Carl Maronich (Host): This is Live Greater, a University of Maryland Medical System podcast. I'm Carl Maronich. And with me today is Dr. Thomas Fitzgerald, a pediatric pulmonologist at the University of Maryland Medical System. And in this podcast, we'll be offering a parent's guide to what is normal sleep and bedtime behaviors, helping parents sort out what's typical, what's worrisome, and how to support better sleep for their children.

Dr. Fitzgerald, welcome to the podcast.

Thomas Fitzgerald, DO: Thank you so much for having me. I appreciate it.

Host: Yeah, glad to have you here. And maybe we can start by talking about how much sleep you recommend for most children?

Thomas Fitzgerald, DO: That's a good question. I think it's a common misconception among parents that eight hours is normal for most kids. It's really a moving target throughout childhood. So, eight hours of sleep is a good number for an adult, but typically even adolescents need more than that. So, it really changes throughout your life. And, you know, as you go from early childhood, you need less and less.

So, anywhere in like in infancy, you'll notice they sleep forever to the point where the majority of time they're actually sleeping. So, we actually kind of view it more in wake windows. So, like zero to three months, you might get 14 to 17 hours of sleep, sometimes eighteen hours of sleep through the entire day.

And so, realistically, like in the first year or so, we don't really think about it trying to calculate exactly how much sleep they're getting. It's mostly how long can they stay awake. And then, we just assume the rest of the time that they're sleeping. When we start getting into toddler years, you know, it's somewhere between probably eleven to fourteen hours for the first two years of life. It kind of starts decreasing. Nap times get a little bit shorter. And then, in preschool age, around three to five years, it's somewhere between probably ten and 13 hours. Between six and 12 cyears age, you know, it's a huge range. It's somewhere between 9 and 12 hours of sleep. And then, when you get into like, you know, later years, between 14 and 17 years old to eighteen years old, we start getting into that more normal like eight to 10 hours of sleep.

But even for a lot of adults, eight hours is a nice number to kind of remember. But me personally, I like at least eight and a half or nine. Some people are fine with like seven. And so, we definitely get a range of changes. And when we get later and later adulthood, definitely shortens up a bit.

Host: Sure. And you mentioned sleep in a day. But for younger small children, infants and such, so that doesn't necessarily mean, 11 or 14 start to finish, but that's broken over naps during the course of the day.

Thomas Fitzgerald, DO: Correct. Yeah. For the first five years or so, we expect kids to probably take a nap. Somewhere between like three five, they'll usually start growing out of it a little bit. You'll notice some of them will stay up the entire day. But yeah, it does include naps. So, you know, you're an infant under one year old, you know, we're expecting that you're going to be awake for an hour or two in the first year of your life, and it does get shortened through that first year, and then, you know, be sleeping the other amount of time.

So, as you start getting into toddler years, especially over a year of age into almost two years of age, we expect that maybe they're going to have a nap. And it might be a few hours a day. And so, somewhere between that first and second year, they'll start moving between two naps and then one nap. And then, you know, by age three to five, somewhere between, they'll probably start losing it. But even a lot of preschools will include the nap during the day.

Host: Sure. As we know, children can be very resistant to bedtime. Why is that? And why do so many kids fear monsters under the bed or in the closet, or those kinds of things?

Thomas Fitzgerald, DO: Well, I usually tell parents, because the most people or the most likely children that are resistant to bedtimes are typically between, like, three to five years of age. And that happens, one, for a good thing. They still like you, and they still like you as parents, so they want to be around you, and they don't want to miss So, try to enjoy that and not to get too frustrated at the fact that kid not want to fall asleep. I'm going through right now. And so, it's a little bit tough. But for the most part, nothing's, you know, poor intention by any means.

As far the monsters under the bed, that really starts developing around three to five years of age, and it kind of coincides with having, like, magical thinking, getting very more of a vivid imagination. And again, I think even in adults, we still have those periods where you wake up in the middle of the night, you see some kind of change in shadow. But you're able to, you know, through decades of having logic and reasoning and things like that, kind of convince yourself to fall back asleep and be like, "All right, it's safe. I can realize that's actually not some other weird figure in the side of my room." But for kids, they just don't have that. So, no, it's really a tough kind of situation. They're typically separated from their parents. They're alone. You know, they have some some anxiety about falling asleep, and there's a good reason for that.

