Insomnia in infants and young children is defined as significant difficulty falling asleep (which can include bedtime resistance, prolonged sleep-onset latency after lights out, or some combination), frequent or prolonged night awakenings (typically requiring parental intervention) or (much less frequently) early morning awakening that has a negative impact on the child and/or the family. Childhood insomnia is common, with approximately 20% to 30% of young children having significant problems going to bed and/or awakening during the night.1,2 Not only is the prevalence of childhood insomnia high, but we now understand the negative health outcomes that chronic insufficient sleep and inadequate sleep quality can have on a child's daytime functioning, including daytime behavior problems, cognitive impairment, and mood disturbances.3 There are also negative social or family dynamic effects associated with childhood insomnia, such as parental sleep disruption and daytime sleepiness, maternal perceived lack of control, depressive symptoms and psychiatric disturbance, and even an increased risk of child abuse.4–6
Illustrative Case: Part 1
A 10-month old baby presents to your office for a well visit. She is smiling, babbling, and playing with a toy. Her parents are noticeably distraught and tired, and tell you that she “just does not sleep” and that she wakes up crying every 2 hours at night. She is only consoled by being taken out of her crib and rocked back to sleep. The parents are at their “wits end” and do not understand why their daughter is not sleeping well.
This scenario is most likely a familiar one to primary care providers during a well-child visit, and with the laundry list of things to review in the short amount of time providers have with families, many primary care practitioners are challenged in assisting parents in getting their baby or young child to sleep well.
The Role of Sleep Duration and Quality in Young Children with Insomnia
In any discussion of childhood insomnia and its impact, it is important to consider what effects insomnia might have on sleep quantity and quality, which, in turn, necessitates some familiarity with developmental norms.1 Although there has been some controversy about the concept of “sleep recommendations”7 in children, the American Academy of Sleep Medicine (AASM) recently published a consensus statement8 on the recommended age-specific ranges for sleep amounts needed per 24 hours to “promote optimal health” (Table 1). But it is also clear that considerable individual variability in sleep times exists, especially in the first year of life;9 thus, additional parameters need to be considered to determine if a child is meeting his or her sleep needs. These include whether a child seems well rested after a night's sleep, wakes spontaneously at the expected time in the morning, does not seem sleepy or “overtired” (other than at naptime) or doze off inappropriately during the day, or does not sleep longer when given the opportunity (such as on weekends).10
American Academy of Sleep Medicine Consensus Recommendations for Amount of Sleep for Pediatric Populations
Sleep consolidation or “sleeping through the night” happens between age 8 weeks and 3 months. Around this time, the establishment of a day-night cycle starts, with most sleep occurring at night and shorter daytime periods of sleep (naps). However, the term “sleeping through the night,” can be somewhat misleading because normal nighttime arousals/awakenings continue to occur in infants and children on average 2 to 6 times throughout the night as they transition through sleep cycles.10 Sleep problems can develop when a child has not learned how to go back to sleep on their own during these nighttime arousals, a process known as sleep regulation or “self-soothing.” The ability to self-regulate sleep develops at approximately age 8 to 12 weeks.10 One key to the infant learning to self-soothe involves educating parents about putting a baby to sleep “drowsy but awake” so that he or she learns to fall asleep independently at bedtime. Studies indicate that sleep at 3 months is an important predictor of future sleep habits, as the ability to fall asleep independently at this age is associated with fewer night awakenings at age 6 and 12 months.11 This may also be viewed as the initial step in encouraging the development of self-regulation skills in young children.12
Defining Childhood Insomnia
The International Classification of Sleep Disorders (ICSD), third edition,2 outlines clinical characteristics associated with childhood insomnia under the diagnostic category of chronic insomnia disorder, defined as occurring at least 3 times per week and present for at least 3 months. Previous iterations of ICSD included several subcategories of insomnia pertinent to the pediatric population, and although these are no longer listed as formal diagnoses, “behavioral insomnia of childhood, sleep onset association and limit setting subtypes” remain a useful construct in clinical practice.
Sleep Onset-Association Type
Sleep associations are learned behaviors that happen when a child gets used to, or “associates” certain behaviors or environment with falling asleep (such as feeding, rocking, pacifier use) that typically require parental intervention. Bedtime is generally not a problem if parents provide these conditions, although they are sometimes quite demanding (eg, the infant needs to be rocked for 45 minutes before falling asleep or will only fall asleep while being driven in the car). The main clinical concern is generally prolonged night awakenings accompanied by protest behavior (eg, crying, screaming, attempting to climb out of the crib, or coming into parents' room) if parents do not provide these same sleep associations after normal night awakenings. Common reports from parents may include: “she will only fall asleep with the bottle and/or pacifier” or “she moves to our bed some time during the night, but often we do not hear her come in, we just find her there in the morning.” Thus, the same conditions on falling asleep should be readily available to the child during the night and thus not involve parental presence or intervention.
