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Richard Ferber, MD, founder and former director of the Center for Pediatric Sleep Disorders at Boston Children’s Hospital, answers some of the most frequently asked questions about children’s sleep.
How much sleep should children generally get?
Young infants may sleep 12 to 13 hours total. But by six months, most children sleep only 11 to 12 hours total, and this number changes only slowly as children grow. Even by mid-childhood the number usually has not dropped below 10 hours.
How those hours are distributed may vary. In the first few months, a third or more may still occur in the day. But after three months, most should occur at night. Still, a child needing 12 hours may distribute it between the night and day as seven and five, eight and four, or nine and three. As the child gets to five months or so, he probably should be getting at least nine hours of sleep at night.
At what age should children stop napping?
Most children stop between the ages of three and four. Some stop at age two, and some continue until kindergarten.
Are some children just better sleepers than others?
There are some children who are naturally good and long sleepers, but basically all healthy, normal babies have the ability to sleep well. If they’re not, then a thorough understanding of the cause of the problem and implementation of corrective behavioral and schedule-related measures should normalize their sleep within a few days. Sleep medication is rarely ever necessary.
The sleep drive is very powerful in children, and if it’s understood and controlled properly, just about all children should be able to sleep pretty well.
At what age should a baby who still wakes at night be considered to have a sleep problem?
By 3 months of age, most babies are waking only once or already have started sleeping through the night; they should definitely be doing so by four or five months. So, for example, if an otherwise healthy child has reached 5 or 6 months of age and is still having problems going to sleep, or is waking up for extended or repeated brief periods during the night, then a problem seems likely.
What’s the best way to diagnose the cause of a sleep problem?
To diagnose sleep problems, physicians must take a good, careful history from the parents. Diagnosis requires an in-depth understanding of normal and abnormal sleep patterns and behavior, but (with proper training and sufficient time) it often can be made in a general pediatrician’s office. Parents are often able to diagnose these problems themselves after reading proper educational materials.
My child snores. Should I be concerned?
Yes, especially if the snoring is present most nights, is present much of the night, and is loud enough to be heard outside of the bedroom. There should also be concern if the child usually sleeps with his or her mouth open or clearly has trouble breathing (chest gets sucked while breathing and there are gasps, snorts, or squeaky sounds).
Children should be able to breathe quietly with mouth closed most of the time, except, perhaps, when ill. The snoring indicates an obstruction somewhere, usually at the back of the throat. But just from watching, it may be difficult to tell just how much trouble there is—that is, whether your child is breathing okay with a little snoring, or suffering from obstructive sleep apnea (with inadequate breathing and sleep disruption). You would be best to discuss this with your doctor, who should examine your child and possibly refer him or her to an ENT (ear, nose and throat) specialist (also called an otolaryngologist) for further assessment, or to our Center for evaluation and possible overnight sleep study.
The most common cause of significant breathing difficulties in a snoring child is enlargement of tonsils or adenoids (spongy tissues at the back of the throat). If indicated, this tissue can be removed surgically. Other common causes include abnormal facial structure, low muscle tone, and obesity. In these cases, other treatments may be called for. The most common non-surgical treatment is nighttime CPAP usage, which is highly effective.
My teenager goes to bed at a decent hour, but has trouble falling asleep quickly and then has difficulty waking in the morning. Why?
The usual cause is a late or delayed sleep phase caused by late wakings on the weekend. The late weekend wakings become internalized, setting the biological clock on a late schedule and leaving the child unready to fall asleep at an appropriate hour and unready to wake at the time necessary to go to school.
The solution requires consistent wake-up times every day (weekday and weekend) as the bedtime gets adjusted to a regular time early enough to allow for sufficient sleep. This should be easy to accomplish until adolescence; then it may become more difficult partly for biological reasons and partly because of children’s desires to be more independent and to stay up very late on weekends as well as to sleep in whenever they can.
My child talks in his sleep or appears to sleep walk. Is this normal or dangerous?
Sleep talking is normal and common and certainly is not a sign of anything worrisome. Most sleep talking takes place between sleep states, during a partial waking as your child is moving about and getting ready to fall back into deeper sleep again. It typically does not occur during a dream. After the waking is more complete, the child settles back to sleep.
Sleepwalking occurs in the same setting, but instead of just talking, a child gets up and moves about. Occasional events are common in young children, and the main job of parents is to assure a safe environment. Little should be necessary except to lead the child back to bed. Frequent events or events where the child could hurt himself (such as running about wildly) may have different triggers related to habits, schedules and personality. Various therapies are possible. Such symptoms should be discussed with your doctor. If questions remain, referral to the sleep center should be considered.
Is it OK for a child to sleep in the same bed with their parents?
