Sudden Infant Death Syndrome (SIDS)

Reducing the Risk

A lack of answers is part of what makes sudden infant death syndrome (SIDS) so frightening. SIDS is the leading cause of death among infants 1 month to 1 year old, and claims the lives of about 2,500 each year in the United States. It remains unpredictable despite years of research.

Even so, the risk of SIDS can be greatly reduced. First and foremost, infants younger than 1 year old should be placed on their backs to sleep — never face-down on their stomachs.

Searching for Answers

As the name implies, SIDS is the sudden and unexplained death of an infant who is younger than 1 year old. It's a frightening prospect because it can strike without warning, usually in seemingly healthy babies. Most SIDS deaths are associated with sleep (hence the common reference to "crib death") and infants who die of SIDS show no signs of suffering.

While most conditions or diseases usually are diagnosed by the presence of specific symptoms, most SIDS diagnoses come only after all other possible causes of death have been ruled out through a review of the infant's medical history and environment. This review helps distinguish true SIDS deaths from those resulting from accidents, abuse, and previously undiagnosed conditions, such as cardiac or metabolic disorders.

When considering which babies could be most at risk, no single risk factor is likely to be sufficient to cause a SIDS death. Rather, several risk factors combined may contribute to cause an at-risk infant to die of SIDS.

Most deaths due to SIDS occur between 2 and 4 months of age, and incidence increases during cold weather. African-American infants are twice as likely and Native American infants are about three times more likely to die of SIDS than caucasian infants. More boys than girls fall victim to SIDS.

Other potential risk factors include:

• smoking, drinking, or drug use during pregnancy
• poor prenatal care
• prematurity or low birth-weight
• mothers younger than 20
• tobacco smoke exposure following birth
• overheating from excessive sleepwear and bedding
• stomach sleeping

Stomach Sleeping

Foremost among these risk factors is stomach sleeping. Numerous studies have found a higher incidence of SIDS among babies placed on their stomachs to sleep than among those sleeping on their backs or sides. Some researchers have hypothesized that stomach sleeping puts pressure on a child's jaw, therefore narrowing the airway and hampering breathing.

Another theory is that stomach sleeping can increase an infant's risk of "rebreathing" his or her own exhaled air, particularly if the infant is sleeping on a soft mattress or with bedding, stuffed toys, or a pillow near the face. In that scenario, the soft surface could create a small enclosure around the baby's mouth and trap exhaled air. As the baby breathes exhaled air, the oxygen level in the body drops and carbon dioxide accumulates. Eventually, this lack of oxygen could contribute to SIDS.

Also, infants who succumb to SIDS may have an abnormality in the arcuate nucleus, a part of the brain that may help control breathing and awakening during sleep. If a baby is breathing stale air and not getting enough oxygen, the brain usually triggers the baby to wake up and cry. That movement changes the breathing and heart rate, making up for the lack of oxygen. But a problem with the arcuate nucleus could deprive the baby of this involuntary reaction and put him or her at greater risk for SIDS.

Going "Back to Sleep"

The striking evidence that stomach sleeping might contribute to the incidence of SIDS led the American Academy of Pediatrics (AAP) to recommend in 1992 that all healthy infants younger than 1 year of age be put to sleep on their backs (also known as the supine position).

Since the AAP's recommendation, the rate of SIDS has dropped by over 50%. Still, SIDS remains the leading cause of death in young infants, so it's important to keep reminding parents about the necessity of back sleeping.

Many parents fear that babies put to sleep on their backs could choke on spit-up or vomit. According to the AAP, however, there is no increased risk of choking for healthy infants who sleep on their backs. (For infants with chronic gastroesophageal reflux disease [GERD] or certain upper airway malformations, sleeping on the stomach may be the better option. The AAP urges parents to consult with their child's doctor in these cases to determine the best sleeping position for the baby.)

Placing infants on their sides to sleep is not a good idea, either, the AAP said, as there's a risk that infants will roll over onto their bellies while they sleep.

Some parents also may be concerned about positional plagiocephaly, a condition in which babies develop a flat spot on the back of their heads from spending too much time lying on their backs. Since the Back to Sleep campaign, this condition has become quite common — but it is usually easily treatable by changing your baby's position frequently and allowing for more "tummy time" while he or she is awake.

Of course, once babies can roll over consistently — usually around 4 to 7 months — they may choose not to stay on their backs all night long. At this point, it's fine to let babies pick a sleep position on their own.

Tips for Reducing the Risk of SIDS

In addition to placing healthy infants on their backs to sleep, the AAP suggests these measures to help reduce the risk of SIDS:

• Place your baby on a firm mattress to sleep, never on a pillow, waterbed, sheepskin, couch, chair, or other soft surface. To prevent rebreathing, do not put blankets, comforters, stuffed toys, or pillows near the baby.

• Make sure your baby does not get too warm while sleeping. Keep the room at a temperature that feels comfortable for an adult in a short-sleeve shirt. Some researchers suggest that a baby who gets too warm could go into a deeper sleep, making it more difficult to awaken.

• Do not smoke, drink, or use drugs while pregnant and do not expose your baby to secondhand smoke. Infants of mothers who smoked during pregnancy are three times more likely to die of SIDS than those whose mothers were smoke-free; exposure to secondhand smoke doubles a baby's risk of SIDS. Researchers speculate that smoking might affect the central nervous system, starting prenatally and continuing after birth, which could place the baby at increased risk.

• Receive early and regular prenatal care.

• Make sure your baby has regular well-baby checkups.

• Breastfeed, if possible. There is some evidence that breastfeeding may help decrease the incidence of SIDS. The reason for this is not clear, though researchers think that breast milk may help protect babies from infections that increase the risk of SIDS.

• If your baby has GERD, be sure to follow your doctor's guidelines on feeding and sleep positions.
• Put your baby to sleep with a pacifier during the first year of life. If your baby rejects the pacifier, don't force it. Pacifiers have been linked with lower risk of SIDS. If you're breastfeeding, try to wait until after the baby is 1 month old so that breastfeeding can be established.

• While infants can be brought into a parent's bed for nursing or comforting, parents should return them to their cribs or bassinets when they're ready to sleep. It's a good idea to keep the cribs and bassinets in the room where parents' sleep. This has been linked with a lower risk of SIDS.

For parents and families who have experienced a SIDS death, many groups, including the Sudden Infant Death Syndrome Alliance, can provide grief counseling, support, and referrals.

And growing public awareness of SIDS and precautions to prevent it should leave fewer parents searching for answers in the future.

Sleepwalking

About Sleepwalking

Hours after bedtime, do you find your little one wandering the hall looking dazed and confused? If you have a sleepwalking child, you're not alone. It can be unnerving to see, but sleepwalking is very common in kids and most sleepwalkers only do so occasionally and outgrow it by the teen years. Still, some simple steps can keep your young sleepwalker safe while traipsing about.