The limit-setting type of behavioral insomnia of childhood is characterized by bedtime struggles and involves a series of stalling behaviors and “curtain calls” (eg, needing another story, hug, drink) after lights out. It may also present primarily as night awakenings if parents are unable/unwilling to set appropriate limits regarding staying in bed during the night. In many cases, this can lead to a reduction of total sleep time as a result of prolonged sleep onset. If each parent responds differently or there is otherwise variability in the degree and type of limit setting applied from night to night, this irregularity reinforces the negative behavior parents wish to extinguish. A consistent, predictable routine may avoid uncertainty and anxiety for both child and caregivers.
Too Much Time in Bed
Another problem that is often missed in clinical practice and that does not fall under the classical definition of insomnia but may be helpful in understanding and treating sleep problems in children is the issue of “too much time in bed” compared to the child's actual sleep needs.13 As noted earlier, there is individual variability in sleep times especially in the first 3 years of life. When a child is in bed longer than he or she is able to sleep, problems can occur with sleep onset, prolonged night awakenings, or early morning awakening. For example, a 2-year-old is put to bed at 7 pm and is out of bed the next morning at 7:30 am. She also takes a 2-hour nap. Her total time in bed is up to 14.5 hours in a 24-hour period, which is likely more time in bed than she may be able to sleep. Her parents complain that she is “wide awake and wants to play” for several hours during the night and even if they stay with her she does not fall back to sleep right away (alternatively, she may take several hours to fall asleep at the expected bedtime or wake several hours earlier than desired). All of these variations can be corrected by adjusting the child's time in bed to an age-appropriate range that also takes into account the child's individual sleep needs (in the case above, 10 hours per night and a 2-hour nap). This is typically done by delaying bedtime by the corresponding amount of time, either all at once or gradually in smaller increments (eg, 15 minutes later every few days). This is often a temporary measure that can then be reversed once sleep onset is easily achieved and a “target bedtime” is set (a process often referred to as “bedtime fading”). Shortening a child's time in bed can also make behavioral interventions much easier to follow through with because it may lessen the amount of crying or protesting involved.
As with many behavioral issues in childhood, “the sleep problem is in the eye of the beholder;” in other words, it is largely determined by the perspective of the caregivers. Some parents may think that waking multiple times a night is normal and acceptable or that the child will eventually “grow out of it,” whereas other parents have a much lower threshold for defining sleep behaviors as problematic and thus are more likely to seek help from their health care provider. There are numerous factors that determine why and when parents identify and look for guidance in dealing with sleep issues, ranging from the child's age, temperament, and presence of comorbid medical conditions, to parental mental health issues and personal history of sleep problems, to environmental and socioeconomic constraints, or to cultural considerations.1
To guide a systematic approach that both provides a framework for identifying and evaluating sleep problems and disentangling some of these confounding factors, several screening tools may be useful in clinical practice. The BEARS (Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity and duration of sleep, Sleep-disordered breathing) sleep screen (Table 2), for example, can be easily and routinely implemented during the well-child examination across the pediatric age spectrum, and has been shown to be more effective than a single question such as “how does your child sleep?”14 It consists of five domains of age-appropriate “trigger questions” or probes for use in a clinical interview. Once a potential sleep problem has been identified with a screening tool, an integral part of an effective evaluation includes a comprehensive sleep history.
BEARS Sleep Screen: Examples of Developmentally Appropriate Trigger Questions for Children Age 2 to 5 Years
A comprehensive sleep history allows the pediatric provider to view a detailed “snapshot” and background of the sleep issue(s) and thus develop an individualized treatment plan that meets the needs of the child and the family.15
The sleep history should include a detailed assessment of the sleep schedule (ie, when, where, and for how long the child sleeps in a 24-hour day, including sleep in car, stroller, swing, or at daycare/school). For example, “cat naps” in the car or stroller can become a problem if they affect a child's regular nap or nighttime sleep (eg, three or four daily 10-minute cat naps in the car can delay night sleep or the next sleep period). Not only is it important to know when a child falls asleep at night, but also when they wake up in the morning, including on weekends versus weekdays.
In addition, an assessment of parameters such as the child's sleep environment (eg, lighting, noise level, room-sharing with parents or siblings, bed type), sleep habits (eg, sleep associations, such as parental involvement at bedtime), and bedtime routines (eg, presence of any routine, types of activities in evening including electronic use, duration and location of routine) are critical to taking a good sleep history.