You know, it's dark out too. So, they really can't get the visual, you know, details that they need to kind of convince themselves that it's not something that's magical or a monster or something they've seen on TV or something else like that that's been scaring them. And so, even if you really try to talk to them, it's tough to convince them out of it without really showing them.

So, around two or three, they start to put boundaries. And so, there'd be some limit setting that I recommend for parents to do that kind of make sure that they kind of have reasonable accommodations on how to get them to fall asleep, to make sure they follow a routine. But after that, you know, it's a totally reasonable expectation that, you know, they're going to be anxious or nervous before they bed. It's a weird concept for, you know, human history that we're spending about a third of our life and during the day asleep, and it's potentially dangerous. So, the idea that you're having a high anxiety, high, you know, kind of stress response right before you fall asleep, that is very reasonable. Again, if you look back in human history, you know, nocturnal predators used to to be a real thing and a real threat. So, making sure that they're not there is a real concern. So, it's very reasonable, and it takes a lot of learning, and really a lot of practice to get good at sleeping and sleeping comfortably.

Host: Sure. One thing that really scares parents are things like terrors or sleepwalking, sudden movements during sleep. What tends be normal and when can parents the difference between what's normal and when something might be a concern?

Thomas Fitzgerald, DO: That's a good question. It's actually a really common one that I get. And so, these typically will fall under something called parasomnias or things that happen with sleep. It's like literally the definition of it. And most typically a few cases that can be concerning. But for overall, they're not really too worrisome.

I will say sleep terrors are terrifying to witness because there's a lot of distress involved. They wake up, they scream, they look like they're panicked, and there's something wrong. And it's not something you should ignore. You know, I think it's a very common and normal response for parents to rush in and try to fix whatever's going on.

But for the most parts, most sleep terrors typically happen in the first half of the night, usually the first third, but usually first half of the night. It happens in a very deep part of your sleep, and it happens because you're having this partial arousal. So, you're still asleep, you're still somewhat awake, and you're kind of caught in between. And so, it can be a little uncomfortable for that. For the most part, though, they don't really remember it. Typically with sleep terrors, they don't remember it. There's no long-term issues with it. But it's very, very common to wake up and see that distress.

For other things like sleepwalking or movements overnight, there can be other concerns. So I mean, for sleep talking, that's probably the most common one. About 50% kids actually do it, you know, sometime through childhood. You know, I would think on any given night, you you have like 5% to 25% chance having it happen, I think, if I remember my statistics correctly. But it's extremely common to the point where we actually consider it a variant of normal. And you can see it happen more if you have more a little bit, you know, issues with sleeping overnight or some deprivation. It can kind of bring it on sometimes.

The movements overnight, I think, are the hardest part to kind of differentiate for parents or even pediatricians or even me sometimes, to be honest. Because we do have lots and lots of normal movements that we don't worry about. We expect them either grow out of it or it's just a concern. We don't do anything about them to the ones where we actually are concerned with it.

And so, sleepwalking can also be pretty common. That's, you know, about, I think, 25% to 30%. If look at some other sources, it might be 15% to 40% of kids have sleepwalking. And I would really describe it as a different entity than what adults have for sleepwalking. So if you look up sleepwalking, I would think, be more reassured for childhood versus an adult. But really, the biggest thing to worry about for sleepwalking is the physical danger of actually crashing into something overnight or navigating in the dark while you're still asleep. So, really creating a safe sleep environment is probably the most important part.

So, I usually tell parents to kind of lock your doors, make sure that, you know, if there's any weapons or firearms in the house, make sure those are locked and out of the way. Knives in the kitchen and things like that, try and keep them away from the stoves or, you know, things that are pretty important.

It does happen. But, you know, the hard part I feel like for parents is to see them walking and try to yell at them and try to tell them to wake up, go back bed. But the goal is actually just to kind of guide them back to bed because they're still in this kind of—just like with the sleep terrors, they're in a very deep stage of sleep but have a partial arousal. And so if you try to wake them up, it might take them like fifteen to twenty minutes to fully get aroused, to fully come back to it. And it can be very disturbing. Some people swing out and get violent and start smacking the parents or something like that. So, the easiest thing is if you just kind of notice, you want to guide them back and make sure their environment is generally safe.

And then, the sudden movements, I think they're the ones are the most common are called hypnic jerks. Right when you fall asleep, you can relax very quickly. And so as you relax very quickly, it almost feels like falling and your body tenses up and jerks to almost to, like, brace for hitting the ground. Those are very common. But again, there's lots of other movements that I do worry about. Like if you're having repetitive stereotype movements, you know, that you're having frequent shaking overnight, like tongue movements, like chewing or something like that, or like movements with your hands that are meaningless and purposeless that you do kind of worry about.

