Accepted Manuscript

Review

What does Sleep Hygiene have to offer Children’s Sleep Problems?

Wendy A Hall, Elizabeth Nethery

PII: S1526-0542(18)30137-4
DOI: https://doi.org/10.1016/j.prrv.2018.10.005
Reference: YPRRV 1294

To appear in: Paediatric Respiratory Reviews

Received Date: 13 September 2018

Accepted Date: 31 October 2018

Please cite this article as: W.A. Hall, E. Nethery, What does Sleep Hygiene have to offer Children’s Sleep Problems?,
Paediatric Respiratory Reviews (2018), doi: https://doi.org/10.1016/j.prrv.2018.10.005

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 1

What does Sleep Hygiene have to offer Children’s Sleep Problems?

Hall, Wendy A.,PhD, RNa, & Nethery, Elizabeth, MSc, MSMb

a
School of Nursing, University of British Columbia, T. 206, 2211 Wesbrook Mall, Vancouver,

British Columbia, Canada, V6T 2B5, wendy.hall@ubc.ca (Corresponding author)

b
School of Population and Public Health, 2206 E Mall, Vancouver, British Columbia, Canada

V6T 1Z3, Elizabeth.nethery@gmail.com

Abstract

Sleep hygiene practices have been described extensively in the literature. There is considerably

less clarity about relationships between particular elements of sleep hygiene and particular sleep

outcomes, and which intervention approaches using sleep hygiene principles are effective. In this

review, we describe themes extracted from a systematic review of the sleep hygiene literature.

We systematically searched Psycinfo, CINAHL, Cochrane, Ovid Medline, Embase, and Web of

Science Search Engines up to August, 2017. We included all studies that associated sleep

hygiene (behaviors adjacent to bedtime and during the night) with sleep duration and/or sleep

onset latency and/or night waking or that used sleep-hygiene based interventions to improve

sleep duration and/or sleep onset latency and/or night waking (n=44). We organized our findings
 2

into themes by age group, sleep hygiene factors, and interventions. We provide evidence-based

recommendations about areas of sleep hygiene that have significant empirical support and those

that require urgent attention.

Keywords: pediatric; sleep; sleep hygiene; sleep quality; sleep duration

Educational aims

The reader will be able to appreciate that:

- Sleep hygiene practices have some similarities across age groups (infancy to

adolescence) and cultures

- Although there is a large body of literature on sleep hygiene the quality of studies is

generally low

- Many studies lack clarity about the components of sleep problems that serve as

dependent or outcome variables

- Reducing negative sleep associations across age groups has potential to improve

children’s sleep

Future Research Directions

Studies are needed that clearly specify particular sleep outcomes, e.g. sleep duration, sleep onset

latency, and night waking. The paucity of intervention studies aimed at improving sleep for

school-aged children and adolescents indicates a need for studies with these populations. Studies

developing consistent, reliable, and valid sleep measures that precisely identify indicators of

sleep quality and duration are needed. Rather than continuing to study relationships between
 3

electronic device use and sleep, attention to interventions aimed at reducing effects of electronic

device use on children’s sleep is necessary.

Funding: This research did not receive any specific grant from funding agencies in the public,

commercial, or not-for-profit sectors.

 4

1.0 Introduction

Behavioral sleep problems are prevalent, affecting about 30% of infants and children [1] .

Insomnia has been defined as repeated difficulty with sleep duration, quality, initiation, and

consolidation occurring despite age-appropriate time and opportunity for sleep resulting in

daytime functional impairment for children and/or families [2]. There is substantial evidence that

children’s insufficient sleep and poor sleep quality are associated with numerous problems, such

as reductions in cognitive and academic performance [3–6], behavioral difficulties [3,7],

difficulties with daily functioning [8,9], risky behaviors [10,11], and increased risk of obesity

[12–15]. Behavioral Insomnias of Childhood (BIC) are linked to dependence on specific

conditions for initiating sleep that the child cannot reproduce without assistance, including limit

setting from caregivers [16], and to environmental factors that interfere with sleep. Although

adolescents typically have delayed sleep-phase syndrome they are also affected by

environmental factors that can potentially exacerbate the problem [17].

The literature makes multiple references to sleep hygiene, which has been defined as behaviors

conducive to proper sleep, including appropriate sleep schedules, healthy sleep habits, an

environment that supports sleep, and physiological practices that aid sleep, e.g. relaxation

exercises [18]. Sleep hygiene is intended to manage the conditions (negative and positive sleep

associations) that influence children’s sleep, including interventions to promote sleep hygiene

[1,19].

Although recent reviews of empirical evidence supporting sleep hygiene have been undertaken

they are generally confined to particular age groups, e.g. children aged 1 -12 [20] or adolescents

aged 13 to 19 [21] and have examined only individual/family level variables affecting sleep
 5

hygiene [20,21] or parents’ knowledge about healthy sleep practices and changes in parental

knowledge following interventions for children between 1 month and 17 years of age [22].

The effects of behavioral sleep problems support the importance of identifying empirically-

supported elements of sleep hygiene and sleep hygiene education interventions. In this review we

pose the question: what elements of sleep hygiene and/or sleep hygiene education have been

linked to improved sleep duration and quality (night waking and sleep onset latency) for healthy

children between ages 6 months and 18 years? It is important to identify particular elements of

sleep hygiene that influence specific elements of sleep duration and quality so that effective

interventions to improve sleep duration and quality can be designed. We present results of a

systematic review on sleep hygiene/sleep and hygiene education, discuss the results in the

context of other relevant literature, and conclude with evidence-based recommendations for sleep

hygiene components to improve sleep duration, night waking, and sleep onset latency.

2.0 Materials and Methods

Six key electronic databases (Psycinfo, CINAHL, Cochrane, Ovid Medline, Embase, and Web of

Science) were searched between June and August, 2017. We used search terms targeted at sleep

OR sleep deprivation OR sleep hygiene OR insomnia OR nap AND child* OR infant OR baby

OR toddler OR preschooler OR adolesc* OR teen OR youth (for detailed information about the

search strategy see Appendix A for CINAHL search terms) to identify relevant published

articles.

