sleep problems in infants and toddlers
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Sleep Problems in Infants and Toddlers
John A. Biever, MDCentral Pennsylvania Institute for Mental
HealthClinical Associate Professor of Psychiatry
PennState Hershey Medical Center
Status of Diagnostic Thought
• International Classification of Sleep Disorders– Subcategorizes as dyssomnias, parasomnias and
sleep problems secondary to medical/psychiatric disorders
– Does not extend diagnostic criteria to infants and toddlers
• DSM-IV– Similar subcategorization as ICSD– Again, developmental norms do not extend to
infants and toddlers.
DC:0-3 Diagnostic Classification System for Infants/Toddlers
Sleep Behavior Disorders
– For children >12 months of age– Sleep-onset disorder: at least 4 weeks of needing
parental contact in order to get to sleep
– Night-waking disorder: at least 4 weeks of wakings that require parental attention
– Sleep problems also included as symptoms in several other disorders
A Proposed Alternative Classification System*
• Takes into account the relational component of sleep disturbances in infants/toddlers
• Considers, therefore, the status of the attachment bond between parent and child
• Considers the dual functions of homeostatic and social/affective regulation in the dyadic interaction
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press. 2000.
“Protodyssomnias”
• “Proto-” because they do not require “functional impairment” as does DSM-IV
• Night Waking Protodyssomnia
• Sleep-Onset Protodyssomnia
• Diagnostic criteria vary by age and severity
Night Waking Protodyssomnia*Age (months) Perturbation
(1 night/wk;2-4 wk duration)
Disturbance(2-4 nights/wk;
2-4+wk duration)
Disorder(5-7 nights/wk;>4 wk duration)
12-24 2 awakings(AW)/night and/or >10
min. AW
2 AW/nightand/or >10 min
AW
2 AW/nightand/or >10 min
AW
24-36 1-2 AW/nightand/or >20 min
AW
1-2 AW/nightand/or >20 min AW
1-2 AW/nightand/or >20 min AW
>36 1 AW/nightand/or >30 min AW
1 AW/nightand/or >30 min
AW
1 AW/nightand/or >30 min AW
Note: Occurs after infant has been asleep for >10 minutes. AW, awakenings from sleep that are accompanied by signaling (crying or calling).
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press. 2000.
Sleep-Onset Protodyssomnia*Age (months) Perturbation
(1 night/wk;2-4 week duration)
Disturbance(2-4 nights/wk;
2-4+week duration
Disorder(5-7 nights/wk;>4 wk duration
12-24 >30 min to fallasleep and/or parent remains in room for sleep onset and/or
more than 1 reunion
>30 min to fall asleep and/or parent remains
in room for sleep onset and/or more
than 1 reunion
>30 min to fall asleep and/or parent remains in room for sleep onset
and/or more than 1 reunion
>24 >20 min to fall asleep and/or parent remains
in room for sleep onset and/or more
than 1 reunion
>20 min to fall asleep and/or parent remains
in room for sleep onset and/or more
than 1 reunion
>20 min to fall asleep and/or parent remains in room for sleep onset
and/or more than 1 reunion
Note: Occurs at bedtime or nap time
Reunions refer to resistances to going to sleep. Reunions may differ in style: (1) repeated bids (kisses, hugs, glasses of water), or (2) struggles (crying, screaming, physical resistance), or (3) mixed. Reunions should be subclassified as to type.
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press. 2000.
Underlying Premises
• Unreasonable to classify sleep disturbances in infants <12 months of age (instead, look at the relationship/attachment)
• Assumes that child is sleeping in own bed• Child is being reared in a diurnal environment
(sleep at night, wake during day)
Clinical Interventions
• Perturbation: normal—reassurance with information
• Disturbance: at risk—parent education and guidance
• Disorder: more intensive treatment, individualized to the particular problem
Proposed Multiaxial Diagnostic System*
Axis I: Perturbation/disturbance/disorderNight waking protodyssomniaSleep-onset protodyssomniaSchedule disruption protodyssomnia (e.g. daytime napping)Parasomnias, sleep apnea
Axis II: Parent-child interaction stylesBalanced/synchronousOverregulating/controllingUnderregulating/distantInconsistent/unpredictable
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press. 2000.
