taming wild families in the exam roomalprazolam (xanax®) 0.75-4 mg 1.5-6 mg see chart below for...

Taming Wild Families in the Exam Room

A step-wise approach to encouraging appropriate behavior during appointments with young children.

Randall Reitz PhD LMFT

1. Be mindful: a) the family’s context b) your own reactions

2. Set up the space for success:

Do not remove the child from the parents. If the child is at the exam table, ask the parent to stand alongside,

Position yourself by or remove dangerous or breakable objects,

Provide safe stimulation (books, safe play objects),

Learn and use everyone’s names.

3. If you have any sense that chaos might be looming, start with parent education and expectation setting:

“I encourage parents to be very involved during appointments”

“It helps me to see your parenting style, so please maintain your parenting authority during the visit, as if you were at home.”

(If you’re concerned about aggressive behavior) “I will rely on you to ensure everyone’s safety”.

4. Ignore minor annoyances. Choose your battles, but be 100% consistent with your

expectations. 5. Commend the parent for anything that works well (i.e. catch them doing good):

“Your child really responded well when you____”,

“Thank you for setting limits with your child”,

“Would you please do____ again? You did that very well.” 6. Use an economy of words to empower the parent(s) to be hands-on and pro-active

rather than preaching or jumping-in and parenting for them:

“Is it OK for you that your child just ____?”

“What typically works for you to re-direct your child when s/he does____?”

“Would you please try that now?”

“I need you to prevent your child from doing_____.”

“Please separate/sit between your children.”

7. In most cases require the parent and child to clean-up any messes.

8. When violence occurs, or if the parent repeatedly declines to intervene, do one or more of the following:

If you feel safe, make one attempt to separate children who are fighting,

Call in a nurse or colleague,

Finish the appointment early and inform the patient that you will see them again when the parent can ensure appropriate behavior,

Dismiss families with habitually egregious behavior from your practice.

Medications for Anxiety

Medication GAD1 SAD2 OCD3 PD4 CommentsSelective Serotonin Reuptake Inhibitors (SSRIs)Citalopram (Celexa®) 20-40 mg 20-40 mg See antidepressant comparison

chart for more details on sideeffects

Escitalopram (Lexapro®) 10-20 mg 10-20 mg 10-20 mg 10-20 mgFluoxetine (Prozac®) 20-40 mg 20-60 mg 20-40 mgFluvoxamine (Luvox®) 100-300 mg 100-300 mg 100-300 mgParoxetine (Paxil®) 20-60 mg 20-50 mg 20-50 mg 20-60 mgSertraline (Zoloft®) 50-150 mg 50-150 mg 50-200 mg 50-150 mg

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)Venlafaxine (Effexor®) 75-225 mg 75-225 mg 75-225 mgDuloxetine (Cymbalta®) 60-120 mg

Tricyclic Antidepressants (TCAs)Clomipramine (Anafranil®) 75-300 mg 75-250 mgImipramine (Tofranil®) 75-200 mg

Monoamine Oxidase Inhibitors (MAOI)Phenelzine (Nardil®) 45-90 mg 45-90 mg 45-90 mg

Atypical AntipsychoticQuetiapine (Seroquel®) 50-300 mg

BenzodiazepinesAlprazolam (Xanax®) 0.75-4 mg 1.5-6 mg See chart below for additional

informationChlordiazepoxide (Librium®) 15-100 mgClonazepam (Klonopin®) 0.5-4 mg 0.5-4 mgDiazepam (Valium®) 5-15 mg 5-20 mgLorazepam (Ativan®) 1-10 mg 1-10 mgOxazepam (Serax®) 30-120 mgClorazepate (Tranxene®) 15-60 mg

Tricyclic AnxiolyticBuspirone (Buspar®) 15-60 mg Augmentation therapy, gradual onset

of action over 2 weeks

OtherMirtazapine (Remeron®) 30-60 mg 30-60 mg

AntihistamineHydroxyzine (Vistaril®) 50-400 mg

AnticonvulsantsGabapentin (Neurontin®) 600-3600 mg Augmentation therapy

1. Generalized anxiety disorder (GAD) – excessive anxiety and worry. Somatic symptoms may include restlessness, irritability,difficulty concentrating, muscle tension, sleep disturbances, and being easily fatigued

2. Social anxiety disorder (SAD) – marked, persistent, and unreasonable fear of being observed/evaluated negatively by others in asocial situation. Feared situations are avoided or endured with intense anxiety or distress

3. Obsessive-compulsive disorder (OCD) – recurrent obsessions (thoughts) and/or compulsions (actions) that interfere withfunctioning.

