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Let me be real for a moment— nobody WANTS to sleep train their child. Although it is both safe and effective, many parents are afraid of doing anything that involves crying. I want to show you the steps I think are key to help make your baby sleep better,  minimize sleep problems, and may help you avoid sleep training your baby altogether.

Regardless of your parenting philosophy, I think everyone agrees that good sleep for baby is great for the whole family. Fortunately, if you take a few simple steps when you bring your child home from the hospital, you can avoid major sleep problems, and potentially avoid sleep training altogether.

Note: Everyone’s child is different. Some children sleep great no matter what. Some will struggle even if parents do everything perfectly. However, there are some best practices which will spare you a lot of wrecked nights if you follow them from the beginning. Trust me, I broke a few of them myself and lived to regret it.

  1. The best time to start a bedtime routine is when you bring your child home from the hospital. The second best time is today. Children thrive on routine. Newborns benefit as well, although the benefits are more for you in the first few weeks. Things feel really chaotic when you bring your child home from the hospital. Having a predictable bedtime routine is one of the anchors to your day. For more on creating the best possible bedtime routine.
  2. If you breastfeed, teach your child to take a bottle once your milk is in. Like most pediatricians, I’m a huge fan of breastfeeding. There are too many benefts for mother and child to list here. However, I’ve seen many families fall into the trap of only having the mom nurse exclusively for the first few months, and then having the child refuse anything but the breast. This makes it really difficult for the whole family, as other adults are sidelined, and Mom is stuck putting the baby down every night and dealing with every night feeding. It can also greatly complicate Mom’s return to work outside the home, if that is her plan. Once your milk supply is established, introduce a bottle, ideally given by Dad, your child’s other mother, or another adult caregiver.
  3. Make sure that the bedtime is simple enough that one grown up can do it. When my first son came home from the hospital, my wife and I did bedtime every night together. Which was lovely, but it was pretty elaborate in terms of the bath, lotion application, song, story, rocking, and nursing. (This also felt necessary because of my congenital inability to find towels, soap, pacifiers, books, etc. at any time). My second son did not have such an elaborate process due to Son #1 and it still worked fine. Babies don’t need complex bedtimes. If bathtime feels overwhelming to Dad (and it is usually Dad who is overwhelmed by these sorts of things) do it at another time. Keep it simple. Story, song, rocking, and put your baby down.
  4. Make sure than all the adults in the household participate in bedtime. I’ve heard the same story from tired moms, over and over: “My husband (or wife) can’t put him down at night! Only I can do it.” This usually means that Mom always put the child down every night for the first few months. Like #2 above, this is a recipe for maternal burn-out. Every parent (or other caregiver) home should feel comfortable doing the bedtime routine and putting the child down at an early age. If you already feel stuck in this situation, the primary caregiver needs to go out with friends for the evening. I promise you that Dad will figure it out. And don’t be afraid to get a babysitter. I don’t think we got a babysitter for the first year of life for my son. Son #2— we went out probably around 3 months of age. Obviously you will be nervous. If you can, start with a grandparent for the first few times you go out.
  5. Put your child to bed drowsy but awake, starting around 3-4 months. Try it out. If it is a disaster the first time, pick your child up and try again in a week or two. Don’t be afraid to let your child fuss a bit. This is natural. Hysterical screaming is another story— this means you may need to wait until your child is slightly older. Try it at naps as well.
  6. Don’t sprint into your child’s room at night at the first sound of wakefulness. I remember sprinting into my son’s room at the first signs of wakefulness so that I could stuff the binky in his mouth and perhaps get back to sleep quickly. This led to him waking up more and more for the contact with me. In Bringing up Bebe(affiliate link), Pamela Druckerman wrote with astonishment that French babies slept through the night earlier than Anglophone babies. Her Parisian friends told her that they would ignore random noises made by their babies, and would only pick them up for full throated, wakeful cries. Remember, any random cry, burp, fart, or snort does not demand immediate attention. After the first few months, it’s a great idea to let your child fuss a bit before you go in. Often, these brief awakenings will self-resolve.
  7. Don’t obsess over the monitor. I can’t believe the amount of technology being hawked to anxious parents these days. Babies’ bedrooms are monitored to a degree that would astound a Cold War spymaster. Temperature, movement, sound, ambient light levels, heart rate, etc. I think that the majority of this technology is cumbersome, expensive, and unnecessary. Human infants have thrived for thousands of years without video monitors. Sure, you should be able to hear your child if she is distressed or crying, but you don’t need multisensor surveillance for this. Save the money and get an audio monitor. Parents often ask me questions like, “I check on her with the monitor and sometimes she is wide awake and quiet during the night. What should I do?” My answer: “Turn off the monitor.”
  8. Talk with your pediatrician about the need for room sharing in the first year. I have grave concerns about the American Academy of Pediatrics recommendation that parents room share with infants for the first year of life to prevent SIDS. Personally, I think the evidence is weak and the potential for development of bad sleep habits is much higher. The majority of pediatricians I know agree with me. For further discussion on this and safe sleep in general, please talk to your pediatrician.

Now, I want to know what you think. If you had a time machine, what would you tell yourself to differently when you brought your baby home to help them sleep better?

The post Eight Steps to Make Your Baby Sleep Better and Avoid Sleep Training appeared first on Craig Canapari, MD.

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This is a transcript of questions from my Facebook live session.You can watch the video here. I’ve also provided a lightly edited transcript below.

Facebook Live Chat 8/28/17 - YouTube

We’re gonna start with a question by Amanda.

What should you do, very specifically, about frequent toddler night wakings? Besides quick check-ins and no remove from the crib, how can you manage longer sleep stretches?

You answer, this, he is still waking at night, but now in a bed, climbing from crib. He needs a bottle to lay with to go back to sleep, or it’s an hour plus of crying and I just don’t have the energy in the middle of the night. Well Amanda, I hear you. And this is a really common problem. Let me just show you guys a few quick pictures that are, explain what we’re talking about here. So essentially, this is what a normal night of sleep should look like.

So, from bedtime to wake time. Your child goes through different stages. Your child’s falling asleep on his or her own, she’ll so through a long stretch of sleep. You know, anywhere from one to three hours. In this early evening, a period of sleep, this is where if you put your child, if your child falls asleep in the car, you could pick your child up, carry them to their bedroom, and they fall asleep. Then about two to three hours in, they have their first REM period. REM sleep is a lot like wake sleep, it’s easy to wake up from REM sleep. And in fact, it’s really common. And this red bar is essentially just what a, a night of him waking up. Generally, if we know how to put ourselves to sleep, we can just roll over and go back to sleep, maybe adjust your pillows. You don’t remember it in the morning. However, if your child needs you to fall asleep, it’s very different. You hold your child, you give them a bottle. He falls asleep. You try to relax for a few hours, and then all of a sudden, you’re getting into bed two hours later, and he wakes up. Then, you need to repeat bedtime again. The next REM period, you’re gonna do it again. And again, and again, and eventually you’re awake for the day. So really, this is, this feels like a middle of the night problem because the middle of the night is really painful.

But what it is, is a bedtime problem. And really what you need to work on is getting your child to fall asleep independently. (Here’s more on toddler night wakings). In Amanda’s situation, if your child is in a bed, it’s a little bit different. And I really don’t think the cry it out approach is particularly feasible or advisable in a child who’s sleeping in a crib. Its difficult to institute, in older children, I just think it’s too painful. Doing something with a mixture of a later bedtime, and slowly withdrawing yourself from bedtime. You know, what is on my website is the camp it out approach. And I want to say I didn’t come up with the term. The term came from Harriet Hiscock in Australia. But I would really work on getting your child to fall asleep independently at night. And the nighttime awakenings should extinguish with time. Really, don’t beat yourself up, don’t feel like you have to solve problems in the middle of the night. Just do it what you’re doing to survive, and work on getting your child to fall asleep.

