January 8, 2018
ARTICLE:

Sleep problems

By Dr Megan Yap - Paediatrician

Sooooooo on the topic of “restfulness” – many of my patient’s parents and friends struggle with their children’s sleep (or lack thereof) and face bedtime battles.  Troy and I are not immune to this ourselves!  For us mainly it’s 2 year old Nicholas not wanting to go to bed, throwing a tantrum and then protest spewing all over the clean sheets, resulting in us having to strip the bed, wash the EVERYTHING (+/- spot cleaning the carpet if necessary), bath him and get him changed, wash and blow dry his comfort toys (he has 3, and won’t go to sleep without them)… and we curse a lot.  It happens at least 3 times a week lately.  Lots of bedtime issues are fairly easily sorted, but some of them are trickier.

So, one of my very early posts was about “Normal sleep patterns in children” (see blog post on August 3rd, 2017).  We discussed what a normal amount of sleep is for children of various ages, and talked about “Sleep Hygeine.”  Now before I launch into “What to do if you are having bedtime/sleep problems with your child” – let’s have a refresher about the main points!  Sleep hygiene is SOOO important – and if you don’t establish good sleep hygiene first up, then quite frankly, you have BUCKLEY’S chance of getting your kid to sleep through the night, or to bed easily.

 

Sleep hygiene – this is for ALL children (and adults too!)

What does it mean?  

  • Set a bedtime and stick to it (for my kids it is “bedtime 7pm; lights out/no talking 7.30pm”)
  • Calm bedtime routine
  • No screen time (iPads, computers, TV, smart phones etc) 2-3 hours prior to bed
  • Playing with Lego, reading, drawing, talking are all good options
  • Avoid caffeine (coffee, tea, chocolate) after 3pm
  • Use the bed only for sleep (no reading in bed, no playing with toys, playing on iPad etc)

 

So what my earlier sleep post failed to cover, was what to DO if bedtime = battle time in your household.

It is important to realise that most types of “sleep training” involve trying to teach the child to “self-soothe” to some extent – because you want your child to be able to settle to sleep on their own. Hence how you approach these problems (and often how quickly the child responds) depends heavily on how you react and how much YOU can tolerate of your child calling out for you/crying.

When I take a sleep history from families in clinic, I often find that their 5/6/7/8/9 year old is still co-sleeping in their parent’s bed.  Now, IF the parents don’t find this to be a problem (ie they LIKE co-sleeping, everyone gets a good night’s sleep, they enjoy the sense of closeness that the co-sleeping creates), then really – this ISN’T a problem.  But if the history of co-sleeping is resulting in terrible interrupted sleep for everyone, parents are too tired to function at work, or they are getting woken 7 times a night with a toe in their ear, then it is a totally different story. Sleep training is rarely easy.  I can honestly say that I think the VAST majority of children would prefer to fall asleep with their parents beside them at night.  And although most if not ALL parents want their children to be happy and not distressed… they also need to sleep.

The “Cry-it out” method of sleep training, would usually work within 2-3 nights BUT most parents will say that they just cannot stand to hear their child crying for prolonged periods of time. And this is okay, there is no real “right” vs “wrong” way.  None of the methods discussed will “emotionally scar” your child long term, BUT… you need to know that the softer you are and the more you give-in to your child’s ransom demands at bedtime – the longer it will take to get their bedtime right.

 

There are different TYPES of sleep problems.  These evolve in different ways and we manage them accordingly.

  • Limit Setting Disorder
  • Sleep association disorder
  • Anxiety
  • True insomnia
  • Early morning waking
  • Delayed sleep phase (common in teens)
  • Medical issues (worms, diabetes, pain, OSA)

Let’s talk about each of these in TURN shall we?

 

LIMIT SETTING DISORDER

This is a HUGELY common sleep problem in kindy and school aged children.  It is when parents (or guardians) are unable to establish an appropriate sleep routine for their child and enforce bedtime limits. It results in the child refusing or stalling bedtime. They come out of their room repeatedly with any one of a myriad of excuses:  “I need another hug,”  “I’m thirsty,”  “I need to do a wee,” “I’m not tired,” “I’m too hot/cold/itchy/sore/awake/hungry/sad/scared of the dark/annoying” etc ad nauseam.  It drives you insane.  You might think that it is too mean to turn your back on a child asking for affection (eg another kiss goodnight, another hug) or that it is dangerous to (repeatedly) deny access to the toilet… and the little opportunists (aka terrors) will take full advantage of you for this!

So what can we do?

