Prevalence, patterns, and persistence of sleep problems in the first 3 years of life.
ABSTRACT Examine the prevalence, patterns, and persistence of parent-reported sleep problems during the first 3 years of life.
Three hundred fifty-nine mother/child pairs participated in a prospective birth cohort study. Sleep questionnaires were administered to mothers when children were 6, 12, 24, and 36 months old. Sleep variables included parent response to a nonspecific query about the presence/absence of a sleep problem and 8 specific sleep outcome domains: sleep onset latency, sleep maintenance, 24-hour sleep duration, daytime sleep/naps, sleep location, restlessness/vocalization, nightmares/night terrors, and snoring.
Prevalence of a parent-reported sleep problem was 10% at all assessment intervals. Night wakings and shorter sleep duration were associated with a parent-reported sleep problem during infancy and early toddlerhood (6-24 months), whereas nightmares and restless sleep emerged as associations with report of a sleep problem in later developmental periods (24-36 months). Prolonged sleep latency was associated with parent report of a sleep problem throughout the study period. In contrast, napping, sleep location, and snoring were not associated with parent-reported sleep problems. Twenty-one percent of children with sleep problems in infancy (compared with 6% of those without) had sleep problems in the third year of life.
Ten percent of children are reported to have a sleep problem at any given point during early childhood, and these problems persist in a significant minority of children throughout early development. Parent response to a single-item nonspecific sleep query may overlook relevant sleep behaviors and symptoms associated with clinical morbidity.
- [Show abstract] [Hide abstract]
ABSTRACT: To longitudinally examine sleep patterns, habits, and parent-reported sleep problems during the first year of life.Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 09/2014; · 2.93 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The aim of this study was to identify, using cluster analysis, novel sleep phenotypes in a population based cohort of infants, and to explore the associations between infant sleep profiles and their mothers' health and well-being. 11,134 mothers of 9-month old infants were interviewed as part of the Growing Up in Ireland National Longitudinal study and reported on their health and infant's sleep patterns. 16 infant sleep variables were recorded together with measures of parental stress, depression, health and well-being. Multiple iterations of a two-step hierarchical cluster analysis were carried out to identify the optimum number of clusters and the subset of parental-reported sleep variables required to identify distinct sleep profiles. Four distinct sleep profiles were identified based on the following variables; (1) infant sleep duration at night, (2) parental sleep duration, (3) does baby wake during night (yes, no)? (4) Usual sleep location for most of the night and, (5) parental reporting of problem infant sleep patterns. This identified two less favorable profiles with both infants and mothers sleeping less and where mothers are more likely to report their infants' sleep patterns as problematic. Mothers of infants belonging to these sleep profiles were more likely to have higher levels of stress, depressive symptoms, and poorer self-reported health than other sleep profiles. Breastfeeding was associated with both groups and rates were highest in a group of infants that were more likely to co-sleep with their parents and have diverse ethnic backgrounds. This study demonstrates, for the first time, two infant sleep profiles with distinct phenotypical frameworks that are significantly associated with maternal stress, depression, and poorer self-report of health.Maternal and Child Health Journal 02/2015; · 2.24 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Background Shorter sleep is a risk factor for weight gain in young children. Experimental studies show that sleep deprivation is associated with higher nighttime energy intake, but no studies have examined the patterning of energy intake in relation to nighttime sleep duration in young children.Objectives The objectives of the study were to test the hypothesis that shorter-sleeping children would show higher nighttime energy intake and to examine whether the additional calories were from drinks, snacks or meals.Methods Participants were 1278 families from the Gemini twin cohort, using data from one child per family selected at random to avoid clustering effects. Nighttime sleep duration was measured at 16 months of age using the Brief Infant Sleep Questionnaire. Energy intake by time of day and eating episode (meal, snack, drink) were derived from 3-day diet diaries completed when children were 21 months.ResultsConsistent with our hypothesis, shorter-sleeping children consumed more calories at night only (linear trend P < 0.001), with those sleeping <10 h consuming on average 120 calories (15.2% of daily intake) more at night than those sleeping ≥13 h. The majority of nighttime intake was from milk drinks. Associations remained after adjusting for age, sex, birth weight, gestational age, maternal education, weight and daytime sleep.Conclusions Shorter-sleeping, young children consume more calories, predominantly at night, and from milk drinks. Parents should be aware that providing milk drinks at night may contribute to excess intake. This provides a clear target for intervention that may help address associations between sleep and weight observed in later childhood.Pediatric Obesity 02/2015; · 2.42 Impact Factor
Prevalence, Patterns, and Persistence of Sleep
Problems in the First 3 Years of Life
WHAT’S KNOWN ON THIS SUBJECT: Sleep problems are common
during childhood, but screening for sleep problems in the clinic
setting is often cursory. Moreover, there are few longitudinal
studies examining the prevalence and persistence of sleep
problems in young children.
