Sleep is the foundation of learning, growth, and emotional well-being, yet many of our children with Down syndrome struggle to get the rest they need. While physical factors such as obstructive sleep apnea (OSA), as well as neurological factors leading to Central Sleep Apnea (CSA), often receive attention, one major but overlooked factor is sensory dysregulation.

For our children, sensory processing challenges—including interoception (the body’s internal awareness), proprioception, and vestibular function—can make it difficult to calm the nervous system and transition into deep, restorative sleep.

But the good news? We can help our children regulate their sensory systems through intentional bedtime routines that support the brain and body.

The Sensory Side of Sleep: Why Our Kids Struggle

Interoception: The Missing Piece in Sleep Challenges

Interoception is our body’s ability to recognize and interpret internal signals—like hunger, thirst, body temperature, and fatigue. For many of our children with Down syndrome, interoception is dysregulated, making it difficult for them to:

• Recognize when they are tired before reaching a meltdown state
• Feel when they are too hot or cold and adjust accordingly
• Sense a full bladder, leading to night wakings for bathroom trips

When the brain struggles to interpret these signals, our children may resist sleep, wake frequently, or struggle to settle into a restful state.

Proprioception & Low Muscle Tone: The Body’s “Heavy Blanket”

Proprioception—the body’s sense of pressure and position – where it is in spaceis essential for feeling secure at bedtime. Many of our children lack strong proprioceptive feedback due to low muscle tone, which can lead to:

• A restless body, tossing and turning in bed
• Difficulty staying comfortable in one position
• A need for deep pressure (hugs, weighted blankets) to feel secure
• Easier to “startle,” complicated by possibly unintegrated Moro Reflex.

Vestibular System & Sensory Overload

The vestibular system, which controls balance and movement, is often dysregulated in our children with Down syndrome. This can lead to:

• A need for constant movement before sleep (rocking, fidgeting, pacing)
• Feeling off-balance when lying flat, making sleep positions uncomfortable
• Increased nighttime waking due to an unsettled nervous system

Other Sensory Challenges

Although the dysregulation coming from the interoception, proprioception, and vestibular systems pose unique challenges for our children as they attempt to organize their system for sleep, they are not the only challenges.

Hypersensitivity in the the hearing, sight, and tactile systems can make sleep elusive. Imagine not being able to filter out any of the incoming sound sensations in the envrionment, each little noise is perceived loudly and clearly – or perhaps visual responses to light which means unless the room is completely dark, the visual system is stimulated. Equally, sleep issues can arise from a hypersensitive tactile system. Maybe the blanket shifted, or the pajama tag is rubbing.

If our children have difficulty with regulating their sensory systems during the day, they will have difficulty when it comes time for sleep.

Ways to Support Sensory Regulation for Better Sleep

Deep Pressure & Proprioceptive Input (30-60 min before bed)

Deep pressure calms the nervous system and helps the body recognize its position in space. Some ideas to add to a bedtime routine:

• A warm bath followed by a gentle but firm massage with lotion
• Snug pajamas that provide compression for proprioceptive regulation (and also will not be shifting around stimulating the tactile system)
• Swaddling or snuggling up for story time prior to turning in for the night.
• *Weighted blankets. I am not a proponent of weighted blankets for children, especially little children with low tone. They need to be able to move freely during sleep. If you have an older child that a weighted blanket would not pose a risk, it may be something to consider after speaking with the child’s doctor.

Oral Sensory Input for Self-Regulation

Chewing and sucking activate the vagus nerve, which lowers heart rate and promotes relaxation. Regulating the vagus nerve directly helps to regulate interoception, as well as shift the nervous systems from fight/flight/freeze, to rest and digest.

• Bedtime routines are a good time to do any oral motor work you may have embarked on. Specifically, the motions of sucking and blowing calm the vagus nerve.
  

The Reticular Activating System

The Reticular Activating System (RAS) is a network of neurons in the brainstem responsible for regulaing wakefulness and sleep-wake transitions. If it is overactive it can make it difficult to fall asleep or fall back to sleep.

