Keywords

At first sight it would appear that sleep is a purely physiological phenomenon, something that our brain and body need in order to restore energy and to rest. As for the brain, sleep represents to engage in a very active process that perhaps is related to consolidation of memories and processing information obtained during the day. Nevertheless, as one starts thinking about the particulars of sleep, its duration, when people sleep, what conditions are necessary for them to do so, the question becomes more complex. Additionally, when one wonders what happens during sleep in the case of pregnant women or young children, immediately social and cultural issues come to the fore (Williams 2007; Jenni and O’Connor 2005).

Sleep and its features are strongly influenced by cultural practices (Williams and Bendelow 1998). Let us examine what we consider a very common and everyday practice: shift work. In many industrialized and poor countries, people work some weeks during the day, some weeks during the night or in the evening. What is the effect of this on their lifestyle and sleep? One can see the highly artificial nature of the practice if we were to compare it with the millennia of humans mostly “sleeping in the night” and the sleep–wake cycle that is maintained in most traditional societies, including perhaps a nap during the daytime.

In many Westernized areas, sleep is considered as a solitary phenomenon, something the individual does alone. This also applies to children, even very young ones. However, in much of the world this is not so. Sleep is not a solitary phenomenon, because people sleep in groups, or in small units (Super and Harkness 2013). This means that there might be different patterns of sleep and disturbances in different culturally determined sleep arrangements.

It might be useful to reflect on the fact that in the world of animals sleep is a very “costly activity” from the evolutionary point of view. It appears that all animals sleep, including fishes and reptiles, although usually not for long stretches of time, but during brief periods of “quietness” throughout the day. During sleep, animals are vulnerable to predation and obviously are not vigilant. Diverse animals have developed different strategies to ensure their survival to achieve sleep, which is essential to the homeostasis of the body. Some sleep for very short periods of time throughout the 24-h day, rather than in a circadian pattern. Many animals, like birds and mammals, sleep in groups, in physical contact with one another in the case of mammals and many birds. If someone is attacked in a larger group, the others realize this quickly and take protections. Another strategy is that one member of the group, as with some birds, is awake while the others sleep so that there is surveillance, and then a sign of alarm is made when a predator is nearby.

Cetaceans and some bird species sleep with only one brain hemisphere at a time. The alert hemisphere can keep partial watch of their surroundings, that is, one eye open and the other closed so there is no total vulnerability. Some migratory birds have developed the ability of sleeping while they are flying in long distances (McNamara et al. 2010).

Primates and humans sleep for a comparatively very long continuous period of time, mostly during the night: this is a “luxury” from an evolutionary point of view. They go through prolonged rituals in order to select a sleeping site (Anderson 1998), then to ensure their safety before going to sleep and waking up a few times during the night for short periods (McNamara et al. 2010). The precondition for sleep is safety and this may be something that many humans may find difficult to feel in: conditions of high stress, such as in neighborhoods in inner cities in the United States, for example, where there are shootings during the night, in high-crime areas, or in war zones.

Many primates sleep in groups so there is a higher chance of survival in case of an attack on a sleeping site, also they exhibit “cryptic behavior” to minimize the chance of being attacked at their sleep site during their repose. In humans there may be a biologically based bias toward sleeping in groups, in contact with another conspecific in order to increase the feeling of safety.

Culture, Pregnancy, and Sleep

It is generally accepted that the sleep of an expecting woman will change due to the processes taking place in her body. In the first trimester there may be more sleepiness and in the third, its opposite, very interrupted sleep. In many cultures this is accepted as a result of the volume of the baby in utero and its effect on the stomach and lungs, the urinary bladder, etc. As a result, the woman usually will have more interrupted sleep, she will wake up to urinate more often, and her breathing is somewhat difficult. She also will have to change positions often and may develop back pain and leg cramps.

There are other sleep difficulties that are not specific to pregnancy but when they manifest during this period, they may be interpreted as the result of extraordinary influences or additional factors. Panic attacks may appear during pregnancy and wake up the woman suddenly, as well as sleep paralysis and nightmares.

