Monday, Oct 2, 2023

Toddler Night Wakings: What Causes Them and How to Fix them

 Toddler night wakings are especially painful as they can cry longer than infants, and are harder to reassure than older children.  One of the most common causes of night wakings in infants, toddlers, and even older children is inappropriate sleep onset associations. This is a disorder which will respond to behavioral management (or sleep training).For more information, here’s my comprehensive review of sleep training methods. The first step to successfully sleep training your child is correctly identifying that your child has a behavioral problem. If your child has a disorder such as asthma or obstructive sleep apnea which is interrupting their sleep, any attempt at sleep training is likely doomed to fail. Behavioral insomnia of childhood is divided into two types: sleep onset association subtype, and limit setting subtype. Toddler night wakings are frequently due to sleep onset association disorder. Frequently children may have characteristics of both. In this post I’m going to talk about inappropriate sleep onset associations.

Let me paint a picture for you. It’s been a long evening in the Smith household. Jimmy is 14 months old. Every night, since he was an infant, his parents have rocked him to sleep every night and then put him in his crib, at around 8 PM. His parents put him to sleep, sit down to watch some television and try to relax, but they are dreading the night ahead. Just when they get into bed, around 11 PM, they hear Jimmy crying out. They rush into his room frantically to try to rub his back so he falls asleep more quickly. These awakenings occur for the rest of the night every hour to an hour and a half. When he gets up for the day at 5:30 AM, Jimmy is quite irritable, and his parents are exhausted. They don’t have the luxury of taking two naps today. Jimmy’s problem is that he has developed inappropriate sleep onset associations, one of the subtypes of behavioral insomnia of childhood. 

Inappropriate Sleep Onset Associations Cause Frequent Awakenings

The typical child with inappropriate sleep onset associations is between 6 and 36 months but may be older or younger. This child needs his parent present to fall asleep and wakes up very frequently during the night. Parents view the awakenings as the problem, but they are a symptom of the primary issue: the child has not learned to fall asleep by himself. To understand why this is the case, I’ve created a few illustrations.

First, let’s look at a night of normal sleep, on a graph called a hypnogram, which represents the various stages of sleep that a child goes through at night. Notice that the child falls asleep into very deep sleep at the beginning of the night, then has more REM or dream sleep as the night goes on. (REM is highlighted in red.)

A normal night of sleep. The vertical red line is a single brief awakening.
A normal night of sleep. The vertical red line is a single brief awakening.



Note that the child briefly awakens after bouts of REM sleep. However, this child is used to falling asleep on his own. Thus, he does not signal to his parents.

Compare this with a child who needs her parents present to fall asleep. She may be held and rocked until she falls asleep. She may need his back rubbed or to nurse to fall asleep. She may even fall asleep with a pacifier in her mouth which falls out during the night. In Jimmy’s example, his parents rock him to sleep.

Kids with inappropriate see onset associations take longer to sleep, have multiple times they wake up during the night, and tend to wake up earlier. Note that the first awakening typically occurs 2-3 hours after falling asleep.
Kids with inappropriate see onset associations take longer to sleep, have multiple times they wake up during the night, and tend to wake up earlier. Note that the first awakening typically occurs 2-3 hours after falling asleep.

This child has not yet learned to fall asleep by himself. Thus, every time he has a normal awakening, he will call out to her parents and need them present to fall back to sleep. If your child falls asleep under a set of circumstances that are not present during the night (being held, having his back rubbed, nursing, even having a pacifier in her mouth) he or she will need the same set of circumstances multiple times during the night. So if he falls asleep in your arms, you are likely going to have to get up multiple times during the night. Dr. Ferber used a great analogy in his classic book (affiliate link). Most of us fall asleep with a pillow and blanket. If we woke up and our pillow and blanket were missing, we would get up and go looking for them. We would likely worry about were they had gone.

The key to fixing to addressing inappropriate sleep onset associations is helping your child to fall asleep on their own. For more advice, please see my post on various sleep training methods.

There are a few other situations where you might deal with a flare up in awakenings. Here are some questions you can consider as you are assessing this problem.

Other causes of night time awakenings

Are you dealing with a sleep regression?

If your child has been sleeping well then started waking up out of the blue, you may be dealing with a sleep regression. I have a comprehensive post on recognizing and addressing sleep regressions. 

Is your toddler waking up hungry?

Toddlers should not need to eat during the night unless there is a medical reason for him to eat. (If you are concerned about your child’s growth, please talk to your pediatrician about this). If you are giving your child a bottle of milk or breast feeding your child during the night,  weaning these feeds will likely help improve your child’s sleep rapidly. Here is my comprehensive post on dealing with night feeds. 

Is there a new baby in the home?

Some parents struggle with their toddler’s sleep when a new baby comes into the home. There are several reasons. If the children share a room, this can be especially challenging. (Of course in early infancy, your infant should likely sleep in your room, provided that you can do so safely). If you have a small home, a crying infant in another room can wake up your toddler, so using a sound machine can be helpful.

Sometimes, just the stress of welcoming a new baby to the home can disrupt your child’s sleep. Usually, these awakenings are brief and last less than a week. If you can spend some time during the day with your toddler (and without the baby), that can help your child feel secure and calm as she goes through the exciting process of welcoming a baby brother or sister to the home.

Is a medical disorder waking up your child at night?

Many common medical problems are overlooked as a cause of sleep disruption. If your child coughs frequently at night they may have asthma which needs to be treated. Acid reflux can be associated with belly pain and vomiting at night. Obstructive sleep apnea is a very common problem associated with snoring which can disrupt sleep. I would definitely recommend seeing your pediatrician about any of these concerns.

Is the environment waking up your child?

These tend to be obvious. Is there a TV on in the room? If so, please take it out of there! Is there loud noise from neighbors or the road outside? Does the child share the room with a sibling or parent who makes a lot of noise? Room sharing with siblings can make it particularly tricky to manage toddler night wakings. If one child wakes up, frequently the other does too. Here’s more information on how to navigate the tricky waters of room sharing.

Is your child in bed for too long?

Some kids suffer from “too much time in bed syndrome”. Brett Kuhn coined this term. This may occur in older toddlers whose parents have kept the same schedule they had previously as they need less and less sleep. Imagine a child who was sleeping from 6 PM to 6 AM at age 1. Age age 3, this is likely too long a sleep opportunity, especially if the child is still napping. This child’s sleep needs may have decreased from 14 to 11 hours per 24 hour period. Thus, if you keep the same nocturnal sleep period, your child may be awake for an hour or two at night. Usually in this scenario, your child is happy when she wakes up at night and is well rested in the morning. This may be right time to get rid of a nap or consider a later bedtime. For more information, here’s my post on how much sleep kids need.

Have you struggled with night time awakenings in your child? Why do you think that is? What has helped? Please leave comments below.



By: Craig Canapari MD
Title: Toddler Night Wakings: What Causes Them and How to Fix them
Sourced From:
Published Date: Fri, 04 Jun 2021 13:30:43 +0000

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