Sleep disorders during childhood: a practical review
Sleep disorders are a common problem during childhood. The consequences are variable, and sleep disorders can influence medical, psychological and developmental aspects of the growing child. It is important to recognize sleep disorders and to treat them correctly. We discuss common sleep disorders during childhood using the 3rd edition of the International Classification of Sleep Disorders. We analyze the different sleep disorders from a clinical approach and provide an overview of adequate treatment options.
What is known:
• Sleep disorders are a common problem during childhood.
• The consequences are variable, and sleep disorders can influence medical, psychological, and developmental aspects of the growing child.
What is new:
• Pediatricians should routinely screen for sleep and sleep disorders.
• It is important to recognize sleep disorders and to treat them correctly.
KeywordsSleep disorders Childhood Insomnia Clinical characteristics Treatment
delayed sleep wake phase disorder
international classification of sleep disorders
multiple sleep latency test
obstructive sleep apnea
periodic limb movement disorder
restless leg syndrome
sleep-onset rapid eye movement period
Sleep is defined as a readily reversible suspension of sensorimotor interactions with the environment, usually associated with recumbence and immobility. Sleeping is an essential process that gives us the opportunity to absorb emotions and impressions we experienced during the day, to recover from physical activities and to gain new energy . Sleep is essential for children’s learning, memory processes, school performance, and general well-being. Sleeping is a more complex and active process than previously thought, with several physiological processes involved.
The consequences of sleep problems can vary from daytime sleepiness to headaches, behavioral problems, poor school results, and more. The reported prevalence of sleep problems in children is at least 25% .
In this review, we will briefly discuss the normal sleep development and needs in children, and we will provide an overview of sleep disorders, based on the 3rd edition of the International Classification of Sleep Disorders [ICSD-3] . Each sleep disorder will be presented with a clinical case, its specific characteristics, and possible treatment.
Sleep development and sleep needs
Sleep architecture consists of two stages: non-rapid eye movement sleep (NREM) and rapid eye movement sleep (REM). These stages are defined by polysomnographic features of electroencephalographic (EEG) patterns, eye movements, and muscle tone. NREM sleep is divided into three stages from stage 1, the lightest sleep, to stage 3, also called deep sleep. Deep sleep occurs mostly in the first part of the night. The amount of deep sleep increases in the first year of life and becomes maximal during childhood. It will decrease during adolescence since adults require less deep sleep than children. REM sleep is characterized by a strong fall in peripheral muscle tone and increased cerebral activity. It is in this phase of our sleep that we experience most of our dreams. Infants younger than 4 months enter sleep through REM. After the age of 3 months, the first REM sleep period occurs between 70 and 100 min after sleep onset and lasts approximately 5 min. REM and NREM sleep progresses cyclically, and every cycle lasts 50 min during infancy (0–1 years old) and between 90 and 110 min in children and adults .
Sleep structure develops and changes according to age
Neonates do not make any differentiation between day and night-time [5, 6]. It is difficult to give guidelines about the amount of sleep necessary for a neonate since there is a wide range of normal variability. A sleep cycle lasts for 40 to 50 min, and they have only three sleep stages: active sleep (REM), quiet sleep (NREM), and indeterminate sleep. During active sleep, infants can express limb movements, sucking movements, and grimaces, and it is in this stage that they will fall asleep. When infants grow older, sleep time declines to approximatively 14 h a day for a baby, and they will experience a day/night differentiation from the age of 1 month. Around the age of 3 months, a diurnal pattern is established with a longer period of sleep at night, shorter naps during the day, and a few hours of wakefulness before the nocturnal sleep period. By the age of 9 months, 70 to 80% of babies will sleep through the night. They still require two naps of 2 to 4 h a day. The four sleep stages will develop, and from the age of 6 months, we can define sleep stages as in adults.
An estimated 25 to 50% of 6- to 12-month-olds and 30% of 1-year-olds have problematic nightwakings with an inability of self-soothing at sleep onset and during night waking. Common sleep disorders in infants are nightwakings, bedtime problems, and sleep-related rhythmic movements such as head banging, body rocking, and body rolling.
Toddlers require approximately 12 h of sleep with one nap during the day; the nap will disappear between 3 and 5 years of age. The amount of REM-sleep decreases, and the amount of deep sleep increases.
In toddlers, sleep problems are very common, occurring in 25–30% of individuals. Common sleep disorders include bedtime problems, nightwakings, and sleep-related rhythmic movements such as head banging, body rocking, and body rolling. These sleep disorders in toddlers may persist into preschool years.
