Second Visit

Sleep Disorders Care Plan (Second Visit)

Night
By this, the second visit, night sleep has hopefully improved. Let us assume that the night sleep is now something like 12 hours per night. Plus or minus 30 minutes at each end. Thus, it might be 11-12-13 hours. Given this level of success, there are a few principles from this point.
1. This improved night sleep is now not negotiable. This is how we expect the child to sleep at night, on the large majority of nights, until approximately school age i.e. 4 - 5 years of age.
2. Bed time is generally predictable and 'clock driven'. (Gently rather than strictly.) For many children the night sleep will be approximately 7 pm to 7 am. The advantage is the predictability it gives the carer. For a busy mother, having a predictable bed time is a large boost to her sense of good management of the family unit.
3. Attempt to be predictable and consistent in your expectations of night sleep.

However…………….
The most common continuing problem.
Approximately 40% of children return to the second visit (this material) with persistent waking at 5:00 to 6:00 am. The reason is shown in the right hand circle in the graph below. As there has been a large accumulation of sleep, children now return to sleep mainly using cues of sleep. There is a strong tendency to 'request' parental care at this time and the child is very cue sensitive. The solution is to quarantine mum and dad. The solution is that no care can be given at that time unless there is a clear and obvious reason e.g. illness or pain. Thus parents must define the start time of the day and not be available until that time. Be meticulously consistent in this as the child is very 'cue' sensitive.
Losing Control
Now that the night is so much better what can cause us to lose it?
1. Illness. The child who is unwell may need care overnight. This may lead to a 're-definition' of the night, by the child's subconscious, to include parental care. Plan to return to a normal night as soon as the child is back to normal health. Do not revisit the 'minimal handling' technique though as this will now work against you. Unfortunately, it has to be almost a 'cold turkey' response.
2. Travel and holidays. Attempt to take your routines with you. If this does not work, then return to normal routines as soon as you return home.
3. Daylight saving. The best response to daylight saving is to go by the clock and not by the sun.

Day
How do you gain confident control of the day? There are three common day time questions.

1. When to put the child down for the first day sleep?

The key to day sleeps is the happy wake time (HWT). This is the time of happy, confident and constructive play which occurs after a good sleep. The most important aspect of the HWT is that it has an END. The beginning of the end is shown by a change in behaviour. This may include, minor tearfulness, rubbing the eyes, blinking heavily or seeking your company more. You probably already know these signals in your child. This time is a window of opportunity to put the child down. If the beginning of the end of the HWT is chosen well, the child will often achieve and maintain sleep efficiently. Thus the child needs to be put down when tired but before overtiredness has appeared. Often the window of opportunity is only 5 - 10 - 15 minutes long. The younger the child, the shorter the window. If this opportunity is missed by say 30 minutes or more, the child will 'pass the time of most efficient entry to sleep' and have increasing trouble achieving sleep.

2. Is the sleep long enough? Is the sleep complete and how do you judge this?

Luckily this is easy. Observe the manner of waking. Happy talkative waking means that the sleep is complete. Demanding behaviour within one to two minutes of waking means that the sleep is incomplete.

3. What to do if the baby requires more sleep but is 'of the opposite opinion'?

Unfortunately of all the principles which I teach about sleep, this is the most difficult. The reason is that life gets in the way of a perfect plan; school drop off for other children, kindergarten pickups, shopping etc. Generally, life has a habit of getting in the way and we give children inconsistent day time experiences. As a result, there are a few guidelines.