Sleep Regulation, Physiology and Development, Sleep Duration and Patterns, and Sleep Hygiene in Infants, Toddlers, and Preschool-Age Children
Sleep Regulation, Physiology and Development, Sleep Duration and Patterns, and Sleep Hygiene in Infants, Toddlers, and Preschool-Age Children
Sleep Regulation, Physiology and Development, Sleep Duration and Patterns, and Sleep Hygiene in Infants, Toddlers, and Preschool-Age Children
Sleep problems are common, reported by a quarter of parents function and behavior in children; thus, understanding
with children under the age of 5 years, and have been optimal sleep duration and patterns is critical for pediatri-
associated with poor behavior, worse school performance, cians. There is little experimental evidence that guides sleep
and obesity, in addition to negative secondary effects on recommendations, rather normative data and expert recom-
maternal and family well-being. Yet, it has been shown that mendations. Effective counseling on child sleep must
pediatricians do not adequately address sleep in routine well- account for the child and parent factors (child temperament,
child visits, and underdiagnose sleep issues. Pediatricians parent–child interaction, and parental affect) and the envi-
receive little formal training in medical school or in residency ronmental factors (cultural, geographic, and home environ-
regarding sleep medicine. An understanding of the physiology ment, especially media exposure) that influence sleep. To
of sleep is critical to a pediatrician’s ability to effectively and promote health and to prevent and manage sleep problems,
confidently counsel patients about sleep. The biological rhythm the American Academy of Pediatrics (AAP) recommends that
of sleep and waking is regulated through both circadian and parents start promoting good sleep hygiene, with a sleep-
homeostatic processes. Sleep also has an internal rhythmic promoting environment and a bedtime routine in infancy,
organization, or sleep architecture, which includes sleep and throughout childhood. Thus, counseling families on
cycles of REM and NREM sleep. Arousal and sleep (REM sleep requires an understanding of sleep regulation, physi-
and NREM) are active and complex neurophysiologic proc- ology, developmental patterns, optimal sleep duration rec-
esses, involving both neural pathway activation and suppres- ommendations, and the many factors that influence sleep
sion. These physiologic processes change over the life course, and sleep hygiene.
especially in the first 5 years. Adequate sleep is often difficult
to achieve, yet is considered very important to optimal daily Curr Probl Pediatr Adolesc Health Care 2017;47:29-42
REM and NREM sleep have defining EEG patterns, NREM sleep occurs mostly during the first 3 h after
and both neurological and physiological features, sleep onset. Adults enter sleep through NREM sleep
though the function of each is not fully understood. starting with stage 1, progressing to 2 and then 3, and
NREM sleep is believed to function primarily as a only then progressing to REM sleep. Each sleep cycle
restful and restorative sleep phase, and a period of is composed of the time it takes to move through the
relatively low brain activity. NREM sleep consists of three stages of NREM sleep and REM sleep. These
three stages: stage 1 (transition from wakefulness to cycles occur in approximately every 90–110 min with
sleep), stage 2 (initiation of true sleep), and stage 3 decreasing non-REM and increasing REM duration
(deep sleep; previously divided into stages 3 and 4). over the course of a night with brief periods of
During the transition from waking.6
wakefulness to sleep, stage REM sleep is thought to have
1 NREM, there is intense sleep- REM and NREM sleep has a role in consolidating and
iness, and sometimes hypno- defining EEG patterns, and both integrating memories and in
gogic hallucinations and/or neurological and physiological the development of the central
brief involuntary muscle con- features, though the function of nervous system (CNS)—both
tractions. In addition, the EEG maintaining and establishing
pattern transitions from alpha
each is not fully understood. new connections particularly
waves associated with wakeful- during times of development.
ness, to shorter frequency theta waves associated with REM sleep is characterized by a burst of rapid eye
sleep. Then there is initiation of true sleep, stage movements; there is a high brain metabolic rate, a
2 NREM sleep, with a decreased awareness of outside variable heart rate, an active suppression of peripheral
stimulus and decreased muscle activity. There are muscle tone, and a lack of normal thermoregulation.
