Bedtime blues
Caroline Swinburne is a freelance journalist

All new parents expect some broken nights but when a child's wakefulness becomes excessive it can lead to exhaustion and even marital breakdown. Sleep counsellors can help but are often in short supply.

For the past seven years community nursery nurse Annette Faamausili has worked alongside a team of five health visitors helping families whose children do not sleep through the night.

Ms Faamausili estimates that as many as one in four families with young children experience difficulty establishing a successful sleep routine, and the number is increasing. 'There are huge pressures on mothers to return to work and for parents to juggle work and family life. They want to enjoy time with their children in the evening, but do so to the detriment of a good, consistent bedtime routine.'

Up to the age of five, children need between 11 and 12 hours unbroken sleep at night. Until they are around two-and-a-half they normally still need a nap during the day, for anything up to two hours or more. If they are deprived of this sleep, the effects on the family can be disastrous.

Demand for Ms Faamausili's services is such that for the past five years she has run a regular sleep clinic every Friday afternoon. Families with children aged between six months and five years can be referred by their health visitor or GP. Occasionally, they self-refer.

Ms Faamausili prefers to see both parents on their own at the clinic. This is partly because a sleep-deprived child is not good company. 'You can immediately tell when a child is sleep-deprived by looking at him or her,' she explains. 'They are often hyperactive, manic and irritable, with poor concentration levels.'

Focus on the problem

But more importantly, seeing the parents on their own gives them the chance to focus on the problem and talk about their situation without the need to concentrate on the child. By the time they reach the clinic, Ms Faamausili's adult clients may also be suffering from depression, feelings of isolation and relationship problems. Coping with the demands of day-to-day life can become impossible.

She first asks the parents to talk her through a typical evening, making a note of when the children have tea and bath time, when parents return home and events leading up to bedtime. Then, using charts, she explains the different phases of sleep.

Ms Faamausili encourages parents to view the night through their child's eyes. If she has been rocked to sleep with the aid of the breast or bottle, the last thing she will remember is being in her mother's arms feeling safe and secure with the taste of warm milk in her mouth. If the child then wakes up an hour or two later to find those things have gone and is alone in her cot, she may become distressed and unable to return to sleep unless the parent reproduces those

Ms Faamausili emphasises the need to establish a good bedtime routine. 'I stress the importance of taking the child upstairs at the same time each night, giving him or her a bath and then going straight into the bedroom - there is absolutely no going back downstairs.

'They should have a bit of quality quiet time - a drink of milk and a story. Even small babies can enjoy a simple story. But after that the child should be tucked up in bed, with a teddy or a blanket. And then mum or dad should leave the room while the child is still awake - that is very important and the key to a successful sleeper.'

Controlled withdrawal

The most important aspect of developing a good sleep routine is for the child to learn to fall asleep by him or herself. Most of Ms Faamausili's clients are advised to use a controlled withdrawal routine. To begin with she recommends that they leave the room for no longer than five minutes. If the child is still crying after this, the parent should return, calmly reassure the child that he or she has not been abandoned and then leave the room again.

This routine then needs to be repeated every five minutes for as long as it takes for the child to eventually fall sleep. The parents must not shout or punish their child, but talk calmly and firmly and leave the room confidently.

Like many new clients, Nikki Robson was sceptical that Ms Faamausili's advice would be effective. 'When Annette told me that if I did what she said my daughter Holly would be sleeping for 12 hours a night within a week, I simply did not believe her,' she says. 'But I knew I had to give it a go because we could not go on as we were.'

To begin with, her scepticism seemed well founded. 'The first night it took until about midnight to get Holly to sleep,' she recalls. 'I was going in and out every five minutes for hours. Basically, it was hell for the first two or three nights - it is far worse getting in and out of bed every five minutes, rather than just leaving her to scream. But I knew I had to do it and be really strict.'

On the fifth night there was a breakthrough. 'I gave Holly her tea, bathed her and put her to bed as usual. Then I started tidying things up, waiting for her to start crying. But things suddenly went quiet. At first, I wondered if Holly was all right. Then, to my amazement, I realised she was fast asleep.'

Within a week Holly was a reformed character, sleeping for 14 hours. For the Robsons, this meant a return to something approaching a normal family life. 'Holly was just so happy,' says Ms Robson. 'She was like a completely different child.'

Ms Faamausili estimates that around 92 per cent of her clients achieve total success after a period of just seven to ten days. Word has spread and she is overwhelmed with pleas for help.

'I did a presentation to a group of nursery nurses in our neighbouring trust,' she says. 'They wanted to hear what I had been doing, because they have been inundated with cases of children who have sleep problems and they did not know how to tackle them. There is a huge amount of interest out there. I believe this sort of service should be more widely available.'

Tips for a successful sleeper

Nursing Standard, Volume 19(44), 13 July 2005, pp 22-23
(C) Copyright 2005 RCN Publishing Company Ltd.
Used with Permission. Do not reproduce without express permission from the Publishers.