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Peter* is an 8 months old boy who attends the sleep wellness clinic for night-wakings for up to about 7 times a night. At bedtime, dad rocks Peter who sleeps in his arms before putting him down in the crib. Overnight, mum needs to breast- or bottle-feed every time he wakes up. Parents are exhausted by the number of night-wakings.

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About 25%  of Singaporean infants and children have problems with “night-wakings”. As seen from the above case, the common scenario is a baby or young child waking up several times in the night, and requiring help (called a sleep association) from a parent in order to fall asleep again – this sleep association commonly being feeding milk and/or rocking the child back to sleep.

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The term “night-waking” is misleading, because all healthy persons (both adults and children) have short awakenings (so short the brain does not realise) throughout his/her sleep, up to several times an hour. Most adults have subconsciously learnt how to comfort themselves back to sleep when they have these short awakenings, e.g. covering with a blanket; hugging the pillow or bolster etc. When a person is able to comfort oneself to back to sleep, this is called a positive sleep association in medical terms.

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Most healthy and developmentally normal children of 6 months and above are capable of developing positive sleep associations, but unfortunately many babies of this age have not learnt this when left in their natural environment. If a child has formed a habit of feeding milk or being rocked to sleep at bedtime, in the middle of the night a short awakening has the potential to become a prolonged awakening when the child desires and cries for milk or rocking in order to fall back asleep. This help from a parent is called a negative sleep association. Most children who develop negative sleep associations do not outgrow them in the short to medium term.

 

What can I do promote good sleep habits in my child?

First, ensure that your child has enough sleep.

The American Academy of Sleep Medicine (AASM) has published recommendations   on sleep duration in children:

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Second, establish a regular sleep routine.

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This usually involves 3-4 relaxing activities before bedtime. An example for an infant may be: change to pyjamas – infant massage – singing a lullaby – put to bed. An example for an older toddler may be: change to pyjamas – brush teeth – read a bedtime story – say prayers – put to bed. The combinations are limitless and you may use your creativity. Keep the routine similar every day, and you may use a shortened version before naps.

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What can we expect at a consultation to manage behavioural sleep problems?

• Because of the detailed nature a typical first consultation would take at least 1 hour.

• The specialist will take a detailed history of how, when and where the child sleeps.

• A diagnosis of the sleep problem will be made.

• The family’s needs and expectations will be evaluated.

• A core skill in developing positive sleep associations in the child will be taught to parents. This is based on a combination of planned ignoring and intermittent comforting by parents, called graduated extinction in medical terms.

• Realistic targets should be set,

  • e.g. one family may wish to see improvement in a week;

  • another family may desire a stepwise improvement. Gentler approaches may be considered if parents are not able to accept graduated extinction throughout the whole night.

• An individualised sleep management plan will be proposed.

 

References

*not his real name

1. Aishworiya R, Chan P, Kiing J, Chong SC, Laino AG, Tay SKh. Sleep behaviour in a sample of preschool children in Singapore. Ann Acad Med Singapore. 2012 Mar;41(3):99-104.

2. Kataria S, Swanson MS, Trevathan GE. Persistence of sleep disturbances in preschool children. J Pediatr. 1987 Apr;110(4):642-6.

3. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med 2016;12(6):785–786.

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