Transcription
Matt Dwyer: Hi, I’m Matt Dwyer and welcome to Sleep where professor Harriet Hiscock and associate professor Emma Sciberras from the Murdoch Children’s Research Institute help you identify sleeping problems in your children from infancy through to secondary school and give you easy to understand steps to improve their sleep cycles and overall health.
So Harriet, at what age do we class an infant becoming a toddler and are their sleep patterns different?
Professor Harriet Hiscock: Yeah, look, certainly probably around the age of one I would say your baby is no longer an infant and they’re becoming a toddler. Certainly by the time they’re two and three years of age, that’s well into toddlerhood.
Overall, the architecture of sleep is the same in terms of sleep cycles and learning to fall asleep by themselves; going into deep sleep for a period then coming up into light sleep and arousing back into deep sleep. So that sort of pattern of deep and light sleep continues as it did for babies but the cycles get a bit longer.
So in a baby, the cycles might be 20, 30, 40 minutes. In a toddler, they’re getting longer, maybe 50 minutes, until the final time when you get to an adult they’re 90 minutes long. So they’re sort of lengthening throughout that time. The main differences, I think, are that we see that a toddler is trying to be a master of their own universe and they like to test the boundaries. That’s a very normal, healthy part of toddler development, but that can play out in sleep. one of the most common things we see is a toddler refusing to go to sleep, whether that’s in the daytime or the start of the night, and they often come in and out of their bedroom multiple times before they settle down.
Matt Dwyer: So the sleep cycles are extending longer. Why do they need that more? Why do they need more sleep as they become older?
Professor Harriet Hiscock: Well, they’re not necessarily getting more sleep. They’re just getting more of that deeper sleep as their cycles extend. And we don’t really understand a lot about why we sleep and what we do, but we know that certain things happen during sleep and toddler’s sleep.
Their immune system is strengthening. They’re producing something called growth hormone that helps them grow taller and larger and we think that also helps to consolidate their memory as well. So, perhaps, the lengthening of these sleep cycles is helping with all of those things.
Matt Dwyer: [00:02:28] So as they’re becoming older, is there a set time that we should start setting them to bed?
Professor Harriet Hiscock: Well, that depends on your household and what you need to do the next day and how your life runs. But certainly a toddler does like routine. It doesn’t have to be that they go to bed on the dot of 6:30 PM and it’s disastrous if you haven’t got them to bed at 6:33 PM, but they will like a routine. So certainly I think, Emma, you’re in the middle of toddlerhood I would say, what time do you aim to get your little one to sleep?
Associate Professor Emma Sciberras: Seven o’clock at the moment. And I think as Harriet said, it really varies as to what you have on the next day. And so when you need to get up for a certain time for childcare, and in our household that generally is out of the house by 7:30, we feel that getting her to bed by seven kind of works.
That gives her time to fall asleep by herself. She probably would go in at seven and then fall asleep by seven thirty. I think it’s such a period of huge cognitive development and, with that development, you can see some settling issues but also there’s some real pros of that cognitive development because toddlers start to understand cause and effect.
So this means that you can start to try some strategies to help them. We sleep and learn. Then, the routines that you’re trying to implement…
Matt Dwyer: how do we begin those routines to get them into a healthy sleep cycle?
Associate Professor Emma Sciberras: Yeah, look, I think I’m really starting with a simple routine. So that might just be for consistent activities that occur prior to bedtime.
It doesn’t have to be really rigid about the exact time that you get into it, but it might be something like, for example, Sophia going for a seven o’clock bedtime. You might be looking at, you know, around 6:30 having a bath that’s really nice and relaxing, it would be a bit of fun too. And then that might lead to a final drink, or some milk before bed if kids are still using that, and then some quiet stories and then off to bed. So I guess, kind of having that predictable routine that becomes more and more relaxing before bed helps toddlers to understand what’s happening next.
Professor Harriet Hiscock: No, I agree, Emma, I think when that works well, it’s really good. and toddlers thrive on that. I do see some toddlers who try and stretch that routine out and you wonder who’s in control of the house. And sometimes it’s the two year old, not the parents. So this is a toddler who says, “one more book, one more story, one more song”. And you find that there’s a 45 minute bedtime routine going on, which is just way too long at this age range, this age and stage.
