Pediatric Annals

Healthy Baby/Healthy Child 

Sleep Training

Amy Liu, MD, MPH

Abstract

Adequate sleep in infancy and beyond is important for development; however, many children are not sleeping the recommended amount. During the first few years of childhood, infants are frequently seen in the pediatric office for well-visits and a myriad of other concerns, including sleep difficulties. As such, pediatricians should be adequately prepared to address these concerns. This article aims to provide clinicians with a basic knowledge of sleep physiology, sleep patterns and development, and current guidelines and options available for parents to address these issues. [Pediatr Ann. 2020;49(3):e101–e105.]

Abstract

Adequate sleep in infancy and beyond is important for development; however, many children are not sleeping the recommended amount. During the first few years of childhood, infants are frequently seen in the pediatric office for well-visits and a myriad of other concerns, including sleep difficulties. As such, pediatricians should be adequately prepared to address these concerns. This article aims to provide clinicians with a basic knowledge of sleep physiology, sleep patterns and development, and current guidelines and options available for parents to address these issues. [Pediatr Ann. 2020;49(3):e101–e105.]

To fully understand pediatric sleep disorders, it is important to have a basic knowledge of sleep physiology. There are two distinct and independent processes, the circadian and homeostatic processes, which are believed to regulate sleep and wakefulness. The circadian process is our body's biological 24-hour clock that corresponds to the world around us. Many factors can affect circadian rhythm, including light exposure, ambient temperature, mealtimes, physical activity, and bedtime routines. The homeostatic process involves the sleep debt that is accumulated during waking hours that leads to the need for sleep.

The sleep cycle is composed of non-rapid eye movement (NREM) sleep and REM sleep. NREM sleep can be further divided into three stages. Stage 1 is the transition from wakefulness to sleep. It typically lasts around 5 minutes and is the lightest stage of sleep. During this stage, brain activity slows and eyelids close, but the eyes continue to move slowly beneath the closed lids. Stage 2 sleep is referred to as light sleep and is characterized by decreased eye movements, tone, heart rate and respirations. Approximately half of sleep time occurs in stage 2. Stage 3 is the deepest state of sleep, characterized by muscle relaxation and slowing of brain waves, breathing, and heart rate. A child is not easily awakened from stage 3 sleep, and if roused, it usually takes a minute or so for him or her to become fully awake. Stage 3 constitutes approximately 20% of sleep time. REM sleep typically occurs after 1 or 2 complete cycles of NREM sleep. It is often referred to as “active sleep” and is the stage during which most dreams occur. REMs, muscle paralysis and twitching, and irregular breathing and heart rate are commonly seen during REM sleep. The first periods of REM sleep usually only last for a few minutes; however, as the night goes on, REM sleep lengthens. Studies suggest that REM sleep is important, allowing the brain to assimilate and learn from experiences during the day as well as to form memories.1,2

Compared to older children, a newborn's sleep has many differences. Around age 4 to 6 weeks circadian rhythms begin to develop, and by age 8 to 12 weeks babies can sleep for a longer period of time and are more responsive to environmental factors such as light-dark exposures. The periods of sleep are equally divided between active (analogous to REM sleep) and quiet (similar to NREM sleep) sleep, with each cycle lasting about 50 to 60 minutes. Given the shorter sleep cycles, infants are more easily interrupted during sleep. Newborn infants can fall directly into active sleep, which can continue to around age 3 months. Gross limb movements, sucking motions, and smiling occur during active sleep as opposed to the REM sleep muscle paralysis in older children. At age 4 to 6 months, most babies are on a regular sleep/wake cycle with sleep onset beginning to occur during NREM sleep by age 6 months. As the central nervous system matures, total sleep duration and proportion of REM sleep decreases, and the REM/NREM cycle lengthens.1,3

For older children and adolescents, sleep onset is during NREM sleep, which comprises approximately 75% of total sleep time. Overall REM/NREM cycles extend to the adult level of 90 minutes by age 5 years. Secondary to a physiologic shift in melatonin release, adolescents tend to have difficulty falling asleep and prefer to stay up late. The increasing irregularity of sleep-wake patterns can lead to a decrease in average sleep duration.

