Sleeping Beauty: How sleep works and how to make it work for you and your child.
By Osteopath Melissa McDougall.
Sleep does not just provide us with rest and restoration. Adequate and healthy sleep habits hold and abundance of body and mind benefits.
Russel Foster, in his ted talk ‘Why Do We Sleep’, highlights that many of us living today, are desperately sleep deprived.
We as adults are no doubt busy. And we sacrifice sleep, willingly (by going to bed late in favour of watching tv, cleaning the house, going out for dinner), or unwillingly (when experience difficulty falling or staying asleep at night, or are woken).
However there are many reasons that we should take sleep seriously… and get it right. Sleep deprivation is associated with many health problems, but getting enough sleep doesn't just help us avoid disease but actually is beneficial for our health. Here's the facts:
Sleep habits in children:
Adequate sleep benefits in Children: a summary:
- Infants and young children spend a majority of their time asleep, suggesting that sleep is essential for the developing brain and body.
- Sleep is believed to play a role in the growth and healing of body tissues, learning and processing of memory, and central nervous system repair.
- Optimal sleep is essential for normal growth and development, emotional health, and immune function.
- Considerable clinical and anecdotal evidence supports that emotional and behavioural problems in children often significantly improve when underlying sleep problems are identified and rectified resulting in the attainment of adequate amounts of sleep.
Inadequate sleep implications in Children: a summary:
- Decreased ability to pay attention and concentrate.
- There is increasing evidence that sleep problems can have a negative effect on children's cognitive (thinking/problem solving), behavioural, and emotional functioning.
- It has been suggested that the rising rates of behavioural and emotional problems in children can be associated with sleep problems.
- Sleep loss has been implicated in childhood injuries such as falls, pedestrian accidents, and bicycling accidents.
- Children involved in traffic accidents as a result of their own behaviour were rated higher on measures of hyperactivity, impulsivity, and attentional difficulties (which are all symptoms of inadequate sleep) than average children of the same age.
Is your child sleepy??… signs of sleep deprivation in children:
Most young children do not have typical symptoms of sleep loss such as yawning or obvious sleepiness, rather children often manifest symptoms that are almost opposite to the signs of sleepiness in adults: irritability, hyperactivity, short attention span, and low tolerance for frustration.
And for grownups….
Sleep Habits in Adults:
Adequate sleep benefits in Adults: a summary:
- Increases concentration & attention.
- Supports decision making.
- Promotes creativity.
- Enhances social skills.
- Supports health.
- Enhances brain processing and memory consolidation: Our ability to come up with novel solutions to complex problems in hugely enhanced by a night of sleep... It seems that a night of sleep enhances our creativity three fold.
- Decreases mood change, stress, anger, impulsiveness and need for stimulants.
- Some genes are turned on a only during sleep, and those genes are to do with restoration and metabolic pathways. This means sleep helps build our physical body structure and improves its function.
Inadequate sleep implications in Adults: a summary:
- Poor memory.
- Increased impulsiveness.
- Poor creativity.
- Poor judgement.
- A tired brain craves things to wake it up... Nicotine, caffeine, sugar. A stimulant fuelled awake state (caffeine, sugar) can leave the tired brain looking for sedation at night, through alcohol. (Once in awhile, a little alcohol is okay- however it is not a recipe for sleep. Because alcohol sedates the brain, it can also impact on the quality of neural processing, memory consolidation and memory recall that's occurring during sleep).
- Weight and sleep: if you sleep 5 hours or less per night, you have a 50% likeliness of being obese. Sleep loss causes rises in the hunger hormone Ghrelin. The brain then seeks out carbohydrates, particularly sugars.
- Tiredness=Stress. Sustained stress associated with sleep loss can lead to suppressed immunity, alterations in blood glucose levels, increases in blood pressure.
How to sleep well?
To establish heathy sleep patterns in infants, children and ourselves as adults, it is essential to understand how sleep works. Understanding how we sleep allows us to make educated choices about the activities we, and our children engage with prior to the onset of sleep that are known to support or hinder healthy sleep. Habits and practices that are conducive to sleeping well on a regular basis are known as ‘sleep hygiene’. Sleep hygiene practices for different ages are outlined later in this article.
So how do we sleep?
