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Behavioral Sleep Interventions in the First Six Months of Life Do not Improve Outcomes for Mothers or Infants: A Systematic Review
Abstract
The United Kingdom's National Institute for Health Research has recently invited proposals for the design of a multicomponent primary care package of behavioral interventions to reduce parental distress caused by excessive infant crying in the first 6 months of life. A systematic review was performed to determine whether behavioral interventions for sleep, when applied by parents to infants younger than 6 months, improve maternal and infant outcomes.
Searches of PubMed, CINAHL, and Cochrane Database of Systematic Reviews were conducted to identify systematic reviews, meta-analyses, clinical trials, and cohort studies investigating the effects of behavioral sleep interventions in infants younger than 6 months (January 1993-March 2013). The evidence is critically analyzed, according to PRISMA guidelines.
Cry-fuss, feeding, and sleep problems emerge out of multiple dynamically interacting and co-evolving variables in early life and are for this reason generically referred to as regulatory problems. Studies that link behavioral interventions for sleep in the first 6 months with positive effects on maternal and infant health demonstrate 3 methodological constraints. They fail to identify and control for feeding difficulties, fail to distinguish between the neurodevelopmentally different first and second halves of the first year of life, and apply reductive analyses to evaluations of complex interventions. Despite substantial investment in recent years in implementation and evaluation of behavioral interventions for infant sleep in the first 6 months, these strategies have not been shown to decrease infant crying, prevent sleep and behavioral problems in later childhood, or protect against postnatal depression. In addition, behavioral interventions for infant sleep, applied as a population strategy of prevention from the first weeks and months, risk unintended outcomes, including increased amounts of problem crying, premature cessation of breastfeeding, worsened maternal anxiety, and, if the infant is required to sleep either day or night in a room separate from the caregiver, an increased risk of SIDS.
The belief that behavioral intervention for sleep in the first 6 months of life improves outcomes for mothers and babies is historically constructed, overlooks feeding problems, and biases interpretation of data.
... Contemporary infant care often comprises a focus on schedules, algorithms, and set routines along with promotion of limited/delayed responses to infants' communication for feeding, sleep, and cry-fuss communication; blanket advice to minimise sensory stimulation for feeding, sleep, and to address cry-fuss problems, without consideration of developmental needs and each individual infant's sensory preferences; and viewing unsettled infant behaviour primarily through medicalized lenses of reflux, allergy, and tongue-tie, without consideration of other infant emotional regulation factors (Ball et al., 2018;Douglas & Hill, 2013a, 2013bDouglas & Hiscock, 2010;McInnes & Chambers, 2008). These common contemporary perspectives exclude consideration of evidence-based, nonmedical interpretations of infant communication based on biomechanical, neuro-hormonal, sensory, and developmental frames of reference. ...
... Caregivers can receive education and support through resources including 1:1 consultation with NDC practitioners, shared medical appointments with other parents/caregivers, NDC focused books for parents, website content with video and written resources and parent/caregiver online support groups (Crawford et al., 2022). It is grounded in strong evidence from systematic reviews and meta-analyses of highquality evidence (Douglas & Geddes, 2018;Douglas & Hill, 2013a, 2013b. ...
... It is based in Brisbane and delivers services online and faceto-face. The NDC program offers a five-domain approach that considers infant health, mother health, sleep, sensory experiences, and feeding (Crawford et al., 2022;Douglas & Hill, 2013b;Whittingham & Douglas, 2016). It acknowledges that difficulties with infant sleep, breastfeeding, cry-fuss behaviours, and maternal mood are commonly influential upon each other (Blunden & Dawson, 2020;Butler et al., 2021;Douglas, 2013;Petzoldt, 2018). ...
... In other words, maternal depression and anxiety are not related to the length of the infant's self-regulated sleep periods, but rather to problems with maternal sleep efficiency, or difficulty of the mother initiating or falling back to sleep. 70 Sleep efficiency is related to anxiety and increased sympathetic tone, not to the number of times a mother wakes to feed. 70 Nonetheless, one study in Western mothers showed increased infant feeding, and more disturbed infant sleep was correlated with increased maternal depression. ...
... 70 Sleep efficiency is related to anxiety and increased sympathetic tone, not to the number of times a mother wakes to feed. 70 Nonetheless, one study in Western mothers showed increased infant feeding, and more disturbed infant sleep was correlated with increased maternal depression. 28 A study in Japanese mothers suggested that breastfeeding frequency, subjective fatigue, and decreased objective total sleep time in the first days postpartum may be associated with higher scores on depression scales. ...
... 80 In addition, having the infant sleep in a separate room as part of sleep training strategy could be associated with an increased risk of SIDS. 70 However, some studies show sleep training conducted under research conditions can be effective when the outcomes relate to maternal self-reported sleep outcomes, maternal reports of infant night waking, or maternal mental health. 82 One randomized control trial of 14 infants 76 showed no connection between graduated sleep interventions and emotional or behavioral problems 12 months later, but these results are too small to be generalizable. ...
A central goal of the Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The ABM empowers health professionals to provide safe, inclusive, patient-centered, and evidence-based care. Pregnant and lactating people identify with a broad spectrum of genders, pronouns, and terms for feeding and parenting. There are two reasons ABM's use of gender-inclusive language may be transitional or inconsistent across protocols. First, gender-inclusive language is nuanced and evolving across languages, cultures, and countries. Second, foundational research has not adequately described the experiences of gender-diverse individuals. Therefore, ABM advocates for, and will strive to use language that is as inclusive and accurate as possible within this framework. For more explanation, please read ABM Position Statements on Infant Feeding and Lactation-Related Language and Gender (https://doi.org/10.1089/bfm.2021.29188.abm) and Breastfeeding As a Basic Human Right (https://doi.org/10.1089/bfm.2022.29216.abm).
... Six studies, published in the last 5 years, describe infant sleep-related interventions with high relevance for the early postnatal period [26-28, 56, 58, 59]. In addition, four reviews summarize earlier studies and discuss the degree to which sleep-related interventions may increase sleep outcomes in the postnatal period of life [29,[53][54][55]. One intervention was started antenatally, two were implemented in maternity wards, and three were designed to support families at postnatal follow-up meetings. ...
... This review will not explore the gaps between different approaches, but some gaps seem important and may reflect the different conclusions reported in the reviews included [29,53,55]. A review from 2013 concluded that behavioral sleep interventions during the first six months of life do not have significant effects on infant sleep [53], while later reviews reported several positive effects [29,54,55]. ...
... This review will not explore the gaps between different approaches, but some gaps seem important and may reflect the different conclusions reported in the reviews included [29,53,55]. A review from 2013 concluded that behavioral sleep interventions during the first six months of life do not have significant effects on infant sleep [53], while later reviews reported several positive effects [29,54,55]. Some studies found that early interventions may increase infants' night-time sleep [26,54], reduce the frequency of nightwakings [71], increase the use of recommended early bedtimes for infants [56], prevent prolonged bedtime routines, eat as the last activity before sleep [27,56], and help infants to sleep more regularly in their own cot [27]. ...
Background
This scoping review focuses on infant sleep-related factors and themes that are relevant when health practitioners provide preventive health services to expectant and new parents.
Methods
A systematic literature search in CINAHL, PubMed, and PsycINFO, published in 2010 or later, identified 1661 records. The search was further narrowed to focus on sleep in healthy term-born infants until the second half of the first year of life. A blinded review by both authors covered 136 papers, of which 43 papers were reviewed in the full text. Finally, 38 articles were included in the data extraction.
Results
The analysis process showed that the selected studies formed three main information categories: 11 studies thematised safe infant sleep issues, 10 studies described design and findings from sleep-related intervention studies, and 17 studies focused on different parent-child interactive aspects that may influence the quality and duration of infant sleep in the first six months of life.
The main finding is that knowledge about early infant sleep is very complex, and includes both child, parent, and environmental factors. Several studies have shown that the concepts and factors related to safe infant sleep also influence the development of healthy infant sleep patterns. Thus, these aspects are interwoven with each other and should be addressed together in communication with parents.
Conclusions
Health practitioners with different professional backgrounds need to search for an agreement on when and how different aspects of sleep-related knowledge should be communicated to new and expectant parents to enable the design of national follow-up programs. Parents want coherent and personalized services regarding infant sleep issues that may allow them to choose sleeping arrangements, routines, and behaviors that fit in with their sociocultural attitudes and traditions. Many different sources and formats may be used to empower parents regarding infant sleep issues. Studies have described the use of group or individual meetings, videos, and written materials. The key issue is the importance of consistent and seamless knowledge-based services.
... Studienresultate werden oftmals verzerrt interpretiert (Douglas & Hill, 2013 (Ferber, 1985) und wurde in 14 Studien evaluiert (Mindell et al., 2006). Obwohl diese Vorgehensweise länger dauert als die reine Extinktion können auch hier kurzfristig positive Effekte wie die Reduzierung von Einschlafproblemen und dem nächtlichen Aufwachen erwartet werden (Mindell et al., 2006). ...
... Neben der reinen und der graduierten Extinktion, bietet laut Papoušek, Scholtes, Rothenburg, Hofacker und Cierpka (2009) Bei allen Methoden bleibt aber unklar, inwiefern sich die Eltern an genaue Vorgehensweisen halten. Die Empfehlung, die Schlafprogramme nicht vor dem 6. Lebensmonat anzuwenden (Douglas & Hill, 2013;Ferber, 2006;Kast-Zahn & Morgenroth, 2013), werden häufig von Eltern ignoriert (Loutzenhiser et al., 2014). In einer Befragung von 411 kanadischen Eltern wendeten knapp die Hälfte (49.6 Prozent) aller Eltern das kontrollierte Schreienlassen an. ...
... It can be suggested that well-rested parents more positively rate their children. One systematic review found that research about behavioral sleep interventions in infancy often does not address other influence parameters or interaction effects when interpreting data (Douglas & Hill, 2013). Instead, the authors argued that behavioral interventions can unintentionally provoke more crying or lead to premature termination of breast-feeding. ...
... In the UK, the US and Australia, there is therefore evidence that babies are particularly vulnerable to the effects of parental sleep disruption, particularly where parents perceive their baby's night-waking or difficulty in settling to be a 'sleep problem' in early infancy (Douglas and Hill 2013;Sadeh and Anders 1993). Such babies may be medicalised (Douglas and Hill 2011), medicated (Owens et al. 2003), punished and, in extreme cases, abused (Reijneveld 2002) for displaying speciestypical infant behaviour, that is waking at night, frequent night-feeding, and crying when left alone (Ball 2013;Ball and Russell 2012). ...
... Such babies may be medicalised (Douglas and Hill 2011), medicated (Owens et al. 2003), punished and, in extreme cases, abused (Reijneveld 2002) for displaying speciestypical infant behaviour, that is waking at night, frequent night-feeding, and crying when left alone (Ball 2013;Ball and Russell 2012). Increasingly babies are subjected to clinic-based (Australia) or parentally imposed (US) sleep-training programmes from an early age (Blunden et al. 2011;Douglas and Hiscock 2010;Hiscock et al. 2007;Mindell et al. 2006), a practice that is not only controversial but developmentally inappropriate for young infants (Blunden et al. 2011) and potentially harmful for parent-infant well-being by increasing maternal anxiety, prematurely terminating breastfeeding, increasing the risk of sudden infant death syndrome (SIDS), increasing infant crying and potentially decoupling maternal-infant physiological synchrony (Douglas and Hill 2013;Middlemiss et al. 2012;Whittingham and Douglas 2014). ...
... 'Limit-setting' is presented as a preventative intervention supporting the development of settled infant night-time behaviour (St James- ). However, this position is challenged (Douglas and Hill 2013) and studies attempting to apply this approach have been unsuccessful in increasing the numbers of infants with long sleep periods at night (Hiscock et al. 2014;Stremler et al. 2013). ...
... Preventive measures and Behavioral Sleep Intervention (BSI) may affect mothers and infants. Without an overall consensus on the effect of BSI on infants, some consider it beneficial and necessary from the first months (Crichton & Symon, 2016;Henderson, France, & Blampied, 2011), while others doubt the effectiveness of these interventions for infants younger than six months (Douglas & Hill, 2013). There is evidence showing the positive effects of BSI on maternal mood (Crichton & Symon, 2016;Hall et al., 2015;Harriet Hiscock et al., 2014;Mindell et al., 2011), as well as no effects (Douglas & Hill, 2013;Galland et al., 2017;. ...
... Without an overall consensus on the effect of BSI on infants, some consider it beneficial and necessary from the first months (Crichton & Symon, 2016;Henderson, France, & Blampied, 2011), while others doubt the effectiveness of these interventions for infants younger than six months (Douglas & Hill, 2013). There is evidence showing the positive effects of BSI on maternal mood (Crichton & Symon, 2016;Hall et al., 2015;Harriet Hiscock et al., 2014;Mindell et al., 2011), as well as no effects (Douglas & Hill, 2013;Galland et al., 2017;. However, few RCTs have been performed to evaluate infant BSI's effectiveness, especially in infants younger vs. older than six months (Kempler, Sharpe, Miller, & Bartlett, 2016;. ...
... Selecting infants merely younger than six months was one of the study's strengths. For the reason that there is a lack of well-controlled studies in this age group (Douglas & Hill, 2013;Kempler et al., 2016;Martins et al., 2018) for claiming possible positive effects of BSI on infants under six months. To omit the impact of attention, the control group also received training about infant safety. ...