So, Lindsey has a question:

How should we manage different sleep needs for two siblings who share a room and like to keep each other up?

“I have a two and a half year old who naps about 90 minutes per day, and no matter what, we won’t sleep until between 8:30 and, he won’t sleep between 8:30 and 8:45. We wait until he’s down to put his older brother, a six and a half year old brother to bed, because if we don’t it’s a circus show of mutual shenanigans. The older kid is really tired in the morning from going to bed that late.”

Well, Lindsey, I feel you because I have two boys, and it can be kind of a disaster sometimes if they get going. And that geographical split can be critical to allowing you to succeed. Now, not everybody has the luxury of a room for each of their children. Or, or, alternatively, how you, you know, maybe your kids want to room together for whatever reason. I think there’s a couple of solutions. One is you can actually try to put the older child down earlier. Now that’s a tough sell, because it’s very unjust to a six and a half year old to go to bed before the brother or sister. Sometimes, a bribe, I’m not trying to say big, can be very helpful to get the child in and settled.

The other thing you could do is try to move the younger child’s nap a little bit earlier in the day.

The final thing you could do is you could take some measures to get them to sleep in a little bit later. It’s a tough sell, again, because little kids get up earlier. But making sure the room is dark, really, really dark, so light from the outside is not waking them up can be helpful. And also, depending on who your early riser is, if its the six year old especially, ask them to come and get you first.

Now, the question here from, from Jen from Food Allergy Buzz, which is a great site, you should really check out.

”How should I wake a teenage who’s a very heavy sleeper. She has a difficult time waking, even if he gets eight or nine hours of sleep.”

It’s telling to me that this is a teenager, cause I think there’s a couple of issues. One is, if your teenager’s getting eight or nine hours of sleep, on average, that’s one thing. But many teenagers aren’t able to do this. And not to get on my hobby horse, but, school really does start too early for teenagers. So I would say that if your child is consistently getting enough sleep at night and still can’t get out of bed in the morning.

If they snore, they certainly should be evaluated for something like, I’m sure if it’s sleep apnea, which can make their sleep not high enough quality. And the other thing is, it is, you know, biologically, it’s hard to get teenagers up in the morning. They want to sleep from midnight to nine. And if they do that, they’re usually pretty easy to get up. But if you’re trying to get them up earlier than that, you’re going against their body clock and it’s a struggle.

So I have another question from Lindsey actually, about sensory processing disorder. And there are a couple questions about this. Those of you not familiar with this, sensory processing disorder is an issue where children have difficulties managing sensory input. And it can be in any domain. But usually we think of sensory issues being around oral or feeding problems, like children that gag on soft mushy foods, such as myself, because I don’t like mushy vegetables. They make me gag. But in all seriousness, some kids with feeding issues have difficulty tolerating certain consistencies. There are also kids that have trouble with loud noises, or need loud noise, to you know. And most commonly in the sleep domain, with sensory issues. So Lindsey writes:

”Can you suggest sleep strategies for a kid with a sensory disorder beyond the usual weighted blanket, sensory diet during the day?”

I do think those daytime interventions are pretty important. And it sounds like you already have an occupational therapist. I prefer actually Lycra sheets to weighted blankets. Weighted blankets are really heavy, and they’re uncomfortable during the summer time. They’re also very expensive. A Lycra stocking for your bed works really well. And what you do is you actually, it’s like a sock that you slide over your kids bed. They slip down into it. You can actually pack stuffed animals around their body, if your child is that sensation seeking when they want to be wrapped up like a twinkie. There is, there is an Etsy storefront called Cohsy Comforts. It’s actually the mom of one of my patients, makes these. She’s had a lot of luck with her son. And on Amazon, there’s something called a SnugBug(affiliate link), you can purchase as well. So you can certainly try that.

Question from Jen on starting sleep training.

What should you do when you start sleep training and your child starts teething or gets sick?

“I delayed starting because those top teeth looked like they’re just about ready to pop through, but actually took three months. So in the end, I started a couple days later, the teething started becoming more painful, and baby got a cold.”

So there’s two questions. A sign when to start sleep training even though teething may be a factor. And what to do when you start sleep training and something comes up. So I’d say the first thing is if you’re starting sleep training, first of all, make sure there’s no major developmental issues on the, on the horizon. If your child’s about to start potty training, if your child’s about to start walking, put it off for a couple of weeks. I wouldn’t worry so much about teething, because those teeth buds, as you said, can linger.

Make sure you have a couple weeks of runway. And by that I mean, weeks where you’re not going anywhere, there’s no major disruptions in schedule, and you know, less helpful in laws aren’t coming to visit. So just kind of plan that out a little bit.

Question from Beth here:

My daughter’s 14 months and still waking once a night to nurse, and then for good between five and six in the morning.

“I don’t know how to wean her. She goes nuts if I try to calm her without nursing. I’m a single mom, so I can’t hand her off to anyone else for comfort. Any advice? I’m dying for a full night’s sleep.”

Beth, I feel your pain. And I think especially single parents struggle with this because, even if you’re not single, some of the parents out there struggle with this as well because, only one of you can nurse typically. I think that I have a couple of thoughts.

One is, you have to think about when you’re ready to wean all together. If you are a parent that works outside of the home, nursing at night may be the only time that you’re nursing. So if you wean those night feedings, it may be the end of your nursing. And that’s totally fine. But it’s really up to you when you’re ready to do that. I think because Beth is kind of alluding to the fact that there’s two parents in the house, will often have the non nursing parent be the one who takes over these feedings. I mean the five or 6:00 A.M. awakening you’re kind of stuck with, but I think you want to think about when you’re ready to stop nursing, and maybe, it may be time to do that. And there’s no magic way to do it. You just kind of have to stop. (For more on weaning feedings, read here).

How do you handle night wakings when they happen? My 19 month old and three year old fall asleep independently but both wake up at night and won’t go back to sleep until I come in and check on them.

Interesting. I wonder if they wake up at the same time, and if they’re in the same room. If that’s the case, there may be one child that’s driving both of these wakings. If kids are really falling asleep independently at night, and they are waking up. My first thought is well, is there a medical issue that could be waking them up at night? The most common in my world is obstructive sleep apnea, so your child snores, you might have them get checked out by their doctor.

If they’re complaining about leg pain, they could have a disorder called restless leg syndrome, which is a problem where you have a lot of kicking, leg restless, and leg discomfort. It occurs in about 1% of kids. And 1% doesn’t sound like a lot but, most kids don’t any medical problems, so that’s fairly common. So I think that I’d sort of look into, you know, make sure you’re not missing any medical cause.

You probably aren’t. Most kids are healthy. And then just sort of see about how you could peel back those, those interventions. And really what you want to do is, do the minimum intervention you can. They’re sharing a room, think about separating the, so one child is not waking up the other. And a check at night should be, I love you, go to sleep, good night, put them back to bed. So let’s keep going.

Katy writes:

My 17 month old falls asleep while being rocked to sleep, but will only stay to sleep two to three hours tops before crying for mom and daddy.

“She refused to go back to sleep in her own crib the second time around. So she ends up in the bed with us, help.”

Katy, many of us have been there, and I feel you. Again, this is a sleep onset association. If you work on the independent sleep, and peeling yourself out at bedtime, that’s going to get rid of those nights of awakenings. Save your energy for bedtime. (On my website, I have a whole bunch of stuff on different ways to use sleep training, whatever your parenting philosophy is.) And then the night time awakenings should drop off.

So Sharon’s writing:

My 18 month old daughter, was sleeping through the night but for a month has been month now waking up a couple times a night. Is it a regression, is it a leap?

