Sleep FAQ

• Leg cramps.
• Awareness of their heartbeats and shortness of breath.
• Needing to pass urine more often.
• A very active baby who seems to be an expert at landing kicks in the mother’s bladder or some other tender spot.
• Difficulty turning over in bed as the uterus gets bigger.
• Backache, especially pains in the lower back.
• More dreams than usual.
• Nightmares that are easier to remember.
• Feeling nervous about the forthcoming delivery.
• Worries about the baby.
• Worrying about whether it’s normal to be worried.

When babies are born they have no sense of night and day. They learn this from the behaviour of human beings around them. The tradition in some continental countries is that people go to sleep much later in the evening and have a siesta in the afternoon. Babies brought up in that sort of environment will learn that kind of sleep pattern.

It is therefore quite normal at the beginning of life to have a chaotic sleep pattern. Babies seem to feed and sleep on a continuous basis throughout about 24 hours, although within a matter of a week or two some of that sleep will clump together, although not always at night-time!

Babies do not know how to fall asleep at will. Sleep is simply something which happens to them and over which they have very little control. The ability to fall asleep at will develops gradually over the first few weeks of life. This is a process and takes time.

During sleep there are different phases. There is an initial phase of deep sleep followed by a phase of light sleep. This light sleep may be accompanied by waking which is usually momentary and is often preceded and followed by episodes of dreaming. This pattern of light sleep followed by the sleep followed by light sleep again continues in adults and animals and young children throughout the night. Each of the sleep cycles takes approximately an hour and a half. This is one of the reasons why babies most commonly sleep and wake after about and an hour and a half or, they may possibly go through the first light phase and end up sleeping for about 3 hours, or two sleep cycles.

When most adults wake at night they commonly turn over or may open their eyes momentarily and then go straight back sleep again. This process is facilitated by the fact that they usually fall asleep in the same situation in which they are likely to wake during the course of the night. Also most animals have an inbuilt sense of time and seemed to know approximately how long they may have been asleep and approximately what time it is. It is not easy to wake animals when they are in the phase of deep sleep but it is much easier to wake them in one of the light phases. This means that if any time you are trying to manipulate your baby’s sleep pattern, you would do better to try to wake them in one of the light sleep phases so that they do not wake miserable and cross.

Premature babies seem to have much more dream sleep than babies born at term and the amount of dream sleep declines in all babies over the first year of life. During phases of dream sleep, the eyelids flicker backwards and forwards continuously while the rest of the body hardly moves. This dreaming phase occurs during light sleep and if you are planning to tactically wake your baby, you would do better to wait until you see their eyelids flickering in the way described.

For the first six months of life, babies will fall asleep pretty much anywhere, any time. However by about six months of age they gradually begin to become more aware of their surroundings and begin to develop some sort of settling routine. By settling routine this might mean anything from eating, having a bath and possibly a bottle and then falling asleep. This settling routine has an important function in that it is part of a process of beginning to quiet down in preparation for a long phase of sleep. This involves a separation from the mother and father and from the world itself. By this stage the baby can voluntarily fall asleep alone and the circumstances in which it does so become much more critical.

This means that if a child is still sleeping in with you, you need to think about where your child is going to sleep in the long-term. If you plan to move your baby out of your room and into a room of their own, you would do best do this before six months of age. If your baby has been sleeping in a Moses basket or cot beside your bed, it would be best to move this into the new room ready for their sleep during the day. It’s much easier for a child to adjust to this kind of process in the daytime and if they do find it difficult or cry frequently for reassurance it’s much easier for you to go and deal with them when you’re feeling slightly more awake. If your child is in a Moses basket you could try putting a Moses basket inside a new cot in a new room to begin with so that you are minimising the difference in their surroundings. Once they become used to the new surroundings, the Moses basket can be removed. If they are in a cot, you could put them in the cot to play during the day while you sit with them, so that they get used to being in the cot in a different room.

It doesn’t matter if you don’t have a separate room to put them in but if you do, you will probably find that they will sleep better. Adults make a lot of noise at night-time, which can be quite disturbing to babies.

There is a very important piece of advice about settling routines which is that, in an ideal world, you should not do anything which you are not prepared to get up and do again at two o’clock in the morning. This is because children need to learn ultimately to fall asleep in the dark and on their own. These are the conditions that they will be in when they wake throughout the night and it is much more likely that they will be able to fall asleep again, if these are the circumstances that they associate with going to sleep in the first place. If they associate falling asleep with being rocked or walked up and down by you, the chances are that they will need that again at two o’clock. Not all babies do and my advice here is guided by the number of parents I see in my clinic who have told me this. I don’t see the parents who rock their babies to sleep and whose babies do not wake at two o’clock in the morning and therefore it isn’t a problem for them. But you never know what kind of child you are going to have and it is slightly better to err on the side of caution.

