14 Sleep and Rest

Every child needs adequate sleep for good health. Without it, serious health and developmental problems may appear. Sleep disturbances may manifest as bedtime resistance, inability to fall asleep, nighttime waking, arousal difficulties, or excessive daytime sleepiness.

Sleep problems represent one of the most common concerns of parents, and children’s sleep is receiving much needed attention, both clinically and in research. Sleep will be an extremely frequent topic for discussion with parents. A variety of studies highlight some of the issues and significant prevalence of sleep problems in children. In the review of sleep studies, it is commonly noted that 20% to 30% of young children experience some form of sleeping difficulty (Boergers et al, 2007; Jenni et al, 2007). Frequent night waking was reported to occur in more than 35% of 2.5-year-olds, decreasing with age to approximately 13% of 6-year-olds (Petit et al, 2007). Similarly, this study found that the number of children having difficulty falling asleep decreased with age as well, from 16% at 3 years to 7.4% at age 6. Canadian researchers Touchette and colleagues (2005) found that 23.5% of 5-month-old children did not sleep 6 consecutive hours. Furthermore, 33% of children who did not sleep 6 consecutive hours at 5 months or 17 months continued to be unable to sleep 6 hours at 2.5 years old. Sleep problems have been identified in greater than 35% of school-age children and adolescents (Rodriguez, 2007). It is estimated that 15 million U.S. children are affected by some form of sleep inadequacy, with a surprising 40% at a moderate or severe level of impairment (Smaldone et al, 2009). On the other hand, sleep disorders are underdiagnosed, with only 3.7% of children with an International Classification of Diseases, 9th revision (ICD-9) sleep disorder diagnosis (Meltzer et al, 2010).

Insufficient sleep affects and is affected by many areas of child and family well-being, including physical and mental health issues. As noted in Box 14-1, many behavioral, mental health, and family problems can be related to sleep problems (Smaldone et al, 2009). Pediatric sleep problems may also produce sleep deprivation and stress in the caregiver(s). As with all other primary care problems in pediatrics, the provider must be vigilant for a myriad of potential causes.

BOX 14-1 Etiology of Sleep Problems in Children

Sleep problems may result from a variety of other problems, including the following:

• Physical factors

Ear infections

Neurological disorders

Hypothyroidism

Obesity

Tonsillar and adenoid hypertrophy

Down syndrome and other genetic conditions

Chronic diseases, such as cystic fibrosis

• Psychological factors

Developmental stage

Stress, depression, separation and other anxieties, or other mental health problems

Attention-deficit/hyperactivity disorder (ADHD), learning and behavior problems

Mental retardation

Autism

• Family factors

Parental mismanagement of sleep routines

Family conflict and violence

Parental physical and emotional health

Maternal depression

• Environmental and temperamental factors

Temperament characteristics, including low sensory threshold, negative mood, and decreased adaptability

Environmental factors, including sleeping arrangements, altered daily routines, and feeding practices

• Caffeine, medications, toxins, or substance abuse

Attention to cultural definitions of normal sleep habits also is essential. Sleep can be considered a biologically driven behavior that is strongly shaped and interpreted by cultural values and beliefs of the parents. Not all cultures expect children to sleep in separate beds or rooms, nor is it expected that most sleep will occur during the nighttime hours in an uninterrupted fashion (Dewar, 2008a). The hours of sleep, methods of helping the child to initiate the sleep cycle, and expectations for normal sleep behavior are also culturally driven.

Normal Sleep Stages and Cycles

The essential functions of sleep are not fully understood. Sleep is traditionally considered a time of renewal for the mind and body, but it is not simply a state of rest. At times the brain is more active in sleep than in wakefulness and, because infants and young children spend the majority of their time in sleep, it is considered a time for essential brain development. Growth and healing, learning and processing information, and many other functions are facilitated by the sleep state. Fewer studies have been done with children, but sleep deprivation in adults has negative effects on concentration, cognition, and emotional functioning (Davis et al, 2004).

Circadian Rhythms and Establishment of Normal Sleep Patterns

Many biological activities are set on a 24-hour cycle. These include sleep and wakefulness, body temperature regulation, hormonal activity, respiratory, cardiac, renal, and intestinal functions. Circadian rhythms are not established in the newborn, and homeostatic mechanisms are also poorly developed. Thus, sleep can occur around the clock with ease although patterns are irregular. Circadian rhythms emerge at about 2 to 3 months old (Sheldon, 2004).

Melatonin secreted by the hypothalamus is responsible for the timing of physiological processes, including the sleep-wake cycle. Light suppresses melatonin production, and darkness is associated with the highest melatonin levels. In normal humans melatonin begins to rise when the sun sets, peaks at 2 am, and falls to almost undetectable levels in the daytime. The day-night melatonin cycle is established between 4 and 6 months old. Levels peak at ages 1 to 3 years and then decline with age. Maternal melatonin crosses the placental barrier and is secreted in breast milk. Prolactin, growth hormone, and testosterone are also on circadian rhythm patterns with maximal secretion at night (Stevens, 2008). Growth hormone appears to be secreted in larger amounts during stages III and IV of sleep (Rodriguez, 2007).

