SLEEP, O Glorious Sleep! By Mark B. Levin, M.D. and Timothy J. Patrick-Miller, M.D. The Pediatric Group, P.A., Princeton

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Most parents feel sleep-deprived during the first few weeks of their child's life. For an unfortunate few, sleep deprivation can continue months. Understanding several factors that influence how a baby sleeps can help parents better cope and ameliorate their baby's sleep problems.

Since newborns grow rapidly, faster than any other time in life, most newborns require feedings every few hours (only fetuses grow faster, but they are continuously fed via the umbilical cord!). Frequent feedings, unfortunately, preclude prolonged sleep. So while parents usually prefer six to eight hours of uninterrupted sleep, babies require frequent short intervals of sleep. Happily, a baby's growth and the frequency of nocturnal feedings eventually slow down.

Total sleep requirement in a twenty-four hour period is greatest for a newborn and decreases with increasing age. A 32-week gestation preemie will spend twenty-one to twenty-two out of twenty-four hours sleeping. A two-year-old averages thirteen to fifteen hours of sleep; a four-years-old, twelve hours, an eight-year-old, ten hours, a sixteen-year-old, eight hours; and a healthy fifty-year-old will rarely sleep more than six hours at night. Nighttime sleep duration (though not always continuous) peaks at about twelve months of age and lasts, on average, eleven and one-half hours. Most children consolidate their naps from two to one between one and two years of age and give up their naps altogether by three to four years old. Statistics, however, never tell the complete story. All of us know someone who gets by with minimal sleep. Although we marvel at their ability, we can not emulate them however hard we try. Some people simply have a genetic ability to revive their energy after a brief rest. Certain genetically determined needs can be recognized as early as infancy. When the union between parents results in a child whose needs replicate one parent but differ starkly from the other, the odd-parent-out is left with little alternative but to learn to cope with the difference. Before concluding that your baby has a sleep disorder, evaluate whether your baby is content, growing and spacing feedings at least one and one-half hours apart. If so, your baby is probably demonstrating normal individual variability, and the problem is likely not a sleep disorder but a poor fit between parental and child needs.

If innate individual differences is the problem, the solution is creating a lifestyle that will satisfy both your and your baby's needs. Taking a nap when the baby naps, tag-teaming the nighttime baby care chores with your mate, utilizing the services of a baby sitter, neighbor or family member and foregoing some of the non-essential housekeeping tasks are all practical strategies. While you might experience guilt when you require more sleep than your child; remember these innate differences are not voluntary. Parents need not feel guilty that they require rest, nor should they blame their infant or spouse for an inherited less stringent sleep requirement. Simply accept these differences as a fact of life, make adjustments and move on to life's next challenges!

Other factors can certainly modify sleep habits. While some infants tend to sleep more soundly when prone, The American Academy of Pediatrics recommends all infants sleep on their back to prevent Sudden Infant Death Syndrome (SIDS). A baby will grow accustomed to back-sleeping, but the process may take several weeks. Similarly, some parents enjoy longer periods of sleep when they co-sleep with their infant, but some experts discourage co-sleeping because of the risk of infant suffocation, especially when the parent has partaken of alcoholic beverages. A soundly sleeping parent may not be aware of the threat their body position poses to their infant.

Hunger is primal. However, it is important not to be fooled into thinking that every awakening calls for a feeding. If a baby is growing well (your pediatrician can help you determine that) and has plenty of urine and stool output (you can tell that on your own), nighttime feedings are rarely necessary after six months of age. Unnecessary feedings will not only add to the child's body burden of fat but can also condition a child to feed at socially disadvantageous times, creating an undesirable habit that is very difficult to break.

The younger the child, the more time during sleep they devote to dreaming in rapid-eye-movement, or REM, sleep. We all experience anxiety-producing dreams, usually four to eight hours after falling asleep, as a result of daily life events. Parents will either brush off their thoughts or use the opportunity to derive plans for alternative behaviors to avoid the adverse experience in their dreams. Having dealt with their dreams rationally, they resume sleep, often unaware of the process they underwent. An infant, however, has not yet developed the ability to rationalize, so fear determines their reaction. Exploring peer interactions and minimizing unpleasant daytime experiences will likely decrease the frequency of nightmares. A reassuring, consistent and supportive approach at night will teach your baby that dreams are not to be feared. During a nightmare, soothe the child and coax him or her back to sleep. Resist the temptation to entertain your baby during the night to avoid inadvertently conditioning awakening.

Night terrors, which may be related to sleepwalking (somnambulism) later in childhood, are often confused with nightmares. The cause of night terrors is unknown, but they are not dream-driven. Children experiencing night terrors seem awake (and the parents certainly are awake!) but, in reality, they are still asleep, emerging from a deep non-REM sleep stage, typically within two hours of falling asleep. Usually by seven years of age, although sometimes not until early adolescence, children outgrow night terrors. No parental intervention is necessary, or has been demonstrated effective, except, perhaps, scheduled awakenings (see below).

Colicky behavior can cause sleep disruption. If a baby wants to suck but refuses the breast or bottle while arching his/her body or doubling over, you can reasonably assume the problem is either a food intolerance, poor burping technique or gastroesophageal reflux. Your baby's pediatrician will be instrumental in helping you deal with these issues.

