When your child is not sleeping well
The article below appeared in the June 7 issue of Health with Perdana, a regular column in The Star by Perdana University faculty members. This week’s article is contributed by Assoc. Prof. Dr. Christina Liew, Academic Lead, Associate Professor in Clinical Competencies, and Assoc. Prof. Dr. Thidar Aung, Associate Professor in Biochemistry/Immunology, Perdana University Royal College of Surgeons in Ireland.
Sleep and children of the modern era
Sleep is vital to maintain general good health and well-being. A child spends about 40% of his or her childhood sleeping. Sleep is crucial for children to grow and learn, stay healthy and function well. Sleep is also essential in the regulation of emotion, behaviour, memory and attention in children. The circadian rhythm, commonly known as the sleep-wake cycle, is regulated by light and dark phases of the day. The sleep-wake cycle starts to develop in newborns and at three to six months of age, most infants have acquired a regular sleep-wake pattern.
Sleep requirement depends on a child’s age. The National Sleep Foundation (NSF) recommends that pre-school children (aged 3-5 years) need 11-13 hours and school-going children (aged 6-13 years) need 9-11 hours of sleep. The recommendation by NSF serves as a guideline because every child is different, and each child’s sleep requirement is different. So, do take some time to understand your child and to figure out what works best for him or her.
In recent years, studies in the area of sleep patterns in children and adolescents have caught the attention of many researchers and national policymakers. The total sleep time for children and adolescents has reduced over the decades. Children in this modern era are getting less sleep compared to those in the previous generations. Sleep loss in children is an alarming trend and is now recognised as one of the major public health issues. Children respond differently to sleep loss compared to adults as the developing brains in children are more sensitive to sleep loss. The long term effects of insufficient sleep are poor memory and concentration. All these adverse effects of sleep deprivation lead to poor academic performance. But why are children in this generation getting less sleep? Several potential reasons include the busy daily schedules, school and social activities, and the use of technology devices, i.e. gadgets or electronic media. And, what can we do to reverse this unwanted trend?
Sleep and electronic gadgets/media use
Television viewing and iPad screen time should be limited, especially in the evenings, before bedtime. Television sets are becoming more affordable, and some homes may have multiple sets of this electronic device. The presence of an electronic media, for example, a television, in a child’s bedroom was documented to reduce total sleep time, increase difficulty in falling asleep and cause sleep disturbances. A higher total number of hours of television viewing in a day could contribute to difficulty in falling asleep in children aged 4-6 years. In comparison to children who watch less than 2 hours of television in a day, those with increased viewing time have a higher chance of difficulty to fall asleep and are likely to experience sleep disturbances. Some studies have found that the use of television is associated with delayed bedtime, later wake up time, and a shorter time in bed, both during weekdays and weekends. To cater for a conducive sleep environment, it is recommended that television should be kept out of the children’s bedroom.
The use of electronic gadgets in the late evening has been reported to harm a child’s sleep. Violent electronic games and activities near bedtime put the body at a stressful state and can impair the onset of sleep. The hormone that promotes sleep, melatonin, is suppressed by light exposure, including exposure to the LED light. So, to promote a night of good sleep, television and computer screens should be switched off, preferably long before bedtime, and bedroom lights should be dimmed.
The chicken and egg situation –sleep and behavioural issues in children
Sleep disorders considerably affect healthy children and adolescents. Children with sleep deprivation may exhibit behavioural changes, impulsivity and emotional lability. The relationship between sleep loss and behavioural changes is like a vicious cycle where problems with sleep lead to behavioural issues, and behavioural issues lead to sleep problems.
Sleep routine is recommended to be kept at about the same time daily with a 15-minute allowance from the norm as an acceptable divergence. A good sleep routine includes a time to allow children to calm down and relax. We live in a 24/7, fast-paced society where children are so caught up with their daily routine that they do not have a substantial time to wind down and relax. Children mostly rushed through the evenings when they reach home, and before long, they are asked to get ready for bed. In a situation like this, which is a norm for many families, some children are not able to cope with the expectation that they should fall asleep soon after they are put in bed. Room lights should be dimmed to help a child to relax and to promote sleep. Relaxing activities such as light reading and foot massage are helpful to promote good sleep.
