I was an art history major in college. The challenge of sorting out ancient Greek sculptures and Renaissance paintings suited my observational skills and avoided my difficulties with numbers. When it came time to practice medicine, it was clear that I would behave more like an artist than a scientist. I have stubbornly resisted requests to attach numbers to things that don’t warrant their specificity.
But, not everyone shares my distrust of numbers. Many – maybe even most – parents crave specific guidelines for navigating what they see as the mysterious waters of child rearing. "How many ounces should he be gaining each week?" One of the most powerful deterrents to breastfeeding is the fact that the human breast is neither transparent nor etched with milliliter markings. Parents don’t usually deal well with the vagueness of biologic variability.
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Many parents crave specific guidelines for raising their kids, including "How long should my child be sleeping?"
I am frequently asked, "How many hours should my child be sleeping?" As you might expect, I don’t usually include a number in my answer, but when I was writing "Is My Child Overtired?" (New York: Simon & Schuster, 2000), my editor wouldn’t accept a nonnumerical answer. So with Dr. Richard Ferber’s permission, I included the table from his classic "Solve Your Child’s Sleep Problems" (New York: Simon & Schuster, 1985). But as much as I respect my former classmate’s experience with sleep problems, I have never felt comfortable with the numbers in that table.
My discomfort has recently been reinforced by a special article in Pediatrics (2012;129:548-56). Australian investigators undertook a systematic review of the literature from 1897 to 2009. What they discovered was that each year, "experts" recommended ¾ minute less sleep on average than had been advised the previous year. However, the amount of sleep that children were actually getting was decreasing by almost exactly the same amount. This means that over the last 100 years, experts have consistently recommended 37 more minutes of sleep than children have been getting. Both the recommendation and the reality have decreased over time. During that century, most observers have usually attributed the decline to the stresses of "modern life."
The researchers correctly concluded that, "there is almost no empirical evidence for the optimal sleep duration for children." So, although parents may crave a number or a graph, there is little or no scientific basis for giving them what they want.
However, this vacuum doesn’t mean that we should stop advising parents about sleep duration. The Australian researchers suggested that the "sleep need could be determined by studies of sleep extension and restriction accompanied by monitoring relative outcome variables." And, this is the approach that I found works for me. I begin by helping parents identify one or more symptoms or behaviors that I suspect are related to sleep deprivation (for example, tantrums, night terrors, and/or migraine headaches). Then I suggest to parents that they gradually add more sleep to their child’s day with earlier bedtimes and naps and/or by restructuring the morning routine to allow the child to sleep later. When the target behaviors have decreased to a tolerable level, then "enough is enough."
Unfortunately, explaining to parents the concept of biologic variability and crafting a child-specific plan takes a hell of a lot more time than handing them a graph or table unsupported by the evidence.
But, some parents just can’t accept a nonnumerical recommendation. Whether it is insecurity or an obsessive personality, they aren’t satisfied without rules to govern their parenting. The only time I feel comfortable playing along is when it comes to television viewing. One hour a day is enough. In fact, it’s probably more than enough.
Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@elsevier.com.