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Infant Sleep

Nicole R. Quint, Dr.OT, OTR/L

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Objectives § Identify sleep standards for infants in terms of

amount of sleep, sleep routines, and variability with infant sleep.

§Describe safety issues for infant sleep related to positioning, environment, and risk factors for SIDS.

§Describe evidence based interventions to promote infant sleep for families, including benefits to parents.

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Basics of Sleep

Restorative§ Non-REM sleep: “quiet”

sleep§ Blood supply to muscles is

increased

§ Energy restored

§ Tissue growth and repair occur

§ Important hormones released for growth and development

Adaptive§ Rapid Eye Movement (REM)

sleep: “active” sleep § Primary activity of the brain

during early development

§ Directly impacts mental and physical development

§ REM and nREM alternate (50/50)§ 50% of baby’s time is sleeping

§ Cycles are 50 min each, 4 cycles within sleep

§ 90 min at preschool (30/70)

5National Sleep Foundation (2018)

Infant and Toddler Sleep 3-12 months Toddlers (1-3yr)

9-12 hours 12-14 hours

Naps: 2-4 (30-120 min) Naps: 1-2 (18 months=1)

Sleep problems common Sleep problems

High Variability in amount of sleep Low Variability in amount of sleep

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National Sleep Foundation (2018)

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Infant Sleep Issues

§ Transition from bassinet to crib

§ Night Wakings

§ Development§ Milestones can

create disruptions

7Zero to Three (2018); Mindell et al. (2006); National Sleep Foundation (2018)

Toddler Sleep Issues

§ Transition§ Crib to bed

§ Development§ Calling out§ Climbing out

§ Night fears

§ Night Wakings (normal)§ 3-6 times/night

Zero to Three (2018); Mindell et al. (2009); National Sleep Foundation (2018)8

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Common Sleep IssuesBedtime Problems

Infants Toddlers

Difficulty falling asleep independently Bedtime resistance and goal of autonomy and independence

Development of object permanenceleads to separation anxiety

Separation anxiety peaks 18-24 months

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Night Wakings

Infants Toddlers

Negative sleep associations Independence

Nighttime feedings Cause and effect

Mindell et al. (2006); National Sleep Foundation (2018)

Variability in Sleep

Infants: HighToddlers: Low

10NIH (2018); Sadeh et al. (2009); Mindell et al. (2009)

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Safe Environment (NIH, 2018)§Safe to Sleep® campaign (NIH)

§ Previously Back to Sleep campaign

§SIDS

§Safe Sleep Environment

§ Tummy Time

§ https://www1.nichd.nih.gov/sts/about/Pages/default.aspx

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Sudden Infant Death Syndrome: Facts

12NIH, 2018

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LET’S HELP THE FAMILIES! (NIH, 2008)

§ How to reduce risks of SIDS and other sleep-related causes of infant death

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LET’S HELP THE FAMILIES! (NIH, 2008)

§ How to reduce risks of SIDS and other sleep-related causes of infant death

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Tired parents…§Question from parent: “What if I fall asleep while

feeding my baby?”

§Answer: It is less dangerous to fall asleep in an adult bed than on a sofa or armchair, so ask yourself how tired you are and if you think you might (even slight chance) fall asleep, then choose the bed and remove ALL SOFT ITEMS and BEDDING before you start

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FAMILY CENTERED CARE (FCC)§ Working with family to ensure safety and well-being of all family

members

§ Strengthening capacity of families to function effectively by focusing on solutions

§ Engaging, empowering, and partnering with families throughout the decision-and goal-making processes

§ Developing a relationship between parents and service providers characterized by mutual trust, respect, honesty, and open communication

§ Providing individualized, culturally responsive, flexible and relevant services for each family

§ Linking families with collaborative, comprehensive, culturally relevant, community-based networks of supports and services

• Source: https://www.childwelfare.gov/topics/famcentered/philosophy/

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Family Centered Care

Matters

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FCC Matters§ Parents of sleep-disturbed infants appear to have lower

tolerance for infant crying (Sadeh, et al. 2016)

§ Maternal sleep predictor of infant sleep (Tikotzky, 2015)

§ Increased involvement of fathers in infant caregiving responsibilities may contribute to improvement in both maternal and infant sleep during first 6 months (Tikotzky, 2015)

§ Lower quality of sleep in infancy significantly predicts compromised attention regulation and behavior problems (Sadeh, et al., 2015)

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AMERICAN ACADEMY OF SLEEP MEDICINE

§ Three key steps1. Set sleep schedule

2. Consistent bedtime routine

3. Self-soothe to sleep § Fall asleep independently§ Focus on bedtime

Behavioral treatments effective

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Infant Sleep Assessment Options § Infant Sleep Questionnaire

§ Sleep and Settle Questionnaire

§ BEARS (Bedtime problems, Excessive sleepiness, Awakenings, Regularity, Snoring)

§ http://keltymentalhealth.ca/sites/default/files/Kelty_ProfToolkit_M5_BEARSSleepScreening.pdf

§ Sleep Disturbance Scale for Children

§ http://www.midss.org/content/sleep-disturbance-scale-children-sdsc

§ Brief Infant Sleep Questionnaire

§ http://www.bayclinicpediatrics.net/getattachment/27a261cc-b54b-413e-b22c-e3f36a37aa2f/Pediatric-Sleep-Questionnaire.aspx

