Sleep Management in Children Explained

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Read what Dr Theodric Lee, Paediatrician at Thomson Paediatric Centre, has to say about how much sleep your child needs, and why and how to recognise sleep disorders.

What is your child’s ideal bed time? How many hours should your child sleep in a day? How many naps should your child take? Do you think your child has a sleep disorder?

Almost every parent has concerns about their child and his or her sleep patterns. In this article, Dr Theodric Lee, Paediatrician at Thomson Paediatric Centre, provides detailed insights on sleep management for your children.

How much sleep does a child need on average

The recommended amount of sleep per day for your child depends largely on his age.  See the following as a guideline:

  1. Newborns (below 2 months): 14 – 16 hours (including naps)
  2. Infants (2 – 12 months): 12 – 14 hours (including naps)
  3. Toddlers (1 – 3 years): 11 – 13 hours (including naps)
  4. Preschoolers (3 – 6 years): 10 – 12 hours (including naps)
  5. School age (6 – 12 years): 9 – 11 hours
  6. Teenagers (12 – 18 years): 8 – 10 hours
  7. Adults (>18 years): 7 – 9 hours
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Infants, preschoolers, teenagers and adults — all need different amounts of sleep.

There is great variation of sleep requirement between individuals. The best test of your child’s sleep requirement is to observe if he is refreshed in the daytime, generally well-behaved, as well as learning well and paying attention in school.

A word of caution – many parents report that their child is “over-active” or “high”, especially in the evenings and that they have difficulty sleeping at bedtime; this is often a sign of “over-tiredness” instead.

It is also important to note that sleep requirement guidelines are mostly derived from research in predominantly Caucasian populations, and that research shows that children in predominantly Asian populations sleep less on average than children in countries of predominantly Caucasian populations1. It is currently unclear whether this is due to a biological differences in sleep requirement between ethnic groups, or due to differences in cultural norms and that children in Asian populations are simply more sleep deprived.

There are currently no sleep requirement guidelines specifically for Asian children; nevertheless it is my opinion that it should not be significantly reduced when compared with the above guidelines.

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Adequate amount of sleep is important for a child’s physical and cognitive development.

Importance of adequate sleep

Sleep is important for both physical health as well as cognitive health, both of which are essential for a developing child. Most beneficial effects to physical health take place in deep (stage N3) sleep, for example secretion of growth hormone.

Research has shown the ill effects of sleep deprivation on physical health, e.g. increasing the risk of obesity2. Sleep is also critical for learning and for development of good behaviour, with most beneficial effects taking place in dream (rapid eye movement) sleep, for example memory consolidation.

Sleep deprivation can have ill effects on learning, e.g. children and teenagers who slept for shorter durations were more likely to have poorer school performance3. It has also been shown that children with poorer sleep habits are more likely to have long-term behaviour issues e.g. attention deficit, anxiety, social problems4.

Click on the next page to learn more about signs of a sleep disorder in your child and how to manage it.

Signs of a sleep disorder

Although there are more than 80 classified sleep disorders and problems, it is useful to classify them into 2 big groups:

  1. Sleep disorders being physical diseases causing sleep disruption.
  2. Behavioural sleep problems which are disruptions in sleep in otherwise healthy children.

Obstructive sleep apnoea, or OSA, is the most common but often underdiagnosed sleep disorder in childhood. Apnoea is defined as pauses during breathing. In this condition, there is obstruction in the upper airway, usually due to enlargement of the tonsils and adenoids as shown in figure 1. Additionally, upper airway obstruction may be caused by increase in fatty tissue around the neck, especially in obese children

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Figure 1: Enlarged adenoid and tonsil in OSA.

It is a misconception that OSA is more common in adults. In one study5, the prevalence of childhood OSA was up to 5%. This is similar to adult OSA which has been estimated to be 4% in men and 2% in women more than 50 years of age6. OSA can occur at any age, including in infants. It is however particularly prevalent between the ages of 2 and 8 years, coinciding with the peak age of enlargement of the adenoids and tonsils.

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If you child is a habitual snorer or has restless sleep, they could be signs of a sleep disorder.

Symptoms of childhood OSA can be divided into night-time and daytime symptoms, of which the most important is habitual snoring. Common symptoms are summarized below:

Night-time symptoms

  1. Habitual snoring: Defined as snoring 3 or more times a week.
  2. Apnoea: Pauses in breathing witnessed by parent.
  3. Heavy breathing: Parents may describe their child struggling to breathe at night.
  4. Restless sleep: Increased movements during sleep.
  5. Abnormal sleeping postures: e.g. sleeping with neck hyperextended, mouth-breathing during sleep

Daytime symptoms

  1. Cognitive problems: Decline or delay in language skills, memory or school performance.
  2. Behavioural problems: Hyperactivity, mood disorders or poor social skills.
  3. Excessive daytime sleepiness: e.g. difficulty waking in the morning, falling asleep in school. Note that children may exhibit cognitive and behavioural problems rather than sleepiness.
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If sleep disorders are left unchecked they can lead to behavioural and cognitive disorders.

