Q&A: The sleepless child
By Richard Ferber, MD

Richard Ferber, MD, Director of The Center for Pediatric Sleep Disorders

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 6-month-old (and certainly an 8-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's the best way to diagnose the cause of a sleep problem?
It's most important to take a good, careful history. This requires a good understanding of normal and abnormal sleep patterns and behavior, but (with proper training and sufficient time) it often can be done in a general pediatrician's office.

What Types of Questions Should a Good Sleep History Include?

How can physicians help parents normalize the sleep environment?
Find out from the parents what setting they want their child to sleep in. It can be their choice—in the room with parents or alone. But whatever way they choose should be the way 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 the parents insist on this consistency, it only takes a night or two to adapt.

What are the most important factors in getting babies to sleep well?
Habits and feedings are two key things in the early months, but a third that's very important and is often least well understood is the schedule. Our bodies evolved with the regular rising and setting of 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 nap time 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 the child to bed at 7 p.m., want them to sleep until 8 the next morning, 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 you try to force them to sleep more (or at the wrong times), the problem will only get worse.

How much sleep should children generally get?
Young infants may sleep 12 to 13 hours total. But by 6 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.

How that sleep is distributed may vary. In the first few months, a third or more 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. As the child gets to 5 months or so, he probably should be getting at least nine 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 also true. If a child is sleeping from 7 p.m. until 6:30 the next morning, he's getting more than 11 hours of sleep, which is enough sleep total, and he may not have enough sleep left to nap well during the day.

At what age should kids stop napping?
Most kids stop between the ages of 3 and 4. Some stop at age 2, 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 also. If they're not, then a thorough understanding of the cause of the problem and implementation of corrective behavioral and schedule-related measures—rarely would medication be necessary—should normalize their sleep within a few days. 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.

	Dr. Richard Ferber 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.