As a sleep coach, I have now talked to thousands of parents and I can usually get a sense of whether the issue is just about patterns that need a nudge…or if something else is going on.
A garden-variety behavioral issue would sound like,
“My baby wakes at midnight, then again at 5am and goes right back to sleep if I feed him.”
Or “My baby is waking, but if we cosleep, he can sleep for hours and hours.”
Or “My toddler wakes for a drink of water, then goes right back to sleep.”
On the other hand, when a mom (or dad) tells me, “Our baby is waking every 1-2 hours…even if we cosleep,” or “My three-year-old is awake from 2-5am every night,” I suspect something may be up.
When any child is waking frequently (like, less than a full sleep cycle), we have to ask why. What’s preventing them from staying comfortable enough to sleep through a full sleep cycle? This is especially true to ask if you have already tried several sleep strategies that have been a total bust. When issues feel immovable, it’s time to check to see if there are physical conditions at play.
Before you consider symptoms, always check to make sure these behavioral pieces are not actually the issue:
Is your child overtired? (Enough naptime? Early enough bedtime? Check my Linktree to download a sleep target handout.)
What’s happening at bedtime? If your child is getting out of bed to find you, are you lying with them at bedtime? If infants are waking frequently, are you feeding/rocking them to sleep?
If either of these sound like reasonable possibilities for why you're having problems, I’d start there. However, if you know that there's more going on, keep readiing.
If you are saying, “Yes, I am lying with my child, but that’s only because if I don’t, it’s a four-hour circus of badness,” read on.
Here are five organic sleep disruptors that may explain why sleep training hasn't been successful until this point:
Low Ferritin/Restless Legs
Obstructed breathing/Sleep apnea
PLEASE NOTE: I am not a medical professional and none of this is diagnostic advice, nor is it the complete list of possible symptoms. These are for general information only. Please seek out evaluation and advice from your medical care providers.
This mostly affects younger babies and resolves (mostly) when babies start solids. Silent reflux is different from regular reflux. I talk to many parents of very fussy, sleepless babies who say, “Oh, it’s not reflux because my baby isn’t spitting up.” The “silent” part of “silent reflux” is the lack of any spitting up.
Silent reflux is like baby heartburn where the stomach acid bubbles up into the esophagus. The muscle that closes the stomach off can take time to really fully come online. When babies have silent reflux, they are just…not…happy. They may have trouble sleeping in any context or, it could just be when they’re lying flat.
Silent reflux is a potent sleep tanker and pediatricians are careful about prescribing medication. Always talk to them first. However, from a parenting and sleep coach perspective, it’s also important to factor in the significant wear and tear on the baby and family of having a child in pain and not sleeping.
Painful cry when lying flat (especially after a feed)
Prefers to be upright most of the time (especially for sleep)
Grimaces (like a bad taste in the mouth) or a gurgling sound in the throat
“Nibble nurses” (eating only a little at a time) or nursing best while drowsy
Arches back while nursing or feeding
Contact: Pediatrician, Pediatric GI specialist
Usual treatment: Variety of adjustments to feeding/sleep space; Medication
This one is tough. Food allergies are relatively easy to spot; children develop rashes, or they vomit immediately after and offending food. The biggest culprits are cow’s milk, wheat, soy, citrus, nuts, and shellfish. Some parents also look at food additives, etc.
Intolerances are really tricky to diagnose and assess in the absence of more obvious signs. We do know that cow’s milk intolerance (and all ages) can be a culprit in sleep problems.
Dark circles under the eyes
Sleep problems that don’t respond to behavioral adjustments
Contact: Naturopath, Allergist, Nutritionist
Usual Treatment: Elimination diet
Eczema is surprisingly common in kiddos who are generally more alert, intense, sensitive, active. Pediatricians and others typically downplay eczema and tell parents to apply a barrier lotion, etc. However, eczema is really itchy and while you can prevent a child from scratching, it does not eliminate the sensation. Eczema has been shown to directly impact nighttime sleep. Investigating root causes (e.g., allergies) and focusing on symptom relief is going to help sleep.
LOW FERRITIN/RESTLESS LEGS SYNDROME
This is more common than you think…especially in really hard sleep problems. Ferritin is the iron storage factor in the blood and helps transport iron into the tissues. Babies get ferritin in utero and then in a big, last burst as the umbilical cord stops pulsing. Early cord clamping has been identified as an underlying cause of low ferritin levels.
Low ferritin alters the architecture of sleep in the brain and in some cases, causes physical discomfort that can look like shenanigans (bedtime battles) in older children and severe nightwaking and resistance to change in younger children and infants.
Signs of low ferritin I’ve seen in past clients:
Mom needed to stand while holding the baby with its feet dangling from 12-5am every night.
Parents had to drive the child in the car every time he woke at night
When starting work on sleep, mom couldn’t even unlatch the 7-month-old to start or the baby would start screaming hysterically.
