Healthy Sleep Habits, Happy Child Read online

  Rarely, some parents want to let their child cry to help him sleep after the peak of fussiness and crying has passed at six weeks of age, but he is under four months of age. One example is the mother who has to return to work and desperately wants to see if her child will sleep better at night with less attention. Another example is the exhausted and overwhelmed mother who is becoming depressed or getting angry or resentful toward her baby. Under these and similar circumstances, I usually try to enlist the assistance of the father to help his wife put the baby to sleep, to feed and soothe the baby at night, and to try to give the mother a well-earned break by making her go somewhere for several hours or a night to get some uninterrupted sleep. Obviously, these suggestions are impractical for some families. Nevertheless, the instructions are to give the child less attention at night, perhaps feeding only twice at night, and ignoring crying for either brief or long periods of time and to do this for only four or five nights. Sometimes the crying quickly diminishes, especially in the child who had common fussiness. Sometimes the crying does not decrease, especially in the child who had extreme fussiness or colic, and the plan is abandoned. Parents then resort to whatever method maximizes sleep and minimizes crying until the child is older.

  Action Plan for Exhausted Parents

  Healthy Sleep

  Think of “healthy” sleep as a collection or group of several related elements grouped together to form a “package.” All must be present to ensure good-quality or healthy sleep. The five elements of healthy sleep are:

  1. Sleep Duration: Night and Day

  Does your child sleep as long as she needs at night and for naps?

  How long your child needs to sleep depends on her age and temperament. Restricted sleep impairs mood, performance, development, and cognitive ability.

  2. Naps

  Is your child taking naps or do you sometimes skip naps?

  If a nap has been missed, try to keep your child up until the next sleep period in order to maintain the timeliness of the sleep rhythm. Move the next sleep period a little earlier before your child becomes extremely overtired. If the naps are too long because your child has become overtired; you might have to wake him from a nap in order to maintain the timeliness of the sleep rhythm at night. The morning nap develops before the afternoon nap and disappears before the afternoon nap. Not all naps are created equal. Babies are born to be short or long nappers. An earlier bedtime may be required when two naps are needed but you can get only one.

  3. Sleep Consolidation

  Is the sleep interrupted (fragmented) or uninterrupted (consolidated)?

  Some arousals from sleep normally occur. Some arousals are protective. Too many arousals fragment sleep and this causes impairments in mood and performance.

  4. Sleep Schedule, Timing of Sleep

  Do naps start and bedtimes begin just when your child is becoming drowsy?

  A bedtime that is too late will produce an abnormal daytime sleep schedule. Variability in activity and length of naps causes some variability in the bedtime. Watch your child more than the clock.

  5. Sleep Regularity

  Do naps or bedtimes occur at approximately the same times?

  Even if the bedtime is a little too late, regular bedtimes are better than irregular bedtimes.

  Back Sleeping Is Best to Prevent SIDS

  Learn to recognize drowsy signs—study the box on page 63.

  If your baby is colicky, begin the soothing to sleep after one to two hours ofwakefulness. Soothing to sleep involves:

  Getting dad to help out

  Encouraging sucking—do not worry if

  your baby falls asleep while sucking

  Rhythmic rocking motions

  Swaddling

  Massage

  HEALTHY SLEEP IMPROVES

  Mood, temperament, cognitive development, and performance.

  Resources for Soothing

  Consider a balance between the baby's disposition to express distress and the parents’ capability to soothe their baby. Not only do babies vary in their expression of fussiness/crying, but parents also vary in their ability to soothe. The resources for parents’ ability to soothe fussiness and crying and promote sleep in their baby include those shown in the box on page 74.

  Never wake a sleeping baby.

  Bedtime Routines

  Study the list on page 75.

  Breast-feeding versus Bottle-feeding

  and Family Bed versus Crib

  Breast-feed: All the time, part time (expressed breast milk versus formula), never.

  For about 80 percent of babies, the common fussy babies, mothers are better rested and feeding is mostly for nutrition. Breast-feeding is usually easy.

  For about 20 percent of babies, those with extreme fussiness/colic, mothers are fatigued from sleep deprivation. The stress from loss of sleep might inhibit lactation. Breast-feeding may be difficult because it is used for nutrition and soothing. Nursing more frequently and for longer durations might cause more discomfort or pain if the skin of the breast becomes cracked or dry. The mother might worry that not enough breast milk or her diet is causing the breast milk to upset the baby because of the extreme fussiness/crying. Consider a single bottle of expressed breast milk given once per twenty-four hours by someone else.

  Family Bed: All the time, part time, never, with or with out a cosleeper.

  For about 80 percent of babies, those who have common fussiness, an early commitment to a family bed usually works well. Sleep problems later are unlikely.

