Establishing healthy sleep habits in young children is vital for optimal functioning for them and, of course, for us as parents. It is difficult to do what we need to do and parent at our best when we are sleep deprived. Also, poor sleep in children often results in negative consequences to daytime behaviour, mood, learning, and physical development.
Recommended Sleep by Age
Young children need lots of sleep! While some children need more or less sleep than others, the table below provides a range of recommended sleep by age.
AgeNightDayTotal
0-3 months—unpredictable, varies widely –
3-6 months11-12 hrs3-4 hrs(in 3-4 naps)14-16 hrs
6-9 months11-12 hrs2-3¼ hrs (in 2-3 naps)13-15¼ hrs
9-12 months11-12 hrs2-3 hrs (in 2 naps)13-15 hrs
12-18 months 11-12 hrs1½-3 hrs (in 1-2 naps)12½-15 hrs
1.5-2 years 11 hrs1½-3 hrs (usually 1 nap)12½-14 hrs
2-3 years11 hrs1½-3 hrs (in 1 nap)12½-14 hrs
3-5 years 11-12 hrs*0-2 hrs (0-1 nap)11-13 hrs
*Children may sleep longer at night after they drop their nap
Source: modified from The Sleepeasy Solution, 2007
Establish Good Sleep Habits (Early!)
It is important for parents to start establishing healthy sleep habits early. This will help ensure that your child gets the sleep he/she needs. Also, it is easier to establish good habits early on than to correct bad habits as children get older. This is because habits (including “bad” habits) become very ingrained and more difficult to change.
Develop a sleep schedule
Developing a sleep schedule is important. In early infancy, a sleep schedule can be flexible. By 3-6 months of age, a sleep schedule should include a regular bedtime and wake time and naps at approximately the same time each day. Most young children do well with a bedtime of 7:00-8:30pm - depending on their age and, if napping, when their last nap ended.
Learning how to fall asleep independently
The most important aspect of getting children to fall asleep quickly and sleep through the night is to have them learn to fall asleep independently without parental assistance. Children need to learn this at bedtime so that when they have arousals during the night, they will know how to return to sleep on their own.
Research has shown that teaching an infant to fall asleep
independently can prevent the development of future sleep problems.
Between 6-12 weeks of age, parents can experiment with putting their baby down to sleep when they are drowsy but awake. However, babies younger than 3 months should not be left to cry for more than 5 minutes (or less, depending on the intensity of the cry). At 3 months of age (full-term and healthy), a child can learn to fall asleep on his own. The younger the skill is learned the better. It is much easier to teach a 3 month old how to fall asleep on his own, compared to a 1 or 2 year old – who has never learned the skill.
Address night wakings
If your child is waking at night, first ensure that she is falling asleep independently. If night wakings persist, ask yourself “what is she waking for?” Things that typically maintain a child waking are nighttime feeds, co-sleeping, and various types of “parental responding”. Most infants who are 6 months of age (full-term) who are gaining weight as expected don’t need to be fed during the night. Developing a plan to gradually eliminate night feeds and other things which are keeping her waking is often necessary. Like most aspects of parenting, consistency is key!
Establish a bedtime and nap routine
A well established bedtime and nap routine is important. The routine should be calming and predictable. The last part of the routine (at least) should take place in the child’s room. The lights should be low and it is important to avoid ‘dozing’ during a bedtime and nap routine as this can decrease the drive to sleep and lead to difficulty settling when it is time for the child to fall asleep. Snacks and t.v. time (if parents wish) should be done prior to the start of a bedtime routine.
Maintain an environment conducive to sleep
A child’s crib and bed area should be all about sleep and toys and mobiles should be removed. The optimal sleep environment includes a temperature on the cool side of comfortable and little to no light or noise. White noise (a constant and even sound) in a child’s room and in the hallway outside his room can help to block external and household noise, and is also believed to be soothing for young children.