Sleep Cycle

Normal sleep can be divided into two distinct phases: rapid eye movement (REM) sleep and nonrapid eye movement (NREM) sleep. Each phase has distinctive levels of arousal, autonomic response, brain activity, and muscle tone. NREM sleep can be further divided into four distinct stages as defined by changes in electroencephalographic (EEG) patterns. Newborn sleep cycles are discussed separately in this chapter.

Duration of Sleep

Children need more sleep time than adults but gradually achieve adult sleep patterns the older they become (Rodriguez, 2007). Sleep requirements over a 24-hour period vary widely and change as children mature. The typical neonate sleeps 16 hours each day, but some may require up to 18 hours of sleep per day. One third of this is daytime sleep. The longest neonate sleep period is 2.5 to 4 hours and can occur at any time during the 24-hour day (Dewar, 2008c). By 3 months, the baby sleeps almost 15 hours, but the sleep times are more clearly organized into daytime wakefulness and nighttime sleep with a 5-hour period of consistent nighttime sleep (Jenni et al, 2006). Most 6-month-old infants sleep through the night and have morning and afternoon naps. At 1 year most children sleep about 13.9 hours. The morning nap is generally given up between 12 and 24 months, but the afternoon nap may persist until the child is 4 or 5 years old. By 2 years the child is probably sleeping 11 to 12 hours at night with a 1- to 2-hour nap after lunch. Five-year-olds sleep 11 hours per night on average. Four- to 6-year-olds generally have an 8 pm bedtime and 7 am wake time on weekdays and slightly later bedtimes on weekends (Touchette et al, 2008). The average sleep requirement for adolescents is believed to be about 8 to 9 hours per night (Table 14-1) (Dewar, 2008b,c; Jenni et al, 2007; Rodriguez, 2007).

TABLE 14 -1 Average Sleep by Age

Age	Nighttime Sleep (hr)	Daytime Sleep (hr)
1 week	8.25	8.25
1 month	8.5	7
3 months	10	5
6 months	11	3.4
9 months	11.2	2.8
12 months	11.7	2.4
18 months	11.6	2
2 years	11.4	1.8
3-5 years	12.5
5-11 years	11
12-17 years	8-9

Adapted from Dewar G: Baby sleep requirements: a guide for the science-minded parents, 2008b. Available at www.parentingscience.com/baby-sleep-requirements.html (accessed Jan 10, 2010); Dewar G: Newborn sleep patterns: a guide for the science-minded parents, 2008c. Available at www.parentingscience.com/newborn-sleep.html (accessed Jan 10, 2010); Jenni O, Molinari L, Caflisch J, et al: Sleep duration from ages 1 to 10 years: variability and stability in comparison with growth, Pediatrics 120:769-776, 2007; Rodriguez A: Pediatric sleep and epilepsy, Curr Neurol Neurosci Rep 7:342-347, 2007.

Sleep Issues

Co-Sleeping Issues

Sleep habits are strongly influenced by culture. Co-sleeping is common in many cultures and has been the human norm for thousands of years. Co-sleeping by family members is probably more common worldwide than is separate sleeping as advocated in the U.S. Warmth, protection, and a sense of well-being are undoubtedly facilitated by having babies sleep with their mothers or siblings (Dewar, 2008a,b). One of the greatest advantages of co-sleeping is the facilitation of breastfeeding. Parents of co-sleeping infants report that not only is breastfeeding improved, but parental sleep and parent-infant bonding is as well, and there is a decrease in nighttime infant crying (Goldberg and Keller, 2007). It is most common in African-American and Hispanic families. Co-sleeping is also common with absence of one parent from the home. Co-sleeping is not in itself a reason for sleep problems. However, some families allow the child to sleep with the adults because of problems with enforcing bedtimes, anxiety about leaving the child alone, problems with the quality of daytime interactions, or a desire to avoid the spouse. Sexual abuse of the child also needs to be considered (see Chapter 17 for further child abuse discussion). In these cases, intervention may be helpful to the family (Howard and Wong, 2001).

