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A Nightly Bedtime Routine: Impact on Sleep in Young Children and Maternal Mood

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  • Johnson & Johnson Group of Consumer Companies
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A Nightly Bedtime Routine: Impact on Sleep in Young Children and Maternal Mood

Abstract and Figures

Establishment of a consistent bedtime routine is often recommended to parents of young children, especially those with sleep difficulties. However, no studies have investigated the efficacy of such a routine independent of behavioral intervention. Thus, the purpose of this study was to examine the impact of a consistent bedtime routine on infant and toddler sleep, as well as maternal mood. 405 mothers and their infant or toddler (ages 7-18 months, n=206; ages 18-36 months, n=199) participated in 2 age-specific 3-week studies. Families were randomly assigned to a routine or control group. The first week of the study served as a baseline during which the mothers were instructed to follow their child's usual bedtime routine. In the second and third weeks, mothers in the routine group were instructed to conduct a specific bedtime routine, while the control group continued their child's usual routine. All mothers completed the Brief Infant Sleep Questionnaire (BISQ) on a weekly basis and a daily sleep diary, as well as completed the Profile of Mood States. The bedtime routine resulted in significant reductions in problematic sleep behaviors for infants and toddlers. Significant improvements were seen in latency to sleep onset and in number/duration of night wakings, P < 0.001. Sleep continuity increased and there was a significant decrease in the number of mothers who rated their child's sleep as problematic. Maternal mood state also significantly improved. Control group sleep patterns and maternal mood did not significantly change over the 3-week study period. These results suggest that instituting a consistent nightly bedtime routine, in and of itself, is beneficial in improving multiple aspects of infant and toddler sleep, especially wakefulness after sleep onset and sleep continuity, as well as maternal mood.
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SLEEP, Vol. 32, No. 5, 2009 599
SLEEP PROBLEMS ARE ONE OF THE MOST COMMON
CONCERNS OF PARENTS OF YOUNG CHILDREN, OCCUR-
RING IN APPROXIMATELY 20% TO 30% OF INFANTS AND
toddlers,1,2 and one of the most common behavioral issues brought
to the attention of pediatricians.3,4 There are a number of studies
on the efcacy of behavioral interventions for the sleep problems,
and the American Academy of Sleep Medicine has even released
a standards of practice document for behavioral treatment of bed-
time problems and night wakings in young children.1,5 Overall, it
was found that of 52 treatment studies reviewed, 94% reported
that behavioral interventions were efcacious and 80% of chil-
dren treated demonstrated clinically signicant improvement.
Noteworthy was that the majority of the intervention studies re-
viewed included a bedtime routine as part of a multi-component
treatment program. However, no studies have ever evaluated the
efcacy of a bedtime routine independent of other treatments.
A bedtime routine is a common and simple behavioral in-
tervention for sleep issues in young children, with over 90%
of pediatricians recommending institution of a bedtime routine
to their patients with sleep difculties.3 Research shows that
daily routines in general lead to predictable and less stressful
environments for young children and are related to parenting
competence, improved daytime behaviors, and lower maternal
mental distress.6-8 A bedtime routine is one such daily family
routine and consists of parents engaging their child in the same
activities in the same order on a nightly basis prior to turning
out the lights (“lights out”). It is expected that a bedtime routine
will similarly improve behavior and will result in children fall-
ing asleep quicker with less disruptive behaviors at bedtime.
Furthermore, in considering the efcacy of sleep-related
interventions on children, it is important to note that sleep is-
sues in young children also have a signicant negative impact
on parents. For example, studies have found elevated levels
of depressed mood in mothers of infants and toddlers having
sleep disturbances.9,10 Conversely, studies indicate that success-
ful treatment of children’s sleep problems with behavioral in-
terventions results in improvements in parental well-being.11,12
Therefore, improvement in parental mood following institution
of a bedtime routine is also expected given that routines overall
result in reduced parental distress, as discussed above.
Thus, the overall objectives of the current studies were to ex-
amine the effects of a consistent bedtime routine on infant and
toddler sleep, as well as its impact on maternal mood. We hy-
pothesized that a bedtime routine would result in (1) decreased
sleep onset latency, (2) reduction of disruptive bedtime behav-
iors, and (3) improved maternal mood.
METHODS
Participants
Overall, 405 mothers and their young child participated in
2 separate studies. The rst study involved 206 mothers and
NIGHTLY BEDTIME ROUTINE FOR CHILDREN
A Nightly Bedtime Routine: Impact on Sleep in Young Children
and Maternal Mood
Jodi A. Mindell, PhD1; Lorena S. Telofski, BA2; Benjamin Wiegand, PhD2; Ellen S. Kurtz, PhD2
1Saint Joseph’s University and The Children’s Hospital of Philadelphia, Philadelphia, PA; 2Johnson & Johnson Consumer Companies, Inc.,
Skillman, NJ
Background: Establishment of a consistent bedtime routine is often
recommended to parents of young children, especially those with sleep
difculties. However, no studies have investigated the efcacy of such
a routine independent of behavioral intervention. Thus, the purpose of
this study was to examine the impact of a consistent bedtime routine on
infant and toddler sleep, as well as maternal mood.