The Sleep of the Expecting Woman and Her Partner

Pregnancy is a time of increased risk for some sleep disturbances, particularly in the second half, with interrupted sleep due to the sheer volume of the uterus and its mechanical effect on other organs, such as the bladder or the digestive system and respiratory apparatus. Toward the end of the pregnancy there may be back pain, and the movements of the baby in utero wake up the mother. The evidence suggests that up to 90% of women in the third trimester have sleep disruptions (Wilson et al. 2011), with decreased duration of sleep phase III and IV, which is the reparative or restful sleep.

There is also an increased risk of restless leg syndrome, which may affect around 20% of women during pregnancy (Balendran et al. 2011) and is related often to iron deficiency. In areas with low access to vegetables and other sources of iron, this could further disrupt the sleep of women and their daytime function. The prevalence of restless leg syndrome increases with subsequent pregnancies.

Anxieties and Dreams

There is scarce empirical information about the common dreams of women during the perinatal period specifically (Margherita et al. 2015). A recent study of women with previous perinatal loss found more anxiety dreams in the subsequent pregnancy (Van et al. 2004). Many mental health clinicians have the impression that pregnant women often report dreams of birth, of the course of the pregnancy (Dagan et al. 2001) and anxieties about the outcome. A recent empirical study found a similar pattern (Coo et al. 2014) in which there were differences between the antenatal and postnatal patterns of dreams.

In the Western world, dreams are now considered as something of little significance or not meaningful, which is a shift from past decades. In many areas of the world, women and the family pay close attention to the nature and content of their dreams, as they are thought to have a meaning. A woman could have an auspicious dream while pregnant, in which she dreams that the baby is beautiful, healthy, and everything goes well. However, many women might worry if they dream of certain topics or images, like knives, which might mean a disruption in the pregnancy in some cultures or dreaming about an ancestor or a person who died, who is taken to attempt to communicate with the pregnant woman. The dream might influence the name given to the child and how the baby is perceived.

A pregnant woman might be tormented by dreams of a posttraumatic nature. We often encounter this in persons who have suffered maltreatment and deprivation during their childhood. Women who experienced a very negative relationship with their mother, and now “they are going to become a mother,” may experience scary dreams in which the baby dies, the mother mistreats the child, the baby is robbed, or disappears, etc. These are common anxieties in pregnant women, which in the case of one who has been traumatized can be exacerbated or intensified.

An exploration of women’s dreams during pregnancy in Israel found an association between more unpleasant and anxious dreams in women who later developed postpartum depression, in comparison with women who did not (Kron and Brosh 2003). In several African cultures, dreams are considered as part of the life of a person in which he or she has access to the world of spirits. A dream with frightful content can be understood as an attack by spirits on the soul of the dreamer, which may lead to negative consequences in the health of the pregnant woman, or on the outcome of the pregnancy (Aina and Morakinyo 2011). The dream can also contain the encounter of the dreamer’s soul with another person’s soul, which attacks one of the dreamers (Gollnhoffer and Silans 1973) and brings about an “unnatural disease.”

In many cultures, like in some African and Australian groups, it is thought that the spirit of the person leaves the body during the night, while the person is dreaming. It is important to wake the person carefully to give the sleeper time to regain her spirit, lest it gets lost (Musharbash 2013).

Sleep Paralysis

Sleep paralysis consists of a disturbance in which the person is “awake.” In the sense that he or she can hear what is happening around, but cannot open the eyes and cannot move, so there are no external signs that the person is awake. It can last minutes, or in rare cases hours. At times it is very frightening for the sleeper, who cannot “get unstuck” from the inability to move and appear awake. Its prevalence in adults has been reported to be as high as 52% for occasional sleep paralysis experiences. In China, it is often interpreted as “ghost oppression” (Wing et al. 1994). In some traditional Chinese beliefs, the soul of a person is vulnerable to attacks during sleep, as it escapes the body. The ghost may attack the sleeper and paralyze her temporarily. Some sleepers report also a heaviness on the chest and even looking at the ghost of a woman holding a baby. Similar interpretations, ghost oppression (called dab tsog) are found in the Hmong immigrants in Wisconsin (Young et al. 2013). Other representations are the Pandafeche phenomenon in Italy (Jalal et al. 2015) which is thought of as a witch or a woman in the form of a cat. A demon attack during the night in Japan (kanashibari, which literally means being bound and unable to move) (Yoshimura 2015), and in Morocco and Egypt, an attack by djinns (evil spirits).