In pre-school children from 3 to 5 years of age, the prevalence of difficulties falling asleep and nightwakings is 15 to 30%. Common sleep disorders are nighttime fears and nightmares, bedtime problems, nightwakings, obstructive sleep apnea, and sleep-disordered breathing and disorders of arousal such as sleepwalking and sleep terrors.
During primary school, children require approximately 11 h of sleep, which will decrease to 8–10 h of sleep for adolescents, even if this amount is often not met. The amount of deep sleep will first still increase but begins to decrease during teenage years.
In school-aged children from 6 to 12 years of age, the prevalence of sleep problems is about 37%, with 15–25% experiencing bedtime resistance, 10% experiencing sleep-onset delay and anxiety, and 10% experiencing daytime sleepiness. Common sleep disorders are sleepwalking and sleep terrors, bruxism, sleep enuresis, obstructive sleep apnea (OSA), insufficient sleep syndrome, unhealthy sleep habits, restless leg syndrome (RLS), and periodic limb movement disorder (PLMD).
The prevalence of sleep problems in adolescents is at least 20%. Common sleep disorders in this group are insufficient sleep syndrome, unhealthy sleep habits, insomnia, delayed sleep-wake phase disorders, OSA, RLS, PLMD, and narcolepsy [5, 6].
The average sleep needs according to age 
12 to 16 h a day
11 to 14 h a day
10 to 13 h a day
9 to 12 h a day
8 to 10 h a day
Classification of sleep disorders
ICSDs are used to describe the most frequent sleep disorders in children. The ICSD-3 identifies seven major categories: insomnia, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, parasomnias, sleep-related movement disorders, and other sleep disorders [3, 8].
We refer to a recent European Respiratory Society Task Force  for the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and to the ICSD-3 for the other categories. In this article, we will only discuss insomnia, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, parasomnias, and sleep-related movement disorders.
The parents of Lisa, a 2.5-year-old girl, consulted their pediatrician because she has problems falling asleep, leading to a low energy level during the day. During the previous 6 months, going to bed has become more and more difficult, and now she can only fall asleep when mum or dad lie next to her holding her hand. Even when she wakes up at night, she cannot get back to sleep without one of them next to her. The parents tried to avoid it, but they end up lying next to her so that she finally falls asleep. It is getting so bad that some nights, one of them has to sleep with her in bed or no one would be able to sleep with her crying all night long.
Types of childhood insomnia
Behavioral insomnia of childhood
Related to sleep-onset associations
Related to inadequate limit-setting by parents
Psychophysiological [conditioned] insomnia
Transient sleep disturbances
Childhood insomnia is very common, with an estimated prevalence of 25 to 40% in children aged 4–10 years old. Bedtime resistance is a problem in 15% of these children, and almost 11% have psychophysiological insomnia . The prevalence of insomnia in adolescents is estimated to be 11% . Children with neurodevelopmental, chronic medical, or psychiatric disorders are at a higher risk for sleep disturbances leading to insomnia  and often require an adapted (behavioral) treatment approach.
Children with sleep-onset association disorder can only fall asleep under certain conditions. This can be a certain object or circumstance that usually requires the presence or intervention of the parents. When the child wakes up at night, he will not be able to get back to sleep without those same conditions being present. This disorder usually disappears around the age of 3 to 4 years old .
Limit-setting insomnia is very common in preschool- and school-aged children. It is characterized by the parent’s difficulty in setting rules and limits for bedtime and having their children follow these rules. Children will protest and show resistance in such a prolonged way that it can result in inadequate and insufficient sleep .
Psychophysiological insomnia is characterized by anxiety about falling or staying asleep due to an excessive physiological or emotional arousal related to sleep and the sleep environment. Children with this condition have difficulty falling asleep, sleeping through the night, or waking up early in the morning. Affected children often have dysfunctional sleep cognitions such as thinking they will never be able to fall asleep. Even during daytime, they are already thinking about how they will fall asleep at night. Other risk factors associated with insomnia are the excessive use of caffeine or the abuse of alcohol, marihuana, and other drugs .
Transient sleep disturbances occur in children with a previously normal sleep pattern in times of a stressful event such as moving or traveling. It is usually self-limiting but can become chronic if the parents respond in a way that reinforces their inappropriate sleep habits.