Methods: 405 mothers and their infant or toddler (ages 7-18 months,
n = 206; ages 18-36 months, n = 199) participated in 2 age-specic
3-week studies. Families were randomly assigned to a routine or con-
trol group. The rst week of the study served as a baseline during
which the mothers were instructed to follow their child’s usual bedtime
routine. In the second and third weeks, mothers in the routine group
were instructed to conduct a specic bedtime routine, while the con-
trol group continued their child’s usual routine. All mothers completed
the Brief Infant Sleep Questionnaire (BISQ) on a weekly basis and
a daily sleep diary, as well as completed the Prole of Mood States
(POMS).
Results: The bedtime routine resulted in signicant reductions in prob-
lematic sleep behaviors for infants and toddlers. Signicant improve-
ments were seen in latency to sleep onset and in number/duration of
night wakings, P < 0.001. Sleep continuity increased and there was a
signicant decrease in the number of mothers who rated their child’s
sleep as problematic. Maternal mood state also signicantly improved.
Control group sleep patterns and maternal mood did not signicantly
change over the 3-week study period.
Conclusion: These results suggest that instituting a consistent nightly
bedtime routine, in and of itself, is benecial in improving multiple as-
pects of infant and toddler sleep, especially wakefulness after sleep
onset and sleep continuity, as well as maternal mood.
Keywords: Sleep, infant, toddler, bedtime routine, bedtime disturbanc-
es, night wakings, behavioral intervention
Citation: Mindell JA; Telofski LS; Wiegand B; Kurtz ES. A nightly bed-
time routine: impact on sleep in young children and maternal mood.
SLEEP 2009;32(5):599-606.
Submitted for publication December, 2008
Submitted in nal revised form January, 2009
Accepted for publication February, 2009
Address correspondence to: Jodi A. Mindell, Ph.D., Department of Psy-
chology, Saint Joseph’s University, Philadelphia, PA 19131; Tel: (610)
660-1806; E-mail: jmindell@sju.edu
Bedtime Routine—Mindell et al
SLEEP, Vol. 32, No. 5, 2009 600
their infants (ages 7-18 months; 45.6% boys) and the second
study included 199 mothers and their toddlers (ages 18-36
months; 48.5% boys). Participants for each study were re-
cruited through an independent market research rm utilizing
contact lists of parents of young children and were screened
by telephone (infant study) or in person (toddler study). Note
that there were originally 209 families in the infant study who
completed the study, however only 206 (98.6%) had complete
data. Similarly, there were complete data for 199 (94.8%) of
the original 210 families in the toddler study. See Table 1 for
complete demographic information for all families with com-
plete data.
Inclusion criteria for the study included that all children must
have an identied sleep problem as noted by the mother, with
all mothers endorsing that their child had a sleep problem that
ranged from “small” to “severe.” However, families were ex-
cluded if the child had an apparent signicant sleep disorder,
as dened as (1) > 3 night wakings per night, (2) awake > 60
minutes per night, (3) total daily sleep duration < 9 hours. Addi-
tional exclusion criteria included: (1) non-English speaking, as
all questionnaires were presented in English, (2) current acute
or chronic illness, and (3) child routinely bathed before bed (af-
ter 16:00) ≥ 4 times per week, as a nightly bath was part of the
bedtime routine in this study.
Measures
Brief Infant Sleep Questionnaire
All mothers completed an expanded version of the Brief In-
fant Sleep Questionnaire (BISQ).13 The BISQ has been vali-
dated against actigraphy and daily-logs and its sensitivity in
documenting expected developmental trends in young chil-
dren’s sleep and the effects of environmental factors have been
established. Test-retest reliability for individual sleep measures
on the BISQ was high (r = 0.81 to 0.95) and Pearson between-
method correlations comparing the BISQ to actigraphy for cor-
responding sleep measures ranged from r = 0.23 to 0.54. All
respondents were asked to describe their child’s behavior over
the past week. The BISQ was completed on days 8, 15, and
22. The expanded version included background demographic
information, specic questions about the child’s daytime and
nighttime sleep patterns, and sleep-related behaviors.
Daily Sleep Diary
All mothers also completed a daily sleep diary that included
information about their child’s sleep patterns (e.g., bedtime,
sleep onset latency, night wakings). The toddler diary included
additional questions about sleep-related behaviors relevant to
this age group, including the number of times the child called
his/her parents, the number of times the child independently got
out of his/her crib/bed, and the number of times the child was
taken out of his/her crib/bed. In addition, parents were asked to
respond on a 5-point Likert scale rating the difculty of bed-
time (1 = very easy to 5 = very difcult), how well the child
slept last night (1 = very well to 5 = very badly), and the child’s
mood when s/he rst woke up in the morning (1 = very happy
to 5 = very fussy).
Profile of Mood States (POMS)
The POMS is a well-validated measure of mood states. The
65-item scale measures 6 identied subscales: tension-anxiety,
depression-dejection, anger-hostility, vigor-activity, fatigue-
inertia, and confusion-bewilderment. Each item is responded
to on a 6-point Likert scale ranging from 0 = “not at all” to 5 =
“extremely.” Higher scores indicate more negative mood state,
except for vigor-activity, for which lower scores denote nega-
tive mood state. The POMS has high internal consistency, as
well as predictive and constructive validity.
Procedure
These studies were approved by an institutional review
board, and informed consent was obtained from all participants.
All families were paid $150-200 for their participation, and no
families were informed of the sponsor of this study.