WHAT THIS STUDY ADDS: Patterns of sleep problems vary across
early development, but sleep problems arising in infancy persist
in 21% of children through 36 months of age. Parent response to
a nonspecific query about sleep problems may overlook relevant
sleep symptoms and behaviors.
OBJECTIVE: Examine the prevalence, patterns, and persistence of
parent-reported sleep problems during the first 3 years of life.
METHODS: Three hundred fifty-nine mother/child pairs participated
in a prospective birth cohort study. Sleep questionnaires were
administered to mothers when children were 6, 12, 24, and 36
months old. Sleep variables included parent response to a
nonspecific query about the presence/absence of a sleep problem
and 8 specific sleep outcome domains: sleep onset latency, sleep
maintenance, 24-hour sleep duration, daytime sleep/naps, sleep
location, restlessness/vocalization, nightmares/night terrors, and
RESULTS: Prevalence of a parent-reported sleep problem was 10% at
all assessment intervals. Night wakings and shorter sleep duration
were associated with a parent-reported sleep problem during
infancy and early toddlerhood (6–24 months), whereas nightmares
and restless sleep emerged as associations with report of a sleep
problem in later developmental periods (24–36 months). Prolonged
sleep latency was associated with parent report of a sleep problem
throughout the study period. In contrast, napping, sleep location, and
snoring were not associated with parent-reported sleep problems.
Twenty-one percent of children with sleep problems in infancy
(compared with 6% of those without) had sleep problems in the
third year of life.
CONCLUSIONS: Ten percent of children are reported to have a sleep
problem at any given point during early childhood, and these problems
persist in a significant minority of children throughout early develop-
ment. Parent response to a single-item nonspecific sleep query may
overlook relevant sleep behaviors and symptoms associated with
clinical morbidity. Pediatrics 2012;129:e276–e284
AUTHORS: Kelly C. Byars, PsyD,a,bKimberly Yolton, PhD,c
Joseph Rausch, PhD,bBruce Lanphear, MD, MPH,dand
Dean W. Beebe, PhDb
Divisions ofaPulmonary Medicine,bBehavioral Medicine and
Clinical Psychology, andcGeneral and Community Pediatrics,
Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
anddFaculty of Health Sciences, Simon Fraser University and
Child and Family Research Institute, British Columbia Children’s
Hospital, Vancouver, British Columbia, Canada
sleep problems, infants, toddlers, prevalence, persistence
OSA—obstructive sleep apnea
Each author made a substantive intellectual contribution to the
study. Dr Byars participated in early conceptualization and
design of sleep measurement methodology and collaborated
with coauthors on data interpretation; he took a lead role with
drafting and revising the article. Dr Rausch provided critical
contributions to formulating the data analytic plan and assisted
with data interpretation as well as reviewing and revising the
article for important intellectual content. Dr Yolton was
a primary investigator in the research laboratory that secured
funding for this project. She had primary responsibility for the
study design and oversight of its execution and participated in
the conceptualization and design of the sleep measurement
tools. Dr Yolton also played a significant role with respect to
data collection and interpretation as well as critically reviewing
and revising the article. Dr Lanphear was the principal
investigator who secured funding for this project. He had
primary responsibility for the study design and oversight of its
execution. Dr Lanphear also played a significant role with
respect to data collection and interpretation as well as critically
reviewing and revising the article. Dr Beebe also participated in
early conceptualization and design of sleep measurement
methodology, conducted data analysis and interpretation of
study findings, and drafted and critically revised the article.