A word about bottles: most babies are most likely to fall asleep while sucking a bottle until they stop sucking bottles basically, although some begin not to towards the end. You should not try deliberately at this point to withdraw the bottle from your child. What you could possibly do is try and give the bottle a little time before bedtime so that there is a slight gap between bedtime and the end of the bottle. Or you could wake them momentarily as you put them down into the cot – not enough to get them agitated and screaming but – enough to have them associate the idea of being in the cot and falling asleep from being awake rather than falling asleep somewhere else. I see many parents whose children fall asleep in front of the television in the evening when the adults are around and the light is on full blast with lots of noise and everything else going on. They then transfer their children to their cot when they themselves go to bed. These children then wake up in the early hours of the morning and scream the place down because they’re terrified of being alone in the dark because that was not the situation they went to sleep in in the first place.

The best way to settle your child is to put them in their cot at a time you have noticed is a common time for them to fall asleep (this could be 9pm or later and won’t necessarily be at 7pm). You should then tell them that it is time to sleep now in a calm and soothing voice and then leave the room. You could then be doing things outside the room that don’t make loud sudden noises but just let your baby know that you are still around. You will commonly notice that they will cry but this is normally just a fussing kind of cry and not real distress. Try not to go back for 10 minutes and give them a chance to fall asleep.

If your child waits repeatedly throughout the night for a bottle, this is extremely common in young babies and it is not something you should worry about. By about 10 months of age babies do not normally need to be fed during the night, although there will be some breast-fed babies who will still feed at this time and it is more difficult to get babies off the breast at this point than it is to get them off the bottle. However that is not a reason to switch over to bottle feeding at this stage necessarily.

If they are still waking and appearing to indicate that they need to feed and you are bottle feeding it is slightly easier to manage this. You can reduce the amount of milk being given at this time or alternatively you can try gradually watering it down over the course of a few weeks, an ounce at a time. You can be confident that if your baby is at least 10 months of age, unless they are ill, or the weather is particularly hot, they do not need a drink or food during the night. If you give lots of milk at night you may find the baby eats less during the day and this will affect weaning. If they are not coping with weaning very well it isn’t a good idea to keep on giving the milk during the night because it will inhibit their hunger during the day which you need to stimulate in order to get them eating food. The other thing is that there begins to be a crossover and instead of the milk being something comforting that sustains them throughout the night, it becomes something uncomfortable for them, rather in the way that eating a large heavy meal just before bedtime is for adults. If you are breastfeeding, you could try removing your nipple just as they appear to be falling asleep, rather than waiting until they are, and thereafter, you could try removing it just a little earlier still. It is worth allowing a few days at each stage of this change to allow them time to get used to it and waiting until they settle easily before you move onto the next stage. If one stage doesn’t work, you can just go back to the previous one that you know worked and then try to move on again from there in a few days’ time.

If your child’s screams when you try to leave the room and refuses to settle without you there are three main methods of dealing with this behaviour.

Cold turkey – (described by Richard Ferber in his book ‘Solve your child’s sleep problems’). 
This method simply involves ignoring your child’s screams and not returning at all. In behavioural terms it is known as extinction and it works very rapidly. By very rapidly I mean that it will work within two to three days. However it involves an awful lot of distress and screaming while children are learning that you will not respond as it is night-time now and time for them to go to sleep. The vast majority of parents that I see in the sleep clinic do not use this method because they find it too traumatic. If they did use it they wouldn’t be coming to see me because it does work very quickly. However is not easy method to use and I would not suggest that anyone uses it with a child under 14 months of age because I think that they are simply too young to cope with it. Normally parents recognise this.

Go back and check method (but there are various names for it). 
This is exactly as it sounds. The idea is that you leave your baby after you have put them down settle to sleep and if they cry, you wait five minutes before you go back to them. Then you leave the room when they are settled again. If they start to cry again there are two variations on the theme this point: there is one method which says that after another five minutes you go back and that you keep doing that. There is an alternative method which says that you leave it 10 minutes the next time and then you go back and that if your child’s screams again you leave it 15 minutes the following time and so on, always adding on five minutes rather than keeping it a constant. The first of these variations adds the 5 minutes on the next night. There are many people who swear by this method but I personally think it’s a bit confusing. It seems to me that just as your baby gets used to doing without you and begins to settle, back you come again. However, there are many who swear by this method.

