Habits are Powerful: This one seems no different

Many of you will know of my interest in sleep and the role we as primary contact practitioners can have on influencing our clients health, wellbeing and recovery, by providing evidenced based advice on improving sleep.

An article published in the August edition of Sleep by Fiese et al, titled 'Bedtimes, bedtime routines, and children's sleep across the first 2 years of life', explores the benefits of establishing a bedtime routine (and what type of routine) on sleep quality.

The relevance? We have a better understanding about the relevance of what we do in the first 5 years of our life. Critical brain development, habit forming, and learning all occur in these early years, which influences the rest of our life. Sleep quality is arguably the most important factor in this process.

 Abstract Sleep, Volume 44, Issue 8, August 2021

 Study Objectives

The first objective of this study was to determine whether establishing bedtime routines in the first year of life predicts better sleep outcomes (i.e. longer sleep duration, less night-time waking, earlier bedtime, shorter sleep latency, fewer sleep problems) across the first 2 years of life. The second objective was to determine whether specific adaptive bedtime activities (e.g. book reading) were associated with sleep outcomes. The third objective was to describe changes in adaptive bedtime activities (hug/kiss caregiver, say goodnight to family) across the first 2 years of life.


Parents of 468 children from the STRONG Kids 2 birth cohort were surveyed about bedtime and bedtime routines, their child's sleep duration, night-time waking, sleep latency, and sleep problems at 3, 12, 18, and 24 months of age. The STRONG Kids 2 is a transdisciplinary project aiming to provide unique insights into how individual biology interacts with the family environment. It is an observational, longitudinal study with no interventions. The study sample includes infants and their families located in small urban communities in central Illinois, USA. Mothers are surveyed about a range of factors including weaning, dietary habits, household routines, and children's emotions.


Cross-lagged panel models revealed partial evidence for reciprocal associations between bedtime routine consistency and adaptive bedtime activities and better sleep outcomes over time. Specifically, more bedtime routine consistency predicted less night-time waking and sleep problems, and more bedtime adaptive activities predicted longer sleep duration and fewer sleep problems.

 Clinical Considerations

After coming out from complete darkness (i.e., birth) our circadian clock hasn't developed, but after a few months of day and night, this rhythm is exerting a regular sway on the development of our sleep pattern. Children usually have an early shifted circadian rhythm,(i.e., go to bed early and wake up early). At this stage we are sleeping approximately 14 hours per day. Not that your parents will remember, as the timing usually didn't suit their routines. In these early months our sleep cycle was split 50/50 between NREM and REM, but over the next few years our total sleep time drops to 12 hours and the amount in REM decreases, with the ratio more 70/30. In these early developmental years, the brain is laying down maximal capacity, a feature of REM sleep. As the brain matures, the development focus shifts from capacity building to efficiencies through learning and remodelling. Areas of the brain not utilised are dialled down or pruned and this is a feature of deep sleep or NREM sleep. The pruning continues based on learning experiences, and while neural cells are pruned, those remaining grow in physical size, so the brain is growing in size overall. Without adequate sleep quality and quantity this process of remodelling is retarded. Lost sleep like a dream, can't be caught up at a later time.

While you may not see yourself as a sleep educator, you probably do see yourself as a source of relevant health information. In a recent survey of patient's expectations of physiotherapy services, things like physical activity, postural advice, weight loss, manual therapy and sleep advice were evaluated. Survey respondents reported on what was 'important' (ranging from extremely to extremely not important) and 'likely' that physiotherapists would provide. From this survey, nearly 60% of respondents believed it was 'extremely important' or 'important' that physiotherapists provide sleep advice, however they reported it was less that 50% extremely likely or likely this education would occur**.

There is a strong expectation from the public that we should be providing sleep education and it really isn't that difficult to up-skill yourself. I have brought together all the relevant research and packaged it in a way that you can immediately incorporate into your current clinical practice. You can dive in real deep and provide an evidenced based service for insomnia or you can pick the tips and provide them to a wide range of clients that you currently assist. Or both. Remember, lost sleep is just that and with it goes recovery, learning, fertility, healthy weight stability and a bunch of cardiovascular protectants. We owe it to our clients to better understand and communicate the importance of sleep. Sleep may be free but it isn't without important value.

**Kunstler B, Fuller R, Pervan S, Merolli M. Australian adults expect physiotherapists to provide physical activity advice: A survey. Journal of Physiotherapy. 2019;65(4):230-6. doi: 10.1016/j.jphys.2019.08.002.