Sleep in Infants and Young Children: Are There Culturally Based Differences?

A somewhat unusual situation has been described in the Maghreb (usually comprehending Northern African mostly Muslim countries) (Jansen 2000) which here is referred to mostly for its symbolic value. It consists of the fetus “falling asleep” in utero leading to a protracted pregnancy, which lasts more than the expected 10 lunar months.

As for sleep in infants, most of the information available in the world’s scientific literature is predominantly from industrialized countries, such as the United Sates, some European countries, and Israel. There may be features of sleep in infants and young children that are mostly based on biological tendencies inherent to our species. It is also possible that there may be unique characteristics of some sleep patterns depending on factors such as geographical, socioeconomic, and cultural ones. In adults in the United States, there is some evidence that there may be “ethnic” differences between the sleep patterns of Caucasians and African Americans (Profant et al. 2002).

Naps for Young Children

Parents often question at what age young children “should” not need a nap during the daytime, whether at age 4 or 5 and ask for advice on this point. There are cultures in which children and adults take a nap in the middle of the day (generally called siesta in Latin America and Spain), while in other countries adults do not do that, and eventually expect their children to do the same, that is, only sleep during the night. Another example of a connection between sleep patterns and cultural factors is the notion of “a bedtime,” which does not exist as such in many social groups, that is, not a time when based on the clock, the children are “put to sleep” (Wortham and Brown 2007). Rather, the moment of going to sleep may depend on light and dark, or on other factors, such as how early activities start the next day and how late the family had dinner. In Spain, for instance, it is commonly seen that families have dinner later at night, and activities even at school start later in the day than would be typical in the United States. In many countries like Spain, Italy, and Latin America children participate in the family’s activities in the night, and they may fall asleep where they are, only to later be transported to the bed, so there is no sleep ritual as such.

In the United States, children who attend day care and preschools are “expected” to take a nap or rest for a period of at least one or up to 3 h in the middle of the day. Some children do not need these naps, and they have difficulties with this “quiet time” on which their teachers insist. If they do sleep for 3 h during the day, it would not be surprising if at bedtime they are not sleepy. Their parents may want to have them sleep, for example, around 7 PM, and this tends to create conflicts between parents and children. This is particularly so if the child has spent a long time in preschool and after care and then gets to spend very little time with their parents after their work, around 5:30 to 7 PM. There is scarce scientific information as to the “need” for a nap, when the sleep pattern becomes biphasic (day and night), when the young child does not require a nap, etc. A recent systematic review suggested that naps after 2 years of age tend to delay the time of sleep onset and more disrupted sleep at night, and in general naps are not of much benefit for health in the long term (Thorpe et al. 2015). However, other studies have suggested a benefit in the capacity of the child to learn in preschool settings (Staton et al. 2015).

Where Should the Baby Sleep?

In most of the medical literature on sleeping in infants and young children, it is assumed without question that the “optimal” sleep pattern for a young child is to sleep by him- or herself and to achieve this with minimal intervention from parents (Mosko et al. 1993; Mindell and Owens 2015), despite which parents in the majority of the world’s population continue to sleep with their young children for multiple reasons (Nelson et al. 2001). In most cultures in the world, at least mothers and small infants always sleep together. There is the suggestion that the touch between the two participants produces a feeling of calmness. In Japan, this is referred to as a feeling of Anshin, which allows both the baby and the caregiver to go to sleep well (Adis Tahhan 2013; Fukumizu et al. 2005).

