5 minute tips on sleep

Please read our introductory post before reading this

As always, you need to know

a) generic advice

b) a formulation that tells you why this child has problems now.

You can then adapt the former according to the latter.

Generic advice

Sleep schedule: Your child’s bedtime and waketime should be about the same time everyday. There should not be more than 1 hour’s difference in bedtime and waketime between school nights and non-school nights. Make your child’s bedtime early so that he can get enough sleep.
Bedtime routine: Your child should have a 20-minute to 30-minute bedtime routine that is the same every night. The routine should include calm activities, such as reading a book or talking about the day, with the last part occurring in the room where your child sleeps.
Bedroom: Your child’s bedroom should be comfortable, quiet, and dark. A nightlight is fine, as a completely dark room can be scary for some children. Your child will sleep better in a room that is cool (less than 75°F). Also, avoid using your child’s bedroom for “time out” or other punishment. You want your child to think of the bedroom as a good place, not a bad one.
Snack: Your child should not go to bed hungry. A light snack (such as milk and cookies) before bed is a good idea. Heavy meals within an hour or two of bedtime, however, may interfere with sleep.
Caffeine: Your child should avoid caffeine for at least 3 to 4 hours before bedtime, although it’s best to avoid it totally. Caffeine can be found in many types of soda, energy drinks, coffee, iced tea, and chocolate.
Evening activities: The hour before bed should be a quiet time. Your child should not get involved in high-energy activities, such as rough play or playing outside, or stimulating activities such as computer games.
Television: Keep the television set out of your child’s bedroom. Children can easily develop the bad habit of “needing” the television to fall asleep. It is also much more difficult to control your child’s television viewing if the set is in the bedroom. Keep all other electronic devices out of the bedroom too, such as computers, cell phones, and hand-held computer games.
Naps: Naps should be geared to your child’s age and developmental needs. However, very long naps or too many naps should be avoided, as too much daytime sleep can result in your child sleeping less at night.
Exercise: Your child should spend time outside every day and get daily exercise.

Sleep problems resistant to first-line advice

Most parents presenting with young children with sleep problems are frustrated by the child’s inability to settle to sleep alone, or by their frequent night wakings. We will not discuss infant sleep, but concentrate on the pre-school child.

Social factors: Historically and cross-culturally, it is highly unusual to expect young children to sleep alone. Nonetheless that is the UK norm, and it is acheivable for most families.

Psychological: Going to sleep alone is a form of separation, and like all separations must be prepared for. If the child is in an anxious or fearful state this will require very slow withdrawal of the protective adult. Usually, if the fear is external to the adult, e.g. of the dark, gradual withdrawal is effective, but where the fear is of the adult, or more commonly about the adult, e.g. in domestic violence, then more specialist work may be needed.

Sleep is also a habit, and habits form very strongly in pre-school children. If sleep is usually with an adult, or in the light, changes to this should be carefully applied one at a time. Likewise, if the physical situation (light, noise, presence of adult) is different between sleep onset and the (normal) awakenings that occur every 1-2 hours, then full arousal will often result.

There is an association between some forms of insecure attachment and sleep problems, and also maternal depression. The precise relationship is unclear, however, and probably varies from family to family.

Biological:sleep is a biological phenomenon, and is therefore affected by biological mechanisms. Chronic symptoms e.g. pain or GI symptoms may prevent sleep, but equally phenomena such as epileptic seizures can disrupt the diurnal rhythm. A far more common way to interfere with sleep initiation is to watch a back-lit screen close to bedtime. These appear to suppress endogenous melatonin secretion, and thus the psysiological ‘cue’ to sleep, and so should be avoided within an hour of bedtime.

Example case:

Louie, 4, has a tantrum every night at bedtime. His health visitor has advised mum to shut the bedroom door and ignore him, but it’s not working.

4p grid constructed as follows:

 

  Biological/ developmental Psychological Social
Predisposing Preterm birth Maternal anxiety  
Precipitating   Break-up of parents’ relationship Domestic violence
Perpetuating Screen use in bedroom up till bedtime Anxiety re: mum Mum unavailable due to depression
Protective Healthy, good communicator Good relationship with mum during the day Family well-supported by grandparents

 

This leads to some simple, hopefully helpful interventions:

  • Stop screen time
  • Mum to seek counselling/ treatment for depression.
  • Grandparents asked to help with domestic tasks so mum can spend time with Louie
  • Gradual withdrawal of mum from bedroom at bedtime, following good ‘wind-down’.

 

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