Common Causes of Sleep Problems
The 2 most common causes of sleep problems are: 1) not falling asleep independently and 2) inappropriate and inconsistent responding, especially during the night. Other things that can cause or worsen sleep problems are greater cognitive awareness (becoming more alert), reaching new developmental milestones, and a poorly timed sleep schedule.
What is Sleep Training?
Sleep training includes a child learning how to fall asleep independently (self-soothing to sleep) and appropriate and consistent responding, on the part of the parents. Also important in a sleep training plan is developing an age-appropriate and well-timed sleep schedule and ensuring that the sleep environment is safe and conducive to sleep.
Safe Sleep Practices - Health Canada & Canadian Paediatric Society Guidelines The Back to Sleep Campaign advocates placing infants on their back to sleep (when first placed in the crib) until 12 months of age. The back to sleep position, until a child can roll or move to his side on his own, is associated with a reduced risk of Sudden Infant Death Syndrome (SIDS). According to the guidelines, however, children do not need to be repositioned during the night or nap, once they can roll or move to another position independently. Young children should sleep on a firm flat surface in their crib for all sleep periods. Room-sharing in the first 6 months may protect against SIDS.
Health Canada and Canadian Paediatric Society guidelines state that soft and non-breathable materials including blankets, bumper pads, stuffed animals, infant positioners, pillows, and pillow-like items should not be in a crib. These objects can prevent air circulation around a child’s face and lead to suffocation. Rather than covering a young child with a blanket, a sleep-sack or wearable sleeper-blanket is recommended for cooler months (see http://www.halosleep.com/ for wearable sleeper blankets).
The guidelines also outline that an adult bed is “not the safest place for a baby to sleep”. This is because young children can be suffocated by an adult, can fall off a bed, and can become trapped between the mattress and wall or headboard. Also, soft materials on a bed are a risk factor for overheating and suffocation. High risk groups to co-sleep with children are those who have consumed alcohol, taken sedating drugs, and those who are sleep deprived – all which can lead to decreased responsiveness. Avoid overheating your child. Being overheated is a risk factor for SIDS and can also lead to discomfort during sleep.
Medical Problems and Sleep
Parents should speak to their child’s physician if they have any concerns regarding his/her sleep. Also, before starting a sleep training plan, parents should consult their child’s physician to rule out any medical cause of their child’s sleep disturbance. Common medical problems that can disrupt a child’s sleep include gastroesophageal reflux disease, ear infections, and sleep apnoea - which is often characterized by loud snoring and pauses in breathing during sleep.
Recommended Readings
The Sleepeasy Solution: The Exhausted Parent’s Guide to Getting Your Child to Sleep – from Birth to Age 5. (Jennifer Waldburger & Jill Spivak, 2007)
Sleeping Through the Night: How Infants, Toddlers, and Their Parents Can Get a Good Night’s Sleep (Revised Edition). (Jodi A. Mindell, 2005)
More than 40% of children have dental caries by the time they reach kindergarten, or their first dental visit. Most, if not all, of these cavities in infants and young children can easily be prevented by providing new parents with the proper information on how to look after their children’s oral health. It is therefore extremely important that early on, new parents be made aware of proper oral care of their new infants by their family doctor, Pediatrician, or most preferably, by a Pediatric Dentist.
The most commonly known dental problem affecting young children is Early Childhood Caries (ECC), which is caused by the excessive use of a baby-bottle containing apple/orange juice or formula/milk. It is also known as Nursing/Baby Bottle Caries and it can be a particularly virulent form of dental caries. It usually begins soon after dental eruption, developing on smooth dental surfaces (specifically behind the upper front teeth thus making it difficult for parents to notice it early), progressing rapidly, and having a potentially lasting and detrimental impact on the dentition.
Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in both the primary and permanent dentitions. Not only does ECC affect teeth, but consequences of this disease may lead to more widespread health issues. Infants with ECC, for example, grow at a slower pace than caries-free infants.
The presence of ECC can cause pain and suffering to young children and its treatment can often times be complicated, costly and very stressful to parents. Therefore, prevention through good parental education, is imperative.
