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The Sleepless Child: Q&A with Dr. Richard Ferber |
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| Richard Ferber, MD |
At what age should a baby who still wakes at night be considered to have a sleep problem?
By 3 months old most babies are waking only once or have started sleeping through the night; they should definitely be doing so by 4 or 5 months old.
So, for example, if an otherwise healthy 5 or 6-month-old is having problems going to sleep, is waking up for extended periods, or is waking repeatedly during the night, then there is definitely a problem.
What is the best way to figure out the cause of a sleep problem so it can be resolved?
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The most important thing is to make note of exactly what is happening, from before your child goes to sleep, through the process of falling asleep at bedtime, and at wakings during the night. The same information is needed across the day. Start by clarifying your child's schedule:
- What time does he go to bed?
- When does he fall asleep?
- If he is up at night, when and for how long?
- What time does he wake up in the morning?
- Does he wake up spontaneously or is he wakened?
- What time does he nap?
- Is his schedule any different on the weekends or on vacations?
- What is the frequency of the sleeping problem and when did it start?
With this information, parents can likely determine if their child is going to bed and waking at proper and consistent times. Then you can look for other contributing factors:
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- Are there things your child associates with falling asleep? If so, are those things present when he wakes up and do they have to be repeated for him to fall back asleep?
- Are there problems with limit setting (enforcing rules and controlling inappropriate behaviors and demands)? If so, just at night or all the time?
- Are there significant anxieties (separation or other)?
- Is your child fed during the night? If so, is he fed more than needed for that particular age? Excess feedings affect hunger, metabolism, body temperature, hormonal release and the internal (circadian) time-keeping system.
- Are there family problems?
- Are there underlying medical problems, or is your child on any medications?
- What is the sleep environment? Does your family live in a home or an apartment? Are you on a noisy street? Does your child sleep alone, with you or with a sibling? Is he in a crib or a bed? Do you use a sleep aid like music or a pacifier?
This information - your child's "sleep history" - can be described to your child's pediatrician if you are unable to improve your child's sleeplessness.
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Parents can choose the setting they want their child to sleep in - in a room with the parents or alone - but it should be that way both when the child goes to sleep and wakes up. He shouldn't fall asleep in the living room with the TV on if he's going to wake up in his bedroom where it's dark and quiet. If parents insist on this consistency, it only takes a night or two for the child to adapt.
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Habits and feedings are two key factors affecting sleep in the early months, but a third one that's very important but often poorly understood by families and health practitioners, is the schedule. Our bodies evolved with the regular rising and setting of the sun, so if we're on an irregular sleep schedule or one that's inappropriate, sleep can suffer. If a child's bedtime, wake time and naptime differ day to day, it's very difficult to know on any given night when a child is capable of sleep.
We see children all the time who don't sleep well at night because they sleep too much during the day, or who can't nap because they sleep too much at night. Many parents try for more sleep than a child can get. They put their child to bed at 7 p.m., want him to sleep until 8 the next morning, and expect him to 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 you try to get them to sleep more (or at the wrong times), the problem will only get worse.
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Young infants may sleep 12-13 hours total. But by 6 months, most children do not sleep much more than 11-12 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 that sleep is distributed may vary. In the first few months, one-third or more of sleep time may still occur in the day. But after three months, certainly 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. Once the child reaches 5 months or so, though, he probably should be getting at least nine of those hours of sleep at night.
Sometimes people have cause and effect backwards. They say, "His problem is that he's not sleeping at night, so we let him sleep more during the day." But it's because he's sleeping so much during the day that he's not sleeping well at night. The opposite can also be true. If a child is sleeping from 7 p.m. until 6:30 the next morning, he's getting 11 ½ hours of sleep, which is enough total sleep for an entire 24-hour period. As a result, he may not have enough sleep left to nap well during the day.
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Most kids stop between ages of 3 and 4 years old. Some stop at age 2, and some continue until kindergarten.
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There are some children who are naturally better and longer sleepers than others, but basically all healthy, normal babies have the ability to sleep well. If they're not sleeping well, then a thorough understanding of the cause of the problem is important. Then implementing corrective behavioral and schedule-related measures should normalize a child's sleep within a few days. Medication is rarely 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.
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Richard Ferber, M.D., is the Director of the Center for Pediatric Sleep Disorders at Children's Hospital Boston, which was established in 1978 as the world's first comprehensive center dedicated to the diagnosis and treatment of sleep disorders in children. He is the author of "Solve Your Child's Sleep Problems" a practical guide to the management of common sleep problems in children of all ages.
Please keep in mind that the text provided is for informational purposes only and is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health professional before starting any new treatment or making any changes to existing treatment.
Children's Hospital Boston©, 2005. This page may be reproduced for educational purposes. Reprint permission is required for all other uses.
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