Infant Study
Of the total 206 families, 134 (65%) families were assigned
to the routine group. Following a one-week baseline period in
which the mothers followed their child’s usual bedtime prac-
Bedtime Routine—Mindell et al
Table 1—Demographic Variables
Infants Toddlers
(n = 206) (n = 199)
Variable Percent (n) Percent (n)
Age of Mother
18-29 31.1 (64) 26.8 (53)
30-39 57.8 (119) 63.1 (125)
40-49 11.2 (23) 10.1 (20)
Married 97.1 (200) 96.5 (191)
School
Graduated high school 16.5 (34) 9.1 (18)
Some college 34.0 (70) 32.3 (64)
College degree or more 49.5 (102) 58.6 (116)
Employed
Full-Time 22.3 (46) 23.4 (46)
Part-Time 22.3 (46) 24.4 (48)
Not Employed 55.4 (114) 52.3 (103)
Income
< $30,000 5.3 (11) 2.5 (5)
$30,000 - $39,999 18.0 (37) 9.1 (18)
$40,000 - $49,999 15.0 (31) 11.1 (22)
$50,000 - $74,999 34.5 (71) 35.9 (71)
$75,000 or more 27.2 (56) 41.4 (82)
Child’s Gender
Boy 45.6 (94) 48.5 (96)
Girl 54.4 (112) 51.5 (102)
Child’s age
7-12 months 43.2 (89)
13-18 months 56.8 (117)
18-24 months 34.9 (68)
25-30 months 37.4 (73)
31-36 months 27.7 (54)
Sleep location
Crib 44.4 (87)
Bed 55.6 (109)
SLEEP, Vol. 32, No. 5, 2009 601
tices, the mothers were instructed to institute a nightly 3-step
bedtime routine for a 2-week period that included a bath (us-
ing a provided wash product), a massage (using a provided
massage product), and quiet activities (e.g., cuddling, singing
lullaby), with lights out within 30 minutes of the end of the
bath. All mothers were provided with the same products in
unmarked containers. Mothers continued to put their child to
bed as they normally did, whether they put their child to bed
awake or stayed with their child until asleep (e.g., rocked to
sleep). Thus, the only recommended change was the institution
of the prescribed bedtime routine. Seventy-two (35%) families
participated as controls. These mothers were instructed to fol-
low their child’s usual bedtime practices throughout the entire
3-week period. They were informed that the study was about
children’s bedtime activities and sleep behaviors.
Toddler Study
Of the 200 families with toddlers, 133 (66.5%) families
were randomly assigned to the routine group and 67 (33.5%)
to the control group. The overall research design was identi-
cal to the infant study, although the bedtime routine included
instructions to apply lotion (using a provided product) rather
than massage, as this was a more age-appropriate activity. The
mothers continued to put their child to bed as they normal-
ly did, whether they put their child to bed awake or stayed
with their child until asleep. Thus, as previously stated, the
only changes made were the institution of the prescribed bed-
time routine. Control families were instructed to follow their
child’s usual bedtime practices throughout the entire 3 weeks.
They were also informed that the study was related to bedtime
activities and sleep behaviors.
Data Analyses
Descriptive analyses (means, frequencies) were used to de-
scribe demographic and sleep variables. Preliminary analyses,
including analysis of variance (ANOVA) and chi-square tests,
were conducted to evaluate whether there were any demograph-
ic differences between the control group and the routine group
that would need to be controlled for when conducting between-
group analyses; however, none were noted. Similar analyses
were conducted to determine whether sleep patterns differed
between the 2 groups. Although randomly assigned, there were
signicant differences in sleep patterns at baseline in both the
infant and toddler study. Specically, there were signicant
differences between the control infants and routine infants at
baseline for night wakings, consolidated sleep, parent percep-
tion of sleep problems, and child’s morning mood, P < 0.05.
Overall, infants in the control group were better sleepers. Simi-
larly, toddlers in the routine group were better sleepers, having
fewer night wakings and greater consolidated sleep than those
randomly assigned to the control group, P < 0.05. Therefore, in-
dividual repeated measures one-way ANOVAs were conducted
separately for each variable within the control groups and the
routine groups, followed by Tukey HSD post hoc testing. Be-
Bedtime Routine—Mindell et al
Table 2—Sleep-Wake Patterns for Infants (BISQ)
Baseline Week 2 Week 3 ANOVA
Variable M (SD) M (SD) M (SD) F P
Sleep latency (min)
Control 20.2 (14.28) 17.9 (11.58) 14.9 (8.69) 3.45 0.03
Interventiona 20.8 (13.76) 13.1 (9.17) 12.4 (9.65) 23.24*** < 0.001
Number of night wakings
Control 1.5 (0.89) 1.4 (0.85) 1.4 (0.97) 0.83 0.44
Interventiona 1.6 (0.86) 1.0 (0.73) 1.0 (0.76) 30.99*** < 0.001
Duration of night wakings (min)
Control 23.5 (26.02) 22.2 (25.56) 18.9 (21.33) 0.66 0.52
Interventiona 21.8 (12.75) 14.8 (11.90) 12.6 (11.79) 20.90*** < 0.001
Longest continuous sleep period (hours)
Control 8.0 (2.87) 8.5 (2.78) 8.5 (2.49) 0.76 0.47
Interventiona 7.6 (2.27) 8.9 (2.47) 9.3 (2.46) 18.23*** < 0.001
Total nighttime sleep (hours)
Control 9.6 (1.36) 9.4 (1.67) 9.5 (1.52) 0.56 0.57
Interventionb 9.5 (1.41) 9.8 (1.52) 10.1 (1.40) 5.12** 0.006
Total naps (hours)
Control 2.5 (1.08) 2.4 (0.98) 2.5 (1.00) 0.05 0.95
Intervention 2.2 (0.96) 2.2 (0.91) 2.3 (1.17) 0.57 0.57
Consider sleep a problem+
Control 1.6 (0.59) 1.7 (0.68) 1.7 (0.66) 0.05 0.95
Interventiona 1.9 (0.56) 1.4 (0.55) 1.3 (0.50) 43.57*** < 0.001
Baby’s mood in morning^
Control 1.9 (0.82) 1.9 (0.87) 1.7 (0.81) 0.99 0.37
Interventiona 2.4 (0.95) 1.8 (0.73) 1.7 (0.83) 23.81*** < 0.001
aSignicant difference between baseline/week 2 and baseline/week 3; bSignicant difference between baseline and week 3; +Higher scores are
better; ^Lower scores are better; BISQ: Brief Infant Sleep Questionnaire; min: minutes; SD: standard deviation
SLEEP, Vol. 32, No. 5, 2009 602
ception by mothers of sleep as a problem, P < 0.001. There was
no change in nap duration, P = 0.57, and a nonsignicant effect
for total nighttime sleep, P = 0.006. Similar results were ob-
served for toddlers, with signicant improvements in number/
duration of night wakings, sleep continuity, and parental per-
ception of sleep as a problem and morning mood, P < 0.001.
