Sleeping Through the Night

Dear Lisa,

I have a 3 year-old son and I am having a hard time with his sleeping lately. For the last few months it seems like he is waking up more frequently during the night. It is almost like clockwork. Every night between 2 and 3 AM regardless of what time he goes to bed, he wakes up and comes running into my bed sometimes crying. Once he's back to sleep, I go back to sleep and sometimes about 15 to 20 minutes later he's right back running into my bed. I have a one year old that sleeps all night by herself in her room (granted it's a crib), but I'd like to stop this pattern before she starts on it... How do I stop this cycle? Could there be something causing my son to wake up routinely at the same time every night like clockwork? Could it be sleep apnea?

“Sleepless Mom of Two”

Dear “Sleepless Mom of Two”,

Three year olds require on average 11 to 13 total hours of sleep per day. (1) This time includes the time a child spends napping. Therefore if a three year old child takes a nap from 12:00 noon to 1:00 p.m. and sleeps at night from 8:30 p.m. to 7:30 a.m. this would be considered normal. Between the ages 2 to 5 years old children stop taking daytime naps. By the time most children reach the age of 5, they eliminate a nap all together. (2)

There are certain childhood medical conditions that cause a child to wake at night. For example, a child with Asthma may wake from coughing or because of the side effects of Asthma medication. Children with Eczema frequently wake at night because they are uncomfortable from the itching. Other medical conditions that lead to night time wakening include Gastroesophageal reflux, pain, seizures, Obstructive Sleep Apnea and side effects of medications. (3)

The signs of Obstructive Sleep Apnea include excess snoring, pauses in breathing, bedwetting, restless sleeping, excessive hyperactivity during the day or excess daytime sleepiness. Children that tend to be at risk for Obstructive Sleep Apnea are those with large tonsils and adenoids, narrow airways, obesity, children with Down’s Syndrome, children with Cerebral Palsy, a small airway, a large tongue, low muscle tone, and children taking sedatives. (4,5) Children with Obstructive Sleep Apnea tend to be mouth breathers and usually have a history of recurrent ear and throat infections due to their large tonsils and adenoids. If your son is demonstrating these signs of Obstructive Sleep Apnea it would be important to talk to your Pediatrician about it.

In many cases waking at night is normal behavior due to a three year old’s developmental stage. It is common for a three year old child to have fears, such as fear of the dark or fear of monsters which ultimately affect their sleep. (2) Something as simple as a shadow on the wall can scare a child. Clothes hanging in the closet can look like a monster. You can help your child by removing items from the room that can be interpreted as spooky, close closet doors and put a night light in the bedroom. (2) If you turn the lights on and explain to a child that what he is seeing is clothes hanging or a shadow it can help a child overcome his fear.

Also, at three years old children learn from fantasy play and many times have difficulty deciphering fantasy from reality. At this stage, a child's dreams become quite vivid and may be very upsetting. (2) It is common for a three year old to wake up crying from a dream. If this is the case, he should be able to tell you that he had a dream, that he “saw pictures in his pillow” or was “afraid of the monster”. If a three year old child has a dream, parental reassurance is needed; clear explanations of what is real and what is not real needs to be reinforced. (2)

All children have a normal sleep pattern which includes cycles of deep sleep alternating with lighter sleep. (6) Factors such as anxiety and stress can affect a child’s ability to go back to sleep on his own when he reaches the lighter stages of sleep. If a child is upset about something that is going on at home or at school he may have difficulties sleeping through the night. Since your son’s night time awakenings are “new” it would be important to talk to him during the day in order to ascertain if there is something upsetting him. Sometimes changes in a child’s social life or home situation may cause stress and manifest itself as night time awakenings. (1) If there has been a family transition such as a move into a new home, the death of a grandparent or a divorce your child may need some extra help adjusting. In some cases, children need to talk to a health care professional to help them with the transition.

A child may also wake at night simply because he is getting too much sleep. This occurs if the nap time during the day is too long. Count the total hours your child is sleeping in a 24 hour period, and if it is greater than 13 hours, you may need to make some adjustments. I recommend limiting a three year old’s nap to one hour per day. In addition, it is not a good idea to have a child nap after 1 p.m. because in most cases, he will not be tired enough to sleep through the night.

Conditioning factors also affect a child’s level of arousal and sleep continuity through the night. (6) In other words, some children are conditioned to require additional help in settling down to go to sleep. The ability to fall asleep on your own is a learned behavior. When a child reaches the light sleep period of the sleep cycle, when he awakens, he should know how to go back to sleep on his own without parental intervention. Some children do not have the ability to do this because they are accustomed to an elaborate ritual to get to sleep. Instead a child will attempt to recreate the rituals that he goes through during the evening hours when first getting to bed. (3) Therefore if a child is used to a lengthy ritual including hours of storytelling, coaxing and rocking in the evening before going to bed, he will attempt to recreate this ritual in the middle of the night when he wakes up. In order to help your child sleep through the night, many times you have to change the child's daytime and evening routine.

There are some steps you can take to help your child sleep through the night. The first step is to choose the correct bedtime as dictated by your child’s circadian rhythm. (3) It is not a good idea to put your child to sleep hours before he is ready to go to sleep. If he is not ready to go to sleep at 7:30 p.m., but you are ready to put him to sleep at this hour then changes need to be made in the daytime routine first. His naps should be shortened and wake up time in the morning should be gradually adjusted to an earlier hour. If a child is forced to go to bed at 7:30p.m. and does not fall asleep until 9:30, the rituals that occur for the two hours before he goes to sleep are the rituals that he learns to follow each time he needs to fall asleep. Therefore, putting a child down when he is sleepy can prevent a lot of problems in the middle of the night.

Next, limit your child’s bedtime routine to something that is easy to replicate in the middle of the night if needed. For example put his pajamas on, give him a hug and kiss and offer a favorite blanket or soft toy that he can hold on to and use as a self soothing item. (7) This way when your child wakes up in the middle of the night he can look for his favorite blanket for comfort and fall back to sleep on his own with no further intervention needed.

From the description that you gave, it sounds like your son is awakened by either a dream or because he’s not tired enough. Then once you put him to sleep he returns most likely because he needs to learn how to self soothe himself and go back to sleep on this own. You can try instituting the measures mentioned above in order to help everyone get a better night’s sleep. It is important to remember that it takes a child a few weeks to adjust to a new routine. One of the most important things to do is be consistent, even though this is very hard to do in the middle of the night. In the long run, the consistency will pay off. Otherwise if you let your son sleep in the bed with you one night and not the next this will only frustrate him. By letting him sleep in your bed he will learn that this is the self soothing ritual that he needs to fall asleep. If this is the case, he may end up in your bed for a while.

(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc 1990:69-73.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:Saunders Company. 1994:252-256.
(3)Rosen G. Conditioned Insomnia in Children. Presented at: Pediatric Sleep Disorders Conference;May 31, 2002:Edison.
(4)Sleep Apnea. Clinician Reviews. 2006;16(6):25.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:438.
(6)Rosen G. General Overview of Neuroanatomy and neurophysiology of Sleep. Presented at: Pediatric Sleep Disorders Conference;:May31, 2002:Edison.
(7) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 394-395.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Bringing Up Healthy Kids