soft bedding and bumpers in cribs or babies sleeping in playpens or alone on couches and getting stuck with their faces wedged up against these hazards. so next time you are getting a friend a baby shower gift, skip the bumper pads.

Knowing the risks and rewards, if you choose to sleep with your children, enjoy the closeness and be careful.

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