Despite its name, sleepwalking (also called somnambulism) actually involves more than just walking. Sleepwalking behaviors can range from harmless (sitting up), to potentially dangerous (wandering outside), to just inappropriate (kids may even open a closet door and urinate inside). No matter what kids do during sleepwalking episodes, though, it's unlikely that they'll remember ever having done it!

As we sleep, our brains pass through five stages of sleep — stages 1, 2, 3, 4, and REM (rapid eye movement) sleep. Together, these stages make up a sleep cycle. One complete sleep cycle lasts about 90 to 100 minutes. So a person experiences about four or five sleep cycles during an average night's sleep.

Sleepwalking most often occurs during the deeper sleep of stages 3 and 4. During these stages, it's more difficult to wake someone up, and when awakened, a person may feel groggy and disoriented for a few minutes.

Kids tend to sleepwalk within an hour or two of falling asleep and may walk around for anywhere from a few seconds to 30 minutes.

Causes of Sleepwalking

Sleepwalking is far more common in kids than in adults, as most sleepwalkers outgrow it by the early teen years. It may run in families, so if you or your partner are or were sleepwalkers, your child may be too.

Other factors that may bring on a sleepwalking episode include:

• lack of sleep or fatigue
• irregular sleep schedules
• illness or fever
• certain medications
• stress (sleepwalking is rarely caused by an underlying medical, emotional, or psychological problem)

Behaviors During Sleepwalking

Of course, getting out of bed and walking around while still sleeping is the most obvious sleepwalking symptom. But young sleepwalkers may also:

• sleeptalk
• be hard to wake up
• seem dazed
• be clumsy
• not respond when spoken to
• sit up in bed and go through repeated motions, such as rubbing their eyes or fussing with their pajamas

Also, sleepwalkers' eyes are open, but they don't see the same way they do when they're awake and they often think they're in different rooms of the house or different places altogether.

Sometimes, these other conditions may accompany sleepwalking:

• sleep apnea (brief pauses in breathing while sleeping)
• bedwetting (enuresis)
• night terrors

Is Sleepwalking Harmful?

Sleepwalking itself is not harmful. However, sleepwalking episodes can be hazardous since sleepwalking kids aren't awake and may not realize what they're doing, such as walking down stairs or opening windows.

Sleepwalking is not usually a sign that something is emotionally or psychologically wrong with a child. And it doesn't cause any emotional harm. Sleepwalkers probably won't even remember the nighttime stroll.

How to Keep a Sleepwalker Safe

Although sleepwalking isn't dangerous by itself, it's important to take precautions so that your sleepwalking child is less likely to fall down, run into something, walk out the front door, or drive (if your teen is a sleepwalker).

To help keep your sleepwalker out of harm's way:

• Try not to wake a sleepwalker because this might scare your child. Instead, gently guide him or her back to bed.
• Lock the windows and doors, not just in your child's bedroom but throughout your home, in case your young sleepwalker decides to wander. You may consider extra locks or child safety locks on doors. Keys should be kept out of reach for kids who are old enough to drive.
• To prevent falls, don't let your sleepwalker sleep in a bunk bed.
• Remove sharp or breakable things from around your child's bed.
• Keep dangerous objects out of reach.
• Remove obstacles from your child's room and throughout your home to prevent a stumble. Especially eliminate clutter on the floor (i.e., in your child's bedroom or playroom).
• Install safety gates outside your child's room and/or at the top of any stairs.

Other Ways to Help a Sleepwalker

Unless the episodes are very regular, cause your child to be sleepy during the day, or your child is engaging in dangerous sleepwalking behaviors, there's usually no need to treat sleepwalking. But if the sleepwalking is frequent, causing problems, or your child hasn't outgrown it by the early teen years, talk to your doctor. Also talk to your doctor if you're concerned that something else could be going on, like reflux or trouble breathing.

For kids who sleepwalk often, doctors may recommend a treatment called scheduled awakening. This disrupts the sleep cycle enough to help stop sleepwalking. In rare cases, a doctor may prescribe medication to help a child sleep.

Other ways to help minimize sleepwalking episodes:

• Have your child relax at bedtime by listening to soft music or relaxation tapes.
• Establish a regular sleep and nap schedule and stick to it — both nighttime and wake-up time.
• Make your child's bedtime earlier. This can improve excessive sleepiness.
• Don't let kids drink a lot in the evening and be sure they go to the bathroom before going to bed. (A full bladder can contribute to sleepwalking.)
• Avoid caffeine near bedtime.
• Make sure your child's bedroom is quiet, cozy, and conducive to sleeping. Keep noise to a minimum while kids are trying to sleep (at bedtime and naptime).

The next time you encounter your nighttime wanderer, don't panic. Simply steer your child back to the safety and comfort of his or her bed.

Sleep and Your Preschooler

Establishing a Bedtime Routine

Preschoolers sleep about 10 to 12 hours during each 24-hour period, but there's no need to be rigid about which 10 to 12 hours these are. The most important thing is to help kids develop good habits for getting to sleep.

A bedtime routine is a great way to ensure that your preschooler gets enough sleep.

Here are a few things to keep in mind when establishing that routine:

• Include a winding-down period during the half hour before bedtime.
• Stick to a bedtime, alerting your child both half an hour and 10 minutes beforehand.
• Set fixed times for going to bed, waking up, and taking naps.
• Keep consistent playtimes and mealtimes.
• Avoid stimulants, such as caffeine, near bedtime.
• Make the bedroom quiet, cozy, and conducive to sleeping.
• Use the bed only for sleeping — not for playing or watching TV.
• Limit food and drink before bedtime.
• Allow your child to choose which pajamas to wear, which stuffed animal to take to bed, etc.
• Consider playing soft, soothing music.
• Tuck your child into bed snugly for a feeling of security.

A Note on Naps

Most preschoolers do still need naps during the day. They tend to be very active — running around, playing, going to school, and exploring their surroundings — so it's a good idea to give them a special opportunity to slow down. Even if your child can't fall asleep, try to set aside some quiet time during the day for relaxing. (And you'll probably benefit from a break too!)

The best way to encourage napping is to set up a routine for your child, just as you do for bedtime. Your preschooler, not wanting to miss out on any of the action, may resist a nap, but it's important to keep the routine firm and consistent. Explain that this is quiet time and that you want your child to start out in bed, but that it's OK to play in the bedroom quietly if he or she can't sleep.

How long should naps last? For however long you feel your child needs to get some rest. Usually, about an hour is sufficient. But there will be times when your child has been going full tilt and will need a longer nap, and others when you hear your child chattering away, playing through the entire naptime.

Sleeping Problems

Preschoolers may have nightmares, or night terrors, and there may be many nights when they have trouble falling asleep.

It may help if you create a "nighttime kit" to keep near your child's bed for these times. That kit might include a flashlight, a favorite book, and a cassette or CD to play. Explain the kit, then put it in a special place where your child can get to it in the middle of the night.

