Published: January 15, 2025

Sweeping Away Poor Sleep Habits

How pediatric otolaryngologists can brush up on healthy sleep recommendations for patients and their families.


Stephen R. Chorney, MD, MPH, Michael A. DeMarcantonio, MD, and Lilun Li, MD, on behalf of the Pediatric Otolaryngology Committee


04 Sweeping Away Sleep Habits AltOtolaryngologists play a crucial role in managing sleep-related breathing disorders in children, but their expertise should extend beyond anatomic and surgical considerations. Many pediatric sleep disturbances, such as snoring and obstructive sleep apnea, are intertwined with behavioral sleep challenges such as poor sleep hygiene and exposure to electronic media and noise. Recognizing and addressing these issues is essential for comprehensive care and successful treatment outcomes. By developing comfort and competence in managing behavioral sleep problems, otolaryngologists can enhance the overall well-being of their young patients and provide more holistic solutions to sleep-related concerns.

Sleep Essentials & Hygiene

Adequate sleep is essential for children’s health, contributing to improved attention, behavior, learning, memory, emotional regulation, and overall quality of life. In 2016, the American Academy of Sleep Medicine (AASM) released a consensus statement detailing the recommended amount of sleep needed within a 24-hour period to support optimal mental and physical health in children. These guidelines, endorsed by the American Academy of Pediatrics, the Sleep Research Society, and the American Association of Sleep Technologists, provide the following age-specific sleep recommendations:

  • Infants (4 to 12 months): 12 to 16 hours of sleep (including naps)
  • Toddlers (1 to 2 years): 11 to 14 hours
  • Preschoolers (3 to 5 years): 10 to 13 hours
  • School-aged children (6 to 12 years): 9 to 12 hours
  • Teenagers (13 to 18 years): 8 to 10 hours of sleep each night.1,2

Meeting these sleep targets is crucial for fostering healthy development and long-term well-being.

Pediatric sleep disturbances are common, with 20% to 30% of children experiencing clinically significant sleep problems.3 Behavioral sleep issues are particularly prevalent, often surpassing the capacity of sleep specialists to manage them effectively.4 This highlights the need for all healthcare providers, including otolaryngologists, to be well-equipped to address these concerns as part of patient care. Sleep hygiene refers to a range of behaviors and environmental factors that can be modified to improve sleep quality and duration.5,6 For otolaryngologists, understanding and integrating key sleep hygiene principles is beneficial in supporting children’s overall health and ensuring they achieve restful, restorative sleep.

Consistent sleep schedules are necessary for children. Bedtimes should be no later than 9:00 pm, and naptimes should remain regular, with only minimal variation (30-60 minutes). For toddlers, skipping naps can lead to longer sleep onset and shorter nighttime sleep.7,8 Children who set their own bedtimes also tend to spend less time in bed compared to those with set bedtimes. Regular sleep schedules—consistent bedtimes, wake times, and naps—are linked to better sleep outcomes, such as improved sleep onset, fewer sleep problems, and adequate sleep duration.8

Bedtime routines can also play a significant role in improving sleep outcomes. Brief routines, such as a 15-minute activity like baths, storytelling, and soft music, have been shown to reduce bedtime resistance, sleep onset delays, night awakenings, and improve sleep continuity. Consistent routines that involve quiet, calming activities, such as reading, may further enhance sleep duration and improve sleep quality. Routines with more active pursuits like snacking or play, on the other hand, are linked to poorer sleep outcomes.8,9

Promoting independent sleep is fundamental for healthy sleep development in children. Teaching children to fall asleep in their own beds without parental presence helps prevent dependence at bedtime and during night wakings. This focus on fostering self-soothing is a key component of behavioral sleep interventions, equipping parents with the tools to encourage independent sleep. Research consistently links independent sleep to longer sleep duration, faster sleep onset, and fewer night wakings. Children who fall asleep independently experience better overall sleep patterns compared to those relying on parental presence. Additionally, bedtime reading has been shown to improve sleep outcomes, while environmental factors such as light and noise are associated with poorer sleep quality.8-10 

Noise Exposure and Sleep

Noise exposure during sleep affects children of all ages and can lead to sleep fragmentation, decreased alertness, poor daytime performance and reduced overall quality of life.11 In addition, nocturnal noise exposure may increase the lifetime risk of noise related hearing loss. Young children and infants are especially vulnerable since they rely on adults to limit their exposure and cannot always extricate themselves from harmful noisy environments. In recent years, infant sleep machines have become increasingly popular and a topic of discussion in the media.12 These machines produce white noise that can sooth the infant and serve to mask disturbing environmental sounds that may disrupt sleep.13 When used appropriately, white noise has been shown to quiet infants and reduce nighttime arousal levels in both neonates and preschool children.14 However, concerns have recently been raised about the safety of white noise use in infants.15 Devices have been shown to reach sound intensity levels of up to 92 dB, far exceeding the National Institutes for Occupational Safety and Health (NIOSH) recommendation of 85 dB over an 8-hour period.13 These guidelines, designed for adult industrial workers, do not account for the effects of noise on sleep, the developing neonatal brain or auditory system.