We are thought sleep by two processes, or rhythms in our body:
(1) the circadian process, or the ‘Light/Dark Clock’: an internal clock, that takes cues from the external environment to regulate the timing of sleep and wakefulness. Light exposure signals waking, and darkness signals sleep. This process matches our sleep to the external environment.
(2) the homeostatic process, or the ‘Sleep Debt Metre’: this process involves the sleep debt that is accumulated during waking hours, which leads to an increase in the sleep drive. In other words, the longer the period of wakefulness, the stronger the drive to sleep.
And what happens when we sleep?
During sleep a third rhythm or process called the ‘ultradian rhythm’ refers to the alternation of two distinct types of sleep throughout the sleep period:
1) nonrapid eye movement (NREM) or Deep Sleep: This type of sleep is divided into four distinct stages 1 being the lightest (characterised by reduced body movements, drowsiness, and reduced responsiveness), and 4 (slow wave or 'very deep sleep') being the deepest (characterised by a relaxed body position, slow and rhythmic breathing, and a decreased heart rate.
2) rapid eye movement (REM), or ‘Dream Sleep’: is characterised by bursts of rapid eye movement, intense brain activity, inability to move the body, and dreaming.
So what is normal?
Firstly it is essential to understand that sleep differs greatly between newborns, young children, adolescents and adults. Understanding these normal variations can help us identify what is normal and abnormal, and the reasons behind why sleep hygiene practices help little ones get enough sleep:
Normal sleep in newborns:
Newborns enter three types of sleep:
- quiet sleep (as NREM sleep: minimal large or small muscle movements and rhythmic breathing cycles)
- active sleep (as REM sleep: sucking motions, twitches, smiles, frowns, irregular breathing, and gross limb movements)
- indeterminate sleep: falls into neither of these categories. As the newborn matures, this type of sleep changes into well defined NREM or REM sleep.
- Opposite to adults, newborn humans enter active sleep (REM/ Dream Sleep) before quiet sleep (NREM/ Deep Sleep).
- Newborns have a shorter sleep cycle of 50-60 minutes (compared 90 minutes in adults).
- Each sleep period lasts only one or two sleep cycles.(Thus, newborn sleep periods are shorter and more frequent than in older children & adults).
- NREM slow waves (associated with very deep sleep) are not present at birth.
- The circadian or light/dark rhythm is not fully established, so sleep can occur as easily during the daytime hours as during the night.
- The newborn has a less efficient sleep cycle than found in older children, resulting in easily interrupted sleep.
- In the first few weeks of life, a sleep cycle consists of both active (Dream Sleep) (50%) and quiet (50%) sleep periods in equal proportion.
- Pattern of sleep in newborns is often co-ordinated by feeding times.
- On average, newborns sleep for 16-18 hours per day.
Normal sleep cycles in older babies, toddlers & young children:
In the briefest summary, many changes occur over the first 5 years of life to organise sleep in children.
- The ability to sleep deeply (NREM stages 3 & 4/slow wave) occurs in the first 2 years of life. This type of sleep is first seen around 3 months.
- Light and darkness begin to influence sleep and wakefulness around 2-3 months of age. At this age, longer awake periods in the day are achieved by less Dream Sleep, and social cues (such as timing of feedings and nighttime routines) begin to influence sleep/wake patterns.
- The proportion of REM (Dream Sleep) begins to decrease to approximately 30% to 40% of total daily sleep at 2-3 months and continues to decline over the first 2 years to approximately 20% to 25%.
- From 3 months to 6 months (and similar to adults), sleep onset begins to occur through NREM (Deep Sleep) periods rather than REM (Dream Sleep) periods, and body movement during Dream Sleep is replaced by the inability to move (this is what happens in adults, and is thought to helps us not act out our dreams!)
- As the child matures, sleep requirements steadily decrease. Total daily sleep need decreases to about:
13 hours by age 2 years
12 hours by age 3 to 4 years
11 hours by age 5 years
.....But all children are different and do not necessarily fit this description.
- Daytime naps are still common in young children and supplement the longer nighttime sleep period to meet a child’s total sleep requirement.
- Sleep cycle length remains stable at approximately 60 minutes at age 3 years, and gradually extends to the adult level of 90 minutes by age 5 years.
- At 5 years, spend 20% to 25% of their total daily sleep in Active/REM/Dream Sleep and 75% to 80% in Quiet/NREM/Deep Sleep. The first third of the night is dominated by NREM slow waves (very deep sleep), whereas REM (Dream Sleep) occurs predominately in the latter half of the night. This pattern is similar to adults.
