Toddlers need sleep. A lot of sleep. Isn’t it ironic, then, that it can be so hard to get them to fall asleep when you want them to? And why is it that the more tired they get, the more they seem to gain the energy to boldly resist the one thing their little bodies are begging for?
While there is no switch that can reliably put the lights out in your toddler, setting the stage for sleep — and the boundaries for what’s acceptable — can go a long way toward making nighttime or nap time a smoother experience for all involved. We talked to Robin Lloyd, M.D., a Mayo Clinic children’s sleep expert, about how to set the foundations for toddler sleep, and how to correct course when things have gotten out of hand.
MAYO CLINIC PRESS: What happens developmentally that cute babies — and the adage “Sleeping like a baby” — turn into toddlers who can’t or won’t get to sleep without major fanfare?
Dr. Lloyd: Kids are constantly changing beings — going through different developmental stages and different growth stages and responding to their environments in different ways. A lot of toddler sleep issues are the result of a complexity of events. Toddlers are in that 2- to 3-year-old age window moving from cribs to beds. This can be a major trigger for sleep problems because all of a sudden they’re not a captive audience in their cribs. With a bed comes freedom, and they’ll exercise those freedoms to explore their environments. Problems also arise when children haven’t learned to sleep well independently by that age, and those problems only become magnified when toddlers are given that freedom without having the crib to contain them.
MCP: Is there an optimal window of time to move a toddler from a crib to a bed?
Dr. Lloyd: When the crib is at the lowest level and the baby is able to crawl out, then it becomes a safety concern and it’s time to look at moving the baby into a bed so the baby doesn’t get injured. There have been significant head injuries from kids falling out of cribs. That being said, I have three kids, and my youngest loved his crib and the safety of its confines. Even though I knew he could crawl out, he never did. He was happy in his crib, so we kept him in there longer than his siblings. There is some individuality, but safety concerns should always be the big driver.
MCP: When parents are tired — and during this phase of childrearing they will be tired like never before — they can’t wait to drop their heads on the pillow. Paradoxically, exhausted toddlers will do anything to avoid sleep, including bounding out of their bedrooms wanting to play, read or watch TV. What causes their inability to self-regulate?
Dr. Lloyd: These are sometimes referred to as curtain calls. Toddlers are at an age where they are gaining more verbal skills. They have increased awareness of things around them — and amazing curiosity. They also may be toilet training. They may say things like, “I need one more hug; I need to go to the bathroom; I need a drink.” Curtain calls then tend to become a reinforced behavior because they’re cute too, right? And sometimes the requests seem like a necessity. But then, at some point, it’s no longer cute; it’s frustrating. Bedtime gets protracted, an hour or two pass, and your child is whining more and more. It can be thought of as the witching hour, oftentimes around 9 p.m. This is when young kids are staying up later and later and they get more hyper and emotional. When toddlers are butting up against that, it makes it harder for them to settle down to sleep. It’s often a combination of events, developmental and behavioral.
Having a nice, quiet, calm bedtime routine and setting firm but loving limits and expectations around going to bed will help this time be a pleasant one of transition to sleep. Having a neutral response or consistent mantra — such as, “Mommy loves you; it’s time for bed” — avoids a favorable response to the curtain call. The child will not get any reinforcement, positive or negative, and the curtain calls will subside.
MCP: So parents need to catch when cuteness is about to turn to frustration and set clear boundaries?
Dr. Lloyd: Boundary setting is very important right from the start because it’s a slippery slope with kids. It’s important therefore for parents to set boundaries that are firm and support expectations in a kind and loving manner. Toddler sleep issues are easier to prevent than to treat. Making sure parents are educated about ways to help their infant fall asleep independently rather than learning maladaptive behaviors around sleep is so important. Some of these behaviors include falling asleep nursing, falling asleep being rocked and held, and requiring a lot of external stimuli to sleep. When parents set boundaries, toddlers learn at an early age that they go down drowsy and learn to put themselves to sleep the rest of the way. This is really important. Also, parents need to know the importance of having a bedtime routine, one that is calming and settling. It should be around the same time all days of the week and occur in the same place where the child will sleep so there is the association of the bed with sleep. There should be no electronics involved in the bedtime routine. Reading is best. The parent should offer brief assurances and leave the room while the child is drowsy, then have the child fall asleep the rest of the way alone. These habits are best started early.