Why is it important to diagnose and treat OSA in time?

We have seen that daytime symptoms in OSA can result in cognitive and behavioural problems. Research has shown that treatment of childhood OSA improves cognitive and behavioural skills5.

There is also increasing evidence that OSA may affect the cardiovascular system from childhood and increase the risk of high blood pressure, heart disease and diabetes later in life.

Other sleep disorders in children

There are other sleep disorders in children which are often underdiagnosed, including periodic limb movement disorder, a condition where a child has frequent leg movements during sleep which disrupts sleep (this often occurs with restless leg syndrome in the daytime when a child complains of an irresistible urge to move the legs); as well as narcolepsy, a condition of excessive daytime sleepiness in unusual situations (e.g. when eating, walking).

Treatment methods for OSA in children

A proper assessment and diagnosis should be made before any treatment is put in place. An overnight polysomnography (PSG), also known as a sleep study, is the gold standard for making a definitive diagnosis of childhood OSA. Figure 2 below shows a typical sleep study setup. Overnight PSG should be performed by qualified sleep technicians and interpreted by doctors trained in paediatric PSG. Sleep study facilities are now available at Thomson Medical Centre.

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Figure 2: Sleep technician preparing a child for a sleep study

The main treatment modalities for childhood OSA are:

  1. Adenotonsillectomy: surgery to remove the adenoids and tonsils: This is the first-line treatment for childhood OSA, and results in complete cure in the majority of cases. However, follow-up is required for these patients, as regrowth of the adenoids after surgery occurs in a minority of children. Additionally, OSA persists in some children (especially obese children) after surgery, and these children may require positive airway pressure.
  2. Continuous positive airway pressure (CPAP): In cases where surgery cannot be performed or if there is persistent OSA after surgery, positive airway pressure (see figure 3) can be delivered via a mask to “splint open” the upper airway during sleep.
  3. Weight management: All children with OSA who are overweight or obese should be encouraged to lose weight via dietary modification and by regular exercise.

 

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Figure 3: Diagram of CPAP machine and mask. There are various machines and mask-types available commercially. 

 

Click on the next page to learn more about common behavioural sleep problems in children and how you can help them sleep well.

Common behavioural sleep problems in children

Behavioural sleep problems are very common in children, but are often dismissed as “normal” by parents and even doctors. In a 2012 Singaporean study7, about 25-50% of children were found to have a sleep problem!

“Night-wakings”: negative sleep associations

About 25% of Singaporean children have a problem with “night-wakings”. The common scenario is a baby or young child waking up several times in the night, and requiring an intervention by a parent in order to fall asleep again – commonly feeding milk and/or rocking the child to sleep.

To understand “night-wakings”, one must understand that the term “night-wakings” is misleading, because a healthy person (both child and adult) has several short awakenings (some children even up to 10 per hour) in his normal sleep structure. We usually do not remember these short awakenings when they are very short (a few seconds to less than a minute).

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If your baby has not learnt to self-soothe then the short night awakenings can become longer and lead to crying.

However, a short awakening has the potential to become a prolonged awakening if a child has not learnt to soothe himself to sleep (self-soothe) at bedtime. A typical scenario is when a child is fed milk (or breastfed) to sleep, or rocked to sleep at bedtime. When the child has a short awakening in the middle of the night, he is unable to self-soothe and cries for his parent – he is only able to sleep when he is given the same intervention he received at bedtime.

Hence a child who is fed to sleep at bedtime will want to be fed to sleep when he awakes in the middle of the night, a child who is rocked to sleep will want to be rocked to sleep when he awakes, and so on. This inappropriate intervention by his parent is called a negative sleep association.

It is a myth that a healthy baby older than 6 months requires middle-of-night feeds – this is more likely due to a negative sleep association. It is also a myth that children with sleep problems often outgrow them – it has been shown that 84% of children with sleep problem at 1-2 years of age, continue to do so at 3 years8.

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Does your child resist bedtime? It could be a sign of a deeper problem.

Bedtime resistance

Another common behavioural sleep problem (often co-existing with negative sleep associations) is bedtime resistance, which is common in toddlers. This may manifest in several forms – the child stalling for time before bedtime (e.g. “just one more TV show”, “just some more time to play”), taking a long time to fall asleep (more than 30 minutes), outright tantrum and refusal to go to bed, refusal to sleep in his own bed or bedroom, or coming to the parents’ bed or bedroom in the middle of the night (“curtain calls”).

This is primarily a discipline issue, and reflects a lack of boundaries and rules surrounding bedtime.

Click on the next page to find out tips that can help your child sleep well.