Infant sleep problems are one of the first challenges for parents, negatively influencing infants and mothers. The present study examined the effects of preventive behavioural sleep intervention (BSI) on infant sleep patterns, maternal sleep quality, and depression. A clinical randomised multicentre controlled trial was conducted involving 82 mothers and their infants aged 2–4 months in Iran from August 2018 to April 2019. The intervention group received BSI, which included one individual 90‐min class session, booklet, voice messages, and follow‐up calls; while the control group received training on general infant safety. Details of infant sleep, maternal sleep quality, and postnatal depression were measured through the sleep diary, Pittsburgh Sleep Quality Index, and Edinburgh Postnatal Depression Scale, respectively, before and at 8 weeks after the training. In the intervention group, both the mean infant “night‐time sleep period” and infant “longest self‐regulated sleep period” were 81 min longer than the controls (p < .001). With an improvement of 160 min, the mean infant bedtime was decreased to 22:20 hours in the intervention group, substantially earlier than the controls (00:30 hours). The mean infant “night‐time awakenings with signals” did not significantly change (2.6‐ and 2.5‐times in the intervention and control groups, respectively). The intervention led to a significant improvement in maternal sleep quality and depression (p < .05). The present study acknowledges the positive effects of an early preventive infant BSI on infant sleep, maternal mood, and maternal sleep. Our present results also imply the importance of considering sleep patterns differences and cultural‐based intervention’s design.
... Sleep cycle develops gradually from the moment of birth, and 47%-81% of 4-month-old infants sleep without waking in the night (Henderson et al., 2011). Although frequent night waking does not seem to induce subsequent abnormal growth for under 6-month-old infants (Douglas & Hill, 2013), caregivers tend to consider it as the most serious sleep problem (Sadeh et al., 2011b). In fact, frequent night waking induces mental health problems in parents, such as parental stress, maternal depression and reduced sense of competence (Sadeh et al., 2011a;Teti & Crosby, 2012). ...
... However, the evidence is inadequate to infer that the same applies to younger infants, given the differences in sleep development between infants under 6 and over 6 months of age (Douglas & Hill, 2013). Therefore, the relationship between caregiver response and night waking in younger infants remains unclear. ...
... This suggests that the relationship between feeding and night waking may be common across cultures or countries. Indeed, a systematic review indicated that inappropriate feeding could induce frequent night waking (Douglas & Hill, 2013). Furthermore, breastfeeding is said to be difficult when performing proper feeding while the mother has low breast milk supply and experiencing physical discomfort (Ong et al., 2014). ...
Objective
To investigate the association between night waking frequency in 3‐ to 4‐month‐old infants and mothers' response to them.
Design
Cross‐sectional survey.
Sample
We examined 663 mothers of infants aged 3–5 months who attended regular health checks for 4 months at 7 public health centres in Japan between September 2006 and March 2007.
Measurements
Mother‐reported questionnaires were used, measuring the frequency of infants' night waking and four types of responses by mothers. Using multiple regression, the association between number of wakings and each response was evaluated adjusting for covariates, that is mother's (e.g. feelings of worry and bed‐sharing) and infant's (e.g. age and sex) demographic variables.
Results
The number of wakings was related to “immediately feeding and/or checking diapers” (β = 0.16, p = .002).This response to infants' night waking may be associated with night waking frequency.
Conclusion
Modifying caregiver responses to infants' night waking by reducing immediate feeding or diaper checks could improve infants' night waking frequency.
... A systematic review focusing on interventions implemented during the first 6 months of life indicated that despite evidence for increased self-regulated sleep following these interventions, they do not improve other infant or mother outcomes. 88 Other systematic reviews and meta-analyses found increases in infant sleep duration, as well as benefits for maternal mood, yet these included studies of sleep in the first 12 months 21 and beyond. 12 Importantly, most studies of behavioral interventions implemented during the first 6 months have evaluated either psychoeducation, bedtime routines, or a combination of both. ...
... Namely, it has been argued that extinction-based methods could be harmful and that they are in fact an unnecessary solution to a "made-up" problem. These claims have been voiced in the academic literature (e.g., Blunden et al. 72 and Douglas and Hill 88 ), yet they are also echoed in social media outlets, websites, and colloquial sleep advice (e.g., "sleep coaches" or "influencers"; Alpha 94 and McKay 95 ). While expressing divergent views has the potential to advance the field by inspiring new theories and paradigms, we recently seem to be witnessing quite the opposite process. ...
... 17 Kempler's study included only randomized controlled trials (RCTs) and had significant heterogeneity in intervention approach and publication bias. However, a review that included more than just RCTs found that psychosocial sleep-focused programs administered to women in the first 6 months postnatal did not improve infant sleep, 18 and another review for 0-3 years ages of infants and children found that behavioral sleep interventions on maternal depression were ineffective. 19 In conclusion, there were inconsistent results of psychosocial sleep interventions on improving infant sleep and maternal depression in previous reviews. ...
... Some studies have shown that behavioral interventions (such as controlled crying and camping out) did not improve outcomes for infants aged < 6 months, and they may have potentially adverse effects on neurodevelopment and aggravate sleep problems. 18,39 In contrast, others indicated that behavioral interventions for infants aged < 6 months were beneficial without above risk. 40,41 However, there are insufficient RCTs to evaluate the effects of behavioral interventions according to different infant ages, especially in infants aged < 6 months. ...
Infant sleep problems are prevalent and have a negative impact on infant growth and development, maternal sleep, and maternal mood. The effects of psychosocial sleep interventions on infant sleep and maternal sleep and mood are unclear. This study aimed to systematically evaluate the effects of psychosocial sleep interventions on improving infant sleep, including nocturnal total sleep time, daytime total sleep, total sleep time, night wakings, and maternal sleep and mood problems (ie, depression and fatigue). We searched PubMed, Web of Science, Cochrane Library, Embase, EBSCO, OpenGrey, DeepBlue, China National Knowledge Infrastructure, and Wanfang databases. We focused on randomized controlled trials examining the effectiveness of psychosocial sleep interventions on infant sleep. The study was preregistered at the International Prospective Register of Systematic Reviews (CRD42022301654). Thirteen studies from 5889 articles were included in the review, which found that psychosocial sleep interventions improved infant nocturnal total sleep time (0.28 [0.04-0.52], p < 0.05, I2 = 83.9%) and maternal depression (-0.10 [-0.28 to -0.08], p < 0.05, I2 = 8.7%). To test and explore heterogeneity, we used the I2 statistic, influence analysis, subgroup analyses, and subgroup meta-analyses. Funnel plots and Egger's tests revealed no evidence of publication bias. Psychosocial sleep interventions improved infant nocturnal total sleep time and maternal depression. Future research should include more randomized controlled trials examining the effect of psychosocial sleep interventions on the improvement of maternal sleep and fatigue.
... In this regard, we respectfully, yet firmly, contest two key statements made by Pattinson et al. 1 First, the authors disregard findings of meta-analyses and systematic reviews (including their own 10 ) which indicate that BSIs enhance infant sleep duration, 10,11 reduce infant sleep problems, 12 and improve infant sleep quality, 13 maternal sleep quality, 12 and maternal mood. 11 Instead, Pattinson et al. 1 choose to indicate the one sleep metric for which improvement was not found (ie, night waking) in two of these systematic reviews. ...
... In this regard, we respectfully, yet firmly, contest two key statements made by Pattinson et al. 1 First, the authors disregard findings of meta-analyses and systematic reviews (including their own 10 ) which indicate that BSIs enhance infant sleep duration, 10,11 reduce infant sleep problems, 12 and improve infant sleep quality, 13 maternal sleep quality, 12 and maternal mood. 11 Instead, Pattinson et al. 1 choose to indicate the one sleep metric for which improvement was not found (ie, night waking) in two of these systematic reviews. ...
... Understanding the important contribution of napping within the range of sleep factors potentially influenced by sleep interventions would give a more comprehensive picture of sleep development. Other reviews of sleep interventions have focused on measures of sleep other than duration [22], are narrative in form [23e27], consider narrow age ranges [26,27], are limited to children with identified sleep problems [22], or include data from retrospective or cross sectional study designs [26,27]. ...
... Understanding the important contribution of napping within the range of sleep factors potentially influenced by sleep interventions would give a more comprehensive picture of sleep development. Other reviews of sleep interventions have focused on measures of sleep other than duration [22], are narrative in form [23e27], consider narrow age ranges [26,27], are limited to children with identified sleep problems [22], or include data from retrospective or cross sectional study designs [26,27]. ...
This review investigated whether randomised controlled trials attempting to improve sleep or prevent sleep problems in 0-5 year olds influenced nocturnal sleep duration, day-time naps, or 24-hour sleep. Medline (Ovid), EMBASE, and CINAHL were searched from inception until 9 July 2020 and supplemented with hand searching. Search results were screened, eligible data were extracted, and risk of bias was assessed by at least two reviewers. Of 8571 publications considered, 32 trials which used a variety of subjective and objective sleep measurements were included in generic inverse variance random effects meta-analysis of nocturnal (n=24), day-time (n=14), and 24-hour (n=13) sleep duration. Overall, sleep interventions increased nocturnal sleep duration by a mean of 9 min (95% CI 4.1 to 13.8, I ²28%) per night when compared with no sleep intervention. Increases were predominantly seen in sleep-only, rather than multi-component interventions. Total 24-hour sleep duration tended to increase by a similar amount (8.6 min (95% CI -2.7 to 19.8, I ² = 59%)), but this was mainly only seen in studies that assessed sleep using diaries. There was no evidence that interventions changed day-time sleep duration. Future studies should involve sleep-only rather than multi-component interventions, and use objective sleep measures. (reviewregistry857)
... BMC Public Health (2024) 24:1913 evidence-based Dutch YHC guidelines [53,54]. These guidelines make a distinction between sleep strategies advised for children below and children older than six months: behavioural strategies that include controlled crying are only considered suitable and effective for children aged six months and older [59]. ...
Background
Sleep problems are common among infants and can have a serious impact on the health and wellbeing of both child and parents. To sustainably promote infant sleep on a population level, it is necessary to develop evidence-based programs that can be implemented on a large scale. The Youth Health Care setting, with its focus on prevention, child health promotion and services widely available for parents, can be a suitable setting to do so. Currently however, sleep health promotion in this setting seems to be suboptimal. To promote healthy infant sleep on a population level, programs need to be accessible and comprehensible for all parents, including parents with limited (health) literacy. Therefore, this study aims to develop, implement and evaluate a program called ‘Sleep on number 1’, that is tailored to Dutch Youth Health Care, to sustainably promote healthy sleep in 0-2-year-old infants.
Methods
The program was developed based on co-creation with parents and Youth Health Care professionals, evidence-based behaviour change theories and sleep health promotion methods. Program effectiveness is investigated with a quasi-experimental study design comparing the program group with the care as usual control group. Participants consist of parents of 0-2-year-old children. Primary outcome is infant sleep quality at the age of 10 weeks and 6, 9, 14 and 24 months, measured with a sleep diary. The primary data analysis focuses on night awakenings at 9 months. Secondary outcomes focus on parental behaviour regarding infant sleep, related behavioural determinants and parental satisfaction with Youth Health Care sleep advice. Program effectiveness is analysed using a linear mixed-model in case of data clustering, and an independent samples T-test or linear regression in case no substantial clustering effects are found. A mixed methods process evaluation is performed with parents and Youth Health Care professionals, assessing program reach, adoption, implementation, maintenance and working mechanisms.
Discussion
The ‘Sleep on number 1’ program is an evidence-based sleep health program for 0-2-year-old children, tailored to Dutch Youth Health Care. If effective, this program has the potential to improve infant sleep on a population level.
Trial registration
ISRCTN, ISRCTN27246394, registered on 10/03/2023. https://www.isrctn.com/ISRCTN27246394.
... Despite the varying recommendations, there is a general consensus that sleep interventions are not recommended for use with infants under six months of age. This is because newborn sleep is initially evenly distributed across each 24-hour period, circadian rhythms begin to emerge at about two or three months of age, and the longest daily continuous sleep episode of about six hours emerges at approximately six months of age (Douglas and Hill, 2013;Patel et al., 2022a). Gold (2017) highlighted that a 'one size fits all' approach may be problematic when it comes to supporting children's sleep. ...
This PRISMA scoping review identifies and summarises 13 research papers, published between 2011 and 2021, specific to interventions aimed at improving the sleep of infants from birth to two years of age. The aim was to identify trends in study characteristics, overarching outcomes and recommendations, and to extract and make further suggestions for professional training and practice. Relevant literature often provides contradictory guidance, and caregivers increasingly seek individualised support via the growing sleep consultancy industry. Papers examining the efficacy, safety and parental perception of a variety of approaches to improving infant sleep-including cry it out, controlled crying, camping out, bedtime fading and educational interventions-were sourced. Findings suggested that authors most commonly recommended supporting caregivers with education about developmentally appropriate sleep, cues for tiredness, settling techniques, positive sleep norland.ac.uk/journal 2 routines, how to increase homeostatic sleep pressure and how to use moderate behavioural interventions if problems remain after the infant reaches six months of age. Outcomes also suggested this combination is safe, can improve infant sleep as well as main and secondary caregiver wellbeing, and helps caregivers improve their understanding of whether their infant has a sleep problem. Based on the scoping review outcomes, the authors recommend the routine inclusion of evidence-based information about common patterns of infant sleep and different approaches to supporting sleep in the professional training of early years and healthcare professionals. This has the potential to facilitate evidence-based individualised support for caregivers with their infant's sleep, promote safe selection and use of interventions, and improve infant, primary and secondary caregiver sleep quality and wellbeing.