To decrease the risk of developing ECC the following practices are suggested:
1. Minimizing saliva-sharing activities (e.g. sharing utensils) between an infant and his family, because caries causing bacteria may be transmitted to your infant by a parent or another child in the family. In addition, decreasing the mother’s/siblings’ oral bacteria levels may decrease the infant’s risk of developing ECC.
2. Implementing oral hygiene measures no later than the time of eruption of the first primary tooth.
• If an infant falls asleep while feeding, the teeth should be cleaned before placing the child in bed.
• Brushing the child’s teeth should be performed twice daily, especially prior to going to sleep.
• Flossing should be initiated when teeth are not spaced apart, irrespective of the child’s age.
3. Avoiding caries-promoting feeding behaviors. In particular:
• Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced.
• Infants should not be put to sleep with a bottle containing anything other than water.
• Infants should be weaned from the bottle at 12 to 14 months of age.
• Repetitive drinking of sweet drinks from a bottle or no-spill training cup should be avoided.
• Between meal snacks and prolonged exposure to sweets and juice should be avoided.
4. Have your child examined by a Pediatric Dentist no later than by age 2 yrs.
Night wakings in young children (and even adults) are very common and often the result of ‘poor’ or negative learned sleep associations (also known as “bad habits”). Children who do not yet have the skill of falling asleep independently are usually unable to return to sleep following periods of normal partial arousal that we all have during the night.
Most children will need the same conditions that were present at sleep onset (bedtime) to be re-established when they wake at night in order to return to sleep. In these circumstances a child may wake up visibly upset at night because she has fallen asleep under one condition (such as while feeding or with a parent in the room) and woken up in a different condition (e.g., alone in a crib or bed). This is akin to us (an adult) falling asleep in the comfort of our bed and waking up on the couch. We would not be happy!
These “behavioural” wakings can be ruled out (or in) as the cause of night wakings by reviewing the way in which your child is falling asleep at night and how he is being responded to when he wakes. Also reviewing the presentation and symptoms of other causes of night wakings such as sleep terrors and nightmares can be helpful.
If poor learned sleep associations are determined to be the cause of your child’s sleep disturbances, sleep training is often helpful (see below for recommended readings). However, note that sleep training methods are not recommended until a child is 3 months of age (full-term) and healthy.
Discussing your concerns with your child’s physician or another health professional with training in the area of parenting issues regarding children’s sleep, may also be helpful in developing an appropriate treatment plan to address these problems.
Recommended Readings for sleep training:
The Sleepeasy Solution: The Exhausted Parent’s Guide to Getting Your Child to Sleep – from Birth to Age 5. (Jennifer Waldburger & Jill Spivak, 2007)
Sleeping Through the Night: How Infants, Toddlers, and Their Parents Can Get a Good Night’s Sleep (Revised Edition) (Jodi A. Mindell, 2005)
Dr. Nicky Cohen is a Registered Psychologist in private practice in Toronto. She received her Ph.D. in Clinical Psychology from York University and developed an interest in parenting issues related to children’s sleep disturbances after having her first child 5 years ago. She is active in the community disseminating information on healthy sleep practices and increasing awareness of the importance of making sufficient sleep a family priority. Dr. Cohen has held various research and clinical positions at the Centre for Addiction and Mental Health, the Hospital for Sick Children, and the University Health Network (Toronto General Hospital). More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.
Sleep is not negotiable. We all need it, and children need lots of it. And usually we don’t feel our best when we don’t get enough. The benefits of sleep are numerous – both physical and psychological. Parents are often aware of how they feel when sleep deprived. Even if your child is sleeping well now, you can probably recall the days when he wasn’t! However, parents sometimes forget to consider the impact that loss of sleep can have on their child and how children may be feeling when they don’t get enough sleep. Like adults, many children who do not get enough sleep display signs of sleep deprivation during the day such as irritability, sleepiness, and difficulty concentrating.