Behavioral insomnia is treated through adequate sleep hygiene and behavioral therapy with the gradual extinction of parental involvement and teaching children to self-sooth. The focus in younger children is mainly on changing parental behavior. It is essential to involve parents in the management of this disorder because they are the ones who should establish the rules and limits and maintain them.
In older children with conditioned insomnia, education of the child about the principles of healthy sleep habits and the use of relaxation techniques can be very helpful in addition to behavioral therapy .
Pharmacological therapy for the treatment of insomnia is not a first-line treatment option and should only be considered in combination with behavioral therapy. Melatonin is an effective, safe, and well-tolerated agent, particularly in cases of sleep-initiation insomnia caused by circadian factors. Several placebo-controlled studies of melatonin in adults and children (in some studies, as young as 3 years of age) showed that melatonin administered at bedtime reduces sleep-onset latency time and increases total sleep time .
Central disorders of hypersomnolence
Sophie, a 6-year-old girl, was referred because of excessive daytime sleepiness; her teacher found her asleep in class, and she also falls asleep watching television. Her parents initially attributed these daytime symptoms to her poor sleep. However, in the last few weeks, she has had sufficient sleep. Sometimes she wakes up in the night and has the feeling she cannot move anymore. She has needed a nap during the day for 1 h for a month. There are no hypnagogic hallucinations present.
Hypersomnolence, or excessive daytime sleepiness that is not attributable to another sleep disorder (e.g., circadian rhythm disorders or sleep deprivation), is the primary complaint in the central disorders of hypersomnolence. It is defined as “daily episodes of an irrepressible need to sleep or daytime lapses into sleep.” Multiple sleep latency tests (MSLTs) are necessary to objectify sleepiness and should only be performed immediately after a PSG because they must be followed by sufficient nocturnal sleep [of at least 6 h], and other sleep disorders must be excluded. The test consists of four or five 20-min nap opportunities at 2-h intervals across the day. The latency until sleep onset is measured for each nap opportunity, and sleep recordings are analyzed to detect sleep stage transitions (based on standard EEG, EOG, and EMG criteria) and the presence or absence of REM sleep during each nap (known as sleep-onset rapid eye movement periods, or SOREMPs when REM latency is less than 10 min). A mean sleep latency of less than 8 min is generally considered to be consistent with objective evidence of excessive daytime sleepiness . Narcolepsy is one of the central disorders of hypersomnolence and is characterized by an abnormal sleep latency of less than 8 min with evidence of minimal 2 SOREMP. However, the second criterion is not always present in children with narcolepsy, certainly not at the onset of the disorder.
There are two types of narcolepsy:
Type 1 includes patients with cataplexy and hypocretin-1 deficiency, which is measured in cerebrospinal fluid. Cataplexy is a condition characterized by transient weakness or paralysis of somatic musculature triggered by an emotional stimulus or physical exertion. Type 2 patients have daily periods of an irrepressible need to sleep or daytime lapses for at least 3 months, a positive MSLT for narcolepsy but the absence of cataplexy, normal hypocretin-1 levels, and no other explanation for hypersomnolence.
Narcolepsy is mostly a sporadic disorder, but familial predisposition has been recognized. Associations between narcolepsy and HLA DQA1 0102 and HLA DQB1 0602 have been demonstrated in several studies. Most patients will show positivity for this HLA allele; however, it is also found in 20% of healthy individuals . The diagnosis is made by a detailed clinical history and a complete physical examination, including neurological assessment in combination with a polysomnography followed by MSLTs. Lumbar puncture can be utilized to measure hypocretin-1 levels. Hypersomnia due to medication or substance abuse should always be excluded.
The estimated prevalence of narcolepsy is 30 in 100,000 patients. The first symptoms usually appear during adolescence, between 15 and 30 years of age, but some cases in toddlers have been described. Narcolepsy is found equally in females and males. The prevalence is known to vary between nationalities and ethnicities, with the highest prevalence in Japan .
Children with narcolepsy present with four main symptoms: excessive sleepiness, cataplexy, sleep paralysis, and hypnagogic hallucinations. Other symptoms of narcolepsy are disrupted or fragmented sleep and metabolic, endocrinological, psychiatric, and psychosocial issues.
Excessive sleepiness with an impact on daily life activities is the most important presenting symptom in patients. Cataplexy is the second most common symptom of narcolepsy and is present in 80% of patients. It is defined as a sudden-onset loss of skeletal muscle tone with maintained consciousness and can vary in severity from only buccofacial cataplexy to whole-body cataplexy. It can last for some seconds to several minutes and is associated with a strong emotion.