“Do we wait out as we have before, try sleep training now? We’ve been weak trying it previously. She was sleeping through.“

The heartbreak when your child is sleeping well at night, and all of a sudden, they’re not anymore. It’s a huge bummer, Sharron, and I’ve got you. I have a couple of thoughts. I’m not crazy about the term sleep regression because I feel like it implies that kids are going back, and it feels that way as a parent. But really, if it’s a change in the sleep pattern associated with a major developmental milestone, I think of it as a step forward. I think that again, if, I’m sorry, let me just look through your question. I’d work on trying to falling asleep independently. I would look to see, you know, if it’s been going on, going on recently. Could she have an ear infection or something like that?

I think the first stop should be your pediatrician. If she’s not falling asleep independently, then I would work on that. I think you should certainly wait a couple of days and see where that gets you. And maybe you don’t have to make any changes.

So Brittany writes asking:

How should I wean a seven month old from multiple sleep associations. At once or in stages?

“Our son needs a bottle before bed, including naps. A pacifier to fall asleep and stay asleep, all while rocking him. Without all of this, he will not go to sleep. He’s unable to self-sooth, which we know is a main part of the problem, but how do we wean him from all these sleep associations at once without all hell breaking loose?”

And it does feel like hell when you’re trying to deal with these issues. Sorry if I’m offending anyone. I would leave the binky as is for right now because it’s pretty common for kids to have that pacifier. The falling asleep with a bottle, I might see if you can move that earlier in the bedtime sequence. So your bedtime sequence is story, song, bottle and rocking. I’d move the bottle earlier. Even if you can do it in a separate room, and then just try rocking him to sleep. And once you’ve broken out that association, then work on getting rid of the rocking and putting him down while he’s still awake.

There may be some crying associated with that. With seven month’s age, it’s difficult to avoid, but typically, it shouldn’t take more than a couple of days to get better. Then you can continue, again, with your middle of the night interventions to survive, but hopefully they’re gonna drop off over time.

So Becky asks:

Can we start sleep training for naps first?

“After six months of sleep deprivation, I broke down and started co-sleeping and nursing all night long with our eight month old. So many bad habits to break. We have a critically ill mother in law. Not a good time to sleep train.”

I agree with you, and I think that self care is an important part of any of these conversations, As parents, we need to decide, do we deal with mom, who’s in the hospital? Do we deal with baby? I haven’t gotten a ton of mileage with sleep training during the day, and a reason is, kids really aren’t that sleepy at nap times, when you think about compared with bedtime. At bedtime, they’ve been awake for most of the day, except for some short sleep periods. Whereas with naps, they’re less tired.

I can tell you Becky, when you child gets a little bit older the naps will get better, say once your he is walking. That was my experience. My older son struggled with naps until he could walk, and then it fell into place. I think that, I would think about what are the small incremental changes you can do.

Where would I start? I think you have to start with where you’re comfortable. I think that, obviously your child is less than a year. I wouldn’t start weaning the breast. I would just again, work on getting your bedtime perfect. Work on removing the, your involvement in your child’s bedtime, and do what you need to in the middle of the night. Your bedtime is your maximum point of energy and strength to deal with these things. So again, if you can kind of step back a little bit from your nursing the child, if your partner could do bedtime, and you could step out. You can go for a walk for an hour or something. Just work on the bedtime. Give yourself a break the rest of the time.

Michelle writes:

How do you wean the baby swing?

“I have a 13 month old who loves her swing. Every night we start in the crib, and she wakes up wanting her swing. If I keep her in the crib, she’s up for hours. If I put the swing in, she’s back to sleep within minutes and sleeps through the night. When you swing wean you?”

First of all Michelle, my oldest son loved the swing. I’m guessing this is your first child, because if your have a second child, there’s no way your leaving them in the swing for periods of time, because now the older child’s going to come and knock him out of it. (Let’s be real here. I have two boys.) I think that, it’s going to happen sooner or later no matter what, because your kid is just gonna get way too big for the swing.

I would again, peel away the swing at bedtime. Do what you need to survive in the middle of the night. Just make sure your kid is safe in the swing, because a 13 month old is probably getting close to exceeding the tolerances for this device.

Kay writes:

For a child with autism, the preschool age, delayed sleep onset and early morning awakenings, what is the best first step in addressing the sleep concerns?

Kay, I think a couple of things. First of all, Beth Malow, wrote a terrific book for parents on dealing with sleep problems in autistic children. (affiliate link). Dr. Malow is a professor at Vanderbilt, School of Medicine, and child neurologist. But she also has two daughters with autism. So she walks the walk. And I would,check out that book.

Here’s step one: get your bedtime just down. Kids with autism will really work well with a visual schedule. So if you actually, just draw it with stick figures, or take pictures of your children doing the things that you want them to do every night at bedtime. Every kid loves this, and I find it works really well with kids with autism.

The other thing is, if you talk to your pediatrician or if your working with, with autism, there maybe a role for medication like melatonin. I’m not the person to tell you if it’s the right thing to do or not, but I’d talk about it with your pediatrician. But, there’s no reason a child with autism can’t sleep better than what you’re describing right now.

Though it is true that some of my autistic patients do seem to need a little bit less sleep than their peers, so also, accepting the early morning awakenings, five to six, and also a later bedtime. It may be meeting your child’s sleep needs. But good luck. It and be challenging,

Natasha, has a 12 month old puts herself to sleep, but wakes once a night for feed.

Will she ever sleep to herself, by herself or do I have to night wean?

Eventually, she’ll give up the night wean, the night feeding. I mean it’s going to happen. So you can either wait for that. I don’t suspect the next couple months, she’s going to raise her hand and say, okay, mom, I’m done with this. So if you want it to stop, you’re probably gonna need to stop it.

Here’s how to do it: if there’s another family member in the house to take care of that awakenings a couple of nights, that would be best. But again, just recognize if you’re not doing a lot of nursing sessions anymore, your risk of weaning all together. That may be desirable for you. Don’t let anyone make you feel bad about weaning. But it can happen.

Katy writes, good Lord, my two year old has decided to resist getting in bed for his nap, every day. Then he naps for two hours. Its just a fight. We did sleep training, he’s in a twin bed. We keep pushing forward, and insisting naps, even though it’s very frustrating.

What should I do when my two year old resists his nap?

There was a study a couple years ago that was looking at napping for, looking at napping in kids with sleep problems at night. And what they found was that a certain subset of kids after age two, napping messes up their sleep at night. And as painful as it is to imagine, giving up that nap, you might try not having the nap, for a week, and doing an early bedtime and seeing if that makes your life better.

The thing is about these nap transitions: they stink. You’re gonna have a period of time where your child is cranky and irritable during the day. It’s never a picnic when they give up the nap. It’s not like they just give it up when they’re ready. But I would try that and see.

Sharon’s writes,

My child takes an hour to fall asleep. Should I stick with the current bedtime or move it later?

Great question. If your child, if you put your bed to, your child to bed at 7:30 and they fall asleep at 8:30, then I would just move the bedtime to 8:30. I promise you it’s going to go more easily. The technical term for this is bedtime fading and it’s often the secret sauce in my sleep training recipes.

Kelly writes:

How do you handle bedtime for a kid who’s overtired after daycare?

Some kids just aren’t ready for bed at bedtime. And we all know melatonin cause it’s in the news and people take it, often fall asleep. Maybe you’ve tried it. Melatonin is made naturally in your brain. What it does is it signals your body to say hey, dude it’s time to go to sleep. The time when that signal starts is called the dim light melatonin..

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The last night of vacation.

Last month, we were leaving for vacation and were en route to the Long Island Ferry. There was heavy traffic on I-95. I looked over at my wife and asked, “Did you pack the kids’ iPads?” She looked at me, with panic in her eyes. “No, did you?”

I’m embarrassed to admit that I was wigging out. What would we do when the kids were bored? How would we have any downtime for ourselves? We were going to a family member’s beach house, with lots of unstructured time ahead of us.

