Last partial update: July 2016 - Please read disclaimer before proceeding
Sleep in children
Good sleep is important for normal growth and development and helps improve a child's mood and behaviour, which in turn facilitates learning. It is also very important for parents.
How much sleep do children need?
- Young babies (first few months of life) - About 16 hours per day in short cycles
- Preschooler - 11 to 12 hours
- Primary school-aged child - 10 hours
- High school adolescent - 8 to 9 hours (They often do not achieve this due to TV, and computer / internet use.)
- Adult - 7 to 8 hours
These figures are approximate and can vary in individuals by up to an hour or two either way and it is therefore important to ask about tiredness, behaviour and ability to concentrate during the day when assessing whether a child is getting adequate sleep.
Establishing a good sleeping routine and environmentis important for all children
There are several factors that are important in ensuring children have a good night's sleep.
- Providing a good sleeping environment: The room should be quiet, dark and well ventilated. The bed should be comfortable and have appropriate bedding so that they are not too hot or too cold. Socks are a good option for cold feet. Hot water bottles should not be used due the risk of scalding.
- Establishing a regular sleeping routine: Children should go to bed at roughly the same time each night. Both parents need to be consistent with this policy. There should be a routine of cleaning teeth and going to the toilet before going to bed and a story that does not cause them to become too excited or scared.
- Avoiding needing to go to the toilet during the night: The best way to do this is to avoid having excessive amounts of fluids before bedtime and making going to the toilet immediately before going to bed part of their 'bedtime routine'.
- Ensuring that their bedroom is a TV / computer free zone: One of the most important things a parent can do to improve their family life is to make sure that TVs and computers are NEVER allowed into bedrooms. This prevents older children staying up late at night watching TV, playing computer games or being on the internet. Mobile phones should also be left outside the bedroom after bedtime. Such a policy will be difficult to police in adolescents if it has been allowed at a younger age.
Advice for children who have problems getting to sleep
- Avoid stimulants before bedtime if getting to sleep is a problem: Caffeine-containing foods, including chocolate, tea and coffee products, should be avoided for several hours before bedtime if children are having problems going to sleep.
- Increasing activity: Tiring the child out by increasing afternoon physical activity can be very helpful in improving sleep and helps regarding health in general. Physical activity close to bed time should be avoided as it increases body temperature and this makes getting to sleep difficult.
- Reduce sleeping time: It may be that the child does not need the amount of sleep that he or she is getting. If the child is not tired during the day then it is reasonable to try reducing sleep by:
- Reducing / stopping day-time naps if the child is still having them.
- Pushing back bed time
- Giving them their own room: Interaction with other siblings may cause problems getting to sleep.
- Addressing fears / anxiety about going to sleep: Many younger children have fears about being left alone in a dark room. Addressing these fears in a concerned manner rather than dismissing them as being silly will usually be sufficient to fix the problem. (It may well require ongoing discussion and reassurance.) Occasionally children with significant anxiety problems will need counselling.
Nightmares and Night terrors
Waking at night in fright is non uncommon in childhood and there are two principal causes.
Night terrors: These episodes involve the young child waking up very agitated and upset and sometimes actually screaming. The child is initially only partially awake and is not aware of his or her surroundings or the parent’s presence and may speak strangely. It takes about 5 to 15 minutes to become fully awake. They occur only once per night, usually within a couple of hours of going to sleep, and the child has no recollection of them in the morning. They often occur for several nights in a row and then go for a period of weeks or months. They are not significant and require explanation only. As the child has no recollection of the event, they can usually be put back to sleep.
Nightmares: These occur at all ages and differ from night terrors in that the child is initially fully awake (and upset) and has some recollection of the event, thus making it difficult for the child to get back to sleep. Parents need to talk about the episode with the child, explaining the cause and providing reassurance. They are less common than night terrors in young children.
In both cases it is best to try to keep to a policy of keeping children in their own beds most of the time. Regularly coming in to sleep in the parent's bed should be discouraged as it does not resolve the child's problem / fears and certainly does not help parents get a good night's sleep. If there is a specific cause of anxiety this can be discussed and removed if possible. Star charts with rewards can be used to keep children in their own beds. Again, children with chronic, deep-seated anxieties may need some counselling.
