What do I do when my baby won't sleep??

This article addresses what action parents should take when their baby won't sleep, and warning signs that could require further attention.

The quest for a good night’s sleep is one of the main reasons parents take their children to a pediatrician.

But doctors familiar with sleep disorders say the issue is often more about behaviour than it is about medicine.

“In my private practice it’s a very common concern, ‘My child doesn’t sleep,’ ” said pediatrician Dr. Wilma Arruda, Island Health medical director of childhood and family health.

“It can start at a very young age and it can cause a fair bit of trouble for a family,” Arruda said in an interview. “As parents, we also need our sleep.”

She said it is entirely appropriate for parents to take their sleep concerns to a doctor. Family doctors are typically the first to be consulted. If further expertise is required, a referral can be made.

Parents should be aware, however, there is likely no easy, medical answer.

“[Doctors] can’t just give them a pill and all of a sudden the kids are falling asleep every night and it’s all perfect,” Arruda said.

“In many cases it is a behavioural situation,” she said. “A lot of things around sleep are related to certain behavioural adaptations that kids will make. And it takes some effort to a manage those behaviours into something that might be more suitable for a family.”

She and other doctors say concerns about children’s sleep appear to be increasing. One suspected reason is the increase in the rates of childhood obesity. Fat in the neck can obstruct the airway, causing snoring and often a cessation of breathing.

Another reason may be the reluctance of parents and doctors in recent decades to remove tonsils. If tonsils become enlarged, they can obstruct the airway.

There is also an increased awareness of the neurobiological disorder of ADHD, attention deficit hyperactivity disorder. Children with ADHD often say they have trouble sleeping — and the lack of sleep aggravates the challenge of their disorder.

Dr. Atul Khullar, medical director of the Northern Alberta Sleep Clinic in Edmonton, said any parent seeking help for a child with a sleep problem should consider keeping a log.

“It’s extraordinarily helpful,” Khullar said. “You can start to see the triggers yourself and that’s really helpful to a doctor.”

He said in his practice, where he treats mostly teens but also some young children, the No. 1 reason for sleep trouble is anxiety.

“We see a lot of kids with the first onset of an anxiety disorder,” Khullar said. “It doesn’t necessarily require medication, but some sort of acknowledgment of the anxiety, perhaps getting them into some sort of therapy or group, is helpful.”

Khullar also said a growing realization is dawning of the medical importance of sleep. An entire family needs to recognize and work to ensure everyone gets a good night’s sleep, he said. Parents and children should acknowledge and speak to its importance and develop good sleep habits.

“Kids tend to model what their parents are doing,” Khullar said. “A kid starts out OK, but they start imitating the maladapted behaviour of their parents.

“The parents, if they have sleep problems, they tend to pass them along to their children — subconsciously, but they do.”

Warning signs

Snoring. Children who struggle to breathe, noisily pause, gasp or choke at night are at risk for obstructive sleep apnea, a treatable condition.
Difficulty falling or staying asleep. Everyone, adults included, has occasional problems falling asleep. But chronic insomnia can make it difficult for children to stay focused and alert during the day.
Sleepwalking, night terrors or other nighttime activities. Many children walk, talk or cry out during sleep. If these incidents become frequent, parents should seek help to learn potential triggers.
Sleeping too much. Children who have trouble waking up in the morning, getting to school on time or fall asleep in class have clear signs of a sleep problem.

Snoring. Children who struggle to breathe, noisily pause, gasp or choke at night are at risk for obstructive sleep apnea, a treatable condition.
Difficulty falling or staying asleep. Everyone, adults included, has occasional problems falling asleep. But chronic insomnia can make it difficult for children to stay focused and alert during the day.
Sleepwalking, night terrors or other nighttime activities. Many children walk, talk or cry out during sleep. If these incidents become frequent, parents should seek help to learn potential triggers.
Sleeping too much. Children who have trouble waking up in the morning, getting to school on time or fall asleep in class have clear signs of a sleep problem.

