’
Sleep Regulation, Physiology and
Development, Sleep Duration and
Patterns, and Sleep Hygiene in
Infants, Toddlers, and Preschool-Age
Children
Eleanor Bathory, MD,a and Suzy Tomopoulos, MDb
Sleep problems are common, reported by a quarter of parents
with children under the age of 5 years, and have been
associated with poor behavior, worse school performance,
and obesity, in addition to negative secondary effects on
maternal and family well-being. Yet, it has been shown that
pediatricians do not adequately address sleep in routine well-
child visits, and underdiagnose sleep issues. Pediatricians
receive little formal training in medical school or in residency
regarding sleep medicine. An understanding of the physiology
of sleep is critical to a pediatrician’s ability to effectively and
confidently counsel patients about sleep. The biological rhythm
of sleep and waking is regulated through both circadian and
homeostatic processes. Sleep also has an internal rhythmic
organization, or sleep architecture, which includes sleep
cycles of REM and NREM sleep. Arousal and sleep (REM
and NREM) are active and complex neurophysiologic proc-
esses, involving both neural pathway activation and suppres-
sion. These physiologic processes change over the life course,
especially in the first 5 years. Adequate sleep is often difficult
to achieve, yet is considered very important to optimal daily
Introduction
leep is not just the absence of waking, but an
S active neurophysiological process and the
primary activity of the developing brain. Sleep
is necessary for survival, but the major function of
sleep remains elusive. Sleep duration, quality, and
From the aDepartment of Pediatrics/Department of Family and Social
Medicine, Montefiore Medical Center, 3455 Jerome Ave, Bronx, NY; and
b
Department of Pediatrics, NYU School of Medicine, New York, NY.
Corresponding author. E-mail: ebathory@montefiore.org
This research was supported in part by Grant UL1 TR000038 from the
National Center for Advancing Translational Sciences, National Institutes
of Health.
Curr Probl Pediatr Adolesc Health Care 2017;47:29-42
1538-5442/$ - see front matter
& 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cppeds.2016.12.001
Curr Probl PediatrAdolesc Health Care, February 2017
function and behavior in children; thus, understanding
optimal sleep duration and patterns is critical for pediatri-
cians. There is little experimental evidence that guides sleep
recommendations, rather normative data and expert recom-
mendations. Effective counseling on child sleep must
account for the child and parent factors (child temperament,
parent–child interaction, and parental affect) and the envi-
ronmental factors (cultural, geographic, and home environ-
ment, especially media exposure) that influence sleep. To
promote health and to prevent and manage sleep problems,
the American Academy of Pediatrics (AAP) recommends that
parents start promoting good sleep hygiene, with a sleep-
promoting environment and a bedtime routine in infancy,
and throughout childhood. Thus, counseling families on
sleep requires an understanding of sleep regulation, physi-
ology, developmental patterns, optimal sleep duration rec-
ommendations, and the many factors that influence sleep
and sleep hygiene.
Curr Probl Pediatr Adolesc Health Care 2017;47:29-42
architecture changes over the lifespan, particularly in
the first 5 years of life. Newborns spend as much as
80% of their day sleeping, and most toddlers and
preschoolers spend half or more of their day asleep.
Sleep has been shown to be as important to animal
survival as food. Animal studies show that rat life
spans are decreased from 2 to 3 years to only 5 weeks
if deprived of REM sleep, and to 2–3 weeks if deprived
of all sleep. Human studies demonstrate that adequate
sleep in children is essential to normal growth and
development, maternal and family well-being, and
child sleep is associated with significant predictors of
adult health. In this review, we discuss sleep regula-
tion, biological rhythms, and sleep architecture; the
neurophysiology of sleep; the development of sleep
patterns in infants and young children; sleep duration
29
and patterns: normative data, recommendations and
influential factors; sleep problems; and recommended
sleep hygiene.1–4

Sleep Regulation, Biological Rhythms,

and Sleep Architecture
Sleep is regulated by two overlapping but distinct
systems—the circadian system and sleep/wake homeo- FIG. 1. Hypnogram: normal distribution of sleep stages
in healthy young adults. (Reproduced with permission from
stasis.5,6 The circadian system endogenously synchro- Mindell et al.11).
nizes biologic rhythms, including sleep, cyclically with
the 24-h day and is adjusted through the influence of but separate system referred to as the homeostatic
exogenous factors. Sleep/wake homeostasis describes system. This is the biological drive to maintain
the body's internal neurophysiologic drive toward equilibrium between sleep and waking. This model
either sleep or waking. Homeostasis is governed by assumes that sleep debt increases with cumulative
the principles of equilibrium; the body is driven toward waking hours, leading to an accumulation of sleep-
a balance between sleep and wakefulness (i.e., there promoting substances called somnogens in the central
is a neurophysiologic drive to sleep after long periods nervous system (CNS). Increasing somnogen levels
of wakefulness and drive to wake after long periods during waking hours drive the body toward sleep,
of sleep).7 followed by the dissipation of somnogens during sleep,
resulting in decreasing drive to
Circadian System sleep. Thus sleep is regulated
Sleep is regulated by two through a biological drive to
The circadian system consists maintain equilibrium or
of cyclic changes in the body— overlapping but distinct homeostasis.5,7
endogenously generated biolog- systems-the circadian system Adenosine is widely accepted
ical rhythms with a periodicity and sleep/wake homeostasis. to be one such somnogen.
of 24 h. Such biological Adenosine is a byproduct of
rhythms include the sleep and biological activity in the brain
wake cycle, alertness, body temperature cycle, daily (from dephosphorylation of ATP) and thus accumu-
cycles of hormonal secretion (e.g., melatonin and lates with activity, increasing sleep propensity, and
cortisol), and blood pressure regulation.5,8,9 The circa- then dissipates with rest and sleep. Adenosine pro-
dian process is driven by the circadian clock that is motes sleep by inhibiting arousal; it activates the
located in the suprachiasmatic nucleus in the ventral hypothalamic ventrolateral preoptic nucleus (VLPO)
hypothalamus. This clock is synchronized by daily neurons that inhibit arousal-promoting centers. In vitro
exogenous environmental cues known as zeitgebers. studies show that adenosine binds to presynaptic sites,
The most powerful zeitgeber is light that activates exciting the VLPO neurons and blocking inhibitory
photoreceptors in the retina inhibiting pineal gland neurons. In vivo studies support this finding; in animal
secretion of the sleep-promoting hormone, melatonin. models, adenosine injected directly into the brain's
Other exogenous cues that help synchronize biological sleep centers results in increased sleep.10
rhythms with the 24-h day are daily routines such as
hearing an alarm clock and eating meals.6,9
Ultradian Rhythms
Sleep and Waking Homeostasis
Thus, sleep and waking are regulated by a circadian
There are many endogenous and exogenous cues that process and by a homeostatic process.8 However, the
help regulate and modify the circadian rhythm, but sleep state itself has a cyclic or rhythmic organization.
level of sleepiness and recent sleep do not directly Sleep alternates between rapid eye movement sleep
influence the circadian system. Rather cumulative (REM) and non-rapid eye movement sleep (NREM), in
sleep influences sleep physiology through a concurrent sleep cycles or ultradian rhythms (Fig. 1).6,11

