Parents worry about their children’s sleep. It is one of the most frequent concerns raised in paediatric consultations and one of the most common reasons families seek sleep medicine referrals. The challenge is distinguishing between normal developmental variation and genuine sleep pathology, because the line between the two is not always obvious.

Roughly 25-40% of children experience some form of sleep difficulty during childhood, according to data from the Australasian Sleep Association. Most of these are behavioural in nature and resolve with appropriate management. A smaller proportion reflect underlying medical conditions that require investigation and treatment.

Normal Sleep Changes by Age

Before deciding that something is wrong, it helps to understand what’s normal. Newborns sleep 14-17 hours in irregular bouts with no established circadian rhythm — nighttime waking for feeds is biologically appropriate. Infants (4-12 months) begin consolidating sleep, typically achieving 6-8 hours uninterrupted by 6-9 months. Toddlers need 11-14 hours with one nap, and bedtime resistance during this period is common and developmentally normal.

School-age children need 9-12 hours. If a school-age child still needs regular daytime naps, that warrants clinical attention. Adolescents need 8-10 hours, but biological changes push their natural sleep onset later. The conflict between late biological timing and early school start times creates chronic sleep deprivation in many teenagers — a systemic problem, not a parenting failure.

Behavioural Sleep Problems

The most common paediatric sleep issues are behavioural, meaning there is no underlying medical disorder — the problem is in how sleep is initiated and maintained.

Bedtime resistance typically peaks between ages 2-4. The child refuses to stay in bed, makes repeated requests (water, toilet, one more story), or becomes distressed when left alone. In most cases, the underlying issue is inconsistent limit-setting or an association between parental presence and sleep onset.

Sleep onset association disorder occurs when a child cannot fall asleep without a specific condition — being rocked, held, nursed, or having a parent lie next to them. The condition itself isn’t the problem; the problem arises when the child wakes naturally during the night (as all humans do) and cannot return to sleep without that same condition being recreated.

Treatment for behavioural sleep problems is well-established. Consistent bedtime routines, age-appropriate sleep schedules, graduated extinction (“controlled crying”) or camping-out methods, and positive reinforcement all have strong evidence bases. The Royal Children’s Hospital Melbourne provides excellent parent-facing resources on these approaches.

These interventions work. Multiple systematic reviews confirm that behavioural sleep interventions improve child sleep and reduce parental distress without measurable negative effects on child attachment or emotional development.

When to Investigate Further

Certain presentations should prompt referral to a sleep specialist rather than behavioural management alone.

Snoring and observed apnoeas. Primary snoring is common in children (8-12% prevalence), but snoring combined with witnessed breathing pauses, gasping, or choking during sleep suggests obstructive sleep apnoea. Paediatric OSA affects 1-5% of children and, if untreated, contributes to behavioural problems, poor school performance, cardiovascular strain, and growth impairment. The most common cause is adenotonsillar hypertrophy, and adenotonsillectomy resolves the condition in approximately 75% of otherwise healthy children.

Excessive daytime sleepiness in school-age children. A child getting adequate sleep but remaining persistently sleepy needs evaluation. Possible causes include fragmented sleep from OSA, periodic limb movement disorder, or narcolepsy, which can present in childhood.

Parasomnias beyond the expected age. Sleepwalking, sleep terrors, and confusional arousals are common in children aged 3-8 and typically resolve by adolescence. However, frequent events (multiple per week), persistence beyond age 12, or dangerous behaviour warrant sleep study evaluation.

Restless legs symptoms. Children with restless legs syndrome often describe symptoms as “growing pains” or “creepy-crawly feelings.” Iron deficiency is a common contributor — serum ferritin below 50 mcg/L is considered relevant — and should always be checked.

The Melatonin Question

Melatonin use in children has increased dramatically over the past decade. In Australia, melatonin is available over the counter in low doses and by prescription for higher doses. Parents often start it without medical guidance, which raises concerns.

For specific populations — children with autism spectrum disorder, ADHD, or neurodevelopmental conditions — melatonin has reasonable evidence supporting its use for sleep onset difficulties. The Therapeutic Goods Administration has approved prolonged-release melatonin for children with ASD-related insomnia.

For typically developing children with behavioural sleep problems, melatonin should generally be considered after behavioural interventions have been properly implemented, not as a first-line solution. Melatonin addresses timing; it does not teach a child to self-settle, manage bedtime anxiety, or maintain sleep without parental presence.

A Practical Framework

Parents asking “should I worry about my child’s sleep?” can consider this simple framework:

• If the child sleeps well when given the opportunity and the problem is primarily bedtime behaviour, start with behavioural strategies.
• If the child snores regularly, see a doctor. Snoring is not benign in children.
• If the child is excessively sleepy despite adequate sleep time, something else is going on.
• If sleep problems are significantly affecting the child’s daytime function, mood, behaviour, or school performance, professional evaluation is appropriate regardless of the suspected cause.

Children’s sleep is important, and most problems are treatable. The first step is knowing which problems need a doctor and which need a consistent bedtime routine.