... The literature, research, and guidelines related to co-sleeping are mainly provided by pediatricians. As suggested by previous studies [86,87] and supported by the findings of the present study, future research on co-sleeping should be more holistic and involve anthropologists, developmental psychologists, and other professionals so that generic guidelines around co-sleeping can be avoided and more specific information can be provided depending on the child's stage of development, the needs of the family, and the social environment. Also, in future research, there should be greater anthropological analysis to further study the importance of the role of cultural factors. ...
Background: This study explores whether the implementation of co-sleeping in infants aged 6–12 months (a) is associated with maternal complaints and mothers’ difficulties regarding their infant’s sleep, (b) is associated with maternal mental health, (c) affects infant sleep characteristics and maternal sleep quality, and (d) is associated with breastfeeding. Methods: This study is a cross-sectional study conducted from July to November 2021. A total of 151 new mothers of infants aged 6–12 months participated. All participants were divided into two different groups, the group of mothers who adopted the co-sleeping method from birth up to the time of the survey and the group of those who did not adopt co-sleeping at that time. The Brief Infant Sleep Questionnaire—Revised Short Form (BISQ-R SF), the Edinburgh Postnatal Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI), and a questionnaire on mothers’ demographics were administered. Results: Regarding the mothers’ complaints, mothers who co-sleep with their children have lower sleep quality than those who do not co-sleep. In respect of the mothers’ mental health, there did not seem to be a statistically significant difference in the two groups. Regarding the difficulties during the sleep process, children who sleep with their parents seem to have more difficulties compared to the others (p = 0.008). It was also shown that co-sleeping children seem to have more disturbed sleep compared to those who sleep alone (p = 0.018), and a general trend obtained of a significantly higher number of awakenings for co-sleeping children (p < 0.001). Finally, breastfeeding appeared to be more related to the children of the present sample sleeping with their parents (p < 0.001). Conclusions: This study showed that co-sleeping is associated with more difficulties in infant and maternal sleep, but no direct correlation with maternal mental health was found. In addition, it showed a positive correlation of co-sleeping with breastfeeding.
... As such, proactively shaping infant sleep regulation through early responsive parenting (RP) practices, such as focusing on reading infant signals and establishing bedtime routines, is a promising approach for addressing infant and maternal sleep disturbances postpartum (Leistikow et al., 2022). Although some behavioral interventions for infant sleep have failed to show significant improvement in maternal or infant outcomes (Douglas & Hill, 2013), others have demonstrated significant effects on infant sleep (Paul et al., 2016). Additional research is needed on whether early RP interventions designed to enhance infant sleep can also enhance maternal sleep in the postpartum period, particularly among racial and ethnic minority groups. ...
Objetivo: Determinar si una intervención diseñada para mejorar las prácticas tempranas de crianza receptiva (RP, por sus siglas en inglés) (p. ej., leer las señales de los bebés, establecer rutinas a la hora de acostarse) y promover el sueño y la tranquilidad de los bebés entre las familias Negras tiene beneficios secundarios para el sueño posparto de las madres. Métodos: Este análisis secundario previamente registrado del ensayo controlado aleatorio Sleep SAAF (Strong African American Families) investigó los efectos de una intervención de RP frente a una condición de control de seguridad en las dificultades de sueño maternas autoinformadas a las 8 y 16 semanas posparto y en las mediciones de sueño materno a las 8 semanas posparto tomadas con actígrafos. Resultados: Las 212 madres asignadas al azar eran Negras/Afroamericanas (100%) y no hispanas (98.6%) y tenían un promedio de 22.7 años (DE = 4.5) de edad. Entre 138 madres con datos actigráficos utilizables, las madres RP tuvieron una media de 20 [95% IC: 2 a 37] minutos más de tiempo total de sueño medido con actígrafo que los controles a las 8 semanas posparto, después de ajustar por edad y otras covariables que probablemente influyan en el sueño de las madres (p = .04). La participación en la intervención de RP no tuvo un impacto significativo en las dificultades de sueño autoinformadas u otros parámetros del sueño medidos con actígrafos (p. ej., eficiencia) en los modelos ajustados o no ajustados, aunque los efectos de RP sobre las dificultades y la eficiencia del sueño estuvieron en las direcciones hipotéticas. Conclusiones: Las intervenciones que apoyan las prácticas de crianza receptiva del sueño para aumentar el sueño infantil también pueden ayudar a las madres Negras primerizas a dormir más durante el período posparto, incluso sin un enfoque explícito en las estrategias de sueño materno.
... 5 I refined clinical and educational delivery iteratively over many years prior in response to parent feedback; conducted key informant interviews 6 ; and with co-authors conducted a number of systematic or meta-narrative reviews concerning unsettled infant behavior, applying the theoretical frames of complexity science and evolutionary biology. [7][8][9] Since 2011, multiple clinical or educational translations of the NDC-MIS have been used by health professionals and parents in Australia and internationally, including the Possums Sleep Program The NDC-MIS uniquely synthesized and interpreted existing interdisciplinary infant sleep research literature through the theoretical lenses of complexity science, evolutionary biology and contextual behavioral science. 2 It located infant sleep in the context of interactions between responsive infant care, breastfeeding, feeds, infant crying, infant sensory-motor needs, infant health, and parent mood and well-being. Because the NDC theoretical frameworks and clinical/educational translations have been developed over time, I apply the label NDC to the early theoretical and clinical/educational research publications retrospectively. ...
... However, parents experiencing postpartum depression and perceiving poor sleep may overestimate (44) and may be harmful. Systematic reviews have indicated that the effectiveness of sleep training to reduce disruption from infant night waking and postpartum fatigue is mixed (12,45), that sleep training is potentially harmful for infants when implemented prior to 6 months (45), causes parental distress (46), and is associated with concerns regarding infant mental health, development and attachment (47). If, as we have seen here, subjectively reported and objectively measured maternal and infant sleep do not align with parental perceptions of sleep or predict postpartum depression symptomatology, sleep training may be an ineffective use of limited resources (individual or governmental (47)) when implemented for this purpose. ...
Introduction
The study objectives were to determine the relationships between postpartum depression and maternal and infant sleep parameters and to examine the impact of infant feeding method on infant and maternal sleep and postpartum depression symptomatology.
Methods
Participants were 61 new mothers aged 18 to 45 years old, and their full-term, normal birth-weight, singleton infants. Participants were recruited from a large teaching hospital in northeast England. Data collection took place in participants’ homes. The study used a prospective longitudinal design, with data collected at six, 12 and 18 weeks postpartum. We collected data on total sleep time, longest sleep period, wake after sleep onset, and night waking for mothers and infants objectively from actigraphic records and subjectively from maternal sleep logs. Participants reported on sleep disturbances using the General Sleep Disturbances Scale, on maternal sleepiness, and on depression symptomatology using the Edinburgh Postnatal Depression Scale.
Results
Scores on the Edinburgh Postnatal Depression Scale and General Sleep Disturbances Scale were consistently correlated with each other (6 weeks r = 0.452, p < 0.01; 12 weeks r = 0.317, p < 0.05; 18 weeks r = 0.493, p < 0.01), and did not correlate with objective measures or subjective reports of maternal or infant sleep. Edinburgh Postnatal Depression Scale scores at six, 12 and 18 weeks were predicted by General Sleep Disturbances Scale, prior Edinburgh Postnatal Depression Scale score, or both, but not by sleep parameters. With regard to infant feeding method, EPDS score was not higher among exclusively breastfeeding than among exclusively formula-feeding participants at any time point (6 weeks t = 0.306, p = 0.762; 12 weeks t = 0.343, p = 0.733; 18 weeks t = 0.426; p = 0.673). Different pathways emerged to predict Edinburgh Postnatal Depression Scale score for exclusively breastfeeding and exclusively formula-feeding women.
Discussion
Postpartum depression may be associated with disturbed sleep due to negative perception of sleep among depressed women, rather than disrupted sleep causing postpartum depression. With regard to infant feeding method, exclusively breastfeeding women are not more likely to suffer from postpartum depression, and different pathways may predict development of postpartum depression symptoms in exclusively breastfeeding and exclusively formula feeding women.
... Despite this, some mothers are encouraged to cease breastfeeding as a management strategy to improve infant sleep [16]. ...
This study evaluated relationships between maternal perceptions of infant sleep, settling and crying patterns and breastfeeding. A prospective observational study of 91 mothers of healthy, term infants was conducted with follow ups over 9 months after discharge from a Western Australian maternity hospital. Feeding information, sleep, settle and cry behaviours, maternal bother at infant behaviours and confidence were measured using the Sleep and Settle Questionnaire. Breastfeeding confidence was measured using the Breastfeeding Self-Efficacy Scale—Short Form. Questionnaires were administered at 2 and 6 weeks, 3, 6 and 9 months. Linear mixed models were used to assess associations between maternal bother, feeding method and infant characteristics. The feeding method was not associated with maternal bother, and cessation of breastfeeding did not result in a change in bother scores (p = 0.34). Duration of infant crying in the day, evening and night, frequency of night waking and duration of settling to sleep in the day were associated with increased bother scores. Higher breastfeeding self-efficacy and maternal confidence were associated with lower bother scores (both p < 0.01). Maternal bother is associated with infant behaviours that require parental input, but not breastfeeding status. Resources that address parental expectations regarding infant sleep while providing strategies to support maternal wellbeing and breastfeeding are needed.
... Attitudes and beliefs about infant sleep inform parental expectations, resulting in perceived sleep problems when the infant's sleep pattern does not match expectations [50]. Traditional behavioural infant sleep interventions that include delayed responses to cues and feed-sleep routines do not improve infant or maternal outcomes and may result in unintended consequences [51]. Anticipatory antenatal and early postnatal education that includes typical infant sleep patterns may assist parents in forming realistic expectations. ...
The COVID-19 pandemic has impacted new mothers’ wellbeing and breastfeeding experience. Women have experienced changes in birth and postnatal care and restricted access to their support network. It is unclear how these impacts may have changed over time with shifting rates of infection and policies restricting movement and access to services in Australia and New Zealand. This study investigated the longitudinal effect of the COVID-19 pandemic on breastfeeding and maternal wellbeing in Australia and New Zealand. Mothers ( n = 246) completed an online survey every 4 weeks for 6 months that examined feeding methods, maternal mental wellbeing, worries, challenges, and positive experiences during the pandemic. Mothers maintained high full breastfeeding rates at 4 months (81%) which decreased to 37% at 6 months. Perceived low milk supply contributed to the earlier cessation of full breastfeeding. Poor infant sleep was associated with stress, perinatal anxiety, mental wellbeing, and breastfeeding status. Although mothers initially reported that lockdowns helped with family bonding and less pressure, prolonged lockdowns appeared to have adverse effects on access to social networks and extended family support.
Conclusion : The results highlight the changing dynamic of the pandemic and the need for adaptable perinatal services which allow mothers access to in-person services and their support network even in lockdowns. Similarly, access to continuous education and clinical care remains critical for women experiencing concerns about their milk supply, infant sleep, and their own wellbeing. What is Known: • The COVID-19 pandemic and lockdown restrictions have significantly affected perinatal mental health, disrupted maternal services, and subsequent breastfeeding.
What is New: • In Australia and New Zealand, breastfeeding women experienced challenges to their mental wellbeing, sleep, and breastfeeding, which was likely exacerbated over time by the pandemic. Lockdowns, while initially beneficial for some families, became detrimental to maternal support and wellbeing.
... This umbrella term encapsulates strategies for helping baby settle, how parents should respond to infant crying or signaling during a sleep period, and various other techniques to promote self-soothing and undisturbed sleep. While research documenting the effectiveness of BSI is robust, data supporting BSI in infants under 6 months is mixed, with feeding patterns appearing to play a role in effectiveness (Douglas and Hill, 2013;Kempler et al., 2016;Honaker et al., 2018). As such, in infants under 6 months of age, parental education and prevention focusing on developing positive night-time habits and knowledge of infant sleep patterns remains one of these most powerful tools available (Crichton and Symon, 2016). ...
The presentation of insomnia varies greatly across human development, from the referral process to evaluation and treatment. For example, adults with insomnia tend to present with difficulties initiating and/or maintaining sleep despite their best efforts to capture sleep. Young children, on the other hand, may actively resist sleep despite their parents' best efforts to coax them to sleep. The current article takes a developmental approach to describing the clinical presentations of insomnia across pediatric populations. Suggestions are provided to health professionals interested in conducting a thorough clinical evaluation of insomnia, then delivering evidence-based or emerging cognitive-behavioral and pharmacological interventions to infants, children and adolescents.
... This Although the literature is favourable towards the implementation of parent-directed behavioural interventions, there are critics, both among professionals and parents. [24][25][26] In some cases, this may be due to insufficient training and knowledge about infant sleep, and misapplications of attachment theory in the field of sleep. According to attachment theory, infants need sensitive, contingent and immediate responses to behavioural cues that express the need for protection, food, contact and care. ...