Evaluation should also include a comprehensive medical, developmental, behavioral, and psychosocial history.10 If the sleep history is unclear or inconsistent, the use of sleep diaries or sleep logs can be helpful to provide a more prospective “real time” assessment of sleep patterns. Often, parents will recall only the most recent nights or the most problematic nights, so having them record their child's sleep over a 2- to 4-week period will provide a more accurate overview of sleep patterns.
In most cases, young children presenting with insomnia do not require an overnight sleep study unless there is a history and/or risk factors suggestive of obstructive sleep apnea (loud frequent snoring, mouth breathing, gasping, adenotonsillar hypertrophy, gastroesophageal reflux, allergies, family history of obstructive sleep apnea) or periodic limb movement disorder (restless sleep, frequent kicking movements, high risk for iron deficiency).
Considerable empirical evidence supports the use of behavioral interventions for bedtime struggles and night awakenings in young children, demonstrating that overall these strategies produce reliable and durable positive changes in sleep in most young children, as well as improvements in child and family well-being.16,17 Those behavioral interventions that have the most robust empirical support and have been employed with success in clinical practice are detailed in the following text. In addition, it is important to keep in mind basic principles of healthy sleep as a key component of any behavioral treatment plan (Table 3).
Principles of Healthy Sleep Practices
Modifying sleep schedule. Prior to starting any behavioral intervention, it is important to understand the child's sleep schedule and circadian timing. For example, temporarily shortening a child's time in bed (eg, delaying the child's bedtime and controlling morning wake times and nap times) can increase the homeostatic sleep drive and may make the implementation of behavioral interventions much easier. The objective is to increase the likelihood of rapid sleep onset and thus decrease the duration and extent of bedtime resistance15 or prolonged awakenings during the night. Once the child routinely falls asleep independently and maintains sleep at night, the bedtime or wake time is gradually shifted back to an age appropriate schedule.
Behavioral intervention for sleep onset-association type. There are two general approaches to addressing behavioral insomnia in young children. The first is unmodified extinction, which involves placing the child in the intended sleep location (eg, their crib in their bedroom) and leaving the room. Any subsequent protest behaviors (eg, crying) is ignored until morning. Although this approach has been shown to be highly effective in research studies, it is often unacceptable to parents and compliance tends to be low. The second approach, often more feasible for parents, involves a graduated extinction approach, which employs a variety of techniques in which parents are instructed to ignore bedtime crying and tantrums for specified periods of time. For example, the caregiver puts the child to bed “drowsy but awake,” leaves the room, and then uses a fixed or progressively longer time interval to check-in on or reassure the child with minimal interactions (eg, keep the checks brief and at doorway of room instead of entering child's room). The goal of both of these methods is to enable the development of “self-soothing” or self-regulation skills to fall asleep independently. Most children on an age-appropriate sleep schedule will have improvement in night awakenings within 3 to 7 days.13 The success is based on the parents' ability to be consistent each night and to anticipate and weather the “extinction burst,” which is the period after the initiation of a behavioral plan during which protest behavior often temporarily escalates before subsiding.10
Variations on graduated extinction include having a parent stay in the room at bedtime and gradually fading attention (eg, sitting in a chair with hand in crib, then sitting in the chair with no physical contact, to moving the chair further and further away from the crib).
Method of behavioral intervention for limit-setting type. For a child with bedtime resistance and limit-setting type of insomnia, establishing clear, concise, and firm bedtime rules with limited choices is critical. “Bedtime fading,” as described above, is also often extremely helpful if the child's natural sleep onset is later than parent-set bedtime.10 Using positive reinforcement (eg, sticker charts and reward systems) can motivate older children (ie, preschool) with more advanced language and impulse control skills to be successful in staying in their room at night and/or falling asleep without requiring parental presence.15 Although many of these interventions are far easier to carry out with younger children who are unable to climb out of a crib, the installation of a physical barrier (gate) at either the child's or parents' bedroom door to establish clear boundaries can be a highly effective strategy that does not involve invoking more anxiety (ie, closing the child's bedroom door). In fact, a gate can take away the parents' job of physical limit setting while allowing them to still act supportively.