MCP: Is melatonin safe for kids? There’s been a lot of talk in the media lately about whether it would be medically appropriate to treat toddler sleep issues with melatonin. There’s also concerning data from the Centers for Disease Control and Prevention reporting that in 2020 melatonin became “the most frequently ingested substance among children reported to national poison control centers.”
Dr. Lloyd: Before even thinking of melatonin, I recommend that parents get back to the basics, because in most developing children, it’s all about routine, habits and limit setting. It seems silly that parents would give a toddler an unregulated supplement for a correctable behavioral problem, and there is little evidence that it helps developing children sleep. The American Academy of Sleep Medicine recently issued a statement advising parents to talk to their health care providers about melatonin before giving it to children. While it may seem benign because it is readily available and comes in child-friendly preparations such as gummies, it is not. It is a supplement and therefore not a regulated medication, so the amount administered can vary significantly from what’s listed on the bottle. Ingestions have significantly increased — with hundreds of ICU admissions, some resulting in death.
MCP: A common sight all around the world these days in restaurants, on trains and on planes is young children clutching tablets. Can technology make toddler sleep issues even worse?
Dr. Lloyd: A lot of parents resort to putting a screen in front of their child’s face and letting their child fall asleep to a screen. It’s amazing how adept 2-year-olds can be with manipulating tablets and games. It’s also very sad because we know those are maladaptive behaviors that are not helpful for sleep or development. Healthy sleep is all about setting the stage with good habits and expectations and good routines, preferably starting at an early age. Avoid having too late a bedtime and avoid involving technologies — including audio bedtime stories on a tablet, which is the same as giving a child a screen because it still emits blue light and therefore suppresses the child’s natural melatonin activity.
MCP: As the world moves evermore toward convenience and people have apps to, for example, instantly order in the missing ingredient for a cake they’re making, have you noticed an exponential impatience in how parents respond to sleep during the toddler years?
Dr. Lloyd: Yes. Parents live in a rapid-response society, but kids have typical developmental milestones and transitions that cannot be rushed. Parents should treasure each of these and help their children learn healthy habits along the way. Fixing sleep problems in toddlers is not like the flip of a switch, and it can be frustrating for families.
MCP: Is there a recommended bedtime for a toddler to get the correct amount of sleep to support healthy development?
Dr. Lloyd: The recommended bedtime is one that allows for sufficient sleep. I meet parents who say, “I have to wake my child up for child care at 5 a.m.,” and it just pains my heart because it means that, depending on the age, their child may not be getting enough sleep. This can have negative impacts on learning, development, mood and growth. The Centers for Disease Control and Prevention’s recommendations for a healthy daily amount of sleep for 1- and 2-year-olds is 11 to 14 hours every 24 hours, including naps. For ages 3 to 5, it’s 10 to 13 hours every 24 hours, including naps. Ideally what I’d like to see is children going down at an early enough time — when they’re tired but calm and settled — and then waking up on their own when they’ve had enough overnight sleep. If a child has to get up for child care at dawn, parents need to count back and make sure the child is getting the recommended daily sleep time, including naps.
MCP: During the toddler years, many parents wave the white flag and sleep in their child’s bed so the child is soothed and goes to sleep. How can parents put a stop to this once it’s started?