There were also decreases in parental report of number of times
the child called out and number of times the child climbed out
of the crib/bed, P < 0.001. No signicant changes were found
for sleep onset latency, P = 0.01; total nighttime sleep, P = 0.61;
or nap duration, P = 0.44.
As seen in Tables 2 and 3, post hoc analyses (Tukey HSD)
indicate that for all sleep variables, for both infants and tod-
dlers, signicant differences occurred between baseline and
both week 2 and week 3. There were no differences for any
sleep variable between week 2 and week 3.
cause of the multiple analyses conducted, ndings were consid-
ered signicant if P < 0.001.
RESULTS
Sleep Patterns
BISQ
For all sleep variables, no signicant differences were found
for any variable across the 3 weeks for the 2 control groups (Ta-
bles 2 and 3). For infants (Table 2), signicant differences were
found for multiple sleep variables following the institution of
the bedtime routine compared to baseline. Overall, infants had
decreased sleep onset latency, decreased number/duration of
night wakings, increased sleep continuity, and decreased per-
Bedtime Routine—Mindell et al
Table 3—Sleep-Wake Patterns for Toddlers (BISQ)
Baseline Week 2 Week 3 ANOVA
Variable M (SD) M (SD) M (SD) F P
Sleep latency (min)
Control 21.8 (15.14) 21.1 (15.91) 2.6 (13.50) 0.11 0.90
Intervention 20.3 (11.55) 16.9 (11.94) 16.3 (12.05) 4.31 0.01
Number of night wakings
Control 1.1 (0.70) 1.2 (1.08) 1.0 (1.01) 0.35 0.71
Interventiona 1.3 (0.85) 0.9 (0.75) 0.6 (0.71) 25.61*** < 0.001
Duration of night wakings (min)
Control 15.1 (14.60) 14.4 (14.84) 13.3 (15.65) 0.24 0.79
Interventiona 14.8 (13.16) 10.0 (12.19) 8.2 (9.85) 11.22*** < 0.001
Longest continuous sleep period (hours)
Control 8.8 (1.97) 8.5 (1.84) 8.5 (1.91) 0.33 0.72
Interventiona 8.1 (2.05) 8.7 (2.11) 9.2 (1.93) 9.22*** < 0.001
Total nighttime sleep (hours)
Control 9.8 (1.10) 9.8 (1.10) 10.0 (1.00) 0.37 0.69
Intervention 9.9 (.94) 9.9 (.95) 10.0 (.89) 0.50 0.61
Total naps (hours)
Control 1.8 (0.79) 1.7 (0.64) 1.7 (0.80) 0.46 0.63
Intervention 1.9 (0.76) 1.7 (0.76) 1.8 (0.76) 0.82 0.44
Consider sleep a problem^
Control 2.6 (0.98) 2.4 (0.95) 2.4 (0.99) 0.70 0.50
Interventiona 2.6 (0.99) 2.0 (0.92) 1.7 (0.82) 31.89*** < 0.001
Toddler’s mood in morning^
Control 2.0 (0.83) 2.0 (0.79) 2.0 (0.83 0.05 0.95
Interventiona 2.2 (0.88) 1.7 (0.70) 1.8 (0.75) 15.39*** < 0.001
Number of times called
Control 1.5 (1.27) 1.5 (1.38) 1.4 (1.07) 0.37 0.69
Interventionb 1.8 (1.53) 1.3 (1.32) 1.1 (1.25) 8.21*** < 0.001
Number of times out of crib/bed
Control 1.2 (1.58) 1.1 (1.41) 1.2 (1.58) 0.16 0.85
Interventiona 1.2 (1.11) 0.7 (0.79) 0.7 (0.88) 6.93** 0.001
How difcult was bedtime?^
Control 2.5 (0.80) 2.5 (0.85) 2.4 (0.89) 0.74 0.48
Interventiona 2.5 (0.83) 2.0 (0.63) 1.8 (0.66) 34.89*** < 0.001
How well did child sleep?^
Control 2.2 (0.76) 2.0 (0.66) 2.1 (0.70) 0.78 0.46
Interventiona 2.3 (0.86) 1.7 (0.68) 1.6 (0.69) 32.77*** < 0.001
aSignicant difference between baseline/week 2 and baseline/week 3
bSignicant difference between baseline and week 3
^Lower scores are better
BISQ: Brief Infant Sleep Questionnaire; min: minutes; SD: standard deviation
SLEEP, Vol. 32, No. 5, 2009 603
Mood State
Again, no signicant differences were found for maternal
mood for either the infant or toddler control group across the 3
weeks (Table 6). Signicant improvements for mothers of infants
in the routine group were found for all subscales of the POMS,
including tension, depression, anger, fatigue, vigor, and confu-
sion, P < 0.001. For mothers of toddlers in the routine group, there
were signicant improvements in tension, anger, fatigue, and
confusion, P < 0.001. As seen in Tables 2 and 3, post hoc analy-
ses (Tukey HSD) indicate that signicant differences were found
between baseline and both week 2 and week 3 for all signicant
subscales of the POMS, for both mothers of infants and toddlers.