Aim:
Parents and professionals receive conflicting recommendations about management of infant sleep problems. The aim of this umbrella review was to provide an overview of summarised research on the prevention and treatment of sleep problems in infants (0-1 year), content of the interventions, and the conditions under which they are delivered.
Methods:
The umbrella review included five systematic reviews of 24 individual studies, mainly randomised controlled trials. Searches were conducted in PsycINFO, Cochrane, Campbell, Epistemonikos, PDQ-Evidence, IN SUM, and the Norwegian Institute of Public Health, for reviews published during 2010-2021.
Results:
The systematic reviews showed that behavioural interventions increased sleep in infants and parents. Interventions entailed reducing parental disturbances during sleep onset and enabling the infant to fall asleep and maintain sleep on their own. Knowledge about infant sleep and the establishment of positive bedtime routines seemed crucial for preventing and treating sleep difficulties. The interventions can be delivered in a few sessions, typically one-on-one during the postnatal period.
Conclusion:
Behavioural interventions can be recommended and adapted to the individual family. Positive outcomes for the infant and the family depends on a close and coordinated collaboration between child health clinics, community psychologists, general physicians, and other services.
... As an example, reported that, although behavioral sleep techniques did not cause long-lasting harms or benefit to child and parents, there were no differences between intervention and control families for any outcome (child's emotion and behavior, sleep problems, parent and child psychosocial functioning). Furthermore, behavioral interventions for infant sleep in the first 6 months of life did not decrease infant crying, nor prevent sleep and behavioral problems in later childhood, nor protect against postnatal depression; instead, they worsened maternal anxiety and increased risk of SIDS (Douglas and Hill, 2013). Another meta-analysis of psychosocial sleep interventions indicated an impact on maternal mood and small improvements in infant nocturnal sleep time with no evidence of reduction of the infant night awakenings (Kempler et al., 2016). ...
This paper aims to review the limitations of the current classification of insomnia of early childhood and propose a new conceptual model allowing a better understanding of its pathophysiology. Our hypothesis is that chronic insomnia of childhood has different phenotypical expressions, associated to different pathophysiological mechanisms. Based on a long-lasting experience in evaluating a very large number of children with specific insomnia symptoms (nocturnal awakenings, difficulty in falling asleep, nocturnal restlessness, early morning awakenings) and on published data, we hypothesize that different phenotypes of insomnia might exist with different therapeutic implications.
We describe three phenotypes of insomnia in early childhood: a) insomnia with motor restlessness; b) insomnia characterized without difficulties in falling asleep but with long-lasting early morning awakenings; c) insomnia with multiple night awakenings and falling asleep difficulty. This type of categorization might have important implications for treatment, based on the different hypothetical neurotransmitter dysfunctions. The early identification of a phenotype of insomnia might guide to specific behavioral and/or pharmacological interventions with the aim to prevent chronic insomnia.
... Drawing on Douglas and Hill (2013), it was hypothesised that a more stressful birth experience for the infant may have triggered a negative feedback loop in the infant's hypothalamic-pituitary-adrenal (HPA) axis responsible for their developing stress response system. Therefore, if a genetically susceptible infant (Belsky & Pleuss, 2009) is further sensitised by early stressors occurring during the birth, this could potentially lead to longer term interactional cry-fuss, feeding and sleeping problems and reduced soothability (Douglas & Hill, 2013b), otherwise known as regulatory problems (Schmid, Schreier, Meyer & Wolke, 2011). ...
PhD thesis about maternal experience of childbirth, infant behaviour and early temperament
... They highlighted that infant sleep significantly improved when parents reduced their involvement at bedtime and during the night (ie, removing positive reinforcement related to crying upon waking during the night; [1,2,4]). To date, there is no support for the use of behavioural sleep interventions in infants under the age of 6 months, and intervening before this time may actually risk adverse outcomes [29]. It should be noted that research has identified a gap in paediatric sleep intervention research for non-white ethnic groups, and lower income families [30]. ...
Behavioural sleep interventions (e.g., extinction-based methods) are among the most efficacious evidence-based techniques in the treatment of infant sleep problems. However, behavioural sleep interventions can be challenging for families to successfully implement. This review aims to summarise current research surrounding the potential barriers that arise when clinicians attempt to implement extinction-based methods with parents of infants. We provide a model that summarises 3 types of contextual-barriers; socio-cultural barriers, parent barriers, and infant barriers. Based on the current evidence, we propose that adopting a stepped care approach, planning ahead, increasing support, motivational interviewing, and/or emotional regulation may serve as useful tools for parents when implementing extinction-based methods. By considering these techniques, more families may receive the benefits of improved infant sleep.
... Studies have shown that only 50% of infants sleep through the night by one year of age. 9 As doctors in primary health care, we are involved in patient care provision, complex decision making, and multidisciplinary team coordination. Medical mothers returning from maternity leave are required to resume work in the same capacity as their colleagues, while navigating the challenges of normal infant sleep patterns. ...
... In a meta-analysis of nine randomized clinical trials, small to moderate effects were found for psychosocial infant sleep interventions on improved maternal mood and improved maternal report of infant nocturnal sleep (Kempler et al., 2016). However, another systematic review of 43 such studies indicated that behavioral interventions aimed at improving infant sleep during the first 6 months of life do not improve long-term outcomes for mothers or infants and may increase risk of unintended outcomes, such as early discontinuation of breastfeeding and increased anxiety among new mothers (Douglas and Hill, 2013). Our results indicate that PREPP, which targets more than infant sleep, can positively influence infant sleep duration and/or maternal assessment of it even in the context of no treatment effect on mood-suggesting the possibility of downstream influence on maternal mood in the future, one that is mediated via changes in the infant (or maternal perception of the infant). ...
BACKGROUND
Prevention studies for perinatal depression rarely focus on the mother–infant dyad or consider the impact of maternal childhood maltreatment (CM).
METHODS
A secondary analysis of two combined randomized controlled trials of Practical Resources for Effective Postpartum Parenting (PREPP) examined the moderating role of CM on the efficacy of preventing perinatal depression and effects on infant behavior at six weeks.
RESULTS
32% of 109 pregnant women endorsed CM (CM+). At six weeks postpartum, women who received PREPP compared to enhanced treatment as usual (ETAU) had significant reductions in depression and anxiety based on the observer-rated Hamilton Rating Scale for Depression (HRSD) and Hamilton Rating Scale for Anxiety (HRSA) (mean difference of M=-3.84 (SD= 0.14, p<0.01) and M=- 4.31 (SD= 0.32, p <0.001) respectively). When CM was added to the models, there no longer was a significant PREPP versus ETAU treatment effect on HRSD and HRSA outcomes in CM+ women though effects remained for CM- women. However, CM+ women who received PREPP vs ETAU reported a mean increase in infant daytime sleep of 189.8 minutes (SE= 50.48, p=0.001). LIMITATIONS: Self-report measures of infant behavior were used.
CONCLUSIONS
CM+ women versus CM- had limited response to an intervention to prevent perinatal depression yet still reported an increase in infant daytime sleep. This study adds to the growing literature that prevention studies may need to incorporate approaches tailored to fit women with childhood trauma histories while also considering infant functioning as both may be treatment targets relevant to maternal mood.
... It should be noted that randomized control trials of behavioral sleep interventions have shown mainly positive results and that many psychologists and health professionals advocate for their use (Gradisar et al. 2016;Hall et al. 2015;Mindell et al. 2011). At the same time, other researchers argue that the interventions are unnecessary and that the studies conducted were methodologically flawed (Blunden et al. 2011;Douglas and Hill 2013). In sum, this is still a highly controversial topic. ...
Sleep is a necessary function of life and plays a key role in development. This chapter will discuss the association between prenatal stress and children’s sleeping behaviors. First, a description of the development of sleep-wake patterns in infancy will be provided. Second, an overview of the literature on the link between prenatal stress and sleep-wake behaviors will be presented from a developmental perspective. Then, key confounding variables that influence the association between prenatal stress and children’s sleep will be discussed. A few of the proposed mechanisms that could explain the relationship between prenatal stress and child sleep outcomes will also be reviewed. Lastly, clinical interventions targeting maternal stress and infant sleep will be discussed.
... Our simulations began at the age of 6 months, before which solids are generally not recommended for breastfed infants and night feeding is encouraged; (27) some literature suggests that behavioral night feeding interventions may not be developmentally appropriate earlier in life. (31) To simulate various success rates for an educational intervention targeting the reduction of night feeding by infants' caregivers, we tested various reductions in the probability of night feeding. We reduced the probability of feeding an infant during each night waking, ranging the probability from 70% to 10% beginning in month 6 (down from 79% when there was no intervention). ...
Teaching caregivers to respond to normal infant night awakenings in ways other than feeding is a common obesity prevention effort. Models can simulate caregiver feeding behavior while controlling for variables that are difficult to manipulate or measure in real life.
We developed a virtual infant model representing an infant with an embedded metabolism and his/her daily sleep, awakenings, and feeds from their caregiver each day as the infant aged from 6 to 12 months (recommended age to introduce solids). We then simulated different night feeding interventions and their impact on infant body mass index (BMI).
Reducing the likelihood of feeding during normal night wakings from 79% to 50% to 10% lowered infant BMI from the 84th to the 75th to the 62nd percentile by 12 months, respectively, among caregivers who did not adaptively feed (e.g., adjust portion sizes of solid foods with infant growth). Among caregivers who adaptively feed, all scenarios resulted in relatively stable BMI percentiles, and progressively reducing feeding probability by 10% each month showed the least fluctuations.
Reducing night feeding has the potential to impact infant BMI, (e.g., 10% lower probability can reduce BMI by 20 percentile points) especially among caregivers who do not adaptively feed.
Teaching caregivers to respond to infant night waking with other soothing behaviors besides feeding has the potential to reduce infant BMI.
When reducing the likelihood of feeding during night wakings from 79% to 50% to 10%, infants dropped from the 84th BMI percentile to the 75th to the 62nd by 12 months, respectively, among caregivers who do not adaptively feed.
Night-feeding interventions have a greater impact when caregivers do not adaptively feed their infant based on their growth compared to caregivers who do adaptively feed.
Night-feeding interventions should be one of the several tools in a multi-component intervention for childhood obesity prevention.
... The primary outcomes of these interventions include teaching infants to self-soothe to sleep, enabling them to have less fragmented nighttime sleep, and longer nighttime sleep periods [9]. Growing evidence supports the use of more responsive methods [12][13][14]. New interventions focusing on meeting infants' needs which enable mothers to continue breastfeeding are needed. ...
For infants and their families, sleep consolidation is important in maturing neural and circadian rhythms, and in family dynamics. The Possums Infant Sleep Program is a cued care approach to infant sleep, responding to infant cues in a flexible manner, dialing down the infant’s sympathetic nervous system. The current study evaluated the effect of the Possums program on infant sleep and breastfeeding in infants (6–12 months) from a well-child outpatient clinic in Turkey, with the program intervention group (n = 91) compared with usual care (n = 92). In total, 157 mother-infant dyads completed the study. Infant sleep and breastfeeding rates were assessed at baseline and after 3 months. Nocturnal wakefulness, daytime sleep duration, naps, and night wakening decreased in both groups. Nocturnal sleep duration and the longest stretch of time the child was asleep during the night increased significantly in both groups without any change in total sleep duration. Night wakening was significantly lower and nocturnal sleep duration was significantly higher in the intervention group. However, mixed effects model analyses indicated no significant differences between the groups on any of the sleep outcomes after adjusting for confounders. Despite this, breastfeeding rates were significantly higher in the intervention group compared with those in the usual care group at follow-up.Conclusion: The Possum infant sleep program provided equivalent positive results on sleep parameters compared to usual care while advocating a more cued response. The critical difference was evident in sustained breastfeeding.
What is Known:
• Responsive sleep programs produce sleep consolidation, by responding to the infant’s cues without ignoring, and then gradually reducing parental interaction.
• Breastfeeding to sleep may be considered an undesirable sleep association in some infant sleep interventions.
What is New:
• The Possums Infant Sleep Program provided equivalent positive results to usual care while advocating a more cued response.
• The critical difference was in sustaining breastfeeding, and the program was associated with better breastfeeding rates.
... A better understanding of infant sleep patterns can benefit parents by informing them of what sleep patterns may emerge in their newborn and when more mature sleep development may be expected, and may also help health professional and childcare advisors in counselling parents and guiding realistic parental expectations. This is especially important in the light of growing evidence that interventions to promote infant sleep can have unintended adverse consequences including increased maternal anxiety or premature weaning from breastfeeding [7]. ...