Studies were included if they met particular criteria: 1) written in English, 2) published in peer-

reviewed journals, 3) used samples of healthy, typically-developing children between the ages of

6 months and 18 years, 4) included measures of sleep duration or quality (night waking or sleep

onset latency), and 5) published between 2010 and 2017. We excluded case studies, qualitative
 6

studies, and systematic reviews combining children’s ages and weekend and weekday sleep

patterns. We also excluded studies linking any day-time (e.g. exercise over the course of the day

or amount of daily screen time) or longer term factors (i.e. external environmental pollutants or

social/structural-level issues) to sleep duration and quality. In particular, our review included

articles that examined positive and negative sleep associations adjacent to bedtime or during the

night rather than activities occurring at any time over the course of the day.

Figure 1 provides an overview of the article review process. For the Cochrane database the only

two papers located had both been withdrawn. After the final search was run the articles were

ported into Refworks™, a reference management system. Across the other five databases 5261

articles were identified. After duplicates were removed 4267 unique records remained. The

records were reviewed and the authors removed conference abstracts, books or book sections,

opinions and editorials, lay journals (e.g., Parents and Good Housekeeping), dissertations, and

any duplicates that were missed in the de-duping process. After excluding those elements 742

records remained. The two authors reviewed the titles and abstracts independently against the

inclusion and exclusion criteria. We retained titles and abstracts indicating elements of sleep

hygiene that were related to sleep duration, sleep onset latency, or night waking. We did not

include daytime sleepiness as a component of sleep quality because it is not equally germane to

all developmental stages, e.g., infants and toddlers.

 7

Figure 1: Flow Diagram of Articles for Inclusion in the Review.

 8

If the two authors could not determine the appropriateness of the paper for the review, full article

screening was carried out. Our weighted Kappa was 0.42. In total, the authors reviewed 294

articles using full article screening with consensus reached on any disagreement through

discussion and a number excluded after closer examination based on criteria; after screening 94

papers were remaining.

2.1 Data Extraction Form

We used a data extraction form that included the reference ID, first author, year of publication,

study design, sample size, labels of contextual factors or behavioral sleep problem intervention

and subcategories for context or intervention types, children’s age group and mean age (when

reported), key sleep outcomes, country of origin, and form of sleep assessment (e.g. diary,

actigraphy, and questionnaires). Table 1 summarizes the articles included in the study.

2.2 Study Quality Assessment

The two authors independently assessed the methodological quality of the articles. We used the

Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health

Practice Project [23]. The quality items included were: selection bias, study design, confounders,

data collection methods, withdrawals and dropouts, and analysis appropriate to question. For

randomized controlled trials we also used intervention integrity. We did not use the blinding

quality item because most trials involved interventions that did not permit blinding. We resolved

any disagreement through discussion. We excluded 31 studies based on ‘weak’ quality scores

from the review. Following review of the remaining 63 articles in detail, we identified a number

that did not adequately specify sleep quality; after they were omitted 44 papers remained

(n=282,613 children).
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3.0 Results

Our search strategy yielded 44 articles that were considered relevant to the research question and

of moderate to strong quality (Table 1). Because the articles demonstrated considerable clinical

and statistical heterogeneity we did not attempt quantitative data extraction or meta-analysis. We

present the results of our review qualitatively. The papers are divided by developmental stage

(i.e., infants (6 months to 1 year) and toddlers (1 to 2.9 years); preschoolers (3 to 5.9 years);

school-aged children (6 to 12.9 years); and adolescents (13 to 18 years). A number of studies

incorporated samples that overlapped our age groupings. In those cases, we either referenced the

sub-analysis for the appropriate age group or included the studies, with no sub-analyses, in the

age-group section that fit with the largest proportion of the sample. The themes are divided by

exploratory studies examining sleep hygiene elements associated with sleep duration and/or

sleep quality (night waking and/or sleep onset latency) and intervention studies. Sleep outcomes

are only reported for weekday nights for older children.

3.1 Infants and Toddlers

3.1.1 Exploratory Studies

Five cross-sectional studies examined factors that enhance infant and toddler sleep duration and

reduce night waking, with a focus on parental behaviors [24–28]. The studies originated in the

United States and the Asia-Pacific region but three had recruited participants from many nations

[26–28]. Most of the studies were of moderate quality, used large sample sizes, and controlled

for some key variables, e.g. infant age and gender, and maternal education. A cross-sectional

study associated English toddlers’ short sleep duration (< 11 hours per night) with watching >

one hour of TV in the evening, after adjusting for age and regular night waking [29]. All studies

used the Brief Infant Sleep Questionnaire (BISQ) to determine sleep duration and quality. Two
 10

longitudinal studies were located [30,31]. Their sample sizes were moderate to large, predicted

sleep duration and night waking from 3 or 6 months of age to 12 to 18 months, and used locally-

designed measures. The most consistent findings across studies were the benefits of bedtime

routines and independently falling asleep (self-soothing) for significantly increased sleep

duration, decreased sleep onset latency, and reduced night waking [25–27,31]. Co-sleeping, and

feeding during the night [24,27,28,30], and breastfeeding predicted more night waking in some

studies [24,27,28]; but breastfeeding significantly reduced night-waking risk in one study, with

infant gender controlled [30].

3.1.2 Intervention Studies

We located 4 randomized controlled trials aimed at reducing infant /toddler night waking and/or

increasing infant/toddler sleep duration [32–35]. They originated in Australia, Canada, China,

and the United States. Two had small sample sizes, n=43 and n=82 [32,34]. Only one study used

intent-to-treat analysis [33]. Two studies used graduated extinction, camping out, or bedtime

fading [32,33] and one study used a mix of routines and customized sleep advice [35,36].

Another study compared cloth and disposable diapers, with groups stratified by sex [34]. Three

studies used actigraphy, in addition to sleep diaries, to determine sleep outcomes [32–34]. One

study used the BISQ [35,36]. Consistent findings were significant decreases in night waking

when comparing intervention and control groups [32–34]. Sleep duration was not significantly

improved in any studies. In one study significant improvements in sleep onset latency, night

wakes, and sleep duration were based only on within-group comparisons [35].

