1. The Ups and Downs of Sleep Development Amy Salisbury, PhD, APRN, BC Assistant Professor of Pediatrics Alpert Medical School at Brown University Women & Infants Hospital Brown Center for the Study of Children at Risk Amy_Salisbury@Brown.edu

2. WHAT WE WILL COVER: • What is sleep? • Sleep 101 - abbreviated • Sleep Throughout Development • Potential Problems and Pitfalls WHAT DO YOU WANT TO KNOW ABOUT?

3. SLEEP BASICS • Sleep-Wake cycles • Entrained by light-dark cycle through brain • Relies on Timed Cues to keep running properly

4. SLEEP BASICS • Sleep is NOT a state of “rest” for the brain or body systems • Within sleep: sleep stages or states cycle • Non-REM (Rapid Eye Movement) Sleep • Stage 1 – very light sleep • Stage 2 – light sleep • Stage 3 – deep sleep (delta begins) • Stage 4 – very deep sleep (delta) • REM Sleep – Eyes move, body twitches, dreaming

5. SLEEP BASICS • Sleep-Wake cycles are basic human need. • Entrained by light-dark cycle through brain • Within sleep: sleep stages or states cycle • Non-REM (Rapid Eye Movement) Sleep • Stage 1 – very light sleep • Stage 2 – light sleep • Stage 3 – deep sleep (delta begins) • Stage 4 – very deep sleep (delta) • REM Sleep – Eyes move, body twitches, dreaming

6. Sleep Basics: Typical Rhythms

7. Sleep Problems Arise from disruptions in the NREM-REM Stage Cycle

8. Sleep Problems Arise from disruptions in the NREM-REM Stage Cycle AWAKE Results in sleep fragmentation

9. Sleep Problems OR Arise from disruptions in the sleep-wake cycle….

10. So Why Do We Need Sleep? • WITHOUT Sleep (<5 Hours/Night): • Decreased alertness and sustained attention • Impaired thinking, reasoning, and short-term memory • Poor health • Leads to (every year): • 25,000 deaths • 2.5 million disabling injuries • 100,000 automobile crashes • 71,000 injuries • 1,550 fatalities

11. Why Do Children Need Sleep? • Learning • Memory • Brain Development • Emotional Stability • Better Health • Better Family Relationships

12. Sleep during Pregnancy

13. Sleep During Pregnancy • What happened? • Hormonal Changes • Physical Changes • Mood Changes • Anxiety • Energy • Potential Problems • Insomnia • Restless Legs Syndrome • Sleep Apnea • Reflux

14. Sleep in the Fetus • Does the sleep of the mother affect the fetus? • Yes and No…. • Yes: • Baby does have sleep -wake cycles before birth • Fetus runs off mothers sleep - wake rhythms (hormones, brain changes, and behavior) • These may change the sleep-wake cycles of the fetus • No: • The fetus is going to sleep even when mother does not • Resilient to typical changes and variations through pregnancy

15. Tips for Healthy Sleep Before Birth • Prioritize Sleep • Exercise 30 minutes per day (per HCP) • Drink lots of water earlier in the day • Insomnia – get up and read or other quiet activity • Sleep on left side • Keep lights dim (red or night light) • Short daytime naps if possible (scheduled is best)

16. Typical Parent & Child Sleep

17. INFANT Sleep and Wake STATES Quiet Sleep (Deep, NREM Sleep) Drowse, Daze Quiet Awake/alert Crying Active Awake Active Sleep (REM Sleep)

18. Sleep in the First Month First 2 Weeks • Baby still running off Mother’s rhythm • Baby is usually sleepy • SOME babies sleep most of the time • Awaken every 3 hours for feedings day & night • Second 2 Weeks • MOST babies “wake up” by the 3rd week • SOME babies have a difficult time settling • Most common time for fussiness to begin

19. Sleep in the 2nd – 3rd Month • Baby’s brain development continues rapidly • Multiple rhythms developing all at once • By 5 weeks, most babies will sleep slightly more at night than during the daytime • By 6-8 weeks, crying is generally at it’s highest point for most babies (even those that are not “fussy”) • By 12 weeks, babies tend to sleep more in the nighttime than daytime (still sleep 15 hours)

20. Sleep During the First Year • Day/Night pattern by 12 weeks • Bedtime routines and some routine to the day helpful when used by 3 months of age • Sleep 8 hour stretches by 4 months • Breast-fed typically wake more often • Redevelop night waking 6-12 months • self-soothers vs. signalers

21. Sleep Problems First Year • Night waking • Unable to fall asleep • Crying • Feeding

22. How much sleep is needed? Roffwarg & Dement, 1964 Coons & Guilleminault,1982 Anders et al, 1983

23. INFANT SLEEP PATTERNS IDEAL COMMON!

24. Toddlers and Preschoolers • •Usually one nap 1 1/2 to 3 1/2 hours • •KEEP THAT NAP (thru 5 if possible)! • •Sleep Problems Common! (20-40% of children) • •Night fears and Nightmares develop • •Power struggles, end of day disorganization • •Bedtime routines, transitional objects more important

25. Toddler Sleep Problems • Bedtime Refusal • Anxiety • Night Awakenings • Nightmares • Night terrors • Uninvited co-sleeping

26. School-Aged Child’s Sleep • “Golden Years” of sleep • Still require more than 10 hours of sleep • Still do better with routines • Most kids actually want to sleep (at some point) • Should not be tired during the day

27. When Things do go Wrong • Sleep Problems vs. Sleep Disorders • Types of Child Sleep Problems/Disorders • Bedtime Refusal (Sleep Deprivation) • Frequent Awakenings (Sleep fragmentation) • Circadian Rhythm Disorders • Adjustment Sleep Disturbance • Obstructive Sleep Apnea • Sleep Terrors/Sleepwalking /Talking in Sleep • Nightmares • Teeth Grinding • Bed-wetting

28. Online Resources National Sleep Foundation: http://www.sleepfoundation.org/ National Institutes of Health Sleep Ed: http://science.education.nih.gov/supplements/nih3/sleep/default.htm http://sids-network.org/risk.htm