And so I advise parents often to, as Emma said, have those set things, but to keep it contained within a half hour period. Yeah.
Matt Dwyer: [00:05:09] If we don’t get those sleep cycles happening early and the routine are there permanent effects that can…?
Professor Harriet Hiscock: Yeah, not usually permanent, but it will make your life a bit trickier.
So if you want your toddler to have a good night’s sleep, then they do need to learn to put themselves to sleep just as we said for babies. And if I do see toddlers or school-age children who have never learned to do that and they’re still sleeping with their parents- and if that’s okay for their parents, that’s fine- but for a lot of parents I see they want to change that. Certainly you can start in that toddler-age group. As Emma said, they understand cause and effect. So you can start to say, “Hey, if you stay here in your bed and lie down and try to go to sleep, I will stay with you. But if you keep getting up, I’m going to leave your bedroom and I’m not coming back until you lie down and try to go to sleep.”
They’ll start to understand that, really, from 18 months onwards.
Associate Professor Emma Sciberras: Yeah.
Matt Dwyer: [00:06:02] Yeah, wow. Are there any telling signs of a toddler that they’re not getting the sleep they need?
Professor Harriet Hiscock: Yeah, they’ll be cranky. Number one, they will be cranky
Matt Dwyer: …and make your life miserable.
Professor Harriet Hiscock: They will and, look, who can blame them? But often toddlers, just another bit on daytime sleep, another transition that happens after the age of one is that they will start to drop their daytime sleep, maybe in that second year of life if you’re unlucky. They’re just transitioning from two sleeps down to one daytime sleep. Then, sometime around the age of two or three or four, they might drop that daytime sleep altogether.
What I have noticed is thata lot of toddlers, even if they have that daytime nap, they often wake up really cranky from it. I don’t really know why. Anecdotally, I found if you can give them something to eat or drink quite quickly after their waking, then they’re happier.
Associate Professor Emma Sciberras: I think it’s also worth looking at the nap timing too. So, I guess if you are kind of following all of that and your child is still taking a really long time to fall asleep, just checking the timing of that daytime nap. Sometimes if it is too long or if it is too close to bedtime, so if it’s going past four o’clock for example, children just aren’t gonna be ready to go to sleep at bedtime. So looking at that and making a decision about capping that a little bit or bringing it forward so that it’s not interrupting the nighttime sleep too.
Professor Harriet Hiscock: I think I’m following on from that Emma, a lot of parents have their children in daycare or childcare at this age and they’ll come and say, “Oh, you know, they let them sleep too long in daycare and they won’t go to sleep until 10 o’clock at night”. That’s a really tricky situation because the daycare often have to manage lots of children and if a child is tired and getting cranky, they’re going to let them sleep. So my suggestion is for the parents to speak with their daycare providers and tell them what they would like.
As Emma said, it might be bringing the nap a little bit earlier in the day. Or, if that’s not possible, because at daycare they tend to all have a sleep at the same time, is shortening it. The trick to that is if the daycare worker can watch the child, they’ll go from their light sleep into their deep sleep and then when they come up into the light sleep, they’ll start to get restless. Their eyes will move under their eyelids, they may flutter their eyelids open, and that’s when the daycare person should wake them up. Instead of giving the toddler two or three sleep cycles, they’d just let them have one. So that means when they get home that night, they’ll be ready to go to bed at their usual seven o’clock or seven thirty or whatever.
Matt Dwyer: So what do you find are the biggest causes of sleep trouble entirely?
Professor Harriet Hiscock: I think what we really see emerging is that little personality coming out in the toddler and they’re testing their parents’ boundaries. It’s what we call “bedtime resistance”. It’s when you put your toddler to bed, you might have a beautiful routine, and then they just get up, in and out of the bedroom, and they come out, ” I want to drink. I want to go to the bathroom. I want to tell you something. I’m scared. There’s monsters.” We call that “curtain calls” in our work line and these toddlers are just testing their parents limits and boundaries. What parents need to do is put some gentle but firm limits on that bedtime behavior.
We use something called a “bedtime pass” to do that, or a “bedtime pass out,” which maybe is a bit of an older toddler thing around two or three years of age that you can start it. You make a little pass out, a physical pass on a card with your toddler, or also it works in primary school kids, and you say, you can come out once at the start of the night to tell me something or have a drink or whatever it might be. Then you give me the pass and there are no more passes for the rest of the night. Then if you stay in your bed until the morning, then we set up a little reward system in the morning for the toddler.
