Guest Article
Pat Britz, Program Director
National Sleep Foundation
[This article first appeared in the PAGER newsletter, Reflux Digest, April 2004]

About sleep

Sleep is a basic biological need for all living creatures, but it is especially important for children who need sleep to develop, grow, be healthy, learn and lead happy and productive lives. Sleep is the primary activity of the brain during early development and once children sleep through the night, getting sufficient, continuous and uninterrupted sleep becomes essential to their overall well-being.

Not only is the brain active during sleep, but timing of the sleep-wake cycle is regulated by a circadian biological clock located in the brain. This clock is affected by light and dark signals, which is why we are driven to sleep when it is dark and become alert when light travels through our optic nerve to the brain. Although newborns have irregular schedules and have periods of sleep around the 24-hour cycle, by 3-6 months, their sleep-wake cycle is developed.

The amount and depth of sleep is also regulated by the brain. The restorative process occurs as a need to sleep in accordance with how long we have been awake as well as the duration and quality of previous sleep. Newborns 0-2 months old generally need 10.5-18 hours of sleep that interacts with periods of hunger and wakefulness. Infants on average require 14.5 hours including naps and toddlers require around 12-14 total hours. Somewhere between 3-5 years old, preschoolers give up naps and need on average 11-13 hours of sleep while school-aged children require 10-11 hours to function at their best.

Sleep Stages

During sleep, both children and adults experience alternating types and stages of sleep. Sleep follows a predictable pattern beginning with Non-Rapid Eye Movement (NREM) sleep stage 1 when we transition from being awake to entering sleep followed by stage 2 or the onset of sleep and breathing is regular and our body temperature drops. Stage 3 and 4 of NREM are the deeper, restorative stages of sleep when breathing is slower, energy is regained, tissue growth and repair occur and hormones are released for growth and development. Finally, there is Rapid-Eye Movement (REM), also a deep state of sleep when the brain is active and dreams occur. There are profound physiological changes which occur during REM to include alterations in temperature and respiratory control. This architecture of sleep alternates every 50 minutes for babies, but occurs every 90 minutes by the time a child reaches preschool age and into adulthood.

Sleep cycles through a typical night showing deep sleep in the darker color and REM sleep in the lighter color

Getting sufficient, continuous sleep contributes to our overall well-being.

What is essential is that children sleep long enough without disruptions so that they benefit from experiencing ALL of the stages of sleep. Disruptions add up to poor quality sleep and not getting enough sleep leaves children sleep deprived all day. As a consequence, children experience daytime sleepiness and are not able to be alert, listen well, pay attention, focus and may exhibit impaired moods, poor behavior or be at risk for injuries, accidents and illness. In the 2004 National Sleep Foundation (NSF) Sleep in America poll, children 3-10 years of age who got less sleep than other children usually or always fussed when they did not get their way, whined or complained during the day. Children who appeared sleepy or overtired during the day were more likely to have difficulty sitting still and were easily distracted.

Parents are also affected when children do not get enough sleep. Not only can they lose sleep at night due to children’s nighttime awakenings, but 62% of these adults reported that they have somewhat/much less energy during the day. Not getting enough sleep at night leads to daytime sleepiness, which has a significant consequences for adults as well.

In NSF’s 2002 poll, adults who got less than six hours of sleep on a weeknight were more likely to be sad, stressed and/or angry. Additionally, of those who report not getting enough sleep, 90% or more stated that this can impair their performance, put them at risk for injuries, and lead to health problems. Approximately 59% also stated that sleepiness during the day makes it more likely they will get upset with children when they are noisy or misbehave.

Sleep is a particularly vulnerable time for children with GERD.

During sleep and in the prone position, the physiology of children with GERD may change, eliciting GERD symptoms. There may be a decrease in sphincter pressure contributing to reflux, which in accordance with the circadian rhythm, peaks from 9:00 pm to midnight. There may be sleep fragmentation secondary to arousal responses.

Sleep presents the following risk factors:

 Increased arousals/awakenings
 Reduced swallow frequency
 Decreased salivary secretion
 Possible fall in upper esophageal sphincter tone
 Supine position
 Prolonged acid clearance time

Infants with GERD swallow less frequently during sleep following a reflux incident; 5.3 swallows while asleep compared to 25/hour during wakefulness. Acid also takes longer to clear; 5.4 minutes during sleep and 1.5 minutes while awake. So, even though many babies reflux less during sleep, damage may occur quicker.

Although GERD has been linked to respiratory problems in adults, demonstrating an association between GERD and sleep-disordered breathing in children has been less clear. However, GERD has been considered a risk factor for Obstructive Sleep Apnea (OSA), a serious sleep disorder that occurs when there is an obstruction of airflow through the airway resulting in pauses or gasps in breathing. An apneic event can occur in response to mucous build-up in the back of the throat. The extra effort to breathe may, in turn, exacerbate GERD and possibly lead to additional reflux.

Difficulty clearing the acid and its discomfort could also result in coughing and wheezing leading to arousals and parental attention. Moreover, this could lead to more serious problems such as esophagitis as well as discomfort and irritability. When it becomes chronic, not only will there be more frequent disruptions to sleep resulting in sleep deprivation, but there is also the potential of mucosal damage and a risk of aspiration. In addition, it is important to check GERD medications to make sure they do not affect sleep.

Healthy sleep tips for a child with GERD for better sleep and to help minimize nighttime reflux:

• Establish a regular bed and wake time*
• Avoid feeding a child before bedtime or when they lie down, particularly spicy or acidic foods, caffeine products including chocolate, carbonated beverages and peppermint or spearmint snacks. Eat smaller, more frequent meals throughout the day and avoid large meals close to bedtime. In general, children with GERD should be upright after eating.
• If overweight, follow a healthy diet, exercise and lose weight. Exercise can contribute to good sleep, but it should occur no less than three hours before bedtime.*
• As applicable, both nicotine and alcohol should be avoided.*
• Maintain a regular, relaxing (non-alerting) bedtime routine that can include taking a bath/shower, reading and/or listening to soothing music.*
• Position the child for sleep by raising the head of the child’s bed approximtely 30 degrees, possibly with extra pillows or a wedge.
☺For infants 0-12 months, although the prone [face down] position minimizes the symptoms of GERD, it is best to position babies in the supine [face up] position during sleep to prevent SIDS as recommended by the American Academy of Pediatrics.
☺For children one year and older, sleeping on the left side is preferred to reduce reflux.
• Sleep with loose, non-binding nightwear.
• Create a sleep-promoting environment that is cool, quiet, dark and comfortable.*

*Healthy sleep tips for all children and adults as well.


Bandla, H. Splaingard, M. Sleep problems in children with common medical disorders, Pediatr Clin N Am 51 (2004) 203-227.
J Pediatr Gastroenterol Nutr. Vol. 32. Suppl. 2. 2001.
Mindell & Owens, A clinical guide to pediatric sleep, (2003) 197.
National Sleep Foundation. 2004 Sleep in America poll, March 2004 and 2002 Sleep in America Poll, April 2002.

PAGER is a partner in
The National Sleep Foundation
Sleep Awareness Week
Check with your
doctor first!