Although studies have shown that co-sleeping facilitates breastfeeding as well as maternal-infant bonding, the American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome (SIDS) states that bed sharing should not be considered as a strategy to reduce SIDS risk (AAP, 2005). The task force recommends “a separate but proximate sleeping environment” in which the young infant sleeps in the same room but in a separate bed, crib, bassinet, or cradle. There is some conflicting evidence as to whether bed sharing is actually a risk factor for SIDS. Some studies have concluded that co-sleeping alongside a parent is not the specific increased risk factor for SIDS, but rather an infant sleeping alongside a non-parent that is the actual threat for SIDS (Goldberg and Keller, 2007). Some leading pediatric sleep, medical, and breastfeeding experts caution that the AAP’s recommendation may cause problems with bonding, quality of sleep, and enhancement of breastfeeding practices (Eidelman and Gartner, 2006; Gessner and Porter, 2006; Pelayo et al, 2006). Richard Ferber (2006), a pediatric sleep expert and longtime critic of co-sleeping, now believes there are benefits to this arrangement when practiced safely. Care should be taken to avoid using soft sleep surfaces such as quilts, blankets, pillows, comforters, or other similar materials. The bed sharer should not smoke or use substances that impair arousal. Parents should understand that safety standards are in place for the design of infant cribs. There are no standards for adult beds, so entrapment may be a possibility. Parents who plan to co-sleep should have an “exit plan,” such as ending the practice at 6 months, before the child will protest excessively (Sobralske and Gruber, 2009). School-age children who want to co-sleep with parents may have significant emotional problems, such as separation anxiety, which may require counseling.

Sleep Positioning

Studies have provided strong evidence that positioning young infants on their backs significantly decreases the incidence of SIDS. The AAP (2005) recommends that all infants sleep in a supine position unless there is some specific medical contraindication to that position. Side sleeping is not recommended. The AAP also recommends use of a crib and avoidance of soft materials in the sleep environment, bed sharing, smoking during pregnancy and afterward, and overheating the infant. Offering a pacifier at sleep times seems to have some effect in reducing SIDS risks (AAP, 2005). SIDS is also discussed in Chapter 38.

The AAP (2005) recommends that parents place the baby on its stomach while awake to encourage upper body motor development and to prevent positional plagiocephaly. Parents seem to understand the “Back to Sleep” guidelines more than they do infant positioning with “tummy time” during awake times (Koren et al, 2010).

Assessment

Assessment of sleep patterns requires an understanding of the developmental progression of sleep patterns, a comprehensive history, and a complete physical examination. Assessment of sleep patterns should be included in all well-child visits. Before a decision is made that a sleep problem exists, the provider must be sure to determine whether the child’s sleep pattern is problematic for the caregiver and/or results in daytime sleepiness with disruption to the child’s health and well-being. The clinician must be careful not to impose his or her ideas of the best sleep habits onto the family and remember that cultural patterns are very strong in this area of childrearing. Late bedtimes, early rising, night waking, and co-sleeping may be upsetting to some parents but not to others. Of course, preventive counseling is always in order.

Indicators of Sleep Problems in Children and Adolescents

Sleepiness in infants is especially difficult to notice because they sleep so many hours normally. They should not have sleepiness that is severe enough to interfere with feeding. Toddlers and preschoolers may show signs of hyperactivity, emotional lability, irritability, and aggressiveness when sleepy. Alternately, the child may fall asleep during activities when alertness would be expected, such as at mealtimes.

School-age children are usually considered to be good sleepers. Taking naps or sleeping at school are not normal behaviors. Other concerning symptoms may include inattention, restlessness, emotional lability, or daydreaming at school. There is considerable overlap of these symptoms with attention-deficit/hyperactivity disorder (ADHD), and indeed the two problems are often related.

Adolescents have many problems with sleep that may manifest as excessive sleepiness, difficulties with mood regulation, impaired academic performance, and increased risk for accidents and obesity. These may be related to adolescent changes in sleep physiology and lifestyle habits of the teen years. Chronic sleep deprivation is a common reason for sleepiness in adolescents (Noland et al, 2009). Sleep loss or disturbances have been associated with increased risk of future depression and anxiety in adolescents (Alfano et al, 2009). Noland and associates (2009) identified the risk of adolescent obesity to increase by 80% due to each hour of chronically lost sleep. Sleep deprivation in adults causes poorer high-order cognitive functioning; accidents and poor judgment are outcomes (Stevens, 2008).

History

Pediatric sleep has become a topic of interest with increasing research and attention to sleep issues in children with a variety of health problems. Several child sleep screening tools can be used by clinicians in everyday practice to assess sleep hygiene (Box 14-2) (Lee and Ward, 2005; Sadeh, 2004). Because sleep problems are so common and tend to persist, it is recommended that sleep be addressed at well-child visits, as a component of care of sick children when sleep is likely to be interrupted, and with all children with chronic conditions because so many have associated sleep problems. The normal sleep pattern, the general health history, sleep habits of the parents and family, and the sleep environment are assessed for factors that may affect sleep and rest. Significant sleep problems need to be referred to sleep centers or other specialists.

BOX 14-2 Sleep Screening Tool

Data from Howard B, Wong J: Sleep disorders, Pediatr Rev 22:327-341, 2001; Lee K, Ward T: Critical components of a sleep assessment for clinical practice settings, Issues Ment Health Nurs 26:739-750, 2005; and Sadeh A: A brief screening questionnaire for infant sleep problems: validation and findings for an Internet sample, Pediatrics 113:e570-e577, 2004.