Obstructive sleep aponea in children
Obstructive sleep aponea (OSA) is an interruption in breathing due to an anatomical blockage in the airway. Children of all ages can suffer from this condition but it is most common in the two to six year age group when tonsil and adenoid enlargement occurs at a greater rate than the normal growth of the surrounding pharynx, causing an upper airway blockage. Removal of tonsils and adenoids fixes the problem in 85 per cent of cases.
Snoring is the most common symptom but it occurs in many children without OSA. Snoring that occurs in all sleeping positions and every night and is associated with pauses in breathing is more likely to indicate the presence of OSA. Frequent pauses in breathing at night together with altered behaviour and poor concentration during the day indicates a more serious problem exists. Only more troublesome cases require treatment and often mild cases can be conservatively managed, with the child gradually growing out of the condition over a period of years.
Diagnosis in cases where the problem appears significant is usually done through a sleep study. OSA that results in more than 10 to 15 breathing pauses per hour generally requires surgical removal of adenoids and tonsils. Occasionally continuous positive airway pressure via nasal prongs is also needed in more severe cases.
Sudden infant death syndrome (SIDS)
Sudden infant death syndrome (SIDS) is defined as the sudden death of a child under the age of 12 months where no reason can be found for the death. (A reason is only found in about 15% of such sudden deaths.) Most cases occur in the first six months of life and are due to the children smothering in their beds. It is an infrequent event with an overall incidence of about one in 1300 infants. The critical issue in reducing the incidence of SIDS to ensure that babies are placed on their backs when going to sleep and the 'Back to sleep' campaign that has promoted this practice has more than halved the incidence of this tragic event. Placement of infants on their stomach or on their side must be avoided always as it increases the risk of suffocation. Babies also need to be positioned so that they can not roll over on to their stomachs. This is best achieved by placing them with their feet at the foot of the cot and ensuring all bed clothes (blankets and sheets) are well tucked in.
The best mattress is a firm one with no side bumpers. There should be no loose bedding or other items in the cot including doonas, snuggle rugs, pillows, duvets, sheep skins and soft toys etc. These should be kept out of the cot. The infant should mot be overly wrapped and it is also best if the room is not too warm. It is best if twins sleep in separate cots. If they do sleep together, they should be placed with heads facing towards the centre with separate covers tucked in at each end.
Not smoking during pregnancy and not smoking near babies (especially if they are sleeping) is also a very important way to reduce the risk of SIDS. Sleeping with an infant on a sofa or a chair can increase the SIDS risk as can sleeping in bed with a baby and these practices should be avoided. Breastfeeding may reduce the incidence of SIDS. Using a dummy at sleeping time may also help reduce SIDS, although it is not critical and parents who have decided not to use them should probably not worry unless there is particular concern regarding the baby’s risk of SIDS.
Continually sleeping on their backs has led to an asymmetrical moulding of the head in some babies. To avoid this, it is important that babies are placed on their sides or front for some of the time when they are awake. The baby must be supervised (i.e. watched by a responsible person) when this is done and should not be left unattended in this position. A good time to do this is when either parent is playing with their baby.
Immunisation is not a cause of SIDS.
As stated above, the adoption of the above recommendations has reduced the incidence of SIDS by about 62 per cent from 1990 to 2000 and it is still falling.
Apparent life-threatening events: Some infants experience what are termed 'Apparent life-threatening events', where the child is seen to be not breathing, often appears blue or pale, and may appear 'floppy'. Such events are associated with an increased risk of SIDS with a mortality rate of up to 10%. Infants who suffer such an episode should be immediately taken to a paediatric hospital (or other hospital where a paediatric hospital is not available) for assessment. (They are usually admitted to hospital.) All parents who have a child who has had one of these episodes should have formal training in CPR (cardiopulmonary resuscitation).
Further reading
Ferber, R. Solve your child's sleep problems. Simon & Schuster, New York, 2006.