Tips for sleeping

Make sleep a priority. Without a good night’s sleep, kids will have trouble participating fully in school, homework, sports or play.
Develop a bedtime routine. Everyone needs a short period of calm time before bed.
Keep schedules consistent between weekdays and weekends. Sleeping in a bit on Saturdays or staying up a little bit late is OK. But try to keep the flex to 45 minutes.
In fact, keep schedules consistent every day. Going to bed and getting up around the same time trains the brain to account for the hours needed for regular activities.
Make the bedroom restful. TVs and videogames are distracting and can produce a bright light that signals the brain to wakefulness.
Sleep in the same place every night. Children who sleep on the couch, on the floor, or in different beds have more trouble developing good sleep habits.
Avoid caffeine. Soft drinks, coffee, tea or energy drinks can keep children and adults awake.
Put your child to bed when they are sleepy, but not fully asleep. Self-soothing and relaxation are good skills for children to learn. Putting them to bed before they are fully asleep gives them a chance to develop them.
Address anxiety. Anxiety makes sleep difficult for everyone.

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Factors affecting a baby's naps and sleep at night

Genetics play a role in if a baby sleeps through the night, but sleep habits determine how well a baby naps during the day.

Genes play the biggest role in getting toddlers to sleep through the night, but environmental factors are more important for daytime naps, a twin study showed.

Genetic influences explained about half the variability in nighttime sleep duration from ages 6 months through 2 years, Jacques Montplaisir, MD, PhD, of Sacré-Coeur Hospital in Montreal, and colleagues reported in the June issue of Pediatrics.

There was a window of greater influence from surroundings and family habits at 18 months, which accounted for 48% of variability at that time. Environmental factors also accounted for up to almost 80% of variation in how long toddlers napped during the day by age 2.

Age 18 months may be a good opportunity to intervene for kids who don't sleep through the night, suggested Shalini Paruthi, MD, a pediatric sleep specialist at Saint Louis University in St. Louis.

"You really want to make sure your environment is as good as it can be," she told MedPage Today, which might include "keeping a dark and quiet room for them to sleep in and making sure they have their own sleep space so they're not bumping into a sibling on the mattress or on the bed."

"That doesn't mean every child in the same family is going to have the same sleep patterns," Paruthi noted, cautioning against overinterpretation.

The study also shouldn't be generalized to older children, she added.

Environment seems the biggest contributor to how long adults sleep at night, with a prior adult twin study suggesting less than 45% heritability.

Teens and pre-teens seem to follow adults in that pattern. However, young children haven't been followed longitudinally in the same way through the period when sleep is shifting toward a mature circadian rhythm.

Montplaisir's study included 995 sets of twins (405 identical) in the population-based Quebec Newborn Twin Study, which included pairs born without major medical conditions in the greater Montreal area from November 1995 through July 1998.

Mothers reported on their twins' sleep at 6, 18, 30, and 48 months of age, with a 2-week period between assessment for the two children to minimize homogenization of answers.

Genetics explained 47% of variability in how long kids slept without waking up their parents at 6 months of age, 58% at 30 months, and 54% at 48 months.

Sleep appeared to be more fragmented than parents were aware of, though, because video recordings in a subgroup showed that even "good sleepers" woke up three times a night on average.

With regard to daytime naps, environmental influences shared by the twins appeared to explain more of the variance in sleep duration as they got older.

These factors accounted for 33% of nap duration at 18 months of age, 48% at 30 months, and 79% at 2 years.

Nap duration seemed moderately stable through age 2 and declined gradually over time, with only 4% having a faster than normal trajectory in that regard.

Only 4% had stopped taking naps by age 2.

Little variation in either daytime or nighttime sleep appeared linked to environmental factors unique to one twin, not shared with the other.

However, the researchers cautioned that the heritability estimate may have been inflated by using a single "informant" for the twin pairs.

Another limitation was use of ordinal categories for daytime and nighttime sleep duration, so the study needs replication with quantitative measures, such as actigraphy or polysomnography, they noted.

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