On the ferry to Long Island, where the kids would usually be absorbed in their screens, we actually talked. (And ahem Daddy had a little computer time to work on a project that I’ll be announcing soon). We hung out with my nieces and nephews for the weekend. They had their devices, which they shared amicably. Mostly, however, the kids just played in the pool. When the cousins left, so did the personal electronics. (In the interests of full disclosure, we did let the kids watch TV. This was pretty limited as the place we were staying did not have access to Netflix).

A few days later, my seven year old said, “Vacation is better without iPads because I’m having more fun.” Of my two children, he is not the one I would have expected to endorse such a thought. That dude loves his screen time.

I tried to restrict my screen time as well. I’d like to think that I put it aside much of the time. But reaching for my phone has become so ingrained that I don’t even always notice it. My seven year old asked me, “Daddy, what do you love better: me, or your phone?” That hurt, but it was a wake up call1. On a lighter note, he also noted that “Mommy has a crush on Instagram.”)

We are not zealots about limiting screen time, but we are more strict that many of our friends. No video games on week days during the school year, although a little TV once the homework is done is OK. We are pretty lax on the weekends, but now I’m rethinking it. We’ve tried “digital sabbaths”, otherwise known as “screen free days”, but they can be pretty impractical. Sometimes, you need to look up the number to the pizzeria.

Our parents didn’t have to contend with smartphones, social media, or online gaming. There was a recent article called “Have Smartphones Destroyed a Generation?” which is worth a read. Certainly, this technology is changing our children, as it is changing us. There are good things as well— community, new ways of expressing ourselves, and the benefits of having all of the world’s information at our fingertips.

I’ve written a few articles on the blog about technology as it relates to sleep:

I feel like I’m fumbling to figure these things out. In our family, we are not planning on getting our kids smartphones or allowing social media until they are in high school. My friends with older kids think that this will be impossible. I’d love to know how you are dealing with screen time and social media. Hit reply and let me know your thoughts.


  1. It wasn’t until later that I realized that he may have been pulling my leg. Later in the week he asked me whether I loved him more than A) corn on the cob B) Reading the paper C) coffee. After option C, I told him not to push his luck. ↩︎

The post Our Accidental Screen-Free Vacation appeared first on Craig Canapari, MD.

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Photo by Varshesh Joshi on Unsplash

Periodically I get emails from subscribers to my list. I like to share some of the more interesting questions that people have. These entries are edited for privacy and brevity, and shared with permission.

S. writes:

Our youngest, Tommy, is almost five. Being the youngest of four, getting him into bed before 8 is almost impossible as he doesn’t want to miss out on what his older siblings and parents are doing (our home is one floor, so he can hear everything). The trouble is, that he doesn’t fall asleep for at least two hours. He’s probably over-tired by then. He wants to play, drink, eat (we don’t let him eat, of course, but I’ll bring him water if he needs). We need to lie with him to get him to fall asleep eventually, and he will come into our room to cuddle many times during the night.

He naps for 40 minutes in school but it is done by 2 PM. If we let him sleep in, he will sleep until 9:30 AM. It’s difficult to get him up in the morning.

How do we get him to fall asleep before 10-10:30?

Generally, when we think about five year olds, we imagine them to be early risers. They are typically the first ones up in the morning. The reason for this is that most children have a strong body clock preference for early to bed and early to rise.

However, some children are on a later schedule. It is usually due to lifestyle, a biological preference for a night time schedule, or both. It also commonly occurs over summer vacations.

Lifestyle is clearly a factor in this case given the fact that he seems to be on the schedule of the older children.

Given his preference for late sleep onset and late wake up, there is likely a body clock preference as well. He is sleeping 11 hours when allowed to be on his preferred schedule (10:30 PM-9:30 AM) which is age appropriate.

There is nothing inherently wrong with this schedule, but it sounds like it is inconvenient for the family to have him up so late, and he may be sleep deprived as he frequently has to be woken up. (It’s a good rule of thumb that children who need to be woken up either have insufficient sleep, a problem with sleep (like obstructive sleep apnea) or both.

If Tommy were my patient, here’s what I would consider.

  1. I would use a sound machine for sound masking in his room so that he would not hear the rest of the family.
  2. He will wake up when he has had sufficient sleep. But we need to move his schedule earlier. It is always easier to get someone to stay up later that to go to bed earlier. The best way to move someone’s body clock earlier is to get them up earlier and ensure morning light exposure and exercise. You could go gently (move his wake time earlier by 15 minutes a day) or just get him up consistently at his desired wake time going forward. Consistent wake times and morning light exposures will move his sleep onset time earlier but it will take a week or two. This will likely result in some irritability as he will be sleep deprived.
  3. His target schedule will be based on the usual time you need him up on school days to allow an eleven hour sleep opportunity. So if he can sleep until 8 AM on school days, his target bedtime is 9PM.
  4. I would also try moving his bedtime earlier by 15 minutes each day, with the goal of him falling asleep within 20 minutes of lights out. I would avoid any napping after 3 PM and not allow him to sleep in the early evening.
  5. Once Tommy is on his desired schedule, then you can work on his sleep onset association disorder, using any number of sleep training techniques.
  6. You will need to be very consistent about maintaining his schedule as he likely has a preference for an evening schedule and will shift back if you keep him up for a few nights on weekends or a vacation.

I would discuss this and any adjustment to your child’s sleep with your pediatrician before proceeding, as this is provided for information and is not medical advice.

If you want to sign up for my email list, I’ll send you the best sleep information on the web. Just sign up below.

The post Late to Bed, Late to Rise in a 5 year old appeared first on Craig Canapari, MD.

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This is a guest post written by Cayla Lemire, a friend and former patient. 

Over my 27 years of being alive, the healthcare system has been a part of my life since I was diagnosed at 9 months old. Since then, the hospital has been my second home, while the staff throughout it, has been a second family. Seriously, if you ever need a tour guide around Massachusetts General Hospital, I’m your girl. If it wasn’t for this hospital, and the staff, I wouldn’t be typing this right now. For those of you that experienced my near-death experience with me in 2009, understand that it was a very close call, several times. Just to have a bed in the PICU, costs $10,000 a day. This didn’t include the visits from my 10 specialists, the ICU team, the surgery, the multiple daily tests, or the rehab afterwards. I racked up well over a million dollars during my 100-day stay.

I got to survive, thanks to Medicaid, and MGH’s Free Care program for picking up, what Medicaid didn’t cover. Yes, that’s a thing for those of you who don’t have Medicaid. It’s actually really hard for us to get what we need because the physicians, therapists, and ourselves have to justify every little thing to get approval, sometimes causing our privacy to be invaded. This makes physicians and therapists so frustrated at times because of the amount of paperwork needing to be done, that a lot of them decide not to accept these patients, which means less access to care. For those that still do it, it’s because they want what is best for their patients, and I’m lucky enough to say that mine will keep fighting no matter how many phone calls they must make, and letters they must send. Presently, I am going through denials of certain, and extremely important medical care that could eventually impact my overall health, as I write this.

Now that I am home, it doesn’t mean my medical costs have disappeared. I need around-the-clock care, frequent visits to specialists, routine and unexpected testing, equipment that keeps me stable, and medical supplies to make this equipment work. All of this is not cheap, and I can tell you from experience, most of the reason for it not being cheap is due to those whom are in charge and don’t experience these medical issues, first hand. A small example, shipping a $15 box with TWO 10cc syringes (look up their size if you’ve never held one before), and two feet worth of filler paper to make it seem like there’s more in it. Or, the fact that you can only get ONE portable suction machine, which only costs $400, but if it breaks, and you can’t breathe, an ambulance must come. Giving each patient TWO, could save thousands of dollars, if not more because the patient could aspirate when needing to be suctioned, end up hospitalized, or even die. For me, that means $10,000 a day for a bed in an ICU.

