Sleep in early childhood: The role of bedtime routines
Sleep changes rapidly from several shorter periods over 24 hours in the first weeks of life to one nap and one long period of sleep at night by age three.
Angela D. Staples, Assistant Professor, Eastern Michigan University
Leah LaLonde, Doctoral Fellow, Eastern Michigan University
Sleep changes rapidly from several shorter periods over 24 hours in the first weeks of life to one nap and one long period of sleep at night by age three. This review covers typical sleep patterns from birth through age three and discusses how parents’ attitudes and behaviors change during this period. In addition to parent education about child sleep, we review two behavioral interventions that have been shown to be effective for addressing parent concerns about bedtime resistance and reducing nighttime awakenings. These interventions—beginning about 6 months of age—aim to help parents reduce over-involvement prior to bedtime and in response to night awakenings, to promote their child’s ability to self-soothe to sleep. Importantly, establishment of a consistent bedtime routine of 15 to 30 minutes may reduce or prevent both resistance at bedtime and frequent nighttime awakenings.
The first three years of a child’s life is a period of rapid growth in all areas from physical movement to changes in emotional expression to increasingly child-initiated and child-directed social interaction. During this time, sleep also changes dramatically from short periods of sleep throughout the day and night in the first weeks of life to a single period of sleep during the night and, for about half of all children, one nap during the day. In addition to consolidating sleep so that most of it occurs at night, children also develop the ability to self-soothe back to sleep should they wake during the night. Difficulty self-soothing back to sleep without parental assistance is a common sleep-related concern that parents of young children raise with their pediatrician (Honaker & Meltzer, 2016). Unfortunately, the number of physicians specially trained in childhood sleep problems and sleep disorders is far fewer than what is needed. For example, in the U.S., pediatric sleep specialists represent less than one-tenth of medical providers (Honaker & Meltzer, 2016). Thus, parents and physicians alike are challenged to find workable solutions for both sleep problems (e.g., bedtime resistance) and sleep disorders (e.g., obstructive sleep apnea). An important caveat is that not all parents view the same sleep behavior as problematic (e.g., Owens, 2008). Thus, the present paper defines a sleep problem as those behaviors that parents identify as problematic while keeping in mind this definition likely differs across individuals, families, and cultures. This contrasts with sleep disorders, which have clearly defined medical criteria.
This review does not address sleep disorders such as sleep apnea, in part, because treatment is primarily the domain of physicians. Additionally, this review does not address specific sociocultural factors such as co-sleeping, feeding practices, or environmental factors (e.g., tobacco use, neighborhood noise, type of bedding)—all of which can impact both parent and child sleep. Instead, this paper provides a selective overview of four interrelated topics regarding sleep in early childhood with a specific emphasis on behavioral interventions for sleep problems. First, we briefly review the typical changes in sleep from birth through age three. Second, we highlight parenting practices in relation to child development and cultural context. Third, we summarize effective sleep interventions for young children. Finally, we emphasize the role of the bedtime routine as a relatively straight forward practice that, when implemented early, may prevent the development of sleep problems.
Typical development of sleep
Newborn infants sleep an average of 14-15 hours per 24-hour period, which drops to an average of 12 hours around two to three years of age (Galland et al., 2012). In the first two months, infants sleep approximately nine hours at night and six hours during the day (Sadeh et al., 2009). However, there is considerable variability in nighttime sleep such that sleeping as few as six hours at night (with more daytime hours) or as many as 11 hours could both be viewed as typical or not problematic. From birth to age three, the number of hours children sleep at night increases, while the number of hours spent sleeping during the day declines (Sadeh et al., 2009).
While the timing, number, and duration of sleep episodes during daytime varies greatly in early infancy, between 8 to 12 months, daytime sleep consolidates into two nap periods, one in the morning and one in the afternoon (Mindell et al., 2016). Around 18 months, children sleep once per day for 1 to 2 hours in the afternoon. By age three, children decrease both the number of naps per week as well as their average duration (Staples et al., 2015) with roughly half of children no longer napping (Iglowstein et al., 2003). There are several factors that contribute to the age at which children stop napping including both internal (e.g., brain development) and external factors (e.g., childcare) (Kurdziel Duclos & Spencer, 2013). While we know that the majority of two-year-old children nap and five-year-old children do not nap, there remain questions about whether there is an optimal or recommended age at which children could or should be encouraged to stop napping (Spencer et al., 2016). One consistent difference between three-year-old children who do versus those who do not nap is that children who nap sleep less at night (Spencer et al., 2016; Ward et al., 2007). However, the total amount of sleep per 24-hour period is similar for children who are and those who are not napping (Ward et al., 2007). One implication is that by age three, some children sleep less at night because they are getting the recommended number of hours of sleep when considered over a 24-hour period. Thus, when determining if a child is getting sufficient sleep, parents and physicians should consider sleep over 24-hours and not just the amount of nightly sleep.
