Pediatric Views

June 2006

Dr. Ferber updates his landmark sleep book

Richard Ferber, MD

By Richard Ferber, MD

Richard Ferber, MD, director of the Center for Pediatric Sleep Disorders at Children's Hospital Boston and author of Solve Your Child's Sleep Problems, which was updated in May for the first time in 20 years.

After 20 years of research, what important issues do you address in the new edition of Solve Your Child's Sleep Problems?
Most of the topics needed some expansion. We've learned a great deal about sleep schedules—how they impact the child's sleep and how they can be a problem. We have a better understanding of partial arousals, including night terrors, sleep walking and related sleep disturbances, why they happen and how to deal with them. We improved guidelines for sleep requirements at different ages, which can help avoid certain common problems, such as parents trying for more sleep than possible. We also tried to clarify common misunderstandings, such as how and when particular treatment programs should be instituted, and to address certain issues, like co-sleeping, that were not well-discussed earlier.

How should parents approach their child's sleep?
In getting a child to sleep well at night, the first thing is to understand the nature of sleep, the development of sleep in children and what should normally happen at each age. If a child is having sleep problems, try to understand all the reasons why. Once the reasons are identified, you can design a solution. If it's simply an issue of an improper schedule, then adjusting the schedule should be all that's necessary. If it's an issue of a young child being overfed at night, then feeding should be cut back. There may be several ways to resolve any problem. Some work better for one family or fit better with that family's philosophy than do others.

Do some children sleep more than others?
Yes, but the range in sleep times is probably narrower than a lot of people think. Most children are within a two-hour window of total sleep time. And changes in sleep requirements are very gradual, only going from about 12 hours at 6 months to about 9 hours at the end of adolescence.

What are the most common schedule problems in babies?
Schedules can go wrong at all ages, in all kinds of ways. One common problem in babies is getting too much sleep during the day in the form of long naps to be able to sleep well at night. Another is going to bed so early in the evening that the baby wakes up earlier in the morning than parents like. Shortening naps or putting the child to bed later are quick solutions. Another problem occurs when babies (usually 6 to 12 months old) still take four or five short naps. The brevity of the naps means the babies get tired again sooner and ready for another brief nap. Often the cycle continues into a night broken into more short sleep periods. Progressively lengthening the time between naps allows the subsequent naps to lengthen, and the cycle to be broken.

When should parents stop comforting a child who wakes in the night?
A child who basically sleeps fine, but has normal wakings that require the parent to repeatedly do something—go to his room to rub his back, pick him up or rock him—to help him go back to sleep can be a problem, especially after the first three to four months. Such habits can be eased away from while teaching a new one that the parents choose based on what circumstances they want their child sleeping under. In just a couple of days, they can teach their child a more independent habit for going back to sleep. If the child is co-sleeping in the parents' bed all night for instance, the mother may not want to let her son twirl her hair, and the father may not want to get up and rock his daughter, to get them back to sleep.

Speaking of co-sleeping, what's your recommendation?
Twenty years ago we had very little direct experience. We've found that youngsters sleep very well in a variety of situations, as seen around the world. From a sleep perspective, we have little evidence for or against any of these arrangements. We like to know families have plans for what they're going to do, for how long they plan to co-sleep and how they will transition to the next step. The American Academy of Pediatrics' recent guidelines against co-sleeping were stronger than past statements. While this is safe advice for the population at large, since it assures avoiding conditions that could be dangerous if not controlled, we've found that individual families can understand that if they make the changes necessary to assure the safety of the baby, they can co-sleep fairly safely. Another option is having the cradle near the bed.

Should parents worry about snoring?
Yes, unless the snoring is only occasional, such as with a cold. Chronic snoring should always be reported to the pediatrician. Snoring means an obstructed airway as may occur, for example, with enlarged tonsils and adenoids, obesity or facial abnormalities. Further investigation may require referral to an ear, nose and throat specialist, a maxillo-facial surgeon, and a weight loss program, and to a sleep center for assessment and formal sleep study.

Do children ever need sleep medications?
Usually when medication is prescribed, the actual cause of the sleep problem has not been identified and treated. Children on an inappropriately late schedule, for example, should have their schedule corrected to resolve both the trouble falling asleep and the subsequent sleep deprivation with its associated school and behavioral problems. These problems should not be treated with medications to fall asleep at night, to wake up and focus in the day, and to control temper outbursts related to lack of sleep.

For more information, visit: www.childrenshospital.org/sleep.

Children's Hospital Boston
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