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

Sleep and Your 4- to 7-Month-Old

By this age, your baby should be well on the way toward an established sleep pattern. Most likely the pattern includes at least two naps a day, plus at least 7 or 8 hours of nighttime sleep.

During these months, your baby will learn to roll over and position himself or herself for sleep. Toward the end of this period, your little one may be able to stay awake or be kept awake by surroundings, so this is the time to instill good sleep habits by sticking to a bedtime routine.

How Long Will My Baby Sleep?

While the average number of hours slept per day at this age is 14, the range of normal is quite wide, with some babies sleeping only 9 hours and others sleeping as much as 18.

The average amount of daytime sleep now is 3-4 hours. Some babies will nap 20 minutes, others will sleep much longer than average.

Remember that your baby would rather be with you than anywhere else. So your tot may need more sleep but wakes after a 20-minute nap because he or she would just rather be playing with you than sleeping. As your baby becomes a toddler and starts resisting naps, it's still a good idea to have a period of quiet time, for both of you.

Naps usually help prevent a baby from becoming too cranky to sleep well at night, allowing your baby (and you) to enjoy the waking hours more. Most babies this age like to nap once in the morning, then again sometime after lunch.

If you feel the naps are interfering with your baby's bedtime, you can wake the baby from an afternoon nap a little earlier. But if your baby is overly tired, he or she will not sleep well at night.

How and Where Should My Baby Sleep?

The American Academy of Pediatrics (AAP) recommends that healthy infants be placed on their backs to sleep, not on their stomachs. The incidence of sudden infant death syndrome (SIDS) has decreased by more than 50% since this recommendation was first made in 1992. It's now also recommended that premature infants sleep only on their backs.

Until your baby is rolling over unaided and picking a position for sleep, place your little one on his or her back to sleep. It is thought that some babies sleeping on their stomachs may have a greater tendency toward sleep obstruction and rebreathing their own carbon dioxide because they're less likely to rouse themselves to change head positions. Another possibility is that they may suffocate on softer bedding if they are lying face-down.

Always keep safety in mind. Make sure your crib meets current safety standards. Don't put anything in the crib that can interfere with your baby's breathing — stuffed animals, blankets, or soft pillows can fall on a baby's face and block breathing. Although bumper pads were widely used in the past, they are no longer recommended. A study, using data from the Consumer Product Safety Commission (CPSC), found a number of accidental deaths appeared to be related to the use of bumper pads in cribs and bassinets. The AAP and other pediatric organizations strongly discourage the use of bumper pads in cribs to avoid accidental suffocation.

Also, avoid items with strings, ties, or ribbons that can wrap around a baby's neck, and objects with any kind of sharp edge or corner. Babies can also get tangled in hanging mobiles, so remove them as well. Don't forget to look around for the things that your baby can touch from a standing position in the crib. Wall hangings, pictures, draperies, and window blind cords are all potentially dangerous if left in a baby's reach.

Many cultures endorse cosleeping. But studies indicate that there is a greater incidence of SIDS in households where the infant slept in the bed with the parents. Use of substances that decrease the parents' awareness, such as alcohol, also may allow a parent to roll over onto the baby.

Encouraging Sleep

You have probably already established a bedtime routine and are staying with it. If you haven't established one, start now. Soothing activities that lead up to "night-night" time can help relax your baby. A warm bath followed by stories or singing will signal transition to sleep, and these same activities can be used at bedtime for years.

You'll probably want your baby to start falling asleep on his or her own. This may mean performing your nighttime routine and putting the baby into the crib while he or she is still awake. If the baby cries, stay away for a few minutes. Your baby may settle down and go to sleep.

If the crying continues, go back in and soothe the baby for a moment without picking him or her up. This may go on a few times until your baby figures out that the crying is not getting anywhere. Expect that this may be a difficult exercise for you, simply because it's upsetting to hear your baby cry. Try to remember that if you know your baby is safe, a little crying now so that you can all sleep better later is ultimately the healthier choice.

Even a baby who has already been sleeping through the night (anywhere from 7-12 hours) will occasionally awaken in the wee hours. After ruling out teething pain, illness, or an extremely soiled diaper, it's best to let your baby struggle back to sleep on his or her own. Give your baby a few fussy minutes before you respond, then after seeing that everything is OK, leave your baby alone to fall back to sleep. Don't forget that any cuddling, feeding, or talking you do may prompt your baby to wake each night for this attention.

If your baby is waking up many times each night, perhaps there is an external reason. Is your baby too big for the bassinet? Move him or her to a full-size crib. Do you still have the baby in your bedroom? Your little one may be sensitive to your presence and may need to be put in his or her own room to get a good night's sleep. Is the baby's room too warm? Too cold? Too dark? Explore these possibilities.

Another common sleep "problem" at this age is the early riser — the baby who begins to babble or cry for you before the crack of dawn. There is probably nothing you can do to prevent your baby from waking when ready, but a few safe toys in the crib may soothe your baby for a while longer and a window shade to keep out the first light of day may let you get another few minutes of sleep.

When to Call the Doctor

If you have ruled out external reasons for nighttime waking and you still think your baby's not sleeping enough (or is even sleeping too much!), don't hesitate to call your doctor.

Teething pain is a common reason for sleep problems at this age, and the doctor may be able to suggest some ways to relieve your baby's discomfort. Perhaps there is an illness involving no other symptoms besides sleeplessness, or maybe your doctor can help you find ways to enhance your nighttime routine with your baby.

Reviewed by: Steven Dowshen, MD
Date reviewed: September 2011