3.2 Preschoolers

3.2.1 Exploratory Studies

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At the preschool stage of development 6 cross-sectional studies included a mix of parenting and

child behaviors attributed to sleep hygiene and examined sleep hygiene, sleep duration, night

waking, and sleep onset latency [26,37–41]. Countries of origin for the work included the United

States, Italy, and Britain. Two studies had small sample sizes, n=62 and n=84 [39,41]. One study

incorporated participants from multiple countries and used child age and maternal education as

co-variates [26]. Measures in the studies varied from questionnaires (BISQ, Children’s Sleep

Habits Questionnaire [CHSQ]) with some evidence for reliability and validity [38,41], to

interview data [37,39] and investigator-developed questionnaires [40]. Bedtime routines were

associated with significantly shorter sleep onset latency, fewer night wakes and longer sleep

duration for children [26]; exposure to electronic devices was associated with significantly

shorter sleep duration for Italian children, after including age, BMI, TV in bedroom, and

drinking fluids before sleep [37]. American children’s exposure to electronic devices was

associated with longer sleep onset latency, after controlling for gender, household income, and

family structure [38]. Reading at bedtime significantly extended English and American

children’s sleep duration [39,41], with one study co-varying co-sleeping, napping, and maternal

education [41]. One study linked American children’s suboptimal sleep environments (too hot,

cold, bright, and loud) to significantly shorter sleep duration, after controlling for age, race,

gender, maternal education, and daily naps [40].

3.2.2 Intervention Studies

Three studies examined interventions for preschoolers [42–44]. Two American trials compared

sleep outcomes following educational interventions for preschoolers [43,44] and one Australian

study provided parents with gradual withdrawal of assistance for children’ settling [42]. The

Australian sample size was small, n=33 and used a pre and post-treatment design [42]. The two
 12

American studies randomized parents and children to sleep education to increase sleep duration

(three messages to promote sleep [no caffeine or bedroom electronics and bed before 9 pm]) [43]

and information for parents and children about sleep hygiene [44]. Outcome measures were sleep

diaries or parental report. Two studies reported a significant increase in sleep duration [42,44],

with only one study adjusting for child ethnicity and maternal education [40]. One study found

no differences between groups [43].

3.3 School-aged Children

3.3.1 Exploratory Studies

Seven cross-sectional studies were located that examined effects of school-aged children’s

behaviors on sleep duration [37,45–50]. Studies originated in Italy, Canada, China, Korea, and

Germany; all studies had large sample sizes. An 8th study examined effects of German

children’s home exposure to mould and dampness on sleep duration and night waking [51].

Measures were parental reports on children’s sleep time [37,46,47,50,51] or children’s report on

sleep duration via author-developed questionnaires [45,48,49].

Consistent findings across studies were effects of electronic device use before sleeping and

during the night on significantly decreased sleep duration [37,45,47,49,50]. The Italian study

adjusted for age, BMI, TV in bedroom, and drinking fluids before sleep [37]. The Canadian

study adjusted for gender, household income, parent education, and area of residence and

reported a dose-response for device exposure [50]. Other evening behaviors significantly

reducing sleep duration were children’s school commuting time [45,49] and homework time

[45–48]. Generally the Chinese studies adjusted for age, parent education [47,48], BMI, siblings,

and academic pressure [45,46]. One Chinese study adjusted for sleep arrangements, school grade
 13

and start time, household income, screen time, and physical activity [46] but only one Chinese

study adjusted for ethnicity and family structure when accounting for short sleep duration [47]. A

study of Korean children adjusted for age when examining nighttime sleep duration [49]. Two

studies of Chinese children controlled for gender [47,48]. Only one study analyzed boys and girls

separately and found no difference on contributors to reduced nighttime sleep [45]. German

children’s exposure to home mould and dampness increased risk of short sleep duration; effects

were adjusted for gender [51]. Caffeine intake was not consistently associated with sleep

outcomes.

3.3.2 Intervention Studies

Four studies focused on sleep education programs for school-aged children [43,52–54], two

studies evaluated interventions aimed at dyads (parents and children) to treat sleep problems

[55,56], and one examined differing exposures to milk-based drinks to promote sleep [57]. The

sleep education programs incorporated differing levels of stakeholder (student, parent, teacher,

school) involvement: a Canadian study included all stakeholders [53]; an Australian study

included students, parents, and teachers [52]; one American study targeted only parents who

received educational messages on three occasions [43]; and a second American study provided

children with a sleep education video [54]. In one study German children and parents each

received 3 components of sleep hygiene education, cognitive therapy, and stimulus control in a

clinic setting [56]. In the Australian study 3 private consultations, with information about sleep

requirements, behavioral strategies to improve sleep, and development of a management plan

were provided [55]. The Indonesian controlled double-blind parallel study provided children

with different morning and evening milk drinks (standard, satiety, and relax) over 6 weeks to

reduce night waking [57].

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Two studies had small sample sizes n= 38 [56], n=71 [53]. Five studies were randomized

controlled trials [43,52,53,55,56]; one was a pre-test, post-test design [54]. Sleep outcomes were

measured via actigraphy and diaries [52,53,57], the CSHQ [54–56], and questions from the

National Sleep Foundation Sleep in America poll [26]. One study had an intent-to-treat analysis

and controlled for gender, family structure, and socio-economic status [55]. Educational

interventions significantly improved sleep duration [52], or sleep duration and sleep onset

latency, using age as a co-variate [53], or night wakes [54]. Private consultations significantly

improved sleep duration at 12 months follow-up [55]. Three studies reported no between-group

differences [43,56,57].

3.4 Adolescents

3.4.1 Exploratory Studies

Seven cross-sectional studies examined relationships between adolescents’ pre-bedtime

behaviors and sleep duration or sleep latency [45,58–63]. Studies were undertaken in Australia,

China, Iran, Japan, New Zealand, Turkey, and the United States of America. Most studies had

moderate [60] to large sample sizes [45,58,59,61–63]. Sleep measures included the Pittsburgh

Sleep Quality Index (PSQI) [58,59], actigraphy [60], and student reports of sleep and wake time

[45,61–63]. Electronic technology exposure before bed or during the night significantly

increased the risk of short sleep duration for New Zealand adolescents after adjusting for age,

gender, ethnicity, BMI, and caffeine intake [59]. For Japanese adolescents electronic technology

exposure after lights out increased the risk for shorter sleep duration after co-varying sex, grade,

alcohol use, smoking, breakfast consumption, extracurricular activities, and mental health [61].

