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Exhaustion Epidemic

Ah, how lovely it is to bring the generations together. At the dinner table sit my dad and his wife, freshly arrived from the East Coast for some quality time with the grandchildren. Enter a shrieking streak of a 4-year-old: my son, Drew, sobbing, screaming, clamoring for food yet refusing to eat. Try as I might to steer the conversation to the woes of airline travel, I can't get a worrisome idea out of my mind  -- my son is displaying what I'm sure will be diagnosed at our next pediatrician appointment as a solid case of hyperactivity.

"Is he tired?" asks my dad's wife, Barbara.

"He got up at five," I admit. "No nap."

Feeling  -- not for the first time since I became a mom  -- that I have some sort of head injury, I dimly remember the great paradox of sleep and children. Unlike sensible adults, who long for sleep in direct proportion to how little of it they get, exhausted children do everything they can to outwit the forces of fatigue. They accelerate. They scream. They flail and babble. They act, in fact, exactly the way Drew is acting.

As dramas go, a sleep-deprivation melt-down is spectacular to watch, particularly for out-of-town relatives, but in our house, I now realize, it's the predictable result of simple fudging on bedtime. For a couple of nights we'd sort of decided "What the heck, let him stay up a little bit later." A little bit turned into a half hour, 45 minutes, an hour. Add to this an unexpected early-morning wakening, and a little howling, laughing, crying banshee was what we had to show for it.

Watching Drew unravel made me feel like Maternalus horribilus. To make matters worse, I've since learned that doctors believe that failing to give a child enough sleep is in some ways like failing to give him enough food: It's bad for his health. According to the National Institutes of Health, a good night's sleep, along with healthy eating and exercise, is the crucial third leg in a child's health triangle.

Why it's so important
Long overlooked, lack of sleep is now considered a key contributor to children's behavior problems and physical well-being. Studies have shown that kids who don't sleep enough are inattentive, restless, irritable, and more likely to injure themselves. The American Academy of Sleep Medicine estimates that one in three kids is sleep-deprived on any given day.

Sleeping well means more than putting in the hours  -- the quality of sleep matters as well. Good sleep is uninterrupted, allowing your child to cycle through its five stages. By 6 months, a baby's sleep pattern resembles an adult's: She progresses into deeper sleep for nearly 90 minutes and then enters a lighter rapid eye movement (REM) phase, when dreaming occurs.

And our kids aren't just resting when they're off in the land of Nod. During the deeper phases of sleep, energy is restored, damaged tissue is repaired, and growth hormones are released, says Rafael Pelayo, M.D., head of the pediatric sleep service at the Lucile Packard Children's Hospital at Stanford University in Palo Alto, California.

Contributing editor Jane Meredith Adams also writes for Health and the Chicago Tribune.

What's enough?

While some children don't sleep well because of medical problems, most of these wound-up, pooped-out kids are just not getting enough time in the sack. But bear in mind that these are not hard-and-fast rules. There have been no experiments in which thousands of babies and children were put to sleep and awakened at specific intervals and then tracked for years. "Honestly, there's not a lot of hard data out there about this," says Judith Owens, M.D., director of the Pediatric Sleep Disorders Center at Hasbro Children's Hospital in Providence and a member of the National Sleep Foundation's Pediatric Sleep Task Force. "These numbers represent pediatricians' best guesses about the amount of sleep the average child needs  -- which means that there are a lot of kids who need less than that, and just as many who need more," she says.

But more important than fretting about whether your child's sleep pattern is the norm, Dr. Owens advises looking at the big picture. Pay attention to how she appears upon awakening: Is she happy and ready for the day? Or is she crabby and tired?

"When Katie wakes up rested, she comes downstairs with the clothes she's picked out, brushes her teeth, and is full of energy," says Stephanie Kushner of New Canaan, Connecticut. But when the 3-year-old is tired, every task becomes difficult. "It doesn't matter what clothes I pick out, nothing's right," says Kushner. "The socks are bumpy, and the shoes aren't comfortable."

Being fussy about socks and shoes is typical preschooler behavior, but Kushner says the intensity of the fussing lets her know fatigue is playing a role. In the same way, lack of sleep makes her son, Daniel, 5, intractable. "I knew he was exhausted this morning because he screamed for half an hour  -- I wouldn't give him six waffles for breakfast," she says. When he has enough sleep, Daniel draws on his reasonable, rational side, she says. After being told "no" twice, he'll say "okay."

Also, take a look at your child's behavior throughout the day. Does she become wild and unruly every night before bed? Could it be she's simply overtired, an imprecise word for an actual physical state?

