Sleep Medicine

Patient and family education is important to us. Here you can learn more about sleep and healthy sleep habits, and view trusted insights from KidsHealth.org, the No. 1 most viewed health site for children, created by the experts at Nemours. We've also provided information from the most-respected non-profit organizations.

Healthy Sleep

All children need a good night’s sleep. It’s not only a time for rest, but sleep gives your child’s brain a chance to sort and store information from their day. When kids don’t get enough sleep or quality sleep, it can affect how they feel, act and do in school. Our pediatric sleep medicine specialists are here to get to the bottom of your child’s sleep problems and set your child on the path to a good night’s rest.

Natural Sleep Cycles: Five Stages of Sleep

Natural brain cycles are responsible for sleep, which is defined by 2 states:
  1. Non-REM (non-rapid eye movement) sleep, considered “quiet sleep” (5- to 20-minute intervals)
  2. REM (rapid eye movement) sleep, considered “active sleep” (60-70 minutes)

Normally, sleep occurs in stages that cycle several times throughout the night.

 
Stage 1: Non-REM Sleep

This is the transition from wakefulness to sleep. During this period the brain reduces activity and polysomnography (sleep study) shows high amplitude theta waves (slow brain waves).

 
Stage 2: Non-REM Sleep

At this time, the body’s temperature begins to decrease and the heart rate begins to slow to prepare for sleep. Bursts of rapid rhythmic brain waves (called sleep spindles) begin to appear.

 
Stages 3 & 4: Non-REM Sleep

These stages mark the transition between light and deep sleep where delta (very slow) brain waves begin to emerge in stage 3 and continue in intensity. Sleep walking and bedwetting often occur at the end of stage 4.

 
Stage 5: REM Sleep

After about 90 minutes of non-REM sleep, brain activity increases as the eyes begin moving rapidly and dreaming begins. REM is referred to as paradoxical sleep because muscles become more relaxed as the brain’s other systems become more active.


Good Sleep Habits

 
Independent Sleep

Consider the following recommendations to help your child develop good habits for getting to sleep on his or her own.

  • Keep your child’s room neat and clean — responsibility for this task will vary depending on your child’s age and abilities.
  • Put a nightlight or small light within your child’s reach.
  • A quiet fan or humidifier may allow for some “white noise” to filter out the noise coming from the rest of the house.
  • Place a few of your child’s favorite items around the bed so it becomes sort of a "mini-home."
  • Have a bedside table or shelf stocked with your child’s favorite books.
  • Give your child plenty of notice that bedtime is approaching. A predictable, consistent bedtime routine helps kids wind down toward sleep.
  • Set aside time to do something special with your child before bed. Avoid any activities that will excite your child. Let your child know your special time together will end at bedtime.
  • Once you finish playing or reading a story, tell your child goodnight and leave the room. If your child comes out, take your child back to bed and leave again.
 
Helping Your Preschool Child Develop Good Sleep Habits

Helping kids get enough sleep involves creating soothing and consistent bedtime routines.

The goal is for your child to learn to:
  • fall asleep on his or her own
  • not rely on your presence for this to happen
  • be able to go back to sleep during the night
  • go to bed at the same time every night — let your child know 30 minutes ahead of that time to get ready
Other ways to help your child develop better sleep habits:
  • make sure your child goes to the bathroom, washes up, and brushes his or her teeth
  • read a book with your child
  • make sure your child has a cup of water, a nightlight or anything else your child may need
  • remind your child to stay quiet and in bed
  • say goodnight
When your child goes to bed, make sure everything is done:
  • teeth brushed
  • said goodnight to everyone
  • had a drink of water
  • used the toilet

After your child is in bed, keep the TV and the rest of the home fairly quiet. Your child can awaken easily in the first hour of sleep.

If your child awakens, the goal is have the same conditions present that were there when your child fell asleep — that means you’re not present when your child falls asleep. Follow these recommendations for naptime too. You may be asked to track your child’s sleep in a sleep diary so you can measure progress made.