Exposure to electronic technology also predicted shorter sleep duration for Australian
 15

adolescents after controlling for chronotype [60] and for American adolescents, after entering

age and gender as covariates [62]. In particular American females with higher exposure to

electronic technology experienced significantly shorter sleep duration [62]. Chinese boys and

girls with more school commuting time and homework reported significantly shorter sleep

duration, after adjusting for age, BMI, parent education, sibling presence, and academic pressure

[45]. Turkish adolescents drinking caffeinated drinks and exposed to passive smoking reported

shorter sleep duration, after adjusting for age and gender [63]. Iranian adolescents, avoiding

exposure to cell phones after 9 pm, had lower risk for longer sleep onset latency, after adjusting

for gender, age, grade-point average, health status, and physical activity [58]. For Australian

adolescents evening family time significantly lengthened sleep duration [60]. For Chinese girls

after-school leisure physical activity significantly lengthened sleep duration [45].

3.4.2 Intervention Studies

Three intervention studies focused on adolescents’ school sleep education programs [64–66]. A

4th study examined the effects of blocking adolescents’ exposure to blue light from screens [67].

Studies were conducted in Hong Kong [66], India [64], Japan [65], and Switzerland [67].

Intervention studies had very small, n=13 [67], moderate [65], and large sample sizes [64,66],

with gender stratified in one study [64]. Educational interventions included: an educational

module, video training, and time management [64]; an educational module and practice of sleep

promoting behaviors [65]; and large and small group seminars about sleep, printed material, and

a website [66]. Two studies used intent-to-treat analyses [65,66], with one study using age and

gender as co-variates [66]. Swiss male adolescents participated in a counter-balanced cross-over

design with blue-blocker versus clear glasses during screen exposure [67]. The Indian

experimental group demonstrated significant improvement in sleep onset latency but not sleep
 16

duration [64] and a Japanese experimental group demonstrated significant improvement in sleep

onset latency and sleep duration [65]. In two studies (Chinese students and Swiss students)

interventions demonstrated no effect on sleep duration or sleep onset latency [66,67].

3.5 Major themes

The studies examining sleep hygiene variables and sleep outcomes (duration, night waking, and

sleep onset latency) varied significantly in quality. In many studies clearly stated sleep hygiene

elements were not provided and sleep problems were measured using subjective impressions of

sleep quality or a mix of sleep quality elements that were dichotomized into poor or good sleep

quality or presence or absence of insomnia [61]. In one study sleep elements were combined

from the Multidimensional Sub-health Questionnaire of Adolescents (MSQA) (difficulty falling

asleep, having difficulty staying asleep, and daytime tiredness) into a dichotomous sleep problem

versus no sleep problem measure [45]. Simplifying data by combining items indicating different

sleep problems obscures understanding of effects of elements of sleep hygiene on aspects of

sleep. Partial findings could only be used from some studies because total scores on measures

like the CSHQ were used rather than specifically examining sleep onset latency or night waking

[38]. Lack of clarity about relationships between sleep hygiene components and particular sleep

outcomes creates difficulties in identifying targets for sleep interventions and hypothesizing

about effects. We excluded many studies from our analysis because independent variables

included any exposure to screens or physical activity or caffeine at any time during the day as

opposed to positive and negative sleep associations adjacent to bedtime or during the night.

A challenge with undertaking this systematic review was the lack of consistency in sleep

outcomes and comparable measures. In four infant and toddler cross-sectional studies, the BISQ
 17

measure, permitted some comparison of sleep hygiene factors influencing sleep duration, sleep

onset latency, and night waking [25–29]. In two studies local measures or interview data were

used [30,31]. The intervention studies for infants and toddlers used actigraphy and sleep diaries

[32–34] or the BISQ [35]. In preschoolers’ cross-sectional studies the BISQ was used in one

study [26], sleep diary/actigraphy in one study [39], the CHSQ in two studies [38,41], and parent

interview/report in two studies [37,44]. Intervention studies used the BISQ [43] or sleep diaries

[42,44]. In school-age and adolescent groups there was virtually no consistency in how sleep was

measured. Cross-sectional studies used parent questions/interview [37,46,47], adapted questions

[50] student report [45,62,63], actigraphy [60]; the CHSQ [47], the PSQI [58,59], or locally

developed questionnaires [48,49,51]. In intervention studies actigraphy and sleep logs/diaries for

all children [53,57] or a subset of the sample [52], the PSQI [64], investigator-designed

questionnaires [65,66], polysomnography [67], and the CHSQ [56] were used. Across all

developmental phases only two studies examined bedroom environmental factors influencing

sleep, specifically bright, hot, noisy, or cold sleep environments [40], and exposure to mould and

dampness in the home [51].

4.0 Discussion

Our findings are similar to those reported in a number of systematic reviews. For young children

our findings clearly demonstrated an association between bedtime routines and increased sleep

duration, decreased sleep onset latency, and reduced night waking. Allen et al.’s [20] systematic

review of articles published between 1983 and 2014 examined common pediatric sleep

recommendations for children aged 1 to 12 years and identified 10 studies exploring associations

between bedtime routines and sleep outcomes, with 7 studies providing support for improving

sleep onset latency and night waking. They also linked reading at bedtime to improved sleep
 18

outcomes. Similarly to the one study we located about bedroom conditions and shorter sleep

duration [40], a number of studies were identified by Allen et al. [20] that linked light and noise

to poorer sleep outcomes. Our systematic review clearly associated independently falling asleep

(self-soothing) with significantly increased sleep duration, decreased sleep onset latency, and

reduced night waking. Allen et al. [20] identified 9 cross-sectional surveys that supported the

importance of falling asleep independently (self-soothing versus parental presence) for improved

sleep onset latency, night waking, and sleep duration.

We found extensive evidence for the association between electronic technology use directly

before settling and during the night with short sleep duration, as early as toddlerhood [29].

