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Behavioral Sleep Clinic

news-2-732x447The children’s sleep disorders center provides a full range of pediatric psychological services related to sleep disorders in children. This includes the education of new mothers regarding the typical development of sleep in newborns and infants; teaching a child to fall asleep independently; the organization of bedtime routines and good sleep hygiene; interventions for bedtime struggles, nightwakings, nighttime fears, nightmares; insomnia and narcolepsy.

The practice evaluates children with suspected disruptive behavioral and mood disorders to ensure that a sleep disorder is not a contributing factor to the child’s behavioral symptoms. These services are part of the emerging science of sleep medicine and have long-term implications including avoidance of unnecessary medication therapy.
Our psychology services also extend to assist pulmonary patients with adherence to medical regimen and the management of anxiety symptoms.

The sleep psychology division is organized by Dr. Akin Ajayi and Dr. Kimberly Justice. Some of the conditions managed under the behavioral program include:

BEDTIME PROBLEMS

After a long day at work, caring for your children, household duties, and the demands of managing a family most parents look forward to the evening where they can put their children to bed and have a little “me” time. However, if you find yourself arguing with your child about getting ready for bed, getting into bed, dealing with requests for one more hug or one more trip to the bathroom, or feeling frustrated with bedtime temper tantrums you are likely dealing with something called Limit-Setting Sleep Disorder. This sleep disorder is common beginning around 2-3 years of age when children typically transition from a crib to a bed. Children engage in bedtime stalling techniques which include any behavior that attempts to delay bedtime. This is typically followed by a response from parents characterized by inadequate enforcement of bedtime limits, sporadic enforcement of limits, or very few or no limits set for a child. An additional good hint that this may be the problem for you and your child is if the child goes to bed and falls asleep quickly for other family members. Bedtime resistance is found in 10% to 30% of toddlers and preschoolers and approximately 15 % of children ages 4 to 10 years. What to expect when you arrive at the sleep clinic Fortunately, even the most extreme cases of bedtime resistance can be addressed with behavioral techniques that can lead to improvement in a few weeks with consistent follow through. When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history. A detailed history of your child’s sleep behaviors will also be discussed. Your child will also likely have a brief physical examination. Treatment Treatment for limit-setting sleep disorders includes the development of good sleep habits including establishing a set bedtime, a consistent sleep/wake schedule, and a consistent bedtime routine. Daytime habits including napping, types of physical activities, and foods consumed will be reviewed to ensure your child is developing good sleep hygiene practices. Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs. This intervention may include multiple behavioral strategies including the use of positive reinforcement, consistent parental response, clear limit-setting, the development of independent sleep skills, graduated extinction, bedtime fading, the door closing procedure, and the bedtime-passcard. Following the initial consultation and treatment session, your family will be asked to complete a 2-week sleep log so that our providers will have detailed information about how the changes you are making are working. The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 weeks following your initial visit.

NIGHTWAKINGS

Nightwakings can occur for many different reasons, but are most often related to negative sleep onset associations. Positive sleep associations are what you want your child to have in order for her to fall asleep quickly and easily on her own. They are the conditions that are present at the time your child falls asleep. They are usually required again following normal nocturnal arousals. Positive sleep associations may include a favorite stuffed animal, sleeping in a certain position, sucking a pacifier, having a night light etc. The sleep onset associations should be consistent at bedtime and throughout the night. Parents often fall into the habit of placing their infants to bed after they have fallen asleep such as following nursing or drinking from the bottle, rocking, singing, or cuddling. Negative sleep onset associations require a parent’s presence or are things that are no longer present when your child wakes in the middle of the night. Negative associations interfere with your child’s ability to learn the important skill of self-soothing and inhibit her ability to fall asleep on her own. It is important to note that we all wake through the night. This is normal. The problem occurs when your child cannot soothe herself back to sleep following a nightwaking. Studies suggest that 25% – 50% of 6- to 12- month-olds and 30% of 1- year-olds have problems with nightwakings. Approximately 15% – 20% of toddlers ages 1- to 3-years old continue to experience nightwakings.