Matt Dwyer: Maybe like a stamp card and every 10th one’s free…
Professor Harriet Hiscock: …for the coffee. That’s right.
Associate Professor Emma Sciberras: You might want it a little bit shorter to work towards. Ten might be a bit hard.
Professor Harriet Hiscock: Exactly. Stamp or a sticker and we usually say after four stickers in a row, just to add a bit more interest and keep it going you offer a lucky dip. That’s where you wrap up a little cheap something, don’t make it expensive or big, in paper. Put it in a bowl and the toddler can pick out a lucky dip. Usually after two weeks of doing this, the novelty of the rewards has worn off, but you hope your toddler’s behaviour has changed to the way that you want it to be.
Matt Dwyer: So if the novelty does start to wear off, but the sleep isn’t improving…
Professor Harriet Hiscock: That’s when you need to see someone, but the bedtime pass can work really well for those kids who are coming in and out multiple times.
The other option is, if they’re a bit too young to understand a bedtime pass, if they’re a bit anxious and they’re coming in and out because they’re a bit anxious, is to actually sit with them. Either do the checking method where you come back and forth into the room and say, “I’m just going out for a minute .I’ll come back and see how you’re going.” We might keep that at a minute and then stretch that to two minutes, three minutes, four minutes and then eventually, you hope you come back and your toddler’s fallen asleep in the cot or in their bed. If they’re really anxious, then that may distress them if you’re out of the room for too long so the camping out method is the other option. That’s where, we talked about this in the infant episode.
Matt Dwyer: Yeah.
Professor Harriet Hiscock: We put a camp bed or a chair right next to the toddler’s cot or bed. The first few nights, you just stay next to them until they fall asleep and that stops them from coming in and out of their room.
You might need to hold their hand or pat them and once they’re falling asleep, within 10 minutes or so like that, then you sit there and you try not to touch them, but you can use your voice to reassure them. Then you slowly move your camp, bed, or chai, a foot away from the out every couple of nights until eventually you’re out the door.
Matt Dwyer: Mmm, that works. Apart from not being cranky, what are the telling signs that your toddler is getting enough sleep?
Associate Professor Emma Sciberras: I think being able to regulate emotions better. Waking up happy, you won’t see as much of the crankiness, the eye rubbing, kind of more of that irritability.
I think when you’ve had a child that hasn’t slept and you’ve been dealing with some of that crankiness, and then you try some of these strategies and see the increased sleep happening, the signs are pretty different. You can really see the difference in the toddlers ,it makes a huge difference.
If you think about how you feel as an adult when you haven’t had much sleep and how yucky you can feel and how that can make you a bit irritable. You have the ability to regulate your emotions better as an adult but the toddler doesn’t have that. So when they’re tired, they’re just, wow!
It’s really hard to manage. They can’t control themselves as well as we can. I think it’s always good for adults, when we’re thinking about child sleep, to really use empathy, to think about, how do we feel if we’re not sleeping? How might this be impacting the toddler? Using this as a way to think about and motivate yourself to try some of these strategies to help them to have a better day.
Professor Harriet Hiscock: So Emma, how do you know when they no longer need a daytime nap or they’re dropping a nap?
Associate Professor Emma Sciberras: Yeah, I think there are a number of different signs to look out for here. So you might be putting them down and it’s taking them a really long time to turn off for their nap and it’s becoming a real struggle for you to get them down.
It can be really tricky to manage sometimes. Some testing of boundaries with naps can align with growth spurts and then it might not necessarily mean it’s time to change the nap; however, if you’re kind of going through and it’s been weeks and weeks of really challenging behaviour at nap time, that might be an indication.
The other one is if it is interfering a lot with the night time sleep. If you are noticing that the days that they have a nap, that they’re not falling asleep until really late, that could be another indication. You might also trials some days when they don’t have a nap and see how their behaviour is going.
If you’re kind of getting through the day and they’re actually doing pretty well without the nap, and they’re getting off to bed pretty well at nighttime, then I’d say that that’s a pretty good indication. It’s tricky because if children don’t have a nap and they get overtired ,it can be harder to settle them at night time. So I think you’ve got to do a little bit of testing out to see what works. You’d be looking at hoping to continue the nap until at least three and then seeing where the toddler is at, but there’s a huge amount of variation, which is important.