And the last one that I think that's really common that's generally normal that I think that a lot of parents might get concerned about because it can cause injury are like rocking or rolling or head banging overnight. Those are those are pretty common behaviors that you'll see really early on in childhood. Usually, like around one-year-old that you end up seeing the behaviors. It's, for the most part, a self-soothing behavior. Usually between six to nine months, they're kind of figuring out how to get themselves to like calm themselves back to sleep because they will have arousals overnight, but they need to kind of learn how to put themselves back asleep. And that's a whole lot of training that we can talk about at a different time.

But the biggest ones I worry about are like the head banging or something that causes injuries overnight or if they're having daytime issues where they're actually waking themselves up from trying to do those movements. But for the most part, they're typically not too worried about.

Host: Is there anything you can identify as causes for these kinds of nighttime behaviors?

Thomas Fitzgerald, DO: So, it probably depends on what it is. I would say for most of the normal behaviors, what usually brings it about is actually not having either consistent sleep or disrupted sleep. We see it higher chances if you're having, one, shorter sleep durations for your age group. So, people who are sleep-deprived tend to have these, you know, bring them on.

For people who sleepwalk, actually sleeping in different environments, having schedule changes can bring them about. So, when they travel or they're, you know, they're going to different time zones, they're more likely have sleepwalking episodes. So, we definitely see like, you know, changes in schedule, like having shorter sleep durations or changes in sleep environment can definitely cause, or at least be related to all of this stuff.

As far as other movements, though, you know, there's rarely a big overlying cause for why all this happens. You know, for periodic limb movement disorder, it's a very common thing we with, like, kids who have restless sleep. Sometimes it can be related to low iron levels, believe it or not. We can, you know, dependently test for that and even supplement it if that's a concern. But some of that's actually diagnosed with, like, a sleep study, and then we can kind of go through that. But that's, you know, a more rare kind of thing that, that does happen sometimes.

Host: Yeah. Do these ultimately affect the quality of sleep children are getting?

Thomas Fitzgerald, DO: Yeah. So, it certainly can affect your sleep quality. So, you know, things that prevent you from falling asleep, like having disturbing leg movements or potentially like hypnic jerks can delay it slightly. But in most children, they usually do fine with it, and it's usually not too much of a problem.

As far as sleep quality overnight, there's definitely movements that can disrupt that. And so, there's something called periodic limb movement disorder, which is of diagnosed on a sleep study that can definitely fragment your sleep. You know, basically, I describe it as almost kicking awake, where some of the abnormal movements actually cause arousals.

And a lot of those are in the same kind of umbrella as like restless leg syndrome or restless sleep, where we do see sometimes see low iron levels that are related to it. And then, I would say more commonly in adults, it can be much more disturbing. But usually, it's something that can just cause some minor sleep disruptions and definitely some tiredness for the day. But usually, it's not to the point where kids can't stay awake for the entire day or just having very disruptive sleep.

Host: Yeah. Is there any advice you'd give parents who are having these issues kids, and travel, or if they're going to spend the night at grandma and grandpa's or they're not going to sleeping at home? Is there some way they can prepare for those kinds of things?

Thomas Fitzgerald, DO: I think if you know it's a pretty common behavior, again, I think the best way to prep for it is trying to make sure that you can mimic your schedule as much as you can. Again, you know, if you're traveling very far and you're having a huge amount of time change, sometimes you can prepare for that by changing their schedule a little bit earlier and just kind of, you know, the week or two beforehand making it more and more appropriate to where you're coming into.

And then, the other part is just making sure that they, you know, if they do have those episodes, making sure they're safe. So again, if they're in a hotel room or someplace at grandma's or something like that, you know, just preparing for the fact that they're going to be in a new sleep environment and then make sure that they have a safe one. But again, it's typically something that out of far as sleepwalking, usually by adolescence. And it's pretty common in early childhood, like through elementary and middle school sometimes.

Host: Yeah. Doctor, if folks, you know, parents are having these issues with their kids, when is it time for them to get checked out?

Thomas Fitzgerald, DO: It's a good question. I think as a blanket statement, it's going to be pretty hard to kind of decide, you know, what exactly I can say everybody. But for the most part, I would say if you're really concerned or if the pediatrician's concerned, it's worth an evaluation. For the most part, there's lots of weird things that happen overnight.