Fig. 13.1
A artwork of a young girl and an infant sleeping closely together on a couch.

Sleeping arrangements. (Original artwork by Ana-Marcela Maldonado-Morales)

Full size image

In the United States, several northern European countries, New Zealand, and others (Gettler and McKenna 2010), there is presently considerable controversy about what is the “best” or the “safest” strategy for the newborn and infant. The recommendations that professionals and parenting experts provide to new parents are often not presented as that, controversies, but as certainties. In many hospitals, at least in the United States, parents are told that they should never sleep with the baby in the same bed, because of an increased risk of sudden infant death syndrome. This at times is taken to the extreme of being considered as risky behavior close to neglect of medical advice (Ball 2002, 2003, 2009).

In the United States, given the frequently voiced “dangers of co-sleeping,” many parents sleep “in secret” with their baby and may not reveal this to their pediatrician. Something similar occurs when immigrant parents from traditional societies are told by well-meaning nurses to “never sleep with the baby,” an injunction which they will find strange and counterintuitive, leading them to conceal what they “really do” in their home. Of course, another possibility is that young children may sleep with their siblings, which sometimes they want to do for a feeling of protection. This has been found to be commonly the case in families of minorities in the United States, particularly in African American young children (Milan et al. 2007).

In contrast with this, the UNICEF (United Nations International Children’s Emergency Fund) in the United Kingdom recommends as the optimal situation for the baby to sleep with his or her mother on the same bed. This promotes breastfeeding, makes it easier for the mother to care for her baby, and protects against the risk of sudden infant death (McKenna and McDade 2005; UNICEF UK n.d.). What are well-intentioned parents to do? There seems to be a clear association between co-sleeping and a higher odds of breastfeeding and its concomitant benefits (Ball 2003, 2009).

Until a few years ago, the American Academy of Pediatrics’ official position regarding newborn and infant sleep was that the newborn should sleep in a separate room from the parents and to be monitored through some electronic device. A few years ago (AAP 2005), this recommendation was changed and now the official advice is that the baby should sleep “in the same room” as the parents, but not on the same bed (Task Force on Sudden Infant Death Syndrome 2011). In many German families, it seems, there is also much emphasis on independence of the infant, to promote this the child is often put to sleep alone (Jenni and O’Connor 2005; Valentin 2005).

Also, until recently the US Consumer Product Safety Commission (US Consumer Product Safety Commission 1999; Drago and Dannenberg 1999) had concluded that the “safest” place for the baby to sleep was inside a crib, which the evidence does not support (Morgan et al. 2006).

On the other hand, parents in most traditional societies and in many industrialized countries practice “co-sleeping” with the baby from birth and certainly later on. It must be mentioned that in many parts of the world houses are not build in the same way as houses or apartments in industrialized societies and the notion of “privacy” and “rooms” is different. The house may have only one, two, or three “rooms,” which are shared by everyone, even to sleep. In many households, the members sleep on the floor, on mats, on straw mats, or they might sleep in hammocks and other similar devices.

Additionally, it must be kept in mind that in many rural environments, undesirable animals, such as rats, mice, scorpions, and others, can “enter the house” and hurt the baby. Parents may prefer to have the baby sleep together with them in order to best protect their child against these dangers. Indeed, in many traditional societies not only the nuclear family, but the extended family sleeps in the same room on the floor or on beds. Among the Maori this was the ancestral custom, and there were meanings associated to the precise sleeping positions of the various family members. This is now disappearing except on ritual celebrations (Van Meijil 2013).

Other “dangers” that may concern parents, particularly likely during the night, may be unwanted or feared “presences” such as ghosts, genies, shadows, and other evil entities that may attempt to kidnap the child, take him or her to the other world, or damage the baby in some way. In rural Ireland, until very recently, Scheper Hughes found that parents still believed that the baby could be “changed” for a different one during the night, and they would have a “changeling” baby instead of their original child. This is more likely when there is something “wrong” with the baby like a malformation or a serious health problem.