30 Curr Probl PediatrAdolesc Health Care, February 2017

TABLE 1. Neurophysiologic activity during wakefulness and sleep1,2.
Anatomic location of nucleus Neurotransmitter Wakefulness NREM REM
LDT/PPT (thalmic branch) Acetylcholine þ 0 þ
LC/DR/TMN (hypothalamic branch) Monoamines þ þ 0
VLPO/MNPO GABA/galanin 0 þ þ
Lateral hypothalamic area that secretes Orexin/hyporetin Orexin/hyporetin þ 0 0
Lateral hypothalamic area that secretes MCH MCH 0 0 þ
LDT/PPT (laterodorsal and pedunculopontine tegmental nuclei), LC/DR/TMN (locus coeruleus, dorsal raphe nucleus, and tuberomammillary
nucleus), VLPO/MNPO (ventrolateral and median preoptic nuclei) GABA (γ-aminobutyric acid), and MCH (melanin-concentrating hormone).
1
España, Rodrigo A, and Scammell, Thomas E. Sleep neurobiology from a clinical perspective. Sleep, 2011;34(7):845.
2
Saper CB, Scammell TE, Lu J. Hypothalamic regulation of sleep and circadian rhythms. Nature. 2005;437(7063):1257–1263.

REM and NREM sleep have defining EEG patterns, NREM sleep occurs mostly during the first 3 h after
and both neurological and physiological features, sleep onset. Adults enter sleep through NREM sleep
though the function of each is not fully understood. starting with stage 1, progressing to 2 and then 3, and
NREM sleep is believed to function primarily as a only then progressing to REM sleep. Each sleep cycle
restful and restorative sleep phase, and a period of is composed of the time it takes to move through the
relatively low brain activity. NREM sleep consists of three stages of NREM sleep and REM sleep. These
three stages: stage 1 (transition from wakefulness to cycles occur in approximately every 90–110 min with
sleep), stage 2 (initiation of true sleep), and stage 3 decreasing non-REM and increasing REM duration
(deep sleep; previously divided into stages 3 and 4). over the course of a night with brief periods of
During the transition from waking.6
wakefulness to sleep, stage REM sleep is thought to have
1 NREM, there is intense sleep- REM and NREM sleep has a role in consolidating and
iness, and sometimes hypno- defining EEG patterns, and both integrating memories and in
gogic hallucinations and/or neurological and physiological the development of the central
brief involuntary muscle con- features, though the function of nervous system (CNS)—both
tractions. In addition, the EEG maintaining and establishing
pattern transitions from alpha
each is not fully understood. new connections particularly
waves associated with wakeful- during times of development.
ness, to shorter frequency theta waves associated with REM sleep is characterized by a burst of rapid eye
sleep. Then there is initiation of true sleep, stage movements; there is a high brain metabolic rate, a
2 NREM sleep, with a decreased awareness of outside variable heart rate, an active suppression of peripheral
stimulus and decreased muscle activity. There are muscle tone, and a lack of normal thermoregulation.
characteristic EEG findings of sleep spindles and K- REM sleep is most likely to occur at the body temper-
complexes. Sleep spindles, also referred to as sigma ature trough of the circadian rhythm. During REM sleep,
waves, are small bursts of higher frequency activity. K- there is desynchronized cortical activity with low-voltage
complexes are brief bursts of high negative voltage, and high-frequency EEG. REM sleep is when dreaming,
followed by larger positive voltage peak, and then a including nightmares, occur.1
larger and slower negative voltage peak. K-complexes
are the largest voltage events on a typical EEG. It is
thought that the K-complex represents a form of sup-
pression of cortical arousal in response to stimuli and
Neurophysiology of Sleep
may be related to sleep-based memory consolidation. Arousal and sleep (both NREM and REM) are
Average adults spend about 50% of the night in stage dynamic physiologic processes regulated through a
2 NREM sleep. In deep, slow wave sleep, stage 3 NREM complex, and only partially understood, network of
sleep, an individual is least responsive to external stimuli. activation and suppression of neurologic pathways
It is characterized by delta waves on EEG, which are from the brainstem through the cerebral cortex
high-amplitude and low-frequency waves. Most para- (Table 1).7 A basic understanding of the neuroanatomy
somnias, such as night terrors, sleep walking, and and neurophysiology is important for understanding
nocturnal enuresis, occur during deep sleep.1 the development of sleep.