4. Panic disorder (PD) – recurrent panic attacks. Panic attacks are discrete periods of intense fear or discomfort, accompanied by atleast four of the following symptoms: palpitations, sweating, trembling, chocking sensations, chest pain, nausea, abdominal distress,dizziness, feeling of unreality, and fear of dying. Panic attacks generally peak within 10 minutes and lasts 30-45 minutes onaverage.

Comparison of benzodiazepinesMedication Indication Onset of

ActionRelativePotency (mg)

Comments

Clorazepate (Treanxene®) Anxiety, EtOH withdrawal,seizure

Rapid 7.5 Long-acting metabolites increase risk foraccumulation

Diazepam (Valium®) Anxiety, EtOH withdrawal,muscle spasms, seizure

Rapid 5 Long-acting metabolites increase risk foraccumulation

Alprazolam (Xanax®) Anxiety, panic disorder Intermediate 0.5 Increased risk for abuse due to greater lipidsolubility

Chlordiazepoxide (Librium®) Anxiety, EtOH withdrawal Intermediate 10 Long-acting metabolites increase risk foraccumulation

Clonazepam (Klonopin®) Panic disorder, seizure Intermediate 0.25Lorazepam (Ativan®) Anxiety, seizure,

chemotherapy induced nauseaIntermediate 1 Preferred in geriatric patients

Triazolam (Halcion®) Insomnia Intermediate 0.25Oxazepam (Serax®) Anxiety, EtOH withdrawal Slow 15 Preferred in geriatric patientsTemazepam (Restoril®) Insomnia Slow 15 Preferred in geriatric patients

EtOH=alcohol

Common side effects of benzodiazepines Central Nervous System (CNS): Drowsiness, sedation, ataxia and poor recall. Anterograde amnesia is more common with

alprazolam and lorazepam Paradoxical effect: Irritability, aggression, and excitement

Tips for tapering benzodiazepines Tapering benzodiazepines reduces risk of relapse or rebound of condition being treated (insomnia, anxiety, agitation, tremor,

nausea, vomiting, sweating, tachycardia), and withdrawal symptoms (tinnitus, hallucinations, perceptual disturbances, seizures).

Risk factors for withdrawal: use over one year, high dose, short or intermediate half-life

Withdrawal symptoms have been seen after as little as six to eight weeks of treatment with alprazolam.

Direct taper option 1: Decrease by 25% the first week, by 25% the second week, then by about 10% every week. Monitor patient forwithdrawal or worsening of condition treated. If needed, continue present dose for a few extra weeks, or return to higher dose ifneeded.

Direct taper option 2: Taper to diazepam 10 mg or equivalent, maintain dose for one to two months, then taper over four to eightweeks.

Direct taper option 3: Taper by 10% every one to two weeks until 20% of the original dose is reached. Then taper by 5% every twoto four weeks.

Diazepam switch & taper (for patients on high doses for over a month, or regular use for over three months, especially if relativelyfast taper desired): Consider switching short or intermediate half-life drug to equivalent dose of diazepam (multiply triazolam doseby 20, alprazolam dose by 10, and lorazepam dose by 5 to get the approximate equivalent dose of diazepam), then taper.

If short-term use of long-half-life agent: (i.e. up to four weeks’ use of clorazepate or clonazepam): taper over one week.

References

1. Bandelow, Borwin, Sher, Leo, Bunevicius, Robertas, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. International Journal of Psychiatry in Clinical Practice, 2012; 16:77-84.