Current Sleep Recommendations

The American Academy of Pediatrics endorses the consensus statement of the American Academy of Sleep Medicine (AASM) regarding sleep duration required on a regular basis for optimal health (Table 1).

Recommended Amount of Sleep by Age

Table 1.

Recommended Amount of Sleep by Age

Despite these recommendations, most children tend to get 30 to 90 minutes less sleep than recommended.5,6 Additionally, 44% and 21% of parents/caregivers of toddlers and school-aged children, respectively, report being awakened at least 3 nights a week. In considering the impact of electronics on sleep, 72% of children age 6 to 17 years have at least one electronic device in the bedroom, with 39% of children reporting that the TV is sometimes left on at night. Results from the study discovered that those who did not have electronics in the bedroom had improved sleep duration.6 Additionally, those who had sleep-related rules (specific bed time, how late the child can watch TV, use electronics, or drink caffeine sources) slept on average 0.6 to 1.1 hours longer than children whose parents did not have these rules.6

As the studies above support, laying the foundation for good sleep cannot be overemphasized. Adherence to a consistent routine helps support a child's circadian and homeostatic process. This may include regular wake times, mealtimes, naptimes, and bedtimes. Children's sleep spaces should only be used for rest and relaxation. To that end, play and punishment should not occur in the bedroom. Caffeine intake should be limited (eg, chocolate, tea, and soda), especially after lunchtime. Active play, exercise, and electronics should be avoided near bedtime. Establishing bedtime routines, such as bathing, brushing teeth, and reading stories, can provide something that children look forward to as well as allow individual time spent with parents. Maintaining a bedroom environment that is dark, set at a comfortable temperature, and with minimum noise can encourage sleep onset and maintenance. A small night light or stuffed animal/blanket can provide additional comfort for those that need it.

Sleep Training: Is it Necessary?

Although there is research demonstrating that decreased total sleep duration is associated with both physical and mental health concerns in childhood, there are mixed results regarding uninterrupted sleep and development. One study determined that a significant percentage of infants, approximately 30% of 6-month-old infants and 40% of 12-month-old infants, did not sleep through the night (defined as 6 consecutive hours of sleep). Further analysis also did not find a statistically significant association between sleeping through the night and mental or psychomotor development or maternal mood. In contrast, sleeping through the night was associated with much lower rates of breast-feeding. Several other studies have noted that fragmented sleep and more frequent nighttime awakenings are associated with poorer cognitive performance.7

Given that there is no consensus regarding the benefits or limitations of consecutive sleep duration, the decision to sleep train is often a personal one for many families. Many experts do recommend sleep training as a way to learn healthy sleep habits early on and address sleep issues such as night awakenings. Furthermore, studies have indicated that behavioral sleep training methods are effective and safe.8

The goal of sleep training is to provide infants and children with the skill of independent sleep as well as positive sleep associations. Positive sleep associations are actions that infants take to fall asleep on their own (eg, humming, holding a stuffed animal/blanket, thumb sucking). Negative sleep associations are actions that another person may take to help a child fall asleep (eg, rocking/bouncing, singing, feeding). External sleep associations are also important to create a welcoming sleep environment (eg, white noise, comfortable room temperature, blackout shades). Most pediatricians would agree that the best time to sleep train is around age 4 to 6 months, as many infants are able to self soothe and they are able to sleep through the night without needing to wake up to feed from a nutritional standpoint.

Behavioral Interventions for Sleep and the Current Literature

The AASM has developed practice parameters for bedtime problems and night awakenings. The recommendations were based on over 50 peer-reviewed studies that found clinically significant improvements in bedtime resistance and night waking with behavioral interventions (Table 2).

American Academy of Sleep Medicine Treatment Recommendations

Table 2.