 
Sleep Tips for Teens
  • Try to stay on a schedule — go to bed and get up at roughly the same time each day, even on weekends. Don't sleep more than 2-3 hours later than usual.
  • Get into bright light as soon as possible in the morning, but avoid it in the evening.
  • Try not to nap during the day; or nap only for 20-30 minutes.
  • Avoid caffeine in the afternoon.
  • Don't exercise within 3 hours before going to bed.
  • Keep the temperature in your room comfortable.
  • Keep the room quiet and dark when sleeping.
  • Use the bedroom only for sleep, not for fun or watching TV. This will signal the body that when you are in your room, it's time to sleep.
  • Leave time to unwind before bed. Avoid stimulating activities like TV or lively music 30 minutes prior to bedtime.
  • Do not go to bed until you are drowsy. Trying to “make yourself fall asleep” will only make you wake up more.
  • Do not go to bed too hungry or too full — a light snack such as pretzels, crackers or popcorn just before bed may help make you drowsy.
  • Use a relaxation exercise, such as progressive muscle relaxation or guided imagery, just before bed.
  • If you are unable to fall asleep within 30 minutes, get out of bed and do something quietly in another room until sleepy.

Common Sleep Conditions

 
Bruxism (Teeth Grinding)

Bruxism can be a serious condition. Kids who grind their teeth are more likely to do it in the first half of the night, when they are less likely to be dreaming.

Teeth Grinding in Babies and Toddlers

Nearly half of all babies grind their teeth. It usually begins at about 10 months old, after the two top front teeth and two bottom front teeth come in. Generally, it’s nothing to worry about and usually goes away on its own without any damage to permanent teeth. After baby teeth are lost, if your child is still grinding, consult with your child’s dentist.


Teeth Grinding in Children and Teens

Children and teens also grind their teeth. Children with disabilities are more likely to grind their teeth, especially children with cerebral palsy and intellectual disabilities. Teeth grinding can cause tooth pain, jaw pain, and headaches. Also, it can wear down teeth.


Treating Bruxism

Nothing needs to be done if a child is grinding teeth once in a while and if it’s not too intense. It is usually nothing to worry about, as long as there is no damage to the teeth and no other symptoms.

 
Delayed Sleep Phase Syndrome

If your child or teen remains awake at least two hours past their usual bedtime because they are unable to fall asleep, it may signal Delayed Sleep Phase Syndrome (DSPS).

Often, it’s hard for someone with DSPS to wake up in the morning. If allowed to sleep until the late morning or early afternoon, your child feels rested and can function well. Many teens with DSPS describe themselves as being at their best in the evening and at night. They tend to “catch up” on their sleep during weekends.


Causes and Symptoms of Delayed Sleep Phase Syndrome

DSPS usually starts during the teen years and affects about 7% (1 out of 15) of teens. While the cause is unknown, sometime after puberty, most teens start staying up later at night and sleeping later in the morning.

Some symptoms may include:
  • Trouble falling asleep at a usual bedtime: Most teens with DSPS fall asleep late at night or in the early morning.
  • Difficulty with awakening in the morning: Since teens fall deeply asleep so late, most have difficulty getting up and ready on time in the morning.
  • Daytime sleepiness: Often teens who fall asleep late at night and awaken early for school suffer from feeling tired and sleepy during
    the day.
  • Other symptoms during the day: Sleepiness during the day and lack of energy may be mistakenly interpreted as depression. In addition, these teens may suffer from poor attention and motivation, sometimes diagnosed as attention deficit disorder.

Diagnosing and Treating DSPS

Keeping a sleep diary for a week gives enough information about when your child goes to sleep and wakes up to make a diagnosis.

Treatment includes resetting your child’s internal clock to establish the habit of being sleepy at a normal bedtime. If your teen isn’t motivated, it’s difficult to change the pattern.

To get back into a more regular schedule:
  • Don’t smoke and avoid caffeine or other stimulating drugs.
  • Limit daytime sleeping to one 15- to 20-minute nap, if any.
  • Go to bed earlier.
  • Gradually move back bedtime by 15 minutes intervals, that is, if your teen is going to bed at midnight, set bedtime at 15 minutes earlier at 11:45 p.m., for one or two nights, then 11:30 p.m. for one or two nights. Continue 15 minutes earlier every two nights, until bedtime is at 10 p.m.
  • Go to bed later: It’s easier for the body to get used to a later bedtime than an earlier one. Using a technique called “phase delay,” bedtime is delayed by 2 to 3 hours each night. For example, if a teenager usually falls asleep at 2 a.m. bedtime is delayed until 4 a.m. one night, 6 a.m. the next night.
  • Melatonin: There is limited evidence to support use of melatonin an hour prior to bedtime and this therapy should be used in consultation with your child’s doctor. Once the desired bedtime is reached, your teen must stick with their schedule every night for several months. Even one night of late night studying or socializing can return the internal clock to the delayed state.
 
