Credit Kim Murton
Credit Kim Murton
Credit Getty Images
Everyone knows that getting a baby to sleep through the night can be a big challenge for parents. But sleep problems are common among preschool and school-age children, too. As we ask children to function in school, academically and socially, fatigue can affect their achievement and behavior.
Australian research on sleep problems in children has included work aimed at the “school transition” year in which children adjust to a school schedule. In a study of 4,460 children, 22.6 percent had sleep problems, according to their parents, at that transition age of 6 to 7 years. “We were surprised, we thought it was all baby sleep” that was the problem, said Dr. Harriet Hiscock, a pediatrician who is a senior research fellow at the Murdoch Childrens Research Institute at the Royal Children’s Hospital in Melbourne who was one of the authors of the study.
Those results led to a randomized controlled trial of a brief intervention for children in their first year of school. A group of 108 parents who felt their children had sleep problems was divided into two groups. One group got a consultation at school, with a program of strategies tailored to the child’s sleep issues, and a follow-up phone consultation; the other group got no special intervention and served as controls. Parents in the intervention group were counseled about a range of possible measures to improve sleep, from consistent bedtimes and bedtime routines to relaxation strategies for anxiety that might be contributing to insomnia. The children in the intervention group resolved their varying sleep problems more quickly, though sleep problems got better over time in both groups. The interventions also produced positive effects on the child’s psychosocial function and parents’ mental health.
The most common sleep issues for children around the age of school entry, Dr. Hiscock said, definitely include limit-setting issues — that is, some of them need their parents to make the rules and routines clear. But there are also children with what sleep specialists call “sleep onset association disorder,” in which a child has become habituated to falling asleep only in a certain context, requiring the presence of a parent, or needing to have the TV on, to cite two common examples. Very anxious children are also often problem sleepers. And then there are children beset by nightmares, night terrors and early morning waking.
Screen use is a major issue in childhood sleep, and more generally in childhood these days. The first recommendation is always to get the screens out of the bedroom, the same recommendation made for improving adolescent sleep, and for adults in the current best-selling book by Ariana Huffington. All of us, old and young, are vulnerable here, but it’s a good place for parents to draw the line for their children, even when they can’t quite manage it for themselves.
Reut Gruber, a psychologist who is an associate professor in the department of psychiatry at McGill University, where she is director of the Attention Behavior and Sleep Lab, said that there is a close association between sleep and a wide range of cognitive functions, including attention, executive function and memory. When children go to school, “they need to pay attention and plan and follow instructions, all of which fall under executive function, which is very much affected by sleep,” she said.
Many parts of the brain work less well when children are tired. “The prefrontal cortex is very sensitive to sleep deprivation, and it is key to the brain mechanisms which underlie executive function and some of the attentional processes,” she said. “The amygdala is affected by sleep deprivation and is essential for emotional processes.”
These different but connected brain pathways led her to be interested in the way that sleep affects many different aspects of academic performance. In an experimental study of a small group of 7- to 11-year-olds who did not have sleep, behavior or academic problems, the children were asked to change their sleep patterns, so that they were sleeping an hour less per night, or an hour more. After five days with less sleep, she said, there was measurable deterioration in alertness and emotional regulation, and after five days with more sleep, there were gains in these areas.
For the past several years, Dr. Gruber and her colleagues have worked with a school board in Montreal to develop a school-based sleep promotion program that was piloted in three elementary schools; results were published in May in the journal Sleep Medicine. The intervention involved a six-week sleep curriculum for the children, to teach them about healthy sleep habits, and materials designed to involve parents, teachers, and school principals, who were asked to consider the sleep ramifications of school schedules, extracurricular activities and homework demands.
The children in the intervention group extended their sleep by an average of 18.2 minutes a night, and also reduced the length of time it took them to fall asleep by 2.3 minutes. These relatively modest changes correlated with improved report card grades in English and math; the control group children’s sleep duration did not change, and their grades did not improve.
The goal of the intervention was to help families make sleep a priority.
“How do you make changes in your priorities, find the way as a family, as a school, as an individual, to reshuffle things, no matter how much homework, no matter how many aunts and uncles coming for a visit, that bedtime will still be respected?” Dr. Gruber asked. “We all agree in principle, but how do we actually incorporate it into daily life?”
