A 3-year-old who screams at the bedroom door for 45 minutes every night is not unusual. Neither is the 18-month-old who falls asleep only while being rocked and wakes three times a night the moment she is set down. Bedtime resistance and repeated night wakings affect between 20% and 30% of infants and toddlers, and they are one of the most common sleep concerns parents bring to their pediatricians.
What actually helps? A 2024 systematic review by Lecuelle and colleagues, published in Sleep Medicine Reviews, offers the clearest answer the research can give. Behavioral therapy has the strongest evidence base. Medication does not have good long-term evidence for neurotypical young children. No single method suits every family, but the review narrows the field to a set of behavioral strategies with real trial data behind them.
What Behavioral Insomnia Looks Like In Young Children
Behavioral insomnia in young children covers two main patterns. The first is bedtime resistance. A child refuses to go to sleep, calls out repeatedly, leaves the room, asks for water or stalls in other ways until a parent gives in or stays. The second is sleep-onset association disorder. A child learns to fall asleep only under specific conditions, such as nursing, being held, rocking or having a parent present, then cannot return to sleep without those same conditions after natural wake periods during the night.
Both are learning problems more than medical ones. The child has learned a specific way to fall asleep and the body now requires those same conditions to restart sleep after the natural arousals that happen between sleep cycles in all children. That framing points toward a behavioral solution. It also removes blame. A parent who rocked their infant to sleep for months did not break their child. They solved an immediate problem. Now the child’s sleep habit needs to change.
Understanding infant sleep patterns and behavior helps families see this more clearly. Young children’s sleep cycles more frequently than adults’, and brief wake periods between cycles are normal. The problem occurs when a child cannot return to sleep without external help.
Bedtime resistance, night wakings and sleep-onset associations
Bedtime resistance can be mild, a few minutes of complaint and requests for one more hug, or significant, with a child who cries intensely, leaves the room repeatedly or becomes visibly distressed at the start of the bedtime routine. Both sit on the same behavioral spectrum. What maintains them is usually the same: a child who has learned that staying up, calling out or leaving bed brings parental attention or delays sleep.
Sleep-onset associations are subtler in how they present. A parent may describe a child who “just doesn’t sleep through” or who “needs help getting back to sleep.” In many of those cases the child is waking at normal intervals but lacks the skill to return to sleep independently. The association, whether it is nursing, patting or presence, is not causing harm in itself. The problem is that it is the only tool the child has.
How caregiver wellbeing shapes the treatment choice
Caregivers are central to this picture. The 2009 bedtime routine trial by Mindell and colleagues found that maternal mood improved significantly alongside infant and toddler sleep, even when the only change was adding a consistent bedtime routine. Earlier work had documented that mothers of children with sleep problems show higher rates of depressed mood, and that treating children’s sleep problems with behavioral methods reliably improves parental wellbeing.
That connection makes choosing a sleep approach a family decision as well as a clinical one. A method that generates significant caregiver distress may not be sustainable, even when its evidence is strong. Choosing something a family can actually do consistently is more likely to succeed than choosing the highest-ranked option on a list.
What The 2024 Systematic Review Found
Lecuelle, Leslie, Gustin, Franco and Putois searched PubMed, Cochrane and PsycInfo using PRISMA guidelines. Of 908 articles identified, 21 randomized controlled trials met inclusion criteria and were fully analyzed. Those trials covered 2,363 children aged from 2 months to 6 years. All participants were neurotypical and had no other known medical or developmental condition explaining their sleep difficulties.
The main conclusion was direct. Treatment for behavioral insomnia in this age group rests primarily on behavioral therapy. No evidence emerged that pharmacological treatments are effective long term for this population.
Behavioral treatment has the strongest evidence base
That finding lines up with a 2006 review by Mindell and colleagues, which formed the evidence base for the American Academy of Sleep Medicine’s practice parameters on bedtime problems and night wakings. That review examined 52 behavioral treatment studies. Across those studies, 94% reported that behavioral interventions were effective, with over 80% of children treated showing clinically significant improvement that was maintained for three to six months. The results held across different behavioral methods, different age groups and different family settings.
The AASM’s 2006 practice parameters rated three approaches as Standards. These were unmodified extinction, extinction with parental presence and preventive parent education. Graduated extinction, bedtime fading/positive routines and scheduled awakenings were rated as Guidelines, indicating effectiveness with somewhat less certainty in the evidence at that time.