Malone’s [21] integrative review stressed the importance of adolescents limiting technology use

just prior to or after bedtime. Allen et al. [20] identified 3 studies that supported negative effects

of evening electronic technology exposure on sleep outcomes. Carter et al.’s [68] systematic

review of studies of school-aged children between 6 and 19 years identified 2.5 times the risk of

inadequate sleep duration for children using electronic technology (cell phones and tablets) at

bedtime and during the night.

We did not find extensive evidence linking evening caffeine consumption to sleep outcomes. We

only located three studies that specifically examined evening caffeine intake before bed for

school-aged children and adolescents. When Clark and Landolt [69] conducted a systematic

review of caffeine and sleep studies they examined total caffeine intake over the course of the

day and reported an association between high levels of caffeine intake and significantly

decreased sleep duration and more night waking in adolescents.

 19

Information provided by Chinese studies and one Korean study linked school-aged children’s

and adolescents’ short sleep duration to long commute times between home and school and large

amounts of evening homework [45,46,48], with a dose-response risk in one study [46]. We were

unable to locate systematic reviews that incorporated those elements of sleep hygiene. While it

could be argued that such associations represent particular cultural practices, this is an important

area for future work because there have been general increases in school homework demands and

children’s distance from school settings.

Similarly to our findings, in their meta-analysis of 16 controlled trials and qualitative analysis of

12 within-subject studies published between 2003 and 2013, Meltzer and Mindell [19] reported

that significant effects were found for sleep onset latency, number of night wakes, and duration

of night wakes in younger children based on behavioral interventions (n=12, infants, toddlers,

preschoolers). We located 7 intervention studies that we ranked as moderate to strong quality and

that included infants, toddlers, and preschoolers. Eight studies in the Allen et al. [20] systematic

review were trials of behavioral sleep interventions designed to enhance self-soothing with

clinically significant improvements in sleep duration, sleep onset, and night waking.

In our systematic review we only identified 10 intervention trials with school-aged and

adolescent samples that explicitly examined sleep duration, sleep onset latency, and/or night

waking with only four studies demonstrating significant between group-differences. Meltzer and

Mindell [19] found only 4 studies with samples of school-aged children and adolescents, which

they ranked as very low quality. They identified no controlled trials including adolescents. We

located 5 studies with moderate to strong quality assessments that tested interventions with

school-aged children. We found only 4 studies that examined interventions specifically for

adolescents. Those studies reported on sleep duration and sleep onset latency as opposed to
 20

Meltzer’s and Mindell’s studies that reported on night waking and sleep efficiency. We agree

with Meltzer’s and Mindell’s assessment that more high quality evidence is required to examine

effectiveness of treatment for insomnia for school-aged children and adolescents and that the

level of evidence is much stronger for effective interventions for younger children [19].

Chung et al.’s [70] systematic review and meta-analysis of effects of school-based sleep

education programs for adolescents found significantly longer weekday total sleep time

immediately post interventions (which usually consisted of sleep education classes) but the

effects were not maintained at follow-up. The two most efficacious studies in our review

incorporated both class time and opportunities to practice skills [65] or included multiple

stakeholders (children, family members, teachers, and decision-makers) when providing the

education program [53]. McDowall and colleagues’ [22] systematic review of parent knowledge

about children’s sleep concluded that parent knowledge was poor with greater accuracy about

healthy sleep practices at sleep onset than child sleep problems through the night. In general,

they found that small interventions only increased parents’ knowledge over the short term.

5.0 Summary

In summary, studies are necessary to link specific sleep hygiene factors to precise sleep

outcomes. More work is necessary to clarify relations between parents’ and children’s

knowledge about sleep and sleep problems. Consistent use of reliable, valid, and appropriate

tools is necessary to draw any conclusions about relationships between sleep hygiene variables

and sleep outcomes. High quality intervention studies to improve school-age children’s and

adolescents’ insomnia are needed.

 21

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 32

Table 1 Summary of all Studies Meeting Inclusion and Quality Criteria

Environment

Intervention
Context or

Co-sleeping
Interventi

Homework
Electronics
Routines

Napping
Hygiene

feeding
Infant
Drugs
Sleep
Country Age Group Sleep

Diet
on
First Author Year of origin Study Design N (Mean) Key Outcomes assessment
Ahn [24] 2016 Korea Cross-sectional survey 1032 I&T (NR) C x x x x x x SD, NW PR
Amra [58] 2017 Iran Cross-sectional survey 2257 A (15.4) C x SD, SQ, SOL SR
Blunden [42] 2011 Australia Pre-test Post-test 33 P (27m) I 0 SD, SOL, NW SD
Brambilla [37] 2017 Italy Structured interview 2030 T, P, SA, A C x x x TST, OS PR
Brown [41] 2015 USA Cross-sectional survey 62 P (53m) C x x x SD, SOL, NW PR
Butler [25] 2016 USA Cross-sectional survey 104 I (6.6m) C x NW, LSP, TST PR
Chahal [50] 2013 Canada Cross-sectional survey 3398 SA (NR) C x SD SR & PR
New
Galland [59] 2017 Zealand Cross-sectional survey 692 A (16.9) C x x SE, SOL, SD SR
Garrison [38] 2011 USA Baseline survey for RCT 617 P (51m) C x SP, SOL, NW PR & MD
Randomized controlled
Gradisar [32] 2016 Australia trial 43 I, T, (10.8m) I x SD, SOL, NW SD & ACT
ACT & SD &
Gruber [53] 2016 Canada Controlled pre and post 71 SA (8.5) I x TST, SOL, SE PR
Randomized controlled SD, NW, LNW, PR & SD &
Hall [33] 2015 Canada trial 235 I (6.7m) I x LSP ACT
Harbard [60] 2016 Australia Longitudinal survey 146 A (16.2) C x TST, SOL ACT
Cohort and longitudinal 5583
Hysing [30] 2014 Norway study 1 I & T (NR) C x x x SD, NW, SOL PR
A & SA
Jiang [45] 2015 China Cross-sectional survey 6247 (11.5) C x x SD, SQ PR & SR
Cluster randomized
John [64] 2017 India controlled trial 660 A (13.6) I x SQ, SOL, SE, SD SR
INT & SD,
Jones [39] 2014 UK Mixed-methods study 84 P (41m) C x SD &ACT
2077
Li [46] 2014 China Cross-sectional survey 8 SA (9) C x SD PR
1929
Li [47] 2010 China Cross-sectional survey 9 SA (9) C x x x x x x x x SD PR
Randomized controlled PR &SD &
Lukowski [34] 2015 China trial 80 I (6m) C x NW ACT
McDonald [29] 2014 UK Cross-sectional survey 1702 T (15.8m) C x SD PR
 33