  For about 20 percent of babies, those with extreme fussiness/colic, an early commitment to a family bed may be associated with sleep-deprived parents for several weeks, but the strong soothing power of bodily warmth, close physical contact, sounds of breathing, or hearing a heartbeat when sucking at the breast, or the smell of breast milk may make the effort worth it. Sleep problems later might occur if the child is allowed to stay up too late when about four months old.

  During the day some parents with extremely fussy/colicky or common fussy babies are overwhelmed because they may have limited resources for soothing. For parents who initially did not want to have a family bed but later made that decision because of its soothing power, sleep problems are more likely to occur. The sleep problems are more likely to occur and persist not because of the family bed but because of the limited resources for soothing to continue.

  Solutions to Help Your Child Sleep Better: “No Cry,” “Maybe Cry,” or “Let Cry”

  Start early, when you come home from the hospital, to put your child to sleep within one to two hours of wakefulness.

  Study the list of sleep solutions on pages 103-104.

  Different solutions are needed for different babies.

  Does your baby require soothing more than three hours a day because he fusses or cries?

  Does this occur more than three days a week?

  Has this been going on for more than three weeks?

  If you answered “yes” to all three questions, your child has extreme fussiness or colic. Enlist all the soothing resources you can to help soothe your baby. If you want to, or if you need to, consider sleeping with your baby day and night for several weeks or months. Always hold your baby and always respond to her. Drowsy signs may be absent, so try to soothe her to sleep after one to two hours of wakefulness. Soothe your baby as long as needed to induce sleep. Motion may be needed during sleep to help your baby sleep longer.

  If you answered “no” to any of the questions, your child has common fussiness. Watch for drowsy signs developing within one to two hours of wakefulness. Soothe your baby and put her down or lie down with her when she is drowsy but awake. Motionless sleep may work well.

  Sleep Problems and Solutions

  Disturbed Sleep

  We really do not know how young children feel because they cannot talk to us; all we can do is observe them and guess their feelings. When they do not sleep well, their behavior changes and presumably they feel worse. I think we should care
fully consider how we feel and behave when our sleep is disturbed, so that we can better understand and sympathize with our children.

  Daytime sleepiness resulting from disturbed sleep typically causes us to feel a mild itching or burning in the eyes. Our eyelids feel heavy. Our limbs feel heavy, too, and we tend to be lethargic. We are less motivated, lose interest easily, and have difficulty concentrating. Our speech slows; we yawn and rub our eyes. As we get sleepier, our eyes begin to close and we may even find our head nodding.

  But this familiar picture of adult sleep is not usually seen in infants and young children who suffer from disturbed sleep. While it is true that infants who are usually well rested yawn on occasions when they are overtired, it seems that chronically tired infants do not yawn much or nod off. Instead, when most tired young kids get sleepy, they get grumpy and excitable. My first son at age three coined the perfect word to describe this turned-on state: upcited, a combination of upset and excited, as in “Don't make me upcited!” when we admonished him for behaving like a monster.

  Mood and Performance

  Before we look at common sleep problems, let's review how disturbed sleep affects mood and performance.

  REMEMBER

  When your infant or young child appears wired, he may be tired.

  Two very interesting Australian studies on adults have helped to shed light on childhood “upcited” behavior. One study showed that the level of activation of the nervous system was associated with certain personality traits, sleep habits, and activity of the adrenal gland. Poor sleepers were more anxious and had higher levels of the hormone cortisol, which typically rises during stressful situations.

  The second study was complex, but I think its results will better help you to understand your child's behaviors.

  Adult volunteers report their moods on four scales:

  Tired to rested

  Sluggish to alert

  Irritable to calm

  Tense to relaxed

  The first two scales reflect degrees of arousal, while the third and fourth scales reflect degrees of stress.

  The researchers measured four different chemicals (cortisol, noradrenaline, adrenaline, and dopamine) that our bodies make naturally. These powerful chemicals affect our brain and how we feel, and they are related to the four scales in different ways.

  For example, fatigue produces an increase in adrenaline concentrations. That is, when we are tired, our body chemically responds with a burst of adrenaline to give us more drive or energy. We become more aroused, alert, and excitable. Concentrations of cortisol, a stress-related hormone, also increase with increasing alertness. In children, cortisol concentrations remain high when they do not nap. Perhaps the nap allows the brain to be alert without needing the added boost cortisol would provide. Increasing irritability and tenseness—stress factors—are both associated with increasing concentrations of adrenaline, noradrenaline, and dopamine. Yet the specific chemical patterns or biochemical fingerprints for irritability and tenseness are not the same.