So it’s about looking for the signs in your child.
Matt Dwyer: Does age play a variant in that? From what, two to five, around that?
Associate Professor Emma Sciberras: Oh, around two to four. Yeah. So most two-year-olds would still be having a nap. Then once we get to three, there’s a lot more variation and then fewer four-year-olds still having a nap. It can be harder for four-year-olds to have a nap, going to kinder and things like that too, and it can really interfere with their nighttime sleep.
Professor Harriet Hiscock: But what you can often do is replace that nap time in a four-year-old with quiet time. So having that as time on the couch, maybe next to you, and sometimes there is a bit of screen time going on which is probably not ideal, but it does calm them down, keep them quiet. Or, also, just having a look at a few books on the couch. So just a bit of time to say, “okay, you’re not sleeping, but this is rest time”. And that can really help toddlers as well as parents. I think that’s a great thing for a four-year-old who has definitely dropped their nap but doesn’t quite make it through the day without being really cranky at night. I guess another thing that’s quite common in this age group as well is early morning waking and I say that anything that’s a wake-up before 6:00 AM, I think that’s rude.
Associate Professor Emma Sciberras: Yep. That’s definitely rude.
Professor Harriet Hiscock: This is tricky because it happens for one of three reasons. One is, and this is uncommon, you’ve put your toddler to bed too early and they’ve got enough sleep and they’re just ready to start the day. So if you’re putting them to bed at 6:00 PM, you can’t expect them to wake up at 7:00 AM. They’re not going to have 13 hours of sleep at this age. The second thing which happens is that they wake up early and you hear them stirring and you get up, go to them and then you inadvertently reward them for waking up and that’s by turning on the TV or giving them a screen to play with. That just reinforces early morning waking. The third and the most common reason is that they’re just wired like that. So we talk about larks and owls; we are born with a preference to be a nighttime person or an early morning person.
If you’ve got a lark, they are just wired to get up early and sometimes there’s nothing you can do to stop that. So what I tend to advise is to put a clock radio on outside the child’s bedroom, set it to 6:00 AM for the music to come on then and tell your toddler they can’t come out of their bedroom until they hear the music.
I tend to say, put that clock outside their bedroom so they’re not looking at the numbers or fiddling with it when they wake up. Sure, they might be awake between 5:30 and 6, but they’re staying in their room and they’re not coming out and disturbing the rest of the household.
Matt Dwyer: [00:17:32] So apart from the reward system, what are the steps and plan of action that we can take to start helping the problem?
Professor Harriet Hiscock: Yeah. So for the early morning waking, it would be making sure you’re not putting your toddler to bed too soon. It would be making sure you’re not rewarding them at 5:30 with a screen or the television. Then it would be saying, “okay, you’re getting up a bit too early for the family. We need you to stay in your room until you hear the music come on.” And then set that clock radio up, outside the bedroom with the music to come on at 6:00 AM. Every morning they are able to stay in their room and not come out till 6, then reward them with that sticker or stamp. Again, usually after a couple of weeks, they get the hang of that.
Matt Dwyer: I’m getting it that there’s no quick fix. There’s always slow increments of change.
Professor Harriet Hiscock: It depends on the temperament of the child too. Certainly if you’ve got a very feisty child or a child who gets a bit anxious about things, you don’t want to do things too quickly because that will just backfire.
I think that’s a really important thing for parents to know that whenever they embark on any sleep strategies: clear your diary for a week or so. Don’t expect to be going out and doing things that are gonna change the routine of the household and be consistent and be persistent and do that for at least seven nights.Be prepared to do that.
Matt Dwyer: What about starting to set them up for childcare and kindergarten? Do we need to start changing things for that?
Associate Professor Emma Sciberras: I think when you’re commencing childcare, it’s really important. Most childcare will ask you about your child’s schedule at home and so having really clear communication about the way that you are managing naps at home so that they can try to mimic that at childcare.
I think you need to be flexible though because there are so many kids in a childcare room and it can be hard. First, the staff has to manage all of the nap times at once. Especially when kids are moving towards having only one nap, it is much easier for staff to have all of the kids napping at once and that’s how they generally manage it.