What to expect when you arrive at the sleep clinic

When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history. A detailed history of your child’s sleep behaviors and nightwakings will also be discussed. Your child will also likely have a brief physical examination. If any medical causes are suspected of contributing to your child’s nightwakings (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended.

Treatment

Treatment for nightwakings related to negative sleep onset associations may include establishing good sleep habits including a consistent sleep/wake schedule, a consistent bedtime routine, the maintenance of a daytime nap (at least through age 3), the encouragement of a transitional object, graduated extinction, fading of adult intervention, weaning/discontinuation of nighttime feedings (when developmentally appropriate), reinforcement strategies, and scheduled awakenings. Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs. Following the initial consultation and treatment session, your family will be asked to complete a 2-week sleep log so that our providers will have detailed information about how the changes you are making are working. The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 weeks following your initial visit.

INSOMNIA

Insomnia is defined as having difficulty falling asleep, staying asleep, or waking early. In many cases, insomnia is a secondary symptom of another sleep or medical disorder. However when insomnia is not related to a sleep, psychiatric, or medical disorder, it is refered to as primary insomnia or psychophysiologic insomnia and is accompanied by learned sleep-preventing associations, physiological arousal, complaints of sleeplessness and decreased daytime functioning. Children and adolescents with insomnia may also complain about racing thoughts, difficulty turning off their brain, negative beliefs about sleep, and worries about difficulties falling asleep. Insomnia theories suggest that this sleep disorder results form a combination of the three Ps – predisposing factors (genetic vulnerability to underlying medical or psychiatric conditions), precipitating factors (stress), and perpetuating factors (poor sleep habits, negative thoughts about sleep, inconsistent sleep schedule). Children and adolescents who struggle with insomnia may experience a change in mood, irritability, excessive fatigue and sleepiness during the day, and declining school performance. Adolescents are especially at risk for excessive use of caffeine to remain awake during the day.

What to expect when you arrive at the sleep clinic

When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical and psychological history), and your child’s behavioral history. A detailed history of your child’s bedtime routine, sleep behaviors, nightwakings, and daytime behavior and activities will also be discussed. Your child will have a brief physical examination. If any medical causes are suspected of contributing to your child’s insomnia (e.g., gastroesophageal reflux, periodic limb movement, restless leg syndrome, sleep apnea, delayed sleep phase, psychiatric disorders, asthma, allergies, etc.), further medical evaluation may be recommended.

Treatment

Identifying all of the factors contributing to your child’s insomnia is a critical inititail step in developing an appropriate treatment plan. Our sleep team will work with your family one-on-one to develop a personally tailored sleep medicine program to fit your family’s needs. Initially, treatment will focus on improving sleep hygiene and the consistency of the sleep/wake schedule. Cognitive behavioral strategies will then be used to disrupt the negative learned associations with sleep and may include: cognitive restructuring, relaxation, sleep restriction, and stimulus control. Our goal as a sleep team is to avoid the use of hypnotic medication when possible, especially for use with children and adolescents. When necessary, we use hypnotics on a short-term basis in conjunction with behavioral interventions to break the cycle of insomnia and improve sleep. The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 weeks following your initial visit.

ANXIETY, NIGHTTIME FEARS, AND SLEEP

Children with anxiety symptoms often complain about sleep disturbances. However, the relationship between sleep and anxiety is complicated. Sleep disturbances are a symptom of anxiety disorders, but sleep disruptions and inadequate sleep can lead to anxiety symptoms. It may be a challenge to determine which is the primary disorder. Therefore, the most effective strategy to address these disorders is an integrated approach that evaluates and treats both concerns at the same time.

Anxiety is healthy because it helps protect and enhance our performance in stressful or dangerous situations. However, experiencing too much anxiety or experiencing anxiety that is overwhelming at inappropriate times can lead to extreme distress and interfere with our ability to complete our daily activities. Given all of the developmental tasks that children need to accomplish, it is important that they learn skills to cope with anxious feelings.

