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Approaching pre-school sleep challenges in primary care

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I’m seeing a lot of kids like Chris* at the moment. Into the consult room strode a rambunctious and cheeky three-year-old with his parent Joy*. Like most families, they’re suffering some COVID-19 impacts.
 
Chris and Joy have had a longstanding set of challenges with sleep. When Chris was seven months old, they were admitted to the parent-baby unit in our state for settling support.
 
The advice and support there helped set up some positive settling routines; however, as a single parent during the pandemic, Joy lost most of her support and Chris steadily returned to co-sleeping as his main source of nighttime security. This has continued for the past two years.
 
Chris becomes highly distressed unless Joy is with him of an evening and they now go through seemingly endless reading of books, singing of lullabies and escorting him back to his toddler bed each evening until by 11.00 pm, an exhausted Joy cuddles him in her bed until he is asleep. He then wakes 3–4 times a night requiring a cuddle again and they both exhaustedly sleep in until 8.00 am.
 
Later, Chris naps for two hours at daycare each afternoon and the cycle repeats.
 
Joy feels that she has nothing left in the ‘parenting tank’ and is feeling guilty about being increasingly frayed in her responses to Chris. She’s now wondering if he could have autism due to his extensive meltdowns and freely admits to having lost hope. Friends have told Joy there must be something wrong with Chris and recommended she order some melatonin for him online.
 
As a GP, one of the service gaps I’m aware of is in toddler/pre-school sleep support.
 
In the community I work in, we don’t have any accessible community services that work in this space and families seem to rely on word of mouth for advice. We know that sleep challenges affect at least 20–30% of Australian 3–5-year-olds and that this number is growing over time.
 
Despite sleep challenges for this age range being nothing new throughout history, we also know that GP melatonin prescribing to Australian children increased 600% between 2011 and 2018, despite a paucity of long-term safety data.
 
Anecdotally, it seems like more families than not that I see have already attempted use of melatonin in their children. I feel strongly that as GPs we are well placed to bolster the confidence of families seeking support and return the focus on sleep to sustainable non-pharmacological basics done well.
 
This mirrors the move away from prescribing for chronic insomnia in adults to a behavioural/psychological model.
 
When a family comes in to discuss a sleep challenge in a young child, I have learned not to forget medical causes, even though they are rare. I ask about restless legs, parasomnias, allergies/itchy eczema and especially obstructive sleep apnoea.
 
I also like to examine the tonsils, anterior nasal passages and growth trajectories of these children.
 
However, I find most of the valuable information comes from asking about family dynamics, daytime sleep patterns, screen use and sugar intake.
 
Broadly speaking, the challenges tend to encompass the following: 

• Relational/limit setting challenges. Young kids are adept at negotiation and often manage to achieve elaborate evening routines that may be so long as to miss their natural sleep cycles. Similarly, they may come out of their bedroom frequently enough that their parents start to lose patience and a meltdown thus ensures
• Oversleeping of a morning/day nap leading to insufficient sleep ‘pressure’ at their natural bedtime
• Nighttime worries and fears in a child with a strong reliance on parents to provide rapid reassurance each and every time
• Excessive use of screen time of an afternoon/evening, especially when combined with fast acting sugar intake and/or inadequate physical activity the impact on sleep can be profound.
• Inconsistency of parental approach. Parents understandably get tired and strong, predictable routines start to break down. This seems to trigger relational insecurity in a child manifesting as boundary pushing/negotiation

I also find that a proactive approach to discussing some normal attributes of young child sleep such as early morning waking, nightmares and night terrors can be very helpful to prepare families before they may encounter them.
 
In the case of Chris, we identified that the main challenges facing his sleep were the over-reliance on day naps and sleeping-in, reducing his evening sleep ‘pressure’, coupled with limit setting difficulties with his evening routine and overarchingly a broad and normal reliance on Joy to be continuously present as a ‘co-regulator’ of his feeling of safety when falling asleep.
 
We instituted a tentative plan to reduce day napping to wake before 3.00 pm, ensure slightly earlier morning wakeup and implement a predictable evening routine. We discussed how Chris’ natural sleep cycles were approximately 90 minutes and that meant settling effort could be linked to these natural sleepy periods.
 
I highlighted that it would be good to see him falling asleep more rapidly once in bed even if this was later and involving Joy’s presence. Once a regular routine was established the parental presence and sleep times could be worked on.
 
The Sleep with Kip resources provided by the Murdoch Children’s Research Institute proved invaluable for Joy to research and decide on her approach.
 
For two weeks, Joy’s evenings focused on allowing Chris to have some gentle play until 7.30–8.00 pm, then a 30-minute gentle wind-down routine before Joy would sit on a chair next to his bed. Joy found it staggering that her dynamo of a child seemed to settle quite quickly into this routine.
 
At the next review we focused on Joy gently ‘fading’ Chris’ bedtime and wakeup time a little earlier in sync every three days. Joy found this meant she could now count on some regular self-care time after Chris went to sleep that boosted her emotional reserve.
 
After six weeks of this approach Joy returned with a triumphant, ‘I’ve got my beautiful boy back’. They are now seeing a marked reduction in meltdowns and Joy is steadily leaving Chris’ room earlier and earlier following a strategy called ‘camping out’.
 
It’s been so rewarding to see their progress and I feel confident that Chris will find a solid long-term sleep routine.
 
Once again, ‘the best bridge between despair and hope is a good night’s sleep’.
 
*Names changed for privacy
 
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children’s health melatonin paediatrics Sleep issues

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