So I think having clear communication about what is generally done at home and most childcares will try to implement some of those things. If there’s a particular little comforter object, for example, that your toddler uses to go to sleep, the childcare should also generally have that present for the child.
I think it’s just about clear communication, but being flexible, and then having an ongoing conversation with staff about what is working well and what might not be working so well.
Matt Dwyer: Would you work towards assisting that with the naps they take it home? So that when they get to childcare, they’re ready to have that nap at that certain time?
Associate Professor Emma Sciberras: Look, I think it is. I think kids and toddlers, they thrive on consistency. So I think if you can kind of make it as consistent as possible between home and childcare, that that’s the best. For toddlers that are having one nap a day, usually they’d be starting that nap between kind of 12 to 1 anyway.
And so within that window of time, even if at home, you might have the nap starting at 12 and your toddler might sleep to 2. At childcare, they might start a little bit later, could be 1, and they might sleep a little bit later into the day, or they might have a shorter sleep cycle cause there’s so much disruption around it.
So you might see shorter naps, but some kids sleep longer. So I think that there’s huge variation and there’s no right or wrong. So I think just evaluating it closely, being flexible, and being confident to be able to have those conversation.S
Matt Dwyer: And when they get home, are they generally wired and ready to?
Associate Professor Emma Sciberras: So I think it depends on how well your child sleeps at childcare. Just as an example, at the childcare that my little one goes to, they have a big whiteboard that has all of the naps that the kids have had. So you can go in and see how long your child’s slept for and I always check it. So I know whether or not it might be a wired kind of afternoon. My toddler now knows that so if I forget to look, she’s like, “check my sleep on the wall”,
which makes me laugh. Sometimes she’ll only sleep for 40 minutes there so I know that that’s get home quickly, give a dinner as soon as possible, and she’ll be ready for bed at about 6:30 on that night.
The longer I keep her up after that, the more overtired she becomes and the harder that it’s going to be to get her off, to sleep at night. Whereas if she’s had a sleep for about two hours like she’d have at home, then we just kind of do business as usual. Kids do get more tired after childcare because there is a lot of activity and stimulation that’s happening. So I think you kind of test it out over the first little while and you’ll begin to see those patterns and how you need to respond when you get home.
Professor Harriet Hiscock: And what about nightmares and night terrors? What are they and how do they differ?
Associate Professor Emma Sciberras: We see an increase in nightmares in this toddler period. Nightmares are really common and they occur when we’re dreaming.
I guess you know, that a child’s had a nightmare as they’ll be able to wake up and tell you about what they’ve dreamed about. I think at this point, in toddlerhood, it’s really important to look at what they’re watching. Sometimes watching television can lead to particular nightmares and the things that toddlers find scary are things that we may not necessarily find scary.
So it could be a big fish on a cartoon that they watch. So I think really looking at that closely and making sure that toddlers aren’t watching TV too close to bedtime is important. They are really common as children in this developmental stage, in toddlerhood ,their imaginations are exploding.
With that comes really exciting and great things and you see increases in imaginative play and it’s really lovely to see some of that. Some of that can manifest by coming into their dreams at nighttime and it can get tricky.
Professor Harriet Hiscock: If your toddler has a nightmare, what do you do?
Associate Professor Emma Sciberras: A lot of comfort and reassurance. So, you know, giving them a cuddle, reassuring them that they’re safe, their bedroom is safe, that a big fish isn’t in the room coming to get them or whatever that thing or that monster might be and giving them a cuddle and putting them back to bed and leaving the room. The tricky thing here can be if you get into a pattern whereby after the nightmare happens, that then the toddler comes into bed with you and then they want to stay in your bed overnight. Then that can kind of lead to you needing to try some of those checking methods or camping out approaches. So it’s really just comfort that’s the main thing.
Professor Harriet Hiscock: What about a night terror? What’s different, how can you tell the difference?
Associate Professor Emma Sciberras: Yeah. So a night terror is something that we’re more likely to see in the earlier parts of the night. So with nightmares, we’d be looking at them in the latter part of the night. And as I said, the child can wake up and tell you about it, they can have a memory of that event, whereas a night terror, they typically don’t have a memory of what has occurred unless you wake them up of course.