Accepted for publication Sep 26, 2011
Address correspondence to Kelly C. Byars, PsyD, Divisions of
Pulmonary Medicine and Behavioral Medicine and Clinical
Psychology, Cincinnati Children’s Hospital Medical Center, ML
2021, 3333 Burnet Ave, Cincinnati, OH 45229-3039. E-mail: Kelly.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
BYARS et al
Sleep problems are common in child-
managed.1–5The importance of de-
tection and treatment of pediatric
sleep disorders is underscored by a
growing literature that links sleep
problems with other morbidities.6–15
For example, cardiovascular morbidity
and metabolic syndrome have been
linked with obstructive sleep apnea
(OSA).9,10Sleep problems are also as-
sociated with impairments in daytime
functioning and decreased quality of
life in affected children6,7,11–15as well
as secondary effects on families (eg,
disrupted parent sleep; marital dis-
cord; maternal stress).16–20
Because sleep is essential to daily
through anticipatory guidance in pe-
diatric settings.21However, research
indicates that pediatric sleep problems
may go undetected during routine clin-
ical care.22–24In a survey of pedia-
do not screen for sleep disturbance or
use singular screening questions when
talking with parents of infants and tod-
dlers (eg, “Does your child have any
sleep problems?”23). Furthermore, little
is known about how parents interpret
ficial inquiry and parent interpretation
about whatconstitutes a sleepproblem
are factors that likely play a role in
the underdiagnosis or misdiagnosis of
pediatric sleep problems. For example,
clinically important symptoms such as
snoring, a hallmark symptom of OSA,
might be missed if they are not en-
compassed within parents’ typical defi-
nitions of a “sleep problem.” Further,
once a sleep problem is identified, the
decisiontointervene restsin part upon
the physician’s beliefabout whether the
problem will persist. The bulk of the
literature supports the persistence of
early-onset sleep problems2–5,25–35but
has relied on nonspecific dichotomous
measures or focused on a narrowly
defined sleep behavior (eg, bedtime
refusal). Few authors have serially
measured a comprehensive measure
of parent-reported sleep patterns dur-
ing early childhood.
Clinical decision-making may be ham-
pered by gaps in our knowledge of the
utility of a nonspecific single sleep
screening question and the prevalence
and persistence of sleep problems
during early childhood. The purpose of
the current study was to fill these gaps
by examining the prevalence, patterns,
and persistence of broadly defined
sleep problems and more specific
domains of sleep behavior during the
first 3 years of life.
The study cohort comprised mother/
child pairs participating in the Health
Outcomes and Measures of the Envi-
birth cohort in the Cincinnati, Ohio,
March 2003, women were identified
from 7 prenatal clinics associated with
3 hospitals. Eligible mothers were
identified at #19 weeks of gestation,
were age $18 years, negative for HIV,
and not taking medications for seizure
or thyroid disorders. Letters were
of the 1263 eligible respondents were
consented and enrolled. Sixty-seven
enrollees dropped out before delivery;
3 children were stillborn. Nine sets of
twins were excluded because their
sleep arrangements could fundamen-
tally differ from those of singleton chil-
singleton live births did not complete
sample of 359 subjects.
The institutional review board of Cin-
cinnati Children’s Hospital Medical
Center provided oversight for the
study. All mothers provided written in-
formed consent before enrollment.
Enrollees received phone calls regu-
the study. Study assessments were
completed annually during clinic and
home visits, and telephone surveys
were conducted at the 6-month mid-
point each year.
Questionnaires were administered via
structured interviews by trained re-
search assistants by telephone when
the children were 6 months of age.
Face-to-face interviews were con-
ducted during a home visit when the
children were 12, 24, and 36 months of
assessment that spans infancy and
early childhood, so 2 questionnaires
were developed based upon previous
scales,26,37–41whereas the question-
naire for 24- to 36-month-olds included
53 items adapted from the Child Sleep
Habits Questionnaire.42 Both ques-
tionnaires included the nonspecific di-
chotomous item “Do you think ____
Because this is similar to the single
question that is often asked in pedia-
tricians’offices,the response comprised
The questionnaires were not direct-
ly parallel because developmental
changes necessitated differences in
item content (eg, sleepwalking items
are not relevant for infants) and the
range of response options. Conse-
quently, we were not able to directly
compare every sleep behavior across
developmentally relevant sleep behav-
ior domains based upon the previous
sleep literature and subsequently
identified specific questionnaire items
PEDIATRICS Volume 129, Number 2, February 2012
representative of these sleep domains.
The sleep behavior domains and their
composition were refined based upon
an examination of item variability and
factor analyses from each time point.
is presented in Table 1 (see Supple-
options and endorsement patterns at
each time point). Items had differing
response options, so we converted
score metric relative to the cohort
mean and SD at each time point. For
multi-item domains, individual item
scores were averaged before further
analyses. The result was a matrix of
continuous domain scores for each
subject at each time point that (a) was
conceptually consistent over time, (b)
was placed on a common statistical
metric, and (c) mirrored the dis-
tributions of the raw data.
Preliminary x2and Mann-Whitney U
characteristics of subjects with avail-
able sleep data at each time point
against those with missing data to as-
sess fordifferentialattrition over time.
