Management of childhood insomnia

The parents must help the child to fall asleep on their own, eg setting a bedtime routine that allows the child cues to the approaching bedtime. Number of calls for glasses of milk should be limited in advance.

Assessment of the presenting sleep pattern may reveal features that are readily treatable:

• the parents may have unreasonable expectations about the sleeping patterns of a young child
• the child may be having too much sleep during the daytime and perhaps the parents should consider getting the child into a playgroup (note that a brief early afternoon nap can improve the quality of night-time sleep)
• the child may have erratic bedtimes and so has not developed a bedtime routine
• the sleep cycle may have been displaced eg a parent has let the child sleep until late in the morning and therefore the child does not get tired until late in the evening

If none of the above are features of the delayed settling then options include:

• behavioural interventions

These can include;

- extinction (e.g., putting the child to bed awake, closing the door, and leaving him/her to cry him/herself to sleep)

- modified extinction (e.g., putting the child to bed awake, leaving the room, and returning to check in on him/her at set intervals, giving the child the message that he/she needs to go to sleep while reassuring the child that he/she has not been abandoned)

- extinction with parental presence (e.g., where the child is put to bed awake and the parent sits in a chair in the bedroom with his/her back to the child without actually going over to the child to soothe him/her to sleep)

- faded bedtime with positive bedtime routines (e.g., in which the child is put to bed later than usual while being given positive bedtime routines)

- scheduled awakenings (e.g., in which the child is awakened at fixed intervals to pre-empt his/her own patterns of awakening)

Though all are generally found to be effective, there is insufficient evidence to recommend one intervention over another. (1)

if your child will not go to sleep without you, the techniques described below can help toddlers (over 12 months) or older children get used to going to sleep without you in the room. It can also be used whenever your child wakes in the middle of the night but be prepared for your child to take a long time to settle when you first start. You can use strokes or pats instead of kisses if your child sleeps in a cot and you cannot reach them to give them a kiss.

• Follow a regular calming bedtime routine.
• Put your child to bed when they're drowsy but awake, then kiss them goodnight.
• Promise to go back in a few moments to give them another kiss.
• Return almost immediately to give a kiss.
• Take a few steps to the door, then return immediately to give a kiss.
• Promise to return in a few moments to give them another kiss.
• Put something away or do something in the room then give them a kiss.
• As long as the child stays in bed, keep returning to give more kisses.
• Do something outside their room and return to give kisses.
• If the child gets out of bed, say: "Back into bed and I'll give you a kiss".
• Keep going back often to give kisses until they're asleep.
• Repeat every time your child wakes during the night

• more sleep tips for under-5s
  • Make sure you have a calming, predictable bedtime routine that happens at the same time and includes the same things every night.
  • If your child complains that they're hungry at night, try giving them a bowl of cereal and milk before bed (make sure you brush their teeth afterwards).
  • If your child is afraid of the dark, consider using a nightlight or leaving a landing light on.
  • Do not let your child look at laptops, tablets or phones in the 30 to 60 minutes before bed – the light from screens can interfere with sleep.
  • If your child wakes up during the night, be as boring as possible – leave lights off, avoid eye contact and do not talk to them more than necessary.
  • Avoid long naps in the afternoon.
    
    

• pharmacological management
  • melatonin improves sleep in children with ASDs (2)
  • melatonin administration can be used to advance sleep onset to normal values in children with ADHD who are not on stimulant medication (2)
    
    
  • with respect to short-term use of sedative antihistamines in childhood insomnia, sedative side effects of antihistamines may speed up behavioural programmes over short periods but seem not to work without behavioural interventions
  • in a placebo-controlled double-blind trial in infants aged 6–27 months with the use of trimeprazine tartrate (3) the authors concluded that it is not recommended as a pharmacological treatment for infant sleep disturbance unless as an adjunct to a behavioural therapy program
  • clinically the short term use of an H1 blocker for transient or extreme insomnia is frequently employed: however, tolerance can develop quickly and some children can experience dramatic and paradoxical over-arousal

References:

1. Macias MI, Malhotra S. Behavioral insomnia of childhood. Am J Respir Crit Care Med. 2021 Apr 15;203(8):P20-P21.
2. Bruni O et al. European Journal of Paediatrics. European expert guidance on management of sleep onset insomnia and melatonin use in typically developing children. Volume 183, pages 2955–2964, (April 2024)
3. France KG, Blampied NM and Wilkinson P .A multiple-baseline, double-blind evaluation of the effects of trimeprazine tartrate on infant sleep disturbance. Exp Clin Psychopharmacol 1999; 7: 502–513.