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Practice Clinical updates

Assessment and initial management of suspected behavioural insomnia in pre-adolescent children

BMJ 2018; 363 doi: (Published 16 October 2018) Cite this as: BMJ 2018;363:k3797
  1. Catherine M Hill, associate professor of child health, honorary consultant in paediatric sleep medicine1 2,
  2. Hazel Everitt, associate professor in general practice3
  1. 1Division of Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
  2. 2Southampton Children’s Hospital, Southampton, UK
  3. 3Division of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, UK
  1. Correspondence to: C M Hill cmh2{at}

What you need to know

  • Aim to identify the sleep disorder rather than just treating the symptoms

  • Behavioural insomnia is the commonest sleep disorder, and behavioural approaches combined with good sleep hygiene are effective treatments

  • In general, do not diagnose behavioural insomnia in infants <6 months of age as disturbed sleep is normal at this age

  • Sleep of family members is often affected, as well as the child, so treatment can benefit the quality of life of the whole family

About 20-30% of parents and caregivers (hereafter referred to as parents) in the developed world report that their children have insomnia (difficulty falling asleep or staying asleep).1234 Reliable data from developing countries is lacking, but adult data suggests that insomnia is a global phenomenon.5 Children born this millennium are likely to sleep for around 70 minutes less each night than generations born 100 years ago.6 Insomnia in children is a public health concern, because short sleep is associated with multiple adverse outcomes (table 1). Numerous meta-analyses confirm the link between short sleep and childhood obesity,131415 behavioural problems,7 and poor school performance.11 A population based prospective cohort study has also associated sleep disturbance after 2 years of age with reduced grey matter volume at 7 years old.19

View this table:
Table 1

Adverse outcomes associated with short sleep in children

The effect on parents is also important. As little as one week of sleep disruption in children affects parents’ mood, emotional regulation, and decision making, and it can take months or years for them to seek help.2021

Parents are generally understanding when a child has short-lived or acute insomnia, such as after a period of illness or the birth of a sibling. However, when insomnia is chronic (defined as occurring for ≥3 nights a week for ≥3 …

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