We can talk about that. That really, you will be seeing more of a thrashing behaviour, they might be screaming and so on. It can actually be quite disturbing for parents to see night terrors. They actually look pretty scary, but they typically are not harmful. The main thing to do with night terrors is to just ensure that the child’s safe because they can be thrashing around.
You don’t want them to hit their head on anything. So the main thing is to make sure that they’re safe and you can be near them while it’s happening, but not to wake them up from it is really important. Also just to kind of move on from it. So in the morning, not to make a big deal about and say, “do you remember when you were doing that thing in the night?” because that can just be really confusing?
Professor Harriet Hiscock: Yeah. They won’t remember.
Associate Professor Emma Sciberras: Yeah, and then that’s scary for them to think, “Oh, well, what is mum even talking about?”
Matt Dwyer: So why don’t you wake them?
Associate Professor Emma Sciberras: Because it just leads to an interruption in their sleep because once the night terror resolves, they will just go back into sleep and it can be really confusing for them to wake up.
Professor Harriet Hiscock: When a night terror happens, as Emma said, it’s in the first half of the night, it’s before midnight, and they’re stuck between their deep and light sleep cycles. So their body’s awake, but their mind isn’t and that’s why they can be thrashing. Their eyes might be open, they’re looking terrified, they can be running around the room, but then the mind’s actually not awake.
So if you go and wake them up, then you have to spend another half an hour longer trying to resettle them back to sleep. It’s much better just to leave them be. They tend to certainly happen more if kids are overtired or if they’re sick and they’ve got a fever. So obviously, you can’t do much about it if they’re unwell and they’re sick, but certainly avoid getting them overtired because night night terrors will be more common then as well as nightmares.
Matt Dwyer: What are some of the other things that start developing?
Professor Harriet Hiscock: Well, another thing that starts developing in toddlerhood is snoring and, with that, obstructive sleep apnea. That’s when you actually stop breathing for periods of time during your sleep. A lot of people think that just happens to adults, the sort of typical thing is a middle-aged or older man or younger men. Sometimes it happens when you’re overweight, but in kids, it starts to happen in toddlerhood and that’s because the things that cause the snoring, your adenoids and tonsils, are quite large in toddlerhood and early primary school while the actual size of your throat is quite small.
So when you go to bed at night, your muscles and your upper airway relax and everything sort of falls in a little bit on the throat. If you’ve got the tonsils and adenoids there, that can obstruct the breathing. We can even see it in babies, but it really starts up in toddler or preschool age that they start with snoring.
If they’re just snoring with colds and things that’s absolutely normal, absolutely fine. If they’re snoring and then stop breathing, and when I say stopping breathing, I’ll do a demonstration: there might be…
and then they start breathing again.
That’s terrifying.
It is terrifying. That will lead to really disturbed sleep so you get a cranky toddler in the morning. Parents are often not sleeping next to their toddler, so they don’t know it’s happening. My advice is to go in before you go to bed, go into your toddler’s room, listen to their breathing if they’re snoring and stopping breathing. You can even lift up their pajama top and take a video of it because you can see them stop breathing and then start breathing again. That video is very helpful for a doctor to look at and see whether or not this child is having obstructive sleep apnea. Certainly if they are, that’s when you do need to seek medical advice.
And we’ll talk about that more in a later episode on snoring and sleep apnea.
Matt Dwyer: At what point then, if they’re not getting that sleep and they are becoming grumpy and quite difficult to handle, do we go and seek someone like yourself?
Professor Harriet Hiscock: Well, I think first port of call is either your general practitioner or your maternal and child health or well-child nurse, because they are often a font of knowledge and information.
There are websites, the Raising Children Network website has a lot of information about sleep in all ages, including toddlerhood, and how to spot what’s normal, how to set up a routine, and how to manage this. The Sleep Health Foundation also has some good information around sleeping children. So I think you can start with that. Listen to our podcast because we’ll come up with more tips. Then if things, simple things, like setting up a routine, the good sleep habits that we talked about in the infant episode-that’s having a dark room, a quiet room, no screens for an hour before bedtime, no caffeine after 3:00 PM, all those things are still really important- if you’ve done all of that and you’ve set up a routine and it’s still a problem and those websites aren’t giving you the help you need, then it’s time to go and see someone face-to-face.
Matt Dwyer: I should take that advice.
Professor Harriet Hiscock: I think many adults should.gr