Objects like stuffed animals and blankets also can help kids feel safe. If your child doesn't have a favorite toy and getting to sleep has become consistently difficult, then it might be worth going out together to pick out a warm, soft blanket or stuffed animal.

Some parents get into the habit of lying down next to their young kids until they fall asleep. While this may do the trick temporarily, it won't help sleeping patterns in the long term. It's important to provide comfort and reassurance, but kids need to fall asleep independently for when parents aren't around. If you establish a routine where you have to be there for your child to go to sleep, then it will be difficult for both of you — and unfair to your child — if you start leaving beforehand.

If you're worried about your child's sleeping patterns, talk with your doctor. Although there isn't one sure way to raise a good sleeper, most kids have the ability to sleep well and work through any sleeping problems. The key is to try from early on to establish healthy bedtime habits.

Should My Daughter Sleep in My Room After Having a Nightmare?

My 6-year-old daughter has been having nightmares, and often asks to come sleep in my bed. Is that OK?

Nightmares are very common for kids so it's important to keep them in perspective and not let them become too big of a deal. A little comfort from you can go a long way toward helping your daughter feel better.

It's not necessary to let her come sleep in your bed or for you to sleep in her room after a nightmare. In fact, offering to let her sleep with you might send a subtle message that you don't believe she can feel safe alone. By helping her feel better and get back to sleep independently, you show confidence in her ability to tackle what she's afraid of. And that's a skill that she can lean on throughout life.

Other ways to make a child feel better after a nightmare:

• Reassure your child that you're there.
• Convey that it was just a scary dream, now it's over, and everything is OK.
• Show that you understand that your child feels afraid and that it's OK.
• Help your child feel safe. You may need to check under the bed for monsters. For older kids, providing a nightlight or a flashlight might do the trick.
• Help your child get back to sleep by talking quietly, offering something comforting like a favorite blanket or stuffed animal, and maybe talk about the pleasant dreams your child would like to have.

Positional Plagiocephaly (Flattened Head)

Passage through the birth canal often makes a newborn's head appear pointy or elongated for a short time. It's normal for a baby's skull, which is made up of several separate bones that will eventually fuse together, to be slightly misshapen during the few days or weeks after birth.

But if you've noticed that your baby is developing a persistent flat spot, either in the back or on one side of the head, it could be a sign of positional plagiocephaly. Also known as flattened head syndrome, this can occur when a baby sleeps in the same position repeatedly or because of problems with the neck muscles.

Fortunately, positional plagiocephaly usually is easy to treat, and with appropriate intervention will correct itself by the time a child is 1 year old.

About Positional Plagiocephaly

Positional plagiocephaly is a disorder in which the back or one side of an infant's head is flattened, often with little hair growing in that area. It's most often the result of babies spending a lot of time lying on their backs or often being in a position where the head is resting against a flat surface (such as in cribs, strollers, swings, and playpens).

Because infants' heads are soft to allow for the incredible brain growth that occurs in the first year of life, they're susceptible to being "molded" into a flat shape.

The number of positional plagiocephaly cases increased sixfold from 1992 to 1994, occurring in approximately 33 out of every 10,000 births. This dramatic increase started when the American Academy of Pediatrics (AAP) began its "Back to Sleep" campaign, which continues to recommend that babies sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS).

Since the AAP's campaign, the incidence of SIDS in the United States has decreased by almost 40% while the incidence of flattened head syndrome has risen. Still, the prevention of SIDS is worth the increased risk of a flattened head, especially because positional plagiocephaly will often correct itself with appropriate intervention.

Causes of Positional Plagiocephaly

The most common cause of a flattened head is a baby's sleep position. Because an infant sleeps so many hours on the back of his or her head, the head sometimes assumes a flat shape.

Another thing that can contribute to flattening is torticollis, which means the neck muscles are too tight, have inadequate tone, or are shorter on one side than the other, causing the head to tilt one way while the chin points in the opposite direction.

Premature babies are more prone to positional plagiocephaly — their skulls are softer than those of full-term babies, and they spend a great deal of time on their backs without being moved or picked up because of their medical needs and extreme fragility after birth, which usually requires a stay in the neonatal intensive care unit.

A baby might even start to develop positional plagiocephaly before birth, if pressure is placed on the baby's skull by the mother's pelvis or a twin. In fact, it's not at all unusual to see plagiocephaly in multiple birth infants.

But the differences in head shape seen in children with positional plagiocephaly shouldn't be confused with those caused by craniosynostosis, a more serious condition that occurs when skull bones fuse together too soon, causing an abnormal skull shape and possible brain damage if the condition is not corrected. A child with craniosynostosis may have deformities in the front of the head and a bony ridge over the abnormally fused skull bones. Craniosynostosis is usually corrected with surgery.

Signs and Symptoms

Positional plagiocephaly is usually easy for parents to notice. Typically, the back of the child's head (called the occiput) and the ear on the flattened side may be pushed forward. In severe cases, there may be bulging on the side opposite from the flattening and the forehead may be asymmetrical (or uneven), although this is unusual in full-term infants. If torticollis is the cause, the neck, jaw, and face may be asymmetrical.

Diagnosis

Most often, a doctor can make the diagnosis of positional plagiocephaly simply by examining your child's head, without having to order lab tests or X-rays. The doctor will also note whether regular repositioning of your child's head during sleep successfully reshapes the growing skull over time (craniosynostosis, on the other hand, typically will worsen).

If there's still some doubt, X-rays or a CT scan of the head will show the doctor if the skull bones are normally separated or if they fused together too soon. If the bones aren't fused, the doctor will probably rule out craniosynostosis and confirm that the child has positional plagiocephaly.

Treatment

Treatment for positional plagiocephaly caused by sleeping position is usually easy and painless, entailing simple repositioning of babies during sleep to encourage them to alternate their head position while sleeping on their backs.

Even though they'll probably move around throughout the night, alternating sides is still beneficial. Wedge pillows are available that keep babies lying on one side or the other, but be sure to check with your doctor before using one to ensure that it's appropriate and safe for your baby. The AAP does not recommend routinely using any devices that might restrict the movement of an infant's head.

In addition, you may want to consider moving your baby's crib to a different area of the room. If there's something in the room (a window or toy, for example) that's catching your baby's attention and causing him or her to hold the head in a similar position day after day, moving the crib will coax your child to look at it from another position.

Always be sure your baby gets plenty of supervised time on the stomach while awake during the day. Not only does "tummy time" promote normal shaping of the back the head, it also helps in other ways. Looking around from a new perspective encourages your baby's learning and discovery of the world. Plus, it helps babies learn to push up on their arms, which helps develop the muscles needed for crawling and sitting up. It also helps to strengthen the neck muscles.

If torticollis is the cause of your baby's flattened head, a course of physical therapy and a home exercise program will usually do the trick. A physical therapist can teach you exercises to do with your baby involving stretching techniques that are gradual and progressive. Most moves will consist of stretching your child's neck to the side opposite the tilt. Eventually, the neck muscles will be elongated and the neck will straighten itself out. Although they're very simple, the exercises must be performed correctly.

