The importance of good sleep habits and practices in children and adolescents cannot be overstated. Read on for a rundown of practical tips and resources that GPs can use to help young patients optimise their sleep hygiene.
The importance of good sleep habits and positive sleep practices in children and adolescents cannot be overstated. Read on for a rundown of practical tips and resources that general practitioners can use to help young patients optimise their sleep hygiene.
THE IMPORTANCE OF SLEEP HYGIENE
It is lousy to be drowsy – a fact well known to everyone both young and old, when the irresistible urge to sleep occurs at inopportune moments for children, resulting in poor school attendance, deteriorating academic performance and emotional dysregulation.
Positive sleep practices and good sleep habits fall under the term ‘sleep hygiene’ – which often entails common empirical knowledge, but in reality is less likely to be adhered to especially when distractions are abound.
A need to start young
The pressing need to optimise sleep hygiene starts right from early childhood, as today’s exhausted kids strive for excellence in both academic and extracurricular pursuits.
Sleep hygiene often takes a backseat particularly in adolescents, amidst competing priorities associated with their preoccupation with body image, self-identity creation, peer acceptance and known preponderance for risk-taking behaviours.
The 4 Keys to Positively Promote Sleep in Children and Adolescents
Here are some helpful tips to optimise sleep hygiene in children and adolescents, focusing on four categories of behaviours that positively promote sleep.
Regulation of sleep (synchronising sleep drive and circadian rhythm)
Winding down for sleep
Conditions that aid sleep
Achieving optimal quantity and quality of sleep
1. Regulation of sleep
The sleep-wake cycle in humans is governed by two processes: one’s innate homeostatic sleep drive and the body’s ‘internal clock’ known as the circadian rhythm.
The body’s sleep drive is dependent on the accumulation of sleep pressure, which starts from the time of the last sleep episode, increasing in strength until it is met with the next sleep opportunity.
The circadian rhythm for sleep runs in the background independent of a sleep episode, relying on the ‘master clock’ known as the suprachiasmatic nucleus (SCN). This master clock is tied to environmental cues such as exercise, social activity, temperature and especially light exposure.
The following practices help regulate the internal clock and synchronise the sleep-wake cycle:
A. Consistent sleep-wake pattern
A consistent bedtime and wake time that differs by no more than an hour between weekdays and weekends is advised.
Dealing with multiple curtain calls and bedtime-delaying tactics is a rite of passage for parents of pre-schoolers. Ensuring a regular daily schedule that includes set meal times and consistent bedtime routines not lasting more than 30 minutes before lights out is key.
Wake times may be delayed on non-school days such as weekends or holidays, especially in adolescents who are known late-risers, and efforts should be made to ensure that this is delayed to no later than 9 or 10am.
B. Napping schedule
Late naps beyond 3.30pm are ill-advised as they do not provide sufficient time for a child’s sleep drive to accumulate by bedtime, potentially delaying it.
Nap schedules should be age-appropriate and consistent in place and timing. Many children start dropping their daytime naps between the ages of three and five years old. Hence, flexibility in adjusting to slightly earlier bedtimes can be helpful in accommodating this phase as the child’s sleep drive may start peaking earlier in the evenings.
C. Environmental light exposure
During the day, light exposure causes the master clock to send signals that generate alertness, promoting wakefulness and activity. Light-induced activation of the SCN prevents the production of melatonin by the pineal gland.
As night falls, the master clock initiates melatonin production and then keeps transmitting signals that help maintain sleep through the night.
The sleep-promoting role of melatonin must be leveraged in the evening to allow it to peak appropriately just before bedtime.
Avoidance of evening direct light exposure is advised. A dim night light for children can be comforting and is appropriate, provided it does not shine directly into the child’s eyes.
Conversely, light exposure in the morning is encouraged for melatonin suppression and to generate alertness. Morning sun exposure through outdoor play or morning jogs can further help regulate the internal clock.
2. Conditions that aid sleep
A. Having a bedtime routine
Children take comfort in routines. Bedtime routines should involve the usual three to four activities that start furthest away from the bedroom and finally end in bed.
For example, taking a bath or changing into pyjamas, followed by the brushing of teeth, and then the reading of a story book or singing of a lullaby before lights out. This should take no longer than 20 to 30 minutes to complete.
A bedtime routine pictorial chart depicting the activities that take place, accompanying a reward chart on tasks achieved that culminates in a weekly reward can help promote adherence in children who are developmentally able to understand the concept of rewards and delayed gratification.
B. Avoiding activities in bed other than sleep
- Screen use for texting, gaming and viewing of exciting or horror TV programmes in the bedroom should be discouraged as such stimulating activities promote wakefulness.
C. Avoiding using the bed as punishment
- Timeouts with the bed as a punishment may cause the child to develop a negative association with the bedroom environment, and hence should be avoided.
D. Keeping the bedroom as the sole place for sleep
- Naps in the car or on the sofa should be avoided.