The last method is that you remain in the room with your child and you stay with them until they fall asleep.
This method is often very useful for parents where there have been concerns about separation or loss. When I take a history of the pregnancy and birth and experiences before pregnancy from parents, I find a striking number of parents who have had losses, or threats of loss, either just before the pregnancy, sometime during the pregnancy or around the time of birth. These experiences often sensitise parents to loss and make them far more anxious and unable to be calm around the separation time with their child. Sleep is of course a separation and this may be the first time that you see this sort of underlying feeling becoming more evident.

This method depends on you sitting beside the bed/cot while your child falls asleep and being very calm and very boring. This will reinforce the idea that daytime is for playing and doing things and having conversations and night-time is a rather boring, uninteresting time when people lie still and do very little and have their eyes closed.

Try not to end up lying down with your child to get them to go to sleep but if you have somehow got into that situation, as many parents do, you have to gradually extricate yourself from this. This might mean instead of lying down beside your child sitting beside them, or sitting on a chair beside the bed, sitting on a chair beside the door to your child’s room, although inside it, etc. These are also stages that you can go through to teach a small child gradually to learn to fall asleep without you.

Commonly when parents come to see me, they have reached the point of lying down on a bed with their child and often falling asleep because they are exhausted! This means that the first stage needs to be sitting up beside your child and as long as you are calm, the message to your child is that you feel they are perfectly safe if you sit there beside them. When they have reached the point that they can fall asleep within five minutes and that’s been going on for at least three or four days, you can then move onto the next level of the hierarchy. By this I mean, instead of sitting on the bed, you could sit on a chair right beside the bed/cot and in that case the child will know that you are still there. You will be a reassuring but rather boring presence. 
Again, when your child can fall asleep within five minutes, allow three or four more days for that to consolidate and then move your chair slightly away from the bed. In an ideal world you should have the lights down low and be reading a book or a newspaper or being very very uninteresting at this point. When that becomes easy, depending on how big your child’s room is, you could move your chair right over by the door. The last step is that you leave the chair in the room and you get up periodically and you wander off bustling about in the corridor outside, putting things away for example, eg. washing or anything you can think of that makes a slight noise to let your child know that you are still there but which means that you are not in the room any more. By this stage your child should be sleeping slightly better.

How should I deal with my child’s distress?
Children are extremely sensitive to the feelings of their parents, especially before they are verbal. They will know from the way you hold them, from the way you touch them, from the way you look at them, from your tone of voice and many other signals that you are feeling anxious about what you are doing, even if you’re not aware of this yourself.

If you have doubts about this I would urge you to try and think about walking into a room where there is a funny atmosphere. How do you know? What tells you? What are you going on? Often people can’t tell you but they will know that there is a funny atmosphere in the room when they walk in but they have absolutely no idea how they reached that conclusion. I would suggest that you and they are tuning into something that involves a mixture of non?verbal behaviour and probably unconscious communication.

Children are much better at this than adults and if you are in the slightest bit anxious when you put them down to sleep your baby will scream or cry for reassurance. If you then pick them up in an attempt to reassure them, they will assume that they were right to be concerned and that you agree because you picked them up. This is where it gets complicated because you have to balance being a nice parent who cares about your child and who is meeting their needs with the message you are giving them by your actions. If you take a child out of cot when they cry, one message is that you care and that you’re looking after them, whilst another message is that you agree with them and they were not safe there which is why you’re taking them out. It depends slightly on the emotional situation in which this happens as to how various messages will be interpreted. However what you must realise, is that not all of the signals from your child relate to how your child is feeling but how they think you might be feeling as well.

A word about noise, parents often feel that you have to be absolutely silent or tiptoe around a baby but this is not necessary. Babies seem to be able to sleep remarkably well when there are vacuum cleaners on and other loud repetitive noises or radios and all manner of things. In fact if you tiptoe around them you teach them to be much more sensitive to any noise that they hear and then it does become like self-fulfilling prophecy that they almost wake up at the drop of a pin.

If you continually make noises your baby will hear these and will be reassured that you are still around and have not left the planet but they will tune them out when they need to fall asleep. In other words these noises are usually quite reassuring. What is more likely to wake them is unfamiliar loud, startling noises and these should be avoided if possible. If you have a baby who appears to have become extremely sensitive to noise, you can put a radio on near them when they are asleep and turn it up so that it becomes slightly louder. They then have to tune it out quite actively to go to sleep. Then you can begin to turn volume down slightly so that they can sleep through pretty much anything.