For kids with severe positional plagiocephaly, doctors may prescribe a custom-molded helmet or head band. These work best if started between the ages of 4 and 6 months, when a child grows the fastest, and are usually less helpful after 10 months of age. They work by applying gentle but constant pressure on a baby's growing skull in an effort to redirect the growth.

But never purchase or use any devices like these without having your child evaluated by a doctor. Only a small percentage of babies wear helmets. The decision to use helmet therapy is made on a case-by-case basis (for example, if the condition is so severe that a baby's face is becoming misshapen or the parents are very upset). Although helmets might not improve the outcome in all children, some kids with severe torticollis can benefit from their use.

Prognosis

The outlook for babies with positional plagiocephaly is excellent. As babies grow, they begin to reposition themselves naturally during sleep much more often than they did as newborns, which allows their heads to be in different positions throughout the night. After babies are able to roll over, the AAP still recommends that parents put them to sleep on their backs, but then allow them to move into the position that most suits them without repositioning them onto their backs.

Most skull-flattening deformities are self-corrected by the time the child is 1 year old. A persistent, severe, or cosmetically obvious deformity can be corrected with reconstructive surgery between 12 and 18 months of age, but very few cases require this.

It's important to remember that plagiocephaly itself does not affect your child's brain growth or cause developmental delays or brain damage.

Prevention

Babies should be put down to sleep on their backs to help prevent SIDS, despite the possibility of developing an area of flattening on the back of the head. However, alternating their head position every night while they sleep and providing lots of tummy time and stimulation during the day while they're awake can reduce the risk of positional plagiocephaly.

Nightmares

It's not clear at what age kids begin to dream, but even toddlers may speak about having dreams — pleasant ones and scary ones. While almost every child has an occasional frightening or upsetting dream, nightmares seem to peak during the preschool years when fear of the dark is common. But older kids (and even adults) have occasional nightmares, too.

Nightmares aren't completely preventable, but parents can set the stage for a peaceful night's rest. That way, when nightmares do creep in, a little reassurance and comfort from you can quickly restore your child's peace of mind.

Helping kids conquer this common childhood fear also equips them to overcome other scary things that might arise down the road.

When Do Nightmares Happen?

Nightmares — like most dreams — occur during the stage of sleep when the brain is very active and sorting through experiences and new information for learning and memory. The vivid images the brain is processing can seem as real as the emotions they might trigger.

This part of sleep is known as the rapid eye movement or REM stage because the eyes are rapidly moving beneath closed eyelids. Nightmares tend to happen during the second half of a night's sleep, when REM intervals are longer.

When kids awaken from a nightmare, its images are still fresh and can seem real. So it's natural for them to feel afraid and upset and to call out to a parent for comfort.

By about preschool age, kids begin to understand that a nightmare is only a dream — and that what's happening isn't real and can't hurt them. But knowing that doesn't prevent them from feeling scared. Even older kids feel frightened when they awaken from a nightmare and may need your reassurance and comfort.

What Causes Nightmares?

No one knows exactly what causes nightmares. Dreams — and nightmares — seem to be one way kids process thoughts and feelings about situations they face, and to work through worries and concerns.

Most times nightmares occur for no apparent reason. Other times they happen when a child is experiencing stress or change. Events or situations that might feel unsettling — such as moving, attending a new school, the birth of a sibling, or family tensions — might also be reflected in unsettling dreams.

Sometimes nightmares occur as part of a child's reaction to trauma — such as a natural disaster, accident, or injury. For some kids, especially those with a good imagination, reading scary books or watching scary movies or TV shows just before bedtime can inspire nightmares.

Themes of a nightmare tend to reflect whatever the child is going through at that age, whether it's struggles with aggressive feelings, independence, or fears of separation. The cast of characters might include monsters, bad guys, animals, imaginary creatures, or familiar people, places, and events combined in unusual ways.

Young kids might have nightmares of being gobbled up, lost, chased, or punished. Sometimes a nightmare contains recognizable bits and pieces of the day's events and experiences, but with a scary twist. A child might not remember every detail, but can usually recall some of the images, characters, or situations, and the scary parts.

Encouraging Sweet Dreams

Parents can't prevent nightmares, but can help kids get a good night's sleep — and that encourages sweet dreams.

To help them relax when it's time to sleep and associate bedtime with safety and comfort, be sure that kids:

• have a regular bedtime and wake-up time
• have a sleep routine that helps them slow down, and feel safe and secure as they drift off to sleep. This might include a bath, a snuggle from you, reading, or some quiet talk about the pleasant events of the day.
• have a bed that's a cozy, peaceful place to quiet down. A favorite toy, stuffed animal, night-light, or dream catcher can help.
• avoid scary movies, TV shows, and stories before bed — especially if they've triggered nightmares before
• know that nightmares aren't real, that they're just dreams and can't hurt them

After a Nightmare

Here's how to help your child cope after a nightmare:

Reassure your child that you’re there. Your calm presence helps your child feel safe and protected after waking up feeling afraid. Knowing you'll be there helps strengthen your child's sense of security.

Label what’s happened. Let your child know that it was a nightmare and now it's over. You might say something like, "You had a bad dream, but now you're awake and everything is OK." Reassure your child that the scary stuff in the nightmare didn't happen in the real world.

Offer comfort. Show that you understand that your child feels afraid and it's OK. Remind your child that everyone dreams and sometimes the dreams are scary, upsetting, and can seem very real, so it's natural to feel scared by them.

Do your magic. With preschoolers and young school-age kids who have vivid imaginations, the magical powers of your love and protection can work wonders. You might be able to make the pretend monsters disappear with a dose of pretend monster spray. Go ahead and check the closet and under the bed, reassuring your child that all's clear.

Mood lighting. A night-light or a hall light can help kids feel safe in a darkened room as they get ready to go back to sleep. A bedside flashlight can be a good nightmare-chaser.

Help your child go back to sleep. Offering something comforting might help change the mood. Try any of these to aid the transition back to sleep: a favorite stuffed animal to hold, a blanket, pillow, night-light, dream catcher, or soft music. Or discuss some pleasant dreams your child would like to have. And maybe seal it by giving your child a kiss to hold — in the palm of his or her hand — as you tiptoe out of the room.

Be a good listener. No need to talk more than briefly about the nightmare in the wee hours — just help your child feel calm, safe, and protected, and ready to go back to sleep. But in the morning, your child may want to tell you all about last night's scary dream. By talking about it — maybe even drawing the dream or writing about it — in the daylight, many scary images lose their power. Your child might enjoy thinking up a new (more satisfying) ending to the scary dream.

For most kids, nightmares happen only now and then, are not cause for concern, and simply require a parent's comfort and reassurance. Talk to your doctor if nightmares often prevent your child from getting enough sleep or if they occur along with other emotional or behavioral troubles.