Environmental noise, defined as unwanted or harmful outdoor sound created by human activities, affects the sleep of both adults and children. The impact of environmental noise may be especially profound in teenagers and older children. In adolescents, even a small increase in neighborhood environmental noise, can delay sleep onset, and decrease the likelihood of getting eight hours of sleep per night.16 When stratifying for risk, physicians should consider that teens with lower socioeconomic status may have greater exposure to environmental noise.17,18

The widespread use of personal listening devices is further complicating sleep during childhood. Up to 64% of children 5 to 12 years of age use ear buds or headphones and 4% use a listening device during sleep.19 The danger from personal listening device use may be even greater than that associated with infant sleep machines, with some devices reaching maximum volume levels of >125 dB.20 Otolaryngologists have a unique opportunity to educate patients and parents about the  dangers of noise exposure during sleep and to adjust sleep habits to minimize risk.

Electronic Devices

04 Sweeping Away Sleep HabitsExposure to electronic devices can significantly impact sleep duration and quality in children. Sleep can be affected in a variety of ways: replacement of sleep time with electronic content viewing, arousal by stimulating media content, and suppression of melatonin with disruption of the sleep-wake cycle due to the blue light emitted from electronic screens. Sleep problems associated with screen exposure include difficulty falling asleep, nightmares, frequent night awakening, and difficulty waking in the morning.21,22

As a child grows, the amount of sleep needed, and the pattern of that sleep, continuously evolves. As children age, sleep becomes increasingly influenced by the light-dark cycle, resulting in fewer daytime naps and a shift of sleep time to the overnight period.23 As such, sleep disruption from electronic device use can affect children of all ages in various ways. Up to 96% of children 6 months to 4 years old have used a mobile device, with most having started before their first birthday. Approximately 66% of children under 2 years old watch television and videos, averaging 56 minutes a day.23 For 97% of adolescents, at least one electronic media device is located in their bedroom.22 During the toddler stage, increased use of electronic media is associated with decreased total sleep time, which includes both daytime and nighttime sleep, as well as more difficulty falling asleep.24 In teenagers, most of whom use at least one electronic device during the last hour before bedtime, increased media use is associated with shorter nighttime sleep duration and difficulty falling asleep.22

Timing of electronic media exposure can also impact sleep quality and quantity. A study of infants aged 6 to 12 months old found that that electronic media exposure after 7 pm was associated with decreased nighttime sleep duration.25 Another study of school-aged children found that evening media use had a greater impact than daytime media use on sleep.21 Multiple studies have found that longer total daily media viewing, both active and passive, can be associated with shorter sleep duration.21,22,24,26,27 Research evaluating the impact of touchscreen media, such as tablets and smartphones, has demonstrated similar effects long attributed to traditional media formats, such as television. However, the portability of these new devices allows for unprecedented access and the potential to increase the total amount of media exposure per day.24 Given the abundance of supporting research, The American Academy of Pediatrics (AAP) has offered the following media recommendations:

  • Children < 2 years old: Avoid all electronic media exposure
  • Children 2-5 years old: One hour daily
  • School-Age Children: Avoid exposure to electronics 1 hour before bedtime, designate media-free times and locations, and remove electronic devices from the bedroom26

What can parents and physicians do to optimize sleep quantity and quality in children? Establishing a consistent and comforting bedtime routine in younger children can mentally prepare them for sleep, decrease night awakenings, and improve sleep onset.23 Healthy independent sleep habits should be encouraged with an emphasis on consistency and adequate good-quality sleep. To mitigate the effects of noise on a child’s sleep and future health, personal listening devices should be avoided during sleep and white noise devices should only be used at a low volume and safe distance. Limiting the total amount, timing and type of media exposure can greatly improve all aspects of pediatric sleep. Physicians should continue to advocate for a safe, quiet, and electronic free sleeping environment for children of all ages.


 References

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