Generally speaking, unless your baby is soaking wet or has had diarrhoea or genuinely seems uncomfortable, it is not necessary to change their nappy in the night. This is likely to wake your baby up completely and is also likely to confuse the difference between night and day. It also means that you will need to have a light on. It doesn’t matter if this is a low, soft light but if you put a main light on, this will reset your sensitivity to time and it is likely to make it very difficult for you and your baby to fall asleep again.

The amount of time for which children sleep varies enormously. At birth the range is anything between 7 and 21 hours out of 24. This means that one baby could be sleeping as much as three times as another baby. However this becomes much more consistent over the course of the first year of life and the average amount of sleep of a baby of a year of age would be about 12 hours. However this still means that some babies will be sleeping more and others will be sleeping less. If your baby is waking repeatedly at night for no particular good reason, it is possible that they are going to bed too early, waking up too late or having too much sleep during the day.

By the time they reach a year of age, most babies will settle to the point where they only need one nap during the day, although they might still be having two. If they appear to be waking a great deal at night it may be worth trying to consolidate these two naps into one. This can be achieved by starting the earlier one slightly later and also by waking them before the end of the second or by putting them down slightly earlier for the second nap.

No child should be put down after about 2.30pm, particularly if you expect them to go to sleep again at 7pm because it is very unlikely that they will be ready to go to sleep at 7pm especially if they did not wake up until 4pm. This of course doesn’t apply to very young babies who can sleep at all sorts of funny times.

Lastly remember that is very unlikely that you are the only person pacing the floorboards at 4am. Unfortunately again most parents come to see me come because they tell me that all their friends’ babies are sleeping wonderfully since they were about four months of age. There are certain constitutional factors that affect sleep which have nothing to do with anything else.

Premature babies are much more wide awake during the night whereas babies who were quite big at birth are more likely to sleep through the night slightly sooner. There is little to you can do to influence any of that. The most important thing that you can do is to be as calm as you can at bedtime.

If you are extremely worried about cot death or anything else then you need to try and think about this during the daytime and to try to put in whatever precautionary measures you can. These days this includes putting your baby down to sleep on their back, not on their stomach and it’s worth having a baby monitor so that you can be aware of your child breathing.

In some cultures, including ours, it is not unusual for children to sleep with their parents all the time. The standard advice is that there is no problem with this providing parents have not taken drugs or large amounts of alcohol. There is a book called ‘Three in a bed,’ although the author’s name escapes me, which talks a lot about managing your life when you have a child in bed with you.

Although most of us take our children into our beds periodically, either because we’re too exhausted, or they’re not well, whatever, in an ideal world, unless you are committed to this particular way of managing things, generally speaking it’s not the greatest habit to get into. If you find yourself persistently doing this, it is worth asking yourself whether you are somehow avoiding a sex life with your partner, or whether there are some unresolved marital difficulties that are too difficult to talk about, that having your baby in bed helps you avoid.

Also remember that up to a fifth of all babies are still waking in the night at one year of age. When everyone you know seems to have a child who is sleeping, remind yourself that this is just relates to your particular circle of friends. In all the community Child Psychology Clinics around and in GP surgeries and paediatric departments, the commonest reason why parents come to talk to somebody is because their child is not sleeping at night. This means that you are by no means the only one and it also means that there are lots of sources of help available and you shouldn’t be ashamed or embarrassed to go and talk to somebody about it.

The decision about whether you need treatment must be made in consultation with your doctor. Obviously if you suffer from the classic symptoms of sleep apnoea with daytime sleepiness and alterations in your mental function or personality, then treatment will be of great importance to you. But some people with sleep apnoea are surprisingly unaware or free of symptoms.

Even asymptomatic patients may be at risk for the cardiovascular complications of obstructive sleep apnoea. You may be at risk of developing hypertension or other medical complications, even if you do not have severe apnoea or marked drops in oxygen levels at night. The decision should therefore be based on both symptoms and signs of sleep apnoea after review with your physician.

Body Position
Sometimes relatively simple measures can help sleep apnoea. Some patients may only have apnoeic episodes when sleeping on their backs. If they can stay on their side apnoea may be reduced or eliminated. Unfortunately this is more difficult to achieve than it would seem. One suggestion has been to sew something such as a tennis ball into the back of the pyjama top. Another suggestion by a patient was to use a pinecone! In addition to the lateral position, elevation of the head of the bed by about 30° will also substantially decrease apnoea in some patients.