• The gentle but firm massage helps calm the RAS. Provide the firmmassage around the child’s “T-zone on their face as well as sides of the nose and upper jaw
• If the child is old enough, slow and deep breathing techniques will calm the RAS as well as the Vagus nerve for positive impacts on the sensory system
• If you listen to music at night, stay away from any music with a high violin content as the high frequency is stimulating. Instead opt for low frequency bass rich music such as Baroque with a slow metronome.
• Roughhousing is such a nighttime delight, but definitely not within 2-3 hours of going to sleep

Vestibular Input

Stimulating our children’s balance centers – everything from inner ear mechanisms to the vestibular centers in the brain ans the cerebellum – is important for the sense of “safety.” I can only imagine the disorienting and fearful state a child would find himself in if movement created insecurity while trying to sleep. If a child has difficulty with balance or postural securtiy during the day, they will have difficulty when trying to sleep at night. Promoting organized balance inputs prior to sleep not only organize the above mentioned systems but they also help to calm the visual motor stseym…which has direct links to the RAS – and primitive reflexes….We begin to understand how the components necessary for sleep are deeply enmeshed and interdependent.

• A warm Epsom salt bath (magnesium supports relaxation) as well as the slow rocking or swaying in water engages the vestibular system
• If your child is small, use a towel or blanket as a swing and sway them gently into all different directions. The compression of the blanket swing will provide proprioceptive input to calm the system and the gentle sway of the movement will calm the vestibular system. (You do not want to do this quickly as that will arouse the system.)
  

Nutrition and Physical Activities in the Afternoon and Evening

When we talk about issues of sleep with our children, our thoughts naturally move to apnea. Any difficulties with apnea are a result of respiratory difficulties whether it results from a positional obstruction or a neurological cause. Carefully considering anything that impacts the respiratory system in the later part of the day is paramount.

• Histamine, a chemical involved in immune responses, digestion, and nervous system regulation, plays a key role in allergic reactions, sensitivies, inflammation, and regulating stomach acid. Histamine naturally peaks at 2:00AM – 3:00AM. Given our children’s propensity for digestive issues, autoimmune issues, and genetic alterations that directly affect histamine production, looking carefully at nutrition is critical for sleep. If you suspect your child has food sensitivities, allergies, or digestive issues such as GERD during the day, that directly affects histamine production at night. Histamine also plays a role in the respiratory system. Again, all things interdependent.
• Physical activity during the day, especially a neurodevelopmental program rich in crosspattern creeping, crawling, walking, or running, will have an effect on the neurological centers responsible to governing breathing. Creep, crawl, walk, run, for distances.
• I goes without saying, but if you are nursing, carefully look at what you are eatingand drinking in the later part of the day.

Thyroid Health

I would be remiss if I did not discuss the possible implications of undertreated thyroid. One of the hallmark symptoms is temperature dysregulation. Does your child’s body temperature dip during sleep or in the early morning? Does their skin look “lacey,” or mottled? These things can certainly be part of a respiratory challenge, but they are also common with hypothyroidism.

Final Thoughts: Small Changes, Big Impact

We tend to think about our children’s sleep in terms of apnea. Whether there is obstructive or central apnea is an issue we must look at and address carefully. But there is much we can do to address sleep issues and set a holistic and integrative foundation for sleep.

Sensory dysregulation is one of the most overlooked factors in sleep difficulties for our children with Down syndrome. By supporting interoception, proprioception, and vestibular input, we can help them feel safe, secure, and ready for sleep. Coupled with sensory regulation, looking carefully at matters of specific physical activities and nutritional approaches can help our children’s sleep tremendously.

All of these things are available to us tonight as foundational integration for sleep.

Every child is unique, and we as parents know them best. With intentional changes to environments and routines, and with intensity, consistency, and frequency, we can set the stage for better sleep, better learning, and better well-being.

It goes without saying that all of these things pertain to us as well, right? Managing our own stress responses, especially at night when the thoughts like to push their way in, is imperative for our own sleep.