Night Terrors

What Are Night Terrors?

Most parents have comforted their child after the occasional nightmare. But if your child has ever experienced what's known as a night terror (or sleep terror), his or her fear was likely inconsolable, no matter what you tried.

A night terror is a sleep disruption that seems similar to a nightmare, but with a far more dramatic presentation. Though night terrors can be alarming for parents who witness them, they're not usually cause for concern or a sign of a deeper medical issue.

During a typical night, sleep occurs in several stages. Each is associated with particular brain activity, and it's during the rapid eye movement (REM) stage that most dreaming occurs.

Night terrors happen during deep non-REM sleep. Unlike nightmares (which occur during REM sleep), a night terror is not technically a dream, but more like a sudden reaction of fear that happens during the transition from one sleep phase to another.

Night terrors usually occur about 2 or 3 hours after a child falls asleep, when sleep transitions from the deepest stage of non-REM sleep to lighter REM sleep, a stage where dreams occur. Usually this transition is a smooth one. But rarely, a child becomes agitated and frightened — and that fear reaction is a night terror.

During a night terror, a child might suddenly sit upright in bed and shout out or scream in distress. The child's breathing and heartbeat might be faster, he or she might sweat, thrash around, and act upset and scared. After a few minutes, or sometimes longer, a child simply calms down and returns to sleep.

Unlike nightmares, which kids often remember, kids won't have any memory of a night terror the next day because they were in deep sleep when it happened — and there are no mental images to recall.

What Causes Night Terrors?

Night terrors are caused by over-arousal of the central nervous system (CNS) during sleep. This may happen because the CNS (which regulates sleep and waking brain activity) is still maturing. Some kids may inherit a tendency for this over-arousal — about 80% who have night terrors have a family member who also experienced them or sleepwalking (a similar type of sleep disturbance).

Night terrors have been noted in kids who are:

• overtired or ill, stressed, or fatigued
• taking a new medication
• sleeping in a new environment or away from home

Night terrors are relatively rare — they happen in only 3-6% of kids, while almost every child will have a nightmare occasionally. Night terrors usually occur between the ages of 4 and 12, but have been reported in kids as young as 18 months. They seem to be a little more common among boys.

A child might have a single night terror or several before they cease altogether. Most of the time, night terrors simply disappear on their own as the nervous system matures.

Coping With Night Terrors

Night terrors can be very upsetting for parents, who might feel helpless at not being able to comfort or soothe their child. The best way to handle a night terror is to wait it out patiently and make sure the child doesn't get hurt by thrashing around. Kids usually will settle down and return to sleep on their own in a few minutes.

It's best not to try to wake kids during a night terror. Attempts usually don't work, and kids who do wake are likely to be disoriented and confused, and may take longer to settle down and go back to sleep.

There's no treatment for night terrors, but you can help prevent them. Try to:

• reduce your child's stress
• establish and stick to a bedtime routine that's simple and relaxing
• make sure your child gets enough rest
• prevent your child from becoming overtired by staying up too late

Understanding night terrors can reduce your worry — and help you get a good night's sleep yourself. But if night terrors happen repeatedly, talk to your doctor about whether a referral to a sleep specialist is needed.

Cosleeping and Your Baby

The image of a baby and parent dozing off together isn't an uncommon one. But the practice of cosleeping, or sharing a bed with your infant, is controversial in the United States. Supporters of cosleeping believe that a parent's bed is just where an infant belongs. But is it safe?

Why Do Some People Choose to Cosleep?

Cosleeping supporters believe — and some studies support their beliefs — that cosleeping:

encourages breastfeeding by making nighttime breastfeeding more convenient

makes it easier for a nursing mother to get her sleep cycle in sync with her baby's

helps babies fall asleep more easily, especially during their first few months and when they wake up in the middle of the night

helps babies get more nighttime sleep (because they awaken more frequently with shorter duration of feeds, which can add up to a greater amount of sleep throughout the night)

helps parents who are separated from their babies during the day regain the closeness with their infant that they feel they missed

But do the risks of cosleeping outweigh the benefits?

Is Cosleeping Safe?

Despite the possible pros, the U.S. Consumer Product Safety Commission (CPSC) warns parents not to place their infants to sleep in adult beds, stating that the practice puts babies at risk of suffocation and strangulation. And the American Academy of Pediatrics (AAP) agrees.

Cosleeping is a widespread practice in many non-Western cultures. However, differences in mattresses, bedding, and other cultural practices may account for the lower risk in these countries as compared with the United States.

According to the CPSC, at least 515 deaths were linked to infants and toddlers under 2 years of age sleeping in adult beds from January 1990 to December 1997:

• 121 of the deaths were attributed to a parent, caregiver, or sibling rolling on top of or against a baby while sleeping
• more than 75% of the deaths involved infants younger than 3 months old

Cosleeping advocates say it isn't inherently dangerous and that the CPSC went too far in recommending that parents never sleep with children under 2 years of age. According to supporters of cosleeping, parents won't roll over onto a baby because they're conscious of the baby's presence — even during sleep.

Those who should not cosleep with an infant, however, include:

• other children — particularly toddlers — because they might not be aware of the baby's presence
• parents who are under the influence of alcohol or any drug because that could diminish their awareness of the baby
• parents who smoke because the risk of sudden infant death syndrome (SIDS) is greater

But can cosleeping cause SIDS? The connection between cosleeping and SIDS is unclear and research is ongoing. Some cosleeping researchers have suggested that it can reduce the risk of SIDS because cosleeping parents and babies tend to wake up more often throughout the night. However, the AAP reports that some studies suggest that, under certain conditions, cosleeping may increase the risk of SIDS, especially cosleeping environments involving mothers who smoke.

CPSC also reported more than 100 infant deaths between January 1999 and December 2001 attributable to hidden hazards for babies on adult beds, including:

• suffocation when an infant gets trapped or wedged between a mattress and headboard, wall, or other object
• suffocation resulting from a baby being face-down on a waterbed, a regular mattress, or on soft bedding such as pillows, blankets, or quilts
• strangulation in a bed frame that allows part of an infant's body to pass through an area while trapping the baby's head

In addition to the potential safety risks, sharing a bed with a baby can sometimes prevent parents from getting a good night's sleep. And infants who cosleep can learn to associate sleep with being close to a parent in the parent's bed, which may become a problem at naptime or when the infant needs to go to sleep before the parent is ready.

Making Cosleeping as Safe as Possible

If you do choose to share your bed with your baby, make sure to follow these precautions:

• Always place your baby on his or her back to sleep to reduce the risk of SIDS.

• Always leave your child's head uncovered while sleeping.

• Make sure your bed's headboard and footboard don't have openings or cutouts that could trap your baby's head.

• Make sure your mattress fits snugly in the bed frame so that your baby won't become trapped in between the frame and the mattress.

• Don't place a baby to sleep in an adult bed alone.

• Don't use pillows, comforters, quilts, and other soft or plush items on the bed.