1008
Mindell [26] 2015 Various Cross-sectional survey 5 I, T, PS (NR) C x SOL, NW, SD PR
2928
Mindell [27] 2010 Various Cross-sectional survey 7 I & T (NR) C x x x SD, NW PR
Randomized controlled
Mindell [35] 2011 USA trial 264 I& T(19.4m) I x SOL, NW, SD PR
Randomized controlled
Mindell [36] 2011 USA trial 171 T&PS (31m) I x SOL, NW, SD PR
Randomized controlled T, PS, SA
Mindell [43] 2016 USA trial 109 (5.7) I x SD PR
Munezawa 9477
[61] 2011 Japan Cross-sectional survey 7 A (NR) C x SD, SQ SR
Polos [62] 2015 USA Cross-sectional survey 3139 A (13.3) C x SD, SQ SR
Randomized controlled
Quach [55] 2011 Australia trial 108 SA (5.7) I x TST PR
Ramamurthy 1032
[28] 2012 Various Cross-sectional survey 1 I (NR) C x NW, SD, SOL PR
Randomized controlled
Rigney [52] 2015 Australia trial 296 SA (12) I x TST SR & ACT
Randomized controlled
Schlarb [56] 2011 Germany trial 38 SA (7.8) I x NW, SD, SOL PR & SD
Randomized controlled TST, SE, WASO,
Sekartini [57] 2017 Indonesia trial. 126 PS (NR) C x NW ACT
Seo [49] 2010 Korea Cross-sectional survey 3639 SA (NR) C x x x x TNS, SOL, NW PR & SD
Sette [31] 2017 Italy Longitudinal study 704 I (NR) C x x NW, SD INT
Randomized controlled
Surani [54] 2015 USA trial 264 SA (NR) I x NW SR
A cluster randomized
Tamura [65] 2016 Japan trial. 243 A (NR) I x SOL, TST SR
Tiesler [51] 2015 Germany Cross-sectional survey 1719 SA (10) C x SD, NW PR
van der Lely Switzerla Counter-balanced cross- SR & SD &
[67] 2015 nd over 13 A (16.5) I x TST ACT
Wilson [40] 2014 USA Cross-sectional survey 133 PS (4.1) C x SD, SOL PR
Randomized controlled
Wilson [44] 2014 USA trial 152 PS (4.1) I x SD PR & SD
A Cluster Randomized
Wing [66] 2015 China Trial 3713 A (14.7) I x SD, SOL SR
Yilmaz [63] 2011 Turkey Cross-sectional survey 3441 A (16.2) C x x x TNS SR
Zhang [48] 2010 China Cross-sectional survey 4470 SA (9.2) C x x x SD SR
 34

Footnote for Table 1

Ages: I&T-infants and toddlers, P-Preschool, SA-School Age, A-Adolescents; Outcomes: LSP-Longest sleep period, SD-sleep
duration, SE-sleep efficiency, NW-night waking, LNW- long night wakes, SQ-sleep quality, SOL-sleep onset latency, TST-total sleep
time, OS-optimal sleep, SP-sleep problem, TNS-total night sleep, WASO-wake after sleep onset; Sleep Assessment: ACT-actigraphy,
SD-sleep diaries, PR-parent report, SR-self report, MD-media diary, INT-interview
 35

Appendix A

CINAHL SEARCH

S1 (MH "Sleep") OR (MH "Sleep Deprivation") OR (MH "Sleep Hygiene") OR (MH

"Insomnia")

S2 TI (sleep* or insomnia or nap) OR AB (sleep* or insomnia or nap)

S3 S1 OR S2

S4 (MH "Child") OR (MH "Infant") OR (MH "Child, Preschool") OR (MH "Adolescence")

S5 TI (infant* or child* or baby OR babies or toddler* OR preschool* OR adolescen* OR teen*

OR youth* ) OR AB ( infant* or child* or baby OR babies or toddler* OR preschool* OR

adolescen* OR teen* OR youth*)

S6 S4 OR S5

S7 S3 AND S6

S8 (MH "Sleep Apnea Syndromes+") OR (MH "Apnea of Prematurity")

S9 TI ("sleep apn#ea" OR "apn#ea of prematurity" OR "sleep disordered breathing" OR oSDB)

OR AB ("sleep apn#ea" OR "apn#ea of prematurity" OR "sleep disordered breathing" OR

oSDB)

S10 S8 OR S9

S11 S7 NOT S10

S12 (MH "Sudden Infant Death")

 36

S13 TI ("Cot Death" OR "Crib Death" OR "Infant Death, Sudden" OR SIDS OR "Sudden Baby

Death" OR "Sudden Infant Death") OR AB ("Cot Death" OR "Crib Death" OR "Infant Death,

Sudden" OR SIDS OR "Sudden Baby Death" OR "Sudden Infant Death")

S14 S12 OR S13

S15 S7 NOT (S10 OR S14)

S16 (MH "Tonsillectomy" OR MH "Bruxism" OR MH "Craniofacial Abnormalities+")

S17 TI (Tonsillectom* OR Bruxism OR Craniofacial Abnormalities OR "22q11 Deletion

Syndrome" OR "DiGeorge Syndrome" OR "Coffin-Siris Syndrome" OR "Craniofacial

Dysostosis" OR "Hallermann Syndrome" OR Hypertelorism OR "Mandibulofacial Dysostosis"

OR "Goldenhar Syndrome" OR "Nager Syndrome" OR Craniosynostoses OR

Acrocephalosyndactylia OR "Michels Syndrome" OR "Crisponi Syndrome" OR "Deformational