2. Dipiro JT, etal. Pharmacotherapy: A Pathophysiologic Approach, 9th edition: Section 6.Psychiatric Disorders; Chapter 37.Generalizedanxiety disorder, panic disorder, and social anxiety disorder; McGraw –Hill Global Education Holdings,LLC

3. PL Detail-Document, Benzodiazepine toolkit. Pharmacist’s Letter/Prescriber’s Letter. 2011;27(4):270406..

1

Medications for the Treatment of Depression

Selection of an antidepressant may be based on side effect profile or to target the most distressing/disruptive symptom.

Comparison of antidepressants side effects and usual adult dosage

DrugsUsualdosage(mg)

Side effects

ACH SeizuresOrthostatic

HypotensionSedation Activation

GIUpset

Sexualdysfunction

Weightgain

SSRI’s Selective Serotonin Reuptake Inhibitors

Citalopram (Celexa®) 20-60 0 ++ 0 + + +++ +++ +

Escitalopram (Lexapro®) 10-20 0 0 0 0 +++ +++ +

Fluoxetine (Prozac®) 20-80 0 ++ 0 0 ++++ +++ +++ +

Fluvoxamine1 (Luvox®) 100-300 0 0 0 + +++ +++ 0

Paroxetine (Paxil®) 20-50 0 ++ 0 + ++ +++ +++ +

Sertraline (Zoloft®) 50-200 0 ++ 0 0 +++ +++ +++ +

*Vilazidone (Viibryd®) 10-40 0 0 0 0 +++ +++ 0*Vortioxetine (Brintellix®) 5-20 0 + 0 0 + +++ +++ 0

SNRI’s Serotonin Norepinephrine Reuptake Inhibitors

Venlafaxine (Effexor®) 150-375 + ++ 0 + +++ +++ ++ 0

Desvenlafaxine (Pristiq®) 50-100 0 ++ 0 + +++ + 0

Milnacipran (Savella®) 100-200 ++ + 0 + +++ + 0

Duloxetine (Cymbalta®) 60 + 0 + 0 +++ + 0Levomilnacipran (Fetzima®) 40-120 + + +++ 0 + +++ +++ 0

TCA’s Tricyclic antidepressants

Amitriptyline (Elavil®) 100-300 +++ +++ +++ +++ 0 + + +++

Clomipramine1 (Anafranil®) 100-250 +++ ++++ ++ + 0 + ++ ++

Desipramine (Naorpramin®) 100-300 + ++++ ++ 0 0 0 + +

Doxepine (Silenor®) 100-300 +++ +++ ++ +++ 0 0 ++ ++

Imipramine (Tofranil®) 100-300 +++ +++ ++++ ++ 0 + + ++

Nortriptyline (Pamelor®) 30-150 + + + ++ 0 0 + ++

MAOI’s2 Monoamine Oxidase Inhibitors

Phenelzine (Nardil®) 60-90 ++ +++ +++ +++ + +++ +++

Isocarboxazide (Marplan®) 10-30 ++ ++ ++ + ++

Selegiline (Eldepryl®/Emsam®) 6 0 0 ++ + + 0 0

Others

Bupropion (SR,XL)(Wellbutrin®)

300-450 0 ++++ 0 0++++

+ 0 0

Mirtazapine (Remeron®) 15-45 + 0 + ++ + 0 0 +++

Trazodone (Desyrel®) 150-375 + ++ +++ ++++ 0 + 0 +*= also serotonin partial agonist; ACH=acetilholinergic effects; 0=absent or rare; + to ++++=some to significant; 1=Not FDA approved for depression approved for OCD; 2 = Low tyramine diet required

Depressedmood

Apathy Sleepdisturbance

Executivedysfunction

Psychomotoragitations/retardation

Weight/appetitechange

Suicidalideation

Guilt/worthlessness

Serotonin X X X X X XNorepinephrine X X X X XDopamine X X X X X

SSRIs = serotoninSNRIs = serotonin and norepinephrineTCAs = primarily norepinephrineMAOIs = serotonin, norepinephrine and dopamine

Bupropion = primarily norepinephrine and dopamineMirtazapine = serotonin and norepinephrineTrazadone = serotonin antagonist/reuptake inhibitor

