Sleep Wellness in Children

by Dr. Theodric Lee

What is sleep?

Sleep is not the opposite of being awake. Sleep is best thought as a different state from being awake; during sleep your body and brain is working actively to maintain your health. 

What can I do promote good sleep habits in my child?

First, ensure that your child has enough sleep. 

The American Academy of Sleep Medicine (AASM) has published recommendations1 on sleep duration in children:

Age                       Recommended sleep hours per 24 hours

4 - 12 mos.            12 to 16 hours (including naps)

1 - 2 year               11 to 14 hours (including naps)

3 - 5 years             10 to 13 hours (including naps)

6 - 12 years           9 to 12 hours

13 - 18 years         8 to 10 hours

Second, establish a regular sleep routine.

This usually involves 3-4 relaxing activities before bedtime. An example for an infant may be: change to pyjamas – infant massage – singing a lullaby – put to bed. An example for an older toddler may be: change to pyjamas – brush teeth – read a bedtime story – say prayers – put to bed. The combinations are limitless and you may use your creativity. Keep the routine similar every day, and you may use a shortened version before naps.

What are common sleep problems in children?

Although there are more than 80 classified sleep problems and disorders, it is helpful to classify them into 2 major categories:

1. Behavioural sleep problems, which are disruptions in sleep in otherwise healthy and developmentally normal children.

2. Sleep disorders, being physical diseases causing sleep disruptions. The most common sleep disorder is obstructive sleep apnoea (OSA) where main symptom is snoring in children, and this is covered in another article.

Common behavioural sleep problems in children

Behavioural sleep problems are very common in children, but are often dismissed as “normal” by parents and even doctors. A study in Singapore2 has shown that about 25-50% of children were found to have a behavioural sleep problem!


a) “night-wakings”: negative sleep associations


About 25% of Singaporean children have a problem with “night-wakings”. The common scenario is a baby or young child waking up several times in the night, and requiring help (called a sleep association) from a parent in order to fall asleep again – this sleep association commonly being feeding milk and/or rocking the child back to sleep.


The term “night-waking” is misleading, because all healthy persons (both adults and children) have short awakenings (so short the brain does not realise) throughout his/her sleep, up to several times an hour. Most adults have subconsciously learnt how to comfort themselves back to sleep when they have these short awakenings, e.g. covering with a blanket; hugging the pillow or bolster etc. When a person is able to comfort oneself to back to sleep, this is called a positive sleep association in medical terms.


Most healthy and developmentally normal children of 6 months and above are capable of developing positive sleep associations, but unfortunately many babies of this age have not learnt this when left in their natural environment. If a child has formed a habit of feeding milk or being rocked to sleep at bedtime, in the middle of the night a short awakening has the potential to become a prolonged awakening when the child desires and cries for milk or rocking in order to fall back asleep. This help from a parent is called a negative sleep association. Most children who develop negative sleep associations do not outgrow them in the short to medium term.


b)    Bedtime resistance


Bedtime resistance is common in toddlers and may co-exist with negative sleep associations. This may manifest in many ways – the child stalling for time before bedtime (“just some more play time”, “one more video”); taking a long time to fall asleep; outright tantrums and refusal to go to bed; refusal to sleep in his/her own bed or bedroom; or coming to the parents’ bed or bedroom in the middle of the night (curtain calls). Bedtime resistance usually reflects a lack of boundaries or rules surrounding bedtime.


Sleep problems do not affect the child only. Often the person who suffers the most is the parent, for example a mother who suffers from physical fatigue and sleep deprivation having to feed or rock her child back to sleep multiple times.

What can we expect at a consultation to manage behavioural sleep problems?

- Because of the detailed nature a typical first consultation would take about 1 hour.

- The specialist will take a detailed history of how, when and where the child sleeps.

- A diagnosis of the sleep problem will be made.

- The family’s needs and expectations will be evaluated.

- Realistic targets should be set,

o    e.g. one family may want their child to sleep in a separate room;

o    another family may desire a stepwise improvement, for their child to require an occasional pat rather than repeated rocking or feeding at night.

- A core skill in developing positive sleep associations in the child will be taught to parents. This is based on a combination of planned ignoring and intermittent comforting by parents, called graduated extinction in medical terms.

- An individualised sleep management plan will be proposed.

- A realistic timeline for expected improvement should be set depending on how much time parents can commit. Because graduated extinction usually results in increased crying and tantrums in the first few days before seeing satisfying results, parents may choose to take a few days leave if they wish to see improvement in a week. Modifications are available for a longer timeline if parents cannot commit to an intensive management plan, which can be physically demanding.

- In older children, more creative means like reward charts, surprise gifts and even games related to sleep can be employed in the sleep management plan.


1. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. 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.

2. Aishworiya R, Chan P, Kiing J, Chong SC, Laino AG, Tay SKh. Sleep behaviour in a sample of preschool children in Singapore. Ann Acad Med Singapore. 2012 Mar;41(3):99-104.