Sleep problems and behavioural interventions

Start by calculating sleep opportunity and likely total sleep rather than asking only whether the child sleeps well. Record usual wake time, bedtime, lights out, estimated sleep onset, awakenings, final waking and naps on weekdays and weekends. Ask what happens at each transition and who must be present. Large weekend catch-up suggests insufficient weekday sleep; a child placed in bed far before biological sleep time may appear to have insomnia.

Behavioural insomnia includes sleep-onset-association and limit-setting patterns. A child who falls asleep only while fed, rocked or beside a caregiver may need the same conditions after normal night arousals. In a limit-setting pattern, inconsistent or unenforceable boundaries prolong bedtime. These descriptions guide support and are not judgments about parenting. Illness, housing, shift work, disability, sibling care and cultural routines determine what is feasible.

Circadian delay produces late sleep and late waking with relatively normal quality when allowed the preferred schedule. It becomes prominent in adolescence and differs from anxious lying awake throughout the night. Morning light, fixed wake time and a gradual phase advance are central; an abrupt very early bedtime often increases wakefulness. Specialist input is appropriate for severe delay, school absence or consideration of timed melatonin.

Parasomnias arise from transitions between sleep states. Confusional arousals, sleepwalking and night terrors usually occur from deep non-REM sleep in the first third or half of the night. The child appears distressed or active but is difficult to console and typically has no clear memory. Nightmares arise later from REM sleep, wake the child fully and are remembered. Sleep deprivation, fever, stress and irregular schedule increase parasomnias.

Obstructive sleep apnoea in children often presents with loud snoring, gasping, unusual sleep positions, sweating, mouth breathing, enuresis, morning headache, irritability or hyperactivity rather than reported sleepiness. Examine tonsils, nasal airway, craniofacial anatomy, growth and blood pressure and consider obesity, neuromuscular weakness and Down syndrome. Absence of obvious tonsillar enlargement does not exclude obstruction.

Restless legs syndrome causes an urge or unpleasant sensation in the legs during rest, worse in the evening and relieved by movement. Children may describe tickling, pain or a need to run, and younger children may simply leave bed repeatedly. Ask about iron-deficient diet, heavy menstrual bleeding, coeliac symptoms and family history. Check FBC and ferritin when the clinical pattern or iron risk supports it, then treat deficiency through paediatric guidance rather than empirically giving iron indefinitely.

A 2-week sleep diary is usually the most useful first investigation. It reveals variability, opportunity and the relation between intervention and outcome. Actigraphy can estimate rest–activity timing over longer periods in specialist circadian or insomnia assessment but cannot identify every sleep stage or replace respiratory studies. Polysomnography records sleep, breathing, oxygenation, carbon dioxide, cardiac and movement signals and is the reference standard for obstructive sleep apnoea.

Behavioural treatment works through predictable cues, appropriate timing and consistent responses. Agree one achievable change at a time. Positive routines pair calm repeated activities with sleep; bedtime fading builds rapid sleep onset; graduated checking increases intervals between brief reassuring checks; and consistent return-to-bed reduces rewarding nighttime interaction. The family should understand the plan, anticipate a temporary increase in protest and know when to pause for illness or distress.

Extinction-based approaches are not mandatory and must never mean locking a child alone, ignoring illness or withholding comfort. Some families prefer caregiver fading, where the adult gradually moves farther away, or a visual schedule and reward plan. For neurodivergent children use concrete language, sensory adjustment and slower change. Review barriers without blame, particularly when overcrowding, caregiver mental health or domestic risk affects implementation.

Medicine has a narrow role. Modified-release melatonin can be considered within its licensed neurodevelopmental indications after sleep-hygiene and behavioural measures have been insufficient, with specialist diagnosis, an explicit target and periodic reassessment. Product formulation and timing determine effect; an immediate-release preparation is not automatically equivalent to a prolonged-release tablet. Routine antihistamines, benzodiazepines, antipsychotics or clonidine are not treatments for uncomplicated childhood insomnia.