NOCTURNAL AWAKENINGS AND INSOMNIA IN THE FIRST THREE YEARS OF LIFE

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A Leaflet written by

Dr. Oliviero Bruni

Child Neuropsychiatry Unit

Ospedale Sant’Andrea

Sapienza University of Rome

Via di Grottarossa 1035 – 00189 - Rome

Tel. (06) 33775859

For further information, advice and consulence write to: oliviero.bruni@uniroma1.it

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QUESTIONS AND ANSWERS

Is it normal that my child doesn’t sleep very much during the day?

Why do children sleep so much?

Where and how should my child sleep?

Why do some children sleep all through the night and others wake up in continuation?

At what age do children normally start sleeping all through the night without waking up?

Why does my child start crying inconsolably in the evening?

Should I give my child something to drink or to eat every time they cry?

Should I use syrups, herbal infusions etc. to help my child get to sleep?

During my child’s development are there key moments for the acquisition of good sleep?

What should I do if my child has difficulty falling asleep?

What should I do if my child suffers from separation anxiety (is frightened of falling asleep or being separated from his mother)?

What should I do if my child suffers from nocturnal awakenings?

Childhood sleep hygiene principals or useful parental advice for a regular sleep rhythm

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These questions and many others torment 30% of pre-school aged children’s parents. In fact one in three children suffer from some form of sleep disorder. A child with a sleep disorder rarely suffers alone, the entire family is involved and often loose their sleep as well.

The sleep-wake cycle in neonates is very different to that of adults. In fact during the first months of life babies don’t recognise the difference between day time and night time. Their cycle is independent of their environment, and is regulated by the babies internal needs, like hunger and thirst, and lasts around 25 hours. During the first months of life being with a baby means adapting your own cycle to theirs and trying not to resist or modify habits in order to continue to do the things that you did beforehand.

During the first 4 months of life the mothers sleep-wake cycle must follow that of the child. After about four months the opposite gradually starts to happen; babies progressively adapt to external rhythms. This is a fundamental step in a child’s development. Regular habits facilitate the synchronisation between babies endogenous rhythms with external rhythms and consequently sleep is concentrated during the night time. Good sleep is a condition learnt in the first months of life. It is of fundamental importance that parents understand how sleep organisation develops in their children in order to adapt themselves to their child’s rhythm, to know when and how the babies rhythm’s should be modified and when they should be respected.

Common replies given to parents by paediatricians

Errors and common parental misunderstanding

“The sleep disorder will go away by itself”
“Don’t worry if your baby doesn’t sleep, give him time (he will sleep)”
“It’s a part of a babies normal development”
“ It’s an anxious parent’s fault”
“Give your child a herbal infusion or some syrup”

Thinking that all children are the same (or similar)
Putting the baby in bed when they’re already asleep
Playing with or excessively exciting or stimulating the child in the evening
Leaving the child to cry by itself
Not to follow or trust maternal instincts
Sleep disorders are normal, unavoidable and typical of modern day western society
Sleep disorders reflect a baby’s need (to eat or to be comforted)
Extinction techniques (leaving the child to cry) are damaging because they go against a parent’s natural instincts

How to help your baby sleep at night

Put the baby in their cot or bed when they’re still awake
Give them an object or toy to fall asleep with
Follow a regular timetable during the day
Try to install a bed time ritual
Separate clearly the activities to do during the daytime from those done in the evening or at night; teaching the child that the night-time is for sleeping

Choose together which activities to do before bed time (e.g. Which pyjamas, which song to sing etc.)
Remind the child in advance that it’s nearly bedtime
During night time feeding try to interact as little as possible with the child
Encourage the child to fall asleep by itself

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Consequences of sleep disorders

Persistence of insomnia (2/3 children with insomnia in the first years of life will continue to sleep badly after their 5 years old)
Behaviour disorders (hyperactivity, aggressiveness etc.) are 3 times more likely to appear in children with insomnia

Tiredness and concentration deficits
Day time napping
Mood disorders (parents and child)
Changes in the mother - child relationship

How to rest?

