Sleeping

睡眠

Sleep behaviors are culturally determined, and problems tend to be defined as behaviors that vary from accepted customs or norms. In cultures where children sleep separately from their parents in the same house, sleep problems are among the most common that parents and children face. Infants generally adapt to a day-night sleep schedule between 4 and 6 mo. Sleep problems beyond these ages take many forms, including difficulty falling asleep at night, frequent nighttime awakening, atypical daytime napping, and dependence on feeding or being held for sleep. These problems are related to parental expectations, the child's temperament and biologic rhythms, and child-parent interactions. Inborn biologic patterns are central to an infant's sleep patterns, whereas emotional factors and established habits become more important in the toddler and older child. In addition, sleep disturbances become common at 9 mo and again around 18 mo, when separation anxiety, increasing ability of the child to move independently and control his environment, long late-afternoon naps, overstimulating play before bedtime, and nightmares tend to become more common.

睡眠行为靠培养，睡眠问题是指违背公认习惯或标准的行为。在儿童与父母同屋单独睡的文化环境中，睡眠问题是父母儿童所面临的最常见问题之一。4－6个月大时的婴儿一般已适应了昼夜睡眠表。大于这个年龄的睡眠问题各不相同，如，夜间难以入睡、夜间频繁醒来、昼间瞌睡无规律，喂着或抱着才能入睡等。这些问题都与父母的期望、儿童性情和生物节律及父母与子女沟通有关。天生的生物形态是婴儿睡眠形态的主轴，情感因素和既成习惯对幼儿和儿童更重要。此外，睡眠紊乱在9个月时较普遍，18个月前后又是如此，此时，分离的焦虑、小儿独立活动与对环境控制能力的增强、长时间午睡、睡前玩耍兴奋过度及梦魇等更为常见。

Evaluation

评估

History: History focuses on the child's sleeping environment, consistency of bedtime, bedtime routines, and parental expectations. A detailed description of the child's average day can be useful. The history should probe for stressors in the child's life, such as difficulties in school, as well as exposure to unsettling television programs and caffeinated beverages (eg, sodas). Reports of inconsistent bedtimes, a noisy or chaotic environment, or frequent attempts by the child to manipulate parents by using sleep behaviors suggest the need for lifestyle changes. Extreme parental frustration suggests tension within the family or parents who are having difficulty being consistent and firm.

病史：病史询问重点是儿童的睡眠环境、固定就寝时间、就寝常规和父母期望。儿童日常情况详细描述很有用。病史应调查儿童生活中的压力因素，如学习困难、及接触一些搅人心神的电视节目与含咖啡饮料（如碳酸钠)等。如反映就寝时间不定、环境噪杂、或儿童经常想利用睡眠行为操纵父母等，都提示有对生活方式改变的必要。父母极度失望提示家庭关系紧张或父母难以始终如一，无法坚持。

A sleep diary compiled over several nights may help identify unusual sleep patterns and sleep disorders (eg, sleepwalking, night terrors). Careful questioning of older children and adolescents about school, friends, anxieties, depressive symptoms, and overall state of mind often reveals a source for a sleep problem.医学 全在.线提供www.med126.com

几个晚上的睡眠日记可以帮助确认异常睡眠形态和睡眠障碍（梦游、夜惊等)。仔细询问儿童少年有关上学、交友、焦虑、抑郁症状及总体心理状态常常可以提示睡眠问题的原因。

Physical examination and testing: Examination and diagnostic testing generally yield little useful information.

体检与化验：检查与诊断化验一般不会提供有用信息。

Treatment

治疗

The clinician's role in treatment is to present explanations and options to parents, who must implement changes to get the child on an acceptable sleep schedule. Approaches vary with age and circumstances. Infants are often comforted by swaddling, ambient noise, and movement. However, always rocking the infant to sleep does not allow the infant to learn how to fall asleep on his own, which is an important developmental task. As a substitute for rocking, the parent can sit quietly by the crib until the infant falls asleep, and the infant eventually learns to be comforted and to fall asleep without being held. All children awaken during the night, but children who have been taught to fall asleep by themselves will usually settle themselves back to sleep. When a child is unable to get back to sleep, parents can check on the child to reassure themselves of the child's safety and to reassure the child, but the child should then be allowed to settle himself back to sleep.

In older children, a period of “winding down” with quiet activities such as reading at bedtime facilitates sleep. A consistent bedtime is important, and a fixed ritual is helpful for young children. Asking a fully verbal child to recount the events of the day often eliminates nightmares and waking. Encouraging exercise in the daytime, avoiding scary television programs and movies, and refusing to allow bedtime to become an element of manipulation also help prevent sleep problems. Stressful events (eg, moving, illness) may cause acute sleep problems in older children; reassurance and encouragement are always ultimately effective. Allowing the child to sleep in the parents' bed in such instances almost always prolongs rather than resolves the problem.

临床医师在治疗中的作用是向家长作出说明，提供解决方案，家长必须作出改变，说服小孩接受睡眠计划。具体方法则依小孩年龄与情况而定。婴儿常常可以从襁褓、周围声音和运动中得到安抚。不过，始终摇婴儿睡觉不会使其学会自行入睡。自行入睡恰恰是一项重要的成长任务。父母可以安静地坐在摇篮边直到婴儿入睡，慢慢地婴儿就会学会感到安抚，不用抱就可以入睡，这是替代摇睡的一个办法。儿童都会在夜间醒来，已学会自行入睡的儿童会自己睡着。如果小孩无法再次入睡，父母可以查看，确信小孩的安全，安抚小孩，然后让小孩自行入睡。大一点的小孩，通过一些安静的活动，如就寝时看看书，使他有一段时间“慢慢放松”，这有助于他入睡。让会说话的小孩讲讲白天的一些事情常常可以消除梦魇和梦游。鼓励白天运动、避免吓人的电视节目和电影、拒绝使就寝时间成为人为操纵的一个因素，这也有助于预防睡眠问题。一些让人感到压力的事情（如搬家、生病)可能引起较大儿童的急性睡眠问题。安慰和鼓励总是最有效的。让小孩睡在父母床上只会延长而不是解决问题。