Outcomes of Behavioral Interventions
Although many caregivers understandably express concern that letting their child cry for a prolonged amount of time will result in psychological harm, there is little published evidence to suggest that behavioral sleep interventions have a negative impact on children's social-emotional development or the parent-child relationship.12 Several recent, prospective, longitudinal studies in particular have failed to demonstrate long-term detrimental effects on children who have undergone behavioral treatment for bedtime problems and night awakenings.18–20 A 5-year follow-up study looked at 173 infants with bedtime problems and night awakenings who received behavioral treatment versus usual care (controls) and found that there were no negative effects on child mental health, child-parent relationships, and parental mental health, and no increase in measures of chronic stress between the intervention group and the control families.18 Another study looked at graduated extinction versus bedtime fading versus sleep education (control) in children ages 6 to 16 months and found a large decrease in time to fall asleep in both treatment groups, while night awakenings decreased only in the graduated extinction group.19 At the 12-month follow-up there was no increase in emotional/behavioral problems or attachment in treatment versus control groups.19 Not only is there a lack of evidence supporting harmful effects of sleep behavioral interventions, but some studies have found positive impacts on outcomes beyond improvements in child sleep, including caregiver depression, fatigue, and sleep, as well as parental cognitions about infant sleep.18,20
Illustrative Case: Part 2
We now return to the case of the 10-month-old baby referred to at the beginning of this article. Further questioning of the parents reveals that she will only fall asleep at bedtime while being bounced or rocked. If her parents then move her to the crib once she is asleep, she sometimes wakes up again almost immediately and needs to be bounced to return to sleep. At other times, she will stay asleep once placed in her crib but then wakes approximately every 2 hours, crying until a parent goes in and rocks her back to sleep. The parents say she will scream for “hours” if they don't pick her up. Sometimes it takes up to 1 hour to get her back to sleep. The parents report that she has “never been a good sleeper.”
Her bedtime routine starts at 6:30 pm. Her mother will hold and rock her to sleep and she falls asleep around 7 pm. She spontaneously wakes for the day around 7 am. She has a nanny during the week. She takes her first nap at 10 am and gets rocked to sleep. She may sleep for up to 1 hour. Her second nap is at 1:30 or 2 pm and she can sleep for up to 2 hours. There are occasional “cat naps” in the car for 15 minutes. She is an otherwise healthy infant with normal development. Her parents both work full-time and this is their first child.
Impression: Chronic Insomnia Disorder
The child has sleep onset-association type chronic insomnia disorder. She only falls asleep while being held and rocked. She also spends too much time in bed. Her time in bed at night is up to 12 hours, plus up to 3 or more hours during the day, for a total time in bed of up to 15 or more hours.
You advise a three-part treatment plan. First, shorten time in bed to a more age-appropriate range and to help with process of getting her to learn to fall asleep on her own. Start with a 10-hour night consisting of bedtime at 8 pm and wake time at 6 am, and allow the first nap at 10 am (1 hour maximum) and the second nap at 2 pm (1.5 hours maximum). No other daytime sleep should be allowed.
Second, once on a sleep schedule for a few nights, work on sleep associations using the graduated extinction method. On the first night, make bedtime 30 minutes later. If there is no improvement after 4 nights, the plan will be to have the parents call the office.
Third, have the parents maintain a “sleep log” and follow up with the parents at 3 weeks.
After 3 weeks, the parents reported an initial “rough few days” but that their daughter's sleep had improved dramatically since implementing the behavioral plan, and both her mood and their stress levels have “turned around”. Happy baby; happy parents!
- Owens J, Mindell J. Pediatric insomnia. Pediatr Clin North Am. 2011;58(3):555–569. doi: . doi:10.1016/j.pcl.2011.03.011 [CrossRef]
- The International Classification of Sleep Disorders. 3rd ed. Westchester, IL: American Academy of Sleep Medicine; 2014.
- Beebe DW. Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents. Pediatr Clin North Am. 2011;58(3):649–665. doi: . doi:10.1016/j.pcl.2011.03.002 [CrossRef]
- Fairbrother N, Woody SR, New mothers' thoughts of harm related to the newborn. Arch Women Mental Health. 2008;11(3):221–229. doi: . doi:10.1007/s00737-008-0016-7 [CrossRef]
- Jennings KD, Ross S, Popper S, Elmore M. Thoughts of harming infants in depressed and nondepressed mothers. J Affect Disord. 1999:54(1–2):21–28. doi:10.1016/S0165-0327(98)00185-2 [CrossRef]
- Martin J, Hiscock H, Hardy P, Davey B, Wake M. Adverse associations of infant and child sleep problems and parent health: an Australian population study. Pediatrics. 2007;119(5):947–955. doi: . doi:10.1542/peds.2006-2569 [CrossRef]
- Matricciani LA, Olds TS, Blunden S, Rigney G, Williams MT. Never enough sleep: a brief history of sleep recommendations for children. Pediatrics. 2012;129(3):548–556. doi: . Epub 2012 Feb 13. doi:10.1542/peds.2011-2039 [CrossRef]
- Paruthi S, Brooks LJ, D'Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–1561. doi:10.5664/jcsm.6288 [CrossRef]
- Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics. 2003;111(2):302–307. doi:10.1542/peds.111.2.302 [CrossRef]
- Mindell JA, Owens JC. Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2015.