Head Banging and Body Rocking

Babies often fall asleep when they are rocked back and forth by adults. Sometimes, babies and children rock themselves to sleep. When these rhythmic movements become intense, it results in head banging and body rocking, and known as “rhythmic movement disorders.” Your child may do this mostly when falling asleep (at naptime or bedtime) and then settle down once asleep.

Should You Worry About Your Child’s Head Banging or Body Rocking?

For most children, this behavior is not a cause for concern and most stop by age 4; however, you may have to watch your child a little closer. Children with other issues such as developmental delay, autism, or blindness may rock or bang their heads more forcefully and hurt themselves; consult your doctor.

Follow these tips:
  • It’s unlikely your child will hurt himself. There is no need to put extra bumpers in the crib or place pillows around it.
  • Be careful not to reinforce the head banging — try not to go to your child every time — you may be accidentally encouraging this behavior.
  • Move the crib or bed — move the crib or bed away from the wall if the noise is disturbing the rest of the family. If your child is in a bed, put guardrails on all sides.
  • Head banging and rocking can loosen the screws and bolts in your child’s crib or bed — tighten these fasteners on a regular basis.
 
Periodic Limb Movement Disorder (Twitching and Jerking at Night)

Periodic Limb Movement Disorder (PLMD) is a repetitive, sometimes intense movement of the limbs — usually the legs — during sleep that typically lasts a few seconds.

Most children and teens are unaware of the movements that feel like a tingling, crawling, creeping pain and look like brief muscle twitches or jerking movements. They tend to occur in groups, and last from a few minutes to a few hours, and can cause your child to awake during the night, which may lead to daytime sleepiness.

Children and teens with PLMD may also experience Restless Leg Syndrome, a related disorder that can happen at night or during times of rest, or on long car rides.


Causes of Periodic Limb Movement Disorder

PLMD may be related to low iron levels in the blood (anemia) or due to chronic illnesses, such as diabetes and kidney disease. However, for most children with PLMD, the cause is not known.

Symptoms may include:
  • leg movements
  • restless sleep
  • sleep disruption
  • daytime sleepiness
  • behavior and academic problems

Diagnosing and Treating Periodic Limb Movement Disorder

Your child’s doctor may order an overnight sleep study or polysomnography, in which you and your child will spend the night in a sleep lab at a hospital or clinic. While your child is sleeping, a sleep technologist will look for movements or wakings.

Treatments may include:
  • avoiding caffeine
  • treatment of iron deficiency
  • medications
Other recommendations may include:
  • keeping your child's room neat, clean and clutter-free
  • using a nightlight or small light within his or her reach which may help your child feel more secure during the night
  • using a quiet fan or humidifier
  • placing favorite items around your child’s bed
  • having a bedside table or shelf stocked with his or her books
  • giving your child notice that bedtime is approaching
  • avoiding activities that may excite your child at bedtime
  • leaving your child’s room after saying goodnight

Apnea of Prematurity

About Apnea of Prematurity

Apnea of prematurity is fairly common in preemies. Doctors usually diagnose the condition before the mother and baby are discharged from the hospital, and the apnea usually goes away on its own as the infant matures. Once apnea of prematurity goes away, it does not come back. But no doubt about it — it's frightening while it's happening.

Apnea is a medical term that means a baby has stopped breathing. Most experts define apnea of prematurity as a condition in which premature infants stop breathing for 15 to 20 seconds during sleep.

Generally, babies who are born at less than 35 weeks' gestation have periods when they stop breathing or their heart rates drop. (The medical name for a slowed heart rate is bradycardia.) These breathing abnormalities may begin after 2 days of life and last for up to 2 to 3 months after the birth. The lower the infant's weight and level of prematurity at birth, the more likely he or she will have AOP.

Although it's normal for all infants to have pauses in breathing and heart rates, those with AOP have drops in heart rate below 80 beats per minute, which causes them to become pale or bluish. They may also appear limp and their breathing may be noisy. They then either start breathing again by themselves or require help to resume breathing.