DISCUSSION
The results of this study suggest that instituting a consistent
nightly bedtime routine is benecial in improving multiple as-
Sleep Diary
Similar results were noted according to parental sleep diary
(Tables 4 and 5). For infants, following implementation of a
consistent bedtime routine, improvements were found in sleep
onset latency, sleep continuity, number/duration of night wak-
ings, and parental perceptions of how well the child slept and
the child’s mood in the morning, P < 0.001. No changes were
noted in the time parents started the bedtime routine or lights
out, wake time, or nap duration, P > 0.05. For toddlers in the
routine group, there were signicant decreases in sleep onset la-
tency, sleep continuity, and number/duration of night wakings,
as well as improvements in parental perception of bedtime ease,
how well their child slept, and morning mood, P < 0.001. No
changes were noted in the time at which the bedtime routine
was started or the time of turning off the light (“lights out”),
wake time, or nap duration, P > 0.05. For the control group, no
signicant changes were found for any variable.
Bedtime Routine—Mindell et al
Table 4—Sleep-Wake Patterns for Infants (Daily Sleep Diary)
Baseline Week 2 Week 3 ANOVA
Variable M (SD) M (SD) M (SD) F P
Sleep latency (min)
Control 19.8 (12.45) 17.9 (12.86) 16.7 (12.81) 1.08 0.34
Interventiona 19.9 (11.69) 14.0 (10.35) 13.4 (10.46) 14.68*** < 0.001
Time started routine
Control 8:08 (1.25) 8:11 (1.06) 8:08 (1.18) 0.03 0.97
Intervention 8:05 (.80) 8:03 (0.23) 8:04 (0.22) 0.10 0.90
Time of lights out (hours)
Control 8:50 (1.15) 8:49 (1.13) 8:49 (1.12) 0.02 0.98
Intervention 8:46 (0.80) 8:40 (0.77) 8:40 (0.80) 0.81 0.45
Longest continuous sleep period (hours)
Control 7.3 (2.17) 7.6 (2.30) 7.6 (2.23) 0.42 0.66
Interventiona 6.9 (1.68) 8.1 (1.85) 8.5 (1.91) 26.55*** < 0.001
Number of night wakings
Control 1.2 (0.95) 1.1 (0.89) 1.1 (0.90) 0.26 0.77
Interventiona 1.4 (0.75) 1.0 (0.77) 0.9 (0.70) 19.50*** < 0.001
Duration of night wakings (min)
Control 20.9 (18.37) 17.5 (16.90) 18.6 (20.25) 0.62 0.54
Interventiona 25.4 (16.60) 16.3 (14.26) 13.3 (14.42) 24.73*** < 0.001
How easy was bedtime?^
Control 2.1 (0.71) 2.0 (0.70) 1.9 (0.73) 1.90 0.15
Interventiona 2.4 (0.64) 1.8 (0.55) 1.7 (0.57) 63.24*** < 0.001
Wake time
Control 7:32 (1.06) 7:29 (1.08) 7:24 (1.03) 0.23 0.80
Intervention 7:31 (0.86) 7:32 (0.90) 7:33 (0.90) 0.01 0.99
How well baby slept^
Control 2.3 (0.81) 2.1 (0.79) 2.2 (0.85) 1.13 0.32
Interventiona 2.7 (0.71) 2.1 (0.72) 1.9 (0.76) 51.36*** < 0.001
Baby’s mood in the morning^
Control 2.0 (0.75) 1.9 (0.71) 1.8 (0.70) 0.53 0.59
Interventiona 2.3 (0.72) 1.9 (0.70) 1.8 (0.74) 21.10*** < 0.001
Total naps (hours)
Control 2.5 (1.11) 2.4 (1.01) 2.3 (.95) 0.41 0.66
Intervention 2.2 (0.89) 2.2 (0.89) 2.3 (.97) 0.14 0.87
aSignicant difference between baseline/week 2 and baseline/week 3
bStart of routine, Lights out, Wake Time expressed by 24-Hour clock, SD expressed in hours
^Lower scores are better
min: minutes; SD: standard deviation
SLEEP, Vol. 32, No. 5, 2009 604
changes in bedtime behaviors were expected, what was surpris-
ing was that sleep throughout the night also improved, includ-
ing a decrease in the number and duration of night wakings, as
well as increased sleep consolidation.
There is a question as to the mechanism for these improve-
ments in nighttime sleep. One possibility was that other changes
were made by the parents in this study beyond the institution of
the bedtime routine. However, this did not seem to be the case.