A recent survey in Switzerland (Jenni et al. 2005) found that preschool children in a very high proportion spend “part of the night” in the parents’ bed, illustrating the tendency of young children to try to sleep together with the parents for many reasons, including emotional needs, common fears, seeking proximity and the like, fears that are very common in the preschool stage. Even in a culture that values independence and self-reliance, parents end up “allowing the children” to spend time in their bed rather than trying to put the child in the middle of the night in their own bed, this probably saves everyone from more sleep deprivation.

As noted before, in many cultures when the child is a little older, or no longer breastfeeding during the night, sometimes because another sibling has been born, the young child will sleep with his or her siblings instead. This has to do with the sheer size of the house, the number of rooms and beds. It is a very common pattern in Latin America, Africa, and many Asian countries (Super and Harkness 2013).

Despite the stated parental beliefs regarding sleep, the reality may be that more parents sleep with their young children in the same bed. A recent study (Mindell et al. 2010) compared the sleeping situation in different countries, several from Asia (China, Hong Kong, India, Indonesia, Korea, Japan, Malaysia, Philippines, Singapore, Taiwan, Thailand, and Vietnam) with those of “predominantly Caucasian countries” (United Kingdom, United States, Australia, Canada, and New Zealand) mostly through an Internet-based questionnaire (Brief Infant Sleep Questionnaire). This is obviously based on a parental report (rather than a face-to-face interview or an objective assessment of sleeping arrangements and patterns). The study comprised over 29,000 infants and toddlers in total. The sample also was biased toward parents with electronics availability (having a computer or other device) and more education. In general, parents report a higher frequency of co-sleeping and sleeping in the same room with their infants in Asian countries than in the “Caucasian” ones. The parents from Asian countries also had higher frequencies of difficulties with the infant going to sleep and waking up during the night. Other surveys have shown, even in the United States that up to 50% of mothers sleep with their baby in the same bed at least part of the night (McKenna and McDade 2005). A study in Japan, contrary to the findings in the previously cited study (Latz et al. 1999), showed that parents rarely complained of sleep problems in their young child, which in the United States is very frequent. In Japan, traditionally parents and children sleep together on futons in the same room, the parents on both edges, and the children in the middle, even throughout childhood and adolescence. Japanese parents do not seem so intent on promoting independence during sleep.

In many cultures, sleeping together with the baby is only one further expression of “sleeping together with others” that is a common practice. The notion of sleeping “all alone” is strange, as closeness and emotion are expressed through the body, even during sleep. Who sleeps next to whom in large sleeping rooms with multiple people demonstrates feelings of tenderness, friendship, protectiveness, while anger and sadness may be represented by sleeping farther away (Musharbash 2013). The notion of “sleeping privately” is not important and is counterintuitive, as people would “naturally” not want to sleep alone.

Swaddling

This is an ancient practice in many cultures. It consists of wrapping the infant so that he or she can move very little, and then sleep better and cry less. It has been practiced traditionally in Native American cultures, as well as in many Asian societies, Russia, the Middle East, and Latin America. It is often used also in the United States and Canada. The available information from studies permits to conclude that it is an overall safe practice, that it leads to more continued sleep in the baby at least in the perception of mothers and from physiological studies (Richardson et al. 2010), and to experiencing less pain during procedures (Van Sleuwen et al. 2007). It is thought that it may give the baby a feeling of contentment and calm. One of the concerns about swaddling is how long should it be implemented. It is recommended only for the first few months of life, as later on the baby tends to roll over and may feel constrained or may be unable to move his or her arms if he were to end up “face down.”

Sleeping in Hammock

In many cultural groups, adults and children sleep in hammocks. It is common that a woman who just had a baby may sleep in the same hammock with the newborn, who when older, may sleep in his own small hammock. The mother may sing to the baby and rock him, providing auditory and vestibular “entraining” stimulation that may promote sleep onset (Valbuena Sarmiento 2004). Hammocks are used in Latin America, South East Asia, and Africa. In the neonatal intensive care units in some countries like Sweden, premature babies spend part of the time in a hammock, as this provides soothing movement and containment that simulates to a degree the position in the womb.