American Academy of Sleep Medicine Treatment Recommendations

Unmodified Extinction

Unmodified extinction or “cry it out” (CIO) as a behavioral strategy is effective although often less palatable to parents. To implement the extinction method, caregivers will provide the normal bedtime routine, put the baby to sleep, then leave the room without checks until a set time the next morning. Behaviors are ignored unless there is concern that the infant is hurt or sick. The premise for the extinction method is that if you go in to help your child, they will continue to cry the same amount the next night because they expect you to come in to rescue them again. Weissbluth9 is commonly credited as an early proponent of this approach. Depending on the age and temperament, he does allow parents to enter to soothe the child; however, if the parent's return results in increased wakefulness and stimulation, he advises that parents do not re-enter the room. Additionally, he advocates for an earlier bedtime (5pm to 6pm). Other studies have found that extinction with parental presence to be an effective and more acceptable strategy.10 Parents remain in the child's room during bedtime but ignore the child. Fading, also known as adult fading or camping out, is a variant of this method in which caregiver presence is gradually withdrawn from the child's room during sleep. The “sleep lady shuffle” supports having the parents stay in the room to comfort the child as he or she falls asleep. With each consecutive night, the parents move further and further from the crib.11

Graduated Extinction

Graduated extinction is commonly known as “controlled crying,” and parental acceptance is higher than unmodified extinction techniques. Many books provide different approaches to implementing this extinction method. Typically, bedtime routines are completed, then infants are placed in the crib drowsy but awake. Ferber12 recommends a progressive checking-in schedule that initially starts at 3 minutes, then 5 minutes, then 10 minutes, and with longer intervals between each visit over the course of the week. The purpose is to allow the infant to know the parent is nearby but also to reassure the parent that she or he is fine as well. Typically, the parent should not pick up or engage the infant, but just offer reassurance provided with voice and perhaps a loving pat for a few minutes.12 The “Sleepeasy Solution”13 is similar to the Ferber method, but instead starts with an interval that feels comfortable to the caregiver, such as 3 minutes or 5 minutes. After the first check-in, the caregiver consistently extends each check-in interval by 5 minutes. When it is time for the check-in, the caregiver should go halfway into the room but not pick up the infant, instead speaking in a calm soothing voice with the whole process lasting maybe 30 seconds, then walk out. Some children may get more upset with each check in, and if this is the case, the check-in time may need to extended by another 5 minutes. Gradually, as the cries lessen, the check-ins will as well. If the child begins to yell and scream, the check-in process should start again. Recommended bedtime is between 7pm and 8pm.14 Additionally, support is provided for weaning children from overnight feedings with goals of only one or two feedings overnight by slowly decreasing breast-feeding by 2 minutes each night or 2 ounces each night if formula feeding. Providers should ensure that patients are gaining appropriate weight and emphasize that daytime feedings may need to increase to accommodate the decrease in nighttime feedings. Progress is usually observed by whining and complaining rather than crying or intermittent crying with longer pauses between crying.

Faded Bedtime

Another method that has demonstrated effectiveness is faded bedtime with response cost and positive bedtime routines. The goal is to strengthen the cues for sleep in the bed and bedroom and weaken cues that interfere with falling asleep. The child's bedtime is temporarily delayed to align with the actual sleep onset time, thereby ensuring rapid sleep initiation. For example, if the infant typically goes to sleep at 9pm, then initial bedtime will be set at 9:30pm to allow a higher likelihood that the child will fall asleep sooner. The child may not go to sleep prior to this time and should not sleep past the scheduled wake time. Daytime sleep is not allowed except for age-appropriate naps. If sleep onset is not achieved during a pre-prescribed time period, parents will then remove the child for a specific time period and try again. Once decreasing sleep onset latency is demonstrated, the bedtime can be moved earlier by 15 to 30 minutes each subsequent night.15 Positive bedtime routines are also encouraged; these can include different activities that are fun for the kids but also calming prior to bedtime to establish the behavioral chain that leads up to sleep onset. Both treatments focus on improving appropriate behaviors and stimulus control.