2

Additional indications for useDrug MD Eating

disorderOCD PMDD PD PTSD Social

anxietyGAD Neuropathy Hot

flashesADHD Bipolar Other

Bupropion x + Smokingcessation

Mirtazapine x + + +anxiety

Dysthymia,cancer

Citalopram x + + + + alcoholismEscitalopram x + + + xFluoxetine x x x x x + + + Dysthymia,

RaynaudFluvoxamine + + x + +Paroxetine x x x x x x x + + Premature

ejaculationSertraline x x x x x x + + MD with

psychoticfeatures

Desvenlafaxin x +Duloxetine x x x Musculo-

skeletal pain,urinary

incontinenceVenlafaxine x + + + x + x social

phobiax + + + Ppx of

tension HATrazodone x Insomnia

MD=major depression; OCD=obsessive compulsive disorder; PMDD=premenstrual dysphoric disorder; PD=panic disorder; PTSD=post traumatic stress disorder;Gad=generalized anxiety disorder; ADHD=attention deficit hyperactivity disorder; HA= headache; x=FDA approval; +=non-FDA labeled use.

Discontinuation reactions More common with shorter acting medications, especially: Paroxetine, Venlafaxine, Desvenlafaxine Symptoms begin a few days (1-3) after stopping medication and include: changes in mood, energy, sleep, appetite, flu-like

symptoms, nausea, and dizziness/lightheadedness With SSRI/SNRI symptoms can be sensory as well: numbness, paraesthesia, electric shock-like, and insomnia Symptoms should resolve in 1-2 weeks without treatment Prevention: Slow taper over 4 weeks; 25% dose reduction every 4-6 weeks for paroxetine and venlafaxine

Switching between antidepressants: Indications for switching medications: lack of efficacy, relapse, and/or adverse effects Collaboration is key for successful switching of medications. Three approaches to pick from

o Abrupt switching: discontinuation of the current medication, with or without a brief washout period, and initiatingthe new medication

Advantage: low risk of drug interactions Disadvantage: discontinuation reactions

o Gradual switching: slow tapering off of the current medication and then slow taper on of the new medication. Mayinclude a short wash out period.

Advantage: low risk of discontinuation reaction and for drug-drug interactions Disadvantage: risk of symptom exacerbation

o Cross-tapering: the new medication is started so that it overlaps with the current medication. The originalmedication is then tapered off

The new medication may be started at therapeutic dose or at an initial dose and tapered up Advantage: lowest risk for relapse Disadvantage: increased risk for drug-drug interactions

Reference:1. Dipiro JT, etal. Pharmacotherapy: A Pathophysiologic Approach, 8th edition: Section 7.Psychiatric Disorders; Chapter 77..Major Depressive Disorder;

McGraw –Hill Global Education Holdings,LLC [available online at: www.accesspharmacy.com.hsl-ezproxy.ucdenver.edu/popup.aspx?aID=7989091 ;Koda-Kimble MA., et al. Applied Therapeutics: the clinical use of drugs. Philadelphia: Walters Kluwer Health/Lippincot Williams & Wilkins, c2009. 9th

edition.2. Micromedex® Healthcare Series, (electronic version). Thomson Micromedex, Greenwood Village, Colorado, USA. Available at: http://0-

www.thomsonhc.com.library.uchsc.edu:80 (cited: 07/2/2013).3. Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM- SSRI FDA-Approved Indications, Hudson, Ohio: Lexi-Comp, Inc.; 2013. Accessed November 24,20154. DynaMed Editorial Team. Antidepressant Medication Overview. Last updated 2013 July. Available online at: http://web.ebscohost.com.hsl-

ezproxy.ucdenver.edu/dynamed/detail?vid=8&sid=c49b873c-8aa9-4185-926f-5a71ed9422fe%40sessionmgr115&hid=126&bdata=JnNpdGU9ZHIuYW1IZC1saXZIJnNjb3BIPXNpdGU%3d#db=dme&AN=113820. Accessed June 23,2013.

© Mindell JA & Owens JA (2003). A Clinical Guide to Pediatric Sleep: Diagnosis and Management ofSleep Problems. Philadelphia: Lippincott Williams & Wilkins.