The American Academy of Pediatrics recently endorsed the 2016 guidelines issued by the American Academy of Sleep Medicine, that 3- to 5-year-olds need 10 to 13 hours of sleep per day (including naps), while 6- to 12-year-olds need nine to 12 hours for optimal health and well-being.
Dr. Gruber advised that a child should wake up naturally, without requiring energetic parental encouragement. If after nine or 10 hours of sleep, a child still seems very tired, parents might wonder about whether a sleep disorder is affecting the quality of the child’s sleep, she said.
But for most school-age children, it’s an issue of habits and routines, screen time and setting limits. Many of us know, as adults, that we don’t get as much sleep as we should, or that we don’t practice very good “sleep hygiene,” as the experts would say when they advise us to get the screens out of our bedrooms, create regular routines and avoid caffeine too close to bedtime. Making school-age sleep a family priority is a good way to get everyone focused on what really matters: waking up rested and ready to function well, in body and mind.
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Preschool children who are in bed by 8 p.m. are far less likely to be obese during adolescence than children who stay up late, a study has found. Their risk of teenage obesity is half the risk faced by preschoolers who stay up past 9 p.m.
The research analyzed data gathered on nearly 1,000 children born in 1991 whose bedtimes were recorded when they were 4½ years old, and whose height and weight were recorded at age 15. The children were part of the Study of Early Child Care and Youth Development, done under the auspices of the National Institute of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Among the children who were in bed by 8 p.m., 10 percent were obese as teens, compared to 16 percent of those who went to bed between 8 and 9 and 23 percent of those who went to bed after 9, according to the study, published in The Journal of Pediatrics.
The researchers adjusted for such factors as socioeconomic status, maternal obesity and parenting style and still found that the children who went to bed by 8 p.m. were at less than half the risk of teenage obesity as those who were up past 9, said Sarah E. Anderson, the paper’s lead author and an associate professor of epidemiology at the Ohio State University College of Public Health in Columbus.
Although the study does not prove that early bedtimes protect against obesity, Dr. Anderson said, “there is a great deal of evidence linking poor sleep, and particularly short sleep duration, to obesity, and it’s possible the timing of sleep may be important, above and beyond the duration of sleep.”
“This provides more evidence that having an early regular bedtime and bedtime routine for young children is helpful,” she said.
Men who do not get enough sleep — or get too much — may have an increased risk for Type 2 diabetes, a new study suggests.
Researchers studied 788 healthy men and women participating in a larger health study, measuring their sleep duration using electronic monitors and testing them for markers of diabetes — how well pancreatic cells take up glucose and how sensitive the body’s tissues are to insulin. The study is in the Journal of Clinical Endocrinology & Metabolism.
The average sleep time for both men and women was about seven hours. As the men diverged from the average, in either direction, their glucose tolerance and insulin sensitivity decreased, gradually increasing the deleterious health effects. There was no such association in women.
The researchers weren’t sure why men but not women showed this association but caution that this was a cross-sectional study, a snapshot of one moment in time, and that they draw no conclusions about cause and effect.
The lead author, Femke Rutters, an assistant professor at the VU Medical Center in Amsterdam, said that it is easy to advise men to get regular and sufficient sleep, but because so many lifestyle and health factors may contribute to poor sleep, acting on that advice is much harder.
“There has been a lot of observational work on sleep, but trying to change it is difficult,” she said. “Ideally, men should try for regular sleep.”
When my first child did not dependably sleep through the night, my parents were puzzled. My mother told me that to the best of her recollection, neither I nor my siblings had ever been troubled by night waking. I suspected that, back in the 1950s and ‘60s, they might have let us cry it out, but they didn’t recall. There might have been some difficult nights, but what was the big deal?
In our era of more anxious parenting, there’s a lot of debate about what has come to be called sleep training, that is, behavioral techniques for getting a baby who is 6 months old or older to fall asleep alone and sleep through the night. The debate comes when these techniques involve some periods of crying and protest on the baby’s part. Parents (and experts) who believe in sleep training feel that babies can develop “self-soothing” skills: learning sleep cues that help them comfort themselves and fall back asleep when they wake at night — as we all tend to do. Opponents of sleep training, many of whom are more generally committed to “attachment parenting,” say that in fact sleep training results in “learned helplessness,” with infants making the agonizing discovery that no matter how hard they cry, no one will come.