Curr Probl PediatrAdolesc Health Care, February 2017 31

Ascending Arousal System
Arousal or wakefulness is mediated by a system of
neurons ascending from the brainstem and hypothal-
amus to the cerebral cortex (Fig. 2). There are two
anatomic branches of the ascending arousal system: the
first branch travels through the thalamus and the
second through the hypothalamus and basal forebrain.
The thalamic branch is primarily composed of chol-
inergic neurons originating in the pedunculopontine
(PPT) and laterodorsal tegmental nuclei (LDT), pro-
viding input to the thalamic-relay nuclei and the
reticular nuclei of the thalamus, resulting in thalamo-
cortical activation. The hypothalamic/basal forebrain
branch originates in the brainstem and posterior
hypothalamus in the locus coeruleus (LC), dorsal raphe
nucleus (DR), and tuberomammillary nucleus (TMN)
and results in cortical and subcortical activation. These
nuclei are composed primarily of monoaminergic
neurons (neurons that secrete neurotransmitters with
amine groups), such as norepinephrine from the LC,
serotonin from the DR, and histamine from the TMN.
Also important to the ascending arousal system is
orexin/hypocretin, an excitatory neuropeptide, synthe-
sized by neurons in the lateral hypothalamus, which
augment the excitation of the nuclei in ascending arousal
system, particularly in the LC and TMN.6,7,12,13
FIG. 2. Neurochemical systems that promote arousal. Cortical
and subcortical regions are excited by monoaminergic neuro-
transmitters including norepinephrine (NE) from the locus
coeruleus (LC), serotonin (5-HT) from the dorsal and median
raphe nuclei, histamine (HA) from the tuberomammillary
nucleus (TMN); and dopamine (DA) from the substantia nigra,
ventral tegmental area, and ventral periaqueductal gray (SN/
VTA/vPAG). Neurons of the basal forebrain (BF) promote cor-
tical activation using acetylcholine (ACh) and γ-aminobutyric
acid (GABA). Neurons in the laterodorsal and pedunculopon-
tine tegmental nuclei (LDT/PPT) release ACh to excite neurons
in the thalamus, hypothalamus, and brainstem. (Reproduced
by permission from España and Scammell.7).
32
Wakefulness requires coordinated activity across
the many neural pathways and neurotransmitters.
Anatomic lesion studies of humans and animals, as
well as studies of pharmacological and genetic
perturbations, demonstrate that the different types of
neurons (neurotransmitter-type and by anatomic loca-
tion) promote subtly different aspects of arousal. For
example, histamine levels are highest during the onset
of arousal. Norepinephrine is particularly high during
periods of stress or when presented with novel
stimuli. Orexin/hypocretin sustains wakefulness and
interestingly is found to be deficient in individuals
with narcolepsy.7,12
Sleep-Promoting System and the Transition
Between Sleep and Waking States
Sleep requires activation of sleep-promoting path-
ways and deactivation of the arousal pathways. The
best understood loci in the sleep-promoting system are
the neurons of ventrolateral preoptic area (VLPO) and
median preoptic area (MNPO). The VLPO/MNPO
innervate the nuclei of the ascending arousal system
(LDT/PPT, LC, DR, TMN, and the orexin/hypocretin
neurons) and secrete inhibitory neurotransmitters/
neuropeptides (GABA and galanin), thus inhibit-
ing arousal.7,12
Interestingly, the neurons of the VLPO are inhibited
by monoamines. Thus, during sleep, the firing of the
VLPO neurons blocks cortical activation by inhibiting
the neurons of the ascending arousal system. Inhibition
of the arousal system leads to a decrease in the local
monoamine levels, leading to VLPO disinhibition, thus
further reinforcing the VLPO activity and therefore
further suppression of the arousal system. Conversely,
during wakefulness, activation of the monoaminergic
neurons leads to arousal through activation of the
ascending arousal system, but also reinforces arousal
by inhibiting the VLPO with increased monoamine
levels.
Sleep and waking states are discrete behavior states
and require a regulatory system that ensures that sleep–
wake transitions happen relatively rapidly, and that
there is very little time spent in a transitional state
between sleeping and waking. This is achieved phys-
iologically through these mutually inhibitory feedback
loops between the sleep-promoting pathways and the
arousal pathways, creating what is referred to as a “flip-
flop” switch.12
Curr Probl PediatrAdolesc Health Care, February 2017
Neurophysiology in REM, NREM Sleep, and typical 1-year-old sleeps 10–12 h at night without
Waking waking, followed by two daily naps.1
These excitatory and inhibitory neurons that regulate Over the first few months, the ability to retain
sleep and wakefulness also regulate sleep phase (REM/ calories increases and caloric need and growth relative
NREM states).7,12 VPLO/MNPO neurons promote to size decreases. This allows infants to consume
sleep through inhibition of the thalamic and hypo- adequate calories during the day and require progres-
thalamic pathways of the arousal system during both sively fewer nighttime meals to sustain growth. Simul-
NREM and REM sleep. The monoaminergic neurons taneously, the biological rhythms that contribute to
are most active while awake, but also have low level sleep regulation also mature, with decreased sleep
activity during NREM sleep and no activity during fragmentation and increased sleep consolidation, mak-
7,12
REM sleep. Though much of the arousal pathway is ing infants capable of sleeping through the night. By 6
inactive during REM sleep, there are a subpopulation months, babies should have consolidated sleep, with a
of cholinergic neurons in the thalamic arousal system long stretch of sleep at night, usually including 0–2
that are active during REM sleep and inhibited by feeds overnight.6
aminergic neurons during wakefulness and NREM During nighttime sleep, there are a number of physio-
sleep. The atonia characteristic of REM sleep is driven logic arousals that occur in between sleep cycles. These
by both the cholinergic and arousals can be disruptive to sleep if
monoaminergic neurons of an infant does not move directly into
the arousal system. The chol- The coordination of these bio- the next sleep cycle, by falling back
inergic neurons cause activa- logical rhythms and their syn- asleep. Infants who have learned to
tion of the neurons in the chronization with the times of self-soothe and self-initiate sleep are
medial medulla which inhibits more likely to fall back asleep more
6,7
motor neurons. The mono-
day develops rapidly over the rapidly after these arousals, without
aminergic excitatory signals, first 6 months of life, highlight- signaling parents, thus allowing
which contribute to muscle ing the importance of effective them to further consolidate sleep.
15