  • Establish clear bedtime rules – establish and discuss these during the day, when everyone is calm, not tired, not in trouble, and write them up on a poster for all to see and refer back to
  • Ignore complaints and protests, returning children to bed – with no conversation, negotiation and with minimal eye contact (ie do not inadvertently “reward” them for coming out)
  • Respond consistently and be persistent (you might have to return them to their bed 40 or more times on the first couple of nights)
  • Bedtime pass – the child gets 1 “pass-outs” of the bedroom (eg a sit on the toilet) and that is it.
  • Positive reinforcement eg reward chart
  • Checking method (see below)
  • Bedtime fading – gradually moving your child’s “too-late” bedtime forward by 15 min every day (until you reach the target time eg 7.30pm) in association with a regular positive bedtime routine (pleasant, relaxing and quiet activities)

 

SLEEP ASSOCIATION DISORDER

This is probably the other most common problem I see in children with sleep problems.  It can occur at any age (and even in adults).  It is a condition in which a child associates their ability to fall asleep with something in their environment or even a person. Examples of these associations include being held, patted, rocked or nursed, and eating or drinking (eg a bottle of milk/breastfeeding), or being in the presence of their parent (eg in their parent’s bed) prior to falling asleep.  Essentially what happens is the child associates security with a certain object/person or situation  so when they wake in the middle of the night, they cannot fall back asleep if that certain learned association(s) are not at hand.  For example, a toddler might easily fall asleep if a parent or object (eg TV) is with them.  They might wake 1-4 times (or more) wanting the parent there or the TV back on to re-settle (and in their absence, struggle to get  back to sleep).

So how do we deal with THIS problem?  Well, there are a couple of different methods.  If “Cry-it-out” isn’t your style, these methods are a little gentler…

     Camping out

  • Place your chair next to the child’s bed
  • First few nights – pat off to sleep
  • Next few nights – just sit next to them
  • Next few nights – move chair 1 metre away from their bed, then 2 metres away, then by the door etc
  • Takes 1-3 weeks to work
  • Leave if playing games or refusing to stay in bed
  • Reward “brave” behaviour in the morning

Checking method

  • After child is in bed, say “good night” and leave
  • Promise to come back and check in 1-2 mins
  • Keep checking (brief visit only) every 3-5 minutes; keep interaction to minimum/do not interact (ie no conversation/eye contact etc)
  • Gradually stretch checking interval times

 

ANXIETY

Anxiety is a normal part of childhood development.  Different anxieties emerge at different stages (eg babies and toddlers might fear separation from a parent, loud noises; a pre-schooler might fear the dark).  If there is anxiety inhibiting your child’s sleep, there are a few strategies that you might find useful to use with your child,

  • Find out what and why AND address if possible (but don’t do this AT bedtime)
  • Worry book (write or draw worries and shut the book on them until morning)
  • Relaxation exercises + visual imagery
  • Positive reinforcement
  • Discuss fears during the day and reinforce safety

If a child has persistent worries/fears/anxiety that doesn’t improve with simple methods (as above) after 2-3 weeks – I would refer them to a child psychologist.

 

TRUE INSOMNIA

This describe kids who just can’t fall asleep (not worried, not coming in and out, not needing a person/object to get to sleep).  There are a few strategies with these kids that I would initially recommend including:

  • Visual imagery and relaxation (you can try a mindfulness exercise/app –> “The Smiling Mind” or “7 cups of Tea – mindfulness exercises”)
  • A simple change in the way of thinking:  “Tonight I will just relax and rest at bedtime”
  • Restricting time in bed (get out of bed after 20 min and do a quiet activity for 20 min before lying down again)

 

DELAYED SLEEP PHASE DISORDER

People with DSPD are unable to fall asleep until late at night, typically somewhere between 2 am and 6am, and sleep correspondingly longer in the daytime (often finding it hard to get up for school),  and if sometimes, if allowed, can sleep well into the afternoon.  This can occur secondary to poor sleep hygiene and can evolve from over-exposure to electronic devices late at night.

  • Common in teens
  • Solution is go bed earlier – to shift the internal body clock
  • Move the bedtime forward by 15 minutes every couple of nights (“bedtime fading”)
  • No day time napping
  • Open the blinds in the bedroom to allow sunlight to shine into the room in the morning whilst avoiding exposure to bright light in the evening hours (“bright light therapy”)
  • Talk to your doctor about other pharmacological options that might help

 

Oh, and I need to warn you about “Extinction burst.”  This is the phenomenon where there is a burst of the behaviour that you thought you had extinguished about 2-3 weeks down the track.  It affects about 20% of children.   Don’t get discouraged (you are not back to square one) – just keep being consistent, it usually resolves after 2 nights.

 

HOPEFULLY some of these strategies will help you with your children… or at the very least help you to understand why your child might be having troubles with their sleep.  If sleep problems persist and are troublesome, make sure you go and see your trusty family GP!!

Until next time – happy parenting!!

xxDr Megs

For more articles from Dr Megan Yap visit her blog – “Dr Megs – Paeds & Feeds” at http://www.kids-health.guru/

 

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