Scheduled Awakenings

The last method that AASM recommends includes scheduled awakenings. This method advises studying the pattern of nighttime awakenings of the child first, then preemptively waking the child approximately 15 to 30 minutes prior to the expected time. Parents would then comfort the child as they would for a spontaneous awakening with the goal of fading them out by increasing the time span between each scheduled awakening. Karp16 implements a similar method of this wake and sleep technique by waking the baby up a little bit (tickle their feet) so that they wake up slightly, but then go back to sleep in 5 to 10 seconds. In that short time period, they learn how to put themselves back to sleep in the middle of the night without your help.

Gentle and No-Cry Methods

Some parents may be interested in gentle and no-cry methods. Often, these can take longer to see effect and can result in more agitation as parents' presence can sometimes be more upsetting than soothing. Additionally, parents should be aware that some amount of crying may occur as the child responds to change. With the “pick up, put down approach,” the baby is picked up when she cries and then placed back into the crib as soon as she is comforted. The process is continued until the baby is settled.17 Sears et al.,14 another proponent of no-cry and attachment parenting, recommends shared sleeping spaces, creating positive sleep conditions, and varying your techniques at night (ie, one night rocking or nursing to sleep, another night singing to sleep, switching off with spouse to put infant to bed). Another popular no-cry advocate, Elizabeth Pantley,18 advises keeping logs of sleep, naps, and night awakenings. Next steps include a game plan that may include key words as sleep cues, soothing pats, earlier bedtime, and sleep routines. The plan is implemented for 10 days then reassessed with continued modification as needed.18

In counseling parents who have tried sleep training with little success, physicians should ensure that they have been consistent and spent enough time with a certain method prior to assessing results. Typically, if no progress is noted after 1 to 2 weeks, this intervention may not be the right one and parents may need to try a different one or take a break and try the same method again. Another thing to counsel parents is that any sleep disruption may require retraining, including travel, milestones, or illness. Also, many infants may respond to sleep training with changes in appetite, clinginess, crankiness, crying, drowsiness, or resistance to daytime naps.

Conclusion

There is an overwhelming amount of information available to both parents and physicians on different sleep approaches. This column aims to provide a brief summary of the techniques that have shown evidence of benefit in studies as well as other methods for parents who would like to sleep train but prefer a method that does not involve crying it out. Above all, parents should be educated about the importance of consistency as well as bedtime routines that can help support any attempts to improve sleep.

