Elsevier

Sleep Medicine

Volume 10, Issue 7, August 2009, Pages 771-779
Sleep Medicine

Original Article
Developmental aspects of sleep hygiene: Findings from the 2004 National Sleep Foundation Sleep in America Poll

https://doi.org/10.1016/j.sleep.2008.07.016Get rights and content

Abstract

Objective

To examine the associations between sleep hygiene and sleep patterns in children ages newborn to 10 years. The relationships between key features of good sleep hygiene in childhood and recognizable outcomes have not been studied in large, nationally representative samples.

Participants and methods

A national poll of 1473 parents/caregivers of children ages newborn to 10 years was conducted in 2004. The poll included questions on sleep hygiene (poor sleep hygiene operationally defined as not having a consistent bedtime routine, bedtime after 9:00 PM, having a parent present when falling asleep at bedtime, having a television in the bedroom, and consuming caffeinated beverages daily) and sleep patterns (sleep onset latency, frequency of night wakings, and total sleep time).

Results

Across all ages, a late bedtime and having a parent present when the child falls asleep had the strongest negative association with reported sleep patterns. A late bedtime was associated with longer sleep onset latency and shorter total sleep time, whereas parental presence was associated with more night wakings. Those children (ages 3+) without a consistent bedtime routine also were reported to obtain less sleep. Furthermore, a television in the bedroom (ages 3+) and regular caffeine consumption (ages 5+) were associated with shorter total sleep time.

Conclusions

Overall, this study found that good sleep hygiene practices are associated with better sleep across several age ranges. These findings support the importance of common US based recommendations that children of all ages should fall asleep independently, go to bed before 9:00 PM, have an established bedtime routine, include reading as part of their bedtime routine, refrain from caffeine, and sleep in bedrooms without televisions.

Introduction

Sleep problems in children are common, affecting 25–40% of the pediatric population [1]. Beyond physiologically-based sleep disorders, such as obstructive sleep apnea or periodic limb movement disorder, many sleep problems are behavioral, often arising at least in part from poor sleep hygiene. “Sleep hygiene” is a term that describes modifiable parent and child practices that promote good sleep quality, allow sufficient sleep duration, and prevent daytime sleepiness [2]. Sleep hygiene practices cover a number of domains, including the sleep environment, sleep routine, and daytime activities [2], [3], [4].

A common recommended sleep hygiene practice is to maintain a consistent sleep schedule for bedtimes, wake up times, and nap times (for young children). In addition, a predictable set of pre-sleep activities (bedtime routine) is associated with improved sleep onset latency and sleep consolidation in young children [5]. As part of a consistent bedtime routine, where and how a child falls asleep can affect sleep onset latency (time to fall asleep) and night wakings. Inappropriate sleep associations (e.g., rocking or nursing to sleep) that involve parental presence at bedtime can result in Behavioral Insomnia of Childhood – Sleep Onset Association type [6]. Studies have consistently found that such negative sleep associations result in disrupted sleep [7], [8]. Thus, the general sleep hygiene recommendation, at least in the United States, is that children should fall asleep independently.

Other sleep hygiene recommendations involve television viewing and caffeine use. A number of studies have found that television viewing has a negative effect on sleep. In one study of 495 school-aged children, almost 25% had a television in their bedroom, with television viewing resulting in bedtime resistance, sleep onset delay, and anxiety around sleep, as well as shortened sleep duration [9]. In addition, Li and colleagues found that media presence in the bedroom was associated with later bedtimes, later awakening times, and shorter sleep duration in a study of almost 20,000 elementary-school children [10].

Finally, caffeine use in preschool and school-aged children, especially late in the day, may interfere with both sleep onset and sleep quality. Caffeine intake lengthens sleep latency, reduces sleep efficiency, and decreases sleep duration in adults [11]. Only one study, however, has examined caffeine use and sleep in children [12]. In this study of 191 seventh-, eighth-, and ninth-graders, caffeine intake was associated with shorter nocturnal sleep duration, increased wake time after sleep onset, and increased daytime sleep.

Few studies have investigated the impact of sleep hygiene in the pediatric population [13], [14] , primarily in special populations. In one study including a community sample, sleep hygiene was found to be an important predictor of sleep quality in 776 Italian and 572 American adolescents, while controlling for several demographic variables (e.g., age, gender circadian preference) [2]. No studies, however, have examined sleep hygiene practices in a large community-based sample of children, the focus of this study.

Since 1998 the National Sleep Foundation (NSF),1 a nonprofit organization dedicated to public education of sleep and sleep disorders, has conducted an annual national poll of sleep patterns, sleep habits, and sleep disturbances in the United States. The focus of the 2004 Sleep in America Poll was sleep in children from birth to 10 years. Questions included information on children’s sleep practices, including sleep hygiene. The purpose of this paper is to examine the associations between sleep hygiene and children’s sleep in this national sample. The three aspects of sleep included as important outcomes were (1) sleep onset latency, (2) the frequency of night wakings, and (3) total sleep time during the night (between the hours of 6 PM and 8 AM). The principal hypothesis was that in children whose caregivers reported poor sleep hygiene practices (operationally defined as not having a consistent bedtime routine, bedtime after 9 PM, having a parent present when falling asleep at bedtime, having a television in the bedroom, and consuming caffeinated beverages at least daily), longer sleep onset latencies, more frequent night wakings, and shorter total sleep time would also be reported.

Section snippets

Participants and procedure

A targeted random sample of telephone numbers was purchased from SDR (Sophisticated Data Research, Inc.) and quotas were established by region and age of child to provide equal representation. Households were polled between September 15 and October 17, 2003. To be eligible, participants had to (1) have a child living in their home aged 10 years or younger and (2) be the primary caregiver or share equally in the child’s care. Approximately 80% of the interviewing was conducted on weekdays

Sample demographics

Most respondents were female (72% = mother or stepmother of child), married (91%), Caucasian (89%), college educated (at least in part, 74%), and employed (71%). Median household income was $57,500 (under $20,000 = 4.3%; $20,000 up to $40,000 = 17.4%; $40,000 up to $75,000 = 36.0%; $75,000 up to $100,000 = 18.2%; $100,000 or more=16.2%; refused = 7.2%). Children were divided equally by gender (males=51%) and represented the following four age groups: infants (n = 210), toddlers (n = 239), preschoolers (n = 387),

Discussion

The results of this poll of caregivers of young children (ages newborn to 10 years) indicate that sleep hygiene is significantly associated with how well children sleep. Across all ages, a late bedtime and having a parent present when the child falls asleep had the strongest negative association with reported sleep patterns. A late bedtime was associated with longer sleep onset latencies and reduced total amounts of sleep, whereas parental presence was associated with increased night wakings.

Acknowledgment

The authors would like to thank the National Sleep Foundation and their staff for their support of this study.

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