Normal sleep cycles in Adults:
- Adults enter sleep through NREM (Deep Sleep), REM (Dream Sleep) does not occur until 80 minutes or longer thereafter.
- NREM (Deep Sleep) and REM (Dream Sleep) sleep alternate through the night. Slow wave (very deep sleep) is longest in the first third of the night, REM (Dream Sleep) is longest in the last one third of the night.
- Brief episodes of wakefulness tend to intrude later in the night, usually near REM sleep transitions, and they usually do not last long enough to be remembered in the morning.
- The adult sleep cycle is approximately 90 minutes.
So what does all this mean?… And how can we sleep soundly?
Any new parent will appreciate that recommendations on establishing healthy sleep patterns in infants and children are everywhere.
As an osteopath and health care professional, I appreciate that all children and families differ in their physiological make up, environment and values. Therefore the tips below are intended only as a guide, some practices may work well in your family, and others not so well, so take what works and leave what doesn't. I hope to clarify the science behind these suggestions, so that families can make informed decisions about sleep practices.
Suggestions for healthy slumber: What we can do, and the reasons for doing it.
Sleep hygiene suggestions for babies, toddlers and children:
- From birth to 3 months: relax… babies can sleep anywhere! Whether in a cot or bassinet, whether in the nursery or the parents’ bedroom, the decision may be based on family values, comfort and convenience. This is because there is a lack of organisation of sleep states in infants in this age range. (Note: there is some concern about the safety of infants co-sleeping in the parents’ bed. For more information on safe sleep, please visit the Royal Children's Hospital page on Safe Sleeping).
- You can wake newborns to feed in the day. Paediatrician David Epstein suggests that infants who sleep longer during the day than at night, and want to feed frequently at night have “the days and nights mixed up.” His solution is to wake the baby frequently during the day for feeds. Epstein maintains that ‘there is no value in teaching a baby to last longer between feeds’ and states ‘in fact, babies who feed frequently during the day sleep better at night’. He suggests that parents let their newborn sleep only 2 or 2½ hours before waking him/her for a feeding during the day. If the infant sleeps longer than 3 hours at a time during the day, he is likely to be up hungry at night. He does not suggest waking a sleeping baby for feeding at night.
- By 3-4 months: establish a sleep routine that suits your family. An infant’s sleep habits begin to be well established by 3 to 4 months of age. So, by that age, parents will want to establish a sleep routine that they themselves are comfortable with; those routines are harder to change after 6 months.
- Are you hungry?? Healthy infants 4-6 months can drop their night feed safely. All children are different, but in general the 4-6 month old's liver is able to maintain blood sugar levels without food overnight. Some infants may learn to expect night feedings around 4 months, and he/she may not eat enough during the day to avoid feeling hungry at night. In this case, Paediatrician David Epstein recommends that families can transition out of this habit by giving water can be given instead of calories after the baby’s bedtime, and increasing feeds during the following days.
- Lightly wrap your baby. This can be used as a temporary measure to ‘buy time’ as often baby’s can wriggle out as they mature. Wrapping may also simulate the feeling of containment and being held. It is of upmost importance that swaddling be light weight to avoid overheating, wrapping should also leave the hips free to move for healthy hip development (see our previous article: ‘positioning for greatness' for swaddle techniques).
- Infants 4-6 months: try a few practices that assist infants sleeping through the night. Sleeping though the night may be important in some families and not others. If this is something you’d like establish in your family, you can try these things:
- Put your child to bed when drowsy, not fully asleep. In both infants and young children, episodes of semiwakefulness during the nighttime sleep are common and are often referred to as night wakings. These short intervals of wakefulness occur about five to seven times per night, are typically seen at the end of a sleep cycle, and last 1 to 5 minutes. Children will often reach semiwakefulness, open their eyes, and survey their surroundings. Familiar surroundings typically result in the return to sleep. However, if the surroundings are unfamiliar or different than those that were present at sleep onset, children may progress to full waking. Putting your child to bed when drowsy, not fully asleep, allows your child to fall asleep in the surroundings that will be present when they awaken at night, such as their crib or bed. This practice is thought to teach children how to fall asleep without parental assistance and encourages self-soothing after a night waking. (note: again, all children are different, and there may be periods where teething, coughs, colds, temperature and growth may make self soothing difficult (...or impossible!) If you suspect your child is experiencing discomfort, best speak to your GP, Paediatrician or Paediatric Osteopath).