Supported by an educational grant from

Nightwakings

Nightwakings in young children is one of the most common problems that parents face. By6 months of age, most babies are physiologically capable of sleeping throughout the nightand no longer require nighttime feedings. However, 25%–50% continue to awaken duringthe night. Nightwaking problems can occur at any age but are most common with infantsand toddlers.

WHY DOES YOUR CHILD WAKE DURING THE NIGHT?When it comes to nightwaking, the most important thing for parents to understand is that

all children, no matter the age, wake briefly throughout the night. These arousals occurbetween four to six times per night. So the problem is rarely the waking during the night butrather why the child is unable to return to sleep on her own. Children who are able to soothethemselves back to sleep (“self-soothers”) awaken briefly throughout the night but theirparents are unaware of these arousals. In contrast, “signalers” are those children who alerttheir parents by crying or going into the parents’ bedroom upon awakening. Many of these“signaler” children have developed inappropriate sleep-onset associations and thus havedifficulty self-soothing.

WHAT ARE SLEEP ASSOCIATIONS?Many parents develop the habit of helping their child to fall asleep by rocking, holding, or

bringing the child into bed with them. Over time, children may learn to rely on this kind ofhelp from their parents in order to fall asleep. Although this may not be a problem atbedtime, it may lead to difficulties with your child failing back to sleep on her own duringthe night. Thus, sleep associations are conditions that the child learns to need in order to fallasleep at bedtime (such as rocking, nursing, or lying next to a parent). These same sleepassociations are then needed in order to fall back to sleep during the night. The bottom lineis that your child needs to learn to fall asleep on her own so that she can put herselfimmediately back to sleep when she awakens.

WHAT CAN YOU DO TO HELP YOUR CHILD SLEEP THROUGH THENIGHT?

There are a number of steps that you can take to help your child sleep through the night:• Develop an appropriate sleep schedule with an early bedtime. Ironically, the more

tired your child is, the more times she will awaken during the night. So be sure to haveyour child continue to take naps during the day and set an early bedtime.



• Security object. Try to introduce your child to a transitional/love object. A transitionalobject, like a stuffed toy, doll, or blanket, helps a child feel safe and secure when you arenot present. Help your child become attached to a transitional object by including it as partof the bedtime routine. Try to include this object whenever you are cuddling or comfortingyour child. Don’t force your child to accept the object, and realize that some children willnot accept one no matter how cute and cuddly the object.

• Bedtime routine. Establish a consistent bedtime routine that includes calm and enjoyableactivities, such as a bath and bedtime stories. Avoid exciting high-energy activities, such asplaying outside, running around, or watching television shows or videos. The activitiesoccurring closest to “lights out” should occur in the room where your child sleeps. Also,avoid making bedtime feedings part of the bedtime routine after 6 months.

• Consistent bedroom environment. Make sure your child’s bedroom environment isthe same at bedtime as it is throughout the night (e.g., lighting).

• Put your child to bed drowsy but awake. After the bedtime routine, put your child inher crib/bed drowsy but awake and leave the room. Remember, the key to having yourchild sleep through the night is to have her learn to fall asleep on her own, so she can putherself back to sleep when she naturally awakens during the night.

• Checking method. If your child cries or yells, check on her. Wait for as long or as shorta time as you wish. For some children, frequent checking is effective; for others,infrequent checking works best. Continue returning to check on your child as long as sheis crying or upset. The visits should be brief (1 minute) and boring. Calmly tell your childit’s time to go to sleep. The purpose of returning to the room is to reassure your child thatyou are still present and to reassure you that your child is okay.

• Respond to your child during the night. In the beginning, respond to your child asyou normally do throughout the night (e.g., nurse, rock). Research indicates that themajority of children will naturally begin sleeping through the night within 1–2 weeks offalling asleep quickly and easily at bedtime. If your child continues to awaken during thenight after several weeks, then use the same checking method during the night as you didat bedtime.

• A more gradual approach. Some parents feel that not being present when their babyfalls asleep feels like too big of a first step for them and their baby. A more gradualapproach is to teach your baby to fall asleep on her own but with you in the room. Thisapproach will take longer but feels more comfortable to some families. The first step is toput your child in her crib/bed awake and sit on a chair next to the crib/bed. Once she isable to consistently fall asleep this way, sit farther and farther away every three to fournights until you are finally in the hallway and no longer in sight.

