Published on April 28, 2021
Read Time: 18 Minutes
Paige Heitman recently sat down with Phelps Health Pediatrician Patricia DeForest, DO, to discuss sleep issues in babies, children and teens. Dr. DeForest is accepting new patients. Please call (573) 426-3225 to schedule an appointment.
Paige Heitman: The Scope is a podcast dedicated to having open conversations about healthcare topics relevant to our patients and community. Today, we're talking about sleep difficulties with babies, children and teens. Our guest is Dr. Patricia DeForest, a pediatrician with Phelps Health Medical Group. Welcome, Dr. DeForest.
Patricia DeForest: Thank you so much. I'm glad to be here.
PH: Before we get started, go ahead and tell us a little bit about yourself.
PD: I am a general pediatrician. I came from San Antonio, Texas. My husband and I wanted to relocate to Rolla, Missouri, slow down a little bit and take care of kids here. Before going into medicine, I was in education for 20 years. I taught middle school, high school and then I taught teachers how to teach. So, I have that experience as well. Coming from San Antonio, I have more experience in [caring for] children with special healthcare needs, [such as] children that have cerebral palsy, transplants or chromosome abnormalities, like Down syndrome. I also can take care of babies all of the way up to 18-year-old children. [My husband and I] have three children of our own; they're all grown [now, but] I will tell you those children had their own sleep difficulties as well.
PH: COVID-19 has changed a lot of things, including sleep patterns for kids of all ages, because they went from being in school all the time to at home doing online learning, and their whole world got flipped [upside down]. We're going to talk about those sleep difficulties and how they affect babies, children and teens. How has the pandemic affected sleep patterns for all age groups?
PD: You are right that it changed everything. The most important element to keep is routine, and with [the] pandemic that routine was disrupted. Children have been pulled out of school and then [put] back into school. Then, [there’s the] hybrid [learning] models. Then, there's quarantine, and everyone has to [be] back home. [These changes have] disrupted parents’ lives and children's lives, but I would venture to say that sleep difficulties were there long before the pandemic began.
PH: Do you think COVID-19 exacerbated those previous sleep issues? [For instance], children or even parents have to work from home now and then also [complete all of these extra duties] on the side.
PD: Exactly. Trying to keep some type of routine in the family is very difficult. I do believe [these changes] exacerbated [sleep difficulties] or brought them to the surface, and it may have caused some new sleep difficulties in children that were regularly sleeping before [the pandemic].
PH: One of the things I think of whenever I think of sleep disorders is anxiety, because there are so many stressors that we have in our life. How does anxiety affect our sleep?
PD: That’s a good question. Anxiety is basically the fear of the unknown, apprehension or concerns, those types of things. [Anxiety is a] very real feeling, and a feeling that has to be validated between the parent and the child. As far as anxiety goes, sometimes that's part of sleep difficulties. For that parent, and for that child, they need to dig deeper to figure out where [the anxiety is] coming from. Maybe for that child, they're trying to fall asleep [and they’re] alone in the room [when] they're not normally alone.
PD: [Anxiety] also can start from when the [child was] very young, [even] an infant, and they were never allowed to fall sleep on their own. [Maybe] they had always been rocked to fall asleep. Then, [a] pattern is set, and suddenly they're expected to [go to sleep] on their own.
PH: That makes me think of a really good question. If you have newborns and they go their whole infancy being put to sleep, [can] that directly affect their sleep as they age?
PD: It definitely can. We talk about self-soothing or learning how to fall asleep. [Self-soothing is] very real for adults as well. If an adult thinks about going to a hotel, or going on a vacation, or staying with friends or family, there's different noises in the room. [Maybe the room] looks different, or the [sheets] feel different, all those types of things. This causes a little bit of anxiety or a little [feeling] that something is different, which then keeps you from being able to self-soothe and fall asleep.
PH: I can absolutely relate to that. When I’m on vacation, I always know the first or second night I will not sleep well because I'm not accustomed to the environment. What questions can parents ask their children if they're suffering from sleep difficulties? Maybe they’re having anxiety. How do we get our kids to open up to us and tell us what's going on?
