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

All About Sleep

Sleep — or lack of it — is probably the most-discussed aspect of baby care. New parents discover its vital importance those first few weeks and months. The quality and quantity of an infant's sleep affects the well-being of everyone in the household.

And sleep struggles rarely end with a growing child's move from crib to bed. It simply changes form. Instead of cries, it's pleas or refusals. Instead of a feeding at 3:00 AM, it's a nightmare or request for water.

So how do you get your child to bed through the cries, screams, avoidance tactics, and pleas? How should you respond when you're awakened in the middle of the night? And how much sleep is enough for your kids?

How Much Is Enough?

It all depends on a child's age. Charts that list the hours of sleep likely to be required by an infant or a 2-year-old may cause concern when individual differences aren't considered. These numbers are simply averages reported for large groups of kids of particular ages.

There's no magical number of hours required by all kids in a certain age group. Two-year-old Sarah might sleep from 8:00 PM to 8:00 AM, whereas 2-year-old Johnny is just as alert the next day after sleeping from 9:00 PM to 6:00 AM.

Still, sleep is very important to kids' well-being. The link between a lack of sleep and a child's behavior isn't always obvious. When adults are tired, they can be grumpy or have low energy, but kids can become hyper, disagreeable, and have extremes in behavior.

Most kids' sleep requirements fall within a predictable range of hours based on their age, but each child is a unique individual with distinct sleep needs.

Here are some approximate numbers based on age, accompanied by age-appropriate pro-sleep tactics.

Babies (up to 6 Months)

There is no sleep formula for newborns because their internal clocks aren't fully developed yet. They generally sleep or drowse for 16 to 20 hours a day, divided about equally between night and day.

Newborns should be awakened every 3 to 4 hours until their weight gain is established, which typically happens within the first couple of weeks. After that, it's OK if a baby sleeps for longer periods of time. But don't get your slumber hopes up just yet — most infants won't snooze for extended periods of time because they get hungry.

After the first couple of weeks, infants may sleep for as long as 4 or 5 hours — this is about how long their small bellies can go between feedings. If babies do sleep a good stretch at night, they may want to nurse or get the bottle more frequently during the day.

Just when parents feel that sleeping through the night seems like a far-off dream, their baby's sleep time usually begins to shift toward night. At 3 months, a baby averages about 13 hours of sleep in a 24 hour period (4-5 hours of sleep during the day broken into several naps and 8-9 hours at night, usually with an interruption or two). About 90% of babies this age sleep through the night, meaning 5 to 6 hours in a row.

But it's important to recognize that babies aren't always awake when they sound like they are; they can cry and make all sorts of other noises during light sleep. Even if they do wake up in the night, they may only be awake for a few minutes before falling asleep again on their own.

If a baby under 6 months old continues to cry, it's time to respond. Your baby may be genuinely uncomfortable: hungry, wet, cold, or even sick. But routine nighttime awakenings for changing and feeding should be as quick and quiet as possible. Don't provide any unnecessary stimulation, such as talking, playing, or turning on the lights. Encourage the idea that nighttime is for sleeping. You have to teach this because your baby doesn't care what time it is as long as his or her needs are met.

Ideally, your baby should be placed in the crib before falling asleep. And it's not too early to establish a simple bedtime routine. Any soothing activities, performed consistently and in the same order each night, can make up the routine. Your baby will associate these with sleeping, and they'll help him or her wind down.

The goal is for babies to fall asleep independently, and to learn to soothe themselves and go back to sleep if they should wake up in the middle of the night.

6 to 12 Months

At 6 months, an infant may nap about 3 hours during the day and sleep about 9 to 11 hours at night. At this age, you can begin to change your response to an infant who awakens and cries during the night.

Parents can give babies a little more time to settle down on their own and go back to sleep. If they don't, comfort them without picking them up (talk softly, rub their backs), then leave — unless they appear to be sick. Sick babies need to be picked up and cared for. If your baby doesn't seem sick and continues to cry, you can wait a little longer, then repeat the short crib-side visit.