Fears and anxiety are a part of normal development. Nighttime fears and nightmares are especially common in preschoolers, but can occur in older children. As children’s cognitive skills develop, they begin to gain a more complete understand that there are things that exist in the world that may hurt them (or a loved one). The following is a list of common fears:

  • INFANTS/TODDLERS (ages 0-2 years) loud noises, strangers, separation from parents, large objects
  • PRESCHOOLERS (ages 3-6 years) ghosts, monsters, supernatural beings, the dark, noises, sleeping alone, animals, blood, needles, thunder, floods
  • SCHOOL AGED CHILDREN (ages 7-12 years) realistic fears such as physical injury, illness, blood, needles, school performance, social situations, death, thunderstorms, supernatural phenomenon (ghosts, witches, aliens) and natural disasters
  • ADOLESCENTS (> 13 years) future events, the unknown, performance failure

It is important for parents to differentiate normal fears from more severe and persistent anxiety across the entire day. Also, some normal bedtime anxieties can become a larger problem if they are accidentally reinforced by parental reactions and attention. Anxiety disorders that may be associated with sleep disturbances include:

  • Stress reactions (e.g., natural disasters, trauma)
  • Adjustment disorders (e.g., reactions to major life changes such as moving, change of school, separation/divorce, death of a family member)
  • Separation anxiety (typically seen in younger children who are extremely unwilling to separate from their major attachment figures such as parents, grandparents or from home. The suggestion of having to separate typically results in crying, trembling, sweating, and physiological complaints)
  • Generalized anxiety disorder (excessive worry about a variety of events that is difficult to control and interferes with daily life)
  • Obsessive-compulsive disorder (recurrent obsessions, or intrusive thoughts, and compulsions/repeated behaviors that are time consuming and cause significant impairment in daily functioning)
  • Posttraumatic stress disorder (PTSD) (the experience or witness of a severely traumatic event that involved actual or threatened death or serious injury including physical, emotional, and sexual abuse)

If your child is exhibiting significant nighttime fears that are not developmentally appropriate, negatively impacting their ability to fall asleep and get an adequate amount of sleep, and/or affecting daytime functioning our sleep psychologist can help to address these issues.

What to expect when you arrive at the sleep clinic

When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history. A detailed history of your child’s sleep behaviors and fears will also be discussed. Your child will also likely have a brief physical examination. If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended.

Treatment

The most effective treatment for sleep problems related to anxiety is to treat both the sleep issues and the anxiety at the same time. Our sleep psychologist will work with your family one-on-one to develop strategies to optimize your child’s sleep while helping him or her to develop appropriate coping skills to “boss back” their worries. Treatments for developmentally appropriate fears may include reassurance of the child’s safety, developmentally appropriate coping skills such as positive self-statements, fostering a sense of mastery and control, encouragement of a security object, use of a nightlight, avoidance of frightening or age inappropriate media, relaxation strategies, appropriate and consistent limit-setting, graduated checking, and rewards for appropriate bedtime behavior. Treatment for significant anxiety symptoms and pervasive worry may include cognitive behavioral therapy techniques that 1) increase awareness of physiological arousal and negative self-talk during anxiety events; 2) develop coping skills including relaxation skills, restructuring negative thoughts into positive, coping thoughts, and problem-solving strategies; and 3) utilize gradual desensitization, bedtime checks, and weaning of parents presence to increase independent sleeping skills. In cases of severe anxiety or where anxiety symptoms are affecting daytime functioning, a referral to a psychiatrist for a medical consultation may be needed. The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 1 – 2 weeks following your initial visit.

ADHD AND SLEEP

Attention-Deficit/Hyperactivity Disorder is a neurobiological disorder characterized by developmentally inappropriate problems with sustaining attention to tasks, persistence of effort, vigilance, inhibiting behavior, impulsiveness, poor self-regulation, and increased activity and restlessness. Hyperactivity symptoms have been shown to decline significantly across the elementary school years, while problems with attention tend to remain stable across time. Although excessive activity levels decrease over time, problems with inhibition are typically exhibited in symptoms of poor self-regulation across development. About 70% of males and females that meet criteria for ADHD in childhood continue to experience significant ADHD impairments through adulthood. The prevalence of ADHD in school-age children is 2% – 7%. There are three primary subtypes of ADHD including: predominately inattentive type, predominately hyperactive-impulsive type, and combined type.
Many parents of children and adolescents with ADHD complain of sleep problems including bedtime struggles, delayed sleep onset, increased nightwakings, restless sleep, and shortened sleep duration. The relationship between sleep and ADHD is complicated by the fact that most of the common behavioral symptoms of ADHD can also result from inadequate and disrupted sleep including mood, attention and behavioral symptoms. Research suggests that some children with ADHD are misdiagnosed and actually have a primary sleep disorder including obstructive sleep apnea, restless leg syndrome, and periodic leg movement. In addition, sleep disorders can worsen symptoms of ADHD when they coexist.