• Don't drink alcohol or use medications or drugs that may keep you from waking and may cause you to roll over onto, and therefore suffocate, your baby.

• Don't place your bed near draperies or blinds where your child could be strangled by cords.

Transitioning Out of the Parent's Bed

Most medical experts say the safest place to put an infant to sleep is in a crib that meets current standards and has no soft bedding. But if you've been cosleeping with your little one and would like to stop, talk to your doctor about making a plan for when your baby will sleep in a crib.

Transitioning to the crib by 6 months is usually easier — for both parents and baby — before the cosleeping habit is ingrained and other developmental issues (such as separation anxiety) come into play. Eventually, though, the cosleeping routine will likely be broken at some point, either naturally because the child wants to or by the parents' choice.

But there are ways that you can still keep your little one close by, just not in your bed. You could:

• Put a bassinet, play yard, or crib next to your bed. This can help you maintain that desired closeness, which can be especially important if you're breastfeeding. The AAP says that having an infant sleep in a separate crib, bassinet, or play yard in the same room as the mother reduces the risk of SIDS.

• Buy a device that looks like a bassinet or play yard minus one side, which attaches to your bed to allow you to be next to each other while eliminating the possibility of rolling over onto your infant.

Of course, where your child sleeps — whether it's in your bed or a crib — is a personal decision. As you're weighing the pros and cons, talk to your child's doctor about the risks, possible personal benefits, and your family's own sleeping arrangements.

Bruxism (Teeth Grinding or Clenching)

When you look in on your sleeping child, you want to hear the sounds of sweet dreams: easy breathing and perhaps an occasional sigh. But some parents hear the harsher sounds of gnashing and grinding teeth, called bruxism, which is common in kids.

About Bruxism

Bruxism is the medical term for the grinding of teeth or the clenching of jaws. Bruxism often occurs during deep sleep or while under stress. Two to three out of every 10 kids will grind or clench, experts say, but most outgrow it.

Causes of Bruxism

Though studies have been done, no one knows why bruxism happens. But in some cases, kids may grind because the top and bottom teeth aren't aligned properly. Others do it as a response to pain, such as an earache or teething. Kids might grind their teeth as a way to ease the pain, just as they might rub a sore muscle. Many kids outgrow these fairly common causes for grinding.

Stress — usually nervous tension or anger — is another cause. For instance, a child might worry about a test at school or a change in routine (a new sibling or a new teacher). Even arguing with parents and siblings can cause enough stress to prompt teeth grinding or jaw clenching.

Some kids who are hyperactive also experience bruxism. And sometimes kids with other medical conditions (such as cerebral palsy) or on certain medications can develop bruxism.

Effects of Bruxism

Many cases of bruxism go undetected with no adverse effects, while others cause headaches or earaches. Usually, though, it's more bothersome to other family members because of the grinding sound.

In some circumstances, nighttime grinding and clenching can wear down tooth enamel, chip teeth, increase temperature sensitivity, and cause severe facial pain and jaw problems, such as temporomandibular joint disease (TMJ). Most kids who grind, however, do not have TMJ problems unless their grinding and clenching is chronic.

Diagnosing Bruxism

Lots of kids who grind their teeth aren't even aware of it, so it's often siblings or parents who identify the problem.

Some signs to watch for:

• grinding noises when your child is sleeping
• complaints of a sore jaw or face in the morning
• pain with chewing

If you think your child is grinding his or her teeth, visit the dentist, who will examine the teeth for chipped enamel and unusual wear and tear, and spray air and water on the teeth to check for unusual sensitivity.

If damage is detected, the dentist may ask your child a few questions, such as:

• How do you feel before bed?
• Are you worried about anything at home or school?
• Are you angry with someone?
• What do you do before bed?

The exam will help the dentist determine whether the grinding is caused by anatomical (misaligned teeth) or psychological (stress) factors and come up with an effective treatment plan.

Treating Bruxism

Most kids outgrow bruxism, but a combination of parental observation and dental visits can help keep the problem in check until they do.

In cases where the grinding and clenching make a child's face and jaw sore or damage the teeth, dentists may prescribe a special night guard. Molded to a child's teeth, the night guard is similar to the protective mouthpieces worn by football players. Though a mouthpiece may take some getting used to, positive results happen quickly.

Helping Kids With Bruxism

Whether the cause is physical or psychological, kids might be able to control bruxism by relaxing before bedtime — for example, by taking a warm bath or shower, listening to a few minutes of soothing music, or reading a book.

For bruxism that's caused by stress, ask about what's upsetting your child and find a way to help. For example, a kid who is worried about being away from home for a first camping trip might need reassurance that mom or dad will be nearby if anything happens.

If the issue is more complicated, such as moving to a new town, discuss your child's concerns and try to ease any fears. If you're concerned, talk to your doctor.

In rare cases, basic stress relievers aren't enough to stop bruxism. If your child has trouble sleeping or is acting differently than usual, your dentist or doctor may suggest further evaluation. This can help determine the cause of the stress and an appropriate course of treatment.

How Long Does Bruxism Last?

Childhood bruxism is usually outgrown by adolescence. Most kids stop grinding when they lose their baby teeth. However, a few kids do continue to grind into adolescence. And if the bruxism is caused by stress, it will continue until the stress is relieved.

Preventing Bruxism

Because some bruxism is a child's natural reaction to growth and development, most cases can't be prevented. Stress-induced bruxism can be avoided, however, by talking with kids regularly about their feelings and helping them deal with stress. Take your child for routine dental visits to find and, if needed, treat bruxism.

Bedwetting

Bedwetting is an issue that millions of families face every night. It is extremely common among young kids but can last into the teen years.

Doctors don't know for sure what causes bedwetting or why it stops. But it is often a natural part of development, and kids usually grow out of it. Most of the time bedwetting is not a sign of any deeper medical or emotional issues.

All the same, bedwetting can be very stressful for families. Kids can feel embarrassed and guilty about wetting the bed and anxious about spending the night at a friend's house or at camp. Parents often feel helpless to stop it.

Bedwetting may last for a while, but providing emotional support and reassurance can help your child feel better until it stops.

How Common Is Bedwetting?

Enuresis, the medical name for bedwetting, is a common problem in kids, especially children under the age of 6 years. About 13% of 6-year-olds wet the bed, while about 5% of 10-year-olds do.

Bedwetting often runs in families: kids who wet the bed often have a relative who did, too. If both parents wet the bed when they were young, it's very likely that their child will.

Coping With Bedwetting

Bedwetting usually goes away on its own. But until it does, it can be embarrassing and uncomfortable for your child. So it's important to provide support and positive reinforcement during this process.

Reassure your child that bedwetting is a normal part of growing up and that it's not going to last forever. It may comfort your child to hear about other family members who also struggled with it when they were young.

