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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


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


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).


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


than 1 reunion

>20 min to fall asleep and/or parent remains


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.


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


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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