What is a normal sleeping pattern?

Before supporting parents with sleep issues, it is important for health visitors to have the confidence to understand what sleep is and to recognise normal sleeping patterns in young children.  Health visitors should also be aware that there are differences in sleeping patterns in babies aged under 6 months and there is recommended guidance regarding when to commence sleep programmes.

Parents often worry that they are doing something wrong if their baby does not sleep through the night at an early age, but is this a realistic expectation?  The easy answer is no! Babies, children and adults all wake during the night as they move through the different sleep cycles, with the difference being that older children and adults can often easily fall back to sleep without remembering that they had woken.

When supporting parents with infant sleep issues, it can often be helpful to explain the sleep process using a hypnogram (see below), which is a visual representation of sleep cycles throughout the night.

Sleep consists of two distinctive stages; rapid eye movement (REM) sleep, which is the stage associated with vivid dreams and non-rapid eye movement (NREM) sleep where the body relaxes and vague thoughts rather than dreaming occurs.

NREM sleep consists of three/four stages:

  • Stage one is brief and describes the process of when moving from being drowsy to falling into light sleep.
  • Stage two is often described as the “scaffolding of sleep” as this is the stepping stone between light and deep sleep and is the stage that most sleep takes place in.
  • Stage three/four describes the deepest levels of sleep, when it is most difficult to be woken.

A sleep cycle involves moving between NREM stage 1-3/4 then into a period of REM sleep, with brief waking often occurring between each cycle.

rem

Although there are differences between the length of sleep cycles between children and adults, from 6 months of age all move through recognisable stages of sleep in cycles throughout the night.   Prior to 6 months of age, babies have not yet developed REM and NREM sleep, instead they move between active sleep and quiet sleep.

It is important to be aware that sleep disorders are not recognised in babies under the age of 6 months.  New-born babies need frequent day and night feeds to maintain their growth, which impacts on sleeping patterns.  In addition, babies do not recognise day and night and have not yet developed the ability to self soothe.  In practice, this means that although babies can be encouraged and supported to develop healthy sleep habits, sleep programmes are generally not offered before the age of 9-10 months, with some areas preferring to wait until a baby has reached the age of 12 months.

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Common Infant Sleep Problems

laurel-851030_640As a health visitor who has undertaken additional training in child sleep disorders, I often work with sleep deprived parents who have sought support to manage their young child’s sleep problems.  Poor infant sleep is recognised to be a leading cause of parental stress and has associated negative impacts on the child.

The most common sleep problems in the under 5 age group are behavioural in nature and include sleep onset association disorder, limit setting disorder or a combination of both.

  • Sleep onset disorder is most common in children aged between 6 months and 3 years and describes children who need specific conditions to fall asleep, such as a dummy, being rocked, parental presence or music. This becomes especially challenging for parents as their child needs the same conditions to fall asleep when they wake overnight as they did at bedtime.
  • Limit setting disorder occurs in early to mid-childhood, often when the child moves from a cot into a bed, and describes children who refuse to go to bed, either through stalling or making multiple requests, such as needing the toilet, wanting a drink or being fearful, with their parents struggling to maintain consistent boundaries.
  • The final disorder comprises of a combination of sleep onset association and limit setting disorders. This most commonly starts as limit setting disorder and can make bedtime a battle ground, with exhausted parents then offering a strategy to their child, such as their presence to help them settle (sleep onset disorder).

When supporting parents with infant sleep issues, it is important to be aware that they may have already have tried strategies at home with limited success and this could potential effect their willingness to try to implement sleep programmes.  It is important the health visitor undertakes a full assessment of the child’s sleep issue and works with the family to design a sleep programme.

Sleep programmes or behavioural interventions, such as controlled crying or gradual retreat, along with implementing a bedtime routine, are the recommended approaches to infant sleep problems.  I will explore each of these interventions in more detail over the next few blog posts.