Among the myriad behaviors and physical changes we blame on teething (without much justification other than stories handed down from generation to generation), sleep disruption tops the list. Folklore dictates that if a baby drools excessively, has a rash on his/her cheeks and is fussy, especially between the ages of five and twenty-four months of age, teething is the likely culprit for nighttime awakenings. Of course, if an infant is in pain from erupting teeth, feedings may be decreased, so one might guess that hunger plays a role in the baby's behavior. Does teething pain occur before, during or after the teeth erupt? No one knows for sure, but many have an opinion. Suffice it to say, if an infant in this age group has these behaviors and you can find no other explanation for the symptoms, you can safely assume the problem relates to teething. Sometimes, a visit to the pediatrician is needed to exclude illness a parent can not diagnose, such as an ear, throat or urinary infection. Teething pain is most often intermittent. If a baby is irritable continually, you must consider other causes.

The treatments promoted for teething are nearly as plentiful as the symptoms ascribed to teething. That should alert you to the fact that there is no reliably successful treatment. Fortunately for the baby, older children and adults do not usually recall having experienced infant teething symptoms. Some parents opt for oral pain medication, such as acetaminophen (at this writing, ibuprofen is not FDA approved for infants less than five months of age). Others prefer topical anesthetics that are marketed as infant teething preparations. We discourage parents from using herbal teas (e.g., "gripe water") because, if given dilute, they are without effect and, if given concentrated, they can poison a baby.

Infants and toddlers can become ill with infections, usually acquired from an adult, an older sibling or a peer during a play activity or in day care. Most infections that disrupt sleep are acquired through the respiratory tract and are often associated with fever in the infant and young child. Consequently, nasal congestion and fever are reliable signs of infection. In this situation, as with colic, your pediatrician is a valuable resource. The treatment you offer should be specific to the symptoms and the illness that is affecting the baby.

Numerous authors have described methods for encouraging babies to go to sleep. Two points are worth considering in this regard. First, if an infant is content to entertain him or herself without your constant attention, there is no need for you to bear witness to that independence. You are free to go to sleep. If your baby needs you, you can rest assured that s/he will make enough of a racket to get your attention. Second, the precise method you choose to condition your child to sleep at night (or at least to leave you alone for a brief spell) is not as important as being persistent and consistent with that method. Children can be trained to be alone at night, just as they can be trained to be up at night. The method you choose should be based more on what is comfortable for you than on the impression that one method works better than another. Some parents choose to let a child fuss or cry him or herself to sleep. This method takes less time to be successful, usually less than one week, but entails more stress in that many parents dislike having to listen to their child cry for what seems like an eternity. If you choose this method and you are comfortable that the baby is not ill, you must make a pact with yourself and your partner not to go in to the baby for any reason once you put the baby to sleep. If you relent and go in to the baby's room, you will be encouraging the baby to believe that prolonged crying gets rewarded with your presence. When you subsequently leave again, the baby is likely to scream louder and longer, venting the fury s/he feels at being misled.

The alternative method is more of a weaning process which takes more time (usually several weeks) but is associated with far less crying (by both infant and the parent!). Parents start this technique by staying with the baby until s/he falls asleep at bedtime and at each nighttime awakening, sometimes at the crib-side, sometimes simply in the baby's room. In homes where the baby shares a room with the parents, a barrier, such as a hung sheet, should be erected to simulate separate rooms. After about a week, the parent stations her or himself at progressively greater distances from the crib. After several weeks, the parent has successfully weaned her or himself out of the room and the baby has learned to go to sleep without the parent being present. Variations on this style include staying with the baby until sleep is achieved but frequently leaving the room for progressively longer periods of time, or staying with the baby but leaving the room for progressively shorter periods of time. These methods intend to promote the baby's independence at bedtime while reassuring the baby that the parent is available.

A third technique is termed scheduled awakenings. An infant awakening at predictable times overnight suggests an arousal phase between sleep stages. The technique of scheduled awakenings involves gently disturbing the baby's sleep about fifteen minutes before the anticipated arousal phase. The first few nights, the baby is likely to awaken as usual. Eventually, when the baby has slept through the arousal phase for a week, the parent stops the pre-arousal intervention.

Lastly, environmental and scheduling factors will affect the sleeping habits of a baby, just as they will an adult. As much as possible notwithstanding the variability imposed on behavior by the various conditions cited above, parents should maintain a consistent bedtime for their child and a consistent (even to the point of boring) bedtime routine leading up to bedtime. Most parents establish a routine that lasts from twenty to forty minutes. The routine will vary according to the child's age. In infancy, the routine may simply be feeding, diaper change and a lullaby. As a child ages, the routine can be altered to include songs, reading or other quiet activities. The routine should not include active play or frightening experiences (even adults may have trouble sleeping after seeing a scary movie or violence on the news). The bedroom should be kept at a comfortable temperature (mildly on the cool side usually promotes more comfortable sleep) and free of bright light and noise. Equally important, arousal time in the morning should be consistent. Sleeping late engenders a later bedtime and skews the entire diurnal pattern.

If you are concerned that your infant does not fit one of the categories cited above or you are not successfully dealing with your baby's sleeping issues, contact your pediatrician for advice. A timely referral to a counselor may allow you in avoiding prolonged sleep deprivation.

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Timothy Patrick-Miller Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

ŠAll rights reserved, The Pediatric Group, P.A. 2004