Plagiocephaly" OR "Dyke-Davidoff-Masson Syndrome" OR "Leopard Syndrome" OR

"Malpuech Syndrome" OR "Marshall-Smith Syndrome" OR "Maxillofacial Abnormalities" OR

"Binder's Syndrome" OR "Dentofacial Deformities" OR "Jaw Abnormalities" OR "Cleft Palate"

OR Micrognathism OR "Yunis-Varon Syndrome" OR "Pierre Robin Syndrome" OR

Prognathism OR Retrognathism OR "Nager Syndrome" OR "Noonan Syndrome" OR

"Orofaciodigital Syndromes" OR "Rubinstein-Taybi Syndrome" OR "Schinzel-Giedion

Syndrome" OR "temporomandibular disorders") OR AB ( Tonsillectom* OR OR Bruxism OR

Craniofacial Abnormalities OR "22q11 Deletion Syndrome" OR "DiGeorge Syndrome" OR

"Coffin-Siris Syndrome" OR "Craniofacial Dysostosis" OR "Hallermann Syndrome" OR

Hypertelorism OR "Mandibulofacial Dysostosis" OR "Goldenhar Syndrome" OR "Nager

Syndrome" OR Craniosynostoses OR Acrocephalosyndactylia OR "Michels Syndrome" OR

 37

"Crisponi Syndrome" OR "Deformational Plagiocephaly" OR "Dyke-Davidoff-Masson

Syndrome" OR "Leopard Syndrome" OR "Malpuech Syndrome" OR "Marshall-Smith

Syndrome" OR "Maxillofacial Abnormalities" OR "Binder's Syndrome" OR "Dentofacial

Deformities" OR "Jaw Abnormalities" OR "Cleft Palate" OR Micrognathism OR "Yunis-Varon

Syndrome" OR "Pierre Robin Syndrome" OR Prognathism OR Retrognathism OR "Nager

Syndrome" OR "Noonan Syndrome" OR "Orofaciodigital Syndromes" OR "Rubinstein-Taybi

Syndrome" OR "Schinzel-Giedion Syndrome" OR "temporomandibular disorders")

S18 S16 OR S17

S19 S7 NOT (S10 OR S14 OR S18)

S20 (MH "Child Development Disorders, Pervasive") OR (MH "Developmental Disabilities")

OR (MH "Learning Disorders") OR (MH "Motor Skills Disorders") OR (MH "Mutism") OR

(MH "Reactive Attachment Disorder") OR (MH "Dyscalculia") OR (MH "Asperger Syndrome")

OR (MH "Autistic Disorder") OR (MH "Pervasive Developmental Disorder-Not Otherwise

Specified") OR (MH "Schizophrenia, Childhood") OR (MH "Attention Deficit Hyperactivity

Disorder")

S21 TI ("child development disorder*" OR "developmental disabilit*" OR "learning disorder*"

OR "motor skills disorder*" OR mutism OR "reactive attachment disorder*" OR dyscalculia OR

"asperger syndrome" OR "autistic disorder" OR autism OR "pervasive developmental

disorder*" OR schizophrenia OR ADHD OR "Attention Deficit Hyperactivity Disorder" OR

"development* disorder*" OR "fetal alcohol syndrome" OR "Down Syndrome" OR "Brain

Injury" OR concussion OR epilepsy) OR AB ("child development disorder*" OR "development*

disabilit*" OR "learning disorder*" OR "motor skills disorder*" OR mutism OR "reactive

 38

attachment disorder*" OR dyscalculia OR "asperger syndrome" OR "autistic disorder" OR

autism OR "pervasive developmental disorder*" OR schizophrenia OR ADHD OR "Attention

Deficit Hyperactivity Disorder" OR "development* disorder*" OR "fetal alcohol syndrome" OR

"Down Syndrome" OR "Brain Injury" OR concussion OR epilepsy)

S22 S20 OR S21

S23 (MH "Adult") OR (MH "Aged") OR (MH "Aged, 80 and Over") OR (MH "Aged,

Hospitalized") OR (MH "Frail Elderly") OR (MH "Middle Age") OR (MH "Young Adult")

S24 TI (adult* or elder or geriatric or elderly OR senior* OR "middle age*") OR AB (adult* or

elder or geriatric or elderly OR senior* OR "middle age*")

S25 S23 OR S24

S26 S7 NOT (S10 OR S14 OR S18 OR S22 OR S25)

S27 TI (narcolepsy OR enuresis OR "Sleep walk*" OR sleepwalking OR "Willis-Ekbom" OR

parasomnias OR "periodic leg movements" OR "Sleep safety" OR "sleep safe" OR "infant safe

sleep" OR "infant sleep safety" or "infant safety" OR "safe sleep" ) OR AB (narcolepsy OR

enuresis OR "Sleep walk*" OR sleepwalking OR "Willis-Ekbom" OR parasomnias OR "periodic

leg movements" OR "Sleep safety" OR "sleep safe" OR "infant safe sleep" OR "infant sleep

safety" or "infant safety" OR "safe sleep")

S28 (MH "Disorders of Excessive Somnolence") OR (MH "Kleine-Levin Syndrome") OR (MH

"Narcolepsy") OR (MH "Parasomnias") OR (MH "Sleep Arousal Disorders") OR (MH "Night

Terrors") OR (MH "Somnambulism")

 39

S29 TI (hospital* OR tertiary OR electroencephalographic OR encephalogram OR

polysomnographic OR sedation OR "homeopathic treatment" OR "hand washing" OR

handwashing OR "pediatric surgery" OR "kangaroo care" OR "physical education") OR AB

(hospital* OR tertiary OR electroencephalographic OR encephalogram OR polysomnographic

OR sedation OR "homeopathic treatment" OR "hand washing" OR handwashing OR "pediatric

surgery" OR "kangaroo care" OR "physical education")

S30 (MH "Pregnancy+")

S31 TI pregnan* OR AB pregnan*

S32 S30 OR S31

S33 S26 NOT S32

S34 TI ("premature infants" OR "preterm infants" OR "infant, premature" OR "children born

premature*" OR "premature babies" ) OR AB ( "premature infants" OR "preterm infants" OR

"infant, premature" OR "children born premature*" OR "premature babies")