And I feel like especially as a first-time parent right now, I'm even going right now, I'm telling you, there's a lot of things can be not normal or you don't know what do with. But for the most part, they're usually benign, self-resolving, and get better over time.

The ones that I do worry about are, you know, if they're really persistent, especially past age groups that I'm worried about. So, if you're having like head banging or rolling past like the first, you know, two years or so, I'm much more worried. You're having stereotypical like non-purposeful movements, like you're like chewing or you're having like shaking or moving your hands or something like that overnight, like repetitively and having multiple times overnight, that's something I worry about. The other ones would be it's just really persistent through childhood, and it's happening multiple times overnight.

Host: Yeah. Are there some sleep habits that can help reduce these episodes?

Thomas Fitzgerald, DO: I think good general term is trying to get consistency, and I think for a lot of parents it's tough. You know, you have crazy schedules that really have a huge amount of demands on child or young children these days. So, that can be school. On top that, you have extracurricular activities or sports, and then they have to do their homework. And then, they have still have to eat dinner and then go bed, and then you're trying to fit all this in in 24 hours and also deal with your own things that you have to figure out how to do. So, it's tough. But I think kind of keeping a good typical bedtime routine and helping them wind down is very helpful.

The other part would be, you know, really consistent scheduling. So if you are going to be going from the weekdays and school days to weekends, or if you're going to be going on vacation or like that, try not to vary in your schedule too much. So, I say, try to keep it no more than an hour or maybe two difference. It's very hard to kind of switch between your daytime work schedule and then go into the weekend where you sleep all day, you know, stay up all night, and then come back week and feel refreshed. Trust me, everybody in healthcare wishes they could do that. But it's very tough to flip-flop between schedules like that. So, I think a lot of consistency and a lot of discipline from parents that kind of set limits on their kids' sleep schedule is the best thing to do.

Host: Sure. It can certainly be a challenge, as we know. Doctor, any key takeaways you'd like listeners to take away from this conversation?

Thomas Fitzgerald, DO: I think that the biggest thing would be is that the good thing majority of sleep movements or things that we see, even some of the pathologic ones, are usually not dangerous and are typically restricted to childhood and do resolve over time, which is good. Sometimes they do require some intervention, but there's not like any blanket medications or anything like that. There's very few things that are FDA-approved in child for sleep, to be honest.

But, you know, if you're really concerned or if your pediatrician is especially concerned or it's really persistent, I think it's worth getting an evaluation. Again, there's a ton of benign things out there, but there are some things that are concerning.

I think the biggest thing I was hoping to also talk about in this that I do see a lot that I think gets overlooked is sleep apnea in children. So, somewhere between like three to seven years old, the tonsils really, you know, start getting large relative to the airway size. And, you know, it potentially can cause some problems.

We have about 25% kids that snore overnight, and it can be very normal, to be honest. If it's just snoring, doesn't wake them up and the breathing's fine, it's just that loud and the parents don't like it. But there are probably about, you know, one out of five of those kids that snore, so maybe 3% to 5% of kids in the U.S., Depending on your source, actually do have sleep apnea, and it can potentially cause sleep fragmentation overnight. So if your kid's snoring like their grandfather and very loud or if they're having a lot of like sleep issues of, you know, where they're sleeping during the day and they just seem tired just by sleeping ten hours overnight or if, you know, they're having like new onset bedwetting that seems like out of the norm, those are kind of concerning signs that maybe something else is going on overnight too.

Host: Yeah. It sounds like sleep apnea in children is another podcast we need to get scheduled.

Thomas Fitzgerald, DO: it's worth talking about. But I think, for a lot of parents, they dismiss the snoring. You know, they have a good chance that it's probably we don't have to do very much about it. But I think there's a decent amount of children that have it that go missed, and there are some, you know, consequences from having fragmented sleep.

Host: Yeah. Dr. Thomas Fitzgerald, a great deal of information and we appreciate your time today.

Thomas Fitzgerald, DO: Of course. Thank you so much. I appreciate it.

Host: And thank you for listening to Live Greater, a health and wellness podcast brought to you Maryland Medical System. Listen to more helpful podcasts at umms.org/podcast, on YouTube your favorite podcast platform. We look forward to you joining us again, and please share this on all your social media channels. Thanks for listening.