Several years ago, in the first nationwide study of its kind, the National Sleep Foundation’s Sleep in America poll investigated sleep habits of children (infants to 10 year-olds) and their parents/caregivers living in the United States. It was found that 76% of parents reported that they would like to change something about their child’s sleep. It was estimated that some parents lose up to 200 hours of sleep a year due to their child’s nighttime wakings and that many children are getting less than the recommended number of hours of sleep a day based on their age. Additionally, many parents/caregivers reported that they get less sleep than they need, with 50% of all parents/caregivers reporting that their sleep is disturbed during the night, at least twice a week, on average, due to their child awakening them. However despite a large majority of parents being dissatisfied about their child’s sleep, the study found that many (52%) doctors don’t ask about children’s sleep habits.
Many parents face challenges regarding their child’s sleep, whether it be stalling and resistance going to bed, night wakings, early morning wakings or daytime sleep problems (just to name a few). Usually these problems translate into less sleep – for everyone – as a result. The following are tips for parents who are looking to make some positive changes in their children’s sleep habits.
1. Establish a consistent and appropriate sleep schedule for your child. Having a predictable bed time will be helpful in getting your child to fall asleep at night more easily and quickly. Similarly a regular wake time is important as it sets the “start” button for the day. A child’s wake time is important in setting a child’s naptime as well as her bedtime. Research has shown that children (and adults) who go to bed at roughly the same time each night, have less difficulty falling asleep than those who don’t have a regular bedtime. Most young children do well with a bedtime between 7:00-8:30pm. Watch for your child’s tired signs and don’t keep her up. If you miss the “window of opportunity” when your child falls asleep most easily, you may have greater difficulty getting her to bed.
2. Make sufficient sleep a family priority. Understanding the importance of getting enough sleep and how sleep affects the overall health of you, as parents, and your children, is the first step towards making sleep a priority for your family. Parents need to determine the amount of sleep their children need and take steps to ensure that each child’s individual sleep needs are met. Parents should strive to make a good night’s sleep a regular part of each family member’s daily routine.
3. Create a predictable and calming bedtime routine. A bedtime routine is important to help your child wind down before bed and signal to her that bedtime is approaching. Children learn that when certain things happen, for example, a bath, pajamas, books and songs, it means that ‘sleepy time’ is coming. Many parents of toddlers and preschoolers report frustration with bedtime resistance. Children of this age are notorious for “curtain calls” – also known as repeated requests - at bedtime. If this is happening in your home, develop an appropriate bedtime routine and stick to it. Be sure to incorporate everything (within reason) that your child needs to have done before falling asleep. Develop a simple bedtime checklist with your child. Checking off the items as you complete them can be helpful. Be careful not to reinforce multiple requests at bedtime. Once you are firm and consistent, your child will quickly learn the new rules.
4. Ensure that your child gets adequate day sleep if she still needs a nap. Most children need to nap until between 3-5 years of age. Sometimes parents drop their child’s nap prematurely for social or other activities. Parents are encouraged to take their child’s lead and maintain the nap as long as the child still needs it. However if napping is preventing your child from going to bed at a reasonable time at night, it may be time to reconsider the nap. Rather than dropping the nap entirely, as a first step, parents can move the nap earlier in the day, or limit the nap to 1 hour, for example.
5. Introduce a transitional object. Many children can benefit from having a transitional object such as a “blankie” when they sleep. If your child is still in a crib, a blankie should be small enough (e.g., 8” by 8”) so that it cannot wrap around her face or neck area. Also, blankies used in cribs, should be breathable, meaning that fresh air can circulate in/out of them. Things that can arouse a child, and prevent her from falling asleep, or wake her if she rolls on it (such as a stuffed animal) are best left as daytime toys and out of the crib.
6. Have your child fall asleep independently. Most healthy full-term babies who are 3-4 months of age and older, can start to learn to fall asleep independently. This is an important life-long skill that we all have to learn. The earlier that parents allow for the development of this skill, the easier it is for children to learn. Falling asleep independently is most easily learned at bedtime (nighttime) when the drive to sleep is relatively stronger than compared to daytime sleep periods. While it is never too late to learn, it is generally an easier and quicker process for younger children. However before 3 months of age, babies should not be left for more than 5 minutes to cry, and possibly even less depending on the intensity of their cry.