tone while awake, are fully behavioral routines that rein- Acquisition of new skills and
inhibited during REM sleep force this development early in abilities can affect infant sleep.
resulting in a decrease in Over the first year of life, infants
muscle tone. In the lateral infancy. develop an understanding of
hypothalamus, there are neu- object permanence and experience
rons that secrete orexin/hypo- separation anxiety. Separation
cretin that target arousal nuclei and are most active anxiety generally peaks between 6 and 18 months,
during wakefulness and not active during sleep sometimes leading to increased sleep disruptions—
(NREM or REM). In this same cluster of neurons in both difficulty separating at bedtime and difficulty self-
the lateral hypothalamus, there are REM sleep active soothing during brief nighttime arousals. Additionally,
neurons that secrete the inhibitory melanin- acquisition of new gross motor skills can negatively
concentrating hormone (MCH) neuropeptide. This influence sleep, particularly sitting up, pulling to stand
complex network of activation and suppression of and walking, as infants will often experiment with new
neural pathways leading to wakefulness or NREM skills during brief nighttime arousals leading to longer
sleep or REM sleep, is only partially understood and more sustained arousals.15
7,14
requires further study.
Development of Biological Rhythms
Biological rhythms integral to the sleep–wake cycle
Development of Sleep Patterns in include changes in body temperature and changes in
Infants and Young Children hormone levels such as melatonin and cortisol. Infants
are born with low levels of maternally transferred
Over the first year of life, infant sleep patterns melatonin, which dissipates by 1 week, and endoge-
change. Newborns usually sleep most of the day and nous melatonin does not rise to detectable levels until
night, waking only for feeding every 1–3 h, whereas a approximately 6 weeks. Melatonin levels are still very