Sleep problems in children with ADHD can have multiple causes:

  • A primary sleep disorder that “mimics” ADHD symptoms. These symptoms may improve or be eliminated with treatment of the sleep disorder.
  • Inadequate sleep related to the environment or lifestyle factors (e.g., inconsistent schedules, noisy environment etc.).
  • Coexisting sleep disorder that may make the cognitive, mood, and behavioral disturbances associated with ADHD worse.
  • Coexisting psychiatric disorders such as oppositional defiant disorder, anxiety and mood disorders, Tourette syndrome, and sensory integration disorder and associated impairments in self-soothing skills may contribute to sleep disturbances.
  • Pharmacologic agents used to treat ADHD and/or comorbid psychiatric conditions may be associated with sleep onset and maintenance problems and restless sleep. Sleep problems may be a result of dosage or dosing schedule of medication.
  • Poor Central Nervous System regulation of arousal/activity associated with ADHD may result in sleep disturbances. Parents may report that their child has difficulty “winding down” at bedtime and may be a result of problems with delayed sleep onset.

The accurate identification of children with ADHD requires careful screening followed by a comprehensive evaluation and diagnosis. Screening for sleep disorders should be part of the evaluation for every child with suspected ADHD in order to rule out or appropriately treat a primary sleep disorder prior to the diagnosis of ADHD. In addition, periodic rescreenings for sleep disorders should be a part of the ongoing management of every child with ADHD.

What to expect when you arrive at the sleep clinic

When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history. A detailed history of your child’s sleep behaviors will also be discussed. Your child will have a brief physical examination. If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended including an overnight sleep study. Our sleep psychologist may also request that you and your child’s teachers complete brief questionnaires to better understand what behavioral and neurocognitive symptoms your child is exhibiting in the home and school setting.

Treatment

If your child has been diagnosed with ADHD, his or her treatment plan likely already includes a behavior management plan, classroom accommodations, individual and family counseling, and medication. Treatment for children who have comorbid ADHD and sleep problems should include the treatment of the primary sleep disorder. Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs. Interventions may include the completion of a sleep log to gather further information, extended bedtime routine to help your child learn to decrease his arousal level, the development of good sleep hygiene, a consistent sleep/wake schedule, bedtime fading, and the development of a reward system for appropriate bedtime skills. Our sleep psychologist and medical providers along with your primary care doctor or psychiatrist will review your child’s current medication regimen and consider if any of the sleep symptoms your child is exhibiting are related to ADHD medication effects or rebound effects as the medication is wearing off. Changing the dose, timing, or type of medication can decrease ADHD behaviors and make bedtime easier. On some occasions a child may present with other behavioral and mental health problems that are negatively impacting both daytime and nighttime functioning. When this is the case, it is recommended that your child participate in a comprehensive psychological evaluation to ensure the appropriate identification and treatment of your child. The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 – 4 weeks following your initial visit.

NIGHTMARES

Most parents can remember a time when they were young and were awaken by a scary dream. You may have needed comfort, reassurance, or just the presence of your mom or dad to return back to sleep. When you consider that 75% of children report experiencing at least one nightmare and 10% to 50% of young children require some type of adult assistance during the night following a nightmare, parents are spending a significant amount of time addressing these issues. Nightmares occur during REM sleep and typically result in awakening from sleep. The content of nightmares varies across the developmental spectrum with younger children exhibiting themes of monsters or separation from caregiver, and older children experiencing themes related to frightening movies or media viewed and disturbing daytime experiences. Life changes, stressors, or traumatic events (e.g., move to a new home, starting school, parental divorce etc.) can also be associated with nightmares.

