Child Care: Sleeping Problems in Childhood

They can be divided into three broad categories:

1. Bedtime struggles: The child finding it difficult to fall asleep.
2. Night waking: The sleep of the child is interrupted during the night.
3. Parasomnias: Nightmares, night walking, night talking and night terrors.

1. Bedtime struggles

It appears that children are in a state of continuous and everlasting love with life and thus are reluctant to withdraw from the events of the day. Hence in spite of their feeling sleepy, they are reluctant to sleep, not wanting to terminate their social activities and wanting to explore and learn more what life is all about. As the child grows older, a struggle for autonomy and independence with his parents regarding who actually is in control of his life may lead to bedtime struggles.

The most important cause for bedtime struggles is an absence of clear cut and consistent limits set by the parents regarding acceptable bedtime behaviour. There may be lack of a fixed bedtime i.e. the child goes to bed sometimes at 8 p.m. and sometimes at 10 p.m. depending upon when the parents go to bed. If the child sometimes sleeps in the afternoon and sometimes not, his night routine will also be disturbed leading to bedtime struggles. So either the child should have an afternoon nap consistently or forgo it completely.

A regular routine allows a circadian (day and night) sleep rhythm to develop. The best remedy for bedtime struggles is that the parents firmly deal with it and set a definite time for “lights out.” If the child resists going to bed, just ignore it and put him to bed at the same time every day. However if you find that the child routinely is keeping awake even 1 hour after being put to bed, it means that the child is not sleepy at that time and so you have to postpone putting him to bed by say half an hour the next time.

Gradually, by trial and error, you will know the appropriate time for putting the child to bed. Having established a regular sleep routine, the parents should put him to bed at that particular bedtime hour every night. Suppose the child goes to bed at 9 p.m. Now if parents put him to sleep at 8 p.m. one day (because they are tired), bedtime struggle may ensue, as the child won’t sleep before the accustomed time.

After being put to bed, the child may try to engage parental attention in various ways like I want water, I want to go to toilet etc. All this is in spite the fact that the child recently had been to toilet or had drunk water. Parents should be firm in not responding to these demands of the child, who uses them to gain parental attention and postpone his sleep.

Don’t bow to these requests (these are just excuses), but rather handle them in a firm but neutral fashion, without getting irritated at the child. For e.g. you can tell him firmly that he just had water or just had peed. If he still insists, firmly tell him that you won’t do it as you feel that it is not necessary. When children realise that nothing will help, no matter what they do, they usually give in to their fatigue and fall asleep.

Other measures to help in making the child sleep are to have a pleasing and relaxing bedtime routine. This may involve bathing the child before bedtime, changing his clothes to a comfortable nightwear, telling him his favourite story etc. Then again, a favourite toy or doll kept beside him, which he likes and enjoys, is a big help in “winding” him down so that he can fall asleep.

2. Night waking

In this, the child frequently arouses from sleep and does not go back to sleep easily, causing discomfort to the parents. It should be kept in mind that almost all children wake up in the night. During the stage of partial arousal, they may moan, but if the parents reassure them verbally and pat them, they will go back to sleep. This is normal. But if night waking is prolonged so that the parents also have to be awake and make all sorts of efforts to put him back to sleep, then it is a problem. There are various reasons why the child does so, and once the parents understand them, the remedy lies in eliminating them.

1. The child routinely doesn’t go to sleep without some sort of active parental intervention like rocking him, carrying him etc. So when he gets up at night, he again requires an active parental intervention for sleep re-induction. Therefore the parents should gradually cut down on their active interventions to lull the child to sleep so that the child is conditioned to sleep without these interventions.

2. Some of the parents are over sensitive, and as soon as the child starts moving or whining in bed, they pay much attention to it. At the slightest noise from the child, the parents will sit up in bed, pick the child up, fondle him and make a lot of fuss about it. This is counterproductive as it perpetuates and encourages night waking. The treatment strategy is to delay the parental response to the baby’s whining for several minutes so as to give an adequate opportunity to him to fall back asleep. Picking the child up is not to be done. Instead the parents should rely on verbal reassurance and gently patting him.

