Health Library

Bedtime and Sleep Problems

If you or your child is facing any of the following concerns, your child may have a sleep disorder:

1. You are spending "too much" time helping your child fall asleep at night.
2. Your child is waking up frequently throughout the night.
3. You are losing sleep (and patience) because of your child's sleep problems.
4. Your relationship with your child is starting to suffer because of lack of sleep.

It is important to understand your child's sleep issues and take steps to improve their sleep. Behavior strategies are often effective in treating the most common childhood sleep disorders.. In most cases, sleep problems will improve within days to weeks. It is important to identify your child’s sleep problem so that the best treatment can be used to help you and your child get a good night’s sleep.

Common Sleep Problems for Young Children

Sleep-Onset Association Disorder

Sleep-onset association disorder occurs when your child closely connects their ability to fall asleep with something in the setting (such as being held by his parent; being rocked to sleep; nursing, drinking, or eating at bedtime; watching television or even sleeping in a parent or sibling's bed). When this "something in the setting" is absent, your child cannot fall asleep. All of us wake up briefly a number of times each night, but we are usually not aware that we wake up because we fall back asleep very quickly. For children with sleep-onset association disorder, when they wake up during the night, they are unable to fall back asleep if their "something in the setting" is not present. If your child is only able to fall asleep with the help of a parent but has trouble returning to sleep after waking during the night, it is possible that they have a sleep-onset association problem.

Nighttime Eating / Drinking Disorder

Nighttime eating / drinking disorder is more common among infants and toddlers and involves the need for "excessive" nighttime feeding (often nursing or bottle-feeding) in order for the child to fall asleep or return to sleep. For infants, feeding during the night is a normal part of development. However, by the age of 5 or 6 months, most children are not drinking more than eight ounces of fluid during the night (or nursing more than once or twice).

Limit-Setting Sleep Disorder

Limit-setting sleep disorder is more common for children who are walking, understand basic instructions and can tell you what they want/need (typically after age 2). With limit-setting problems, children refuse or stall bedtime (e.g., "I need to go to the bathroom, get a drink of water, one more hug, tell you something really, really important, etc.). They make it hard for the parent to leave their room without the child getting out of bed. Attempts to have the child return to bed may result in behavioral outbursts (e.g., crying; screaming; destruction of property or aggression).

Treatment for Bedtime Problems

1. A consistent sleep routine is helpful for treating and / or preventing the most common childhood sleep disorders. Routines that combine relaxing pre-sleep activities and a setting free of over stimulating or distracting activities are best for your child.
2. Spending time with your child before bed each night is a critical part of the bedtime ritual. Do not replace personal time with television or videos. Positive parent-child interactions before bed help calm your child and feel comfortable with the transition to bed.
3. For children with a sleep-onset association problem, a bedtime routine that helps your child fall asleep by themselves is important. You can use the same routine anytime your child needs to sleep, including naps.
   1. Create a setting at bedtime that does not require a response from you. Some suggestions are to play music, put on a nightlight, or provide comfort items. Avoid having your child fall asleep in your arms or while you are rocking them. Place them in their own bed before they fall asleep.
   2. For the young child that is still napping, it may be easiest to start the relearning process at night.
   3. Your child is expected to cry at first during this process.
   4. You are not abandoning your child when you ignore mild distress for set periods. When you allow your child to have increasingly longer periods alone in bed followed by brief encouragement and reassurance, your child can learn to fall asleep without your presence.
   5. Place your awake or drowsy child in their bed after you have completed a calming and quiet bedtime routine.
   6. Say goodnight and leave the room. You may keep the door open to allow some dim light into the room or use a nightlight.
   7. If your child begins to cry and is still crying after a few minutes, return to the room and provide brief words of comfort or lightly touch them (placing hand on their back or belly). Do not pick up your child, turn on the lights, or respond to requests (e.g., another bedtime story). Do not stay in the room longer than one or two minutes. Repeat this process, extending the time that you give your child to fall asleep by themselves (e.g., two minutes; then five minutes; then 10 minutes; then 15 minutes). Increase the time that you are out of the room in increments of five minutes to help your child slowly become more comfortable being alone in their bed.
   8. On the following nights, increase the intervals of time that you allow your child to self-soothe. For example, on the second night, start at five minutes and on the third night, start at 10 minutes.
   9. The first few nights are going to be the hardest for you and your child as you learn this new routine. The time that you spend away from your child when they are upset can be very hard for you. However, it is important to keep in mind that you are teaching them very important developmental skill (falling asleep by themselves).
4. If you are able to use this approach consistently on consecutive nights, you are likely to see results in five to 10 days.
5. If your child becomes sick or there is some other event that interferes with this process, you will likely have to start the process again.
6. If you feel you have been consistent with this approach for a two-week period and you are not seeing results, you should consider having your child evaluated for another underlying sleep disorder.
7. For a child with nighttime feeding problems it is important to gradually wean your child from this habit by reducing the number of nighttime feedings (i.e., increase the time between feedings). It may help to set defined time intervals to offer your child their bottle (e.g., every two hours) and slowly increase the interval until you are no longer offering the bottle at night. If your child wakes up and signals hunger before the time you have set for feeding/drinking, reassure them and give them an opportunity to fall back asleep without providing food/drink. (see above for guidelines on helping your child to self-soothe and fall asleep by themselves).
8. For a child with limit-setting problems at bedtime it is important to have a consistent bedtime routine as well as very clearly defined behavioral limits for bedtime. Focus on having a relaxing pre-sleep ritual each night, however, the transition to bed may require a more "matter of fact" approach. A firm and consistent response to your child's delay at bedtime will prevent you from inadvertently reinforcing your child's "delay behaviors." Limit-setting during the day and ni