Even when cosleeping, parents reported having to dodge their toddler’s flailing limbs.
One parent reported that even when cosleeping, the child needed to have his legs up on a parent.
A 3-year-old took hours to fall asleep at bedtime (with lots of changes in location) and then was up again from 2-5am.
Low ferritin and Restless Legs Syndrome in children under school age isn’t on pediatricians’ radar, unfortunately. Current diagnosis typically involves a child saying their legs hurt. There are some studies out that have found that the majority of children who later get diagnosed with RLS had symptoms starting in infancy. Given the role of ferritin in motor and nervous system development, more early screening will eventually start happening.
Possible Symptoms (at bedtime and/or middle of the night)
Kicking, thrashing, lots of movement, wanting to stand or get picked up
Banging legs on the mattress
Restless even when cosleeping
Takes a long time to go to sleep with difficulty getting comfortable
Very frequent waking or awake for long periods in the middle of the night (and nothing works to get them back to sleep)
(Older children) Complaints of pain in the legs (“growing pains”)
BIG distress in the face of sleep training attempts (lots and lots of crying with no change over time)
Mom was anemic during pregnancy
Child has or had food intolerance, reflux. Parent has gluten intolerance or celiac disease
Family history of low iron or Restless Legs
Umbilical cord was clamped early at birth
Contact: Pediatrician, Pediatric Pulmonologist, Sleep Doctor (for a blood draw)
Treatment: Prescription iron supplementation
OBSTRUCTED BREATHING/SLEEP APNEA
In my training with a pediatric sleep doctor, he said, “Children should never snore outside of having a cold or allergies.” Persistent snoring or mouth breathing can be a sign of obstruction. Children’s heads grow at disproportionate rates and their tonsils and/or adenoids can block airflow. Not every child will need surgery, but it’s good to get things checked by an ENT. They may recommend a “wait and see” approach.
Child snores or routinely breathes through their mouth (outside of having a cold)
Sweaty head while sleeping
Restless sleeper/Sleeps with head thrown back
(Older child) Awakens at night “afraid” (These could be regular nighttime fears, but it also could be a child who had briefly not been able to breathe and awoke).
Contact: Pediatric Ear, Nose, and Throat Doctor (ENT)
Believe it or not, babies can have tight or pinched muscles. This is especially true if it was a hard, long labor and/or tricky birth. If we think about a baby with some tightness or misalignment, nighttime sleep might be really hard. Lying on a flat surface and maybe being unable to get into a more comfortable position may cause a baby to cry, get picked up, and resettled. A session or two with either a pediatric chiropractor or craniosacral therapist may be all that’s needed.
Late on some motor milestones (Here’s a great tracker for this https://www.healthychildren.org/English/MotorDelay/Pages/default.aspx#/chooseactivity)
Physical asymmetry (one side looks or behaves differently: one arm is weaker, baby only looks in one direction, etc.)
Looks like some tasks (e.g., tummy time, rolling) are hard and/or painful
CONTACT: Pediatric chiropractic, Craniosacral therapy, Early intervention (if motor milestones are late and/or other milestones are of concern).
In infants under 6 months, sleeping problems can be largely related to feeding issues. The younger the baby, the truer this is. Always check with lactation (for breast or bottle feeding) to check for latch issues, tongue/lip ties, etc.
Not gaining weight well
Persistent gas or constipation
Crying while nursing
Taking a very long time to eat (>30 minutes)
Arches back or stiffens when feeding
Contact: Lactation consultant
FEEDING ISSUES (Sensory Processing)
Even infants who have started solids can show signs of sensory sensitivities to food texture and taste. Children who are sensitive to foods/textures are likely sensitive to other sensory modalities. Sensory processing sensitivities are a major culprit in sleep issues. Here, if a child is not eating well because of sensory sensitivity, it’s likely that they’re also not sleeping well. (I’m going to do a whole issue on sensory processing and sleep in a later newsletter…because it’s huge with livewires.)
Refusing purees by 8 months
Refusing foods or gagging with certain textures
Refusing to touch certain foods
CONTACT: Pediatric Occupational Therapist for a sensory assessment
Most of these physiological symptoms get overlooked by primary care providers who will often say either, “Eh, this is normal” or “You just have to sleep train them.” Not all of them dismiss behaviors like this, but I hear it a lot. If any of these sound like your non-sleeping child, get it checked out. Once an underlying cause is addressed, the problem will either disappear or it will be so much easier to manage. ◉
Macall Gordon has a B.S. from Stanford in Human Biology and an M.A. from Antioch University, Seattle in Applied Psychology, where she is currently a Sr. Lecturer in the mental health counseling and art therapy departments. She researches and writes about the relationship between temperament and sleep, and the gap between research and parenting advice. She is a certified pediatric sleep consultant working with parents of alert, non-sleeping children in private practice, as well as on the women’s telehealth platform, Maven Clinic. She comes to this work because she had two sensitive, intense children and she didn’t sleep for 18 years.