Try to sleep when the child sleeps. Avoid trying to do the housework or working when the child’s asleep and rest even if you don’t manage to fall asleep
Try to organise yourself before night-time feeding
Try to take at least one form of exercise everyday. Taking walks with the child and getting out of the house if possible
Ask people close to you for help
Be careful of how your feeling psychologically; sleep deprivation can contribute to postpartum depression and interfere with your child’s attachment
Remind yourself that it’ll get better

Childhood sleep hygiene principles

(useful parental advice to get the child to adapt to a regular sleep rhythm)

Programme the night as a time to dedicate to sleeping; avoid playing and enjoying yourselves with your child during the night, leaving these activities for the daytime.
Help your child to associate their bed with sleeping. Try to get the child to fall asleep in their own room and avoiding where possible that the child falls asleep in your arms or in other places to then put them in bed. When the child wakes up, (having fallen asleep in a parent’s arms) they’ll find themselves in a place that they don’t know and will want to go back to a parent’s arms and need physical contact to fall back to sleep again.
The environment in which the child sleeps should be tranquil, with little illumination and as silent as possible.
The room temperature should be comfortable (around 20°c). Temperatures that are too high disturb sleep.
The child should never be too covered (with blankets etc.).
The bed shouldn’t be too big as children will often look for the bed’s edge to fall asleep against. Children never wake up when they bang against the bars of the cot or bed so padding or cushioning on the cot’s sides should be avoided. These can be dangerous as the child can use them to climb up the cot's bars and they don’t enable the child to actively explore and control the environment when they’re lying down.
Try to get the child to fall asleep on their side or on their back, avoiding that they fall asleep on their tummy. Don’t keep potentially dangerous objects in the cot.

The time in which the child habitually wakes up and goes to sleep should always be the same everyday.
Food and drink that contain caffeine or theine should be avoided for quite a while before bedtime. These substances can be found in many different foods and drinks used regularly (Coca-Cola, chocolate, coffee, and tea). Also some medicines contain alcohol and caffeine and can disturb sleep.
The child must learn to fall asleep by himself or herself without a parent’s help.
Some games can excite the child and interfere with sleep and should be avoided for about 1 to 2 hours before habitual bedtime.
Some games, music or mobiles (with small pictures of animals that rotate) put above the cot can cause visual or auditory over excitement and interfere with the child’s sleep so it’s far better to use old methods like singing a song or a lullaby to get the child to fall asleep. A mother’s voice is always better than mechanical music.
Having a bath can be an exciting activity for some babies and should be moved to another time in the child’s daily routine if the child has problems sleeping.
If the child cries stay near them but avoid smothering them with attention.
Reassure the child with a short massage or change their nappy if necessary (when possible without taking the child out of their cot). Don’t switch on the main light and try to keep your voice low with out creating too much confusion.
Even though daytime naps are linked to the age of the child, frequent or long daytime naps should be avoided, especially near bedtime.

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The sleep–wake cycle in newborn babies and children

New born babies don’t know the difference between night and day; they often need to eat, with a rhythm modulated by hunger of between 3 and 4 hours. Subsequently it doesn’t matter what time of day or night it is, babies frequent awakenings are modulated by a feeling of hunger and satiety and also seem to be determined genetically. Sleep is made up of cycles that repeat themselves regularly during the night. The length ant the structure of these cycles varies with age. A Child’s sleep cycle is much shorter than that of an adult and new born babies have a greater quantity of light sleep than adults do. The cycle in new born babies, is made up of an initial phase of active sleep or REM* and a following phase of calm sleep or non-REM sleep. During the first two months of life this cycle lasts about 50 minutes and is evenly distributed in 24 hours. If 3 or 4 cycles follow on one to another the child will sleep solidly for 3 or 4 hours. In the arc of 24 hours the new born baby will follow 18-20 cycles without taking into account the day or night time. At around 6 months these cycles last for around 70 minutes and are concentrated mainly during the night time; even at this age non-REM sleep begins to differentiate into the different phases of light sleep and deeper sleep. Gradually the cycles get longer until they arrive at being about 90 – 120 minutes long and repeat themselves 4 –5 times a night as in normal adult sleep that lasts around 8 hours.

