Category Archives: Growth and development

How much sleep do children need?

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Suzanne Berman, M.D.

Parents are often unsure if their child is getting enough sleep. In addressing this, we look at several things:

Where does the child compare to the normal range for his or her age?
A 2003 study (Pediatrics, 1111:2, Feb 2003, pp. 302-307) performed by Swiss researchers showed that 96% of children at a given age fell in the following ranges of total sleep hours (nighttime and daytime naps combined):

  • 1 month old: 9 to 19 hours a day (average, 14.4 hours)
  • 3 months old: 10.3 to 18.8 hours a day (average, 14.6 hours)
  • 6 months old: 10.4 to 18.1 hours a day (average, 14.2 hours)
  • 9 months old: 10.5 to 17.4 hours a day (average, 13.9 hours)
  • 1 year old: 11.4 to 16.5 hours a day (average, 13.9 hours)
  • 2 years old: 10.8 to 15.6 hours a day (average, 13.2 hours)
  • 3 years old: 10.3 to 14.8 hours a day (average, 12.5 hours)
  • 4 years old: 9.7 to 14 hours a day (average, 11.8 hours)
  • 5 years old: 9.5 to 13.3 hours a day (average, 11.4 hours)
  • 6 years old: 9.3 to 12.6 hours a day (average, 11 hours)
  • 7 years old: 9.2 to 12.1 hours a day (average, 10.6 hours)
  • 8 years old: 9 to 11.7 hours a day (average, 10.4 hours)
  • 9 years old: 8.8 to 11.4 hours a day (average, 10.1 hours)
  • 10 years old: 8.6 to 11.1 hours a day (average, 9.9 hours)
  • 11 years old: 8.3 to 10.9 hours a day (average, 9.6 hours)
  • 12 years old: 8 to 10.7 hours a day (average, 9.3 hours)
  • 13 years old: 7.7 to 10.4 hours a day (average, 9 hours)
  • 14 years old: 7.3 to 10.1 hours a day (average, 8.7 hours)
  • 15 years old: 7 to 9.9 hours a day (average, 8.4 hours)
  • 16 years old: 6.6 to 9.6 hours a day (average, 8.1 hours)

These guidelines may be helpful, but remember 2% of healthy, normal children sleep more than this and 2% of healthy, normal children sleep less than this. Children with different levels of physical activity, stress levels, illnesses, etc. will also show a lot of variability in how much sleep they require.

Does the child’s sleep seem like it refreshes him or her?
Sometimes, the answer is definitely no: a child who is ill, in a strange environment, etc. will have difficulty getting enough rest. But when the child is otherwise well and on a normal schedule, a child who is getting enough sleep should wake up refreshed and ready to go. Sometimes kids seem to “drag” in the morning on school days, but do better on weekends or holidays when that extra 30 minutes of sleep in the morning can make a difference. If you notice this is the case, try moving the child’s bedtime back by about 30 minutes.

Children who constantly wake up unrefreshed from sleep and fall asleep during the day should probably be evaluated for a sleep disorder.

How can I help my baby sleep better?

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Suzanne Berman, M.D.

How much sleep does my baby need?

Most experts recommend 14 to 15 hours of sleep per day for babies 3 to 11 months old. Surveys show that most American babies go to bed 1-2 hours later than babies born 20-30 years ago. However, morning awakening times haven’t changed in the past few generations. This means that many American babies average 12-13 hours of sleep in a 24-hour period, less than what is needed for adequate rest.

What makes sleep so important for babies?
A good night’s sleep is important for everyone, young and old. In children, poor sleep causes mood changes, impulsivity and attention problems, and poor school performance. We are learning that sleep deprivation is also linked to overweight and obesity. Sleep in babies is important for learning and development, and we’re also learning that it plays an important role in the development of vision

How do I know if my baby is getting enough sleep?
Some of the following clues may indicate that a baby may not be well rested:

  • The baby sleeps less than 3 hours total during the day.
  • The baby doesn’t sleep for more than 30 minutes at a time.
  • The baby always seems to fall asleep in the car, swing, or stroller, or while being nursed or fed. In fact, the baby seems to have trouble falling asleep outside these particular situations.
  • The baby’s daytime and nighttime sleep schedule seems irregular.

