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3/9/18
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13/9/18
Infant
Sleep
Nicole R. Quint, Dr.OT, OTR/L
3
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.
4
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Basics of Sleep
Restorative Adaptive
§ Non-REM sleep: “quiet” § Rapid Eye Movement (REM)
sleep: “active” sleep
sleep
§ Primary activity of the brain
§ Blood supply to muscles is during early development
increased § Directly impacts mental and
§ Energy restored physical development
§ Tissue growth and repair § REM and nREM alternate
occur (50/50)
§ Important hormones § 50% of baby’s time is sleeping
released for growth and § Cycles are 50 min each, 4
development cycles within sleep
§ 90 min at preschool (30/70)
National Sleep Foundation (2018) 5
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
National Sleep Foundation (2018)
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Infant Sleep Issues
§ Transition from
bassinet to crib
§ Night Wakings
§ Development
§ Milestones can
create disruptions
Zero to Three (2018); Mindell et al. (2006); National Sleep Foundation (2018)
7
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)
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Common Sleep Issues
Bedtime Problems
Infants Toddlers
Difficulty falling asleep independently Bedtime resistance and goal of
autonomy and independence
Development of object permanence Separation anxiety peaks 18-24
leads to separation anxiety months
Night Wakings
Infants Toddlers
Negative sleep associations Independence
Nighttime feedings Cause and effect
Mindell et al. (2006); National Sleep Foundation (2018) 9
Variability in
Sleep
Infants: High
Toddlers: Low
NIH (2018); Sadeh et al. (2009); Mindell et al. (2009) 10
53/9/18
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/de
fault.aspx
11
Sudden Infant Death Syndrome: Facts
12
NIH, 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
13
LET’S HELP THE FAMILIES! (NIH, 2008)
§ How to reduce risks of SIDS and other sleep-related
causes of infant death
14
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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
(NIH, 2008)
15
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/
16
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Family
Centered Care
Matters
17
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)
18
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§ Three key steps
1. Set sleep schedule
AMERICAN
ACADEMY OF
2. Consistent bedtime
SLEEP routine
MEDICINE
Behavioral treatments 3. Self-soothe to sleep
effective
§ Fall asleep independently
§ Focus on bedtime
19
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_B
EARSSleepScreening.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
20
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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)
21
Control Groups Routine Groups
§ No change in status § Sleep onset latency
reduction (37%/ 27%)
§ Duration night wakings
(30% reduction)
§ Longest continuous
sleep* (90 min, 60+ min
increase)
§ Maternal tension and
fatigue decreased
Metzer & Mindell (2006)
22
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Infant Feedings & Sleep
23
Toddlers: Routine Builders
Mindell et al. 2009; Metzler & Mindell 2006; National Sleep Foundation (2018) 24
123/9/18
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.
25
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
26
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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.
27
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.
28
143/9/18
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
29
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