*REM sleep (Rapid Eye Movement: because in this phase one can see sudden eye bulb movements; look at your child's eye lids when they are asleep and you will see these movements; they correspond with the period of sleep in which you dream, our brain is active whilst are body’s are practically motionless)

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During active sleep, babies often present eye movements, small visual movements, and innate visual expressions such as fright, surprise, anger and joy. Facial expressions, big smiles or small jolts are all signs of the underlying cerebral activity taking place that is associated with the learning of emotions and the ability to communicate.

During calm sleep the child moves very little, the face is very inexpressive, there are no eye movements but sometimes sucking movements are observed.

Sometimes a child may make noises or babble while asleep, erroneously leading parents to believe that they’re awake. A baby is awake when they have their eyes wide open, follow movements with their eyes and are ready, when calm to communicate (calm wakefulness) while in active wakefulness babies may wail, make faces, move their arms and legs, bend double, and sometimes cry loudly and are very difficult to comfort.

New born babies sleep between 16-18 hours a day and sleep is distributed evenly through out the arc of 24 hours. (Figure 1). However there are big inter-individual differences. It’s already possible at this age to see who will be a brief or a long sleeper: some babies sleep for 20 hour while others need only 14 hours; some begin to sleep continuously all through the night while others wake up every 30-60 minutes.

It should also be taken into consideration that today's children probably sleep far less than children born more than a decade ago. Recent research on the amount of sleep in children of Rome found that they sleep far less than the amount considered to be normal in other international studies.

During the first months of life babies structure and define their own circadian rhythm. This happens very gradually, without brisk variations or sudden modifications. If we evaluate the development of sleep we can see how the most important modifications happen during the first 6 months of life, while the differences that happen afterwards are minimal:

Between 1-6 months the day - night rhythm appears. A period of wakefulness distributed in the late afternoon and evening appears and there are progressive modifications in the circadian rhythm of body temperature, of heart and lung activity and of hormonal secretion. At an encephalographic level, sleep matures and becomes gradually more similar to that of an adult.
Between 4-6 months, babies begin to be influenced by the light-dark rhythm, they start to sleep continuously for about 6 hours during the night and manage to stay awake for longer periods during the daytime. The total quantity of sleep is usually between 12-14 hours and is prevalently distributed during the night time. The first sign of the circadian rhythm appears between 3-4 weeks and is characterised by a long daily phase of wakefulness between 17.00 and 22.00. During these moments the child is often in a state of active wakefulness and presents uncontrollable crying, which can be recognised or associated with hunger or abdominal pain (colic).
Between 6 months and 4 years of age, the total time spent sleeping is progressively reduced to about 10-12 hours and consequently the child spends more time awake; at 1 year a child sleeps 13 hours a day, between 3-4 years they sleep 12 hours a day,
Day time napping is frequent in neonates and gradually decreases with age. From 3-4 naps a day at 6 months to 2 naps a day at around 12 months. At about 18 months children tend to have just one long afternoon nap.
At around 9 months there is an increase in the frequency of nocturnal awakenings between 21.00 - 24.00 and 3.00 – 6.00 (84% of babies wake up at least once) which often continues up until 2-3 years of age. While the child is gradually gaining more consciousness of the world around them, external stimulus can start to disturb them and their imagination more often during the night, this is translated into dreams and nightmares which can start to interfere with sleep.
Between the ages of 5 and 12, sleep is at it's best period and there is a better capacity for being vigil ant attentive. Sleep develops towards an adult pattern lasting between 8-9.5 hours. Daytime napping disappears and sleep structure becomes more stable. Falling asleep becomes faster and while the time to wake up remains stable the time to go to bed becomes progressively later.
During adolescence, sleep lasts around 8-9 hours a day. Sleep rhythms at this age are often influenced by social habits. It is not unusual that sleep is suddenly reduced to 2-3 hours a night which determines a sleep debt associated with a physiological increase in day time sleepiness caused by hormone modifications. Often daytime napping reappears during the adolescence. (In 23% of adolescence’s between 15-18 years old).

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Is it normal that my child doesn’t sleep very much during the daytime?

Our children shouldn’t be constantly stimulated, they also need the calmness, serenity and stability. Today even more so than a decade ago, we should learn to respect children’s rhythms and provide a protective environment for them to live in. The more stimuli that they receive the less quiet and the more agitated and hyperactive they will become during the day.