School performance is a marker of cognitive functioning in children. Persistent sleep loss in school-going children may result in behavioural problems and classroom inattentiveness. The increment of sleep duration for 30 min to 1 hour daily may help to improve cognitive performance in school-going children.
Sleep loss and tiredness
A small amount of sleep loss could lead to tiredness in children. A child who has sleep loss the night before and is exhausted, combats the feeling of fatigue by fighting it off. To remain alert and well awake, the body produces in excess, the adrenaline hormone. The child will continue to stay alert and active but deeply exhausted. So, a tired child may initially look alert and active. The sense of irritability and crankiness will soon set in. By then, the child will not be able to concentrate, stay calm and learn.
Sleep and diseases
Restorative sleep strengthens the immune system and promotes healthy growth in children. Sleep deprivation has a negative impact on a child’s growth and weakens the ability for the body to resist infections. Although sleep loss for a single night will not stunt growth, we all know that children need a consistent good quality sleep to thrive. That is because growth hormone is typically released during sleep. In sleep loss, our body is not able to make cytokines, an immune system type of protein that is effective at combating infections and inflammation. The immune system is, therefore, weakened in sleep deprivation.
There are many reasons for a child to find it difficult to fall asleep or hard to stay asleep throughout the night. Some of these reasons are related to behavioural issues, and others are linked to medical conditions. The examples of some common sleep-related medical conditions are sleep-related breathing disorder, allergic conditions causing a stuffy nose or itchy skin from eczema, and some children may experience pain due to other related diseases. Sleep deprivation and pre-existing medical conditions often exist in a reciprocal cause-and-effect relationship. One condition triggers the other, and the pattern revolves repetitively in a vicious cycle. Sleep apnoea is an example of sleep-related breathing disorder, a condition that occurs during sleep and sufferers have short or brief but multiple involuntary breathing pauses. These breathing pauses cause sufferers to wake up multiple times at night, and are disruptive to a good, restorative sleep.
Obesity may put children at risk for sleep apnoea. There are a number of evidence that could be found in the literature documenting the link between sleep deprivation and obesity. Sleep loss alters eating behaviour and increases the desire for food. Altered or delayed sleeping time influences snacking behaviour, and increases one’s craving for sugary food. Another phenomenon seen in sleep deprivation is insulin insensitivity, a condition that makes it difficult for the body to process glucose properly and that is another cause for obesity. The lack of sleep also results in tiredness and subsequently, a reduction in physical activity.
Excessive daytime sleepiness (EDS) is a consequence of long-term sleep fragmentation and sleep deprivation. EDS contributes to poor daytime cognitive function and many other unwanted psychosocial problems.
How should we respond to changes in a child’s sleep pattern?
It is inevitable that at times, we would lend ourselves to situations where our children’s bedtimes have to be delayed, for instance when there is a special family or social occasion or when we are on holidays. It is acceptable that once in a while a later bedtime is imposed but it is imperative that the daily bedtime routine is restored as soon as possible to allow adequate recovery and rest.
There are times when a child may wake up in the middle of the night. The reasons for night waking include the need to use the toilet, bedwetting, woken up from a nightmare or sleepwalking. Try to do the necessary to cater for the child’s current demand and then walk the child back to the bedroom without creating any commotion. Try to comfort and settle the child back to sleep as soon as possible. If your child has an increased number of “wake-up time” in the night and is causing concern, do go and see your family doctor.
In a family, a consistent bedtime routine is essential to ensure good quality sleep. Children must follow a regular sleep routine and parents are to set a good example for them. Experts in this field recommend that preschoolers and school-aged children should maintain a regular and consistent sleep schedule. Children should sleep in the same sleeping environment with an optimum temperature conducive for sleep. The room should also be cool, quiet and dark, without TV and computers. The bedtime routine should be relaxing. Avoid caffeine. Maintaining good sleep hygiene is essential to prevent sleep condition from becoming worse. We have to safeguard our children’s sleep as much as we would care for their food intake and safety. For a healthier family, make sleep a priority!