Issues and Meanings of Sleep Onset

When and how should young children go to sleep? The sleeping situation.

In many traditional and modern cultures, the sleep onset of the young child is an opportunity for an intimate moment of sharing, time, interactions, perhaps songs and stories. In contrast, in many families the child is “sent to sleep” or put to bed and he or she is hoped to go to sleep on his or her own, or with minimal intervention from the parents, in order to promote putting oneself to sleep.

Even in the case of small infants, several experts in the Western world recommend that parents should never “allow” the baby to sleep in one’s arms while rocking. It is preferred that as the child is “almost sleep,” he or she be put on the crib, and if the child cries a little, the baby should soothe himself with little intervention and thus go to sleep through self-soothing techniques. The same recommendation is made for older infants and preschool children, some authors even advice to put a “barrier” in the door of the child’s room so he or she cannot get out, a maneuver called “setting limits.”

Berceuses or Lullabies and Storytelling

Parents from many cultures around the world, for many generations used the sleep time as an opportunity for interpersonal exchanges, and the shared experiences included singing of songs to promote sleep (Parrat-Dayan 1991) and storytelling. There are berceuses(lullabies) in many cultures, and many mothers and fathers still practice this (Altmann de Litvan 2012). A recent small survey in Germany indicated that 95% of mothers sing lullabies to their babies (Valentin 2005). In Uruguay, some researches explored whether when the mother or a caregiver sings lullabies, there is a more secure attachment toward caregiver, denoting increased sensitivity in the adult toward the emotional needs of the child. This practice is quickly being lost in many industrialized countries and could be replaced by devices that sing songs mechanically (Valbuena Sarmiento 2004), or by nothing except perhaps some transitional objects.

Traditionally lullabies were songs that were sung by the caregiver, mother, grandmother, or father to induce the baby to sleep. It is usually a psycho-corporal experience in the sense that there is the musical-auditory component, as well as the attention to the baby and the rhythmic movement or rocking so that the child will relax and fall asleep. Certainly, many lullabies are a mixture of praise and loving declarations, mixed with threats (throwing to the wolves, hitting, falling down) if the child does not go to sleep, a fact pointed out by Winnicott (1949) decades ago. In a small rural village in Iran, a researcher analyzed the berceuses, which were accompanied by “youncing,” a sort of rocking mixed with being thrown a little in the air, a few inches and caught which is expected to help the baby go to sleep more easily (Friedl 1997).

Also under threat of disappearance, parents in many industrialized countries “read books” to their young children at bedtime. At times, the child insists on one book after another. Storytelling is a strategy that was passed from generation to generation and is still practiced in many parts of the world, among other things, because there may be little access to “children’s books.” The storytelling of the same stories night after night, in a soft voice and monotonous way as the story progresses in detail (Hill 2011), may induce a hypnotic or relaxed state in the child that may facilitate sleep onset (Lenox 2000).

Insomnia

Difficulties going to sleep: Describing sleep problems as a purely “physiological” or brain problem does not take into account the interpersonal and cultural nature of sleep. For example, parents in Italy, in many Asian and Latin American countries might think it is inappropriate to have a young child sleep in a separate room (Jenni and Werner 2011). This issue is important as many young children want to sleep with their parents and report various fears when one insists they sleep in a darkened room or with the door closed.

One of the most common sleep difficulties in young children is precisely the difficulty to fall asleep, which are identified in around 15–20% of children in the United States and Canadian samples of young children (Calhoun et al. 2014; Petit et al. 2007). Although on surface this appears as a purely “biological problem,” often it is not so, but a mixture of the predispositions of the individual child in interaction with parental practices and expectations. In several industrialized countries like France (Parrat-Dayan 1991) and the United States (Zito et al. 2000) in the past few decades there has been an enormous increase in the demand for medications and prescriptions to induce sleep in young children, given the perceived difficulty to get them to go to sleep. There are also a number of sleep aides that are sold in stores without prescription, like anti-histaminic and melatonin that are widely used by parents to get their young children to sleep.

