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As much as we’re learning about sleep and how integral it is to our health and livelihood, there’s still so much we don’t know. It’s fascinating to me how much mystery still surrounds it. Maybe less fascinating when you have a toddler that just will not get with the sleep program… which is why I invited Dr. Sujay Kansagra to share his wealth of wisdom.
Dr. Sujay is the expert behind the super popular Instagram account, @thatsleepdoc. By training, he is a child neurologist and also completed a fellowship in sleep medicine, making him the perfect practitioner to chat with about sleep disorders in children. Oh, he’s also a professor and director of the child neurology sleep program at Duke University and author of the book, My Child Won’t Sleep, so… he knows a little bit about sleep.
Dr. Sujay answered some of my sleep science questions, then joined me in answering questions submitted by my Instagram followers especially for this conversation, so I just know you’re going to get so much out of our chat.
Let’s jump right in!
>>Watch this blog on my Awesome Little Sleepers YouTube channel! 👇
What’s the importance of sleep, according to science?
"I constantly hear from families who are struggling with sleep challenges with their toddlers and preschoolers. They’re concerned about trying to hold boundaries and worried about the pushback that they're going to get from their kids. So, I spend a lot of time explaining to families that sleep isn't just a “nice to have.” I had to get Dr. Sujay to explain more about the science of sleep.
“It really is a foundation for our health. We know that if you don't sleep, just about every single medical, behavioral, and psychiatric condition gets worse because sleep is a biological imperative.
If you think about it, even just from an evolutionary standpoint, when you're sleeping, you're not really doing anything to promote your survival. So there's got to be a really good reason why we sleep, right?
And the reason is because it does so much for the development and the continued maintenance of our brains.
Young children that are developing very quickly as far as their brains tend to sleep a lot more. And one of the main things that impact day-to-day life for children is how much sleep impacts behavioral regulation and learning.”
When should families seek out a sleep consultant versus a doctor?
“It probably depends on access to care for you, depending on where you live.
When I first started, I was seeing the more typical behavioral issues with sleep onset association issues for infants and limit-setting issues for toddlers. Over time, the clinic has shifted to more of an intractable insomnia clinic for children that have other neurologic comorbid conditions. I have [treated] children that have had, for example, hypoxic ischemic injury at birth, have intractable seizures, children have genetic disorders that are associated with neurodevelopmental challenges and sleep is often affected. I also see children on the autism spectrum very frequently that have challenges with sleep.
If the child is snoring and has some sort of daytime manifestation or a sign or symptom of obstructive sleep apnea, that's a good reason to get into a sleep lab for a sleep study or come see a pediatric sleep doc. Other medical sleep disorders like restless leg, for example, for older children, are oftentimes confused with growing pains. Restless leg is much more common than we think amongst young children and often diagnosed very late.
When it comes to our world of sleep consultants who tend to be huge advocates for the sleep science and the behavioral approaches for sleep, I always say you want to make sure that your sleep consultant is abiding by what we know about the sleep science, because there are lots of different approaches out there.
As long as who you’re getting advice from is a believer in the science behind sleep and is keeping up with the science behind sleep, that's the main goal. And they can provide a lot of one-on-one guidance to personalize intervention for your child.”
Does science give guidance about crying during sleep training?
"The whole question behind crying is first and foremost, nobody wants infants to cry.
In my book, I say that we're actually trying to prevent crying because having to wake up multiple times and get caregivers' attention because you can't fall back asleep on your own may be a little uncomfortable for the child.
I equate it to, if you fall asleep on your bed and then while you're asleep, somebody puts you on your kitchen floor and you wake up on your kitchen floor, you're not going to be happy about that. Similarly, if children are used to falling asleep in a certain environment, a certain set of circumstances and then they wake up in the middle of the night and those circumstances are no longer there, they're not going to be happy about it, and they express that discontent with crying.
So our goal is to teach them how to become self-soothing. They don't have to cry. They rely on their own mechanisms to get back to sleep, and make them enjoy the process of falling asleep and staying asleep.
As long as they've hit a certain age and are otherwise healthy, growing well, et cetera, the science behind outcomes when it comes to what happens to sleep training, in the data, there's really no debate. The debate is in the social media world. If you're a believer in the science of sleep and the data behind sleep, there's zero debate about sleep training.”
And after eight years of sleep consulting and talking to families, I find that there is less crying when you have a plan.
When you have a consistent plan, you're doing the same thing night after night, your child is getting used to a new experience. New experiences are hard. They can feel different. They can feel a little bit unnerving. That's why they're crying.
But the more consistent you are with giving them a new experience, the crying only lasts for a little bit of time compared to potentially months or years of parents dealing with stalling tactics or refusing to sleep at bedtime.
Addressing nighttime fears: stalling tactic, legit, or red flag?
"For young children, toddlers in particular, a lot, if they're, if they have an intrinsic disposition to anxiety, oftentimes it presents a separation anxiety very early.
There's going to be some difficulty of separation when you're first dropping your child off at daycare for the first time, and that's all normal. But if it's persistent, to the point that it's causing weeks and weeks of challenges, you've got to think, well, maybe my child has some underlying separation anxiety tendencies or some generalized anxiety tendencies.
Anxious tendencies we know that there is a genetic predisposition. Is there a family history of anxiety? Do they fixate on routine? Does it really bother them when you do things out of routine? Do they end up asking frequent repetitive questions, even though you've tried to reassure them?
I'm always wondering, is there bedtime-related anxiety? In which case it affects the method that we use to help them with sleep and transitioning to sleep, particularly toddlers. Parents are usually pretty good at perceiving what is a delay tactic versus what is true anxiety by reading the expressions of their child.
We want to build their confidence in the sleep environment and make sure that they feel safe, secure while we're going through the nighttime equation. But if they're fighting hard against you just at sleep, do you feel like in that situation they're anxious or worried about something like the dark or being alone, or do you think they're just pushing their limits?”
I added that kids who only seem anxious or clingy at night can also be displaying that as a symptom of overtiredness, and Dr. Sujay agreed, then clarified the concept of ‘overtired.’
"We talk about this concept of overtired, but what it ends up likely being is that we're hitting the peak in our circadian wakefulness at nighttime. What’s helping offset that is that throughout the day, there's another sleep drive called the homeostatic drive, making your brain feel sleepier. Then at nighttime, the homeostatic drive is very high, wanting you to go to bed, but your circadian rhythm may also be a little bit high, wanting you to stay awake, which develops a bit of a push flow in your brain, and the child is having a really hard time.
In that situation, sometimes it does help to move bedtime earlier. Try to get them settled before that peak occurs so that they're asleep before their circadian peak."
How do naps affect bedtime, and when should parents drop their toddler’s nap from the routine?
"There's so much variability from child to child. I've seen somewhere between [age] three and five in some children, even until close to six may still be wanting that nap. I think it really just depends on individual differences regarding sleep needs and their overall sleep drive.
If your child is consistently able to fall asleep around that nap time around noon, one o'clock, then give them the nap.
But it all depends on your goals for the night. If a child is falling asleep at two o'clock and sleeps until 4:30, it is probably not the best situation to get your child to sleep by 7:30, 8 o'clock. They're likely going to be up till 9:30, 10 o'clock in that scenario.
Ideally, still try to shoot for that nap around noon, which tends to be when our circadian rhythm takes a little bit of a dip and makes us feel sleepy anyway, and ideally being awake by 2 or 3, if we're going to shoot for that 7:30-ish bedtime."
Don’t forget, you can learn more about Dr. Sanjay and the work he does on Instagram, @thatsleepdoc.