In a study published this week in the journal Pediatrics, 43 infants in Australia, 6 to 16 months old, all healthy, but identified by their parents as having sleep problems, were randomized to three different groups. In one group, the parents tried graduated extinction, the technique in which babies are allowed to cry for short, prescribed intervals over the course of several nights. The second group tried a technique called bedtime fading, in which parents delay bedtime in 15-minute increments so the child becomes more and more tired. And the third group, as a control, was just given sleep information.
The researchers measured the babies’ stress by sampling their levels of cortisol, a hormone indicating stress, and also looked at the mothers’ stress; 12 months after the intervention, they evaluated parent-child attachment and looked at whether the children had emotional and behavioral problems.
“What we were interested in is this hypothesis that there are these long-term consequences from doing something like graduated extinction,” said Michael Gradisar, an associate professor of psychology at Flinders University in Adelaide who was the first author on the new study.
Both sleep techniques – graduated extinction and bedtime fading — decreased the time it took children to fall asleep and graduated extinction reduced night wakings, compared to the control group. All the salivary cortisol levels were within the normal range in all three groups, but the afternoon levels in the two sleep training groups declined over time more than the controls. And there was no difference among the groups, 12 months later, in the measures of the children’s emotional and behavioral well-being.
Although critics of graduated extinction believe that strategy disrupts parent-child attachment, Dr. Gradisar said: “We couldn’t find any differences. The more studies we get, the more confident we can feel that this is actually safe to perform.”
This research builds on a follow-up study that appeared in Pediatrics in 2012, which looked at a large group of Australian children who, as babies, had participated in a controlled study of the effectiveness of behavioral sleep techniques. The original study, from 2006, had found that these techniques were effective both in reducing parents’ report of sleep problems in their 10-month-olds and also in reducing maternal depression, which has been linked to children’s sleep issues.
The 2012 research looked at those children at age 6, and checked out their mental health, stress regulation, sleep and a variety of measures of the parent-child relationship.
“We measured cortisol in saliva,” said Dr. Anna Price, a postdoctoral researcher in pediatric psychology at Murdoch Childrens Research Institute in Melbourne, who was the first author. “We also looked at parents’ mental health as well, all the effects the early program might have had on their later development and behavior, and the two groups looked very similar on all the measures.” The researchers found no differences between the children whose parents had been advised about the behavioral sleep techniques and the controls.
Another study of infant cortisol levels, published in 2012 in the journal Early Human Development, has been cited as showing that these behavioral techniques can be highly stressful for infants; it suggested that babies might be in distress even though they were not crying. Wendy Middlemiss, an associate professor of educational psychology at the University of North Texas, who was the first author on that study, said: “You have to be responsive. You can’t let them cry for long periods of time.”
But how cortisol is measured and interpreted is thus at the very center of this debate. Dr. Price and Dr. Gradisar were both among the authors of a letter responding to the Middlemiss article and challenging the cortisol methodology.
All these researchers agree that parents shouldn’t do anything that makes them uncomfortable; parents know best what their children need. But not-so-subtly, there’s a sense on one side that parents feel pressured and guilted into leaving their tiny babies to cry and cry at night, and on the other, that parents feel pressured and guilted into not letting their children cry for even a moment. And both may be true.
If what we really mean is, parents should do what they’re comfortable doing, and our job as pediatricians and pundits is to help them feel confident in their parenting, we have to accept that different families will make different reasonable choices.
There’s some good evidence that the various methods of “sleep training,” none of which should involve letting a small infant cry for hours in a dark room, work for many children and many families. There’s no evidence that they do lasting damage to the child or the parent-child bond and, in fact, some reassuring evidence that they don’t.
There also doesn’t seem to be evidence that you do harm by deciding to forgo “sleep training” and waiting for the child to outgrow the night waking — as long as that doesn’t damage your marriage or your mental health.
As a pediatrician, I think about the baby, but I also try to take into account how the parents are doing. I sometimes wonder how the people who are most strongly opposed to any form of sleep training would feel about having their children’s teachers, or doctors or bus drivers, coming to work sleep deprived after really disrupted nights. Sleep matters, as we have learned to acknowledge in medical training. Babies matter, and so do parents.