• Be consistent and don’t give up. The first few nights are likely to be very challengingand often the second or third night is worse than the first night. However, within a fewnights to a week, you will begin to see improvement.



Sleep in Infants (2–12 Months)

WHAT TO EXPECTInfants sleep between 9 and 12 hours during the night and nap between 2 and 5 hours

during the day. At 2 months, infants take between two and four naps each day, and by 12months, they take either one or two naps. Expect factors such as illness or a change inroutine to disrupt your baby’s sleep. Developmental milestones, including pulling tostanding and crawling, may also temporarily disrupt sleep.

By 6 months of age, most babies are physiologically capable of sleeping through thenight and no longer require nighttime feedings. However, 25%–50% continue to awakenduring the night. When it comes to waking during the night, the most important point tounderstand is that all babies wake briefly between four and six times. Babies who are able tosoothe themselves back to sleep (“self-soothers”) awaken briefly and go right back tosleep. In contrast, “signalers” are those babies who awaken their parents and need helpgetting back to sleep. Many of these signalers have developed inappropriate sleep onsetassociations and thus have difficulty self-soothing. This is often the result of parentsdeveloping the habit of helping their baby to fall asleep by rocking, holding, or bringing thechild into their own bed. Over time, babies may learn to rely on this kind of help from theirparents in order to fall asleep. Although this may not be a problem at bedtime, it may lead todifficulties with your baby failing back to sleep on her own during the night.

HOW TO HELP YOUR INFANT SLEEP WELL• Learn your baby’s signs of being sleepy. Some babies fuss or cry when they are tired,

whereas others rub their eyes, stare off into space, or pull on their ears. Your baby will fallasleep more easily and more quickly if you put her down the minute she lets you knowthat she is sleepy.

SAFE SLEEP PRACTICES FOR INFANTS• Place your baby on his or her back to sleep at night and during naptime.• Place your baby on a firm mattress in a safety-approved crib with slats no greater

than 2-3/8 inches apart.• Make sure your baby’s face and head stay uncovered and clear of blankets and

other coverings during sleep. If a blanket is used, make sure the baby is placed“feet-to-foot” (feet at the bottom of the crib, blanket no higher than chest-level,blanket tucked in around mattress) in the crib. Remove all pillows from the crib.

• Create a “smoke-free–zone” around your baby.• Avoid overheating during sleep and maintain your baby’s bedroom at a temperature

comfortable for an average adult.• Remove all mobiles and hanging crib toys by about the age of 5 months, when your

baby begins to pull up in the crib.• Remove crib bumpers by about 12 months, when your baby can begin to climb.



• Decide on where your baby is going to sleep. Try to decide where your baby is goingto sleep for the long run by 3 months of age, as changes in sleeping arrangements will beharder on your baby as he gets older. For example, if your baby is sleeping in a bassinet,move him to a crib by 3 months. If your baby is sharing your bed, decide whether tocontinue that arrangement.

• Develop a daily sleep schedule. Babies sleep best when they have consistent sleeptimes and wake times. Note that cutting back on naps to encourage nighttime sleep resultsin overtiredness and a worse night’s sleep.

• Encourage use of a security object. Once your baby is old enough (by 12 months),introduce a transitional/love object, such as a stuffed animal, a blanket, or a t-shirt that wasworn by you (tie it in a knot). Include it as part of your bedtime routine and whenever youare cuddling or comforting your baby. Don’t force your baby to accept the object, andrealize that some babies never develop an attachment to a single item.

• Develop a bedtime routine. Establish a consistent bedtime routine that includes calmand enjoyable activities, such as a bath and bedtime stories, and that you can stick with asyour baby gets older. The activities occurring closest to “lights out” should occur in theroom where your baby sleeps. Also, avoid making bedtime feedings part of the bedtimeroutine after 6 months.

• Set up a consistent bedroom environment. Make sure your child’s bedroomenvironment is the same at bedtime as it is throughout the night (e.g., lighting). Also,babies sleep best in a room that is dark, cool, and quiet.