characteristic EEG findings of sleep spindles and K- REM sleep is most likely to occur at the body temper-
complexes. Sleep spindles, also referred to as sigma ature trough of the circadian rhythm. During REM sleep,
waves, are small bursts of higher frequency activity. K- there is desynchronized cortical activity with low-voltage
complexes are brief bursts of high negative voltage, and high-frequency EEG. REM sleep is when dreaming,
followed by larger positive voltage peak, and then a including nightmares, occur.1
larger and slower negative voltage peak. K-complexes
are the largest voltage events on a typical EEG. It is
thought that the K-complex represents a form of sup-
pression of cortical arousal in response to stimuli and
Neurophysiology of Sleep
may be related to sleep-based memory consolidation. Arousal and sleep (both NREM and REM) are
Average adults spend about 50% of the night in stage dynamic physiologic processes regulated through a
2 NREM sleep. In deep, slow wave sleep, stage 3 NREM complex, and only partially understood, network of
sleep, an individual is least responsive to external stimuli. activation and suppression of neurologic pathways
It is characterized by delta waves on EEG, which are from the brainstem through the cerebral cortex
high-amplitude and low-frequency waves. Most para- (Table 1).7 A basic understanding of the neuroanatomy
somnias, such as night terrors, sleep walking, and and neurophysiology is important for understanding
nocturnal enuresis, occur during deep sleep.1 the development of sleep.
tone while awake, are fully behavioral routines that rein- Acquisition of new skills and
inhibited during REM sleep force this development early in abilities can affect infant sleep.
resulting in a decrease in Over the first year of life, infants
muscle tone. In the lateral infancy. develop an understanding of
hypothalamus, there are neu- object permanence and experience
rons that secrete orexin/hypo- separation anxiety. Separation
cretin that target arousal nuclei and are most active anxiety generally peaks between 6 and 18 months,
during wakefulness and not active during sleep sometimes leading to increased sleep disruptions—
(NREM or REM). In this same cluster of neurons in both difficulty separating at bedtime and difficulty self-
the lateral hypothalamus, there are REM sleep active soothing during brief nighttime arousals. Additionally,
neurons that secrete the inhibitory melanin- acquisition of new gross motor skills can negatively
concentrating hormone (MCH) neuropeptide. This influence sleep, particularly sitting up, pulling to stand
complex network of activation and suppression of and walking, as infants will often experiment with new
neural pathways leading to wakefulness or NREM skills during brief nighttime arousals leading to longer
sleep or REM sleep, is only partially understood and more sustained arousals.15
7,14
requires further study.
Development of Biological Rhythms
Biological rhythms integral to the sleep–wake cycle
Development of Sleep Patterns in include changes in body temperature and changes in
Infants and Young Children hormone levels such as melatonin and cortisol. Infants
are born with low levels of maternally transferred
Over the first year of life, infant sleep patterns melatonin, which dissipates by 1 week, and endoge-
change. Newborns usually sleep most of the day and nous melatonin does not rise to detectable levels until
night, waking only for feeding every 1–3 h, whereas a approximately 6 weeks. Melatonin levels are still very
durations in children is lacking, and adequate sleep is Sleep Duration Recommendations: How Much
best defined more vaguely as the number of hours of Sleep do Young Children Need?
sleep that an individual child or baby requires to be
well rested and optimally functional.23 This varies Bright Futures, a national health promotion and
from child to child and among cultural and ethnic prevention initiative led by the American Academy
groups. It is not well understood why some individ- of Pediatrics (AAP), provides the most widely
uals tolerate less sleep or require more sleep.24 Thus, accepted recommendations for preventive pediatric
there is a wide-range of “normal” sleep durations and health care, including information about typical sleep
patterns, and sleep duration recommendations (sim- patterns and daily sleep duration.25 The data presented
ilar to body BMI standards) are based on population in Table 2 references a manual produced in 1999 by the
averages.6 Nursing Child Assessment Satellite Training (NCAST)
organization to train health care providers to better
counsel families regarding sleep–wake behavior and
self-regulation. The NCAST sleep manual uses data
from NCAST unpublished data (1985) and data from a
longitudinal study by Jacklin et al.26 Although the
source material for these recommendations does not
reference the most current studies, it does provide daily
sleep durations similar to the most recent sleep
duration recommendations made in consensus state-
ments by the National Sleep Foundation (2015) and the
American Academy of Sleep Medicine (2016) and
based on a synthesis of expert opinion and a systemic
review of the literature.25,27–30
There are limited recent large studies that report on
child sleep patterns and duration. One large study of
child sleep habits, using a nationally representative
sample, was published in 2004 by the National Sleep
Foundation. This cross-sectional study collected child
FIG. 3. Percentile curves: total daily sleep time by age group. sleep durations from a stratified random sample of
Filled circles represent group means, blank circles repre- 1473 parents through short-structured telephone inter-
sent 25th and 75th percentiles, and triangles represent
5th and 95th percentiles. (Reproduced with permission from views. This study reported total average daily sleep
Sadeh et al.33). times of 12.8 h for infants (0–11 months), 11.7 h for