There is no recommended age at which children should be encouraged to stop napping
In addition to changes in the amount of daytime and nighttime sleep, children also develop the ability to self-soothe back to sleep beginning around three months of age with roughly 80% of children sleeping through the night by nine months (Owens, 2008). Yet, waking once each night every night of the week is common for children ages 6 to 11 months (Sadeh et al., 2009). By age three, waking once during the night declines to approximately three nights each week. The length of time children are awake at night also declines from more than one hour in newborns, to less than 20 minutes by age three (Sadeh et al., 2009), though it should be noted that, like hours of nighttime sleep, there is wide variability in both the number and duration of night wakings. It should also be noted that brief periods of arousal happen several times per night, but children do not always signal (e.g., cry) that they are awake (Tikotzky & Sadeh, 2009). Thus, the majority of sleep research on awakenings, which use parent report, provide information about signaled awakenings as opposed to the total number of nighttime arousals (Goodlin-Jones et al., 2001).
Parenting practices and sleep
With changes in when and how long children sleep in early childhood, it probably appears self-evident that parenting behaviors surrounding sleep also change. For example, the majority of parents either nurse or bottle feed their infant before putting to bed for the first nine months of life (Sadeh et al., 2009). In contrast, the percentage of children who are nursed or bottle fed after waking during the night declines rapidly from birth to 4 months and then continues to decline through age three (Sadeh et al., 2009). As infants develop, their need for nourishment during the night decreases rapidly, which is typically matched by a decline in parents offering nourishment. In addition to changes in nourishment, attitudes or beliefs about why their infant is waking during the night are another reason for changes in parental response.
A longitudinal study of first-time mothers, who were followed from pregnancy through their child’s first birthday, found changes in why mothers thought their infants were waking and how they viewed their own role in responding to the awakening (Tikotzky & Sadeh, 2009). During pregnancy, mothers indicated that infants should learn to self-soothe back to sleep and, thus, parents should work to minimize interactions with their child during the night. However, when their infants were one and six months of age, these same mothers reported greater concern about their infants’ distress upon awakening and reported more intervention during the night than they had anticipated during pregnancy. When the infants were 12 months old, mothers’ beliefs about the importance of minimal interaction in response to an awakening had returned to what they had reported during pregnancy. Thus, maternal perceptions about the reason for nighttime awakenings are related to how and if they respond to their infant. Additionally, these maternal perceptions change over the first year of life.
Mothers’ perceptions of why their babies wake at night change over the first year of life
Furthermore, mothers—likely fathers, too—who continue to attribute infant distress as the reason for waking, irrespective of the child’s age, tend to increase their involvement (e.g., holding, rocking) in an effort to help their child fall asleep. It is precisely this over-involvement beyond when it is needed that has been shown to contribute to the persistence of sleep problems for young children. One implication is that educating parents on the difference between times when their child needs their presence at night (true distress) from times when they do not (brief arousals) may help reduce over-involvement at night.
Along with developmental stage, cultural norms and values also impact parent perceptions of and response to sleep problems. Frequent night wakings, for example, were more likely to be regarded as problematic among parents from primarily-Caucasian (PC) countries compared to parents from primarily-Asian (PA) countries, whereas the number of naps was more likely to be perceived as problematic from parents in PA countries (Sadeh Mindell & Rivera, 2011). There are also differences in parental practices across cultures. For example, fewer than 5% of children from PA countries fall asleep independently compared to about 50% of children from PC countries (Mindell Sadeh Kohyama et al., 2010). Children from PA countries are also more likely to go to bed later and share a room with parents than children from PC countries (Mindell Sadeh Wiegand et al., 2010). While these findings demonstrate large scale cultural differences, there are also likely to be more nuanced differences between parenting practices surrounding children’s sleep. One implication is that cultural norms and beliefs may not only play a role in when and why parents seek advice about their child’s sleep, but they may also impact whether parents are willing to change their parenting practices, particularly if these changes run counter to their cultural beliefs.
Interventions for sleep problems
Sleep problems for children are classified into two categories: night waking and bedtime resistance (Mindell et al., 2006). At this time, there are no standards for determining when a sleep problem has reached a clinical level as opposed to a behavior that, while problematic, is likely to be temporary (Morgenthaler et al., 2006). For example, awakenings increase around the time infants learn to crawl and then return to pre-crawling levels within two weeks (Scher & Cohen, 2015). Bedtime resistance, such as stalling or refusing to stay in bed, also tends to increase from 12 to 36 months (Jenni et al., 2005), which parallels increasing independence during the day. Thus, parents and practitioners alike are challenged to separate typical age-related changes in children’s sleep from those that are frequent, persistent sleep problems. A key factor in determining whether a sleep behavior is temporary, or a sign of a more serious problem, is the extent to which parents view the behavior as problematic.