PD: First, I'm going to back it up just a little bit. A parent has to question themselves and the situation. They need to [determine] when the sleep difficulty showed up. Is the child having difficulty falling asleep? Are they delaying sleep like asking for a glass of water, and then [they have to] go to the bathroom? Do they need their [stuffed animal] or one more kiss? Or, are they able to fall asleep okay, but then wake up multiple times [during the night], and come into the [parent’s] bedroom to find the parent? Are they waking up in their bedroom and then playing, so by 2:00 AM they’re wide awake? The first step [for parents] is trying to figure out when [the child’s sleep difficulties began] happening. What is the piece that we need to work with? Then, you can kind of start to dig in with children [to try and] figure out what they need in order to fall asleep.
PH: So many parents run into a habit, where their child does a great job of sleeping in their own bed, but then come into their parents’ room at two or three in the morning. What's the cause of that? How do we teach our children, “Hey, you’re okay. You can sleep in your own bed.” Is the child just wanting to be close to their parent?
PD: This can often happen following an illness, so the child was sick, and so they did a lot of co-sleeping maybe because that's the only way everyone could sleep. I am definitely a parent who woke up in the middle of the night and there's a child standing there. I’d think, “Okay, what are you doing here?” The knee-jerk reaction is to grab that child, pull him into your bed, and everybody goes back to sleep. Within 20 to 30 minutes, you've got a leg across you, or [your child] peed in the bed. There’s all kinds of things that happen, and you really don't get good sleep. The most important thing is finding a routine and getting [your] child used to that.
PD: The thing that I recommend my parents [to do] is [take care of] middle of the night business only in the dark. Take care of business, and then get back into bed. [This] may take three or four repetitions, but once you have that child back in bed and asleep, you're going to get back into your own bed and you're going to sleep better than you would if that child was in bed with you all night.
PD: I think the argument usually is, “Well, I'll sleep better,” or “I'll be able to go back to sleep, and my child to be able to go back to sleep,” and I completely understand that. However, you're not teaching them how to self-soothe; [you’re] not helping them to get into a pattern that they need to get back to sleep.
PH: So, what are some good sleep hygiene habits that help create an environment that's conducive to sleep? I know you’ve already mentioned turning the lights down and taking care of any business past bedtime in the dark.
PD: All of the resources and research out there tells us the most important key ingredient is routine, so setting up a good bedtime routine, for example, [is important. For instance], we’ve all had dinner together, the dishes are done and the kids go to play for a little bit. [Maybe] you go and spend some time with your children. [Then], maybe everyone gets a bath. Another key is turning down the lights. Turn down those lights; turn off the big heavy living room lights, that kind of thing. Turn off the TV for a little while and [spend] some quiet time reading or playing quietly before bed. Then, get [your child] into bed, cuddle, turn down the temperature in the room to make the room cooler, make sure that the sheets are comfy, etc. Ultimately, moving [your child] into sleep is important.
PH: You mentioned the physiological effect of turning down lights. What happens whenever we turn down the lights for adults and children?
PD: Our bodies create two different hormones. One is cortisol, and it is released in the morning. [Cortisol] wakes us, stimulates us and gets us going. [The second one is] melatonin, a natural hormone that is created in our brains. When the sun goes down and [it starts to] get darker, [melatonin] is released. However, if in the time period when the sun is going down, you've turned on all the bright lights, or you have the TV on, or you’re looking at [your electronics], then you’re telling your brain, “There's no need to make the melatonin. It's not getting dark, and that can really make falling asleep and using our natural hormones to [get to] sleep difficult.
PH: I think that's such a great idea. In my house, in the evening, we will only keep the small light on to keep the house dimmer.
PD: And naturally, your body is getting ready to go to bed.
PH: [So, maybe a child already has] a good bedtime routine that their parents have helped them establish, but how do you know when a child is suffering from insomnia or asthma or even sleep apnea? How do you know when to go to that next step?
