Wake-Up Call

While his brothers kept up a steady chatter during car trips, our middle child used to conk out the moment his seat belt was buckled. On nights when his brothers argued to reopen bedtime negotiations, he pulled on his pajamas and climbed under the covers. When his brothers woke up eager for breakfast, he stayed curled up like a fifty-pound possum, sleeping so long into the morning that we signed him up for afternoon preschool, knowing he’d never make it to class before noon. We thought of him as our most accomplished sleeper—a four-year-old with a frat boy’s internal clock.

He might have maintained his status had we not had to share a hotel room with him in Chicago last spring. After a long day of museum-hopping along Michigan Avenue, we put the kids to bed and repaired to our side of the family suite. Ten minutes later, a strange sound rose from the other side of the thin walls, revealing what the plaster ones at home had concealed—a pneumatic wheezing from our son’s laboring windpipe. Even more troubling than his Dolby-strength snores were the long, longer, should-we-call-an-ambulance? moments when he made no sound at all.

“No wonder,” said Barbara Malone, a pediatric otolaryngologist we took him to almost the minute we got back to the Twin Cities. Armed with tongue depressor and penlight, she invited me to see what happened when he opened his mouth and said, “Ahhh.” There, blossoming in the back of his throat, were tonsils the size of tulip bulbs. Their advancing real estate holdings in his upper airway (and the adenoids hidden from view) were the reason for his turbulent nighttime breathing and the likely cause of his sleep apnea—a common but serious condition in children that, left untreated, can cause learning and behavioral problems and even stunt a child’s growth. “No wonder he was your best rester,” Malone said. “He probably hasn’t been getting any actual sleep.”

But how could I have been forcing Flintstones vitamins into my kids every day without noticing that one of them was missing an ingredient even more essential to good health? “You’re not alone—a lot of parents have no idea that sleep is a problem for their kids,” says Mary Sheedy Kurcinka, a St. Paul “parent educator” and author of Sleepless in America: Is Your Child Misbehaving or Missing Sleep? She says some of the most sleep-deprived children she sees in her practice are “the ones who seem to resist sleep, who wake up early, who seem to spin faster and faster, running around with all this frenzied energy.”

Though adults can articulate how they feel when they’re not well rested, the estimated three in five school-age children who don’t get the sleep they need are more likely to express their exhaustion through emotional meltdowns, carbohydrate cravings, concentration difficulties, and an inclination toward accidents. (A study of overtired Italian preschoolers found that they were far more likely to end up in an emergency room after falling down or crashing their bikes than their better-rested peers.) “They’re more likely to be in conflict with siblings—and with you,” says Kurcinka. “They’ll bug the pets just to keep some level of arousal going.” And I just thought our boy had something against Border collies.

Enlarged tonsils turn out to be only one of a long list of obstacles—from television and computer games to caffeinated beverages and crack-of-dawn bus schedules—that keep kids from getting a good night’s rest. While doctors recommend eleven to thirteen hours of sleep a night for preschoolers, a 2004 study by the National Sleep Foundation found that the average preschooler was sleeping fewer than ten and a half hours a night. Teenagers need more than nine hours of sleep, but a University of Kentucky study found that high school seniors average only six and a half a night.

And as our children’s sleep debt has accumulated, so has the science showing the serious downside of missing those zzzzz’s: decreased concentration and memory, increased risk of obesity and diabetes, and behavioral problems that can be confused with attention deficit hyperactivity disorder. More rest won’t solve everything kids do that keeps their parents awake at night, Kurcinka says, “but sometimes if you solve the difficulties with sleep, a lot of the issues that parents have with their children just go away.”

While we spend a third of our lives in slumber, science still doesn’t know why sleep is so essential. “We certainly understand the serious consequences of not getting enough sleep,” says pediatrician Gerald Rosen, director of the pediatric sleep department at Children’s Hospitals and Clinics of Minnesota. “But when you look at the neuroscience of sleep, we still haven’t truly figured out what it’s for.”