Here's the reason sleepy kids become wired and unreasonable: "When you're tired, your ability to control impulses is reduced," says David Gozal, M.D., director of the Division of Pediatric Sleep Medicine at the University of Louisville's School of Medicine in Kentucky. "Adults who are tired tend to eat more, for instance. But with kids there's also a tendency to stimulate themselves with enormous activity, to try to keep themselves awake." Combine this with a faltering impulse-control mechanism and you've got a time-out in the making.

Working against parents, too, is that children don't know how much sleep they need and don't naturally monitor their tiredness  -- so you'll have to. After dinner, start to look for signs of bed-readiness, including yawning, eye rubbing, slowing down, crankiness, lying down, spacing out, and clinginess. Chances are, it'll happen around the same time every night, and it's best for your child (and easiest for you) if you schedule bedtime accordingly.

The bedtime question

Most families have less flexibility in the morning than at night, so in figuring out when to turn in, work backward from when you wake up. If the family has to be up by 7 a.m. to get out of the house on time, then your 3-year-old who naps for an hour each afternoon should be in bed by around 8:00 at night.

If bedtime is at 8:00, does that mean that's when the light goes out, or is that when your tired tot climbs into bed, teeth brushed and pj's on, for a few stories? Or is that when you first start trying to coax her in from the yard and into pajamas? Depending on your child and your style, saying good night could be a quick kiss at 7:55 or a longer routine of back rubbing and singing that starts at 7:30. Regardless, the target is eyes-closed snoozing at or about the same time every night.

Before you modify your routine, take a look at other factors that can reduce the amount and quality of sleep that kids get.

Caffeine According to the recent Sleep in America poll by the National Sleep Foundation, 26 percent of kids ages 3 and up have at least one caffeinated beverage a day, and those who did lost an average of 3½ hours of sleep per week. And caffeine isn't just in soft drinks  -- it's in iced tea, chocolate, and even some kids' pain relievers.

TV The more television a child watches, the more difficulty he'll have falling asleep and the more likely he'll be to experience sleep disturbances during the night.

Napping Most kids stop needing an afternoon nap at around age 4, but if you notice that your 3-year-old's bedtime is creeping later and later, it may be time to forgo midday sleeping in favor of some after-lunch quiet time.

Exercise If bedtime is a battle every night, maybe she needs more stimulation and exercise during the day. Tire her out by letting her run around the park with other kids in the late afternoon  -- but not too close to bedtime, when the activity could rev her up even more.

Temperament It's also possible that your child is just not wired to go to bed early. "Some kids are natural night owls," says Dr. Owens. "If you're trying to get that child to bed early, you'll have a big-time struggle on your hands." The problem, of course, is that his wake-up time might be different from your family's. In that case, if at all possible, adjust the morning schedule so your child can sleep later. Not an option? See Exercise, above.

Sleep disorders

If your child is spending a reasonable number of hours asleep but still regularly behaves like a kid who went to bed at midnight and woke at 4 a.m., something hidden may be affecting the quality of his sleep. One of the most obvious trouble signs is snoring, which affects up to 20 percent of children. An occasional snore is nothing to worry about, but loud, frequent snoring is a common symptom of sleep apnea, a condition in which breathing becomes interrupted during sleep.

Slawomir Krysmalski and his wife, Rachel Baker, of Berkeley, California, began to worry about their son's sleep habits when he was 2. Although Ari slept through the night, his breathing was punctuated by loud snoring and brief silences.

"Every morning he'd wake up, climb into our bed, and rest," says Krysmalski. After talking to their pediatrician, it all came together.

Typically, sleep apnea is caused when the tonsils and adenoids block the flow of air in the throat during sleep. With the airway narrowed, oxygen levels drop, carbon dioxide levels rise, and the child briefly awakens. In the effort to catch his breath, he gives a loud, gasping snore. These brief awakenings can occur hundreds of times a night, so it's no surprise that kids wake up exhausted.

At 3, Ari had his tonsils and adenoids removed. "He's a different guy now," says Krysmalski two months after the surgery. "He wakes up at 7 a.m. and jumps on our bed. He has so much energy."

In addition to snoring, keep an eye on your child's movements in bed. If he's constantly shifting his legs because they have "pins and needles," ask your pediatrician about restless legs syndrome (RLS), which can make it difficult to sleep deeply.

In fighting their fatigue, kids with sleep disorders may appear hyperactive during the day. "In survey after survey, these kids get labeled as having ADHD," says Dr. Pelayo, "when in fact all they are is tired."

While you might not ever convince your child that it's fun to go to bed, one trick that's helped in our family is to explain to Drew and his twin sister, Claire, that their bones grow only when they're sleeping. I explain to them that Dr. Pelayo tells all the children who have sleep problems that if they want to grow taller, they need to have better sleep.It's working. At least sometimes. The other morning Drew sat down to breakfast, stretched out his legs, and boasted, "Look how much I grew last night. I had a good sleep."