Abstract Background Infant sleep is of great interest to new parents. There is ongoing debate about whether infants fed with breastmilk substitutes sleep longer than those exclusively or partially breastfed, but what does this mean for the mother? What expectations are realistic for mothers desiring to exclusively breastfeed as recommended by health authorities? There are both biological and social influences on infant and maternal sleep. More accurate information on average maternal sleep hours for diverse feeding practices may help guide realistic expectations and better outcomes for mothers, infants and families. Methods Using a unique time use dataset purposefully designed to study the time use of new mothers, this study investigated whether the weekly duration of maternal sleep, sleep disturbance, unpaid housework, and free time activities differed by detailed feeding method. The study collected 24/7 time use data from 156 mothers of infants aged 3, 6 and/or 9 months between April 2005 and April 2006, recruited via mother’s groups, infant health clinics, and childcare services throughout Australia. Sociodemographic and feeding status data were collected by questionnaire. Statistical analysis used linear mixed modelling and residual maximum likelihood analysis to compare effects of different infant feeding practices on maternal time use. Results There were no significant differences in time spent asleep between lactating and non lactating mothers, though lactating mothers had more time awake at night. Lactating mothers spent more time (8.5 h weekly) in childcaring activity (p = 0.007), and in employment (2.7 vs. 1.2 h, p
Breastfeeding is the most cost-effective intervention for reducing infant morbidity and mortality, offering benefits for infants and mothers. Despite extensive promotion, global adherence remains below 50 %, resulting in significant clinical, economic, and environmental impacts. Thus, this overview of reviews aims to synthesize barriers and facilitators of breastfeeding, analyze research trends, and identify gaps to guide future research. A comprehensive literature search was conducted, including systematic reviews that examine these factors. The search covered seven electronic data repositories. The methodological quality was assessed using the Risk of Bias in Systematic Reviews tool. Bibliometric analysis focused on identifying top journals, authors, and countries, assessing their impact, and exploring trends over time. Findings were classified and analyzed thematically through line-by-line coding, theme description, and analytical formulation. A total of 123 reviews were included, mostly of high quality and published in top journals. Key trends comprised a growing focus on psychosocial and cultural factors, increased representation from low- and middle-income countries, and improved methodological rigor. However, geographical representation remains biased towards high-income countries, and some breastfeeding outcomes need further exploration. Thematic analysis revealed four categories: Therapeutic and care interventions; Support networks and education; Maternal-infant health issues; and Societal and environmental context. In conclusion, this overview of reviews identifies barriers and facilitators of breastfeeding and emphasizes the need for more inclusive research and tailored support. Addressing gaps in evidence for enhancing healthcare systems and policies can improve breastfeeding practices and outcomes worldwide.
Study Objectives
Insomnia symptoms are common during the perinatal period and are linked to adverse outcomes. This single-blind 3-arm randomised controlled trial examined whether two interventions targeting different mechanisms prevent postpartum insomnia.
Methods
Participants were nulliparous females 26-32 weeks gestation with Insomnia Severity Index (ISI) scores≥8, recruited in Australia and randomised 1:1:1 to: (a) a responsive bassinet designed to support infant sleep and reduce maternal sleep disruption until 6 months postpartum (RB), (b) therapist-assisted cognitive behavioural therapy for insomnia (CBT-I) delivered during pregnancy and postpartum, or (c) a sleep hygiene booklet (control; CTRL). Outcomes were assessed at baseline (T1), 35-36 weeks gestation (T2), and 2, 6, and 12 months postpartum (T3-T5). The primary outcome was ISI scores averaged T3-T5. Primary analyses were regressions controlling for baseline outcomes.
Results
127 participants (age M±SD=32.62±3.49) were randomised (RB=44, CBT-I=42, CTRL= 41). Both interventions were feasible and well-accepted, with few related adverse events reported. Compared to CTRL, the average ISI across T3-T5 was lower for CBT-I (p=.014, effect size [ES]=0.56, medium) but not RB (p=.270, ES=0.25, small). Exploratory findings on maternal insomnia diagnosis, sleep disturbance, sleep-related impairment, beliefs and attitudes about sleep, depression, anxiety, as well as infant sleep outcomes were also presented.
Conclusions
CBT-I but not RB reduced prenatal insomnia (very large effect) and prevented postpartum insomnia (medium effect). Further research is needed to examine the effects of both CBT-I and RB on other outcomes such as sleep-related wellbeing, postpartum depression, and maternal postpartum sleep duration.
Background:
Developmental care is designed to optimize early brain maturation by integrating procedures that support a healing environment. Protecting preterm sleep is important in developmental care. However, it is unclear to what extent healthcare professionals are aware of the importance of sleep and how sleep is currently implemented in the day-to-day care in the neonatal intensive care unit (NICU).
Purpose:
Identifying the current state of knowledge among healthcare professionals regarding neonatal sleep and how this is transferred to practice.
Methods:
A survey was distributed among Dutch healthcare professionals. Three categories of data were sought, including (1) demographics of respondents; (2) questions relating to sleep practices; and (3) objective knowledge questions relating to sleep physiology and importance of sleep. Data were analyzed using Spearman's rho test and Cramer's V test. Furthermore, frequency tables and qualitative analyses were employed.
Results:
The survey was completed by 427 participants from 34 hospitals in 25 Dutch cities. While healthcare professionals reported sleep to be especially important for neonates admitted in the NICU, low scores were achieved in the area of knowledge of sleep physiology. Most healthcare professionals (91.8%) adapted the timing of elective care procedures to sleep. However, sleep assessments were not based on scientific knowledge. Therefore, the difference between active sleep and wakefulness may often be wrongly assessed. Finally, sleep is rarely discussed between colleagues (27.4% regularly/always) and during rounds (7.5%-14.3% often/always).
Implications:
Knowledge about sleep physiology should be increased through education among neonatal healthcare professionals. Furthermore, sleep should be considered more often during rounds and handovers.
Introduction
In Western cultures, parents often view infant sleep as problematic. Family, friends, and doctors may advise parents to “sleep train” assuming it is safe and effective, without considering its possible side effects, including its impact on breastfeeding. Unfortunately, it may reduce night feeds and result in earlier supplementation or weaning. The larger question is whether sleep training is worth the risk (i.e., does it improve infant sleep?). Our goal was to examine the data on the effectiveness of sleep training interventions on infant/toddler sleep.
Methods
PubMed and Google Scholar were searched for specific terms to identify articles that included behavioral sleep interventions and objective measures of sleep pre-and postntervention. Two objective infant sleep measures were examined: Night wakings and total sleep duration. Articles were then reviewed for evidence of the effectiveness of these interventions to reduce night wakings and increase total sleep duration.
Results
Five articles were identified that met the criteria for inclusion. Overall, there was no evidence that sleep training improves infant sleep.
Applications for Practice
The claim that sleep training is effective in changing infant sleep is not warranted. Given the potential side effects on breastfeeding, parents should be cautioned about engaging these behavioral sleep interventions if they have breastfeeding goals they want to achieve.
Purpose
To examine the factors associated with the early initiation of breastfeeding and exclusive breastfeeding among mothers in Vietnam during the first 6 months postpartum.
Design and methods
A cross-sectional study including 200 mother-infant dyads was conducted at community health stations. Information on demographic characteristics, modes of delivery, infant sleep problems, and breastfeeding practices was collected using structured questionnaires. The main independent variable of social support was assessed using the Multidimensional Scale of Perceived Social Support. Multivariable logistic regression analysis was used.
Results
Among the study cohort, 37.5% of mothers had initiated breastfeeding within 1 h after birth, and 27.5% continued exclusive breastfeeding for the first 6 months postpartum. Mothers living in urban areas or who had undergone cesarean delivery were less likely to have initiated breastfeeding within 1 h after birth (p < 0.05). The odds of exclusive breastfeeding were lower among infants with longer waking hours at night (≥4 h) and sleep problems (p < 0.05). Support from the mother's significant other and friends was significantly associated with exclusive breastfeeding (p < 0.05).
Conclusions
Early initiation of breastfeeding and exclusive breastfeeding were not common in a community sample of Vietnamese mothers. Identifying and assessing mothers who lack breastfeeding support is necessary to promote and sustain breastfeeding practices.
Practice implication
Further comprehensive breastfeeding interventions and support are needed for postpartum women in Vietnam.
This systematic review and meta-analysis was conducted to investigate the effectiveness of behavioral sleep interventions (BSIs) on the number of child night awakenings, and maternal sleep quality and depression. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) using PubMed, CINAHL, Cochrane, and EMBASE databases and retrieved studies published until April 2021. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) for child sleep problems, and the mean differences (MD) and 95% CI for the number of child night awakenings, and maternal sleep quality and depression. Ten studies of 1628 initial searched were included in the final analysis. Two of the 10 studies were divided into two subgroups by participants and intervention type; thus, 12 subgroups were included in the meta-analysis. BSIs significantly reduced child sleep problems (OR 0.51; 95% CI 0.37–0.69) and improved maternal sleep quality (MD − 1.30; 95% CI − 1.82 to − 0.77) in the intervention group. There were no significant differences in the number of child night awakenings and maternal depression between the two groups. More RCTs to examine the effect of BSIs considering children’s age, duration of intervention, and outcome measuring time points are needed.
Night-waking is typical across infancy and early childhood, inevitably disrupting family sleep. For some children, sleep problems develop and endure throughout childhood. This systematic review focused on fathers, and synthesised the evidence pertaining to the effects of children’s sleep (from birth to 12 years) on fathers’ health and wellbeing. A total of 29 studies were included. Key outcomes reported for fathers were: sleep and fatigue; mental and general health; and family functioning. An association between child sleep and father's sleep was observed when child's sleep was measured via actigraphy or paternal report, but not when measured via maternal report, suggesting that mothers may not always be aware of disruptions that awaken fathers. Findings showed poorer child sleep was associated with poorer general health and wellbeing among fathers, however, associations of poor child sleep with depression were fewer, and less frequent than those reported for mothers in the same households. Poor child sleep was negatively associated with the quality of family relationships, both within the couple and between parent and child. Future studies seeking to understand the interplay of child sleep and family wellbeing should apply objective measurement of sleep and integrate formal measures of family dynamics into the study design.
Global rates of obesity and Type 2 diabetes mellitus (T2DM) are increasing globally concomitant with a rising prevalence of sleep deprivation and sleep disorders. Understanding the links between sleep, obesity and T2DM might offer an opportunity to develop better prevention and treatment strategies for these epidemics. Experimental studies have shown that sleep restriction is associated with changes in energy homeostasis, insulin resistance and β-cell function. Epidemiological cohort studies established short sleep duration as a risk factor for developing obesity and T2DM. In addition, small studies suggested that short sleep duration was associated less weight loss following lifestyle interventions or bariatric surgery. In this article, we review the epidemiological evidence linking sleep duration to obesity and T2DM and plausible mechanisms. In addition, we review the impact of changes in sleep duration on obesity and T2DM.
Sleep during infancy and toddlerhood is a high-priority issue for parents, especially at night, because when the baby doesn’t sleep, neither do the parents. Many mothers and fathers resume their work within a few months after the birth, and working after a poor night’s sleep is both difficult and exhausting. Babies often nap during the day, but many parents cannot afford that luxury, especially if they do not remain at home during the day. This chapter systematically reviews the evidence about the “normal” evolution of night- and daytime sleep in babies and toddlers as the child ages and about factors other than age that may influence sleeping behaviors: infant feeding, the sleeping arrangements of the baby and parents, the baby’s sleeping position, noise and light in the baby’s bedroom, and the use of pacifiers. After a brief section summarizing the evidence concerning possible effects of the baby’s sleep on long-term health and brain development, most of the chapter summarizes the evidence from randomized trials of interventions designed to help the baby sleep through the night.
Study objectives:
This study evaluated the effect on infant sleep of a novel intervention (Play2Sleep) that combined infant sleep information with self-modeled video feedback on parent-infant interactions.
Methods:
An explanatory sequential mixed methods design consisting of a randomized controlled trial with 63 mother-father-infant triads randomized to Play2Sleep or comparison home visit interventions was used. We used RM-ANCOVA to detect changes in infant night wakings, nocturnal wakefulness, and sleep durations and Wilcoxon signed rank test to evaluate changes in perception of infant sleep problems. Family interviews (n = 20) were used to explain the quantitative findings and analyzed qualitatively using thematic analysis.
Results:
Play2Sleep was effective in reducing maternal-reported infant wakefulness, F(1, 55) = 5.33, p = .03, partial η2 = .09, and the number of paternal-reported naps, F(1, 58) = 4.90, p = .03, partial η2 = .08. Parents in the Play2Sleep group reported significant improvements in problematic infant sleep that were not observed in the comparison group, however Play2Sleep was not effective in reducing the number of parent-reported night wakings. Information overwhelm, learning infant cues, and working together with a subtheme of father involvement were key qualitative themes developed to explain the quantitative results. Unplanned exploratory analyses revealed a significant improvement in maternal depression symptoms in the Play2Sleep group.
Conclusions:
This study suggests Play2Sleep could improve infant sleep by promoting parental awareness of infant cues and father involvement and improving maternal depression. Additional research is needed to determine the optimal number and timing of sessions.
Clinical trial registration:
Registry: ClinicalTrials.gov; Identifier: NCT02742155.
Health visitors play a central role in assessing and supporting families to manage sleep concerns; but with little evidence-based guidance on managing infant sleep difficulties this can be challenging, says Bethany Boddy
Infants evolved in the context of close contact (including co-sleeping). Evolutionary context is rarely considered in psychological infant sleep research, and Western sleep researchers make assumptions about what optimal “normal” infant sleep is and how to achieve early, deep, infant sleep consolidation and avoid infant sleep problems. However, an evolutionary and anthropological view of infant sleep as species-typical recognizes that human evolution likely prepared the infant brain for optimal development within its evolutionary context – co-sleeping. Thus, “normal” infant sleep, sleep consolidation, and sleep problems should all be understood within the framework of co-sleeping infants, not the historically new-phenomenon of solitary-sleeping infants. Much work needs to be done in order to understand “normal” infant sleep as species-typical and how adaptive infants are to environments that stray from their evolutionary norm.