What are “sleepy” signals in infants?
Just as babies show signs of readiness for a feeding, babies will also show signs of sleepiness, such as:

  • crying, fussing, whimpering, and moaning
  • rubbing eyes and ears, yawning, dropping held objects, falling down, loss of coordination
  • loss of attention, “zoning”, sudden loss of interest in play

Babies tend to show sleepy signals for a few minutes about every 90 minutes while they’re awake. This doesn’t mean a baby must fall asleep every ninety minutes — but if given the opportunity to fall asleep during this window, a baby usually will. However, if after a few minutes, the opportunity passes, the baby becomes more alert again and won’t fall asleep, even if put down to sleep.

How old are babies before they can sleep on their own?
As with many milestones, it varies from child to child. Most healthy, well-rested infants can “self-soothe” themselves to sleep (or back to sleep) between 5 and 7 months old. By this time, they do not need nighttime feedings to grow and gain weight. (Many babies this age and older will continue to eat at night if offered, but it’s not necessary. In fact, many babies have trained themselves to wake up, just because their body expects a feeding!)

Infants who are poor sleepers tend to have difficulty with learning self-soothing. If your baby is having trouble getting back to sleep at night on his own, work on his daytime nap schedule first. Once his daytime sleep pattern is regular, and you are more familiar with his particular “sleepy” signals, it will be easier to work on nighttime sleeping.

If my baby is sleep-deprived, then why does she have a hard time falling asleep and staying asleep?
This is true of humans of all ages: even adults who are sleep deprived can have trouble falling asleep (or staying asleep). At certain times of day, it’s harder to fall asleep than others. For example:

  • People of all ages find that it’s very hard to fall asleep in the hour or two before one’s usual bedtime.
  • Travelers who are “jet lagged” find that it’s hard to stay up later, or go to bed earlier, while traveling.
  • Parents who work night shifts find that it’s hard to fall asleep during the day, no matter how tired they are.
  • Teenagers, who are often sleep-deprived, tend to stay up late playing Nintendo and Facebooking. The next morning, it practically takes a tractor to drag them out of bed! However, despite getting poor sleep the previous night, teens have trouble falling asleep the next night and repeat the cycle.

What should I know about my child’s teeth?

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Robert Berman, M.D.

What is the usual schedule of baby teeth?
It used to be that babies got their first tooth around six months old. Many babies have teeth before that these days, but it’s also not abnormal to be toothless at twelve months old. Rarely, babies can even be born with a front tooth! Babies born with teeth other than a front tooth need to be evaluated by a doctor. There are twenty baby teeth total. Usually eight of those are lost between ages 6 to 8 and the rest by around age 12.

How do I care for my child’s teeth?
As soon as your baby has teeth, it’s time to start cleaning them. This should include daily brushing, and flossing at least once a week. Ideally, the first dentist visit should be about six months after the first tooth. Unless you can locate a pediatric dentist (or “pediodontist”), that may not be possible, since most adult dentists will not see children until they are 2 or 3 years old.

One important way to protect your baby’s teeth is to take care of your own teeth. All adults have bacteria in their mouths; that’s why we brush our teeth. Babies are not born with bacteria in their mouths, but the bacteria in parents’ mouths eventually take up residence in the baby’s mouth due to kissing, shared cups and utensils, etc. If you don’t brush and floss your own teeth, your mouth will have both more bacteria and worse bacteria, and that will ultimately affect your baby’s teeth, as well as your own.

When food or drink other than water enters the mouth, it causes saliva to be released. Saliva is an acid, and exposure to increased amounts of saliva all day (or night) long can harm the teeth. Therefore, toddlers should not carry around a sippy cup filled with juice, since drinking small amounts from it frequently will result in acid damage to the teeth. Besides, juice has added sugar which is not good for the child’s diet, and it also increases the bacteria in the mouth. 4-8 ounces of juice a day is plenty for children younger than school age.

What about cavities?
Severely decayed teeth may require capping. Silver caps have historically been used, but ceramic caps are now available also, even for children. The advantage of ceramic caps is that they look very similar to regular teeth instead of looking metallic. If your child’s teeth require caps, ask if ceramic caps can be used.

What if my child gets hit and breaks or loses a tooth?
Broken teeth should be examined by a dentist as soon as possible. If a permanent tooth is knocked completely out, the best thing is to replace it immediately. Don’t wait to come to the doctor or dentist’s office. The sooner the tooth is replaced, the better the chance that it will survive. Scrubbing a tooth “clean” before replacing it is a bad idea, since that removes cells that help the tooth to stick in. If a tooth can’t be replaced or is filthy, stick it in milk and get to your dentist (or at night, the hospital) as soon as possible. If a baby tooth is knocked out, before trying to stick it back in, consider whether it may be time for that tooth to come out. If you’re not sure, call your dentist.

