Sleep Problems in Infants and
Toddlers
John A. Biever, MD
Central Pennsylvania Institute for Mental
Health
Clinical Associate Professor of Psychiatry
PennState Hershey Medical Center
Status of Diagnostic Thought
• International Classification of Sleep Disorders
– Subcategorizes as dyssomnias, parasomnias and
sleep problems secondary to medical/psychiatric
disorders
– Does not extend diagnostic criteria to infants and
toddlers
• DSM-IV
– Similar subcategorization as ICSD
– Again, developmental norms do not extend to
infants and toddlers.
DC:0-3 Diagnostic Classification System
for Infants/Toddlers
Sleep Behavior Disorders
– For children >12 months of age
– Sleep-onset disorder: at least 4 weeks of needing
parental contact in order to get to sleep
– Night-waking disorder: at least 4 weeks of wakings
that require parental attention
– Sleep problems also included as symptoms in several
other disorders
A Proposed Alternative Classification
System*
• Takes into account the relational component of sleep
disturbances in infants/toddlers
• Considers, therefore, the status of the attachment bond
between parent and child
• Considers the dual functions of homeostatic and
social/affective regulation in the dyadic interaction
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in
Handbook of Infant Mental Health. Second edition. Guilford
Press. 2000.
“Protodyssomnias”
• “Proto-” because they do not require
“functional impairment” as does DSM-IV
• Night Waking Protodyssomnia
• Sleep-Onset Protodyssomnia
• Diagnostic criteria vary by age and severity
Night Waking Protodyssomnia*
Age (months)
Perturbation
(1 night/wk;
2-4 wk duration)
Disturbance
(2-4 nights/wk;
2-4+wk duration)
Disorder
(5-7 nights/wk;
>4 wk duration)
12-24
2 awakings(AW)/
night and/or >10
min. AW
2 AW/night
and/or >10 min
AW
2 AW/night
and/or >10 min
AW
24-36
>36
1-2 AW/night
1-2 AW/night
and/or >20 min AW and/or >20 min AW
1-2 AW/night
and/or >20 min AW
1 AW/night
1 AW/night
1 AW/night
and/or >30 min AW and/or >30 min AW and/or >30 min AW
Note: Occurs after infant has been asleep for >10 minutes. AW, awakenings from sleep
that are accompanied by signaling (crying or calling).
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental
Health. Second edition. Guilford Press. 2000.
Sleep-Onset Protodyssomnia*
Age (months)
Perturbation
(1 night/wk;
2-4 week duration)
Disturbance
(2-4 nights/wk;
2-4+week duration
Disorder
(5-7 nights/wk;
>4 wk duration
12-24
>30 min to fall
asleep and/or parent
remains in room for
sleep onset and/or
more than 1 reunion
>30 min to fall asleep
and/or parent remains
in room for sleep
onset and/or more
than 1 reunion
>30 min to fall asleep
and/or parent remains
in room for sleep onset
and/or more than 1
reunion
>20 min to fall asleep >20 min to fall asleep
and/or parent remains and/or parent remains
in room for sleep
in room for sleep
onset and/or more
onset and/or more
than 1 reunion
than 1 reunion
>20 min to fall asleep
and/or parent remains
in room for sleep onset
and/or more than 1
reunion
>24
Note: Occurs at bedtime or nap time
Reunions refer to resistances to going to sleep. Reunions may differ in style: (1) repeated bids
(kisses, hugs, glasses of water), or (2) struggles (crying, screaming, physical resistance), or (3)
mixed. Reunions should be subclassified as to type.
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition.
Guilford Press. 2000.
Underlying Premises
• Unreasonable to classify sleep disturbances in
infants <12 months of age (instead, look at the
relationship/attachment)
• Assumes that child is sleeping in own bed
• Child is being reared in a diurnal environment
(sleep at night, wake during day)
Clinical Interventions
• Perturbation: normal—reassurance with
information
• Disturbance: at risk—parent education and
guidance
• Disorder: more intensive treatment,
individualized to the particular problem
Proposed Multiaxial Diagnostic
System*
Axis I: Perturbation/disturbance/disorder
Night waking protodyssomnia
Sleep-onset protodyssomnia
Schedule disruption protodyssomnia (e.g. daytime napping)
Parasomnias, sleep apnea
Axis II: Parent-child interaction styles
Balanced/synchronous
Overregulating/controlling
Underregulating/distant
Inconsistent/unpredictable
*Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health.