• Put your baby to bed drowsy but awake. After your bedtime routine, put your baby tobed drowsy but awake, which will encourage her to fall asleep independently. This willteach your baby to soothe herself to sleep, so that she will be able to fall back to sleep onher own when she naturally awakens during the night.

• Sleep when your baby sleeps. Parents need sleep also. Try to nap when your babynaps, and be sure to ask others for help so you can get some rest.

• Contact your doctor if you are concerned. Babies who are extremely fussy orfrequently difficult to console may have a medical problem, such as colic or reflux. Also,be sure to contact your doctor if your baby ever seems to have problems breathing.



Sleep in Newborns (0–2 Months)

WHAT TO EXPECTNewborns sleep between 11 and 18 hours per day, with no regular or defined pattern. For

the first few weeks, your baby will sleep for anywhere from a few minutes to a few hours ata time, although babies who are breast-fed tend to sleep for shorter periods (2–3 hours ofsleep) than bottle-fed babies (3–4 hours). There will also be little difference between nightand day in the first few weeks. However, you will start to see a more regular sleep scheduledevelop between 2 and 4 months of age. Expect your baby to be quite active while shesleeps. All babies smile, grimace, suck, snuffle, and move (twitch, jerk) while they sleep.This is perfectly normal, and your baby is getting sound sleep.

WHERE AND HOW SHOULD YOUR BABY SLEEP?

• Sleeping arrangements. There are many choices as to where your newborn sleeps,whether in a bassinet or a crib in the parents’ bedroom, a sibling’s bedroom, or thebaby’s own room. Some parents prefer to have their baby sleep with them, althoughcaution should be taken as there is a risk of suffocation.

• Back to sleep. All babies should be put to sleep on their backs to reduce the risk ofsudden infant death syndrome (SIDS).

HOW TO HELP YOUR NEWBORN BECOME A GOOD SLEEPER

• Learn your baby’s signs of being sleepy. Some babies fuss or cry when they are tired,whereas others rub their eyes, stare off into space, or pull on their ears. Your baby will fallasleep more easily and more quickly if you put her down to sleep when she lets you knowthat she is tired.

SAFE SLEEP PRACTICES FOR NEWBORNS• Place your baby on his or her back to sleep at night and during naptime.• Place your baby on a firm mattress in a safety-approved crib with slats no greater

than 2-3/8 inches apart.• Make sure your baby’s face and head stay uncovered and clear of blankets and

other coverings during sleep. If a blanket is used, make sure your baby is placed“feet-to-foot” (feet at the bottom of the crib, blanket no higher than chest-level,blanket tucked in around mattress) in the crib. Remove all pillows from the crib.

• Create a “smoke-free–zone” around your baby.• Avoid overheating during sleep and maintain your baby’s bedroom at a

temperature comfortable for an average adult.



• Encourage nighttime sleep. Many newborns have their days and nights reversed,sleeping much of the day and being awake much of the night. To help your baby sleepmore at night, keep lights dim during the night and keep play to a minimum. During theday, play with your baby and be sure to wake her regularly for feedings and play time.

• Respond to your baby’s sleep needs. Newborns often need to be rocked or fed tosleep, which is fine for the first few weeks or months. However, once your baby is 3months old, begin to establish good sleep habits.

• Develop a bedtime routine. Even babies as young as a few weeks respond well tobedtime routines. Your newborn’s bedtime routine should be soothing and can includeany activities you choose, such as bathing, rocking, and cuddling.

• Sleep when your baby sleeps. Parents need sleep also. Try to nap when your babynaps, and be sure to ask others for help so that you can get some rest.

• Contact your doctor if you are concerned. Babies who are extremely fussy orfrequently difficult to console may have a medical problem, such as colic or reflux. Also,be sure to contact your doctor if your baby ever seems to have problems breathing.



Sleep in Preschoolers (3–5 Years)

WHAT TO EXPECTPreschoolers need between 11 and 13 hours of sleep. The number of hours a preschooler

sleeps will be different for each child, but expect your preschooler to sleep for about thesame amount of time each day. Most preschoolers stop taking naps between 3 and 5 yearsof age. Some preschoolers continue to awaken during the night, usually as a result of poorsleep habits. All children wake briefly throughout the night. However, a preschooler whohas not learned how to fall asleep on her own at bedtime will not be able to return to sleepwithout help from her parents.