Hypnagogic hallucinations are a third symptom of narcolepsy. They are generated when REM-sleep occurs just before sleep onset or just before awakening. They are mostly visual hallucinations and can occur together with sleep paralysis. Sleep paralysis is reported as an inability to move for a few minutes and occurs typically on awakening from sleep.
Type 1 narcolepsy in childhood is also associated with overweight and obesity due to hypocretin deficiency impairing satiety .
Behavioral therapy is necessary to implement strategies for managing the daytime sleepiness. This includes sleep hygiene counseling with scheduled naps during the day. It is important to integrate the entire family and school in the therapy. Weight management and the management of associated disorders should always be included. Medical therapy for narcolepsy includes stimulating drugs such as methylphenidate, modafinil, amphetamines, or sodium oxybate. Specifically, for cataplexy tricyclic antidepressants, selective serotonin or noradrenalin re-uptake inhibitors (fluoxetine, venlafaxine) can be prescribed, although they are rarely used in children, and this requires a referral of these children to a specialized sleep center .
Other central disorders of hypersomnolence are idiopathic hypersomnia, hypersomnia due to a medical or psychiatric disorder or due to a medication or substance and insufficient sleep disorder. We refer to the ICSD-3 for more information about those disorders.
Circadian rhythm sleep-wake disorders
Alex is a 15-year-old boy who goes to bed around 22h30 but lies awake for 2 or more hours in bed before falling asleep. When he is finally sleeping, he has a good night of sleep without waking up. In the morning, he is still sleeping when the alarm goes off, and his mom usually has to push him to get him up. At school, he often complains about a headache and sleepiness, and his teacher believes that he has concentration difficulties. During the weekend he’s allowed to stay up until midnight and then he falls asleep within thirty minutes but he sleeps until noon.
Delayed sleep-wake phase disorder (DSWPD) is the most frequent sleeping disorder during adolescence. It involves a habitual and persistent phase shift of more than 2 h in the sleep-wake schedule that conflicts with the individual’s normal school, work, and/or lifestyle demands. The timing is problematic; there normally are no problems with the quality of sleep. Studies suggest that DSWPD affects 7 to 16% of adolescents. In sleep clinics, it has been observed in approximately 10% of cases. Young men are more likely to have an evening preference. The onset is typically during adolescence .
Patients typically present with a history of lying awake in bed for several hours before they finally fall asleep. They will sleep through the night but have trouble waking up. The resulting sleep deprivation leads to sleepiness, petulance, headache, and concentration problems. Differential diagnosis should be made with insomnia, RLS, school avoidance or refusal, psychiatric disorders including depression, anxiety disorders, or abuse.
The goal of the therapy is to reset the sleep-wake cycle to normal. This can be achieved by some simple life rules such as no daytime naps, regular bedtimes and wake times during the week and weekends, no caffeine or other stimulating drinks or food in the evening, no computer or TV in the bedroom, and more light exposure in the morning. If this fails, chronotherapy is indicated, where bedtime is gradually delayed until the desired hour of falling asleep is reached . Melatonin can sometimes help to reset the sleep-wake cycle by decreasing sleep onset latency and increasing total sleep time. However, it will not decrease night awakenings. Melatonin is in this case most effective when administered 3 to 5 h before bedtime [25, 26].
The parents of Adam, a 4-year-old, consulted their pediatrician because they are really worried about their son. Almost every night, he wakes up screaming loudly. When the parents arrive in his room, he looks anxious with big eyes, he is sweating, and they feel that his heart is beating very fast. When they talk to him, he does not really respond but remains agitated. When asking him in the morning what happened, he cannot remember anything.
Parasomnias are sleep phenomena characterized by abnormal behavior or physiological events that occur during sleep or during the transition from sleeping to awakening. In general, the sleep quality remains unaffected, but this episodic complex behavior can lead to significant worry for parents. Parasomnias are divided into NREM-related, REM-related, and other parasomnias. For a complete overview of all parasomnias, we refer to the ICSD-3 . Sleepwalking, sleep-talking, and sleep terrors are NREM-related parasomnias that occur during deep sleep, that is, mostly during the first third of the night.
Nightmares are disturbing dreams that bring up negative emotions and will usually awaken the dreamer. Since they occur during REM-sleep, nightmares will occur more during the second part of the night.
