Sleep Problems in Children

Most children sleep for a stretch of at least 5 hours by age 3 months but then experience periods of night-waking later in the first years of life, often associated with illness. With maturation, the amount of rapid eye movement (REM) sleep increases, with increasingly complex transitions between sleep stages. For most people, non-REM sleep predominates early in the night, with increasing REM as the night progresses. Thus, non-REM phenomena cluster early in the night, and REM-related phenomena occur later. Differentiating between true sleep (REM or non-REM)–related phenomena and awake behaviors can help direct treatment.

It is important to determine whether parents view the child sleeping with them as a problem, because there is much cultural variation among sleep habits (1, 2). The American Academy of Pediatrics 2022 recommendations for reducing deaths in the sleep environment suggest that infants sleep in the same room as parents but not in the same bed; this is thought to decrease the risk of sudden infant death syndrome (SIDS), a subset of sudden unexpected infant death (SUID).

Nightmares are frightening dreams that occur during REM sleep. A child having a nightmare can awaken fully and vividly recall the details of the dream.

Nightmares are not a cause for alarm, unless they occur very often. They can occur more often during times of stress or even when the child has seen a movie or television program containing frightening content. If nightmares occur often, parents can keep a diary to see whether they can identify the cause.

Night terrors are non-REM episodes of incomplete awakening with extreme anxiety shortly after falling asleep; they are most common between the ages of 3 and 8.

The child screams and appears frightened, with a rapid heart rate and rapid breathing. The child seems unaware of the parents’ presence, may thrash around violently, and does not respond to comforting. The child may talk but is unable to answer questions. Usually, the child returns to sleep after a few minutes. Unlike with nightmares, the child cannot recall these episodes in detail. Night terrors are dramatic because the child may scream and may be inconsolable during the episodes.

About one third of children with night terrors also sleepwalk (the act of rising from bed and walking around while apparently asleep, also called somnambulism). About 15% of children between the ages of 5 and 12 have at least one episode of sleepwalking.

Night terrors and sleepwalking almost always stop on their own, although occasional episodes may occur for years. Usually, no treatment is needed, but if a disorder persists into adolescence or adulthood and/or is severe, treatment may be necessary. In children who need treatment, night terrors may sometimes respond to a sedative or certain antidepressants. There is some evidence that disrupted sleep associated with periodic leg movements often responds to iron supplementation (1, 2), even in the absence of anemia. If children snore and thrash, evaluation for obstructive sleep apnea also should be considered.

Children, particularly between the ages of 1 and 2, often resist going to bed because of separation anxiety

Resistance to going to bed is not helped if parents stay in the room at length to provide comfort or let children get out of bed. In fact, these responses reinforce night waking, in which children attempt to reproduce the conditions under which they fell asleep. To avoid these problems, a parent may have to sit quietly in the hallway in sight of the child and make sure the child stays in bed. The child then establishes a sleep-onset routine of falling asleep alone and learns that getting out of bed is discouraged. The child also learns that the parents are available but will not provide more stories or play. Eventually, the child settles down and goes to sleep. Providing the child with an attachment object (like a teddy bear) often is helpful. A small night-light, white noise, or both also can be comforting. Some parents set limits by giving the child a "sleep pass" that the child can turn in for one time out of bed.

If the child is accustomed to falling asleep while in physical contact with a parent, the first step in establishing a different bedtime routine is to gradually lessen the contact from full body to a hand touching the child to a parent sitting next to the child's bed. Once the child is regularly falling asleep with a parent next to the bed, the parent can leave the room for increasing durations.

Everyone awakens multiple times each night. Most people, however, usually fall back to sleep with no intervention. Children often experience repeated night awakening after a move, an illness, or another stressful event. Sleeping problems may be worsened when children take long naps late in the afternoon or are overstimulated by playing before bedtime.

Allowing the child to sleep with the parents because of the night awakening reinforces the behavior. Also counterproductive are playing with or feeding the child during the night, spanking, and scolding. Returning the child to bed with simple reassurance is usually more effective. A bedtime routine that includes reading a brief story, offering a favorite doll or blanket, and using a small night-light (for children > 3 years of age) is often helpful. To prevent arousal, it is important that the conditions under which the child awakens during the night are the same as those under which the child falls asleep. Parents and other caregivers should try to keep to a routine each night so that the child learns what is expected. If children are physically healthy, allowing them to cry for a few minutes often allows them to settle down by themselves, which diminishes the night awakening. Extended crying is counterproductive, however, because parents then may feel the need to revert to a routine of close contact. Gentle reassurance while keeping the child in bed is usually effective.

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

1. American Academy of Pediatrics (AAP): Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

2. For patients and caregivers: How to Keep Your Sleeping Baby Safe: AAP Policy Explained

3. For patients and caregivers: Honor the Past, Learn for the Future: What does a safe sleep environment look like? (American Indian/Alaska Native Outreach)