These tests and Spearman correla-
tions also examined whether the sleep
domain scores or rate of overall sleep
problems differed reliably by child
gender, family income, or race. Finally,
using Fisher’s z test, we examined
whether the correlations described in
our primary analyses varied signifi-
cantly by race or gender. Finding no
substantivedifference in thepattern of
correlations among the subgroups, we
subsequently used the full sample for
report of a nonspecific sleep problem
at the 6-, 12-, 24-, and 36-month as-
sessments. We also examined which of
the 8 sleep behavior domains were
associated with parent report of a
sleep problem at each time point. We
calculated Spearman correlations to
determine the association between con-
tinuous sleep behavior domain scores
at each time point with analogous
scores obtained later. Finally, to de-
termine the risk for persistence of
parent-reported sleep problems, we
calculated odds ratios and associated
Fisher’s exact tests. A two-tailed signifi-
across all analyses.
TABLE 1 Sleep Domains, Interpretation, and Item Composition
Scale NameMeaning of a High Score Items Included in 6- to 12-Month Assessments
(Timeframe: “On average, over the past month”)
Items Included in 24- to 36-Month Assessments
(Timeframe: “During a typical week”)
Sleep onset latencyFalls asleep quickly
After the bedtime routine (eg, bath),
how long does it take to get ___ to sleep at night?
How many times per week have you had problems
getting ___ to sleep at night?
How often does ___ …
…fall asleep within 20 min after going to bed?
…resist going to bed at bedtime?
…struggle at bedtime (eg, cry, refuse to
stay in bed)?
How often is ___ ready to go at bedtime?
How often does ___ wake up…
…once during the night?
…more than once during night?
What is ___’s usual amount of sleep each day,
combining nighttime sleep and naps?
Sleep maintenance Few night wakingsHow many…
…nights per week has ___ woken during sleep?
…times has ___ woken each night?
How much time does ___ spend…
24-h sleep durationLonger sleep
…sleeping each night?
…napping each day?
…days per week has ___ napped during the day?
…naps has ___ taken per day?
Where is ___ initially laid down to sleep?
(data collapsed to parent bed versus not)
Where has __ slept most of the night?
(data collapsed to own bed/crib versus not)
NapsMore daytime naps How often does ___ nap during the day?
Sleep locationSleeping in own bed/cribHow often does ___ fall asleep…
…alone in his or her own bed?
…in a parent’s or sibling’s bed?
Calm, quiet sleepHow many nights per week have you
seen or heard ___
…talking or vocalizing during sleep?
…being restless or moving around during sleep?
How many nights per week have you seen
or heard __ wake up sweating,
screaming, and inconsolable?
…does ___ talk or vocalize during sleep?
…is__ restless and moving a lot during sleep?
How often does ___ …
…awaken during the night and is sweating,
screaming, and inconsolable?
…awaken alarmed by a frightening dream?
How often does ___ snore loudly?
SnoringMinimal snoringHow many nights per week have you seen
or heard ___ snoring loudly during sleep?
BYARS et al
Of the 359 eligible mother/child dyads,
months. Demographic characteristics
which was evenly divided by gender,
was comprised primarily of first- and
second-born children and covered
broad socioeconomic strata. At the 6-
month survey point, the sample was
64% white participants and 31% Afri-
can American participants. There was
differential attrition over time among
African Americans and those in the
lowest education and income groups
(P , .005).
African American children and those
reported to have longer sleep onset
latency, shorter overall sleep duration,
less independent sleep, and more
snoring than were white children and
time points (P , .01; Supplemental
Tables 5 and 6). However, the overall
rate of parent-reported nonspecific
sleep problems and behaviors around
differ by race or family income at any
time point. Reported napping/daytime
sleep, vocalization/restlessness, and
nightmares/night terrors differed by
race or family income at only 1 time
point each. Sleep variables differed by
child gender in only 3 of 36 analyses,
well within expectations based upon
chance variation alone.
Prevalence and Patterns of
Parent-Reported Sleep Problems
As shown in Fig 1, the presence of a
nonspecific sleep problem was repor-
ted by roughly 10% of parents at each
time point. Parent report of a sleep
problem was significantly associated
all age ranges, aswellas poorer sleep
maintenance and shorter sleep dura-
at 36 months (Table 3). Nightmares/
vocalization were significantly associ-
ated with parent report of a sleep
problem from 12 to 36 months of age.
Parent report of a sleep problem was
significantly associated with snoring
only at 12 months and with the location
of a child’s sleep only at 24 months. The
frequencyofnaps ordaytime sleepwas
never significantly associated with pa-
rental report of a sleep problem.
Stability of Sleep-Related Behaviors
and Parent-Reported Sleep
Table 4 presents correlations between
sleep domain scores obtained at each
time point with the equivalent domain
score collected at later time points.