Nightmares should be differentiated from sleep terrors. Nightmares have the following characteristics:

  • typically occur in the latter half of the night when our sleep cycle is predominated by REM sleep
  • your child remembers partial or whole descriptions of the nightmare
  • they will remember waking up and interacting with you
  • they will not be confused or disoriented during the awakening
  • they may have difficulty returning back to sleep

Frequent and chronic nightmares can be associated with psychiatric disorders such as anxiety disorders, bipolar disorders, and schizophrenia. However, it is important to remember that most nightmares are common and are part of the normal developmental process.

What to expect when you arrive at the sleep clinic

When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history. A detailed history of your child’s sleep behaviors and the frequency and severity of nightmares will also be discussed. Your child will have a brief physical examination. If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended including an overnight sleep study.

Treatment

Treatment for nightmares includes reducing the likelihood of experiencing a nightmare by avoiding exposure to frightening or age inappropriate images and media, reducing stress, and ensuring adequate sleep. Our sleep psychologist will work one-on-one with your family to help parents provide appropriate reassurance without providing excessive attention to the nightmares. Your child will be encouraged to develop individual coping skills including use of their imagination to facilitate a sense of master and control, relaxation strategies, and systematic desensitization. Use of a nightlight and security object may also be recommended. If nightmares are persistent and unresponsive to behavioral interventions, a referral for a psychiatric consultation may be needed.

SLEEP HABITS/SLEEP HYGIENE/INSUFFICIENT SLEEP

Every child needs a certain amount of sleep and this depends on many factors including developmental stages. When the amount of sleep a child is getting falls short of the amount of sleep she needs to function during the day, this results in chronic sleep deprivation. Children may go from a well-mannered, well-behaved and attentive to sleepy and/or overactive, irritable, and defiant. Insufficient sleep is the leading cause of excessive daytime sleepiness. The table below provides a guideline for the estimated average sleep time by a child’s age. Keep in mind that these are averages and some children need more or less sleep to functioning well during the day.

In addition, the most common cause of problems getting to sleep and staying asleep in children is poor sleep habits. These habits or behaviors affect how we sleep and can include what we eat and drink, the temperature in our bedroom, our exercise routine, noises in the environment, the activities we choice to participate in before sleep, and the light we are exposed to before bedtime.

  • Develop a 30-minute bedtime routine with the same calming activities completed in the same order each night. The last step in the bedtime routine should happen in your child’s bedroom. Stick to a consistent limit and do not extend the bedtime routine (e.g., “one more book, please?!?!)
  • Avoid activities that tend to increase arousal such as running, jumping, wrestling, or video games. Establish quiet time for about one hour prior to bed (e.g., reading stories, listening to music, working on a simple art project, etc.)
  • Your child’s bedtime and wake-time should be the same time each night. This should be consistent across weekdays and weekends. Some flexibility is fine on the weekends, but the difference in the schedule should not be more than about one hour.
  • Your child will sleep better in a cool, quiet, and dark environment. A night light can help those children that are scared of the dark. Avoid bright overhead lights. The temperature in the bedroom should be cool (< 75 degrees F).
  • Reduce any noise from other family members moving around the house, watching television, and other noisy activities.
  • Provide your child with a light, healthy snack prior to bed. Heavy meals within 1 to 2 hours of bedtime can disrupt sleep. Your child should avoid caffeine (e.g., soda, tea, chocolate, etc.) at least 3 to 4 hours before bedtime.
  • Your child should spend time during the day exercising and playing outside.

SLEEP INFANTS

Sleep in Infants (2–12 Months)

WHAT TO EXPECT

Infants sleep between 9 and 12 hours during the night and nap between 2 and 5 hours during the day. At 2 months, infants take between two and four naps each day, and by 12 months, they take either one or two naps. Expect factors such as illness or a change in routine to disrupt your baby’s sleep. Developmental milestones, including pulling to
standing and crawling, may also temporarily disrupt sleep.