Curr Probl PediatrAdolesc Health Care, February 2017 33

low at 12–16 weeks, but by 6 months they are a stable
part of the sleep–wake cycle. Thus, exposure to
morning light, which will decrease daytime melatonin
production, is important even at an early age. Temper-
ature rhythms mature faster and are significant by
1 week. Early morning waking coordinates with
increased body temperature by about 6 weeks, at
approximately the time when melatonin levels first
become detectable. A few weeks later, evening sleep,
sunset, and decrease in body temperature become
coordinated. Cortisol secretion is related to the sleep–
wake cycle; its secretion peaks early in the morning
and is lowest around midnight to 4 AM. Cortisol
increases blood sugar and metabolism and so is higher
during the day when there is a greater demand for
energy. The coordination of these biological rhythms
and their synchronization with the times of day
develops rapidly over the first 6 months of life,
highlighting the importance of effective behavioral
routines that reinforce this
development early in infancy.16
Circadian sleep–wake rhythm Thus, sleep patterns, including
and ultradian REM-NREM circadian and ultradian
rhythm both change as the rhythms, change dramatically change dramatically over the first
biologic clock matures and
becomes better coordinated
over the first 5 years of life.
with light and dark cycles,
ambient temperature, noise, hunger, core temperature,
and hormone production.17
Development of Ultradian Rhythms
Infancy is a time of rapid brain development and
significant change in the internal organization of sleep.
Newborn sleep is not described as REM or NREM
sleep but rather as “active,” “indeterminate,” or “non-
active.” Active sleep is similar to REM sleep, and non-
active sleep is similar to deep or NREM sleep. Active
sleep consists of continuous medium activity EEG
patterns that are similar to those seen during wakeful-
ness. Newborns enter the sleep cycle through active
sleep (REM-like sleep) for the first 3–6 months and
then transition to deeper quiet sleep. However, in active
sleep, newborns do not have inhibition of muscle move-
ment the way adults do during REM sleep, and thus
newborns frequently look restless early in sleep. Non-
active sleep has a characteristic trace-alternant pattern on sleep has negative impacts on neurobehavioral
EEG-bursts of slow waves, intermixed with sharp waves,
and periods of relative quiescence with very low-
amplitude activity—which usually disappears by 3–4
34
weeks of age. This classic early infancy non-active sleep
pattern is replaced by continuous high-amplitude slow
waves more consistent with NREM sleep. At about 4–8
weeks of age sleep spindles can be seen, and by 6 months
high-amplitude slow wave spikes or K-complexes can
been.1,18
Ultradian sleep cycles are also shorter in children and
get progressively longer into adulthood; infant active/
non-active sleep phases cycle about every 45–60 min
extending to about 90–110 min for adult NREM/REM
sleep phases. Active/REM sleep is 50% of sleep at
birth, 40% at 3–5 months of age, and close to the adult
level of 25–30% by about 1 year of age.1 REM sleep is
thought to be important in brain development and
growing and strengthening new neural connections.
Thus, it has been suggested that infants have propor-
tionally more REM sleep that stimulates structural
development, neural differentiation, and the develop-
ment of neural pathways during the neonatal period
where there is a relative lack of
external stimulation.19
Thus, sleep patterns, including
circadian and ultradian rhythms,
5 years of life. Sleep becomes
consolidated—with a long block
of nighttime sleep and with a
diminishing number of naps. Sleep also becomes
coordinated with other biologic rhythms. Sleep cycles
change: becoming longer with less REM and more
NREM sleep. There are physiologic changes that are
universal, but there are also many changes and differ-
ences in sleep patterns that are influenced by environ-
mental, cultural, and behavioral differences among
children and their families.1,6,18
Sleep Duration and Patterns:
Normative Data, Recommendations,
and Influential Factors
In the first 5 years of life, many parents and children
struggle with sleep and sleep-related behaviors.
Adequate sleep duration is a topic that is frequently
discussed among parents and pediatricians, and pedia-
tric sleep research has clearly shown that insufficient
and cognitive functions, health and well-being.1,20–22
Due to methodological difficulties, experimental evi-
dence detailing best and most appropriate sleep
Curr Probl PediatrAdolesc Health Care, February 2017
TABLE 2. American Academy of Pediatrics and National Sleep Foundation/American Academy of Sleep Medicine: recommended age-related ranges for
sleep duration.
Age group AAP/bright futures (2008)1 National Sleep Foundation/American
average sleep per day (range) Academy of Sleep Medicine (2015)2,3,4
recommended sleep per day (range)
0–3 mo 14 h (12–16) 14–17 h (11–19)
3–6 m 13 h (12–15) 12–15 h (10–18)
6–9 mo 13 h (10–14) 12–15 h (10–18)
9–12 mo 13 h (10–14) 12–15 h (10–18)
1–2 y 12–13 h (12–14) 11–14 h (10–16)
3–5 y 12–13 h (12–14) 10–13 h (8–14)
1
Hagan JF, JS Shaw, PM Duncan. Bright futures: Guidelines for health supervision of infants, children, and adolescents. Elk Grove Village, IL:
American Academy of Pediatrics; 2008.
2
Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation's sleep time duration recommendations: methodology and results
summary. Sleep Health, 2015;1(1):40–43.
3
Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation's updated sleep duration recommendations: final report. Sleep Health.
2015;1(4):233–243.
4
Paruthi S, Brooks LJ, D'Ambrosio C, et al. Recommended amount of sleep for pediatric populations: a consensus statement of the American
Academy of Sleep Medicine. J Clin Sleep Med, 2016;12(6):785–786.

durations in children is lacking, and adequate sleep is
best defined more vaguely as the number of hours of
sleep that an individual child or baby requires to be
well rested and optimally functional.23 This varies
from child to child and among cultural and ethnic
groups. It is not well understood why some individ-
uals tolerate less sleep or require more sleep.24 Thus,
there is a wide-range of “normal” sleep durations and
patterns, and sleep duration recommendations (sim-
ilar to body BMI standards) are based on population
averages.6
FIG. 3. Percentile curves: total daily sleep time by age group.
Filled circles represent group means, blank circles repre-
sent 25th and 75th percentiles, and triangles represent
5th and 95th percentiles. (Reproduced with permission from
Sadeh et al.33).
Sleep Duration Recommendations: How Much
Sleep do Young Children Need?
Bright Futures, a national health promotion and
prevention initiative led by the American Academy
of Pediatrics (AAP), provides the most widely
accepted recommendations for preventive pediatric
health care, including information about typical sleep
patterns and daily sleep duration.25 The data presented
in Table 2 references a manual produced in 1999 by the
Nursing Child Assessment Satellite Training (NCAST)
organization to train health care providers to better
counsel families regarding sleep–wake behavior and
self-regulation. The NCAST sleep manual uses data
from NCAST unpublished data (1985) and data from a
longitudinal study by Jacklin et al.26 Although the
source material for these recommendations does not
reference the most current studies, it does provide daily
sleep durations similar to the most recent sleep
duration recommendations made in consensus state-
ments by the National Sleep Foundation (2015) and the
American Academy of Sleep Medicine (2016) and
based on a synthesis of expert opinion and a systemic
review of the literature.25,27–30
There are limited recent large studies that report on
child sleep patterns and duration. One large study of
child sleep habits, using a nationally representative
sample, was published in 2004 by the National Sleep
Foundation. This cross-sectional study collected child
sleep durations from a stratified random sample of
1473 parents through short-structured telephone inter-
views. This study reported total average daily sleep
times of 12.8 h for infants (0–11 months), 11.7 h for