Dr. Lloyd: Co-sleeping is a major topic. If co-sleeping in a family is about cultural practice across many generations, there’s no need to change someone’s culture. But when parents are doing it out of desperation, that’s where work on behavioral modification strategies is needed to help the child learn to sleep independently. Co-sleeping is best avoided. If it is being done because it’s the quickest and easiest way to get the child to sleep, it ultimately just kicks the can down the road and protracts the problem. We use behavioral modification techniques to help the child gradually learn to transition to sleep. One technique is gradual extinction of parental presence, which involves gradually decreasing the time parents spend at the bedside so children learn to fall asleep on their own. This can be done by parents gradually moving further from the bedside every couple of nights and then eventually checking back on the child during the transition to sleep. The child knows parents are nearby but does not have to have them in the room for transition. Rewarding the child for staying in bed with simple, brief praises — and ultimately earning a reward for the desired behavior — helps enhance this process.
MCP: If parents try to stop sleeping in their child’s bed, they are often met with tantrums and crying. Is it cruel to let a toddler cry it out after a long, exhausting battle refusing co-sleeping?
Dr. Lloyd: Using the gradual extinction method is less stressful than the old cry-it-out method. However, when parents are trying to modify behavior, there are oftentimes called extinction bursts, where kids will have an escalation in emotion before they realize, “OK, this is how it is now.” The counter to that is that once the child gets over that little extinction burst, behaviors usually modify within 3 to 5 days. It can be stressful in the short term, but over the long haul, the child has learned some self-regulation strategies. And parents are going to be so much more rested and they might be better able to parent a busy toddler because they are getting more sleep. When parents are tired and frustrated and at their wits’ end, then children have a higher risk of abuse. Kids who don’t sleep well put a big stress on the family.
A child who falls asleep with a parent gets used to that scenario. Since all children awaken a couple of times a night to the point of awareness, if they need a parent in bed, they’ll think, “Wait a minute, where is my mom?” and fuss or cry. That then breaks the parent’s sleep and becomes a big deal in the family. In contrast, a child who does not need the parent there to sleep just goes back to sleep during typical little episodes of waking. The story of toddlers and sleep is really about a child’s first introduction to self-regulation. It has been said that one of the best gifts we can give children is to help them learn to fall asleep independently. I try to share this with parents to help encourage them in the process.
MCP: Does this still apply if your child is sick?
Dr. Lloyd: If your child is sick or recovering from surgery, of course you’re going to cuddle and love on them. When they truly need you for comfort during times of distress, you’re going to be there.
MCP: How does your guidance change if parents have twins, triplets, quadruplets and so on?
Dr. Lloyd: It’s even that much more important to keep bedtime routines consistent. It’s hard because after two kids, parents run out of hands!
MCP: Can difficulties with toddler sleep be caused by an underlying medical condition?
Dr. Lloyd: Absolutely. There can be conditions like sleep apnea or excessive restlessness in sleep that can rouse kids from sleep. Conditions such as asthma tend to be worse at night with coughing, as does acid reflux. So yes, there are medical conditions that can lead to sleep fragmentation. Generally, we screen for issues that may be primary sleep disorders or medical conditions that may impact sleep. If no issues are identified and a sleep problem appears to be purely behavioral, we focus on behavioral modifications.
MCP: Lastly, in a multichild family where the toddler is finding it difficult to sleep because, for example, the 6-year-old brother is gaming, the 11-year-old sister is playing the horn and the toddler wants to join in on all the fun, what can parents do to conduct that orchestra of children?
Dr. Lloyd: That’s real life. For most people, life interferes with sleep. When I talk to families, I try not to make it a kid-specific thing because it’s truly a family thing. It’s important that parents model good behavior around sleep. When parents say to a child, “We need to remove the TV from the bedroom,” oftentimes the first thing the child will say back is, “But Mom and Dad watch TV in the bedroom!” I put sleep discussions in the context of the family. This would mean that instead of the 6-year-old brother playing a video game, he should be reading. To the 11-year-old, parents should say, “Please practice your horn earlier in the day.” Making sleep a priority within the family is the single most important thing when there’s a toddler in the home, whether you have one, two or five kids. That — along with good habits, good routines and clear limits — will make the toddler years a whole lot easier.
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