Why long-term medication evidence is weak
No pharmacological agent has shown durable long-term benefit in randomized controlled trials for neurotypical young children. Short-term effects have appeared in some older drug studies, but they did not persist, and the 2024 review found no medications meeting the bar for long-term recommendation. Medication is still used in pediatric sleep, though not primarily for this group. For children with neurodevelopmental conditions such as autism or ADHD, the clinical picture is more complex. For healthy neurotypical children, behavioral strategies remain the first line.
Melatonin sits in a grey area. It is widely used and increasingly available without a prescription in many countries. The 2024 review did not find strong evidence for its long-term effectiveness or safety in neurotypical young children. Medical guidance varies by country, and the question is worth raising with a pediatrician rather than acting on independently. Melatonin does not replace behavioral work, and getting the timing and dose right is more consequential than many parents expect.
What the review says is still uncertain
Even with 21 trials, the review does not answer every question. Most trials were short, so the field lacks strong long-term follow-up data past six months across all settings. Studies varied in how they defined treatment success and measured sleep. More research is needed on which method works best for which child temperament, how delivery format affects outcome and how cultural context shapes what families can apply consistently.
Related: more from our sleep training coverage.
Evidence-Based Options Parents May Hear About
The fact that behavioral treatment works does not tell a family which approach to choose. The AASM parameters cover several distinct methods. They suit different children, ages and families.
Starting with evidence-backed sleep hygiene practices helps with any method. Consistent wake times, age-appropriate nap schedules, a calm pre-sleep environment and a regular routine all support behavioral approaches. They do not replace specific interventions, but they improve the conditions in which those interventions work.
Bedtime fading and positive routines
Bedtime fading moves the child’s bedtime temporarily later, to a time when they are naturally sleepy, then shifts it gradually earlier once they are falling asleep reliably. It reduces time awake in bed, which reduces the frustration and resistance that can reinforce the problem. It suits families where a child is being put to bed before they are ready, often a mismatch that develops as children get older and their sleep pressure builds more slowly.
Positive routines pair an established sequence of calm activities with the bedtime signal. A consistent, familiar routine acts as a conditioned cue for sleep. The 2009 bedtime routine trial by Mindell and colleagues tested this directly. Families in the intervention group followed a three-step routine that included bath, massage and quiet activities for infants, and lotion application and quiet activities for toddlers. That routine alone, with no other behavioral intervention, produced significant reductions in sleep latency and night wakings in both age groups after two to three weeks. Maternal mood also improved significantly.
Graduated extinction and parental presence methods
Graduated extinction involves putting the child to bed while still awake and waiting progressively longer intervals before briefly checking in when the child cries. Check-ins are brief and calm and do not reinstate the sleep-onset association. This method has strong trial evidence across multiple reviews.
Extinction with parental presence uses a gentler version. The parent stays in the room while the child falls asleep but does not physically soothe. The parent’s position in the room moves gradually toward the door over several nights. This may suit families where the child’s distress or the parent’s distress with a graduated approach is too high to sustain.
Unmodified extinction, sometimes called cry-it-out, involves putting the child to bed and not returning until morning unless safety is a concern. The evidence for its efficacy is strong. Many families do not find it acceptable. Clinical evidence shows similar outcomes across graduated and unmodified methods, so family fit is a legitimate basis for choosing.
Scheduled awakenings and parent education
Scheduled awakenings involve the parent waking the child just before the child’s typical night waking time, soothing them back to sleep and then gradually extending the interval. The approach interrupts the learned pattern before it starts. It is less widely used but has controlled trial support.
Parent education refers to interventions delivered before sleep problems become established, often in antenatal or early postnatal settings. When families receive information and a plan before persistent habits form, the likelihood of developing behavioral insomnia drops. The AASM rates preventive parent education as a Standard. That reflects both its evidence base and its practical value: preventing a problem is easier than solving one.
How To Choose A Method That Fits The Child And Family
No single method suits every family. The evidence shows that most behavioral approaches work when applied consistently. The bigger variable is usually whether a family can apply the chosen method consistently given their home, their child’s temperament and their own capacity.
Age, temperament, anxiety and family sleep setup
A younger infant may respond differently from a toddler. A child who is generally anxious, has experienced disruption or shares a room with an older sibling needs a plan that accounts for those realities. Shared rooms require quieter approaches. Families with shift-working caregivers may not be able to maintain two-person synchrony on a schedule.
Temperament also plays a role. A child who escalates quickly when distressed may not do well with extended graduated intervals. A child who settles after brief check-ins may respond well. Parents know their child’s baseline better than any guideline does.