Remind your child to go to the bathroom one final time before bedtime. Try to have your child drink more fluids during the daytime hours and less at night. Fluids given later in the day should not have caffeine. Some parents try waking their kids in the middle of the night to use the bathroom. Many also find that using a motivational system, such as stickers for dry nights with a small reward (such as a book) after a certain number of stickers, can work well. Bedwetting alarms also can be helpful.

When your child wakes with wet sheets, don't yell or spank him or her. Have your child help you change the sheets. Explain that this isn't punishment, but it is a part of the process. It may even help your child feel better knowing that he or she helped out. Offer praise when your child has a dry night.

When to Call the Doctor

Bedwetting that begins abruptly or is accompanied by other symptoms can be a sign of another medical condition, so talk with your doctor.

The doctor may check for signs of a urinary tract infection (UTI), constipation, bladder problems, diabetes, or severe stress.

Call the doctor if your child:

• suddenly starts wetting the bed after being consistently dry for at least 6 months
• begins to wet his or her pants during the day
• starts misbehaving at school or at home
• complains of a burning sensation or pain when urinating
• has to urinate frequently
• is drinking or eating much more than usual
• has swelling of the feet or ankles
• your child is still wetting the bed at age 7 years

Also let the doctor know if you're feeling frustrated with the situation or could use some help. In the meantime, your support and patience can go a long way in helping your child feel better about the bedwetting.

Remember, the long-term outlook is excellent and in almost all cases dry days are just ahead.

Bedtime Basics

Apnea

Everyone has brief pauses in their breathing pattern called apnea. Usually these brief stops are completely normal.

Sometimes, though, apnea can cause a prolonged pause in breathing, making the breathing pattern irregular. Someone with apnea might actually stop breathing for short amounts of time, decreasing oxygen levels in the body and disrupting sleep.

Types of Apnea

The word apnea comes from the Greek word meaning "without wind." Although it's perfectly normal for everyone to experience occasional pauses in breathing, apnea can be a problem when breathing stops for 20 seconds or longer.

There are three types of apnea:

• obstructive
• central
• mixed

Obstructive Apnea

A common type of apnea in children, obstructive apnea is caused by an obstruction of the airway (such as enlarged tonsils and adenoids). This is most likely to happen during sleep because that's when the soft tissue at back of the throat is most relaxed. As many as 1% to 3% of otherwise healthy preschool-age kids have obstructive apnea.

Symptoms include:

• snoring (the most common) followed by pauses or gasping
• labored breathing while sleeping
• very restless sleep and sleeping in unusual positions
• changes in color

Because obstructive sleep apnea may disturb sleep patterns, these children may also show continued sleepiness after awakening in the morning and tiredness and attention problems throughout the day. Sometimes apnea can affect school performance. One recent study suggests that some kids diagnosed with ADHD actually have attention problems in school because of disrupted sleep patterns caused by obstructive sleep apnea.

Treatment for obstructive apnea involves keeping the throat open to aid air flow, such as with adenotonsillectomy (surgical removal of the tonsils and adenoids) or continuous positive airway pressure (CPAP), which is delivered by having the child wear a nose mask while sleeping.

Central Apnea

Central apnea occurs when the part of the brain that controls breathing doesn't start or properly maintain the breathing process. In very premature infants, it's seen fairly commonly because the respiratory center in the brain is immature. Other than being seen in premature infants, central apnea is the least common form of apnea and often has a neurological cause.

Mixed Apnea

Mixed apnea is a combination of central and obstructive apnea and is seen particularly in infants or young children who have abnormal control of breathing. Mixed apnea may occur when a child is awake or asleep.

Conditions Associated With Apnea

Apnea can be seen in connection with:

Apparent Life-Threatening Events (ALTEs)

An ALTE itself is not a sleep disorder — it's a serious event with a combination of apnea and change in color, change in muscle tone, choking, or gagging. Call 911 immediately if your child shows the signs of an ALTE.

ALTEs, especially in young infants, are often associated with medical conditions that require treatment Examples of these medical conditions include gastroesophogeal reflux (GERD), infections, or neurological disorders. ALTEs are scary to observe, but can be uncomplicated and may not happen again. However, any child who has an ALTE should be seen and evaluated immediately.

Apnea of Prematurity (AOP)

AOP can occur in infants who are born prematurely (before 34 weeks of pregnancy). Because the brain or respiratory system may be immature or underdeveloped, the baby may not be able to regulate his or her own breathing normally. AOP can be obstructive, central, or mixed.

Treatment for AOP can involve the following:

• keeping the infant's head and neck straight (premature babies should always be placed on their backs to sleep to help keep the airways clear)
• medications to stimulate the respiratory system
• continuous positive airway pressure (CPAP) — to keep the airway open with the help of forced air through a nose mask
• oxygen

Premature infants with AOP are followed closely in the hospital. If AOP doesn't resolve before discharge from the hospital, an infant may be sent home on an apnea monitor and parents and other caregivers will be taught CPR. The family will work closely with the child's doctor to have a treatment plan in place.

Apnea of Infancy (AOI)

Apnea of infancy occurs in children who are younger than 1 year old and who were born after a full-term pregnancy. Following a complete medical evaluation, if a cause of apnea isn't found, it's often called apnea of infancy. AOI usually goes away on its own, but if it doesn't cause any significant problems (such as low blood oxygen), it may be considered part of the child's normal breathing pattern.

Infants with AOI can be observed at home with the help of a special monitor prescribed by a sleep specialist. This monitor records chest movements and heart rate and can relay the readings to a hospital apnea program or save them for future examination by a doctor. Parents and caregivers will be taught CPR before the child is sent home.

If You Think Your Child Has Apnea

If you suspect that your child has apnea, call your doctor. If you suspect that your child is experiencing an ALTE, call 911 immediately.

Although prolonged pauses in breathing can be serious, after a doctor does a complete evaluation and makes a diagnosis, most cases of apnea can be treated or managed with surgery, medications, monitoring devices, or sleep centers. And many cases of apnea go away on their own.

All About Sleep

Sleep — or lack of it — is probably the most-discussed aspect of baby care. New parents discover its vital importance those first few weeks and months. The quality and quantity of an infant's sleep affects the well-being of everyone in the household.

And sleep struggles rarely end with a growing child's move from crib to bed. It simply changes form. Instead of cries, it's pleas or refusals. Instead of a feeding at 3:00 AM, it's a nightmare or request for water.

So how do you get your child to bed through the cries, screams, avoidance tactics, and pleas? How should you respond when you're awakened in the middle of the night? And how much sleep is enough for your kids?

How Much Is Enough?

It all depends on a child's age. Charts that list the hours of sleep likely to be required by an infant or a 2-year-old may cause concern when individual differences aren't considered. These numbers are simply averages reported for large groups of kids of particular ages.

There's no magical number of hours required by all kids in a certain age group. Two-year-old Sarah might sleep from 8:00 PM to 8:00 AM, whereas 2-year-old Johnny is just as alert the next day after sleeping from 9:00 PM to 6:00 AM.