Weight Loss
The severity of obstructive sleep apnoea is also related to weight in many though not all patients. Even modest weight loss may significantly decrease apnoea. In general a 10-15% weight loss will decrease the severity of apnoea by half.

Alcohol Avoidance
Most agents that cause sedation will somewhat worsen OSA. Clearly, however, alcohol is the most important. Alcohol results in a decrease in upper airway tone and often leads to marked worsening of OSA. Avoidance or at least decreasing the amount of alcohol, especially close to bedtime, is of great importance in managing sleep apnoea medically. If the patient is on treatment such as CPAP, then modest amounts of alcohol may be better tolerated.

Hypothyroidism (low thyroid hormone)
Untreated hypothyroidism has been associated with OSA. This may be due to the body changes, the size of the thyroid gland or the effects of low thyroid hormone on breathing pattern. Treatment may help, but usually the improvement is not enough to completely treat OSA and eliminate the need for other treatment.

Electrical Stimulation of the Upper Airway
Since OSA occurs when the muscle tone in the throat (pharynx) is not strong enough to hold the airway open, it would seem logical that if the muscles were stimulated the apnoea would be corrected. There is promising research in this area, which does suggest this may be the case. Unfortunately, no device is readily available for clinical use yet.

Nasal Dilators
Since resistance to airflow in the nose increases airway collapse in OSA, reducing nasal obstruction would seem likely to help. Several devices that dilate the nose, both internal and external, are available. While they seem to help some snorers, no significant consistent benefit for sleep apnoea has been seen.

Medication
Antidepressants have been tried for sleep apnoea. None has proven to consistently or completely treat OSA though some improvement is sometimes seen in the severity of apnoeic episodes. There is ongoing interest in finding a medication that would help but no immediate choice is available now.

Continuous Positive Airway Pressure (CPAP)
CPAP involves the delivery of air (not oxygen) under pressure to the pharynx. This pressure acts as an air splint, holding the airway open and preventing the partial or complete collapse that is the main event in OSA. Usually this is delivered through a mask that fits over the nose only. In almost all cases this eliminates the signs and symptoms of OSA as well as the snoring. Most patients get relief quickly, some the first night they use it. In others it may take 1-2 weeks to adapt to the sensation of using the machine.

CPAP was first used in Australia in 1981. The major difficulty then, and now, was devising a mask to fit comfortably but snugly over the nose. Since the first masks a great deal of research has gone in to finding comfortable masks. There are now a variety of masks of different designs and different materials. Most still fit over the nose but some are designed to fit into the nasal opening. These are particularly helpful if you have any degree of claustrophobia. Because some patients cannot adapt to nasal breathing, masks that fit over both the nose and mouth are also available. There are also newer units, which actually adjust the amount of pressure as needed throughout the night. For some people this is more comfortable. Another choice for difficult cases, particularly for those with more severe OSA, is BIPAP or bi-level CPAP where the pressure during inspiration can be different than during expiration. This too can be more comfortable for some, especially when high pressures are needed.

For more information on our CPAP Services, please contact us.

For some patients CPAP is not an acceptable choice. This may be because of their inability to tolerate it or just unwillingness to use it. Many of these patients are candidates for surgery.

Surgery for sleep apnoea focuses on correcting the obstruction of the upper airway. The goal of surgery is cure of sleep apnoea, which means relief of the obstruction. Obstruction of the upper airway can occur at several levels including the palate, the base of the tongue or both. Surgery is aimed at correcting whichever obstruction is present. Nasal obstruction may also be present and contribute to the tendency for the airway to collapse, even though it is rarely the sole cause of OSA. Overall there is success with surgery alone in 20-50% of all patients. The surgery is not complicated or dangerous, but is quite painful.

In the last several years, many devices, which can be worn inside the mouth, have been tried for sleep apnoea. The goal is generally to hold the mandible (lower jaw bone) in its normal position or to pull it slightly forward. This prevents the jaw and tongue from falling backward during sleep and causing obstruction. There have been as many as 55 devices tried with largely the same goal. More recent ones allow some adjustability of the jaw position. The devices are generally well tolerated if the patient has no major tooth or jaw problems to begin with. They seem most helpful in mild to moderate cases but some success has occurred in more severe cases as well. The success is not like that with CPAP but offers an alternative to those who cannot use CPAP and may not want or be candidates for surgery.