Medium (r = 0.30) to large (r = 0.50)
effects43were observed for nearly all
correlations from 1 time point to the
next, and significant correlations
were evident between our 2 most
distant measurement points (6 and
duration, sleep location, restlessness/
vocalization, and snoring.
Compared with those who were not
reported to have an early sleep prob-
lem, infants and toddlers with a repor-
ted sleep problem had much higher
rates of such problems at later time
points (Figs 2, 3, and 4). Only 6% to 8%
of children without a reported sleep
of those who were reported to have
showed persistent sleep problems 1 to
2 1/2 years later.
Prevalence and Patterns of Sleep
Our findings indicate that the overall
prevalence of parent-reported sleep
problems remains stable during early
development. At each time point, 1 in
10 parents reported the presence of
nonspecific screening question that
TABLE 2 Sample Demographics
Total Sample6 mo12 mo24 mo 36 mo
Sample size, n
Age, mean 6 SD, mo
Gender, % girls
Race, % white
% African American
Parity (median [25th,
Maternal education at birth
(median years [25th,
Family income at birth
(median in $1000s [25th, 75th
6.4 6 0.5
1 (0, 1)
12.9 6 1.2
1 (0, 1)
25.1 6 1.0
1 (0, 1)
37.3 6 1.5
1 (0, 1)1 (0, 1)
Demographic differences between retained and missing subjects via x2or Mann-Whitney U test, *P , .05, **P , .01; ***P , .001. NA, not available.
PEDIATRICS Volume 129, Number 2, February 2012
is similar to what many physicians
use during routine clinic visits.22–24
This falls well within the broad range
of reported prevalence rates (2%–
33%) based on cross-sectional re-
There appear to be developmental
parents mean when they report a non-
specific sleep problem. Our data sug-
gest that sleep onset difficulties are
considered problematic by parents
throughout early childhood, consistent
with previous studies documenting
that this is a common complaint of
parents with young children.5,25,29,33
Our findings also suggest that night
wakings and shorter sleep duration
were perceived as sleep problems by
6 months of age and then remained
particular concerns for parents through
2 years of age. In contrast, parental
endorsement of a sleep problem was
not linked to sleep behaviors char-
acteristic of partial arousal para-
sleep) until 12 to 36 months of age.
Parents who reported that their child
had a sleep problem did not report
atypical snoring, sleep location, or
napping/daytime sleeping behaviors
and report problems related to these
decision making. For example, 12% to
20% of our sample snored multiple
nights per week, placing them at high
risk for OSA, a nocturnal breathing
disorder associated with medical mor-
bidity and neurobehavioral deficits in
children.44However, parents did not
seem to associate snoring with sleep
problems, and previous research has
shown that routine screening for
snoring occurs in only 25% or less of
well-child visits.42As a result, snoring
could be completely overlooked during
well-child visits, despite its known risk
for morbidity. The American Academy
of Pediatrics recommends that all
children be specifically screened for
snoring and that children deemed
at risk for OSA be referred for sub-
Sleeping arrangements, particularly
infant sleep location, has received
considerable attention in the pediatric
in North America and other indus-
trialized countries and is an accepted
and common practice in many ethnic
location were collapsed to examine
solitary sleeping versus sleeping in
other contexts (eg, parent’s/sibling’s
bed). Across all time points, the ma-
jority of children (62.5%–81.9%) were
sleeping in their own bed; infants and
toddlers 16.6% and 17.2%, respec-
tively, were sleeping with a parent. Our
Prevalence of parent-reported sleep problems. Percent of children reported by their parent to have
a sleep problem at 6, 12, 24, and 36 months of age.
TABLE 3 Associations between Parental Endorsement of an Overall Sleep Problem and Sleep
6 mo 12 mo 24 mo 36 mo
Sleep onset latency
24-h sleep duration
Two-tailed point-biserial correlation significance: *P , .05, **P , .01, ***P , .001.
TABLE 4 Correlations of Sleep Domain Data Collected at 6, 12, and 24 Months With the Same
Domain at Later Time Point(s)
Correlation of Data at 6 Mo
With That Collected Later at…
Correlation of 12-Mo
Data With Data Collected at…
Correlation of 24-Mo
Data With Data From
…12 mo …24 mo …36 mo
Sleep onset latency 0.35***
24-h sleep duration 0.44***
0.37*** 0.19**0.23***0.31*** 0.23***0.29***
Two-tailed significance values for Spearman rank-order correlations: *P , .05, **P , .01, ***P , .001.
