A Matter of Minutes? The Magnitude of Pediatric Sleep Extension Interventions

When caregivers discuss their children’s habitual sleep duration, they typically reference sleep hours, not minutes. Indeed, national consensus panel recommendations for optimal functioning are provided in hours, by age, driving clinician assessment practices and patient/family-facing sleep health education. Recommendations for young children (aged 3–5 years) are 10 to 13 hours total (including naps), 9 to 12 hours for school-aged children (aged 6–12 years), and, ambitiously, 8 to 10 hours for those aged 13 to 18 years. For many caregivers, anything shorter than the minimum recommended number of sleep hours can feel like a failure, with ominous warnings about consequences for attention, behavior, and learning. These recommendations may be especially challenging for caregivers of children with developmental differences, who tend to have short sleep duration and were not well represented in consensus panel data.Yet, for all children, families, and pediatric clinicians, a dose of practical optimism is needed here. Experimental research with adolescents also shows that extending sleep by a little as 13 minutes benefits cognitive functioning and reduces depressive symptoms.1,2 Another experimental study of school-aged children found that extending sleep by about 28 minutes was associated with better emotional and behavioral regulation and less daytime sleepiness.3 A meta-analysis of experimental at-home sleep extension interventions also found benefits for externalizing and internalizing symptoms, cognitive functioning, and physical activity for adolescents.4 Longer extensions in sleep are associated with even larger benefits at both the individual and societal level. At the individual level, in a meta-review of 39 systematic reviews, which included experimental data, longer sleep duration was consistently associated with reduced adiposity and better emotional-behavioral functioning.5 And at the societal level, moderate extensions in sleep can lead to safer roads. For instance, after Fairfax County, Virginia, implemented a later school start time, adolescents were sleeping about 30 minutes more per school night.6 This extension led to a reduction in adolescent car crashes by about 6%, whereas other parts of the state without delayed start times showed no change over time.6 Data from the National Highway Traffic Safety Administration indicate that there were 5588 fatalities due to teenager drivers in the US in 2023.7 A rough calculation shows that a 6% reduction in fatal crashes translates into 335 fewer fatalities per year—a meaningful reduction given that car crashes remain one of the top causes of pediatric deaths.Although awareness of the minimum sleep duration thresholds by age is important, caregivers and clinicians should focus on how to improve sleep health in smaller, more manageable and sustainable increments. Indeed, the American Academy of Pediatrics suggests that pediatricians support healthy sleep and other lifestyle behaviors through plans that involve “small changes” and emphasize “practical changes that are likely to be sustainable for the child and family.”8 Decades of research indicate that although there are a variety of strategies to benefit child sleep duration, most successful interventions extend sleep by less than 20 minutes per night. We argue that even 10 to 15 minutes of sleep extension is valuable, can be beneficial for daytime functioning, and is achievable with the integration and tailoring of existing intervention strategies. In Table 1, we summarized the average effectiveness of common psychoeducational, cognitive-behavioral, and structural interventions on extending child sleep duration. Meta-analytic data from the most recent high-quality peer-reviewed publications are included. In the absence of a meta-analysis, we reference experimental data with strong study designs.A meta-analysis of interventions focused on reducing overall child screen time and promoting healthy lifestyle habits, including healthy sleep, benefited sleep duration by about 11 minutes per night.9 An intervention that focused on restricting mobile devices 1 hour before bedtime in teens yielded about a 21-minute extension in sleep duration.10 Another experimental study of teens included both sleep hygiene psychoeducation and gradual sleep schedule advancement by 5 minutes per night (max = 55 minutes),1 which improved actigraphy-assessed sleep duration by 13 minutes among teens in the intervention compared with controls.1 A meta-analysis of interventions explicitly focused on extending child sleep duration found that the average benefit was 11 minutes per night. Additionally, interventions that included certain behavior change techniques (sleep psychoeducation, role-playing to practice bedtime routines, developing time management and bedtime routines) yielded a benefit of 14 minutes per night, although this was not statistically different than the 8 minutes per night benefit of interventions without those techniques.11 As a comparison, at the structural level, a meta-analysis of school start time data shows that delaying school start time by 1 hour improves sleep duration by about 40 minutes more per night.12A total of 10 to 15 more minutes of sleep per night amounts to 4 to 7 more hours per month. These additional hours of sleep can translate into meaningful improvements in physical, mental, and cognitive functioning. For example, the teen sleep extension study that improved sleep duration by 13 minutes also found statistically significant improvements in depressive symptoms,1 which are increasingly common in adolescence and a major public health concern. And the literature on delaying high school start times is rife with examples of far-reaching benefits for teens.12 Additional research to estimate the full range of impacts that habitual sleep extension—in minutes as well as hours—can have on pediatric performance and well-being may strengthen the case for families and communities to prioritize sleep health.Table 1 is instructive but only provides part of the story. The mean changes reported in total sleep duration can mask individual variation in effectiveness. That is, some individuals may experience limited or no intervention-related improvements, whereas others may benefit in a much larger way. Those who are most sleep deficient are more likely to benefit the most. Second, some strategies may not be appropriate, depending on the child. For instance, children with insomnia (difficulty falling/staying asleep) should receive cognitive-behavioral treatment, which includes additional strategies and typically involves initially reducing rather than extending time in bed. Of note, meta-analytic research indicates that treating childhood insomnia also extends sleep duration by 11.5 minutes.13 Finally, other aspects of sleep, such as regularity (consistency of sleep schedule), are important to consider and evaluate. Lastly, although existing sleep extension strategies are effective when implemented as individual treatment approaches, combining multiple strategies through tiered approaches may lead to even larger gains in sleep health and beneficial sequelae. For instance, enacting later school start time policies in conjunction with universal healthy lifestyle education (ie, sleep hygiene, reduced bedtime screen use, physical activity) and targeted insomnia treatment for children identified with symptoms could collectively improve sleep health.9Future pediatric sleep duration extension interventions for short-sleeping children should further examine the potentially synergistic benefits of combining multiple strategies (eg, screentime reduction, sleep schedule advancement) and specific behavior change techniques.11 Applying these approaches and setting an initial, achievable goal for sleep extension can build self-efficacy and motivation, which are crucial for initiating and sustaining health behavior change.14 In the study restricting smartphone use 1 hour before bedtime, only 26% of adolescents approached agreed to participate, suggesting a need to integrate motivational interviewing strategies10 and, perhaps, a “harm reduction” approach with more gradual reductions in screen use before bedtime or taking steps toward an end goal of removing devices from the bedroom altogether. Focusing on consistent improvements in sleep health, even if this looks like getting into bed 10 to 15 minutes earlier for now or turning off devices 15 to 20 minutes before bedtime (or ideally, removing them from the bedroom altogether), may be more feasible and sustainable for many families. Habitual sleep extension by 10 to 15 minutes is both realistic and beneficial. As with other health behaviors, establishing healthy habits takes time and consistency. We encourage clinicians and families to consider starting with small sleep duration extensions that are feasible, sustainable, and tailored to the child and family. This approach can benefit pediatric sleep and overall well-being, particularly for a child that is already sleep deprived, in addition to enhancing broader family functioning.