For example, no differences in the children’s schedules were
found following institution of the bedtime routine, including
bedtimes and wake times. Furthermore, no recommendations
were made regarding how children fell asleep, thus there were
pects of infant and toddler sleep, resulting in shorter sleep onset
latency, decreased wakefulness after sleep onset, and increased
sleep consolidation. No comparative changes were seen in the
control group. Parental perception of sleep also changed, in-
cluding perception of their child having a sleep problem, sleep
quality, bedtime ease, and morning mood. In addition, maternal
mood state improved following intervention.
As was expected, children fell asleep faster following the
institution of the consistent bedtime routine, and there were im-
provements in bedtime behaviors. For example, toddlers were
less likely to call out to their parents or get out of their crib/
bed following institution of the bedtime routine. Although these
Bedtime Routine—Mindell et al
Table 5—Sleep-Wake Patterns for Toddlers (Daily Sleep Diary)
Baseline Week 2 Week 3 ANOVA
Variable M (SD) M (SD) M (SD) F P
Sleep latency (min)
Control 19.8 (12.45) 17.9 (12.86) 16.7 (12.81) 0.87 0.42
Interventiona 21.9 (11.43) 18.6 (11.85) 16.1 (9.25) 9.38*** < 0.001
Time started routine
Control 8:19 (0.70) 8:18 (0.79) 8:22 (0.76) 0.21 0.81
Intervention 8:15 (0.74) 8:14 (0.71) 8:18 (0.83) 0.29 0.75
Time of lights out (hours)
Control 8:58 (0.76) 8:55 (0.75) 8:56 (0.77) 0.10 0.90
Intervention 8:53 (0.77) 8:48 (0.71) 8:53 (0.77) 0.54 0.58
Longest continuous sleep period (hours)
Control 8.4 (1.59) 8.4 (1.57) 8.4 (1.59) 0.07 0.94
Interventiona 8.0 (1.57) 8.7 (1.58) 8.9 (1.53) 13.15*** < 0.001
Number of night wakings
Control 0.8 (0.56) 0.7 (0.58) 0.7 (0.65) 0.30 0.74
Interventiona 1.0 (0.74) 0.6 (.57) 0.5 (0.57) 23.47*** < 0.001
Duration of night wakings (min)
Control 12.5 (14.90) 10.27 (10.74) 11.7 (14.14) 0.48 0.62
Interventiona 13.3 (12.23) 8.4 (10.4) 9.3 (.81) 12.88*** < 0.001
Number of times called
Control 1.5 (1.41) 1.5 (1.87) 1.3 (1.95) 0.18 0.84
Interventiona 1.8 (1.89) 1.1 (1.10) 1.0 (1.15) 10.57*** < 0.001
Number of times got out of bed/crib
Control 1.0 (1.21) 1.0 (1.28) 0.9 (1.17) 0.20 0.82
Intervention 1.0 (0.92) 0.7 (0.70) 0.6 (0.79) 4.31 0.01
How difcult was bedtime?
Control 2.4 (0.62) 2.4 (0.72) 2.3 (0.73) 0.72 0.49
Interventiona 2.3 (0.58) 1.9 (0.49) 1.8 (0.55) 28.20*** < 0.001
Wake time
Control 7:35 (0.95) 7:32 (0.99) 7:42 (0.96) 0.53 0.59
Intervention 7:30 (0.87) 7:29 (0.88) 7:29 (0.90) 0.02 0.98
Total sleep time (hours)
Control 10.0 (0.88) 10.1 (0.95) 10.2 (.87) 0.58 0.56
Intervention 9.8 (0.79) 10.1 (0.82) 10.2 (.85) 2.10 0.12
How well toddler slept^
Control 2.1 (0.49) 2.0 (0.57) 2.0 (0.54) 0.42 0.66
Interventiona 2.1 (0.63) 1.8 (0.60) 1.6 (0.56) 28.26*** < 0.001
Toddler’s mood in the morning^
Control 2.1 (0.65) 2.0 (0.74) 2.0 (0.72) 0.18 0.83
Interventiona 2.2 (0.73) 1.9 (0.58) 1.8 (0.63) 18.35*** < 0.001
Total naps (hours)
Control 1.7 (0.65) 1.6 (0.75) 1.6 (0.75) 0.09 0.91
Intervention 1.7 (0.71) 1.7 (0.75) 1.7 (0.70) 0.04 0.96
aSignicant difference between baseline/week 2 and baseline/week 3; bStart of routine, Lights out, Wake time expressed by 24-Hour clock,
SD expressed in hours; ^Lower scores are better; min: minutes; SD: standard deviation
SLEEP, Vol. 32, No. 5, 2009 605
tive changes in the children’s sleep. Given the design of this
study, it is not possible to determine what led to the improve-
ment in mood. It may be that as the children in this study slept
better, mothers obtained more sleep, leading to improved mood.
Another possibility is that with a designated bedtime routine,
mothers of children with sleep issues felt more in control at
bedtime, which resulted in improvements in mood, similar to
previous studies that have reported decreased parental distress
with institution of daily routines.6 Future studies should include
measures of maternal sleep and parental control to further elu-
cidate this relationship.