  These studies support the notion that when an overtired child appears wired, wild, edgy, excitable, or unable to fall asleep easily or stay asleep, he is this way precisely because of his body's response to being overtired. Think of how you feel when you work hard and lose sleep in order to finish a major project. You are highly motivated and fight the daytime sleepiness. The impairments of performance and discomfort of sleepiness increase. After a while, you feel keyed up. This hyperalert state is a natural, protective, biologically adaptive response that enabled Neanderthal man to fight, flee, or hunt prey even when tired. Thankfully, modern man is able to get out of this state by taking vacations. But have you noticed how, at the start of a vacation, it takes a few days to unwind?

  IMPORTANT POINT

  Some chronically tired children are always keyed up and never unwind.

  It's a vicious circle: sleep begets sleep, but sleeplessness also begets sleeplessness. When babies miss the sleep they need, the fatigue causes a physical or chemical change in their bodies. These chemical changes directly affect their behavior and interfere with maintaining either the quiet alert wakeful state or blissful sleep. The children are fractious because they are overtired.

  Other studies also have proven that adults who sleep for only brief durations are more anxious. When we study adults who are irritable, feel tense, are poor sleepers, and have high concentrations of these hormones, we find the old chicken-or-egg dilemma: Which came first?

  I think an experience familiar to all of us can help resolve the dilemma. As previously described, if we work hard to get an important job done, we can push our bodies with lots of caffeine-laden coffee and cola and very little sleep. At the end of the project, though, if we suddenly stop and take a vacation, it takes a few days to get rid of our accumulated nervous energy. We really cannot enjoy low-intensity pleasures, like walking barefoot on the grass or playing quietly with children, because we are all keyed up. After a few days, we eventually calm down, unwind, and relax, and then we can enjoy recreational reading and quiet activities. This tells me that our lifestyle and sleep habits can affect our internal chemical machinery, which in turn causes us to feel certain ways. In a study at Dartmouth College, coronary-prone type A students had more night wakings than type B students. A vicious circle could develop whereby the fragmented sleep causes increased arousal, the student feels more energized, and, sensing this greater level of energy, works even harder late into the night to achieve more, but at the same time loses more sleep.

  IMPORTANT POINT

  Loss of sleep produces central nervous system hyperarousal.

  Babies only two or three days old also have elevated cortisol levels during the period of behavioral distress following circumcision. Infants over four months of age as well as older children can push themselves hard fighting sleep in order to enjoy the pleasure of their parents’ company and play. The resulting sleep disturbances might produce fatigue, and the body would naturally respond by turning up production of those chemicals, such as cortisol, responsible for maintaining alertness and arousal. Perhaps researchers may someday find that different patterns of sleep deprivation (total sleep loss, abnormal schedules, nap deprivation, or sleep fragmentation) produce different patterns of chemical imbalances.

  Here are some terms used by professionals to describe the behavior of hyperalert, or “wired,” children with disturbed sleep:

  Physiological activation

  Neurological arousal

  Excessive wakefulness

  Emotional reactivity

  Heightened sensitivity

  Obviously we all get slightly irritable, short-tempered, and grumpy when we do not get the sleep we need. Jokes and cartoons don't seem very funny when we're tired. But children might be even more sensitive to mild sleep loss, and yet simply appear to be wilder or more unmanageable. Perhaps off-the-wall behavior in children is due to sleep loss that is severe, chronic, and prolonged but not recognized as such by parents.

  So often I have heard comments like “She's so tired, she's running around in circles.” This is not a new observation; a classic paper published in 1922 described the “increased reflex-irritability of a sleepy child.” In dramatic contrast, over and over again I have seen well-rested children in my practice who spend enormous amounts of time in a state of quiet alertness. They take in everything with wide-open eyes, never missing a thing. They find simple little toys amusing or curious. They never appear bored, although the toy they pick up is one they have played with many times. Parents of children four to twelve months of age can dramatically change their children's behavior depending on how much sleep they allow their kids to get.

  In a study published in 2002 of four-to five-year-olds, author John E. Bates stated, “In clinical treatment of young, oppositional children, we have seen some spectacular improvements in manageability associated with the parents instituting a more adequate schedule of sleep for their children. Our clinical impression in these cases was that th
e changes were too rapid to be accounted for by other changes, such as parental discipline tactics.”

  REMEMBER AGAIN

  A sign of sleeping well is a calm and alert state. Upon awakening, well-rested children are in good cheer and are able to play by themselves.

  I believe that in infants and young children, a cause-and-effect relationship exists between disturbed sleep and fitful, fussy behaviors. In addition, as described in Chapter 2, the harmful effects of excessive daytime sleepiness do not stay the same, but rather tend to accumulate. This means that there is a progressive worsening in a child's mood and performance even when the amount of lost sleep each day or night is constant. So a baby becomes increasingly crabby even if her nightly sleep is constantly just a little too brief.