Age also shapes which methods are most studied. Scheduled awakenings are most researched in infants. Bedtime fading and graduated extinction have been studied across a wider age range. Parent education works best as prevention before patterns form.
A note for families who have been extending the sleep window in hopes of wearing the child out: understanding when more time in bed is not the solution can prevent one of the most common mistakes. A child who is not sleepy at 7:30 p.m. will not fall asleep at 7:30 p.m. regardless of method. The window must match the child’s actual sleep pressure.
Making the plan consistent without ignoring distress
Consistency is the active ingredient in behavioral sleep work. An approach applied for three nights and then abandoned because of caregiver distress is unlikely to succeed and may make the problem harder to address next time. At the same time, distress is real and should not be dismissed. A parent who is severely sleep-deprived, managing mental health concerns or caring for multiple young children should be honest about capacity before settling on a method.
A practical way to hold both truths is to separate short-term distress during a structured change from ongoing distress in a situation that is not improving. Most families who apply a chosen method consistently for two to three weeks see real change. That time frame can help reframe the difficulty of the early nights.
Why a calm bedtime routine is often the first step
The 2009 Mindell trial showed that a bedtime routine on its own, without any other behavioral intervention, reduced sleep latency, night wakings and duration of disturbance in both infants and toddlers. Maternal mood also improved. The routine had three consistent steps done in the same order each evening.
Families who are unsure where to start can try a consistent routine first. It is low-demand, has direct trial evidence and often improves sleep without requiring families to manage the distress of graduated or unmodified extinction. If a consistent routine over three to four weeks does not improve sleep, the broader evidence base for graduated methods is clear and a pediatrician or child sleep professional can help map the choice to the child’s age and situation.
When Bedtime Problems Need Extra Help
Some bedtime problems in young children are behavioral. Some have a medical cause. And some need a professional to help distinguish the two.
Snoring, breathing, pain and developmental concerns
A child who snores loudly, struggles to breathe, has long pauses in breathing or wakes gasping may have obstructive sleep apnea or another sleep disorder. These patterns do not respond to behavioral intervention. They need medical evaluation.
A child who wakes crying in apparent pain, arches the back or shows other signs of discomfort during the night may have a medical cause for their waking. Young children cannot reliably report how they feel, so the waking behavior is often the only signal.
Developmental differences, including autism spectrum conditions, ADHD, sensory processing differences and high anxiety, can all affect sleep significantly. Behavioral strategies often help, but they may need adaptation and should be discussed with the appropriate specialist rather than applied without guidance.
Melatonin questions
Before starting melatonin, speak with a pediatrician. Dosing varies, timing is consequential and identifying the reason for the sleep problem is the most important step. A behavioral sleep-onset association does not resolve with melatonin. A circadian rhythm issue, where the child’s body clock is running late, may respond differently. Without knowing which problem is present, the intervention may miss.
What to track before speaking with a pediatrician or sleep specialist
Keep a simple sleep log for one to two weeks before an appointment. Note bedtime, wake time, approximate time to fall asleep, night wakings with duration and the child’s mood on waking. Note whether the child snores, sounds congested, appears restless across the whole night or only at the start of sleep.
A sleep log is not about finding the right data. Sleep-deprived parents often underestimate or overestimate specific aspects of their child’s sleep. A log gives both the parent and the clinician a shared, accurate starting point.
For most healthy children between 2 months and 6 years with standard bedtime resistance or night waking, the evidence is clear: consistent behavioral work, fitted to the child and the family, produces reliable improvement. The hardest part is usually not finding the right method. It is applying it long enough and consistently enough to let it work.
References
Lecuelle, F., Leslie, W., Gustin, M.-P., Franco, P., & Putois, B. (2024). Treatment for behavioral insomnia in young children with neurotypical development under 6 years of age: A systematic review. Sleep Medicine Reviews, 74, 101909. https://doi.org/10.1016/j.smrv.2024.101909
Mindell, J. A., Kuhn, B., Lewin, D. S., Meltzer, L. J., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 29(10), 1263-1276. https://pubmed.ncbi.nlm.nih.gov/17068979/
Mindell, J. A., Telofski, L. S., Wiegand, B., & Kurtz, E. S. (2009). A nightly bedtime routine: Impact on sleep in young children and maternal mood. Sleep, 32(5), 599-606. https://pmc.ncbi.nlm.nih.gov/articles/PMC2675894/
Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B., Brown, T. M., Coleman, J., Jr., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 29(10), 1277-1281. https://pubmed.ncbi.nlm.nih.gov/17068980/