References

  1. Davis KF, Parker KP, Montgomery GL. Sleep in infants and young children: part one: normal sleep. J Pediatr Health Care. 2004;18(2):65–71. doi:10.1016/S0891-5245(03)00149-4 [CrossRef] PMID:15007289
  2. Moon RY. Sleep: What Every Parent Needs to Know. Elk Grove Village: American Academy of Pediatrics; 2013.
  3. El Shakankiry HM. Sleep physiology and sleep disorders in childhood. Nat Sci Sleep. 2011;3:101–114. doi:10.2147/NSS.S22839 [CrossRef] PMID:23616721
  4. Paruthi S, Brooks LJ, D'Ambrosio C, et al. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med. 2016;12(6):785–786. doi:10.5664/jcsm.5866 [CrossRef] PMID:27250809
  5. National Sleep Foundation. 2004 Sleep in America poll: children and sleep. https://www.sleepfoundation.org/sites/default/files/inline-files/FINAL%20SOF%202004.pdf. Accessed February 14, 2020.
  6. National Sleep Foundation. 2014 Sleep in America poll: sleep in the modern family. https://www.sleepfoundation.org/professionals/sleep-americar-polls/2014-sleep-modern-family. Accessed February 14, 2020.
  7. Pennestri MH, Laganière C, Bouvette-Turcot AA, et al. Mavan Research Team. Uninterrupted infant sleep, development, and maternal mood. Pediatrics. 2018;142(6):e20174330. doi:10.1542/peds.2017-4330 [CrossRef] PMID:30420470
  8. Price AM, Wake M, Ukoumunne OC, Hiscock H. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics. 2012;130(4):643–651. doi:10.1542/peds.2011-3467 [CrossRef] PMID:22966034
  9. Weissbluth M. Healthy Sleep Habits, Happy Child: A Step-by-Step Program for a Good Night's Sleep. 4th ed. New York, NY: Ballantine Books; 2015.
  10. Morgenthaler TI, Owens J, Alessi C, et al. American Academy of Sleep Medicine. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep.2006;29(10):1277–1281. PMID:17068980
  11. West K, Kenen J. The Sleep Lady's Good Night, Sleep Tight: Gentle Proven Solutions to Help Your Child Sleep Well and Wake Up Happy. New York, NY: Hachette Book Group; 2009.
  12. Ferber R. Solve Your Child's Sleep Problems: New, Revised, and Expanded Edition. New York, NY: Simon & Schuster; 2006.
  13. Waldburger J, Spivack J. The Sleepeasy Solution: The Exhausted Parent's Guide to Getting Your Child to Sleep from Birth to Age 5. New York, NY: Simon & Schuster; 2007.
  14. Sears W, Sears M, Sears R, Sears J. The Baby Sleep Book: The Complete Guide to a Good Night's Rest for the Whole Family. New York, NY: Little, Brown Spark; 2005.
  15. Piazza CC, Fisher W. A faded bedtime with response cost protocol for treatment of multiple sleep problems in children. J Appl Behav Anal. 1991;24(1):129–140. doi:10.1901/jaba.1991.24-129 [CrossRef] PMID:2055796
  16. Karp H. The Happiest Baby on the Block. New York, NY: Bantam; 2003.
  17. Hogg T, Blau M. Secrets of the Baby Whisperer: How to Calm, Connect, and Communicate with Your Baby. New York, NY: Random House; 2005.
  18. Pantley E. The No-Cry Sleep Solution: Gentle Ways to Help Your Baby Sleep Through the Night. New York, NY: McGraw Hill; 2002.

Recommended Amount of Sleep by Age

Age Recommended Hours of Sleep per 24-Hour Period a
Infants (4 to 12 months) 12 to 16 hours
Toddlers (1 to 2 years) 11 to 14 hours
Preschoolers (3 to 5 years) 10 to 13 hours
Grade schoolers (6 to 12 years) 9 to 12 hours
Teenagers (13 to 18 years) 8 to 10 hours

American Academy of Sleep Medicine Treatment Recommendations

Behavior Intervention Description Objective
Unmodified extinction ± parental presence Parents put child to bed at designated bedtime and then ignore the child until morning. Parents monitor for safety and illness concerns Reduce undesired behaviors (eg, prolonged bedtime protests) by eliminating any reinforcement (eg, parental attention)
Graduated extinction Parents ignore bedtime crying and tantrums for specific periods before briefly checking on child. A progressive (“graduated”) checking schedule (eg, 5 minutes, then 10 minutes) or fixed checking schedule (every 5 minutes) may be used Enable a child to develop “self-soothing” skills and independent sleep without negative sleep associations
Positive routines/faded bedtime with response cost Parents develop a set bedtime routine involving enjoyable and quiet activities leading up to sleep onset. Faded bedtime involves temporarily delaying bedtime to more closely coincide with the child's natural sleep onset time, then fading it earlier as the child gains success falling asleep quickly Rely on stimulus control as the primary agent of behavior change and target reduced affective and physiological arousal at bedtime
Scheduled awakenings Parents preemptively awaken their child prior to typical spontaneous awakening and provide “usual” responses (eg, feeding, rocking, soothing) as if the child awakened spontaneously
Authors
Amy Liu, MD, MPH

Amy Liu, MD, MPH, is an Assistant Professor and General Pediatrician, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine.

Address correspondence to Amy Liu, MD, MPH, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, 333 S. Columbia Street, Room 231 MacNider Hall, CB 7225, Chapel Hill, NC 27599-7225; email: amy.liu@med.unc.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20200218-01

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