The prevalence of sleepwalking in the overall population is estimated to be between 1 and 15%. The prevalence is 17% in children and 4% in adults. Peak incidence occurs between the ages of 8 and 12 years old . Approximately 3% of all children experience sleep terrors, which will mostly disappear without intervention. The age of onset is usually between 3 and 10 years of age . The prevalence of children who report at least one nightmare in their lifetime is approximately 75%. The overall prevalence of at least one parasomnia event by the age of 13 years has been reported to be as high as 78% .
Sleepwalking can vary from mild episodes, in which the child sits up and crawls around the bed, to more agitated episodes with running around throughout the house. Sleepwalkers typically have a poor memory of sleepwalking episodes.
Sleep terrors are another NREM-related parasomnia and are characterized by a sudden arousal accompanied by autonomic and behavioral manifestations of intense fear. They can also show tachycardia, sweating, and mydriasis. The child is not responsive, is agitated, and will not remember what happened in the morning.
Nightmares are dreams that seem vivid and real and are associated with negative emotions such as fear, but not so intense as with sleep terrors. Once awakened, full alertness returns immediately, and the child will often remember his nightmare in contrast to sleep terrors. Differential diagnosis should be made with sleep terrors and posttraumatic stress syndrome. A polysomnography can be indicated since nightmares and parasomnias can be related to OSA.
It is important to explain to parents that parasomnia is a neurodevelopmental phenomenon; it is not indicative of an underlying psychological issue and will not result in psychological harm. There is no real treatment for sleepwalking or sleep terrors. Preventive measures must be taken so the patient cannot hurt himself, and the parents must be reassured that it will usually disappear with time. Healthy sleep habits are important because insufficient sleep is the primary contributor: adequate sleep and the discipline to maintain a regular sleep-wake schedule are necessary, and adolescents should avoid caffeine [it can increase sleep disruption]. It is important to explain the response during an event: they must avoid awakening the child because this can cause agitation and prolong the event. Parents can guide the child back to bed.
Scheduled awakening is a behavioral technique that is most likely to be successful in situations in which episodes occur on a nightly basis. The parent wakes the child 15 to 30 min prior to the time that the first episode typically occurred during the past 2–4 weeks. Pharmacologic treatment may be indicated in cases of frequent or severe episodes with a high risk of injury or violent behavior; however, this is rarely indicated in children. The primary agents are suppressants of slow-wave sleep such as benzodiazepines (diazepam, 1–2 mg for 3–6 months before bedtime or intermittent in clusters of days/weeks) and tricyclic antidepressants (in case of nonresponse to benzodiazepines) . An alternative medical treatment for sleep terrors is the use of L-5-hydroxytryptophan that has proven his efficacy in certain studies .
The best treatment for nightmares is reassurance of the child that it was only a bad dream. When nightmares become problematic and recurrent, further evaluation to assess anxiety and an underlying cause is indicated. Treatment is based on behavioral therapy .
Sleep-related movement disorders
Case 1: Martha, a 10-year-old girl, resists going to bed every evening. She says that she has an annoying, electric feeling in her legs and starts shaking her legs when lying in bed. This makes it difficult for her to fall asleep and sometimes the feeling also wakes her up during the night.
Case 2: The parents of Jim, a 7-year-old boy, noticed that his legs move vigorously when he’s sleeping. He always seems to have disturbed sleep. He just started primary school but has difficulty concentrating in the classroom.
Sleep-related movement disorders are characterized by simple, often stereotypical movements that occur during sleep, contrary to the complex movements of parasomnias. There are several types of sleep-related movement disorders such as head banging, body rocking, head rolling, bruxism, RLS, and PLMD.
Head banging, body rocking, or head rolling are sleep-related rhythmic movements and are common in young children (59%). Body rocking is the most common (43%), followed by head rolling (24%) and head banging (22%).
Body rocking begins at approximately 6 months of age and presents without head banging. Only the body is rocking back and forward.
Head banging starts at approximately 9 months of age and can occur by lifting the head to bang down into the pillow, rocking on hands and knees, or sitting upright and banging.
Head rolling involves side-to-side movements of the head and starts at the age of 10 months. Body rolling is less common.
These body movements can occur at sleep onset, following normal nighttime arousals, and while sleeping. Sleep is not really disrupted, and significant injury is rare. These behaviors occur in normally developing children, and in most cases, there is no association with an underlying neurologic or psychological problem. The parents should be instructed about safety and behavioral management. The most important aspect is reassurance that this is a normal, common, benign, and self-limited phenomenon. Most children will outgrow the condition by the age of 2 or 3 years. The prevalence is 33% in children 18 months old and only 5% by 5 years of age .