- Implement a consistent daytime and nighttime routine that matches your childs physical and developmental sleep needs. These include preparation for ‘bedtime’ and consistent ‘lights out’ time…. as well as consistent morning wake time, naptimes, and feeding/meal times. These routines help strengthen the child's circadian (light/dark) and homeostatic (sleep debt) processes and reduce the likelihood that the child will suffer from insufficient sleep.
- Treat your child’s bedroom as a place for relaxation and sleep. Suggestions to make this work are to move playtime out of the bedroom, and to avoid using the bedroom as a place of punishment.
- Limit your child’s caffeine intake (ie, chocolate, tea, and cola), especially after lunchtime. Caffeine can delay sleep onset, reduce total sleep time, and increase the amount of light sleep. These effects of caffeine can last greater than 8 hours.
- Provide calming, unhurried, consistent bedtime routines that include "one on one” special time with the parent. Routines such as bathing, reading stories, and brushing teeth with a loving yet firm parental direction make for a positive experience at bedtime, and children will often look forward to this time rather than struggling and resisting. This time can also foster feelings of security and promote the child's ability to fall asleep independently. Near bedtime it is best to avoid or limit active play, exercise, and stimulating television and computer programs.
- The bedroom environment is also important; the child's room should be as dark as possible, the temperature comfortable (not too warm), and noise kept to a minimum to enhance sleep onset and maintenance. (A note on night lights: Of course, if the child feels more comfortable with a night light, one should be provided. It is natural for changes in exposure to light or darkness can shift the circadian rhythm. Light exposure prior to the onset of sleep can interfere with sleep onset, such as with a child exposed to bright indoor lights, television, or sunlight on long summer days, and light exposure near sleep's end can accelerate awakening. This is just something to be aware of.)
- Many young children enjoy the comfort of a transitional object such as a special toy, doll, or blanket.
It is important to note that these suggestions support normal physical processes in healthy children. Structural and functional sleep problems in children need to be ruled out if sleeping problems persist, and are beyond the scope of this article. It is best to speak with your GP, paediatrician or paediatric osteopath if you suspect your child is having persistent sleeping difficulties due to a medical cause.
Sleep hygiene for adults:
- Make your room as dark as possible, and slightly cool.
- Reduce your amount of light exposure 30minutes before bed. Light increases levels of alertness and will delay sleep.
- Wind down, do things before bed that you know help you relax. A bath, reading, breathing, stretching... Whatever works for you.
- Turn off your phone, tablet, TV, computer.
- Make effort to limit your caffeine intake to the morning only. Enjoy caffeine free drinks after lunch into the evening.
- Seek out morning light, a 10 minute walk before breakfast, or drinking your first cuppa by a brightly sunlit window will do nicely.
All these things help to strengthen our circadian (Light/Dark) and homeostatic (Sleep Debt) rhythms for improved self regulation sound sleep.
Part two…. osteo-moves and audio for sound sleep: to be continued....
Finn Davis K, Parker KP, Montgomery GL. (2004). Sleep in Infants and Young Children: Part One: Normal Sleep. J Pediatr Health Care, 18 (2).
Finn Davis K, Parker KP, Montgomery GL. (2004). Sleep in Infants and Young Children: Part Two: Common Sleep Problems. J Pediatr Health Care, 18 (3).
Carskadon MA, Dement WC. (2011). Monitoring and staging human sleep. In MH Kryger, T Roth, WC Dement (Eds.), Principles and practice of sleep medicine, 5th edition, (pp 16-26). St. Louis: Elsevier Saunders.
Epstien D. (2007). Sleep Advice for Babies. Retrieved September 30, 2014 from http://api11.team-logic.com/downloadPubFileFile.cfm?i=492&t=10&f=122
Foster R. (2013). Why Do We Sleep? [Videorecording]. Retrieved July 21, 2014 from https://www.ted.com/talks/russell_foster_why_do_we_sleep?language=en
Leeson R, Barbour J, Romaniuk D, WARR R. (1994). Management of infant sleep problems in a residential unit. Child: Care, Health and Development, 20 (2):89-100. DOI : 10.1111/j.1365-2214.1994.tb00856.x