Curr Probl PediatrAdolesc Health Care, February 2017 35

toddlers (12–35 months), and 10.4 h for preschool-age
31
children (3–5 years old). All of these average
durations are at the lower end of the sleep duration
ranges recommended by Bright Futures, and the 2015
consensus statement made by sleep experts from the
National Sleep Foundation and the American Academy
of Sleep Medicine (Table 2).25,27–29,31
Some studies present their pediatric sleep duration
data using percentile curves, similar to the BMI curves
that are widely used in clinical practice. Normative
percentile curves have the potential to be easy to use
and instructive in the clinical setting. The percentile
curves published by Iglowstein et al.,32 Sadeh et al.,33
and Williams et al.34 all provide excellent graphical
representation of normative sleep duration and the
reduction in mean sleep duration and narrowing of the
range of sleep duration with advancing age (Fig 3).
Iglowstein et al. (2003) were the first to publish sleep
duration study data in the form of percentile curves that
could be used as a clinical
tool to evaluate sleep disor-
ders in pediatric practice. The cultural milieu is important times and shorter nighttime and
Data for these curves were to understanding and evaluat- total sleep duration among young
collected from parent inter- ing child sleep duration and
views, using structured
questions, in a longitudinal patterns.
study of Swiss children
(n ¼ 493) from the 1970s through 1990s. The daily
sleep duration data presented in these curves fall at the
higher end of most recent recommendations and used a
relatively small samples size, and thus may not be the
most clinically instructive in all popula-
tions.25,27,29,30,32 Sadeh et al. (2009) created a new
daily sleep duration percentile curve for children 0–36
months old using data from a large, cross-sectional, US
and Canadian Internet study (n ¼ 5006). The authors
report that the study population was skewed toward
more Caucasian participants and more participants
with higher levels of education than the general
population, potentially limiting its applicability to
some patient populations. However, the median data
reported in these percentile curves correlate well with
6,27,29,30
the most current recommendations (Fig 3).
Most recently, Williams et al. (2013) published a daily
sleep duration percentile curve for children from birth
to 20 years old. Data were collected from prospective
sleep diaries completed by parents of 1506 children,
over three time points (1997, 2002, and 2007), as part
of the nationally representative longitudinal Child
Development Supplement of the Panel Study of
36
Income Dynamics.23 The median sleep duration data
presented in the Williams study also correlate well with
the current recommendations, and spans the pediatric
age range, making these percentile curves instructive
for clinical use.23,25,27,28,32,33
Influence of Cultural, Social, and
Environmental Factors
The cultural milieu is important to understanding and
evaluating child sleep duration and patterns.35 There
are a number of studies that compare sleep duration
and patterns in young children in different countries
and cultures. A large Internet-based study (n ¼ 29,278)
compared infants and toddlers from predominantly
Asian countries (China, Hong Kong, India, Indonesia,
Korea, Japan, Malaysia, Philippines, Singapore, Tai-
wan, Thailand, and Vietnam) to predominantly Cau-
casian countries (Australia, Canada, New Zealand,
United Kingdom, and the United
States). This study found later bed-
children in predominately Asian
countries.24 Similarly, a study com-
paring Chinese elementary school
age children to children in the
United States found that Chinese children went to
bed late and woke up earlier, resulting in about 1 hour
less sleep daily.36 Another study compared 0–6 years
old children from Italy to those in the United States and
found that Italian children went to bed later and slept
fewer hours.37
In addition to these international comparisons, there
are also a few studies of young children and infants
within the United States that demonstrate cultural and
racial/ethnic variations in sleep duration in young
children. Shorter nighttime and longer daytime sleep
durations were observed in 2–8 years old Black
children in Southern Mississippi compared to White
children.38 Similarly, a contemporaneous study
showed that 2–7 years old African American children
in Jefferson, Kentucky, had later bedtimes, similar
wake times, and shorter sleep durations when com-
pared to Caucasian children.39 Another study showed
shorter nighttime, but longer daytime, and equivalent
daily sleep durations, when comparing 2–5 years old
White children in the Chicago area to Hispanic and
Black children.40 A more recent study found that
Black, Hispanic, and Asian 2-year-old children in
Curr Probl PediatrAdolesc Health Care, February 2017
eastern Massachusetts were more likely to have shorter
41
daily sleep duration than White children. Differences
have also been demonstrated in urban compared to less
urban neighborhoods. For example, 1-year-old infants
in Eastern Massachusetts who lived in more urban
areas were found to have shorter daily sleep duration
42
than those who lived in less urban areas. These
differences in early childhood sleep duration and
patterns among children from different geographic
locations and cultures have been noticed throughout
35
childhood.
Parent–child relationships and parenting factors,
specifically parental affect (depression and anxiety)
influences infant and child sleep. Depression, in
particular, has been linked to poor maternal and infant
sleep. A large longitudinal study in England showed
that mothers with prenatal depression were more likely
to have infants with sleep problems at 18 months and
43
30 months. In a study in
Southern California, maternal
depression and anxiety were Media exposure may lead to growing concern that media neg-
associated with infant sleep sleep difficulties through nega- atively impacts child sleep.
problems at infant age 6 and
12 months.44 Similarly, in a
tive impacts on sleep schedules to why media may disrupt sleep.
study of low-income, primarily and routines.
Spanish-speaking Mexican-
American mothers in Arizona, those with more depres-
sive symptoms when their infants were 5 months of
age were found to have infants with more nighttime
45
awakenings at age 9 months. In a study done in
Brazil, mothers with chronic and more severe depres-
sion had infants with worse sleep problems at 12
months of age.46 Additionally, young children with
more sleep disruptions had mothers with more sleep
disruptions, negative maternal mood, and more parent-
ing stress.47 Similarly, a sleep intervention in Australia and quality, and may lead to sleep difficulties.
that improved infant sleep also improved maternal
depressive symptoms.48 Infant temperament has also