3. Another reason may be that the parents are giving the child middle of the night feeds, e.g. a bottle of milk. Feeding at night is a learned habit after the age of 6 months. Normally, a child after 6 months of age doesn’t require nighttime feeds, unless parents have made this a learned habit, in which case the child will frequently awake at night. The solution is to initially make the night feedings “brief,” substitute it with water and then gradually to cut it down completely.

Finally and most importantly, if the parents are firm and can continually ignore waking, whining and fussiness of their child in the middle of the nights (this may result in increased crying initially, which the parents have to ignore completely), the problem is solved within a week.

3. Parasomnias (nightmares, somnambulism etc.)

Parasomnias are specific events happening only during sleep. These are of 4 types:

i. Nightmare: It is a bad, frightening dream. An occasional nightmare occurs now and then in most individuals throughout life and is normal. But if the nightmares are recurrent, cause frequent nightime awakenings and also distress during the daytime (by recollecting them), it is troublesome. A child awakening immediately after a nightmare will be alert and remember the contents of the dream. If he doesn’t wake up, then next day he can recall the dream, if not completely, at least partially.

To reduce nightmares, the child should not be allowed to watch or listen to horrifying, violent or frightening things, especially prior to bedtime. Neither should the child be made to believe and imagine about ghosts, devils, spirits etc. Parents, particularly if their child is not behaving properly and irritating them, sometimes try to frighten the child into submission by the idea of ghost e.g. they may say, “if you don’t behave, the ghost will come and take you.” A night-light or keeping the door slightly ajar also may help to alleviate the childhood fears.

Whenever the child has a nightmare, the parents should reassure him that it is only in his dreams and that nothing of this sort happens or is going to happen in real life. The best way is to talk out the contents of the dream and convince the child that the dream is over and that he is safe in bed. By and large nightmares do not have an adverse effect on the psyche of a child, unless they are frequent, in which case a psychological assessment may be needed.

ii. Night terrors: The child becomes frightened and agitated in the middle of his sleep. He may scream, cry, thrash around; his eyes may be open and dilated and give the appearance of a “glassy stare” ahead. But although seemingly awake, the child actually is in a state of deep sleep and difficult to arouse, so much so that he even refuses to acknowledge parental presence in the bed. Upon awakening, the child has no memory of the event (compare it with nightmares). Although frightening to the parents, night terrors are benign and self-limited.

The parents should not worry about it. The only thing required of them is to simply observe the child while he is having such an episode and not to intervene by trying to wake him up, because it only prolongs the event. When night terrors are too frequent and disturbing to the parents (it never harms or disturbs the child, as he doesn’t have any memory of it!), then several nights of anticipatory awakening before the usual time of the event will eliminate future episodes. Supposing the child is having recurrent episodes at 3 a.m. Then the parents should awaken him at 2.45 a.m. for several nights (i.e. before the event actually takes place). This is recommended only when the night terrors are a source of chronic stress to the parents.

iii. Sleep walking: Also called somnambulism, it is a phenomenon in which the child gets out of bed and then moves about in a confused and clumsy state. As is the case with night terrors, the child seemingly appears awake, but actually he is in a state of deep sleep and difficult or impossible to arouse to full awareness.

The treatment lies in the understanding that the condition is self-limiting and not dangerous to others. The parents should not make efforts to “shake” the child to wakefulness as it may lead to agitation. Rather, the environment should be made safe so that the child doesn’t self-injure himself; the child merely observed and gently led back to bed. As in the case with night terrors, if the episodes are frequent and disturbing, then several nights of anticipatory awakening before the usual time of sleep walking is of help.

iv. Sleep talking: In this benign condition, the child utters something while asleep. The parents are often aroused and alarmed by their child’s verbalisations. It may persist throughout life, but the condition is benign. No treatment is warranted for it.

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