By 6 months of age, most babies are physiologically capable of sleeping through the night and no longer require nighttime feedings. However, 25%–50% continue to awaken during the night. When it comes to waking during the night, the most important point to understand is that all babies wake briefly between four and six times. Babies who are able to soothe themselves back to sleep (“self-soothers”) awaken briefly and go right back to sleep. In contrast, “signalers” are those babies who awaken their parents and need help getting back to sleep. Many of these signalers have developed inappropriate sleep onset associations and thus have difficulty self-soothing. This is often the result of parents developing the habit of helping their baby to fall asleep by rocking, holding, or bringing the child into their own bed. Over time, babies may learn to rely on this kind of help from their parents in order to fall asleep. Although this may not be a problem at bedtime, it may lead to difficulties with your baby failing back to sleep on her own during the night.

SAFE SLEEP PRACTICES FOR INFANTS

  •  Place your baby on his or her back to sleep at night and during naptime.
  • Place your baby on a firm mattress in a safety-approved crib with slats no greater than 2-3/8 inches apart.
  • Make sure your baby’s face and head stay uncovered and clear of blankets and other coverings during sleep. If a blanket is used, make sure the baby is placed “feet-to-foot” (feet at the bottom of the crib, blanket no higher than chest-level, blanket tucked in around mattress) in the crib. Remove all pillows from the crib.
  • Create a “smoke-free–zone” around your baby.
  • Avoid overheating during sleep and maintain your baby’s bedroom at a temperature comfortable for an average adult.
  • Remove all mobiles and hanging crib toys by about the age of 5 months, when your baby begins to pull up in the crib.
  • Remove crib bumpers by about 12 months, when your baby can begin to climb.

HOW TO HELP YOUR INFANT SLEEP WELL

  • Learn your baby’s signs of being sleepy. Some babies fuss or cry when they are tired, whereas others rub their eyes, stare off into space, or pull on their ears. Your baby will fall asleep more easily and more quickly if you put her down the minute she lets you know that she is sleepy.
  • Decide on where your baby is going to sleep. Try to decide where your baby is going to sleep for the long run by 3 months of age, as changes in sleeping arrangements will be harder on your baby as he gets older. For example, if your baby is sleeping in a bassinet, move him to a crib by 3 months. If your baby is sharing your bed, decide whether to continue that arrangement.
  • Develop a daily sleep schedule. Babies sleep best when they have consistent sleep times and wake times. Note that cutting back on naps to encourage nighttime sleep results in overtiredness and a worse night’s sleep.
  • Encourage use of a security object. Once your baby is old enough (by 12 months), introduce a transitional/love object, such as a stuffed animal, a blanket, or a t-shirt that was worn by you (tie it in a knot). Include it as part of your bedtime routine and whenever you are cuddling or comforting your baby. Don’t force your baby to accept the object, and realize that some babies never develop an attachment to a single item.
  • Develop a bedtime routine. Establish a consistent bedtime routine that includes calm and enjoyable activities, such as a bath and bedtime stories, and that you can stick with as your baby gets older. The activities occurring closest to “lights out” should occur in the room where your baby sleeps. Also, avoid making bedtime feedings part of the bedtime routine after 6 months.
  • Set up a consistent bedroom environment. Make sure your child’s bedroom environment is the same at bedtime as it is throughout the night (e.g., lighting). Also, babies sleep best in a room that is dark, cool, and quiet.
  • Put your baby to bed drowsy but awake. After your bedtime routine, put your baby to bed drowsy but awake, which will encourage her to fall asleep independently. This will teach your baby to soothe herself to sleep, so that she will be able to fall back to sleep on her own when she naturally awakens during the night.
  • Sleep when your baby sleeps. Parents need sleep also. Try to nap when your baby naps, and be sure to ask others for help so you can get some rest.
  • Contact your doctor if you are concerned. Babies who are extremely fussy or frequently difficult to console may have a medical problem, such as colic or reflux. Also, be sure to contact your doctor if your baby ever seems to have problems breathing.