been found to influence sleep duration and quality.1
The relationship between sleep duration/quality and
maternal affect is likely to be particularly important
when considering interventions to promote sleep.6
Interestingly, it has been shown that child sleep
duration has been declining over time, particularly
since the start of the 20th century.49 In a systematic
review, Matricciani et al. found that over the past
century daily sleep duration has decreased by 41 h. It
has been theorized that the major cultural-historical
changes over the past century, such as all night stores,
televisions and computers, have affected sleep
Curr Probl PediatrAdolesc Health Care, February 2017
patterns.49 With the proliferation of computers, video
games, television sets, and particularly hand-held
personal electronic devices, there is increasing evi-
dence and increasing concern that media use is
interfering with sleep both neurophysiologically and
by replacing sleep time.50,51
Influence of Media
Young children have been exposed to significantly
more media over the past few decades. Studies show
that 66% of children under the age of 2 years watch
television, videos, or DVDs, averaging 56 min daily.52
The popularity of mobile devices such as tablets and
smartphones in recent years has compounded this
problem.52 One study looking at children aged
6 months to 4 years found that almost all (96.6%)
had used a mobile device and most had started before
the age of one.53 As media has
become ubiquitous, there is
There are several hypotheses as
First, light exposure before sleep
may alter the sleep/wake cycle
through changing melatonin levels.54,55 Second, inap-
propriate content such as violence may negatively
impact behaviors.56,57 Third, increased media use can
result in reduced sleep duration through displacement
of sleep time.56–61 Lastly, it may be that parents who
allow longer duration or poorer quality media may also
not be less likely to enforce rules regarding bedtime
routines and sleep hygiene.56 Each of these hypotheses
suggest that media negatively impacts sleep duration
Decreasing sleep duration in children is a source of
concern voiced by sleep specialists, pediatricians, and
even by mass media. Decreased sleep duration can lead
to poor behavior, learning, and health outcomes. It has
been suggested that TV and other electronic media
devices may be to blame, at least in part, for decreasing
sleep durations over the 20th/21st centuries.62 Vijak-
khana et al. studied 6- and 12-month-old media
exposure in the evening (after 7 PM) and nighttime
sleep duration in 12-month-old children. This study
found that infants exposed to evening screen media at
6- and 12-months of age had decreased 12-month
nighttime sleep duration.59 Cespedes et al. showed a
correlation between increased television viewing and
37
decreased sleep duration among study participants in
Massachusetts at 6 months, 3 years, and 7 years of
age.63 In a longitudinal study of Australian children,
starting at ages 4–5 years and followed at ages 6–7
years and 8–9 years, Magee et al. showed that shorter
daily sleep duration at earlier ages predicted increased
media use at a later age. In addition, this study
demonstrated that longer daily media viewing pre-
dicted decreased sleep duration.64 Shorter sleep dura-
tions were found to be related to increased television
viewing among primary school children by both
Owens et al.58 (Kindergarten—4th grade) and Van
den Bulck et al.65 (4–10 years old). Paavonen et al. also
found shorter sleep durations among 5–6 years old
children with increasing quantity of both active and
passive media viewing.56
In addition to its effects on reducing sleep duration, it
has also been shown that media exposure may lead to
sleep difficulties through negative impacts on sleep
schedules and routines. Thompson et al. studied 4–35-
month-old children and found that more hours of
television viewing per day were associated with an
irregular naptime schedule and an irregular bedtime
schedule.51 Garrison et al. studied 3–5-year-old chil-
dren and found that overall increased daily media
consumption was associated with more sleep prob-
lems. Specifically, evening media viewing and daytime
viewing of violent programs were both correlated with
increased sleep problem scores.57 In slightly older
elementary school-aged children, Owens et al.58 found
TV viewing associated with sleep quality; specifically,
bedtime resistance, sleep-onset delay, and anxiety
around sleep. Paavonen et al.56 found higher rates of
Sleep–Wake Transition Disorder (difficulty falling
asleep) among 5–6-year-old children who actively or
passively watched more adult television programs
(with the exception of sporting events). Additionally,
in a study of 1–6 years old Chilean children, Brock-
mann et al. found that those who watched television in
the evening, rather than the daytime, were more likely
to report sleep disturbances. Media exposure has been
associated with sleeping difficulties such as
sleep-onset delay, frequent night awakenings, and
disturbed sleep.
Television in the bedroom, regardless of television
viewing duration, has been associated with more sleep
problems in preschoolers.57 Many children of all ages
now have televisions or other portable media devices
in their bedrooms. Greater than 20% of infants and
young children have a television sets in their
38
bedroom.66 One study of 2–13-year-old children
showed that 470% of Black and Hispanic children
compared to 22% of White children in the Boston area
had TVs in their bedroom.67 Brockmann et al. found
that 1–6-year-old Chilean children who had televisions
in their bedroom were more likely to have sleep
distrubances than those without televisons in their
room; specifically, more sleep terrors, more night-
mares, more sleep talking, and more likely to report
being tired when waking up in the morning.61
Thus, in clinical practice, clinicians making sleep
duration recommendations must consider the social,
cultural, and environmental context of the child,
particularly media exposure. The complexity of the
varied influences on children's sleep duration under-
scores the need for further study of the biology of
normal and disturbed sleep as a means to better
understand age-specific optimal sleep durations.6
Though precise optimal sleep duration remains
unknown, there is considerable normative data, and
we know that inadequate sleep is associated with many
negative outcomes for children and their families. As
such, the implementation of effective sleep hygiene
recommendations is critical to helping children and
families get more high-quality sleep.
Sleep Problems
Sleep problems are common and often behavioral in
origin, due to factors such as child temperament and
development, parenting style or affect, child–parent
interactions, and environmental factors. There are also
parasomnias, which are episodic, undesirable behaviors