S35 (MH "Infant, Premature") OR (MH "Infant, Very Low Birth Weight")

S36 S34 OR S35

S37 S33 NOT S36

S38 T1 ("chronic disease*" OR "chronic kidney disease" OR "cardiometabolic risk" OR obesity

OR obes* OR "cystic fibrosis" OR "cerebral palsy" OR "sickle cell" OR "diabetes mellitus" OR

"diabetes type 1" OR "type 1 diabetes" OR "atopic disease" OR delirium OR "musculoskeletal

pain" OR musculoskeletal OR "chronic pain" OR eczema OR dementia OR arthritis OR "eating

 40

disorders" OR hypothyroidism OR stillbirth OR "allergic rhinitis" OR constipation OR "chronic

illness" OR "physical disabilities" OR "lower respiratory illness" OR cirrhotic OR encephalitis or

"Hunter Syndrome" OR hemangioma OR cancer* or neoplasm* or oncology or tumo#r or

malignanc*) OR AB ("chronic disease*" OR "chronic kidney disease" OR "cardiometabolic

risk" OR obesity OR obes* OR "cystic fibrosis" OR "cerebral palsy" OR "sickle cell" OR

"diabetes mellitus" OR "diabetes type 1" OR "type 1 diabetes" OR "atopic disease" OR delirium

OR "musculoskeletal pain" OR musculoskeletal OR "chronic pain" OR eczema OR dementia OR

arthritis OR "eating disorders" OR hypothyroidism OR stillbirth OR "allergic rhinitis" OR

constipation OR "chronic illness" OR "physical disabilities" OR "lower respiratory illness" OR

cirrhotic OR encephalitis or "Hunter Syndrome" OR hemangioma OR cancer* or neoplasm* or

oncology or tumo#r or malignanc*)

S39 (MH "Chronic Disease") OR (MH "Disease+") OR (MH "Obesity+") OR (MH "Arthritis+")

OR (MH "Constipation") OR (MH "Neoplasms+") OR (MH "Nervous System Diseases+") OR

(MH "Nutritional and Metabolic Diseases+") OR (MH "Behavioral and Mental Disorders") OR

(MH "Behavioral Symptoms+") OR (MH "Affective Symptoms+") OR (MH "Agitation") OR

(MH "Behavior, Addictive+") OR (MH "Catatonia") OR (MH "Communicative Disorders+")

OR (MH "Compulsive Behavior") OR (MH "Couvade") OR (MH "Delirium, Dementia,

Amnestic, Cognitive Disorders+") OR (MH "Delusions") OR (MH "Eating Disorders+") OR

(MH "Depersonalization") OR (MH "Enuresis+") OR (MH "Frigidity") OR (MH "Hearing Loss,

Functional") OR (MH "Helplessness, Learned") OR (MH "Hypochondriasis") OR (MH

"Hysteria") OR (MH "Impotence") OR (MH "Malingering") OR (MH "Mass Hysteria") OR (MH

"Mental Fatigue+") OR (MH "Powerlessness") OR (MH "Psychomotor Disorders+") OR (MH

"Self-Injurious Behavior") OR (MH "Self Neglect") OR (MH "Sleep Disorders") OR (MH

 41

"Dyssomnias") OR (MH "Sleep Disorders, Circadian Rhythm+") OR (MH "Jet Lag Syndrome")

OR (MH "Sleep Disorders, Intrinsic") OR (MH "Disorders of Excessive Somnolence") OR (MH

"Kleine-Levin Syndrome") OR (MH "Narcolepsy") OR (MH "Restless Legs") OR (MH

"Parasomnias+") OR (MH "Sleep-Wake Transition Disorders+") OR (MH "Social Behavior

Disorders+") OR (MH "Stress+") OR (MH "Suicide+") OR (MH "Neoplasms+")

S40 T1 ("sexual abuse" OR "sexually abused" OR suicid* OR suicidality OR "internalizing

behavior" OR "externalizing behavior" OR "internalizing problems" OR "externalizing

problems" OR "internalizing symptoms" OR "externalizing symptoms" OR depression OR

anxiety OR "bipolar disorder" OR "mental health symptoms" OR "psychiatric disorders") OR

AB ("sexual abuse" OR "sexually abused" OR suicid* OR suicidality OR "internalizing

behavior" OR "externalizing behavior" OR "internalizing problems" OR "externalizing

problems" OR "internalizing symptoms" OR "externalizing symptoms" OR depression OR

anxiety OR "bipolar disorder" OR "mental health symptoms" OR "psychiatric disorders")

S41 S38 OR S39 OR S40

S42 S37 NOT S41

S43 TI ("in-patient" OR inpatient OR hospital* OR tertiary OR electroencephalographic OR

encephalogram OR polysomnographic OR sedation OR "homeopathic treatment" OR "hand

washing" OR handwashing OR "pediatric surgery" OR "kangaroo care" OR "physical

education") OR AB ("in-patient" OR inpatient OR hospital* OR tertiary OR

electroencephalographic OR encephalogram OR polysomnographic OR sedation OR

"homeopathic treatment" OR "hand washing" OR handwashing OR "pediatric surgery" OR

"kangaroo care" OR "physical education")

 42

S44 (MH "Health Facilities") OR (MH "Academic Medical Centers") OR (MH "Alternative

Health Facilities") OR (MH "Ambulatory Care Facilities+") OR (MH "Ancillary Services,

Hospital") OR (MH "Bed Occupancy") OR (MH "Dental Facilities+") OR (MH "Dialysis

Centers") OR (MH "Facility Design and Construction+") OR (MH "Health Facility Closure+")

OR (MH "Health Facility Departments+") OR (MH "Hospital Units+") OR (MH "Hospitals+")

OR (MH "Laboratories+") OR (MH "Patients' Rooms+") OR (MH "Rehabilitation Centers+")

OR (MH "Residential Facilities+") OR (MH "Tissue Banks+")

S45 (MH "Diagnosis+")

S46 (MH "Pediatric Surgery")

S47 (MH "Kangaroo Care")

S48 S43 OR S44 OR S45 OR S46 OR S47

S49 S42 NOT S48

S50 S42 NOT S48 [Limiters - Published Date: 20070101-20171231; English Language]