To my point, it should not matter what side you are on, politically. There should not be discussions on who gets to have GREAT medical care, and who doesn’t. When it comes to healthcare, or really anything, no one should be above another person. As far as I see it, your life is not worth saving more than mine because I live off of “free” state insurance. I didn’t choose to be born with a rare genetic disease, and decide that, one day, I was going to get H1N1 and be hospitalized for 100 days. I didn’t choose the need for a $30,000+ custom power wheelchair because I would fall out of the basic one that costs $3,000. Also, I absolutely shouldn’t have to choose whether or not I stop living because of the burden of medical costs that can be put on myself, and my family. This has nothing to do with entitlement. Everyone wants to see the diseases that are advertised on the media to be eradicated, and the epidemic of substance abuse to disappear. Federal funding is what keeps the medical research that finds cures for such diseases going, which is also about to be cut. Unfortunately, most private insurances only cover a percentage of costs for cancer treatments, which means that most families must apply for Medicaid to pick up the rest because it’s impossible to afford. We can all argue about those who have Medicaid that get treatment for substance abuse, yes there are those that abuse the system, but surprisingly, there is a large percentage of people getting treatment due to becoming addicted to pain medications, from those cancer treatments. You can’t judge a book by its cover, or in this case, you can’t judge a person by the insurance card they hand you.

Without Medicaid, I wouldn’t be here, or be able to live a little more equally to those without medical issues. So, before you judge those who use Medicaid, think about the possibility that one of your family member’s could be diagnosed with Muscular Dystrophy, Multiple Sclerosis, Diabetes, ALS, a form of cancer, and so many others, but be told “sorry, we can’t cover you because that’s a pre-existing condition,” and can’t afford to pay out of pocket. Maybe you’re lucky enough to afford the out-of-pocket fees, but don’t assume everyone can. You just never know what can happen in life, to anyone, and politicians should not be the ones to decide. If the most important associations in the medical field, and the top hospitals in this country, such as Boston Children’s Hospital refuse to back up this new proposed bill, then there needs to be more discussions, as well as, input from those that are actually working, and seeing patients, like myself, in healthcare. Maybe I am crazy, but there should also be input from families and individuals, whose lives basically revolve around the healthcare system. Like those who were disabled, pulled out of their wheelchairs (to us, our legs), and thrown out of Capitol Hill for protesting. Just hearing their logical ideas, might actually save this country some money, but what do I know?

You can learn more about Cayla on her Facebook Page Cayla’s Independence. She just finished her bachelor’s degree from Wheelock and is now working on her master’s degree in social work. You can connect with her on Linked In as well.

The post Saving Medicaid– One Woman’s Perspective appeared first on Craig Canapari, MD.

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Last year, the American Academy of Pediatrics (AAP) updated their safe sleep recommendations . This statement reinforced much of what we already knew about how babies should sleep to reduce the risk of sudden infant death syndrome(SIDS) and addressed other causes of death in infancy— specifically accidental suffocation.

According to the AAP, The best way for your infant to sleep is:

  • On a flat firm surface
  • On his back
  • Without any soft covers or blankets (including no crib bumpers or crib blankets

Other ways to reduce the risk of SIDS include:

  • Avoidance of exposure to tobacco smoke during pregnancy and afterwards
  • Avoidance of exposure to alcohol or drugs
  • Routine immunizations
  • Use of a pacifier
  • Continued breastfeeding.

All of these are excellent recommendations. There was one major change, however, that got my attention: the new recommendation that parents room share but not bed share for AT LEAST six months, and ideally up to one year of age, claiming that this could reduce the risk of babies dying in their sleep by “up to 50%”.

Let that sink in for a minute. The American Academy of Pediatrics said that if you have your baby in his own room, he is twice as likely to die. Does that freak you out? It would freak me out.

The Problems with Room Sharing

Anyone who’s shared a room with their infant knows that infants make a lot of noise when they sleep. They snort, cough, cry out, and move.

Now imagine you have just been told by the AAP that it is merely your presence in the room that reduces your child’s risk of dying. You literally have been told that you actively need to keep your child alive all night.

How do you think you are going to sleep at night?

We know that parents who room share sleep less, have more interrupted sleep, and may have less closeness with their partners. Let’s be frank here— having a newborn baby in the room is not going to put you in the mood.

Room sharing is also potentially dangerous as tired parents don’t always make good decisions about, say, falling asleep next to their child which increases the risk of suffocation. Tired parents also may be prone to health issues, and are more likely to get into car accidents. Maternal sleep deprivation is associated with a higher risk of post-partum depression, which is not good for children either.

What’s good about room sharing

Certainly, room sharing can facilitate closeness with your baby. It does make it easier to breastfeed, and to continue breastfeeding, which we know is healthy for both mother and child. And we know that such arrangements are common in much of the world, even if they may not be considered the “gold standard” in how we like to sleep in the United States.

The Problems with the Room Sharing Recommendation

Dr. Aaron E. Carroll examined the evidence sited by the AAP, which was comprised of three studies and an out of print book. He noted a few issues with these studies.

  1. These are “case-control” studies. The issue with these types of studies (which match children with SIDS with similar children in terms of age and gender) is that they may prove a relationship, but cannot prove causation. (Note that SIDS is fortunately rare; the downside is that this type of study is really only the way to study this problem).
  2. These studies were performed in the 1990s. Since the 1990s, there has been a marked decline in the rate of SIDS worldwide, due to education about “back to sleep” and other safe sleep practices. Since the risk of SIDS is much lower now, it is unclear if room sharing is still protective.
  3. These studies were performed in Europe where room sharing is much more common than in the US. Again, this makes it harder to generalize.
Room sharing may be associated with decreased sleep and increased risk to babies

A recent study just examined the relationships between mother-infant room sharing and sleep. It examined the sleep of infants in 259 families. The authors compared the sleep of children at four and nine months of age. They compared three groups of infants:

  1. “Early independent sleepers” who were sleeping in different rooms from the parents at 4 months of age (62%).
  2. “Late independent sleepers” who started sleeping independently between ages 4 and 9 months (27%).
  3. Infants still room sharing at 9 months of age (11%).

The authors examined both sleep habits and safe sleep practices. They found:

  1. Children who were sleeping independently by 9 months of age were sleeping 45 minutes more than room sharers at 30 months of age. Interestingly, there was no difference at 9 months of age. Room sharers were more likely to have night time awakenings and feedings, and to be fed back to sleep.
  2. Early independent sleepers were almost more than twice as likely as room sharers to have a consistent bedtime routine and go to bed prior to 8 pm.
  3. Room sharing infants were twice as likely to have an unapproved soft object on their sleep surface. Moreover, infants who room shared at 4 and 9 months of age were four times more likely to bring their infant into their bed at night. It’s important to remember that co-sleeping is not safe for young infants. 

This study had some significant limitations— it was a secondary analysis, meaning that the original study was not designed to assess these particularly findings. And, like the studies above, the study was designed in such a way that it shows correlation but not causation.

However, this does suggest that babies (and their parents) who room share sleep less— even close to three years of age. It also suggests that the parents who have infants in their room are more likely to perform risky sleep practices at night.

This is of course, one study. But the authors echo Dr. Carroll’s concerns about the new AAP recommendations. They state in their conclusion:

While substantial progress has been made over the past several decades to improve the safety of infant sleep, the AAP recommendation that parents room-share with their infants until the age of 1 year is not supported by data, is inconsistent with the epidemiology of SIDS, is incongruent with our understanding of socioemotional development in the second half of the first year, and has the potential for unintended consequences for infants and families. Our findings showing poorer sleep-related outcomes and more unsafe sleep practices among dyads who room-share beyond early infancy suggest that the AAP should reconsider and revise the recommendation pending evidence to support room-sharing through the age of 1 year.

So what the heck are you supposed to do?