that occur with sleep.11 Nightmares occur during REM
sleep, typically early in the morning, most commonly in
primary school-age children, though do occur in 1.9–
3.9% of preschool-age children.11 Management includes
avoidance of frightening television, games, books, or
movies that may be influencing dreams, providing
comfort, and most importantly, maintaining good sleep
hygiene with regular routines and adequate sleep.11,68
Partial arousal parasomnias, such as sleep walking,
confusional arousals, and night terrors, occur during
NREM sleep, early in the night, typically during the
transition out of the first and deepest period of NREM
sleep.69 During episodes, children misperceive and are
unresponsive to their environment and do not remember
episodes in the morning. Night terrors are most common in
children 4–12 years old, but can occur in infancy through
Curr Probl PediatrAdolesc Health Care, February 2017
adulthood. Events can last from a few minutes to an hour with activity transitions. They also moderate impulsiv-
with autonomic and behavioral characteristics of fear, ity and self-regulation.11 Routines are also believed to
11,69
agitation, and confusion. Confusional arousals are more benefit family well-being by decreasing caregiver–
common in infants and toddlers, and less common in older child conflict.71 Presence of regular bedtime routines
children. Episodes are characterized by confusion rather improves sleep, both sleep latency (time to fall asleep)
than fear and are accompanied by some movement ranging and frequency of night waking in infants and
from more subtle moaning and crying to thrashing. toddlers.72
Episodes typically last about 10 min but can range from Bedtime routines provide external clues that sleep is
1 to 40 min.69 Sleep walking typically starts in children coming, and assist children to prepare for sleep
4–6 years old and peaks in children 8–10 years old.11 mentally by being both predicable and calming. By
Partial arousal parasomnias are often associated with about 6 months of age, parents should begin using a
inadequate sleep (both chronic and acute), changes in sleep regular bedtime routine. Bedtime routines should be
patterns, or sleep disruptions. Inadequate sleep can lead to relatively brief (no more than 30–45 min) and involve
increased slow wave sleep, thus leading to an increased the same few relaxing activities prior to bed every day,
probability of NREM-associated such as warm bath, reading
parasomnias. Partial arousal para- stories, and singing lullabies.73
somnias are generally treated with Healthy sleep patterns can be Following the soothing pre-
reassurance and education, primar- established and sleep problems bedtime activities, children
ily focused on behavioral manage- can be prevented and managed should have a comfortable
ment of the episodes, with good sleep environment which is
sleep hygiene practices and main- through sleep-promoting calm, quiet, dark and warm,
taining routines.11,69 parenting practices, or good with no TV present.74 In addi-
When diagnosing parasomnias, “sleep hygiene.” tion to a regular sequence of
it is always important to consider events that precede sleep, reg-
and rule out nighttime seizures. ular bedtimes, nap times, and
Some characteristics of seizure episodes can be similar, corresponding wake times provide useful routines and
but there are a number of distinguishing features: help to synchronize sleep and wake cycles with the
nocturnal seizures have more variable timing of occur- circadian rhythm.1,11
rences, may happen multiple times in one night, are Children should be appropriately stimulated during
associated with low arousal, and may include findings waking times, specifically, they should be exposed to
like incontinence, tongue biting, drooling, and stereo- bright light in the morning and encouraged to have
typic repetitive behaviors.68,69 Behavioral sleep prob- regular vigorous exercise during the day. Children
lems and parasomnias are quite common, particularly should avoid stimulating activity and foods near sleep
early in childhood, and are often discussed during times. In particular, parents should avoid sugar and
pediatric visits. Healthy sleep habits and routines should caffeine prior to bedtime.75 Nap and nighttime sleep
be recommended to help prevent sleep problems schedules need to be timed appropriately so that nap
and to help manage sleep problems when they times are not too late in the afternoon, thus making
happen. children less sleepy at bedtime.18 Additionally, there
has been increasing attention to the negative impact of
Recommended Sleep Hygiene media on sleep. Children should avoid media viewing,
particularly with violent content, before bed.51,57
Healthy sleep patterns can be established and sleep One of the most important learned sleep behaviors in
problems can be prevented and managed through infancy is the ability to self-soothe and fall asleep
sleep-promoting parenting practices, or good “sleep independently. To promote self-soothing, it is recom-
hygiene.” Good quality sleep, particularly nighttime mended that infants learn how to fall asleep independ-
sleep, encourages full daytime alertness.51,70 ent of a caregiver, after a bedtime routine. This ability
Routines are critical to good sleep hygiene, specifi- to self-soothe allows infants to more rapidly return to
cally consistent sleep schedules and pre-sleep routines. sleep after the many physiologic arousals that occur
Routines benefit young children by providing them throughout the night, and thus have more consolidated
with a sense of predictability and security, and help and less fragmented nighttime sleep.15,62 Appropriate

Curr Probl PediatrAdolesc Health Care, February 2017 39

sleep-onset associations include a bedtime routine that
is consistent, age appropriate, and helps a young child
become sleepy, but leaves them to go from drowsy to
asleep on their own. For young infants, starting
between 2 and 4 months of age, this usually means
feeding or rocking and then laying them down in crib
drowsy but awake. For older infants (4 6 months old)
and toddlers, this usually entails a bedtime routine
followed by being put into crib or bed drowsy but
not yet asleep.11,76
Conclusion
There are many aspects of sleep that have significant
effects on child and family health and well-being.
Pediatricians report little formal training in sleep
medicine, yet patients frequently report infant and
child sleep problems. Basic physiology and develop-
ment of sleep patterns, normative sleep durations, and
the many influencing factors are important to under-
standing and diagnosing child sleep problems. Pedia-
tricians should discuss sleep hygiene and early
adoption of healthy sleep habits during routine antici-
patory guidance in an effort to shape long-term healthy
child sleep patterns and prevent sleep problems.
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