BYARS et al
findings suggest that parents do not
systematically consider the sleep loca-
tion of their 6- to 36-month-old child to
be, in and of itself, a problem. Sleep lo-
cation may be more relevant in the
context of specific sleep symptoms/
behaviors. For example, night wakings
may be considered more problematic
to parents if they cosleep with their
child. Future research examining sleep
should consider more refined analyses
of specific sleep symptoms/behaviors
(eg, breastfeeding; smoking exposure)
that were not a focus of this study.
anecdotal evidence indicating that pa-
rents of young children struggle with
nap issues (eg, irregular nap sched-
ule).45Our data show that parents of
infants and toddlers do not systemati-
cally relate napping behavior to the
presence of a sleep problem; if a clini-
cian is interested in learning about nap-
ping, specific queries are necessary.
Stability of Sleep Problems and
Our findings provide guidance to
pediatricians about the persistence of
the same age, children reported by
any time point in early childhood had
of children who were reported to have
age went on to also have a similar
problem at later measurement points.
These observations are generally con-
sistent with other longitudinal studies
that have documented the persistence
40% of children through 36 months of
infants and toddlers identified as hav-
ing a sleep problem at any given time
are not identified as having such a
problem later, a significant minority
continue to have problems over spans
of months to years.
We also examined the stability of more
specific domainsof sleep behavior (eg,
measured closer in time correlated
age (open bars) versuswithout asleep problem at6 months(black bars) who went on tohavea sleep
.01, ***P , .001.
.01, ***P , .001.
.01, ***P , .001.
PEDIATRICS Volume 129, Number 2, February 2012
longer time spans, suggesting partic-
ular stability in sleep behaviors across
6- to 12-month time spans. Second,
there was generally moderate stability
in sleep behaviors over time, with the
greatest stability in sleep behaviors
tending to be in the domains of sleep
onset latency, sleep duration, sleep lo-
cation, restlessness/vocalization, and
snoring. Thus, parent-report in these
areas cannot be expected to change
markedly across the infant and pre-
school years. In contrast, daytime
sleep/naps, nightmares/terrors, and
nocturnal arousals were less stable
over time. Finally, significant corre-
lations between our 2 most distant
measurement points (6 and 36
months) in sleep onset latency, sleep
duration, sleep location, restlessness/
vocalization, and snoring suggest that
these sleep behaviors, or at least
parent-report of these behaviors, may
establish themselves quite early in
should be considered when interpret-
ing our results. First, sampling error
may have influenced prevalence esti-
mates of sleep problems; approxi-
completed baseline study procedures
and approximately one fourth of the
original sample was lost to attrition by
in light of the sampling methodology
involving recruitment from prenatal
results may not be applicable to the
general population of children across
North America. Second, all sleep mea-
sures were based on parent-report,
and although this is likely to be the
primary source of information in the
clinic, rater bias cannot be ruled out.
instrument for assessing sleep prob-
were required to pool data from 2 in-
dependent sleep questionnaires. We
reassuring that the correlations be-
tween behavior domain scores col-
lected at 12 and 24 months (spanning
the infant and preschool question-
naires) were similar to those between
6 and 12 months or between 24 and 36
months (within a given questionnaire).
Nevertheless, measurement impreci-
lack of parallel measures at all as-
sessment points. Fourth, because the
that were the focus of this study are
culturally defined to varying degrees,
the potential impact of cultural differ-
ences in defining sleep problems must
be considered. Our analyses indicated
there were differences between the
majority and minority groups with re-
spect to several domains of sleep
behaviors. However, there were no
differences in the prevalence and per-
sistence of sleep problems between
groups and thus the cultural differ-
influenced our study findings. Finally,
this descriptive study did not pro-
pose nor examine potential mecha-
nisms underlying sleep problems.
Consequently, we did not consider po-
tential confounding variables during
data analysis. Future investigations
examining the persistence of sleep
mechanisms and potential confounding
Parent interpretation and report of
may be inconsistent with clinical cri-
teria for diagnosing pediatric sleep
disorders, especially when assessed
via a nonspecific query. To clarify pa-
rental concerns about sleep during
early development and ensure that
clinically relevant sleep issues are not
overlooked, we recommend that sleep
problems be screened by using a flexi-
ble family-centered approach while
addressing specific sleep behaviors
significance. Owens and Dalzell50have
developed a tool that has proven utility
in the clinic setting, facilitates brief
sleep screening, is developmentally
sensitive, and is behavior/symptom
specific. Although we did not directly
test the utility of that tool, the current
study confirms the importance of fo-
cused screening for sleep problems
during infancy and early childhood that
goes further than merely asking if the
child has problems sleeping.
This work was partially supported by
vironmental Health Sciences (R01
ES015517-01A1, P01 ES11261).