There are a number of limitations to this study. First, this
study was based on parental report without an objective mea-
sure of sleep, such as actigraphy. Future studies should include
such additional measures. Second, the results may have been a
result of demand characteristics in that there were expectations
no changes in any negative sleep associations, which are typi-
cally the primary inuence on night wakings.1 Thus, it seems
that the bedtime routine specically improved nighttime sleep,
as well as the expected changes at bedtime. Similar to studies
on the impact of daily routines, the presence of a routine may in
and of itself have resulted in overall improvements beyond the
immediate behaviors.6-8 It also may be that a bedtime routine
led to an overall decrease in arousal level, resulting in improved
sleep throughout the night beyond just bedtime. And the nal
possibility is that the inclusion of a bath as part of the recom-
mended routine, which affects core body temperature, resulted
in improved sleep. Studies in adults have found that a bath im-
proves sleep,14,15 and similar effects may have been found in
this study.
In addition to the impact on the infants and toddlers, it is
noteworthy that maternal mood improved concurrent with posi-
Bedtime Routine—Mindell et al
Table 6—Maternal Mood for Infants and Toddlers (POMS)
Baseline Week 2 Week 3 ANOVA
Variable M (SD) M (SD) M (SD) F P
Infants
Tension^
Control 7.4 (4.89) 7.0 (5.01) 5.7 (3.99) 2.73 0.07
Interventiona 8.4 (5.28) 5.4 (3.57) 4.2 (3.44) 34.83*** < 0.001
Depression^
Control 4.9 (5.97) 4.3 (5.01) 3.4 (4.63) 1.54 0.22
Interventiona 6.2 (7.22) 2.9 (5.63) 1.7 (2.77) 22.69*** < 0.001
Anger^
Control 4.9 (3.79) 4.7 (4.53) 3.5 (3.65) 2.08 0.13
Interventiona 5.9 (5.89) 2.7 (3.20) 2.0 (3.12) 31.49*** < 0.001
Fatigue^
Control 8.0 (5.57) 7.4 (5.68) 5.7 (4.72) 3.78 0.02
Interventiona 9.9 (6.20) 5.4 (4.79) 4.1 (4.53) 43.79*** < 0.001
Vigor+
Control 13.6 (6.60) 13.6 (7.31) 13.9 (7.70) 0.03 0.97
Interventiona 12.3 (6.06) 15.0 (5.59) 16.0 (6.21) 14.26*** < 0.001
Confusion^
Control 5.7 (3.95) 5.2 (3.72) 4.5 (3.60) 1.97 0.14
Interventiona 6.0 (4.10) 3.9 (2.76) 3.2 (2.56) 27.57*** < 0.001
Toddlers
Tension^
Control 8.2 (5.22) 8.1 (5.35) 6.9 (4.93) 1.27 0.28
Interventiona 8.9 (5.10) 6.5 (4.15) 5.7 (4.49) 17.34*** < 0.001
Depression^
Control 5.9 (8.51) 5.0 (7.87) 4.4 (8.32) 0.54 0.59
Interventiona 5.6 (6.92) 3.7 (5.38) 3.1 (6.13) 5.90*** 0.003
Anger^
Control 5.8 (5.85) 4.9 (5.16) 4.4 (5.95) 0.96 0.39
Interventiona 6.2 (5.43) 4.3 (4.80) 3.6 (4.94) 9.19*** < 0.001
Fatigue^
Control 8.7 (5.65) 7.5 (4.95) 7.1 (5.81) 1.51 0.22
Interventiona 9.5 (5.43) 6.9 (4.86) 5.9 (5.23) 16.90*** < 0.001
Vigor+
Control 14.0 (5.55) 14.1 (5.84) 14.6 (5.74) 0.27 0.77
Interventiona 13.0 (6.13) 14.2 (5.68) 14.2 (6.34) 1.70 0.18
Confusion^
Control 5.6 (4.11) 5.6 (3.94) 4.8 (4.01) 0.73 0.48
Interventiona 6.3 (3.64) 4.9 (3.08) 4.4 (2.96s) 13.46*** < 0.001
aSignicant difference between baseline/week 2 and baseline/week 3; ^Lower scores are better; +Higher scores are better; POMS: Prole of
Mood States; SD: standard deviation
SLEEP, Vol. 32, No. 5, 2009 606
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that sleep would improve. However, it is quite interesting to
note that changes were not observed for those sleep variables
that would not be expected to be affected by the institution of a
bedtime routine. For example, as discussed above, there was no
change in rise times or nap duration for the infants and toddlers
in either routine group. None of these variables should have
been affected by the implementation of the bedtime routine.
Another limitation was the lack of a longer-term follow-up. It
is not known whether improvements in sleep were maintained
following the 2-week intervention period. Future studies of the
efcacy of implementation of a bedtime routine would benet
from longer-term follow-up. A nal limitation was that only
one specic bedtime routine was evaluated, with all families
instituting the same routine of a bath, massage/lotion, and quiet
activities. Thus, no conclusions can be made as to whether this
specic routine led to the improvements in sleep or whether any
routine would lead to improved sleep. Furthermore, this study
did not allow for an evaluation of whether all components of the
routine were essential. Further evaluation of a myriad of bed-
time routines would help elucidate whether there are specic
aspects of a bedtime routine that lead to more or less improve-
ment in sleep.
Overall, this study found that institution of a consistent
nightly bedtime routine improves sleep in infants and toddlers,
as shown here with mild to moderate sleep problems. Such a
routine appears to be highly efcacious; it can be easily adopted
by practicing pediatricians and other pediatric providers as a
routine recommendation for both prevention and treatment of
sleep problems in young children. Primary care practitioners
play an instrumental role in helping families institute positive
sleep practices and improving sleep in infants and toddlers.