My child seems awfully small for her age. Should I be concerned?

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Suzanne Berman, M.D.

We are frequently asked by parents whether their child is an “okay size.” In addressing this, we look at several things:

How are the child’s height and weight measurements on a standard growth chart?

A child’s height and weight can be about average (25th – 75th percentile), above average (greater than the 75th percentile), or below average (less than the 25th percentile.) “Above average” doesn’t necessarily mean “too big,” and “below average” doesn’t necessarily mean “too small.” Remember, that these growth charts were compiled using thousands of children from different races and ethnic groups, health histories, and so on.

How big are the child’s parents (and brothers and sisters if he or she has any) ?

It is common for a child to be petite, in the 3-10% percentiles for height and weight, if one or both parents are small.

How do the child’s height and weight compare to each other?

Generally, we expect a child’s height and weight to be proportionate. A child who is somewhere in the middle for height should have a weight that is about average. Short children should weigh less. Disproportionate growth, when a child is very heavy or very slim for his height, can be a cause for concern.

More importantly:

How have the child’s height and weight progressed over time? Children who stay at about the same percentile from year to year are much less concerning than children who grow well for several years and then suddenly stop, or significantly slow down, their growth rate.

There’s an important, but common, exception: the first two years of life. Size at birth reflects prenatal factors, for example: Was the baby full-term or premature? Did the mother smoke or use drugs? Was the mother’s diet during pregnancy adequate? Therefore, infants of even very small mothers can be relatively large, even 8 or 9 pounds, if the mother had a healthy pregnancy. By two years of life, a child’s size correlates to the adult height and weight of parents. Therefore, a healthy, medium to large infant with small parent(s) will slow down and gradually seem “smaller” for age by the age of two.

Most importantly:

How is the child’s overall health and development? Small children with other medical or developmental issues, such as deafness, seizures, headaches, feeding problems, difficulty walking, or unusual physical features (such as certain kinds of birthmarks) concern pediatricians. Children with these features may have genetic syndromes or other treatable causes of being small, such as hormone problems. Children who are vigorous, happy, developmentally normal, and good eaters, who just happen to be small, are much less concerning.

How do I keep a sleep diary?

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Kristel Hassler, CPNP

Keeping a sleep diary is an important step in figuring out the reason you are having difficulty sleeping. A sleep diary keeps track of common behaviors and habits that interfere with sleep and will help determine what the problem is. When requested by your provider, a sleep diary can help to identify what issues may be causing your difficulty sleeping. To get an accurate picture, it is important to keep the diet diary for several days (preferably one week.)

  • What time did you/your child go to bed?
  • What time did you/your child wake up?
  • Were any naps taken during the course of the day? What time? How long?
  • What physical activities did you/your child engage in during the day? When? For how long?
  • What did you/your child do for the last 30 minutes – 1 hour prior to bedtime?
  • What foods and beverages have you/your child had today? What time?
  • Please list any and all medications and what time they were taken. Please include over-the-counter and herbal medications.

Be sure to bring this information, along with a completed Sleep Log with you to your appointment.

Does my child really need a physical every year? She’s very healthy!

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Suzanne Berman, M.D.

Many parents may wonder why we are so insistent on “well child checks.” Here are just a few of the reasons:

  • We pick up subtle things on physicals that could be missed otherwise. Hernias, unusual moles or skin lesions, high blood pressure, abnormal heart murmurs, and scoliosis are all examples of what we can detect on physicals that generally won’t be noticed during a sick visit.
  • We want to annually assess your child’s development and environment. This includes checking height and weight, diet and nutrition, family environment, school performance, behavioral and discipline topics, and safety and prevention issues. Discussing all these things takes time and can’t be crammed into sick visits.
  • We want to answer any questions you have about your child’s growth and development. This is easier on you if your child is well at the time: a cranky, ill child can make a relaxed pace for asking questions difficult.
  • We recommend that children get screening blood work, vision and hearing testing, and/or vaccines several times during their childhood and young adulthood. Again, it’s better to do these things when your child is well rather than battling a cold.
  • Most schools, as well as daycares, summer camps, and sports programs, require physicals to participate. If your child has been getting annual physicals, you won’t have to rush to the office when your teenage basketball star comes home and says, “Dad, I need this physical form filled out by Wednesday.”
  • Last but not least, we like to see healthy kids in our office as well as sick ones! Establishing a doctor-patient relationship when your child is well saves us (and you) time, later when she’s ill.