Between 6 and 12 months, separation anxiety, a normal developmental phase, comes into play. But the rules for nighttime awakenings are the same through a baby's first birthday: Try not to pick up your baby, turn on the lights, sing, talk, play, or feed your child. All of these activities do not allow your baby to learn to fall asleep on his or her own and encourage repeat awakenings.

Toddlers

From ages 1 to 3, most toddlers sleep about 10 to 13 hours. Separation anxiety, or just the desire to be up with mom and dad (and not miss anything), can motivate a child to stay awake. So can simple toddler-style contrariness.

Parents sometimes make the mistake of thinking that keeping a child up will make him or her sleepier for bedtime. In fact, though, kids can have a harder time sleeping if they're overtired. Set regular bedtimes and naptimes. Though most toddlers take naps during the day, you don't have to force your child to nap. But it's important to schedule some quiet time, even if your child chooses not to sleep.

Establishing a bedtime routine helps kids relax and get ready for sleep. For a toddler, the routine may be from 15 to 30 minutes long and include calming activities such as reading a story, bathing, and listening to soft music.

Whatever the nightly ritual is, your toddler will probably insist that it be the same every night. Just don't allow rituals to become too long or too complicated. Whenever possible, allow your toddler to make bedtime choices within the routine: which pajamas to wear, which stuffed animal to take to bed, what music to play. This gives your little one a sense of control over the routine.

But even the best sleepers give parents an occasional wake-up call. Teething can awaken a toddler and so can dreams. Active dreaming begins at this age, and for very young children, dreams can be pretty alarming. Nightmares are particularly frightening to a toddler, who can't distinguish imagination from reality. (So carefully select what TV programs, if any, your toddler sees before bedtime.)

Comfort and hold your child at these times. Let your toddler talk about the dream if he or she wants to, and stay until your child is calm. Then encourage your child to go back to sleep as soon as possible.

Preschoolers

Preschoolers sleep about 10 to 12 hours per night. A preschool child who gets adequate rest at night may no longer need a daytime nap. Instead, a quiet time may be substituted.

Most nursery schools and kindergartens have quiet periods when the kids lie on mats or just rest. As kids give up their naps, bedtimes may come earlier than during the toddler years.

School-Age Children and Preteens

School-age kids need 10 to 12 hours of sleep a night. Bedtime difficulties can arise at this age for a variety of reasons. Homework, sports and after-school activities, TVs, computers, and video games, as well as hectic family schedules might contribute to kids not getting enough sleep.

Lack of sleep can cause irritable or hyper types of behavior and may make it difficult for kids to pay attention in school. It is important to have a consistent bedtime, especially on school nights. Be sure to leave enough time before bed to allow your child to unwind before lights out.

Teens

Adolescents need about 81/2 to 91/2 hours of sleep per night, but many don't get it. Because of early school start times on top of schedules packed with school, homework, friends, and activities, they're typically chronically sleep deprived.

And sleep deprivation adds up over time, so an hour less per night is like a full night without sleep by the end of the week. Among other things, an insufficient amount of sleep can lead to:

  • decreased attentiveness
  • decreased short-term memory
  • inconsistent performance
  • delayed response time

These can cause bad tempers, problems in school, stimulant use, and driving accidents (more than half of "asleep-at-the-wheel" car accidents are caused by teens).

Teens also experience a change in their sleep patterns — their bodies want to stay up late and wake up later, which often leads to them trying to catch up on sleep during the weekend. This sleep schedule irregularity can actually aggravate the problems and make getting to sleep at a reasonable hour during the week even harder.

Ideally, a teen should try to go to bed at the same time every night and wake up at the same time every morning, allowing for at least 8 to 9 hours of sleep.

Bedtime Routines

No matter what your child's age, establish a bedtime routine that encourages good sleep habits. These tips can help kids ease into a good night's sleep:

  • Include a winding-down period in the routine.
  • Stick to a bedtime, alerting your child both half an hour and 10 minutes beforehand.
  • Encourage older kids and teens to set and maintain a bedtime that allows for the full hours of sleep needed at their age.

Reviewed by: Mary L. Gavin, MD
Date reviewed: January 2011