SLEEP IN TODDLERS

Sleep in Toddlers (1–3 Years)

WHAT TO EXPECT

Toddlers sleep between 12 and 14 hours across the day and night. By 18 months, most toddlers have given up their morning nap and are taking one long afternoon nap of 1.5–3 hours. The number of hours a toddler sleeps will be different for each child, but expect your toddler to sleep about the same amount each day. Continue to expect that sleep will be disrupted by illness, changes in routine, and other stressful events. Separation anxiety may also cause problems at bedtime. Most toddlers switch from a crib to a bed between 2 and 3 years of age. If the change happens too early, it can disrupt sleep.

Many toddlers continue to awaken during the night, usually as a result of poor sleep habits. All children wake briefly throughout the night. However, a toddler who has not learned how to fall asleep his own at bedtime will not be able to return to sleep without help from his parents.

HOW TO HELP YOUR TODDLER SLEEP WELL

  • Develop a daily sleep schedule. Have regular nap times and a bedtime that ensures enough nighttime sleep. Napping too late in the afternoon can make it hard for your toddler to fall asleep at bedtime, but avoid cutting back on naps to encourage nighttime sleep as this will result in overtiredness and a worse night’s sleep.
  • Encourage use of a security object. Helping your toddler become attached to a security object that he can keep in bed with him can be beneficial. This often helps a child feelmore relaxed at bedtime and throughout the night.
  • Develop a bedtime routine. Establish a consistent bedtime routine that includes calm and enjoyable activities, such as a bath and bedtime stories. The activities occurring closest to “lights out” should occur in the room where your toddler sleeps.
  • Set up a consistent bedroom environment. Make sure your child’s bedroom environment is the same at bedtime as it is throughout the night. Some older toddlers may find a nightlight reassuring. Also, toddlers sleep best in a room that is dark, cool, and quiet.
  • Put your toddler to bed drowsy but awake. Encourage your toddler to fall asleep independently by putting him to bed drowsy but awake. This will enable him to fall back to sleep on his own when he naturally awakens during the night.
  • Set limits. If your toddler stalls at bedtime, be sure to set clear limits, such as how many books you will read.

Contact your child’s doctor if:

  • Your child appears to have any trouble breathing, snores, or is a noisy breather.
  • Your child has unusual nighttime awakenings or significant nighttime fears that are concerning.
  • Your child has difficulty falling asleep, staying asleep, and/or if sleep problems are affecting his behavior during the day.

SLEEP TIPS FOR CHILDREN

Sleep Tips for Children

The following recommendations will help your child get the best sleep possible and make it easier for him or her to fall asleep and stay asleep:

  • Sleep schedule. Your child’s bedtime and wake-up time should be about the same time everyday. There should not be more than an hour’s difference in bedtime and wake-up time between school nights and non-school nights.
  • Bedtime routine. Your child should have a 20- to 30-minute bedtime routine that is the same every night. The routine should include calm activities, such as reading a book or talking about the day, with the last part occurring in the room where your child sleeps.
  • Bedroom. Your child’s bedroom should be comfortable, quiet, and dark. A nightlight is fine, as a completely dark room can be scary for some children. Your child will sleep better in a room that is cool (less than 75°F). Also, avoid using your child’s bedroom for time out or other punishment. You want your child to think of the bedroom as a good place, not a bad one.
  • Snack. Your child should not go to bed hungry. A light snack (such as milk and cookies) before bed is a good  idea. Heavy meals within an hour or two of bedtime, however, may interfere with sleep.
  • Caffeine. Your child should avoid caffeine for at least 3 to 4 hours before bedtime. Caffeine can be found in many types of soda, coffee, iced tea, and chocolate.
  • Evening activities. The hour before bed should be a quiet time. Your child should not get involved in high-energy activities, such as rough play or playing outside, or stimulatingactivities, such as computer games.
  • Television. Keep the television set out of your child’s bedroom. Children can easily develop the bad habit of “needing” the television to fall asleep. It is also much more difficult to control your child’s television viewing if  the set is in the bedroom.
  • Naps. Naps should be geared to your child’s age and developmental needs. However, very long naps or too many naps should be avoided, as too much daytime sleep can result in your child sleeping less at night.
  • Exercise. Your child should spend time outside every day and get daily exercise.