Sleep behaviors are culturally determined, and behaviors tend to be defined as problems when they vary from accepted customs or norms. In cultures where children sleep separately from their parents in the same house, sleep problems are among the most common issues that parents and children face.
Infants usually adapt to a day-night sleep schedule between 4 months and 6 months of age. Sleep problems beyond this range take many forms, including difficulty falling asleep at night, frequent nighttime awakening, atypical daytime napping, and dependence on feeding or on being held before being able to go to sleep. These problems are related to parental expectations, the child’s temperament and biologic rhythms, and child–parent interactions.
Factors that influence sleep patterns vary by age. For infants, inborn biologic patterns are central. Sleep disturbances become common after 9 months of age because:
Separation anxiety develops.
Children can move independently and control their environment.
They may take long late-afternoon naps.
They may become overstimulated while playing before bedtime.
Nightmares tend to become more common.
Partial arousals from sleep are common among all age groups. Infants who are always held and rocked or driven in a car to help them fall asleep will have a hard time learning to fall asleep on their own and may develop problems with frequent night awakenings. These problems can be avoided by always placing infants in their crib or bassinet when drowsy but still awake and allowing them to fall asleep on their own. In toddlers and older children, emotional factors and established habits become more important. Stressful events (eg, moving, illness, new siblings) may cause acute sleep problems in older children.
Safe Sleep
The supine sleep position is recommended for every sleep period for all infants to reduce the risk of sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS). Prone or side sleep positions place infants at high risk of SUID, particularly for those who are placed on their side and found on their stomach (1). See also Prevention of SUID and SIDS.
Co-sleeping is when parent and infant sleep in close proximity (on the same surface or different surfaces) so as to be able to see, hear, and/or touch each other. Co-sleeping arrangements can include
Bed-sharing (the infant sleeps on the same surface as the parent)
Room-sharing (the infant sleeps in the same room as the parent in close proximity)
Parent–infant bed-sharing is common but highly controversial. There are often cultural and personal reasons why parents choose to bed-share, including convenience for feeding, bonding, believing their own vigilance is the only way to keep their infant safe, and believing that bed-sharing allows them to maintain vigilance even while sleeping. However, bed-sharing has been associated with an increased risk of SUID related to suffocation, strangulation, and entrapment. The American Academy of Pediatric does not recommend bed-sharing, under any circumstances, in infants (0 to 12 years of age) (2).
Room-sharing without bed-sharing allows for close proximity to the infant and for the facilitation of feeding, comforting, and monitoring; is safer than bed-sharing or solitary sleeping (the infant sleeps in a separate room); and is associated with a decreased risk of SUID and SIDS (1). For these reasons, room-sharing without bed-sharing is the only recommended sleeping arrangement for parents and infants in the first 6 months of life (2).
References
1. Moon RY, Carlin RF, Hand I; TASK FORCE ON SUDDEN INFANT DEATH SYNDROME and THE COMMITTEE ON FETUS AND NEWBORN. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics. 2022;150(1):e2022057991. doi:10.1542/peds.2022-057991
2. Moon RY, Carlin RF, Hand I; TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990
Evaluation
History
History is focused on the child’s sleeping environment, consistency of bedtime, bedtime routines, and parental expectations. A detailed description of the child’s average day can be useful. The history should probe for stressors in the child’s life, such as difficulties in day care or school, as well as exposure to unsettling television programs and caffeinated beverages (eg, sodas). Reports of inconsistent bedtimes, a noisy or chaotic environment, or frequent attempts by the child to manipulate parents by using sleep behaviors suggest the need for lifestyle changes. Extreme parental frustration may make being consistent and firm about bedtime routines difficult.
A sleep diary compiled over several nights may help identify unusual sleep patterns and sleep disorders (eg, sleepwalking, night terrors).
Careful questioning of older children and adolescents about school, friends, anxieties, depressive symptoms, and overall state of mind often reveals a source of a sleep problem.
Physical examination and testing
Examination and diagnostic testing generally yield little useful information.
Treatment
Behavioral sleep interventions
Supportive measures to help children fall asleep on their own
Learning to fall asleep is an important developmental task. The clinician’s role in treatment is to present explanations and options to parents, who must implement changes to get the child on an acceptable sleep schedule.
All children awaken during the night, but children who have been taught to fall asleep by themselves usually settle themselves back to sleep. Infants are often comforted by swaddling, ambient noise, and movement. However, always rocking infants to sleep does not allow them to learn how to fall asleep on their own, which is an important developmental task.
Behavioral sleep interventions that are effective for sleep training include (1):
Unmodified extinction: Putting the child to bed and ignoring them (except for safety concerns), leading to the extinction of undesired behaviors such as crying and screaming.
Graduated extinction: Ignoring the child for a set period of time before responding; gradually lengthening the period of time before response.
Bedtime fading: Starting with a bedtime that is the child's natural sleep onset; gradually moving it earlier to the desired bedtime.
Scheduled awakenings: Waking the child prior to spontaneous awakening and comforting them as if they had awakened on their own.
All behavioral sleep interventions involve the education of caregivers about self-soothing skills and creating a positive bedtime routine.
As a substitute for rocking, the parent can sit quietly by the crib until the infant falls asleep; the infant eventually learns to be comforted and to fall asleep without being held.
In older children, a period of winding down with quiet activities, such as reading at bedtime, facilitates sleep. A consistent bedtime routine is helpful for all children. Asking fully verbal children to recount the events of the day often eliminates nightmares and nighttime waking. Encouraging exercise in the daytime, avoiding scary television programs and movies, and refusing to allow bedtime to become an element of manipulation can also help prevent sleep problems. Finally, minimizing or avoiding screen time, digital media use, and exposure to blue light before bedtime help with sleep (2, 3).
If stressful events are the cause, reassurance and encouragement can be helpful. Allowing children to sleep in their parents’ bed often prolongs rather than resolves the problem.
Treatment references
1. Morgenthaler TI, Owens J, Alessi C, et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29(10):1277-1281.
2. Munzer T, Milkovich LM, Madigan S, et al. Digital Ecosystems, Children, and Adolescents: Technical Report. Pediatrics. 2026;157(2):e2025075321. doi:10.1542/peds.2025-075321
3. Martin KB, Bednarz JM, Aromataris EC. Interventions to control children's screen use and their effect on sleep: A systematic review and meta-analysis. J Sleep Res. 2021;30(3):e13130. doi:10.1111/jsr.13130