What your baby needs most is a loving family, which ideally includes parents who are enjoying the adventure. And no expert can tell whether you are enjoying the adventure better than you yourself.
See you in the morning.
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Swaddling a baby may increase the risk for sudden infant death syndrome, or SIDS, a new analysis concludes.
The practice of swaddling — wrapping an infant with a light cloth, with the head exposed — has grown in the United States with reports that it promotes better sleep.
Researchers pooled data from four observational studies of SIDS and swaddling that included 760 SIDS cases and 1,759 controls.
Over all, swaddling increased the risk for SIDS by about one-third. The risk was greatest in babies sleeping on their stomachs, less in those sleeping on their sides, and least in infants sleeping on their backs. The study is in Pediatrics.
The lead author, Anna S. Pease, a research associate at the University of Bristol in England, said that the results should be interpreted with caution, because there are few studies of the subject, and the amount of good evidence is limited.
Still, she said, “We already know that side and prone sleeping are unsafe for young babies, so the advice to place children on their backs for sleep is even more important when parents choose to swaddle them.”
The risk also increased with the age of the infant.
“We suggest that parents think about what age they should stop swaddling,” Dr. Pease said. “Babies start to roll over between four and six months, and that point may be the best time to stop.”
Credit Stuart Bradford
For six weeks after delivering my son, I had postpartum thyroiditis. Every afternoon around the same time, I would shake uncontrollably. Anxiety about night feedings and colic (which my son didn’t have) plagued my thoughts all evening. One night while my husband put our son, Jackson, to sleep, my sister put me to sleep. We watched “Romancing the Stone” and she rubbed my back until I drifted off — as if I were the baby.
Moreover, I lost all the baby weight within weeks. At my two-week checkup with my obstetrician, I had lost over 25 pounds. I left that appointment proud, feeling like I could be on the cover of Us Weekly. It must be the breast-feeding, pumping and healthy eating. But I was kidding myself. I breast-fed for all of three days. Sure, I pumped a few bottles, but Jackson got mostly formula. And I wasn’t eating healthfully. I was eating takeout.
About two months after Jackson’s birth, my thyroid burnt out. I didn’t know it at the time, but I later learned that mild hyperthyroidism had given way to Hashimoto’s disease, a potentially more serious, and chronic, thyroid condition in which the thyroid becomes underactive. Over the next few months, I gained about 30 pounds and became extremely lethargic. When I woke each morning, my first thought was: When can I take a nap today?
My body was just transitioning, I thought. And I had a baby now. Most new moms were tired, right? Still I sensed that something intense was happening: I was a different person.
My husband and I had some traumatic fights during those months. I feared that our marriage, the very foundation for loving this new child, was falling apart. He said things like “you’ve changed” and “I can’t live like this anymore.” And the truth was that we really couldn’t live like this anymore.
To make matters worse, I felt that my internist largely dismissed my concerns. He ran my blood work for virtually everything except my thyroid hormone level. We spent the follow-up appointment discussing my elevated cholesterol (also a symptom of hypothyroidism). He offered me Xanax and suggested I talk to a therapist about postpartum depression. Even most friends and family members chalked up these physical changes to the stresses of being a new mom.
Finally, when Jackson was 6 months old, I saw my O.B. again. She, too, bet on postpartum depression but ran thyroid tests to rule it out. I vividly remember when the doctor called with the results, “I’m surprised you can get out of bed in the morning, much less work full-time and take care of a baby.” When I hung up, I wept. I wasn’t losing my mind. I wasn’t just having a hard time adjusting. My thyroid, this little butterfly-shaped gland in my throat that I last worried about in high school biology, was having a hard time keeping my body up and running.
The synthetic thyroid hormone Synthroid helped with losing weight and energy levels. And ever since, I’ve had routine blood work and sonograms to monitor my hormone levels and the small lumps on my thyroid. During my second pregnancy, I saw an endocrinologist and had blood taken every month. My endocrinologist told me that it was important that I have my medication adjusted every month during the pregnancy since the thyroid helps the body stay pregnant.