Behavioral treatments are effective in reducing the two most common types of sleep problems in early childhood—bedtime resistance and frequent night waking (Meltzer & Mindell, 2014; Mindell et al., 2006). In general, these interventions aim to reduce excessive involvement by parents at sleep onset and in response to a night waking. Broadly speaking, treatments fall into three categories: extinction, routines, and preventative education (Morgenthaler et al., 2006). At its core, extinction involves a consistent bedtime routine and requires that parents ignore problematic bedtime behaviors (e.g., whining, fussing, and crying). Graduated extinction, a modified version of the treatment that parents tend to be more comfortable enforcing, involves gradually lengthening the time to respond to a child’s stalling at bedtime or in response to nighttime awakening. Notably, it is suggested that gradual non-responding should begin around six months of age as a method of preventing the development of sleep problems, though more research is needed to determine whether this approach plays a causal role in preventing sleep problems (Morgenthaler et al., 2006). Routines involve setting a consistent time for getting ready for bed, time to be in bed, and a consistent set of activities prior to bedtime (Meltzer, 2010). Parent over-involvement during the bedtime routine (e.g., putting the child to bed after they fall asleep) tends to result in frequent awakenings where the child is unable to soothe themselves back to sleep without parental intervention (Ribeiro et al., 2015). Therefore, the bedtime routine should end with the child being drowsy, but not asleep, so that they learn to fall asleep without the presence of a parent. The same principle applies to nighttime awakenings. For children who are already exhibiting sleep problems—bedtime resistance or frequent awakenings—establishment of a nightly routine is recommended along with gradual (or abrupt) non-responding (Meltzer, 2010). Finally, preventative education covers a variety of topics and methods that includes information about typical sleep development as well as methods for responding to problematic behaviors without inadvertently reinforcing them.
Benefits of a bedtime routine
Of the recommended treatments for sleep problems, two are also recommended practices that are likely to reduce the likelihood of the development of future sleep problems: education and bedtime routines. Notably, education includes information about bedtime routines; specifically, how to set a nighttime schedule that supports the development of a child’s independence from their parent in falling asleep as well as returning to sleep upon waking at night. There are several aspects of a bedtime routine including parental warmth, consistency of schedule, and consistency of activities. Parental warmth includes expressing positive emotions, setting appropriate limits, being responsive to child cues, and not expressing frustration or anger. Greater observed parental warmth prior to bedtime was associated with fewer awakenings in a community sample of children from one to 24 months of age (Teti et al., 2010). There is also preliminary evidence that increasing parental warmth prior to bedtime for children who had a sleep problem was effective in reducing both bedtime resistance and the number of awakenings (Burke et al., 2004).
Bedtime routines include consistency of schedule and activities and parental warmth
Greater consistency in the timing and steps of a bedtime routine in a community sample was associated with fewer signaled awakenings and a greater percentage of sleep while in bed (Staples et al., 2015). Importantly, studies have found that it was not the number of steps involved in the bedtime routine, rather it was the consistency of the bedtime routine that was predictive of better sleep (Mindell et al., 2015; Staples et al., 2015). Furthermore, there was a dose-dependent response such that as consistency in routine increased, so did the improvement in the child’s sleep (Mindell et al., 2015). Establishing a bedtime routine for children who have already developed sleep problems has also been effective in correcting the problematic behavior within just three nights (Mindell et al., 2017). A separate study found that the benefits of improved sleep following the establishment of a bedtime routine persisted a year following the intervention (Mindell et al., 2011). Of particular interest for parents and practitioners was that the bedtime routine intervention consisted of three steps—bath, massage, quiet activity—that lasted between 15 to 30 minutes. This suggests that to be effective, the bedtime routine need not be elaborate in activities, steps, or time to complete. Finally, establishment of a consistent bedtime routine not only reduces frequent nighttime awakenings, but it also has been linked to improvement in daytime behavior, regulation of negative emotions, and improved parent-child interaction (for a complete review see Mindell & Williamson, 2018).
A consistent bedtime routine is linked to improved daytime behavior
For parents of children with sleep problems, particularly when children are resisting going to bed and/or need their parent to return to sleep after a nighttime awakening, establishment of a bedtime routine is strongly recommended. The specific steps in the routine are not as important as the overall tone (calming and positive) and consistency. Specifically, the entirety of the routine should be consistent including the type of activities, the ordering of activities, and the time at which the routine begins and ends. Finally, the bedtime routine should be repeated as many nights as possible, with every night being best practice. For those working with parents of young children, educating parents early on appears to be the most effective and economical method of reducing or preventing sleep problems. Specific recommendations for parents should also take into consideration individual preferences (e.g., sleep location), family dynamics (e.g., number of children, parent work schedule), and cultural values (e.g., co-sleeping, room sharing) surrounding sleep practices.
Key elements of a bedtime routine
• Establishment of a consistent bedtime routine is recommended for the two most common sleep problems in early childhood: bedtime resistance and frequent nighttime awakenings.
• Begin establishing a consistent nighttime routine when the child is six-months-old.
• The bedtime routine should happen at the same time each night (+/- 30 minutes).
• The steps, or activities, of the bedtime routine should be the same each night and in the same order.
• Suggested bedtime activities are those that convey a sense of calm, warmth, security, and safety such as snuggling while reading a book, rocking while singing a lullaby, or a brief (3-5 minute) massage.
• Bedtime activities to avoid include watching TV or using portable electronic devices.
• A bedtime routine—consisting of two to four steps—that lasts between 15 and 30 minutes seems sufficient for promoting good sleep and reducing sleep problems.
• The child should be drowsy at the end of the bedtime routine, but not asleep.
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