The foster mother of a 3-year-old boy called asking for an immediate intervention with her foster son. She discussed the issue with the child psychiatrist. She was alarmed that the foster child had enormous difficulties to go to sleep and it had taken about 2 h for him to go to sleep last night. When the child psychiatrist asked for more details, it turned out that this had been the first night that this little boy had been placed with her and he had been removed from his mother’s home during the day. The foster mother had sent the child to bed “in his own room” and the boy kept coming out of it with multiple “pretexts” such as being thirsty, going to the bathroom, being hungry, and being scared. The foster mother requested a pharmacological treatment to put the child to sleep that next night. The psychiatrist suggested to her that it would be very normal and expectable for a young child to have difficulty to go to sleep in a stranger’s home, as probably he missed his mother, other relatives, and his home. The foster mother was frustrated and puzzled, as she saw the sleep as a purely physiological phenomenon, and thought the child “should be tired” and just go to sleep like her other foster children.

This vignette is used to illustrate the cultural expectations for a very young child, who has experienced a lot of stress while living with his mother, and now without her. It also illustrates the transactional nature of “going to sleep” and the fact that it is not merely a biological phenomenon, but one which is influenced strongly by culture, relationships, and the need to feel safe and secure before going to sleep. Incidentally, in the United States, foster parents are not allowed to sleep with children, even very young ones, in the same bed, as specified by the child protection agencies, for fear of misinterpretations about sexual abuse.

There is evidence that emotional difficulties in the mother have a negative impact on the sleep of the infant, such as intense anxiety, traumatic events, tension and discord in the family, an insecure attachment, and mother–infant separation (Sadeh 1996).

The above is obviously related to the life experience of the family. In many places in the world, there is great insecurity, such as in “war zones,” there are millions of displaced families, parents who live in constant stress, in conditions of poverty and high crime areas, or who have undergone many traumatic events themselves during childhood. It also appears that the more the mother worries about the baby’s fears and worries during the night, the more disrupted the sleep in the baby tends to be (Tikotzky and Sadeh 2009). It is also clear that the characteristics and sleep issues in the child have an impact on the perceptions of the parents regarding infant sleep, that is, a bidirectional effect. It scarcely needs to be mentioned that in most cultures in the world people believe in evil beings that are lurking around, such as evil spirits, witches, demons, ghosts, etc. When young children hear these stories, which often the parents endorse in reality, the children would be afraid to sleep alone.

The notion that a preschool age child may struggle to go to sleep and that he or she may want proximity with the parent is a very obvious one in some cultures, but a less accepted one in other cultures. It seems that an essential condition to fall asleep is to feel safe and not to be scared, which may be hard for some preschool age children.

Sleeping patterns that have been in existence for centuries, may give way to a more “scientific” pattern of putting the child to sleep based on the advice of medical or psychological experts. For instance, even the International Association for Sleep Medicine contemplates a category of sleep disorder called “limit setting sleep disorder” (American Academy of Sleep Disorders 2006). This indicates the notion that parents should enforce, insist, and not relent in their expectation that a young child stay in his or her room, on the bed, or in the room at all costs, and failure to do that constitutes a transactional problem of “difficulty to set limits” (Mindell and Owens 2015). We frequently have the experience that a child who is particularly anxious, temperamentally cautious, or who has experienced a troubling event may seek to sleep with the parent at least temporarily, and the caregivers are caught between their intuitive need to comfort their child and the advice from experts who warn against the dangers of this practice of “giving in” (Sadeh et al. 2010). The cultural basis for this transactional difficulty is made even more obvious when one thinks of many homes in the world in which children do not have “their own room” but always sleep accompanied by adults (Rowe 2003).

