My Child Has Trouble Sleeping, What Now?

As every parent, grandparent, relative, and friend of a child with difficulty sleeping knows, sleep problems have a strong impact not only on the child's life but also on the sleep and daytime functioning of other family members. What is not as well-known is that there are effective medical and behavioral treatments available for childhood sleep problems. Because such problems tend to persist or recur from infancy to adulthood, early identification and management by a sleep specialist is critical to improving the quality of life of the child and the entire family.

Here are answers to common questions from parents about their child's sleep apnea and other sleep problems.

My child has just been diagnosed with sleep apnea. What can I expect next?

After your child is diagnosed with sleep apnea, you will have a discussion with your sleep specialist about next steps. Often a referral to an ear, nose and throat doctor is recommended to see if surgery (typically removal of the tonsils and/or adenoids) is a good option. About 75 percent of children will be cured by this type of surgery. Several months after surgery, it is recommended that your child have a follow-up study in order to see if the sleep apnea has resolved.

You may also be asked to come back to the clinic to discuss other treatment options such as CPAP (continuous positive airway pressure) if your child is not a candidate for surgery, or if a follow-up sleep study shows that s/he still has sleep apnea after surgery.

What questions should I ask the sleep doctor or pediatrician?

Describe your worries openly. Often in sleep medicine, the details will help the doctor make the best plan for your child. Additionally, you should discuss any concerns about your child's growth and development, feeding (including reflux), ear infections, eczema, or other health concerns that could impact your child's sleep.

Will my insurance cover the equipment?

In most cases if your child has been diagnosed with sleep apnea by polysomnography, it will be covered.

What if my child is having problems adjusting to the CPAP? What different things could we try?

It is important to consider the child's age when developing a strategy, as the focus will be different at each stage of development. For example, teenagers have more social concerns and are likely worried about what their friends will think. A realistic discussion about the costs and benefits of CPAP may be helpful. On the other hand, younger children often have difficulty keeping the mask on. No matter what your child's age, CPAP can feel strange at first, so a gradual approach is best.

Allow your child to investigate his/her CPAP machine with you present. Reassure him/her that although it makes noise, it is still safe. Focus on the benefits that your child may notice, such as having more energy at school or being able to get up earlier to play on weekends.

Once your child has adjusted to the idea, it's time to actually use the machine. This can be a little tricky and may take a few days, depending on your child's comfort level and age. First you may want to have the child put the mask on for a few minutes, then a little bit longer without the pressure turned on. Then you may want to put the mask on your child with the air on just for a few seconds, then a minute, then a few minutes, etc. It is crucial to reinforce each of these steps with praise and even with a small treat. The best reinforcements are things that can be given immediately and that the child likes. For example, 10 minutes of computer time or playing a game with a parent.

What can I do to ensure that my child is receiving the best treatment?

Find a sleep professional who specializes in pediatric sleep is ideal, but they are not everywhere. Look for a doctor who is board certified in sleep medicine at the minimum. If you suspect your child has a behavioral sleep problem such as difficulty falling asleep or frequent night wakings, look for a psychologist who specializes in sleep or in cognitive behavioral therapy with children.

My baby won't stop crying, and I can't get her to sleep. Of course, I can't sleep either. What can I do?

Keep in mind that some babies cry a total of 3-4 hours per day, which can feel like an eternity. From birth until your baby is several weeks old, the best advice may be to ask your friends or family for help (this is a good time to schedule that visit from a relative) and to try and sleep when the baby sleeps. Eventually at 2-3 months, you can help your baby differentiate night from day by keeping your baby active and in a light room during the day and the opposite at night. When you're ready, you can help your little one learn to self soothe and to sleep through the night. The key to this is to pick a consistent bedtime and allow your baby to fall asleep independently (with as little help as possible). In time, your baby will develop the skills s/he needs to fall asleep and stay asleep without you.

What should I keep in mind when setting up the nursery?

The ideal sleep environment should be a cool yet comfortable temperature, quiet, and dark. Let's face it though; many parents are faced with creaky floors, crying siblings, or an otherwise noisy house. Consider using a white noise machine or even just a loud fan to block out nighttime sounds. If the nursery is near a street lamp or is especially light, consider room-darkening shades. For infants it is most important to minimize blankets, pillows, and other fluffy items in the crib in order to reduce the risk of sudden infant death syndrome (SIDS). Also remember that babies should be put on their backs to sleep.

I get home very late from work. Is it wrong to let my baby stay up so I can see him?

It is tough for many working parents who worry about developing healthy bonds with their children. Remember that relationships are formed whenever you are with your child, not just at night. It is the quality of your time together that is most important. Sleep is critical for developing infants and children, and sacrificing sleep is like cutting down on other important needs such as food.

How much sleep do my 10- and 15-year-olds need?

Ten-year-olds need about 10 hours of sleep per night, and contrary to popular belief, teens do not need much less. The recommended amount of sleep for adolescents is just over 9 hours. This is easier said than done, as a combination of biological and social factors makes it difficult for teens to get to bed on the early side. Keeping a consistent sleep schedule on weekdays and weekends can help (in other words, no sleeping in until 2:00 pm on weekends).

What strategies might help in getting my child to settle down for bed?

A consistent sleep schedule and bedtime routine are absolutely essential. Children generally have a "window" when they are most likely to fall asleep and once that window has passed, it can seem like they have boundless energy. Deciding on a bedtime and sticking to it will help. A regular routine will signal your child's brain that it is time for sleep. A good routine is one that is the same every night, is short, and involves activities that your child likes. For an infant this might be a bath, baby massage, and a song. For a toddler, this could be a bath, a book, a drink of water, and a goodnight kiss. The routine should all go in one direction - toward the bedroom.

Is it normal for kids to snore?

Three to 12 percent of children snore and 1 to 12 percent have a sleep disorder called obstructive sleep apnea (OSA), where the airway may be fully or partially blocked during the night, causing difficulty breathing during sleep. The American Academy of Pediatrics has recommended that all children who snore have an overnight sleep study (polysomnography) to determine if they have OSA.

What kinds of sleep problems and symptoms should I discuss with my pediatrician?

A pediatrician can provide advice (or a referral to a sleep specialist) if your child is having trouble falling asleep, staying asleep, or waking up too early. Noisy breathing or snoring, repetitive movements, and sleep walking or talking during the night can also be discussed.

Melisa Moore, PhD, a clinical psychologist at the Pediatric Sleep Center in Fairfax, VA.

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