Still, sleep is very important to kids' well-being. The link between a lack of sleep and a child's behavior isn't always obvious. When adults are tired, they can be grumpy or have low energy, but kids can become hyper, disagreeable, and have extremes in behavior.

Most kids' sleep requirements fall within a predictable range of hours based on their age, but each child is a unique individual with distinct sleep needs.

Here are some approximate numbers based on age, accompanied by age-appropriate pro-sleep tactics.

Babies (up to 6 Months)

There is no sleep formula for newborns because their internal clocks aren't fully developed yet. They generally sleep or drowse for 16 to 20 hours a day, divided about equally between night and day.

Newborns should be awakened every 3 to 4 hours until their weight gain is established, which typically happens within the first couple of weeks. After that, it's OK if a baby sleeps for longer periods of time. But don't get your slumber hopes up just yet — most infants won't snooze for extended periods of time because they get hungry.

After the first couple of weeks, infants may sleep for as long as 4 or 5 hours — this is about how long their small bellies can go between feedings. If babies do sleep a good stretch at night, they may want to nurse or get the bottle more frequently during the day.

Just when parents feel that sleeping through the night seems like a far-off dream, their baby's sleep time usually begins to shift toward night. At 3 months, a baby averages about 13 hours of sleep in a 24 hour period (4-5 hours of sleep during the day broken into several naps and 8-9 hours at night, usually with an interruption or two). About 90% of babies this age sleep through the night, meaning 5 to 6 hours in a row.

But it's important to recognize that babies aren't always awake when they sound like they are; they can cry and make all sorts of other noises during light sleep. Even if they do wake up in the night, they may only be awake for a few minutes before falling asleep again on their own.

If a baby under 6 months old continues to cry, it's time to respond. Your baby may be genuinely uncomfortable: hungry, wet, cold, or even sick. But routine nighttime awakenings for changing and feeding should be as quick and quiet as possible. Don't provide any unnecessary stimulation, such as talking, playing, or turning on the lights. Encourage the idea that nighttime is for sleeping. You have to teach this because your baby doesn't care what time it is as long as his or her needs are met.

Ideally, your baby should be placed in the crib before falling asleep. And it's not too early to establish a simple bedtime routine. Any soothing activities, performed consistently and in the same order each night, can make up the routine. Your baby will associate these with sleeping, and they'll help him or her wind down.

The goal is for babies to fall asleep independently, and to learn to soothe themselves and go back to sleep if they should wake up in the middle of the night.

6 to 12 Months

At 6 months, an infant may nap about 3 hours during the day and sleep about 9 to 11 hours at night. At this age, you can begin to change your response to an infant who awakens and cries during the night.

Parents can give babies a little more time to settle down on their own and go back to sleep. If they don't, comfort them without picking them up (talk softly, rub their backs), then leave — unless they appear to be sick. Sick babies need to be picked up and cared for. If your baby doesn't seem sick and continues to cry, you can wait a little longer, then repeat the short crib-side visit.

Between 6 and 12 months, separation anxiety, a normal developmental phase, comes into play. But the rules for nighttime awakenings are the same through a baby's first birthday: Try not to pick up your baby, turn on the lights, sing, talk, play, or feed your child. All of these activities do not allow your baby to learn to fall asleep on his or her own and encourage repeat awakenings.

Toddlers

From ages 1 to 3, most toddlers sleep about 10 to 13 hours. Separation anxiety, or just the desire to be up with mom and dad (and not miss anything), can motivate a child to stay awake. So can simple toddler-style contrariness.

Parents sometimes make the mistake of thinking that keeping a child up will make him or her sleepier for bedtime. In fact, though, kids can have a harder time sleeping if they're overtired. Set regular bedtimes and naptimes. Though most toddlers take naps during the day, you don't have to force your child to nap. But it's important to schedule some quiet time, even if your child chooses not to sleep.

Establishing a bedtime routine helps kids relax and get ready for sleep. For a toddler, the routine may be from 15 to 30 minutes long and include calming activities such as reading a story, bathing, and listening to soft music.

Whatever the nightly ritual is, your toddler will probably insist that it be the same every night. Just don't allow rituals to become too long or too complicated. Whenever possible, allow your toddler to make bedtime choices within the routine: which pajamas to wear, which stuffed animal to take to bed, what music to play. This gives your little one a sense of control over the routine.

But even the best sleepers give parents an occasional wake-up call. Teething can awaken a toddler and so can dreams. Active dreaming begins at this age, and for very young children, dreams can be pretty alarming. Nightmares are particularly frightening to a toddler, who can't distinguish imagination from reality. (So carefully select what TV programs, if any, your toddler sees before bedtime.)

Comfort and hold your child at these times. Let your toddler talk about the dream if he or she wants to, and stay until your child is calm. Then encourage your child to go back to sleep as soon as possible.

Preschoolers

Preschoolers sleep about 10 to 12 hours per night. A preschool child who gets adequate rest at night may no longer needs a daytime nap. Instead, a quiet time may be substituted.

Most nursery schools and kindergartens have quiet periods when the kids lie on mats or just rest. As kids give up their naps, bedtimes may come earlier than during the toddler years.

School-Age Children and Preteens

School-age kids need 10 to 12 hours of sleep a night. Bedtime difficulties can arise at this age for a variety of reasons. Homework, sports and after-school activities, TVs, computers, and video games, as well as hectic family schedules might contribute to kids not getting enough sleep.

Lack of sleep can cause irritable or hyper types of behavior and may make it difficult for kids to pay attention in school. It is important to have a consistent bedtime, especially on school nights. Be sure to leave enough time before bed to allow your child to unwind before lights out.

Teens

Adolescents need about 8½ to 9½ hours of sleep per night, but many don't get it. Because of early school start times on top of schedules packed with school, homework, friends, and activities, they're typically chronically sleep deprived.

And sleep deprivation adds up over time, so an hour less per night is like a full night without sleep by the end of the week. Among other things, an insufficient amount of sleep can lead to:

• decreased attentiveness
• decreased short-term memory
• inconsistent performance
• delayed response time

These can cause bad tempers, problems in school, stimulant use, and driving accidents (more than half of "asleep-at-the-wheel" car accidents are caused by teens).

Teens also experience a change in their sleep patterns — their bodies want to stay up late and wake up later, which often leads to them trying to catch up on sleep during the weekend. This sleep schedule irregularity can actually aggravate the problems and make getting to sleep at a reasonable hour during the week even harder.

Ideally, a teen should try to go to bed at the same time every night and wake up at the same time every morning, allowing for at least 8 to 9 hours of sleep.

Bedtime Routines

No matter what your child's age, establish a bedtime routine that encourages good sleep habits. These tips can help kids ease into a good night's sleep:

• Include a winding-down period in the routine.

• Stick to a bedtime, alerting your child both half an hour and 10 minutes beforehand.

• Encourage older kids and teens to set and maintain a bedtime that allows for the full hours of sleep needed at their age.