I was surprised to find that several of my women friends also turned out to have thyroid problems. They tell the same story about discovering their condition either later in life or surrounding a pregnancy. Toni had three miscarriages in one year because of a mismanaged thyroid. Lisa was diagnosed accidentally at 41 when she saw a doctor for a double ear infection and bronchitis. “He felt my neck and noticed that my thyroid was quite enlarged,” she writes.
All the women had weight troubles. Eat less carbs. Exercise more. Take the baby out for walks. You’re getting older so it’s harder. That was the advice I got, along with speeches about the American diet of processed foods and sedentary lifestyle. But I’ve never been sedentary, and becoming a mother certainly didn’t have me sitting on the couch eating potato chips. My friend Jen remembers being patronized at her doctor’s office. “I was literally patted on the leg and told it’s just going to be hard for you to lose weight, dear,” she said. Her endocrinologist prescribed her a medication for diabetes and told her to eat 1,100 calories a day.
My takeaway from those six months is this: Even amid the huge life change that is motherhood, I knew something was really wrong with my body. And if I had put my health first, I would’ve figured it out much faster and with much less heartache. But prioritizing yourself isn’t something many new moms do very well.
Of course the early weeks with a newborn are exhausting for all parents, but if you don’t start to feel normal once the baby’s sleep schedule stabilizes, it’s worth getting your thyroid checked. A simple blood test can make all the difference.
Kristin Sample is a writer, teacher and dancer. Her novel “North Shore South Shore” is available on Kindle. Follow her on Twitter and Instagram @kristinsample or check out her blog, kristinsample.com.
Credit Tony Cenicola/The New York Times
Eating a high-fat diet may lead to daytime sleepiness, a new study concludes.
Australian researchers studied 1,800 men who had filled out food-frequency questionnaires and reported on how sleepy they felt during the day. They were also electronically monitored for obstructive sleep apnea, which causes people to wake up many times during the night.
After adjusting for factors that could influence sleep — smoking, alcohol intake, waist circumference, physical activity, medications, depression and others — they found that compared with those in the lowest one-quarter for fat intake, those in the highest one-quarter were 78 percent more likely to suffer daytime sleepiness and almost three times as likely to have sleep apnea.
The connection of fat intake to apnea was apparent most clearly in people with a high body mass index, but the positive association of fat intake with daytime sleepiness persisted strongly in all subjects, regardless of B.M.I. Thestudy is in the journal Nutrients.
“The possible mechanism could be meal timing, but we didn’t have that information,” said the lead author, Yingting Cao, a doctoral candidate at the University of Adelaide. “But we have reason to believe that circadian rhythm, hormones and diet all work together to create these effects.
“Everyone knows that diet has an important effect on health,” she continued. “Extremely high fat intake is not good for sleep. So the key message here is to eat healthy. But that’s easier to say than to do.”
Credit Stuart Bradford
If you tell your child’s pediatrician that your child is having trouble sleeping, she might respond by asking you how well you sleep yourself.
A team of Finnish researchers found that parents with poor sleep quality tended to report more sleep-related difficulties in their children than parents who slept well. But when the researchers looked at an objective monitor of the children’s sleep, using a bracelet similar to a commercial fitness tracker that monitored movement acceleration, a measure of sleep quality, they found that the parents were often reporting sleep problems in their children that didn’t seem to be there.
“The only thing that was associated with sleeping problems, as reported by the parents, was their own reported sleeping problems,” said Marko Elovainio, a professor of psychology at the University of Helsinki and one of the authors of the study, which was published this month in the journal Pediatrics.
The study was relatively small, involving 100 families with children aged 2 to 6. But the findings suggest that parents’ report of sleep problems in their children are influenced by their own attitudes and behaviors surrounding sleep.
The researchers were inspired to do their study, in part, by research showing that mothers with depression over-report behavioral problems in their children, seeing issues that teachers do not see. In pediatrics, the researchers noted, doctors rely heavily on parental reports for information — and if that information is biased by a parent’s own experience, diagnosis becomes more difficult.
“Sleep is a good measure of stress,” said Dr. Elovaino, and it is one tool doctors use to evaluate how much stress a child is experiencing. But when making a diagnosis involving a child’s sleeping patterns, “we can’t rely on reports of parents. We need to use more objective measures.” One reason to look at sleep in this context, he said, is that unlike other possible markers of stress, it can be measured objectively.