My children were born prior to this very strong recommendation. Room sharing had a soft recommendation. We found that my wife and I slept better in with the children in separate rooms. The children slept better as well.

Some parents sleep better knowing their children are in the same room as them. Some children may sleep better as well. That’s fine. Other families don’t have an extra room for their children. That’s fine as well.

I’m worried about the mental state of frazzled parents who feel that they have to literally sacrifice their sleep to keep their children alive by constant vigilance.

I’m concerned about the quality of the evidence. I’m also concerned about the effect of short and long term sleep deprivation in parents and children. Finally, I believe that long term room sharing may lead to persistent sleep problems like sleep onset association disorder.

I believe that having your infant sleep on her back, avoiding soft materials in the crib, and continuing to breastfeed are more important, especially as they have clear mechanisms to explain why they keep babies safe.

I think that you should talk about this with your pediatrician if you are concerned, but to the parents of my patients who have asked me about this, I say that I believe that sleeping in separate rooms is safe, provided that they adhere to all of the other SIDS prevention recommendations.

I would love to know what you think about this very fraught topic. Leave a comment below.

The post Why Room Sharing in Infancy Isn’t Necessary for Safe Sleep appeared first on Craig Canapari, MD.

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Pediatricians  frequently recommend melatonin for children with sleep problems, or parents might try it themselves. However, the proper use of melatonin is frequently misunderstood. Here is a guide for parents and pediatricians to decide if a child should try it, and to understand how it should be used.

Five Things Parents Should Know About Melatonin - YouTube

A common thread I find in children coming to Sleep Clinic is that many or all of them have been on melatonin at some point, or are taking it currently. Melatonin is an important tool in the treatment of sleep disorders in children, and because it is naturally derived, there is a widespread perception that it is safe. However, I have become concerned by the frequency of its use, especially in an unsupervised way.

Melatonin sales have doubled in the past ten years, increasing from $90 million in 2007 to $260 million in 2012. I worry that the widespread availability of melatonin has led to some parents using it as a shortcut to good sleep practices. An article in the Wall Street Journal (which also provided the sales figures above), quoted a father’s review on Amazon:

OK, yes, as parents my wife and I should do a better job starting the bedtime routine earlier, turning off the TV earlier, limiting sweets, etc., etc. Well, for whatever reason, this is not our strong suit. This 1 mg light dosage of melatonin is very helpful winding our kids down and getting them ready for bed.

In one regard it is safe— unlike many other medications which cause you to fall asleep, you cannot overdose on it. However, parents need to know that melatonin is a hormone with effects throughout the body and we do not yet know what the long-term effects of melatonin use will be. Many parents in the US would be surprised to know that melatonin is only available with a prescription in the European Union or Australia.

NOTE: For the vast majority of kids, I recommend behavioral interventions to treat insomnia, commonly referred to as sleep training. Here’s an overview of the best sleep training techniques. Start there before trying melatonin. 

What is melatonin? What does melatonin do?

Melatonin is a hormone which is naturally produced by the pineal gland in your brain. It is both a chronobiotic agent, meaning that it regulates your circadian or body clock; and a hypnotic, meaning that at higher doses it may induce sleep. Melatonin is usually used for its hypnotic effect, but it does not have this effect in everyone. Only the chronobiotic effect occurs in all individuals.
The natural rise of melatonin levels in the body 1-3 hours before sleep onset is known as the “dim light melatonin onset” (DLMO). This is the signal involved in body clock scheduling of sleep and corresponds to the end of the “wakefulness” signal produced by the circadian system. Children with insomnia may be given melatonin after their scheduled bedtime passes; what this means is that their bodies are not yet ready for sleep. This is one reason why bedtime fading can be so effective for some children. The doses used clinically (0.5–10 mg or higher) greatly exceed the amount secreted in the body.

There are a few things to be aware of:

  • Blue-white light exposure in the evenings shift the DLMO later. This is why bright light exposure in the evenings can worsen insomnia. I highly recommend eliminating ANY screen time for preschool through elementary school children for an hour prior to bedtime. That means no light emitting Kindles, iPads, smartphones, computers, or (God forbid) television in the bedroom For students in junior high and beyond who need to use computers to complete school work, I highly recommend lowering brightness settings and using software to reduce the blue light frequencies. (For more on this read my post about going on a “light diet” here).
  • The effect of dosing melatonin (and light therapy for that matter) are phase dependent. What that means is that the timing of giving melatonin determines both the magnitude and direction of effect. Many people do not realize that the optimal time to dose melatonin for shifting sleep period is actually a few hours before bedtime– that is to say, before the DLMO. The other facet of this is that in teenagers with severely shifted sleep schedule (delayed sleep phase syndrome) may actually have a later shift in their sleep schedule if this is not dosed correctly. Thus I would leave the timing of this to a sleep physician. Jet lag is a similar case[1].
  • “All natural” melatonin is from cow or pig brains and should be avoided. Most preparations around now are synthetic, which is preferable.

Here’s a short video I put together to explain how when you give the melatonin dose really matters. (Maybe just for the supernerds out there like myself).

Understanding Melatonin: The Effect of Timing - YouTube

How effective is melatonin for sleep problems in children?

The overall effects of melatonin include falling asleep more quickly and an increase in sleep time. Like all medicines used to help children fall asleep, there is fairly limited information available. This means that most studies have small groups followed for short periods of time. Furthermore, melatonin not regulated as a pharmaceutical in the U.S. Thus, there is no large pharmaceutical company bankrolling larger and long-term studies (more on this below) . Rather it is regulated as a food supplement by the FDA.  For a terrific review, including dosing recommendations, I highly recommend this article by Bruni et al.

Chronic sleep onset insomnia and Melatonin:

Problems with falling asleep are common in children, just like in adults. In children with chronic difficulty falling asleep within 30 minutes of an age-appropriate bedtime. [2] Use of melatonin results in less difficulty with falling asleep, earlier time of sleep onset, and more sleep at night. The initial studies used pretty high doses, but later studies comparing different doses showed that dose didn’t matter, and that the lowest dose studied was as effective as the highest.[3] This is likely due to the fact that ALL these doses were well above the amount produced naturally in the children. Timing between 6–7 PM was more effective than later doses. The authors point out that a midafternoon dose would have the best effect (due to the phase response curve) but that afternoon dosing would have the unpleasant side effective of making children sleepy in the afternoon. (For more info, read here and here and here).

Autism and Melatonin

Sleep problems are common in children with autism. Multiple types of problems occur, including prolonged time to fall asleep, less sleep during the night, and problems with nocturnal and early morning awakenings. Some children with autism have decreased levels of melatonin as well as decreased variation in melatonin secretion throughout the day. Because of this, melatonin has commonly been used in autistic children, which seems to result in less difficulty falling asleep and more sleep at night. Some studies used immediate release preparations, whereas others use long acting forms of melatonin. The majority of studies involved melatonin dosing 30–60 minutes prior to bedtime.
Interestingly, these studies also demonstrated improvement in other domains in some children– specifically, communication, social withdrawal, stereotyped behaviors, and anxiety.
As in other children, melatonin should be added to a behavioral management plan. For pediatricians, there is a great practice pathway which suggests the addition of medication only after a behavioral intervention has failed. Two great resources for families are the Autism Speaks Sleep Toolkit, and the book Solving Sleep Problems in Children with Autism Spectrum Disorders: A Guide for Frazzled Families(affiliate link). Here is a terrific review article on this topic as well.

ADHD and Melatonin

Attention deficit hyperactivity (ADHD) is commonly associated with sleep problems, just as sleep problems can cause attentional issues. As many as 70% of children with ADHD may have sleep problems. Sleep problems include difficulty falling asleep, abnormalities in sleep architecture (e.g. the proportions of different stages of sleep), and daytime sleepiness. Trials of melatonin (in doses ranging from 3–6 mg) showed that it helped children with ADHD to fall asleep more quickly, although there was no evidence of improvement in attentional symptoms during the day. Side effects reported included problems with waking up at night and daytime sleepiness in some children. There is a nice review article here.