Sleep can seem just as mysterious to new parents, who discover that their babies have an entirely random pattern of sleep and will take months before settling into a rhythm that mirrors that of the rest of the family. “After about a year, kids will usually declare themselves as morning kids who wake up bright and early or night owls who want to stay awake later, and that’s a reflection of their internal circadian rhythm,” Rosen explains. Traditional bedtime rituals such as bathing, brushing their teeth, and listening to a story serve as behavioral cues that it’s time to turn off the jets for the day, he says, “and, if you set those rituals at the right circadian time, most kids do pretty well on automatic pilot.”

Problems arise when there’s a change in this timing—some schedule demand or stimulation that pushes bedtime beyond the point where it belongs. Perhaps the most obvious distraction is the television set, one of which is found in the bedrooms of 43 percent of America’s grade school children, according to the National Sleep Foundation. Though you might think it’s a soporific (especially if you don’t have cable), TV can have a supercharging effect on kids. A 2007 study in the journal Pediatrics found that boys who played a high-energy video game or watched an exciting television program two to three hours before bed took longer to fall asleep and spent less time in slow-wave sleep—the type that helps us form memories and remember what we’ve learned. Similarly disruptive, says Rosen, is “exposure to light from a bright monitor—whether it’s a TV screen, a computer monitor, or a cell phone—which pushes back natural sleep rhythms” until even later in the evening, subtracting from the hours available for sleep.

The shift toward a later sleep time occurs naturally in teenagers, who require more than nine hours of sleep and rarely get it, thanks to everything from Facebook and Red Bull to school times that require a morning alarm before a child enters REM sleep, the “dream” stage with the longest interval in the hour or two before morning. “There are probably three teenagers in the entire state who aren’t sleep-deprived, and they’re all home-schooled,” Rosen jokes. But the consequences of that lack of sleep are no laughing matter: More than half of the 100,000 car accidents caused nationwide each year by sleepy drivers involve teens.

Sleep debt might also weigh heavily on the one in three children now considered overweight or obese. A Canadian study published last fall found that children who sleep fewer than ten hours a night have a one in four chance of becoming overweight by the age of six. The reason, researchers say, is that the less sleep we get, the more our bodies secrete hormones that stimulate appetite and the less our bodies produce hormones that make us feel sated.

While there’s no such thing as “catching up on sleep,” simple changes in sleep hygiene can keep kids from missing out on more of it. Obvious steps include turning off the TV, curbing caffeine and computer time, sticking to a regular bedtime, and making sleep as important a priority as homework. Kurcinka counsels parents of overtired children to block out the hours needed for adequate rest on the family calendar first and then add time for everything else. For more serious insomnia or sleep disorders, a detailed sleep history or a few nights in a sleep clinic can help get at what’s keeping a child awake. Problems such as our son’s sleep apnea may require a surgical solution.

Malone estimates that two-thirds of the estimated 6,000 tonsils she’s removed in her career were the cause of the kind of breathing obstruction or sleep apnea we observed in our son. And while such numbers would suggest a relatively common condition, it’s not normal. “Kids shouldn’t have sleep apnea,” Rosen says. Healthy adults may experience prolonged pauses in their breathing during the night, she says, but “in kids what’s normal is zero.”

Malone says obstructed sleep apnea can sneak up on parents who have grown accustomed to a child’s noisy nighttime breathing or who aren’t aware of a child’s real nocturnal rhythms until they share a hotel room, tent, or upstairs at Grandma’s house. Parents can watch for other signs of a problem as well—snoring, bedwetting, the need to be roused in the morning, or the resumption of naps after a child has grown out of them.

Hyperactivity and lack of focus can be additional daytime manifestations of what’s missing at night—Kurcinka refers to the kids who display them as the “tired and wired.” While sleep disorders are common among children with ADHD, Malone points out, “some kids who don’t actually have ADD can be labeled that way because their ability to concentrate is decreased.” A recent University of Michigan study published in Pediatrics found that half of the children diagnosed with ADHD prior to a tonsillectomy were not diagnosed as such after the surgery. As for solving obstructed sleep apnea, removing tonsils and adenoids has been shown to be effective in nine out of ten children.

It certainly seems to have worked for our son, who six months after his surgery appears to be getting along famously with his brothers and our Border collie. We knew he was cured only a few weeks into his recovery when he woke us up one morning and asked a question rarely heard during the months when he was sleeping until noon. “What’s for breakfast?” he wanted to know.