3. Winding down for sleep
Screen devices in the bedroom have been associated with increased sleep problems and emotional or behavioural difficulties in young children, particularly in children with neurodevelopmental disorders.
In helping a child wind down for sleep, the following measures are recommended:
Keep electronic devices such as mobile phones and television sets (and their remote controls) outside of the bedroom.
Avoid play activities or exercises that are too stimulating closer to bedtime.
Heavy meals should be avoided one to two hours before bedtime as this can interfere with digestion, increasing the risk of reflux and affecting sleep onset.
Be aware of certain beverages, sweets, chocolates and ice cream flavours that contain caffeine and limit or eliminate them from the child’s diet in the late evening or night.
Relaxing activities such as reading, storytelling and singing in soothing tones can be included in the bedtime routine.
4. Achieving optimal quantity and quality of sleep
For optimal sleep quality, families should aim for a match between the child’s sleep need, sleep opportunity and amount of sleep obtained.
Bedtimes should be developed with the child and caregivers, appropriate for the child’s age and development.
Wake times should be designated to allow ample opportunity for sufficient sleep duration.
One must take into account that interindividual variations for amount of sleep required exist, attributed to factors such as neurodevelopment, genetic factors and tolerance for sleep deprivation. The table below shows the 2016 American Association of Sleep Medicine (AASM) guidelines for age-related recommendations on sleep duration:
Age | Recommended sleep hours per day |
Infants (4-12 months) | 12 to 16 hours (including naps) |
Toddlers (1-2 years) | 11 to 14 hours (including naps) |
Pre-schoolers (3-5 years) | 10 to 13 hours (including naps) |
Children (6-12 years) | 9 to 12 hours |
Teens (13-18 years) | 8 to 10 hours |
- The child’s bedroom environment should be purposed for sleep, with low light levels and noise, cool ambient room temperatures and safe sleeping surfaces that are age appropriate.
Have a consistent bedtime and wake time Have a consistent bedtime routine Get appropriate light exposure during daytime Avoid excessive direct light exposure at night Have age-appropriate naps, avoiding napping in the late afternoon / evening Associate the bedroom only with sleeping Avoid exercise or excessive screen time closer to bedtime Avoid heavy meals and caffeine-containing food/beverages closer to bedtime Promote calming/relaxing activities closer to bedtime
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USEFUL RESOURCES FOR GPs TO HELP OPTIMISE SLEEP HYGIENE
1. Sleep diary
A sleep diary is useful to track the child’s sleep habits across a period of one to two weeks. Once actual sleep patterns are established and known to both the caregiver and healthcare professional, only then can lifestyle modifications and behavioural advice be appropriately implemented, and improvements to the child’s sleep tracked over a period of time.
A sample sleep diary can be found at www.sleepfoundation.org/sleep-diary.
2. Epworth Sleepiness Scale
The Epworth Sleepiness Scale for children and adolescents (ESS-CHAD) is a helpful representation of the level of daytime somnolence experienced by the patient based on a score. The resource and score interpretation of this simple-to-use eight-item questionnaire can be found at https://epworthsleepinessscale.com/about-the-ess-chad.
3. Reward charts and sleep information resources for children and teenagers
Available at www.healthhub.sg/programmes/183/parent-hub/preschool/good-sleep-captain-sleep.
WHEN GPs SHOULD REFER A PATIENT
It is well known that a child’s temperament, sleep difficulties and parental reactions all interact in a reciprocal manner to produce or maintain sleep problems. Optimising sleep hygiene in children and adolescents remains an important first step in helping a family cope with sleep issues.
A referral to a sleep clinic can be considered when:
- It is established that there is a severe impact on the child or family members’ daytime functioning due to poor sleep quality or quantity that has not improved with the above discussed measures, and/or
- A sleep disorder (e.g., obstructive sleep apnoea, parasomnia) is suspected
REFERENCES
- Pediatric sleep. Diagnosis and management of sleep problems. Jodi A. Mindell, Judith A. Owens. 3rd edition, Wolters Kluwer. 2015
- The relationship among screen use, sleep and emotional/behavioural difficulties in preschool children with neurodevelopmental disorders. Lin J, Magiati I, Chiong SHR, Wong CM, et al. J Dev Behav Pediatr. 2019
- Recommended amount of sleep for pediatric populations: a statement of the American Academy of Sleep Medicine. J Clin Sleep Med. 2016
- When children don’t sleep well. Interventions for pediatric sleep disorders. V. Mark Durand. Oxford University Press. 2008
- Behavioural sleep problems in children. Ting CY, Thomas B. Singapore Med J. 2023
Dr Cheng Zai Ru is a Staff Physician with the Respiratory Medicine Service at KK Women’s and Children’s Hospital, treating patients with general respiratory conditions, asthma and sleep conditions. Her clinical research interests are in paediatric respiratory and sleeprelated disorders.
GPs can call the SingHealth Duke-NUS Sleep Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women's and Children's Hospital: 6692 2984
National Dental Centre Singapore: 6324 8798
National Neuroscience Institute: 6330 6363