- Burnham MM, Goodlin-Jones BL, Gaylor EE, et al. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry. 2002;43(6):713–725. doi:10.1111/1469-7610.00076 [CrossRef]
- Sadeh A, Mindell JA, Owens J. Why care about sleep of infants and their parents?Sleep Med Rev. 2011;15(5):335–337. doi: . doi:10.1016/j.smrv.2011.03.001 [CrossRef]
- Ferber R. Solve Your Child's Sleep Problems. New York, NY: Fireside; 2006.
- Owens J, Dalzell V. Use of the “BEARS” sleep screening tool in a pediatric residents' continuity clinic: a pilot study. Sleep Med. 2005; 6(1):63–69. doi: . doi:10.1016/j.sleep.2004.07.015 [CrossRef]
- Kuhn BR. Practical strategies for managing behavioral sleep problems in young children. Sleep Med Clin. 2014;9(2):181–197. doi: . doi:10.1016/j.jsmc.2014.03.004 [CrossRef]
- Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh AAmerican Academy of Sleep Medicine. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29(10):1263–1276.
- Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol. 2014;39(8):932–948. doi: . doi:10.1093/jpepsy/jsu041 [CrossRef]
- Price AM, Wake M, Ukoumunne OC, Hiscock H. Five-year follow-up on harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics. 2012;130(4):643–651. doi: . doi:10.1542/peds.2011-3467 [CrossRef]
- Gradisar M, Jackson K, Spurrier NJ, et al. Behavioral Interventions for infant sleep problems: a randomized controlled trial. Pediatrics. 2016;137(6). pii: e20151486. doi:10.1542/peds.2015-1486 [CrossRef]
- Hall WA, Hutton E, Brant RF, et al. A randomized controlled trial of an intervention for infants' behavioral sleep problems. BMC Pediatrics. 2015;15:181. doi: . doi:10.1186/s12887-015-0492-7 [CrossRef]
American Academy of Sleep Medicine Consensus Recommendations for Amount of Sleep for Pediatric Populations
Infantsa age 4–12 months should sleep 12–16 hours per 24 hours (including naps) on a regular basis to promote optimal health
Children age 1–2 years should sleep 11–14 hours per 24 hours (including naps) on a regular basis to promote optimal health
Children age 3–5 years should sleep 10–13 hours per 24 hours (including naps) on a regular basis to promote optimal health
BEARS Sleep Screen: Examples of Developmentally Appropriate Trigger Questions for Children Age 2 to 5 Years
||Does your child have any problems going to bed?
|Excessive daytime sleepiness
||Does your child seem overtired or sleepy a lot during the day?
Does your child still take naps?
|Awakenings during the night
||Does your child wake up a lot at night?
|Regularity and duration of sleep
||Does your child have a regular bedtime and wake time?
What are they?
||Does your child snore a lot or have difficulty breathing at night?
Principles of Healthy Sleep Practices
|Practices promoting sleep regulation (circadian and sleep drive)
Maintain an organized and consistent sleep–wake cycle
Set and enforce a consistent bedtime for weekdays and weekends
Set and enforce a consistent wake time for weekdays and weekends
Keep a regular daily schedule of activities, including meals
Avoid bright light in the bedroom at bedtime and during the night
Increase light exposure in the morning
Establish an appropriate napping schedule
Practices promoting sleep conditioning
Establish a regular and consistent bedtime routine
Limit activities that promote wakefulness while in bed (watching television, cell phone use); use the bed for sleep only
Don't use bed for punishment (“time out”)
Avoid using staying up late as a reward for good behavior and going to bed as a punishment for undesired behavior
Avoid sleeping in environments other than the bedroom (eg, couch, car)
Practices reducing arousal and promoting relaxation
Keep electronics out of the bedroom and limit use of electronics before bedtime
Reduce stimulating play at bedtime
Avoid heavy meals and vigorous exercise close to bedtime
Reduce cognitive and emotional stimulation before bedtime
Include activities in the bedtime routine that are relaxing and calming
Practices promoting adequate sleep quantity and quality
Set a bedtime and wake time to ensure an adequate sleep opportunity for age
Maintain a safe and comfortable sleeping environment (low noise and light levels, cooler temperatures, age-appropriate bedding and sleeping surface)