The importance of a child learning to fall asleep on her own at night is related to her ability to sleep through the night. This is because children who fall asleep under certain conditions (e.g., with parental presence, being fed, bounced or rocked) at bedtime, often need these same conditions re-established upon waking at night in order to return to sleep. These children (“signalers”) will call or cry out to get the help they need to return to sleep. This may happen several times a night, as we all have several periods of brief arousal throughout the night. However children who have learned to fall asleep independently, without parental intervention, usually return to sleep on their own following periods of partial arousal. These children (“self-soothers”) will return to sleep, often without their parents being aware that they were briefly awake.
7. Respond to your child appropriately and consistently during the night. Once a child has acquired the skill of falling asleep independently at night, she will likely start applying the skill following night wakings. However if night wakings continue to be inappropriately or inconsistently reinforced, they may continue. So develop a plan and stick to it. Consistency is key. For young infants who still need nighttime feeds, scheduled feeds initiated by parents can be helpful.
8. Make sure your child’s sleeping environment is conducive to sleep. Most children sleep best on their own, in their own sleep space. Research has shown that children and adults who co-sleep usually do not sleep through the night as everyone is disturbed by each others noises and movements. As well, parents are more likely to reinforce night wakings due to close proximity. Children, like adults, sleep best in an environment that is on the cool side of comfortable, quiet, and dark. White noise and room darkening shades can be helpful. Research has shown that children who have a computer or television in their room, sleep less on average, than children who don’t.
9. Practice safe sleep hygiene. Ensure that the area where your child sleeps is safe and that your baby is always put on her back to sleep to decrease the risk of sudden infant death syndrome (SIDS). While room sharing for the first few months may be a protective risk factor against SIDS, sleeping in the parental bed (bed-sharing) is not considered to be the safest place for young children to sleep. This is because many parents do not use guard rails to protect against accidents such as falls off the bed. Also soft materials on beds such as blankets/duvet covers and pillows are not recommended for young children due to safety concerns. Parents are encouraged to speak with their child’s physician regarding safe sleep practices. For additional information, the Canadian Paediatric Society website (www.caringforkids.cps.ca) has helpful handouts for parents on healthy and safe sleep habits for children.
10. Get some sleep yourself! With research showing that many adults get less sleep than they need, make sleep a priority for yourself! The better rested we are as parents, the better able we are to effectively parent and cope with the many challenges we face during the day. Often it is helpful for adults to have a bedtime routine and some wind down time before bed. Having shifts with your spouse if you have a young infant who is still waking at night can be helpful.
Parents are encouraged to pay attention to sleep problems in their children and to follow-up with their child’s physician or other health care professional with training in this area. While the more common sleep disturbances in young children include difficulty falling asleep, bedtime stalling, nighttime wakings, sleep terrors, and nightmares, other problems such as trouble breathing while sleeping, including pauses in breathing, snoring, and restless legs also require discussion with a medical professional.
While sleep disturbances are one of the most chronic behavioural problems in children, often times these problems are easily solved through behavioural interventions. Though the anticipation of trying to deal with these issues can be overwhelming – especially if you are sleep deprived to begin with – usually the anticipation is actually worse than tackling these problems.
Pleasant dreams!
Dr. Nicky Cohen is a Registered Psychologist in private practice in Toronto. She received her Ph.D. in Clinical Psychology from York University and developed an interest in parenting issues related to children’s sleep disturbances after having her first child 5 years ago. She is active in the community disseminating information on healthy sleep practices and increasing awareness of the importance of making sufficient sleep a family priority. Dr. Cohen has held various research and clinical positions at the Centre for Addiction and Mental Health, the Hospital for Sick Children, and the University Health Network (Toronto General Hospital). More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.