Bruxism is defined as nonfunctional repetitive grinding or clenching of teeth during sleep. It can lead to dental erosion, jaw and/or facial pain, and tissue damage over time. It typically occurs during stages 1 and 2 of NREM sleep and infrequently during REM sleep. Prolonged breastfeeding, decreased nighttime sleep, dental trauma, stress, light and noise in the bedroom, reflux, and a history of cerebral palsy are risk factors for bruxism. Thereby, it persists in adults in two-thirds of cases. Treatment could be focused on stress management techniques. Sometimes, there is need for pain relief with medication or dental appliances. Pharmacotherapy with REM-suppression is rarely indicated in children .
Restless leg syndrome (RLS) is a well-known diagnosis in adults and probably underestimated in children since many adult patients report symptoms that started before the age of 20 years. RLS can be mistaken in children with attention-deficit hyperactivity disorder (ADHD) since symptoms can be similar .
The diagnostic criteria for RLS in adolescents are as follows: the urge to move legs starting or worsening when sitting or lying down. This urge to move declines or disappears when getting up and worsens or exists only in the evening or at night. In children, the same diagnostic criteria are used with the addition of a description of the unpleasant feeling in their legs in the child’s own words. This syndrome may lead to sleep avoidance, difficulty falling asleep, and waking up at night. Polysomnography may show a periodic limb movement index of more than 5 per hour (which is also necessary in the diagnosis of PLMD). RLS is associated with a higher risk for depression and anxiety .
PLMD is diagnosed in children when polysomnography shows a periodic limb movement index of more than 5 per hour, associated with a clinically disturbed sleep or functional impairment and no other underlying sleep disorders such as RLS. The major difference between PLMD and RLS is that PLMD is a disorder of limb movements (without sensory symptoms) while RLS there is a sensory symptomatology.
In both RLS and PLMD, genetic factors, dopamine disturbance, and iron deficiency seem to play a role . It can be helpful to start iron supplements for a child with a limb movement disorder and a ferritin level below 50 ng/ml. General recommendations about daily physical exercise before bedtime, stretching, massage, and heat and cold patches can give relief of symptoms. Caffeine, alcohol, antihistamines, and cold circumstances should be avoided since they can trigger RLS. Medical therapy for both disorders includes gabapentin, clonidine, clonazepam, or dopamine-receptor agonists but should be started by a specialist since large trials in children with these disorders are lacking [35, 36].
Useful tips for good sleep hygiene
Many people think sleep problems are a normal part of childhood and education, which is often true. However, in some cases, sleep problems can have a serious impact on the child and its family. With some simple advice and rules, we can help parents and children [when old enough] provide insight into sleep habits and teach them healthy sleep behaviors.
A good night’s sleep starts at daytime
Maintain a clear daytime schedule
Explain which behaviors are accepted and which are not by positive reinforcement of the good behavior and ignoring the bad behavior.
Do not punish a child by sending him/her to bed.
A bedroom is only for sleeping, not for playing.
Avoid heavy or stimulating food and drinks before bedtime.
Reward the child when he had a good night.
Preparing for bedtime
Warn the child that it is almost bedtime; indicate when the last activity starts so he/she can prepare for bedtime.
Try to ease your child down and to have a regular bedtime.
Take your time and do not give your child the impression that you are working against them.
Parents should provide consistency by working together as a team Teach the child to fall asleep by themselves and do not stay with him/her until he/she sleeps.
Use the same ritual every day but keep it short.
If reading is part of the bedtime ritual, make clear rules about the reading time.
Some older children can experience benefits from relaxing exercises.
A dark, calm and not too warm [approximately 18°] room is the best.
If the child is afraid of the dark, use a dimmed light in the room or keep the door slightly open to reassure the child.
Remove computers and televisions from the bedroom
Avoid “blue light” from screens before going to sleep.
At the beginning, send the parent who can be the firmest to the child.
Use the same strategy as your partner.
Do not react on the first call but do not wait until the child is completely upset.
Try to stay calm, keep the lights low, and talk softly. Keep the child in his room and even better in his bed. Do not stay too long with the child.
Let the child sleep in his own bed.
Do not approach your child if you are feeling angry
Concept of the manuscript: D.O., M.S. and S.V.; Acquisition of data: D.O., M.S. and S.V.; Drafting of the manuscript: D.O., M.S. and S.V.; Critical revision of the manuscript: A.B., I.G. and K.V.H.; Final manuscript: all authors.
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