1. Lozoff B, Wolf AW, Davis NS. Sleep problems
seen in pediatric practice. Pediatrics. 1985;
2. Pollock JI. Predictors and long-term asso-
ciations of reported sleeping difficulties in
infancy. J Reprod Infant Psychol. 1992;10
3. Pollock JI. Night-waking at five years of age:
predictors and prognosis. J Child Psychol
4. Zuckerman B, Stevenson J, Bailey V.
Sleep problems in early childhood:
continuities, predictive factors, and be-
havioral correlates. Pediatrics. 1987;80
BYARS et al
5. Kataria S, Swanson MS, Trevathan GE.
Persistence of sleep disturbances in pre-
school children. J Pediatr. 1987;110(4):642–
6. Beebe DW, Gozal D. Obstructive sleep apnea
and the prefrontal cortex: towards a com-
prehensive model linking nocturnal upper
airway obstruction to daytime cognitive
and behavioral deficits. J Sleep Res. 2002;
7. Beebe DW, Groesz L, Wells C, Nichols A,
McGee K. The neuropsychological effects of
obstructive sleep apnea: a meta-analysis of
norm-referenced and case-controlled data.
8. Lumeng JC, Chervin RD. Epidemiology of
pediatric obstructive sleep apnea. Proc Am
Thorac Soc. 2008;5(2):242–252
9. Amin RS, Kimball TR, Kalra M, et al. Left
ventricular function in children with sleep-
disordered breathing. Am J Cardiol. 2005;
10. Larkin EK, Rosen CL, Kirchner HL, et al.
Variation of C-reactive protein levels in
disordered breathing and sleep duration.
11. Goodwin JL, Kaemingk KL, Fregosi RF, et al.
Clinical outcomes associated with sleep-
disordered breathing in Caucasian and
Hispanic children—the Tucson Children’s
Assessment of Sleep Apnea study (TuCASA).
12. O’Brien LM, Mervis CB, Holbrook CR, et al.
disordered breathing in children. J Sleep
13. Sadeh A, Gruber R, Raviv A. Sleep, neuro-
problems in school-age children. Child Dev.
14. Owens J, Opipari L, Nobile C, Spirito A.
Sleep and daytime behavior in children
with obstructive sleep apnea and behav-
ioral sleep disorders. Pediatrics. 1998;102
15. Lavigne JV, Arend R, Rosenbaum D, et al.
Sleep and behavior problems among pre-
schoolers. J Dev Behav Pediatr. 1999;20(3):
16. Dahl RE, El-Sheikh M. Considering sleep in
a family context: introduction to the special
issue. J Fam Psychol. 2007;21(1):1–3
17. Hiscock H, Wake M. Randomised con-
trolled trial of behavioural infant sleep
intervention to improve infant sleep and
maternal mood. BMJ. 2002;324(7345):1062–
18. Wolfson A, Lacks P, Futterman A. Effects of
parent training on infant sleeping patterns,
parents’ stress, and perceived parental
competence. J Consult Clin Psychol. 1992;60
19. Durand VM, Mindell JA. Behavioral treat-
ment of multiple childhood sleep disorders:
effects on child and family. Behav Modif.
20. Adams LA, Rickert VI. Reducing bedtime
tantrums: comparison between positive
routines and graduated extinction. Pediat-
21. Olson LM, Inkelas M, Halfon N, Schuster MA,
O’Connor KG, Mistry R. Overview of the
content of health supervision for young
children: reports from parents and pedia-
22. Meltzer LJ, Johnson C, Crosette J, Ramos M,
Mindell JA. Prevalence of diagnosed sleep
disorders in pediatric primary care prac-
tices. Pediatrics. 2010;125(6). Available at:
23. Owens JA. The practice of pediatric sleep
medicine: results of a community survey.
Pediatrics. 2001;108(3). Available at: www.
24. Meissner HH, Riemer A, Santiago SM, Stein
M, Goldman MD, Williams AJ. Failure of
physician documentation of sleep com-
plaints in hospitalized patients. West J Med.
25. Wake M, Morton-Allen E, Poulakis Z, Hiscock
H, Gallagher S, Oberklaid F. Prevalence,
stability, and outcomes of cry-fuss and
sleep problems in the first 2 years of life:
prospective community-based study. Pedi-
26. Lam P, Hiscock H, Wake M. Outcomes of
infant sleep problems: a longitudinal study
of sleep, behavior, and maternal well-being.
Pediatrics. 2003;111(3). Available at: www.