Delayed Sleep Phase Syndrome and Melatonin

Delayed sleep phase syndrome (DSPS) is a common disorder in teens, where their natural sleep period is shifted significantly later than the schedule which their commitments (usually school) mandates. Thus, teens with this disorder an unable to fall asleep by 1–2 AM in the morning or even later. I have seen kids who are routinely falling asleep between 4–5 AM. Melatonin has a clear role in this disorder, as small doses 3–4 hours earlier than sleep onset (along with light exposure limitation, sleep hygiene measures, and gradual changes in schedule [chronotherapy]) can be effective in managing this disorder. The reason for the delay is a marked delay in the DLMO, so melatonin dosing can move sleep periods earlier. For children with DSPS, giving a dose 4–6 hours prior to the current time of sleep onset, then moving it earlier every 4–5 days, is recommended, with low dose preparations. Of all the conditions mentioned here, this has the clearest benefit from melatonin. Here is a terrific review article.

Children With Neurodevelopmental Delay and Melatonin

Children with various causes of neurodevelopmental delay may have significant insomnia and melatonin may help. However, in some children melatonin use caused persistently high daytime blood levels of melatonin (and daytime sleepiness).

Blindness and Melatonin

Some children with blindness may have issues with sleep wake time as they do not have light regulating their circadian clock and may thus develop sleep disorders. Very small trials in adults have shown benefit (here’s one) but the data is very limited.

Eczema and Melatonin:

Eczema is associated with dry, itchy skin and kids with it can have problems with insomnia and non-restorative sleep. Some research has suggested that children with eczema may have low melatonin levels, and a recent trial suggest that melatonin may be helpful.

It sounds great. Why should I worry about melatonin?

There are several areas for concern, specifically known and theoretical side effects, and problems with preparations.

  • Side effects (known): In the short-term, melatonin seems to be quite safe. Unlike many other sleep inducing agents, “no serious safety concerns have been raised” (from Bruni review below). The most common side effects include morning drowsiness, bedwetting, headache, dizziness, nausea, and diarrhea. These effects are generally mild, and in my practice only the morning drowsiness seems to be significant. It can also interact with other medications (oral contraceptives, fluvoxamine, carbemazepine, omeprazole, and esomeprazole, to name a few).
  • Side effects (theoretical): Melatonin given to children may lead to persistently elevated blood melatonin levels throughout the day. This can be associated with persistent sleepiness, but the other effects are unclear. It is important to know that melatonin has NOT been tested as closely as a pharmaceutical as the FDA regulates it as a food supplement. The studies following children who have been using melatonin long-term have relied mostly on parental reports as opposed to biochemical testing. A physician in Australia named David Kennaway has published two editorials this year pointing out the inadequacy of information on long-term use in children. (You can read these here and here). He states his point of view in a pithy fashion]”

    …parents should always be informed that (1) melatonin is not registered for use in children, (2) no rigorous long-term safety studies have been conducted in children and by the way (3) melatonin is also a registered veterinary drug used to alter the reproduction of sheep and goats .”

  • Problems with preparations– poor labeling:Melatonin preparations have been shown have to variable concentrations from preparation to preparation. Moreover, the amount that a child’s body absorbs may vary.  Remember how I told you that melatonin was treated as a food supplement by the FDA? This is a common preparation. . . . . .but the label is not clear that it is 0.25 mg in each dropperful. Many parents think it is 1 mg / dropperful.

    This means there is substantially less regulatory oversight in terms of safety and efficacy. I also find that the labelling of preparations is frequently misleading. Take the example of this liquid preparation, which many of my patients have tried. It is labeled as “1 mg” but each dropperful contains 0.25 mg.

    You need to go to the web to get this information as it is not on the bottle. (It may be in the package insert, but I suspect few people read these).

  • Problems with preparations– inaccurate dosing: A recent study showed that the amount of melatonin can vary anywhere from -83% to +478% from the labeled dose. This means that if you are giving your child a dose of 3 mg, the actual dose may actually be anywhere from 0.5 mg to 14 mg. Moreover, the lot to lot variability was as high as 465%– meaning that you may buy a different bottle of medicine, from the same manufacturer, and still one bottle may have more than four times as much as melatonin as another, Finally, the researchers found serotonin (a medicine used in other conditions, and also a neurotransmitter) in 71% of samples. To me, this is the most concerning issue with melatonin– you don’t know what you are getting. 
 My child is already on melatonin. Do I need to freak out?

I don’t think so, as there is little concrete evidence of significant harm. However, if you started melatonin on your own I beg you to discuss it with your child’s physician to see if it is really necessary. If your child has been using it long-term and sleeping well, you can consider slowly reducing the dose and seeing if it is still really necessary. Try to use it as needed as opposed to nightly. Also, I would take a hard look at sleep hygiene and ensure that you are ensuring good bedtime processes such as a high quality bedtime routine and avoidance of screen time for at least an hour prior to bedtime. I would try to reduce the dose, and potentially only use it as needed as opposed to nightly.

My doctor and I have talked about it. What should we consider regarding how and when to give melatonin?

Melatonin can be a tricky medication to dose. Effects change depending on when you give it compared to your child’s usual sleep schedule. Thus, a small dose a few hours before bedtime can have more of an effect than a large dose given at bedtime. In some situations (as with people whose sleep schedules may be flipped to a daytime sleep schedule) dosing may the opposite effect. This is a special case and should be addressed with your physician. A couple of rules of thumb.

  • Timing: For shifting sleep schedules earlier 3–6 hours before current sleep onset is best. For the sleep onset effects, 30 minutes before bedtime is recommended. Remember, not every child gets sleepy with melatonin.
  • Dosing: In general, I would start at a low dose (0.5–1 mg) and increase slowly. Recognize that melatonin, unlike other medications, is a hormone, and that lower doses are sometimes more effective than higher ones, especially if the benefit of it reduces with time.
  • Good Sleep Hygiene is Critical: Melatonin is not a substitute for good sleep hygiene practices and should only be used in concert with a high quality bedtime, limitation on light exposure, and an appropriate sleep schedule.
  • When possible, purchasing a USP Verified preparation may indicate that the product is manufactured to the requirements of the U.S. Pharmacopeial Convention, which could mean that the quality controllers are tighter.
What is the take home? Should my child take melatonin?

I have not met a parent who is eager to medicate their child. Such decisions are made with a lot of soul-searching, and frequently after unsuccessful attempts to address sleep problems via behavioral changes. Treatment options are limited. There are no FDA-approved insomnia medications for children except for chloral hydrate which is no longer available. Personally, I use it commonly in my practice. It is very helpful for some children and families. I appreciate Dr. Kennaway’s concerns but I have seen first hand the consequences of poor sleep on children and families. I always investigate to make sure that I am not missing other causes of insomnia (such as restless leg syndrome). My end goal is always to help a child sleep with a minimum of medications. I know that this is the goal of parents as well. Some children, especially those with autism of developmental issues, will not be able to sleep without medication. So, melatonin may be a good option for your child if:

  • Behavioral changes alone have been ineffective
  • Other medical causes of insomnia have been ruled out
  • Your physician thinks that melatonin is a safe option for your child and is willing to follow his or her insomnia over time

So, this has been quite a long post. Do you have questions about melatonin use in children and teens? What has your experience been?

A special thanks to Bob Young R.Ph (aka the legendary “Bob from Pharmacy”) for his assistance with this.

