Darius A. Loghmanee and Jamie A. Cvengros

Introduction

Of the myriad pediatric sleep disorders children in our society face, inadequate total sleep time provides perhaps the greatest challenge. Families tend to underestimate children’s sleep need and lack understanding of the relationship between inadequate sleep and behavioral, health, and neurocognitive problems. Developments in technology have given increasing numbers of stimulation-seeking children access to movies, video games, and social media 24 hours a day, 7 days a week. Advertising and media have normalized consumption of wake-promoting agents such as caffeine, guarana, ginseng, and taurine in the form of energy drinks, increasingly utilized by children and adolescents to fend off sleep in order to have enough time to complete homework assignments, study for tests, or participate in extracurricular activities. Early school start times for adolescents, a population with a physiologic delay in sleep phase, also contributes to insufficient sleep. In this context, the importance of the role of health care providers, parents, and family members in helping children and adolescents recognize the importance of adequate sleep and assisting them as they develop healthy sleep habits comes into focus. This chapter will review guidelines for total sleep need over the lifetime, identify some of the sequelae associated with inadequate total sleep time, and provide an overview of concepts essential to establishing healthy sleep habits, often referred to as good sleep hygiene.

Allowing for Adequate Sleep Time

From a clinical perspective, there is no magic number of hours that a child or adolescent must sleep. The adequacy of the quality and quantity of a child’s sleep can be determined based on descriptions of sleep continuity, time spent in bed awake after bedtime, and signs of sleepiness during the day. It is clear, however, that children and adolescents need more sleep than adults, and accommodations must be made to enable children to achieve the amount of sleep they require. These accommodations may include limiting after-school and evening activities to allow for an adequately early bedtime, preparation for the next day (e.g., packing backpack, laying out clothes) to allow for later waketimes, and the establishment of a consistent timeframe for daytime napping. As children grow, new accommodations such as monitoring of nighttime socialization (e.g., talking on telephone, texting, and computer use) or media consumption may also be required to assure that adolescents are able to achieve their ideal total sleep time.

Although it is known that individual sleep requirements can vary significantly, there are reliable guidelines to help establish target total sleep times by age. Sleep need varies throughout the life span with infants sleeping 14–15 hours per day, toddlers sleeping 12–14 hours per day, preschoolers sleeping 11–13 hours, school-aged children sleeping 10–11 hours, and teenagers needing 8.5–9 hours per day.¹ Epidemiological research suggests that children and adolescents are frequently getting less sleep than needed. The 2004 Sleep in American Poll found that 54% of school-aged children are getting less than 10 hours of sleep per day; the median hours of total sleep time among children aged 6–10 year was 9.5 hours.² Eighty percent of parents reported that their children are getting ‘just the right amount of sleep,’ suggesting that parents are aware of the increased sleep need among children and adolescents as compared to adults. In addition, 27% of school-aged children were getting more sleep on the weekends, suggesting that these children are building up a sleep debt throughout the week and have significant variability in their sleep–wake schedule between school days and weekends.⁶

Consequences Associated with Insufficient Sleep

Insufficient total sleep time among children and adolescents has been associated with significant health consequences. A recent meta-analysis which included 12 studies (with data for over 30 000 children) found that short sleep duration was significantly associated with increased weight, defined as a body weight greater than 85th percentile for age.³ Furthermore, short sleep time is associated with metabolic changes (e.g., insulin resistance, increased fasting plasma glucose) among overweight and obese children.⁴ In a longitudinal study of 200 children from birth to 5 years, normal-weight and overweight children did not differ in terms of nighttime sleep duration; however, overweight children demonstrated significantly less daytime napping, and thus shorter total sleep times.⁵ While these studies highlight the importance of adequate total sleep time, a potential moderating factor of the relationship between sleep duration and weight may be timing of sleep. In the Spruyt et al. study of 2011, variability in total sleep time was associated with metabolic changes, as was total sleep time itself. Similarly, a recent study found that adolescents with later bedtimes and rise times were significantly more likely to be overweight as compared to adolescents with earlier bed- and rise-times, despite similar total sleep times between the two groups.⁶

Developing Healthy Sleep Habits

Traditionally, the term ‘sleep hygiene’⁷ has been used to include a wide variety of behaviors aimed at creating an environment conducive to sleep and avoiding activities that are disruptive to sleep. Although education about good sleep hygiene is frequently used as part of treatment for insomnia in adult populations, there is no standard definition of sleep hygiene.⁸ For example, good sleep hygiene in adults is commonly presented as: (1) maintaining a cool, quiet, and dark sleep environment, (2) avoiding caffeine and alcohol near bedtime, and (3) not watching television or reading in bed, representing a conceptual overlap with stimulus control treatment for insomnia.⁹ Given the non-standard definition of sleep hygiene, the present chapter instead presents recommendations to promote ‘healthy sleep practices’ among children and adolescents. Specifically, the chapter will review the importance of allowing for adequate time for sleep, maintaining a consistent sleep–wake pattern, creating a comfortable sleep environment, avoiding physiological barriers to sleep, and establishing effective bedtime routines. This chapter will not focus on specific treatments for childhood insomnia, as this is presented elsewhere (see Chapters 16 and 17).

Maintaining a Consistent Sleep–Wake Pattern

As currently understood, the sleep–wake cycle depends on the interactions between two processes: process C, the circadian wakefulness drive, and process S, the homeostatic sleep drive. These processes are presented in Figure 8-1.¹⁰