Objective:
To describe the changes in temporal characteristics of sleep-wake cycle, which can serve as non-motor manifestations of an early stage of Parkinson's disease (PD), using the model of preclinical PD in rats of two age groups.
Material and methods:
A prolonged (up to 21 days) model of preclinical PD in middle-aged (7-8 month) and aged (19-20 month) rats was created. The model was based on cumulative inhibition of proteasomal system of the brain caused by intranasal administration of lactacystin, a specific proteasome inhibitor. Polysomnographic data were recorded daily using telemetric Dataquest A.R.T. System (DSI, USA) in unrestrained animals.
Results and conclusion:
Aging was accompanied with increased sleepiness during the active (dark) phase of the day (as was implied by a two-fold increase in the total time of drowsiness) and with 1.5-fold growth of light sleep during the inactive phase of the day. A common feature of sleep disturbances in the model of preclinical PD in both middle-aged and aged rats was hypersomnia during the active phase of the day. It was suggested to be similar to the excessive daytime sleepiness in humans. Hypersomnolence was more pronounced in aged rats because it added to sleepiness developing with aging. In both age groups, the model of preclinical PD was also associated with a decrease in EEG delta power during slow-wave sleep. It is considered dangerous because it might represent the decrease in protein synthesis rate and the weakening of restorative processes in neurons, occurring with the prolonged inhibition of proteasomal system of the brain. Sleep disturbances, identified the model of preclinical PD in rats of different age, may be recommended for clinical validation as low-cost early signs indicating the initial stage of PD.
Behavioral insomnia is the most common sleep disorder in young children. It significantly reduces the quality of parent's life and is one of the common complaints to a pediatrician or neurologist. The basis treatment of childhood insomnia is behavioral therapy, which includes sleep hygiene, age-appropriate daily routine and sleep associations, stable bedtime routines, positive reinforcement, bedtime fading, scheduled awakenings. Although a systematic ignoring («crying it out») is effective and widely used in behavioral therapy, it has low compliance and its safety is insufficiently studied. Therefore, a systematic ignoring is not a priority method of behavioral therapy and should not be used in children under 6 months of age. Behavioral therapy of childhood insomnia is complemented by psychological and informational support from parents, and in some cases, drug therapy. Prevention includes education of expectant parents on baby sleep hygiene.
First-time parent couples from childbirth classes were randomly assigned to a four-session training group (n = 29) or a control group (n = 31) . Members of the training group were taught behavioral strategies to promote healthy, self-sufficient sleep patterns in their infants, whereas the control group received the same amount of personal contact without the behavioral training. Six sleep variables were derived from a daily infant sleep diary completed by parents at two time points. Results show that at age 6–9 weeks, infants in the training group displayed significantly better sleeping patterns than did control infants. Training group parents awakened and responded less often to infant signaling and reported greater parental competence. By contrast, control group parents indicated increased stress over time.
This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodifi ed extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7].
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA
Completing a Systematic Review Is an Iterative Process
The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
When a breastfeeding mother is depressed--or even at risk for depression--she is often advised to supplement with formula so that she can get more sleep. Results of recent studies suggest, however, that exclusively breastfeeding mothers actually get more sleep than their mixed- or formula-feeding
counterparts. The present study examines the relationship between feeding method, maternal well-being, and postpartum depression in a sample of 6,410 mothers of infants 0-12 months of age. Our findings revealed that women who were breastfeeding reported significantly more hours of sleep, better
physical health, more energy, and lower rates of depression than mixed- or formula-feeding mothers. Further, there were no significant differences on any measure between mixed- and formula-feeding mothers, suggesting that breastfeeding is a qualitatively different experience than even mixed
feeding.
Problem crying in the first few months of life is both common and complex, arising out of multiple interacting and co-evolving factors. Parents whose babies cry and fuss alot receive conflicting advice as they seek help from multiple health providers and Emergency Departments, and may be admitted into tertiary residential services. Conflicting advice is costly,and arises out of discipline-specific interpretations of evidence. An integrated, interdisciplinary primary care intervention ("The Possums Approach") for cry-fuss problems in the first months of life was developed from available peer-reviewed evidence. This study reports on preliminary evaluation of delivery of the intervention. A total of 20 mothers who had crying babies under 16 weeks of age (average age 6.15 weeks) completed questionnaires, including the Crying Patterns Questionnaire and the Edinburgh Postnatal Depression Scale, before, and three to four weeks after, their first consultation with trained primary care practitioners. Preliminary evaluation is promising. The Crying Patterns Questionnaire shows a significant decrease in crying and fussing durations, by 1 hour in the evenings (p=0.001) and 30 minutes at nights (p=0.009). The median total amount of crying and fussing in a 24 hour period is reduced from 6.12 to 3 hours. The Edinburgh Postnatal Depression Scale shows a significant improvement in depressive symptoms, with the median score decreasing from 11 to 6 (p=0.005). These findings are corroborated by an analysis of results for the subset of 16 participants whose babies were under 12 weeks of age (average age 4.71 weeks). These preliminary results demonstrate significantly decreased infant crying in the evening and during the night and improved maternal mood, validating an innovative interdisciplinary clinical intervention for cry-fuss problems in the first few months of life. This intervention, delivered by trained health professionals, has the potential to mitigate the costly problem of health professionals giving discipline-specific and conflicting advice post-birth.
A variety of arbitrary and often unphysiological rules for breastfeeding are frequently suggested to breastfeeding mothers. Many of these rules duplicate strategies commonly used to increase milk supply, and thus, when undertaken by the many women who already have a generous milk supply, can lead to overproduction. Oversupply, or hyperlactation, is a frequent yet often unrecognized problem that can present with a variety of distressing symptoms for the breastfeeding mother and her infant. Infants may present with symptoms suggesting colic, milk protein allergies, or gastroesophageal reflux, or may present with unusually rapid or slow growth. Mothers may present with tender leaking breasts, sore infected nipples, plugged ducts or mastitis, or even the perception of insufficient milk supply. With an understanding of the pathophysiology of these symptoms, proper diagnosis and breastfeeding management can allow milk production to return to homeostatic levels and provide dramatic symptom relief.
Knowledge of what constitutes normal sleep behavior during development is a prerequisite for understanding sleep disorders in children and adolescents. This article describes normal sleep patterns in children and adolescents, depicts sleep stages and sleep electrophysiology, and identifies changes in sleep-wake (homeostatic) and circadian regulatory processes across early human development. Two basic principles guide the consideration of normal sleep during childhood: sleep patterns exhibit large variability among children, and sleep behavior must be viewed within a biopsychosocial framework.
#### Summary points
Community cohort studies report that a fifth of parents say that their otherwise healthy baby has cry-fuss problems at two months of age.1 2 Excessive crying is usually a transient neurodevelopmental phenomenon, although it may herald problems that are more long term and serious. Various studies have found that it is often difficult for parents to access the help they need when they experience problem crying; that they resort to use of multiple health services, including of emergency departments; and that they receive conflicting advice.3 w1 We review evidence from heterogeneous studies across multiple health disciplines to provide a practical guide to the management of term infants who cry excessively in the first few months of life. Our review is aimed at paediatricians, general practitioners, community child health nurses, and midwives. Although definitions of infant crying vary considerably, for practical purposes we use the terms cry-fuss behaviour, excessive crying, colic, and unsettled infant behaviour interchangeably to refer to any crying behaviour that parents report …
This paper explores two areas in which the translation of research into practice may be improved in the management of cry-fuss behaviours in the first few months of life. Firstly, babies who cry excessively are often prescribed proton pump inhibitors, despite evidence that gastro-oesophageal reflux disease is very rarely a cause. The inaccuracy of commonly used explanatory mechanisms, the side-effects of acid-suppressive medications, and the failure to identify treatable problems, including feeding difficulty when the diagnosis of 'reflux' is applied, are discussed. Secondly, crying breastfed babies are still prescribed lactase or lactose-free formula, despite evidence that the problem of functional lactose overload is one of breastfeeding management. The mechanisms and management of functional lactose overload are discussed. These two problems of research translation need to be addressed because failure to identify and manage other causes of cry-fuss problems, including feeding difficulty, may have adverse outcomes for a small but significant minority of families.
Objective To evaluate the effectiveness of a behavioural-educational sleep intervention delivered in the early postpartum in improving maternal and infant sleep.
Design Randomised controlled trial.
Setting Postpartum units of two university affiliated hospitals.
Participants 246 primiparous women and their infants randomised while in hospital with an internet based randomisation service to intervention (n=123) or usual care (n=123) groups.
Interventions The behavioural-educational sleep intervention included a 45-60 minute meeting with a nurse to discuss sleep information and strategies to promote maternal and infant sleep, a 20 page booklet with the content discussed, and phone contacts at one, two, and four weeks postpartum to reinforce information, provide support, and problem solve. The usual care group received calls at weeks one, two, and four to maintain contact without provision of advice.
Main outcome measures Primary outcome was maternal nocturnal (9 pm to 9 am) sleep (minutes) and secondary outcome was longest stretch of infant nocturnal sleep (minutes) measured at six and 12 weeks postpartum by actigraphy. Other outcomes measured at six and 12 weeks were number of maternal and infant night time awakenings by actigraphy, fatigue visual analogue scale, general sleep disturbance scale, and Edinburgh postnatal depression scale. Rates of exclusive breast feeding were measured at 12 weeks postpartum only.
Results All women who completed any outcome measures at six or 12 weeks were included in analysis. Sleep outcomes were completed at one or both of six and 12 weeks postpartum for 215 of 246 (87%) women (110/123 intervention and 105/123 usual care). Longitudinal mixed effects model analyses indicated no significant differences between the groups on any of the outcomes. The estimated mean difference in maternal nocturnal sleep between the intervention and usual care groups was 5.97 minutes (95% confidence interval −7.55 to 19.5 minutes, P=0.39). No differences in any outcomes were noted based on the specific nurse delivering the intervention or the number of phone contacts received.
Conclusion A behavioural-educational intervention delivered in the early postpartum, in hospital, and in the first weeks at home, was ineffective in improving maternal and infant sleep or other health outcomes in the first months postpartum.
Trial registration ISRCT No 13501166.
The objectives of this study were to analyse the perspectives of key informants with clinical expertise in the care of unsettled babies in the first few months of life and their families, concerning changes required to improve outcomes. The research used a purposive selection strategy and thematic analysis of key informant interviews of 24 health professionals from 11 disciplines. Informants were selected for extensive experience in the management of unsettled babies and their families. Participants corroborated existing evidence that post-birth care in Australia is fragmented. All held the view that, first, early primary care intervention for unsettled infants and their families, and second, improved cross-professional communication, are vital if the burden of this problem to the infant, family and health system are to be minimised. There was consensus, third, that significant gaps exist in health professionals' knowledge base and management behaviours. The development of education resources, best practice guidelines, shared assessment frameworks for primary care practitioners and strategies for improved cross-professional communication are necessary to improve the health outcomes and decrease the burden of this common yet complex post-birth problem.
Australia's Early Parenting Services support families and intervene early in mental health problems in parents. The Victorian Early Parenting Strategy, a platform for government policy recommended a stronger evidence base for early parenting services. Tweddle Child and Family Health Service (TCFHS) is a not-for-profit public sector early parenting centre, which provides residential, day stay, home visiting and outreach programs. This study aimed i) to examine the health, social circumstances and presenting needs of clients attending the Tweddle Day Stay Program (DSP) with infants under 12 months old and ii) to assess the parent mental health and infant behaviour outcomes and the factors associated with program success.
A cohort of clients was recruited prior to admission and followed-up 8 weeks after discharge. Data were collected using standardised measures in a study specific questionnaire at baseline, participant's Tweddle records and a follow-up telephone interview. Health, social circumstances and presenting needs of clients were described. Changes in parents' symptoms of depression and infants' sleep and settling between admission and follow-up were calculated. Multiple regression analyses were conducted to examine factors associated with changes in primary outcomes.
Of the total 162 clients who were eligible and invited to participate, 115 (72%) were recruited. Parents admitted to the DSP had worse general self-reported physical and mental health than community samples. Infants of DSP participants were no more likely to be premature or have low birth weight, but significantly more unsettled than other community samples. Participants' mental health and their infants' behaviours were significantly improved after DSP admission. In multivariate analysis, higher depression score at baseline and greater educational attainment were significantly associated with improvements in parents' mental health. Worse unsettled infant behaviours and longer time between discharge and follow up were significantly associated with improvements in infant sleep and settling.
Tweddle DSPs appear to respond effectively to the needs of families presenting with substantial physical and emotional health morbidity and a range of vulnerabilities by treating parental mental health and infant behaviour problems together. DSPs offer important potential benefits for prevention of more serious family problems and consequent health care cost savings.
Problems experienced within the first year of an infant's life can be precursors of later mental health conditions. The purpose of this study was to examine the frequency and continuity of difficult behaviors in infants at 3 and 6 months of age and the associations of these difficulties with biomedical and psychosocial factors.
This study was a part of an ongoing prospective birth-cohort study. Study participants were 189 uniparous mothers and their full-term newborns. The index of infant difficult behavior was constructed. This index was then associated with the following factors: delivery mode, newborn function after birth, maternal emotional well-being, risk behavior, subjective evaluation of the quality of the relationship of the couple, and attitudes toward infant-rearing.