Tips to help your child sleep well

There are 3 basic steps to manage behavioural sleep problems.

  1. Regular sleep schedule

Ensure that your child has sufficient sleep, because sleep begets sleep. An over-tired child is often cranky and “over-active” during bedtime and difficult to settle to sleep. Fix a regular time for bedtime, and a regular time for wake time, for these help to adjust your child’s body clock (via secretion of melatonin by the brain).Keep lights dim 1-2 hours before bedtime (tip: you can use night lights, and reading lights that do not shine directly on the eye), and these include screen light like TV and smartphones/tablets which have been shown to suppress melatonin secretion and make sleep initiation difficult! Expose your child to bright sunlight during wake time – this is refreshing and also regulates the body clock. Naps are important to most children preschool age and below, and offer them at regular timings as well (child care centres do a good job in ensuring this).

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A defined sleep schedule and a regular bedtime help children sleep well.

  1. Bedtime routine

A bedtime routine is a set of 3-4 relaxing activities just before bedtime. It is a signal to go to bed, especially for young children who have not learnt to tell the time, and is an invaluable time of bonding for the family as well. These activities can be anything relaxing, e.g. brushing teeth, changing pyjamas, saying prayers, singing lullabies/songs, reading a bedtime book; it usually lasts about 10-30min.

It will be more effective and enjoyable to keep the order and content of the routine similar from night-to-night, and to do the most enjoyed activity last and in the child’s bedroom. A similar but shortened version of the routine can be used before naptimes as well.

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Put your baby to bed when they are drowsy but still awake.

  1. Put down drowsy but awake

This is a critical step in sleep training, but the most difficult as well. The child has to eventually learn how to self-soothe to sleep, and the parent has to put the child in bed drowsy but not asleep yet. For a child already with negative sleep association or bedtime resistance, the parent will meet great resistance the first few times this is tried. In these circumstances, it is my practice to employ a technique called planned ignoring and checking (called graduated extinction in medical terminology).

The child is left to cry while the parent leaves the room for a short period (typically a few minutes). The parent comes back to pat the child and reassure him in a neutral manner for a short period (about a minute) and leaves again. This cycle is repeated with the parent outside the room longer each time, and he does a final check when the child is asleep.

This method conveys the message that “daddy or mummy loves me, but I have to work so hard to get his/her attention that it isn’t worth the effort”. For this method to work, all caregivers in the household have to agree (think: grandparents, domestic helpers etc.), and persistence is essential even though the crying may worsen for a few days before improving – if not the child learns that “mum and dad will give in to me as long as I cry very hard”.

Research has not shown any harm in employing this technique, but rather benefit to both parent and child, for e.g. improves parent-child relationship9. It is recommended to seek advice from a behavioural sleep specialist for a tailored sleep training programme to ensure best results. There are modifications available to make sleep training gentler depending on the family’s situation.

 

This article has been written by Dr Theodric Lee, Paediatrician with special interest in respiratory and sleep medicine, Thomson Paediatric Centre at Thomson Medical. He is also a Visiting Consultant, Respiratory and Sleep Service, KK Women’s and Children’s Hospital.

 

References:

1.      Mindell JA, Sadeh A, Wiegand B, How TH, Goh DY. Cross-cultural differences in infant and toddler sleep. Sleep Med. 2010 Mar;11(3):274-80.
2.     Ayas NT. If you weigh too much, maybe you should try sleeping more. Sleep. 2010 Feb;33(2):143-4.
3.     Dewald JF, Meijer AM, Oort FJ, Kerkhof GA, Bögels SM. The influence of sleep quality, sleep duration, and sleepiness on school performance in children and adolescents: a meta-analytic review. Sleep Med Rev 2010;14(2):179–89.
4.     Yokomaku A, Misao K, Omoto F, Yamagishi R, Tanaka K, Takada K, Kohyama J. A study of the association between sleep habits and problematic behaviors in preschool children. Chronobiol Int. 2008 Jul;25(4):549-64.
5.     Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Ward SD, Sheldon SH, Shiffman RN, Lehmann C, Spruyt K; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):e714-55.
6.     J. Strollo Jr., R.M. Rogers. Obstructive sleep apnea. N Engl J Med, 334 (1996), pp. 99–104.
7.     Aishworiya R, Chan P, Kiing J, Chong SC, Laino AG, Tay SKh. Sleep behaviour in a sample of preschool children in Singapore. Ann Acad Med Singapore. 2012 Mar;41(3):99-104.
8.     Kataria S, Swanson MS, Trevathan GE. Persistence of sleep disturbances in preschool children. J Pediatr. 1987 Apr;110(4):642-6.
9.     Hiscock H, Bayer JK, Hampton A, Ukoumunne OC, Wake M. Long-term mother and child mental health effects of a population-based infant sleep intervention: cluster-randomized, controlled trial. Pediatrics. 2008 Sep;122(3):e621-7.