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Consistent Bedtime Routine§Sleep hygiene: 3-4 quiet activities each night

§Set a sleep schedule (same sleep times for all)

§ EBP: research study with 130 infants (7-18 mos)

§ EBP: research study with 200 toddlers (18-36 mos)§ Control: usual routine

§ Routine: bath, massage/lotion, quiet activities (cuddles, stories, etc.; talking about day for toddlers)

• Mindell et al. (2006)

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Control Groups§ No change in status

Routine Groups§ Sleep onset latency

reduction (37%/ 27%)

§ Duration night wakings(30% reduction)

§ Longest continuous sleep* (90 min, 60+ min increase)

§ Maternal tension and fatigue decreased

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Metzer & Mindell (2006)

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Infant Feedings & Sleep

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Toddlers: Routine Builders

24Mindell et al. 2009; Metzler & Mindell 2006; National Sleep Foundation (2018)

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Case Study§ Julie is 8 months and her mother states she “is a bad

sleeper.” Her parents have two other children, one who is 5 and one who is 2, and they share a room. Julie sleeps in her parents’ bedroom in an approved crib. Julie’s mother, Hannah, says that their schedule is “all over the place sometimes” and she often falls asleep feeding Julie while feeding her sitting on the couch. Hannah expressed concerns about safety with SIDS, needs help promoting sleep routine, and is also indicating that her 2 year old, K.C., is also “not the greatest sleeper” and resists going to bed.

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Resources § http://www.youtube.com/watch?v=TI7Bh0qkNP

4 (Sleep facts)

§ https://www.youtube.com/watch? v=dW8wmNzDg_Q (Sleep Interventions)

§ https://www.johnsonsbaby.com/bedtime(Johnson’s Baby Bedtime)

§ https://www.johnsonsbaby.com/baby-sleep-app(Johnsons baby sleep app)

§ Zero to Three

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References§ Douglas, P. S. (2016). High level evidence does not support first wave behavioural

approaches to parent-infant sleep. Sleep medicine reviews, 29, 121-122.

§ Kempler, L., Sharpe, L., Miller, C. B., & Bartlett, D. J. (2016). Do psychosocial sleep interventions improve infant sleep or maternal mood in the postnatal period? A systematic review and meta-analysis of randomised controlled trials. Sleep medicine reviews, 29, 15-22.

§ Lam, P., Hiscock, H., & Wake, M. (2003). Outcomes of infant sleep problems: a longitudinal study of sleep, behavior, and maternal well-being. Pediatrics, 111(3), e203-e207.

§ Meltzer, L. J., & Mindell, J. A. (2006). Sleep and sleep disorders in children and adolescents. Psychiatric Clinics, 29(4), 1059-1076.

§ Meltzer, L. J., & Mindell, J. A. (2007). Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: a pilot study. Journal of Family Psychology, 21(1), 67.

§ Mindell, J. A., Meltzer, L. J., Carskadon, M. A., & Chervin, R. D. (2009). Developmental aspects of sleep hygiene: findings from the 2004 National Sleep Foundation Sleep in America Poll. Sleep medicine, 10(7), 771-779.

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References§ NIH. Safe to Sleep®. About SIDS and safe infant sleep. Retrieved from

https://www1.nichd.nih.gov/sts/about/Pages/default.aspx

§ Paul, I. M., Savage, J. S., Anzman-Frasca, S., Marini, M. E., Mindell, J. A., & Birch, L. L. (2016). INSIGHT responsive parenting intervention and infant sleep. Pediatrics, e20160762.

§ Sadeh, A., De Marcas, G., Guri, Y., Berger, A., Tikotzky, L., & Bar-Haim, Y. (2015). Infant sleep predicts attention regulation and behavior problems at 3–4 years of age. Developmental neuropsychology, 40(3), 122-137.

§ Sadeh, A., Juda-Hanael, M., Livne-Karp, E., Kahn, M., Tikotzky, L., Anders, T.F, …& Sivan, Y. (2016). Low parental tolerance for infant crying: an underlying factor in infant sleep problems? Journal of Sleep Research, 25(5), 501-507.

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References§ Shapiro-Mendoza, C. K., Colson, E. R., Willinger, M., Rybin, D. V., Camperlengo, L.,

& Corwin, M. J. (2015). Trends in infant bedding use: National infant sleep position study, 1993–2010. Pediatrics, 135(1), 10-17.

§ Sadeh, A. V. I., Mindell, J. A., Luedtke, K., & Wiegand, B. (2009). Sleep and sleep ecology in the first 3 years: a web‐based study. Journal of sleep research, 18(1), 60-73.

§ Tikotzky, L., Sadeh, A., Volkovich, E., Manber, R., Meiri, G., & Shahar, G. (2015). VII. Infant sleep development from 3 to 6 months postpartum: Links with maternal sleep and paternal involvement. Monographs of the Society for Research in Child Development, 80(1), 107-124.

§ Zero to Three. (2018). Sleep challenges: Why it happens, what to do. Retrieved from https://www.zerotothree.org/resources/331-sleep-challenges-why-it-happens-what-to-do

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