Yes, at least after the first six months and if certain precautions are followed. When bed sharing is chosen, ideally this choice should be the parents’, not the child’s. If co-sleeping fits into the parents’ philosophy and desires, there should be no problem as long as conditions are safe.
This is especially a concern for young infants who might be safer sleeping adjacent to the parents’ bed until they are bigger. In fact, a task force of the American Academy of Pediatrics recently concluded bed sharing was potentially risky for young infants, saying “that bed sharing, as practiced in the United States and other Western countries, is more hazardous than the infant sleeping on a separate sleep surface and, therefore, recommends that infants not bed share during sleep.” (For the full statement of the Academy, click here).
Some of the conditions known to increase risk of problems include improper bedding and parental alcohol intake and smoking.
When there is bed sharing, parents may have to adapt to a schedule that fits their child more than themselves, and they may have to accept both the loss of privacy and their child’s (possibly considerable) nighttime restless body movements. Finally, parents should decide how long (until what age) they want their child sleeping with them, and have plans for how to move their child to his or her own bed when that point is reached.
How can parents normalize the sleep environment?
Consider where you prefer your child to sleep, with you or in his own room alone. Whatever way you choose should be the way the child goes to sleep and wakes up. He shouldn’t fall asleep being rocked in the living room with the TV on if he’s going to wake alone normally during the night in his dark and quiet bedroom.
What are the most important factors in getting babies to sleep well?
Avoiding improper habits from becoming associated with falling asleep and being sure that nighttime feedings are not excessive are two key factors after the first few months. A third factor that’s very important (and often least recognized) is the schedule. All of our body’s systems (including those that control sleep) function best when on a regular and appropriate schedule.
If we’re on an irregular sleep schedule, sleep can suffer. If a child’s bedtime, wake time, and nap times differ day to day, one cannot know on any given night or day when that child is even capable of sleep. Or a schedule may be regular but inappropriate. Thus, children may be unable to sleep well at night because they sleep too much during the day, or they can’t nap well during the day because they sleep too much at night.
Many parents try for more sleep than a child can get. They put the child to bed at 7 p.m. and want him to sleep until 8 a.m. and take two two-hour naps each day. Children can’t do that, and they have a number of ways of showing you that. They’ll get only the total amount of sleep they need, and if parents try to force them to sleep more (or at the wrong times), there will only be frustration.
How do I encourage my child to sleep with the light off?
If your young child insists on having more than a night light on at night, you can stay with him a little after the main light is turned off to show him how much he can actually see once his eyes get used to the dark. Or you can gradually move to less light with lower wattage light bulbs or through the use of a dimmer control.
Here at Boston Children's Hospital, countless families have experienced firsthand the importance of a sleep study.
Providing a baseline for each child's health
A sleep study yields essential information about several child health indicators, including:
Making key determinations
Sleep studies are critical diagnostic tools that can make all the difference in identifying—and ruling out—a wide variety of sleep disorders and sleep-related breathing disorders in infants, children and teens, including:
central sleep apnea
obstructive sleep apnea (OSA)
nocturnal events vs. nocturnal seizures
periodic limb movements of sleep (PLMS)
sleep state misperception
a need for titrate positive airway pressure therapy (Continuous Positive Airway Pressure, or CPAP, and Bilevel Positive Airway Pressure, or BiPAP)
The Boston Children's Hospital Sleep Laboratories combine the multidisciplinary resources of a world-renowned pediatric hospital with focused expertise in sleep medicine and sleep technology.
The Labs are part of our acclaimed Center for Pediatric Sleep Disorders, the only pediatric institution in the nation to be named an American Academy of Sleep Medicine Program of Distinction.
Expert, compassionate care team
Our Sleep Laboratories are staffed by a team of specially trained sleep physicians, sleep nurses and polysomnographic technologists who have years of experience working with children of all ages and their families.
Our Sleep Lab Director is Umakanth Khatwa, MD, a pediatric pulmonologist who also co-directs Boston Children's Center for Aero-Digestive Disorders. He is board-certified in pediatric sleep medicine and in pulmonology, and is a member of the faculty at Harvard Medical School.
State-of-the-art, child-centered accommodations
Despite the name, our Sleep Laboratories look and feel nothing like a "laboratory."
They feature clean, quiet and spacious private rooms in a well-lit, soothing, child-friendly atmosphere ... complete with games and movies to help children settle in and feel at home.
Families come first
Our Sleep Laboratories are designed with the needs of families firmly in mind. All rooms include a comfortable cot for parents to spend the night alongside their children.
Exceptional patient satisfaction
As numerous testimonials can attest, our Sleep Laboratories offer an exceptional patient experience across the board.
The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”