Sleep problems are common during the preschool years, including nighttime fears andnightmares. Nighttime fears and nightmares are a part of normal development. Sleepwalkingand sleep terrors are also common during the preschool years and peak in this age group.

HOW TO HELP YOUR PRESCHOOLER SLEEP WELL• Develop a regular sleep schedule. Your preschooler should go to bed and wake up

about the same time each day. You may find that your preschooler has a “second wind”in the evening. Move bedtime earlier or later to a time when your child is morephysiologically ready for sleep. Also, be sure that your child is ready for sleep beforeputting her to bed. This may seem obvious, but sometimes parents set a bedtime based ontheir own convenience. For example, some children’s biological clocks make them morelikely to be “night owls.” These children may have difficulty with an earlier bedtime.

• Maintain a consistent bedtime routine. Establish a bedtime routine that is the sameevery night and includes calm and enjoyable activities, such as a bath and bedtime stories.The activities occurring closest to “lights out” should occur in the room where yourpreschooler sleeps.

• Set up a soothing sleep environment. Make sure your child’s bedroom is comfortable,dark, cool, and quiet. A nightlight is fine; a television is not.

• Set limits. If your preschooler stalls at bedtime, be sure to set clear limits, such as howmany books you will read.

• Contact your child’s doctor if:• Your child appears to have any trouble breathing, snores, or is a noisy breather.• Your child has unusual nighttime awakenings or significant nighttime fears that are

concerning.• Your child has difficulty falling asleep, staying asleep, and/or if her sleep problems

are affecting her behavior during the day.



Sleep in Toddlers (1–3 Years)

WHAT TO EXPECTToddlers sleep between 12 and 14 hours across the day and night. By 18 months, most

toddlers have given up their morning nap and are taking one long afternoon nap of 1.5–3hours. The number of hours a toddler sleeps will be different for each child, but expect yourtoddler to sleep about the same amount each day. Continue to expect that sleep will bedisrupted by illness, changes in routine, and other stressful events. Separation anxiety mayalso cause problems at bedtime. Most toddlers switch from a crib to a bed between 2 and 3years of age. If the change happens too early, it can disrupt sleep.

Many toddlers continue to awaken during the night, usually as a result of poor sleephabits. All children wake briefly throughout the night. However, a toddler who has notlearned how to fall asleep on his own at bedtime will not be able to return to sleep withouthelp from his parents.

HOW TO HELP YOUR TODDLER SLEEP WELL

• Develop a daily sleep schedule. Have regular nap times and a bedtime that ensuresenough nighttime sleep. Napping too late in the afternoon can make it hard for yourtoddler to fall asleep at bedtime, but avoid cutting back on naps to encourage nighttimesleep as this will result in overtiredness and a worse night’s sleep.

• Encourage use of a security object. Helping your toddler become attached to a securityobject that he can keep in bed with him can be beneficial. This often helps a child feelmore relaxed at bedtime and throughout the night.

• Develop a bedtime routine. Establish a consistent bedtime routine that includes calmand enjoyable activities, such as a bath and bedtime stories. The activities occurring closestto “lights out” should occur in the room where your toddler sleeps.

• Set up a consistent bedroom environment. Make sure your child’s bedroomenvironment is the same at bedtime as it is throughout the night. Some older toddlers mayfind a nightlight reassuring. Also, toddlers sleep best in a room that is dark, cool, andquiet.

• Put your toddler to bed drowsy but awake. Encourage your toddler to fall asleepindependently by putting him to bed drowsy but awake. This will enable him to fall backto sleep on his own when he naturally awakens during the night.

• Set limits. If your toddler stalls at bedtime, be sure to set clear limits, such as how manybooks you will read.

• Contact your child’s doctor if:• Your child appears to have any trouble breathing, snores, or is a noisy breather.• Your child has unusual nighttime awakenings or significant nighttime fears that are

concerning.• Your child has difficulty falling asleep, staying asleep, and/or if sleep problems are

affecting his behavior during the day.

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