Common difficult behaviors, including crying, sleeping and eating problems, were characteristic for 30.2% of 3 month old and for 22.2% of 6 month old full-term infants. The expression of infant difficult behaviors at the age of 3 months increased the likelihood of the expression of these difficulties at 6 months by more than 5 times. Factors including younger maternal age, poor prenatal and postnatal emotional well-being, prenatal alcohol consumption, low satisfaction with the couple's relationship before pregnancy, and deficiency of infant-centered maternal attitudes towards infant-rearing increased the likelihood of difficult behaviors in infants at the age of 3 months. Low maternal satisfaction with the relationship of the couple before pregnancy, negative emotional reactions of both parents toward pregnancy (as reported by the mother) and the deficiency of an infant-centered maternal attitude towards infant-rearing increased the likelihood of infant difficult behaviors continuing between the ages of 3 to 6 months. Perinatal biomedical conditions were not related to the difficult behaviors in infants.
Our study suggests that early onset of difficult behavior highly increases the risk for the continuation of difficult behavior during infancy. In general, the impact of prenatal psychosocial environment on infant behavior decreases from the ages of 3 to 6 months; however, some prenatal and preconceptional psychosocial factors have direct associations with the continuity of difficult behaviors through the first half-year of an infant's life.
There is a common belief that children are not getting enough sleep and that children's total sleep time has been declining. Over the century, many authors have proposed sleep recommendations. The aim of this study was to describe historical trends in recommended and actual sleep durations for children and adolescents, and to explore the rationale of sleep recommendations.
A systematic literature review was conducted to identify recommendations for children's sleep requirements and data reporting children's actual total sleep time. For each recommendation identified, children's actual sleep time was determined by identifying studies reporting the sleep duration of children of the same age, gender, and country in the same years. Historical trends in age-adjusted recommended sleep times and trends in children's actual sleep time were calculated. A thematic analysis was conducted to determine the rationale and evidence-base for recommendations.
Thirty-two sets of recommendations were located dating from 1897 to 2009. On average, age-specific recommended sleep decreased at the rate of -0.71 minute per year. This rate of decline was almost identical to the decline in the actual sleep duration of children (-0.73 minute per year). Recommended sleep was consistently ∼37 minutes greater than actual sleep, although both declined over time.
A lack of empirical evidence for sleep recommendations was universally acknowledged. Inadequate sleep was seen as a consequence of "modern life," associated with technologies of the time. No matter how much sleep children are getting, it has always been assumed that they need more.
To examine the relationship between breastfeeding and maternally-rated infant temperament at age 3 months, 316 infants in the prospective Cambridge Baby Growth Study, UK had infant temperament assessed at age 3 months by mothers using the Revised Infant Behavior Questionnaire, which produces scores for three main dimensions of temperament derived from 14 subscales. Infant temperament scores were related to mode of infant milk feeding at age 3 months (breast only; formula milk only; or mixed) with adjustment for infant's age at assessment and an index of deprivation.
Infant temperament dimension scores differed across the three infant feeding groups, but appeared to be comparable between exclusive breast-fed and mixed-fed infants. Compared to formula milk-fed infants, exclusive breast-fed and mixed-fed infants were rated as having lower impulsivity and positive responses to stimulation (adjusted mean [95% CI] "Surgency/Extraversion" in formula-fed vs. mixed-fed vs. breast-fed groups: 4.3 [4.2-4.5] vs. 4.0 [3.8-4.1] vs. 4.0 [3.9-4.1]; p-heterogeneity = 0.0006), lower ability to regulate their own emotions ("Orienting/Regulation": 5.1 [5.0-5.2], vs. 4.9 [4.8-5.1] vs. 4.9 [4.8-5.0]; p = 0.01), and higher emotional instability ("Negative affectivity": 2.8 [2.6-2.9] vs. 3.0 [2.8-3.1] vs. 3.0 [2.9-3.1]; p = 0.03).
Breast and mixed-fed infants were rated by their mothers as having more challenging temperaments in all three dimensions; particular subscales included greater distress, less smiling, laughing, and vocalisation, and lower soothability. Increased awareness of the behavioural dynamics of breastfeeding, a better expectation of normal infant temperament and support to cope with difficult infant temperament could potentially help to promote successful breastfeeding.
Background: Many popular childcare books recommend feeding babies to a schedule, but no large-scale study has ever examined the effects
of schedule-feeding. Here, we examine the relationship between feeding infants to a schedule and two sets of outcomes: mothers’
wellbeing, and children’s longer-term cognitive and academic development. Methods: We used a sample of 10 419 children from the Avon Longitudinal Study of Parents and Children, a cohort study of children
born in the 1990s in Bristol, UK. Outcomes were compared by whether babies were fed to a schedule at 4 weeks. Maternal wellbeing
indicators include measures of sleep sufficiency, maternal confidence and depression, collected when babies were between 8
weeks and 33 months. Children’s outcomes were measured by standardized tests at ages 5, 7, 11 and 14, and by IQ tests at age
8. Results: Mothers who fed to a schedule scored more favourably on all wellbeing measures except depression. However, schedule-fed babies
went on to do less well academically than their demand-fed counterparts. After controlling for a wide range of confounders,
schedule-fed babies performed around 17% of a standard deviation below demand-fed babies in standardized tests at all ages,
and 4 points lower in IQ tests at age 8 years. Conclusions: Feeding infants to a schedule is associated with higher levels of maternal wellbeing, but with poorer cognitive and academic
outcomes for children.
To examine the potential for publication bias, data availability bias, and reviewer selection bias in recently published meta-analyses that use individual participant data and to investigate whether authors of such meta-analyses seemed aware of these issues.
In a database of 383 meta-analyses of individual participant data that were published between 1991 and March 2009, we surveyed the 31 most recent meta-analyses of randomised trials that examined whether an intervention was effective. Identification of relevant articles and data extraction was undertaken by one author and checked by another.
Only nine (29%) of the 31 meta-analyses included individual participant data from "grey literature" (such as unpublished studies) in their primary meta-analysis, and the potential for publication bias was discussed or investigated in just 10 (32%). Sixteen (52%) of the 31 meta-analyses did not obtain all the individual participant data requested, yet five of these (31%) did not mention this as a potential limitation, and only six (38%) examined how trials without individual participant data might affect the conclusions. In nine (29%) of the meta-analyses reviewer selection bias was a potential issue, as the identification of relevant trials was either not stated or based on a more selective, non-systematic approach. Investigation of four meta-analyses containing data from ≥10 trials revealed one with an asymmetric funnel plot consistent with publication bias, and the inclusion of studies without individual participant data revealed additional heterogeneity between trials.
Publication, availability, and selection biases are a potential concern for meta-analyses of individual participant data, but many reviewers neglect to examine or discuss them. These issues warn against uncritically viewing any meta-analysis that uses individual participant data as the most reliable. Reviewers should seek individual participant data from all studies identified by a systematic review; include, where possible, aggregate data from any studies lacking individual participant data to consider their potential impact; and investigate funnel plot asymmetry in line with recent guidelines.
To estimate the prevalence of insomnia and examine its correlates (for example, demographics and physical and mental health) and treatments.
A sample of 2000 Canadians aged 18 years and older responded to a telephone survey about sleep, health, and the use of sleep-promoting products. Respondents with insomnia were identified using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and the International Classification of Diseases, Tenth Edition, criteria.
Among the sample, 40.2% presented at least 1 symptom of insomnia (that is, trouble falling or staying asleep, or early morning awakening) for a minimum of 3 nights per week in the previous month, 19.8% were dissatisfied with their sleep, and 13.4% met all criteria for insomnia (that is, presence of 1 insomnia symptom 3 nights or more per week for at least 1 month, accompanied by distress or daytime impairment). Insomnia was associated with female sex, older age, and poorer self-rated physical and mental health. Thirteen per cent of respondents had consulted a health care provider for sleep difficulties once in their lifetime. Moreover, 10% had used prescribed medications for sleep in the previous year, 9.0% used natural products, 5.7% used over-the-counter products, and 4.6% used alcohol. There were differences between French- and English-speaking adults, with the former group presenting lower rates of insomnia (9.5%, compared with 14.3%) and consultation (8.7%, compared with 14.4%), but higher rates of prescribed medications (12.9%, compared with 9.3%) and the use of natural products (15.6%, compared with 7.4%).
Insomnia is a prevalent condition, although few people seek professional consultation for this condition. Despite regional differences in the prevalence and treatments used to manage insomnia, prescribed medications remain the most widely used therapeutic option.
This overview attempts to synthesise current understandings of the neuroendocrine basis of parenting. The parent-infant bond is central to the human condition, contributes to risks for mood and anxiety disorders, and provides the potential for resiliency and protection against the development of psychopathology. Animal models of parenting provide compelling evidence that biological mechanisms may be studied in humans. This has led to brain imaging and endocrine system studies of human parents using baby stimuli and concerted psychological and behavioural measures. Certain brain circuits and related hormonal systems, including subcortical regions for motivation (striatum, amygdala, hypothalamus and hippocampus) and cortical regions for social cognition (anterior cingulate, insula, medial frontal and orbitofrontal cortices), appear to be involved. These brain circuits work with a range of endocrine systems to manage stress and motivate appropriate parental caring behaviour with a flexibility appropriate to the environment. Work in this field promises to link evolving models of parental brain performance with resilience, risk and treatment toward mother-infant mental health.
Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management.
New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended.
The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Excessive crying, sleeping or feeding problems are found in approximately 20% of infants and may predict behavioural problems in childhood.
A quantitative meta-analysis of 22 longitudinal studies from 1987 to 2006 that statistically tested the association between infant regulatory problems and childhood internalising, externalising and attention-deficit/hyperactivity disorder (ADHD) problems was carried out; 1935 children with regulatory problems were tested. Cohen's d was used to express the association between regulatory problems and behavioural problems. Heterogeneity of the effect sizes was assessed using the I(2) statistic and meta-analysis of variance and meta-regressions were conducted to assess the influence of moderators. Rosenthal's classic fail-safe N and correlation of sample sizes to effect sizes were used to assess publication bias.
The weighted mean effect size for the main regulatory problems-behavioural problems association was 0.41 (95% CI 0.28 to 0.54), indicating that children with previous regulatory problems have more behavioural problems than controls. Externalising and ADHD problems were the strongest outcome of any regulatory problem, indicated by the highest fail-safe N and lowest correlation of sample size to effect size. Meta-analyses of variance revealed no significant moderating influences of regulatory problem comorbidity (I(2)=44.0, p>0.05), type (I(2)=41.8, p>0.05) or duration (I(2)=44.0, p>0.05). However, cumulative problems and clinical referral increased the risk of behavioural problems.
The meta-analyses suggest that children with previous regulatory problems have more behavioural problems than controls, particularly in multi-problem families. Further studies are required to assess the behavioural outcomes of previously sleep, feeding or multiply disturbed children.
The present paper addresses the relationship between community based child health nursing services and social constructions of motherhood within Australia during the 1920s. Following the First World War, child health nursing services (then generally known as infant welfare or child welfare services) were established in all Australian states. The focus of the paper is mainly upon the development of the Tasmanian child health service, with some reference to similar services in other states. Within two decades of their establishment, most child-bearing women in Tasmania were in contact with child health services and this apparent success meant that, thereafter, women in Tasmania cared for their children under the ‘expert’ guidance of nurses. As the 1920s progressed, child health nurses increasingly promoted one particular, and ultimately extremely influential, construction of motherhood, ‘scientific motherhood’, based upon the philosophy of Dr Truby King. I argue that an understanding of how nursing services have historically reinforced and promoted ideological constructions of motherhood enhances the practice of present day nurses working with women. This argument is supported by reference to present day nursing practice in relation to postnatal depression.
While infant behaviour is influenced by maternal care, infant crying and dysregulated sleep can reciprocally affect maternal mood. The temperament and behaviour of two 4–12-months-old infant cohorts admitted with their mothers to a residential parenting program were examined using behaviour charts and the Short Infant Temperament Questionnaire (SITQ). One group was re-assessed one and six months later. Infant temperament was significantly more difficult than population norms and most had dysregulated sleep. One month after treatment, total infant crying and fussing, frequency of night-time waking, and sleep and feeding dysregulation were significantly (p
Our purpose was to determine if babies breastfed at 6 months of age were more likely to wake at night and less likely to sleep alone than formula-fed babies.
Data were drawn from the first wave of The Longitudinal Study of Australian Children, an ongoing, nationally representative study of the growth and development of Australia's children. The 4507 participants met the criteria for this study. The measures examined infant sleep problems as the outcome and breastfeeding at 6 months of age as the exposure in addition to the demographic data, maternal mental health, infant birthweight and gestational age at delivery.
After adjustment for covariates, reports by mothers of infants that breastfed at 6 months of age suggested infants were 66% more likely to wake during the night and 72% more likely to report difficulty sleeping alone. However, breastfeeding had a strongly protective effect on wheezing, coughing, snoring and breathing problems, and it was not associated with restless sleep or problems getting to sleep for the infant.
Breastfeeding was found to be associated with increased night waking and this is consistent with other studies. There are biological reasons why this might be required to ensure breastfeeding continues to 6 months and beyond. The current low rates of sustained breastfeeding in many Western countries needs to be reconsidered in relation to parental and public health practices promoting prolonged nocturnal infant sleep patterns.