Second edition. Guilford Press. 2000.
Multiaxial System, cont’d.
Axis III: Infant Factors
Temperament
Developmental quotient
Medical illnesses
Axis IV: Context factors
Family/marital stress
Parenting stress/hassle
Family psychopathology
Family trauma/violence
Neurobiology of Sleep
• Circadian rhythm: the 24 hour sleep-wake
cycle
• Ultradian rhythm: the 60-90 minute sleep
cycle of alternating REM (rapid eye
movement) and non-REM phases of sleep
• Diurnal: the circadian cycle that gets entrained
into light-dark conditions.
Infant Evolution of the Diurnal Cycle
• Average newborn daily sleep is 18 hours, ranging
from 10 to 22, with typically a period of
wakefulness every 3-4 hours.
• By 6 months, periods of sleep stretch out to as
long as 6 hours, and begin to concentrate during
dark hours, while wakefulness concentrated
during light hours.
• By 1 year, typically 1-2 long nighttime sleep
periods, 1-2 short daytime naps.
Later Evolution of Sleep
• Second year: one long nighttime sleep period
and 1 nap, usually afternoon
• Later, nap may be eliminated depending on
social circumstances, although naps may be
preserved throughout life.
Ultradian Cycle Evolution
• 1st 3 months: 50% of sleep is REM (syn.
“dream”, “active sleep”, “paradoxical sleep”),
other half in n-REM (“slow wave”, “quiet”)
sleep
• 2-3 y/o child: 35% REM
• Adult: 20% REM
Ultradian Cycle Evolution, cont’d.
• By 3 months of age, cycles remain at 50-60
minutes but REM duration diminishes.
• REM becomes more prominent in later phase
of sleep (toward morning) and n-REM in
earlier phase.
• By adolescence, cycle lengthens to 90
minutes.
Night Waking Problems
• By 8 months, most (60-70%) infants soothe
selves when they awaken.
• During second year, often an increase in
nighttime awakenings.
• Infants and toddlers have more awakenings
than “signaled” (crying, etc.) awakenings. i.e.
often they return to sleep without signaling.
Sleep-Onset Problems
• Going-to-bed and falling-asleep problems.
• By 12 months, 70% infants placed in crib awake at
night—gives them opportunity to learn to fall
asleep on own
• 2nd yr. of life: separation anxiety, and also…
– limited family time
– maternal depression
– marital problems
Parasomnias
• Begin in toddlerhood
• Boys > girls
• Night terrors: stage 4 n-REM sleep (deepest
stage), normally outgrown by adolescence
• Nightmares: REM sleep, child alert when they
cause awakening, unlike in night terrors.
Reassurance and decreasing daytime stress are
recommended.
• Rhythmic movements: 58% down to 22% by 2
years: parental reassurance, unless head banging
is injurious.
Sleep Apnea
• Central or obstructive: screen for asthma,
snoring, mouth breathing
• Normally, decreased oxygen saturation causes
micro-arousal and restoration of breathing, with
person unaware of the arousal.
• In children, apnea can cause inability to achieve
stage IV sleep, resulting in diminished growth
hormone secretion and growth retardation.
Causes of Sleep Problems
• Nutritional and/or physical discomfort,
including food/milk allergies, colic
• Temperament, especially low sensory
threshold, low adaptability, high distractibility,
negativity of mood.
• Parental conflict, maternal psychopathology,
family stress, traumatic events
Co-sleeping
• In infants, correlates with more sleep time at
night, especially when breast-fed.
• More frequent, but brief arousals: Protective
against SIDS?
• In older toddlers, is co-sleeping a cause or
effect of sleep problems?
Assessment
• Importance: ½ of children with infanttoddlerhood sleep problems will continue to have
sleep problems later on.
• Ask routine screening questions re the above,
including child’s degree of rested-ness and
wakefulness during the day.
• Suggest keeping a diary if sleep problem is
suspected.
Treatment
• Behavioral approaches, based on the idea that sleeponset problems represent learned interactional
patterns between child and caregiver
• Interpersonal/psychodynamic approaches: looking at
the relationship between caregiver and child for
problems and for solutions
• The transitional object: thumb, special blanket
• Brief period of parent sleeping in same room