Why do children sleep so much?

One of the functions of sleep in small children is associated with brain development. During sleep the necessary hormones for the child’s growth are produced and information received during the day is consolidated so subsequently they learn. The new-born baby is an extraordinary being and is in a constant state of learning. The elevated necessity to sleep is parallel to the intense growth that happens at this age.

Where and how should my child sleep?

In the first few months of life the child’s cot should be placed along side the parent’s bed. The child’s room is too far away when the child wakes up so often to feed. There are different schools of thought as to whether or not a child should be allowed to sleep in the parent’s bed; many parents are frightened of hurting their child by mistake while asleep; some researchers believe that babies who have physical contact with their mothers while asleep have improved psycho-physical development and that it prevents “cot deaths”. Having decided where your child is going to sleep, it’s a good idea to always put the child to bed in the same place both at night and during the daytime. (e g. Don’t let the child sleep in the pram or pushchair during the day to then put them to bed in their cot during the night time). It is also better to try to get the child to fall asleep on their side or on their back, avoiding that they fall asleep on their tummy, unless there have been given specific instructions to do so (paediatrician’s advice etc.). Between the 4^th and the 7^th month babies acquire the ability to move themselves and turn over and will choose themselves the right position in which to sleep.

Why do some babies sleep all through the night while others wake up continuously?

There is definitely a genetic component involved: ask your grandparents how you parents slept when you were small and you will often hear about experiences similar to those that you’re going through at the moment. As with adults some babies need less sleep (short sleepers) while others need more sleep (long sleepers); some babies are less active during the evening and wake up full of energy while others never want to go to bed at night and have difficulty waking in the morning.

When a child wakes up during the night it’s extremely important to be patient; don’t run to the child straight away but wait a second; try to judge the intensity of the child’s crying and try to resist. When you go near the child avoid switching on lights or picking them up, it’s far better to comfort them with a calm, soft tone of voice and a few caresses while their still lying down. If it’s not an absolute necessity, avoid giving your child camomile tea, milk or similar beverages; leave the room before the child’s completely asleep. By following these guidelines you can avoid becoming the only way of getting your child to fall asleep.

At what age do babies start sleeping without waking up during the night?

In general babies of around 4-6 months start sleeping all through the night but there is a lot of individual variability. The most important thing to do at this age is to regulate the child’s timetable by making sure that bed time, getting up time and meal times are always at the same hour of the day. Another important thing to do is to make sure that the child has contact with daylight and plays during the day, while they do less activity and avoid intense light during the evenings.

Why does my child start crying inconsolably in the evening?

At the same time as the child acquires a circadian rhythm and adapts to the light-dark cycle, the child who lives a calm and regular day can often become nervous and start crying during the evening. In the first months these phases are often associated with abdominal pains or gaseous colic. It is still unknown whether or not the child really has abdominal pains however it is clear that children effected intensely by this disturbance will have more difficulties sleeping. Crying and irritation in the evening are normal manifestations of the maturation of the mechanisms that predispose sleep. They’re associated with the normal phase of hyperactivity at the end of the day which corresponds to an adult’s day time phase of maximum vigilance. The first sign of circadian rhythmically appears between 3-4 weeks and is associated with a long daily phase of wakefulness between 17.00 and 22.00. Some children go through a light and brief

phase of wakefulness, while others have a longer phase that can go on until late at night; others again wake up later in the evening. During these phases the child’s circadian rhythm is stabilising itself and therefore the correct handling of the child’s agitated state is very important. By providing the child with a tranquil environment, by avoiding intense light and stimulating or rocking the child, you can give your child the opportunity of falling asleep by themselves.

Should I give my child something to drink or to eat every time they cry?

In the first weeks of life the rhythm of the new born baby is regulated by internal necessities so it could be right to feed them every time they wake up . After about 4-6 months babies no longer need to feed during the night if they have regular meals during the day. Therefore you shouldn’t give your child food or beverages if they wake up during the night. The large quantities of liquids that some children drink at night (especially herbal infusions) will often lead to bed wetting and consequently more frequent awakenings and crying. Moreover a bottle will become the only way of getting the child to fall asleep and often they’ll wake up at night because they’re used to having a drink.