  1. If you would like more information on this I recommend this Cochrane review on the topic, and this WebMD article.  ↩
  2. An age appropriate bedtime was defined as 8:30 PM + 15 minutes x (age in years – 6). These children had had problems for at least a year for at least four nights per week.  ↩
  3. The initial trials both used 5 mg around 6 PM. A later trial tried multiple doses. Interestingly, the dose did not matter, and the lowest dose (0.05 mg/ kg of the child’s weight) was equally effective. [So, for a 40 lb child– 40/2.2 = 18. 2 kg. 18.2 * 0.05mg/kg = 0.91 mg].  ↩

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The post Melatonin For Children? A Guide for Parents appeared first on Craig Canapari, MD.

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Teenagers are more sleep deprived than ever before— about 85% don’t get enough sleep at night. There are lots of reasons for this: excessive homework, too early school start times, and the intrusion of the internet into the bedroom. Here are some of my best teen sleep tips which I suspect you haven’t heard before.

I’m sympathetic— I see a lot of tired teenagers in my clinic. I know it isn’t easy for either teens are parents. I also know that some advice is easy to give, but hard to follow (like “GO TO BED EARLIER”) when teenagers are hardwired to stay up later and get up later. (Young people naturally want to sleep from midnight to 9 AM— if school started at 10 AM, teens would be a lot healthier and happier).

In a perfect world, the best way to ensure that teenagers get enough sleep is to work in your community is to start school later (and I encourage you, dear reader, to contact your school superintendent right now and ask him or her why school starts so early in your town). But change takes a long time— and you may be a desperate, exhausted junior right now.

Here are the tips I have found that work, and you can realistically accomplish.

1. Get extra sleep in the morning by avoiding the snooze button

Do you like hammering away at that snooze button? Me too. But here’s the thing— it feels great to get those extra ten minutes of sleep, but you are really cheating yourself. If you set your alarm at 6 AM but never get out of bed before 6:45 AM, just set the alarm to 6:45 and get out of bed. Even if you need 45 minutes to wake up at 6AM, that does not mean it will take you that long to get up at 6:45. Why? Because you have had an extra 45 minutes of uninterrupted sleep.

2. Tactical napping (and caffeine if necessary)

The dogma in the sleep hygiene field is that both napping and caffeine should be avoided— for the reason that they can interfere with the ability to fall asleep at night. However, if you can’t keep your eyes open, you need to do something, especially if, say, you need to finish your history paper or drive somewhere. (Driving drowsy is like driving drunk— please don’t do it). Instead, take a tactical nap. I define this as a short nap (15-20 minutes) preferably in the afternoon. Here’s the key to tactical napping: don’t do it in your super comfortable couch or bed. Do it with your head down on a desk or reclining in your car— someplace you are unlikely to fall asleep for prolonged periods.

Sleep experts have actually studied small doses of caffeine— say, a cup of tea or small coffee— prior to a short nap. (this is sometimes called a napuccino–I can’t decide if I find this adorable or horrifying) It turns out that it is a pretty great way to wake up in a short period of time. I would experiment with short tactical naps first as that is often equivalent to having a cup of coffee.

3. Keep an eye on the homework

In college, I only pulled an all-nighter once— to get a lousy B- on my Biochemistry final. I should have known better. Research has actually shown that getting sleep will help you perform better on a test than staying up all night studying. If you can’t finish your homework at night, go to bed. Trust me. It will be there in the morning. If this happens a lot, please talk to your parents and your teachers. Believe it or not, there’s not a lot of evidence that homework helps kids learn.

4. Digital liberation:

Ok. I don’t win a lot of popularity contests here. But cell phones are totally corrosive to a good nights’ sleep. Why is this?

  • They emit light that keeps you awake at night by suppressing melatonin secretion in your brain, which keeps you from falling asleep.
  • They are powerfully addictive. You know how you want to scroll down Instagram just a few more photos or read a few more tweets? Guess what? Social media sites and apps have been engineered by people richer and smarter than you or I to keep you checking in, commenting, posting, liking, etc. That is how they get paid.
  • They fragment sleep by emitting alerts during the night Just the other night, my wife and I woke up because I received a text message. Here’s the thing— my phone was silenced and in the bathroom, but the light was still sufficient to wake up two sleep deprived adults at 1 AM.
  • They can generate anxiety and frustration right before bedtime.  Anxiety and stress are contagious, and if you are an anxious or stressed teen, your peers probably are too. Trust me, those Instagram posts will be there in the morning.

(If you want more information here’s more on why electronics in the bedroom are a bad idea.)

There’s a couple of things you can do so you can control your phone, instead of it controlling you.

  1. Keep it out of your room. Give it to Mom and Dad and ask them to charge if for you. Tell them to lock it in their car if you are worried you can’t resist the temptation.
  2. Turn on “Do Not Disturb” and “Night Shift” (on Apple Devices). These options limit interruptions from your apps and lower the color temperature on your phone. These means there is less blue white light, which is the kind of light that suppresses melatonin. (Note that this is not as good as avowing light altogether. 
  3. Use an app like Freedom to limit your digital consumption. I love this service. It allows you to block apps and websites across all of your devices. You can schedule it or do it on demand. I use it to block all of my social media sites every night from 11 PM-8 AM (a routine code-named “Night Sanity”) to break my bad habit of scrolling through Twitter right before bed.  Right now I have it running so that I can’t go read any of my favorite sites or check Instagram while I am writing this.

    This is what it looks like when Freedom is blocking Twitter.

Now, I know you sometimes actually do need to use electronics to complete your schoolwork. I highly recommend the free f.lux software to limit your blue white light exposure from sunset to sunrise.

5. Less light at night, more in the morning

So, light at night is bad for sleep— but in the morning it’s great. There was a recent study showing that teenagers camping out without electronic devices rapidly reset their body clock by going camping:

End all artificial lights at night for at least a weekend and drench your eyes in natural morning light, says a professor of integrative physiology at the University of Colorado, Boulder and senior author on a study on resetting sleep cycles. The most straightforward way of doing this is to forbid any electronics on a camping trip.

One easy way to do this is get an alarm clock that uses light to wake you up. I got one of these, and it is shockingly effective. (It also does not wake up my six year old, who is out of bed like a shot when my alarm goes off).

The clock starts increasing lightly slowly for 30 minutes prior to a more conventional (read noisy) alarm goes off. Since starting with this I am falling asleep more easily at night and getting up more easily in the morning. I highly recommend this model.

5. On weekends and vacations, stay on the “Plus Two” Schedule

Here’s where I differ a little bit from the traditional sleep dogma. In a perfect world, you should sleep on the same schedule every day. However, most teenagers are so sleep deprived that I don’t think that this is fair.

For my patients, I generally advocate for a “plus two” schedule. What this means is getting up two hours later than you get up for school. This lets you catch up a bit on weekends but should not throw your schedule out of whack. I also recommend keeping this schedule on school vacations.

7. Consider melatonin— if your doctor thinks it is a good idea.

Melatonin is a frequently misunderstood medication. (I wrote more on melatonin here if you want the details). In a nutshell, it has two effects. It can alter sleep schedules, and it can make you sleepy.

Most of my teenage patients actually need help with their schedule. Thus, the most effective way to use it is 0.5 mg at dinner time, as this will help move your sleep schedule a bit earlier. Sometimes I may add a small dose at bedtime (1-3 mg as well).

Note that melatonin is a medication and I’m not recommending that you take it. I recommend you discuss it with your pediatrician.

8. Have someplace besides your bed to relax

One of the principles of managing insomnia is called stimulus control. This is a fancy way of saying, if you are having problems sleeping, stop doing stuff in your bed besides sleeping. If you do your homework, watch TV, eat fried chicken, etc in your bed, tell your parents to take you to Ikea and get you a nice chair for you to relax in. Trust me, this will help.

So here are my practical tips for sleep deprived teenagers. Let me know what works for you in the comments.

Note that there are affiliate links in this article which help to defray the cost of running this website.

The post Eight Teen Sleep Tips You Haven’t Heard Before appeared first on Craig Canapari, MD.

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