Objective:
To examine the effect of cognitive-behavioral therapy for insomnia (CBT-I) on the underreporting of sleep relative to objective measurement, a common occurrence among individuals with insomnia.
Method:
Pre-treatment and post-treatment self-report measures of sleep were compared with those obtained from home-based polysomnography (PSG) in 60 adults (mean age = 69.17; 42 women) with comorbid insomnia. The self-report data were published previously in a randomized controlled trial demonstrating the efficacy of CBT-I compared with a placebo treatment.
Results:
Self-report measures significantly underestimated sleep at pre-treatment and CBT-I led to a correction in this discrepancy. There were no significant changes in PSG after CBT-I. Path analysis showed that an increase in an objective proxy measure of sleep quality (i.e., decreased stage N1 sleep) after CBT-I was significantly related to improvements in self-report of sleep, with full mediation by reductions in discrepancy.
Conclusions:
This is the first CBT-I outcome study to analyze discrepancy changes and demonstrate that these changes account for a significant portion of self-report outcome. In addition, improved sleep quality as measured by a decrease in percentage of stage N1 sleep following treatment may be one mechanism that explains why sleep estimation is more accurate following CBT-I.
Objectives:
To determine whether maternal report of infant behavioral dysregulation at 6 months is associated with a higher prevalence of behavioral concerns at 5, 14, and 21 years of age; and to assess the extent to which maternal and social factors may affect reported child behavior outcomes.
Methods:
From the Mater-University of Queensland Study of Pregnancy cohort of 7223 live singleton babies, information on dysregulation was available for 6389 children at 6 months. Of those children, behavior data were available for 4836 at 5 years by using a modified Child Behavior Checklist, 4746 at 14 years by using a full Child Behavior Checklist and Youth Self-Report, and 3558 at 21 years by using a Young Adult Self-Report. Of the youth with dysregulation data at 6 months, 2308 completed the Composite International Diagnostic Interview at 21 years. Potential confounding and mediating factors were analyzed by using logistic regression.
Results:
Maternal-reported behavioral dysregulation at 6 months was associated with a significantly higher prevalence of maternal-reported behavior problems at 5 and 14 years (P < .001), but not youth self-reported problems at 14 or 21 years, or Composite International Diagnostic Interview-Diagnostic and Statistical Manual diagnoses at 21 years. The strength of association between infant dysregulation and maternal-reported behaviors was greater at 5 years than at 14 years, and was substantially reduced by adjusting for maternal, social, and infant factors, especially potentially the mediating factors of maternal anxiety and depression.
Conclusions:
Infant behavioral dysregulation was a risk factor for maternal-reported behavior concerns at 5 and 14 years, although was unrelated to young adult mental health.
To examine whether infant sleep problems predict (1) sleep problems and (2) poorer outcomes at the age of six years.
We studied a community-based cohort of 326 six-year-olds recruited to a randomized trial of a behavioral sleep intervention for sleep problems at age seven months. Predictors were parent-reported child sleep problems at ages 4, 12, and 24 months ("yes" vs. "no"). There were a number of parent reported six-year-old outcomes: (1) Child sleep problem ("moderate/large" vs. "none/small") and Child Sleep Habits Questionnaire (CSHQ); (2) child and maternal mental and global health, child health-related quality of life (HRQoL, also child-reported), and child-parent relationship. The analyses were composed of multivariable models, adjusting for potential confounders and six-year sleep problems, examining whether each outcome was predicted by each infant sleep problem entered simultaneously. In a second set of analyses the predictor was the count of the number of waves with a sleep problem.
A total of 225 (69%) families participated at six years. The CSHQ Total increased 0.5 points (95% CI: 0.4 to 2.4, p=0.006) with each additional infant sleep problem, but there was little evidence that sleep problems at one or more time points during early childhood predicted other child, maternal, or child-parent outcomes at six years.
Infant sleep problems, whether transient, recurring, or persistent, do not predict long-term outcomes. Clinicians should focus on reducing child sleep problems and their considerable short-to-medium term impacts as they arise during childhood.
To better understand the mechanisms behind breastfeeding and childhood obesity, we assessed the association of weight gain with the mode of milk delivery aside from the type of milk given to infants.
A longitudinal study of infants followed up from birth to age 1 year. Multilevel analyses were conducted to estimate infant weight gain by type of milk and feeding mode.
Pregnant women were recruited from a consumer mail panel throughout the United States between May 2005 and June 2007.
One thousand eight hundred ninety nine infants with at least 3 weight measurements reported during the first year.
Six mutually exclusive feeding categories and proportions of milk feedings given as breastmilk or by bottle.
Weight measurements reported on 3-, 5-, 7-, and 12-month surveys.
Compared with infants fed at the breast, infants fed only by bottle gained 71 or 89 g more per month when fed nonhuman milk only (P < .001) or human milk only (P = .02), respectively. Weight gain was negatively associated with proportion of breastmilk feedings, but it was positively associated with proportion of bottle-feedings among those who received mostly breastmilk. Among infants fed only breastmilk, monthly weight gain increased from 729 g when few feedings were by bottle to 780 g when most feedings were by bottle.
Infant weight gain might be associated not only with type of milk consumed but also with mode of milk delivery. Regardless of milk type in the bottle, bottle-feeding might be distinct from feeding at the breast in its effect on infants' weight gain.
Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).
To characterize sleep patterns and sleep problems in a large sample of young children (birth to 36 months) in Australia (AU) and New Zealand (NZ). Methods: Parents and caregivers of 2154 infants and toddlers in AU and NZ completed an expanded version of the Brief Infant Sleep Questionnaire.
Overall, young children in AU and NZ go to bed relatively early (19:35), awaken on average 1.08 times per night for an average of 23 min, have a low likelihood of bed-sharing with parents (7.2%) and obtain an average of 13.24 h total sleep. However, a significant percentage of parents perceive that their child has a sleep problem (30.69%). Sleep patterns in these children demonstrate clear developmental changes, including a decrease in daytime sleep and total sleep time, as well as consolidation of sleep during the night (decrease in night wakings and nocturnal wakefulness). Parents in AU and NZ are also highly likely to encourage independence and self-soothing, especially after the age of 3 months.
These findings provide parents and professionals reference data for assessing sleep in young children, as well as common parenting practices related to sleep behaviours.
This is a systematic review of the scientific literature with regard to normal sleep patterns in infants and children (0-12 years). The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Mean and variability data for sleep duration, number of night wakings, sleep latency, longest sleep period overnight, and number of daytime naps were extracted from questionnaire or diary data from 34 eligible studies. Meta-analysis was conducted within age-bands and categories. In addition, fractional polynomial regression models were used to estimate best-fit equations for the sleep variables in relation to age. Reference values (means) and ranges (±1.96 SD) for sleep duration (hours) were: infant, 12.8 (9.7-15.9); toddler/preschool, 11.9 (9.9-13.8); and child, 9.2 (7.6-10.8). The best-fit (R(2)=0.89) equation for hours over the 0-12 year age range was 10.49-5.56×[(age/10)^0.5-0.71]. Meta-regression showed predominantly Asian countries had significantly shorter sleep (1h less over the 0-12 year range) compared to studies from Caucasian/non-Asian countries. Night waking data provided 4 age-bands up to 2 years ranging from 0 to 3.4 wakes per night for infants (0-2 months), to 0-2.5 per night (1-2 year-olds). Sleep latency data were sparse but estimated to be stable across 0-6 years. Because the main data analysis combined data from different countries and cultures, the reference values should be considered as global norms.
Neural correlates of stress regulation via the hypothalamic-pituitary-adrenal (HPA) axis have been identified, but little is known about how these apply to real-world interpersonal stress contexts such as mother-infant interaction. We extended stress regulation research by examining maternal neural activation to infant cry related to HPA regulation with their infants.
Twenty-two primiparous mothers listened to the cry sounds of their own 18-month-old infant and an unfamiliar infant and a control sound during functional magnetic resonance imaging scanning. Salivary cortisol was collected at four timepoints in a separate session involving the Strange Situation stressor. Cortisol trajectories were modeled with hierarchical linear modeling, and trajectory terms were used to predict neural response to own infant cry.
Mothers who showed less HPA reactivity-indexed by trajectory curvature rather than level-showed increased activation to the cry of their infant relative to control sound across limbic/paralimbic and prefrontal circuits. These included periaqueductal gray, right insula, and bilateral orbitofrontal cortex as well as anterior cingulate-medial prefrontal cortex. Activations overlapped to some extent with previous HPA regulation findings and converged more extensively with circuits identified in other maternal response paradigms.
Maternal stress regulation involves both circuits found across stressor types (i.e., prefrontal) and areas unique to the mother-infant relationship (i.e., limbic/paralimbic). The shape of the HPA response trajectory of mothers was more important than the level of such response in defining stress-related neural correlates. Future research should consider dimensions of the stress context and of physiological trajectories to define stress-regulatory circuits.
To investigate factors associated with health service use by women and their infants in Victoria, Australia.
Cross-sectional screening survey of 875 women with 4-month-old infants attending immunisation clinics in five local government areas in Melbourne between May 2007 and August 2008. The self-report instrument assessed socio-demographic characteristics, unsettled infant behaviour, maternal mood (Edinburgh Postnatal Depression Scale) and, the outcome, health service use during the first 4 months post-partum.
Mothers and their infants used on average 2.8 different health services in the first 4 months post-partum (range 0-8). After adjustment for other factors, high health service use (defined as >3 different services) was more common in mothers whose infants were unsettled with persistent crying, resistance to soothing and poor sleep. A one-point increase on the unsettled infant behaviour measure was associated with an 8% (2-14%) increase in the use of >3 services, 9% (3-16%) in use of emergency departments, 7% (2-13%) in use of telephone helplines and 9% (3-14%) of parenting services. Poorer maternal mental health was also implicated with a one-point increase on the Edinburgh Postnatal Depression Scale associated with a 4% (0.4-8%) increase in the likelihood of using more than three services.
Unsettled infant behaviour is associated with increased use of multiple health services. The high use of emergency departments by families with unsettled infants found in this study suggests that enhancement of primary health-care capacity might be required.
We undertook a descriptive study in 2-month-old healthy infants to determine the factors that affect breastfeeding score. Mother's breastfeeding was evaluated and scored according to the World Health Organization/UNICEF B-R-E-A-S-T Feeding Observation Form.
The breastfeeding score (BFS) was higher in female than male babies (p=0.005). The babies with regurgitation had lower BFS than the babies without (p=0.016). The BFS was lower in babies who had repeated, without cause, inconsolable crying than in those without such crying (p<0.004). When the crying was problematic for the family, BFS was lower (p=0.028). Babies who had another sibling with a history of colic had a lower BFS (p=0.038). A low BFS was associated with short duration of night sleeping (p=0.032).
A decreased BFS may be a risk factor or indicator for infant crying, regurgitation, and short sleeping duration. As a result, tracking the BFS and appropriate breastfeeding intervention during the newborn period may assist in decreasing the frequency of regurgitation and infant crying.
Citation is a powerful method for establishing belief. Published statements gain credibility when followed by citations. Citation in its purest form consists of the scholarly connection of authors' ideas and claims to existing literature, yet there are also non-scholarly uses of citation that are best called citation distortions. Unfounded biomedical belief systems arising from citation distortions may become widely accepted as fact. The development of methodology for the study of citation distortions and belief systems regarding scientific claims was recently described. Here, I discuss further the methodological approaches to studying published scientific belief systems and identifying citation distortions.
Major depression is a frequent complication of the postpartum period. Untreated postpartum depression increases the risk of maternal suicide and can impair parenting capability with resultant adverse effects on offspring development. A number of factors influence a woman's vulnerability to postpartum depressive episodes. This article summarizes processes for assessing these risk factors and implementing primary preventive interventions, and summarizes methods of early detection to promote secondary and tertiary prevention.
Infant regulatory problems, that is, excessive crying, feeding and/or sleeping difficulties, are precursors of adverse development. However, the aetiology of regulatory problems is still unclear. The aim of this study was to investigate pre-, peri- and post-natal neurophysiological and psychosocial predictors of single and multiple regulatory problems at 5 months of age.
This prospective longitudinal study included all children born at neonatal risk in a geographically defined area in southern Germany. The data of n = 5093 singleton infants (83.6%) were analysed using crude and multivariate logistic regression analyses. As outcome measures we used single and multiple regulatory problems, that is, crying, feeding and/or sleeping difficulties at 5 months of age, which were assessed via a standardized interview with the parents by study paediatricians as part of a neurodevelopmental examination.
In total, 30.7% of the sample suffered from single or multiple regulatory problems at 5 months. Breastfeeding increased the odds of single sleeping problems 5.12-fold, but decreased the odds of single feeding problems [odds ratio (OR) 0.51; 95% confidence interval (CI) 0.35-0.74]. Very preterm birth was predictive of single feeding (OR 1.79; 95% CI 1.25-2.55) and multiple regulatory problems (OR 2.03; 95% CI 1.19-3.46), and foetal abnormalities increased the odds of single feeding and multiple regulatory problems from 1.53- to 1.64-fold. Family adversity and psychosocial stress factors were associated with single crying and multiple regulatory problems.
Pre-, peri- and post-natal neurophysiological and psychosocial factors are predictive of single and multiple regulatory problems. The results may be useful in terms of early recognition of at risk groups for regulatory problems.