PD: [That’s a] very good question. I tell my parents all the time that if you're concerned about something, I'm concerned about it, and we need to talk about it. [Parents should] do some questioning [and] look at symptoms and signs, [and] red flags. Some red flags that I think are very important is not being able to fall asleep [and] feeling restless. Kids will sometimes talk about [having] electric feelings in their legs, like restless leg syndrome. That's when you need to look back to what they're eating and what they're drinking before bedtime. Maybe [they’re having] too much caffeine. Maybe [they’re having] caffeine after four o'clock in the afternoon, because that can actually interfere [with their sleep]. If they've been sleeping through the night and then they're suddenly wanting to get up, and they're very thirsty all the time, or they're having to urinate a couple of times during the night, that needs to be investigated. [This] can be a sign of diabetes. There are several other things that could be going on if they're waking up coughing, profusely coughing, [or] maybe even coughing until they vomit; they can't sleep in that way, [so] that needs to be investigated, [because] that can be allergies or asthma. If they're waking up hot and sweaty, and they're not wearing a lot of clothes, but they're just having what we call “night sweats” or having fevers or any of those types of things, [those] need to be investigated. So, [we’re] trying to figure out, if [they are] just waking up or if there is something causing that wakefulness.
PH: If a parent comes in to see you and says, “I'm at the point of concern for my child,” what's the next step? Are there sleep studies for them? Do parents need to keep a journal? What’s the best practice?
PD: First off, [we will establish] a good history and every doctor will do this. That's why we ask so many questions, because we're trying to figure out what is happening and then what we need to be worried about. [Maybe] your child is snoring more often or longer, then we need to check their airway, and [they may] have smaller tonsils, etc. There are sleep studies out there, but the questions that we ask [helps us to] try to figure out what the problem may be. [These questions] help us know if we need to refer them. Do they need to go to an ear, nose and throat doctor? Do they need to go to an endocrinologist? Do they need to go to sleep medicine? As far as pediatric sleep clinics go, I know that Springfield, Columbia and St. Louis definitely have those. We [also] have our sleep clinic here.
PH: Something else I think about whenever I think of sleep with children, babies and teens is how much sleep should they have on average? Do they need more sleep or less sleep than adults?
PD: As we grow, we do need less sleep; however, eight to 10 hours is a definite number for everyone. If we start at teens and adults as [needing] eight to 10 hours, [then] school-aged children need along the lines of nine to 10 hours. Then, three- to five-year-olds on down to 12 months or less need around 16 hours. All of these times include naps. Children do need [extra sleep], mostly because they're growing.
PH: So, [children] sleep a lot more because their bodies are growing?
PD: Yes. When we're sleeping, our bodies are releasing toxins and the cells are resting. All of that is very important. Our brains are resting and rejuvenating, so sleep is that natural process that allows our bodies to work better and more efficiently.
PH: I think something else that comes up a lot with babies [is when you hear] parents say, “Let them cry it out,” or “Do I let them cry it out”? How long do I let them cry before I [should] come in and console them? When should a parent know, “Okay, my baby has been crying for X amount of time, so now I need to go console them”?
PD: Good question. I'm sure that is probably the most difficult and frustrating part of parenting and sleep. So, there are two houses. One house, of course, says to let them completely cry it out. I don't necessarily think that's the best way, because your children do need to know and understand that you are there for them. [They need to know that] you're there to console, support and encourage them. I usually recommend something called gradual expansion. If you are trying to help your child learn how to fall asleep, getting that bedtime routine in place is the most important. We talked about how routine is the most important. [We need to make sure we are] turning the lights down, cooling things down, calming things down and making the environment comfortable for [our children]. Then, [when] it comes time to go to sleep, take them in, get them comfortable and talk to them about falling asleep. A parent can do a couple of different things; they can put a chair in the room, and they can sit in that chair, but they’re not going to actually speak or say anything to their child.
PD: Right away, if the child calls out to [the parent], wait a few seconds, and then [the parent] can call back, “I'm still here. I'm going to stay right here.” You’re consoling them, but you're not actually giving them a lot of extra attention. Then, each time [the child calls out] you delay responding. The next night, maybe you sit outside the room instead. You’re still answering; you're still checking on them, [but you’re] never picking them up, never engaging with them. [You’re keeping interactions] all business-like and quiet, until gradually they've learned how to fall asleep. It’s like coaching; it's like teaching them a new skill or helping them ride a bike.