Parents might be surprised at the advice of medical or sleep disorder experts who recommend strategies such as “shutting the door” to prevent the young child from leaving the room or coming out of it. The same can be said about the use of “gates” so that the child stays behind that very gate or even a “cover” over a crib to prevent the toddler from climbing out of it. Many parents in every culture would find these recommendations rather insensitive or scary to the child. On the other hand, it must be added that many of the parents who hear the advice from experts desperately need to sleep themselves, as they have to work the next day and need a “radical solution” to the problem of the child seeking proximity. This demand may be one of the drives to seek a rapid cure for the problem, including the use of medications, even for quite young children. One can see that the lifestyle of the parents, the need for sleep, and the demands of their schedule dictate the search for a solution to a difficult problem, which may be that the child wants to spend as much time with his or her parents.

Difficulties staying asleep: There is also controversy as to what parents “should” do when the baby wakes up and cries during the night. The sleep physiology of young children determines that every young child would wake up briefly about every 90 min or so and then go back to sleep. In many cultures, as the parents sleep with the baby this may not be a question. In some countries, like the United States and some North European ones, parents hear the advice that the baby should sleep separately. Another recommendation is that during the night, they should not pick the infant up; rather, after ensuring the child is safe, they should let the baby “cry it out” until he falls asleep. Parents worry if they are doing the correct thing. This used to be the uniform advice from pediatricians to parents 20 years ago (Ferber 2008). Nowadays there are other approaches that parents may find more acceptable, such as intervention to soothe the baby during the night and gradual extinction (Minde 2002). Another method is using a sleep aid such as an item of clothing with the odor of the mother or father during the night (Goodlin-Jones et al. 1997). A further idea is to reflect or think about what might be the baby’s emotional state, imagine being the child, and think of how to reassure the baby and how to deal with his distress. The point here would be to help the child feel less distressed and safe, rather than just getting him or her to be quiet and fall asleep, or be resigned that nobody will be there to assist the infant.

Immigrant parents and parents who have had losses and trauma in the past may find it difficult to follow advice geared toward ignoring the baby’s cries at night because they fear that something bad might happen to the child. Also, many babies cry very intensely, and they may start coughing, vomiting, or be inconsolable for a long period of time. This makes it impossible to follow those recommendations.

Snoring in Young Children

Snoring results from the forced passage of air through the upper airways during sleep, which may or may not lead to episodes of obstructive apnea. There are cultural variations in the meaning of snoring. In the industrialized Western world, it may be either ignored, overlooked, or thought to be a problem to be further investigated as “not normal.” It has been reported that in China, snoring can be celebrated by parents as a sign that their child is very strong “like a man” (Owens 2005). One often finds “hyperactive” or irritable children who are sleeping poorly due to obstructive sleep apnea, which affects around 3–4% of young children (Lumeng and Chervin 2008).

Parasomnias

Parasomnias are sleep abnormalities that occur during non-REM sleep, that is, during the deep states of sleep. They are considered a “problem of arousal” to speak because manifestations that normally do not take place during sleep occur during parasomnias. These include sleepwalking (somnambulism), sleep terrors or pavor nocturnus (in which the child speaks, appears frightened, but is not really awake), and confusional awakenings (the child wakes up but not fully, he or she is still partially asleep) (Kotagal 2009). In the toddler that hardly walks, sleepwalking may manifest by crawling and moving around the crib. All the parasomnias are quite frequent in young children and tend to diminish in frequency with age. It is understandable that a number of “explanations” would be proposed in different cultural groups for the occurrence of these problems and for their solution. As noted, in many cultures the spirit of the person is thought to have a “life of its own” and the surround spirits do also, being able to attack and frighten vulnerable people, that is, young children. One frequent association in many traditional cultures is between sleepwalking and a state of trance. Parasomnias are thought to occur more frequently in children under intense stress, so it is possible that preschool children and infants exposed to difficult circumstances, including separation anxiety, and sleep deprivation would have more sleep difficulties in general, and parasomnias in particular (Kotagal 2009, 2012).

Other parasomnias are associated with REM sleep, like frequent nightmares. Catathrenia, or groaning during sleep, occurs during both REM and non-REM sleep. Bruxism, or teeth grinding, is considered as a movement disorder related to sleep.