But an accurate evaluation of sleep quality should also include an individual’s subjective perception of tiredness in the morning and throughout the day, said Candice A. Alfano, the director of the Sleep and Anxiety Center of Houston and an associate professor at the University of Houston. She and her colleagues published research in 2015 describing a similar disconnect between perceived sleep difficulties and measurable sleep. Although both anxious children and their parents reported greater sleep difficulties than children and parents with lower levels of anxiety, there was no significant difference between the measured sleep patterns of the two groups.
“Children who are anxious at night often attempt to avoid bed, ask parents to sleep with them, and complain of nightmares,” Dr. Alfano said. Those are observable behaviors for parents, but they might not be reflected in the quality of a child’s sleep once sleep is achieved, or how that child feels about sleep.
In general, said Jamie Howard, a clinical psychologist at the Child Mind Institute, a nonprofit group that deals with pediatric mental health issues, parents are better reporters of children’s external behaviors, while children are better reporters of their internal emotions. “If the parent is saying that a child seems sad or depressed, we listen,” she said. But it’s also important to talk to the child as well, in order to understand “how much is the parent’s perception and how much is actually what the child is experiencing.”
Sleep, especially when considered as a measure of stress or anxiety, sits somewhere between the external and the internal. Knowing that parents may be misperceiving a child’s sleep experience can remind practitioners to look further than a parent’s assessment of a child’s other emotional symptoms. “When we work with children, we’re really working with the whole family,” Dr. Howard said. “You have to always remember that reports of the children are coming through the filter of the parents.”
Placing the proper weight on the influence of that “filter” is a challenge for both professionals and parents, many of whom are well aware that they may see their children through a distorted lens. “I have a family history of mental illness,” says Judy Batalion, who wrote about her own anxieties and her mother’s hoarding in “White Walls: a Memoir about Motherhood, Daughterhood and the Mess in Between.” “I’m a professional worrier.”
Ms. Batalion is aware that she’s “hypervigilant” about the kinds of psychological issues she has seen in family members, and she’s also aware that she can take it too far. “When my older daughter was a toddler, there was a period where she just wanted bags, and to put stuff in bags, colored disposable spoons and straws.” The bags reminded Ms. Batalion of her mother’s bags. “I had to tell myself, she’s a toddler, not a hoarder.”
A good practitioner, experts agree, should never dismiss a parent’s concerns. Even in cases in which there is no objectively measurable sleep problem, a parent or child’s anxiety about sleep may itself be a problem. Similarly, notes Dr. Howard, if a parent perceives a child as being anxious, and the child herself isn’t feeling that emotion, the child still has to deal with a parent who thinks she’s anxious.
“Parents do such a good job of observing their children’s behaviors,” she said, but since they can’t always know what’s inside a child’s head, “they don’t know exactly what they’re thinking or feeling.”
It’s not surprising that parents might interpret a child’s actions through their own perceptions, Dr. Howard said. But, she added, “I’m much more concerned about a parent who doesn’t notice things than I am about a parent who sees things that aren’t there.”
Women with sleeping difficulties are at increased risk for Type 2 diabetes, researchers report.
Scientists used data from 133,353 women who were generally healthy at the start of the study. During 10 years of follow-up, they found 6,407 cases of Type 2 diabetes.
The researchers looked at four sleep problems: self-reported difficulty falling or staying asleep, frequent snoring, sleep duration of less than six hours, and either sleep apnea or rotating shift work. The study is in Diabetologia.
Self-reported difficulty sleeping was associated with higher B.M.I., less physical activity, and more hypertension and depression. But even after adjusting for these and other health and behavioral characteristics, sleeping difficulty was still associated with a 22 percent increased risk for Type 2 diabetes.
Compared to women with no sleep problems, those with two of the sleep conditions studied had double the risk, and those with all four had almost four times the risk of developing the illness.
The senior author, Dr. Frank B. Hu, a professor of nutrition and epidemiology at Harvard, said that sleep problems are associated with excess secretion of two hormones: ghrelin, which increases appetite, and cortisol, which increases stress and insulin resistance. Both are linked to metabolic problems that increase the risk for diabetes.
“And,” he added, “it’s not just quantity of sleep, but quality as well” that is associated with these health risks.