PD: One of the mistakes that parents often make is not planning for this event to happen. I always tell my parents, “You've got a pick a weekend, where everyone can be onboard.” Maybe you start on a Friday night. You know as a parent, you're not going to get a lot of sleep, because you're going to be coaching. This is your job; you’re a coach. The other thing you can't do is use your own electronics while you're sitting in that chair, while your child’s trying to fall asleep. You can do some deep breathing, because you're emulating what you want them to hear, but you can't be on your phone, your iPad or any of those types of things. So, it's real commitment to make [this] happen, but the results are good.
PH: Absolutely! I've never heard the ideology of coaching your child to sleep. I've only heard that you just have to let them cry, or you go in and console them. I think [coaching] is a perfect middle ground. You talked about electronics. Do electronics have an effect on us before we go to sleep, regardless of age?
PD: Yes, definitely. For one, we talked about melatonin. Your brain is receiving the light [from electronics], and it's telling our brains that it's not dark yet. It’s not time to go to bed yet. We always [recommend that you] should stop all electronics an hour before bed. So, an hour before we want to go to sleep, [we stop using electronics as part of our] bedtime routine, and that’s important. Secondly, [electronics emit] a blue light that comes [directly] into your eyes, so your brain may tell you that it's not dark and not dim enough.
PH: Yes, [and that] it's still time to stay awake. What about teens? I know we've been talking a lot about babies [and younger children], but teens are probably some of the most sleep-deprived people I have ever met.
PD: What’s funny is that teens will tell you, “I can do things on three hours of sleep.” I guess you can, except that you are causing all kinds of other physical problems for yourself. The difficulty with teens is that their melatonin release is actually later than it is as a young child. So, [a teen’s melatonin is released] several hours after dark, and we have to work with that. The other difficult thing for teens is that they usually have these huge schedules; they're getting up really early to go to practice, or they’re practicing late. They have games, and then they come home and they have to do homework. It takes real precision by a family to [help teens] figure out how to use their time wisely, and teens also need to have a bedtime, a routine. They have to make it [a priority] to turn off their electronics, turn down the lights and keep the room cool. The other thing is [parents need to be] having conversations with them about establishing good sleep pattern. It’s important for their brain health and for the emotional health that they get good sleep.
PH: Do you ever want to talk about the negative side effects of not getting that good sleep with your teens or their parents?
PD: Yes. We [should] talk about it. A lot of times [poor sleep] comes up if [a teen is] having some depression or anxiety, those types of things, or their school work is suffering in any way. Several of our teens, [have] talked [about their poor sleep habits] in the past. [We’ve discussed their difficulties] with changing schedules, with the pandemic, and going from the hybrid schedule, where they would go to school on some days and then sleep in on the other days. [We’ve talked about how] their schedules were all haphazard, and [then have] helped them think about what they feel like when they get a good night’s sleep. [We should always] try to track to focus on the positive side of something as opposed to the negative side.
PH: Is sleep deprivation a trigger for mental illness?
PD: Rather than trigger, I would [say] that [sleep deprivation] can exacerbate something. So, if you’re depressed or anxious, and you don't get the sleep that you need, [sleep deprivation] can make [those conditions] more pronounced. You [can become] much more irritable, much more moody, and you [may not] attack problems the way that you should. Or, maybe you don't always handle things in the way that you should, because you're just more edgy. As adults, we’ve seen [the effects of sleep deprivation happen in] ourselves. I always have to worry about my parents with newborns. If you're sleeping maybe a couple hours at a time, or every few hours because of feeding, you become much more moody.
PH: How can a parent know if their child or teen is suffering from a sleep disorder or ADHD, since both of those cause attention problems?
PD: Definitely. Well, the biggest thing is to know whether or not the [symptoms started] happening prior to the sleep disturbance or has suddenly been exacerbated. If [your child has] normally been sleeping well, that's a red flag. Something else [may be] going on. Kids who have attention deficit and hyperactivity disorder (ADHD) notoriously have difficulty sleeping. Some of these children benefit from taking melatonin, but no more than one or two milligrams to start with. [Starting melatonin at night is] something to talk over with your doctor, rather than just starting it on your own, but sometimes [children with ADHD] need a little extra melatonin before they go to sleep, and that can be very helpful.
PH: Thank you so much for [talking with me] today. I don't have kids yet, but I feel like I learned so much from you.
PD: Good. I’m glad to help. If anyone has any other questions, or any other worries, I'd be glad to help them as well.