Should I use syrups, herbal infusions etc. to help my child get to sleep?

NO. Both the so called herbal remedies and medicines should be avoided under 2 years of age as they usually don’t solve the problem and symptoms often reappear when the cure is interrupted. Sometimes they can have the opposite of the desired affect, that is to excite rather than calm. The majority of cases of insomnia at this age are associated with a problem adapting to normal rhythms, conditioning or viscous circles that should be modified in order to solve the problem. Often parents have guilty feelings when they give their children sedatives. If medicines are administered following a doctors orders sometimes they can be useful and sometimes essential in the process of modifying bad sleep habits.

Are there key moments for the acquisition of good sleep during my child’s development?

Yes, there are 2 developmental moments that are extremely important for a correct circadian rhythm and good sleep.

At around 3-4 months, babies start to be influenced by environmental stimulus and gradually adapt to the 24 hour light-dark cycle. The child should be exposed to direct day light during the day and stay in a darker environment during the night. As mother or father come home from work, the evening can become a moment in which the child plays and gets excited, however it’s better that external stimuli are reduced during these hours. It is therefore important to install a regular timetable for bed time and getting up time.
At about 8-9 months babies develop a fear of strangers and their separation anxiety increases, both of which are part of a normal developmental phase. This phase is often associated with a physiological increase in night time awakenings ( see the section on separation anxiety )

What should I do if my child has difficulty falling asleep?

Try to install fixed rituals that the child associates with relaxing and bed time. Singing a lullaby or changing and washing the child can be a good signal for the child. Always try to put the child in their bed or cot when they’re still awake and give the child time to fall asleep by themselves. By 4-6 months you can already start putting these guidelines into practise. Before picking the child up when they move, make noises or cry it is very important to wait and see what happens. It is important to give babies time to communicate what they want. Often (hopefully) the child will fall asleep by itself without help. If the babies difficulties are persistent and the child “fights against sleep” then you could try a gradual extinction technique (see section on night time awakenings).

What should I do if my child suffers from separation anxiety (is frightened of falling asleep or being separated from his mother)?

At about 8-9 months babies develop a physiological increase in night time awakenings associated with a fear of strangers connected to an increase in anxiety when separation from the mother occurs. The child starts crying and can become desperate if separated from the mother, and when together will constantly look for maternal physical or eye contact. This is a crucial moment in the acquisition of good sleep. You can try adopting the “minimal checking technique” which consists in installing the usual ritual for going to bed, leaving the room, and then checking up every 2 or 3 minutes even if the child’s not crying or calling. When you go into the room you should calm the child down by talking sweetly to it and then leave the room again before the child falls asleep. This process should be repeated until the child falls asleep and can be repeated or used in the same way if the child suffers from night time awakenings, even though more than a few check ups shouldn’t be necessary.

What should I do if my child suffers from multiple night awakenings?

Children and parents have different ways of reacting to bed time and night time awakenings making it impossible to give sound advice without taking into consideration the particular child and it’s parents. Apart from “minimal checking” another general technique to try is that of “gradual extinction”. By taking one small step at a time one tries to help the child acquire the desired behaviour. For example by getting the child used to being progressively further away from parents when falling asleep or when they wake up at night. If the child starts crying or calling; wait 30 seconds before going to calm them down, keep reciprocal interaction to a minimum and leave the room when the child’s still awake. The time you wait before going to calm the child down should be progressively longer every time the child calls out again. Passing from 1 to 2 minutes etc. Until the child manages to fall asleep by itself. The following night the time you wait before going to calm the child down should be doubled etc. After about a week things should get better. Always put a small light in the room and provide the child with the possibility of controlling its immediate surroundings. Don’t feel guilty when your child cries and you don’t interfere because your not creating any sort of psychological trauma. If you persist and are constant in the use of these techniques you will gain the desired results.

A Leaflet written by

Oliviero Bruni, MD

Center for Pediatric Sleep Disorders

University of Rome “La Sapienza”

Via dei Sabelli 108 - 00185 - Rome

Tel. (06) 44712257

e-mail: oliviero.bruni@uniroma1.it