This study provides pediatric practitioners with a simple mes-
sage that parents can easily implement and one that requires
minimal practitioner time.
DISCLOSURE STATEMENT
This study was supported by Johnson & Johnson Consumer
Companies, Inc. Dr. Mindell has consulted for and participated
in speaking engagements for Johnson & Johnson. The other au-
thors are employees of Johnson & Johnson Consumer Compa-
nies, Inc.
Bedtime Routine—Mindell et al
... Infants' sleep disorders, including sleep latency, constant waking up, and insufficient sleep are among the most common problems of parents (Mindell and Lee, 2015)with a prevalence of about 20-30% (Mindell et al., 2009).The sleep pattern varies a lot in the first year of life. Newborns sleep about 16 h a day on average (Arora et al., 2005), which reduces gradually as the infant grows older in a manner that the average becomes 12.1-14.6 ...
... The infant's sleep characteristics have an effect on the parents' condition as well. This means that the fatigue caused by insomnia leads to mood changes in the parents, reduced motivation, impaired short-term memory, distorted emotional relationship with the infant, decreased quality of life, family problems, car accidents, postpartum depression, and stress (Mindell et al., 2009Mirmohammadali et al., 2011). These effects of sleep disorders that are harmful to babies and their families have led to numerous studies conducted with the aim of finding solutions to reduce or improve these effects. ...
... Regarding the effectiveness of using different bedtime routines, various studies have been conducted during which different methods have been used to improve the sleep quality of newborns, infants, and kids alone or together. Among these methods, educational-behavioral interventions that included the minimum parental involvement in the baby's sleep (Symon and Crichton, 2017), the use of routine bedtime procedures including bathing, singing or lullabies, swaddling, moving back and forth, and massaging were done together (Mindell et al., 2009;Mindell and Williamson, 2018). However, the effects of each of these methods alone and on their own have not been accurately and vastly studied. ...
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Background and Purpose: Infants' sleep disorders and parents' insufficient sleep are common problems in the infant care. The current study was conducted to assess the effectiveness of infant massage on infants' night-time sleep condition and mothers’ sleep quality. Methods 140 number of 15–20 days old infants were randomly put into two different groups, one with bedtime messages and the other with normal infant routine care. For the intervention group, in addition to usual bedtime procedures such as changing diapers and breastfeeding, a 15-min massage was done before sleep for a period of two weeks. For the control group, only the usual above-mentioned bedtime procedures were followed. One week before the intervention, at the end of the first week, and two weeks after the intervention, the information was recorded for both groups. The Brief Infant Sleep Questionnaire, a personal information submission form, and Pittsburgh Sleep Quality Index for the mothers were the tools used to gather data in this study. Results Infants in two control and experimental groups showed meaningful differences in variables such as, sleep latency (P = 000, eta = 0.099), number of night waking (P = 0.03, eta = 0.027), and longest continuous sleep period (P = 0.03, eta = 0.026). As for other variables related to the infants' sleep, no meaningful differences were observed. In this study, there was no indication of a meaningful difference in the mother's overall night-time sleep quality between the two groups (P = 0.184, eta = 0.012) except for the duration of the mother's night-time sleep (P = 0.028, eta = 0.026) and the reduction of maternal sleep disorder (P = 0.020 eta = 0.029). As for other sub-factors of maternal sleep quality, no meaningful differences were seen. Conclusion The findings of this study indicated that infants’ bedtime massages would improve some of the sleep markers of mothers and infants, and therefore, can be suggested as a practical, harmless, and cost-free method to improve sleep.
... After 33 full-text studies were reviewed, 23 studies were excluded according to specific exclusion criteria: non-English language (n = 1); irrelevant participants (n = 9); irrelevant intervention (n = 4); and non-RCTs design (n = 9), which included one mixed-method study, one second-data analysis, one study protocol, and six quasi-experimental designs using one group pre-post test. Finally, 10 studies were included in this study 24,30,31,[40][41][42][46][47][48][49] . However, two of these studies were divided into two subgroups based on their participants and intervention type 41,47 ; thus, a total of 12 subgroup analyses were included in the meta-analysis. ...
... Finally, 10 studies were included in this study 24,30,31,[40][41][42][46][47][48][49] . However, two of these studies were divided into two subgroups based on their participants and intervention type 41,47 ; thus, a total of 12 subgroup analyses were included in the meta-analysis. ...
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... Several factors are known to influence infants' sleep health, including maternal mental health, 21 sleep environment, bedtime routines, 22 and family socioeconomic status (SES). 23, 24 Sadeh et al outlined a socio-ecological model, which views sleep as nested within a broader context (culture, environment, family), and more proximal factors, including intrinsic child characteristics and parenting factors, all shaping the parent-child interactive context, which in turn has a bidirectional relationship with infant sleep. ...
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... Uspavljivanje danas u našoj kulturi (ali i u drugim kulturama) predstavlja rutinu i ritual koji olakšava tranziciju od budnosti do sna (Đorđević i Matejević, 2020). U tom kontekstu, "rutina za spavanje" definiše se kao svakodnevni stav porodice prema kojem roditelji, pre nego što ugase svetla, uključe svoju decu u slične aktivnosti, po istom redosledu i pritom se ističe njihov značaj za kvalitet sna (Mindell et al., 2009). ...
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