AOP should not be confused with periodic breathing, which is also common in premature newborns. Periodic breathing is marked by a pause in breathing that lasts just a few seconds and is followed by several rapid and shallow breaths. Periodic breathing is not accompanied by a change in facial color (such as blueness around the mouth) or a drop in heart rate. A baby who has periodic breathing resumes regular breathing on his or her own. Although it can be frightening, periodic breathing typically causes no other problems in newborns.

Treatment

Most of the time, premature infants (especially those less than 34 weeks' gestation at birth) will receive medical care for apnea of prematurity in the hospital's neonatal intensive care unit (NICU). When they are first born, many of these premature infants must get help breathing because their lungs are too immature to allow them to breathe on their own.

Medications

Many babies with AOP are given oral or intravenous (IV) caffeine medication to stimulate their breathing. Like the caffeine in coffee or soft drinks, a low dose of caffeine helps keep infants alert and breathing regularly. Most infants are taken off the caffeine while still in the NICU, although a small number will be discharged on the medication.

Monitoring Breathing

Babies are monitored continuously for any evidence of apnea. The cardiorespiratory monitor (also known as an apnea and bradycardia, or A/B, monitor) also tracks the infant's heart rate. An alarm on the monitor sounds if there's no breath for a set number of seconds. When the monitor sounds, a nurse immediately checks the baby for signs of distress. False alarms are not uncommon.

If a baby doesn't begin to breathe again within 15 seconds, a nurse will rub the baby's back, arms, or legs to stimulate the breathing. Most of the time, babies with apnea of prematurity spells will begin breathing again on their own with this kind of stimulation.

However, if the nurse handles the baby, and the baby still hasn't begun breathing unassisted and becomes pale or bluish in color, oxygen may be administered with a handheld bag and mask. The nurse or doctor will place the mask over the infant's face and use the bag to slowly pump a few breaths into the lungs. Usually only a few breaths are needed before the baby begins to breathe again on his or her own.

AOP can happen once a day or many times a day. Doctors will closely evaluate your infant to make sure the apnea isn't due to another condition, such as infection.

When Your Baby Is on a Home Apnea Monitor

Although apnea spells are usually resolved by the time most preemies go home, a few will continue to have them. In these cases, if the doctor thinks it's necessary, the baby will be discharged from the NICU with an apnea monitor. Your baby may also need to take caffeine medication for a short time at home.

An apnea monitor has two main parts: a belt with sensory wires that a baby wears around the chest and a monitoring unit with an alarm. The sensors measure the baby's chest movement and breathing rate while the monitor continuously records these rates.

Before your baby leaves the hospital, the NICU staff will thoroughly review the monitor with you and give you detailed instructions on how and when to use it, as well as how to respond to an alarm. Parents and caregivers will also be trained in infant CPR, even though it's unlikely they'll ever have to use it.

If your baby isn't breathing or his or her face seems pale or bluish, follow the instructions given to you by the NICU staff. Usually, your response will involve some gentle stimulation techniques and, if these don't work, starting CPR and calling 911. Remember, never shake your baby to wake him or her.

It can be very stressful to have a baby at home on an apnea monitor. Some parents find themselves watching the monitor, afraid even to take a shower or run to the mailbox. This usually becomes easier with time. If you're feeling this way, it can help to share your feelings with the NICU staff. They may be able to reassure you and even put you in touch with other parents of preemies who have gone through the same thing.

Your doctor will determine how long your baby wears the monitor, so be sure to ask if you have any questions or concerns.

Caring for Your Baby

Apnea of prematurity usually resolves on its own with time. For most preemies, this means AOP stops around 44 weeks of postconceptional age. Postconceptional age is defined as the gestational age (how many weeks of pregnancy at the time of birth) plus the postnatal age (weeks of age since birth). In rare cases, AOP continues for a few weeks longer.

Healthy infants who have had AOP usually do not go on to have more health or developmental problems than other babies. The apnea of prematurity does not cause brain damage. A healthy baby who is apnea free for a week will probably never have AOP again.

Although sudden infant death syndrome (SIDS) does occur more often in premature infants, no relationship between AOP and SIDS has ever been proved.

Aside from AOP, other complications with your premature baby may limit the time and interaction that you can have with your little one. Nevertheless, you can bond with your baby in the NICU. Talk to the NICU staff about what type of interaction would be best for your baby, whether it's holding, feeding, caressing, or just speaking softly. The NICU staff is not only trained to care for premature babies, but also to reassure and support their parents.

Reviewed by: Jay S. Greenspan, MD
Date reviewed: October 2011