Multiaxial System, cont’d.
Axis III: Infant FactorsTemperamentDevelopmental quotientMedical illnesses
Axis IV: Context factorsFamily/marital stressParenting stress/hassleFamily psychopathologyFamily trauma/violence
Neurobiology of Sleep
• Circadian rhythm: the 24 hour sleep-wake cycle
• Ultradian rhythm: the 60-90 minute sleep cycle of alternating REM (rapid eye movement) and non-REM phases of sleep
• Diurnal: the circadian cycle that gets entrained into light-dark conditions.
Infant Evolution of the Diurnal Cycle
• Average newborn daily sleep is 18 hours, ranging from 10 to 22, with typically a period of wakefulness every 3-4 hours.
• By 6 months, periods of sleep stretch out to as long as 6 hours, and begin to concentrate during dark hours, while wakefulness concentrated during light hours.
• By 1 year, typically 1-2 long nighttime sleep periods, 1-2 short daytime naps.
Later Evolution of Sleep
• Second year: one long nighttime sleep period and 1 nap, usually afternoon
• Later, nap may be eliminated depending on social circumstances, although naps may be preserved throughout life.
Ultradian Cycle Evolution
• 1st 3 months: 50% of sleep is REM (syn. “dream”, “active sleep”, “paradoxical sleep”), other half in n-REM (“slow wave”, “quiet”) sleep
• 2-3 y/o child: 35% REM
• Adult: 20% REM
Ultradian Cycle Evolution, cont’d.
• By 3 months of age, cycles remain at 50-60 minutes but REM duration diminishes.
• REM becomes more prominent in later phase of sleep (toward morning) and n-REM in earlier phase.
• By adolescence, cycle lengthens to 90 minutes.
Night Waking Problems
• By 8 months, most (60-70%) infants soothe selves when they awaken.
• During second year, often an increase in nighttime awakenings.
• Infants and toddlers have more awakenings than “signaled” (crying, etc.) awakenings. i.e. often they return to sleep without signaling.
Sleep-Onset Problems• Going-to-bed and falling-asleep problems.
• By 12 months, 70% infants placed in crib awake at night—gives them opportunity to learn to fall asleep on own
• 2nd yr. of life: separation anxiety, and also…– limited family time– maternal depression– marital problems
Parasomnias• Begin in toddlerhood• Boys > girls• Night terrors: stage 4 n-REM sleep (deepest
stage), normally outgrown by adolescence• Nightmares: REM sleep, child alert when they
cause awakening, unlike in night terrors. Reassurance and decreasing daytime stress are recommended.
• Rhythmic movements: 58% down to 22% by 2 years: parental reassurance, unless head banging is injurious.
Sleep Apnea• Central or obstructive: screen for asthma,
snoring, mouth breathing
• Normally, decreased oxygen saturation causes micro-arousal and restoration of breathing, with person unaware of the arousal.
• In children, apnea can cause inability to achieve stage IV sleep, resulting in diminished growth hormone secretion and growth retardation.
Causes of Sleep Problems
• Nutritional and/or physical discomfort, including food/milk allergies, colic
• Temperament, especially low sensory threshold, low adaptability, high distractibility, negativity of mood.
• Parental conflict, maternal psychopathology, family stress, traumatic events
Co-sleeping
• In infants, correlates with more sleep time at night, especially when breast-fed.
• More frequent, but brief arousals: Protective against SIDS?
• In older toddlers, is co-sleeping a cause or effect of sleep problems?
Assessment• Importance: ½ of children with infant-
toddlerhood sleep problems will continue to have sleep problems later on.
• Ask routine screening questions re the above, including child’s degree of rested-ness and wakefulness during the day.
• Suggest keeping a diary if sleep problem is suspected.
Treatment• Behavioral approaches, based on the idea that sleep-
onset problems represent learned interactional patterns between child and caregiver
• Interpersonal/psychodynamic approaches: looking at the relationship between caregiver and child for problems and for solutions
• The transitional object: thumb, special blanket
• Brief period of parent sleeping in same room
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