27. Anders TF, Halpern LF, Hua J. Sleeping
through the night: a developmental per-
spective. Pediatrics. 1992;90(4):554–560
28. Simard V, Nielsen TA, Tremblay RE, Boivin M,
Montplaisir JY. Longitudinal study of pre-
school sleep disturbance: the predictive
role of maladaptive parental behaviors,
early sleep problems, and child/mother
psychological factors. Arch Pediatr Ado-
lesc Med. 2008;162(4):360–367
29. Jenni OG, Fuhrer HZ, Iglowstein I, Molinari L,
Largo RH. A longitudinal study of bed
sharing and sleep problems among Swiss
children in the first 10 years of life. Pedi-
atrics. 2005;115(1 Suppl):233–240
30. Gaylor EE, Goodlin-Jones BL, Anders TF.
Classification of young children’s sleep
problems: a pilot study. J Am Acad Child
Adolesc Psychiatry. 2001;40(1):61–67
31. Gaylor EE, Burnham MM, Goodlin-Jones BL,
Anders TF. A longitudinal follow-up study of
young children’s sleep patterns using a de-
velopmental classification system. Behav
Sleep Med. 2005;3(1):44–61
32. Wolke D, Meyer R, Ohrt B, Riegel K. The
incidence of sleeping problems in preterm
and fullterm infants discharged from neo-
natal special care units: an epidemiological
longitudinal study. J Child Psychol Psychi-
33. Jenkins S, Owen C, Bax M, Hart H. Conti-
nuities of common behaviour problems in
preschool children. J Child Psychol Psy-
34. Jones NB, Rossetti Ferreira MC, Farquar
M, Macdonald BL. The association be-
tween perinatal factors and later night
waking. Dev Med Child Neurol. 1978;20(4):
35. Bernal JF. Night waking in infants during
the first 14 months. Dev Med Child Neurol.
36. Geraghty SR, Khoury JC, Morrow AL,
Lanphear BP. Reporting individual test
results of environmental chemicals in
breastmilk: potential for premature wean-
ing. Breastfeed Med. 2008;3(4):207–213
37. Morrell J. The infant sleep questionnaire: A
new tool to assess infant sleep problems
for clinical and research purposes. Child
Adolesc Ment Health. 1999;4(1):20–26
38. Matthey S. The sleep and settle question-
naire for parents of infants: psychometric
properties. J Paediatr Child Health. 2001;37
39. Richman N. A community survey of char-
acteristics of one- to two-year-olds with
sleep disruptions. J Am Acad Child Psychi-
40. Johnson CM. Infant and toddler sleep:
a telephone survey of parents in one
community. J Dev Behav Pediatr. 1991;12(2):
41. Sadeh A. A brief screening questionnaire
for infant sleep problems: validation and
findings for an Internet sample. Pediatrics.
2004;113(6). Available at: www.pediatrics.
42. Owens JA, Spirito A, McGuinn M. The
(CSHQ): psychometric properties of a sur-
vey instrument for school-aged children.
43. Cohen J. Statistical Power Analysis for the
Behavioral Sciences, 2nd ed. Hillsdale, NJ:
Lawrence Erlbaum Associates; 1988
44. Section on Pediatric Pulmonology, Sub-
committee on Obstructive Sleep Apnea
Syndrome. American Academy of Pediat-
rics. Clinical practice guideline: diagnosis
PEDIATRICS Volume 129, Number 2, February 2012
and management of childhood obstructive
sleep apnea syndrome. Pediatrics. 2002;109
45. Mindell JA, Owens JA. Sleep in infancy,
childhood, and adolescence. In: Mindel JA,
Owens JA, eds. A Clinical Guide to Pediatric
Sleep: Diagnosis and Management of Sleep
Problems, 2nd ed. Philadelphia, PA: Lippin-
cott Williams & Wilkins; 2010:12–29
46. Hauck FR, Signore C, Fein SB, Raju TN. In-
fant sleeping arrangements and practices
during the first year of life. Pediatrics.
47. Horsley T, Clifford T, Barrowman N, et al.
Benefits and harms associated with the prac-
tice of bed sharing: a systematic review. Arch
Pediatr Adolesc Med. 2007;161(3):237–245
48. American Academy of Pediatrics Task Force
on Sudden Infant Death Syndrome. The
changing concept of sudden infant death
syndrome: diagnostic coding shifts, contro-
versies regarding the sleeping environment,
and new variables to consider in reducing
risk. Pediatrics. 2005;116(5):1245–1255
49. US Consumer Product Safety Commission.
CPSC Warns Against Placing Babies in
Adult Beds. Washington, DC: US Consumer
Product Safety Commission; 1999; Report
SPSC, Document 5091
50. Owens JA, Dalzell V. Use of the ‘BEARS’sleep
screening tool in a pediatric residents’
continuity clinic: a pilot study. Sleep Med.
BYARS et al